NICE1 recommends ‘track and trigger’ systems for all adult acute hospital admissions and the RCP2 advocates the use of the National Early Warning Score (NEWS) to promptly highlight high risk patients. In non-selected medical patients a higher admission NEWS correlates with higher mortality, with a step-wise increase as the score increases. Anecdotally patients with COPD have high rates of NEWS alerting. No studies have looked at the validity of the NEWS in COPD patients though the issue was raised in a previous abstract. We retrospectively interrogated an electronic observation database in our Trust (two acute sites) over a year (February 2012–January 2013). We compared acute medical unit (AMU) admissions aged over 50 years (n = 13,291) with patients admitted with a primary diagnosis of COPD (n = 1119). Despite a similar age profile (median 74 & 77) and inpatient mortality (5.3% & 6.2%), the COPD cohorts admission NEWS was double that of the AMU patients (median 4 vs 2). This difference persisted throughout admission to discharge. Admission NEWS showed a step-wise increase in mortality amongst the AMU patients. In contrast, the COPD cohort with NEWS of 5 or 6 had lower in-patient mortality compared to COPD patients scoring 2–4. NEWS of ≥7 is used to trigger urgent medical attention and 20% of patients with COPD fulfilled this criteria (compared to 6.6% of non-COPD patients). When NEWS score was ≥10, mortality in both groups was high (31.6% in COPD patients, 40% in AMU patients)(graph 1). In conclusion, we have shown that acute COPD patients have similar mortality to other emergency medical admissions yet persistently higher NEWS. This requires addressing possibly by adjusting the NEWS to take into account lower oxygen saturation targets in selected COPD patients (median 93% compared to 96% in AMU patients) and thus reduce over-alerting of those not necessarily at high risk of death. References Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital. http://www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf National Early Warning Score (NEWS) Standardising the assessment of acute-illness severity in the NHS - Report of a working party July 2012 http://www.rcplondon.ac.uk/sites/default/files/documents/national-early-warning-score-standardising-assessment-acute-illness-severity-nhs.pdf

NICE1 recommends ‘track and trigger’ systems for all adult acute hospital admissions and the RCP2 advocates the use of the National Early Warning Score (NEWS) to promptly highlight high risk patients. In non-selected medical patients a higher admission NEWS correlates with higher mortality, with a step-wise increase as the score increases. Anecdotally patients with COPD have high rates of NEWS alerting. No studies have looked at the validity of the NEWS in COPD patients though the issue was raised in a previous abstract. We retrospectively interrogated an electronic observation database in our Trust (two acute sites) over a year (February 2012–January 2013). We compared acute medical unit (AMU) admissions aged over 50 years (n = 13,291) with patients admitted with a primary diagnosis of COPD (n = 1119). Despite a similar age profile (median 74 & 77) and inpatient mortality (5.3% & 6.2%), the COPD cohorts admission NEWS was double that of the AMU patients (median 4 vs 2). This difference persisted throughout admission to discharge. Admission NEWS showed a step-wise increase in mortality amongst the AMU patients. In contrast, the COPD cohort with NEWS of 5 or 6 had lower in-patient mortality compared to COPD patients scoring 2–4. NEWS of ≥7 is used to trigger urgent medical attention and 20% of patients with COPD fulfilled this criteria (compared to 6.6% of non-COPD patients). When NEWS score was ≥10, mortality in both groups was high (31.6% in COPD patients, 40% in AMU patients)(graph 1). In conclusion, we have shown that acute COPD patients have similar mortality to other emergency medical admissions yet persistently higher NEWS. This requires addressing possibly by adjusting the NEWS to take into account lower oxygen saturation targets in selected COPD patients (median 93% compared to 96% in AMU patients) and thus reduce over-alerting of those not necessarily at high risk of death. Abstract S67 Figure 1. References Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital. http://www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf National Early Warning Score (NEWS) Standardising the assessment of acute-illness severity in the NHS - Report of a working party July 2012 http://www.rcplondon.ac.uk/sites/default/files/documents/national-early-warning-score-standardising-assessment-acute-illness-severity-nhs.pdf

The National Early Warning Score (NEWS) system is in use throughout NHS Acute Trusts. It reliably picks up the small proportion of patients at high risk of death during their admission. However, during Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD), where target saturations are 88–92% in selected patients, a high proportion of patients have NEWS ‘alerts’ when their oxygen levels are within the target range set by their clinician. This results in referral for urgent review by medical staff and/or an inappropriate increase of inspired oxygen which could exacerbate hypercapnic respiratory failure. We therefore propose a simple modification to the NEWS system in patients at risk of hypercapnic respiratory failure. Three points are added for target saturations of 85% or less and two points are added for target saturations of 86–87%. For target saturations of 88–92%, no additional points will be added. This modification would be at the senior clinicians’ discretion. We reviewed the observations of 1119 patients admitted with a primary diagnosis of AECOPD and compared them to 15,953 patients aged over 50 admitted to one of two acute medical units. Admission saturations were reviewed and compared with in-patient mortality. Use of the current NEWS system resulted in 40% of patients with AECOPD scoring 2–3 points on their saturation alone despite most being in the saturation range recommended by the BTS1. In addition, their risk of mortality was significantly lower than patients without COPD in the same saturation range (See table 1). Our proposed modified NEWS system results in an improved ability to identify the patients at higher risk of mortality, thereby resulting in more efficient utilisation of medical resources and the reduction of inappropriate use of oxygen and risk of hypercapnic respiratory failure. We have shown that the current NEWS system leads to a significant number of patients with AECOPD alerting when they have nationally recommended target oxygen saturations. A simple adjustment of the alerting threshold in this cohort could improve the system. This could also be applicable to other respiratory patients with or at risk of hypercapnic respiratory failure. 1. BTS guideline for emergency oxygen use.

Genital and perianal ulcers seen in patients with HIV are commonly due to herpes simplex virus (HSV) infection. While it is well known that the characteristic presentation of HSV is a vesicular rash or crops of erosions, the clinical presentation of genital HSV infection in HIV is varied and can assume vegetative, hypertrophic, condyloma-like, nodular, ulcerative and tumour-like nodules or plaques. These unusual presentations often lead to a delayed diagnosis. We describe five immunocompromised HIV-positive patients with CD4 counts ranging from 114 to 326 cells/μL with unusual presentations of anogenital herpes.

A 61 year old man was referred to our outpatient department because of breathlessness. He was able to walk only 50 metres before having to stop to catch his breath. He denied any chest pain or cough. In the 1980s he had fallen down a lift shaft, which had caused substantial trauma. He had needed mechanical ventilation in the intensive care unit, with tracheostomy formation and prolonged respiratory wean. He had never smoked. Examination of his chest was normal. Oxygen saturations on room air were 96%. His chest radiograph was normal. Figure 1⇓ shows the results of another test that was performed.### 1 What test has been performed?#### Short answerSpirometry was performed, and maximal expiratory and inspiratory flow volume loops and a flow volume curve were produced. The expected expiratory curve is shown in black and the patient’s observed expiratory and inspiratory curves are shown in blue.#### Long answerA variety of pulmonary functions tests are available, including spirometry, flow volume curves, measurement of diffusion capacity, and lung volumes. These tests are effort dependent and require patient cooperation. Predicted values depend on age, height, sex, and race and are determined by published studies of large …

Introduction and Objectives Pulmonary hypertension (PH) in Sickle cell disease (SCD) is defined as tricuspid regurgitation jet velocity ≥2.5 m/s on trans thoracic echocardiogram. It is an important complication of SCD and is associated with significant mortality. Haemolysis with impairment of the nitric oxide pathway is felt to play a major part in its pathogenesis. We have examined the association of haemolytic markers and inflammatory cytokines in haemoglobin SS (HbSS) adults with PH (TRV≥ 2.5 m/s) and without PH (TRV <2.5 m/s). Cytokines studied included interleukin 8 (IL-8), which may have a role in promoting adhesion of sickled red cells to vascular endothelium and stem cell factor (SCF), which acts on erythroid progenitor cells. Methods 32 adult HbSS patients (mean age 37 years ± 11.6, median 37 years) were recruited at steady state defined as 2 weeks or more following an acute crisis. Serum levels of haemolytic markers (haemoglobin, lactate dehydrogenase LDH, bilirubin), asymmetric dimethylarginine (ADMA a naturally occurring nitric oxide synthase inhibitor), SCF and IL 8 were measured. Results Results are given in Abstract P35 Table 1 and expressed as mean ± SD. TRV was significantly correlated with Hb (p=0.003 r= − 0.51), ADMA (p< 0.05, r= 0.35), IL 8 (p= 0.009, r= 0.48) and SCF (p=0.006, r= 0.51). Conclusion PH in SCD is associated with lower haemoglobin and ADMA but not other markers of haemolysis. There is a significant association of TRV with IL 8 and SCF, which has not been previously described in adults. Inflammatory mediated endothelial dysfunction is likely to also play an important role in the pathogenesis of PH associated with SCD. The roles of IL 8 and SCF warrant further investigation.

Primary cutaneous amyloidosis is a chronic pruritic disorder with characteristic amyloid deposits in the papillary dermis. The manifestations of primary localised cutaneous amyloidosis (PLCA) are usually confined to the skin. The aetiopathogenesis of PLCA has not been clearly elucidated. We report a patient who developed PLCA after a short intense period of sun-exposure which we postulate that it may be the triggering factor in the development of macular amyloidosis.

Introduction and Objectives WHO Functional class (FC) is an important tool in the management of patients with pulmonary arterial hypertension. There is an increasing awareness of pulmonary hypertension (PH) as a complication of Sickle cell disease (SCD). We wished to evaluate functional class and gas transfer (diffusion capacity DLCOc, KCOc) in patients with SCD (HbSS) with and without PH based on trans thoracic echocardiogram. Methods 32 patients were reviewed and their functional class was determined. Trans thoracic echocardiograms were reviewed in these patients for evidence of PH (defined as a tricuspid regurgitation jet velocity TRV ≥ 2. 5 m/s). Haematological and lung function data were also reviewed. Only patients in steady state and without a crisis in the preceding 2 weeks were included. Results Of patients with PH 36% (5/14) were FC ≥3 compared to 6% (1/18) without PH. There was a significant difference in functional class in patients with and without PH on echocardiogram (p<0.05). There was a significant correlation between TRV and WHO functional class (p=0.002, r= 0.54). The correlation between TRV and functional class remained significant after correction for haemoglobin. Mean haemoglobin was 8.3±1.3 g/dl in those with PH and 10.1±1.4 g/dl in those without PH (p=0.001). Neither PH nor FC was associated with parenchymal abnormalities visible on CT and/or chest radiograph. PH was also associated with a lower diffusion capacity (DLCOc mmol/min/kPa: 3.60±0.79 vs 7.60±2.66, p=0.034) and a lower diffusion capacity corrected for alveolar volume (KCOc mmol/min/kPa/l: 1.04±0.31 vs 1.96±0.3, p=0.034). TRV was significantly correlated with DLCOc only (p=0.036 r= −0.79). Conclusion Although patients with Sickle cell disease may have a number of reasons to account for their breathlessness, functional class and measurements of gas transfer may be useful markers in screening patients for pulmonary hypertension regardless of low steady state anaemia.

Endobronchial interventions including the deployment of endobronchial stents have a clear role in the management of central airway problems. The use of endobronchial stents has rapidly increased since the first airway stent was developed in the 1960s and with the subsequent manufacture of improved silicone and metallic stents. They provide effective relief for symptoms of intrinsic and extrinsic airway obstruction secondary to a wide range of pathologies including lung cancer, lymphoma, thyroid carcinoma and benign disease such as tracheal strictures and tracheobronchomalacia. Endobronchial stents can also seal defects within the airway including malignant broncho-oesophageal fistulae and posterior wall tracheal tears. They can be placed safely under conscious sedation at flexible bronchoscopy or under general anaesthetic at rigid bronchoscopy. Rigid bronchoscopy under general anaesthesia provided by a multidisciplinary team is safe with few contra indications. Complications of endobronchial stents include infection, granulation tissue formation and metallic stent fracture sometimes requiring removal, although serious life-threatening complications are very rare. Increasing numbers of patients are being referred to specialist centres for airway intervention. This article reviews the history of endobronchial stents, the different stents available, and the indications, outcomes and complications involved in deploying endobronchial stents.