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Introduction and objectives Asthma and COPD present a significant resource impact to the NHS. Earlier diagnosis may reduce morbidity and improve quality of life. In the UK, premature mortality from COPD is almost twice the European average and for asthma over 1.5 times the European average. This project sponsored by Teva Respiratory aims to identify differences in perceptions of various stakeholder groups regarding effective outcome improvements in asthma and COPD and make relevant recommendations. Methods This group met with the objective of defining consensus statements for the future development of services in asthma and COPD. These statements were tested across a broad respondent sample by questionnaire. A Delphi methodology was used to assess levels of agreement with each statement. Questionnaires were offered to health care professionals across specialties reflecting the roles of this group for completion as paper documents at Teva Respiratory sponsored UK meetings between June 2015 and January 2016. Results 184 respondents, split across varied professional roles, completed questionnaires. 24 out of 42 statement scores (57%) exceeded the 66% agreement threshold and are thus regarded as supportive of the statements. Some variance was seen in responses between care settings (Figure 1), with primary care respondents commonly indicating lower levels of agreement than their secondary care colleagues (24 out of 42 statements (57%)). Conclusions Most respondents indicate that it is possible to deliver effective care across all care settings that the patient will encounter. The need for further development of local integrated care approaches is well recognised. Respondents are ambivalent regarding the prioritisation of asthma and COPD, the variance may reflect differences in prioritisation between localities. There is strong agreement that definition of appropriate outcomes will support value-based care models and that interaction between professions is critical to effective integration of care. Respondents agreed there is a sound rationale for the use of branded inhaler therapies in asthma and COPD, which may liberate finite resources for other areas. Based on this consensus exercise, 10 key recommendations for optimising outcomes in asthma and COPD are offered. more...

Introduction Burkholderia spp infection in cystic fibrosis (CF) confers a worse prognosis, with increased morbidity and mortality. Treatment can be problematic because strains are often resistant to many of the commonly available intravenous antibiotics, leading to a search for new therapies. We have studied the use of Temocillin, a derivative of Ticarcillin with promising in-vitro activitiy against Burkholderia spp, 1 in the treatment of acute exacerbations in CF patients infected with Burkholderia spp. Methods We have used Temocillin in IV form, often in combination, in acute respiratory exacerbations in CF patients attending our large adult unit who are chronically infected with Burkholderia spp. We present our two year data, looking at the subspecies treated, length of treatment, improvement in clinical parameters, and co-antibiotic use. Results Nineteen courses of IV Temocillin were administered to 7 CF patients (mean age 29 years, [range 23–42 years], 2 males, 1 infected with B Cenocepacia, 6 with B Multivorans.) All patients completed their treatment without complication. Median length of Temocillin treatment was 9.7 days (range 3–16 days), and most patients finished their therapy as outpatients (mean inpatient stay 5.2 days). All patients had clinical improvement, with all gaining weight (mean 3 kg [range 6.5 to 0.9]) and most increased spirometry (mean change in FEV1% predicted 6 [17 to -3]). As regards the efficacy of co-antibiotic use, the 11 courses accompanied by Ceftazidime had a mean 3% improvement in FEV1, 8% with Meropenem (6 courses) and 9% with Colomycin (2 courses). Discussion This clinical study has shown that Temocillin is well tolerated by CF patients and is associated with clinical improvement in those infected with Burkholderia spp when given in combination with other antibiotics. Temocillin adds to the limited antibiotic armamentarium available to treat these difficult infections in CF patients and we recommend its use to other clinicians. Reference 1 Bonacorsi S, Fitoussi F, Lhopital S, Bingen E. Comparative in vitro activities of meropenem, imipenem, temocillin, piperacillin, and ceftazidime in combination with tobramycin, rifampin or ciprofloxacin against Burkholderia cepacia isolates from patients with cystic fibrosis. Antimicrob Agents Chemother . 1999; 43 :213–217 more...

Introduction and objectives FDG PET-CT scans are a valuable tool in the diagnosis and staging of lung cancer, but their growing use in other diseases can cause resource issues, and in some cases they may be ordered by non-specialists further congesting the patient pathway. To study this further, we looked at referral patterns for PET-CT scans in the diagnosis of lung cancer at our hospital, paying particular attention to the reason for the scan and the referring clinician. Methods A retrospective audit was undertaken of all PET-CT scans performed for the investigation of suspected lung cancer in 2014 by the Liverpool Lung Cancer Unit (LLCN). The LLCN consists of Liverpool Heart and Chest Hospital, a specialist cardiothoracic centre in the North West of England and the Royal Liverpool University Hospital, a teaching hospital. Results All 253 PET-CT scans (186 for outpatients) carried out during 2014 for the investigation of suspected lung cancer were reviewed. One hundred and seventy five (69%) found malignancy. Scans ordered by lung cancer specialists were more likely to demonstrate a cancer diagnosis (145 cancer versus 52 benign) compared to those requested by non-specialists (30 cancer versus 26 benign), (Chi2 = 8.21, P The commonest causes for a negative scan result were mass 27 (34%), nodule follow up 17 (22%) and new nodule assessment 14 (18%) respectively. Of 31 patients (39%) who had a PET-CT scan for nodule assessment, 8 (26%) were Conclusions We have shown that scans arranged by lung cancer specialists are more likely to give a positive yield, and also that the guidance for their use in nodule investigation is not being strictly followed. The results indicate that there is a need for better guidelines and patient pathways to ensure the most appropriate use of expensive resources. more...

We read with interest the case report by Ledson et al 1 describing a non-cystic fibrosis individual with chronic Burkholderia cepacia bronchiectasis. Although B cepacia most commonly affects patients with cystic fibrosis, it is also known to infect patients with chronic ventilatory requirements or immunocompromised patients.2 The immunocompromised patient population who appear most vulnerable to B cepacia infection are those with chronic granulomatous disease … more...

Introduction The advent of CT scanning as a routine test in the work-up of pulmonary disease has brought with it the unexpected detection of large numbers of pulmonary nodules, most of which are of a benign aetiology, even in high risk groups. Previous lung cancer screening studies have shown that likelihood of malignancy in nodules Methods Two trained readers independently reviewed 100 randomly selected CT thorax scans from individual patients (mean age 63 years [SD 15]) and noted the number, size and characteristics of any nodules present. Economic analysis was based on costs of CT scan (low dose CT = £115) and the number of additional follow-up CT scans required. Results Overall, 249 nodules were detected in 86 patients; 9 with a solitary calcified nodule were excluded. Of the remainder, 22 (28%) had nodule (s) 8mm. Assuming that all patients were high risk, based on Fleischner guidelines the total number of CT scans required over 2 years would be 15 ( Discussion Over three quarters of our patients in this random sample had significant incidental pulmonary nodules, and their surveillance according to current guidelines would result in a significant burden to the healthcare system, not only in terms of cost but also through increased clinician time and patient anxiety. New protocols for the follow up of these low-risk patients are required if the healthcare economy is to cope with this increasing surveillance burden. more...

Totally implantable vascular access devices (TIVADs) provide a semi-permanent route for administering intravenous medication in patients who receive repeated courses. They are relatively easy to look after and cosmetically acceptable, but may be associated with complications [1] . A 17-year-old male with cystic fibrosis while undertaking a course of home antibiotics for a pulmonary exacerbation, through a left internal jugular TIVAD (3 years old), developed pain and tenderness around the TIVAD site. At review there was a small swelling above the left clavicle. The screening linogram ( fig. 1 ) revealed the catheter had fractured where it traversed the left clavicle and the distal portion projected over the heart and left lung base, suggesting fragment embolisation. At right heart catheterisation via the femoral vein (local anaesthetic and 2-mm percutaneous access), the fragment having migrated through the pulmonary valve was within the left lower-lobe pulmonary artery and was retrieved using a goose neck snare device. It seems likely that stretching forces applied to the catheter as the patient grew, plus friction where the catheter passed over the clavicle, caused the line to wear until it cracked. This is the first report of embolisation of a catheter fragment beyond the right ventricle in an adult with cystic fibrosis. Any unusual symptoms related to the device should prompt immediate discontinuation of use and urgent imaging by means of chest radiography and screening linography. Published online: April 20, 2012 more...