139. Improving Skin and Soft Tissue Infection Antibiotic Duration Concordance with National Guidelines in Pediatric Urgent Care Clinics

Abstract Background Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. Children with SSTIs often receive > 7 days of antibiotics, although current guidelines recommend 5-7 days for most diagnoses. At Children’s Mercy Hospital (CMH) urgent care clinics (UCC), only 58% patients received the recommended 5-7 days of antibiotics. We aimed to increase the percentage of patients receiving 5-7 days of oral antibiotics for SSTIs from 58% to 75% by December 31st, 2021. Methods We formed a multidisciplinary team in April 2020. A provider survey assessed factors influencing prescribing habits. We completed cause-and-effect analyses and developed a driver diagram (Figure 1). Interventions were chosen based on the potential for highest impact and lowest effort. Our first Plan-Do-Study-Act (PDSA) cycle provided an update on current guidelines for UCC providers. The second PDSA cycle updated prescription sentences in the electronic health record (EHR) and organized them from shortest to longest duration. The third PDSA cycle provided a project update via email to UCC providers. Our outcome measure is the percentage of patients receiving 5-7 days of antibiotics for SSTIs. Process measure is the number of updated prescriptions used. Balancing measure is the number of patients returning for SSTI within 14 days of their visit. Results are displayed using a run chart. Results After initiation of the project in April 2020, the percentage of patients receiving 5-7 days of antibiotics increased to 68% (Figure 2). This percentage increased to our goal of 75% after the 1st PDSA cycle (October-December 2020), 80% following the second PDSA cycle in February 2021, and 90% following the third PDSA cycle in April 2021. There was no change in balancing measure numbers. Run Chart Conclusion Prior to our project, only 58% of children seen in CMH UCCs for SSTIs received the recommended antibiotic duration. By addressing the primary drivers uncovered through QI methodology, we surpassed our goal of 75%. Additional PDSA cycles are planned along with expansion to other departments. This work will allow us to expand antibiotic stewardship efforts to other infectious diagnoses as well. Disclosures Brian R. Lee, PhD, MPH , Merck (Grant/Research Support)Pfizer (Grant/Research Support)

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#4: Antibiotic Durations for Skin and Soft Tissue Infections in Pediatric Urgent Care Clinics

Journal of the Pediatric Infectious Diseases Society ◽

10.1093/jpids/piab031.009 ◽

2021 ◽

Vol 10 (Supplement_2) ◽

pp. S6-S6

Author(s):

Megan Hamner ◽

Amanda Nedved ◽

Holly Austin ◽

Donna Wyly ◽

Alaina Burns ◽

...

Keyword(s):

Soft Tissue ◽

Antibiotic Stewardship ◽

Day Treatment ◽

Topical Therapy ◽

Urgent Care ◽

Ambulatory Setting ◽

Soft Tissue Infections ◽

Mild Improvement ◽

Common Diagnosis ◽

Antibiotic Duration

Abstract Background Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. However, most antibiotic stewardship programs have mainly focused on the latter. Children seen in the ambulatory setting for SSTIs often receive >7 days of antibiotics, although current society guidelines recommend 5–7 days for most diagnoses. Objectives To determine the baseline percentage of patients receiving antibiotic prescriptions for >7 days for SSTIs in urgent care clinics (UCC)s of a pediatric health system and to evaluate factors that influence providers towards longer durations. Methods We built a report that extracted patient encounters from the three UCCs based on International Classification of Diseases (ICD)-10 codes for common SSTIs including impetigo, abscesses, cellulitis, erysipelas, folliculitis, paronychia, and animal bites. Data was pulled from June 2019 through June 2020. The report included patient age, concomitant diagnoses, antibiotics prescribed and their duration. We excluded encounters if the patient was transferred to the emergency department or admitted, the patient was younger than 3 months of age, no antibiotics were prescribed, or if there was a concurrent infectious diagnosis affecting antibiotic duration. We sent a 22-question survey to UCC providers to understand prescribing habits particularly focusing on factors prompting administration of longer antibiotic courses. Findings From June 2019-June 2020, we reviewed 2,575 encounters; we excluded 208 of those (8%). 823 (35%) of patients received >7 days of antibiotics for SSTIs while 1181 (50%) received 5–7 days and 35 (1%) received <5 days of antibiotics. 328 (14%) received topical therapy only. Most common antibiotics prescribed included cephalexin, clindamycin, and trimethoprim-sulfamethoxazole. A mild improvement in the 5–7 days duration was noted through our study period (Figure 1). The survey was sent to 50 providers with 27 responding (54% response rate). Of providers surveyed, 5 (19%), 7 (26%), and 8 (29%), expressed being uncomfortable with a 5-day treatment course for cellulitis, erysipelas, and abscesses respectively. Barriers for shorter treatment courses included concern for acute rheumatic fever development, parental pressure, fear of complications, and accustomed antibiotic duration. Conclusion A third of children with SSTIs in our UCCs receive long courses of antibiotics. A mild improvement noted in our study period may be due to existing antibiotic stewardship interventions. Specific provider concerns leading to overprescribing will be targeted by quality improvement efforts.

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The burden of bone, native joint and soft tissue infections on orthopaedic emergency referrals in a city hospital

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2015.0050 ◽

2016 ◽

Vol 98 (1) ◽

pp. 34-39 ◽

Cited By ~ 1

Author(s):

A Howell ◽

S Parker ◽

K Tsitskaris ◽

MJ Oddy

Keyword(s):

Soft Tissue ◽

Length Of Stay ◽

Soft Tissue Infection ◽

Tissue Infection ◽

City Hospital ◽

Soft Tissue Infections ◽

Suspected Infection ◽

Number Of Patients ◽

Common Diagnosis ◽

Prosthetic Joint Infections

Introduction Bone, native joint and soft tissue infections are frequently referred to orthopaedic units although their volume as a proportion of the total emergency workload has not been reported previously. Geographic and socioeconomic variation may influence their presentation. The aim of this study was to quantify the burden of such infections on the orthopaedic department in an inner city hospital, determine patient demographics and associated risk factors, and review our current utilisation of specialist services. Methods All cases involving bone, native joint and soft tissue infections admitted under or referred to the orthopaedic team throughout 2012 were reviewed retrospectively. Prosthetic joint infections were excluded. Results Almost 15% of emergency admissions and referrals were associated with bone, native joint or soft tissue infection or suspected infection. The cohort consisted of 169 patients with a mean age of 43 years (range: 1–91 years). The most common diagnosis was cellulitis/other soft tissue infection and the mean length of stay was 13 days. Two-thirds of patients (n=112, 66%) underwent an operation. Fifteen per cent of patients were carrying at least one blood borne virus, eleven per cent were alcohol dependent, fifteen per cent were using or had been using intravenous drugs and nine per cent were homeless or vulnerably housed. Conclusions This study has shown that a significant number of patients are admitted for orthopaedic care as a result of infection. These patients are relatively young, with multiple complex medical and social co-morbidities, and a long length of stay.

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OP0182 PROTEOGLYCAN LOSS IN ARTICULAR CARTILAGE IS ASSOCIATED WITH JOINT INFLAMMATION SEVERITY IN PSORIATIC ARTHRITIS – A COMPOSITIONAL MAGNETIC RESONANCE IMAGING STUDY

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.5557 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 113.2-113

Author(s):

P. Sewerin ◽

D. Abrar ◽

S. Nebelung ◽

M. Frenken ◽

T. Ulrich ◽

...

Keyword(s):

Psoriatic Arthritis ◽

Bone Erosion ◽

Joint Inflammation ◽

Resonance Imaging ◽

Research Support ◽

Weighted Image ◽

The Third ◽

Deutschland Gmbh ◽

Pip Joint ◽

Flexor Tenosynovitis

Background:Even though cartilage loss is a known feature of psoriatic arthritis (PsA), little is known about its role in the pathogenesis of PsA. Using delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) as a non-invasive marker of the tissue’s proteoglycan content, such early (i.e. pre-morphological) changes have been associated with inflammation in rheumatoid arthritis (RA). Yet, this association has not been studied before in PsA.Objectives:Is the severity of local joint inflammation associated to local proteoglycan loss in PsA patients?Methods:Metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints of 17 patients with active PsA were evaluated by high-resolution clinical standard morphological and dGEMRIC sequences using a 3T MRI scanner (Magnetom Skyra, Siemens) and a dedicated 16-channel hand coil. Images were analyzed by two independent raters for dGEMRIC indices, PsA MRI scores (PsAMRIS) and total cartilage thickness (TCT). Kendall-Tau correlation coefficients (τ) were calculated.Results:We found significant negative correlations between dGEMRIC indices and total PsAMRIS (τ = -0.5, p= 0.012), synovitis (τ = -0.56, p= 0.006), flexor tenosynovitis (τ = -0.4, p= 0.049), and periarticular inflammation (τ = -0.72, p< 0.001). Significant positive correlations were found between TCT and dGEMRIC indices in all joint levels (τ = 0.43, p<0.001). No significant correlations were determined between dGEMRIC indices and bone erosion, bone edema or bone proliferation.Conclusion:In PsA, proteoglycan loss as assessed by dGEMRIC is associated with periarticular inflammation, synovitis, and flexor tenosynovitis, but not with bone erosion or proliferation, thereby highlighting the need for effective anti-inflammatory treatment regimes. Beyond morphology, advanced MRI techniques may be used to assess cartilage composition in PsA and to identify early changes in cartilage as an imaging biomarker with potential application in detection and monitoring of PsA.Figure 1Right hand of a 26-year-old male with psoriatic arthritis Coronal STIR image (A) of digits 1-5, transversal fat-saturated (fs) T2-weighted image of digits 2-4 (B) and the corresponding transversal fs contrast-enhanced T1-weighted image (C) at the distal portion of the proximal phalanges. Horizontal white bar in (A) indicates level of transversal slices (B) & (C). Sagittal fs Proton Density-weighted image of the third digit (D). A: Increased signal at the collateral ligaments and synovitis of the proximal interphalangeal (PIP) joint of the third digit (white arrow). Periarticular inflammation around the PIP joint and the body of the proximal phalanx of the third digit (arrowhead). B & C: Extensive flexor tenosynovitis (asterix) and periarticular inflammation in the subcutaneous tissues (arrowhead) alongside thickened flexor tendon pulleys (arrow). D & E: Representative sagittal T1-weighted images of the MCP, PIP and DIP joint of the 3rd digit. Following iv contrast administration and appropriate delay of 40 min, A gives the morphological T1 map, while B gives the corresponding parameter map with dGEMRIC values [ms] overlaid. Note the significant decrease in dGEMRIC indices of the PIP joint as compared to the MCP joint.Disclosure of Interests:Philipp Sewerin Grant/research support from: AbbVie Deutschland GmbH & Co. KGBristol-Myers Squibb Celgene GmbHLilly Deutschland GmbHNovartis Pharma GmbH Pfizer Deutschland GmbHRheumazentrum Rhein-Ruhr, Consultant of: AMGEN GmbH AbbVie Deutschland GmbH & Co. KG Biogen GmbHBristol-Myers Squibb Celgene GmbH Chugai Pharma arketing Ltd. / Chugai Europe GmbHHexal Pharma Janssen-CilagGmbH Johnson & Johnson Deutschland GmbHLilly Deutschland GmbH / Lilly Europe / Lilly Global Novartis Pharma GmbH Pfizer Deutschland GmbH Roche Pharma Rheumazentrum Rhein-Ruhr Sanofi-Genzyme Deutschland GmbH Swedish Orphan Biovitrum GmbH UCB Pharma GmbH, Speakers bureau: AMGEN GmbH AbbVie Deutschland GmbH & Co. KG Biogen GmbHBristol-Myers Squibb Celgene GmbH Chugai Pharma arketing Ltd. / Chugai Europe GmbHHexal Pharma Janssen-CilagGmbH Johnson & Johnson Deutschland GmbHLilly Deutschland GmbH / Lilly Europe / Lilly Global Novartis Pharma GmbH Pfizer Deutschland GmbH Roche Pharma Rheumazentrum Rhein-Ruhr Sanofi-Genzyme Deutschland GmbH Swedish Orphan Biovitrum GmbH UCB Pharma GmbH, Daniel Abrar: None declared, Sven Nebelung: None declared, Miriam Frenken: None declared, Tim Ulrich: None declared, Karl Ludger Radke: None declared, Gerald Antoch: None declared, Stefan Vordenbäumen: None declared, Ralph Brinks: None declared, Matthias Schneider Grant/research support from: GSK, UCB, Abbvie, Consultant of: Abbvie, Alexion, Astra Zeneca, BMS, Boehringer Ingelheim, Gilead, Lilly, Sanofi, UCB, Speakers bureau: Abbvie, Astra Zeneca, BMS, Chugai, GSK, Lilly, Pfizer, Sanofi, Benedikt Ostendorf: None declared, Christoph Schleich: None declared

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67 The Evolution of A Frailty Service

Age and Ageing ◽

10.1093/ageing/afab030.28 ◽

2021 ◽

Vol 50 (Supplement_1) ◽

pp. i12-i42

Author(s):

C Abbott ◽

K Bishop ◽

F Hill ◽

C Finlow ◽

R Maraj

Keyword(s):

Cost Effectiveness ◽

Patient Outcomes ◽

Local Population ◽

Management Team ◽

Pdsa Cycle ◽

North Wales ◽

Number Of Patients ◽

Constant State ◽

Clinical Resource ◽

Improve Patient

Abstract Introduction In September 2017 our frailty service was started within our medium sized DGH in North Wales. Working with our management team we secured a significant clinical resource including: We describe how resources, setting and staffing develop over a 2 year period in order to create a service which meets the needs of the local population. Method The service has been in a constant state of development since it has been in operation, utilising a PDSA model with regular meetings of clinical and managerial staff to analyse performance. Results With each new PDSA cycle the amount of patients reviewed has increased. With the move to AMU we increased the monthly number of patients reviewed from 29 to 172 patients reviewed, 97 of which were discharged directly from the unit. Conclusion Using QI methodology our Frailty Service has improved dramatically since its inception. We will continue to analyse how we work to improve patient outcomes and cost effectiveness.

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Prevalence of Psychological Distress and Its Risk Factors in Patients with Primary Bone and Soft Tissue Tumors

Healthcare ◽

10.3390/healthcare9050566 ◽

2021 ◽

Vol 9 (5) ◽

pp. 566

Author(s):

Masato Ise ◽

Eiji Nakata ◽

Yoshimi Katayama ◽

Masanori Hamada ◽

Toshiyuki Kunisada ◽

...

Keyword(s):

Risk Factors ◽

Psychological Distress ◽

Soft Tissue ◽

Rating Scale ◽

Numeric Rating Scale ◽

Soft Tissue Tumors ◽

Number Of Patients ◽

Primary Bone ◽

Associated Risk Factors ◽

Numeric Rating

Psychological distress is common in patients with soft tissue and bone tumors. We first investigated its frequency and the associated risk factors in patients with pre-operative bone and soft tissue tumors. Participants included 298 patients with bone and soft tissue tumors who underwent surgery in our institution between 2015 and 2020. Psychological distress was evaluated by the Distress and Impact Thermometer (DIT) that consists of two types of questions (questions about the severity of the patient’s distress (DIT-D) and its impact (DIT-I)). We used a cut-off point of 4 on the DIT-D and 3 on the DIT-I for screening patients with psychological distress. We therefore investigated: (1) the prevalence of psychological distress as assessed with DIT or distress thermometer (DT), which can be decided by DIT-D ≥ 4, (2) what are the risk factors for the prevalence of psychological distress, and (3) what is the number of patients who consulted a psychiatrist for psychological distress in patients with pre-operative bone and soft tissue tumors. With DIT and DT, we identified 64 patients (21%) and 95 patients (32%), respectively, with psychological distress. Multivariate logistic regression revealed that older age, sex (female), malignancy (malignant or intermediate tumor), a lower Barthel Index, and higher numeric rating scale were risk factors for psychological distress. Two patients (3%) consulted a psychiatrist after surgery. In conclusion, careful attention to psychological distress is needed, especially for female patients, older patients, and those with malignant soft or bone tissue tumors who have more than moderate pain.

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P189 Comparison of secukinumab versus adalimumab efficacy on skin outcomes in psoriatic arthritis: 52-week results from the EXCEED study

Rheumatology ◽

10.1093/rheumatology/keab247.184 ◽

2021 ◽

Vol 60 (Supplement_1) ◽

Author(s):

Alice Gottlieb ◽

Frank Behrens ◽

Peter Nash ◽

Joseph F Merola ◽

Pascale Pellet ◽

...

Keyword(s):

Psoriatic Arthritis ◽

Missing Data ◽

Multiple Imputation ◽

Plaque Psoriasis ◽

Stock Ownership ◽

Research Support ◽

Acr20 Response ◽

Number Of Patients ◽

Pasi Score ◽

To Receive

Abstract Background/Aims Psoriatic arthritis (PsA) is a heterogeneous disease comprising musculoskeletal and dermatological manifestations, especially plaque psoriasis. Secukinumab, an interleukin17A inhibitor, provided significantly greater PASI75/100 responses in two head-to-head trials versus etanercept or ustekinumab, a tumour necrosis factor inhibitor (TNFi), in patients with moderate-to-severe plaque psoriasis. The EXCEED study (NCT02745080) investigated whether secukinumab was superior to adalimumab, another TNFi, as monotherapy in biologic-naive active PsA patients with active plaque psoriasis (defined as having ≥1 psoriatic plaque of ≥ 2 cm diameter, nail changes consistent with psoriasis or documented history of plaque psoriasis). Here we report the pre-specified skin outcomes from the EXCEED study in the subset of patients with ≥3% body surface area (BSA) affected with psoriasis at baseline. Methods In this head-to-head, Phase 3b, randomised, double-blind, active-controlled, multicentre, parallel-group trial, patients were randomised to receive subcutaneous secukinumab 300 mg at baseline and Weeks 1-4, followed by dosing every 4 weeks until Week 48, or subcutaneous adalimumab 40 mg at baseline followed by the same dosing every 2 weeks until Week 50. The primary endpoint was superiority of secukinumab versus adalimumab on ACR20 response at Week 52. Pre-specified outcomes included the proportion of patients achieving a combined ACR50 and PASI100 response, PASI100 response, and absolute PASI score ≤3. Missing data were handled using multiple imputation. Results Overall, 853 patients were randomised to receive secukinumab (n = 426) or adalimumab (n = 427). At baseline, 215 and 202 patients had at least 3% BSA affected with psoriasis in the secukinumab and adalimumab groups, respectively. At Week 52, more patients achieved simultaneous improvement in ACR50 and PASI100 response with secukinumab versus adalimumab (30.7% versus 19.2%, respectively; P = 0.0087). Greater efficacy was demonstrated for secukinumab versus adalimumab for PASI100 responses and for the proportion of patients achieving absolute PASI score ≤3 (Table 1). Conclusion In this pre-specified analysis, secukinumab provided higher responses compared with adalimumab in achievement of combined improvement in joint and skin disease (combined ACR50 and PASI100 response) and in skin-specific endpoints (PASI100 and absolute PASI score ≤3) at Week 52. P189 Table 1:Skin-specific outcomes at Week 52Endpoints, % responseSEC 300 mg (N = 215)ADA 40 mg (N = 202)P value (unadjusted)PASI10046300.0007Combined ACR50 and PASI10031190.0087Absolute PASI score ≤379650.0015P value vs ADA; unadjusted P values are presented. Multiple imputation was used for handling missing data. ADA, adalimumab; ACR, American College of Rheumatology; N, number of patients in the psoriasis subset; PASI, Psoriasis Area and Severity Index; SEC, secukinumab. Disclosure A. Gottlieb: Grants/research support; A.G. has received research support, consultation fees or speaker honoraria from Pfizer, AbbVie, BMS, Lilly, MSD, Novartis, Roche, Sanofi, Sandoz, Nordic, Celltrion and UCB. F. Behrens: Consultancies; F.B. is a consultant for Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer Ingelheim, Janssen, MSD, Celgene, Roche and Chugai. Grants/research support; F.B. has received grant/research support from Pfizer, Janssen, Chugai, Celgene, Lilly and Roche. P. Nash: Consultancies; P.N. is a consultant for AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer Inc., Roche, Sanofi and UCB. Member of speakers’ bureau; for AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, MSD, Novartis, Pfizer Inc., Roche, Sanofi and UCB. Grants/research support; P.N. has received research support from AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, MSD, Novartis, Pfizer Inc, Roche, Sanofi and UCB. J. Merola: Consultancies; J.F.M. is a consultant for Merck, AbbVie, Dermavant, Eli Lilly, Novartis, Janssen, UCB Pharma, Celgene, Sanofi, Regeneron, Arena, Sun Pharma, Biogen, Pfizer, EMD Sorono, Avotres and LEO Pharma. P. Pellet: Corporate appointments; P.P. is an employee of Novartis. Shareholder/stock ownership; P.P. is a shareholder of Novartis. L. Pricop: Corporate appointments; L.P. is an employee of Novartis. Shareholder/stock ownership; L.P. is a shareholder of Novartis. I. McInnes: Consultancies; I.M. is a consultant for AbbVie, Bristol Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer and UCB. Grants/research support; I.M. has received grant/research support from Bristol Myers Squibb, Celgene, Eli Lilly and Company, Janssen and UCB.

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COMBINED IMMUNIZATION AGAINST DIPHTHERIA, TETANUS AND PERTUSSIS IN NEWBORN INFANTS

PEDIATRICS ◽

10.1542/peds.3.2.181 ◽

1949 ◽

Vol 3 (2) ◽

pp. 181-194

Author(s):

PAUL A. DI SANT'AGNESE

Keyword(s):

Booster Dose ◽

Newborn Infants ◽

Active Immunization ◽

Striking Difference ◽

Tetanus Antitoxin ◽

The Third ◽

Number Of Patients ◽

Diphtheria Antitoxin ◽

Antibody Titers ◽

One Year

Additional serologic studies are presented of a group of newborn infants whose antibody production following combined prophylactic inoculation against tetanus, diphtheria and pertussis was reported in a previous paper. Duration of Antibody Titers: In the 10 months following the last injection of triple combined antigen a steady decline in diphtheria antitoxin titers was observed which was more marked in patients who had achieved high antibody levels. A similar decrease was found in the percentage of infants with high titers of tetanus antitoxin, but there were no cases whose tetanus antitoxin level dropped to less than the "protective" titer (0.1 unit/cc.). Progressive decrease in diphtheria and tetanus antitoxin titers with passage of time is in agreement with findings of others. After the third and last immunizing injection, a rapid initial decrease was noted in the number of patients with "protective" pertussis agglutinin titers (1:400 or higher); then a levelling off took place and no further change was noted in the next six months. On the other hand, a steady decline was found in the percentage of infants with "high" agglutinin levels (1:3200). To our knowledge this has not been observed before. The young age of our patients at the time of the basic injections may have been responsible for the findings. Antibody Titers After Booster Dose: One group of infants was reinjected at the age of six months (four months after the third and last immunizing injection), another group at one year of age (10 months after the last injection). All booster doses consisted of 0.5 cc. of the same triple combined antigen used in basic immunization. After booster a marked increase was noted in diphtheria antitoxin titers to a level higher than that observed following the basic immunizing injections. Tetanus antitoxin response was considered to have been equally good, although more difficult to evaluate because of the high antitoxin levels present before reinjection. In the case of pertussis agglutinins, it appeared as if there were a "ceiling" of about 60% of infants who could, even after reinjection, develop a "protective" agglutinin titer (1:400 or higher). A striking difference was observed in both pertussis agglutinin levels and diphtheria antitoxin titers achieved by infants reinjected at six months and one year of age. This was thought to be due to immaturity of the immune mechanisms in the younger age group. An added factor in the case of diphtheria antitoxin in some patients may have been the persistence of passive antibodies acquired transplacentally. Antibody titers also were determined six months after booster dose in the infants who had been reinjected at the age of six months. A marked decrease was observed in the percentage of patients with "protective" pertussis agglutinin titers and "high" (1.0 unit/cc.) diphtheria antitoxin levels. No reduction was noted in tetanus antitoxin titers. Effects of Passive immunity to Diphtheria on Active immunization with Diphtheria Toxoid: With only one exception, all infants tested after a booster dose had been administered between 6 and 12 months of age had "protective" diphtheria antitoxin titers (0.03 units/cc. or more). Active immunization against diphtheria was therefore considered to have been achieved in all cases (with one exception) despite the passively transmitted antitoxin present at birth in over half the cases. While passive diphtheria antitoxin present at birth did not prevent "sensitization" of the antibody-forming tissues to the diphtheria antigen, it did decrease significantly the amounts of antitoxin actively produced in response to basic inoculation. Reasons for the success of active diphtheria immunization in this series are discussed. Arguments against active immunization of mothers in pregnancy for protection of their offspring are considered.

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‘CPR for Feet’ care bundle to improve foot assessment in inpatient diabetes

BMJ Open Quality ◽

10.1136/bmjoq-2017-000196 ◽

2018 ◽

Vol 7 (3) ◽

pp. e000196 ◽

Cited By ~ 1

Author(s):

Rhea O’Regan ◽

Ross MacDonald ◽

James G Boyle ◽

Katherine A Hughes ◽

Joyce McKenzie

Keyword(s):

Quality Improvement ◽

Nursing Staff ◽

Quality Improvement Project ◽

Care Bundle ◽

Staff Education ◽

Pressure Relief ◽

Improvement Project ◽

The Third ◽

Inpatient Diabetes ◽

Pdsa Cycle

AimsThe Scottish Inpatient Diabetes Foot Audit conducted in 2013 revealed that 57% of inpatients had not had their feet checked on admission, 60% of those at risk did not have pressure relief in place and 2.4% developed a new foot lesion. In response, the Scottish Diabetes Foot Action Group launched the ‘CPR for Feet’ campaign. The aim of this project was to raise awareness of the ‘Check, Protect and Refer’ (CPR) campaign as well as improve the assessment and management of inpatients with diabetes.MethodsA quality improvement project underpinned by Plan-Do-Study-Act (PDSA) methodology was undertaken. The first and second cycles focused on staff education and the implementation of a ‘CPR for Feet’ assessment checklist using campaign guidelines, training manuals and modules. The third and fourth cycles focused on staff feedback and the implementation of a ‘CPR for Feet’ care bundle.ResultsBaseline measurements revealed 28% of patients had evidence of foot assessment. Medical and nursing staff reported to be largely unaware of the ‘CPR for Feet’ campaign (13%). Fifty-two per cent of inpatients with diabetes had their feet assessed and managed correctly following the second PDSA cycle. After completion of the third and fourth PDSA this number improved further to 72% and all staff reported to be aware of the campaign.ConclusionsThe introduction of a ‘CPR for Feet’ care bundle improved the assessment of inpatients with diabetes.

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COLLOID CYST OF THE THIRD VENTRICLE

The Professional Medical Journal ◽

10.29309/tpmj/2010.17.01.2206 ◽

2010 ◽

Vol 17 (01) ◽

pp. 156-163

Author(s):

NAVEED ASHRAF ◽

MUHAMMAD AKMAL AZEEMI ◽

FAUZIA SAJJAD ◽

Asma Ghouri

Keyword(s):

Clinical Success ◽

Standard Procedure ◽

Third Ventricle ◽

Colloid Cyst ◽

Invasive Approach ◽

Keyhole Surgery ◽

The Third ◽

Number Of Patients ◽

Colloid Cysts ◽

Microsurgical Resection

Objectives: Cerebrospinal fluid shunting or microsurgical resection of the colloid cysts of the third ventricle have long been a standard treatment. The emergence of neuroendoscopy has lead to its application in various neurosurgical problems. Colloid cyst of the third ventricle is one such pathology where endoscopic treatment has been performed with great clinical success during the past decade. We now Although considered less efficacious than microsurgical excision endoscopic excision is less invasive and much simpler.Objectives: (1) to assess the extent of excision (2) to assess the morbid anatomy of the colloid cyst (3) to assess the risk of complications (4) to assess the functional outcome. Period: Eight years (Jul 2001-June 2009) Materials and Methods: Endoscopic resections of 15 colloid cysts of the third ventricle with obstruction of Foramina of Monroe in all cases. Results: Total removal was achieved in 10 (66.7%) cases. In 5 (33.3%) patients the colloid material was evacuated completely while the remnant of the capsule adherent to its origin was left behind. Two (13.3%) patients developed meningitis one week postoperatively and one diedsubsequently. Nine (60%) patients had excellent recovery as the symptoms were relieved during a period of 3 to 24 months. Five (33.3%) of the total patients required ventriculoperitoneal shunt for obstructivey drocephalus which developed with in 2 weeks after surgery. One out of the total number of patients deteriorated postoperatively on the existing neurological deficit. There has not been any recurrence until now with subtotal excision of the capsule. Conclusions: Keyhole surgery under endoscopic visual control offers an alternative, very effective minimally invasive approach for the excision of colloid cyst of the third ventricle and is likely to replace microsurgical resection as a standard procedure.

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Rehydration of Dried-Out Specimens: a New Approach

Collection Forum ◽

10.14351/0831-4985-34.1.73 ◽

2020 ◽

Vol 34 (1) ◽

pp. 73-86

Author(s):

F. Neisskenwirth

Keyword(s):

Water Vapor ◽

Soft Tissue ◽

Second Step ◽

Phosphate Solution ◽

Glycerol Solution ◽

New Approach ◽

The Third ◽

Demineralized Water ◽

Chemically Induced

Abstract Different procedures are proposed in the literature for the rehydration of dried-out specimens. These procedures vary greatly in their efficiency and application. This work describes a new procedure that is inspired by the literature but that avoids heating the specimens. This method was applied to reconditioning dried-out specimens from a historical collection (Swiss freshwater fishes, bird brains, and bird eyes), stored at the Naturhistorisches Museum Bern in Switzerland. The procedure consists of five steps. The first step is the softening of hardened soft tissue with benzaldehyde and demineralized water. The second step is an indirect rehydration with water vapor. The third step is a chemically induced direct hydration using a trisodium phosphate solution that allows the specimen to swell in size before being washed with water to remove all additives. Finally, the rehydrated specimen is transferred into new preserving fluid. Because the dehydrating properties of ethanol as a preservative are problematic, this paper presents the results of an experimental case study using a glycerol solution as a preservation fluid.

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