Scalded Skin Syndrome Caused by a Methicillin Sensitive Staphylococcus aureus of a type not commonly associated with exfoliative toxins in Scotland

A three-year-old boy was admitted to the hospital with a three-day history of chickenpox and a one-day history of fever and enlarging skin lesions on his chest, trunk, and around his neck. The lesions were enlarged and skin peeling over the chest wall was noted. Despite starting him on Flucloxacillin/Aciclovir, new lesions were noted with blisters over chest, legs, arms and buttocks. A clinical diagnosis of Staphylococcal Scalded Skin Syndrome (SSSS) was made and laboratory results confirmed Methicillin sensitive Staphylococcus aureus (MRSA) isolation. The isolates were sent to Scottish MRSA reference lab (SMRSARL) for typing and toxin detection. The isolate from this child was positive for the exfoliative toxin A (eta) gene and negative for exfoliative toxin B, toxic shock syndrome toxin, panton-valentine leukocidin and entertoxins A, B, C, D, E. By Pulse Field Gel Electrophoresis (PFGE) this isolate was identified as MLST Type 88 clone which has been associated with skin lesions in other countries.

Associated systemic and ocular disorders in patients with congenital unilateral cataracts: the Infant Aphakia Treatment Study experience

PurposeFive-year prospective data on children enrolled in the Infant Aphakia Treatment Study (IATS) provided an opportunity to explore ocular and systemic associations in patients with a unilateral congenital cataract.MethodsInfants <7 months of age with a unilateral cataract were eligible for IATS screening. We reviewed data pertaining to the exclusion of patients as well as data collected on standardized study forms used at any time for documentation of ocular or systemic disorders.ResultsOverall, 227 infants were referred for possible enrollment. Of these, 10 had insignificant cataracts and 32 refused to participate. Of those excluded, 3 were premature, 27 had significant ocular disease (usually persistent fetal vasculature (PFV) or corneal diameter <9 mm), and 4 had systemic disorders. An additional 26 were excluded at the time of the first EUA, most often because of PFV or variants thereof. On follow-up, in the 114 enrolled patients, the following disorders were diagnosed: Stickler syndrome (1), mitochondrial disease (1), autism (1), and presumed congenital rubella syndrome (1). No patient developed a cataract in the fellow eye.DiscussionSome conditions that can feature unilateral cataracts are diagnosed at birth or very early in life, but others may be diagnosed at varying periods thereafter. PFV and its variants are the most common associated ocular findings in about a quarter of cases of unilateral congenital cataracts.ConclusionAlthough patients with a unilateral cataract may have significant associated abnormalities in the affected eye, most commonly PFV and its variants, the prevalence of associated significant systemic disease is quite low.

Findings from a pilot Randomised trial of an Asthma Internet Self-management Intervention (RAISIN)

OBJECTIVE

To evaluate the feasibility of a phase 3 randomised controlled trial (RCT) of a website (Living Well with Asthma) to support self-management.

DESIGN AND SETTING

Phase 2, parallel group, RCT, participants recruited from 20 general practices across Glasgow, UK. Randomisation through automated voice response, after baseline data collection, to website access for minimum 12 weeks or usual care.

PARTICIPANTS

Adults (age≥16 years) with physician diagnosed, symptomatic asthma (Asthma Control Questionnaire (ACQ) score ≥1). People with unstable asthma or other lung disease were excluded.

INTERVENTION

'Living Well with Asthma' is a desktop/laptop compatible interactive website designed with input from asthma/ behaviour change specialists, and adults with asthma. It aims to support optimal medication management, promote use of action plans, encourage attendance at asthma reviews and increase physical activity.

OUTCOME MEASURES

Primary outcomes were recruitment/retention, website use, ACQ and mini-Asthma Quality of Life Questionnaire (AQLQ). Secondary outcomes included patient activation, prescribing, adherence, spirometry, lung inflammation and health service contacts after 12 weeks. Blinding postrandomisation was not possible.

RESULTS

Recruitment target met. 51 participants randomised (25 intervention group). Age range 16-78 years; 75% female; 28% from most deprived quintile. 45/51 (88%; 20 intervention group) followed up. 19 (76% of the intervention group) used the website, for a mean of 18 min (range 0-49). 17 went beyond the 2 'core' modules. Median number of logins was 1 (IQR 1-2, range 0-7). No significant difference in the prespecified primary efficacy measures of ACQ scores (-0.36; 95% CI -0.96 to 0.23; p=0.225), and mini-AQLQ scores (0.38; -0.13 to 0.89; p=0.136). No adverse events.

CONCLUSIONS

Recruitment and retention confirmed feasibility; trends to improved outcomes suggest use of Living Well with Asthma may improve self-management in adults with asthma and merits further development followed by investigation in a phase 3 trial.

TRIAL REGISTRATION NUMBER

ISRCTN78556552; Results.

Details of development of the resource for adults with asthma in the RAISIN (randomized trial of an asthma internet self-management intervention) study

Background

Around 300 million people worldwide have asthma and prevalence is increasing. Self-management can be effective in improving a range of outcomes and is cost effective, but is underutilised as a treatment strategy. Supporting optimum self-management using digital technology shows promise, but how best to do this is not clear. We aimed to develop an evidence based, theory informed, online resource to support self-management in adults with asthma, called ‘Living well with Asthma’, as part of the RAISIN (Randomized Trial of an Asthma Internet Self-Management Intervention) study.

Methods

We developed Living well with Asthma in two phases.

Phase 1: A low fidelity prototype (paper-based) version of the website was developed iteratively through input from a multidisciplinary expert panel, empirical evidence from the literature, and potential end users via focus groups (adults with asthma and practice nurses). Implementation and behaviour change theories informed this process.

Phase 2: The paper-based designs were converted to a website through an iterative user centred process. Adults with asthma (n = 10) took part in think aloud studies, discussing the paper based version, then the web-based version. Participants considered contents, layout, and navigation. Development was agile using feedback from the think aloud sessions immediately to inform design and subsequent think aloud sessions. Think aloud transcripts were also thematically analysed, further informing resource development.

Results

The website asked users to aim to be symptom free. Key behaviours targeted to achieve this include: optimising medication use (including inhaler technique); attending primary care asthma reviews; using asthma action plans; increasing physical activity levels; and stopping smoking. The website had 11 sections, plus email reminders, which promoted these behaviours. Feedback on the contents of the resource was mainly positive with most changes focussing on clarification of language, order of pages and usability issues mainly relating to navigation difficulties.

Conclusions

Our multifaceted approach to online intervention development underpinned by theory, using evidence from the literature, co-designed with end users and a multidisciplinary panel has resulted in a resource which end users find relevant to their needs and easy to use. Living well with Asthma is undergoing evaluation within a randomized controlled trial.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-015-0177-z) contains supplementary material, which is available to authorized users.

1000 Port-A-Cath ® placements by subclavian vein approach: single surgeon experience

INTRODUCTION

Totally implantable venous access ports are widely used for the administration of chemotherapy in patients with cancer. Although there are several approaches to implantation, here we describe Port-A-Cath(®) (PAC) placement by percutaneous puncture of the subclavian vein with ultrasonographic guidance.

PATIENTS AND METHODS

Data on our vascular access service were collected prospectively from June 2004. This service included port-a-caths and Hickman lines. Once 1000 consecutive port-a-caths(®) had been reached the study was closed and data analysed for the port-a-caths(®) alone. The left subclavian vein was the preferred site for venous access, with the right subclavian and jugular veins being the alternative choices if the initial approach failed. Patients were followed up in the short-term, and all the procedures were carried out by a single surgeon at each one of two institutions.

RESULTS

Venous access by PAC was established in 100 % of the 1,000 cases. Of the 952 patients where the left subclavian vein was chosen for the first attempt of puncture, the success rate of PAC placement was 95 % (n = 904). Pneumothorax occurred in 12 patients (1.2 %), and a wound haematoma occurred in 4 (0.4 %) out of the total 1,000 patients. No infections were recorded during the immediate post-operative period but only in the long-term post-operative use with 8 patients requiring removal of the PAC due to infection following administration of chemotherapy.

CONCLUSION

This is a very large series of PAC placement with an ultrasound-guided approach for left subclavian vein and X-ray confirmation, performed by a single surgeon, demonstrating both the safety and effectiveness of the procedure.

A Randomized trial of an Asthma Internet Self-management Intervention (RAISIN): study protocol for a randomized controlled trial

Background

The financial costs associated with asthma care continue to increase while care remains suboptimal. Promoting optimal self-management, including the use of asthma action plans, along with regular health professional review has been shown to be an effective strategy and is recommended in asthma guidelines internationally. Despite evidence of benefit, guided self-management remains underused, however the potential for online resources to promote self-management behaviors is gaining increasing recognition. The aim of this paper is to describe the protocol for a pilot evaluation of a website ‘Living well with asthma’ which has been developed with the aim of promoting self-management behaviors shown to improve outcomes.

Methods/Design

The study is a parallel randomized controlled trial, where adults with asthma are randomly assigned to either access to the website for 12 weeks, or usual asthma care for 12 weeks (followed by access to the website if desired). Individuals are included if they are over 16-years-old, have a diagnosis of asthma with an Asthma Control Questionnaire (ACQ) score of greater than, or equal to 1, and have access to the internet. Primary outcomes for this evaluation include recruitment and retention rates, changes at 12 weeks from baseline for both ACQ and Asthma Quality of Life Questionnaire (AQLQ) scores, and quantitative data describing website usage (number of times logged on, length of time logged on, number of times individual pages looked at, and for how long). Secondary outcomes include clinical outcomes (medication use, health services use, lung function) and patient reported outcomes (including adherence, patient activation measures, and health status).

Discussion

Piloting of complex interventions is considered best practice and will maximise the potential of any future large-scale randomized controlled trial to successfully recruit and be able to report on necessary outcomes. Here we will provide results across a range of outcomes which will provide estimates of efficacy to inform the design of a future full-scale randomized controlled trial of the ‘Living well with asthma’ website.

Trial registration

This trial is registered with Current Controlled Trials ISRCTN78556552 on 18/06/13.

Digital asthma self-management interventions: a systematic review

BACKGROUND

Many people with asthma tolerate symptoms and lifestyle limitations unnecessarily by not utilizing proven therapies. Better support for self-management is known to improve asthma control, and increasingly the Internet and other digital media are being used to deliver that support.

OBJECTIVE

Our goal was to summarize current knowledge, evidenced through existing systematic reviews, of the effectiveness and implementation of digital self-management support for adults and children with asthma and to examine what features help or hinder the use of these programs.

METHODS

A comprehensive search strategy combined 3 facets of search terms: (1) online technology, (2) asthma, and (3) self-management/behavior change/patient experience. We undertook searches of 14 databases, and reference and citation searching. We included qualitative and quantitative systematic reviews about online or computerized interventions facilitating self-management. Title, abstract, full paper screening, and quality appraisal were performed by two researchers independently. Data extraction was undertaken using standardized forms.

RESULTS

A total of 3810 unique papers were identified. Twenty-nine systematic reviews met inclusion criteria: the majority were from the United States (n=12), the rest from United Kingdom (n=6), Canada (n=3), Portugal (n=2), and Australia, France, Spain, Norway, Taiwan, and Greece (1 each). Only 10 systematic reviews fulfilled pre-determined quality standards, describing 19 clinical trials. Interventions were heterogeneous: duration of interventions ranging from single use, to 24-hour access for 12 months, and incorporating varying degrees of health professional involvement. Dropout rates ranged from 5-23%. Four RCTs were aimed at adults (overall range 3-65 years). Participants were inadequately described: socioeconomic status 0/19, ethnicity 6/19, and gender 15/19. No qualitative systematic reviews were included. Meta-analysis was not attempted due to heterogeneity and inadequate information provision within reviews. There was no evidence of harm from digital interventions. All RCTs that examined knowledge (n=2) and activity limitation (n=2) showed improvement in the intervention group. Digital interventions improved markers of self care (5/6), quality of life (4/7), and medication use (2/3). Effects on symptoms (6/12) and school absences (2/4) were equivocal, with no evidence of overall benefits on lung function (2/6), or health service use (2/15). No specific data on economic analyses were provided. Intervention descriptions were generally brief making it impossible to identify which specific "ingredients" of interventions contribute most to improving outcomes.

CONCLUSIONS

Digital self-management interventions show promise, with evidence of beneficial effects on some outcomes. There is no evidence about utility in those over 65 years and no information about socioeconomic status of participants, making understanding the "reach" of such interventions difficult. Digital interventions are poorly described within reviews, with insufficient information about barriers and facilitators to their uptake and utilization. To address these gaps, a detailed quantitative systematic review of digital asthma interventions and an examination of the primary qualitative literature are warranted, as well as greater emphasis on economic analysis within trials.

Mental health in female veterinarians: effects of working hours and having children

BACKGROUND

Personal, interpersonal and organisational factors have been suggested as possible causes of stress, anxiety and depression for veterinarians. We used established psychological scales to measure (1) levels of distress and work-related stress (anxiety and depression) and (2) the demographic and work characteristics of female veterinarians in relation to anxiety, depression and mental health.

METHODS

A national cross-sectional survey of a cohort population was conducted and self-administered questionnaires were received from 1017 female veterinarians who completed the mental health section of the survey. Using linear and logistic regression analyses, we examined demographic and work-related factors associated with overall stress measured by the General Health Questionnaire scale and the Affective Well-Being scale (Anxiety-Contentment Axis and Depression-Enthusiasm Axis).

RESULTS

More than one-third (37%) of the sample was suffering 'minor psychological distress', suggesting the stressful nature of veterinary practice. Women with two or more children had less anxiety and depression compared with those who had never been pregnant or were childless. Longer working hours were associated with increased anxiety and depression in female veterinarians overall and in stratified samples of women with and without children.

CONCLUSION

Among the work characteristics of veterinary practice, long working hours may have a direct effect on a veterinarian's health in terms of anxiety, depression and mental health. The finding also indicates that women with two or more children have less anxiety and depression than women who have never been pregnant or childless women.

Spatial relationships between lead sources and children's blood lead levels in the urban center of Indianapolis (USA)

Urban children remain disproportionately at risk of having higher blood lead levels than their suburban counterparts. The Westside Cooperative Organization (WESCO), located in Marion County, Indianapolis, Indiana, has a history of children with high blood lead levels as well as high soil lead (Pb) values. This study aims at determining the spatial relationship between soil Pb sources and children's blood lead levels. Soils have been identified as a source of chronic Pb exposure to children, but the spatial scale of the source-recipient relationship is not well characterized. Neighborhood-wide analysis of soil Pb distribution along with a furnace filter technique for sampling interior Pb accumulation for selected homes (n = 7) in the WESCO community was performed. Blood lead levels for children aged 0-5 years during the period 1999-2008 were collected. The study population's mean blood lead levels were higher than national averages across all ages, race, and gender. Non-Hispanic blacks and those individuals in the Wishard advantage program had the highest proportion of elevated blood lead levels. The results show that while there is not a direct relationship between soil Pb and children's blood lead levels at a spatial scale of ~100 m, resuspension of locally sourced soil is occurring based on the interior Pb accumulation. County-wide, the largest predictor of elevated blood lead levels is the location within the urban core. Variation in soil Pb and blood lead levels on the community level is high and not predicted by housing stock age or income. Race is a strong predictor for blood lead levels in the WESCO community.

Qualitative systematic reviews of treatment burden in stroke, heart failure and diabetes - methodological challenges and solutions

BACKGROUND

Treatment burden can be defined as the self-care practices that patients with chronic illness must perform to respond to the requirements of their healthcare providers, as well as the impact that these practices have on patient functioning and well being. Increasing levels of treatment burden may lead to suboptimal adherence and negative outcomes. Systematic review of the qualitative literature is a useful method for exploring the patient experience of care, in this case the experience of treatment burden. There is no consensus on methods for qualitative systematic review. This paper describes the methodology used for qualitative systematic reviews of the treatment burdens identified in three different common chronic conditions, using stroke as our exemplar.

METHODS

Qualitative studies in peer reviewed journals seeking to understand the patient experience of stroke management were sought. Limitations of English language and year of publication 2000 onwards were set. An exhaustive search strategy was employed, consisting of a scoping search, database searches (Scopus, CINAHL, Embase, Medline & PsycINFO) and reference, footnote and citation searching. Papers were screened, data extracted, quality appraised and analysed by two individuals, with a third party for disagreements. Data analysis was carried out using a coding framework underpinned by Normalization Process Theory (NPT).

RESULTS

A total of 4364 papers were identified, 54 were included in the review. Of these, 51 (94%) were retrieved from our database search. Methodological issues included: creating an appropriate search strategy; investigating a topic not previously conceptualised; sorting through irrelevant data within papers; the quality appraisal of qualitative research; and the use of NPT as a novel method of data analysis, shown to be a useful method for the purposes of this review.

CONCLUSION

The creation of our search strategy may be of particular interest to other researchers carrying out synthesis of qualitative studies. Importantly, the successful use of NPT to inform a coding frame for data analysis involving qualitative data that describes processes relating to self management highlights the potential of a new method for analyses of qualitative data within systematic reviews.

Uncovering treatment burden as a key concept for stroke care: a systematic review of qualitative research

BACKGROUND

Patients with chronic disease may experience complicated management plans requiring significant personal investment. This has been termed 'treatment burden' and has been associated with unfavourable outcomes. The aim of this systematic review is to examine the qualitative literature on treatment burden in stroke from the patient perspective.

METHODS AND FINDINGS

The search strategy centred on: stroke, treatment burden, patient experience, and qualitative methods. We searched: Scopus, CINAHL, Embase, Medline, and PsycINFO. We tracked references, footnotes, and citations. Restrictions included: English language, date of publication January 2000 until February 2013. Two reviewers independently carried out the following: paper screening, data extraction, and data analysis. Data were analysed using framework synthesis, as informed by Normalization Process Theory. Sixty-nine papers were included. Treatment burden includes: (1) making sense of stroke management and planning care, (2) interacting with others, (3) enacting management strategies, and (4) reflecting on management. Health care is fragmented, with poor communication between patient and health care providers. Patients report inadequate information provision. Inpatient care is unsatisfactory, with a perceived lack of empathy from professionals and a shortage of stimulating activities on the ward. Discharge services are poorly coordinated, and accessing health and social care in the community is difficult. The study has potential limitations because it was restricted to studies published in English only and data from low-income countries were scarce.

CONCLUSIONS

Stroke management is extremely demanding for patients, and treatment burden is influenced by micro and macro organisation of health services. Knowledge deficits mean patients are ill equipped to organise their care and develop coping strategies, making adherence less likely. There is a need to transform the approach to care provision so that services are configured to prioritise patient needs rather than those of health care systems.

Kinetics of transient hiatus hernia during transient lower esophageal sphincter relaxations and swallows in healthy subjects

BACKGROUND

Proximal displacement of the gastro-esophageal junction (GEJ) is present in hiatus hernia but also occurs transiently during transient lower esophageal sphincter relaxations (TLESRs) and swallows. Using a novel magnetic-based technique we have performed detailed examination of the GEJ movement during TLESRs and swallows in healthy subjects.

METHODS

In 12 subjects, a magnet was endoscopically clipped to the GEJ and combined assembly of Hall-Effect locator probe and 36 channel high-resolution manometer passed nasally. After a test meal the subjects were studied for 90 min.

KEY RESULTS

The median amplitude of proximal movement of GEJ during TLESRs was 4.3 cm (1.6-8.8 cm) and this was substantially greater than during swallowing at 1.2 cm (0.4-2.7 cm), P = 0.002. With both TLESRs and swallows proximal GEJ movement coincided with lower esophageal sphincter (LES) relaxation and return to its original position occurred 4 s after return of LES tone. Kinetic modeling of the movement of the GEJ during TLESRs indicated two return phases with the initial return phase having the greater velocity (0.9 cm s(-1) ) and being strongly correlated with amplitude of proximal movement (r = 0.8, P < 0.001).

CONCLUSIONS & INFERENCES

The marked proximal GEJ migration during TLESRs represents very severe herniation of the GEJ. The rapid initial return of the GEJ following TLESRs when the crural diaphragm is relaxed and its correlation with amplitude suggest it is due to elastic recoil of the phreno-esophageal ligament. The marked stretching of the phreno-esophageal ligament during TLESRs may contribute to its weakening and development of established hiatus hernia.