Ethical planning for an influenza pandemic.

A U.K. Pandemic Influenza Contingency Plan was developed in 2006 but little research has since been carried out as to how ethically acceptable it will be to society. A survey containing two hypothetical scenarios was distributed to 1,018 hospital staff. The survey considered their attitudes to the professional and ethical responsibilities of healthcare workers, and to resource allocation on the intensive care unit (ICU). Of those distributed, 406 (40%) surveys were returned. During a pandemic, 320 (79%) healthcare professionals would continue to work and 339 (83%) felt it would be unprofessional for doctors to leave work. Only 218 (54%) chose the same patient for the last ICU bed. Most staff surveyed felt they should (professionally) and would (voluntarily) work during a pandemic despite high personal risk. A wide diversity of opinion existed regarding resource allocation of ICU beds. These ethical issues require open debate to ensure U.K. pandemic plans are ethically acceptable and practically applicable.

Current concepts in the management of sarcoidosis.

Sarcoidosis can affect almost every organ. It has diverse clinical presentations and a variable natural history. Lungs and intrathoracic lymph nodes are the most commonly involved tissues. A major challenge to clinicians is the early identification of those patients with aggressive disease in whom therapy might arrest progression. Although lung uptake of 67Ga citrate, elevated serum angiotensin converting enzyme (ACE) levels and elevated T lymphocyte count in bronchoalveolar lavage fluid are all thought to reflect disease activity, they are by no means reliable markers. Because recent studies have shown that corticosteroid treatment does not avert pulmonary fibrosis and permanent impairment of pulmonary function, the use of these agents is restricted to the palliative treatment of disabling symptoms and physiological derangements. Corticosteroids are effective in reducing ocular inflammation, correcting hypercalcaemia, improving pulmonary function and alleviating symptoms related to hepatic, splenic, articular, myocardial, neural and cutaneous involvement. In the small proportion of patients who do not respond to moderate tolerable doses of steroids, alternative drug therapy such as immunosuppressives or immune modulators must be considered.

A case of primary amebic meningoencephalitis in a Nigerian farmer.

A fatal case of primary amebic meningoencephalitis (PAME) in a 35-year-old Nigerian Muslim farmer is described. The disease was contracted during ritual washing before prayers, which involved the sniffing of water up his nose to clean it. The water came from a man-made pond at his farm. The clinical presentation, isolation of the ameba from the cerebrospinal fluid and nasal passages, poor response to amphotericin B, and ultimate fatal outcome prove this to be a case of PAME. On the basis of its ability to grow at 42 degrees C, morphology of the trophozoite, cyst, and flagellate forms, animal pathogenicity, and nuclear division the ameba was identified as Naegleria fowleri. Pathogenic N. fowleri were recovered from samples of water and soil from the pond. This represents the fourth proven case of PAME from northern Nigeria.

An epidemic of meningococcal infection at Zaria, Northern Nigeria. 2. The changing clinical pattern.

1,003 patients with meningococcal disease admitted to a single hospital during the course of a three-month epidemic were studied. A progressive decline in mortality, especially among patients with acute meningococcaemia, and a falling incidence of systemic and severe neurological complications among patients with meningitis were observed. It is suggested that the virulence of the causative group A meningococcus declined as the epidemic progressed.

Single injection treatment of meningococcal meningitis. 2. Long-acting chloramphenicol.

A single injection of a long-acting oily preparation of chloramphenicol (Tifomycine) was compared with a five-day course of crystalline and procaine penicillin in the treatment of 131 adult patients with meningococcal meningitis. The clinical response to treatment was similar in the two groups of patients. Serial lumbar punctures showed a parallel fall in CSF cell count, protein and lactate and all posttreatment cultures were sterile. Single injection chloramphenicol treatment was cheaper and much easier to administer than penicillin. Long-acting chloramphenicol is thus an effective form of treatment for meningococcal meningitis and is likely to prove of particular value in the management of epidemics in areas with limited medical resources.

An epidemic of meningococcal infection at Zaria, Northern Nigeria. 1. General epidemiological features.

In 1977 Zaria, in Northern Nigeria, was affected by a severe epidemic of group A meningococcal infection, 1,257 patients being admitted to hospital with the disease during a three-month period. The epidemic started towards the end of the dry season when it was hot, dry and dusty and finished shortly after the onset of the rains. The over-all attack rate was 3.6 per 1,000 but this varied considerably from area to area within the town. Few cases occurred amongst those belonging to the upper social classes. The disease was seen most frequently amongst those from five to 14 years old and there was a strong male preponderance. The over-all mortality was 8.3% but mortality was much higher (40.6%) amongst 67 patients with acute meningococcaemia.

Single injection treatment of meningococcal meningitis. 1. Long-acting penicillin.

A single injection of a long-acting preparation of penicillin (Triplopen) was compared with a five-day course of crystalline and procaine penicillin in the treatment of meningococcal meningitis. The clinical response of patients treated with Triplopen was very similar to that of patients treated with crystalline penicillin and much more convenient to administer. However, four patients treated with Triplopen had a positive CSF culture 48 or 72 hours after their injection. One injection of Triplopen cannot, therefore, be recommended as an entirely safe form of treatment for meningococcal meningitis unless patients can be carefully followed.

Early management of younger adults dying of community acquired pneumonia.

We identified all patients under the age of 65 dying from CAP over a 3-yr-period in hospital in our health district. Most had chronic underlying illnesses. The early management of those who had previously been in good health was studied in greater detail, and was not ideal. Recommendations have been made to try and improve the assessment and treatment of patients with severe community-acquired pneumonia.

A survey of thoracic actinomycosis.

We have reviewed the case notes of 19 patients with thoracic actinomycosis. The median age at presentation was 42 (range 9-66) years, 15 were male and 12 were urban residents. Cough, sputum production, chest pain and weight loss were the commonest symptoms. Six patients reported haemoptysis. In contrast with the classical appearances of thoracic actinomycosis, only four patients had cutaneous abnormalities, and only one patient had radiological evidence of bone involvement. The provisional diagnosis was bronchial carcinoma in nine patients, and in seven patients the diagnosis of actinomycosis was only made after resection of the lesion, in two cases by pneumonectomy. The median delay between presentation and diagnosis was 3.5 (range 1-24) weeks. Two patients developed extrathoracic complications, but all patients made a full recovery after receiving antibiotic therapy for a median of 6 (range 1-24) weeks. Thoracic actinomycosis is rare, but should still be considered in the differential diagnosis of a pulmonary lesion thought to be malignant.

Audit of pleural biopsies: an argument for a pleural biopsy service.

We audited 203 consecutive pleural biopsies performed by medical and geriatric firms over a 3-yr period in our hospital (1987-9). For firms without a special respiratory interest only two to three biopsies per yr were performed, compared with 23 per yr for a respiratory team. Twenty percent of biopsies failed to obtain pleural tissue, 50% revealed normal or non-diagnostic pleural changes and 30% provided a diagnosis. For the respiratory team that performed a third (68) of the biopsies the failure rate for obtaining pleura was 9% compared with 27% for other teams. In view of this disparity a pleural biopsy service was offered by the respiratory team during routine bronchoscopy lists. A repeat audit (1990-2) following the introduction of this service revealed that 60% (84) of 141 biopsies were performed by the respiratory team with their failure rate for obtaining pleura being lower at 6% as compared to 16% for the general physicians. Thirty-one percent of biopsies provided a definitive diagnosis, being higher for those performed by the respiratory team (37%) as opposed to 23% for general physicians.

Respiratory rate measurement in adults--how reliable is it?

Measurement of respiratory rate (RR) is essential in the evaluation of respiratory disorders. However, the variability in RR measurement in adults has never been adequately assessed. Respiratory rate was measured twice in 245 patients; the two measurements were performed by the same observer in 137 patients, by different observers in 58 patients and simultaneously by different observers in 50 patients. The mean (SD) difference between the first and second measurements was 0.03 (3); 95% limits of agreement-4.86-4.94 breaths min(-1), -5.7-5.7 breaths min(-1), and -4.2 to 4.4 breaths min(-1) for the same observer, different observer and simultaneous observer groups, respectively. The difference in RR measurements did not vary with RR. In conclusions on average, there is very good agreement between observers in RR measurement. Inter-observer variability may account for a difference of up to 6 breaths min(-1). This is relevant when applying clinical prediction rules based on threshold RR values.

Risk factors for community-acquired pneumonia diagnosed by general practitioners in the community.

The purpose of this study was to identify risk factors for pneumonia diagnosed in the community by general practitioners, using a case control study in 29 general practices in Nottingham, U.K. Patients with radiographically confirmed pneumonia were compared with adults randomly selected from electoral registers corresponding to the catchment areas of the general practices taking part in the study. Sixty-six cases and 489 controls participated. Significant risk factors in univariate analysis included age, chronic obstructive pulmonary disease, congestive heart failure and lifetime consumption of cigarettes. Multiple logistic regression analysis of these four variables showed that age [adjusted odds ratio = 2.69 (for 30 year increment), 95%CI = 1.66-4.35] and chronic obstructive pulmonary disease (adjusted odds ratio= 1.99, 95%CI = 1.15-3.45) were independent risk factors. Only age and chronic obstructive pulmonary disease were independent risk factors for pneumonia in this study. Since cigarette smoking is the major cause of chronic obstructive pulmonary disease, these data suggest that cigarette smoking is the main avoidable risk factor for community-acquired pneumonia in adults.

The rise and fall of Legionnaires' disease in Nottingham.

The annual number of confirmed cases of Legionnaires' disease in both Nottingham, and England and Wales, reached a peak in 1980 and has since declined. Legionella infection is a rare cause of community-acquired pneumonia managed at home (accounting for less than 1% of cases), more common in those admitted to hospital (5-15%) and more common still in patients with severe pneumonia as seen on an intensive care unit (up to 30% of cases). Antibiotic therapy for any patient with moderate or severe pneumonia of uncertain aetiology should cover legionella infection.

Aetiology and outcome of severe community-acquired pneumonia.

Between January 1972 and December 1981, 50 patients with severe community-acquired pneumonia were admitted to the intensive care unit of a district general hospital. A causal pathogen was identified in 41 cases (82%). Streptococcus pneumoniae (16 cases), Legionella pneumophila (15 cases) and Staphylococcus aureus (5 cases) were the commonest. Assisted ventilation was required in 44 patients, of whom 25 died (57%). All 5 patients with staphylococcal pneumonia and 12(75%) with pneumococcal pneumonia died. Only 5 (33%) with Legionnaires' disease died. Mortality was significantly associated with age. Recommendations for the management of severe pneumonia are made.

Erythromycin compared with a combination of ampicillin and amoxycillin as initial therapy for adults with pneumonia including Legionnaires' disease.

In a double blind trial erythromycin was compared with a combination of ampicillin and amoxycillin for treating adults admitted to hospital with primary pneumonia. The clinical course of 42 patients treated with ampicillin and amoxycillin was similar to that of the 49 in the erythromycin group. Fall in temperature, symptomatic recovery and radiographic improvement were similar (two-thirds made an uncomplicated recovery). Infusion-related phlebitis was more common with erythromycin. Otherwise adverse reactions were unusual. The outcome was related principally to the cause of the pneumonia with bacteraemic/antigenaemic pneumococcal pneumonia, Legionnaires' disease, other bacterial pneumonias and psittacosis having a poor prognosis. Both forms of antibiotic therapy gave similar results but we suggest that a combination of erythromycin with ampicillin may be logical initial treatment for severe pneumonia of unknown cause.

Sequential bacteriological findings in the cerebrospinal fluid of Nigerian patients with pneumococcal meningitis.

Sequential bacteriological observations were made on the cerebrospinal fluid (CSF) of 28 patients with pneumococcal meningitis treated with high doses of penicillin for 2 weeks. The organism was isolated from the CSF of four patients 48 h or more after the start of treatment and from a further patient 48 h after treatment was stopped. Positive cultures were obtained in spite of the demonstration in the CSF of penicillin at a concentration well above the minimum inhibitory concentration for the organism isolated. Persistence of bacteria and their products in the CSF of patients with pneumococcal meningitis contrasts with the rapid clearance of bacteria from the CSF of patients with meningococcal meningitis and may contribute to the difference in the prognosis of these forms of meningitis.

The influence of antibiotics and other factors on reconsultation for acute lower respiratory tract illness in primary care.

BACKGROUND: Antibiotics are prescribed to the majority of patients consulting their general practitioner (GP) for lower respiratory tract illness (LRTi). A common reason for prescription is the belief that antibiotics reduce re-attendance; a motive supported by the high reconsultation rates for this largely self-limiting illness. Information about reconsultation following treatment of LRTi, and the factors that influence it, is scarce. AIM: To explore factors associated with reconsultation after initial management of LRTi. METHOD: Analysis of data collected prospectively during presentation of acute LRTi in primary care. RESULTS: Seventy-six per cent of 518 patients were prescribed antibiotics, and 30% reconsulted for similar symptoms within the next 28 days (29% of those who were given antibiotics and 33% of those who were not). Forty-one per cent of patients who had seen their GP 15 or more times in the previous two years reconsulted, compared with 13% of those who had made fewer than five visits. Reconsultation was more common in patients with a history of underlying disease (38.6% versus 24.3%) and in patients who reported dyspnoea (41.5% versus 24.3%). CONCLUSION: Reconsultation is common in acute LRTi and is associated with a heightened consulting habit prior to the index consultation, the presence of previous ill health, and dyspnoea. It appears not to be influenced by prescribing antibiotics.

Reducing reconsultations for acute lower respiratory tract illness with an information leaflet: a randomized controlled study of patients in primary care.

BACKGROUND: General practitioners (GPs) prescribe antibiotics to three-quarters of patients who consult with a lower respiratory tract illness (LRTi). In spite of this management, around a quarter of patients reconsult for the same symptoms within a month. AIM: To investigate the impact of providing a simple leaflet regarding the natural history of lower respiratory tract symptoms on reconsultation rates for previously well adults presenting to their GP with an LRTi. METHOD: Seventy-six GPs studied 1014 previously well adults presenting with an illness defined as an LRTi. Management was left to the GP's discretion. Half of the patients were randomly allocated to receive an information leaflet at the end of the consultation, blinded from the GP. The endpoint was reconsultation for the same symptoms within one month. RESULTS: Follow-up data was available for 1006 adults, of whom 182 (18%) reconsulted. Fewer patients who received the leaflet (75/505; 14.9%) returned to the surgery compared with those who did not (107/501; 21.4%; P = 0.007). The same benefit was found for the 723 (72%) adults treated initially with antibiotics; 16% (60/369) in the leaflet group returned compared with 23% (81/354) in the no leaflet group (P = 0.02). CONCLUSION: Informing previously well patients about the natural history of LRTi symptoms is an effective strategy for reducing reconsultations, benefiting the patient and the GP; it is likely to reduce antibiotic prescriptions and future patient consultation habits.

Symptoms, signs, and prescribing for acute lower respiratory tract illness.

BACKGROUND: Most patients who consult with acute lower respiratory symptoms receive antibiotics, usually without evidence of significant infection. The physical signs at presentation of acute lower respiratory tract illness and the rate at which symptoms resolve and normal activities recover is not well documented. AIM: To examine in patients with lower respiratory tract infection (LRTi), their physical signs at presentation, their relationship to antibiotic prescribing, and symptom resolution and resumption of normal activities. DESIGN OF STUDY: Analysis of data collected prospectively during presentation of acute LRTi in primary care and from patient symptom diary cards. SETTING: Forty GPs who were members of an informal Community Respiratory Infection Interest Group recruited 391 patients to the study. METHOD: Information was collected on pulse, oral temperature, respiratory rate, abnormalities on auscultation, and details of any antibiotic prescription. Patients completed symptom diary cards for the following 10 days. RESULTS: Of the 391 patients who consulted 71% received antibiotics. A minority had abnormal physical signs: 17% had a pulse greater than 90 bpm, 15% a respiratory rate greater than 20 breaths per minute, 4% had a temperature greater than 38 degrees C, and 25% had an abnormality on auscultation. Antibiotic prescribing was more common in the presence of abnormal chest signs (odds ratio = 8.71, 95% confidence interval = 3.69-20.61) or discoloured sputum (OR = 2.67, 95% CI = 1.57-4.56). Ten days after consultation, 58% of patients were still coughing and 29% had not returned to normal activities. CONCLUSION: Abnormal physical signs at presentation do not explain the high rates of antibiotic prescribing nor do they predict persisting cough and functional impairment at 10 days. Reconsultation for the same symptoms within a month is common and is strongly related to persisting cough, but not abnormalities at presentation.