Background: Long-term nitrofurantoin (NF) treatment can result in pulmonary and hepatic injury. Current guidelines do not outline the type or frequency of monitoring required for detection of these injuries. Aim: To assess 1) awareness of NF complications among prescribers; 2) monitoring practice; and 3) to describe the pulmonary sequelae of NF-related complications. Design & setting: Evaluation of prescribing habits by questionnaires and review of GP databases, and case-note review in secondary care. Method: The following study procedures were undertaken: 1) an electronic questionnaire was distributed to prescribers, interrogating prescribing and monitoring practices, and awareness of complications; 2) an analysis was undertaken (June–July 2020) of NF monitoring among GPs in the local clinical commissioning group (CCG); and 3) a case review was carried out of patients diagnosed with NF-induced interstitial lung disease (NFILD) at the interstitial lung disease (ILD) centre (2014–2020). Results: A total of 125 prescribers of long-term NF responded to the questionnaire (82.4% GPs; 12.0% urologists). Many were unaware of the potential for liver (42.4%) and lung (28.0%) complications; 40.8% and 52.8% never monitored for these, respectively. Only 53.3% of urologists believed themselves responsible for arranging monitoring, while nearly all GPs believed this to be the prescriber’s responsibility (94.2%). One-third of all responders considered current British National Formulary (BNF) guidelines 'not at all sufficient/clear', with mean clarity scoring of 2.2/5. Among patients with NFILD (n = 46), NF had been prescribed most often (69.6%) for treatment of recurrent UTI and 58.6% (n = 27) were prescribed for >6 months. On withdrawal of the medication 61.4% displayed resolution (completely or minimal fibrosis), while 15.9% of patients had progressive lung fibrosis. Conclusion: NF can cause marked or irreversible lung complications and there is currently a shortfall in awareness and monitoring. Existing monitoring guidelines should be augmented.

This case report discusses a 76-year-old man who presented with symptomatic diffuse alveolar-septal and tracheobronchial amyloidosis with a low-grade monoclonal gammopathy. This patient had a combination of both symptomatic diffuse alveolar-septal interstitial disease and tracheobronchial amyloidosis, features that contradict the widely accepted presentations seen in this disease. First, tracheobronchial amyloidosis has been documented as localised disease without systemic involvement. Second, diffuse alveolar-septal interstitial disease is rarely identified with clinical symptoms unless there is significant cardiac involvement. This case highlights a number learning points in the diagnosis and management of systemic amyloid light chain amyloidosis;(1) There is a need for a high index of suspicion for diagnosis due to the potential subtlety of a plasma cell clone underlying AL amyloidosis, requiring serum-free light chain assays to increase sensitivity; (2) Haematological response and recovery of organ dysfunction are not a linear relationship due to the slower reversal of amyloid deposition; therefore, ongoing monitoring is required to identify those in need of repeated therapy. However, haematological response is a marker of overall survival and (3) Multisystem assessment and multidisciplinary collaboration are critical in optimising the care of patients with systemic AL amyloidosis.

Radiological monitoring of malignant pleural mesothelioma (MPM) using modified RECIST criteria is limited by low sensitivity and inter-observer variability. Serial serum mesothelin measurement has shown utility in the assessment of treatment response during chemotherapy but has never been assessed in the longer term follow up of patients.

Purpose The purpose of this study was to compare the use of fluorine-18-fluorodeoxyglucose (18F-FDG) PET with computed tomography (CT) and dynamic contrast-enhanced (DCE) MRI to predict prognosis and monitor treatment in malignant pleural mesothelioma. Patients and methods 18F-FDG PET/CT and DCE-MRI studies carried out as part of the South West Area Mesothelioma Pemetrexed trial were used. 18F-FDG PET/CT and DCE-MRI studies were carried out before treatment, and after two cycles of chemotherapy, on patients treated with pemetrexed and cisplatin. A total of 73 patients were recruited, of whom 65 had PET/CT and DCE-MRI scans. Baseline measurements from 18F-FDG PET/CT (maximum standardized uptake value, metabolic tumour volume and total lesion glycolysis) and DCE-MRI (integrated area under the first 90s of the curve and washout slope) were compared with overall survival (OS) using Kaplan–Meier and Cox regression analyses, and changes in imaging measurements were compared with disease progression. Results PET/CT and DCE-MRI measurements were not correlated with each other. Maximum standardized uptake value, metabolic tumour volume and total lesion glycolysis were significantly related to OS with Cox regression analysis and Kaplan–Meir analysis, and DCE-MRI washout curve shape was significantly related to OS. DCE-MRI curve shape can be combined with 18F-FDG PET/CT to give additional prognostic information. Changes in measurements were not related to progression-free survival. Conclusions 18F-FDG PET/CT and DCE-MRI give prognostic information in malignant pleural mesothelioma. Neither PET/CT nor DCE-MRI is useful for monitoring disease progression.

Introduction: Radiological monitoring of malignant pleural mesothelioma (MPM) using modified RECIST is limited by low sensitivity and inter-observer variability. Serum mesothelin (SM) has utility in the assessment of response to chemotherapy but has never been assessed in longer term follow up. Methods: Single centre study of consecutive patients with MPM who received chemotherapy or best supportive care. Patients had SM measurements with paired 6 monthly CT scans (minimum follow up 12 months). Changes in SM were correlated with radiological progression and overall survival. Results: Forty-one patients with MPM were recruited, the majority (n=23) received chemotherapy with pemetrexed/cisplatin. A rise in SM could predict radiological progression with a sensitivity of 96% (IQR; 79-100) and specificity of 74% (IGR; 50-91), see Figure 1. Sensitivity fell to 80% in sarcomatoid only disease. Patients with a rising SM at 6 months had significantly worse overall survival (161 days) compared to stable/falling levels (448 days) (p=0.015). Conclusions: This is the first study to assess SM’s ability to monitor MPM at later timepoints. It showed excellent sensitivity at predicting progressive disease. Mesothelin measurement has several advantages over serial CT imaging including reducing hospital visits and cost. Figure 1. Waterfall plot of change in mesothelin, split by CT assessment.

OBJECTIVE Diffuse pleural thickening (DPT) refers to extensive visceral pleural fibrosis with adhesion formation to the parietal pleura obliterating the pleural space. The radiological definition of DPT remains controversial with most of the literature requiring the presence of an obliterated costophrenic angle (CPA) for defining DPT. We conducted a study to investigate the variable distributions of DPT and associated lung function deficit. METHODS 85 patients referred to a pleural clinic with suspected pleural thickening were screened for our study. Data were collected from 37 patients with DPT confirmed on CT by size criteria (≥3 mm thick, ≥5 cm wide and ≥8 cm in length), and 21 controls with pleural plaques but no other pleuroparenchymal pathology. 27 patients were excluded. Groups were matched to age, body mass index and smoking history. RESULTS The percentage of predicted forced vital capacity showed a gradual decline from 98.9% for the control group to 83.5% in the DPT without CPA obliteration group (p < 0.05), to 79.5% in the unilateral DPT group (p < 0.001) and 66.7% in the bilateral group (p < 0.001). Similar reductions were seen in the percentage of predicted total lung capacity in the DPT with no CPA obliteration group and the bilateral DPT group. CONCLUSION Our study shows an incremental reduction in the forced vital capacity and total lung capacity in DPT without CPA obliteration, unilateral and bilateral DPT when compared with a matched control group. Advances in knowledge: Different distributions of DPT including no CPA obliteration can cause respiratory impairment, with bilateral DPT being the worst affected.

British Journal of Hospital MedicineVol. 78, No. 1 Case ReportBronchogenic cyst mimicking an isolated paratracheal lymph nodeRenate Homewood, Michael Darby, Andrew RL MedfordRenate HomewoodSearch for more papers by this author, Michael DarbySearch for more papers by this author, Andrew RL MedfordSearch for more papers by this authorRenate Homewood; Michael Darby; Andrew RL MedfordPublished Online:9 Jan 2017https://doi.org/10.12968/hmed.2017.78.1.52AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Cardinale L, Ardissone F, Cataldi A, Gned D, Prato A, Solitro F, Fava C (2008) Bronchogenic cysts in the adult: diagnostic criteria derived from the correct use of standard radiography and computed tomography. Radiol Med 113(3): 385–394. https://doi.org/10.1007/s11547-008-0255-8 Google ScholarComoglio C, Sansone F, Delsedime L et al. (2000) Foregut cysts of the mediastinum in infants and children. In: Shields TW, LoCicero J III, Ponn RB, eds. General Thoracic Surgery. 5th edn. Vol 2. Williams & Wilkins, Philadelphia, Pa: 2393–9 Google ScholarEsme H, Eren S, Sezer M, Solak O (2011) Primary mediastinal cysts: clinical evaluation and surgical results of 32 cases. Tex Heart Inst J 38(4): 371–4 Medline, Google ScholarJeon HG, Park JH, Park HM et al. (2014) Non-infected and infected bronchogenic cyst: the correlation of image findings with cyst content. Tuberc Respir Dis (Seoul) 76(2): 88–92. https://doi.org/10.4046/trd.2014.76.2.88 Google ScholarJeyabalan A, Medford ARL (2014) Endobronchial ultrasound-guided transbronchial needle aspiration: patient satisfaction under light conscious sedation. Respiration 88(3): 244–250. https://doi.org/10.1159/000363063 Google ScholarJeyabalan A, Bhatt N, Edey AJ, West DG, Medford ARL (2014) A node or not a node; that is the question? QJM 107(4): 309–310. https://doi.org/10.1093/qjmed/hcs090 Google ScholarKirmani B, Kirmani B, Sogliani F (2010) Should asymptomatic bronchogenic cysts in adults be treated conservatively or with surgery? Interact Cardiovasc Thorac Surg 11(5): 649–659. https://doi.org/10.1510/icvts.2010.233114 Google ScholarMedford ARL, Bennett JA, Free CM, Agrawal S (2009) Mediastinal staging procedures in lung cancer: EBUS, TBNA and mediastinoscopy. Curr Opin Pulm Med 15(4): 334–342. https://doi.org/10.1097/MCP.0b013e32832b8a45 Google ScholarMouroux J, Venissac N, Leo F, Guillot F, Padovani B, Hofman P (2003) Usual and unusual locations of intrathoracic mesothelial cysts. Is endoscopic resection always possible? Eur J Cardiothorac Surg 24(5): 684–688. https://doi.org/10.1016/S1010-7940(03)00505-0 Google ScholarPatel SR, Meeker DP, Biscotti CV, Kirby TJ, Rice TW (1994) Presentation and management of bronchogenic cysts in the adult. Chest 106(1): 79–85 Crossref, Medline, Google Scholar FiguresReferencesRelatedDetailsCited byCongenital Incidental Findings in Children that Can Be Mistaken as True Pathologies in AdultsRadiologic Clinics of North America, Vol. 58, No. 3 2 January 2017Volume 78Issue 1ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 9 January 2017 Published in print 2 January 2017 Information© MA Healthcare LimitedPDF download

BACKGROUND:The effect of chemotherapy on health-related quality of life (HRQoL) in malignant pleural mesothelioma (MPM) is poorly understood. Patient-individualised prognostication and prediction of treatment response from chemotherapy is useful but little evidence exists to guide practice. METHOD:Consecutive patients with MPM who were fit for first-line chemotherapy with pemetrexed and cisplatin\carboplatin were recruited and followed up for a minimum of 12 months. This study focussed on the HRQoL outcomes of these patients using the EQ-5D, EORTC QLQ-C30 and LC13. RESULTS:Seventy-three patients were recruited of which 58 received chemotherapy and 15 opted for best supportive care (BSC). Compliance with HRQoL questionnaires was 98% at baseline. The chemotherapy group maintained HRQoL compared with the BSC group whose overall HRQoL fell (P=0.006) with worsening dyspnoea and pain. The impact of chemotherapy was irrespective of histological subtype although those with non-epithelioid disease had worse HRQoL at later time points (P=0.012). Additionally, those with a falling mesothelin or improvement on modified-RECIST CT at early follow-up had a better HRQoL at 16 weeks. CONCLUSIONS:HRQoL was maintained following chemotherapy compared with a self-selected BSC group. Once chemotherapy is initiated, a falling mesothelin or improved RECIST CT findings infer a quality-of-life advantage.

Pleural infection is increasing in incidence. Despite optimal medical management, up to 30% of patients will die or require surgery. Case reports suggest that irrigation of the pleural space with saline may be beneficial. A randomised controlled pilot study in which saline pleural irrigation (three times per day for 3 days) plus best-practice management was compared with best-practice management alone was performed in patients with pleural infection requiring chest-tube drainage. The primary outcome was percentage change in computed tomography pleural fluid volume from day 0 to day 3. Secondary outcomes included surgical referral rate, hospital stay and adverse events. 35 patients were randomised. Patients receiving saline irrigation had a significantly greater reduction in pleural collection volume on computed tomography compared to those receiving standard care (median (interquartile range) 32.3% (19.6–43.7%) reduction versus 15.3% (−5.5–28%) reduction) (p<0.04). Significantly fewer patients in the irrigation group were referred for surgery (OR 7.1, 95% CI 1.23–41.0; p=0.03). There was no difference in length of hospital stay, fall in C-reactive protein, white cell count or procalcitonin or adverse events between the treatment groups, and no serious complications were documented. Saline irrigation improves pleural fluid drainage and reduces referrals for surgery in pleural infection. A large multicentre randomised controlled trial is now warranted to evaluate its effects further.