Utility of immunology, microbiology, and helminth investigations in clinical assessment of severe asthma.

OBJECTIVE: Systematic assessment of patients with potential severe asthma is key to identification of treatable traits and optimal management. Assessment of antimicrobial immune function is part of that assessment at many centers although there is little evidence-base on its added value in clinical assessment of this patient group. As part of reviewing our local pathway, we have retrospectively reviewed these tests in 327 consecutive referrals to our severe asthma service, in an evaluation to describe the utility of these tests and allow refinement of the local guideline for patient assessment. METHODS AND RESULTS: Serum immunoglobulin concentrations were in the normal range in most patients though 12 patients had serum IgG < 5.5 g/L and many had suboptimal anti-Haemophilus (127 of 249 patients tested) and anti-Pneumococcal (111 of 239) immune responses. As expected many patients had evidence of sensitization to Aspergillus although specific IgG was not confined to those with evidence of allergic sensitization/allergic bronchopulmonary aspergillosis (ABPA). Eighteen of 277 patients tested had serological evidence of Strongyloides infection. Bacteria and/or yeast were cultured from the sputum in 76 out of 110 patients productive of sputum, and the most common microbes cultured were Candida sp. (44 patients), Staphylococcus aureus (21 patients), Haemophilus influenzae (18 patients). CONCLUSIONS: Many patients had evidence of infection, colonization, or sensitization to potential pathogens relevant to asthma. Strongyloides infection was evident in several patients, which may be a major issue when considering the risk of hyper-infection following immunosuppression and supports our local screening strategy.

Survey of early discharge schemes from the 2003 UK National COPD Audit.

BACKGROUND: Early discharge for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) has been shown to be effective by clinical trials. To evaluate its implementation and efficacy in clinical practice, data concerning early discharge schemes (EDS) from the 2003 National COPD Audit were collected and analysed. METHODS: All acute Trusts in the UK were surveyed in Autumn 2003 by two means: one a questionnaire relating to organisation of care and second an audit of 40 clinical cases admitted with AECOPD. RESULTS: Data were available for both organisation of care and clinical activity for 233 units, of which 103 (44%) had EDS. Models of care included admission prevention in the accident and emergency department (5%), rapid discharge in <48h (27%), assisted discharge occurring 2 days or more after admission (24%) and combinations of these (12%). There was wide variation in organisation of care overall. 30% of patients in units with EDS were discharged early from hospital. Units with EDS had an average LOS 1-day shorter with no increase in readmission rate (32% vs. 32%) as for those without an EDS and no increase in mortality. CONCLUSIONS: There is wide variation in the availability of EDS for AECOPD in the UK, with increasing implementation of schemes. Thirty percent of patients can effectively be put into EDS which is higher than the figure of 25% from randomised controlled trials (RCTs). Mortality and readmission rates are the same as for units where no EDS is available and similar to results reported in RCTs. EDS therefore appears to be effective in routine clinical practice.

Practical prescribing course: a student evaluation.

BACKGROUND: Prescribing errors occur in up to 10 per cent of junior doctor prescriptions, and medical students feel underprepared for the challenges of prescribing once qualified. A number of studies have looked into the effectiveness of new interventions, in particular pharmacist-taught prescribing courses, but there is little data on how students perceive these new strategies. The aim of this project was to evaluate a teaching programme of practical prescribing skills, conducted by hospital pharmacists, via a series of focus groups. METHODS: A pharmacist-taught course in practical prescribing was introduced to final-year medical students during clinical placements at five different hospitals. A focus group was conducted at each participating hospital and emerging themes were identified. RESULTS: Key emerging themes from the focus group analysis showed that students felt more confident in prescribing after completing the course. Students valued the opportunity to gain practical prescribing experience by using problem-based exercises, which encouraged them to prescribe on real drug charts, or to spot prescribing errors or drug interactions on charts constructed by pharmacists. Pharmacists were felt to be knowledgeable and approachable teachers. Students highlighted controlled drug prescriptions and familiarity with the British National Formulary (BNF) as key topics that hadn't been covered in conventional pharmacology teaching. DISCUSSION: A practical prescribing course can help prepare medical students by giving them the tools to tackle complex prescribing scenarios. Pharmacists as teachers were well received, and specific topics, including controlled drug prescribing and using sample drug charts, should be the focus of these types of courses.