Non-tuberculous mycobacteria (NTM): A review of local prevalence and management of pulmonary NTM (2019)

Type of publication:
Conference abstract

Author(s):
*Ibrahim J.; *Ali A.; *Mahmoud M.; *Hamze H.; *Crawford E.; *Makan A.; *Srinivasan K.; *Moudgil H.; *Ahmad N.

Citation:
American Journal of Respiratory and Critical Care Medicine; May 2019; vol. 199 (no. 9)

Abstract:
Introduction Prevalence of NTM varies worldwide. Guidelines for the diagnosis and management of Pulmonary NTM have been published recently and in light of this; we aimed to look at our local data of NTM isolates with particular attention to the pulmonary isolates. Methods Patient details were obtained for all positive NTM isolates from 2002 to 2017. Further details on microbiology, radiology and treatment of these patients were searched from clinical portal, Patient archives communication system for radiology and outpatient clinic letters. Results 147 NTM were isolated from pulmonary and extra pulmonary sites (figure 1). This included 53% (n=78) female patients with a mean age (SD) of 62 (21) years. 90 pulmonary isolates were considered for further analysis. 33/90 (37%) received treatment with >=3 drugs (n = 19), <=2 drugs (n = 13) and data unavailable for one patient. Where data on duration of treatment was available (n = 30), 19/30 (63%) were treated for >=18 months and 11 (37%) treated for <18 months. With reference to current guidelines [1][2], 25/90 met microbiological and radiological criteria for treatment, 15/25 (60%) were treated, 8 (32%) not treated and no data on treatment available for the remaining 2 (8%). NTM types treated include Mycobacterium Avium Complex (MAC) (n=18), M.Malmonse (n=6), M.Kansasii (n=4), M.Szulgai (n=2), M.Abscessus (n=1), M.Gordonae (n=1), M.Xenopi (n=1). 78/90 (87%) patients had underlying lung disease. Of these most common were COPD (27), bronchiectasis (27), Asthma (13), Aspergillus infection/sensitization (7), Cystic Fibrosis (3) and previous TB (3). Conclusion Our local data prior to the publishing of current guidelines shows 40% couldn’t be treated for NTM disease. This may be due to the challenges of age at diagnosis, risk of side effects, difficulty in differentiation between colonised or pathological isolate; looking ahead, the current guidance may enable a more standardised approach towards diagnosis and management.

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Uptake of influenza vaccination as a preventive health care strategy (2019)

Type of publication:
Conference abstract

Author(s):
*Ibrahim J.; *Ali J.; *Ali A.; *Makan A.; *Crawford E.; *Ahmad N.; *Srinivasan K.; *Moudgil H.

Citation:
American Journal of Respiratory and Critical Care Medicine; May 2019; vol. 199 (no. 9)

Abstract:
Introduction: Whether our local Health Care Economy is adequately prepared with uptake of targeted preventative strategies of seasonal influenza vaccination for the consequential burden on secondary health care is poorly documented. Auditing patients admitted acutely through our Acute Medical Unit, objectives were to (1) provide a point prevalence measure to the uptake of influenza vaccine among patients stratified by at risk groups, and (2) document reasons for nonadherence to current recommendations. Method(s): Auditing on three alternate days during one week in January 2018 coinciding with peak season for influenza, adult patients (>16yrs) acutely admitted were categorized and individually questioned using National Institute for Health and Care Excellence (NICE) guidelines for “immunization against Seasonal Influenza” as a benchmark identifying targeted strategies by clinical risk grouping: Group A was based on age years, and Group B on those below this age but with defined clinical risks. Comparative but surrogate standards for the groups were adopted from World Health Organization (WHO) targets and from Public Health England for uptake achievements by patients under local General Practitioners (GPs) in the West Midlands (WM) region. This audit did not consider the impact of vaccination on illness. Result(s): 120/136 (88.2%) admitted patients were audited; of these 75/120 (62.5%) had been vaccinated. Comparisons with standards adopted are shown in figure 1. Featured among 37.5% not vaccinated were GP appointments (60%), allergy (24%), low risk (9%) and mis-trust (7%). At risk groups were chronic respiratory (32%), cardiac (19%), neurological (14%) disease and diabetes (12%), cancer (7%), and others (16%). Conclusion(s): Among those admitted to secondary care, local Health Care Economy (figure 1) fall short of adopted standards from the WHO and regionally for WM region for Group A but with better figures for Group B comparing regionally, and (2) identify access at local GPs as among primary reasons for non-uptake of vaccination. (Figure Presented).

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Follow up chest radiograph in community acquired pneumonia (CAP)-are we meeting the standards? (2019)

Type of publication:
Conference abstract

Author(s):
*Zeb M.S.; *Hamze H.; *Ali A.; *Annabel M.; *Ahmad N.; *Moudgil H.; *Ibrahim J.; *Srinivasan K.S.; *Crawford E.

Citation:
American Journal of Respiratory and Critical Care Medicine; May 2019; vol. 199 (no. 9)

Abstract:
Introduction and objectives CAP accounts for 29,000 deaths per annum in the UK with In-patient mortality of 17.7% [1]. In older population (>65years) associated malignancy is 9.1%. Current guidelines [2] recommend chest radiograph (CXR) follow up 6 weeks after CAP in high risk patients. We aimed to audit our follow up practice with a view to service improvement for early detection of malignancy and complications from CAP. Methods Patients were identified via retrospective review of local database of patients recorded as “CAP” on discharge from 02/01/2017 to 01/31/2018. CXR reports were reviewed using patient archives communication system for radiology and clinical portal. Results 97 patients were identified with discharge diagnoses recorded as “CAP”. We excluded patients below 50 years of age (n=7), those without radiographic pneumonia (n= 26), CXR not reported (as patient deceased) (n=2) and patients with CAP who died within 6 weeks of presentation (n=25, mean age 83 years; this included inpatients as well as those died post discharge from hospital). Patients included (n=37). Mean age 74 years. Female patients (n=19, 50.1%). 14 (37.8%) patients had follow up CXR. One of these showed incomplete resolution with no further follow up or investigation arranged. Three patients were considered not suitable for follow up in view of their co-morbidities. 20/37 (58%) patients didn’t have appropriate follow up arranged. Conclusion(s): Our results underestimated CAP incidence at secondary level based on the discharge diagnosis of CAP. Mortality in this cohort was high signifying the severity of pneumonia, particularly with increasing age. There was one unresolved consolidation with no lung cancers diagnosed implying small sample size as a limitation in our study. Nevertheless 26 (27%) of patients had clinical diagnosis of CAP with no radiographic evidence. There was heterogeneity in the follow up CXR arrangements with patients shared between hospital specialists and primary care. For improvement we need to ensure appropriate follow up CXR (streamlined by staff education), radiology reports (highlighting the need for repeat CXR) and virtual clinics are arranged.

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The multidisciplinary team (MDT) management of chronic obstructive pulmonary disease in the community (2019)

Type of publication:
Conference abstract

Author(s):
*Ali A.; *Khan T.; *Ahmed J.; *Sesan A.; *Moudgil H.; *Makan A.; *Nawaid A.; *Ibrahim J.; *Crawford E.; *Srinivasan K.S.

Citation:
American Journal of Respiratory and Critical Care Medicine; May 2019; vol. 199 (no. 9)

Abstract:
Introduction: Chronic Obstructive Pulmonary Disease (COPD) is a disease state characterized by progressive airflow limitation that is not fully reversible. It encompasses chronic bronchitis and emphysema. This condition is both treatable and preventable. The incidence of COPD in the UK is estimated to be 3 million out of which 900,000 are diagnosed and 2 million remain undiagnosed. Acute exacerbation of COPD is one of the most common causes of emergency hospital admissions with 115,000 admissions per year with a mortality rate of 12 deaths during hospital stay and 6 dying within 90 days of admission.1&2 In the current state of increased healthcare costs related to hospital admissions, there is a service need to manage patients with long-term conditions in the community through development of specialist teams. The multidisciplinary community team consists of specialist nurses, doctors, therapists and community matrons who deliver services through community clinics, domiciliary visits, pulmonary rehabilitation and MDT meetings[3]. Studies have shown the benefits of promoting self-management and providing care closer to home in terms of reducing unnecessary primary care contacts as well as hospital admissions; thereby reducing mortality [4]. Aim The primary aim was to evaluate the role of MDT in reducing or preventing hospital admissions and secondary aim was to look at overall mortality in this cohort. Method(s): This was a retrospective study looking at the clinical notes and MDT letters for all patients with COPD (with post bronchodilator FEV1 of <70%) discussed in a local MDT meeting at a District General Hospital in the UK. Data on mortality and hospital admissions was obtained from our Clinical Portal, which is an electronic patient information system. Result(s): 151 patients were discussed at the local MDT meeting. 55.6% of females (graph 1) with a mean age of 72 years. After discussion at MDT, the number of hospital admissions were either reduced or remained the same in 65% (n= 98) but only 28% (n=42) of patients had more admissions. Data was not available for 9 patients. 64% (n=96) patients are alive 3 years from the discussion at the MDT meeting. Conclusion(s): Our study suggests that, the approach of community based MDT management of patients with COPD has got the advantage of reducing the healthcare expenditure on this cohort of patients, with no negative effect on mortality. As such, we propose these services to be funded in the near future.

Top research priorities for preterm birth: Results of a prioritisation partnership between people affected by preterm birth and healthcare professionals (2019)

Type of publication:
Journal article

Author(s):
Oliver S.; Uhm S.; Duley L.; Crowe S.; David A.L.; James C.P.; Chivers Z.; Gyte G.; Gale C.; Turner M.; Chambers B.; Dowling I.; McNeill J.; Alderdice F.; Shennan A.; *Deshpande S.

Citation:
BMC Pregnancy and Childbirth; Dec 2019; vol. 19 (no. 1) 528

Abstract:
Background: We report a process to identify and prioritise research questions in preterm birth that are most important to people affected by preterm birth and healthcare practitioners in the United Kingdom and Republic of Ireland. Method(s): Using consensus development methods established by the James Lind Alliance, unanswered research questions were identified using an online survey, a paper survey distributed in NHS preterm birth clinics and neonatal units, and through searching published systematic reviews and guidelines. Prioritisation of these questions was by online voting, with paper copies at the same NHS clinics and units, followed by a decision-making workshop of people affected by preterm birth and healthcare professionals. Result(s): Overall 26 organisations participated. Three hundred and eighty six people responded to the survey, and 636 systematic reviews and 12 clinical guidelines were inspected for research recommendations. From this, a list of 122 uncertainties about the effects of treatment was collated: 70 from the survey, 28 from systematic reviews, and 24 from guidelines. After removing 18 duplicates, the 104 remaining questions went to a public online vote on the top 10. Five hundred and seven people voted; 231 (45%) people affected by preterm birth, 216 (43%) health professionals, and 55 (11%) affected by preterm birth who were also a health professional. Although the top priority was the same for all types of voter, there was variation in how other questions were ranked. Following review by the Steering Group, the top 30 questions were then taken to the prioritisation workshop. A list of top 15 questions was agreed, but with some clear differences in priorities between people affected by preterm birth and healthcare professionals. Conclusion(s): These research questions prioritised by a partnership process between service users and healthcare professionals should inform the decisions of those who plan to fund research. Priorities of people affected by preterm birth were sometimes different from those of healthcare professionals, and future priority setting partnerships should consider reporting these separately, as well as in total.

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Identification of a thra mutation in a 2yr old child with clinical features of hypothyroidism and multisystem involvement (2019)

Type of publication:
Conference abstract

Author(s):
*Sakremath R.; Moran C.; Lyons G.; Chatterjee K.; Rajanayagam O.; Boelaert K.; Mohamed Z.

Citation:
Hormone Research in Paediatrics; Sep 2019; vol. 91 ; p. 272

Abstract:
Background: Thyroid hormones act via receptors (TRalpha; TRbeta) encoded by separate genes (THRA, THRB). Mutations in THRA are a recently-recognised cause of Resistance to Thyroid Hormone alpha (RTHalpha), a disorder with tissue-specific hypothyroidism but near-normal thyroid function tests. Aim(s): We describe the youngest recorded case of RTHalpha, in a 2yr old boy with disproportionate short stature, global developmental delay, constipation and a heterozygous missense mutation (p.G291S) in THRA. Case Report: A 16-month old male was referred to endocrine clinic with short stature. He had disproportionate stature with reduced subischial leg length (Table 1). He is in care, with a maternal antenatal history of substance abuse (exposure to methadone, heroine and alcohol in utero). He has global developmental delay and is mildly dysmorphic with constipation, all attributed to chromosome 16p13.11 microduplication. Examination revealed coarse facial appearance, depressed nasal bridge, long philtrum and central hypotonia. He had delayed visual maturation, hypermetropia, small kidneys and gastroesophageal reflux. His motor milestones (unable to sit without support) and speech are delayed. Laboratory analysis revealed normocytic anaemia, elevated creatine kinase levels, low-normal T4 and elevated T3 levels leading to altered T4:T3 ratio, with normal TSH levels. THRA sequencing identified a heterozygous missense (p.G291S) mutation, which is homologous to a known pathogenic mutation in THRB (G345S), causing RTHbeta. Correlation of genotype with phenotype and assessment of response to thyroxine therapy (25mcg/day) is being undertaken. Conclusion(s): We suggest that THRA sequencing should be considered in patients with clinical features of hypothyroidism, raised CK, anaemia and near-normal thyroid function tests but altered T4:T3 ratio. This case broadens the phenotypic spectrum of RTHalpha. (Table Presented).

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CT Calcium Score In The Elderly With Aortic Stenosis (2020)

Type of publication:
Conference abstract

Author(s):
*Pastfield E.; *Botley S.; *Pakala V.; *Ingram T.; *Lee E.

Citation:
Journal of Cardiovascular Computed Tomography; 2020; vol. 14 (no. 1)

Abstract:
Introduction: Degenerative aortic stenosis is a common condition. Many elderly frail patients with multiple comorbidities now have an alternative to conventional surgery since the availability of transcutaneous aortic valve implantation (TAVI). Echocardiography (echo) remains the key tool for the diagnosis of aortic stenosis. CT calcium scoring, has proven a useful adjunct to diagnosis, when there are discordant echo measurements. The current societies’ consensus propose a cut-off score (>2000 for men and >1200 for women) above which ‘severe aortic stenosis is likely’. However, many elderly patients have discordant echo measurements, low calcium score despite having severe aortic stenosis. We propose that the adverse event rates in elderly patients, regardless of calcium score category, are not significantly different. Method(s): We retrospectively examined the records of consecutive patients undergoing CT calcium score between Jan 2017 and Sep 2019. These investigations were done, either for TAVI procedure planning or as an adjunct to assessing the severity of aortic stenosis (in the case of discordant echo measurements). All these patients were followed up for adverse events, defined as a composite of heart failure, chest pain or death. Statistical analysis was performed using SPSS 25 (IBM). Result(s): 88 patients, age 82+/-6 years, 55% men, underwent CT aortic valve calcium scoring and echo. Peak aortic velocity 3.9 +/- 0.8 m/s, mean gradient 35 +/- 13 mmHg, aortic valve area 0.8 +/- 0.2cm2, stroke volume index (SVI) 38 +/- 11 ml/m2. 52.4% of the study population had discordant echo measurements and 43.6% had SVI<35ml/m2. The calcium score for women and men were 2230 +/- 1250 and 3866 +/- 1997 respectively. 24% of these patients had calcium score below the cut-off value for ‘likely severe aortic stenosis’. Median follow up was 382 days (range 66-1381 days) from the initial echo. Adverse events occurred in 20+/-4% and 29+/-5% in the ‘high’ and ‘low’ calcium score groups, independent t-test, p=0.40. Using Kaplan-Meier survival curve, there is no difference in the event free survival days between the two groups, 888 days for the ‘low’ and 702 days for the ‘high’ calcium score groups, Log rank Chi-square=0.26, p=0.61. Conclusion(s): In an elderly population with aortic stenosis, there is no difference in short term adverse event rates (composite of heart failure/death/chest pain) as categorised by their calcium scores. Therefore, the current diagnostic approach may under estimate the severity of aortic stenosis in some patients. [Formula presented]

Penicillin allergy in patients being treated for pneumonia-making a case for quality improvement project (2019)

Type of publication:
Conference abstract

Author(s):
*Mahendiran T.; *Omar M.K.; *Moudgil H.; *Crawford E.; *Srinivasan K.; *Makan A.; *Ahmad N.

Citation:
Thorax; Dec 2019; vol. 74 (Suppl. 2)

Abstract:
Background Penicillin allergy is reported by approximately 10% of the UK population, however only 20% of these actually have a true allergy.1 In addition, a documented penicillin ‘allergy’ may be associated with a prolonged length of stay (LOS) related to longer duration of treatment, complications and adverse effects related to second-line antibiotic use.2 Aim Our primary aim was to establish a documentation of the type of allergy to Penicillin within a cohort of patients presenting to our hospitals with community acquired pneumonia. Secondary aim was to compare the length of hospital stay, readmission within 30 days, complications and 30-day mortality between patients with and without penicillin allergy. Method We obtained data on all hospital admissions with a coded diagnosis of Pneumonia for the period covering October-December 2017. We divided this cohort into those with and without penicillin allergy; allergy information being obtained from discharge summaries and local pharmacy information system. Microsoft Excel and http://vassarstats.net/was used for statistical evaluation. Results 308 admissions were coded as pneumonia in this period. We excluded 77 admissions due to lack of data. Of the remaining, 187 had no penicillin allergy and 44 were allergic to penicillin. This gives a prevalence of 19% (44/231), which is higher than the reported prevalence above, of which 95% (42/44) did not have the type of allergy mentioned. Allergic group was older with a mean age (SD) 75 (15) v 72 (16) years [p value=0.0005], had more females 69% (31/44) v 41% (77/187) [p value=0.02], same LOS 6 days [p value=0.39], more readmissions 20% (9/44) v 16% (29/187) [p value=0.56], no greater complications 20% (9/44) v 20% (37/187) [p value=0.92] and a higher unadjusted overall mortality 14% (6/44) v 10% (18/187) (p value=0.61) Conclusion Data shows: 1. Poor documentation of the type of allergy to Penicillin. This needs a Quality improvement project as it is likely that most patients may not have a true allergy as shown in previous studies.1 2. Allergic group were older, with more females but the other variables were not statistically significant. We would recommend further research in this area to inform future practice.

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Domiciliary NIV (DOMNIV) in a real world setting: A retrospective study in a District General Hospital (2019)

Type of publication:
Conference abstract

Author(s):
*Craik S.; *Nasir A.; *Ali A.; *Moudgil H.; *Srinivasan K.; *Makan A.; *Crawford E.; *Wilson J.; *John N.; *Ahmad N.

Citation:
Thorax; Dec 2019; vol. 74 (Suppl 2).

Abstract:
Introduction: DomNIV in patients with chronic Type 2 respiratory failure results in improved survival. HOT-HMV study produced encouraging results in patients with COPD treated with home oxygen and DomNIV. [Murphy et al, JAMA, 317(21), 2177-2186] DomNIV usage with or without oxygen has been prevalent in our hospital setting over for 10 years. Objective Our primary aim was to look at the indications for prescription of DomNIV in our local hospital. Our secondary aim was to look at overall unadjusted mortality in this cohort and in particular any relationship with different types of oxygen provision.
Methods: We collected data on all patients who have received DomNIV from 2008-2018 with or without oxygen prescription from our local database. Data on mortality was obtained from our Clinical Portal. We used MS Excel and Vassar stats (http://vassarstats.net/) for statistical analysis.
Results: 105 patients commenced DomNIV; 60% were female with a mean (SD) age of 61 (13) years. Indications were Obesity hypoventilation (OH), Overlap syndrome, COPD, Neuromuscular disease, Bronchiectasis and others. 40% of patients did not receive oxygen with DomNIV (wO2), 36% received long term oxygen therapy (LTOT), 15% received overnight oxygen (OO2) and the rest received PRN oxygen. 43% of patients (N=45) died during the study period, of these 40% (N=18) died within the first 12 months. 29% died with LTOT versus 17% wO2 and 0% with OO2 in the first 12 months. This was statistically significant between LTOT and OO2 groups: RR 0.71 (95% CI 0.58-0.87), and also between wO2 and OO2 groups: RR 0.83 (95% CI 0.72- 0.95).
Conclusion: Majority of patients received DomNIV treatment for OH; 36% (N=38) had received long term oxygen therapy (LTOT) along with DomNIV; Patients receiving overnight oxygen with DomNIV survived longer compared to those who had it as LTOT or who didn’t have any oxygen at all.

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