Background

The updated British Thoracic Society (BTS) Guidelines for the management of Community Acquired Pneumonia (CAP) in adults was published in October 2009. In conjunction with the Guidelines, the first national BTS audit of adult CAP was conducted.

Methods

An audit tool was developed as part of the Guidelines. Members of the BTS were invited to participate in the audit capturing data relating to acutely ill adults admitted to hospitals in the UK and treated for CAP within the period 1 December 2009 and 31 January 2010. Data entry using the web-based audit tool closed in May 2010.

Results

Of 2749 submissions from 64 institutions; 8 were excluded due to inconsistent data. The mean age of patients was 71 years (range 16–105 years). The CURB65 score was 0 to 1 in 40% of patients, 2 in 30% and 3 to 5 in 30%. Five hundred and three (18.3%) patients died in hospital within 30 days, 101 (20.1%) within 1 day of admission. Initial empirical antibiotics were in accordance with local CAP guidelines in 1478 (55.5%) patients and were administered intravenously in 712 (65%), 603 (74%) and 743 (90%) patients with CURB65 scores 0 to 1, 2 and 3 to 5 respectively. Within 4 hours of admission, a chest x-ray was obtained in 83% of patients and the first dose of antibiotics was administered in 58%.

Conclusions

The burden of CAP is high. Efforts should be directed at improving adherence to local CAP guidelines and specific processes of care.

Background: The loose and stringent Asthma Predictive Indices (API), developed in Tucson, are popular rules to predict asthma in preschool children. To be clinically useful, they require validation in different settings.Objective: To assess the predictive performance of the API in an independent population and compare it with simpler rules based only on preschool wheeze.Methods: We studied 1954 children of the population-based Leicester Respiratory Cohort, followed up from age 1 to 10 years. The API and frequency of wheeze were assessed at age 3 years, and we determined their association with asthma at ages 7 and 10 years by using logistic regression. We computed test characteristics and measures of predictive performance to validate the API and compare it with simpler rules.Results: The ability of the API to predict asthma in Leicester was comparable to Tucson: for the loose API, odds ratios for asthma at age 7 years were 5.2 in Leicester (5.5 in Tucson), and positive predictive values were 26% (26%). For the stringent API, these values were 8.2 (9.8) and 40% (48%). For the simpler rule early wheeze, corresponding values were 5.4 and 21%; for early frequent wheeze, 6.7 and 36%. The discriminative ability of all prediction rules was moderate (c statistic ≤ 0.7) and overall predictive performance low (scaled Brier score < 20%).Conclusion: Predictive performance of the API in Leicester, although comparable to the original study, was modest and similar to prediction based only on preschool wheeze. This highlights the need for better prediction rules.

Background: The evidence on whether the atopic march observed in childhood (ie, the progression from eczema to allergic rhinitis and asthma) extends to adulthood is sparse, and there is no evidence on whether the progression leads to a specific phenotype of asthma.Objective: We sought to assess whether childhood eczema and rhinitis are risk factors for specific phenotypes of adult asthma.Methods: Participants of the Tasmanian Longitudinal Health Study recruited in 1968 (age range, 6.0-7.0 years) were followed up at age 44 years. The risk of current atopic or nonatopic asthma in middle age characterized by sensitization to aeroallergens given childhood eczema, rhinitis, or both was calculated by using multinomial logistic regression.Results: No association was found between childhood eczema or rhinitis and nonatopic adult asthma. In contrast, childhood eczema and rhinitis in combination predicted both new-onset atopic asthma by middle age (adjusted multinomial odds ratio [aMOR], 6.3; 95% CI, 1.7-23.2) and the persistence of childhood asthma to adult atopic asthma (aMOR, 11.7; 95% CI, 3.6-37.9). Participants with childhood eczema alone were at increased risk of new-onset atopic asthma (aMOR, 4.1; 95% CI, 1.9-8.8), whereas rhinitis alone predicted the persistence of childhood asthma to atopic asthma (aMOR, 2.7; 95% CI, 1.3-5.6). Of all asthma, 29.7% of persistent atopic asthma and 18.1% of new-onset atopic asthma could be attributed to having childhood eczema and rhinitis.Conclusion: Childhood eczema and rhinitis are strongly associated with the incidence and persistence of adult atopic asthma.

Primary immunodeficiencies (PIDs) are commonly characterized by an increased susceptibility to specific infections and, in certain instances, a higher than usual incidence of malignancies. Although improved diagnosis and early treatment of PIDs have reduced early morbidity and mortality from infection, the development of cancer remains a significant cause of premature death. The emergence of cancer in patients with PIDs often results from impairments in the immune response that lead to weakened surveillance against oncogenic viruses, premalignant or malignant cells, or both. Here we review the clinical and biologic features of several PIDs associated with enhanced susceptibility to viral infections and cancer, including X-linked lymphoproliferative disease; IL-2–inducible T-cell kinase deficiency; epidermodysplasia verruciformis; warts, hypogammaglobulinemia, infections, and myelokathexis syndrome; autosomal recessive hyper-IgE syndrome; X-linked agammaglobulinemia; and common variable immunodeficiency. It is of importance that we gain in-depth insights into the fundamental molecular nature of these unique PIDs to better understand the pathogenesis of virus-associated malignancies and to develop innovative therapeutic strategies.