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Objectives The increasing social needs of people with Tuberculosis (TB), and the poor adherence to anti-TB therapy (ATT) associated with homelessness, drug or alcohol abuse, and prison history, led us to introduce a social care team (SCT) to support patient engagement with care within this low TB incidence setting. Methods Using a risk assessment, patients with social risk factors (SRF) for non-adherence to ATT are identified and a referral made to the SCT, who then provide intensive casework support for areas including homelessness, housing, benefits, debt and immigration. Retrospective data analysis of the social care database from 2017 to 2019 was conducted. Patients who were (n = 170) and were not referred to the SCT (n = 734) were compared. Results Patients referred were significantly more likely to complete treatment for TB than those not (88.2% versus 77.7% respectively, p = 0.0025), irrespective of receipt of Directly/Video Observed Therapy and adjusting for confounders. Conclusions This paper demonstrates important evidence for the positive impact of a dedicated SCT within a TB service, and these improved treatment outcomes provide a strong argument for development of similar SCTs within UK TB services and similar healthcare settings.

SARS-CoV-2 has resulted in a global pandemic and an unprecedented public health crisis. Recent literature suggests the emergence of a novel syndrome known as ‘long COVID’, a term used to describe a diverse set of symptoms that persist after a minimum of 4 weeks from the onset of a diagnosed COVID-19 infection. Common symptoms include persistent breathlessness, fatigue and cough. Other symptoms reported include chest pain, palpitations, neurological and cognitive deficits, rashes, and gastrointestinal dysfunction. We present a complex case of a previously well 28-year-old woman who was diagnosed with COVID-19. After resolution of her acute symptoms, she continued to experience retrosternal discomfort, shortness of breath, poor memory and severe myalgia. Investigations yielded no significant findings. Given no alternative diagnosis, she was diagnosed with ‘long COVID’.

The increasing social needs of people with Tuberculosis (TB), and the poor adherence to anti-TB therapy (ATT) associated with homelessness, drug or alcohol abuse, and prison history, led the North Central London TB Network (NCLTBN) to introduce a social care team (SCT) in 2008 to support patient engagement with care. We report our experience of a specialist SCT and the impact on treatment outcomes within this large UK network. Using the Royal College of Nursing-endorsed case management risk assessment, patients with social risk factors (SRF) for non-adherence to ATT are identified and a referral made to the SCT. The SCT provides intensive casework support for areas including homelessness, housing, benefits, debt and immigration, and makes referrals to drug and alcohol and mental health services. Retrospective data analysis of the NCLTBN social care database from 2017 to 2019 was conducted. Patients who were (n = 170) and were not referred to the SCT (n=734) were compared. The majority (84.7%) of patients referred had more than 1 SRF. Referrals were most often for benefits (49.4%), and housing (47.1%). Following SCT input, 83.4% of benefits referrals were supported with new and existing benefits applications. For housing referrals, almost two-thirds of issues could be resolved with specialist advice (66.1%). Additionally, 19.4% of patients were referred for homelessness, of which 66.1% were rehoused. Patients referred to the SCT were significantly more likely to complete their planned ATT than those without reason to be referred (88.2% versus 77.7% respectively, p=0.0025). This remained the case when stratifying by receipt of Directly Observed Therapy and adjusting for possible confounders in a logistic regression model (table 1). The dedicated SCT helped to improve TB patients’ living environments and financial security - factors conducive to good treatment adherence. Furthermore, input from the SCT was associated with significantly improved treatment outcome. Given that across England the proportion of TB patients with SRF and complex needs is increasing, our data provide a strong argument for the development of similar SCTs, in addition to planned or existing DOT, within other UK TB services.

Background: The fast-evolving COVID-19 pandemic poses a significant diagnostic challenge all over the world. An understanding of the sensitivity/specificity of SARZ-CoV-2 RT-PCR helps to address the clinical challenges associated with the management of admissions with COVID-19. Aim: To determine the relative proportion of RT-PCR positive and negative adult hospital COVID-19 admissions and determine whether there are significant differences between them. Methods: In this retrospective cohort study we examined the demographics, clinical and biochemical characteristics of COVID-19 adult admissions to Barnet Hospital in the first month of the disease outbreak in the UK. SARS-CoV-2 RT-PCR-negative patients were diagnosed if alternative diagnosis was unlikely and 3 of 4 of the following were present: -classical symptoms (new persistent cough) -fever/tachypnea/hypoxia -lymphopaenia -CXR changes The primary endpoint was death at 30 days from initial presentation. Results: 572 patients were admitted with COVID-19, of whom 450 were RT-PCR positive (79%) and 122 were RT-PCR negative (21%). infection at Barnet Hospital in the first month. There was no significant difference in most of the studied parameters between the PCR-positive and PCR-negative COVID-19 patients. The only exception was the neutrophil count, which was found to be higher in the PCR-negative cohort (p

Objectives To describe the presenting features and outcomes of patients with COVID-19 in a UK hospital, with a focus on those patients over 80 years and patients with hospital onset infection. Design Retrospective cohort study with data extracted from the electronic records of patients with PCR-confirmed COVID-19 admitted to our institution. Setting Suburban general hospital serving London’s most populous borough. Participants The first 450 inpatients admitted to our hospital with swab-confirmed COVID-19 infection. Primary outcome The primary outcome measure was death during the index hospital admission. Results The median (IQR) age was 72 (56, 83), with 150 (33%) over 80 years old and 60% male. Presenting clinical and biochemical features were consistent with those reported elsewhere. The ethnic breakdown of patients admitted was similar to that of our underlying local population with no excess of BAME deaths. Inpatient mortality was high at 38%. Patients over 80 presented earlier in their disease course and were significantly less likely to present with the typical features of cough, breathlessness and fever. Cardiac co-morbidity and markers of cardiac dysfunction were more common, but not those of bacterial infection. Mortality was significantly higher in this group (60% vs 28%, p 31 (7%) of patients were classified as having hospital-onset COVID-19 infection. The peak of hospital-onset infections occurred at the same time as the overall peak of admitted infections. Despite being older and more frail, the outcomes for this cohort were no worse. Conclusions Inpatient mortality was high, especially among the over-80s, who were more likely to present atypically. The ethnic composition of our caseload was similar to the underlying population. While a significant number of patients presented with COVID-19 while already in hospital, their outcomes were no worse. Strengths and Limitations of this Study This study captures almost 80% of the admitted cases in our institution providing an accurate representation of the experiences of a London hospital during the early peak of the COVID-19 pandemic The focus on the clinical and biochemical presentation and outcomes in patients over 80 years of age has a high relevance to UK population which is older and frailer than previously reported cohorts from elsewhere The ethnicity of patients admitted to our hospital was similar to that of the underlying local population To our knowledge this study is the first to report the prevalence and outcomes of hospital onset disease in the UK This study is subject to the usual limitations of retrospective observational research, including a proportion of missing data

As the COVID-19 pandemic sweeps across the UK there remain issues with reverse-transcription polymerase chain reaction (RT-PCR), the gold standard diagnostic method. Delays in obtaining results have been particularly problematic. Some patients, including those with high clinical suspicion of COVID-19, test falsely negative on initial RT-PCR test, sometimes requiring multiple subsequent tests to return an eventual positive result. Suggested possible reasons for this include: suboptimal clinical sampling techniques; variations in viral load; and manufacturer test kit sensitivity.1 With surging caseloads, managing these RT-PCR ‘negative’ patients is proving hugely challenging. An emerging bottleneck to effective care is dealing with isolation capacity. Inpatients who are truly PCR negative can be moved to a non-isolation ward, thereby freeing up isolation beds for COVID-19 positive patients and also reducing risk of nosocomial virus transmission. Patients with high index clinical suspicion of COVID-19, but who test negative on initial RT-PCR test, continue to be managed with respiratory isolation precautions, often undergoing repeat PCR testing. However, this means further delay while awaiting subsequent test results. Against this backdrop, an effective pathway to deal with negative COVID-19 RT-PCR results in the setting of high clinical probability is urgently needed. A further important concern is developing regarding deisolation on patient discharge to either home or community care: a confirmed COVID-19 diagnosis - or confirmed alternative, non-COVID-19 diagnosis - is key to imparting advice to families and carers. Imaging has been suggested as a potential solution to some of these problems. Most patients undergo chest radiograph (CXR) at presentation to hospital, with CXRs being hot-reported using a template …

Patients with thoracic malignancies often have more than one site of pulmonary, nodal or pleural disease within one hemithorax. In addition, large heterogeneous lesions may comprise distinct, mixed pathological entities. Histological analysis of these lesions can alter tumour staging and treatment options. We investigated the feasibility, safety and benefit of performing image-guided percutaneous lung biopsy (PLB) of two lesions in the same hemithorax at a single sitting.Ten consecutive outpatients with two or more potential disease foci within the same hemithorax were analysed over a 15-month period. The mean age of the patients was 66 years (range 46-81 years). Patients underwent CT-guided coaxial 20G core biopsy of both lesions, with separate coaxial punctures for each lesion. Patients were managed as per established local institution ambulatory lung biopsy protocol using small-calibre Heimlich-valve chest drain (HVCD) to treat significant post-PLB pneumothorax in an outpatient setting. Data regarding lesion characteristics, diagnoses and complications were recorded.All 10 patients (n = 20 biopsies, 100% technical success) received informative histological diagnosis on both lesions. This altered management in all cases. Although a high rate of pneumothorax occurred (60%; 6/10), only two of these patients required treatment with HVCD. No other significant complications occurred in those patients with small asymptomatic pneumothoraces or those that required HVCD placement.Dual-site lung biopsy, performed as a single procedure, is potentially a safe and effective technique for diagnosing patients with multiple thoracic lesions, and can provide useful staging information to guide patient management.

Introduction2018 World Health Organization (WHO) guidelines for the treatment of isoniazid (H)-resistant (Hr) tuberculosis recommend a four-drug regimen: rifampicin (R), ethambutol (E), pyrazinamide (Z) and levofloxacin (Lfx), with or without H ([H]RZE-Lfx). This is used once Hr is known, such that patients complete 6 months of Lfx (≥6[H]RZE-6Lfx). This cohort study assessed the impact of fluoroquinolones (Fq) on treatment effectiveness, accounting for Hr mutations and degree of phenotypic resistance.MethodsThis was a retrospective cohort study of 626 Hr tuberculosis patients notified in London, 2009–2013. Regimens were described and logistic regression undertaken of the association between regimen and negative regimen-specific outcomes (broadly, death due to tuberculosis, treatment failure or disease recurrence).ResultsOf 594 individuals with regimen information, 330 (55.6%) were treated with (H)RfZE (Rf=rifamycins) and 211 (35.5%) with (H)RfZE-Fq. The median overall treatment period was 11.9 months and median Z duration 2.1 months. In a univariable logistic regression model comparing (H)RfZE with and without Fqs, there was no difference in the odds of a negative regimen-specific outcome (baseline (H)RfZE, cluster-specific odds ratio 1.05 (95% CI 0.60–1.82), p=0.87; cluster NHS trust). Results varied minimally in a multivariable model. This odds ratio dropped (0.57, 95% CI 0.14–2.28) when Hr genotype was included, but this analysis lacked power (p=0.42).ConclusionsIn a high-income setting, we found a 12-month (H)RfZE regimen with a short Z duration to be similarly effective for Hr tuberculosis with or without a Fq. This regimen may result in fewer adverse events than the WHO recommendations.

The current methods available to diagnose antimicrobial-resistant Mycobacterium tuberculosis infections require a positive culture or only test a limited number of resistance-associated mutations. A rapid accurate identification of antimicrobial resistance enables the prompt initiation of effective treatment., The current methods available to diagnose antimicrobial-resistant Mycobacterium tuberculosis infections require a positive culture or only test a limited number of resistance-associated mutations. A rapid accurate identification of antimicrobial resistance enables the prompt initiation of effective treatment. Here, we determine the utility of whole-genome sequencing (WGS) of M. tuberculosis directly from routinely obtained diagnostic sputum samples to provide a comprehensive resistance profile compared to that from mycobacterial growth indicator tube (MGIT) WGS. We sequenced M. tuberculosis from 43 sputum samples by targeted DNA enrichment using the Agilent SureSelectXT kit, and 43 MGIT positive samples from each participant. Thirty two (74%) sputum samples and 43 (100%) MGIT samples generated whole genomes. The times to antimicrobial resistance profiles and concordance were compared with Xpert MTB/RIF and phenotypic resistance testing from cultures of the same samples. Antibiotic susceptibility could be predicted from WGS of sputum within 5 days of sample receipt and up to 24 days earlier than WGS from MGIT culture and up to 31 days earlier than phenotypic testing. Direct sputum results could be reduced to 3 days with faster hybridization and if only regions encoding drug resistance are sequenced. We show that direct sputum sequencing has the potential to provide comprehensive resistance detection significantly faster than MGIT whole-genome sequencing or phenotypic testing of resistance from cultures in a clinical setting. This improved turnaround time enables prompt appropriate treatment with associated patient and health service benefits. Improvements in sample preparation are necessary to ensure comparable sensitivities and complete resistance profile predictions in all cases.

Invasive pneumococcal pneumonia is associated with high rates of mortality. Clinical assessment tools have poor sensitivity for predicting clinical outcomes. Molecular measurements of bacterial load correlate closely with clinical outcome but require specialist facilities and expertise. This study describes how routine blood culture testing can estimate bacterial load and predict clinical outcome for invasive pneumococcal pneumonia. Between December 2009 to March 2014, clinical and laboratory data were collected for 50 patients with Streptococcus pneumoniae bacteraemia secondary to community-acquired pneumonia. Fluorescence rates (FR) were calculated from growth curves generated by BACTEC blood culture analysers by dividing change in fluorescence units (FU), measured at the first point of detectable fluorescence and at the point of automated BACTEC positivity, by time in hours. The mean age of the patients was 70.6 years (49.6-86.3). Forty patients survived invasive pneumococcal disease and ten patients died. These two groups did not significantly differ by demographic or clinical characteristics. The mean FR for the non-survival group (3.62 × 10(-3) FU/h) was significantly higher (p 0.001) than that of the survival group (1.73 × 10(-3) FU/h). FR did not vary by serotype. We determined that an FR of 2.59 × 10(-3) FU/h might represent a useful threshold for predicting high mortality risk with a sensitivity of 91 % and a specificity of 97 %. Our FR calculation uses cheap and accessible routine blood culture techniques to predict mortality in a small retrospective cohort study. In patients admitted to hospital with pneumococcal bacteraemia and, potentially, other organisms, this single tool could guide early escalation of clinical care.

A 16-year-old girl with no medical history presented to our emergency department with rapid onset and progressive facial and neck swelling, dyspnoea and dysphonia. The previous night she had attended a nightclub, had sniffed ketamine and inhaled nitrous oxide. On examination she had swelling of her face, neck and upper torso with palpable crepitus. Scattered bilateral expiratory wheeze was present on auscultation. She was mildly tachycardic and tachypnoeic but other observations were normal. Neurological examination was normal. A chest radiograph demonstrated extensive subcutaneous emphysema. CT scan of the neck, chest and abdomen without intravenous contrast confirmed the presence of extensive subcutaneous gas within …

Introduction: Ventilators utilised for patients requiring home NIV have capacity to record estimated ventilation parameters. Typically estimated values are available for; tidal volume (Vt), leak, respiratory rate, minute ventilation, patient triggered breaths, achieved pressures and patient compliance. Data are downloaded into manufacturers9 software, allowing clinicians to review the information. Aims: The aim of this study was to assess the impact of ventilator data downloads on management of patients receiving domiciliary NIV. Methods: As part of a service redesign, a cohort of existing domiciliary NIV patients were reviewed between December 914 and April 915. All patients were using a Philips Respironics Harmony or Synchrony ventilator. Data downloads had not previously been examined. Data were reviewed in Philips Respironics EncoreAnywhere data management system. Adjustments were made to patients9 ventilation prescription to optimise ventilation, minimise leak and optimise compliance. Values for leak, Vt and compliance were collected retrospectively at patients9 first review and 6 weeks later. Results: Data were collected for 52 patients. Results are presented in table 1. as median(IQR). Conclusion: In this study, using ventilator data downloads facilitated optimisation of ventilation and improved compliance. Employing ventilator data can have a clinically significant impact on patients9 outcome.

Background: Many centres continue to decline percutaneous lung biopsy (PLB) in patients with poor lung function (particularly FEV 1 Method: We performed a retrospective single-centre analysis of 212 patients undergoing PLB, all performed prospectively and blinded to lung function, comparing patients with low lung function (defined as FEV 1 1 ≥1 l or TLCO ≥40%) Results: All 212 biopsies provided a histological diagnosis with no biopsies aborted without successful completion at the same sitting and no patients required a hospital admission post biopsy. HVCD insertion was not significantly associated with poor lung function parameters and all ambulatory drains were removed within 24 to 48 hours. There was a significantly higher incidence of pneumothorax in the low TLCO group, which was not observed in the low FEV 1 group. Binary logistic regression demonstrated however that neither FEV 1 nor predicted TLCO were found to be independent predictors of HVCD insertion or pneumothorax outcomes. Conclusion: Using ambulatory Heimlich-valve chest drain (HVCD) to treat significant post biopsy pneumothorax facilitates safe, diagnostic, early discharge lung biopsy irrespective of lung function. Incorporating ambulatory HVCD into standard PLB practice thereby elegantly bridges the gap that currently exists between tissue diagnosis in poor lung function patients and the advanced therapeutic options available for this cohort.

IntroductionVentilation parameter data from patients receiving home mechanical ventilation can be collected via secure data cards and modem technology. This can then be reviewed by clinicians and ventilator prescriptions adjusted. Typically available measures include tidal volume (VT), leak, respiratory rate, minute ventilation, patient triggered breaths, achieved pressures and patient compliance. This study aimed to assess the potential impact of ventilator data downloads on management of patients requiring home non-invasive ventilation (NIV).MethodsA longitudinal within-group design with repeated measurements was used. Baseline ventilator data were downloaded, reviewed and adjustments made to optimise ventilation. Leak, VT and compliance data were collected for comparison at the first review and 3–7 weeks later. Ventilator data were monitored and amended remotely via a modem by a consultant physiotherapist between the first review and second appointment.ResultsAnalysis of data from 52 patients showed increased patient compliance (% days used >4 hours) from 90% to 96% (p=0.007), increased usage from 6.53 to 6.94 hours (p=0.211) and a change in VT(9.4 vs 8.7 mL/kg/ideal body weight, p=0.022). There was no change in leak following review of NIV prescriptions (mean (SD): 43 (23.4) L/min vs 45 (19.9)L/min, p=0.272).ConclusionVentilator data downloads, via early remote assessment, can help optimise patient ventilation through identification of modifiable factors, in particular interface leak and ventilator prescriptions. However, a prospective study is required to assess whether using ventilator data downloads provides value in terms of patient outcomes and cost-effectiveness. The presented data will help to inform the design of such a study.

Necrotising pneumonia (NP) is a rare but life-threatening complication of pulmonary infection. It is characterised by progressive necrosis of lung parenchyma with cavitating foci evident upon radiological investigation. This article reports the case of a 52-year-old woman, immunocompetent healthcare professional presenting to Accident and Emergency with NP and Staphylococcus aureus septicaemia. The cavitating lesion was not identified on initial chest X-ray leading to a delay in antimicrobial optimisation. However, the patient went on to achieve a full symptomatic recovery in 1 month and complete radiological recovery at 2-year follow-up. Long-term prognosis for adult cases of NP currently remains undocumented. This case serves as the first piece of published evidence documenting full physiological and radiological recovery following appropriate treatment of NP in an immunocompetent adult patient.

Intro: Guidelines advise screening patients for latent TB infection (LTBI) prior to initiation of biologic therapy. We examined the impact of interferon gamma release assay (IGRA) availability on rates of adequate screening and treatment for LTBI prior to biologic therapy in a low TB incidence setting. Method: We analysed clinic letters, laboratory and pharmacy data to assess LTBI screening for patients starting biologics at a UK district general hospital between 2009-14. We used logistic regression to identify predictors of LTBI treatment. Results: 450 patients initiated biologics 2009-14: 116 before, and 334 after, IGRA availability (Jan 2010). 100/334 (30%) were IGRA tested. Adequate screening, defined as any immunological test and clinical review, increased with IGRA availability but remained low (105/334 vs 14/116; p Conclusion: LTBI screening in patients starting biologics improved after IGRA availability, but 69% were inadequately screened. Historically a negative IGRA has not influenced the decision to treat, but improved data on the negative predictive value of IGRAs may reduce treatment rates. In our limited sample, this did not adversely affect outcomes.

A prospective study of 489 consecutive outpatient image-guided percutaneous lung biopsies was conducted to determine whether early discharge, incorporating ambulatory Heimlich valve drain, is potentially advantageous to the National Health Service. Patients were discharged at 30 or 60 min, with significant pneumothoraces treated using Heimlich valve. 485 (99.2%) patients were successfully discharged early, 402 at 30 min. 87 (17.8%) patients developed pneumothorax: 52 required Heimlich valve; 5 proceeded to biopsy with Heimlich valve in situ. All drains were removed within 48 h, 38/52 (73.1%) at 24 h. Our results provide evidence for a paradigm shift in UK practice: early discharge lung biopsy, facilitated by ambulatory Heimlich valve, is safe with significant clinical and economic benefits.

Background: Lower respiratory tract infections (LRTI) are a common reason for consulting general practitioners (GPs). In most cases the aetiology is unknown, yet most result in an antibiotic prescription. The aetiology of LRTI was investigated in a prospective controlled study. Methods: Eighty adults presenting to GPs with acute LRTI were recruited together with 49 controls over 12 months. Throat swabs, nasal aspirates (patients and controls), and sputum (patients) were obtained and polymerase chain reaction (PCR) and reverse transcriptase polymerase chain reaction (RT-PCR) assays were used to detect Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneumophila, influenza viruses (AH1, AH3 and B), parainfluenza viruses 1–3, coronaviruses, respiratory syncytial virus, adenoviruses, rhinoviruses, and enteroviruses. Standard sputum bacteriology was also performed. Outcome was recorded at a follow up visit. Results: Potential pathogens were identified in 55 patients with LRTI (69%) and seven controls (14%; p

Many centres continue to decline percutaneous lung biopsy (PLB) in patients with poor lung function (particularly FEV1

Mycoplasma amphoriforme is a recently described organism isolated from the respiratory tracts of patients with immunodeficiency and evidence of chronic infection. Novel assays for the molecular detection of the organism by real-time quantitative PCRs (qPCRs) targeting the uracil DNA glycosylase gene ( udg ) or the 23S rRNA gene are described here. The analytical sensitivities are similar to the existing conventional M. amphoriforme 16S rRNA gene PCR, with the advantage of being species specific, rapid, and quantitative. By using these techniques, we demonstrate the presence of this organism in 17 (19.3%) primary antibody-deficient (PAD) patients, 4 (5%) adults with lower respiratory tract infection, 1 (2.6%) sputum sample from a patient attending a chest clinic, and 23 (0.21%) samples submitted for viral diagnosis of respiratory infection, but not in normal adult control subjects. These data show the presence of this microorganism in respiratory patients and suggest that M. amphoriforme may infect both immunocompetent and immunocompromised people. Further studies to characterize this organism are required, and this report provides the tools that may be used by other research groups to investigate its pathogenic potential.

Patients with influenza respond best to rapid diagnosis and treatment, but this is often hindered by the difficulty of diagnosing symptoms that are not specific to influenza. Dr Dean Creer and Professor Sebastian Johnston review the problem.

Mycobacterium tuberculosis complex (MTC) organisms form serpentine cords in fluid culture medium. Reporting of a presumptive identification of MTC based on cording allows rapid identification of patients with tuberculosis. A total of 612 positive mycobacterial cultures from 316 patients over 3 years (2008-2010) were evaluated for the presence of cord formation. Cording was identified in 426 (69.6%) specimens, while the reference laboratory confirmed M. tuberculosis in 424 specimens (69.3%). Sensitivity of the test in our laboratory was 99.1% (95%CI 97.4-99.7) and specificity was 96.8% (95%CI 92.8-98.7). Presumptive identification of M. tuberculosis by the presence of cording formation is both sensitive and specific.

Aim To determine if an early discharge radiology-led percutaneous lung biopsy (PLB) service, incorporating ambulatory outpatient small calibre Heimlich valve chest drain (HVCD) to treat pneumothorax, is potentially safe and advantageous to the NHS. Methods A prospective study of 489 consecutive outpatient image-guided PLBs, performed between March 2011–March 2015, was conducted. Patients were discharged at 30 min if no pneumothorax was present; repeat 60-minute CXR was performed if a small asymptomatic pneumothorax was noted. If stable, patients were discharged. In enlarging or symptomatic pneumothorax, patients were discharged with HVCD in situ and followed up for drain removal. Data on complications was concurrently collected, including pneumothorax rates, numbers of patients requiring HVCD and failed early discharge. A retrospective blinded pulmonary function test (PFT) analysis was also performed at the end of the study period. Results 489 PLBs were performed with diagnostic accuracy of 97.8%. 402 (82.2%) patients were discharged at 30 min, all without further incident. 87 patients developed pneumothorax (17.8%). 35 patients with a small stable, asymptomatic pneumothorax were discharged at 60 min without complication. 52 patients required HVCD, with 5/52 proceeding to PLB with drain in-situ: 38/52 (73.1%) had drain removal at 24 h and 14/52 (26.9%) at 48 h, with none requiring HVCD greater than 48 h. 4/489 patients were admitted, for social issues. A blinded retrospective review of PFT data, available in 212/489 patients, revealed 28 with FEV1 Conclusion This prospective study of 489 consecutive outpatient PLBs, novel in the NHS setting, provides evidence for a paradigm shift in current UK lung biopsy practice: (i) early discharge PLB, facilitated by use of ambulatory HVCD, is safe and expeditious, thereby enabling more prompt lung cancer diagnosis; and (ii) use of outpatient HVCD is clinically and economically beneficial, saving precious hospital beds whilst also facilitating lung biopsy in severely emphysematous patients with negligible morbidity.

Background Measurement of the C-reactive protein (CRP) is widely available and is often part of the diagnostic evaluation of patients with suspected Tuberculosis (TB) yet there are little published data regarding its use in this context. We sought to determine CRP’s relationship with TB disease and whether normal CRP levels were seen in those without active TB. Method We undertook a retrospective review of electronic records from the London TB service between 2004–2013, obtained blood results from hospital computer systems and reviewed case-notes where there was uncertainty regarding sites of disease or availability of culture results. Results Using data from 533 subjects with active TB, 23% of all cases and 16.5% of culture-confirmed cases had a CRP of ≤5 mg/L. Individuals with HIV co-infection had significantly higher median CRP (see Table). There was a significantly higher CRP in smear-positive pulmonary disease and those with a positive culture. Sites of disease that could be expected to have a high mycobacterial load (e.g. pulmonary disease and disseminated disease) had a significantly higher CRP than those such as skin, lymph node or CNS disease, where the mycobacterial load is typically low in HIV negative subjects. HIV status, site of disease and culture status remained significantly associated with CRP in a multivariable linear regression analysis. Conclusions These data suggest that CRP cannot be used as a rule-out test for active TB but does reflect mycobacterial load. This has clinical implications given that individuals with a high mycobacterial load may be more infectious (and hence require enhanced contact tracing), be at greater risk of developing drug resistance if non-adherent, and may require prolonged duration of treatment.

Introduction and objectives Tuberculosis (TB) has re-emerged as an important public health problem in the UK. Subsequent to the publication of ‘Stopping Tuberculosis in England: An Action Plan from the Chief Medical Officer’ in 2004, the London TB Metrics was produced, against which the performance of local TB services can be measured. This audit recorded relevant aspects of diagnosis and management of all adult TB patients in a local district hospital TB clinic, and compared them against the Metric targets. Methods Eight of the nine Metric indices were selected (neonatal BCG vaccination coverage excluded). Data were collected on all adult patients seen in an outpatient TB clinic in 2008 and compared against targets set in the London TB Metrics. Results 73 adults (35 males, 38 females) were diagnosed, of which 38 (49.4%) were pulmonary cases. 69 patients (94.5%) were offered an HIV test; 63 patients attended for testing, with two patients testing positive for HIV. Abstract P57 Table 1 summarises results achieved. Discussion We have audited performance of a local TB clinic against targets set in the London TB Metrics. Achieving a microbiological diagnosis in 65% is difficult as patients are often already on treatment before referred into the service. Changes were instituted in laboratory workflow patterns to improve sputum smear result availability within one working day, increasing to 93.8% in the first 2 months of 2010. Conclusion The London TB Metrics targets are achievable (seven of eight targets met) and provide an audit tool that may facilitate improvements in the standard of TB care.