Interstitial lung disease on the acute take for the non-respiratory physician.

Interstitial lung diseases (ILDs) are a heterogeneous group of diseases characterised by varying degrees of fibrotic and/or inflammatory abnormalities of the lung parenchyma. Management of ILD is often challenging for non-respiratory physicians. We discuss the respiratory assessment and management of patients with ILD presenting with acute breathlessness on the acute take, including acute exacerbations of ILD.

Update in the diagnosis and management of acute pulmonary embolism for the non-respiratory physician.

An increasingly common scenario on the acute medical take is that of 'possible pulmonary embolism'. The aim of this article is to update the reader about the available clinical decision tools that can help to avoid the over investigation of such patients, as well as other tools that can support an outpatient management strategy in appropriate patient groups. The importance of risk stratification methodologies in acute pulmonary embolism management is emphasised. We address the evidence on the long-term risk of venous thromboembolism recurrence and show how this can be used to make decisions about duration of anticoagulation. Finally, we discuss a number of special scenarios, including the implications of incidentally discovered isolated subsegmental pulmonary embolus and the management of pulmonary embolus in malignancy and pregnancy.

Restarting training and examinations in the era of COVID-19: a perspective from the Federation of Royal Colleges of Physicians UK.

COVID-19 has proven to be a potent disruptor of postgraduate training, assessment and learning. In so doing, it has equally proved to be a potent catalyst and has driven innovation. Here we discuss the response of the Federation of the three UK Royal Colleges of Physicians to the challenges presented in these areas by the COVID-19 pandemic.

Respiratory advice for the non-respiratory physician in the time of COVID-19.

COVID-19, the disease caused by the SARS-CoV-2 beta-coronavirus, has changed clinical practice in a matter of weeks. Among the physician specialties, respiratory physicians have been at the forefront of the response to this new challenge. Here we provide advice for non-respiratory physicians on the ward-based care of patients with this disease. This includes recommendations on hydration, thromboprophylaxis, nutritional support and on the importance of the early detection of deterioration, setting ceilings of care and use of anticipatory drugs where appropriate. We also discuss oxygen support modalities, proning, safe working practices and a new approach to multi-professional working. We include references to a number of important research studies.

Interstitial lung disease: effects of thin-section CT on clinical decision making.

PURPOSE: To retrospectively quantify the change in the diagnosis and management of suspected interstitial lung disease when thin-section computed tomography (CT) is added to pretest probabilities. MATERIALS AND METHODS: The institutional review board does not require approval or patient informed consent for retrospective study of case records and CT studies. Six pulmonologists reviewed data sheets containing clinical information and results of pulmonary function tests and chest radiographs of 168 consecutive patients (86 women and 82 men; mean age, 59.8 years; age range, 22-86 years) suspected of having interstitial lung disease. Differential diagnoses and responses to specific questions regarding patient care were recorded before and after assimilation of thin-section CT findings. Both unweighted and weighted kappa analyses were used to determine agreement between pulmonologists before and after CT. RESULTS: First-choice diagnosis changed in 520 (51%) of 1008 cases, and agreement on first-choice diagnosis increased from 0.47 to 0.72 after thin-section CT. In addition, confidence in the first-choice diagnosis increased, and there was a reduction in the number of differential diagnoses offered by all pulmonologists (P < .005 and P < .001, respectively). Agreement on diagnostic probabilities for individual disorders increased substantially, particularly for diagnoses of idiopathic pulmonary fibrosis (weighted kappa = 0.58-0.89). With CT findings, pulmonologists changed their pre-CT responses regarding the use of bronchoalveolar lavage, transbronchial biopsy, and thoracoscopic biopsy in 242 (24.0%), 282 (28.0%), and 292 (29.0%) of 1008 cases, respectively. However, agreement for the use of these investigations was low both before and after CT. The request rate for thoracoscopic biopsy in patients in whom idiopathic fibrosis was diagnosed decreased from 48 of 179 (26.8%) to 26 of 233 (11.2%) after CT. CONCLUSION: Thin-section CT resulted in a change in first-choice diagnosis in half the cases. Diagnostic confidence improved, and CT findings increased agreement between pulmonologists on diagnostic probabilities across a range of interstitial lung diseases.

Antinuclear antibody positive pleural effusion in a patient with tuberculosis.

A patient with tuberculosis presented with a pleural effusion that was highly positive for antinuclear antibody (ANA). The pleural fluid autoimmune profile was positive for ANA IgG at a titre of 1 : 1280. Antibodies to double-stranded DNA were not detected in the pleural fluid or in serum. The serum autoimmune profile was positive for ANA IgG at 1 : 160 and IgM at 1 : 40. Pleural fluid was positive on culture for Mycobacterium tuberculosis after 8 weeks. Pleural biopsy for histology showed chronic inflammation and culture revealed no growth. The pleural fluid resolved with the anti-tuberculous treatment, and signs and symptoms of systemic lupus erythematosus or malignancy did not occur, which suggests that tuberculous pleural effusion is one of the causes of high ANA in pleural fluid.