Question 56#

Which one the following statements regarding asbestos is not correct?

A. Pleural plaques are premalignant

Correct Answer A: 

Asbestos and the lung:

Asbestos can cause a variety of lung disease from benign pleural plaques to mesothelioma.

Pleural plaques:

Pleural plaques are benign and do not undergo malignant change. They are the most common form of asbestos related lung disease and generally occur after a latent period of 20-40 years.

Pleural thickening:
Asbestos exposure may cause diffuse pleural thickening in a similar pattern to that seen following an empyema or haemothorax. The underlying pathophysiology is not fully understood. 

Asbestosis:

The severity of asbestosis is related to the length of exposure. This is in contrast to mesothelioma where even very limited exposure can cause disease. The latent period is typically 15-30 years. Asbestosis typically causes lower lobe fibrosis. As with other forms of lung fibrosis the most common symptoms are shortness-of-breath and reduced exercise tolerance.

Mesothelioma:
Mesothelioma is a malignant disease of the pleura. Crocidolite (blue) asbestos is the most dangerous form.

Possible features: 

• Progressive shortness-of-breath
• Chest pain
• Pleural effusion

Patients are usually offered palliative chemotherapy and there is also a limited role for surgery and radiotherapy.

Unfortunately the prognosis is very poor, with a median survival from diagnosis of 8-14 months.

Lung cancer:

Asbestos exposure is a risk factor for lung cancer and also has a synergistic effect with cigarette smoke

Question 57#

Which of the following features is associated with a good prognosis in sarcoidosis?

A. Insidious onset

Correct Answer E: Erythema nodosum is associated with a good prognosis in sarcoidosis.

Sarcoidosis: prognostic features:

Sarcoidosis is a multisystem disorder of unknown aetiology characterized by non-caseating granulomas. It is more common in young adults and in people of African descent. Sarcoidosis remits without treatment in approximately two-thirds of people.

Factors associated with poor prognosis: 

• Insidious onset, symptoms > 6 months
• Absence of erythema nodosum
• Extrapulmonary manifestations: e.g. lupus pernio, splenomegaly
• CXR: stage III-IV features
• Black people

Question 58#

A 43-year-old man is admitted due to shortness of breath and is noted to have a cavitating lesion on his chest x-ray.

Which one of the following conditions is not part of the differential diagnosis?

A. Lung cancer

Correct Answer D: 

Chest x-ray: cavitating lung lesion:

Differential: 

• Abscess (Staph aureus, Klebsiella and Pseudomonas)
• Squamous cell lung cancer
• Tuberculosis
• Wegener's granulomatosis
• Pulmonary embolism
• Rheumatoid arthritis
• Aspergillosis, histoplasmosis, coccidioidomycosis

Question 59#

A 45-year-old woman who is a known asthmatic comes for review. In the past two years she has had around six exacerbations of asthma requiring oral steroids. Her current medication includes salbutamol 2 puffs prn, salmeterol 50mcg bd and beclomethasone 200 mcg 1 puff bd. You note from the records that her BMI is 31 kg/m^2, she is a non-smoker and has a good inhaler technique.

What is the most appropriate next step in management?

A. Increase beclomethasone to 200 mcg 2 puffs bd

Correct Answer A: 

Asthma: stepwise management in adults:

The management of stable asthma is now well established with a step-wise approach:

*beclomethasone dipropionate or equivalent.

Additional notes:

Leukotriene receptor antagonists:

• e.g. Montelukast, zafirlukast
• Have both anti-inflammatory and bronchodilatory properties
• Should be used when patients are poorly controlled on high-dose inhaled corticosteroids and a long acting b2-agonist
• Particularly useful in aspirin-induced asthma
• Associated with the development of Churg-Strauss syndrome

Fluticasone is more lipophilic and has a longer duration of action than beclomethasone Hydrofluoroalkane is now replacing chlorofluorocarbon as the propellant of choice. Only half the usually dose is needed with hydrofluoroalkane due to the smaller size of the particles.

Long acting B2-agonists acts as bronchodilators but also inhibit mediator release from mast cells. Recent metaanalysis showed adding salmeterol improved symptoms compared to doubling the inhaled steroid dose.

Question 60#

A 57-year-old female presents to the Emergency Department with shortness of breath and pleuritic chest pain. She has no past medical history of note and enjoys good health. Investigations reveal a non-massive pulmonary embolism.

What is the recommended length of warfarinization for this patient?

A. 6 weeks

Correct Answer C: There are no transient risk factors for venous thromboembolism therefore the patient should be anticoagulated for 6 months.

Recent NICE guidelines advise to 'offer a VKA* beyond 3 months to patients with an unprovoked PE'.

*Vitamin K antagonists, i.e. warfarin.

Pulmonary embolism: management:

The NICE guidelines of 2012 provided some clarity on how long patients should be anticoagulated for after a pulmonary embolism (PE):

• Low molecular weight heparin (LMWH) or fondaparinux should be given initially after a PE is diagnosed. An exception to this is for patients with a massive PE where thrombolysis is being considered. In such a situation unfractionated heparin should be used.
• A vitamin K antagonist (i.e. warfarin) should be given within 24 hours of the diagnosis
• The LMWH or fondaparinux should be continued for at least 5 days or until the international normalized ratio (INR) is 2.0 or above for at least 24 hours, whichever is longer, i.e. LMWH or fondaparinux is given at the same time as warfarin until the INR is in the therapeutic range
• Warfarin should be continued for at least 3 months. At 3 months, NICE advise that clinicians should 'assess the risks and benefits of extending treatment'
• NICE advise extending warfarin beyond 3 months for patients with unprovoked PE. This essentially means that if there was no obvious cause or provoking factor (surgery, trauma, significant immobility) it may imply the patient has a tendency to thrombosis and should be given treatment longer than the norm of 3 months
• For patients with active cancer NICE recommend using LMWH for 6 months 

Thrombolysis: 

• Thrombolysis is now recommended as the first-line treatment for massive PE where there is circulatory failure (e.g. hypotension). Other invasive approaches should be considered where appropriate facilities exist