Subcutaneous sarcoidosis (Darier-Roussy sarcoidosis) with extensive disease on positron emission tomography: A case report and review of the literature.

Cutaneous manifestations of sarcoidosis are common, but subcutaneous nodules are rare, originally described in 1904 by Darier and Roussy and thought to represent isolated skin disease. We present a 61-year-old male who presented with 3 months of subcutaneous nodules on the forearms and knees. Biopsy confirmed sarcoidosis. An [F-18] fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) showed confluent uptake in the skin of forearms and knees, along with thighs and buttocks, mediastinal, hilar and upper abdominal lymph nodes, and multiple bones. He was well and treated with hydroxychloroquine 400 mg/day. The nodules resolved and a repeat FDG PET/CT at 5 months showed a significant decrease in the uptake at all involved sites. Although a PET scan can demonstrate extensive disease in a patient presenting with subcutaneous nodules, the literature suggests prognosis is good and treatment should start simply with the least toxic approach, such as with hydroxychloroquine therapy.

Understanding cough in interstitial lung disease: a cross-sectional study on the adequacy of treatment.

BACKGROUND: Cough is a common symptom in interstitial lung disease (ILD), often leading to treatment dissatisfaction for patients and physicians. AIM: To identify the prevalence and subjective adequacy of control of cough in patients with ILD. METHODS: A cross-sectional study of patients with ILD attending a tertiary ILD clinic in Perth was undertaken using a pre-designed questionnaire that patients were invited to complete when attending clinic. Cough severity and impact on quality of life were assessed using a visual analogue scale and the validated Leicester cough questionnaire. Participants were asked to list triggers of their cough and strategies or medications trialled to control cough. RESULTS: Of 164 respondents, 118 (72%) had cough, with prevalence common in all ILD subtypes. A lower forced vital capacity (FVC) was found in the cough group versus non-cough group (74.6 ± 18.7 vs 87.0 ± 15.9, P-value < 0.0001). Common reported triggers were lung irritants, exertion and doing routine daily activities. Avoidance of triggers was a common strategy to control cough. A high prevalence of non-ILD causes of cough was recorded in both groups. A variety of medications had been trialled, including anti-fibrotics, immunosuppression drugs, inhalers and proton pump inhibitors, with moderate benefit reported by 18% of participants. CONCLUSIONS: Cough is prevalent in ILD but is not adequately suppressed. Cough has a significant impact on quality of life, leading patients to adopt their own strategies to control their cough. More research is needed to understand cough mechanisms in ILD and the interplay of other potential co-pathologies.

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.

Idiopathic and immune-related pulmonary fibrosis: diagnostic and therapeutic challenges.

Interstitial lung disease (ILD) encompasses a large group of pulmonary conditions sharing common clinical, radiological and histopathological features as a consequence of fibrosis of the lung interstitium. The majority of ILDs are idiopathic in nature with possible genetic predisposition, but is also well recognised as a complication of connective tissue disease or with certain environmental, occupational or drug exposures. In recent years, a concerted international effort has been made to standardise the diagnostic criteria in ILD subtypes, formalise multidisciplinary pathways and standardise treatment recommendations. In this review, we discuss some of the current challenges around ILD diagnostics, the role of serological testing, especially, in light of the new classification of Interstitial Pneumonia with Autoimmune Features (IPAF) and discuss the evidence for therapies targeted at idiopathic and immune-related pulmonary fibrosis.

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.

Interprofessional learning in ambulatory care.

BACKGROUND: Interprofessional practice amongst health care professionals can facilitate effective collaboration and can improve health outcomes for patients. Interprofessional clinical placements have mainly been established within inpatient settings; however, ambulatory care settings can also provide interprofessional education. This study evaluates an interprofessional placement in ambulatory care for medical and nursing students. METHODS: Medical and nursing students undertook a 2-week interprofessional placement in respiratory, diabetes and chronic pain clinics, as well as within the patient's home. An electronic post-placement survey including 14 fixed-response and five open-ended questions was conducted to evaluate the students' experiences. RESULTS: Ninety-two students undertook the interprofessional placement: 74% were medical students and 26% were nursing students. The overall response rate was 81%. Students strongly supported the model of clinical supervision with the nurse educator and teaching registrar working collaboratively to facilitate the placement. Both medical and nursing students felt that the placement facilitated the development of interprofessional principles, with 78.7% agreeing or strongly agreeing with the statement 'the clinical placement allowed me to reflect on interprofessional learning and practice'. In terms of future practice, 67% of medical students and 81% of nursing students agreed that 'this placement has altered how [they] will practice as a professional in the future'. Interprofessional practice can facilitate effective collaboration and can improve health outcomes for patients DISCUSSION: Medical and nursing students found that the ambulatory care setting facilitated a mix of learning opportunities that complemented learning from the inpatient setting, and the interactions with other health professionals provided a valuable learning experience that contributed to their understanding of interprofessional practice.

Shifts in nursing and medical students' attitudes, beliefs and behaviours about interprofessional work: An interprofessional placement in ambulatory care.

AIM AND OBJECTIVES: To examine students' beliefs, behaviours and attitudes in relation to interprofessional socialisation, and their expectations and experience, before and after a 2-week clinical placement in ambulatory care. BACKGROUND: Interprofessional clinical placements for students are important for developing an understanding of interprofessional collaboration and identity, for the benefit of patient care. Ambulatory care environment involves collaborative management of complex chronic problems. This educator supported placement that enabled final-year nursing and medical students to work together. DESIGN: A descriptive matched before-after study was conducted. METHODS: Students' completed an online questionnaire before and after their clinical placement. The questionnaire comprised of three sections: demographic information, the Interprofessional Socialisation and Valuing Scale and open-ended questions. Descriptive analysis and paired t-tests were conducted for the three subscales, and thematic analysis of qualitative responses was conducted. RESULTS: Sixty-two of the 151 students between 2011-2014 completed both surveys. There was a significant increase after placement in the overall Interprofessional Socialisation and Valuing Scale scores. The change was greater for nursing students compared with medical students, although for both groups the change was small. The majority had a good-to-very good experience learning each other's and their own professions and identified the nurse educator and teaching registrar as key to success. CONCLUSION: A clinical placement in an ambulatory setting for nursing and medical students resulted in an increase in self-perceived ability to work with others and in valuing working with others. RELEVANCE TO CLINICAL PRACTICE: Interprofessional clinical placements are essential for students to understand interprofessional practice for better patient outcomes and developing their own perspective of future work within an interprofessional team. Ambulatory care is an ideal environment for nursing and other health professional students to engage in interprofessional clinical placements.

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.

Predicting performance of junior doctors: Association of workplace based assessment with demographic characteristics, emotional intelligence, selection scores, and undergraduate academic performance.

INTRODUCTION: Predicting workplace performance of junior doctors from before entry or during medical school is difficult and has limited available evidence. This study explored the association between selected predictor variables and workplace based performance in junior doctors during their first postgraduate year. METHODS: Two cohorts of medical students (n = 200) from one university in Western Australia participated in the longitudinal study. Pearson correlation coefficients and multivariate analyses utilizing linear regression were used to assess the relationships between performance on the Junior Doctor Assessment Tool (JDAT) and its sub-components with demographic characteristics, selection scores for medical school entry, emotional intelligence, and undergraduate academic performance. RESULTS: Grade Point Average (GPA) at the completion of undergraduate studies had the most significant association with better performance on the overall JDAT and each subscale. Increased age was a negative predictor for junior doctor performance on the Clinical management subscale and understanding emotion was a predictor for the JDAT Communication subscale. Secondary school performance measured by Tertiary Entry Rank on entry to medical school score predicted GPA but not junior doctor performance. DISCUSSION: The GPA as a composite measure of ability and performance in medical school is associated with junior doctor assessment scores. Using this variable to identify students at risk of difficulty could assist planning for appropriate supervision, support, and training for medical graduates transitioning to the workplace.

Interprofessional clinical supervisor training.

BACKGROUND: The burden on clinicians in busy health care settings to provide teaching and supervision for students has grown as training numbers have increased, and to address this there are more short courses available to build competency, with many including multidisciplinary offerings; however, the efficacy of providing interprofessional training for clinical supervisors has not been adequately explored. METHODS: Eight hundred and seventy participants self-reported their confidence, motivation and effectiveness as a clinical supervisor prior to and after their participation in interprofessional clinical supervisor training. Means and standard deviations were calculated and mean difference values were compared using t-tests or anova. The burden on clinicians ... to provide teaching and supervision for students has grown RESULTS: The programme had the greatest impact on self-reported confidence (mean difference = 0.77), particularly among female participants, followed by self-reported effectiveness (mean difference = 0.67). Participants aged 60+ years (n = 28) reported less change in self-reported effectiveness (p < 0.039) and self-reported confidence (p < 0.000) compared with other age groups. Those individuals working primarily as educators reported less impact than those in clinician or manager/coordinator roles. The change in self-reported effectiveness was most significant (p = 0.014) for those who attended between four and six workshops. DISCUSSION: Interprofessional clinical supervisor training provides opportunities for cross-profession dialogue that may highlight commonalities and differences, as well as offering the potential for shared problem solving. In addition, it may provide cost-effective, convenient training, which is important given that few clinicians are formally trained as educators and have busy schedules.

The interstitial lung disease multidisciplinary meeting: A position statement from the Thoracic Society of Australia and New Zealand and the Lung Foundation Australia.

Interstitial lung diseases (ILD) are a diverse group of pulmonary diseases for which accurate diagnosis is critical for optimal treatment outcomes. Diagnosis of ILD can be challenging and a multidisciplinary approach is recommended in international guidelines. The purpose of this position paper is to review the evidence for the use of the multidisciplinary meeting (MDM) in ILD and suggest an approach to its governance and constitution, in an attempt to provide a standard methodology that could be applied across Australia and New Zealand. This position paper is endorsed by the Thoracic Society of Australia and New Zealand (TSANZ) and the Lung Foundation Australia (LFA).

Metastatic pancreatic carcinoma masquerading as cystic lung disease: a rare presentation.

This 52-year-old male ex-smoker presented with a six-month history of progressive breathlessness and weight loss. He deteriorated acutely, and was admitted with severe type 1 respiratory failure. Apart from diffuse coarse crackles on chest auscultation, physical examination was unremarkable. High-resolution computed tomography (HRCT) showed diffuse cystic changes throughout the lungs. A diagnosis of pulmonary Langerhans cell histiocytosis (PLCH) was considered. Further workup identified a coincidental pancreatic lesion of uncertain significance, which remained indeterminate on magnetic resonance imaging (MRI) and on positron emission tomography (PET). Transbronchial biopsy revealed enteric differentiated adenocarcinoma exhibiting lepidic spread, and autopsy later confirmed primary pancreatic malignancy. This case demonstrates that metastatic pancreatic malignancy can present with severe respiratory failure and masquerade as cystic lung disease.

An examination of students' perceptions of their interprofessional placements in residential aged care.

It is essential that health professionals are trained to provide optimal care for our ageing population. Key to this is a positive attitude to older adults along with the ability to work in teams and provide interprofessional care. There is limited evidence on the impact an interprofessional education (IPE) placement in a residential aged care facility (RACF) has on students. In 2015 in Western Australia, 51 students (30% male, median age 23 years), from seven professions, undertook a placement between 2 and 13 weeks in length at 1 RACF. Pre- and post-placement measurements of attitudes to the elderly were collected using the Ageing Semantic Differential (ASD) questionnaire and level of readiness for interprofessional learning with the Readiness for Interprofessional Learning Scale (RIPLS). A total of 47 students completed matched ASD and RIPLS surveys. The mean total score on the ASD survey decreased significantly from pre- to post-placement from 116.0 to 108.9 (p = 0.033), indicating attitudes became increasingly positive towards older adults. Significant differences post-placement were seen indicating better readiness for interprofessional learning, for two out of four subscales on the RIPLS, namely "teamwork & collaboration" (42.1-44.0; (p = 0.000)) and "positive professional identity" (18.2-19.3 (p = 0.001)). The degree of change is similar to findings from other settings. The results support IPE-focussed student placements within RACF positively influence student's attitudes towards the older adult as well as increase student's readiness for interprofessional learning, confirming RACF are valuable places for training health professionals.

Interstitial pneumonitis secondary to leuprorelin acetate for prostate cancer.

Androgen blockade is standard treatment for advanced prostate cancer. We report an uncommon case of interstitial pneumonitis induced by leuprorelin acetate.

Current Australasian practice for diagnosis and management of idiopathic pulmonary fibrosis: Where are we now?

BACKGROUND AND OBJECTIVE: Recent international consensus statements have refined evidence-based guidelines for the diagnosis and management of idiopathic pulmonary fibrosis (IPF). This study sought to investigate how closely these guidelines are adhered to and to compare current practices with those of a similar cohort 15 years ago. METHODS: A questionnaire on IPF diagnosis and management was distributed to respiratory physicians practising in Australia and New Zealand, in 2012-2013, and results were compared with a similar survey conducted in 1999. RESULTS: A total of 172 and 144 questionnaires were completed in 1999 and 2012-2013, respectively. The most important investigations in both survey populations were high-resolution computed tomography scans, spirometry, diffusing capacity for carbon monoxide, chest X-ray, static lung volumes and autoimmune serology. In 1999, physicians were more likely to perform arterial blood gases, bronchoalveolar lavage and transbronchial lung biopsy. In the 2012-2013 cohort, 6-min walk tests and pulse oximetry were more widely utilized. Treatment choices differed considerably between the two survey populations. In 1999, the majority would offer a steroid-based regimen, whereas most would not use any specific treatment or would refer for trial participation in 2012-2013. CONCLUSIONS: Approach to IPF diagnosis and management is not uniform and has changed over 15 years. Surveyed respiratory physicians were generally practising in accordance with clinical guidelines, although significant variation in practice was identified in both cohorts. This study identifies the need to standardize care of IPF patients across Australia and New Zealand.

Relationships between academic performance of medical students and their workplace performance as junior doctors.

BACKGROUND: Little recent published evidence explores the relationship between academic performance in medical school and performance as a junior doctor. Although many forms of assessment are used to demonstrate a medical student's knowledge or competence, these measures may not reliably predict performance in clinical practice following graduation. METHODS: This descriptive cohort study explores the relationship between academic performance of medical students and workplace performance as junior doctors, including the influence of age, gender, ethnicity, clinical attachment, assessment type and summary score measures (grade point average) on performance in the workplace as measured by the Junior Doctor Assessment Tool. RESULTS: There were two hundred participants. There were significant correlations between performance as a Junior Doctor (combined overall score) and the grade point average (r = 0.229, P = 0.002), the score from the Year 6 Emergency Medicine attachment (r = 0.361, P < 0.001) and the Written Examination in Year 6 (r = 0.178, P = 0.014). There was no significant effect of any individual method of assessment in medical school, gender or ethnicity on the overall combined score of performance of the junior doctor. CONCLUSION: Performance on integrated assessments from medical school is correlated to performance as a practicing physician as measured by the Junior Doctor Assessment Tool. These findings support the value of combining undergraduate assessment scores to assess competence and predict future performance.

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.

Rheumatoid arthritis and lung disease: from mechanisms to a practical approach.

Rheumatoid arthritis (RA) is a common chronic systemic autoimmune disease characterized by joint inflammation and, in a proportion of patients, extra-articular manifestations (EAM). Lung disease, either as an EAM of the disease, related to the drug therapy for RA, or related to comorbid conditions, is the second commonest cause of mortality. All areas of the lung including the pleura, airways, parenchyma, and vasculature may be involved, with interstitial and pleural disease and infection being the most common problems. High-resolution computed tomography of the chest forms the basis of investigation and when combined with clinical information and measures of physiology, a multidisciplinary team can frequently establish the diagnosis without the need for an invasive biopsy procedure. The most frequent patterns of interstitial lung disease (ILD) are usual interstitial pneumonia (UIP) and nonspecific interstitial pneumonia (NSIP), with some evidence for the prognosis being better than for the idiopathic equivalents. Risk factors depend on the type of disease but for ILD (mainly UIP and NSIP) include smoking, male gender, human leukocyte antigen haplotype, rheumatoid factor, and anticitrullinated protein antibodies (ACPAs). Citrullination of proteins in the lung, frequently thought to be incited by smoking, and the subsequent development of ACPA appear to play an important role in the development of lung and possibly joint disease. The biologic and nonbiological disease modifying antirheumatic drugs (DMARDs) have had a substantial impact on morbidity and mortality from RA, and although there multiple reports of drug-related lung toxicity and possible exacerbation of underlying ILD, overall these reactions are rare and should only preclude the use of DMARDs in a minority of patients. Common scenarios facing pulmonologists and rheumatologists are addressed using the current best evidence; these include screening the new patient; monitoring and choosing RA treatment in the presence of subclinical disease; treating deteriorating ILD; and establishing a diagnosis in a patient with an acute respiratory presentation.