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OBJECTIVE: To determine potential effects of humidification on the volume of airway secretions in mechanically ventilated patients. METHODS: Water vapor delivery from devices providing non-heated-wire humidification, heated-wire humidification, and heat and moisture exchanger (HME) were quantified on the bench. Then, patients requiring 24-hour mechanical ventilation were exposed sequentially to each of these humidification devices, and secretions were removed and measured by suctioning every hour during the last 4 hours of the 24-hour study period. RESULTS: In vitro water vapor delivery was greater using non-heated-wire humidification, compared to heated-wire humidification and HME. In vivo, a total of 9 patients were studied. Secretion volume following humidification by non-heated-wire humidification was significantly greater than for heated-wire humidification and HME (P = .004). CONCLUSIONS: The volume of secretions appeared to be linked to humidification, as greater water vapor delivery measured in vitro was associated with greater secretion volume in vivo. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

BACKGROUND: Practitioners often presume there is adequate humidification in the ventilator circuit if the Y-piece is at a specified temperature, but control of Y-piece temperature may be inadequate to ensure adequate humidification. METHODS: In an in vitro bench model we measured water-vapor delivery with several heated humidification setups and a wide range of minute volume (V (E)) values. The setup included a condenser, hygrometry, and thermometer. First, we calibrated the system with a point-source humidifier and water pump. Then we tested the water-vapor delivery during non-heated-wire humidification and during heated-wire humidification with a temperature gradient of +3 degrees C, 0 degrees C, and -3 degrees C between the humidifier and the Y-piece. We compared the results to 2 recommended humidification values: 100% saturated (absolute humidity 44 mg H(2)O/L) gas at 37 degrees C (saturated/37 degrees C); and 75% saturated (absolute humidity 33 mg H(2)O/L), which is the humidity recommended by the International Organization for Standardization (the ISO standard). In all the experiments the setup was set to provide 35 degrees C at the Y-piece. RESULTS: Our method for measuring water-vapor delivery closely approximated the amount delivered by a calibrated pump, but slightly underestimated the water-vapor delivery in all the experiments and the whole V (E) range. At all V (E) values, water-vapor delivery during non-heated-wire humidification matched or exceeded saturated/37 degrees C and was significantly greater than that during heated-wire humidification. During heated-wire humidification, water-vapor delivery varied with the temperature gradient and did not reach saturated/37 degrees C at V (E) > 6 L/min. Water-vapor delivery with the negative temperature gradient was below the ISO standard. CONCLUSIONS: Maintaining temperature at one point in the inspiratory circuit (eg, Y-piece), does not ensure adequate water-vapor delivery. Other factors (humidification system, V (E), gradient setting) are critical. At a given temperature, humidification may be significantly higher or lower than expected. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Integrating physiology core concepts into the clinical years of medical education has been challenging despite efforts. This article describes a fourth-year medical school elective, Advanced Physiology in Critical Care Medicine, that focused on integrating physiology core concepts in a case-based learning approach. The elective used interdisciplinary faculty in a virtual forum. Senior students were asked to generate mechanism of disease (MOD) maps, highlight the physiology core concepts associated with paper cases of critically ill patients, and discuss with faculty the relevance of the underlying basic science. The weekly footprint consisted of a student-led session presenting MOD maps for three cases, which examined aspects of core physiology concepts, and, later in the same week, student presentation of order sets for the management of the cases. Students ended the 4-wk elective with a mini-grand rounds presentation on a topic of their choice incorporating the core concept paradigm. Student perception data and faculty reflections of the elective course are included. Student data and faculty observations suggest that students appreciate and can apply physiological core concepts to patient care. Faculty experience in the course suggests that this senior elective helped them better approach all preclinical teaching with the Core Concepts framework in mind. NEW & NOTEWORTHY This article presents an innovative approach to integration of physiology core concepts with clinical management using cases of critically ill patients in an online senior elective for medical students. It uses a multidisciplinary faculty conducting a course primarily using case-based learning led by student presentations and discussions of concept maps and order sets.

Background: Commercial-off-the-shelf learning platforms developed for medical education (herein referred to as MedED-COTS) have emerged as a resource used by a majority of medical students to prepare for licensing examinations. As MedED-COTS proliferate and include more functions and features, there is a need for an up-to-date review to inform medical educators on (a) students' use of MedED-COTS outside the formal medical school curriculum, (b) the integration of MedED-COTS into the formal curriculum, and (c) the potential effects of MedED-COTS usage on students' national licensing exam scores in the USA., Methods: Due to the limited number of studies published on either the use or integration of MedED-COTS, a focused review of literature was conducted to guide future research and practice. Data extraction and quality appraisal were conducted independently by three reviewers; with disagreements resolved by a fourth reviewer. A narrative synthesis was completed to answer research questions, contextualize results, and identify trends and issues in the findings reported by the studies included in the review., Results: Results revealed consistent positive correlations between students' use of question banks and their licensing exam performance. The limited number of integration studies, combined with a number of methodological issues, makes it impossible to isolate specific effects or associations of integrated commercial resources on standardized test or course outcomes. However, consistent positive correlations, along with students' pervasive use and strong theoretical foundations explaining the results, provide evidence for integrating MedED-COTS into medical school curricula and highlight the need for further research., Conclusions: Based on findings, we conclude that students use exam preparation materials broadly and they have a positive impact on exam results; the literature on integration of MedED-COTS into formal curriculum and the use by students of resources outside of exam preparation is scant.

Purpose: Trust in and comparability of assessments are essential in clerkships in undergraduate medical education for many reasons, including ensuring competency in clinical skills and application of knowledge important for the transition to residency and throughout students' careers. The authors examined how assessments are used to determine internal medicine (IM) core clerkship grades across U.S. medical schools., Methods: A multisection web-based survey of core IM clerkship directors at 134 U.S. medical schools with membership in the Clerkship Directors in Internal Medicine was conducted in October through November 2018. The survey included a section on assessment practices to characterize current grading scales used, who determines students' final clerkship grades, the nature/type of summative assessments, and how assessments are weighted. Respondents were asked about perceptions of the influence of the National Board of Medical Examiners (NBME) Medicine Subject Examination (MSE) on students' priorities during the clerkship., Results: The response rate was 82.1% (110/134). There was considerable variability in the summative assessments and their weighting in determining final grades. The NBME MSE (91.8%), clinical performance (90.9%), professionalism (70.9%), and written notes (60.0%) were the most commonly used assessments. Clinical performance assessments and the NBME MSE accounted for the largest percentage of the total grade (on average 52.8% and 23.5%, respectively). Eighty-seven percent of respondents were concerned that students' focus on the NBME MSE performance detracted from patient care learning., Conclusions: There was considerable variability in what IM clerkships assessed and how those assessments were translated into grades. The NBME MSE was a major contributor to the final grade despite concerns about the impact on patient care learning. These findings underscore the difficulty in comparing learners across institutions and serve to advance discussions for how to improve accuracy and comparability of grading in the clinical environment., (Copyright © 2020 by the Association of American Medical Colleges.)

Competing Interests: There are no conflicts of interest.

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.

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.

Purpose: The Accreditation Council for Graduate Medical Education requires that internal medicine (IM) core curricula include end-of-life care and pain management concepts and that fellows in hematology/oncology, pulmonary/critical care, and geriatrics should receive formal instruction and clinical experience in palliative and end-of-life care. We aimed to assess the effectiveness of current teaching methods for housestaff in these fields., Method: All of the IM residents, geriatric medicine fellows, hematology/oncology fellows, and pulmonary/critical care fellows from four regional graduate medical education sites were asked to participate in an online survey at the beginning and end of the 2008-2009 academic year. We evaluated seven domains of knowledge of palliative care and pain management with a self-assessment of competence in these areas. We also asked participants to describe their current curriculum and training in palliative medicine., Results: There were 326 e-mailed survey invitations. There were 180 responses for the start-year survey and 102 responses for the end-year survey. All sites were represented in the responses. The only learners to significantly improve their palliative knowledge during a year of training were PGY-1s and PGY-4s. The majority of housestaff surveyed report that their current palliative medicine training is inadequate. The vast majority (84.6%) said a dedicated palliative medicine rotation would be "useful" or "very useful.", Conclusions: Housestaff recognize their lack of experience and training in palliative medicine and are interested in many teaching venues to improve their skills. A more focused curriculum in palliative and end-of-life care is required at both resident and subspecialty fellowship levels.

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.

Background: Sentinel cases of lymphocytic bronchiolitis in flock production and coating operations triggered a five-plant study of airborne respirable dust and fiber exposures and health symptoms., Methods: Job histories from 219 current workers were linked to a job-exposure matrix derived from personal exposure measurements of respirable dust and fibers. Univariate group comparisons and multivariate modeling tested for relations between indices of cumulative and current exposure, and respiratory and systemic symptom outcomes., Results: Respiratory symptoms and repeated flu-like illnesses were associated with use of compressed air to clear equipment (blow-downs) and with respirable dust exposure (current and cumulative) after controlling for smoking. Blow-downs had an equal or greater effect than smoking status on most symptoms., Conclusions: Eliminating compressed air cleaning, engineering control of dust exposure, and respirators are needed to limit exposures to particulates. Longitudinal follow up may provide guidance for a dust or fiber level without adverse respiratory health effects.

Aerosolized crab allergens are suspected etiologic agents for asthma among crab-processing workers. The objectives of this study were to characterize crab allergen concentrations and respiratory symptom prevalence among processing workers aboard crab-processing vessels. A cross-sectional survey of five crab-processing vessels was conducted near Dutch Harbor, Alaska. Crab allergen concentrations were quantified during specific work activities with 25 personal air samples collected on polytetrafluoroethylene filters and analyzed by a competitive IgE immunoassay technique. Two standardized respiratory questionnaires were used to assess respiratory symptoms suggestive of bronchitis or asthma in 82 workers. Aerosolized crab allergen concentrations ranged from 79 ng/m3 to 21,093 ng/m3 (mean = 2797 ng/m3, SD = 4576 ng/m3). The highest concentrations were measured at butchering/degilling work stations, which were combined on the smallest vessel. A significant percentage of workers reported development of respiratory symptoms during the crab-processing season. Cough developed in 28% of workers, phlegm in 11% of workers, and wheeze and other asthma-like symptoms developed in 4% of workers. Despite variations in crab allergen levels, respiratory symptom prevalence was similar across all job categories. Substantial concentrations of crab allergen exposure were measured, as well as the potential for wide variability in exposure during crab processing aboard vessels. The high prevalence of reported respiratory symptoms across all job categories suggests potential adverse respiratory effects that should be further characterized by prospective studies using pulmonary function and serology testing, and rigorous exposure characterization.

Background: Crab processing workers may develop respiratory symptoms and specific IgE responses, but the risk factors have not been fully described., Methods: In 1998, 107 workers at a crab processing facility completed a survey both at the beginning and end of the processing season. The surveys included standardized symptom questionnaires, spirometry, and serological testing, as well as measurement of workplace airborne crab allergens and microscopic analysis of aerosolized materials., Results: Over the crab processing season, asthma-like symptoms developed in 26% of study participants and bronchitic symptoms in 19%. Only 9% of those with new asthma-like symptoms were IgE-sensitized to crab at the end of the season. Among the crab processing jobs, butchering and degilling workers had the highest incidence of respiratory symptoms., Conclusions: Both personal and process-related factors appear to affect the development of respiratory symptoms in crab processing workers. In this study, crab specific IgE was not detected in most of the workers with new symptoms. Published 2001 Wiley-Liss, Inc.