Scabies outbreaks in ten care homes for elderly people: a prospective study of clinical features, epidemiology, and treatment outcomes

Background

Scabies outbreaks in residential and nursing care homes for elderly people are common, subject to diagnostic delay, and hard to control. We studied clinical features, epidemiology, and outcomes of outbreaks in the UK between 2014 and 2015.

Methods

We did a prospective observational study in residential care homes for elderly people in southeast England that reported scabies outbreaks to Public Health England health protection teams. An outbreak was defined as two or more cases of scabies (in either residents or staff) at a single care home. All patients who provided informed consent were included; patients with dementia were included if a personal or nominated consultee (ie, a family member or nominated staff member) endorsed participation. Dermatology-trained physicians examined residents at initial clinical visits, which were followed by two mass treatments with topical scabicide as per local health protection team guidance. Follow-up clinical visits were held 6 weeks after initial visits. Scabies was diagnosed through pre-defined case definitions as definite, probable, or possible with dermatoscopy and microscopy as appropriate.

Findings

230 residents were examined in ten outbreaks between Jan 23, 2014, and April 13, 2015. Median age was 86·9 years (IQR 81·5–92·3), 174 (76%) were female, and 157 (68%) had dementia. 61 (27%) residents were diagnosed with definite, probable, or possible scabies, of whom three had crusted scabies. Physical signs differed substantially from classic presentations. 31 (51%) of the 61 people diagnosed with scabies were asymptomatic, and only 25 (41%) had burrows. Mites were visualised with dermatoscopy in seven (11%) patients, and further confirmed by microscopy in three (5%). 35 (57%) cases had signs of scabies only on areas of the body that would normally be covered. Dementia was the only risk factor for a scabies diagnosis that we identified (odds ratio 2·37 [95% CI 1·38–4·07]). At clinical follow-up, 50 people who were initially diagnosed with scabies were examined. No new cases of scabies were detected, but infestation persisted in ten people.

Interpretation

Clinical presentation of scabies in elderly residents of care homes differs from classic descriptions familiar to clinicians. This difference probably contributes to delayed recognition and suboptimal management in this vulnerable group. Dermatoscopy and microscopy were of little value. Health-care workers should be aware of the different presentation of scabies in elderly people, and should do thorough examinations, particularly in people with dementia.

Funding

Public Health England and British Skin Foundation.

Long-Term Conditions Questionnaire (LTCQ): initial validation survey among primary care patients and social care recipients in England

OBJECTIVE

The aim of this study was to validate a new generic patient-reported outcome measure, the Long-Term Conditions Questionnaire (LTCQ), among a diverse sample of health and social care users in England.

DESIGN

Cross-sectional validation survey. Data were collected through postal surveys (February 2016-January 2017). The sample included a healthcare cohort of patients recruited through primary care practices, and a social care cohort recruited through local government bodies that provide social care services.

PARTICIPANTS

1211 participants (24% confirmed social care recipients) took part in the study. Healthcare participants were recruited on the basis of having one of 11 specified long-term conditions (LTCs), and social care participants were recruited on the basis of receiving social care support for at least one LTC. The sample exhibited high multimorbidity, with 93% reporting two or more LTCs and 43% reporting a mental health condition.

OUTCOME MEASURES

The LTCQ's construct validity was tested with reference to the EQ-5D (5-level version), the Self-Efficacy for Managing Chronic Disease scale, an Activities of Daily Living scale and the Bayliss burden of morbidity scale.

RESULTS

Low levels of missing data for each item indicate acceptability of the LTCQ across the sample. The LTCQ exhibits high internal consistency (Cronbach's α=0.95) across the scale's 20 items and excellent test-retest reliability (intraclass correlation coefficient=0.94, 95% CI 0.93 to 0.95). Associations between the LTCQ and all reference measures were moderate to strong and in the expected directions, indicating convergent construct validity.

CONCLUSIONS

This study provides evidence for the reliability and validity of the LTCQ, which has potential for use in both health and social care settings. The LTCQ could meet a need for holistic outcome measurement that goes beyond symptoms and physical function, complementing existing measures to capture fully what it means to live well with LTCs.

Is it worth it? Patient and public views on the impact of their involvement in health research and its assessment: a UK-based qualitative interview study

BACKGROUND

There are mounting calls for robust, critical evaluation of the impact of patient and public involvement (PPI) in health research. However, questions remain about how to assess its impact, and whether it should be assessed at all. The debate has thus far been dominated by professionals.

OBJECTIVE

To explore the views of PPI contributors involved in health research regarding the impact of PPI on research, whether and how it should be assessed.

DESIGN

Qualitative interview study.

SETTING AND PARTICIPANTS

Thirty-eight PPI contributors involved in health research across the UK.

RESULTS

Participants felt that PPI has a beneficial impact on health research. They described various impactful roles, which we conceptualize as the 'expert in lived experience', the 'creative outsider', the 'free challenger', the 'bridger', the 'motivator' and the 'passive presence'. Participants generally supported assessing the impact of PPI, while acknowledging the challenges and concerns about the appropriateness and feasibility of measurement. They expressed a range of views about what impacts should be assessed, by whom and how. Individual feedback on impact was seen as an important driver of improved impact and motivation to stay involved.

CONCLUSIONS

While there appears to be widespread support for PPI impact assessment among PPI contributors, their views on what to assess and how are diverse. PPI contributors should be involved as equal partners in debates and decisions about these issues. Individual feedback on impact may increase PPI contributors' potential impact and their motivation to stay involved.

Using psychological theory and qualitative methods to develop a new evidence-based website about acupuncture for back pain

INTRODUCTION

Potential acupuncture patients seek out information about acupuncture from various sources including websites, many of which are unreliable. We aimed to create an informative, scientifically accurate and engaging website to educate patients about acupuncture for back pain and modify their beliefs in a way that might enhance its clinical effects.

METHODS

We used psychological theory and techniques to design an evidence-based website, incorporating multimedia elements. We conducted qualitative "think aloud" audio-recorded interviews to elicit user views of the website. A convenience sample of ten participants (4 male; aged 21-64 years from the local community) looked at the website in the presence of a researcher and spoke their thoughts out loud. Comments were categorised by topic.

RESULTS

The website comprises 11 main pages and addresses key topics of interest to potential acupuncture patients, including beneficial and adverse effects, mechanisms of action, safety, practicalities, and patients' experiences of acupuncture. It provides information through text, evidence summaries and audio-clips of four patients' stories and two acupuncturists' descriptions of their practice, and three short films. Evidence from the think aloud study was used to identify opportunities to make the website more informative, engaging, and user-friendly.

CONCLUSIONS

Using a combination of psychological theory and qualitative interviews enabled us to produce a user-friendly, evidence-based website that is likely to change patients' beliefs about acupuncture for back pain. Before using the website in clinical settings it is necessary to test its effects on key outcomes including patients' beliefs and capacity for making informed choices about acupuncture.

Informing Patients About Placebo Effects: Using Evidence, Theory, and Qualitative Methods to Develop a New Website

Background

According to established ethical principles and guidelines, patients in clinical trials should be fully informed about the interventions they might receive. However, information about placebo-controlled clinical trials typically focuses on the new intervention being tested and provides limited and at times misleading information about placebos.

Objective

We aimed to create an informative, scientifically accurate, and engaging website that could be used to improve understanding of placebo effects among patients who might be considering taking part in a placebo-controlled clinical trial.

Methods

Our approach drew on evidence-, theory-, and person-based intervention development. We used existing evidence and theory about placebo effects to develop content that was scientifically accurate. We used existing evidence and theory of health behavior to ensure our content would be communicated persuasively, to an audience who might currently be ignorant or misinformed about placebo effects. A qualitative ‘think aloud’ study was conducted in which 10 participants viewed prototypes of the website and spoke their thoughts out loud in the presence of a researcher.

Results

The website provides information about 10 key topics and uses text, evidence summaries, quizzes, audio clips of patients’ stories, and a short film to convey key messages. Comments from participants in the think aloud study highlighted occasional misunderstandings and off-putting/confusing features. These were addressed by modifying elements of content, style, and navigation to improve participants’ experiences of using the website.

Conclusions

We have developed an evidence-based website that incorporates theory-based techniques to inform members of the public about placebos and placebo effects. Qualitative research ensured our website was engaging and convincing for our target audience who might not perceive a need to learn about placebo effects. Before using the website in clinical trials, it is necessary to test its effects on key outcomes including patients’ knowledge and capacity for making informed choices about placebos.

Lower incidence of inappropriate shock therapy in patients with combined cardiac resynchronisation therapy defibrillators (CRT-D) compared with patients with non-CRT defibrillators (ICDs)

INTRODUCTION

A significant number of patients experience inappropriate shock therapy (IST) from implantable cardioverter-defibrillators (ICD). An increasing number of patients with advanced heart failure receive combined ICD and cardiac resynchronisation therapy devices (CRT-D). The incidence of IST in this group is less well described. We aimed to assess the incidence and predictors of IST in CRT-D patients.

METHODS

A retrospective cohort study of prospectively collected data on patients who received an ICD and CRT-D between October 2007 and January 2009 at our institution were studied. The primary outcome measures were the IST event rate and all-cause mortality.

RESULTS

A total of 185 patients with ICD/CRT-D (100/85) were included in the analysis. Eighteen patients experienced 35 episodes of IST during the follow-up (21 ± 13 months). There was a significantly lower IST cumulative event rate in the CRT-D vs. ICD group, 5% (CI: 1-13%) vs. 19% (95% CI: 11-30%) by 24 months, (p = 0.017). The majority of the IST was caused by atrial arrhythmias with atrial fibrillation accounting for 28 episodes of IST in nine patients. Multivariate analysis using Cox hazard model including baseline characteristics and coexisting appropriate shock therapy showed that a history of atrial fibrillation/flutter was the strongest independent predictor of IST with a hazard ratio of 3.53 (p = 0.019).

CONCLUSION

Patients with CRT-D had a significantly lower incidence of IST compared with patients receiving an ICD. Given that atrial arrhythmia remained the commonest trigger for IST, our finding lends support to the hypothesis that CRT may reduce atrial fibrillation burden in patients receiving CRT-D.

Trends, indications and outcomes of cardiac implantable device system extraction: a single UK centre experience over the last decade

BACKGROUND

The rising number of device implantation has seen a parallel in the rising numbers of lead extraction. Herein we have analysed our experience in cardiac device and lead extraction in a single tertiary centre over the last decade.

METHOD

Retrospective analysis of all consecutive patients undergoing lead extractions performed between 2001 and 2010. Procedural success and complications as defined by the Heart Rhythm Society policy.

RESULTS

A total of 745 leads were extracted with a procedural success of 98.9% [382 cases; partial success in 6.9% (26) cases] and failure in 1.1% (4). Major complication rate was 1% (four cases) and minor complication rate was 3.6%. By both univariate and multivariate analysis only duration of lead implantation was an indicator for success (p < 0.0001). The mean implantation time for failed lead extraction was 203 ± 64 months compared with 71.8 ± 16.5 months in the successful cohort (p < 0.0001). Laser-assisted extraction was required in 176 cases. With regard to extraction indication, lead malfunction/recall showed a significant increase during the study period (p = 0.03). On time trend analysis the rise in coronary sinus (CS) lead extraction over time was significant. (p = 0.02) Despite a trend for increased laser use over time this did not achieve statistical significance, p = 0.06.

CONCLUSIONS

A decade's experience of percutaneous lead extraction suggests that a high procedural success rate with a low complication rate is achieved in a high-volume centre. During this time, an increase in both defibrillator and CS lead explantation and a rising trend in laser assistance with almost 50% of cases needing laser usage were observed.

Biophysical modeling to simulate the response to multisite left ventricular stimulation using a quadripolar pacing lead

BACKGROUND

Response to cardiac resynchronization therapy (CRT) is reduced in patients with posterolateral scar. Multipolar pacing leads offer the ability to select desirable pacing sites and/or stimulate from multiple pacing sites concurrently using a single lead position. Despite this potential, the clinical evaluation and identification of metrics for optimization of multisite CRT (MCRT) has not been performed.

METHODS

The efficacy of MCRT via a quadripolar lead with two left ventricular (LV) pacing sites in conjunction with right ventricular pacing was compared with single-site LV pacing using a coupled electromechanical biophysical model of the human heart with no, mild, or severe scar in the LV posterolateral wall.

RESULT

The maximum dP/dt(max) improvement from baseline was 21%, 23%, and 21% for standard CRT versus 22%, 24%, and 25% for MCRT for no, mild, and severe scar, respectively. In the presence of severe scar, there was an incremental benefit of multisite versus standard CRT (25% vs 21%, 19% relative improvement in response). Minimizing total activation time (analogous to QRS duration) or minimizing the activation time of short-axis slices of the heart did not correlate with CRT response. The peak electrical activation wave area in the LV corresponded with CRT response with an R(2) value between 0.42 and 0.75.

CONCLUSION

Biophysical modeling predicts that in the presence of posterolateral scar MCRT offers an improved response over conventional CRT. Maximizing the activation wave area in the LV had the most consistent correlation with CRT response, independent of pacing protocol, scar size, or lead location.

Male gender and chronic obstructive pulmonary disease predict a poor clinical response in patients undergoing cardiac resynchronisation therapy

AIMS

Current guidelines advocate cardiac resynchronisation therapy (CRT) in patients with class III/IV New York Heart Association (NYHA) heart failure, depressed left ventricular function and a broad QRS. However, a significant proportion of patients do not derive any benefit from CRT. The aim of this study was to identify clinical, electrocardiographic and echocardiographic predictors of response to CRT.

METHODS

A retrospective analysis of patients undergoing CRT in our institution was performed. A favourable clinical response to CRT was defined as an improvement in NYHA Heart failure class of ≥ 1 and lack of hospitalisation with heart failure. Comparisons were made between responders and non-responders in terms of baseline characteristics and potential predictors of CRT response (QRS width, presence of left bundle branch block, atrial fibrillation, evidence of mechanical dyssynchrony on echocardiography and LV lead position).

RESULTS

A total of 164 patients had full follow-up data. The mean follow-up was 293 days. Of patients undergoing CRT, 90 (58.9%) had a favourable clinical response to CRT. Predictors of a lack of clinical response to CRT were male gender (p = 0.012) and chronic obstructive pulmonary disease (COPD) (0.008). Pre-implant echocardiographic dyssynchrony assessment appeared not to predict response to CRT (p = 0.87); however, there was a trend towards a positive response in those patients with significant dyssynchrony (p = 0.09) defined as interventricular delay > 40 ms or maximal LV delay of > 80 ms.

CONCLUSION

Male gender and coexisting COPD were shown to be independent predictors of non-response to CRT in this cohort of patients fulfilling current criteria for CRT.

Atrial flutter ablation: efficacy and cost-effectiveness of a single decapolar electrode to demonstrate bidirectional isthmus block

AIMS

To evaluate whether a single decapolar electrode is a reliable and cost-effective substitute for the 'Halo' catheter to map the circuit and detect bidirectional isthmus block during atrial flutter (AFL) ablation.

METHODS AND RESULTS

Twenty-four patients underwent AFL ablation by using the decapolar electrode in the infero-lateral wall of right atrium (group A) while a 'Halo' catheter was used in 11 patients (group B). Both groups had similar clinical characteristics. Anti-clockwise rotation (20 patients), clockwise (3 patients) or both forms of AFL (1 patient) were detected in group A. All patients in group B had anti-clockwise AFL. Bidirectional isthmus block was completed in 22 patients of group A and in 9 of group B (P=NS) while incomplete isthmus block was detected in 2 patients in each group (P=NS). Mean fluoroscopy and procedure time was 27 +/- 47 min, 107 +/- 36 min in group A and 14 +/- 19 min, 114 +/- 65 min in group B (P=NS). AFL relapsed in 3 patients of group A (follow-up 7 +/- 4 months) and in 2 of group B (4 +/- 2 months).

CONCLUSION

A single decapolar electrode is a reliable method to map the circuit and demonstrate bidirectional isthmus block during AFL ablation. The cost of the decapolar electrode is a quarter of that of the 'Halo' catheter. This represents a significant saving particularly for centres with a substantial number of AFL ablations.

Unguarded tricuspid orifice with pulmonary atresia: successful radiofrequency ablation of an accessory pathway in an infant

A male infant with the rare lesion of unguarded tricuspid orifice in the setting of pulmonary valve atresia, intact ventricular septum, and a hypoplastic right ventricle is described. The patient presented with cyanosis at 1 day old; transcutaneous oxygen saturations were between 20% and 30% in room air, and 60% in 100% inspired oxygen. Pre-excitation was found incidentally on the ECG and the potential for rapid antegrade conduction of atrial tachyarrhythmias, after eventual extended palliation with the Fontan procedure, was demonstrated at electrophysiological study. By 11 months old the patient was becoming increasingly cyanosed and interim palliation with a bidirectional cavopulmonary shunt was proposed. Successful radiofrequency ablation of the accessory pathway was performed before bidirectional cavopulmonary shunt, which would have prevented access to the heart via the superior vena cava. Difficulty with femoral venous access because of previous occlusion of a femoral vein was overcome by the use of 2 F pacing electrodes and a 5 F ablation catheter.

Use of an atrial loop to extend the duration of endocardial pacing in a neonate

Use of an atrial loop has been proposed as a means of extending the longevity of endocardial pacing systems in small children who require ventricular pacing. A few reports have demonstrated the effectiveness of this method at reducing the number of interventions in infants and small children, but there is little reported experience in neonates. Permanent endocardial ventricular demand pacing was performed in a 3.4-kg neonate. The generator was placed in a prepectoral pocket and a redundant loop of lead was left in the atrium to cater for further growth. At 32 months he weighs 13.6 kg and the loop has uncoiled leaving additional lead slack for further growth.

Single pass VDD pacing in children and adolescents

Use of a single pass lead for VDD pacing in complete heart block is well described in adults, but there are only brief reports of its use in children. We have used standard adult size single pass leads in 13 children and adolescents aged 3.7-17.2 years (mean 10.1 years) and weighing 13.5-76 kg (mean 34.8 kg). Congenital complete heart block was present in 7 patients, surgical complete heart block in 5 patients and 2:1 AV block of unknown cause in 1 patient. In four patients, the VDD system was their first pacing system. In nine of the patients, 1-6 previous systems had been used and simultaneous extraction of ventricular leads and/or atrial leads was performed. Leads of four different types were used: Brilliant IMP15Q, Brilliant + IMR15Q, CapSure 5032, and Unipass 425-13 with 4 different generators: Saphir 600, Saphir II 620, Thera VDD 8948, and Unity 292-07. At implantation, via a subclavian vein puncture, excess lead was advanced into the right atrium to allow both atrial sensing and slack for further growth. Ventricular thresholds ranged from 0.2-0.7 V. The minimal atrial amplitude was 0.7-4 mV and the maximum amplitude was 2.5-8 mV. There were no complications. All patients have maintained adequate atrial signals for reliable pacing with follow up of 3-36 months (mean 17.6 months) during which time some have undergone considerable growth. Reliable atrial synchronous ventricular pacing is possible in growing children with complete heart block using a standard adult single pass lead.

VDD pacing in children with congenital complete heart block: advantages of a single pass lead

A single pass lead for VDD pacing in complete heart block is well described in adults but there are only brief reports of its use in children. We used standard adult size single pass leads in ten children and adolescents aged 3.7-17.2 years (mean 9.9 years) and weighing 13.5-76 kg (mean 35.4 kg) with congenital complete heart block. One patient had coexisting congenital heart disease and had undergone surgery. A 2:1 atrioventricular block in one patient was presumed to be congenital in origin. In four patients, the VDD system was their first pacing system. In six of the patients, 1-4 previous systems had been used and simultaneous extraction of ventricular leads (6) and/or atrial leads (2) was performed. Four different types of lead were used: Brilliant IMP15Q (Vitatron); Brilliant + IMR15Q (Vitatron); CapSure 5032 (Medtronic); and Unipass 425-13 (Intermedics) with four different generators: Saphir 600 (Vitatron); Saphir II 620 (Vitatron); Thera VDD 8948 (Medtronic); and Unity 292-07 (Intermedics). All leads were introduced via a subclavian vein puncture and the atrial dipole was placed low in the right atrium to provide slack for further growth while maintaining atrial sensing. Ventricular thresholds ranged from 0.2-0.8 V. The minimal atrial amplitude was 0.7-4 mV and the maximum amplitude was 2.5-8 mV. There was one early microdisplacement and the lead was repositioned. Over a follow-up period ranging from 1-39 months (mean 20.4 months), all patients have maintained low ventricular pacing thresholds and adequate atrial signals for reliable pacing at rest and with exercise. During this time some have undergone considerable growth. The patient with coexisting congenital heart disease died suddenly at 3 years, but the pacing system had no fault at autopsy. The standard adult size single pass lead provides a simple means to enable reliable atrial synchronous ventricular pacing in growing children with complete heart block.