Clinical characteristics of pertussis-associated cough in adults and children: a diagnostic systematic review and meta-analysis

Background: Pertussis (whooping cough) is a highly infective cause of cough that causes significant morbidity and mortality. Existing case definitions include paroxysmal cough, whooping and post-tussive vomiting but diagnosis can be difficult. We determined the diagnostic accuracy of clinical characteristics of pertussis-associated cough. Methods: We systematically searched CINAHL, Embase, Medline and SCI-EXPANDED/CPCI-S up to June 2016. Eligible studies compared clinical characteristics in those positive and negative for Bordetella pertussis infection, confirmed by laboratory investigations. Two authors independently completed screening, data extraction and quality and bias assessments. For each characteristic RevMan was used to produce descriptive forest plots. We used the bivariate meta-analysis method to generate pooled estimates of sensitivity and specificity. Results: Of 1969 identified papers, 53 were included. Forty-one clinical characteristics were assessed for diagnostic accuracy. In adult patients, paroxysmal cough and absence of fever had a high sensitivity (93.2%, CI 83.2-97.4 and 81.8%, CI 72.2-88.7 respectively) and low specificity (20.6%, CI 14.7-28.1 and 18.8%, CI 8.1-37.9 respectively), whereas post-tussive vomiting and whooping had low sensitivity (32.5%, CI 24.5-41.6 and 29.8%, CI 8.0-45.2 respectively) and high specificity (77.7%, CI 73.1-81.7 and 79.5%, CI 69.4-86.9 respectively). Post-tussive vomiting in children is moderately sensitive (60.0%, CI 40.3-77.0) and specific 66.0%, CI 52.5-77.3). Conclusions: In adult patients the presence of whooping or post-tussive vomiting should rule in a possible diagnosis of pertussis, whereas the lack of a paroxysmal cough or the presence of fever should rule it out. In children, post-tussive vomiting is much less helpful as a clinical diagnostic test

Intraperitoneal drain placement and outcomes after elective colorectal surgery: international matched, prospective, cohort study

Despite current guidelines, intraperitoneal drain placement after elective colorectal surgery remains widespread. Drains were not associated with earlier detection of intraperitoneal collections, but were associated with prolonged hospital stay and increased risk of surgical-site infections.Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien-Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk

Predicting inhaled steroid responsiveness using blood eosinophil counts: personalising long-term management of COPD in primary care

Background Management of chronic obstructive pulmonary disease (COPD), including initiation of inhaled corticosteroids (ICS), has thus far generally been based on a ‘one-size-fits-all’ approach. However, benefits of ICS are unclear, and they may harm some patients. Blood eosinophils have been identified as a readily available biomarker to guide decisions about ICS treatment in COPD, but they have not been studied in an ICS-naïve, primary care population. A device for estimating blood eosinophil counts at the point of care is now available. This doctoral project aimed to characterise blood eosinophils and ICS responsiveness in people with COPD in primary care, as well as assess agreement between near-patient vs. laboratory testing for blood eosinophils. Methods This project comprises two major studies, each with several constituent parts. First, a study of 30,378 routinely-collected primary care records were used for descriptive and hypothesis-testing components. Second, a prospective cohort study recruited 96 participants to obtain laboratory and near-patient blood eosinophil data at multiple visits over a six-month period. Results Approximately half of patients fell into a ‘medium’ category of eosinophils in the range 0.15 to 0.34 x10*9/L. Repeatability of eosinophil counts was either ‘good’ or ‘excellent’ in the two cohorts. There was a lower risk of acute exacerbations in patients with higher eosinophil counts who were prescribed an ICS, with a clear ‘dose-response’ by eosinophil count. There was no clinically important difference between near-patient and laboratory eosinophil values. Conclusions Patients with higher blood eosinophils are more likely to benefit from ICS. Blood eosinophil counts are generally repeatable and are applicable for guiding ICS treatment decisions in primary care. Blood eosinophil categories in combination with other clinical features such as acute exacerbation frequency could provide a more personalised approach to pharmacological management of COPD. Near-patient eosinophil count testing could support rapid decisions about ICS treatment in primary care.</p

Determining immunisation status of children from history: a diagnostic accuracy study

OBJECTIVES: Children presenting unplanned to healthcare services are routinely asked about previous immunisations as part of their assessment. We aimed to assess the accuracy of screening children for immunisation status by history. DESIGN: Diagnostic accuracy study. We compared information from patient history by a retrospective review of notes and used a central database of child immunisation records as the reference standard. SETTING: Paediatric emergency department in a tertiary hospital in Oxford, UK. PARTICIPANTS: Consecutive children aged 6 months to 6 years presenting over a 2-month period. OUTCOME MEASURES: Proportion of children with documented immunisation history; sensitivity and specificity of detecting overdue immunisations by history compared to central records. RESULTS: 1166 notes were surveyed. 76.3% children were asked about immunisations. The proportion of children who were fully immunised on central records was 93.1%. History had a sensitivity of 41.3% (95% CI 27% to 56.8%) and a specificity of 98.7% (95% CI 97.5% to 99.4%) for detecting those who were overdue. Negative predictive value was 95.8% (95% CI 93.9% to 97.2%). Only around a third of children with overdue immunisations are detected by the current screening methods, and approximately 1 in 20 children stated as being up to date are in fact overdue. CONCLUSIONS: History had poor sensitivity for identifying overdue immunisation. Strategies to improve detection of children overdue with immunisation should focus on alternative strategies for alerting clinicians, such as linkage of community and hospital electronic records

What are General Practitioner perceptions of workload in England? A qualitative study

Background General Practitioner (GP) morale is the lowest amongst doctors, job satisfaction is low, and the GP workforce is diminishing. Workload is frequently cited as negatively impacting on commitment to a career in general practice, and many GPs report their workload to be unmanageable. Aim To gather in-depth understanding of GPs’ perceptions and attitudes towards workload. Design and Setting All GPs working within NHS England were eligible. Of those who responded to advertisements, a maximum variation sample was selected until data saturation was reached. Semi-structured, qualitative interviews were conducted. Data were analysed thematically. Results 171 GPs responded, and 34 were included. GPs described an increase in workload over recent years, with current working days being long and intense, which raised concerns over wellbeing of GPs and patients. Full-time partnership was generally not considered to be possible, and many participants felt workload was unsustainable, particularly given the diminishing workforce. Four major themes emerged to explain increased workload: 1) increased patient needs and expectations, 2) changing relationship between primary and secondary care, 3) bureaucracy and resources, and 4) the balance of workload within a practice. Continuity of care was perceived to be being eroded by changes in contracts and working patterns to deal with workload. Conclusion This study highlights the urgent need to address perceived lack of investment and clinical capacity in general practice; and suggests that influencing patient expectations of what primary care can deliver and reducing bureaucracy have become key issues, at least until the capacity issues are resolved.</p

GPs' perceptions of workload in England: a qualitative interview study.

Background General Practitioner (GP) morale is the lowest amongst doctors, job satisfaction is low, and the GP workforce is diminishing. Workload is frequently cited as negatively impacting on commitment to a career in general practice, and many GPs report their workload to be unmanageable. Aim To gather in-depth understanding of GPs’ perceptions and attitudes towards workload. Design and Setting All GPs working within NHS England were eligible. Of those who responded to advertisements, a maximum variation sample was selected until data saturation was reached. Method Semi-structured, qualitative interviews were conducted. Data were analysed thematically. Results 171 GPs responded, and 34 were included. GPs described an increase in workload over recent years, with current working days being long and intense, which raised concerns over wellbeing of GPs and patients. Full-time partnership was generally not considered to be possible, and many participants felt workload was unsustainable, particularly given the diminishing workforce. Four major themes emerged to explain increased workload: 1) increased patient needs and expectations, 2) changing relationship between primary and secondary care, 3) bureaucracy and resources, and 4) the balance of workload within a practice. Continuity of care was perceived to be being eroded by changes in contracts and working patterns to deal with workload. Conclusion This study highlights the urgent need to address perceived lack of investment and clinical capacity in general practice; and suggests that influencing patient expectations of what primary care can deliver and reducing bureaucracy have become key issues, at least until the capacity issues are resolved.</p