Airborne occupational exposures associated with pulmonary sarcoidosis: a systematic review and meta-analysis.

The aetiology and pathophysiology of sarcoidosis is ill defined-current hypotheses centre on complex genetic-immune-environmental interactions in an individual, triggering a granulomatous process. The aim of this systematic review is to define and describe which airborne occupational exposures (aOE) are associated with and precede a diagnosis of pulmonary sarcoidosis. The methodology adopted for the purpose was systematic review and meta-analyses of ORs for specified aOE associated with pulmonary sarcoidosis (DerSimonian Laird random effects model (pooled log estimate of OR)). Standard search terms and dual review at each stage occurred. A compendium of aOE associated with pulmonary sarcoidosis was assembled, including mineralogical studies of sarcoidosis granulomas. N=81 aOE were associated with pulmonary sarcoidosis across all study designs. Occupational silica, pesticide and mould or mildew exposures were associated with increased odds of pulmonary sarcoidosis. Occupational nickel and aluminium exposure were associated with a non-statistically significant increase in the odds of pulmonary sarcoidosis. Silica exposure associated with pulmonary sarcoidosis was reported most frequently in the compendium (n=33 studies) and was the most common mineral identified in granulomas. It was concluded that aOE to silica, pesticides and mould or mildew are associated with increased odds of pulmonary sarcoidosis. Equipoise remains concerning the association and relationship of metal dusts with pulmonary sarcoidosis.

A multicentre observational study of the prevalence, management, and outcomes of subsegmental pulmonary embolism.

BACKGROUND: The incidence of subsegmental pulmonary embolism (SSPE) has increased with improvements in imaging technology. There is clinical equipoise for SSPE treatment, with conflicting evidence of improved mortality or reduced venous thromboembolism recurrence with anticoagulation. SSPE studies have significant heterogeneity and often lack adequately matched disease comparator groups. OBJECTIVES: To determine the prevalence, management, and outcomes of SSPE and compare them to patients with main, lobar, segmental, and no pulmonary embolism (PE). PATIENTS/METHODS: All adult patients undergoing CT pulmonary angiography (CTPA) between 2013 and 2019, at 3 UK hospitals were included in the study. CTPA reports were text mined for language relating to PE, and then further manually screened for the presence and anatomical location of PE. Patient groups were propensity matched by age, sex, and year of CTPA prior to analysis. 3-month outcomes of major bleeding, VTE recurrence, and death were recorded. RESULTS: 79 (3.8%) SSPEs were identified from 2,055 diagnoses of PE, and 14,300 CTPA reports. 44 (56%) of SSPEs were single artery emboli, 25 (32%) were multiple unilateral emboli, and 10 (13%) were multiple bilateral emboli. Mortality, VTE recurrence and major bleeding were similar at 3 months across all groups. 87.3% of SSPE imaging reports had an additional radiological diagnosis, with pleural effusion (30%), consolidation (19%), and cardiomegaly (19%) being the most common. CONCLUSION: The prevalence of SSPE was 3.8% of all PEs and there were a substantial number of additional radiological findings in the SSPE group that may have accounted for their symptoms.

An update on hypersensitivity pneumonitis: what a clinician wants to know.

PURPOSE OF REVIEW: A recent international collaboration has updated the clinical definition and diagnostic recommendations for hypersensitivity pneumonitis, focusing on fibrotic and non-fibrotic phenotypes. However, how these transfer to clinical practice and their impact upon clinical management and prognosis of hypersensitivity pneumonitis is unclear. This review will focus on recent advances in the understanding of the clinical aspects of hypersensitivity pneumonitis, predominantly its epidemiology, diagnosis, classification and treatment. RECENT FINDINGS: Hypersensitivity pneumonitis is a rare disease within the general population, with variable geographical incidence because of environmental, cultural and occupational factors. Confidence in diagnosis relies upon the presence of clinical features with a temporal relationship to an associated exposure, radiological and histopathological features, bronchiolo-alveolar lavage lymphocytosis and precipitating antibodies/specific immunoglobulin G to antigens. Although emerging evidence regarding nintedanib use in progressive fibrotic interstitial lung disease is promising, the majority of therapies (corticosteroids and immunosuppressive agents) used traditionally in hypersensitivity pneumonitis lack a robust evidence base. SUMMARY: With a clear definition of fibrotic and nonfibrotic hypersensitivity pneumonitis phenotypes now established, clinical research trials (predominantly randomized controlled trials) should clarify and resolve the discussion regarding antigen avoidance, corticosteroid therapy, immunosuppressive therapy and antifibrotic therapy in fibrotic and nonfibrotic subtypes of hypersensitivity pneumonitis.

Palliative care for chronic respiratory disease: integrated care in outpatient settings.

Chronic respiratory diseases are progressive and often life-limiting illnesses. Patients experience debilitating and troubling symptoms that impact on their quality of life. Despite this, there is under-recognition of patients who may be entering the final year of their life and require palliative care services. The Royal Wolverhampton NHS Trust in partnership with Compton Care has established chronic respiratory disease multidisciplinary team meetings and a combined respiratory and palliative care outpatient clinic to address these issues. This article presents the impact of this service, now in to its fourth year, of delivering palliative care services to patients with chronic respiratory disease.

Examining the role of positive and negative metacognitive beliefs in depression.

Many psychological models have been developed to explain the development and maintenance of depression. The most widely evaluated model is the cognitive model of depression, and it is against this model that emerging models should be compared. Accordingly, this cross-sectional study examined whether metacognitive beliefs, as specified in the metacognitive model of depression, would explain additional variance in depressive symptoms over dysfunctional attitudes; the core feature of the cognitive model. Moreover, mediational relationships between metacognitive beliefs, rumination, and depressive symptoms, predicted by the metacognitive model were also explored, whilst controlling for dysfunctional attitudes. A sample of 715 students completed self-report questionnaires measuring depressive symptoms, rumination, dysfunctional attitudes, and metacognitive beliefs. Regression analyses showed that metacognitive beliefs made a significant statistical contribution to depressive symptoms, after controlling for age, gender, rumination and dysfunctional attitudes. Furthermore, as predicted by the metacognitive model, the relationship between positive metacognitive beliefs and depressive symptoms was fully mediated by rumination, whilst the relationship between negative metacognitive beliefs about uncontrollability and danger and depressive symptoms was partially mediated by rumination. The results provide further empirical support for the metacognitive model of depression and indicate that positive and negative metacognitive beliefs play an integral role in the maintenance of depressive symptoms.

Exploring the causes of COPD misdiagnosis in primary care: A mixed methods study.

BACKGROUND: Within primary care there exists a cohort of patients misdiagnosed with Chronic Obstructive Pulmonary Disease (COPD). Misdiagnosis can have a detrimental impact on healthcare finances and patient health and so understanding the factors leading to misdiagnosis is crucial in order to reduce misdiagnosis in the future. The objective of this study is to understand and explore the perceived causes of COPD misdiagnosis in primary care. METHODS: A sequential mixed methods study, quantifying prevalence and features of patients misdiagnosed with COPD in primary care followed by a qualitative analysis to explore perceived causes of misdiagnosis. Quantitative data was collected for 206 patients identified as misdiagnosed with COPD within the INTEGR COPD study (NCT03482700). Qualitative data collected from 21 healthcare professionals involved in providing COPD care and 8 misdiagnosed patients who were recruited using a maximum variation purposive sampling. RESULTS: Misinterpretation of spirometry results was the prevailing factor leading to patients initially being misdiagnosed with COPD, affecting 59% of misdiagnosed patients in this cohort. Of the 99 patients who were investigated for their underlying diagnosis; 41% had normal spirometry and 40% had asthma. Further investigation through qualitative methodology uncovered reluctance to challenge historical misdiagnoses and challenges in differential diagnosis as the underlying explanations for COPD misdiagnosis in this cohort. CONCLUSIONS: Patients historically diagnosed with COPD without spirometric evidence are at risk of remaining labelled and treated for COPD despite non-obstructive respiratory physiology, leading to a persistent cohort of patients misdiagnosed with COPD in primary care. The lack of spirometry services during and after the COVID19 pandemic in primary care risks adding to the cohort of misdiagnosed patients. Support from respiratory specialists can potentially help to reduce the prevalence of COPD misdiagnosis in primary care. TRIAL REGISTRATION: NCT03482700.

Novel occupational causes of hypersensitivity pneumonitis.

PURPOSE OF REVIEW: Hypersensitivity pneumonitis (HP) remains a challenging diagnosis, and a cause is not established in up to 50% of cases. This paper aims to update clinicians on traditional and novel occupational causes of HP, and clinical tools for identifying of causative exposures and antigens. RECENT FINDINGS: Metalworking fluid has become the most frequently cited occupational cause of HP, though geographical variations in exposures exist. Occupational HP is usually associated with work-related symptoms. Systematically derived questionnaires and compendia for HP have been developed for use in cryptogenic disease, though have previously lacked validation; these may help identify inciting antigens or relevant occupational exposures. SUMMARY: Clinicians should enquire about job roles and work-relatedness of symptoms when considering a diagnosis of HP. Outbreaks of metalworking fluid associated HP from around the world are well described, so clinicians should remain vigilant. The usual classification for causative antigen includes animal and plant proteins, fungi, bacteria, low-molecular weight chemicals and metals; however novel occupational exposures and work processes are frequently reported.

Adaptive Goal Processes and Underlying Motives That Sustain Mental Wellbeing and New Year Exercise Resolutions.

Exercise resolutions are the most common goals people set each New Year. However, research has rarely examined adaptive goal processes and motives that may maintain wellbeing and resolution pursuit. We therefore investigated if (1) personal goal flexibility and tenacity maintain mental wellbeing and adherence to New Year exercise resolutions and if (2) underlying intrinsic and extrinsic motives maintain wellbeing and sustained exercise resolution adherence. A community sample (N = 297) completed an online longitudinal study. At baseline, participants listed their most important exercise-related New Year resolution. Participants then completed measures to assess goal flexibility and tenacity, resolution motives, and mental wellbeing at baseline. At three follow-up surveys over a two-month period, participants completed self-report measures of wellbeing and adherence to their exercise resolution. As predicted, goal flexibility and tenacity each independently predicted wellbeing across time. Counter to prediction, neither goal flexibility nor tenacity predicted sustained exercise adherence. Notably, underlying intrinsic motives (but not extrinsic motives) maintained mental wellbeing and exercise adherence across time. Our findings indicate that goal flexibility and tenacity are beneficial in maintaining mental wellbeing and that pursuing resolutions for internalised motives is beneficial for one's mental wellbeing and exercise adherence.

Occupational lung disease: when should I think of it and why is it important?

Exposure to toxic inhalants in the workplace has the potential to cause (in susceptible individuals) almost any major type of lung disease, such as asthma, COPD and interstitial lung diseases. Patients with occupational lung disease will often present to or will be managed by respiratory specialists without training in occupational respiratory medicine, and patients (or their clinicians) may not identify a link between their disease and their current or a past job. Without an awareness of the range of different occupational lung diseases that exist, their similarity to their non-occupational counterparts, and without directed questioning, these conditions may go unidentified. Patients with occupational lung diseases are often in lower paid work and are disproportionally affected by health inequality. Both clinical and socioeconomic outcomes generally improve if cases are identified early. This allows appropriate advice to be given about the risks of ongoing exposure, clinical management, occupational mobility and, in some cases, eligibility for legal compensation. As respiratory professionals, it is important that these cases are not missed, and if needed, are discussed with a physician with specialised expertise. Here we describe some of the most common occupational lung diseases and outline the diagnostic and treatment approach.

LUCAS: a theoretically informed instrument to assess clinical communication in objective structured clinical examinations.

OBJECTIVES: We reviewed papers describing the development of instruments for assessing clinical communication in undergraduate medical students. The instruments had important limitations: most lacked a theoretical basis, and their psychometric properties were often poor or inadequately investigated and reported. We therefore describe the development of a new instrument, the Liverpool Undergraduate Communication Assessment Scale (LUCAS), which is intended to overcome some of these limitations. We designed LUCAS to reflect the theory that communication is contextually dependent, inherently creative and cannot be fully described within a conceptual framework of discrete skills. METHODS: We investigated the preliminary psychometric properties of LUCAS in two studies. To assess construct and external validity, we examined correlations between examiners' LUCAS ratings and simulated patients' ratings of their relationships with students in Year 1 formative (n = 384) and summative (n = 347) objective structured clinical examination (OSCE) samples. Item-total correlations and item difficulty analyses were also performed. The dimensionality of LUCAS was examined by confirmatory factor analysis. We also assessed inter-rater reliability; four raters used LUCAS to rate 40 video-recorded encounters between Year 1 students and simulated patients. RESULTS: Simulated patient ratings correlated with examiner ratings across two OSCE datasets. All items correlated with the total score. Item difficulty showed LUCAS was able to discriminate between student performances. LUCAS had a two-dimensional factor structure: we labelled Factor 1 creative communication and Factor 2 procedural communication. The intraclass correlation coefficient was 0.73 (95% confidence interval 0.54-0.85), indicating acceptable reliability. CONCLUSIONS: We designed LUCAS to move the primary focus of examiners away from an assessment of students' enactment of behavioural skills to a judgement of how well students' communication met patients' needs. LUCAS demonstrated adequate reliability and validity. The instrument can be administered easily and efficiently and is therefore suitable for use in medical school examinations.

Testing times: the association of intolerance of uncertainty and metacognitive beliefs to test anxiety in college students.

BACKGROUND: Test anxiety has a detrimental effect on test performance but current interventions for test anxiety have limited efficacy. Therefore, examination of newer psychological models of test anxiety is now required. Two transdiagnostic psychological models of emotional disorders that can account for anxiety are the intolerance of uncertainty model (IUM) and the Self-Regulatory Executive Function (S-REF) model. Intolerance of uncertainty, the stable disposition to find uncertainty distressing, is central to the IUM, while beliefs about thinking, metacognition, are central to the S-REF model. We tested for the first time the role of both intolerance of uncertainty and metacognitive beliefs in test anxiety. METHODS: A cross-sectional design was used, with college students (n = 675) completing questionnaires assessing their test anxiety, intolerance of uncertainty, and metacognitive beliefs. Hierarchical linear regressions examined if intolerance of uncertainty and metacognitive beliefs were associated with test anxiety, after controlling for age and gender. RESULTS: Females reported significantly more test anxiety than males. Partial correlations, controlling for gender, found intolerance of uncertainty and metacognitive beliefs were significantly and positively correlated with test anxiety. Hierarchical linear regressions found metacognitive beliefs explained an additional 13% of variance in test anxiety, after controlling for intolerance of uncertainty. When the order of entry was reversed, intolerance of uncertainty was only able to explain an additional 2% of variance, after controlling for metacognitive beliefs. In the final regression model, gender, intolerance of uncertainty and the metacognitive belief domains of 'negative beliefs about the uncontrollability and danger of worry' and 'cognitive confidence' were all significantly associated test anxiety, with 'negative beliefs about the uncontrollability and danger of worry' having the largest association. CONCLUSIONS: Both intolerance of uncertainty and metacognitive beliefs are linked to test anxiety, but results suggest metacognitive beliefs have more explanatory utility, providing greater support for the S-REF model. Modification of intolerance of uncertainty and metacognitive beliefs could alleviate test anxiety and help students fulfil their academic potential.

Pulmonary function test and computed tomography features during follow-up after SARS, MERS and COVID-19: a systematic review and meta-analysis.

Background: The COVID-19 pandemic follows severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) coronavirus epidemics. Some survivors of COVID-19 infection experience persistent respiratory symptoms, yet their cause and natural history remain unclear. Follow-up after SARS and MERS may provide a model for predicting the long-term pulmonary consequences of COVID-19. Methods: This systematic review and meta-analysis aims to describe and compare the longitudinal pulmonary function test (PFT) and computed tomography (CT) features of patients recovering from SARS, MERS and COVID-19. Meta-analysis of PFT parameters (DerSimonian and Laird random-effects model) and proportion of CT features (Freeman-Tukey transformation random-effects model) were performed. Findings: Persistent reduction in the diffusing capacity for carbon monoxide following SARS and COVID-19 infection is seen at 6 months follow-up, and 12 months after MERS. Other PFT parameters recover in this time. 6 months after SARS and COVID-19, ground-glass opacity, linear opacities and reticulation persist in over 30% of patients; honeycombing and traction dilatation are reported less often. Severe/critical COVID-19 infection leads to greater CT and PFT abnormality compared to mild/moderate infection. Interpretation: Persistent diffusion defects suggestive of parenchymal lung injury occur after SARS, MERS and COVID-19 infection, but improve over time. After COVID-19 infection, CT features are suggestive of persistent parenchymal lung injury, in keeping with a post-COVID-19 interstitial lung syndrome. It is yet to be determined if this is a regressive or progressive disease.

'Attorneys of the poor': Training physicians to tackle health inequalities.

The stellar gains in life expectancy and health over the past century have been accompanied by an increase in societal and health inequalities. This health gap between the most and least fortunate in our society is widening, driven by complex social determinants of health, as well as healthcare systems themselves. Physicians are not just well-qualified and well-placed to act as advocates for change, but have a moral duty to do so: to stand by silently is to be complicit. Following a workshop on health inequalities and medical training at the Royal College of Physicians Trainees Committee, we sought to examine how health inequalities could be addressed through changes to the medical education system. We discuss the arguments for reform in recruitment to medicine, and changes to undergraduate, postgraduate and continuing medical education in order to equip the profession to deliver meaningful improvements in health inequalities. We propose a population health credential as a mechanism by which specialists can gain additional skills to take on leadership roles addressing health inequalities, allowing them to support colleagues in public health and bring in specialty-specific knowledge and experience.

Self-Regulatory Goal Motivational Processes in Sustained New Year Resolution Pursuit and Mental Wellbeing.

Recent research suggests people typically "give up" pursuing their New Year resolutions within the first month. The present study investigated goal features proposed to be implicated in promoting both mental wellbeing and sustained New Year resolution pursuit. Australian and UK participants (n = 182) took part in an online longitudinal study, including four timepoints over a two-month period. At baseline, participants listed the New Year resolution to which they were most committed, and completed self-report measures to assess mental wellbeing, goal flexibility and tenacity. At the follow-up surveys, participants completed the wellbeing measure and their New Year resolution commitment, effort and stickability. As predicted, flexibility predicted wellbeing across time, however, tenacity did not. Counter to prediction, neither flexibility nor tenacity reported at baseline predicted "sticking" with one's New Year resolution. The predicted interaction between flexibility and tenacity was not significant. New Year resolutions focused predominantly on "diet" and "exercise" were predominantly the same resolutions previously pursued and tended to be relatively abstract. Although goal flexibility predicted greater wellbeing, the findings overall tend to support the view that people are not particularly good at sticking with their New Year resolutions. Implications of the findings are discussed.

The questionable efficacy of manualized psychological treatments for distressed breast cancer patients: An individual patient data meta-analysis.

Previous meta-analyses conclude that psychological treatments are efficacious for emotional distress in breast cancer (BCa). However, the practical relevance of these meta-analyses is questionable; none focused specifically on clinically distressed patients or whether treatment effects were clinically significant. In a two-stage individual patient data (IPD) meta-analysis of 17 randomized controlled trials of manualized psychological treatments in BCa, we evaluated treatment efficacy in distressed BCa patients (n = 1591) using clinical significance and effect size analyses. Outcomes were anxiety, depression, and general distress, evaluated at post-treatment and follow-up. Moderators examined were treatment type, treatment format, therapists' profession, control condition, age, outcome measure, and trial quality. Treated patients were more likely than controls to recover from anxiety and general distress at post-treatment (14-15% more treated patients recovered), but not at mean 8-months follow-up. Overall recovery rates were low: across outcomes, at post-treatment, only 30-32% of treated patients and 15-25% of controls recovered; at follow-up, only 21-30% of treated patients and 18-35% of controls recovered. Small between-group effect sizes in favour of treatment were found across outcomes at post-treatment (g = 0.32-0.34) but not at follow-up. Across the different analysis methods, few moderator effects were found. More efficacious psychological treatments are needed for distressed BCa patients.

The efficacy of interventions for test-anxious university students: A meta-analysis of randomized controlled trials.

Test anxiety (TA) is highly distressing and can significantly undermine academic performance. Many randomized controlled trials (RCTs) of interventions for university students with TA have been conducted, but there has been no systematic review of their efficacy. This meta-analysis examines the efficacy of interventions for test-anxious university students in: (i) reducing TA, and (ii) improving academic performance. We searched for RCTs published in English language peer-reviewed journals. Forty-four RCTs met our eligibility criteria (n = 2,209). Interventions were superior to control conditions at post-treatment for reducing TA (g = -0.76) and improving academic performance (g = 0.37). Interventions were superior to control conditions at follow-up. Subgroups analyses found most support for behaviour therapy. Cognitive-behavioural therapy, study skills training, and combined psychological and study skills training interventions show promise but lack evidence for their longer-term efficacy, and results are based upon a small number of studies. Evidence of publication bias was found and poor quality of reporting meant that confidence in results should be moderated. Future RCTs should be conducted and reported with greater rigour, have larger samples, and examine newer interventions.

A systematic review of the quality of randomized controlled trials of psychological treatments for emotional distress in breast cancer.

OBJECTIVE: Meta-analyses of trials of psychological treatments for emotional distress in breast cancer (BCa) conclude that efficacious treatments exist. Subsequently, their implementation in routine care is widely promoted by health policy. However, the methodological quality of these trials has not been systematically evaluated. The present review investigates this issue. METHOD: A systematic search identified randomized controlled trials of psychological treatments for emotional distress in BCa. The Psychotherapy Outcome Study Methodology Rating Form was used to assess the quality of trials. Generic design elements, including representativeness of sample, control of concomitant treatments, reporting clinical significance outcomes, and design elements specific to psychotherapy trials, including manualisation, therapist training, and therapist adherence and competence were evaluated. RESULTS: 91 trials were eligible. Overall, methodological quality was low. Generic design elements were limited in most trials: 15% specified as an inclusion criterion that participants were distressed; 10% controlled for concomitant treatments; and 11% reported the clinical significance of findings. Design elements specific to psychotherapy trials were also implemented poorly: 51% used treatment manuals; 8% used certified trained therapists; and monitoring of adherence and competence occurred in 15% and 4%, respectively. CONCLUSION: The methodological quality of psychological treatment trials for emotional distress in BCa is improving. However, if relevant health policies are to be adequately empirically informed, trials of greater methodological rigour are essential. Trials should include participants with clinical levels of distress, control for concomitant treatments and report the clinical significance of findings. Trialists must also consider the specific requirements of psychotherapy trials.

What are the key elements of cognitive analytic therapy for psychosis? A Delphi study.

OBJECTIVE: There has been growing interest in the use of cognitive analytic therapy (CAT) with those facing experiences of psychosis. However, there is little research on how CAT is best applied to working with psychosis. This study aimed to identify what the key aspects of CAT for psychosis are or whether this approach requires adaptation when applied to those with experiences of psychosis, drawing on expert opinion. METHOD: An adapted Delphi methodology was used. Items were generated during an initial workshop (N = 24) and then rated for agreement or importance via an online survey by a sample of experts with experience of CAT and working clinically with psychosis (N = 14). RESULTS: Following two rounds of ratings, consensus was reached on most items. Additional comments emphasized the need to be flexible with regard to the varying needs of individual clients. CONCLUSIONS: Results highlight the specific relational understanding of psychosis provided by CAT as one of the key elements of this approach. Responses emphasized the need for some level of adaptation to work with psychosis, including greater flexibility with regard to the treatment frame. PRACTITIONER POINTS: When working with experiences of psychosis, aspects of the CAT model, such as session length, pacing, and duration of therapy, are open to change and may require modification. When working with experiences of psychosis, narrative reformulation letters and sequential diagrammatic reformulation (SDR) remain essential to the therapy. This Delphi methodology study essentially relies on opinion. Further empirical research could test assumptions about the most important or therapeutically effective components of CAT in psychosis. CAT is still not widely used in the context of psychosis limiting the pool of experts available for the current sample.