Search

Introduction: Septicemia is a leading cause of morbidity and mortality in India. Blood culture remains the gold standard for the diagnosis of septicemia. The antimicrobial sensitivity pattern differs in different studies. Knowledge of likely causative organisms of septicemia and their antimicrobial sensitivity pattern can help to start appropriate therapy in order to minimize morbidity and mortality. Aim: To isolate the etiological organisms causing sepsis and study the antimicrobial susceptibility profile and its mechanism of resistance pattern. Materials and Methods: The observational study of 206 positive blood culture was carried out in the Department of microbiology, tertiary Care Hospital during the period from December 2015 to November 2016 and processed by standard conventional method. Antibiotic susceptibility pattern of isolates was studied by Kirby Bauer Disc diffusion technique. Observations & Results: Total 1281 samples were received during the study period of which 206 (16.08%) samples were found to be positive. Bacteria isolated include CONS (15.04%), S.aureus (14.08%), Klebsiella pneumonia (19.90%), Acinetobacter spp (10.19%), Escherichia coli (8.74%), Pseudomonas spp (7.77%), Salmonella typhi (1.46%) and Salmonella paratyphi A (0.49%). Majority of organisms Isolated were resistant to commonly used antibiotics. Imipenem showed 83% and colistin 94.69% sensitivity for gram negative organisms. Methicillin resistance was found in 2.91% Staphylococcus aureus Isolated. The Gram positive bacteria showed high resistance to Penicillin G (75%) but they were highly susceptible to Azithromycin (70%), Levofloxacin (80%) Linezolid (100%) and Vancomycin (98%) Conclusions: Klebsiella pneumoniae was the most predominant etiological agent of septicemia. Every hospital should monitor its antibiotic sensitivity pattern against the common isolates that can serve as a basis for empirical therapy in emergency conditions. Considering the burden of mortality resulting from s

Background The relationship between smoking and COVID-19 disease severity is uncertain;one meta-analysis found smoking increases the risk of developing severe COVID-19 two-fold 1 No previous study has reported whether smokers have worse outcomes at follow-up We hypothesised that smokers admitted to hospital with COVID-19 would have a greater symptom and radiological severity at follow-up Methods We prospectively followed up swab-positive COVID-19 patients in two hospitals discharged between 03 05 20 and 19 06 20 Telephone calls were conducted 8-10 weeks post discharge Demographics, co-morbidities, smoking history and symptom burden data were collected Symptom burden was quantified using a numerical rating scale for breathlessness, cough and fatigue Patients were offered a follow-up chest radiograph (CXR) if abnormal on discharge Results 782 patients were reviewed post-discharge, median (IQR) time to review: 63 (54-79) days Smoking history was obtained for 537 patients Outcomes for 181 (34%) current/ex-smokers were compared to 356 (66%) never-smokers Table 1 demonstrates baseline characteristics and symptom burden between groups at follow-up Never-smokers were significantly younger (59 5±16 3 vs 65 1±15 5 years, p

Using functional technology, majority of the farmers had average to above average technology utilization behaviour in paddy farming. All the variables except experience in paddy farming, extension participation and risk orientation, all other independent variables showed significant influence in determination of technology utilization behaviour. Annual income and scientific orientation had shown maximum influence on technology utilization behaviour. Annual income contributed 49.40 per cent total variation in predicting technology utilization behaviour and total joint contribution of all independent variable together contributed 62.40 per cent variation in determining technology utilization behaviour. As far as direct, indirect and substantial effects are concerned age was key variables in exerting positive and direct effect on technology utilization behaviour in paddy growers. Whereas, annual income had positive and highest indirect effect and economic motivation, animal possession and annual income were the key variables in determination of substantial indirect effect on technology utilization behaviour of paddy growers.

Objective: Transposition of the great arteries is a common congenital heart disease. Arterial switch is the gold standard operation for this complex heart disease. Arterial switch operation in the presence of intramural coronary artery is surgically the most demanding even for the most experienced hands. We are presenting our experience with a modified technique for intramural coronary arteries in arterial switch operation. Methods: This prospective study involves 450 patients undergoing arterial switch operation at our institute from April 2006 to December 2013 (7.6 years). Eighteen patients underwent arterial switch operation with intramural coronary artery. The coronary patterns and technique used are detailed in the text. Results: The overall mortality found in the subgroup of 18 patients having intramural coronary artery was 16% (n=3). Our first patient had an accidental injury to the left coronary artery and died in the operating room. A seven-day old newborn died from intractable ventricular arrhythmia fifteen hours after surgery. Another patient who had multiple ventricular septal defects with type B arch interruption died from residual apical ventricular septal defect and sepsis on the eleventh postoperative day. The remainder of the patients are doing well, showing a median follow-up duration of 1235.34±815.26 days (range 369 - 2730). Conclusion: Transposition of the great arteries with intramural coronary artery is demanding in a subset of patients undergoing arterial switch operation. We believe our technique of coronary button dissection in the presence of intramural coronary arteries using coronary shunt is simple and can be a good addition to the surgeons' armamentarium.

Garhwal Himalaya in northern India has emerged as one of the most prominent hot spots of landslide occurrences in the Himalaya mainly due to geological causes related to mountain building processes, steep topography and frequent occurrences of extreme precipitation events. As this region has many pilgrimage and tourist centres, it is visited by hundreds of thousands of people every year, and in the recent past, there has been rapid development to provide adequate roads and building infrastructure. Additionally, attempts are also made to harness hydropower by constructing tunnels, dams and reservoirs and thus altering vulnerable slopes at many places. As a result, the overall risk due to landslide hazards has increased many folds and, therefore, an attempt was made to assess landslide susceptibility using 'Weights of Evidence (WofE)', a well-known bivariate statistical modelling technique implemented in a much improved way using remote sensing and Geographic Information System. This methodology has dual advantage as it demonstrates how to derive critical parameters related to geology, geomorphology, slope, land use and most importantly temporal landslide distribution in one of the data scarce region of the world. Secondly, it allows to experiment with various combination of parameters to assess their cumulative effect on landslides. In total, 15 parameters related to geology, geomorphology, terrain, hydrology and anthropogenic factors and 2 different landslide inventories (prior to 2007 and 2008-2011) were prepared from high-resolution Indian remote sensing satellite data (Cartosat-1 and Resourcesat-1) and were validated by field investigation. Several combinations of parameters were carried out using WofE modelling, and finally using best combination of eight parameters, 76.5 % of overall landslides were predicted in 24 % of the total area susceptible to landslide occurrences. The study has highlighted that using such methodology landslide susceptibility assessment can be carried out in vast stretches of Himalaya in short time in order to assess the impact of development as well as climate change/variability. The resultant map can play a critical role in selecting areas for remedial measures for slope stabilisation as well planning for future development of the region.

Summary form only given. Fast and portable pulse power systems especially in the megavolt range have always been in demand for years. Use of such fast rise time, high voltage generators are considered to be of great interest for variety of application like - driving portable X-ray sources and special free electron lasers. Their use with pulse forming lines results in the production of relatively compact particle beam accelerators. They have also been found useful in driving wide band electromagnetic radiators. In reference to above mentioned applications a battery powered and portable, nanosecond rise time megavolt system has been developed. In this system, 60 Watt SMPS DC to DC converter has been used for charging 0.24 /spl mu/F capacitor, which acts as a primary source of energy. The SMPS is driven by two normal 12 V Panasonic batteries and gives an output of 30 KV @ 2 mA. The capacitor is made to discharge into the primary of 'pulse transformer' through spark gap switch. It is an air-core transformer with the coupling coefficient of 0.66 which can produce maximum output voltage up to 1.5 MV. In the coaxial geometry, it has single turn primary to achieve fast rise time and multi-turn secondary. For attaining high reliability and repeatability, trade off has been made between good coupling coefficient and high voltage stand off while designing. Low leakage inductance and low distributed capacitance is also required in order to obtain fast rise time hence due considerations have been made in the design to fulfill the same. After making trade off among these parameters carefully, a pulse transformer with rise time of less than 10 ns has been designed and built. In the presented paper attempt has also been made to create the methodology of designing pulse transformers delivering high power impulses with faster rise times on secondary side.

Introduction Cardiovascular risk is elevated following COPD exacerbations requiring systemic therapy (Donaldson et al , Chest 2010:137; 1091–7). We have recently shown that a potential mechanism is increased arterial stiffness during COPD exacerbations compared to the stable state (Patel et al , AJRCCM 2012:185; A5853). We hypothesised that arterial stiffness may be mediated by airway infection and inflammation during COPD exacerbations. Methods We used aortic pulse wave velocity (aPWV) as a non-invasive validated measure of arterial stiffness using Vicorder apparatus (Skidmore Medical, UK) in outpatients from the London COPD cohort when they presented within seven days of exacerbation symptom onset and prior to any systemic therapy. These events were defined using our usual symptomatic criteria (Seemungal et al , AJRCCM 1998:157; 1418–22). We collected spontaneous sputum at the same clinic visit to identify typical bacterial ( S pneumoniae, H influenzae and M catarrhalis ) and rhinovirus infection using PCR. We also measured IL-6 and IL-8 in sputum supernatant using commercial ELISA kits (R&D Systems, USA). Results 32 exacerbating COPD patients produced a spontaneous sputum sample during the same clinic visit as an aPWV measurement. Their stable clinical characteristics were: 69% male; 25% current smokers; median (IQR) 39 (21.74) pack year smoking history; mean±SD age 72.4±8.1 years; FEV1 1.18±0.41L and 46.8±18.0%predicted; FEV1/FVC ratio 0.44±0.15 and BMI 25.4±3.8 kg/m2. Arterial stiffness was higher in patients with airway infection at exacerbation presentation (mean ±SD aPWV 12.3±2.3 (n=19) vs 10.8±1.8 (n=13) m/s, p=0.030) (Figure 1A). Arterial stiffness was strongly correlated with sputum IL-6 at exacerbation (n=32, rho=0.495, p=0.003) (Figure 1B) but not IL-8 (n=31, rho=0.100, p=0.591). Conclusions Arterial stiffness is related to airway infection and inflammation during COPD exacerbations. Interventions to prevent and reduce airway infection and inflammation may lower cardiovascular risk during COPD exacerbations.

Introduction Clinical trials in chronic obstructive pulmonary disease (COPD) have spirometric criteria for enrolment, and published screening failure rates against these criteria have been reported as low as 7% 1 . Primary care databases provide a source of patients with COPD to recruit into clinical trials. However, UK COPD lists are heterogenous, with only 73% having confirmed COPD when retested 2 . This may result in a higher than expected screening failure rate. We reviewed this using our experience of recruiting to a COPD trial through primary care databases. Methods Local GP surgeries were requested to contact all patients on their COPD database after applying exclusion criteria for age and co-morbidities. Patients were sent an invitation letter with a reply slip to return directly to the study team and those interested in participating were contacted for screening spirometry and medical history. Surgeries were reimbursed up to £500 administrative costs. Patients fulfilled diagnostic inclusion criteria if the FEV1/FVC ratio was Results Approximately 1400 letters were sent from 29 GP surgeries between February and July 2012; 283 replies were received by the study team (20%). Of these, 180 were not screened (125 [69%] declined to participate, 9 [5%] had diseases other than COPD, 9 [5%] were enrolled in other research, and 37 [21%] were unsuitable for other reasons). 8 appointments were pending with screening data available for 95 patients (Table 1). 40 patients (42%) did not satisfy the spirometric inclusion criteria; 27 did not show airflow obstruction, 10 had mild COPD, and 3 had asthma. Approximately 25 contact letters and up to £260 were therefore required per eligible patient identified. Conclusion A high proportion of patients on primary care databases fail to meet spirometric criteria for COPD trials and the screening failure rate via this recruitment pathway is much higher than previously reported. A large number of initial contacts are required for each patient identified. COPD patients are increasingly managed in primary care and these findings therefore have implications for planning future studies. Albert, NEJM, 2011; 365(8):p689–98. Jones, Respir Res, 2008; 9:p62.

Introduction IL-18 is a proinflammatory cytokine implicated in COPD pathophysiology, causing pulmonary inflammation and emphysema in murine models. IL-18 receptor expression is increased on alveolar macrophages in COPD.1 IL-18 levels are elevated in serum and sputum of stable COPD patients. We hypothesised that airway and systemic IL-18 concentrations increase further at exacerbation. Methods Sputa and sera prospectively collected from the London COPD cohort were analysed using ELISA (eBioscience®, Vienna). Patients had an FEV 1 =80% predicted and FEV 1 /FVC ratio=0.7. Baseline was defined as at least 6 weeks after, and 2 weeks before, an exacerbation. An exacerbation was defined as an increase for two consecutive days in respiratory symptoms, with at least one major symptom (dyspnoea, sputum purulence or volume) plus another major or minor (wheeze, cold, sore throat or cough) symptom. Exacerbation frequency was calculated from daily diary cards collected over the previous 12 months. When unavailable, patient9s recall of exacerbations over the preceding year was used. Frequent exacerbators had ≥2 exacerbations in the preceding year, infrequent exacerbators Results 94 COPD patients had serum analysed, of whom 48 also had sputum analysed. 60% were male, mean age was 71.6 years (SD 8.5), mean FEV 1 predicted 50.6% (18.1). Sputum IL-18 levels increased significantly from baseline to exacerbation (median 1.46 log 10 pg/ml (IQR 0.96–2.01) vs 1.95 (0.96–2.23), n=48, p=0.023, Abstract P119 figure 1). However, serum IL-18 concentrations were not significantly greater at exacerbation compared to paired baseline levels (median 2.17 log 10 pg/ml (1.97–2.37) vs 2.08 (1.91–2.36), n=31, p=0.299).There was no correlation between baseline serum IL-18 concentrations and exacerbation frequency (n=94, ρ=0.096, p=0.357) or FEV 1 % predicted (n=93, ρ=0.081, p=0.443). No significant difference was found in baseline serum IL-18 concentrations between frequent and infrequent exacerbators (median 148 pg/ml (95–235; n=46) vs 120 (78–219; n=48), p=0.431). There was no correlation between baseline serum IL-18 concentrations and paired sputum levels (n=42, ρ=−0.149, p=0.348). Conclusions Sputum but not serum IL-18 increases at COPD exacerbation. Treatment options for exacerbations are limited and there is a need for novel anti-inflammatories. The results of this study suggest IL-18 as a potential target for exacerbation therapy.

Introduction It is not known whether systemic inflammation reflects lower airway inflammation in non-CF bronchiectasis. If confirmed, blood biomarkers may provide useful information on pulmonary disease burden in both stable and exacerbated states. Serum C reactive protein (CRP) is readily measurable in many clinical settings, including at point-of-care, and procalcitonin (PCT) has a potential role with documented utility in other respiratory diseases. This study explored the relationship between airway and systemic inflammatory biomarkers in adult patients with non-CF bronchiectasis. Method Serum CRP (for systemic inflammation) and PCT, and sputum interleukin (IL)-6 (for airway inflammation) were measured in 31 well-phenotyped stable patients from The London Bronchiectasis Cohort. Six exacerbation samples were obtained from patients who had been previously sampled at baseline, with the exacerbation sample obtained at exacerbation onset, prior to initiation of additional antibiotic therapy. Sputum IL-6 was measured using ELISA, serum PCT using TRACE, and CRP using immunoturbidimetry techniques. Data were analysed using SPSS V.14.0. Results Of the 31 patients, 23 (74.2%) patients were female, with a mean (SD) age of 54.7 (14.9) years, FEV 1 2.09 (0.90) l (75.71% predicted), and FVC 3.12 (1.01) l. The predominant aetiologies were primary immunodeficiency (mostly CVID, n=13, 42%), post-infectious (10, 32%) and idiopathic (4, 13%). The median (IQR) baseline sputum IL-6 was 101 (30–701) pg/ml, baseline serum PCT was 0.030 (0.021–0.040) μg/ml and CRP 3.0 (1.0–6.0) mg/l. The degree of systemic inflammation in stable bronchiectasis reflected that occurring in the airways as evidenced by a significant correlation between sputum IL-6 and serum CRP in the 31 stable samples (r=0.43, p=0.027). There was also a correlation between the two systemic markers (PCT and CRP: r=0.42, p=0.029), but the relationship between serum PCT and sputum IL-6 concentration was not statistically significant (r=0.28, p=0.127). In the six patients with paired samples, serum PCT increased significantly from baseline to exacerbation (0.031 vs 0.147 μg/ml p=0.043). Changes in sputum IL-6 and blood serum CRP did not reach statistical significance. Conclusion We report a direct relationship between airway and systemic inflammation in stable patients with non-CF bronchiectasis. This suggests that systemic biomarkers may be useful for monitoring local disease activity in this neglected condition.

Introduction Effective recognition and appropriate management of comorbidities is an important aspect of modern COPD care. In particular, cardiovascular diseases are a leading cause of morbidity and mortality. There is increasing interest in the differential impact of gender in COPD. This study aims to characterise gender differences in the profile of comorbidities in COPD. Methods We analysed the recruitment records of 386 well-characterised patients enrolled into the London COPD Cohort. Comorbidities, medication, age, gender, height, weight, spirometry, St George9s Respiratory Questionnaire (SGRQ) and MRC dyspnoea scores were recorded. Results There were no significant differences between females (n=164) and males (n=222) in terms of mean ± SD age; 67.5±8.3 vs 69.0±9.0 years, p=0.102, median (IQR) smoking pack year history 47 (27–62) vs 44 (27–65), p=0.769 or body mass index 25.3 (22.1–29.4) vs 25.5 (22.8–29.0), p=0.311. Females had milder airflow limitation at recruitment with a higher mean ± SD FEV 1 % predicted; 53.5±19.9 vs 46.4±18.9, p 1 % predicted, there were no gender differences in SGRQ (51.2±18.6 vs 49.8±19.5, p=0.127) or MRC dyspnoea scores (3.0 (2.0, 4.0) vs 3.0 (2.0, 4.0), p=0.104). Cardiovascular conditions were more common in male COPD patients (Abstract P46 figure 1), whereas of the clinically significant comorbidities, only osteoporosis was more common in females (10.4% vs 2.7%, p=0.001). Conclusions The excess cardiovascular disease in COPD patients is predominantly found in men despite lower gender differences in cardiovascular risk factors such as smoking history, diabetes, hypercholesterolaemia and hypertension. This may partly represent under-diagnosis of cardiovascular disease in COPD patients. Clinical vigilance must be maintained to identify and optimally manage important comorbidities in all COPD patients, although clinicians should be aware of the increased prevalence of cardiovascular disease in men and osteoporosis in women.

Introduction COPD exacerbations are clinically important events, commonly triggered by bacterial infection. Defective phagocytosis of potentially pathogenic microorganisms (PPMs) in stable COPD has been demonstrated in both alveolar and monocyte-derived macrophages (MDMs). We hypothesised that phagocytosis may be suppressed further during an acute COPD exacerbation and relate to bacterial aetiology of the exacerbation. Methods Whole blood was collected from patients in the London COPD cohort at both stable state and at exacerbation, as defined by prospectively completed daily symptom diary cards (Seemungal et al ., 1998). Monocytes were isolated and cultured with GM-CSF (2ng/ml) for 12 days to generate MDMs. MDM phagocytosis of fluorescently-labelled polystyrene beads, Haemophilus influenzae (HI) and Streptococcus pneumoniae (SP) was measured by fluorimetry. Diary card data was used to determine prodromal symptoms, exacerbation duration and exacerbation symptom intensity. Sputa collected at exacerbation were cultured for PPMs. Results MDMs were cultured from 13 COPD patients at paired stable and exacerbation states. 54% were male, mean age 72.8 years (SD 6.2), FEV 1 predicted 55.7% (20.5) and 38% current smokers. The median time between stable and exacerbation states was 147 days [IQR 75–212]. Two distinct patterns of change in phagocytic ability were seen between the stable and exacerbation state. Eight patients significantly decreased their phagocytic capacity compared to stable state for beads, HI and SP (p = 0.004, p = 0.008 and p = 0.020 respectively, Figure 1A). Five of these eight patients (63%) had a PPM isolated in their exacerbation sputum sample. Five of 13 patients increased phagocytosis at exacerbation (Figure 1B), but only SP reached statistical significance (p = 0.031). Only one of these five (20%) had a PPM in their exacerbation sputum sample. There was no significant difference between the presence of prodromal symptoms, exacerbation duration or symptom intensity between the two patterns. Conclusion Phagocytosis of bacteria is suppressed further during some COPD exacerbations. This may contribute to bacterial aetiology of these exacerbations. Phagocytosis appears partially more effective in other exacerbations. Further work is needed to understand these apparently dichotomous changes and their impact on clinical outcomes.

Introduction Cardiac biomarkers of myocardial injury and dysfunction are commonly raised in patients hospitalised with COPD exacerbations and are independent predictors of mortality. The relevance of this to the majority of community-treated events has not previously been studied. Methods We prospectively measured serum troponin T and N-terminal brain pro-natriuretic peptide (NT-proBNP) in 55 patients from the London COPD Cohort in the stable state, at exacerbation onset and thereafter at days 3 (n = 44), 7 (n = 39), 14 (n = 38), and 35 (n = 25) during recovery. Exacerbation assessments were undertaken within one week of symptom onset, prior to therapy, and defined by two consecutive days of new or increased respiratory symptoms on prospectively-completed daily patient diary cards requiring at least one major (dyspnoea, sputum purulence, sputum volume) and another major or minor symptom (coryza, wheeze, sore throat and cough). Results Cardiac biomarkers rose from the stable state to exacerbation (mean ( ± SD) troponin T 0.012 ( ± 0.011) vs 0.017 ( ± 0.016) µg/L, p Cardiac biomarkers did not fall during the initial five-week exacerbation recovery period (troponin T -0.0003µg/L/day (95% CI -0.0008 to 0.0004), p = 0.431; NT-proBNP -0.096 pg/ml/day (95% CI -0.631 to 0.438), p = 0.723). They remained more elevated in those with IHD (n = 12) than in those without IHD (n = 43) during the five week recovery period (troponin T AUC 0.368 ± 0.311 µg/L/35days vs 0.088 ± 0.174 µg/L/35days, p Longer exacerbations were associated with greater myocardial injury at exacerbation (higher serum troponin T) and the magnitude of change from the stable state (rho = 0.323, p = 0.027; rho = 0.390, p = 0.007 respectively). Conclusions Myocardial injury and dysfunction is common and clinically significant during COPD exacerbations in those with underlying IHD and relates to exacerbation length. Alternative approaches to mitigate cardiovascular complications, in stable COPD and at exacerbation, require further study.

Introduction Viral infections are associated with more severe COPD exacerbations in terms of greater burden of symptoms, resulting in longer recovery times and a greater likelihood of hospitalisation (Seemungal et al . 2000). Human rhinoviruses (HRV) are the main aetiological agents of virus-associated COPD exacerbations; however the association of HRV infection and exacerbation frequency has not been fully investigated. We aimed to examine the relationship between HRV presence and load, and the number of exacerbations patients experienced per year. Methods London COPD cohort patients recorded any new or increased respiratory symptoms on daily diary cards and contacted the clinical team when symptoms worsened. Exacerbations were defined using our usual symptomatic criteria; an increase in respiratory symptoms for two consecutive days, with at least one symptom being major (dyspnoea, sputum purulence or volume). Reverse-transcription quantitative PCR was used to detect HRV prevalence and load in sputum samples collected at exacerbation presentation (median 2 days after exacerbation onset). Results Patients positive for HRV (n = 42) had significantly more exacerbations per year than those without HRV (n = 31); the median (IQR) number of exacerbations per year in those with HRV infection was 3.01 (2.02–5.30) which was significantly greater than those without HRV infection 2.51 (2.00–3.51); p = 0.038 ([Figure 1A][1]). At exacerbation, a higher HRV load significantly correlated with the number of exacerbations patients experienced per year; r = 0.145; p = 0.024 ([Figure 1B][1]). ![Abstract S111 Figure 1.][2] Abstract S111 Figure 1. (A) The number of exacerbations per year in patients with HRV (n = 42) was significantly higher than in those without HRV (n = 31), p= 0.038. (B) There was an association between the number of exacerbations had by patients per year and the HRV load (r= 0.145; p= 0.024). Conclusion Patients with positive HRV infection at the time of exacerbation had experienced more exacerbations per year than those who did not have HRV. In patients with a higher exacerbation frequency, the HRV load at exacerbation was greater suggesting that patients with a history of frequent exacerbations are more susceptible to viral infection. This susceptibility may provide the mechanisms for the development of the frequent exacerbator phenotype. Thus these findings emphasise the importance of preventing viral infections and exacerbations in COPD patients. [1]: #F1 [2]: pending:yes

Introduction Gastro-oesophageal reflux disease (GORD) has been associated with increased COPD exacerbation frequency (Terada et al, Thorax 2008) and was independently associated with the frequent exacerbator phenotype in the ECLIPSE study (Hurst et al, NEJM 2010). We aimed to quantify any changes in GORD symptoms during COPD exacerbations. Methods Outpatients from the London COPD cohort completed the Frequency Scale for the Symptoms of Gastro-oesophageal reflux (FSSG) and Hull Airway Reflux Questionnaire (HARQ) during stable-state clinic visits and at exacerbation, within a week of symptom-onset, and prior to systemic therapy. FSSG and HARQ scores range from 0–48 and 0–70 respectively, with significant reflux thought to be associated with scores of ≥8 and ≥13 respectively. Exacerbations were defined using our usual symptomatic criteria from daily diary cards (Seemungal et al, AJRCCM 1998). Results 42 COPD patients had a mean±SD age of 72.7±8.7 years, 64% male, 17% current smokers, median(IQR) 46 (19.71) pack years, mean±SD stable FEV1 1.22±0.64L and 50.7±21.5%predicted, BMI 27.7±7.4kg/m2. 13 (31%) patients had a diagnosis of GORD, of whom 12 (92%) were taking regular acid suppression therapy. There was a median (IQR) interval of 141(80,233) days between the stable and exacerbation visits. Although median (IQR) FSSG and HARQ scores were higher at exacerbation compared to the stable state, this was not statistically significant due to high variability (6.5 (4.0,13.0) vs 5.0 (1.5,11.5), p=0.247 and 15.5 (9.0,23) vs 18.5 (11.5,24.5), p=0.096 respectively). 16/42 (38%) patients had a high FSSG score (≥8) in the stable state compared with 20/42 (48%) at exacerbation (p=0.378). 10/42 (24%) changed from a low stable FSSG to a high score at exacerbation. 27/42 (64%) patients had a high HARQ score (≥13) in the stable state compared with 30/42 (71%) at exacerbation (p=0.483). 7/42 (17%) changed from a low stable HARQ to a high score at exacerbation. Conclusions GORD symptom scores are not significantly higher during acute COPD exacerbations. Due to high variability, approximately one fifth of COPD patients had a low GORD symptom score when stable and high scores at exacerbation implicating worsening reflux in some exacerbations. Further work is required to understand the potential mechanisms. ![Abstract P214 Figure 1][1] Abstract P214 Figure 1 [1]: pending:yes

Introduction COPD is characterised by breathlessness, leading to reduced physical activity. Breathlessness varies dependent upon the degree and intensity of physical activity (1). Common logic dictates that weather variation such as temperature and sunshine could influence physical activity in the general population, especially walking. The aims of this study were to evaluate the effect of weather variation on daily activity and the variation in activity during the days of the week in COPD patients. Methods Fifty-five stable COPD outpatients from the London COPD cohort wore a pedometer (Yamax Digi-Walker SW-200) daily for 30 days during waking hours. We excluded exacerbating patients and those using walking sticks or oxygen. All patients were asked to record their step count on daily diary cards. Weather data for London Heathrow were obtained with permission from the British Atmospheric Data Centre. Stable COPD was defined as having no symptom-defined exacerbations in the preceding six weeks and subsequent two weeks, according to prospectively-collected diary cards, with no change in long-term inhaled and oral medications in the preceding two weeks. Results The clinical characteristics of the 55 patients were mean (±SD) age 70.3 (8.7) years; FEV1% predicted 51.0% (±14.1); male gender 67%; current smoker 25%, BMI 27.2 kg/m2. The mean (±SD) daily step count was 4327 (±2944). COPD patients were more active as temperatures increased (Figure 1A) and on sunny as opposed to no sunshine days (Figure 1B, p Conclusion Daily activity in stable COPD markedly affected by outdoor temperature and sunshine and patients had highest activity during weekdays. Further work is required to ascertain whether some patients are more active than others. Reference Pitta F et al ., Quantifying Physical Activity in Daily Life with Questionnaires and Motion Sensors in COPD, ERJ 27, no. 5 (April 2006): 1040–1055.

Introduction Physical activity and exercise capacity are among the important patient-relevant parameters in COPD. COPD patients are less active and less likely to go outside when compared with the general population and this worsens during exacerbation (1). The aim of this study was to determine whether step-counts measured by a pedometer (Yamax Digi-walker SW-200) would be a useful method of quantifying physical activity in stable COPD patients on the community. Methods Stable COPD outpatients wore a pedometer for 30 days, had a six minute walk distance (6MWD) assessed according to ATS protocols and completed the SGRQ (St. George’s Respiratory Questionnaire) and MRC dyspnoea score. The pedometer was worn on the left-hand side during waking hours. Patients recorded daily step counts and time spent outdoors on written daily diary cards. Results Fifty-five COPD patients had a mean (±SD) age 70.3 (8.7) years and FEV1 51.0% predicted (±14.1); male gender 67%. The mean (±SD) 6MWD was 416 (±88) metres, with an average of 4327 (±2944) steps/day and spent 3.1 (±1.4) hours outdoors. [Figure 1][1] shows that patients with greater 6MWD took more steps per day during normal activity [r=0.47; p=0.001], [Fig. 1A][1], and stayed outdoors for longer [r=0.41; p=0.003], Fig. 1B. Patients with lower step counts tended to have a poorer health status in terms of SGRQ score[r= –0.31; p=0.025], [Fig. 1C][1], and a higher level of dyspnoea on the MRC score [Rho= –0.39; p=0.005], [Fig. 1D][1]. ![Abstract P79 Figure 1][2] Abstract P79 Figure 1 Conclusions Daily step counts measured by a pedometer averaged over 30 days correlated well with objective tests of physical capacity, time outdoors, health status and dyspnoea. Thus pedometry is a useful method of quantifying daily physical activity in COPD patients. References 1. Donaldson GC et al ., Exacerbations and Time Spent Outdoors in Chronic Obstructive Pulmonary Disease, Am J Resp Crit Care Med (2005) 171: 446–452. [1]: #F1 [2]: pending:yes

Introduction Gastro-oesophageal reflux disease (GORD) has been associated with increased COPD exacerbation frequency (Terada et al, Thorax 2008) and was independently associated with the frequent exacerbator phenotype in the ECLIPSE study (Hurst et al, NEJM 2010). We aimed to quantify the prevalence and impact of GORD in stable COPD in terms of airflow limitation, dyspnoea, health status and exacerbation frequency in a well-characterised cohort. Methods Stable outpatients from the London COPD cohort completed the Frequency Scale for the Symptoms of Gastro-oesophageal reflux (FSSG), Hull Airway Reflux Questionnaire (HARQ), MRC dyspnoea score, and St George’s Respiratory Questionnaire (SGRQ) during clinic visits. Spirometry was performed in accordance with ATS/ERS guidance. Comorbidities including GOR and all medications were recorded by clinical research staff. Exacerbations were defined using our usual symptomatic criteria from daily diary cards (Seemungal et al, AJRCCM 1998). Results 156 stable COPD patients had a mean±SD age of 72.2±9.7 years, 63% male, 29% current smokers, median (IQR) 46 (25,59) pack years, mean±SD FEV1 1.34±0.57L and 54.4±20.2%predicted, BMI 26.5±5.7kg/m2. 60 (38%) patients had a diagnosis of GORD, of whom 45 (75%) were taking regular acid suppression therapy (42 proton pump inhibitors, 3 H 2 antagonists). COPD patients with GORD had a higher exacerbation frequency than those without (median (IQR) 2.0 (1.0,3.4) vs 1.2 (0.0, 3.0) per year, p=0.028). In those with GORD, the use of acid suppression therapy did not impact exacerbation frequency (median (IQR) 2.0 (1.0,4.0) (n=45) vs 2.0 (1.0, 3.0) (n=15) per year, p=0.431). FSSG and HARQ scores were both related to COPD exacerbation frequency (rho=0.159, p=0.050 and rho=0.185, p=0.021 respectively) and more strongly to SGRQ (r=0.425, p Conclusions GORD is common in COPD and is associated with higher exacerbation frequency, although acid suppression therapy does not appear to affect this. Higher GORD symptom scores relate to worse health status and higher exacerbation frequency but not to airflow limitation or dyspnoea. Understanding the mechanisms may lead to novel effective interventions in COPD.

Introduction Influenza vaccination prevents substantial morbidity, and mortality, and the spread of infection, but patients still sometimes refuse vaccinations due to concerns over adverse reactions. Our aim was to determine the relative risk of COPD exacerbations post-vaccination. Methods We analysed data before and after 162 vaccinations given to 112 patients in the London COPD cohort between 2009 and 2011. Patients recorded on daily diary cards increase in respiratory symptoms. Exacerbations were defined as ≥2 days of 2 major symptoms (new or increased breathlessness, sputum volume or purulence) or 1 major and 1 minor symptom (cold, increased cough, increased wheeze, sore throat). Patients were telephoned in Oct 2011 and asked about recent or forthcoming vaccinations; other dates were known from previous years when recorded diary cards or reported at clinic visits. The risk of COPD exacerbation in the two post-vaccination periods, days 1–2 and 3–14 were calculated relative to the patient’s baseline risk assessed over the year before and after vaccination using a self-controlled case series approach. The data was also simply analysed with a Chi-squared test of the proportion of exacerbations in the two weeks before and after vaccination. Results There was a 3.31 fold (95% CI 1.5–7.4; P=0.004) increased risk of COPD exacerbation 1–2 days post influenza vaccination, and a 1.8 fold risk (1.2–2.9; p=0.007) 3–14 days afterwards. In the two weeks prior to vaccination there were 5/162 exacerbations and 26/162 in the two weeks post vaccination (p Conclusion The incidence of COPD exacerbation increases immediately after influenza vaccination. COPD patients should be warned about increased respiratory symptoms after their influenza vaccination. Future studies should investigate the mechanisms underlying these increased symptoms in order to intervene and prevent them effectively.

Background BTS guidance for Emergency Oxygen Use recommends that local anaesthesia should be used for all routine arterial blood gas (ABG) sampling [1]. Intradermal and/or subcutaneous local anaesthetic (LA) via small gauge needle has been shown to reduce pain associated with the procedure by more than half [2]. We aimed to quantify the prevalence of this practise and ascertain potential barriers. Methods 160 FY1 doctors with at least eight months working experience, from five hospitals in London were given a ten-item anonymised questionnaire to measure practise and opinions regarding local anaesthesia before ABG sampling. Results All 115 respondents (72% response rate) performed ABG sampling regularly, with 84% doing so at least weekly. Only 27% of respondents had ever used intradermal and/or subcutaneous LA before ABG sampling, although only 5% did this regularly. The commonest needles used were 25 gauge (orange) (49%), 28 gauge (insulin needle) (18%), and 23 gauge (blue) (16%). 70% of respondents had never used LA of any kind for ABG sampling. Topical LA use was rare. 14% of respondents had never heard of LA used for ABG sampling; 24% were unfamiliar with how to do it; 14% believed it was potentially dangerous; 34% claimed not to have time, 21% believed that LA would not reduce the overall pain of the procedure (Figure 1). Allen’s test was usually perfomed by only 25% of doctors before ABG sampling. Only 30% of respondents believed using LA would lead to less repeated ABG sampling attempts. 93% of respondents had never personally been sampled for an ABG, although 44% would prefer LA to be used on them. Conclusion The regular use of local anaesthesia before ABG sampling among FY1 doctors is rare. Awareness of the technique is poor, and education is needed. Prominence and promotion in teaching sessions and local guidelines, along with quick access to supplies is likely to help to prevent unnecessary pain in unwell patients. O’Driscoll, Howard LS, Davison AG. BTS guideline for emergency oxygen use in adult patients. Thorax. 2008; 63 (Suppl VI):vi1–vi73. Giner J, Casan P, Belda J, et al., Pain during arterial puncture. Chest 1996; 110:1443–5.

Introduction Airway bacteria and viruses are aetiological triggers of COPD exacerbations. Changes in prevalence of rhinovirus and typical airway bacteria together have not been examined during COPD exacerbation recovery. We compared the prevalence of the clinically relevant microorganisms (CRMs) human rhinovirus and typical pathogenic bacteria ( H. influenzae , M. catarrhalis and S. pneumoniae ) at five time points during COPD exacerbation recovery. Methods London COPD cohort patients recorded any new or increased respiratory symptoms on daily diary cards and contacted the clinical team when symptoms worsened. Exacerbations were defined using our usual symptomatic criteria; an increase in respiratory symptoms for two consecutive days, with at least one symptom being major (dyspnoea, sputum purulence or volume) and the other a major or minor symptom (wheeze, cold, sore throat, cough). Reverse-transcription quantitative PCR was used to detect rhinovirus and real-time quantitative PCR was utilised to identify typical bacteria in sputum samples collected at exacerbation presentation (median 2 days after symptom onset), and at days 3, 7, 14 and 35 post-presentation. Results Nineteen patients with moderate to severe COPD (mean age 68.8 years (SD±8.1); FEV1 48.4% predicted (±19.2%); current smoker 37%; FEV1/FVC 0.46 (SD±0.14); FEV1 1.2L (SD±0.4); male gender 74%) provided 89 of 110 potential sputum samples at 5 time points during 22 exacerbations. Rhinovirus prevalence progressively fell from 71.4% at exacerbation presentation to 0% at day 35 with significant decreases in prevalence between presentation and days 7, 14 and 35 (all p Conclusion The prevalence of CRMs varies during recovery from a COPD exacerbation. Rhinovirus prevalence steadily decreases over 2 weeks whilst bacterial prevalence is more variable, presumably due to the background effects of lower airway bacterial colonisation. This emphasises the importance of rhinovirus as a major exacerbation trigger.

Background Measures of patient satisfaction have become increasingly important in modern healthcare and clinical research. We aimed to assess and quantify factors relating to patient satisfaction in the London COPD cohort. Methods Questionnaires were posted to patients in the London COPD cohort (anonymised to clinic staff) including categorical items (Likert scale or Yes/No) and freetext boxes. Data were analysed from the last stable state visit before October 2010 including demographics, spirometry, MRC dyspnoea, and St George9s Respiratory Questionnaire (SGRQ) scores. Data were analysed using Spearman9s rank correlation, Mann–Whitney U and χ2 tests. Results 130 respondents (response rate 68%) had a mean (±SD) age of 73.4 (±8.8) years and mean FEV1 50.6% (±19.3%) predicted. 55% were male, 26% were current smokers with median (IQR) pack year history of 47 (26–73). There were no significant differences between respondents and non-respondents. 96% of respondents reported that they were very satisfied (74%) or satisfied (22%) with the COPD research (Abstract P217 figure 1). Satisfaction correlated with providing prompt and appropriate treatment at exacerbation onset (r=0.419, p Conclusions Patient satisfaction is very high in the London COPD cohort and was associated with positive staff interactions, prompt exacerbation treatment and detailed explanations. Involvement in the cohort also led most patients to feel less anxious, reportedly attending A&E and GP services less frequently.

Introduction Human rhinoviruses (HRV) are the main aetiological agents of virus-associated COPD exacerbations (Seemungal et al, 2001). However the importance of the level of viral load as a trigger for naturally occurring exacerbations is not fully understood. We aimed to assess and quantify HRV prevalence and load in stable and exacerbating patients from the London COPD cohort. Methods A real-time qPCR protocol was utilised to detect HRV presence and quantify load in sputum samples taken at baseline (n=58) and at COPD exacerbation onset (n=57). COPD patients were defined as stable if exacerbation-free for at least 42 days since the previous exacerbation and more than 14 days before the next. Exacerbations were defined using our usual symptom criteria; an increase in respiratory symptoms for two consecutive days, with at least one symptom being a major symptom; dyspnoea, sputum purulence or volume and the other a major or minor symptom; wheeze, cold sore throat, and cough (Anthonisen criteria). A χ2 test was used to compare HRV prevalence of the two disease phases, and an independent-samples t test was used to compare the differences in viral load. Results Sixty-four patients provided 115 sputum samples: mean age 70.5 years (SD±8.1); FEV1 45.8% predicted (±20.0%); current smoker 31.3%. There is a significantly higher prevalence of HRV at exacerbation onset, 31.6% (18/57) compared to baseline 15.5% (9/58) (p=0.042). Similarly, the mean viral load was significantly greater at exacerbation onset 1.70 (±1.67) log10 pfu/ml than baseline 0.30 (±0.69) log10 pfu/ml (p=0.025), exhibiting a 25-fold increase in viral load from baseline to exacerbation. 6.9% (4/58) of patients were positive for HRV at baseline only, 26.3% (15/57) at exacerbation only and 8.8% (4/45) at both time points (p=0.006). Conclusions HRV load is significantly greater at COPD exacerbation than when detected in the stable state. This emphasises the importance of HRV as a key trigger of COPD exacerbations. HRV can be detected in the stable state; however the loads are very low suggesting asymptomatic carriage rather than chronic infection.

Introduction Physical activity is reduced at COPD exacerbation but there is little information on the quantification of this activity. Activity can be assessed using walking tests or questionnaires or with expensive accelerometer based monitoring devices that require regular clinic visits to download data. Both approaches are not well suited to prospectively capturing activity during an exacerbation in a large observational cohort as patients will need to be monitored continuously in order to capture the prodrome and early stages of these events. The aim of this study was to determine whether step-counts measured by a pedometer (Yamax Digi-Walker SW-200) were sufficiently correlated with other measures of physical activity prospectively, to show that the device can be used in COPD patients. Methods Patients with COPD (n=33) wore the pedometer and a SenseWear Armband (BodyMedia, Inc.) during a 6-min walk test (6MWT). FEV 1 , height, age and gender were recorded prior to the test. The pedometer was worn on a belt on the left-hand side and a SenseWear device on the left arm. Patients performed a 6MWT according to ATS protocols when stable and while having an exacerbation. Results The 33 patients had a mean age (±SD) 71.5 (±6.2) and FEV 1 % predicted 48.2% (±13.2); 26 were men. The patients walked a mean 415 (±117) metres in 6 min, taking 587 (±132) steps and expending 26.3 calories (±9.8). Twenty-four patients completed the 6MWT when stable and five completed it during an exacerbation. Four patients were assessed at both baseline and exacerbation. Abstract P44 figure 1 shows that there was a strong correlation between steps counted by the pedometer and distance covered [r=0.82; p Conclusion Step count correlates well with 6 min walking distance and energy expenditure in COPD patients. Thus pedometers may be a useful way to prospectively monitor and quantify physical activity during COPD exacerbations in a large observational cohort.

Introduction Ischaemic heart disease (IHD) is a major cause of morbidity and mortality in COPD patients. Effective cardiovascular therapies may have significant impact in COPD populations. In particular, β-blockers have been shown to be safe and effective in COPD. We aimed to quantify the changing prevalence of emerging cardiovascular medications in this group over the last decade. Methods We analysed the recruitment records of well-characterised patients enrolled into the London COPD Cohort from 1995 to 2010. Date of enrolment, comorbidities, medications, demographics, smoking history and spirometry results were analysed. Prescribing data reflects that of the patients9 primary physicians. Results The mean±SD age of 386 COPD patients was 68.4±8.7 years, FEV 1 was 1.22±0.55 l or 49.5±19.6% predicted. 57% were male, 24% were current smokers with a median (IQR) pack year history of 45 (25–65). 64 (17%) patients had IHD of whom half had a previous myocardial infarction, 4% had heart failure, 6% had a previous stroke, 5% had peripheral vascular disease (PVD), 9% had a tachyarrhythmia. The overall prevalence of at least one cardiovascular disease was 30%. 36% had hypertension, 8% had hypercholesterolaemia and 7% had diabetes. Common cardiovascular medications included statins (28%), aspirin (23%), calcium-channel blockers (21%), ACE-inhibitors (18%), loop diuretics (15%), thiazides (14%) and angiotensin receptor blockers (7%). β-blockers were indicated in 25% of patients (IHD ± heart failure ± tachyarrhythmia; 22% when those with the contraindication of PVD are excluded). The prevalence of β-blockers was only 5% overall and prescribed to only 8/84 (10%) in those with a clinical indication and no PVD (χ 2 test, p=0.020). In the 64 patients with IHD, statins and angiotensin pathway drugs became more prevalent in the last decade of the study period (Abstract P264 figure 1) in keeping with emerging evidence of benefit. β-blockers did rise in prevalence as evidence of safety emerged, although to a much smaller extent than statins and angiotensin pathway drugs. Conclusions Emerging cardiovascular medications have become more common in COPD patients reflecting greater recognition of cardiovascular risk. However, β-blockers were underused despite clear indications and evidence of safety and benefit in COPD. Measures are required to improve evidence-based prescribing to overcome historical beliefs.

Introduction Airway bacterial infections are associated with COPD exacerbations. The most frequently identified bacteria in COPD are Haemophilus influenzae (HI), Moraxella catarrhalis (MC) and Streptococcus pneumoniae (SP) (Wilkinson et al , 2006), though studies have used culture techniques, with little data available on PCR methodology in airway infection. Using the London COPD cohort, we aimed to assess and quantify bacterial prevalence and load via quantitative PCR, in paired baseline and exacerbation sputum samples. Methods Quantitative PCR was utilised, measuring prevalence and load on paired baseline and exacerbation samples, with baseline samples obtained within 1 year prior to its paired exacerbation. SP, HI and MC gene targets were Spn9082; Haemophilus influenzae P4 lipoprotein gene; copB outer-membrane-protein gene, respectively. The baseline state was defined as being at least 6 weeks after, and 2 weeks before, an exacerbation. Exacerbation was defined as two consecutive days of at least two increased symptoms (Anthonisen criteria), at least one of which is a major symptom (dyspnoea; sputum purulence; sputum volume). Results Sixty-nine paired baseline and exacerbation sputum samples were obtained from 56 patients: mean (±SD) age 71.0 years (±8.4); predicted FEV 1 46.4% (±17.0); male gender 60.4%; current smoker 30.2%. Bacteria were detected at significantly higher rate at exacerbation, being seen in 36/69 (52.2%) exacerbations, and 19/69 (27.5%) baseline samples (χ 2 -test; p=0.003). Mean bacterial load was significantly higher at exacerbation, with mean load of 8.3 (±1.1) log 10 cfu/ml, compared with mean of 7.3 (±1.8) log 10 cfu/ml at baseline (paired-samples t test; p Conclusion Prevalence and load of airway bacteria in COPD increases from baseline to exacerbation. This confirms that bacteria play an important role in exacerbation aetiology, implicating increasing bacterial load as a key underlying mechanism, and emphasises the importance of prompt antibiotic therapy at COPD exacerbation.

Introduction Comorbid ischaemic heart disease (IHD) is associated with an adverse impact on health status, symptoms ( ARJCCM 2011;183:A2614) and exacerbation recovery in COPD patients ( ERJ 2010;954s:E5209). Any impact on exercise capacity is poorly understood. We aimed to assess and quantify differences in exercise capacity in stable COPD patients with and without IHD. Methods We assessed 6-min walking distance (6MWD) in accordance with ATS guidance ( AJRCCM 2002;166:111–117) in patients from the London COPD cohort. All assessments were performed in the stable state with no symptom-defined exacerbations recorded on daily diary cards for 6 weeks prior and 2 weeks following the visit. Dyspnoea and fatigue were measured before and after the test using the Borg scale, as were saturations from a pulse oximeter. Data were analysed using unpaired t-tests, Mann–Whitney U, χ 2 tests and multiple regression techniques. Results 115 patients had a 6MWD assessment, 19 (17%) had IHD (Abstract P47 table 1). COPD patients with IHD had a lower mean ± SD 6MWD than those without (310±138 vs 354±107 m) although this was not statistically significant (p=0.119). Following adjustment for age, gender, FEV 1 % predicted, BMI and smoking pack year history, IHD was found to be independently related with a 66 m reduction in 6MWD (95% CI 5 to 127 m), p=0.035. Median (IQR) dyspnoea on the Borg scale before the test was not higher in those with IHD (1(1,2) vs 1(0,3), p=0.135), this increased more in those with IHD compared to those without during the test (2(1,3) vs 1(0,3), p=0.043). Fatigue measured on the Borg scale was higher at the start of the test in those with IHD (1.5(0,3) vs 0(0,2), p=0.038), however, the increase after the test was not different between the groups (0(0,2) vs 0(0,2), p=0.831). The mean ± SD pre-test oxygen saturations and post-test change were similar in those with and without IHD (93.8±2.6% vs 94.1±2.4%, p=0.684; −0.9±4.4% vs −1.4±3.2%, p=0.595). Conclusions Comorbid IHD is independently associated with a clinically significant lower exercise capacity in COPD patients. Such patients may have a higher level of fatigue before exercise and develop more dyspnoea during exercise. Such patients may be an appropriate target for further intervention such as tailored pulmonary rehabilitation.

Introduction Airway bacterial infections are associated with exacerbations of COPD. The potential role of atypical bacteria as a trigger for exacerbations is not well understood. Atypical bacteria such as Chlamydophila pneumoniae (CP), Legionella pneumophila (LP) and Mycoplasma pneumoniae (MP) are difficult to culture as they are intracellular pathogens. LP can be detected by urinary antigen, and serology can be performed for MP, but these techniques give no indication as to the atypical bacterial load. Quantitative PCR (qPCR) offers an alternative approach to identification and quantification of bacteria in sputum. Methods Multiplex qPCR was used to detect and quantify CP, LP and MP in 238 samples prospectively collected from 87 patients in the London COPD Cohort: mean (±SD) age 71.4 (±8.1); predicted FEV 1 43.4% (±17.5%); male gender 47.9%; current smoker 49.2%. Baseline (n=104), exacerbation (n=95), and follow-up (n=39) samples were tested: Baseline was defined as at least 6-weeks without exacerbation, and exacerbation was defined as 2 consecutive days of two symptoms (Anthonisen criteria), at least one of which is a major symptom (dyspnoea; sputum purulence; sputum volume). Follow-up involved taking samples 2 or 5 weeks post-exacerbation onset. Using a qPCR developed by our clinical diagnostic service, the CP, MP and LP gene targets were RNA-polymerase β-chain; P1 adhesin protein; and MIP respectively. Routine microbiological analysis was also performed on these samples. Results No samples were positive for the atypical organisms using culture. With qPCR analysis 6/238 samples (six separate patients) were positive for LP (2.5%), four at baseline and two at exacerbation/follow-up. One baseline sample was positive for MP (0.42%), and no samples were positive for CP. Atypical bacteria were present at 0.83% of exacerbations. Median (IQR) bacterial load was 4.3x10 4 cfu ml −1 (2.0x10 4 –8.55x10 4 ) for LP PCR-positive samples; the MP-positive sample load was 2.64x10 7 cfu ml −1 . Conclusion Quantitative PCR was more sensitive and informative than standard microbiological culture for the detection of atypical bacteria. Atypical bacteria in sputum were detected at very few exacerbations of COPD; moreover, when they were detected by qPCR, the load was low, indicating little or no significance in the aetiology of these events.

Introduction and objectives New trainees typically perform initial bronchoscopies on real patients under supervision. This model of training has safety and comfort implications relying on timely acquisition of skills, potentially compromised by a reduction in the number of bronchoscopies performed by trainees. Simulators have been validated in training novice practitioners. We present a model for initial bronchoscopy training by registrars for registrars. Methods We developed a course based on survey data from North-East Thames trainees. We provided first year trainees with precourse material consisting of BTS guidelines and a presentation of bronchial anatomy. The day involved 1 h of theory, including indications, contra-indications, sedation, local anaesthesia, consent and management of complications. This was followed by a practical session with specialist nurses including assembling a bronchoscopy stack, troubleshooting and effective team-working. Most of the day was divided into three stations: Use of two simulators (Accutouch, Immersion Corporation, USA), each trainee had 45 min of 1:1 tuition. Trainees were objectively scored using the validated Bronchoscopy Skills and Tasks Assessment Tool (Bronchoscopy International, USA). This score and freetext comments were sent to the trainees to discuss with consultants. A slideshow of airway anatomy and pathology followed by MCQs addressing pre-course material. Hands-on flexible bronchoscopy through a static bronchial tree model. Feedback was assessed using a questionnaire at the end of the day. Results 9/11 trainees were within 3 months of starting StR training, 2/11 were within 12 months, having performed a median of five bronchoscopies (interquartile range 5–30). All trainees felt the course was pitched at the right level. They would all recommend this course to others, giving a rating of 4.8/5. 90% thought the course should be carried out within the first 3 months of training. All participants would change their practice as a result of what had been learnt on the course. Suggestions for improvement included grey cases and even more hands-on simulation time. Conclusions This potential model for bronchoscopy training was: Pitched at the right level. Delivered at an appropriate time. Received overwhelmingly positive feedback. Can be effectively delivered by experienced peers.

Introduction and objectives Simulation training is widely employed by several medical and surgical specialties for inexperienced practitioners to acquire and consolidate practical skills. This approach is not routinely employed in respiratory medicine to train bronchoscopists. Survey data indicates a lack of confidence in performing bronchoscopy among new registrars. This study examined whether a 1-day simulated bronchoscopy course designed and delivered by experienced SpRs could improve this. Methods Most of the 1-day course was divided in to three stations: Hands-on use of two simulators (Accutouch, Immersion Corporation, USA), each trainee had at least 45 min of 1:1 tuition. A slideshow of airway anatomy and pathology followed by MCQs addressing BTS guidelines. Hands-on flexible bronchoscopy through a static bronchial tree model. Trainees completed the Bronchoscopy Self-Assessment Tool (http://www.bronchoscopy.org), including an 8-item questionnaire (5-point Likert scale) measuring confidence at the beginning and end of the course. The questionnaire included identification of further training needs (I would like to learn more about: anatomy, abnormalities, technique, equipment, interpretation of findings). Results 11 trainees (Male:Female, 8:3) attended the course, having performed a median of five bronchoscopies (interquartile range 5–30). Nine trainees had completed Conclusions A training course focusing on hands-on simulation run by experienced registrars for new registrars clearly increases confidence in technical aspects of performing bronchoscopy and interpreting findings. Although a proportion of training needs for most trainees appear to have been met by the course, it is not sufficient to meet them all. Early peer-to-peer simulated bronchoscopy training is a helpful addition to the current ‘on-the-job’ model.

Introduction Patients with chronic obstructive pulmonary disease (COPD) may not recover swiftly from exacerbations. In 23% of patients, symptoms do not recover within 35 days.1 It would be valuable for clinicians to have a systemic biomarker that taken at initial consultation for an exacerbation could predict exacerbation length. We hypothesised that inflammation, measured by serum C-reactive protein (CRP) predicts the time to symptomatic resolution. Methods We analysed daily diary cards prospectively collected from the London COPD cohort between October 1995 and January 2010. All patients had an FEV1≤80% predicted and an FEV1/FVC ratio ≤70%. An exacerbation was defined as an increase for 2 consecutive days in respiratory symptoms, with at least one major symptom (dyspnoea, sputum purulence or volume) plus another major or minor symptom (wheeze, cold sore throat and cough). Exacerbations were separated by five symptom free days. Patients were assessed and sampled at clinic visits within a median of 2 days of exacerbation onset. Exacerbation length was defined as the number of days from onset that increased airway symptoms were still recorded, and resolution time was defined as the time from clinic assessment to symptom cessation. Results 268 patients with ≥365 days of diary card data experienced at least one exacerbation. Median baseline CRP was 4 mg/l. CRP at onset was available for 172 recovered exacerbations (Abstract P114 Figure 1). Mean age was 68.0 years (SD 8.3), with mean FEV1 1.11 l (0.45), FEV1 predicted 44.6% (16.2). Patients with a CRP Conclusions COPD exacerbations can occur without an elevated systemic inflammatory response. These events are associated with a short resolution time. Thus, using CRP as a biomarker, it may be possible to identify patients that have a short recovery period and potentially may not require systemic treatment for their exacerbation.

A laboratory activity that draws attention to the growing field of "small-particle" research.

Fabrication of a new pressure jump cell made entirely from Plexiglas is described. Chemical relaxation effects greater than 50 μsec can be measured when the pressure on a chemical system is suddenly released from 40 atm by means of a bursting phosphor-bronze diaphragm and the resulting conductance change is measured by a Wheatstone bridge arrangement.

Labour was successfully induced in 10 women at or near term with prostaglandin F(2alpha) infusion. In no case was there an increase in the resting tone of the myometrium, and complete relaxation between contractions was recorded.

The effect of intravenous infusion of the prostaglandin F2alpha on the intact human uterus was investigated in 35 women between the 30th and 45th weeks of pregnancy. Labor would otherwise have been induced in all these cases by amniotomy or intravenous oxytocin or a combination of the 2. Induction of labor was successful in 33 cases. In 29 of the 35 cases induction of labor was successful with 1 infusion of prostaglandin F2alpha administered at the rate of 0.05 ug/kg/min. The infusion period varied from 1 hour to ll-1/2 hours. Contractions stopped after cessation of infusi n in 4 cases. In all these cases the infusion had been discontinued before the cervix had reached 5 centimeters dilatation. In these cases uterine activity slowed gradually and returned to preinfusion levels over 2-4 hours. The following morning or on the same day the infusion was started again and for 2 cases the delivery was completed within 5 hours. Of the 35 cases the average infusion delivery interval in the 33 successful inductions was 9 hours 35 minutes. In all cases the 3rd stage of labor was normal. All the infants delivered alive showed immediate spontaneous respirations without any effort at resuscitation and no discernible abnormality on physical examination.

Summary The effect of prostaglandin E2 on the activity of the pregnant human uterus in vivo has been studied in 50 women at or near term and in need of induction. Labour was successfully induced in all cases with a continuous infusion of 0·5 μg./min. The uterine activity produced by prostaglandin infusion resembled that of normal spontaneous labour. No unphysiological increase in uterine tonus was observed. The average infusion time was 5·5 hours and the average infusion-delivery interval was 10 hours.

The COVID-19 pandemic has forced Indian engineering institutions (EIs) to bring their previous half-shut shades completely down. Fetching new admissions to EI campuses during the pandemic has become a ‘now or never’ situation for EIs. During crisis situations, institutions have struggled to return to the normal track. The pandemic has drastically changed students’ behavior and family preferences due to mental stress and the emotional life attached to it. Consequently, it becomes a prerequisite, and emergencies need to examine the choice characteristics influencing the selection of EI during the COVID-19 pandemic situation.The purpose of this study is to critically examine institutional influence and pandemic influence due to COVID-19 that affects students’ choice about an engineering institution (EI) and consequently to explore relationships between institutional and pandemic influence. The findings of this quantitative research, conducted through a self-reported survey, have revealed that institutional and pandemic influence have governed EI choice under the COVID-19 pandemic. Second, pandemic influence is positively affected by institutional influence. The study demonstrated that EIs will have to reposition themselves to normalize pandemic influence by tuning institutional characteristics that regulate situational influence and new enrollments. It can be yardstick for policy makers to attract new enrollments under pandemic situations.

International audience; Purpose: In addition to create challenging and congruent learning opportunities, it is important for Technical Education providers to create a supportive learning environment to help learners acclimate, connect with others and as well as access well-matched student support services to help them complete their studies and make them employable.Skill building is verycrucial to ensure employability of academia to understand and make sure good jobs. Unfortunately, most of the Technical Education institutes in India have not identified the importance of such services, resulting huge unemployment and dissatisfied students. The purpose of this paper is to highlight supporting and extension services in connection to operating services in Technical Education and students' perception on them. Design methodology: A qualitative research by a survey (through a structured questionnaire) of students who are studying or have studied Technical Education affiliated to the North Maharashtra University, Jalgaon on their perception regarding operating, supporting and extension services offered by TE institutes. Findings: The research revealed that TE institutes, no doubt, are offering good operating services however lags in supporting and extension services. It is also found that students' satisfaction of selecting TE institute is highly associated to supporting and extension service than operating services offered by the institute. Research limitations: The survey is delimited to the Technical Education belonging to North Maharashtra University, Jalgaon and located in Khandesh region of India. Practical implications: India, compared to other nations, lacks formally trained manpower. In Korea, for example, the skilled workforce is 96 per cent, in Japan 80 per cent, in Germany 76 per cent and in Britain 70 per cent but in India it is only 10 per cent.Technical Education Institutes of India, can gain competitive edge in the future, by effective and creative ways to attract, retain and foster stronger relationships with students by interaction and mechanism of the market and industry. This is only possible by lubricating; operating, supporting and extension services, all services combined.

International audience; Despite of increasing pressure related to enrollment in Technical Education, some Institutes of Technical Education, successfully have taken on a corporate mentality to attract and retain high-quality students through their e-Promotion. Successful branding and marketing strategies have become most important for the Institutes of Technical Education to appeal to a growing and diversified student and to differentiate from competitors. Effective branding can be helpful in increasing enrollment and in developing relationships and bonding. This article explores internet based promotions that Technical Education institutes have focused on branding and marketing initiatives and its influence on the students in selecting institute. It also focuses on effectiveness of internet based promotions. The research study showed that Institute Website and Social Networking are the most influential promotion tools for making their decision of selection than the other traditional promotion tools. In addition, these tools are reported to be very powerful and effective in making satisfaction of decision of selection which is highly associated with such a promotion tools. More surprisingly, it is found to be productive in the rural area. This article presents an adaptation of established qualitative research methodsby a survey (through a structured questionnaire) of students who are presently enrolled (Current-students) and those who have completed their study (Post-students) belonging to the institutes offering Technical Education situated in Khandesh region of India and affiliated to the North Maharashtra University, Jalgaon. The survey is delimited to the enrollments of Technical Education belonging to North Maharashtra University, Jalgaon and located in Khandesh region of India.