The diaphragm is the main inspiratory muscle, and diaphragmatic weakness can lead to respiratory failure. Diaphragmatic weakness or paralysis commonly presents in association with more generalised neuromuscular disorders. However, it can be caused by other pathologies, such as trauma, compression, infection and inflammation [1]. Isolated diaphragmatic palsy (DP) is well-described [2], but often missed in adults [3], especially in bilateral diaphragmatic palsy (BDP) where both domes of the diaphragm are elevated.
We sought to establish whether an expedited or 'fast-track' NHS service to diagnose obstructive sleep apnoea (OSA) and establish vocational drivers on continuous positive airway pressure (CPAP) within 4 weeks of referral was possible. This model is recommended by the OSA Partnership Group. In total, 55 vocational drivers were referred to two sleep services. Assessment showed 73% had moderate or severe OSA on sleep study. Of those commenced on CPAP, review was a mean of 15 days after initiation (range 3-62 days). Median time from referral (or fi rst clinic visit) to review on CPAP was 32 days, showing a 'fast-track' pathway is deliverable.
A 64-year-old man, resident in Arizona for 3 years, presented with a week-long history of a dry cough and 'flu-like symptoms'. He had recently been renovating his house. A chest radiograph showed a left mid-zone opacity. Investigations for lung cancer were performed and he underwent CT-guided biopsy of the lesion. A coccidioidal fungus known to cause 'Valley Fever' was isolated. Treatment with fluconazole led to a complete recovery. This fungal infection is endemic in parts of the USA and Mexico and usually presents with respiratory symptoms. Additional complications include disseminated disease and meningitis.
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