Andrew RL Medford

North Bristol NHS Trust · North Bristol Lung Centre

Acute respiratory distress syndrome (ARDS), the most severe form of acute lung injury (ALI), remains a devastating condition with a high mortality. It is characterised by alveolar injury and increased pulmonary vascular permeability. Vascular endothelial cell growth factor (VEGF) was identified by its properties to increase permeability and act as...

The recognition of potentially harmful microorganisms involves the specific recognition of pathogen-associated molecular patterns (PAMPs) and the family of Toll-like receptors (TLRs) is known to play a central role in this process. TLR-4 is the major recognition receptor for lipopolysaccharide (LPS), a component of gram-negative bacterial cell wall...

Background and objectiveEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive mediastinal node sampling technique used for lung cancer staging and diagnosis of mediastinal lesions. The four published studies assessing sampling with 21-G or 22-G needles conflict. The study objective is to evaluate the d...

Background Malignant pleural effusion (MPE) causes debilitating breathlessness and predicting survival is challenging. This study aimed to obtain contemporary data on survival by underlying tumour type in patients with MPE, identify prognostic indicators of overall survival and develop and validate a prognostic scoring system. Methods Three large...

Background: Histological diagnosis by surgical lung biopsy for interstitial lung disease (ILD) is currently limited. Transbronchial cryobiopsy via flexible bronchoscope may this for more patients. The relative costs, diagnostic yields and safety of this approach and more traditional approaches have not been determined. Objectives: To perform a syst...

Introduction Literature reports of pleural fluid analysis can be found from the late 19th century onwards. Yet, despite nearly 150 years of practice, pleural fluid analytic tests remain relatively limited in diagnostic accuracy, leading to requirements for further investigations and uncertainty for physician and patient.Metabolomics combines high-r...

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. Aims To assess (1) awareness of NF complications among prescribers, (2) monitoring practice and (3) to describe the pulmonary sequelae of NF-r...

Background: Malignant pleural effusions (MPE) often cause symptoms and guidelines recommend early definitive intervention. However, observational data suggest systemic anti-cancer treatment (SACT) may control MPE due to certain pharmacologically-sensitive tumours. Research question: Is SACT associated with higher rates of MPE resolution in peopl...

Treatment for non‐small cell lung cancer (NSCLC) is now personalised using molecular mutation testing. Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) biopsy suitability for anaplastic lymphoma kinase (ALK) and epidermal growth factor receptor (EGFR) mutation testing is established. Less is currently known about EBUS‐TB...

We describe the case of a 61-year-old woman who presented with progressive respiratory symptoms and imaging demonstrating multiple opacities in the right lung with hilar and mediastinal lymphadenopathy suggestive of multifocal adenocarcinoma. Subsequent biopsies were consistent with focal changes of organising pneumonia (OP) and no evidence of mali...

Introduction Nitrofurantoin (NF) is prescribed for urinary tract infections (UTIs). Associated adverse pulmonary and hepatic side-effects are known. Current monitoring guidelines1 2 lack specific recommendations for monitoring. This work formed part of a clinical effectiveness project to raise awareness of side effects of prophylactic NF and allow...

Pleural empyema represents a significant healthcare burden due to extended hospital admissions and potential requirement for surgical intervention. This study aimed to assess changes in incidence and management of pleural empyema in England over the last 10 years and the potential impact of influenza on rates. Hospital Episode Statistics (HES) data...

The use of thoracic CT for patients presenting with a unilateral pleural effusion is well established. However, there is no consensus with regard to the inclusion of the entire abdomen and pelvis in the initial imaging protocol. In this prospective UK-based study, 249 patients presenting with a unilateral effusion had a CT thorax/abdomen/pelvis per...

Rationale: Parapneumonic effusions have a wide clinical spectrum. The majority settle with conservative management but some progress to complex collections requiring intervention. For decades, physicians have relied on pleural fluid pH to determine the need for chest tube drainage despite a lack of prospective validation and no ability to predict...

Introduction Sarcoidosis is a multi-system granulomatous disease. Thoracic involvement can sometimes present asymptomatically, only being detected incidentally during imaging studies for other conditions or non-specific symptoms. Appropriate follow up of these patients has not been well defined. Objective To define the clinical course of incidenta...

Introduction and objectives Initial manifestations of lung disease in rheumatoid arthritis often occur in the small airways which can be challenging to measure using traditional lung function tests. The lung clearance index (LCI), measured by the nitrogen multiple breath washout (MBW) is a non-invasive measure of ventilation inhomogeneity and has b...

The vast majority of undiagnosed unilateral pleural effusions have fluid sent for cytological analysis. Despite widespread use, there is uncertainty about its sensitivity to diagnose malignant pleural effusions (MPEs). Our aim was to ascertain the utility of cytology using a large prospective cohort. Consecutive patients presenting with an undiagno...

EBUS-TBNA is a recent mediastinal staging and diagnostic technique. We have previously reported superior characterisation with 21G biopsies over 22G biopsies for benign and malignant mediastinal nodes. A new 19G needle now exists but there are limited studies. We hypothesised 19G biopsies would improve both benign and malignant characterisation due...

IgG4-related disease is an immune-mediated fibro-inflammatory disease, characterised by distinct pathological features. An increasing number of clinical phenotypes are described, from single-organ disease to a multisystem disorder, which can present to a variety of different specialities. Recognition is key; its protean manifestations can mimic oth...

We report a case of a 68-year-old gentleman, found to have a right hilar soft tissue mass whilst undergoing CT staging for prostate cancer. MRI imaging showed a heterogenous, enhancing solid mass without evidence of fat content. A linear probe endobronchial ultrasound-guided transbronchial needle aspiration was performed using a 19G needle. This co...

A 71-year-old female with a history of pulmonary embolism treated with rivaroxaban presented with acute onset shortness of breath, chest pain and palpitations. Computed tomographic pulmonary angiography (CTPA) revealed multiple bilateral pulmonary emboli. The patient was concurrently prescribed carbamazepine and was later diagnosed with recurrence...

Introduction and Objectives Eosinophilic pleural effusions (EPE) are a relatively uncommon finding in the investigation of undifferentiated pleural effusions. Traditionally defined as a cell count ≥10% eosinophils, it was initially felt to be a marker of benign disease, however, subsequent studies found malignancy to be the commonest aetiology,¹ wi...

Background: Haematological malignancy is an important cause of pleural effusion. Pleural effusions secondary to haematological malignancy are usually lymphocyte predominant. However, several other conditions such as carcinoma, tuberculosis, and chronic heart failure also cause lymphocytic effusions. Lymphocyte subset (LS) analysis may be a useful...

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) diagnoses and stages mediastinal lymph node pathology. This retrospective study determined the relationship between EBUS-TBNA utility and non-small cell lung cancer (NSCLC) stage, lymph node size, and positron emission tomography (PET) standard uptake values (...

Background: Trainees are performing fewer bronchoscopies as a result of the increased use of endobronchial ultrasound-guided transbronchial needle aspiration. Workforce planning and changes in trainee working patterns may also have compounded this situation. We investigated current trends in endobronchial biopsy (EBB) and transbronchial biopsy (TB...

There has been increasing interest in transbronchial cryobiopsy for diagnosis in interstitial lung disease. As we highlighted in our systematic review and cost analysis, this has the potential to be cost saving in the setting of a payment by results system.1 Recently, it has been demonstrated in a porcine model that a new sheath cryoprobe gives equ...

Editor – The recent paper by Dafydd et al1 is a welcome attempt to quantify the service contribution of specialist registrars. However, the cost calculation is more complex. The paper focuses more on financial modelling for surgical registrars; independent operations and high volume outpatient clinic consultations lend themselves more easily to cos...

Background: Pleural effusions secondary to a non-malignant aetiology can represent significant morbidity and mortality. These non-malignant pleural effusions (NMPE) are common, with congestive heart failure (CHF) representing the leading cause. Despite this, there is limited data on mortality risk and the factors which influence them. Methods: W...

Introduction and objectives Non-Malignant Pleural Effusions (NMPE) have an estimated annual incidence of 200,000 in the UK.¹ They are often secondary to underlying organ dysfunction, with congestive heart failure (CHF) the leading cause. CHF itself carries a high mortality risk, with 28% of patients with New York Heart Association(NYHA) class IV dy...

Das klinische Syndrom der akuten Lungenschädigung (ALI; acute lung injury) entwickelt sich basierend auf einer vorausgehenden akuten systemischen Entzündungsreaktion. Diese kann auf direktem oder indirektem Wege vielfältige Schäden an der Lunge hervorrufen. Diese Schäden wiederum führen zu einer erhöhten epithelialen Permeabilität und damit zum Ein...

Editor – The summary paper from the British Society for Heart Failure 7th meeting highlights some important aspects for the general physician with respect to heart failure management.1 With respect to diagnosis, however, I would make one comment regarding the use of brain natriuretic peptide (BNP) and NT-proBNP in ruling out heart failure. While it...

We report a case of a mediastinal mass indenting the left lateral tracheal wall of a 35-year-old male who presented with weight loss, cough and breathlessness. Flow volume loop and thyroid function tests were normal and thyroid peroxidase antibodies were negative. Technetium scintigraphy and positron emission tomography both showed no uptake. Endob...

Phenotyping non-small-cell lung cancer is becoming increasingly important with the advent of molecular testing. Tumours harbouring somatic mutations in the gene that encodes for the tyrosine kinase domain of the epidermal growth factor receptor (EGFR) have been found to increase responsiveness to tyrosine kinase inhibitors. Endobronchial ultrasound...

A 72 year old lady smoker with pre-existing Chronic Myelomonocytic Leukaemia (CMML) presented with short history of dyspnoea and night sweats. Radiologically she had florid bilateral miliary nodularity with small areas of cavitation sparing the peripheries and lung bases. A VATS biopsy contained bronchiolocentric nodular infiltrates of histiocytes,...

The radiological finding of mediastinal lymph node enlargement following surgery for lung cancer often signifies locoregional recurrence. The use of oxidised cellulose haemostatic agents (OCHAs) during staging mediastinoscopy is common. We report a case of 18-fluorodeoxyglucose-avid subcarinal lymphadenopathy in a patient in whom OCHAs had been use...

Increasing numbers of doctors are experiencing burnout now more than ever before and the worrying part is that what we see is just the tip of the iceberg. Burnout, a state of mental exhaustion caused by the doctor’s professional life, is characterised by emotional exhaustion, depersonalisation and a reduced sense of accomplishment or success. Burno...

We welcome the comments of Nguyen et al. and agree that we cannot discount that differences in methodology between the studies may have had some bearing in the differences between our results and theirs. The purpose of our study was to address the issue of greyscale textural analysis in a real-life setting and set up in an environment that would ha...

The clinical syndrome of acute lung injury (ALI) occurs as a result of an initial acute systemic inflammatory response. This can be consequent to a plethora of insults, either direct to the lung or indirect. The insult results in increased epithelial permeability, leading to alveolar flooding with a protein-rich oedema fluid. The resulting loss of...

Previous studies have assessed the diagnostic ability of pleural fluid adenosine deaminase (pfADA) in detecting tuberculous pleural effusions, with good specificity and sensitivity reported. However, in North Western Europe pfADA is not routinely used in the investigation of a patient with an undiagnosed pleural effusion, mainly due to a lack of ev...

Background and objectiveRecent data suggest that grey-scale textural analysis on endobronchial ultrasound (EBUS) imaging can differentiate benign from malignant lymphadenopathy. The objective of studies was to evaluate grey-scale textural analysis and examine its clinical utility.Methods Images from 135 consecutive clinically indicated EBUS procedu...

Organising pneumonia is one of the responses of the lung to injury and can mimic bacterial pneumonia but importantly it does not respond to antibiotic therapy. We present the case of a 67-year-old male who was diagnosed with organising pneumonia secondary to dronedarone. Drug reactions are a common cause and early identification of the culprit is m...

Current guidelines state that patients over 40 years of age with a first unprovoked pulmonary embolism should be offered limited screening for possible cancer and considered for intensive screening (abdomino-pelvic computed tomography and mammography), despite no evidence for the latter. The aim of this study was to evaluate the clinical utility an...

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an important minimally invasive technique in lung cancer staging and diagnosis. Aim A retrospective analysis of EBUS-TBNA performance in patients with suspected malignancy referred between November 2009 and December 2013 to a UK tertiary EBUS centre. Methods We reviewed...

This summer brings a mostly new editorial team to the JRCPE (Andrew Medford continues to manage the Education section), and, with a significant changing of the guard, now is perhaps a good time to stop and reflect on what the JRCPE is for. Who is our readership? What is the JRCPE's mission? What niche should the JRCPE occupy in the publishing lands...

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an increasingly used mediastinal sampling technique. Many centres use conscious sedation in an ambulatory setting to optimise the flow of patients, save costs and shorten recovery time. The only EBUS-TBNA patient satisfaction study published so far used dee...

Learning Point for Clinicians Lung malignancy is the most important differential in unexplained CXR lesions especially in heavy smokers. However, it is also important to consider benign disorders and intrapleural lipoma should be considered when the lesion is very fatty on CT. This can potentially avoid unnecessary invasive investigations and allev...

Conventional transbronchial needle aspiration (cTBNA) has a long history over three decades of utility for mediastinal sampling in lung cancer (1) especially in more bulky disease and can achieve high yields (nearly 80% or above) even in relatively new services (2). It has also been utilised in the diagnosis of benign mediastinal disease (3). The a...

Brill et al. [1] report on the potential utility of mycophenolate mofetil (MMF) as a steroid-sparing agent in chronic pulmonary sarcoidosis in 10 patients with some success in the reduction of systemic steroids while preserving lung function and clinical stability. Although this provides a welcome possible alternative to other steroid-sparing agent...

Broncho-alveolar lavage (BAL) is an important diagnostic tool in many areas of thoracic medicine. On the intensive care unit (ICU), BAL is often required for a variety of indications, including assessment of possible ventilator-associated pneumonia (VAP). Recent data suggest BAL may be superior to less invasive techniques in the assessment of VAP....

Acute respiratory distress syndrome (ARDS) is the most severe form of lung injury, characterised by alveolar oedema and vascular permeability, in part due to disruption of the alveolar capillary membrane integrity. Vascular endothelial growth factor (VEGF) was originally identified as a vascular permeability factor and has been implicated in the pa...

Introduction EBUS-TBNA has avoided the need for patients to undergo mediastinoscopy and can be done under conscious sedation with minimal complications for mediastinal lymph node sampling for lung cancer. The sample analysis varies depending on local expertice. Objective Methods We reviewed all EBUS procedures performed at Glenfield Hospital, UK fr...

Worsening breathless in a patient with severe chronic obstructive pulmonary disease (COPD) is a common diagnostic and management challenge in primary care. A systematic approach to history-taking and examination combined with targeted investigation of pulmonary, cardiovascular, thromboembolic and systemic causes is essential if co-morbidities are t...

Introduction Blood and tissue lymphocyte subsets (LS) analysis are routinely used in the diagnosis of a number of haematological conditions. Samples cost £25 to process and are technically labour intensive. The 2010 BTS pleural guidelines suggest LS may be useful in cases of suspected lymphoma, but there is no evidence supporting their utility or p...

Background Outpatient management of undiagnosed pleural effusions is increasing. Payment for managing these patients is usually based on standard outpatient Healthcare Resource Group (HRG) codes. For 2013/14, a new Best Practice Tariff (BPT) of £1534 has been introduced to further disincentivize emergency inpatient management. We audited our servic...

Introduction Epidermal growth factor receptor (EGFR) gene mutations in non-small cell lung cancer have been shown to confer improved responsiveness to tyrosine kinase inhibitors. NICE recommends tyrosine kinase inhibitors as first line therapy in patients with locally advanced or metastatic tumours with EGFR gene mutations. Evidence from a multicen...

A recent issue of CHEST (April 2013) highlights an important issue pertaining to the safety of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). In the issue, Çoruh et al 1 report on an adverse effect of fentanyl used for bron-choscopy and EBUS-TBNA. We have calculated the mean dose in our institution administered for co...

A previously fit 25-year-old man presented with cavitating lung infection and evidence of cystic bronchiectasis. Computed tomography showed a 4.7cm soft tissue mass containing patchy calcification occluding the basal bronchus of the right lower lobe, resulting in atelectasis and marked distal airway dilatation with endoluminal air-fluid levels and...

The recently published article by Moua et al1 (February 2013) is timely but raises more questions about how to study patients with mediastinal lymphadenopathy (MLAD) and idiopathic pulmonary arterial hypertension (IPAH). It would be particularly helpful for clinicians who treat such patients to be able to perform a risk assessment of the need for m...

Competition for posts in higher specialist training (and thereafter consultant posts) is increasing, with an emphasis on specializing down a particular path at an earlier stage. Producing and maintaining a high quality curriculum vitae (CV) is an important step in getting shortlisted for interviews. Of course, there is an application form to comple...