Search

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.

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 (DLWe retrospectively compared data, including DLThe mean DLDL

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.

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 poses a great environmental risk to health. Outdoor fine particulate matter (particulate matter with an aerodynamic diameter 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.

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.

Evidence-based diagnostic and treatment guidelines for occupationally related interstitial lung diseases (ILDs) have been developed and are summarized herein.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.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.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.

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.

Occupational asthma refers to asthma induced by exposure in the working environment to airborne dusts, vapors, or fumes, with or without preexisting asthma. Potential triggers of occupational asthma are diverse and involve a variety of postulated mechanisms. After confirming the presence of asthma, diagnosis hinges on obtaining a detailed and accurate occupational and environmental history and documenting a temporal association of symptoms or signs with workplace exposure. Management of occupational asthma centers on prescribing standard asthma therapies in conjunction with instituting preventive strategies, such as appropriate avoidance of environmental triggers, providing work restrictions, and using environmental controls and /or personal respiratory protection. If a worker is determined to be ill or injured, there are a variety of compensation systems that are designed to protect workers financially from disability related to respiratory impairments; however, the administrative process is frequently difficult to navigate for patients and their providers. Focusing on obtaining a detailed occupational and environmental history, establishing clear objective data to substantiate illness, and estimating or apportioning workplace contribution to the condition is important for the diagnosis and treatment of this relatively common form of asthma.

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.

Background Little is known about a fairly frequent abnormal pattern of pulmonary function test results: reduced FEV1 and FVC with a normal FEV1/FVC and normal total lung capacity. We term this a nonspecific pattern (NSP). We sought to identify medical conditions having this pattern and to explore mechanisms producing it. Methods From a database of 80,929 test results, the NSP was found in 7,702 subjects from whom was drawn a random sample of 100 subjects. Medical records and all available tests were examined. Results Airway hyperresponsiveness (AHR) and obesity were common. Two groups of subjects were identified. Group A consisted of 68 subjects with evidence of airway disease, including AHR and chronic lung disease. A volume derecruitment model was proposed to explain their NSP. Group B consisted of 32 subjects with no evidence of airway disease. Restricted expansion of the thorax or lung may explain the NSP in most of these subjects. Forty subjects had repeated tests, and in only 17 were the test results consistently nonspecific. Conclusions In a random sample of 100 subjects with the NSP, the probable underlying cause of the pattern in 68 subjects was airway disease. In most of the remaining 32 subjects, restricted expansion of the thorax or lung may be implicated.

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.

Background: Chronic liver failure may be associated with pallidal MRI T1 hyperintensity and heterogeneous neurologic syndromes, including parkinsonism, cognitive impairment, and others. Manganese accumulation may be responsible for the imaging and clinical findings. Objective: To measure manganese plus other metal concentrations in pallidum and additional brain regions and to examine the corresponding neuropathology in cases of chronic liver failure. Methods: Regional brain metal concentrations were measured in seven chronic liver failure cases, four with pallidal T1 hyperintensity and three with normal MRI, plus five controls. Neuropathologic examination employed α-synuclein and tau immunohistochemistry. Results: In patients with pallidal T1 hyperintensity, pallidal manganese concentrations were increased sevenfold over controls and over fourfold vs liver patients with normal MRI; manganese concentrations were also significantly elevated in all other brain regions. Copper was additionally increased in all brain regions, whereas other metal concentrations were similar to control values. Neuropathology revealed mild to moderate Alzheimer type II gliosis in the liver failure groups and negative α-synuclein and tau immunostaining except for one case (intermediate Alzheimer disease pathology). Conclusion: In chronic liver failure, manganese accumulation is responsible for the pallidal MRI T1 hyperintensity. Pallidal copper was also elevated in affected cases, but copper does not have the paramagnetic properties to generate isolated T1 hyperintensity. Basal ganglia manganese or copper accumulation may be responsible for the parkinsonism sometimes seen in chronic liver failure. Pallidal MRI T1 hyperintensity is a biomarker of manganese overload.

Background: Neurologic symptoms have been attributed to manganese fumes generated during welding. Increased T1 MRI signal in the basal ganglia is a biologic marker of manganese accumulation. Recent studies have associated welding and parkinsonism, but generally without MRI corroboration.Objective: To characterize the clinical and neuropsychological features of patients with MRI basal ganglia T1 hyperintensity, who were ultimately diagnosed with neurotoxicity from welding fumes.Methods: The medical records of welders referred to the Department of Neurology with neurologic problems and basal ganglia T1 hyperintensity were reviewed.Results: All eight patients were male career welders with increased T1 basal ganglia signal on MRI of the brain. Several different clinical syndromes were recognized: a parkinsonian syndrome (three patients), a syndrome of multifocal myoclonus and limited cognitive impairment (two patients), a mixed syndrome with vestibular–auditory dysfunction (two patients), and minor subjective cognitive impairment, anxiety, and sleep apnea (one patient). Neuropsychometric testing suggested subcortical or frontal involvement. Inadequate ventilation or lack of personal respiratory protection during welding was a common theme.Conclusions: Welding without proper protection was associated with syndromes of parkinsonism, multifocal myoclonus, mild cognitive impairment, and vestibular–auditory dysfunction. The MRI T1 hyperintensity in the basal ganglia suggests that these may have been caused by manganese neurotoxicity.

Background Hypersensitivity pneumonitis has been described with exposure to aerosolized Mycobacterium avium complex (MAC) in indoor hot tubs (hot tub lung). Objectives To describe a case of MAC-associated hypersensitivity pneumonitis-like reaction possibly from showering and review previous hot tub lung reports. Methods For the case report, we investigated a patient with histologically diagnosed hypersensitivity pneumonitis and MAC-positive sputum culture findings. Mycobacterial cultures were obtained from his home and workplace. Isolates were typed using pulsed-field gel electrophoresis. For the review, MEDLINE and EMBASE were searched for hot tub lung reports, which were reviewed and summarized. Results A 50-year-old man had progressive dyspnea and episodic fever and myalgias. Pulmonary function testing results revealed obstruction and impaired diffusion; a chest CT scan found diffuse, centrilobular, ground-glass nodules, and air trapping, and a lymphocytic alveolitis with an elevated CD4/CD8 ratio. Transbronchial biopsy showed multiple well-formed nonnecrotizing granulomas. Multiple respiratory samples and shower and bathtub specimens grew MAC, with matching pulsed-field gel electrophoresis patterns. The patient changed from showering to tub bathing. Prednisone and antimycobacterial drugs were administered for approximately 1 year. His symptoms, pulmonary function abnormalities, and CT scan findings resolved. The literature review yielded 36 cases of hot tub lung. Clinical features included dyspnea (97%), cough (78%), and fever (58%). Pulmonary function testing showed obstruction (67%), restriction (55%), and impaired diffusion (75%). A chest CT scan showed ground-glass opacification (95%) and nodules (67%). Granulomas were well-formed in 95%. Treatments included discontinuation of hot tub use and prednisone, antimycobacterial drugs, or both. Outcomes were favorable Conclusions A hypersensitivity pneumonitis-like reaction to mycobacteria can occur from exposures other than hot tubs. There are key differences between classic hypersensitivity pneumonitis and MAC-associated hypersensitivity pneumonitis. Antimycobacterial therapy may be required. The possibility of MAC hypersensitivity pneumonitis from showering raises potential implications in the investigation of patients with hypersensitivity pneumonitis.

Occupational asthma is the most prevalent form of occupational lung disease in industrialized nations. As increasing numbers of new chemicals are produced and new manufacturing processes are introduced, the variety of environments in which individuals may become exposed to respiratory sensitizers and irritants makes diagnosing and treating this illness even more challenging. In addition to adverse pulmonary effects, the diagnosis of occupational asthma may bring with it negative social and financial implications that may ultimately affect the patient's quality of life. For this reason, it is important for clinicians to recognize work-related respiratory symptoms early on in their course, maintain a high clinical suspicion for an occupational cause in the diagnostic work-up of asthma, and have a high degree of certainty in the diagnosis. While a number of classification schemes have been proposed to simplify the diagnostic approach to occupational asthma, the inciting factors typically involve sensitization (often by an IgE mechanism), direct airway inflammation, various pharmacologic responses, or irritant reflex pathways. Clinicians must first document the presence of asthma, then establish a relationship between asthma and the work-place. The occupational history is the key diagnostic tool, and clinical suspicions may be evaluated further by serial peak expiratory flow measurements, nonspecific hypersensitivity challenges with histamine or methacholine, collaboration with industrial/occupational hygienists to obtain workplace exposure measurements, and specific challenge testing at tertiary referral centers providing specialized laboratories. Removal from the inciting exposure is the mainstay of therapy, and pharmacologic treatment of patients with occupational asthma is similar to the treatment of patients with other forms of asthma.

Background Anticholinergic medications have been utilized frequently prior to bronchoscopy and are thought to facilitate the drying of secretions to limit the amount of required topical anesthetic on the airway mucosa, prevent cardiac arrhythmias during the procedure, and increase patient comfort. Objective To determine if atropine or glycopyrrolate, two anticholinergic agents utilized most frequently in this setting, have any significant role for this purpose. Design Double-blind, placebo-controlled study, in which patients were randomly selected to receive atropine (0.01 mg/kg body weight, IM injection), glycopyrrolate (0.005 mg/kg, IM injection), or saline solution placebo (approximately 2 mL, IM injection) 15 to 45 min prior to being sedated with midazolam until judged to be lightly sedated. Setting A large academic teaching hospital in the midwestern United States. Participants Two hundred seventeen outpatients referred for bronchoscopy who satisfied inclusion and exclusion criteria. Measurements and results Using a modified visual analog scale (0 to 100 mm), the bronchoscopist and the nurse anesthetist estimated the antisialagogic effect, effectiveness in cough suppression, and overall patient comfort during the procedure. The patients completed a similar questionnaire after recovering from the procedure. Patients were also monitored for complications (cardiac arrhythmias, oxygen desaturation, hypertension, wheezing, or coughing severe enough to curtail the procedure). There was no significant difference found among atropine, glycopyrrolate, and placebo for the primary end point of secretion control. In addition, there was no difference found between either medication and placebo for effectiveness of cough suppression, amount of topical anesthetic used, complication rates, or overall patient comfort. Conclusion The use of anticholinergic agents prior to bronchoscopy did not affect performance of bronchoscopy or complication rates, and there was no appreciable benefit from the resultant reduction in airway secretions in a population of patients receiving concurrent sedation with benzodiazepines.

This position statement reviews several aspects of spirometric testing in the workplace, where spirometry is employed in the primary, secondary, and tertiary prevention of occupational lung disease. Primary prevention includes pre-placement and fitness-for-duty examinations as well as research and monitoring of health status in groups of exposed workers; secondary prevention includes periodic medical screening of individual workers for early effects of exposure to known occupational hazards; and tertiary prevention includes clinical evaluation and impairment/disability assessment. For all of these purposes, valid spirometry measurements are critical, requiring: documented spirometer accuracy and precision, a rigorous and standardized testing technique, standardized measurement of pulmonary function values from the spirogram, adequate initial and refresher training of spirometry technicians, and, ideally, quality assessment of samples of spirograms. Interpretation of spirometric results usually includes comparison with predicted values and should also evaluate changes in lung function over time. Response to inhaled bronchodilators and changes in relation to workplace exposure may also be assessed. Each of these interpretations should begin with an assessment of test quality and, based on the most recent ATS recommendations, should rely on a few reproducible indices of pulmonary function (FEV1, FVC, and FEV1/FVC.) The use of FEF rates (e.g., the FEF25-75%) in interpreting results for individuals is strongly discouraged except when confirming borderline airways obstruction. Finally, the use of serial PEF measurements is emerging as a method for confirming associations between reduced or variable pulmonary function and workplace exposures in the diagnosis of occupational asthma. Throughout this position statement, ACOEM makes detailed recommendations to ensure that each of these areas of test performance and interpretation follow current recommendations/standards in the pulmonary and regulatory fields. Submitted by the Occupational and Environmental Lung Disorder Committee on November 16,1999. Approved by the ACOEM Board of Directors on January 4,2000.

OBJECTIVE: To determine the opinion of current residents and recent graduates of internal medicine training programs regarding an additional mandatory year of residency training. METHODS: A survey was made of 2,000 associate members of the American College of Physicians from five geographic regions. RESULTS: Of 917 respondents, 70.3% thought a fourth year of training would impact negatively on their choice of a career in internal medicine, and 82.9% believed a mandatory fourth year should not be required of residents choosing a subspecialty career. Furthermore, 58.1% of physicians surveyed thought a mandatory fourth year would discourage individuals from pursuing subspecialty careers. If a mandatory fourth year of training were required, 50.7% respondents indicated that it should consist of ambulatory training in a number of general fields, while 49.6% physicians believed the training should focus on one or two subspecialty fields. CONCLUSIONS: A mandatory fourth year of training is not supported by residents and recent graduates of the programs surveyed.

Assessment and management of administrative issues surrounding occupational and environmental lung disease are often one of the more challenging aspects of caring for individuals encountering illnesses or injuries associated with workplace exposures. Lack of formalized training in providing the forensic aspects of diagnosing and treating these types of conditions is often the reason why many health care providers experience significant frustration in prosecuting this type of work. This includes being able to define and understand the essential concepts of impairment and disability, recognizing the need for work restrictions and how to compose useful recommendations to the employer in order to avoid unnecessary time away from work when the individual patient could be accommodated in alternative work environments, and understanding the variety of programs available to compensate individuals affected by work-related exposures or injuries. The ability to perform these administrative tasks is vital to adequately serve the patient with these conditions.

It is important for clinicians to consider lymphatic malformations in the differential diagnosis of chronic skin lesions, no matter where they appear anatomically. We report a case of deep surgical excision of an extensive lymphatic malformation of the scrotum using regional flaps from uninvolved scrotal tissue. Removal of the lesion not only allowed the patient more comfort but also may have ultimately cured his symptomatology.

OBJECTIVE To assess the impact of direct-to-consumer (DTC) predictive genomic risk information on perceived risk and worry in the context of routine clinical care. PATIENTS AND METHODS Patients attending a preventive medicine clinic between June 1 and December 18, 2009, were randomly assigned to receive either genomic risk information from a DTC product plus usual care (n=74) or usual care alone (n=76). At intervals of 1 week and 1 year after their clinic visit, participants completed surveys containing validated measures of risk perception and levels of worry associated with the 12 conditions assessed by the DTC product. RESULTS Of 345 patients approached, 150 (43%) agreed to participate, 64 (19%) refused, and 131 (38%) did not respond. Compared with those receiving usual care, participants who received genomic risk information initially rated their risk as higher for 4 conditions (abdominal aneurysm [P=.001], Graves disease [P=.04], obesity [P=.01], and osteoarthritis [P=.04]) and lower for one (prostate cancer [P=.02]). Although differences were not significant, they also reported higher levels of worry for 7 conditions and lower levels for 5 others. At 1 year, there were no significant differences between groups. CONCLUSION Predictive genomic risk information modestly influences risk perception and worry. The extent and direction of this influence may depend on the condition being tested and its baseline prominence in preventive health care and may attenuate with time.

Occupational asthma refers to asthma induced by exposure in the working environment to airborne dusts, vapors, or fumes, with or without preexisting asthma. Potential triggers of occupational asthma are diverse and involve a variety of postulated mechanisms. After confirming the presence of asthma, diagnosis hinges on obtaining a detailed and accurate occupational and environmental history and documenting a temporal association of symptoms or signs with workplace exposure. Management of occupational asthma centers on prescribing standard asthma therapies in conjunction with instituting preventive strategies, such as appropriate avoidance of environmental triggers, providing work restrictions, and using environmental controls and/or personal respiratory protection. If a worker is determined to be ill or injured, there are a variety of compensation systems that are designed to protect workers financially from disability related to respiratory impairments; however, the administrative process is frequently difficult to navigate for patients and their providers. Focusing on obtaining a detailed occupational and environmental history, establishing clear objective data to substantiate illness, and estimating or apportioning workplace contribution to the condition is important for the diagnosis and treatment of this relatively common form of asthma.

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.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.Consensus was achieved on all but 9 of 32 statements.Consensus was not achieved for nine statements. These statements may be topics for future research.

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).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.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.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.

Background An atypical form of parkinsonism has been described in patients with chronic liver disease, associated with increased T1 signal in the basal ganglia on magnetic resonance imaging. The magnetic resonance imaging signal changes are characteristic of manganese accumulation, which has been neuropathologically confirmed. Manganese neurotoxicity may result in additional neurologic findings besides parkinsonism. Objective To fully characterize patients with chronic central nervous system symptoms and chronic liver failure associated with basal ganglia T1 hyperintensity. Design Prospective and retrospective case study. Setting Mayo Clinic, Rochester, Minn. Participants Eight patients referred for neurologic evaluation and studied prospectively, and 7 additional retrospectively identified patients who had been examined by Mayo Clinic neurologists. Main Outcome Measures Neurologic syndromes identified. Results Three syndromes were recognized in these 15 patients with liver failure and basal ganglia T1 hyperintensity on magnetic resonance imaging: (1) isolated parkinsonism, (2) gait ataxia plus other neurologic findings (ataxia-plus), and (3) cognitive impairment with psychiatric features. All but 1 patient had elevated blood manganese levels. Ammonia levels were normal in most, and the neurologic syndromes did not appear to reflect the well-known toxic-metabolic encephalopathy of liver disease. Conclusions Chronic liver failure may result in heterogeneous neurologic syndromes that cut across a variety of liver diseases. We selected cases on the basis of evidence of brain manganese accumulation, and this may be a crucial component of these syndromes. Further studies are necessary to explore this issue.

Single-breath diffusing capacity of the lung for carbon monoxide (DLCO) is used as a pulmonary function test (PFT) to assess gas transfer in the lungs. The implications of a low DLCO are well-recognized, but the clinical significance of a high DLCO is not clear. The aim of this study was to identify the clinical correlates of a high DLCO.We identified 245 patients with a high DLCO (ie,140% predicted) and a matched group of 245 patients with normal DLCO (ie, 85 to 115% predicted), who were selected from a laboratory database of 45,000 patients tested between January 1997 and December 1999. We compared the demographic features, clinical diagnoses, and PFT data between the two groups.Large multispecialty group practice.The patients in the high DLCO group were heavier (mean [+/- SD] weight, 96.0 +/- 22.9 vs 85.0 +/- 21.3 kg, respectively; p0.001), had a higher mean body mass index (32.9 +/- 7.4 vs 29.4 +/- 6.4 kg/m(2), respectively; p0.001), larger body surface area (p0.001), and larger mean total lung capacity (p = 0.007) and alveolar volume (p0.001). The clinical diagnoses of obesity (p0.001) and asthma (p0.001) were more common among patients with high DLCO values. The majority of patients (62%) with a high DLCO had a diagnosis of obesity, asthma, or both. Polycythemia, hemoptysis, and left-to-right shunt were uncommon.A high DLCO on a PFT is most frequently associated with large lung volumes, obesity, and asthma. Other conditions are much less common. A clinical condition, which typically reduces DLCO, may deceptively normalize DLCO in such patients.

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.

Catamenial pneumothorax is a rare entity of unknown etiology characterized by recurrent accumulation of air in the thoracic space during or preceding menstruation. We documented the presence of a diaphragmatic fenestration during thoracoscopy, lending support for hypotheses involving diaphragmatic defects as possible avenues of air collection in the thorax.

We report the use of polymerase chain reaction (PCR) techniques from a bronchoalveolar lavage (BAL) specimen for the successful early diagnosis in a case of atypical but severe varicella-zoster virus (VZV) pneumonitis. Atypical presentations of disseminated VZV frequently prolong the time required for accurate diagnosis, resulting in increased morbidity, or mortality. Although further investigation is necessary to determine the sensitivity and positive predictive value of this test, PCR analysis of bronchoscopic specimens may expedite the diagnosis of disseminated VZV.

Context.—Despite the increased popularity of hot-air balloon flight, data on injuries and fatalities associated with hot-air balloon crashes are limited.Objective.—To determine factors associated with injury and death in hot-air balloon crashes.Design.—Retrospective review of data collected from reports and investigations by the Civil Aeronautics Board and the National Transportation Safety Board.Study Subjects.—Individuals involved in US hot-air balloon crashes from 1964 to 1995.Main Outcome Measures.—Total number of crashes and factors associated with fatality or serious injury.Results.—From 1964 to 1995, a total of 495 hot-air balloon crashes involving 1533 persons were reported and included 92 fatalities and 384 serious injuries. Pilot error or incapacitation was determined subjectively by crash investigators to contribute to 85.1% of the crashes. In univariate analysis, collision with the ground was the most significant predictor of a fatality or serious injury (P

The third-generation cephalosporin, ceftazidime, is widely used for the treatment of serious gram-negative infections. As is true of cephalosporins in general, reported adverse effects have been few. We report a case of ceftazidime-induced status epilepticus in a patient with Pseudomonas aeruginosa meningitis and compare the clinical manifestations of this case with those of two previously described cases of ceftazidime-related encephalopathy. This diagnosis should be entertained and an electroencephalogram should be obtained in all patients with myoclonus and/or altered mental status while they are receiving ceftazidime therapy.

In Reply. —It is important to note that the statistics in the article are lifetime prevalence rates rather than annual incidence rates, a point that is easily confused. The American Cancer Society's annual publication, Cancer Facts and Figures , estimates that in 1991 approximately 175 000 women will develop breast cancer. 1 Overall, 1.1 million new cases of cancer will be diagnosed this year, and 514 000 women will die from the disease (1400 women each day). The lifetime risk for women developing breast cancer has recently been determined to increase from one in 10 women to one in nine women, a change reflecting both a rising incidence of breast cancer and an aging population. 1 These results are compiled by the American Cancer Society using data collected through the National Cancer Institute's Survey of Epidemiological End Results, an accumulation of actual incidence rates from 10 US oncologic registries.