Document knXgL8B95VdL88dawyYxnZMJ

cu/t&r i/?/ mi r auscultatory skill. The physician who does not concen A joint committee of the ACCP/ATS, chaired by Dn trate because he is distracted or hurryingwill miss faint Raymond H. L. Murphy, was charged with the respon sounds. sibility of providing a consensus view on diagnostic Our cardiologic teachers are challenged to improve issues in the group ofnonmalignant diseases for which auscultatory education in the face of the exciting new compensation is being sought by thousands of former diagnostic technology that may overshadow more workers who allege injury due to their asbestos expo mundane bedside findings. Surely a sign as simple and sure. The resulting statement has recently been pub informative as the S, ofheart failure is worth preserving lished.* Because there is often alarming abuse ofsound and emphasizing. It is particularly appropriate that medical principles and distortion of scientific knowl internists, pediatricians and family physicians--the edge, frequently perceived orjustified as being benefi "gatekeepers"--retain the ability to detect such basic cial to claimants, several points covered in this report findings as bedside evidence ofheart failure. will be highlighted. The comments are mine and do Let us hope that the next group assessment of not necessarily reflect the views of the committee. auscultatory skill will find that most observers can hear Asbestosis is a term which indicates diffuse lung Sj. fibrosis due to asbestos exposure. Its use is not correct John F. Stapleton, M.D. in reference to pleural abnormalities. The diagnosis of . . _ ___ -------u.-... Washington, DC asbestosis is most often established by one or more Medical Director Georgetown University Hospital. clinical or laboratory findings, in conjunction with a history of nontrivial exposure. In fact, this diagnosis will almost always depend primarily on a radiographic appearance compatible with diffuse interstitial infiltra tions, in addition to any other abnormalities which may Diagnosis of Asbestos-related Disease be present on the chest radiograph. While it is rarely necessary, or possible, to examine lung tissue in order to make a diagnosis of asbestosis, when a pathologic diagnosis is made it must be based on the demonstra tion ofboth asbestos bodies and fibrosis. Neitheralone is sufficient As in the pathologic diagnosis of other sound scientific and medical knowledge. The catego diffuse lung diseases, attention must be paid to ade ries of these policy issues are: 1) estimation of risks, quate size and representativeness ofthe tissue sample. which may not be measurable at current levels of As indicated, the chest x-ray film plays a central role exposure but which could lead to disease if exposures iu the diagnosis of asbestosis. Improved radiographic are not sufficiently controlled, and 2) adequate and technique and quality assurance make possible the equitable compensation of workers who have been sensitive detection, by experienced readers, of as injuredby past exposures to asbestos in the workplace. bestosis of even minimal extent The international The first requires a data base derived from epi classification for the pneumoconioses1 includes grad demiologic studies of populations exposed to asbestos ing ofthe irregular and linear opacities characteristic of for whom valid quantitative health and exposure infor asbestosis. The classification was designed to be used mation is available-BesulUag exposure-response rela for epidemiologic research and has been helpful in tionships can lead to the setting ofprotective occupa encouraging the training ofqualified readers. Indeed, tional standards and the appropriate allocation of many physicians have taken tests, using standard films, resources to maximize health benefit when competing ui order to become "certified readers," often for the risks are presented to policy-makers for amelioration. purpose of establishing credibility when making a The second issue can only be sensibly addressed radiographic diagnosis of asbestosis (or other pneu when, as in other areas ofmedicine, diagnosis is based moconiosis) in the litigation/compensation arena. on generally accepted criteria which are supported by There have been undesirable consequences ofthe use the known pathophysiology of the disease. With the of the ILO Classification for this purpose. asbestos-induced illnesses, there is no absolute speci The classification is intended to be descriptive, ficity, as it relates to causation, only degrees of non- albeit quantitative. The 12 categories of profusion of specifidty. Mesothelial tumors in asbestos-exposed small opacities cover the range from normal to marked. individuals are very likely to be caused by this expo It is at the lower categories (0/1 to L/l) that the greatest sure, in contrast to lung cancer which, even in exposed degree of interobserver variability (disagreement) oc persons, is more likely the result ofsmoking. A similar curs. No one category will constitute the lower limit of range in the degree ofcausal specificity is found in the abnormalities which is "diagnostic" ofasbestosis for all onmalignant conditions known to result bom asbestos qualified readers. For one reader this levelwill more or exposure. - - - less be equivalent to an ILO reading of 1/1 for irregular 802 - - - Editorial* I' small opacities, for another 110. In the p^.t, categories Improving the standard . diagnosis in the asbestos- high uS 2/2 have been suggested. ' related diseases is important not only because limited . It is unfortunate that some readers have interpreted public and private resources should go to those with the ACCP/ATS statement to suggest that a reading ofat true occupationally-induced injury. As physicians, we least 1/1 for small opacities is required to support a have a responsibility to be truthful and humane in our ~ diagnosis of asbestosis. It is more appropriate to dealings with patients, including those being evalu consider that level as illustrative of a film compatible ated for an occupational disease. Both over;- and under- -- with asbestosis. So might also a category 1/0 film; it diagnosis can be detrimental. Overdiagnosis wifi evoke depends on the reader Should there be any who think needless fear and perceived incapacity in normal that "mandating" a category sufficient to make a individuals---too great a price for possible (usually diagnosis of asbestosis will lead to standardization, it minimal) economic gain. Underdiagnosis can delay should t>e remembered that any such category can be appropriate compensation, increasing die burden of inappropriately chosen by a given reader, just as now disease on an ill worker and his family. Either pre interstitial fibrosis is often "read" on a negative film. mature or delayed diagnosis can, depending on state Choosing a "diagnostic" category will not, regrettably, law, result in loss of any chance for compensation. ' . suffice to confer credibility on the system. Diagnostic standards are needed and achievable, A physiologic pattern of reduced lung volumes and even in occupational disease. Credentialing in the disturbed-gw transfer "ar~the*fhidiiig ofinspiratory- - --specialties" of medieme^depends on-evaluaiiag can-_ crackles are supportive of the diagnosis but are too didates on their cognitive knowledge regarding, nonspecific to be helpful in isolation. Clubbing (also among other things, diagnostic criteria. Some in the nonspecific)is too rare to be useful; dyspnea is almost legal community are determined to resist medical . _ always present in claimants and can therefore not be a standards for diagnosing these diseases, citing .the discriminating feature. undermining of the tort system (ever)' claimant should . The Sbrotic process of asbestosis begins in peri have his day in court). They frequently have allies bronchiolar areas of the lung. Peripheral airways among their medical consultants and witnesses._The ` dysfunction has been demonstrated in population large number ofclaims and lawsuits for asbestosis, and ' studjes and the pathologic analog described. However; other asbestos-related diseases, makes the need for clinical and epidemiologic evidence is now more than credible diagnosis even more urgent ......... r-. sufficient to firmly conclude that clinically significant _ Hans Weill, M.D., EC.C.E chronic airways obstruction is not an expected conse quence ofasbestos exposure in the absence offar more A'ets Orleans . - ------- ------- - .... - - -------...-- v .. important causal factors, most notably, smoking. Pleural thickening, focal (plaques) or diffuse, results from asbestos exposure. Plaques do not affect lung Schlieder Foundation Professor of Pulmonary Medicine, Tulane Medical Centec ` lUprint requests: Dr. WeiU, Tulane Medical Center 1700 Serdida' - Street, New Orleans 70112 __ function, and diffuse pleural thickening reduces lung volumes only when it is very extensive. It is still not References ".. clear if the presence of benign pleural abnormalities 1 Statement of the American Thoracic Society. The of ' constitutes a risk factor (beyond exposure) for the development of asbestos-related tumors. Whether pleural effects are compensable is, ofcourse, a societal^ decision. It should, however, be based on accurate information. nonmalignant dileases related to asbestos. Am Rev Kespir Dis 1986; 134:363-68 2 International Labour Office. Cuidcliac* Cx the use of HjO -- international cluiiGoation ofradiograph* cfpneumocoaioii**, rrv ed 1980. Occupational Safety and Health series No 22. Geneva: International Labour Office, 1980 - \ CHEST / 91 / 8 / JUNE. 1987 803