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Biomedical subjects

Richard S Irwin

Publications and source records attributed to Richard S Irwin.

At least 19 recordsLinked to original sources
PubMed2006

Habit cough, tic cough, and psychogenic cough in adult and pediatric populations: ACCP evidence-based clinical practice guidelines.

OBJECTIVES: To review the literature on habit, tic, and psychogenic cough, and to make evidence-based recommendations regarding diagnosis and treatment. DESIGN/METHODOLOGY: For data on adults, an Ovid MEDLINE literature review (through February 2005) was performed for all studies published in the English language, including case series and case reports, since 1966 using the medical subject heading terms "habit cough," "psychogenic cough," "tic disorder," "vocal tic," "Tourette's syndrome," "honking cough," and "barking cough." For pediatric data, articles were identified dating from 1966 from searches of the Cochrane Library, PubMed, EMBASE, the list of references in relevant publications, and the authors' collection of references with the last search performed in February 2005. The search terms used were "children" and "vocal tics" or "habit cough," or "psychogenic cough" or "chronic cough." RESULTS/CONCLUSIONS: The methodologies used and rigor of the diagnostic and therapeutic interventions reported in the literature are inconsistent. The putative clinical characteristics of habit cough and psychogenic cough, for the most part, have not been prospectively or systematically studied. Therefore, on the basis of expert opinion, the diagnoses of habit cough or psychogenic cough can be made only after an extensive evaluation is performed that includes ruling out tic disorders and uncommon causes of chronic cough, and when cough improves with behavior modification or psychiatric therapy. In adult patients with chronic cough that remains persistently troublesome despite an extensive and thorough evidence-based evaluation, and after behavior modification and/or psychiatric therapy have failed, unexplained cough should be diagnosed rather than habit cough or psychogenic cough. In children, the depth of investigations to rule out uncommon causes must be individualized as some investigations and/or treatment may increase morbidity. In adult and pediatric patients with chronic cough that is associated with troublesome psychological manifestations, psychological counseling or psychiatric intervention should be encouraged after other causes have been ruled out.

Cough↗
PubMed2006

An empiric integrative approach to the management of cough: ACCP evidence-based clinical practice guidelines.

OBJECTIVE: Review the literature to provide a comprehensive approach, including algorithms for the clinician to follow in evaluating and treating the patient with acute, subacute, and chronic cough. METHODS: We searched MEDLINE (through May 2004) for studies published in the English language since 1980 on human subjects using the medical subject heading terms "cough," "treatment of cough," and "empiric treatment of cough." We selected case series and prospective descriptive clinical trials. We also obtained any references from these studies that were pertinent to the topic. RESULTS: The relative frequency of the disorders (alone and in combination) that can cause cough as well as the sensitivity and specificity of many but not all diagnostic tests in predicting the cause of cough are known. An effective approach to successfully manage chronic cough is to sequentially evaluate and treat for the common causes of cough using a combination of selected diagnostic tests and empiric therapy. Sequential and additive therapy is often crucial because more than one cause of cough is frequently present. CONCLUSION: Algorithms that provide a "road map" that the clinician can follow are useful and are presented for acute, subacute, and chronic cough.

Algorithms↗
PubMed2006

Assessing cough severity and efficacy of therapy in clinical research: ACCP evidence-based clinical practice guidelines.

OBJECTIVES: To review the literature on identifying cough and to make evidence-based recommendations for assessing the efficacy of cough-modifying agents in clinical research. DESIGN/METHODOLOGY: Ovid MEDLINE literature review (through March 2004) for all studies published in the English language since 1953 using the medical subject heading terms "assessing the impact of cough," "assessing the efficacy of cough treatments," "tussigenic challenges," "cough counting," "character and timing of cough," "visual analog scales," "cough scoring systems," "health related quality of life instruments," "cough-specific health-related quality of life instruments," "citric acid challenge," "capsaicin challenge," "flow-volume loops," "assessing airway inflammation," "lipid laden macrophages in sputum," and "exhaled nitric oxide." RESULTS/CONCLUSIONS: To optimally evaluate the efficacy of cough-modifying agents, investigators should use both subjective and objective methods, because they have the potential to measure different things. A patient's subjective response is likely the only one that measures the impact of the intensity of cough. With respect to subjective methods, it is recommended that a cough-specific health-related quality-of-life instrument be utilized because valid and reliable instruments exist. Even though visual analog scales have not been psychometrically tested, they are recommended because they are commonly used and valid, and they are likely to yield different but complementary results. Because there are cough-specific health-related quality-of-life instruments that have been fully psychometrically tested, and the same cannot be said for visual analog scales, this is a reason to use cough-specific health-related quality-of-life instruments as the primary, subjective outcome measure of choice. With respect to objective methods, tussigenic challenges can be used before and after the intervention to assess the effect of therapy on cough sensitivity. They are most likely to be helpful in disease states in which cough reflex sensitivity is known to be heightened. Because the act of coughing has the potential to traumatize the upper airway (eg, vocal cords), assessing the presence of upper airway edema before and after therapy with flow-volume loops may be useful. Investigators must be cautious and not assume that observing changes suggestive of inflammation and edema of upper airway structures is specific for any particular disease. Cough counting is recommended with a computerized methodology that is reliable and accurate, noninvasive and portable, and easy to use in unattended, ambulatory real-life settings within a subject's home environment when it can be done over a 24-h period of time.

Clinical Trials as Topic↗
PubMed2006

Complications of cough: ACCP evidence-based clinical practice guidelines.

OBJECTIVES: To review the spectrum and frequency of complications associated with coughing. DESIGN/METHODOLOGY: Ovid MEDLINE literature review (through March 2004) for all studies published in the English language, including case series and case reports, since 1966 using the MeSH terms "cough" and "complications." RESULTS: The complications of cough appear to stem from physiologic events. The magnitude of pressures, velocities, and energy that is generated during vigorous coughing allow coughing to be an effective means of clearing the airways of excessive secretions and foreign material, and providing cardiopulmonary resuscitation; however, they can also cause a variety of profound physical and psychosocial complications. The adverse occurrences include cardiovascular, constitutional, GI, genitourinary, musculoskeletal, neurologic, ophthalmologic, psychosocial, respiratory, and skin complications, and a decrease in health-related quality of life. CONCLUSIONS: Knowledge of the spectrum of complications should enable clinicians to appreciate (1) the impact of cough on patients, (2) why it is imperative to exhaust all possible diagnostic and therapeutic options to eliminate cough, and (3) why it is inappropriate to minimize a patient's complaint of cough and/or advise him/her to "live with it."

Cardiovascular Diseases↗
PubMed2006

Chronic cough due to gastroesophageal reflux disease: ACCP evidence-based clinical practice guidelines.

OBJECTIVES: To critically review and summarize the literature on cough and gastroesophageal reflux disease (GERD), and to make evidence-based recommendations regarding the diagnosis and treatment of chronic cough due to GERD. DESIGN/METHODOLOGY: Ovid MEDLINE literature review (through March 2004) for all studies published in the English language and selected articles published in other languages such as French since 1963 using the medical subject heading terms "cough," "gastroesophageal reflux," and "gastroesophageal reflux disease." RESULTS: GERD, singly or in combination with other conditions, is one of the most common causes of chronic cough. In patients with normal chest radiographic findings, GERD most likely causes cough by stimulation of an esophageal-bronchial reflex. When GERD causes cough, there may be no GI symptoms up to 75% of the time. While 24-h esophageal pH monitoring is the most sensitive and specific test in linking GERD and cough in a cause-effect relationship, it has its limitations. In addition, there is no general agreement on how to best interpret the test, and it cannot detect non-acid reflux events. Therefore, when patients fit the clinical profile that has a high likelihood of predicting that GERD is the cause of cough, antireflux medical therapy should be empirically instituted. While some patients improve with minimal medical therapy, others require more intensive regimens. When empiric treatment fails, it cannot be assumed that GERD has been ruled out as a cause of chronic cough. Rather, an objective investigation for GERD is then recommended because the empiric therapy may not have been intensive enough or medical therapy may have failed. Surgery may be efficacious when intensive medical therapy has failed in selected patients who have undergone an extensive objective GERD evaluation. CONCLUSIONS: Accurately diagnosing and successfully treating chronic cough due to GERD can be a major challenge.

Chronic Disease↗
PubMed2006

Side effects with inhaled corticosteroids: the physician's perception.

The National Asthma Education and Prevention Program 1997 guidelines and 2002 update provide an overview of potential local and systemic side effects associated with inhaled corticosteroids (ICS) and suggest ways of minimizing the risk of these side effects occurring. Despite the guidelines and extensive clinical experience of the safe use of ICS, a significant number of physicians retain concerns regarding side effects. Local side effects may lead to patients discontinuing therapy, with or without the knowledge of their physicians. In particular, concerns regarding systemic side effects, such as growth retardation in children and osteoporosis, remain relatively widespread. Pharmacokinetic studies reveal that different ICS compounds and formulations result in different degrees of systemic bioavailability, indicating possible differences in their potential to cause systemic side effects. However, clinical studies that can be used to differentiate between ICS formulations are generally lacking. Consequently, there is a need to continue to further our understanding of side effects with ICS, with the aim of identifying formulations, devices, and doses with an optimal risk/benefit ratio. The introduction of new agents with potentially improved safety profiles may reassure physicians and patients as to the relative benefits of ICS therapy in asthma.

Administration, Inhalation↗
PubMed2006

Patient-focused care: using the right tools.

Patient-focused or patient-centered care is not a new concept, but its value has been overlooked in preference to the technology-based, disease-centered model that has prevailed in medicine for the last 50 years. Patient-focused care includes four broad areas of intervention: communication with patients, partnerships, health promotion, and physical care (medications and treatments). We can conceptualize patient-focused care as being the care we would like our loved ones to receive. There is considerable evidence that patients prefer a patient-focused approach. Unfortunately, there are also many studies detailing physicians' disconnection with patients' needs, particularly the need for information, and misunderstandings and assumptions based on poor communication. However, it is possible to develop physicians' skills in patient-focused care and provide physicians with the tools to overcome the barriers to this approach. The patient-focused approach has been shown to improve physicians' performance, patient satisfaction, and health outcomes without requiring additional investment in time or resources. Patient-focused care has also been shown to improve adherence to medication/advice, a well-known problem in asthma. There are also benefits to the physician in terms of improved outcomes for their patients, higher patient retention, and potentially a reduced risk of litigation. Patient-focused care may be a particularly valuable approach for the management of "difficult-to-treat" patients. In summary, the "three Cs" of patient-focused care-communication, continuity of care, and concordance (finding common ground)-are highly relevant to the effective treatment of pulmonary disease and should be a key component of asthma management.

Adolescent↗
PubMed2006

Interpreting the histopathology of chronic cough: a prospective, controlled, comparative study.

HYPOTHESIS: Trauma from chronic coughing produces airway inflammation similar to diseases causing cough. DESIGN: Prospective, cross-sectional, controlled, clinicopathologic correlation study in four groups: group 1, cough from intrapulmonary diseases; group 2, cough from extrapulmonary diseases; group 3, cough that was unexplained; and group 4, nonsmoking, asymptomatic control subjects. METHODS: Patients with chronic cough underwent a standardized workup including endobronchial biopsies before treatment. Causes were determined by a favorable response to therapy. Bronchial biopsy samples from control subjects were obtained from surgical specimens. RESULTS: There were 24 adult subjects (13 women and 11 men) with mean cough duration of 8.6 +/- 7.4 years (+/- SD). Thirteen patients had cough due to a specific disease: intrapulmonary diseases in 5 patients, and extrapulmonary diseases in 8 patients. Eleven patients had unexplained cough. Compared to control subjects, there was minimal-to-moderate chronic inflammation in all coughers (p < or = 0.0004), in group 1 (p < or = 0.039), group 2 (p = 0.061), and group 3 (p < or = 0.025) diseases that were not correlated with cough duration. There was no difference in type of inflammation, cough duration, or smoking history between groups, nor were there histologic differences between subjects with explained causes of cough compared with unexplained cough. CONCLUSIONS: Our findings suggest that airway inflammation associated with chronic cough, assessed on morphologic appearance and inflammatory cell counting in hematoxylin-eosin-prepared samples, may be due to the trauma of coughing, and the inflammation may be similar to that seen with diseases putatively thought to cause chronic cough. Investigators must be cautious when attributing pathogenic importance to observed inflammatory changes in airways of coughing subjects.

Asthma↗
PubMed2006

Changing the work environment in ICUs to achieve patient-focused care: the time has come.

The American Association of Critical-Care Nurses (AACN) Standards for Establishing and Sustaining Healthy Work Environments and the American College of Chest Physicians (ACCP) Patient-Focused Care Project are complementary initiatives that provide a road map for creating practice environments where interdisciplinary, patient-focused care can thrive. Healthy work environments are so influential that failure to address the issue would result in deleterious effects for every aspect of acute care and critical care practice. Skilled communication and true collaboration are crucial for transforming work environments. The ACCP project on patient-focused care was born out of a realization that medicine as currently practiced is too fragmented, too focused on turf battles that hinder communication, and too divorced from a real understanding of what patients expect and need from their health-care providers. Communication as well as continuity and concordance with the patients' wishes are the foundational premises of care that is patient-focused and safe. Some individuals may achieve some level of genuine patient-focused care even when they practice in a toxic work environment because they are gifted communicators who embrace true collaboration. At best, those efforts will most likely be hit-or-miss, and such heroism will be impossible to sustain if the environment is not transformed into a model that reflects the standards and initiatives set out by the AACN and the ACCP. Other innovative models of care delivery remain unreported. The successes and failures of these models should be shared with the professional community.

Communication↗
PubMed2006

Changing the work environment in intensive care units to achieve patient-focused care: the time has come.

The American Association of Critical-Care Nurses Standards for Establishing and Sustaining Healthy Work Environments and the American College of Chest Physicians Patient-Focused Care project are complementary initiatives that provide a road map for creating practice environments where interdisciplinary, patient-focused care can thrive. Healthy work environments are so influential that failure to address the issue would result in deleterious effects for every aspect of acute and critical care practice. Skilled communication and true collaboration are crucial for transforming work environments. The American College of Chest Physicians project on patient-focused care was born out of a realization that medicine as currently practiced is too fragmented, too focused on turf battles that hinder communication, and too divorced from a real understanding of what patients expect and need from their healthcare providers. Communication as well as continuity and concordance with the patients' wishes are foundational premises of care that is patient-focused and safe. Some individuals may achieve some level of genuine patient-focused care even when they practice in a toxic work environment because they are gifted communicators who embrace true collaboration. At best, most likely those efforts will be hit-or-miss and such heroism will be impossible to sustain if the environment is not transformed into a model that reflects standards and initiatives set out by the American Association of Critical-Care Nurses and the American College of Chest Physicians. Other innovative models of care delivery remain unreported. The successes and failures of these models should be shared with the professional community.

Health Facility Environment↗
PubMed2005

Chronic cough in adults with interstitial lung disease.

PURPOSE OF REVIEW: Although dyspnea is the most common and distressing symptom in patients with chronic interstitial lung disease, chronic cough, a potentially debilitating symptom that impairs health-related quality of life, has been described as another common symptom in these patients. RECENT FINDINGS: Many patients with interstitial lung disease have their chronic cough mistakenly attributed to that condition when, in fact, the cough is due to more common disorders such as asthma, upper airway cough syndrome (previously referred to as postnasal drip syndrome), or gastroesophageal reflux disease. This article presents new data on a select group of patients and shows that more than 50% of patients with interstitial lung disease who are referred to a cough clinic for evaluation can have cough caused by these other more common causes of chronic cough. It is also clear, however, that chronic interstitial lung disease, by itself, can cause chronic cough, perhaps related to an increased cough reflex sensitivity. SUMMARY: Clinicians should be cautious when ascribing chronic cough to interstitial lung disease without first completely evaluating for other possible causes of cough. When cough is attributed to interstitial lung disease, therapy, when available, should be directed at the specific underlying diagnosis. Corticosteroids may be helpful in alleviating chronic cough in some cases of interstitial lung disease, but, because of the potential side effects of corticosteroids and lack of proven efficacy for some types of interstitial lung disease (e.g. idiopathic pulmonary fibrosis), treatment should weigh the risks and benefits for each patient individually. Nonspecific antitussive therapies shown to be clinically effective for chronic cough in general are codeine and dextromethorphan, but these have not been studied specifically in interstitial lung disease.

Chronic Disease↗
PubMed2005

A comparison of gender differences in health-related quality of life in acute and chronic coughers.

STUDY OBJECTIVES: To determine whether the health-related quality of life (HRQOL) of women and men is adversely affected by acute cough (AC), affected differently by AC, or affected differently by AC and chronic cough (CC). DESIGN: Analysis of consecutively and prospectively collected AC data from two time periods, and previously prospectively and consecutively collected CC data that had not been previously analyzed. When no differences were found in the two cohorts of acute coughers, as was the case in the greatest majority of comparisons, the two samples were pooled, treated as one sample of acute coughers, and compared with chronic coughers. SETTINGS: Primary care and cough clinics in an academic, tertiary care medical center. PARTICIPANTS: Subjects prospectively seeking medical attention complaining of AC for < 3 weeks and CC for at least 8 weeks. MEASUREMENT: All subjects completed the cough-specific quality-of-life questionnaire (CQLQ) prior to contact with a physician and medical intervention. RESULTS: Of 62 acute coughers, 32 were women and 30 were men (p = 0.25). Total CQLQ scores for women were 59.9, and for men they were 59.2. (There was no difference in total CQLQ scores in the two cohorts of acute coughers.) The mean (+/- SD) combined total CQLQ score of women and men of 59.57 +/- 10.4 was higher (t90 = 11.39; p < 0.0001) than the score in an historical control group of women and men who were not complaining of cough (35.06 +/- 8.40). In acute coughers, there were no gender differences in the total or six subscale scores when the two cohorts were considered separately or combined. Of 172 chronic coughers, 116 were women and 56 were men (p < 0.0001). Women with CC rated themselves significantly higher than did women with AC on the total CQLQ and on five of the six subscales. Women with AC did not rate themselves higher on any of the CQLQ subscales. Total CQLQ scores for men with AC and CC were similar. Men with CC, compared with men with AC, scored significantly higher in two of six subscales (and significantly lower in one subscale) and scored similarly in three subscales. CONCLUSIONS: AC, like CC, adversely affected the HRQOL of women and men. Unlike CC, AC did not adversely affect the HRQOL of women more than men. The HRQOL of women is more adversely affected than the HRQOL of men, the longer a cough lasts.

Acute Disease↗