IntroductionThe aetiology of acute exacerbations of chronic obstructive pulmonary disease (COPD) remains incompletely understood and strategies for treatment and prevention have not altered significantly for many years. Improved understanding of the role of respiratory pathogens in acute exacerbations of COPD (AECOPD) is required and the use of molecular microbiological techniques may lead to insights into host–pathogen interactions and the development of more targeted therapeutic approaches.Methods and analysesAcute Exacerbation and Respiratory InfectionS in COPD (AERIS) is a longitudinal epidemiological study to assess how changes in the COPD airway microbiome contribute to the incidence and severity of AECOPD. Patients with COPD aged 40–85 are followed monthly for 2 years, and reviewed within 72 h of onset of symptoms of AECOPD. Exacerbations are detected using daily electronic diary cards. Blood, sputum, nasopharyngeal and urine samples are collected at prespecified timepoints. Molecular diagnostic and typing techniques are used to describe the dynamics of airway infection during AECOPD and stable disease, and associations with clinical outcome. This study aims to refine the case definition of AECOPD to reflect the possible microbiological aetiology. AERIS will assess the impact of AECOPD on health-related quality of life and healthcare resource utilisation, and the possible interactions between nutritional status, infection and immune responses.Ethics and disseminationAERIS is conducted in accordance with the Declaration of Helsinki and Good Clinical Practice, and has been approved by the institutional ethics and review board. All participants must provide written informed consent. The results obtained will be disseminated at international medical conferences and in peer-reviewed publications.DiscussionFew other studies have addressed the complexity of the microbiological and systemic components of COPD or employed real-time electronic tracking of symptoms to identify AECOPD and potential aetiological triggers.ResultsResults of AERIS will increase our understanding of the contribution of pathogens to AECOPD, potentially leading to new targeted therapeutic and preventative interventions.Trial registration numberClinicalTrials.gov NCT01360398.

Background/Aims: Publications on acute kidney injury (AKI) have concentrated on the inpatient population. We wanted to determine the extent of AKI in the community, its follow-up and patient impact. Method: Primary Care creatinine results for May 2012-April 2013 from Cornwall, United Kingdom, were screened for AKI. Results: Over 12 months, 991 AKI episodes were identified (0.4% of all Primary Care creatinine requests); 51% were AKI1, 29% AKI2 and 10% AKI3. Of these, 51% AKI1s, 72% AKI2s and 77% AKI3s had a repeat creatinine requested within 14 days as per National Institute for Health and Care Excellence (NICE) guidelines. Admissions (May 2012-July 2013) were identified on 46% AKI1s, 58% AKI2s and 65% AKI3s (p < 0.05). The median time from AKI identification to hospital admission was 33 days for AKI1, 12 days for AKI2 and 1 day for AKI3 (p < 0.05); with a median length of stay of 2, 4 and 7 days, respectively (p < 0.05). The 90-day mortality from AKI identification for the admitted patients was 12% AKI1s, 20% AKI2s and 27% AKI3s (p < 0.05) vs. 11, 21 and 65% (p < 0.05) for those that were not admitted. There was no significant difference in mortality for admitted patients vs. non-admitted patients, except for the AKI3s. Conclusion: AKI is associated with increased admission and mortality rates; although a large proportion of patients had repeat creatinine testing within 14 days, there was still a significant number with delayed follow-up. Education within Primary Care is required on how to prevent, identify, follow-up and manage AKI.

Thirty patients were examined to test the hypothesis that a depletion of iron levels is associated with symptoms of akathisia. Fifteen akathisic patients were pair-matched with 15 non-akathisic patients. Plasma ferritin levels were significantly decreased in the akathisic patients, and there was a significant inverse correlation between plasma iron levels and akathisia rating. In addition, akathisia ratings were found to be correlated with a scale measuring symptoms of tardive dyskinesia. They were pair-matched with 15 patients by age, sex, length of illness, length of recent inpatient stay, and dose of neuroleptic medication. Patients on iron supplements, on nonsteroid anti-inflammatory drugs, on antacids, and cimetidine were excluded. Since the hypothesis was based on a presumptive interactive effect of neuroleptic medication and iron at the receptor level, patients receiving

Guidelines on making do not resuscitate (DNR) decisions have changed in recent years in keeping with changing attitudes and legislation. Decisions should now be discussed with all competent patients, and nursing staff should be involved in the process. The views of nursing staff in 1989 and 2003 were compared, focusing on what factors they thought were important in coming to a DNR decision and any implications it had for other treatment. A patient's wishes, their previous quality of life and the chances of successful resuscitation were rated highly in both studies. Advanced age was rated as important less often in 2003 but was still thought to be an important factor by 61% respondents. In 2003 nurses were significantly more likely to state that active treatment, such as admission to an intensive care unit or surgical intervention, could be appropriate for patients with DNR orders. However, the number of respondents who considered intravenous fluids (18%) or antibiotics (26%) inappropriate for patients not for resuscitation was concerning.

Background/Aims: In February 2017, our laboratory implemented an electronic AKI flagging system for primary care using the NHS England AKI detection algorithm. Our study investigated the impact on patient follow-up, hospital admission, length of stay, and mortality. Methods: Primary care results March 2017-February 2018 with an AKI test code were downloaded from the pathology computer. Results: Over 12 months, 1,784 AKI episodes were identified; 81.3% AKI1, 11.3%, AKI2, and 7.5% AKI3. A repeat creatinine was requested within 14 days on 55% AKI1s, 84% AKI2s, and 86% AKI3s. Primary care took the repeat sample in 73.2% AKI1s and 56.7% AKI2s and acute hospital locations for 47.4% AKI3s. Median time to hospital admission was 34 days for AKI1, 6 for AKI2, and 1 for AKI3 (p < 0.05). Length of stay was found to be 1, 2, and 4 days for AKI 1/2/3, respectively (p < 0.05). The 90-day mortality for admitted patients was 15, 18, and 21% for AKI 1/2/3, respectively (p = 0.180). The 90-day mortality for the non-admitted patients was 4, 9, and 50% for AKI 1/2/3, respectively (p < 0.05). AKI patient outcome data pre versus post the start of the AKI flag system were compared. A statistically significant reduction was found in the median length of stay for AKI1 and AKI3 and in mortality for AKI1 and AKI3 patients and for all AKIs as a whole. A further analysis was performed to take into account the difference in pre-and post-alert populations. Mortality overall was significantly improved (p < 0.001), and length of stay was reduced in AKI3 patients (p = 0.048). Discussion/Conclusion: Our study demonstrates that an electronic AKI warning alert system for primary care appears to be associated with a beneficial impact on patient management and outcome.