National benchmarking as a support system for clinical governance.

Audit of the management of acute asthma in hospital has developed in tandem with guidelines produced and updated by the British Thoracic Society (BTS), on the principle that agreed guidelines combined with systematic review of practice by periodic audit are more likely to result in improvements in practice than guidelines alone. A short audit data set was distilled from previous experience with more elaborate tools and made available nationally to audit departments and through letters to consultant members of the BTS. Hospitals have been able to contribute since 1990. The data set reflects key items of the process of care: peak flow measured on admission and twice daily during the hospital stay; blood gases on admission; systemic corticosteroids as an inpatient; discharged with inhaled and oral corticosteroids; written self-management plans; follow-up arrangements. Data from 4,741 admissions over a seven year period are presented. The proportion of patients nationally receiving these items of asthma care is given. The median values for hospital performance improved significantly over the seven years, although there is potential for further improvement. If these data represent the national picture, they could form the basis upon which to set national standards for the care of patients with acute asthma in hospital. A further result of the developing audit has been the recognition of the value of external benchmarking in providing a context for the interpretation of local audit results. This audit system provides hospitals with a quick and easy method of obtaining an overview of local performance, with comparative national data for the same year. This has potential as a tool for clinical governance with much wider applicability, providing the data are handled carefully, particularly as the variability between hospitals diminishes over time.

A prospective study of asthma during pregnancy and the puerperium.

Thirty-one asthmatic women recruited in an ante-natal clinic were followed during pregnancy and for six weeks of the puerperium. Subjectively 22 (69%) women considered their asthma to have improved, two were worse and in seven (22%) there was no change. Analysis of peak flow rate, symptoms score and bronchodilator use showed that in ten pregnancies there was improvement in the third trimester and that in 11 there was deterioration in the puerperium. The results suggest that in patients with mild or moderate asthma an improvement is likely to occur during pregnancy, particularly in the last trimester, but that in over one-third there may be a post-natal deterioration. Review of the literature suggests that severe asthmatics are at greater risk of deterioration, particularly late in pregnancy.

Mortality in cases of asbestosis diagnosed by a pneumoconiosis medical panel.

One hundred and fifty five male cases of asbestosis certified by the London Pneumoconiosis Medical Panel during 1968-74 were followed up during 1978-9, 4-11 (mean 7.5) years after certification. Fifty nine patients had died, 23 (39%) from lung cancer, 6 (10%) from mesothelioma, and 11 (19%) from other respiratory causes. The number of observed deaths was 2.25 times greater than expected and 7.4 times greater than expected for lung cancer. Adenocarcinoma was the commonest histological type but other cell types were also increased. Finger clubbing (p less than 0.01) and percentage of predicted FEV1 (p less than 0.01) were of value in predicting death, but increasing profusion of small opacities greater than 1/0 (ILO/U-C international classification of radiographs of pneumoconiosis, 1971), duration of exposure to asbestos, time from first exposure to asbestos, and percentage of predicted vital capacity and transfer factor did not predict death.

Significance of finger clubbing in asbestosis.

The prognostic significance of finger clubbing in asbestosis has been assessed in 167 cases certified by the London Pneumoconiosis Medical Panel from 1968 to 1974. Finger clubbing developed early in the clinical course of the disease and was associated with a lower gas transfer, a higher mortality and a greater likelihood of progression in intrapulmonary fibrosis than was found among cases without finger clubbing. Finger clubbing was not associated with heavier asbestos exposure. Its presence appears to be associated with a more severe form of disease.

Clinical and radiographic features of psittacosis infection.

Forty three cases of psittacosis infection were identified retrospectively over a five year period. The commonest clinical presentation was of a bronchitic illness with a productive cough and features of systemic upset. In 12 (28%) cases no radiographic abnormality was detected on the chest film. Segmental shadowing was the commonest abnormality but lobar and more extensive consolidation occurred. There were no radiographic features that allowed confident differentiation from other causes of pneumonia. The total and differential white cell counts were usually normal and this feature may help to differentiate psittacosis from bacterial pneumonia.

Premenstrual exacerbation of asthma.

Questionnaires and twice daily peak expiratory flow measurements were used to evaluate the effects of the menstrual cycle in asthmatic women. Forty per cent of women reported premenstrual deterioration in their symptoms and this was confirmed by peak flow recordings. No correlations were found between premenstrual exacerbation of asthma and symptoms of premenstrual tension, consumption of aspirin, use of the contraceptive pill, cycle length, or behaviour of asthma during pregnancy.

Interstitial lung disease and asthma in hard-metal workers: bronchoalveolar lavage, ultrastructural, and analytical findings and results of bronchial provocation tests.

Five patients with respiratory disorders associated with hard metal exposure are described. In four patients electron microprobe analysis of bronchoalveolar lavage cells or lung tissue was used to show tungsten and other hard-metal components. Three patients had interstitial pneumonia and fibrosis with unusual multinucleate giant cells. Electron microscopy showed that the giant cells comprised both type II alveolar epithelial cells and alveolar macrophages. The multinucleate macrophages formed a distinctive feature of the bronchoalveolar lavage material but the multinucleate alveolar epithelial lining cells were evident only in lung tissue. The other two patients both suffered from work-related asthma, one of whom also had pulmonary opacities. Bronchial provocation tests in these patients supported the diagnosis of hard-metal-induced asthma and implicated cobalt as the agent responsible.

Tuberculosis in renal transplant recipients.

Of more than 400 patients who received renal transplants in Cambridge, five subsequently developed tuberculosis. All had pulmonary involvement. Radiological abnormalities included miliary opacities, bilateral lower zone shadowing or typical upper zone shadowing with cavitation. Lung biopsy was required for diagnosis in two cases. Three patients recovered after treatment with antituberculosis drugs and none has relapsed. One died during chemotherapy despite drug-susceptible organisms. The problems encountered during chemotherapy are discussed.