A narrative review of the definition of 'flare' in hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, inflammatory condition that can have periodic worsening or flares. Measurement of flare is important because it can inform treatment efficacy; however, it is unclear how HS flare should be defined.

OBJECTIVES

This study reviewed the literature for definitions of HS flare.

METHODS

The PubMed MEDLINE online database was searched on 10 January 2018 and the search was repeated on 8 December 2018 for new publications. Titles and abstracts were screened for inclusion. Subsequently, full articles were screened for inclusion. Papers were included if the publication was a systematic review, clinical trial, cohort study, case report or series, or cross-sectional study. Studies were excluded if they were journalistic reviews, did not discuss clinical findings of HS or did not use the words 'flare', 'exacerbation', 'relapse' or 'recurrence'.

RESULTS

Two hundred and seventy-four papers were identified and 154 fulfilled the study criteria. Of these, 27 (17.5%) included the term 'flare' and 16 (10.4%) included the term 'exacerbation'. Two of the 27 papers (7%) defined the term flare and both included patient report of changes in symptoms or signs. One of 16 papers (6%) defined exacerbation, which was taken as one new HS lesion. The terms 'recurrence' and 'relapse' were more apt to be defined: 13% (13 of 100) and 14% (six of 44), respectively.

CONCLUSIONS

The lack of a specific and measurable definition of HS flare is a barrier to assessment of this important outcome. Once a specific and measurable definition is established, validated and reliable measures of HS flare can be incorporated into future studies. What's already known about this topic? Hidradenitis suppurativa (HS) is a chronic, relapsing inflammatory skin condition. The ability to assess flares is important to people who have HS; however, it is unclear how this is defined. HS flare is one of the core outcomes in the core outcome set for HS clinical trials; however, it is unclear how this should be assessed. What does this study add? This literature review reveals the paucity of measurable definitions associated with the use of the term 'flare' in the HS literature. It also highlights the variation and lack of a validated and reliable measure of HS flare.

Food for thought. Malnutrition risk associated with increased risk of healthcare-associated infection

BACKGROUND

Infection and malnutrition are interconnected. UK and Irish guidelines recommend the Malnutrition Universal Screening Tool (MUST) for nutritional risk screening. Patients with a MUST score of ≥2 are considered at high risk of malnutrition and referral for nutritional assessment is recommended.

AIM

To explore the association between healthcare-associated infection (HCAI) and the MUST score categories of patients.

METHODS

This was a cross-sectional study in May 2017 on ten representative wards in our institution. Patient demographics, MUST score, presence of medical devices, HCAI and antimicrobial use were collected.

FINDINGS

Of 240 patients, the HCAI prevalence was 10.4% (N = 25) and 26% (N = 63) were at high risk of malnutrition (MUST score ≥2). Patients with HCAI were more likely to have had surgery (odds ratio (OR): 5.5; confidence interval (CI): 2.1-14.3; P < 0.001), a central vascular catheter (OR: 10.0; CI: 3.6-27.2; P < 0.001), or a urinary catheter in situ (OR: 7.5; CI: 2.8-20.0; P < 0.001), and to have a high risk of malnutrition (OR: 4.3; CI: 1.7-11.2; P < 0.001). A higher MUST score remained a significant predictor of a patient having HCAI on multivariate regression analysis (CI: 0.2-0.6; P < 0.001).

CONCLUSION

Patients at risk of malnutrition when assessed with the MUST were more likely to have HCAI. However, prospective studies are required to investigate the temporal association between MUST and HCAI and which interventions best address malnutrition risk and HCAI reduction in different settings.

Resistance of corals and coralline algae to ocean acidification: physiological control of calcification under natural pH variability

Ocean acidification is a threat to the continued accretion of coral reefs, though some undergo daily fluctuations in pH exceeding declines predicted by 2100. We test whether exposure to greater pH variability enhances resistance to ocean acidification for the coral Goniopora sp. and coralline alga Hydrolithon reinboldii from two sites: one with low pH variability (less than 0.15 units daily; Shell Island) and a site with high pH variability (up to 1.4 pH units daily; Tallon Island). We grew populations of both species for more than 100 days under a combination of differing pH variability (high/low) and means (ambient pH 8.05/ocean acidification pH 7.65). Calcification rates of Goniopora sp. were unaffected by the examined variables. Calcification rates of H. reinboldii were significantly faster in Tallon than in Shell Island individuals, and Tallon Island individuals calcified faster in the high variability pH 8.05 treatment compared with all others. Geochemical proxies for carbonate chemistry within the calcifying fluid (cf) of both species indicated that only mean seawater pH influenced pH_cf pH treatments had no effect on proxies for Ω_cf These limited responses to extreme pH treatments demonstrate that some calcifying taxa may be capable of maintaining constant rates of calcification under ocean acidification by actively modifying Ω_cf.

Cost Analysis of Tuberculosis Diagnosis in Cambodia with and without Xpert® MTB/RIF for People Living with HIV/AIDS and People with Presumptive Multidrug-resistant Tuberculosis

BACKGROUND

The Xpert^® MTB/RIF (Xpert) test has been shown to be effective and cost-effective for diagnosing tuberculosis (TB) under conditions with high HIV prevalence and HIV-TB co-infection but less is known about Xpert's cost in low HIV prevalence settings. Cambodia, a country with low HIV prevalence (0.7%), high TB burden, and low multidrug-resistant (MDR) TB burden (1.4% of new TB cases, 11% of retreatment cases) introduced Xpert into its TB diagnostic algorithms for people living with HIV (PLHIV) and people with presumptive MDR TB in 2012. The study objective was to estimate these algorithms' costs pre- and post-Xpert introduction in four provinces of Cambodia.

METHODS

Using a retrospective, ingredients-based microcosting approach, primary cost data on personnel, equipment, maintenance, supplies, and specimen transport were collected at four sites through observation, records review, and key informant consultations.

RESULTS

Across the sample facilities, the cost per Xpert test was US$33.88-US$37.11, clinical exam cost US$1.22-US$1.84, chest X-ray cost US$2.02-US$2.14, fluorescent microscopy (FM) smear cost US$1.56-US$1.93, Ziehl-Neelsen (ZN) smear cost US$1.26, liquid culture test cost US$11.63-US$22.83, follow-on work-up for positive culture results and Mycobacterium tuberculosis complex (MTB) identification cost US$11.50-US$14.72, and drug susceptibility testing (DST) cost US$44.26. Specimen transport added US$1.39-US$5.21 per sample. Assuming clinician adherence to the algorithms and perfect test accuracy, the normative cost per patient correctly diagnosed under the post-Xpert algorithms would be US$25-US$29 more per PLHIV and US$34-US$37 more per person with presumptive MDR TB (US$41 more per PLHIV when accounting for variable test sensitivity and specificity).

CONCLUSIONS

Xpert test unit costs could be reduced through lower cartridge prices, longer usable life of GeneXpert^® (Cepheid, USA) instruments, and increased test volumes; however, epidemiological and test eligibility conditions in Cambodia limit the number of specimens received at laboratories, leading to sub-optimal utilization of current instruments. Improvements to patient referral and specimen transport could increase test volumes and reduce Xpert test unit costs in this setting.

Mentoring for newly appointed consultant psychiatrists

The south-west Mentoring Scheme has developed in the context of a general and increasing concern for the health and morale of senior doctors (British Medical Association (BMA), 2000). Their problems are now well described (Allen, 1999; Ghodseet al, 2000), but there is little evidence of effective intervention. The aspirations of the National Service Framework and the NHS Plan will come to nothing if there are not sufficient trained and experienced staff to implement them, and senior staff are increasingly looking forward to early retirement rather than the continued satisfactions of working within the NHS. Recruitment and retention of consultant psychiatrists is the most problematic of all medical specialities, with 14% of posts empty or occupied by locums (Sainsbury Centre for Mental Health, 2000). There is a clear need to find ways of preventing work-related ill health, stress and burn-out among practitioners (Roberts, 1997; Department of Health, 1999: p 115), and to sustain their creative and productive engagement in health care. A demotivated profession cannot be expected to deliver an effective service (McBride & Metcalf, 1995; Appletonet al, 1998) and policy is not a substitute for personnel.

Development and evaluation of an online educational resource about cancer survivorship for cancer nurses: a mixed-methods sequential study

Cancer survivorship is recognised globally as a key issue. In spite of the key role played by nurses in survivorship care, there is an identified gap in nurse's knowledge in this area. This study reports on the development and evaluation of an educational resource for nurses working with people affected by cancer. The resource was designed using adult learning principles and includes a variety of learning materials and point of care resources. A mixed-methods sequential exploratory design was used to undertake an evaluation of the programme. This included the use of online surveys and semi-structured interviews with pilot participants. A total of 21 participants completed an online survey and 11 participants completed a telephone interview. Overall, the participants found the Cancer Survivorship resource to be engaging, practical and intuitive. A major theme emerging from the survey and interview data was that the resource was applicable to practice and useful in developing survivorship care plans. Respondents requested additional information be included on the role of various health professionals working in survivorship as well as guidelines on when to make referrals. This study provides evidence that the Cancer Survivorship tool may be a promising vehicle for delivering evidence-based education on survivorship care.

The eye of the Barbary sheep or aoudad (Ammotragus lervia): reference values for selected ophthalmic diagnostic tests, morphologic and biometric observations

The purpose of this study was to describe the normal ocular anatomy and establish reference values for ophthalmic tests in the Barbary sheep or aoudad (Ammotragus lervia). Aoudad eyes are large and laterally positioned in the head with several specialized anatomic features attributed to evolutionary adaptations for grazing. Normal values for commonly used ophthalmic tests were established, Schirmer tear test (STT) - 27.22 ± 3.6 mm/min; Predominant ocular surface bacterial microbiota - Staphylococcus sp.; Corneal esthesiometry- 1.3 ± 0.4 cm; Intraocular pressure by rebound tonometry- 19.47 ± 3.9 mmHg; Corneal thickness- 630.07 ± 20.67 µm, B-mode ultrasonography of the globe-axial eye globe length 29.94 ± 0.96 mm, anterior chamber depth 5.03 ± 0.17 mm, lens thickness 9.4 ± 0.33 mm, vitreous chamber depth 14.1 ± 0.53 mm; Corneal diameter-horizontal corneal diameter 25.05 ± 2.18 mm, vertical corneal diameter 17.95 ± 1.68 mm; Horizontal palpebral fissure length- 34.8 ± 3.12 mm. Knowledge of these normal anatomic variations, biometric findings and normal parameters for ocular diagnostic tests may assist veterinary ophthalmologists in the diagnosis of ocular diseases in this and other similar species.

Investigating a Novel Measure of Brain Networking Following Sports Concussion

Clinicians managing sports-related concussions are left to their clinical judgment in making diagnoses and return-to-play decisions. This study was designed to evaluate the utility of a novel measure of functional brain networking for concussion management. 24 athletes with acutely diagnosed concussion and 21 control participants were evaluated in a research laboratory. At each of the 4 post-injury time points, participants completed the Axon assessment of neurocognitive function, a self-report symptom inventory, and the auditory oddball and go/no-go tasks while electroencephalogram (EEG) readings were recorded. Brain Network Activation (BNA) scores were calculated from EEG data related to the auditory oddball and go/no-go tasks. BNA scores were unable to differentiate between the concussed and control groups or by self-report symptom severity. These findings conflict with previous work implementing electrophysiological assessments in concussed athletes, suggesting that BNA requires additional investigation and refinement before clinical implementation.

Northward expansion of paddy rice in northeastern Asia during 2000-2014

Paddy rice in monsoon Asia plays an important role in global food security and climate change. Here we documented annual dynamics of paddy rice areas in the northern frontier of Asia, including Northeastern (NE) China, North Korea, South Korea, and Japan, from 2000-2014 through analysis of satellite images. The paddy rice area has increased by 120% (2.5 to 5.5 million ha) in NE China, in comparison to a decrease in South Korea and Japan, and the paddy rice centroid shifted northward from 41.16 °N to 43.70 °N (~310 km) in this period. Market, technology, policy, and climate together drove the rice expansion in NE China. The increased use of greenhouse nurseries, improved rice cultivars, agricultural subsidy policy, and a rising rice price generally promoted northward paddy rice expansion. The potential effects of large rice expansion on climate change and ecological services should be paid more attention in the future.

Association between marijuana use and adverse obstetrical and neonatal outcomes

OBJECTIVE

To evaluate associations between marijuana exposure and adverse outcomes excluding women with polysubstance abuse and stratifying for concurrent maternal tobacco use.

STUDY DESIGN

We performed a retrospective cohort study evaluating various obstetrical and neonatal outcomes including: preterm delivery, pre-eclampsia, gestational diabetes, cesarean delivery, fetal growth restriction, a composite which included stillbirth or neonatal intensive care unit admission, and perinatal mortality. We stratified study groups according to the maternal tobacco use and performed a logistic regression analysis.

RESULTS

We included 6468 women, 6107 nonusers and 361 marijuana users. After adjustment for maternal age, race, parity, body mass index and no prenatal care, we found higher rates of small for gestational age (aOR 1.30 (95% CI 1.03 to 1.62)) and neonatal intensive care unit admission (aOR 1.54 (1.14 to 2.07)) in women who were not tobacco users. Other obstetrical outcomes including preterm delivery and fetal anomalies were not increased with maternal marijuana use.

CONCLUSION

Maternal marijuana use does not increase the risk of adverse obstetrical outcomes or fetal anomalies, but does increase the risk for small for gestational age and neonatal intensive care unit admission.