Research Interests:
IntroductionThe rising incidence of pleural disease is seeing an international growth of pleural services, with physicians performing an ever-increasing volume of pleural interventions. These are frequently conducted at sites without... more
IntroductionThe rising incidence of pleural disease is seeing an international growth of pleural services, with physicians performing an ever-increasing volume of pleural interventions. These are frequently conducted at sites without immediate access to thoracic surgery or interventional radiology and serious complications such as pleural bleeding are likely to be under-reported.AimTo assess whether intercostal vessel screening can be performed by respiratory physicians at the time of pleural intervention, as an additional step that could potentially enhance safe practice.MethodsThis was a prospective, observational study of 596 ultrasound-guided pleural procedures conducted by respiratory physicians and trainees in a tertiary centre. Operators did not have additional formal radiology training. Intercostal vessel screening was performed using a low frequency probe and the colour Doppler feature.ResultsThe intercostal vessels were screened in 95% of procedures and the intercostal art...
Research Interests:
Research Interests:
Research Interests:
Research Interests: Medicine and Lung Cancer
Research Interests:
ABSTRACT We report a case of Renal Vein Thrombosis (RVT) thought to be a complication of actue pyelonephritis in a 44 year old female presenting to the acute medical take. The most common cause of RVT is nephrotic syndrome, due to a... more
ABSTRACT We report a case of Renal Vein Thrombosis (RVT) thought to be a complication of actue pyelonephritis in a 44 year old female presenting to the acute medical take. The most common cause of RVT is nephrotic syndrome, due to a hyper-coaguable state. RVT is also seen in renal cell carcinoma due to tumour invasion. A possible theory relating RVT to acute pyelonephritis may relate to concomitant thrombophlebitis of the renal vein in pyelonephritis, which then predisposes to thrombosis. The patient was subsequently investigated for possible causes of this thrombotic event and anticoagulated. The management of RVT is also discussed. We hope this case highlights the importance of keeping an open mind and adding to the original management when a new, but unexpected finding is made.
IgG4-related disease (IgG4-RD) is a multi-system fibro-inflammatory disorder with classical histopathological findings, often in the context of elevated serum IgG4 levels. The thoracic manifestations of IgG4-RD are numerous and can mimic... more
IgG4-related disease (IgG4-RD) is a multi-system fibro-inflammatory disorder with classical histopathological findings, often in the context of elevated serum IgG4 levels. The thoracic manifestations of IgG4-RD are numerous and can mimic several common and better known conditions. The objective of this study was to outline the frequency and nature of thoracic involvement in a prospective cohort of IgG4-RD patients who met defined diagnostic criteria. Over 40% of IgG4-RD patients had clinicoradiological and/or histological evidence of thoracic involvement, predominantly mediastinal lymphadenopathy, the majority associated with multi-system disease outside the chest. Thoracic involvement was associated with a higher serum IgG4 level, potentially representing greater disease activity or spread. Our data highlight the diverse nature of thoracic IgG4-RD, and the importance of knowledge and recognition of the condition among respiratory physicians who are likely to encounter this disease ...
Research Interests:
Research Interests:
Introduction: The indications of non-invasive ventilation (NIV) have widened in the recent years, which is now used in treating hypercapnia with acidosis in a variety of patients. However, in many of the patients treated with NIV, the... more
Introduction: The indications of non-invasive ventilation (NIV) have widened in the recent years, which is now used in treating hypercapnia with acidosis in a variety of patients. However, in many of the patients treated with NIV, the acidosis may have preceded the hypercapnia. The current case series from our 11-bedded ward based NIV unit describes such acidotic hypercapnia: hypercapnic respiratory failure following metabolic acidosis. Methods: Time series of Arterial Blood Gas (ABG) findings in 4 patients with acidotic hypercapnia with a background of COPD confirmed with spirometry. Results:The ABGs for cases 1 and 2 showed a rising CO2 following the onset of a metabolic acidosis; a mixed metabolic and respiratory acidosis in patients 3 & 4 - with the acidosis preceding hypercapnia (Case 3) or being out of proportion to CO2 rise (Case 4). All four patients improved with initiation of NIV combined with active fluid/electrolyte management. A sample ABG time series (Case 3) showing i...
Computed tomography (CT) scanning is part of the routine diagnostic work up of patients with suspected pleural malignancy but has a wide variation in the reported sensitivity and specificity. This review was to appraise the recent... more
Computed tomography (CT) scanning is part of the routine diagnostic work up of patients with suspected pleural malignancy but has a wide variation in the reported sensitivity and specificity. This review was to appraise the recent literature on the utility of CT scanning. When investigating patients for suspected pleural malignancy, the sensitivity of a malignant CT report may be higher than previously reported (68%), but the specificity seems significantly lower (78%). The predictive value of CT scanning (on all patients with pleural effusions) may be increased using a CT scoring system. Recent meta-analyses of the utility of PET give differing opinions on the value of this imaging modality. Further work needs to be done to define its place in the diagnostic pathway. CT scoring systems may allow further risk stratification. However, a low negative predictive value of a 'negative' CT scan could lead to false reassurance and missed malignancy. PET/CT does not currently appear to add additional diagnostic value. Pulmonary emboli should be considered in all patients being investigated for clinically suspected malignant pleural disease. Respiratory physicians should be mindful of rare or unusual presentations.
Research Interests:
Intercostal chest drain (ICD) insertion is considered a core skill for the general physician. Recent guidelines have highlighted the risks of this procedure, while UK medical trainees have reported a concurrent decline in training... more
Intercostal chest drain (ICD) insertion is considered a core skill for the general physician. Recent guidelines have highlighted the risks of this procedure, while UK medical trainees have reported a concurrent decline in training opportunities and confidence in their procedural skills. We explored clinicians' attitudes, experience and knowledge relating to pleural interventions and ICD insertion in order to determine what changes might be needed to maintain patient safety and quality of training. Consultants and trainees delivering general medical services across five hospitals in England were invited to complete a questionnaire survey over a 5-week period in July and August 2014. 117 general physicians (32.4% of potential participants; comprising 31 consultants, 48 higher specialty trainees, 38 core trainees) responded. Respondents of all grades regarded ICD insertion as a core procedural skill. Respondents were asked to set a minimum requirement for achieving and maintaining ...
Research Interests:
We present the case of a 25-year-old Afro-Caribbean man with a longstanding history of ulcerative colitis and primary sclerosing cholangitis. The patient presented to clinic and reported pleuritic-type chest pain. A routine chest... more
We present the case of a 25-year-old Afro-Caribbean man with a longstanding history of ulcerative colitis and primary sclerosing cholangitis. The patient presented to clinic and reported pleuritic-type chest pain. A routine chest radiograph requested from the clinic revealed an incidental right middle zone opacity in the right lung. A subsequent high-resolution CT showed multiple lung nodules. The patient also had a positive cytoplamic anti-neutrophil cytoplasmic antibody (cANCA) and proteinase 3 antibodies. Bronchoscopy was inconclusive. A video-assisted thoracoscopic surgery biopsy was then taken. The histology revealed changes suggestive of bronchiolitis obliterans organising pneumonia. The pulmonary manifestations of inflammatory bowel disease are poorly characterised. Our literature search has revealed cases hypothesising that immune system dysregulation could display pulmonary complications of ulcerative colitis. The aetiology is thought to be related to the treatment with mes...
Research Interests:
An 86-year-old gentleman presented with a 3-month history of nausea, anorexia and excruciating generalised abdominal pain. He had been discharged a week earlier from another hospital. No diagnosis had been made. Clinically the patient was... more
An 86-year-old gentleman presented with a 3-month history of nausea, anorexia and excruciating generalised abdominal pain. He had been discharged a week earlier from another hospital. No diagnosis had been made. Clinically the patient was feverish, with a palpable, tender and poorly defined mass in his epigastrium. He had elevated inflammatory markers and deranged electrolytes. An ultrasound scan revealed thickening and hyper echogenicity of the small bowel mesentery. A CT scan was recommended; this revealed a diagnosis of mesenteric panniculitis. First described in 1924, mesenteric panniculitis is a benign inflammatory condition of the bowel mesentery. With only a handful of cases being reported in the UK, the authors thought that they had come across a rarity. This case report focuses on the aetiology, diagnosis, pathology and treatment of mesenteric panniculitis. By examining the literature, the authors also suggest that it is relatively underdiagnosed and may be more common than...
Research Interests:
A 53-year-old woman with a history of end-stage renal disease on peritoneal dialysis (PD) presented with a 3-month history of intermittent numbness and paraesthesia over the anterior aspect of the right thigh. The patient noticed the pain... more
A 53-year-old woman with a history of end-stage renal disease on peritoneal dialysis (PD) presented with a 3-month history of intermittent numbness and paraesthesia over the anterior aspect of the right thigh. The patient noticed the pain was worse on walking and related to dialysis sessions. An examination revealed no neurovascular abnormalities or abdominal masses. However, there was subjective paraesthesia in the distribution of the right lateral cutaneous nerve. Subsequent nerve conduction studies revealed the cause of the patient's symptoms. She was diagnosed with meralgia paraesthetica. Her symptoms resolved when the dialysis regime was modified.
Research Interests:
Research Interests:
Research Interests:
Local anaesthetic thoracoscopy (LAT) is performed by a growing number of respiratory physicians in the context of an expanding population with pleural disease. Most LATs occur in patients with moderate to large effusions where the... more
Local anaesthetic thoracoscopy (LAT) is performed by a growing number of respiratory physicians in the context of an expanding population with pleural disease. Most LATs occur in patients with moderate to large effusions where the presence of fluid allows safe access to the pleural space. Patients with little or no fluid, but other features concerning for pleural disease, are usually investigated by surgical means. Advanced LAT practitioners can also provide this service through pneumothorax induction, although there is little published data on the safety or efficacy of this technique. We present data from a series of 77 consecutive patients in whom ultrasound-guided pneumothorax induction and LAT were attempted. 67 procedures (87.0%) were successful, with the most common histopathological diagnoses being chronic pleuritis (58.2%) and mesothelioma (16.4%). No adverse events were reported secondary to the procedure. These findings demonstrate the utility of this approach and should i...
Research Interests:
Secondary care physicians caring for people with long-term conditions (LTCs) are under increasing pressure to discharge long-term follow-up patients to primary care. In respiratory medicine, the 2008 British Thoracic Society (BTS)... more
Secondary care physicians caring for people with long-term conditions (LTCs) are under increasing pressure to discharge long-term follow-up patients to primary care. In respiratory medicine, the 2008 British Thoracic Society (BTS) statement on criteria for specialist referral, admission, discharge, and follow-up for adults with respiratory disease remains the only available basis for this dialogue. There is widespread concern about reforming outpatient clinics to meet these demands and the impact of discharging people with respiratory LTCs to primary care. To examine the impact of implementing BTS guidance on secondary care follow-up of patients with respiratory disease. We undertook a clinic reform project, which included one-stop medical reviews, providing more open access appointments, and implementing the BTS criteria. The impact on patients was assessed by patient survey, and the impact on GPs was assessed by an analysis of referral patterns pre- and post-reform. There was a si...