Introduction The ASSIST-CKD project is a national quality improvement programme, aiming to decrease the number of patients presenting late to renal services by enabling laboratories to review up to five years of estimated glomerular filtration rate results graphically and report deteriorating patients to their general practitioner. Aim To assess the impact of the project on the laboratory, and of patient reporting on general practitioner management and the local renal service. Method Each week two searches were performed (Search A: maximum age 65 years, maximum eGFR 50 ml/min/1.73 m 2 and Search B: Age 66–120 years, maximum eGFR 40 ml/min/1.73 m 2 ) on patients with an estimated glomerular filtration rate requested by their general practitioner within the previous seven days. Patients showing deterioration in estimated glomerular filtration rate had a printed graph sent to their general practitioner. Feedback on the graphs and their impact on patient management were obtained from the general practitioners via a questionnaire. Results A median of 37 patients/week were listed for review for Search A, with 32% reported; and Search B a median of 227 patients/week listed, 32% reported. General practitioner surgery questionnaires (29) showed the reports were well received. Of general practitioners responding to the questionnaire, 67% had reviewed a patient earlier than intended, 54% had reviewed local guidance, 48% had emailed the renal team and 48% had referred a patient on receipt of a graph; 34% had shown a graph to their patients, of whom 70% found that useful. Conclusion There is some evidence that ASSIST-CKD reporting has enhanced patient care; however, further long-term assessment is still required.
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are characterised by an acute worsening of symptoms beyond the normal day-to-day variability. Pneumonic episodes, confirmed by new chest X-ray (CXR) infiltrates, are common in patients with COPD but are difficult to distinguish in primary care from non-pneumonic exacerbations. It is uncertain whether AECOPD and pneumonic episodes in COPD patients are distinct clinical events in terms of aetiology and/or response to oral therapy. We performed a longitudinal study to characterise these events and to determine clinically meaningful differences associated with CXR changes in the outpatient setting.
Methods
The Acute Exacerbation and Respiratory Infections in COPD (AERIS) study is a longitudinal epidemiological study to assess how changes in the COPD airway microbiome contribute to the incidence and severity of AECOPD. Patients with moderate to very severe COPD aged 40–85 years were followed monthly for 2 years, and reviewed within 72 h of onset of symptoms of AECOPD. We compared markers of systemic and airway inflammation between pneumonic AECOPD characterised by new CXR infiltrates, and non-pneumonic AECOPD, in a sub-cohort of 36 patients.
Results
In the first year of study participation 122 exacerbations were recognised of which 120 had a CXR performed. Of these, 20 (16.7%, n = 12 patients) were identified as having new radiographic infiltrates. Statistically significant differences occurred in mean white blood cell count, blood neutrophil count, C-reactive protein, fibrinogen and sputum percentage neutrophil count between those AECOPD with new CXR infiltrates and those without (Table 1). Furthermore, there was a trend towards more severe symptom scores with pneumonic episodes using the EXACT-PRO score (p = 0.057).
Conclusion
Pneumonic episodes are common in the context of clinical events presenting as outpatient AECOPD. The profile of airway and systemic inflammation is greater during these events than those without CXR changes. Understanding whether the biology and clinical course of these events is distinct from other exacerbations is key, particularly as patients are encouraged to self-manage based on symptom changes alone. Further study of the AERIS cohort will investigate links between aetiology, outcomes and prognostic markers at exacerbation including radiological and clinical indices.
The aetiology of acute exacerbations of chronic obstructive pulmonary disease (COPD) remains incompletely understood and strategies for treatment and prevention have not altered significantly for many years. Improved understanding of the role of respiratory pathogens in acute exacerbations of COPD (AECOPD) is required and the use of molecular microbiological techniques may lead to insights into host-pathogen interactions and the development of more targeted therapeutic approaches.Acute Exacerbation and Respiratory InfectionS in COPD (AERIS) is a longitudinal epidemiological study to assess how changes in the COPD airway microbiome contribute to the incidence and severity of AECOPD. Patients with COPD aged 40-85 are followed monthly for 2 years, and reviewed within 72 h of onset of symptoms of AECOPD. Exacerbations are detected using daily electronic diary cards. Blood, sputum, nasopharyngeal and urine samples are collected at prespecified timepoints. Molecular diagnostic and typing techniques are used to describe the dynamics of airway infection during AECOPD and stable disease, and associations with clinical outcome. This study aims to refine the case definition of AECOPD to reflect the possible microbiological aetiology. AERIS will assess the impact of AECOPD on health-related quality of life and healthcare resource utilisation, and the possible interactions between nutritional status, infection and immune responses.AERIS is conducted in accordance with the Declaration of Helsinki and Good Clinical Practice, and has been approved by the institutional ethics and review board. All participants must provide written informed consent. The results obtained will be disseminated at international medical conferences and in peer-reviewed publications.Few other studies have addressed the complexity of the microbiological and systemic components of COPD or employed real-time electronic tracking of symptoms to identify AECOPD and potential aetiological triggers.Results of AERIS will increase our understanding of the contribution of pathogens to AECOPD, potentially leading to new targeted therapeutic and preventative interventions.ClinicalTrials.gov NCT01360398.
Abstract H. haemolyticus is often misidentified as NTHi due to their close phylogenetic relationship. Differentiating between the two is important for correct identification and appropriate treatment of infective organism and to ensure any role of H. haemolyticus in disease is not being overlooked. Speciation however is not completely reliable by culture and PCR methods due to the loss of haemolysis by H. haemolyticus and the heterogeneity of NTHi. Haemophilus isolates from COPD as part of the AERIS study (ClinicalTrials - NCT01360398) were speciated by analysing sequence data for the presence of molecular markers. Further investigation into the genomic relationship was carried out using average nucleotide identity and phylogeny of allelic and genome alignments. Only 6.3% were identified as H. haemolyticus . Multiple in silico methods were able to distinguish H. haemolyticus from NTHi. However, no single gene target was found to be 100% accurate. A group of omp2 negative NTHi were observed to be phylogenetically divergent from H. haemolyticus and remaining NTHi. The presence of an atypical group from a geographically and disease limited set of isolates supports the theory that the heterogeneity of NTHi may provide a genetic continuum between NTHi and H. haemolyticus .
<b><i>Background/Aims:</i></b> Publications on acute kidney injury (AKI) have concentrated on the inpatient population. We wanted to determine the extent of AKI in the community, its follow-up and patient impact. <b><i>Method:</i></b> Primary Care creatinine results for May 2012-April 2013 from Cornwall, United Kingdom, were screened for AKI. <b><i>Results:</i></b> Over 12 months, 991 AKI episodes were identified (0.4% of all Primary Care creatinine requests); 51% were AKI1, 29% AKI2 and 10% AKI3. Of these, 51% AKI1s, 72% AKI2s and 77% AKI3s had a repeat creatinine requested within 14 days as per National Institute for Health and Care Excellence (NICE) guidelines. Admissions (May 2012-July 2013) were identified on 46% AKI1s, 58% AKI2s and 65% AKI3s (p < 0.05). The median time from AKI identification to hospital admission was 33 days for AKI1, 12 days for AKI2 and 1 day for AKI3 (p < 0.05); with a median length of stay of 2, 4 and 7 days, respectively (p < 0.05). The 90-day mortality from AKI identification for the admitted patients was 12% AKI1s, 20% AKI2s and 27% AKI3s (p < 0.05) vs. 11, 21 and 65% (p < 0.05) for those that were not admitted. There was no significant difference in mortality for admitted patients vs. non-admitted patients, except for the AKI3s. <b><i>Conclusion:</i></b> AKI is associated with increased admission and mortality rates; although a large proportion of patients had repeat creatinine testing within 14 days, there was still a significant number with delayed follow-up. Education within Primary Care is required on how to prevent, identify, follow-up and manage AKI.
Thirty patients were examined to test the hypothesis that a depletion of iron levels is associated with symptoms of akathisia. Fifteen akathisic patients were pair-matched with 15 non-akathisic patients. Plasma ferritin levels were significantly decreased in the akathisic patients, and there was a significant inverse correlation between plasma iron levels and akathisia rating. In addition, akathisia ratings were found to be correlated with a scale measuring symptoms of tardive dyskinesia.
A 50-year-old man presented with a four-year history of unsteadiness, with recent falls and tingling in his fingers. Neurological examination found an ataxic gait, with a positive Romberg's sign. There was distal wasting and weakness in all four limbs and impaired co-ordination, with pseudoathetosis in the arms. Initial investigations showed a normochromic, normocytic anaemia, leucopenia, neutropenia and a low vitamin B 12 (172 ng/L). Treatment with intramuscular cobalamin injections showed no clinical improvement. Further investigations showed an undetectable caeruloplasmin (<0.085 g/L), a very low serum copper (1.1 μmol/L) and a markedly raised serum zinc concentration (36.2 μmol/L). On detailed questioning it became apparent that he had ill-fitting dentures requiring excessive use of denture fixative with high zinc content. The patient was switched to a non-zinc containing denture fixative and commenced copper supplementation. Although within three months the bone marrow suppression had resolved, there was no clinical improvement in neurological presentation. Questioning a patient about their denture fixative usage and checking if zinc is an ingredient may be considered during an investigation for myelopolyneuropathy when vitamin B 12 deficiency is not a cause.
Acute exacerbations of COPD have a major impact on patients’ health related quality of life (HRQoL), and the utilisation of health care resources. Current guidelines recommend oral corticosteroids and/or antibiotics for the treatment of acute exacerbations of COPD based on patients’ symptoms. With increasing bacterial resistance to antibiotics and the rising costs of COPD treatment, further research into diagnostic tools to aid the management of COPD in its stable and exacerbating states is required. Sputum colour (SC) is an accessible marker of underlying bronchial inflammation. We investigated the contribution of objective measures of SC as a component of the clinical assessment of exacerbations and relationships with symptom severity.
Methods
Data from 36 patients with moderate to very severe COPD was assessed in this prospective observational cohort study (AERIS). There were 122 exacerbations in total over a year. Sputum and blood sampling were performed at enrolment, routine follow up and exacerbation visits. A five-point sputum colour chart was developed to objectively report the SC. Sputum samples from all visits were graded against this chart by the trained laboratory staff. Data from mild, moderate and severe exacerbations were included in the analysis.
Results
We found a correlation between SC at exacerbations and disease severity (FEV1%) at exacerbations. SC was also related to sputum neutrophilia at exacerbations. SC was significantly associated with systemic markers such as blood neutrophilia, CRP and fibrinogen. Interestingly, we observed no statistically significant correlation between SC and Procalcitonin levels. We also found no statistically significant relationship between SC and symptom scores (CAT and EXACT-PRO) at exacerbations. However, we found a significant association between CAT and EXACT-PRO scores (rho 0.46; p < 0.01).
Conclusion
We observed that visual colour score of sputum at exacerbations is related to underlying airway and systemic inflammation but not to symptom scores. The use of a SC combined with other clinical and laboratory biomarkers, as part of a multicomponent diagnostic tool, may further improve its clinical utility to better guide effective exacerbation treatment. Further analysis of the full AERIS cohort will explore this.
Background Bacterial infections are associated with acute exacerbations of chronic obstructive pulmonary disease (AECOPD), but the mechanism is incompletely understood.Method In a COPD observational study (NCT01360398), sputum samples were collected monthly at the stable state and exacerbation. Post-hoc analyses of 1307 non-typeable Haemophilus influenzae (NTHi) isolates from 20 patients and 756 Moraxella catarrhalis isolates from 38 patients in one year of follow-up were conducted by multilocus sequence typing (MLST). All isolates came from cultured sputum samples that were analyzed for bacterial species presence, apparition (infection not detected at the preceding visit), or acquisition (first-time infection), with the first study visit as a baseline. Strain apparition or new strain acquisition was analyzed by MLST. The odds ratio (OR) of experiencing an exacerbation vs. stable state was estimated by conditional logistic regression modelling, stratified by patient.Results The culture results confirmed a significant association with exacerbation only for NTHi species presence (OR 2.28; 95% confidence interval [CI]: 1.12–4.64) and strain apparition (OR 2.38; 95% CI: 1.08–5.27). For M. catarrhalis, although confidence intervals overlapped, the association with exacerbation for first-time species acquisition (OR 5.99; 2.75–13.02) appeared stronger than species presence (OR 3.67; 2.10–6.40), new strain acquisition (OR 2.94; 1.43–6.04), species apparition (OR 4.18; 2.29–7.63), and strain apparition (OR 2.78; 1.42–5.42). This may suggest that previous M. catarrhalis colonization may modify the risk of exacerbation associated with M. catarrhalis infection.Conclusions The results confirm that NTHi and M. catarrhalis infections are associated with AECOPD but suggest different dynamic mechanisms in triggering exacerbations.
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