Review series: old age: pneumonia in old age.

At the end of the 19th century William Osler noted key differences in the presentation of pneumonia in the elderly. His observational perspicuity has withstood the passage of time. The following article pays deference to this Canadian physician, summarizing not only differences in clinical presentation but also including an update on epidemiology, aetiology and management.

Putting an end to Black Wednesday: improving patient safety by achieving comprehensive trust induction and mandatory training by day 1.

The term 'Black Wednesday' has been used to describe the August national changeover day, a day when a new cohort of inexperienced doctors start work, many of whom are absent from patient care to attend organisational induction and mandatory training. In this paper, we report on the development and implementation of a novel, interactive e-learning programme for induction and mandatory training for junior doctors in a district general hospital in south-west England from August 2013. This comprehensive mandatory-training programme with summative assessment saved 19.5 hours of trust time per trainee. Since the programme's inception, the completion rate has been 100% (n = 370). Subgroup analysis of starters from August 2013 (n = 141) showed that 85.7% completed by day 1 (mean time of completion 3.0 days before day 1, standard deviation 14.2 days). Importantly, 90 minutes of induction was freed on Black Wednesday, enabling earlier, ward-based clinical orientation, thereby enhancing patient safety. We believe that this is the first programme to combine induction with fully assessed, comprehensive mandatory training in a single package. Such an approach is suitable for widespread application and is to be implemented regionally.

Isolates of Pneumocystis jirovecii from Harare show high genotypic similarity to isolates from London at the superoxide dismutase locus.

Pneumocystis jirovecii is the cause of Pneumocystis pneumonia (PCP) in humans. Isolates of P. jirovecii obtained from patients in Harare, Zimbabwe were genotyped at the superoxide dismutase locus. High genotypic similarity to isolates of P. jirovecii obtained from patients in London, UK was observed. These data provide additional support for the hypothesis that P. jirovecii is genetically indistinguishable in isolates from geographically diverse locations.

Outcomes of Pseudomonas eradication therapy in patients with non-cystic fibrosis bronchiectasis.

Pseudomonas aeruginosa infection is associated with poorer outcomes in non-cystic fibrosis bronchiectasis. It is unknown whether early eradication improves outcomes. This retrospective study assessed clinical and microbiological outcomes of eradication therapy following initial Pseudomonas infection. All patients undergoing Pseudomonas eradication therapy from 2004 to 2010 were identified retrospectively and assessed for microbiological eradication, exacerbation frequency, hospital admissions, clinical symptoms and lung function. 30 patients were identified with median follow-up time 26.4 months. Eradication therapy involved intravenous antibiotics (n = 12), intravenous antibiotics followed by oral ciprofloxacin (n = 13) or ciprofloxacin alone (n = 5), combined with 3 months of nebulised colistin. Pseudomonas was initially eradicated from sputum in 24 patients (80.0%). 13/24 patients remained Pseudomonas-free and 11/24 were subsequently reinfected (median time 6.2 months). Exacerbation frequency was significantly reduced from 3.93 per year pre-eradication and 2.09 post-eradication (p = 0.002). Admission rates were similar, at 0.39 per year pre-eradication and 0.29 post-eradication (p = NS). 20/30 patients reported initial clinical improvement, whilst at one-year follow up, 19/21 had further improved or remained stable. Lung function was unchanged. This study demonstrates that Pseudomonas can be eradicated from a high proportion of patients, which may lead to prolonged clearance and reduced exacerbation rates. This important outcome requires confirmation in a prospective study.

Genotypes of Pneumocystis jiroveci isolates obtained in Harare, Zimbabwe, and London, United Kingdom.

Isolates of Pneumocystis jiroveci from sulfa-exposed and nonexposed patients from London, United Kingdom, and Harare, Zimbabwe, were genotyped. At the dihydropteroate synthase (DHPS) locus, there was evidence of selection pressure from sulfa drug exposure, and reversal of DHPS genotype ratios occurred when selection pressure was absent or was removed.