Physician Health Series, Part 3: Physician Mental Health.

This article is the third of 3 articles in a series about managing the care of physicians as patients. In part 1, the authors reviewed unique characteristics of physicians as patients with some general guidance for how to approach their care. Part 2 highlighted role clarity for the treating physician with discussion of the physical and cognitive issues that commonly arise when treating physician-patients along with licensure issues and reporting requirements. This final installment will focus on physician mental health and work-related stress.

Part Two: Managing Physicians as Patients and Their Safe Return to Work.

This second installment in a 3-part series about physicians as patients explores challenges in communication and role definition while managing their care and safe return to work. In the first article of the series, authors reviewed unique characteristics that make physicians different as patients, with some general guidance about how to approach their care. Although most treating physicians receive little occupational training, health issues commonly have an impact on work with imperative to address work issues promptly for best outcome. This paper demystifies the challenge of managing work status and discusses navigating common physical and cognitive issues while maintaining role clarity. The treating clinician reading this paper will learn to avoid common pitfalls and be better equipped to provide initial assessments and interventions to keep physicians working safely, keeping in mind licensure issues and reporting requirements. Part Three of the series will focus on the most common mental health issues seen in physicians.

Physician Health Series Part One: Characteristics of Physicians as Patients.

This is the first article of a 3-part series about physician health. In this installment, we outline the unique characteristics of physicians as patients, challenges and opportunities presented by physician-patients, and recommendations for treating physicians. Future articles will delve into role clarity, occupational considerations, mental health, and interactions with third parties such as the physician's employer or licensing board. Ultimately, this series will help treating clinicians provide the best care to their physician-patients and successfully navigate the unique challenges that may arise, especially when the diagnosis may have an impact on their ability to practice medicine.

Outcomes From a Physician Health Center.

This retrospective cohort study describes the population of physicians seeking medical evaluation in a dedicated physician health center and identifies factors associated with needing practice restrictions. Participants had an initial evaluation between January 1, 2016, and December 31, 2022. We report personal and professional demographics and types of medical conditions in this cohort. An ordinal logistic regression analysis was used to identify factors associated with occupational outcomes. Physicians in a wide variety of specialties from 34 different states presented for evaluation of diverse medical problems. More than half of the participants presented with occupational concerns. The presence of a neurologic or psychiatric illness were the only factors associated with temporary or permanent restrictions. Physicians with medical conditions impacting their ability to practice have a professional obligation to obtain a thorough, objective medical evaluation. Such evaluations should support and protect patients, employers, and the physicians themselves.

Elementary Overview of Heavy Metals.

BACKGROUND: Exposure to heavy metals is common as a result of environmental contamination of air, water, and soil as well as accumulation in food, tobacco, herbal medicines, and occupational contact. However, clinically relevant toxicity is much less prevalent. Toxic effects, when they occur, may present with non-specific symptoms, resulting in a very large differential for clinicians to consider. CONTENT: Arsenic, cadmium, lead, and mercury are four heavy metals with no biological role in humans. However, these metals are commonly used in industrial applications and consumer products. Since these elements are not biodegradeable, their potential toxic effects may be long-lasting within the environment. These heavy metals have the potential to accumulate in vital organs such as the brain, heart, and kidney where they may disrupt normal cellular functioning and if exposures are repetitive or of high concentration, toxicity may result. SUMMARY: The objective of this review is to provide an overview of arsenic, cadmium, lead, and mercury physical properties, common sources of exposure, basic toxicokinetics and health effects, and to review clinical guidelines and treatment strategies. Acute and chronic symptoms and recommended laboratory biomarker testing are also discussed.

Effect of Race and Ethnicity on Pulmonary Function Testing Interpretation: An American College of Chest Physicians (CHEST), American Association for Respiratory Care (AARC), American Thoracic Society (ATS), and Canadian Thoracic Society (CTS) Evidence Review and Research Statement.

BACKGROUND: Calls have been made to discontinue the routine use of race and ethnicity in medicine. Specific to respiratory medicine, the use of race- and ethnicity-specific reference equations for the interpretation of pulmonary function test (PFT) results has been questioned. RESEARCH QUESTIONS: Three key questions were addressed: (1) What is the current evidence supporting the use of race- and ethnicity-specific reference equations for the interpretation of PFTs? (2) What are the potential clinical implications of the use or nonuse of race and ethnicity in interpreting PFT results? and (3) What research gaps and questions must be addressed and answered to understand better the effect of race and ethnicity on PFT results interpretation and potential clinical and occupational health implications? STUDY DESIGN AND METHODS: A joint multisociety (American College of Chest Physicians, American Association for Respiratory Care, American Thoracic Society, and Canadian Thoracic Society) expert panel was formed to undertake a comprehensive evidence review and to develop a statement with recommendations to address the research questions. RESULTS: Several assumptions and gaps, both in the published literature and in our evolving understanding of lung health, were identified. It seems that many past perceptions and practices regarding the effect of race and ethnicity on PFT results interpretation are based on limited scientific evidence and measures that lack reliability. INTERPRETATION: A need exists for more and better research that will inform our field about these many uncertainties and will serve as a foundation for future recommendations in this area. The identified shortcomings should not be discounted or dismissed because they may enable flawed conclusions, unintended consequences, or both. Addressing the identified research gaps and needs would allow a better-a more informed-understanding of the effects of race and ethnicity on PFT results interpretation.

Reduced Diffusing Capacity in Humidifier Disinfectant-Associated Asthma Versus Typical Asthma: A Retrospective Case Control Study.

BACKGROUND: Humidifier disinfectant-related lung injury (HDLI) is a severe form of toxic inhalational pulmonary parenchymal damage found in residents of South Korea previously exposed to specific guanidine-based compounds present in humidifier disinfectants (HD). HD-associated asthma (HDA), which is similar to irritant-induced asthma, has been recognized in victims with asthma-like symptoms and is probably caused by airway injury. In this study, diffusing capacity of the lung for carbon monoxide (DLCO) in individuals with HDA was compared to that in individuals with pre-existing asthma without HD exposure. METHODS: We retrospectively compared data, including DLCO values, of 70 patients with HDA with that of 79 patients having pre-existing asthma without any known exposure to HD (controls). Multiple linear regression analysis and logistic regression analysis were performed to confirm the association between HD exposure and DLCO after controlling for confounding factors. The correlation between DLCO and several indicators related to HD exposure was evaluated in patients with HDA. RESULT: The mean DLCO was significantly lower in the HDA group than in the control group (81.9% vs. 88.6%; P = 0.021). The mean DLCO of asthma patients with definite HD exposure was significantly lower than that of asthma patients with lesser exposure (P for trend = 0.002). In multivariable regression models, DLCO in the HDA group decreased by 5.8%, and patients with HDA were 2.1-fold more likely to have a lower DLCO than the controls. Pathway analysis showed that exposure to HD directly affected DLCO values and indirectly affected its measurement through a decrease in the forced vital capacity (FVC). Correlation analysis indicated a significant inverse correlation between DLCO% and cumulative HD exposure time. CONCLUSION: DLCO was lower in patients with HDA than in asthma patients without HD exposure, and decreased FVC partially mediated this effect. Therefore, monitoring the DLCO may be useful for early diagnosis of HDA in patients with asthma symptoms and history of HD exposure.

Post-COVID-19 Syndrome (Long Haul Syndrome): Description of a Multidisciplinary Clinic at Mayo Clinic and Characteristics of the Initial Patient Cohort.

OBJECTIVE: To describe characteristics of a series of patients reporting prolonged symptoms after an infection with coronavirus disease 2019 (COVID-19). PATIENTS AND METHODS: This study describes the multidisciplinary COVID-19 Activity Rehabilitation Program, established at Mayo Clinic to evaluate and treat patients with post-COVID syndrome, and reports the clinical characteristics of the first 100 patients receiving evaluation and management during the timeframe of June 1, 2020, and December 31, 2020. RESULTS: The cohort consisted of 100 patients (mean age, 45.4±14.2 years; 68% women; mean body mass index, 30.2 kg/m2; presenting a mean of 93 days after infection). Common preexisting conditions were respiratory (23%) and mental health, including depression and/or anxiety (34%). Most (75%) had not been hospitalized for COVID-19. Common presenting symptoms ware fatigue (80%), respiratory complaints (59%), and neurological complaints (59%) followed by subjective cognitive impairment, sleep disturbance, and mental health symptoms. More than one-third of patients (34%) reported difficulties in performing basic activities of daily living. Only 1 in 3 patients had returned to unrestricted work duty at the time of the analysis. For most patients, laboratory and imaging tests showed no abnormalities or were nondiagnostic despite debilitating symptoms. Most patients required physical therapy, occupational therapy, or brain rehabilitation. Face-to-face and virtual care delivery modalities were feasible. CONCLUSION: Most of the patients did not have COVID-19-related symptoms that were severe enough to require hospitalization, were younger than 65 years, and were more likely to be female, and most had no preexisting comorbidities before severe acute respiratory syndrome coronavirus 2 infection. Symptoms including mood disorders, fatigue, and perceived cognitive impairment resulted in severe negative impacts on resumption of functional and occupational activities in patients experiencing prolonged effects.

Incidental Diagnosis of Swyer-James-MacLeod Syndrome in a Military Pilot.

BACKGROUND: Swyer-James-MacLeod syndrome (SJMS) is a specific form of bronchiolitis obliterans that occurs rarely, but represents recognized sequelae of common pediatric respiratory illness, and presents as unilateral hyperlucency on chest imaging. This case study describes such an incidental radiographic finding identified during the assessment of chest wall discomfort in a military pilot.CASE REPORT: A 35-yr-old military pilot presented to his flight surgeon with vague intermittent chest discomfort. Initial evaluation revealed an abnormal chest radiograph with unilateral hyperlucency and mild expiratory airflow limitation on pulmonary function testing. The evaluation also included computed tomography imaging with contrast infusion and echocardiography, though the presenting complaint had resolved. The airman was referred to our clinic for further evaluation and aeromedical recommendations regarding returning to flight duties. He was diagnosed with SJMS and recommended to be returned to flight duties.DISCUSSION: SJMS can be challenging to recognize to the untrained eye. An inflammatory response from viral or bacterial infection in childhood results in dysfunctional growth of the affected region of the lung, causing radiographic asymmetry. Although destruction of the alveoli and emphysema may occur, for most cases, there are minimal clinical sequelae. SJMS is not known to be progressive and is not associated with systemic conditions. The pilot likely had the abnormal chest radiograph at the time of commission and had not experienced any in-flight complications. His chest pain had resolved without intervention and SJMS was determined to be unlikely to impact his flight performance (such as response to supplemental oxygen) or life expectancy.Harrison MF, Cowl CT. Incidental diagnosis of Swyer-James-MacLeod syndrome in a military pilot. Aerosp Med Hum Perform. 2021; 92(4):281285.

Assessment and treatment of acute toxic inhalations.

PURPOSE OF REVIEW: Acute toxic inhalation exposures affect thousands of individuals worldwide each year. The acute evaluation of these inhaled exposures is often fraught with difficulty in identifying a specific agent, may involve multiple compounds, and a wide variety of responses are seen depending on the physical properties of the specific toxicant, the length of time of inhalation, and the concentration of the exposure. Recognizing key aspects of the most common acute toxic inhalations is useful in developing a diagnosis and treatment strategy. RECENT FINDINGS: Use of sequential observations with flexible bronchoscopy has been the standard of care for assessing airway injury, and virtual bronchoscopy using computed tomographic images in a three-dimensional reconstructed image can now better identify airway narrowing. Use of [F]-fluorodeoxyglucose uptake, as measured by PET, has the potential for early recognition of delayed acute lung injury in toxic inhalation exposures. Development of a standardized respiratory injury grading system is ongoing with a recent multicenter trial nearly complete, allowing for more accurate estimates of eventual outcomes and guide levels of intensity of care for patients with acute inhalation injury. Removal from the source of exposure and airway support remain the first critical aspect of treatment, and additional therapies have been studied recently that focus on altering molecular mechanisms of acute cellular injury, expanding potential treatments beyond other pharmacotherapeutic strategies utilized previously such as mucolytics, bronchodilators, and inhaled anticoagulants. SUMMARY: Although a prevalent source of airway injury, exposure to acute toxic inhalants is often difficult to assess and prognosticate, and challenging to treat.

Air Pollution and Noncommunicable Diseases: A Review by the Forum of International Respiratory Societies' Environmental Committee, Part 1: The Damaging Effects of Air Pollution.

Air pollution poses a great environmental risk to health. Outdoor fine particulate matter (particulate matter with an aerodynamic diameter < 2.5 µm) exposure is the fifth leading risk factor for death in the world, accounting for 4.2 million deaths and > 103 million disability-adjusted life years lost according to the Global Burden of Disease Report. The World Health Organization attributes 3.8 million additional deaths to indoor air pollution. Air pollution can harm acutely, usually manifested by respiratory or cardiac symptoms, as well as chronically, potentially affecting every organ in the body. It can cause, complicate, or exacerbate many adverse health conditions. Tissue damage may result directly from pollutant toxicity because fine and ultrafine particles can gain access to organs, or indirectly through systemic inflammatory processes. Susceptibility is partly under genetic and epigenetic regulation. Although air pollution affects people of all regions, ages, and social groups, it is likely to cause greater illness in those with heavy exposure and greater susceptibility. Persons are more vulnerable to air pollution if they have other illnesses or less social support. Harmful effects occur on a continuum of dosage and even at levels below air quality standards previously considered to be safe.

Air Pollution and Noncommunicable Diseases: A Review by the Forum of International Respiratory Societies' Environmental Committee, Part 2: Air Pollution and Organ Systems.

Although air pollution is well known to be harmful to the lung and airways, it can also damage most other organ systems of the body. It is estimated that about 500,000 lung cancer deaths and 1.6 million COPD deaths can be attributed to air pollution, but air pollution may also account for 19% of all cardiovascular deaths and 21% of all stroke deaths. Air pollution has been linked to other malignancies, such as bladder cancer and childhood leukemia. Lung development in childhood is stymied with exposure to air pollutants, and poor lung development in children predicts lung impairment in adults. Air pollution is associated with reduced cognitive function and increased risk of dementia. Particulate matter in the air (particulate matter with an aerodynamic diameter < 2.5 µm) is associated with delayed psychomotor development and lower child intelligence. Studies link air pollution with diabetes mellitus prevalence, morbidity, and mortality. Pollution affects the immune system and is associated with allergic rhinitis, allergic sensitization, and autoimmunity. It is also associated with osteoporosis and bone fractures, conjunctivitis, dry eye disease, blepharitis, inflammatory bowel disease, increased intravascular coagulation, and decreased glomerular filtration rate. Atopic and urticarial skin disease, acne, and skin aging are linked to air pollution. Air pollution is controllable and, therefore, many of these adverse health effects can be prevented.

Occupational Interstitial Lung Diseases.

OBJECTIVE: Evidence-based diagnostic and treatment guidelines for occupationally related interstitial lung diseases (ILDs) have been developed and are summarized herein. METHODS: Comprehensive literature reviews were conducted with article abstraction, critiquing, objective grading, and evidence table compilation. A multidisciplinary expert panel drafted evidence- and consensus-based guidance. External peer-review was incorporated. RESULTS: Recommendations for diagnosis (n = 12) and management (n = 4) of ILD were developed. Spirometric testing, chest radiographs, and high-resolution computerized tomographic scans were recommended based upon evidence. In addition to a detailed clinical history, carbon monoxide diffusion capacity, sputum sampling, exposure assessment, 6-minute walk test, and bronchoalveolar lavage were also recommended. There was no recommendation regarding chest magnetic resonance imaging due to lack of evidence. CONCLUSIONS: Recommendations for diagnosis and management of ILD are supported by quality evidence. These guidelines may be useful to help guide providers who are tasked with diagnosing and/or treating patients with occupationally related ILD.

Air travel and pneumothorax.

The number of medical emergencies onboard aircraft is increasing as commercial air traffic increases and the general population ages, becomes more mobile, and includes individuals with serious medical conditions. Travelers with respiratory diseases are at particular risk for in-flight events because exposure to lower atmospheric pressure in a pressurized cabin at cruising altitude may result in not only hypoxemia but also pneumothorax due to gas expansion within enclosed pulmonary parenchymal spaces based on Boyle's law. Risks of pneumothorax during air travel pertain particularly to those patients with cystic lung diseases, recent pneumothorax or thoracic surgery, and chronic pneumothorax. Currently available guidelines are admittedly based on sparse data and include recommendations to delay air travel for 1 to 3 weeks after thoracic surgery or resolution of the pneumothorax. One of these guidelines declares existing pneumothorax to be an absolute contraindication to air travel although there are reports of uneventful air travel for those with chronic stable pneumothorax. In this article, we review the available data regarding pneumothorax and air travel that consist mostly of case reports and retrospective surveys. There is clearly a need for additional data that will inform decisions regarding air travel for patients at risk for pneumothorax, including those with recent thoracic surgery and transthoracic needle biopsy.

Health assessment of commercial drivers: a meta-narrative systematic review.

BACKGROUND: Motor vehicle accidents associated with commercial driving are an important cause of occupational death and impact public safety. OBJECTIVES: We summarise the evidence regarding the type, prevalence and impact of medical conditions discovered during health assessment of commercial drivers. EVIDENCE REVIEW: We conducted a systematic review of multiple electronic databases and made a manual search for relevant studies that enrolled commercial drivers in any country and reported the outcomes of health assessment carried out in the context of commercial driving through November 2012. Data were extracted by a pair of independent reviewers and synthesised using a metanarrative approach. RESULTS: We identified 32 studies of moderate methodological quality enrolling 151 644 commercial drivers (98% men). The prevalence of multiple health conditions was high (sleep disorders 19%, diabetes 33%, hypertension 23% and obesity 45%). Some conditions, such as sleep disorders and obesity, were linked to increased risk of crashes. Evidence on several other highly relevant medical conditions was lacking. Cost-effectiveness data were sparse. CONCLUSIONS: Several medical conditions are highly prevalent in commercial drivers and can be associated with increased risk of crashes, thus providing a rationale for health assessment of commercial drivers.