Inhalational Constrictive Bronchiolitis: The Evolution of our Understanding of this Disease.

The case definition of inhalational constrictive bronchiolitis (CB) has changed over the generations. We identify changes in the description of this illness over time associated with different exposures and present the natural history of CB in a case attributed to military burn pit exposure. The initial descriptions of this disease began with nitric acid spills and silage exposures. In these events, there was an acute exposure, typically a short-term resolution of the adverse respiratory events, and then a progression, leading to disability or a respiratory death. The life-saving role of corticosteroid therapy in this situation was recognized. War gas exposures of World War I and then Saddam Hussein's use of sulfur mustard gas in the Iran-Iraq War followed. More recently the findings associated with diacetyl exposure in commercial popcorn workers remained consistent with previously described presentations, but then the clinical presentation in troops returning from deployment to Southwest Asia was very different, yet with the same histologic findings. We recognize unreconciled disparities in the clinical, physiologic, and imaging presentation in those with inhalational bronchiolitis and acknowledge this as perhaps one of the difficult diagnoses in respiratory medicine.

The effect of a clinical medical librarian on in-patient care outcomes.

OBJECTIVE: The research sought to determine the effect of a clinical medical librarian (CML) on outcomes of in-patients on the internal medicine service. METHODS: A prospective study was performed with two internal medicine in-patient teams. Team 1 included a CML who accompanied the team on daily rounds. The CML answered questions posed at the point of care immediately or in emails post-rounds. Patients on Team 2, which did not include a CML, as well as patients who did not require consultation by the CML on Team 1, served as the control population. Numerous clinical and library metrics were gathered on each question. RESULTS: Patients on Team 1 who required an answer to a clinical question were more ill and had a longer length of stay, higher costs, and higher readmission rates compared to those in the control group. Using a matched pair analysis, we showed no difference in clinical outcomes between the intervention group and the control group. CONCLUSIONS: This study is the largest attempt to prospectively measure changes in patient outcomes when physicians were accompanied by a CML on rounds. This approach may serve as a model for further studies to define when and how CMLs are most effective.

Assessing the FACTTS: an evidence-based medicine and critical appraisal course for medical students.

The Fourth-year Academic Clinical Training and Teaching Selective (FACTTS) is a course taught by medical and library faculty on the practice of evidence-based medicine and critical appraisal of the medical literature. This study assesses the impact of the course on students' understanding of the subject matter by examining three years of pre- and post-test data and addresses whether the number of sessions in the course affects the knowledge gained by the students. The data show an improvement in the students' understanding of course material, but no benefit was found in having two versus three sessions.

Critical appraisal process: step-by-step.

We present information describing how to search to identify those reports that provide insight into the answer to the query. We have presented a reasonable approach to searching, with our end-point being the identification of published articles which appear to answer our queries. The decision as to whether these articles are applicable to the patient under discussion is determined by our clinical knowledge and the specifics of the patient's medical concerns. This process is recognized as critical analysis. Our structure for optimal searching includes use of the PICO model, formulating a focused clinical question, and defining key search terms. Using these principles, we have addressed an example important controversy in the practice of clinical medicine; in other words, the effectiveness of screening for prostate cancer and whether it alters the natural history of this illness.

Final tips in interpreting evidence-based medicine.

In this issue, the Southern Medical Journal presents a series of articles to help students of medicine understand the principles of evidence-based medicine. These articles are not meant to be a comprehensive review, but rather an easy-to-read primer. In this final article, the authors offer suggestions to aid the reader in navigating the ever-expanding amount of information. These tips address a number of points that are commonly encountered in the medical literature, but are not all-inclusive.

The Effectiveness of Whole Lung Lavage in Pneumoconiosis: A Systematic Review and Meta-Analysis.

OBJECTIVE: This study aimed to evaluate the role of whole lung lavage (WLL) in the treatment of pneumoconiosis and compare changes in lung function over time in treated and untreated miners. METHODS: We systematically reviewed and identified eight controlled studies with treated and comparison groups with lung function tests before WLL and a year or more later. Two hundred ninety-two patients were included in our meta-analysis. RESULTS: Studies consistently showed a slowing of the rate of lung function decline with WLL at 1, 2, and 4 years. In some reports, details of the population under study, reliability of lung function tests, the adequacy of matching, technical aspects of the procedure, and adverse effects associated with WLL were not available. CONCLUSIONS: Despite recognized weaknesses in the presentation of information, this procedure may show promise in altering the natural history of pneumoconiosis.

Constrictive Bronchiolitis Attributable to Inhalation of Toxic Agents: Considerations for a Case Definition.

OBJECTIVE: We identified cases of constrictive bronchiolitis (CB), an inflammatory injury obliterating the small airways, in adults caused by inhalational exposure to determine an appropriate case definition. METHODS: We performed a systematic review with meta-analysis for these cases from 1990 to 2017. Publications were included if there was 1) inhalational exposure; 2) respiratory symptoms/signs; 3) pulmonary function test results; and 4) computerized tomographic chest imaging. Many had a lung biopsy. RESULTS: Two hundred seventy-four articles were retrieved; 22 manuscripts comprising 102 cases were included. Diagnostic criteria from cases associated with military deployment to southwest Asia were statistically different from criteria of other etiologies. CONCLUSION: In three cases, the scan was consistent with CB, the biopsy nondiagnostic, yet the diagnosis was made. CB associated with military deployment presented with diagnostic features statistically different from features in the other cases.

Decreased hospital length of stay associated with presentation of cases at morning report with librarian support.

OBJECTIVE: The research sought to determine whether case discussion at residents' morning report (MR), accompanied by a computerized literature search and librarian support, affects hospital charges, length of stay (LOS), and thirty-day readmission rate. METHODS: This case-control study, conducted from August 2004 to March 2005, compared outcomes for 105 cases presented at MR within 24 hours of admission to 19,210 potential matches, including cases presented at MR and cases not presented at MR. With matching criteria of patient age (+/- 5 years), identical primary diagnosis, and secondary diagnoses (within 3 additional diagnoses) using International Classification of Diseases (ICD-9) codes, 55 cases were matched to 136 controls. Statistical analyses included Student's t tests, chi-squared tests, and nonparametric methods. RESULTS: LOS differed significantly between matched MR cases and controls (3 days vs. 5 days, P < 0.024). Median total hospital charges were $7,045 for the MR group and $10,663 for the control group. There was no difference in 30-day readmission rate between the 2 groups. DISCUSSION/CONCLUSION: Presentation of a case at MR, followed by the timely dissemination of the results of an online literature review, resulted in a shortened LOS and lower hospital charges compared with controls. MR, in association with a computerized literature search guided by the librarians, was an effective means for introducing evidence-based medicine into patient care practices.

Is Fecal Leukocyte Test a good predictor of Clostridium difficile associated diarrhea?

BACKGROUND: Fecal leukocyte test (FLT) is widely used to screen for invasive diarrheas including C. difficile associated diarrhea (CDAD), which account for more than 25 % of all antibiotic associated diarrhea. METHOD: 263 stool samples from patients with suspected CDAD were studied simultaneously for fecal leukocyte test (FLT) and Clostridium difficile toxin assay (CDTA). FLT was performed by the Giemsa technique and CDTA was performed by enzyme immuno assay (EIA). RESULTS: Sensitivity, specificity, positive predictive value and negative predictive value of FLT as compared to CDTA were 30%, 74.9%, 13.2% and 89.3% respectively. CONCLUSION: Considering the poor sensitivity of FLT, and the comparable cost and time of obtaining a CDTA at our institution, we conclude that FLT is not a good screening test for CDAD. Possible reasons for FLT being a poor predictor of CDTA are discussed.

Use of the specific challenge in the diagnosis of occupational asthma: a 'gold standard' test or a test not used in current practice of occupational asthma?

PURPOSE OF REVIEW: This review, an assessment of the role of inhalational challenge testing in the diagnosis of occupational asthma, focuses on the difficulties associated with making the correct diagnosis of occupational asthma. This report contrasts the apparent discrepancy between the clinical diagnosis and the diagnosis made by inhalational challenge testing, the 'gold standard'. This disparity has been pointed out by a number of authors, yet this approach to making the diagnosis of this illness continues. RECENT FINDINGS: Because of the disparity between the clinical mode for diagnosis and using specific challenge testing for diagnosis, awarding compensation to a worker based on the clinical diagnosis of occupational asthma, or using this clinical approach to identify the incidence or prevalence of occupational asthma in a population, is suspect. In the absence of specific inhalational challenge, physicians have attempted to understand changes in flow rates over time through the use of serial peak-flow assessments, a relatively cost-effective way to sort out the diagnosis. Yet, there is an increasing body of knowledge which presents information casting concern on the adequacy of these measurements. In addition, recent data suggest that chest physicians, occupational medicine physicians, and allergists most often make a diagnosis of occupational asthma by usual clinical methodology, which is a routine part of their hospital's pulmonary function laboratory. SUMMARY: The apparent lack of training in the approach to specific inhalation challenge testing in fellowship programs, the relatively few specialized centers, and the apparent lack of recognition by many physicians who are presented with a patient with suspected occupational asthma means that the use of routine methods to make the clinical diagnosis may often be incorrect, making it unlikely that this approach to the diagnosis of occupational asthma will change in the near future.

Clinical aspects of asbestos-related diseases--what are the unresolved topics?

OBJECTIVE: Despite awareness of the health risks associated with asbestos fiber inhalation and the decline in U.S. utilization (about 0.1% of the yearly peak amount), illnesses associated with exposure persist. Those with disease typically describe excessive exposures in the remote past, yet excessive exposures can occur today, most likely related to careless asbestos abatement procedures. The intent is to address unanswered questions associated with asbestos exposure. METHODS: The author summarizes clinical information addressing the case definition of asbestosis, the world-wide rate of mesothelioma, and clinical follow-up for those with exposure. RESULTS: The author describes information relevant to issues which remain unresolved. CONCLUSION: Perhaps somewhat surprisingly, even though there have been a great number of manuscripts reporting on the health risks of asbestos exposure, there remain unanswered questions regarding the pathogenesis of this disease.

Morning report: can an established medical education tradition be validated?

BACKGROUND: Morning report is accepted as an essential component of residency education throughout different parts of the world. OBJECTIVE: To review the evidence of the educational value, purpose, methods, and outcomes of morning report. METHODS: A literature search of PubMed, Ovid, and the Cochrane Library for English-language studies published between January 1, 1966, and October 31, 2011, was performed. We searched for keywords and Medical Subject Heading terms related to medical education, methods, attitudes, and outcomes in regard to "morning report." Title and abstract review, followed by a full-text review by 3 authors, was performed to identify all pertinent articles. RESULTS: We identified 71 citations; 40 articles were original studies and 31 were commentaries, editorials, or review articles; 56 studies (79%) originated from internal medicine residency programs; 6 studies (8%) focused on ambulatory morning report; and 63 (89%) originated from the United States. Identified studies varied in objectives, methods, and outcome measures, and were not suitable for meta-analysis. Main outcome measures were resident satisfaction, faculty satisfaction, preparation for professional examinations, use of evidence-based medicine, clinical effects on patient care, adverse event detection, and utilization of a curriculum in case selection. CONCLUSIONS: Morning report has heterogeneous purposes, methods, and settings. As an educational tool, morning report is challenging to define, its outcome is difficult to measure, and this precludes firm conclusions about its contribution to resident education or patient care. Residency programs should tailor morning report to meet their own unique educational objectives and needs.

American College of Chest Physicians consensus statement on the respiratory health effects of asbestos. Results of a Delphi study.

BACKGROUND: The diagnosis of and criteria for the evaluation of asbestos-related disease impairment remains controversial after decades of research. Assessing agreement among experts who study pneumoconiosis, and diagnose and treat patients with asbestos-related respiratory conditions may be the first step in clarifying clinical and forensic/administrative issues associated with asbestos-related pulmonary conditions. METHODS: We conducted a Delphi study, an iterative method of obtaining consensus among a group of experts. An expert panel was identified using an objective, nonbiased algorithm, based on the number of asbestos-related disease publications authored during the preceding 10-year period. Identified experts were invited to participate by accessing an Internet site. Each expert was presented statements developed by the authors regarding the diagnosis or treatment of asbestos-related disease; experts then ranked their degree of agreement or disagreement utilizing an 11-level modified Likert scale for each statement. Each expert was asked to justify their selection and to suggest references in support of their opinion. The Wilcoxon signed rank test and the interquartile range were used to define "consensus." The results of the collective Likert rankings, deidentified comments, and suggested references as well as the initial consensus results were then provided to the participating experts. Each panel member then ranked their extent of agreement with a modified statement for which consensus was not achieved. The process was repeated three times. RESULTS: Consensus was achieved on all but 9 of 32 statements. CONCLUSIONS: Consensus was not achieved for nine statements. These statements may be topics for future research.

Occupational asthma, work-related asthma and reactive airways dysfunction syndrome.

PURPOSE OF REVIEW: Over the past twenty years, work-related asthma has been increasingly recognized to focus on three entities; occupational asthma, work-aggravated asthma, and reactive airways disease syndrome. Of these three entities, work-aggravated asthma has been recently identified to be important in worker health, but little is known about its impact on worker health. RECENT FINDINGS: In this review, it is our intent to summarize the different 'types' of work-related asthma and to emphasize what is known about the outcomes of these three types, with emphasis on work-aggravated asthma. Although data is scanty, compared to occupational asthma and reactive airways dysfunction syndrome, it appears that work-aggravated asthma may well have a very important level of impact on worker health that has not been well recognized in the past. SUMMARY: All of these entities have the potential to adversely alter the health of workers and, in many instances, require the worker to leave the job. Of these three entities, it appears that most is known about the natural history of occupational asthma. The recognition that workers must leave the workplace when this diagnosis is made is generally agreed upon. The second entity, reactive airways dysfunction syndrome, is not as clearly understood, particularly when one recognizes that there appears to be a considerable difference in the prevalence of this illness when one compares prospective and retrospective reporting of the disease. Finally, work-aggravated asthma remains the least well described and has only been accepted as a part of the triad of work-related asthma in the past several years. The most appropriate clinical response to the diagnosis of this entity in workers has yet to be fully explored.