We describe five patients with severe nocturnal cough and daytime somnolence in whom the coughing attacks are triggered by assuming the supine body position. Quantity and quality of the nocturnal cough were evaluated in the sleep laboratory with and without nasal continuous positive airway pressure (N-CPAP). Air flow characteristics were assessed using flow volume and airway resistance loops. Airway anatomy was evaluated bronchoscopically. In all five patients, the cough had a barking quality. Flow-volume loops showed an expiratory collapse phenomenon in two of the patients. Endoscopically, all five patients had signs of airway collapse. All patients had difficulty falling asleep because of coughing and were awakened by it frequently. Sleep times ranged from 2.5 to 4.5 h per night. With N-CPAP pressures ranging from 5 to 13 cm H2O, all five patients had clinically significant improvement in their symptoms. Their sleep times increased to a range of 5 to 7.5 h per night and the daytime somnolence markedly improved or resolved. All five patients requested a N-CPAP unit for home use. We conclude that a cough that is predominantly associated with or exacerbated by the supine body position may be treated effectively with N-CPAP.

A 54-year-old woman developed signs and symptoms consistent with reflex sympathetic dystrophy in her left upper extremity following arterial puncture. Diagnosis was confirmed by bone scan, and sympathetic blockade with intravenous regional bretylium completely relieved her severe, intractable pain.

We report a case of complete torsion of the right lung induced by transthoracic needle biopsy. While a delay in diagnosis occurred, viability of the torsed lung was maintained, thereby allowing for effective surgical repair.

A case of mediastinal malignant epithelioid schwannoma (MES) is reported. The tumor probably arose in the vagal nerve, and the trachea was involved. A few months after excision of the primary tumor, multiple metastases appeared in lung, cervical spine, and neck lymph nodes. Microscopically, the tumor showed a highly cellular area resembling melanoma or carcinoma. Immunolabeling was done for S-100 protein, keratin, and melanoma-associated antigen. Examination of the entire lesion and in situ characteristics of the tumor involving the vagal nerve were helpful in making the correct diagnosis. Mediastinal MES, to our knowledge, has not been reported to date in the English-language medical literature.

We report an 18-year-old patient with severe mitral stenosis complicated by right lower lobe pneumonia, sepsis, and shock. Intractable low cardiac output led to an emergency percutaneous balloon mitral valvotomy in a patient, resulting in immediately improved hemodynamic parameters. We are unaware of another report of percutaneous balloon mitral valvotomy performed in a patient with sepsis and shock. This case supports previous isolated reports of the benefit from emergency percutaneous balloon mitral valvotomy in critical situations where thoracotomy is not possible due to coexisting medical problems.

Despite reports of the clinical presentations and devastating consequences of paradoxical embolus (PDE) for more than a century, this diagnosis continues to be frequently missed. Because the prevalence of patent foramen ovale (PFO) is 27 to 35% in the normal population and the presence of deep vein thrombosis or pulmonary embolus may not be clinically obvious, a high suspicion for PDE is needed in the event of unexplained arterial occlusion. While contrast echocardiography and transcranial Doppler ultrasound have facilitated clinical recognition of PDE, the optimum approach to diagnosis requires clarification. Primary therapy for patients with PDE is anticoagulation, with thrombolytics considered in carefully selected individuals, but there is little published information regarding long-term treatment and outcomes. Prevention remains essential whenever possible. It is not yet defined whether prophylactic treatment of persons with recognized predispositions to PDE (eg, PFO and pulmonary hypertension) is beneficial.

The incidence of malignant pleural mesothelioma is increasing. Untreated, patients with this disease experience a rapid and horrendous clinical decline. Surgery plays a role in the diagnosis, staging, and treatment of this malignancy. Surgery, chemotherapy, and radiotherapy alone have been unable to achieve major improvements in survival for most patients. More recent phase II trials suggest that surgery, at one time a purely palliative approach, may have a potentially curative role when used in combination with chemotherapy and radiotherapy.

Malignant mesothelioma of the pleura occurs primarily in individuals who were exposed to asbestos either in the workplace or home. The incidence of malignant mesothelioma is rising and, reflective of the malignancy's long latency period, is expected to continue to increase into the next century. Current treatment measures, including surgery, radiation therapy, chemotherapy, intrapleural therapy, and combined-modality therapies, have had varying impacts on survival. This paper explores current trends in the treatment of malignant pleural mesothelioma.

Surgical resection remains an important form of treatment for pulmonary metastases from a variety of solid tumors. The most significant factors in selecting patients for operation include control of the primary tumor, ability to resect all metastatic disease, absence of extrathoracic metastases, lack of better alternative systemic therapy, and sufficient cardiopulmonary reserve for the planned resection. A solitary pulmonary nodule and long tumor doubling times and disease-free intervals usually define patients who experience better long-term survival after pulmonary resection but do not constitute absolute criteria by which to select such patients. Complete surgical resection is critical to achieving long-term survival and is best accomplished via a standard or "clamshell" thoracotomy or a median sternotomy. The decision to proceed with the surgical resection of pulmonary metastases should be a multidisciplinary one, made jointly by the thoracic surgeon and the medical oncologist.

Treatment of lung cancer remains frustrating. Most patients with lung cancer are not candidates for curative therapy, and new therapies have not made a substantial impact on survival. Consequently, some clinical investigators have focused their efforts on developing prevention strategies. Chemoprevention, the administration of agents to block or reverse carcinogenesis, is being investigated in ongoing trials. Studies of chemoprevention in lung cancer have included trials to reverse premalignant lesions such as sputum atypia or squamous metaplasia of the bronchial epithelium. Clinical trials of lung cancer prevention have often studied groups of participants with tobacco or asbestos exposure. Other clinical trials are being conducted among patients who have been treated for an early-stage lung cancer. As the result of diffuse epithelial injury, these patients are at very high risk for developing second primary tumors, predominantly in the lungs and upper aerodigestive tract. It is our hope that these studies may establish a new strategy for preventing lung cancer.

With lung resection remaining the cornerstone of curative therapy in patients with lung cancer, aggressive perioperative management continues to play a critical role. This review summarizes the most important factors in successful perioperative management. These include patient selection, with an emphasis on which patient variables and hemodynamic assessments are most useful in determining operability. Postoperative management, in particular, patient-controlled analgesia, and pulmonary toilet, are essential to facilitate early patient mobility and to minimize complications, respectively. Aggressive perioperative management can result in reduced postoperative morbidity and mortality, reduced length of hospital stay and expenditures for complications, and it expands the population that can receive potentially curative therapy.

The identification of new chemotherapeutic agents for the treatment of non-small cell lung cancer should proceed in a structured, logical fashion. Agents should be evaluated on the basis of multiple objective and subjective end points. A 15% or greater major objective response rate, demonstrated in multiple single-agent phase II trials, is considered the lower limit for an agent to be deemed clinically active in this disease. A number of drugs previously have been identified in this category, including cisplatin, ifosfamide, mitomycin, paclitaxel, and the vinca alkaloids vinblastine and vindesine. Most of these conventional agents have been explored alone, in a variety of doses and schedules, and in combination. In the last several years clinical development has produced new agents, including chloroquinoxaline sulfonamide, docetaxel, edatrexate, gemcitabine, irinotecan, topotecan, and vinorelbine, which hold promise for more successful treatment of this lethal disease.

Radiologic evaluation of the patient with non-small cell lung cancer (NSCLC) includes chest radiographs for detecting nodules, computed tomography (CT) for further characterizing them, CT and magnetic resonance imaging (MRI) to evaluate the mediastinum, and extrathoracic imaging of bones, the adrenal gland, the central nervous system, and liver. The current practice standards for each are reviewed. Asymptomatic solitary pulmonary nodules, which are usually detected on chest radiographs obtained for other indications, inevitably require a precise diagnosis. The radiologic characteristics that differentiate benign from malignant pulmonary lesions are given. Mediastinal CT is the preferred modality for examining the mediastinum in patients with NSCLC. Magnetic resonance imaging is used selectively, eg, in patients with superior sulcus tumors who are candidates for surgery. When evaluation for N2/N3 disease is requested, mediastinoscopy should replace CT using the latter as a "roadmap." The role of extrathoracic imaging in evaluating asymptomatic patients with NSCLC at initial presentation is equivocal. Computed tomographic scanning of the head is reasonable in most patients with lung cancer, given the significant incidence of occult brain metastases in this population and that solitary brain lesions may be resected in some protocol settings. Routine liver and adrenal gland scanning is similarly controversial. Bone scans do not appear to be useful in patients with NSCLC unless they have clinical signs, symptoms, or laboratory findings to indicate possible metastases. Although heavily affected by local practice, radiologic evaluation of the patient with NSCLC should attempt to provide accurate determination of local disease and a search for distant metastases.