MRCP (Dr. Bhatia Academy)

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Option D is correct: Cystic fibrosis 1. One Australian study suggested that colonisation rates for Aspergillus in patients with cystic fibrosis approach 19%. 2. Rates of ABPA however are much lower at around 5%. 3. Allergic bronchopulmonary aspergillosis (ABPA) rates are lower in patients with obstructive lung disease at around 1%. 4. HIV patients with a known history of P. jirovecii are at increased risk of aspergilloma. 5. Bronchial carcinoma is not particularly associated with Aspergillus positivity.

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Option C is correct: Hoarse voice for longer than three weeks 1. Under NICE guidelines a hoarse voice for three weeks or more is an indication for investigation to exclude malignancy. 2. This is particularly the case in patients with a history of alcohol consumption or smoking. 3. Whilst alcohol and smoking history would both increase the suspicion of an underlying carcinoma it is the duration of hoarseness which would raise most concern. 4. A history of cough might be expected given he is a smoker and a response to steroid inhaler would not be expected anyway.

A 59-year-old man presents to the general medical on call with a hoarse voice. He is known to smoke some 20 cigarettes per day. He has not lost any weight over the past few months but has a chronic cough for which he has been prescribed a steroid inhaler. He drinks 30 units of alcohol per week.

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Option B is correct: pCO₂ 6.5 kPa 1. The BTS guidelines on NIV from 2008 recommend considering NIV in patients who present with acute respiratory failure due to COPD and have decompensated respiratory acidosis within 60 minutes of admission, after maximal medical therapy has been instituted. 2. pCO₂ >6.0 fits the criterion for respiratory acidosis and is therefore the correct answer. 3. The criteria for initiating NIV are largely independent of the underlying disease process. 4. pH 6.0 fits the criterion for respiratory acidosis and is therefore the correct answer. 5. According to the guidelines, "maximal medical therapy" is defined as: Controlled oxygen to maintain SaO₂ 88–92% -Nebulised salbutamol 2.5–5 mg -Nebulised ipratropium 500 µg -Prednisolone 30 mg -Antibiotic agent (when indicated)

You are reviewing use of non-invasive ventilation (NIV) by the acute medical admissions team as part of a hospital audit. According to the latest BTS guidelines, which of the following features on history, examination or investigations would be a criterion for considering NIPPV?

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Option A is correct: Coagulase negative Staphylococcus 1. Around 10–30% of cases are culture negative. 2. At 20–25% overall, coagulase negative Staphylococcus is the most commonly cultured organism. 3. With improved hygiene and technique, rates of staphylococcal infection are falling. Intra-abdominal pathology (such as a ruptured viscus) should be considered if more than one organism is grown, especially if Gram-negative or anaerobic. 4. Repeated treatment increases the risk of resistant organisms. 5. This may require loss of catheter and switch to haemodialysis. 6. Coagulase negative Staphylococcus is the most commonly cultured organism in peritoneal dialysis peritonitis. 7. It represents 20–25% of cases. 8. It is a skin commensal that opportunistically causes infection through the catheter site. 9. Enterococcus represents 1–5% of cases and occurs less frequently than coagulase-negative Staphylococcus. 10. Escherichia coli is less common. Overall, Gram-negative organisms represent 10–15% of cases. 11. Pseudomonas represents 5% of cases and occurs less frequently than coagulase-negative Staphylococcus. 12. Staphylococcus aureus represents 10–15% of cases and occurs less frequently than coagulase-negative Staphylococcus.

You are auditing the nephrology department's rates of peritoneal dialysis peritonitis, observing the proportion of cases that are culture positive and the associated organism.