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Introduction. Sarcoidosis is a chronic granulomatous disease of unknown aetiology with a variable clinical course and prognosis. There is an urgent need to identify new and novel biomarkers to help differentiate between clinical phenotypes and guide clinical decisions with respect to commencing and monitoring treatment. Across the spectrum of respiratory disease there has been a growing interest in the role of breath-based biomarkers given their non-invasive nature and ability to repeat sampling with ease for serial monitoring. Soluble interleukin-2 receptor (sIL2R) in bronchoalveolar lavage and serum correlates with disease activity in sarcoidosis; however, no previous study has evaluated sIL2R in exhaled breath. Objectives. The main aim of this cross-sectional case-controlled pilot study was to determine the concentration of sIL2R in exhaled breath condensate (EBC) from patients with recently diagnosed sarcoidosis compared to healthy volunteers and to establish, if present, if this correlated with markers of disease activity, pulmonary function tests and serological markers used in current clinical practice. Methods. Paired serum and EBC samples were collected from twelve treatment naïve patients with histologically proven sarcoidosis diagnosed during the previous six months and compared to twelve healthy volunteers matched for age and gender. Results. Mean concentration of serum sIL2R was significantly elevated in participants with sarcoidosis compared to healthy controls (1584.3 ± 489.1 versus 874.2 ± 235.7 pg mL−1; p = 0.001). Soluble interleukin-2 receptor in EBC was detectable in only five subjects including three participants with sarcoidosis. The range of sIL2R across all five samples was 148.0–288.2 pg mL−1 with the two highest concentrations observed in two participants with sarcoidosis. There was no significant difference observed in EBC sIL2R between sarcoidosis and healthy controls (p = 0.71). No apparent correlations were observed between EBC sIL2R and radiological stage, pulmonary function tests or serological markers. Conclusion. Soluble interleukin-2 receptor is detectable in EBC; however, the findings from our study do not support its role as a diagnostic marker in sarcoidosis. Further research is required to evaluate its prognostic utility.

Introduction: Exhaled biomarkers may indicate disease processes in idiopathic pulmonary fibrosis (IPF). We performed a PRISMA-compliant systematic review to investigate whether such markers discriminate between patients with IPF and healthy controls or correlate with lung function. Methods: Database searches were performed using the terms (Pulmonary fibrosis OR Lung Diseases, interstitial OR Fibrosing Alveolitis OR Diffuse Parenchymal Lung Disease OR Usual Interstitial Pneumonia) AND (Breath tests OR Volatile Organic Compounds OR Metabolomics OR Breath analysis OR Breath biomarkers OR Breathomics OR exhaled breath). Study selection was limited to adults with a diagnosis of IPF as per international guidelines. Results: 1014 studies were screened, 53 underwent full text review and 15 fulfilled selection criteria. The mean number of IPF patients included was 19 (range 6-40). 20 individual biomarkers discriminated between IPF and healthy controls, and four correlated with lung function. Metanalysis of three studies indicated alveolar nitric oxide levels were higher in IPF (8.5±5.5 ppb) than controls (4.4±2.2 ppb). Measurements of oxidative stress, such as hydrogen peroxide and 8-isoprostane were also found to discriminate between IPF and controls. Two breathomic studies, one using exhaled breath condensate and the other using volatile organic compounds have isolated discriminative compounds using mass spectrometry. One, p-cymene, correlated with lung function. Conclusions: Evidence suggests alveolar nitric oxide is higher in patients with IPF, however in general studies were limited by small sample size. Further breathomic work may identify biomarkers with diagnostic and prognostic potential.

Purpose of Review: We review recent studies of patients with septated malignant pleural effusions, to understand what the clinical implications for patients are and what evidence-based methods should be used to manage these effusions. Recent Findings: Fibrinolytics improve effusion size assessed radiologically in patients with a chest drain inserted for septated malignant pleural effusions but this does not translate into an improvement in breathlessness relief or pleurodesis success. Fibrinolytics have also been used in patients with septated effusions associated with indwelling pleural catheters, but dyspnoea relief has not been assessed in this population. Patients with septated effusions or extensive adhesions appear to have a worse prognosis. Summary: Patients with septated malignant pleural effusions have a poor prognosis and do not gain clinical benefit from fibrinolytics via chest drain. The role of fibrinolytics for septated effusions associated with indwelling pleural catheters requires further study.

INTRODUCTION: Sarcoidosis is a chronic granulomatous disease of unknown aetiology with a variable clinical course and prognosis. There is a growing need to identify non-invasive biomarkers to differentiate between clinical phenotypes, identify those at risk of disease progression and monitor response to treatment.OBJECTIVES: We undertook a systematic review and meta-analysis, to evaluate the utility of breath-based biomarkers in discriminating sarcoidosis from healthy controls, alongside correlation with existing non-breath based biomarkers used in clinical practice, radiological stage, markers of disease activity and response to treatment.METHODS: Electronic searches were undertaken during November 2017 using PubMed, Ebsco, Embase and Web of Science to capture relevant studies evaluating breath-based biomarkers in adult patients with sarcoidosis.RESULTS: 353 papers were screened; 21 met the inclusion criteria and assessed 25 different biomarkers alongside VOCs in exhaled breath gas or condensate. Considerable heterogeneity existed amongst the studies in terms of participant characteristics, sampling and analytical methods. Elevated biomarkers in sarcoidosis included 8-isoprostane, carbon monoxide, neopterin, TGF-β1, TNFα, CysLT and several metallic elements including chromium, silicon and nickel. Three studies exploring VOCs were able to distinguish sarcoidosis from controls. Meta-analysis of four studies assessing alveolar nitric oxide showed no significant difference between sarcoidosis and healthy controls (2.22ppb; 95% CI -0.83, 5.27) however, a high degree of heterogeneity was observed with an I2 of 93.4% (pCONCLUSIONS: The evidence for using breath biomarkers to diagnose and monitor sarcoidosis remains inconclusive with many studies limited by small sample sizes and lack of standardisation. VOCs have shown promising potential but further research is required to evaluate their prognostic role.

A 31-year-old female presented to the emergency department with a 5-day history of feeling generally unwell, with a sore throat, breathlessness and a productive cough with expectoration of clear mucoid sputum. Her exercise tolerance, previously unlimited, had declined to approximately 90 m. She denied any pyrexia, rigors, haemoptysis or night sweats., Can you diagnose this patient presenting to the emergency department with a short history of productive cough and breathlessness and a history of recurrent admission for chest infections? http://ow.ly/PoHQ30kmGPi

The incidence of tuberculosis in England has shown a year-on-year decline over the past four years. The main burden of disease has been concentrated in larger urban areas. The East of England is an area of low prevalence and in 2015, had the lowest rate of TB cases notified per 1 00 000 people (6.2). London, the West Midlands and the North-West had the highest rates in the country. The population demographic of Norfolk shows a variation when compared to the rest of England. In 2011, 21.4% of Norfolk’s population was aged 65 or over compared with 16.5% in England. Similarly, 94.3% of people in Norfolk were identified as white compared to 87.5% in England.1 We hypothesised that these differences would be reflected in the demographics of patients treated for Tuberculosis at the Norfolk and Norwich University Hospital (NNUH). We analysed data over a 3 year period between 2014 and 2016. While most patients were diagnosed and treated locally, patients had been diagnosed elsewhere and moved to the local area after commencing treatment. One patient moved abroad following diagnosis. Our incidence of Tuberculosis was significantly lower than the national rate. Forty-six patients were diagnosed with TB in the 3 year period. This equates to 2.47 new cases per 1 00 000 people compared to 10.5 per 1 00 000 nationally in 2015. Four cases were Isoniazid resistant (8.7% compared to 6.9% nationally). There was one case of multi drug-resistant TB. Fourteen cases did not have microbiological cultures. In our patient group, 67.3% were born outside the UK compared to 72.5% nationally. Twenty-one of the twenty-three patients aged less than 40 were born abroad. However, all of the seven patients 65 and above were UK-born. Additionally, of the twenty patients with extra-pulmonary disease (with or without pulmonary involvement), only two were born within the UK. These trends are similar to those seen nationally. Furthermore, the incidence of TB locally peaked in the 25–29 age group reflecting national figures.2 Our analysis shows that contrary to our hypothesis, there is no significant difference in the TB population in a low-incidence area compared to high-incidence areas. References http://www.cprenorfolk.org.uk/wp-content/uploads/2012/05/Demography-and-Information-in-Norfolk.pdf http://www.tbalert.org/wp-content/uploads/2016/09/PHE_TB_Annual_Report_2016.pdf

Background: A chylothorax is a rare cause of pleural effusion resulting in the accumulation of chyle in the pleural space due to disruption or obstruction of the thoracic duct or its tributaries. We present an extremely unusual cause for a chylothorax following posterior cervical decompression. Case Report: A 27 year-old-female with a history of persistent neck pain presented with acute onset lower limb paralysis, retention and paraesthesia. Urgent MRI demonstrated cord compression at the level of C7 and she was transferred to a tertiary centre and underwent posterior cervical decompression. Four weeks post-operatively she presented with worsening dyspnoea and a chest radiograph demonstrated a moderate right-sided effusion. Intercostal chest drain was inserted and drained greasy purulent fluid initially thought to represent an empyema, however her inflammatory markers remained within normal parameters. Furthermore pleural glucose was 4.5mmol/L. As a result of the greasy appearance further analysis revealed elevated triglycerides at 10.4mmol/L. A CT neck and thorax was unremarkable other than the effusion. She was commenced upon a fat-free diet and the drain output significantly improved from >2L/day to 300-600mls/day. In addition she was referred for consideration of thoracic duct ligation. Discussion: Chylothorax is a rare complication recognised following anterior spinal surgery, however is reported in only a handful of cases of following a posterior approach. This therefore highlights the need to consider chylothorax in any patient presenting with a pleural effusion following spinal surgery and need for specific analysis of fluid for triglycerides and chylomicrons to confirm or refute a diagnosis.

In order to make evidence-based decisions in clinical environments, therapists must use psychometrically sound measures of client skill and performance (Ellenberg, 1996). In the area of driver assessment and rehabilitation, suitably qualified occupational therapists in Australia currently use a variety of unstandardised assessments or parts of standardised tests in the off-road environment (Lovell & DiStefano, 2003). Therapists combine the results of these assessments with on-road test results to make licence recommendations for older and functionally impaired individuals to the state licensing authority. The aim of this paper is to document and review off-road driver assessments reported in the published literature or used by occupational therapists in Australia. No other driver test review papers could be found in the published literature. Specifically, the paper examines assessments that purport to measure client skill and performance in the areas of basic cognitive and perceptual skills, reaction time, and road law knowledge. As a resource for clinicians, a summary of each assessment is included in Appendix 1, and it includes information such as aims, scoring, cost and availability, strengths and weaknesses and the level of skills measured according to Michon’s model of driver behaviour (van Zomeren, Brouwer & Minderhound, 1987). The findings of this review can be used to guide occupational therapy driver assessors in their selection of off-road assessments, and contribute to future research to develop a standardised off-road driver assessment for occupational therapists.