Respiratory surveillance for coal mine dust and artificial stone exposed workers in Australia and New Zealand: A position statement from the Thoracic Society of Australia and New Zealand.

Coal mine lung dust disease (CMDLD) and artificial stone (AS) silicosis are preventable diseases which have occurred in serious outbreaks in Australia recently. This has prompted a TSANZ review of Australia's approach to respiratory periodic health surveillance. While regulating respirable dust exposure remains the foundation of primary and secondary prevention, identification of workers with early disease assists with control of further exposure, and with the aims of preserving lung function and decreasing respiratory morbidity in those affected. Prompt detection of an abnormality also allows for ongoing respiratory specialist clinical management. This review outlines a medical framework for improvements in respiratory surveillance to detect CMDLD and AS silicosis in Australia. This includes appropriate referral, improved data collection and interpretation, enhanced surveillance, the establishment of a nationwide Occupational Lung Disease Registry and an independent advisory group. These measures are designed to improve health outcomes for workers in the coal mining, AS and other dust-exposed and mining industries.

Pulmonary embolism: clinical presentation and diagnosis in the oldest old.

The incidence of pulmonary embolism (PE) in the oldest old (persons aged ≥85) is increasing, but there are limited data on its clinical features and diagnosis. We performed a retrospective cohort study of 302 consecutive patients with confirmed PE and compared the oldest old to the young (aged <65) and the younger old (aged 65-84). The most common symptoms in the oldest old were dyspnoea (74.3%) and tachypnoea (71.4%), but the prevalence of chest pain decreased with advancing age. Delayed diagnosis was most common in the oldest old and was associated with increasing age, absence of dyspnoea, presence of cardiorespiratory disease and a higher Charlson Comorbidity index. Better age-specific diagnostic pathways are required in this population.

Iatrogenic empyema secondary to the malposition of a nasogastric tube.

Blind NGT insertion can lead to tube misplacement into the respiratory tract. This can lead to multiple pulmonary complications including lung injury, pneumothorax, pneumonia, empyema and diaphragmatic injury. We present the case of an 80 year-old female who required an NGT insertion for severe oropharyngeal dysphagia from an acute stroke. Her admission was complicated by multiple pneumothoraces from repeated insertions, as well as the unusual complication of a recurrent nasogastric feeding-related empyema requiring multiple intercostal chest drain insertions for drainage. This case highlights the importance of careful NGT insertion and placement with imaging confirmation before use.

Diffuse alveolar haemorrhage as a rare complication of antiphospholipid syndrome.

Diffuse alveolar haemorrhage (DAH) is a rare complication of antiphospholipid syndrome. With a mortality rate of 46%, early diagnosis and management remain an ongoing challenge. Case reports are limited, and management guidelines are not yet definitive. In this case report, we present a 43-year-old male with DAH who required high-dose oral steroids, intravenous methylprednisolone cyclophosphamide and rituximab over 18 months to control life-threatening episodes of pulmonary bleeding.

Central airway obstruction caused by adenoid cystic carcinoma in pregnancy: a case report and review of the literature.

Malignancy complicates one in a thousand pregnancies. The most frequently diagnosed of these are breast, cervical, melanoma, ovarian, and haematological neoplasms. Tumours of respiratory origin are very uncommon during pregnancy. We present a case of tracheal adenoid cystic carcinoma (ACC), a rare type of primary airway tumour, diagnosed in a pregnant woman. To our knowledge, this is the third reported case of tracheal ACC complicating pregnancy. We discuss potential barriers to timely diagnosis of malignancies during pregnancy and consider optimal management strategies, taking into account the potential harm to the mother and foetus in a field with a limited evidence base.

Management of pulmonary embolism in the home.

AIM: To describe the characteristics, outcomes and treatment complications of patients with pulmonary embolism (PE) who were treated at home and as outpatients in an ambulatory care program. METHODS: Retrospective descriptive study of patients with PE who were treated in the ambulatory care unit during 2003. Ambulatory care unit data and medical record information were reviewed. Data collected included demographic and clinical data, standard clinical indicators of unplanned admission during treatment program, incidence of major bleeding, recurrent venous thromboembolism (VTE), and death within 3 months of admission into the ambulatory care program. RESULTS: 130 patients with PE were treated: 46% were treated totally as outpatients and 54% as early discharge patients. Mean age was 66.4 years; 61% were women. The program was successfully completed for 89% of patients; one patient was lost to follow-up. There were three episodes of major bleeding (2%; 95% CI, 0.5%-7%), all in patients aged > 70 years. Four patients died (3%; 95% CI, 0.8%-8%) within 3 months of admission into the program, but none in the first week, no death being directly attributable to PE. There were seven episodes of recurrent VTE (5%; 95% CI, 2%-11%). CONCLUSION: Appropriately selected patients with sub-massive PE can be treated as outpatients and in the home. Although the outcome is good in most patients, a significant proportion will require admission, emphasising the need for a well defined protocol and close medical supervision. Further study will more closely define at-risk patients and refine the care pathways.