Feroza Daroowalla

Diagnosis and Management of Work-Related Asthma: American College of Chest Physicians Consensus Statement

BACKGROUND A previous American College of Chest Physicians Consensus Statement on asthma in the workplace was published in 1995. The current Consensus Statement updates the previous one based on additional research that has been published since then, including findings relevant to preventive measures and work-exacerbated asthma (WEA). METHODS A panel of experts, including allergists, pulmonologists, and occupational medicine physicians, was convened to develop this Consensus Document on the diagnosis and management of work-related asthma (WRA), based in part on a systematic review, that was performed by the University of Alberta/Capital Health Evidence-Based Practice and was supplemented by additional published studies to 2007. RESULTS The Consensus Document defined WRA to include occupational asthma (ie, asthma induced by sensitizer or irritant work exposures) and WEA (ie, preexisting or concurrent asthma worsened by work factors). The Consensus Document focuses on the diagnosis and management of WRA (including diagnostic tests, and work and compensation issues), as well as preventive measures. WRA should be considered in all individuals with new-onset or worsening asthma, and a careful occupational history should be obtained. Diagnostic tests such as serial peak flow recordings, methacholine challenge tests, immunologic tests, and specific inhalation challenge tests (if available), can increase diagnostic certainty. Since the prognosis is better with early diagnosis and appropriate intervention, effective preventive measures for other workers with exposure should be addressed. CONCLUSIONS The substantial prevalence of WRA supports consideration of the diagnosis in all who present with new-onset or worsening asthma, followed by appropriate investigations and intervention including consideration of other exposed workers.

Aerosolized antibiotics and ventilator-associated tracheobronchitis in the intensive care unit.

Context:In critically ill intubated patients, signs of respiratory infection often persist despite treatment with potent systemic antibiotics. Objective:The purpose of this study was to determine whether aerosolized antibiotics, which achieve high drug concentrations in the target organ, would more effectively treat respiratory infection and decrease the need for systemic antibiotics. Design:Double-blind, randomized, placebo-controlled study performed from 2003 through 2004. Setting:The medical and surgical intensive care units of a university hospital. Patients:Critically ill intubated patients were randomized if: 1) ≥18 yrs of age, intubated for a minimum of 3 days, and expected to survive at least 14 days; and 2) had ventilator-associated tracheobronchitis defined as the production of purulent secretions (≥2 mL during 4 hrs) with organism(s) on Gram stain. Of 104 patients monitored, 43 consented for treatment and completed the study. No patients were withdrawn from the study for adverse events. Intervention:Aerosol antibiotic (AA) or aerosol saline placebo was given for 14 days or until extubation. The responsible clinician determined the administration of systemic antibiotics (SA). Patients were followed for 28 days. Main Outcome Measures:Primary: Centers for Disease Control National Nosocomial Infection Survey diagnostic criteria for ventilator-associated pneumonia (VAP) and clinical pulmonary infection score. Secondary: white blood cell count, SA use, acquired antibiotic resistance, and weaning from mechanical ventilation. Results:Most patients had VAP at randomization. With treatment, the AA group had reduced signs of respiratory infection: reduced Centers for Disease Control National Nosocomial Infection Survey VAP (14/19; 73.6%) to (5/14; 35.7%) vs. placebo (18/24; 75%) to (11/14; 78.6%), reduction in clinical pulmonary infection score, lower white blood cell count at day 14, reduced bacterial resistance, reduced use of SA, and increased weaning (all p ≤ .05). Conclusions:In critically ill patients with ventilator-associated tracheobronchitis, AA decrease VAP and other signs and symptoms of respiratory infection, facilitate weaning, and reduce bacterial resistance and use of systemic antibiotics.

Use of the All Patient Refined-Diagnosis Related Group (APR-DRG) Risk of Mortality Score as a Severity Adjustor in the Medical ICU.

Objective To evaluate the performance of APR-DRG (All Patient Refined—Diagnosis Related Group) Risk of Mortality (ROM) score as a mortality risk adjustor in the intensive care unit (ICU). Design Retrospective analysis of hospital mortality. Setting Medical ICU in a university hospital located in metropolitan New York. Patients 1213 patients admitted between February 2004 and March 2006. Main results Mortality rate correlated significantly with increasing APR-DRG ROM scores (p < 0.0001). Multiple logistic regression analysis demonstrated that, after adjusting for patient age and disease group, APR-DRG ROM was significantly associated with mortality risk in patients, with a one unit increase in APR-DRG ROM associated with a 3-fold increase in mortality. Conclusions APR-DRG ROM correlates closely with ICU mortality. Already available for many hospitalized patients around the world, it may provide a readily available means for severity-adjustment when physiologic scoring is not available.

Reforming the 4th-Year Curriculum as a Springboard to Graduate Medical Training: One School's Experiences and Lessons Learned.

ABSTRACT Problem: Concerns regarding the quality of training in the 4th year of medical school and preparation of graduates to enter residency education persist and are borne out in the literature. Intervention: We reviewed the published literature regarding Year 4 concerns as well as institutional efforts to improve the 4th-year curriculum from several schools. Based on input from key stakeholders, we established 4 goals for our Year 4 curriculum reform: (a) standardize the curricular structure, (b) allow flexibility and individualization, (c) improve the preparation for residency, and (d) improve student satisfaction. After the reform, we evaluated the outcomes using results from the Association of American Medical Colleges Questionnaire, student focus groups, and program director surveys. Context: This article describes the context, process, and outcomes of the reform of the Year 4 curriculum at Stony Brook University School of Medicine. Outcome: We were able to achieve all four stated goals for the reform. The significant components of the change included a flexible adaptable curriculum based on individual needs and preferences, standardized learning objectives across the year, standardized competency-based evaluations regardless of discipline, reinforcement of clinical skills, and training for the transition to the workplace as an intern. The reform resulted in increased student satisfaction, increased elective time, and increased preparedness for residency training as perceived by the graduates. The Program Director survey showed significant changes in ability to perform a medical history and exam, management of common medical conditions and emergencies, clinical reasoning and problem-solving skills, working and communication with the healthcare team, and overall professionalism in meeting obligations inherent in the practice of medicine. Lessons Learned: Lessons learned from our 4th-year reform process are discussed. Listening to the needs of the stakeholders was an important step in ensuring buy-in, having an institutional champion with an organizational perspective on the overall institutional mission was helpful in building the guiding coalition for change, building highly interactive collaborative interdisciplinary teams to work together addressed departmental silos and tunnel vision early on, and planning a curriculum is exciting but planning the details of the implementation can be quite tedious.

Effect of Bedside Physical Diagnosis Training on Third-Year Medical Students' Physical Exam Skills

Background: Graduating medical students, when surveyed, noted a deficit in training in physical examination skills. Purposes: In an attempt to remedy this deficit we implemented a pilot program for 3rd-year medical students consisting of twice-weekly bedside diagnosis rounds as part of their 8-week medicine clerkship. Methods: To assess the success of this program we reviewed students’ objective structured clinical exam (OSCE) scores at the completion of the clerkship compared with prior years’ students who did not have the bedside physical diagnosis training. Results: Students who were trained (n = 109) had an overall higher OSCE physical exam score (p < .01) than students without the training (n = 85). Conclusions: Bedside physical diagnosis rounds appear to have elevated the overall OSCE score for 3rd-year medical students.