Diagnostic accuracy of a clinical diagnosis of idiopathic pulmonary fibrosis: An international case-cohort study

We conducted an international study of idiopathic pulmonary fibrosis (IPF) diagnosis among a large group of physicians and compared their diagnostic performance to a panel of IPF experts.A total of 1141 respiratory physicians and 34 IPF experts participated. Participants evaluated 60 cases of interstitial lung disease (ILD) without interdisciplinary consultation. Diagnostic agreement was measured using the weighted kappa coefficient (κw). Prognostic discrimination between IPF and other ILDs was used to validate diagnostic accuracy for first-choice diagnoses of IPF and were compared using the C-index.A total of 404 physicians completed the study. Agreement for IPF diagnosis was higher among expert physicians (κw=0.65, IQR 0.53–0.72, p less than 0.0001) or physicians with access to multidisciplinary team (MDT) meetings (κw=0.54, IQR 0.45–0.64, p less than 0.0001). The prognostic accuracy of academic physicians with greater than 20 years of experience (C-index=0.72, IQR 0.0–0.73, p=0.229) and non-university hospital physicians with more than 20 years of experience, attending weekly MDT meetings (C-index=0.72, IQR 0.70–0.72, p=0.052), did not differ significantly (p=0.229 and p=0.052 respectively) from the expert panel (C-index=0.74 IQR 0.72–0.75).Experienced respiratory physicians at university-based institutions diagnose IPF with similar prognostic accuracy to IPF experts. Regular MDT meeting attendance improves the prognostic accuracy of experienced non-university practitioners to levels achieved by IPF experts

Bronchiectasis and autoimmune disease

The association between bronchiectasis and autoimmune disease is well recognised, and best described with rheumatoid arthritis. The prevalence of bronchiectasis in rheumatoid arthritis varies considerably in studies, with obliterative bronchiolitis a common feature. The prognosis of rheumatoid arthritis with bronchiectasis seems to be worse than either condition alone. The advent of high-resolution computed tomography has increased the sensitivity of detecting bronch- iectasis, but this should be assessed for clinical significance. Traction bronchiectasis results from interstitial fibrosis pulling the airway wider, rather than damage weakening the bronchial wall, and is less likely to lead to bronchial suppuration. Bronchial wall damage in bronchiectasis is caused by inflam- mation, but it is difficult to differentiate damage caused by severe or recurrent infections, predisposed to by immunosup- pression related to the autoimmune disease itself or its treatment, from damage caused by the autoimmune process. Increased use of new immunomodulatory or immunosuppres- sive agents has proved successful in modifying autoimmune disease processes, but has also led to emergence of infective complications that can cause bronchiectasis or exacerbate pre-existing disease

Bronchiectasis and autoimmune disease

The association between bronchiectasis and autoimmune disease is well recognised, and best described with rheumatoid arthritis. The prevalence of bronchiectasis in rheumatoid arthritis varies considerably in studies, with obliterative bronchiolitis a common feature. The prognosis of rheumatoid arthritis with bronchiectasis seems to be worse than either condition alone. The advent of high-resolution computed tomography has increased the sensitivity of detecting bronch- iectasis, but this should be assessed for clinical significance. Traction bronchiectasis results from interstitial fibrosis pulling the airway wider, rather than damage weakening the bronchial wall, and is less likely to lead to bronchial suppuration. Bronchial wall damage in bronchiectasis is caused by inflam- mation, but it is difficult to differentiate damage caused by severe or recurrent infections, predisposed to by immunosup- pression related to the autoimmune disease itself or its treatment, from damage caused by the autoimmune process. Increased use of new immunomodulatory or immunosuppres- sive agents has proved successful in modifying autoimmune disease processes, but has also led to emergence of infective complications that can cause bronchiectasis or exacerbate pre-existing disease

Post-partum transverse sinus thrombosis presenting as acute psychosis

Whilst cerebral vascular disease and mental illness in the post-partum period are well recognised, their co-existence and the concept of organic psychoses in pregnancy, parturition and the puerperium remains poorly appreciated (Brockington 2006; Brockington Arch Women's Ment Health 10: 177-178, 2007a; Brockington Arch Women's Ment Health 10: 305-306, b). We report a woman who was referred to the Medical team on-call with a mixed presentation of euphoria, mutism and aggressive behaviour but ultimately demonstrated to have a transverse sinus thrombosis and recovered well with anti-coagulation. This serves an important reminder of the implications of a missed medical diagnosis in this high-risk and vulnerable group of patients.</p

Post-partum transverse sinus thrombosis presenting as acute psychosis

Whilst cerebral vascular disease and mental illness in the post-partum period are well recognised, their co-existence and the concept of organic psychoses in pregnancy, parturition and the puerperium remains poorly appreciated (Brockington 2006; Brockington Arch Women's Ment Health 10: 177-178, 2007a; Brockington Arch Women's Ment Health 10: 305-306, b). We report a woman who was referred to the Medical team on-call with a mixed presentation of euphoria, mutism and aggressive behaviour but ultimately demonstrated to have a transverse sinus thrombosis and recovered well with anti-coagulation. This serves an important reminder of the implications of a missed medical diagnosis in this high-risk and vulnerable group of patients.</p