An outbreak of mycobacterial furunculosis associated with footbaths at a nail salon

BACKGROUND

In September 2000, a physician in northern California described four patients with persistent, culture-negative boils on the lower extremities. The patients had received pedicures at the same nail salon. We identified and investigated an outbreak of Mycobacterium fortuitum furunculosis among customers of this nail salon.

METHODS

Patients were defined as salon customers with persistent skin infections below the knee. A case-control study was conducted that included the first 48 patients identified, and 56 unaffected friends and family members who had had a pedicure at the same salon served as controls. Selected M. fortuitum isolates, cultured from patients and the salon environment, were compared by pulsed-field gel electrophoresis.

RESULTS

We identified 110 customers of the nail salon who had furunculosis. Cultures from 34 were positive for rapidly growing mycobacteria (32 M. fortuitum and 2 unidentified). Most of the affected patients had more than 1 boil (median, 2; range, 1 to 37). All patients and controls had had whirlpool footbaths. Shaving the legs with a razor before pedicure was a risk factor for infection (70 percent of patients vs. 31 percent of controls; adjusted odds ratio, 4.8; 95 percent confidence interval, 2.1 to 11.1). Cultures from all 10 footbaths at the salon yielded M. fortuitum. The M. fortuitum isolates from three footbaths and 14 patients were indistinguishable by electrophoresis.

CONCLUSIONS

We identified a large outbreak of rapidly growing mycobacterial infections among persons who had had footbaths and pedicures at one nail salon. Physicians should suspect this cause in patients with persistent furunculosis after exposure to whirlpool footbaths.

An outbreak due to multiresistant Acinetobacter baumannii in a burn unit: risk factors for acquisition and management

OBJECTIVES

To describe the investigation and management of an outbreak due to multiresistant Acinetobacter baumannii and to determine risk factors for acquisition of the organism.

SETTING

A 14-bed regional burn unit in a Canadian tertiary-care teaching hospital.

DESIGN

Case-control study with multivariate analysis of potential risk factors using logistic regression analysis. Surveillance cultures were obtained from the hospital environment, from noninfected patients, and from healthcare providers.

RESULTS

A total of 31 (13%) of 247 patients with acute burn injuries acquired multiresistant A. baumannii between December 1998 and March 2000; 18 (58%) of the patients were infected. The organism was recovered from the hospital environment and the hands of healthcare providers. Significant risk factors for acquisition of multiresistant A. baumannii were receipt of blood products (odds ratio [OR], 10.8; 95% confidence interval [CI95], 3.4 to 34.4; P < .001); procedures performed in the hydrotherapy room (OR, 4.1; CI95, 1.3 to 13.1; P = .02); and increased duration of mechanical ventilation (OR, 1.1 per day; CI95, 1.0 to 1.1; P= .02).

INTERVENTIONS

Improved compliance with hand hygiene, strict patient isolation, meticulous environmental cleaning, and temporary closure of the unit to new admissions.

CONCLUSIONS

Acquisition of multiresistant A. baumannii was likely multifactorial, related to environmental contamination and contact with transiently colonized healthcare providers. Control measures addressing these potential sources of multiresistant A. baumannii were successful in terminating the outbreak. Ongoing surveillance and continued attention to hand hygiene and adequate environmental cleaning are essential to prevent recurrent outbreaks due to antibiotic-resistant bacteria in burn units.

Epidemiology of infections with Pseudomonas aeruginosa in burn patients: the role of hydrotherapy

Pseudomonas aeruginosa remains a cause of serious wound infection and mortality in burn patients. By means of restriction fragment length polymorphism analysis and a DNA probe for the pilin gene of Pseudomonas, a lethal strain of nosocomial P. aeruginosa was identified as the cause of an outbreak of wound infections among burn patients. Environmental surveys suggested an association of the outbreak with hydrotherapy provided to many patients in a common facility. In a trial of burn wound care without hydrotherapy, overall mortality was reduced significantly, mortality associated with pseudomonas sepsis was eliminated, and the strain of P. aeruginosa associated with earlier mortality was eradicated. Moreover, fewer nosocomial pseudomonas infections, lower levels of pseudomonas resistance to aminoglycoside antibiotics, significantly fewer pseudomonas infections of skin graft donor sites, and later appearance of Pseodomonas species in burn patients were found during the period when hydrotherapy was not used.

Aquatic exercise training for fibromyalgia

BACKGROUND

Exercise training is commonly recommended for individuals with fibromyalgia. This review examined the effects of supervised group aquatic training programs (led by an instructor). We defined aquatic training as exercising in a pool while standing at waist, chest, or shoulder depth. This review is part of the update of the 'Exercise for treating fibromyalgia syndrome' review first published in 2002, and previously updated in 2007.

OBJECTIVES

The objective of this systematic review was to evaluate the benefits and harms of aquatic exercise training in adults with fibromyalgia.

SEARCH METHODS

We searched The Cochrane Library 2013, Issue 2 (Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, NHS Economic Evaluation Database), MEDLINE, EMBASE, CINAHL, PEDro, Dissertation Abstracts, WHO international Clinical Trials Registry Platform, and AMED, as well as other sources (i.e., reference lists from key journals, identified articles, meta-analyses, and reviews of all types of treatment for fibromyalgia) from inception to October 2013. Using Cochrane methods, we screened citations, abstracts, and full-text articles. Subsequently, we identified aquatic exercise training studies.

SELECTION CRITERIA

Selection criteria were: a) full-text publication of a randomized controlled trial (RCT) in adults diagnosed with fibromyalgia based on published criteria, and b) between-group data for an aquatic intervention and a control or other intervention. We excluded studies if exercise in water was less than 50% of the full intervention.

DATA COLLECTION AND ANALYSIS

We independently assessed risk of bias and extracted data (24 outcomes), of which we designated seven as major outcomes: multidimensional function, self reported physical function, pain, stiffness, muscle strength, submaximal cardiorespiratory function, withdrawal rates and adverse effects. We resolved discordance through discussion. We evaluated interventions using mean differences (MD) or standardized mean differences (SMD) and 95% confidence intervals (95% CI). Where two or more studies provided data for an outcome, we carried out meta-analysis. In addition, we set and used a 15% threshold for calculation of clinically relevant differences.

MAIN RESULTS

We included 16 aquatic exercise training studies (N = 881; 866 women and 15 men). Nine studies compared aquatic exercise to control, five studies compared aquatic to land-based exercise, and two compared aquatic exercise to a different aquatic exercise program.We rated the risk of bias related to random sequence generation (selection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), blinding of outcome assessors (detection bias), and other bias as low. We rated blinding of participants and personnel (selection and performance bias) and allocation concealment (selection bias) as low risk and unclear. The assessment of the evidence showed limitations related to imprecision, high statistical heterogeneity, and wide confidence intervals. Aquatic versus controlWe found statistically significant improvements (P value < 0.05) in all of the major outcomes. Based on a 100-point scale, multidimensional function improved by six units (MD -5.97, 95% CI -9.06 to -2.88; number needed to treat (NNT) 5, 95% CI 3 to 9), self reported physical function by four units (MD -4.35, 95% CI -7.77 to -0.94; NNT 6, 95% CI 3 to 22), pain by seven units (MD -6.59, 95% CI -10.71 to -2.48; NNT 5, 95% CI 3 to 8), and stiffness by 18 units (MD -18.34, 95% CI -35.75 to -0.93; NNT 3, 95% CI 2 to 24) more in the aquatic than the control groups. The SMD for muscle strength as measured by knee extension and hand grip was 0.63 standard deviations higher compared to the control group (SMD 0.63, 95% CI 0.20 to 1.05; NNT 4, 95% CI 3 to 12) and cardiovascular submaximal function improved by 37 meters on six-minute walk test (95% CI 4.14 to 69.92). Only two major outcomes, stiffness and muscle strength, met the 15% threshold for clinical relevance (improved by 27% and 37% respectively). Withdrawals were similar in the aquatic and control groups and adverse effects were poorly reported, with no serious adverse effects reported. Aquatic versus land-basedThere were no statistically significant differences between interventions for multidimensional function, self reported physical function, pain or stiffness: 0.91 units (95% CI -4.01 to 5.83), -5.85 units (95% CI -12.33 to 0.63), -0.75 units (95% CI -10.72 to 9.23), and two units (95% CI -8.88 to 1.28) respectively (all based on a 100-point scale), or in submaximal cardiorespiratory function (three seconds on a 100-meter walk test, 95% CI -1.77 to 7.77). We found a statistically significant difference between interventions for strength, favoring land-based training (2.40 kilo pascals grip strength, 95% CI 4.52 to 0.28). None of the outcomes in the aquatic versus land comparison reached clinically relevant differences of 15%. Withdrawals were similar in the aquatic and land groups and adverse effects were poorly reported, with no serious adverse effects in either group. Aquatic versus aquatic (Ai Chi versus stretching in the water, exercise in pool water versus exercise in sea water)Among the major outcomes the only statistically significant difference between interventions was for stiffness, favoring Ai Chi (1.00 on a 100-point scale, 95% CI 0.31 to 1.69).

AUTHORS' CONCLUSIONS

Low to moderate quality evidence relative to control suggests that aquatic training is beneficial for improving wellness, symptoms, and fitness in adults with fibromyalgia. Very low to low quality evidence suggests that there are benefits of aquatic and land-based exercise, except in muscle strength (very low quality evidence favoring land). No serious adverse effects were reported.

Contrast water therapy and exercise induced muscle damage: a systematic review and meta-analysis

The aim of this systematic review was to examine the effect of Contrast Water Therapy (CWT) on recovery following exercise induced muscle damage. Controlled trials were identified from computerized literature searching and citation tracking performed up to February 2013. Eighteen trials met the inclusion criteria; all had a high risk of bias. Pooled data from 13 studies showed that CWT resulted in significantly greater improvements in muscle soreness at the five follow-up time points (<6, 24, 48, 72 and 96 hours) in comparison to passive recovery. Pooled data also showed that CWT significantly reduced muscle strength loss at each follow-up time (<6, 24, 48, 72 and 96 hours) in comparison to passive recovery. Despite comparing CWT to a large number of other recovery interventions, including cold water immersion, warm water immersion, compression, active recovery and stretching, there was little evidence for a superior treatment intervention. The current evidence base shows that CWT is superior to using passive recovery or rest after exercise; the magnitudes of these effects may be most relevant to an elite sporting population. There seems to be little difference in recovery outcome between CWT and other popular recovery interventions.

Rapidly growing mycobacterial infections after pedicures

BACKGROUND

Rapidly growing mycobacteria (RGM) can cause a variety of cutaneous and systemic diseases. The causative organisms are typically Mycobacterium fortuitum or Mycobacterium chelonae (also known as Mycobacterium abscessus). Primary cutaneous lesions may develop after a variable latent period, from weeks to several months, and usually result from direct inoculation after trauma, from injections, or during surgery via contaminated medical instruments. Recently, investigators from the Centers for Disease Control and Prevention, Atlanta, Ga, and the California Department of Health Services, Berkeley, documented a large, unprecedented outbreak of community-acquired RGM infection, during which more than 100 patrons of a northern California nail salon contracted furunculosis in their legs as a result of exposure to whirlpool footbaths that were contaminated with M fortuitum.

OBSERVATIONS

We report the clinical and epidemiological findings in 3 cases of lower extremity RGM infections that occurred after similar whirlpool footbath exposure at several different nail salons in southern California. These infections typically presented as recurrent furunculosis, causing considerable morbidity as a result of scarring, delayed diagnosis, and the need for long-term polymicrobial therapy.

CONCLUSIONS

Rapidly growing mycobacterial infections related to pedicures may continue to occur in a sporadic fashion. Clinicians should consider the possibility of RGM infection and inquire about recent pedicures in a patient with recurrent lower extremity furunculosis and abscesses that are unresponsive to conventional antibiotic therapy.

Importation of Acinetobacter baumannii into a burn unit: a recurrent outbreak of infection associated with widespread environmental contamination

A burn patient was infected with Acinetobacter baumannii on transfer to the hospital after a terrorist attack. Two patients experienced cross-infection. Environmental swab samples were negative for A. baumannii. Six months later, the bacteria reemerged in 6 patients. Environmental swab samples obtained at this time were inoculated into a minimal mineral broth, and culture results showed widespread contamination. No case of infection occurred after closure of the unit for disinfection.

Lochgoilhead fever: outbreak of non-pneumonic legionellosis due to Legionella micdadei

Analysis of case histories from 187 people who had visited a hotel and leisure complex in Lochgoilhead, a village on the west coast of Scotland, indicated that 170 had had an acute illness characterised by headache, fatigue, arthralgia, myalgia, cough, and breathlessness. These symptoms were consistent with Pontiac fever-like illness. Legionella micdadei was isolated from the leisure complex whirlpool spa at the time that 60 of 72 individuals with symptoms seroconverted to L micdadei antigen. This outbreak is thought to be the first of a Pontiac fever-like illness ascribed to L micdadei and the first large-scale outbreak of its kind to have occurred outside North America. Whirlpool spas can be a major reservoir of legionella organisms; they must therefore be properly maintained and operated to prevent outbreaks of infection.

Neonatal sudden death due to Legionella pneumonia associated with water birth in a domestic spa bath

We report the first case of neonatal Legionnaires' disease associated with water birth in a spa bath at home. Legionella pneumophila serogroup 6 was detected from postmortem lung tissue.

Hot tub lung: infection, inflammation, or both?

Increasing numbers of patients have presented with a hypersensitivity pneumonitis-type course in association with hot tub exposure. Mycobacterium avium complex (MAC) organisms have been isolated from both patient specimens and hot tub water with matching fingerprints by restricted fragment length polymorphism and electrophoresis when performed. Review of the clinical, microbiologic, and radiographic presentations of 9 patients to the Mayo Clinic with this diagnosis are compared with 32 patients in the published literature. The diagnosis, treatment, and prognosis of MAC hot tub lung are reviewed.

Computer tablet distraction reduces pain and anxiety in pediatric burn patients undergoing hydrotherapy: A randomized trial

BACKGROUND

Distraction is often used in conjunction with analgesics to minimize pain in pediatric burn patients during treatment procedures. Computer tablets provide many options for distraction items in one tool and are often used during medical procedures. Few studies have examined the effectiveness of tablet distraction in improving the care of pediatric burn patients.

AIM

This study examines the effectiveness of tablet distraction provided by a child life specialist to minimize pain and anxiety in pediatric burn patients undergoing hydrotherapy.

METHODS

Thirty pediatric patients (4-12) undergoing hydrotherapy for the treatment of burns participated in this randomized clinical trial. The tablet distraction group received tablet distraction provided by a child life specialist while those in the control group received standard care. Pain was assessed through self-reports and observation reports. Anxiety was assessed through behavioral observations. Length of procedure was also recorded.

RESULTS

Nurses reported significantly less pain for the tablet distraction group compared to the control group. There was no significant difference between groups on self-reported pain. The tablet distraction group displayed significantly less anxiety during the procedure compared to the control group. Also, the tablet distraction group returned to baseline after the procedure while those in the control group displayed higher anxiety post-procedure. There was no difference in the length of the procedure between groups.

CONCLUSIONS

These findings suggest tablet distraction provided by a child life specialist may be an effective method for improving pain and anxiety in children undergoing hydrotherapy treatment for burns.

A Randomized Controlled Trial on the Effectiveness of Mild Water-filtered Near Infrared Whole-body Hyperthermia as an Adjunct to a Standard Multimodal Rehabilitation in the Treatment of Fibromyalgia

OBJECTIVES

To evaluate whether mild water-filtered near infrared whole-body hyperthermia (NI-WBH) produces an additional benefit when applied as an adjunct to a standard multimodal rehabilitation (MR) compared with MR only in patients with fibromyalgia (FM).

METHODS

One hundred thirty-nine patients of a German inpatient rehabilitation hospital meeting the ACR 1990 criteria for FM were randomly allocated to NI-WBH (heating-up to 38.1 degrees C body core temperature followed by a 15 min heat retention period) and MR or MR only, twice a week over 3 weeks. Main outcome measures were affective and sensory pain assessed by a German version of the McGill Pain Questionnaire, measured at baseline, postintervention, 3 and 6 months postintervention and analyzed by intention to treat.

RESULTS

Repeated measures analysis of covariance showed significant differences between groups for both primary outcome measures in favor of NI-WBH and MR compared with MR only (P<0.001 for affective pain, P=0.001 for sensory pain). Secondary analyses on pain intensity, FM-related quality of life and tender point assessment yielded similar results. Moderate effect sizes were observed for all outcome measures considered (range, 0.41 to 0.75). NI-WBH related side effects were observed in 14 of 69 participants (20%) but all disappeared in less than 30 minutes.

DISCUSSION

The study indicates that NI-WBH is a worthwhile adjunct to MR in the treatment of FM.

Pseudomonas aeruginosa in public swimming pools and bathroom water of patients with cystic fibrosis

INTRODUCTION

Acquisition of Pseudomonas aeruginosa (PA) in the lungs of patients with cystic fibrosis (CF) is a marker of poor survival. PA is a ubiquitous pathogen prevalent in humid conditions. This study aimed to identify the prevalence of PA in public swimming pools, as well as from water taps.

METHODS

Water was collected from public indoor and outdoor pools in the area of St. Gallen, Switzerland. In addition, standing and running water was sampled from bathroom water taps of 50 patients with CF.

RESULTS

Outdoor pools: In 2002, none of the 72 specimens from 28 pools revealed PA. In 2003, three specimens from 46 pools (7%) revealed PA, each were from a different paddling pool. Indoor pools: two of 128 specimens from 56 pools (4%) identified PA, both were from non-public hydrotherapy pools. Water taps: in winter, none of the 102 specimens was colonized with PA. in summer, only two out of 50 specimens of the standing water were positive for PA but none of the running water revealed PA.

CONCLUSION

The prevalence of PA in public swimming pools and bathroom water taps in the eastern part of Switzerland is very low. On hot summer days, outdoor paddling pools and standing tap water can contain PA. This study does not support recommendations to avoid public swimming pools or running tap water if the water is maintained according to hygiene guidelines.

Hot tub use during pregnancy and the risk of miscarriage

To examine whether hot tub or whirlpool bath use during pregnancy increases the risk of miscarriage, the authors conducted a 1996-1998 population-based prospective cohort study at the Kaiser Permanente Medical Care Program in Oakland, California. Of 2729 eligible women, 1063 completed the interview. Miscarriage before 20 weeks of gestation was ascertained for all participants. Information on hot tub or whirlpool bath use was obtained during an in-person interview conducted early in the pregnancy. A Cox proportional hazards model was used to estimate the hazard ratio after adjustment for potential confounders. Compared with nonuse, use of a hot tub or whirlpool bath after conception was associated with a twofold increased risk of miscarriage (adjusted hazard ratio (aHR) = 2.0, 95% confidence interval: 1.3, 3.1). The risk seemed to increase with increasing frequency of use (aHR = 1.7 for less than once a week, aHR = 2.0 for once a week, and aHR = 2.7 for more than once a week) and with use during early gestation (aHR = 2.3 for initial use within the first 4 weeks of the last menstrual period and aHR = 1.5 for initial use after 4 weeks of the last menstrual period). Findings suggest an association between use of a hot tub or whirlpool bath during early pregnancy and the risk of miscarriage.

Low airloss hydrotherapy versus standard care for incontinent hospitalized patients

OBJECTIVE

To determine whether low airloss hydrotherapy reduces the incidence of new skin lesions associated with incontinence in hospitalized patients and results in more rapid healing of existing pressure sores compared with standard care. To assess subjectively patient and nursing satisfaction related to using low airloss hydrotherapy beds.

DESIGN

Randomized, prospective, unblinded study.

SETTING

Acute and chronic hospital wards.

PARTICIPANTS

A total of 116 newly admitted, incontinent, hospitalized patients with and without existing pressure sores.

INTERVENTION

Low airloss hydrotherapy compared with treatment on hospital beds and mattresses ordered by the patient's attending physician.

MEASUREMENTS

Incidence rates of new skin lesion development, e.g., pressure sores, candidiasis, and chemical irritation; improvement in existing pressure sore size, volume, and status; subjective assessment of patient and nursing satisfaction.

RESULTS

Possible hypothermia was identified in two patients during the first week of the study, and patient and nursing dissatisfaction with low airloss hydrotherapy remained high throughout the first months of the study. Therefore, two major modifications in the initial protocol were made: (1) increased patient temperature monitoring for hypothermia was initiated in Week 2 of the study and (2) increased staff resources for in-service training on bed use began in Week 18 of the study. After the latter change, 58 subjects were randomized to low airloss hydrotherapy and 58 to standard care. Subjects were old (median age > or = 80 years), and almost all were bedbound or nonambulatory. The median (range) length of follow-up for subjects in the treatment group was significantly shorter than for those in the control group (4 (1-60) days versus 6 (1-62) days, respectively, P = .017) because there were more dropouts from the treatment group (24 (36%) of 58 versus 2 (3%) of 58, P = .0001). The major reasons dropout occurred were patient or family dissatisfaction (12 (21%)), new or worsened skin lesions thought to be related to bed use (4 (7%)), and hypothermia < 97 degrees F (4 (7%)). The total cumulative incidence of new truncal skin lesions within 9 days of enrollment was greater in the treatment than in the control group (48% versus 14%, respectively, P < 0.01). Too few patients with existing pressure sores were treated for too short a period of time to assess the effect of low airloss hydrotherapy on pressure sore healing. Because only 10 patients treated on low airloss hydrotherapy beds were able to complete satisfaction surveys meaningfully, interpretation of these data is difficult. Only nine (21%) of 44 nurses subjectively reported overall satisfaction using the low airloss hydrotherapy bed.

CONCLUSIONS

This study shows the value of a rigorously designed clinically based evaluation of a new product developed for older patients. The results of the study led to re-engineering of the prototype low airloss hydrotherapy bed as well as a change in marketing strategy. Studies of products targeted to the prevention and treatment of pressure sores in older patients should be undertaken before generalized marketing begins.

Complications from therapeutic modalities: results of a national survey of athletic trainers

OBJECTIVE

To understand better the frequency and type of complications encountered by athletic trainers.

DESIGN

A descriptive questionnaire.

SETTING

Athletic training facilities at the high school, college, and professional levels, as well as physical therapy clinics.

PARTICIPANTS

A total of 3012 certified athletic trainers employed in above-mentioned settings.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Frequency and types of complications encountered for different modalities were computed. Primary modality type used and frequency of complications in different settings were explored.

RESULTS

Of the 3012 surveyed, 905 (30%) responded, 26% of whom reported a complication; 362 total complications were documented. Cryotherapy accounted for 42% of complications, with allergic reactions (n=86), burns (n=23), and intolerance/pain (n=16) most commonly listed. Electric stimulation accounted for 29% of complications, with skin irritation (n=41), burns (n=40), and intolerance/pain (n=18) most commonly listed. Therapeutic heat accounted for 22% of complications; therapeutic exercise accounted for 7% of complications.

CONCLUSIONS

Compared with documented complications in the peer-reviewed literature, our survey results differed vastly with regard to the complications encountered. This may reflect a learning phenomenon, a shift in modality usage, or a general underreporting of complications.

Pseudomonas keratitis and folliculitis from whirlpool exposure

A local outbreak of pseudomonal folliculitis from whirlpool exposure occurred in 12 persons. A corneal ulcer developed in one patient within 48 hours of using the whirlpool. Treatment with fortified gentamicin resolved the corneal infiltrate and vision returned to normal. A second patient, who had not showered immediately after leaving the whirlpool, was left with areas of skin hyperpigmentation and scarring despite treatment with ultraviolet rays and tetracycline. Although the skin rash may be self-limited, the potential for visual loss from pseudomonal keratitis emphasizes the need for proper disinfection of swimming and whirlpool water.

Irritant contact dermatitis due to 1-bromo-3-chloro-5,5-dimethylhydantoin in a hydrotherapy pool. Risk assessments: the need for continuous evidence-based assessments

A physiotherapist working in hydrotherapy presented to occupational health with irritant contact dermatitis. Subsequent investigation revealed that the likely causative agent was 1-bromo 3-chloro 5,5 dimethylhydantoin which was used to disinfect the hydrotherapy pool. A COSHH risk assessment had been performed which failed to take full account of current knowledge and this agent had been introduced into the workplace. The development of adverse health effects among staff and other pool users lead to a review of this risk assessment and eventually a return to less hazardous chlorine-based disinfection. Had an evidence-based approach been combined with an appropriate COSHH assessment prior to and following changes in the workplace then unnecessary risk to employees would not have occurred.

Duration of whirlpool-spa use as a risk factor for Pseudomonas dermatitis

Pseudomonas dermatitis occurred among 16 of 49 whirlpool-spa bathers in a Vermont hotel during a weekend in November 1983. Pseudomonas aeruginosa, serotype 0:4, was isolated from a patient and the whirlpool-spa water. Since duration of whirlpool-spa use had been previously postulated as a risk factor for dermatitis, a historical cohort study was designed to test this hypothesis. Each bather was carefully interviewed about the duration in minutes of whirlpool-spa and swimming pool exposure on the weekend. Total duration of whirlpool-spa use was significantly associated with rash illness both on contingency and logistic regression analysis. Females were also found to be at increased risk, after controlling for the study hypothesis. Duration of whirlpool-spa use was an important determinant of risk for Pseudomonas dermatitis in this outbreak.

The health hazards of saunas and spas and how to minimize them

BACKGROUND

The rapidly increasing number of spas, hot tubs, and saunas intensifies the potentials for deaths from hyperthermia and drowning.

METHODS

I analyzed 54 such deaths reported to me by 55 medical examiners and coroners in the United States and 104 deaths reported to the US Consumer Product Safety Commission (CPSC).

RESULTS

Only seven of the 158 deaths analyzed occurred in saunas. All of the remaining deaths occurred in spas, jacuzzis, or hot tubs, which were far more numerous. The chief risk factors identified were alcohol ingestion, heart disease, seizure disorders, and cocaine ingestion (alone or in combination with alcohol ingestion). These factors accounted for 71 or 44.7% of the 159 fatalities. Of these risk factors, alcohol represented 38%; heart disease, 31%; seizure disorders, 17%; and cocaine ingestion, alone or in combination with alcohol, 14%. Sixty-one of the 151 spa-associated deaths occurred in children under 12 years of age. Accidental drownings from uncovered or improperly covered spas and, to a lesser extent, entrapment by suction, were the chief causes of childhood drownings.

CONCLUSIONS

Children and older persons who have heart disease or seizure disorders or who use alcohol or cocaine are especially vulnerable. Recommended preventive measures include shortening the time of exposure, lowering the temperature, establishing safety standards for covers and for baffles for suction outlets, and using warning notices.

[Supplementary history and occupational dermatologic evaluation of medical bath workers, masseurs, and physical therapists]

The various noxious agents to which these occupational groups can be exposed are described in detail. We have constructed a supplementary questionnaire to aid the occupational dermatologist in evaluating such individuals. We describe measures for skin protection, and methods for reduce exposure of harmful agents.

Control ofLegionella pneumophilaContamination in a Respiratory Hydrotherapy System With Sulfurous Spa Water

Objective.

To evaluate the effectiveness of different disinfection treatments in a spa water system contaminated byLegionella pneumophilaand associated with a case ofLegionellapneumonia.

Design.

During an 18-month period, the spa water was analyzed by taking samples from the well, the recirculation line, and the final distribution devices (nebulizers and nasal irrigators). Various attempts were made to eradicateLegionellaorganisms by chemical and thermal shock. The final protocol consisted of heat shock treatment at 70°C-75°C for 3 hours, 2 nights per week, followed by a lowering of the water temperature to 30°C ± 1°C for use in the plant. In addition, 3 times a week superheated steam (at a pressure of 1 atmosphere) was introduced for 1 hour into the nebulization machines.

Setting.

A spa at which sulfurous water was used for hydrotherapy by means of aerosol and nasal irrigation.

Patient.

A 74-year-old woman with legionnaires disease.

Results.

After the case of infection occurred,L. pneumophilawas isolated from the recirculation line at a concentration of 400,000 cfu/L and from the nebulizers and nasal irrigators at levels ranging from 3,300 to 1,800,000 cfu/L. The colonizing organisms consisted of a mixture ofL. pneumophilaserogroup 1 (12%) and serogroup 5 (88%). The shock treatment with chlorine dioxide and peracetic acid resulted in the eradication ofLegionellaorganisms from the recirculation line but not from the water generated from the final distribution devices. After the restructuring of the plant and the application of thermal shock protocol, an evaluation after 12 months revealed no evidence ofLegionellacontamination.

Conclusion.

To preventLegionellacolonization, disinfection treatment is effective if associated with carefully selected materials, good circuit design, and good maintenance practices.

Jacuzzi jet-induced pneumoperitoneum

Pneumoperitoneum outside the setting of recent surgical intervention usually indicates perforation of the gastrointestinal tract. Following radiologic evidence of pneumoperitoneum, surgical exploration of the abdomen may be indicated depending on the nature of the patient's presentation. We present the radiological findings of a healthy young woman who presented with acute onset of abdominal pain and was found to have extensive pneumoperitoneum. No visceral disruption was evident by multidetector CT or by single-contrast barium fluoroscopic evaluation of the upper gastrointestinal tract. Knowledge of benign causes of pneumoperitoneum by the radiologist may avert an unnecessary laparotomy.

Hydrotherapy pools of the future--the avoidance of health problems

The need to minimize the threat of infection to patients and the high incidence of health problems in hydrotherapy pool workers, have led to recommendations especially tailored to the design and operation of the water and air treatment plant of hydrotherapy pools. Hitherto unpublished surveys are detailed which confirm that pathogenic species of Pseudomonas aeruginosa in pools (in which ears may be wetted) cause a high incidence of otitis externa, but rarely cause body rashes (pseudomonas folliculitis) unless there has also been prolonged skin wetting. In brominated pools contact dermatitis is common and can be distinguished clinically from pseudomonas folliculitis by the onset of a pruritic rash less than 12 hours after exposure to the pool and reactivation of the rash on re-exposure to the brominated pool.