Diagnosis and management of idiopathic pulmonary fibrosis: Thoracic Society of Australia and New Zealand and Lung Foundation Australia position statements summary.

INTRODUCTION: Idiopathic pulmonary fibrosis (IPF) is a fibrosing interstitial lung disease associated with debilitating symptoms of dyspnoea and cough, resulting in respiratory failure, impaired quality of life and ultimately death. Diagnosing IPF can be challenging, as it often shares many features with other interstitial lung diseases. In this article, we summarise recent joint position statements on the diagnosis and management of IPF from the Thoracic Society of Australia and New Zealand and Lung Foundation Australia, specifically tailored for physicians across Australia and New Zealand. Main suggestions: A comprehensive multidisciplinary team meeting is suggested to establish a prompt and precise IPF diagnosis. Antifibrotic therapies should be considered to slow disease progression. However, enthusiasm should be tempered by the lack of evidence in many IPF subgroups, particularly the broader disease severity spectrum. Non-pharmacological interventions including pulmonary rehabilitation, supplemental oxygen, appropriate treatment of comorbidities and disease-related symptoms remain crucial to optimal management. Despite recent advances, IPF remains a fatal disease and suitable patients should be referred for lung transplantation assessment.

Descriptive analysis of junior doctor assessment in the first postgraduate year.

INTRODUCTION: Preparing graduates for the role of the junior doctor is the aim of all medical schools. There has been limited published description of junior doctor performance in the workplace within Australia. METHODS: This cohort study describes junior doctors' performance in the first postgraduate year, the influence of gender, rotation type and amount of experience and explores the feedback process used for junior doctors across a two year period. RESULTS: Participants obtained lower scores for performing procedures, managing emergencies and adverse event identification and highest scores for interpersonal skills, teamwork, written communication and professional behavior. There were no observed effects of the amount of experience but, were effects of the discipline in which the rotation occurred. Five juniors doctors, two female and three male, were classified as having overall borderline performance, 2.5% of the respondents. These findings were supported by content analysis of the written feedback. While feedback was documented in 94% of occasions, this was not given to the junior doctor 25% of the time. CONCLUSIONS: The findings in this study support the claim that the tools and processes being used to monitor and assess junior doctor performance could be better. The Australian medical board appears to be looking for an assessment process that will both discriminate the poorly performing doctor and provide educational guidance for the training organization. These two intents of the assessment may be in opposition to each other.

Clinical teaching and learning: from theory and research to application.

Learning in the clinical setting is the cornerstone of medical school education, but there are strong imperatives to optimise the ways in which students acquire clinical expertise. Deliberate practice is characterised by attention, concentration, effort and repetition of skills; it is an important tool for developing and maintaining professional expertise. Research has led to a greater understanding of how medical students develop core clinical skills, especially in the areas of diagnostic reasoning, communication and physical examination. Advances in information technology and instructional design are helping to strengthen the links between formal educational activities and opportunistic learning in the clinical setting.

Peer-assisted learning in teaching clinical examination to junior medical students.

BACKGROUND: In medical education, peer-assisted learning (PAL) refers to teaching occurring between fellow students. Few descriptions of its use to teach clinical examination have been published. Student Grand Rounds (SGR) is a student-led initiative whereby senior students volunteer to teach clinical examination to pre-clinical peers. Student tutors attend a modified Teaching on the Run (TOTR) course originally designed to train clinicians to teach students and junior doctors. AIM: We investigated the value of SGR in teaching pre-clinical students, and evaluated the effectiveness of TOTR. METHODS: Over 9 months, tutors and participants in each SGR tutorial completed an online survey. At the conclusion of annual TOTR workshops (2004-2010), participants evaluated their impressions of the course. RESULTS: A total of 64 SGR tutorials were attended by a total of 321 students. All agreed that tutorials were beneficial and enjoyable, with a threefold increase in the number of students self-identifying as able to perform the skills required. TOTR participants classified the course as both relevant and beneficial, and all course outcomes were achieved. SGR tutors reported improved knowledge and confidence in teaching following SGR and TOTR. CONCLUSION: PAL is effective in supplementing teaching of clinical examination. Senior students learn valuable skills and gain experience in teaching.

Development and evaluation of a consumer information resource, including Patient Decision Aid, for lung cancer screening: a quasi-experimental study.

Lung cancer screening of high-risk individuals with computed tomography is a promising intervention to reduce lung cancer mortality. Patient Decision Aids (PtDAs) may assist eligible individuals assess the risks and benefits associated with screening. Screening preference is high among lower-risk, screening-ineligible individuals and strategies are needed to reduce screening demand among this group. We developed and evaluated a resource comprising a recruitment pamphlet combined with either a PtDA for screening-eligible individuals or an education pamphlet for screening-ineligible individuals. Quasi-experimental pre-post pamphlet exposure design. Ever-smokers aged 55-80 years attending hospital outpatient clinics were invited. Among screening-eligible participants, the assessed outcome was change in score on the Decisional Conflict Scale (DCS). Among screening-ineligible participants, the assessed outcomes were change in screening preference. In the study 51% (55/107) of invited individuals participated, with mean ± standard deviation age 66.9 ± 6.4 years, 53% (29/55) male, and 65% (36/55) eligible for screening. Median (interquartile range) DCS among screening-eligible participants reduced from 28.9 (22.7-45.3) pre-PtDA to 25 (1.6-29.7) post-PtDA (p < .001), but there was no significant change in the proportion that reached the accepted threshold for decisional certainty (DCS < 25, 10/36 [28%] pre-exposure vs. 14/36 [39%] post-exposure, p = .1). Screening preference among screening-ineligible individuals reduced after viewing the screening-ineligible brochure (pre-exposure median of "Prefer" to post-exposure median of "Unsure," p = .001). Our consumer information pamphlets about lung cancer screening may reduce decisional conflict and improve alignment of screening preference with eligibility.

Autoantibodies in interstitial lung diseases.

The role of autoantibody testing for patients with interstitial lung disease is an evolving area. Recent guidelines recommend routine anti-nuclear antibodies, rheumatoid factor, and anti-citrullinated cyclic peptide antibody testing for patients undergoing diagnostic evaluation for interstitial lung disease, with further autoantibody testing reserved for selected cases guided by rheumatological features. Even this approach may miss patients with clinically significant autoantibodies when interstitial lung disease is the dominant or first manifestation of autoimmune disease. We retrospectively performed autoimmune serology in a clinically well characterised cohort of interstitial lung disease patients. Using stored serum, additional testing was performed to ensure all patients had complete autoantibody profiles including anti-nuclear antibodies, extractable nuclear antigen antibodies, double-stranded DNA antibodies, rheumatoid factor, anti-citrullinated cyclic peptide antibodies, anti-neutrophil cytoplasmic antibodies, and myositis antibodies. Eighty patients with interstitial lung disease, and available stored serum, were assessed. Mean age at interstitial lung disease diagnosis was 65.2 years and 42 patients were male. Positive autoimmune serology was found in 56 of 80 (70.0%) patients; the most common positive result was anti-nuclear antibodies (n=34; 42.5%). Myositis antibodies were detected in 13 of 80 (16.2%) patients. Four (5%) patients had elevated anti-citrullinated cyclic peptide antibodies, and two (2.5%) patients had detectable myeloperoxidase antibodies. Eleven (13.7%) patients with negative anti-nuclear antibodies had other significant disease associated autoantibodies. An extended panel of autoantibody testing may detect cases of connective tissue disease associated interstitial lung disease, regardless of clinical or radiological subtype, and prior to extra-pulmonary manifestations of systemic autoimmunity.

Short- and long-term hospital and community exercise programmes for patients with chronic obstructive pulmonary disease.

OBJECTIVE: Pulmonary rehabilitation in patients with COPD has been shown to be beneficial but the optimal setting is not known. In the present study, the efficacy of a short-term community-based exercise programme was compared with a standard hospital outpatient programme. Additionally, the usefulness of community or home programmes in maintaining improvements in the longer term was studied. METHODOLOGY: Forty-three patients with moderate to severe COPD were randomized to one of the following three groups: a 3-month hospital programme then a 9 month home programme (Hospital/Home); a 3-month hospital programme then a 9-month community programme (Hospital/Community); or a 12-month community programme (Community/Community). The initial 3-month programme was analysed by comparing the Hospital group (Hospital/Home plus Hospital/Community) with the Community group (Community/Community). Six-minute walking distance (6MWD), quality of life (Guyatt chronic respiratory disease questionnaire, CRQ) and lung function were measured at 0, 3, 6 and 12 months and results were analysed using the Wilcoxon rank sum test. RESULTS: At 3 months, there was a significant improvement from baseline in 6MWD in the Hospital group (81.3 +/- 18.3 m, P < 0.05, anova) but not the Community group (14.4 +/- 28.5 m, not significant). The difference between the groups was not significant (P = 0.058). At 3 months, there was a significant improvement in quality of life in the Hospital group (CRQ +16.3 +/- 3.1, P < 0.01, anova) and in the Community group (CRQ +10.2 +/- 4.9, P < 0.05, anova) but the difference between the groups was not significant. Following the initial 3-month programme, the dropout rate was high overall (73% by 12 months), and therefore data from the maintenance programme could not be analysed. CONCLUSIONS: A 3-month community-based exercise programme for patients with COPD did not improve 6MWD. The long-term retention rates in the programmes were poor.

A new unsupported upper limb exercise test for patients with chronic obstructive pulmonary disease.

UNLABELLED: PURPOSE This study aimed to develop a new unsupported upper limb exercise test (UULEX) for patients with chronic obstructive pulmonary disease (COPD). METHODS: The reproducibility of the UULEX was assessed in nine patients with COPD who performed the test on three occasions. A comparison of the UULEX and a supported incremental upper limb exercise test (SULEX) using an arm ergometer also was performed with 18 patients who had COPD. RESULTS: There were no significant differences in the maximum values for each cardiorespiratory variable and sensation of dyspnea between the three repetitions of the UULEX, and all the variables showed high reproducibility. During the supported test, maximum values for the cardiorespiratory variables were significantly higher, but the ratio of minute ventilation to carbon dioxide output was lower than during the unsupported exercise test. There were significant correlations for cardiorespiratory responses, arm muscle fatigue, and sensation of dyspnea between the two tests. CONCLUSIONS: The findings suggest that the new UULEX test is a reproducible and acceptable exercise test for patients with COPD that can be used as a simple method to evaluate upper limb function in these patients. Further studies are required to determine the external validity of the test and its sensitivity to interventions such as pulmonary rehabilitation.