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1.  Intermittent swelling in the chest; a case of spontaneous intermittent lung herniation 
BMJ Case Reports  2013;2013:bcr2013201380.
Herniation of the lung is uncommon and occurs due to protrusion of the lung beyond the confines of the thoracic cavity through an abnormal opening in the chest wall. Any condition associated with raised intrathoracic pressure or that which weakens the thoracic wall may result in lung herniation. We present a case of spontaneous lung herniation which was managed successfully by minimally invasive thoracic surgery.
doi:10.1136/bcr-2013-201380
PMCID: PMC3822208  PMID: 24177461
2.  Inhaled corticosteroids in chronic obstructive pulmonary disease: a pro–con perspective 
Current guidelines limit regular use of inhaled corticosteroids (ICS) to a specific subgroup of patients with chronic obstructive pulmonary disease (COPD) in whom the forced expiratory volume in 1 s is <60% of predicted and who have frequent exacerbations. In these patients, there is evidence that ICS reduce the frequency of exacerbations and improve lung function and quality of life. However, a review of the literature suggests that the evidence available may be interpreted to favour or contradict these observations. It becomes apparent that COPD is a heterogeneous condition. Clinicians therefore need to be aware of the heterogeneity as well as having an understanding of how ICS may be used in the context of the specific subgroups of patients with COPD. This review argues for and against the use of ICS in COPD by providing an in-depth analysis of the currently available evidence.
doi:10.1111/bcp.12334
PMCID: PMC4137821  PMID: 25099256
adverse events; budesonide/formoterol; fluticasone/salmeterol; inhaled corticosteroids; mortality; pneumonia
3.  Bilateral chylothorax: an unusual complication of cervical rib resection 
Bilateral chylothorax is a rare cause of pleural effusions. Here we report an unusual acute presentation of bilateral chylothorax following thoracic outlet surgery. Unique to this case was the disparate characteristics of pleural fluid analyses with an exudate on the left and a transudate on the right. This report describes the recognition and management of bilateral chylothoraces, an uncommon but potentially serious complication of this frequently performed surgical procedure.
doi:10.1177/2040622314552072
PMCID: PMC4269611  PMID: 25553240
bilateral chylothorax; cervical rib; exudative effusion; pleural effusion; transudative effusion
4.  Pins and needles and unilateral foot drop: a presentation of sarcoidosis 
BMJ Case Reports  2012;2012:bcr2012007395.
We describe a case of sarcoidosis in a 57-year-old man who presented with neurological symptoms of pins and needles in  both of his hands, left leg weakness and left foot drop. Neurophysiological examination revealed asymmetric motor and sensory polyneuropathy. Common peroneal nerve involvement accounted for the left foot drop. Thoracic CT scan revealed bilateral hilar and mediastinal lymphadenopathy. He had hypercalcaemia and raised serum ACE level. Histological examination of a mediastinal lymph node showed non-caseating epithelioid cell granulomas consistent with the diagnosis of sarcoidosis. There was no evidence of acid-fast bacilli or fungi on special stains. This case highlights the importance of considering sarcoidosis as a potential diagnosis in patients presenting with peripheral neuropathy. Although response to corticosteroids and immunosuppressive therapy may be seen, in our case the patient's neurological deficit remained persistent despite treatment.
doi:10.1136/bcr-2012-007395
PMCID: PMC4544169  PMID: 23087290
5.  Pleural abnormalities: thoracic ultrasound to the rescue! 
Diaphragmatic hernias that are diagnosed in adulthood may be traumatic or congenital in nature. Therefore, respiratory specialists need to be aware of the presentation of patients with these conditions. In this report, we describe a case series of patients with congenital and traumatic diaphragmatic hernias and highlight a varied range of their presentations. Abnormalities were noted in the thorax on the chest radiographs, but it was unclear as to the nature of the anomaly. The findings on thoracic ultrasound conducted by a pulmonologist helped to direct appropriate investigations avoiding unnecessary interventions. Instead of pleural effusions, consolidation or collapse, thoracic computed tomography demonstrated diaphragmatic hernias which were managed either conservatively or by surgery. There is increasing evidence that pulmonary specialists should be trained in thoracic ultrasonography to identify pleural pathology as well as safely conducting pleural-based interventions.
doi:10.1177/2040622313482997
PMCID: PMC3697842  PMID: 23819018
acquired diaphragmatic hernia; Bochdalek hernia; chest ultrasound; congenital diaphragmatic hernia; diaphragmatic hernias; Morgagni hernia
6.  Management of patients with chronic cough using a clinical protocol: a prospective observational study 
Background and aims
Chronic cough is a common symptom the aetiology of which can be challenging to diagnose. Diagnostic protocols for chronic cough have required the use of specialist investigations which are not always easily available. We wanted to determine whether patients with chronic cough can be successfully managed using a clinical algorithm.
Methods
112 consecutive patients with chronic cough were prospectively recruited into this study. They were assessed by history, physical examination, chest radiograph, spirometry and reversibility to nebulised salbutamol. A clinical diagnosis was made and the patient had an 8-week trial of appropriate therapy. Further therapeutic trials were carried out depending on response to treatment and the possible differential diagnoses. Investigations were carried out in cases of failed clinical trials and to exclude specific pathology. The “clinical arm” comprised patients managed on the basis of clinical assessment and without any investigations. The “investigative arm” comprised those who needed further investigations.
Results
81 (72%) were managed in the clinical arm. Of these 74 (66%) were discharged following response to therapy. 31 (28%) patients were converted to the investigative arm after failure of diagnosis in the clinical protocol. The commonest causes of cough were gastroesophageal reflux, asthma and chronic rhinitis. 51 (45.5%) patients responded to therapy based on diagnosis at initial assessment while a further 23 (20.5%) patients responded to sequential clinical trials for the commonest causes of cough. Cough severity score improved by a mean of 3.6 points on a numeric response score (from 0–10, p < 0.0001).
Conclusion
It is possible to manage a majority of chronic cough patients successfully using a protocol based on presenting symptoms and therapeutic trials for the common causes of cough.
doi:10.1186/1745-9974-9-2
PMCID: PMC3565860  PMID: 23347748
Cough; Differential diagnosis; Diagnostic techniques and procedures
7.  Comparison of the effect of high-dose inhaled budesonide and fluticasone on adrenal function in patients with severe chronic obstructive pulmonary disease 
Annals of Thoracic Medicine  2012;7(3):140-144.
INTRODUCTION:
Chronic obstructive pulmonary disease (COPD) is a leading cause of respiratory-related morbidity and mortality. Inhaled steroids are frequently used in patients with moderate to severe disease and may lead to adrenal suppression.
OBJECTIVES:
The aim of this study was to compare the effect of inhaled budesonide/formoterol with inhaled fluticasone/salmeterol in severe COPD.
METHODS:
It was a prospective open-label crossover study of 22 patients. Adrenal suppression was measured by overnight urinary cortisol/creatinine ratio. The measurements were taken while patients were on either combination for at least 4 weeks.
RESULTS:
A total of 12 patients completed the study. The mean age was 64 years (8 males, 4 females). The mean FEV1 was 1 L (range, 0.5-1.8). There was no significant difference in adrenal suppression measured by overnight urinary cortisol/creatinine ratio (budesonide 5.2 ± 4.3, fluticasone 4.7 ± 3.1; 95% CI -2.2 to 1.2; P = 0.52) and urinary cortisol concentration (budesonide 51 ± 53, fluticasone 43 ± 31 [nmol/l]; 95% CI -35 to 20; P = 0.56).
CONCLUSION:
Inhaled budesonide and fluticasone have no significantly different effect on adrenal function in moderate to severe COPD. The adverse event profile of high-dose inhaled steroids should not influence the choice of medication.
doi:10.4103/1817-1737.98846
PMCID: PMC3425045  PMID: 22924071
Adrenal suppression; COPD; cortisol-creatinine ratio; inhaled corticosteroids
8.  Unusual Asthma Syndromes and Their Management 
Asthma usually presents with symptoms of wheeze, dyspnoea and cough. However, clinicians should be aware of atypical presentation of this disorder when cough is the main or only symptom in conditions such as cough-variant asthma, nonasthmatic eosinophilic bronchitis and atopic cough. Early diagnosis and treatment of these conditions with inhaled corticosteroids improves symptoms in the majority of patients. Up to 10% of patients with asthma remain poorly controlled in spite of optimal standard therapy. These patients have been encompassed under the term ‘treatment-refractory asthma’ (TRA), have the greatest morbidity and are responsible for more than 50% of healthcare costs. In this review we discuss investigations, management and pathophysiology of the various phenotypes of atypical presentations of asthma as well as novel biological agents licensed and those that have been reported in clinical trials in terms of their efficacy and safety in TRA.
doi:10.1177/2040622311407542
PMCID: PMC3513887  PMID: 23251753
atopic cough; biologics; cough; eosinophilic bronchitis; monoclonal antibodies; severe asthma
9.  Concurrent pulmonary zygomycosis and Mycobacterium tuberculosis infection: a case report 
A non-smoking 77-year old gentleman of Indian origin was admitted with a 4-month history of intermittent night sweats, haemoptysis and 6 kg of weight loss. CT scan of thorax demonstrated a 2.5 cm mass in the right middle lobe with multiple small nodules within the right lung and confirmed the presence of mediastinal and hilar lymph nodes.
Fibreoptic bronchoscopy demonstrated a distorted right main bronchus, anterior shift of the right upper lobe and occlusion of the right middle lobe bronchus with a black necrotic ulcer. Mycobacterium tuberculosis was found in the bronchoalveolar lavage and histology demonstrated numerous fungal hyphae with a morphological appearance of zygomycetes within necrotic areas of tissue. Medical management with anti-fungal and anti-mycobacterial treatment was instigated as the patient's pre-existing IHD did not permit surgical intervention. Subsequently CT imaging following completion of therapy demonstrated improvement of the mass and a resolution of the associated nodules. The patient has been followed for 6 months to date and there has been no recurrence of symptoms. Recent bronchoalveolar lavage cultures have been negative for M. tuberculosis and zygomycetes.
doi:10.1186/1752-1947-1-17
PMCID: PMC1868082  PMID: 17477864
10.  Chronic persistent cough in the community: a questionnaire survey 
Background
Chronic cough is a common symptom which causes significant levels of morbidity. It is becoming increasingly well characterised by research taking place in specialist cough clinics, where successful treatment rates are high. However, there is a paucity of data regarding the symptom complex of chronic cough in the community. This report details the results of a postal questionnaire survey sent to individuals requesting further information on chronic cough.
Methods
856 chronic cough questionnaires were sent out to members of the public who requested an information sheet following a national UK radio broadcast. Information regarding demography, history of cough, previous treatment and physical, psychological and social effects of the cough was elicited.
Results
373 completed questionnaires were returned. Mean age was 65.3 years (SD 12.0, range 9–88 years). 73% were female and 2% current smokers. Median duration of cough was 6.5 years. 66% had no other coexisting respiratory diagnosis, whilst 24% reported asthma. Of those who responded, 91% had consulted a general practitioner regarding the cough and of them, 85% had been prescribed some sort of treatment. 61% had seen at least one hospital specialist. Commonly reported associated physical symptoms included breathlessness (55%), wheeze (37%), fatigue (72%) and disturbed sleep (70%). Incontinence occurred in 55% of women. Similarly, the majority reported psychological effects such as anger or frustration (83%), anxiety (69%) and depression (55%). 64% felt that the cough interfered with their social life.
Conclusion
Chronic cough causes a high level of morbidity in the community, which results in a correspondingly high rate of healthcare utilisation. Demography and symptomatology seems to be similar to that reported from specialist centres, but successful treatment of the cough was uncommon, despite a high number of medical consultations in both primary and secondary care. If understanding of this debilitating but eminently treatable condition is enhanced, management of chronic cough will improve and many patients will be helped.
doi:10.1186/1745-9974-3-5
PMCID: PMC1847685  PMID: 17381836
11.  Cough challenge in the assessment of cough reflex 
doi:10.1046/j.0306-5251.2001.01475.x
PMCID: PMC2014577  PMID: 11678780

Results 1-11 (11)