PurposeTo assess the incidence, clinical ocular involvement and effectiveness of anti-tuberculous treatment in patients with chronic uveitis presumed to be associated with tuberculosis in a non-endemic community.Patients and methodsRetrospective case series of patients with uveitis and evidence of tuberculosis, with no other identified cause of uveitis, who underwent a 6-month course of standard anti-tuberculosis treatment between 2008 and 2015. The response to treatment was assessed at 6 and 12 months after initiation of treatment.ResultsForty-eight patients were included of whom 36 (75%) were born outside the United Kingdom. Only five had concurrent active pulmonary or nodal tuberculosis. There were 85 affected eyes, including 25 with granulomatous anterior uveitis, 32 with retinal vasculitis (occlusive in 21), and 20 with multifocal choroiditis or serpiginous-like retinochoroiditis. Gamma-interferon testing was positive in 95%. Complete resolution at end point was seen in only 60%, but a further 19% were inflammation-free on topical steroid only. Resolution was lower (50%) in those with panuveitis compared to other anatomical types (75%). Sixty-four eyes (75%) had a LogMAR visual acuity of 0.1 or better at the end of the study.ConclusionsThe incidence of presumed tuberculosis-associated uveitis (TBU) has almost quadrupled in this region. The efficacy of treatment has not been enhanced by the introduction of gamma-interferon testing to support diagnosis. Some patients may require more prolonged antibiotic therapy to ensure quiescence, but chronic non-infective anterior uveitis may in any case follow treated TBU.

Introduction EBUS guided trans-bronchial needle aspiration with ROSE ensures adequacy of specimen samples and provides preliminary cytological diagnosis. Few studies have explored the utility of ROSE in granulomatous mediastinal lymphadenopathy. This retrospective study looks to further assess the validity of ROSE in the setting of non-malignant granulomatous disease. Methods We reviewed a prospectively maintained database of ROSE and laboratory cytology Results for all EBUS procedures performed during a 12 month period from 1 st January to 31 st December 2015 at our institute. We included all patients who had granuloma (including probable or possible granuloma) identified at ROSE or final cytology analysis, or both. We then reviewed clinico-radiological data to ascertain the final diagnosis and excluded those patients with malignant disease. Results During the study period, 366 EBUS were performed, with granuloma identified in 51 patients. Three patients were found to have malignancy and were excluded therefore 48 were included in the final analysis. The final diagnoses for the 48 patients are shown in Table 1. Patients with TB were more likely to have at least one granuloma at ROSE (84%) than patients with sarcoidosis (67%). Patients with granuloma identified at ROSE had a slightly lower number of nodes sampled per patient compared to those with no granuloma at ROSE (mean 1.8 vs 2.4 nodes per patient). The positive predictive value of ROSE for granuloma in our cohort was 100%, with a sensitivity of 71%. This is comparable to other studies. Conclusions In our cohort of patients, ROSE had a high positive predictive value and a sensitivity of over 70% for the diagnosis of granuloma in non-malignant disease. Our Results suggest that with the use of ROSE fewer nodes are sampled which may reduce procedure time and potential complications. This study is limited due to the small sample size but supports the use of ROSE in this context. We plan to carry out further work with larger data sets, and to look at the characteristics of those subsequently diagnosed with sarcoidosis or tuberculosis.

Background: The utility of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) for investigating suspected mediastinal and hilar tuberculosis (TB) in adults is established, however there is limited data on the paediatric population. We reviewed the adequacy, cytology and microbiological yield from EBUS-TBNA on suspected paediatric TB at our institute. Methods: Analysis was performed of prospectively maintained bronchoscopy and cytology databases to identify all cases of EBUS-TBNA performed in patients aged ≤18 years at our institute between 1/1/2014 and 31/12/2016. Identified cases had medical case notes, correspondence, bronchoscopy report, cytology and microbiology reviewed to identify those in whom TB was being investigated and gather information on the procedure, adequacy and clinical outcome. Results: 8 cases were identified. Age range 13-18, male 63%, female 37%. Total 15 nodes sampled, mean 2.5 passes per node. Rapid on site evaluation (ROSE) revealed ≥1 node with granuloma (5/8 patients), necrosis alone (1/8 patients) with all (6/6) showing necrotic granulomatous lymphadenitis on final cytology. Of these 4/6 cultured fully sensitive M Tuberculosis. A further 1/6 was culture negative but had a significant clinico-radiological response to TB chemotherapy. 1/6 had fully treated TB previously and was treated as right middle lobe syndrome. 2/8 adequate on ROSE, reactive lymphadenopathy on cytology and culture negative and final diagnosis was not TB. No procedural complications were recorded. Conclusion: EBUS-TBNA in our experience is a safe, useful tool in the diagnosis of children suspected of having TB with 80% of those with TB having positive culture on EBUS.

Introduction and objectives Tuberculosis cohort audit (TBCA) was introduced across the North West in 2012 as recommended by NICE. The approach taken and the outcome measures of the 1,515 TB cases reviewed are presented in a companion abstract. TBCA over a large geographical area has not undergone formal qualitative evaluation in the UK. We conducted a qualitative evaluation to explore perceptions about implementation and impact of TBCA in the North West. Methods One researcher conducted face to face, semi-structured, recorded interviews between 06/01/14 and14/03/14 with 26 purposively sampled respondents from three groups involved in TBCA: (a) TB nurse specialists; (b) Consultant physicians; (c) Public health practitioners. Transcripts were analysed descriptively and thematically using the Framework Method. Themes were triangulated with eight key informants from the TBCA Steering Group. Results Four themes were identified: Preconceptions: Participants were optimistic about the potential of audit to improve practice but worried about time demands and scrutiny from colleagues. Experience of TBCA: All groups felt engaged and appreciated TBCA. Nurses requested more engagement from consultant colleagues. Fears about time demands and scrutiny were not realised. Changes as a result of TBCA: Improvements to practice were identified including harmonisation of approaches, increased HIV testing, and improved documentation. TBCA was felt to provide peer support and learning through discussion and a no-blame atmosphere. Looking Ahead: Suggestionsfor further improvement were captured, such as more in-depth discussion around complex cases. If TBCA were to be discontinued (e.g. because of funding contraints), adverse consequences were predicted: e.g. disappointed and disenfranchised professionals, financial and patient harms. Conclusions Overall, TBCA in the North West has led to the development of a unique and valuable community of practice. The interchange of experience and ideas across a large number of teams and professionals has enhanced mutual respect between different roles and a shared sense of purpose. TBCA is appreciated by health professionals who participate. Continuing success will require increased engagement of consultant physicians and public health practitioners, a secure an ongoing funding stream and establishment of reporting mechanisms within the new commissioning structures.

The NHS Outcomes framework classes respiratory deaths in those aged under 75 as potentially avoidable. In practise the level of care available is often limited in those who are unlikely to benefit from invasive interventions which may limit death ‘avoidability’. We sought the frequency of such limitations by investigation of the use of ‘Do not actively resuscitate’ (DNAR) orders in adults with pneumonia. Adult admissions for pneumonia (ICD10 J12-J18) to one NHS Trust between 01/01/2012 and 31/05/2012 were retrospectively identified. Case details were gleaned from the case records. 293 cases were found of which 81 (28%) died. After exclusions (no radiographic pneumonia (12), no radiograph within 24 hours (1) and no radiograph (1)), 67 deaths remained. From these, 20 case notes were obtained and compared with the 40 subsequent surviving admissions. DNAR orders were present in 18 (30%) cases. 11 DNAR orders were recorded within 48 hours of admission, 2 within the next 48 hours and 5 in the following 5 days. They were more frequent in those who died (13/20 – 65%) than those that survived (5/40 – 12.5%; p<0.001). There was a non-significant trend for DNAR to be less frequent in those ≤75 (6/31 – 33%) than those aged >75 (12/29 – 67%; p=0.091) and they were more frequent in those admitted from nursing homes (5/7 – 71.4%) than from their own home (9/49 – 18.4%; p<0.001). 11/60 (18.3%) were admitted to ICU but patients with DNAR were no more or less likely to be so managed (5/18 – 27.8% cf 6/42 – 14.3%; p=0.279). There was a trend for DNAR to have been recorded more often in the more severely ill. Rates by CURB65 score were 0 – 1/5 (20%), 1 – 2/17 (11.8%), 2 – 3/15 (20%), 3 – 8/17 (47.1%), 4 – 3/5 (60%), 5 – 1/1 (100%); p=0.063. The high frequency of DNAR orders suggests that pneumonia deaths may not be as preventable as might be considered at first sight. This may be especially true for those aged >75. In any assessment of the predictability of death the use of DNAR orders should be considered.

As part of an initiative to improve the quality of care within the North West Strategic Health Authority, five ‘quality markers’ (QMs) were measured in all adult admissions with pneumonia in all 23 Acute Trusts in the North West Region. Results for discharges for 30 months from October 2008 are presented. Data reporting was changed to match the financial year in 2009 so cohorts from October 2008-September 2009, October 2009-March 2010 and April 2010-March 2011 are presented. Only adults who fulfilled a prescribed definition of ‘pneumonia’ were included. QMs were taken from a USA initiative and adapted for UK use. Patient identification was based on clinical coding. Data was recorded in each individual Trust and centrally collated. Data on 31,972 pneumonia episodes were included (11,127, 6,683, 14,162 in each time period respectively). Mean results of % compliance for each variable for each Trust, together with standard deviation as a measure of variability across hospital sites, are presented in the Table for each cohort. Initial compliance was worst for administration of smoking cessation advice and best for oxygenation assessment. While variability between hospitals was least for oxygenation it was greatest for the performance of blood cultures prior to antibiotic administration. Over the 3 cohorts overall compliance with QM assessment steadily improved for all QMs and variability between Trusts declined for all but smoking cessation advice.ConclusionsThe Advancing Quality Programme has resulted in improved quality of pneumonia care as assessed by both the improvement in overall compliance and the reduction in inter-hospital variability.

Introduction and Objectives There is no ideal outcome measure for studies in community-acquired pneumonia (CAP). Readmission to hospital within 30 days is one proposed measure which coincidentally the NHS now imposes financial penalties on Trusts for. We sought to investigate the frequency and validity of this measure for CAP and to examine factors predictive of readmission in CAP. Methods All adult cases (ICD10 J10–J18) admitted in 2010 were identified from Trust Information records. Those readmitted within 30 days of discharge were regarded as cases and reason for readmission was ascertained. The two consecutive admissions after each readmission case were used as controls to identify features predictive of readmission. All were validated as CAP by inspection of radiographs and case records. Results 562 cases were identified. 93 were excluded. 96 (20%) of the remaining 469 died. 55 (12%) were readmitted. Eight of these were excluded and six case notes were lost leaving 41 cases who were compared with 72 controls who had not been readmitted. Of these 113, mean age was 61 (95% CIs 57–65), 59% were male, 85% had one or more comorbid disease, 83% were admitted from their own home, 54% were CURB65 0–1, 26% CURB65 2, 23% CURB65 3–5. Readmission was considered by the admitting physician to be CAP-related in only 16 (39%), but even in these CRP was raised at readmission in only 81%. Non-CAP reasons for readmission were varied and were distributed across at least 8 disease areas. Only 13 (32)% of all readmissions were considered to have been preventable at the first admission. Age (OR 0.995; 95%CI 0.959 to 1.033), presence of comorbid disease (2.045; 0.415 to 10.089), Charlson comorbidity index (1.082; 0.785 to 1.491), initial length of stay (1.009; 0.984 to 1.034), CURB65>0 (2.003; 0.551 to 7.282) and initial treatment with tazocin (2.502; 0.804 to 7.784) were significantly related to readmission, but CIs all included unity. Conclusion The low frequency, lack of relationship to CAP in the majority and lack of preventability at the index admission suggest that readmission within 30 days of discharge is not a valid outcome marker for CAP. Age and markers of biological unfitness predict readmission.

Purpose To assess the effectiveness of anti-tuberculous treatment in patients with chronic uveitis and either active systemic or latent tuberculosis (TB) in a non-endemic community. Methods Retrospective study of patients with chronic uveitis, non-ocular evidence of latent or active TB and no other identified cause of uveitis who underwent a 6-month course of standard anti-tuberculous chemotherapy. Response to treatment was assessed at 6 and 12 months after initiation of treatment. Results A total of 27 patients were included of whom 59% were female. In all, 19 were Asian, 4 Caucasian, and 4 Black. More than half of patients had a history of contact with another person treated for TB. Inflammation resolved after chemotherapy in 70.3% of patients, 18.5% had a change in the nature of their inflammation and 11.1% had no benefit. Conclusions There were no uveitis features characteristic of TB uveitis and a wide range of manifestations was seen ranging from non-granulomatous anterior uveitis to occlusive retinal vasculitis. TB is not endemic in the United Kingdom, therefore consideration of ethnicity, immigration, and history of TB contact remain important to direct investigations. In a patient with uveitis and latent TB, a full 6-month course of anti-tuberculous chemotherapy is recommended although it may not be curative of the uveitis.

Introduction TB incidence is rising in the UK, with drug resistance becoming increasingly problematic. Diagnosis with microbiological culture and confirmation of sensitivity is therefore vital. This study investigated how often we are not achieving microbiological diagnosis at our centre, what factors influence this and whether opportunities to obtain microbiological samples were missed. Methods A retrospective study of all 156 cases (adult and paediatric) diagnosed with TB at Central Manchester Teaching Hospitals in 2009 was carried out. Demographic details, site of disease, types of specimens and results of TB culture were recorded. Cases where there were no specimens or cultures were negative were analyzed in detail. Results Most disease was pulmonary (n=69). Other disease sites included lymph node (n=34), ocular (n=12) and pleura (n=10). 128 (82%) patients had samples sent for microbiology. 92 (59%) patients were culture positive and 36 (23%) were culture negative. 28 (18%) patients had no specimens sent for culture. Factors which were associated with whether samples were sent for culture included site of disease (p<0.0001), with ocular disease being the least likely to be sampled, and age of patients (p=0.002). 45% patients <17 years did not have samples sent compared with 12.5 % patients 17–64. Ethnicity did not influence the frequency of sampling. A negative culture result was related to the specimen type (p<0.0001) and patient9s age (p=0.019), with fewer paediatric samples positive. Site of disease or ethnicity did not affect culture results. In 25/28 cases with no microbiological specimens it was considered reasonable that specimens were not sent, as most of these were either ocular (n=12) or paediatric (n=9). In 3/28 (11%) samples could have been sent and all involved adult patients not born in the UK who had procedures whereby specimens were sent only for histology. 32/36 culture negative cases were considered to have been managed appropriately. 4/36 (11%) culture negative cases were potential missed opportunities for further sampling and were all due to patients with pleural TB not having pleural biopsies. Conclusion In our centre, despite a microbiology negative rate of 41%, reasonable opportunities to obtain a microbiological diagnosis are seldom missed.

Clinical practice should be directed by scientifi c evidence in this era of evidencebased medicine. It might then appear curious that paradoxes between practice and the evidence can still occur. Take the example of the use of antibiotics in exacerbations of chronic obstructive pulmonary disease (COPD). A recent systematic review of placebo-controlled antibiotic trials in

In addition to direct antibacterial actions, 14- and 15-member-ring macrolides have immune modulating effects that appear to be the reason for clinical benefit in diffuse panbronchiolitis. A literature search was conducted for studies of the clinical effectiveness of macrolides in other chronic lung conditions. A number of studies were identified that showed short-term beneficial outcomes or the potential for such outcomes in cystic fibrosis, bronchiectasis, chronic obstructive pulmonary disease, asthma and post-transplant obliterative bronchiolitis. The studies were limited by small patient numbers, different outcome measures and short-term follow-up, and were not designed to assess potentially harmful effects. Further large prospective and long-term studies are required in order to identify potential benefit and harm before these agents can be recommended routinely for these conditions.

CytopathologyVolume 21, Issue 4 p. 273-275 Diagnosis of alveolar rhabdomyosarcoma in effusion cytology: a diagnostic pitfall S. A. Thiryayi, S. A. Thiryayi Manchester Cytology CentreSearch for more papers by this authorD. N. Rana, D. N. Rana Manchester Cytology CentreSearch for more papers by this authorJ. Roulson, J. Roulson Department of HistopathologySearch for more papers by this authorP. Crosbie, P. Crosbie Department of Respiratory Medicine, Manchester Royal InfirmarySearch for more papers by this authorM. Woodhead, M. Woodhead Department of Respiratory Medicine, Manchester Royal InfirmarySearch for more papers by this authorB. P. Eyden, B. P. Eyden Department of Histopathology, Christie NHS Foundation Trust, Manchester, UKSearch for more papers by this authorP. S. Hasleton, P. S. Hasleton Department of HistopathologySearch for more papers by this author S. A. Thiryayi, S. A. Thiryayi Manchester Cytology CentreSearch for more papers by this authorD. N. Rana, D. N. Rana Manchester Cytology CentreSearch for more papers by this authorJ. Roulson, J. Roulson Department of HistopathologySearch for more papers by this authorP. Crosbie, P. Crosbie Department of Respiratory Medicine, Manchester Royal InfirmarySearch for more papers by this authorM. Woodhead, M. Woodhead Department of Respiratory Medicine, Manchester Royal InfirmarySearch for more papers by this authorB. P. Eyden, B. P. Eyden Department of Histopathology, Christie NHS Foundation Trust, Manchester, UKSearch for more papers by this authorP. S. Hasleton, P. S. Hasleton Department of HistopathologySearch for more papers by this author First published: 07 July 2010 https://doi.org/10.1111/j.1365-2303.2009.00700.xCitations: 11 Sakinah A. Thiryayi, Manchester Cytology Centre, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UKTel.: +44 161 276 5111; Fax: +44 161 276 5149;E-mail: sakinah.a.t@hotmail.co.uk Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume21, Issue4August 2010Pages 273-275 RelatedInformation