Serotype Distribution and Disease Severity in Adults Hospitalized with Streptococcus pneumoniae Infection, Bristol and Bath, UK, 2006‒2022

Pneumococcal conjugate vaccinations should be evaluated and considered in formulating future public health policy recommendations.

Ongoing surveillance after pneumococcal conjugate vaccination (PCV) deployment is essential to inform policy decisions and monitor serotype replacement. We report serotype and disease severity trends in 3,719 adults hospitalized for pneumococcal disease in Bristol and Bath, United Kingdom, during 2006–2022. Of those cases, 1,686 were invasive pneumococcal disease (IPD); 1,501 (89.0%) had a known serotype. IPD decreased during the early COVID-19 pandemic but during 2022 gradually returned to prepandemic levels. Disease severity changed throughout this period: CURB65 severity scores and inpatient deaths decreased and ICU admissions increased. PCV7 and PCV13 serotype IPD decreased from 2006–2009 to 2021–2022. However, residual PCV13 serotype IPD remained, representing 21.7% of 2021–2022 cases, indicating that major adult PCV serotype disease still occurs despite 17 years of pediatric PCV use. Percentages of serotype 3 and 8 IPD increased, and 19F and 19A reemerged. In 2020–2022, a total of 68.2% IPD cases were potentially covered by PCV20.

Putting an end to Black Wednesday: improving patient safety by achieving comprehensive trust induction and mandatory training by day 1

The term 'Black Wednesday' has been used to describe the August national changeover day, a day when a new cohort of inexperienced doctors start work, many of whom are absent from patient care to attend organisational induction and mandatory training. In this paper, we report on the development and implementation of a novel, interactive e-learning programme for induction and mandatory training for junior doctors in a district general hospital in south-west England from August 2013. This comprehensive mandatory-training programme with summative assessment saved 19.5 hours of trust time per trainee. Since the programme's inception, the completion rate has been 100% (n = 370). Subgroup analysis of starters from August 2013 (n = 141) showed that 85.7% completed by day 1 (mean time of completion 3.0 days before day 1, standard deviation 14.2 days). Importantly, 90 minutes of induction was freed on Black Wednesday, enabling earlier, ward-based clinical orientation, thereby enhancing patient safety. We believe that this is the first programme to combine induction with fully assessed, comprehensive mandatory training in a single package. Such an approach is suitable for widespread application and is to be implemented regionally.

Outcomes of Pseudomonas eradication therapy in patients with non-cystic fibrosis bronchiectasis

Pseudomonas aeruginosa infection is associated with poorer outcomes in non-cystic fibrosis bronchiectasis. It is unknown whether early eradication improves outcomes. This retrospective study assessed clinical and microbiological outcomes of eradication therapy following initial Pseudomonas infection. All patients undergoing Pseudomonas eradication therapy from 2004 to 2010 were identified retrospectively and assessed for microbiological eradication, exacerbation frequency, hospital admissions, clinical symptoms and lung function. 30 patients were identified with median follow-up time 26.4 months. Eradication therapy involved intravenous antibiotics (n = 12), intravenous antibiotics followed by oral ciprofloxacin (n = 13) or ciprofloxacin alone (n = 5), combined with 3 months of nebulised colistin. Pseudomonas was initially eradicated from sputum in 24 patients (80.0%). 13/24 patients remained Pseudomonas-free and 11/24 were subsequently reinfected (median time 6.2 months). Exacerbation frequency was significantly reduced from 3.93 per year pre-eradication and 2.09 post-eradication (p = 0.002). Admission rates were similar, at 0.39 per year pre-eradication and 0.29 post-eradication (p = NS). 20/30 patients reported initial clinical improvement, whilst at one-year follow up, 19/21 had further improved or remained stable. Lung function was unchanged. This study demonstrates that Pseudomonas can be eradicated from a high proportion of patients, which may lead to prolonged clearance and reduced exacerbation rates. This important outcome requires confirmation in a prospective study.

Review Series: Old age: Pneumonia in old age

At the end of the 19th century William Osler noted key differences in the presentation of pneumonia in the elderly. His observational perspicuity has withstood the passage of time. The following article pays deference to this Canadian physician, summarizing not only differences in clinical presentation but also including an update on epidemiology, aetiology and management.

Double blind randomised placebo controlled trial of adjunctive prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patients

OBJECTIVE

To determine the effect of adjunctive prednisolone on morbidity, pericardial fluid resolution, and mortality in HIV seropositive patients with effusive tuberculous pericarditis.

DESIGN

Double blind randomised placebo controlled trial.

SETTING

Two medical school affiliated referral hospitals in Harare, Zimbabwe.

PATIENTS

58 HIV seropositive patients aged 18-55 years with tuberculous pericarditis.

INTERVENTIONS

All patients received standard short course antituberculous chemotherapy and were randomly assigned to receive prednisolone or placebo for six weeks.

MAIN OUTCOME MEASURES

Clinical improvement, echocardiographic and radiologic pericardial fluid resolution, and death.

RESULTS

29 patients were assigned to prednisolone and 29 to placebo. After 18 months of follow up there were five deaths in the prednisolone treated group and 10 deaths in the placebo group. Mortality was significantly lower in the prednisolone group (log rank chi(2) = 8. 19, df = 1, p = 0.004). Resolution of raised jugular venous pressure (p = 0.017), hepatomegaly (p = 0.007), and ascites (p = 0.015), and improvement in physical activity (p = 0.02), were significantly more rapid in the prednisolone treated patients. However, there was no difference in the rate of radiologic and echocardiographic resolution of pericardial effusion.

CONCLUSIONS

Adjunctive prednisolone for effusive tuberculous pericarditis produced a pronounced reduction in mortality. It is suggested prednisolone should be added to standard short course chemotherapy to treat HIV related effusive tuberculous pericarditis.

Can and should level II nurseries care for newborns who require mechanical ventilation?

Perinatal regionalization was conceived roughly 25 years ago to provide centralized care for critically ill newborn infants. As for many 25-year-old concepts, the obligatory centripetal design of many regionalization policies may need to be modified. This article presents the outcomes of 408 surviving patients who required mechanical ventilation (136 born in one community hospital and 272 birthweight-matched infants born in our tertiary center), and were cared for in our perinatal network. Mechanical ventilation of a resident population of newborns at a community NICU appeared to be as effective as ventilatory care at a regionalized tertiary neonatal intensive care unit, when assessed by comparing birthweight-matched populations for length of hospital stay, days on ventilator, and the need for home O2. Some may still claim that every baby who requires mechanical ventilation must be transferred to a tertiary care center. In an era of heightened interest in health services, health outcomes, and cost-effectiveness analysis, however, the authors believe that such claims will be subjected to increasing scrutiny. Our study represents a first attempt at determining the shape such scrutiny might take, and the sort of data analyses that may be required to reformat a perinatal network.

A self-psychological approach to the analysis of resistance: a case report

This paper attempts to explore the understanding of resistance from a self-psychological perspective through presenting a case report. This view is contrasted to the traditional psychoanalytic model which assumes that whatever impedes the analysis is a resistance, and construes such resistance in terms of the drive-defence model. The motivation for this blockade of the analysis is the protection of the ego from anxiety. By contrast, a self-psychological model suggests that 'so called defence-resistances' (Kohut, 1984, p. 141) are required for the protection of the weakened self. There is no blockade of the analytic process; rather, the 'resistance' safeguards the self so that the analysis may continue. The motivation for 'resistance' is to protect the self so that it will be ready to resume development when a safe, attuned selfobject environment is available. In the case presented the patient beseeched the analyst to refrain from speaking. The analyst's dilemma is discussed and the resolution of the resistance is described.

HIV infection among heterosexual travellers attending the Hospital for Tropical Diseases, London

OBJECTIVE

To determine the prevalence of HIV infection in travellers attending the Hospital for Tropical Diseases, London, and to assess correlates and behavioural risk factors for infection.

DESIGN

All patients tested for HIV infection during a 28-month period were included. Information was obtained from clinical records and standardised serological request forms.

SETTING

Hospital for Tropical Diseases, London, UK.

SUBJECTS

298 patients (in-patient and out-patient) were tested.

RESULTS

258 of those tested were exclusively heterosexual and not injecting drug users. 5.4% of these were HIV-1 antibody positive. Rates in those originating from the UK and those from outside the UK were 1.8% and 33.2% respectively. Most non-UK citizens were symptomatic when tested; UK citizens were generally tested as part of a routine screening, therefore the two groups are not comparable. Rates of risk behaviour were high in both groups.

CONCLUSION

The rate of HIV infection in heterosexual travellers was 5.4%. Amongst UK citizens the rate was 1.8%. All travellers should be made aware of the potential risk of acquiring HIV infection through sexual contact.

Fusobacterium nucleatum bacteraemia with multiple liver abscesses in an HIV-I antibody positive man with IgG2 deficiency

Liver abscess formation due to Fusobacterium nucleatum is rare. We describe an HIV-I antibody positive man, with normal surrogate markers of cell-mediated immunity, who presented with F. nucleatum bacteraemia and liver abscess formation. He was found to have IgG2 subclass deficiency. This case illustrates the clinical importance of altered B-cell function in patients who are at an early stage of HIV disease.

A health shop to meet public needs. A health visiting service in the market place

People who have the greatest need for health information are often reluctant to seek it out. A 'health shop' was set up in a busy town market to help bring health education to the heart of the community. It resulted in an increased uptake of community services and helped boost the health visiting profile.

Sputum induction for the diagnosis of pulmonary disease in HIV positive patients

We prospectively compared sputum induction with bronchoalveolar lavage (BAL) in HIV positive patients presenting with acute respiratory episodes and also assessed the effects of using an experienced respiratory physiotherapist on the diagnostic yield from induced sputum. One hundred and fifty-one consecutive patients underwent sputum induction, in 96 the procedure was supervised by nursing and medical staff with no specific expertise (group I); in 55 patients a physiotherapist supervised sputum induction (group 2). Nine patients refused BAL having undergone sputum induction. Of the remaining 142 patients sputum induction failed (no sample expectorated) in 28 patients (25 from group 1 and three from group 2), the sample was inadequate (the material expectorated was not from the lower respiratory tract) in 29, and was adequate in 85 patients. Pneumocystis carinii was diagnosed in 82 patients (51 from group 1 and 31 from group 2). The sensitivity of induced sputum for the diagnosis of P. carinii was 13% and of BAL was 77%. In the subgroup of patients with an adequate induced sputum sample, the sensitivity of induced sputum was 28% and of BAL was 73%. Of the remaining 60 patients, 27 had other diagnoses made by induced sputum and BAL (eight patients), BAL only (15 patients) and induced sputum only (four patients). Eleven patients had bronchitis and responded to oral antibiotics. In 22 patients induced sputum and BAL were negative; alternative diagnoses were established by lung biopsy or by culture of blood, urine or CSF. During sputum induction, 15 patients had nausea and vomiting, eight became dyspnoeic, three had intractable cough and one developed acute bronchoconstriction; 17 patients found the procedure unpleasant. Compared with BAL, induced sputum has a lower diagnostic yield for P. carinii and other pathogens. Use of experienced, dedicated personnel increases the number of successful attempts at sputum induction but does not increase the diagnostic yield. Fibreoptic bronchoscopy and bronchoalveolar lavage remain necessary for patients with negative results from induced sputum and those whose disease course is at variance with the diagnosis made by sputum induction.

NADP+ reduction by human lymphocytes

The hexose monophosphate shunt (HMPS) is known to be responsible for the reduction of NADP+ by lymphocytes. We tried to find other enzymatic systems that might provide the lymphocytes with NADPH. By measuring the absorbance at 340 nm we noted that the addition of NADP+ to a preparation of disrupted lymphocytes resulted in the formation of NADPH at a rate of 4 nmol/10(6) cells per min. This phenomenon could not be changed by negative feedback inhibition of HMPS, and could not be attributed to the low concentration of glucose, glucose-6-phosphate (G-6-P) and isocitrate found in the cell preparation (NADP(+)-dependent isocitrate dehydrogenase in addition to HMPS NADP+ reducing enzymes was found to be present in lymphocytes). Because of the activity of a NADP(+)-dependent lactate dehydrogenase, pyruvate oxidized the NADPH as it was being formed. Here we demonstrate the presence of an unknown NADP+ reducer in lymphocytes which seems to play an additional role to HMPS in NADP+ reduction by lymphocytes. NADP(+)-dependent lactate dehydrogenase may play a role in regulating the NADP+/NADPH ratio.