Influenza but not pneumococcal vaccination protects against all-cause mortality in patients with COPD.

BACKGROUND: Influenza and pneumococcal vaccination are recommended in patients with chronic obstructive pulmonary disease (COPD). A recent study from Tayside found a reduced risk of all-cause mortality with vaccination in patients with COPD. The Health Improvement Network (THIN) database was used to test this hypothesis in a different data source. METHODS: The THIN database was searched for patients with COPD. Vaccination status against Pneumococcus and the annual influenza vaccination status were determined. Mortality rates were calculated in the periods December to March and April to November. Relative risks for the effect of vaccination on all-cause mortality were estimated by Poisson regression, adjusting for age, sex, year and serious co-morbidities. RESULTS: 177,120 patients with COPD (mean age 65 years) were identified, with a mean follow-up of 6.8 years between 1988 and 2006. Vaccination rates against influenza rose from <30% before 1995 to >70% in 2005 in patients aged 60 years or more. The cumulative vaccination rate against pneumonia rose from almost zero to 70% in patients aged 70 years or more over the same period. For all-cause mortality the adjusted relative risks associated with influenza vaccination were 0.59 (95% CI 0.57 to 0.61) during the influenza season and 0.97 (95% CI 0.94 to 1.00) outside the season in patients not vaccinated against pneumonia, and 0.30 (95% CI 0.28 to 0.32) and 0.98 (95% CI 0.96 to 1.11), respectively, in patients vaccinated against pneumonia. The relative risk associated with pneumococcal vaccination was >1 at all times of the year. CONCLUSIONS: Influenza but not pneumococcal vaccination was associated with a reduced risk of all-cause mortality in COPD.

Lipoprotein fractions and antithrombin III consumption during clotting.

Plasma and serum antithrombin levels were measured in functional (initial rate measurement) and immunological assays together with serum lipid levels in normal subjects and patients with coronary artery disease. Specific antithrombin activity in plasma showed a negative correlation with triglyceride levels. The consumption of antithrombin activity during blood clotting was negatively correlated with both serum total triglyceride and heparin precipitable lipoprotein and positively correlated with serum high density lipoprotein cholesterol. Different blood lipoprotein fractions may influence the activity of the antithrombin III molecule.

Individualisation of oral anticoagulant therapy.

The hepatic synthesis of vitamin K dependent coagulation factors is modified by oral anticoagulant drugs, resulting in the release of functionally deficient coagulation factors into the circulation and consequently anticoagulation. Since their introduction into clinical medicine over 30 years ago, both clinical and scientific evidence has demonstrated the value of oral anticoagulants in the treatment and prophylaxis of venous thrombosis. In the treatment of arterial disease, however, both the indications for and usefulness of oral anticoagulants remain very much in doubt despite their widespread use in the 1950s and 1960s and in numerous clinical trials. The initiation and continuation of oral anticoagulant therapy is a co-operative venture involving the patient, the clinician and the laboratory. The clinician must have a thorough knowledge of the indications for and contraindications to the use of these drugs, and regular, accurate laboratory control is essential if haemorrhage, the major side effect, is to be avoided or reduced to a minimum. The patient must bear the responsibility for regular clinic attendance, abstinence from proprietary medications, and must immediately seek medical advice if any sign of haemorrhage occurs.

C-reactive protein. A clinical marker in community-acquired pneumonia.

STUDY OBJECTIVE: To assess the range of plasma C-reactive protein (CRP) in patients presenting with community-acquired pneumonia and to compare the serial changes of this acute-phase protein with clinical outcome. DESIGN: Prospective hospital-based study, including separate retrospective case series. PATIENTS: Twenty-eight consecutive patients (mean age, 60 years) admitted to our hospital with community-acquired pneumonia were studied. Serial daily plasma samples were taken and assayed for CRP, tumor necrosis factor-alpha (TNF-alpha), and interleukin 6 (IL-6). Clinical parameters, laboratory data, and response to treatment were recorded. Four other patients considered to be antibiotic failures (three empyemas, one death) were studied separately. RESULTS: Two patients died. Of those who survived, mean (+/- SD) CRP values for days 1,2,3,4, and 5 were as follows: 136 +/- 43, 96 +/- 44, 53 +/- 36, 54 +/- 43, and 44 +/- 31 mg/L. CRP levels on day 1 in patients who had received antibiotics prior to hospital admission were significantly lower than those who had not, 107 +/- 42 and 152 +/- 44 mg/L (p < 0.05). CRP levels did not correlate with other laboratory parameters or with recognized predictors of mortality. A CRP value that continued to rise despite antibiotic treatment was associated with infective complications or death. Only 52% of patients had detectable TNF-alpha and 24% detectable IL-6 at some point during their hospital stay. CONCLUSIONS: CRP is a sensitive marker of pneumonia. A persistently high or rising CRP level suggests antibiotic treatment failure or the development of an infective complication. These results suggest that CRP, rather than TNF-alpha or IL-6, may have a role as a clinical marker in pneumonia.

Preoperative antithrombin III activities and lipoprotein concentrations as predictors of venous thrombosis in patients with fracture of neck of femur.

The presence or absence of venous thrombosis was determined by the technique of autologous 111indium-labelled platelets in 64 patients following reduction and fixation of fractures of the neck of femur. Venous thrombosis was found in 41 (64%) of these patients. Compared to the thrombosis-negative group, the thrombosis-positive group had a significantly lower mean serum antithrombin, and higher mean antithrombin consumption during clotting in the immediate preoperative period. No significant differences were seen between the two groups in plasma ATIII activities, fibrinogen, alpha-2-macroglobulin, serum lipoproteins or age. Significant correlations were seen between ATIII activities and lipoprotein fractions; these are discussed.

How to deal with a hospital outbreak of Legionnaires' disease.

The outbreak of Legionnaires' disease in Glasgow Royal Infirmary is discussed together with the problems such an outbreak poses to the microbiologist. The importance of early diagnosis is stressed. The outbreak was managed by a team drawn up from various disciplines within the hospital. Frank daily reports to the press, together with regular staff meetings with staff representatives helped to allay public anxiety. The subsequent maintenance and monitoring of the wet cooling tower required for the hospital ventilation system have resulted in considerable additional work for the microbiology department but especially for the hospital engineers.

A repeat audit of hospital discharge letters in patients admitted with acute asthma.

Subsequent to the implementation of recommendations from a previous audit of acute asthma admission discharge letters from our specialist respiratory unit, a repeat audit of typed discharge letters of 86 patients (33 male, mean age 29 SD 9 years) admitted with acute asthma to the same unit over a 12 month period was performed. There was significant improvement in the discharge letter documentation of precipitating factors (p < 0.001), previous admissions with acute asthma (p < 0.01), admission arterial blood gas analysis (p < 0.001), admission peak flow rates (p < 0.05), discharge peak flow rates (p < 0.001), corticosteroid (p < 0.01) and inhaled beta 2 agonist (p < 0.01) prescription on discharge and on the specification of inhaler delivery device on discharge (p < 0.001). No significant differences in discharge letters were found in the documentation of acute therapy or post discharge follow up plan. The improvement in discharge letter quality was attributed to closing the feed back loop from the previous audit though continuing deficiencies in discharge letter contents have been identified again. These deficiencies need to be rectified and the results reaudited.

Reaudit of acute asthma admissions using a severity marker stamp and determinants of an outcome measure.

Subsequent to the implementation of a severity marker stamp in case notes, an audit was performed in 86 admissions with acute asthma to a specialist centre over a 12 month period. Compared to previous audit the documentation of severity markers was significantly better (PEFR: 52% vs 83% p = 0.001, Respiratory rate: 44% vs 81% p = 0.001, ABG: 72% vs 80% p = 0.04, air entry: 58% vs 86% p = 0.001, speech: 27% vs 86% p = 0.001, exhaustion: 4% vs 86% p = 0.001). In contrast to the previous audit where no patient received FiO2 > 0.35, 66% of the cases in the repeat audit received FiO2 0.60 (p = 0.001). The mean duration of admission was five days and showed highest partial correlation (r = 0.6) to the time in hours for the pulse to fall to 80/min. Multiple linear regression showed that this was the only variable best predicting the duration of admission (R2 = 0.3). Admission pulse rate (p = 0.04) and serum K+ (p = 0.04) best discriminated between patients admitted for over and under five days. Logistic regression identified only the admission pulse as significant in calculating the odds of the patient staying in the hospital for > 5 days.

Empyema of lung associated with Streptococcus milleri infection.

Empyema of the lung is a very serious illness which must be detected quickly and treated aggressively. We report an unusual case of empyema of the lung associated with a boating accident while the patient was fishing in a sea loch off the west coast of Scotland.

An audit of hospital discharge letters in patients admitted with acute asthma. Tayside Asthma Audit Group.

The management of patients following discharge with acute asthma is dependent on effective communication with general practitioners. A retrospective audit was therefore performed on copies kept of 81 typed discharge letters with a diagnosis of acute asthma between March and October 1991. A subset of 42 interim (handwritten) letters were also audited where case notes could be retrieved. Details on clinic follow up were also obtained from the case notes (n = 42). In the typed letter documentation of severity and treatment of the acute attack was accurate in most cases. Information concerning a precipitating factor was provided in 54% of cases and a smoking history in 57%. Deficiencies were found in specifying inhaler delivery devices (40% recorded), and whether inhaler technique had been formally assessed whilst in hospital (17%). Drug prescribing on discharge was as follows: oral steroid (69%), inhaled steroids (77%), inhaled B2-agonists (92%), theophylline slow release (38%), salbutamol controlled release (20%), and antibiotics (30%). The implementation of a self-management plan and domiciliary peak flow was mentioned in 66% of the letters. The interim letter was generally poor in particular for mention if discharge peak flow (2%), clinic follow-up (64%) and prednisolone regime (61%). Mean +/- s.d. time for clinic follow-up (n = 42) was 4.7 +/- 1.7 weeks (range 1-13 weeks) with 24% non-attendance. Thus, improvements in discharge letters are clearly required for optimum continuity of care in the community.

Lymphangioleiomyomatosis. A series of three case reports illustrating the link with high oestrogen states.

Lymphangioleiornyomatosis is a rare lung disorder characterised by cystic air spaces and smooth muscle proliferation. The condition, which most commonly presents with dyspnoea, pneumothoraces or cough, is only described in females and is most commonly diagnosed during childbearing years. Three cases are presented which illustrate typical features of the disease and the association with high oestrogen levels. The first had recurrent pneumothoraces during her first pregnancy. The second lady was post menopausal at diagnosis but her symptoms predated her menopause. The third, presented with dyspnoea, abnormal chest sensations and a pneumothorax. She had a history of hyperprolactinaemia with secondary amenorhoea due to low oestrogen levels which had been corrected prior to her presentation. All three patients had reduced gas transfer and abnormalities in spirometry, two had reticular shadowing on their chest radiograph and all had typical appearances on lung computerised tomography. Although disease progression was variable, all patients showed a gradual decline in lung function.

Chest X-rays in COPD screening: are they worthwhile?

The BTS/NICE COPD guideline recommends a chest X-ray at initial COPD evaluation; this is a grade D recommendation based on expert opinion. We have investigated which pathologies other than COPD are detected by chest X-ray and how they alter management. Dundee smokers aged 40 or over and receiving bronchodilators are assessed for COPD by their practice nurse and offered a chest X-ray if there is no record of a chest X-ray within the previous three years. We retrospectively analysed the chest X-ray reports and case records of these patients. The chest X-ray report was structured with 7 specific questions, most importantly "Are there any features of other disease likely to be causing dyspnoea?" and "Are there any features to suggest lung cancer?" Management of patients with chest X-ray findings suggesting other disease causing dyspnoea or lung cancer was assessed by questionnaire and case record study. Five hundred forty-six consecutive chest X-ray reports were analysed. Fourteen percent of all chest X-rays detected potentially treatable dyspnoea causing disease; where management following receipt of X-ray reports was audited, 84% were thought to help. Eleven lung cancers were detected, 3 had stage 1 disease. Considerable benign and malignant pathology is detected by chest X-ray performed at initial COPD assessment. Clinical management is changed in the majority with a potentially treatable abnormality. This evidence suggests that the NICE guideline to perform chest X-ray at initial COPD evaluation should be elevated from a grade D to grade C recommendation.

The scope of lower respiratory tract infection.

Lower respiratory tract infections (LRTI) are commonly classified as either bronchitis or pneumonia, and these infections are associated with an extremely high morbidity in the community, as well as a high mortality in those patients that require hospitalisation. Therefore, such infections place a huge burden, both economically and as a user of health services, on the entire health care system. The antibiotic treatment of community-acquired pneumonia caused by gram-negative organisms or staphylococci is controversial, and these organisms may cause one-third of the cases of community-acquired pneumonia. Nosocomial pneumonia is caused even more often by gram-negative bacteria, and as such the development of rational and effective antibiotic therapy to cover these organisms is very important.