All that Wheezes is not Asthma or Bronchiolitis.

Wheezing is a common finding across patients of all age groups presenting to the emergency department and being hospitalized for respiratory distress, with most patients responding to standard therapeutics and having readily apparent diagnoses of asthma or bronchiolitis. We describe several clinical entities that may present with wheezing and respiratory distress, calling attention to the broad differential that may masquerade as asthma or bronchiolitis, and potentially lead to misdiagnosis, delayed diagnosis, or inappropriate treatment.

The effects of beta-lactam allergy relabeling on antibiotic prescribing practices.

BACKGROUND: Beta-lactam antibiotic allergy labels are highly prevalent but rarely indicate an allergic intolerance. These patient-reported allergies lead to broad-spectrum antibiotic use, conferred resistance, increased expense, and adverse effects. OBJECTIVE: To implement and assess the impact of a history-based clinical guideline that directs antibiotic management and beta-lactam allergy relabeling for patients reporting beta-lactam allergies. METHODS: Patients with beta-lactam allergy labels were identified by our trained multidisciplinary team in diverse clinical settings. This quality improvement project was conducted to evaluate the safety and impact of the guideline on antibiotic use by comparing prescribing practices before and after guideline implementation. RESULTS: A total of 79 patients with beta-lactam allergies were identified (penicillins-90%, cephalosporins-10%). After guideline implementation, outcomes of allergy relabeling included the following: (1) complete removal, indicating an unlikely true allergy (27%); (2) updated to detail successfully tolerated beta-lactam courses (48%); or (3) no change made to current label (25%). Beta-lactam antibiotic courses before and after guideline implementation compared with total antibiotic courses: allergy removed (44% vs 70%; P < .001), allergy updated (32% vs 68%; P < .001), and no change (27% vs 41%; P = .08). Compared with before guideline implementation, beta-lactam antibiotics were 3 times more likely to be prescribed after allergy assessment (odds ratio, 3.22; 95% confidence interval, 2.4-4.3; P < .05). CONCLUSION: The implementation of the beta-lactam allergy clinical guideline resulted in most patients' allergy labels being removed or advantageously updated. These allergy label changes correlated with a substantial increase in the percentage of beta-lactam antibiotics prescribed. After guideline implementation, beta-lactam antibiotics had a 3-fold increased odds of being prescribed independent of allergy label outcome.

Assessment and feedback methods in competency-based medical education.

Graduate and continuing medical education programs have transitioned to a competency-based medical education model, in which abilities necessary for the practice of medicine, called competencies, are defined as learning outcomes. Each competency contains milestones that describe stages of development from novice to master and provide criteria for assessing learners along this continuum. Assessments in competency-based medical education are formative and are intended to assist learners in achieving the next stage in mastery rather than render a final evaluation. Although written examinations are typically used to evaluate learners, assessments measuring the performance of skills, such as direct observation or patient registries, provide stronger evidence of achievement of learning outcomes. Once assessments identify strengths and areas of improvement in a learner, effective feedback is critical in assisting their professional development. Feedback should be routine, timely, nonthreatening, specific, and encourage self-assessment. The "ask-tell-ask" feedback method follows this framework by asking for the learner's self-assessment first, telling the observer's own assessment next, and then finally asking for the learner's questions and action plan to address the issues raised. Effective assessment and feedback in competency-based medical education assists learners in their continued professional development and aims to provide evidence of their impact on the health status of patients and communities.

Nasal airway obstruction: allergy and otolaryngology perspectives.

BACKGROUND: Diagnostic test preferences and management strategies for nasal airway obstruction (NAO) may vary depending on medical specialty. OBJECTIVE: To discern current attitudes and practices of different medical specialties regarding diagnostic and management strategies for patients with NAO. METHODS: Cross-sectional survey of all practicing otolaryngologists and medical allergists in Wisconsin and parts of northern Illinois (N = 268). Survey participants were asked to rank the tests they most commonly perform to differentiate causes of NAO and to rank the diagnostic tests they believed were most sensitive and specific (criterion standard) for NAO. The second portion of the survey provided 3 distinct patient scenarios, and participants were surveyed on their treatment plans. RESULTS: The survey response rate was approximately 50% for both specialties. Nasal endoscopy was the most common diagnostic test for otolaryngologists vs allergists (58% vs 2%, P < .001), and allergy testing was most commonly used first by allergists (92% vs 0%, P < .001). Nasal endoscopy was considered the criterion standard for evaluating NAO by 70% of otolaryngologists vs 29% of allergists (P < .001), although nasal endoscopy was ranked in the top 3 for both specialties without a statistically significant difference. Patient scenario responses, however, demonstrated no statistically significant differences between the specialties. CONCLUSION: Differences were demonstrated in the diagnostic workup preferences and perceptions of the criterion standard for NAO between the 2 medical specialties. Specialty bias, practitioner comfort level, and patient selection likely accounted for differences in responses. However, patient management decisions, medical or surgical, seemed to be similar between the specialties.

Anaphylaxis: drug allergy, insect stings, and latex.

The highest rates of anaphylaxis in humans occur in early childhood associated with food allergy. Latex allergy, pharmaceutical drugs, and stinging insect reactions are important later in childhood, with drug allergy peaking in adult populations. Knowledge about diagnosis and therapy of anaphylaxis is critical, because a large percentage of subjects are not previously known to be at risk at the time of initial reactions. This article summarizes the basic clinical knowledge of anaphylaxis in childhood.

The treatment of allergic bronchopulmonary aspergillosis.

Allergic bronchopulmonary aspergillosis (ABPA) is a disease characterized by asthma, peripheral eosinophilia, pulmonary infiltrates, hypersensitivity to Aspergillus fumigatus and bronchiectasis. The treatment of ABPA depends on the stage of the disease, and includes following clinical symptoms, serum IgE levels, pulmonary function tests, and chest radiographs. This review covers the current treatment options for ABPA.

Latex hypersensitivity in Department of Veterans Affairs health care workers: glove use, symptoms, and sensitization.

BACKGROUND: This report of the prevalence of latex glove allergy in 3 Department of Veterans Affairs (VA) medical centers was a collaboration of the VA, the Centers for Disease Control and Prevention, and the National Institute for Occupational Safety and Health. OBJECTIVE: To enroll and evaluate personnel from across the entire hospital workforce for latex hypersensitivity and to determine the type and extent of latex glove use. METHODS: A questionnaire was administered that covered demographics, job category, latex glove use, and current latex glove allergic symptoms. Skin testing to aeroallergens was performed to evaluate the presence of atopy. Blood was drawn for analyses of serum antilatex IgE antibody by CAP assay. RESULTS: Of 1,959 subjects, 158 (8.1%) had latex glove-allergic symptoms, a positive latex CAP assay result, or both. In 1,003 subjects who reported latex glove use, 915 (91.4%) used nonpowdered gloves. A total of 133 subjects reported latex glove allergic symptoms, and 36 subjects had positive CAP assay results. Latex sensitization was correlated with atopy, race, and latex glove exposure. Latex symptoms were correlated with atopy, a positive CAP assay result, and latex glove exposure. Of the 133 subjects with latex glove allergic symptoms, only 11 had positive CAP assay results, giving a prevalence of confirmed latex glove allergy of 0.6%. CONCLUSIONS: Symptoms attributed to latex gloves and/or latex sensitization occurred in 8.1% of the employee population, with exposure, race, and atopy being the major risk factors. Few symptomatic individuals were sensitized to latex (0.6%). This low rate of confirmed latex glove allergy may have been related to nonpowdered glove use.