Uncertainty about cellulitis and unmet patient information needs: a mixed methods study in primary and secondary care

Background: Cellulitis is a painful infection of the skin and underlying tissues, commonly affecting the lower leg: approximately a third of people experience recurrence. Patients’ ability to recover from cellulitis or prevent recurrence is likely to be influenced by their understanding of the condition.Aim: To explore patients’ perceptions of cellulitis and their information needs.Design and Setting: Mixed methods study comprising semi‐structured, face‐to‐face interviews and a cross‐sectional survey, recruiting through primary care, secondary care and advertising.Methods: Adults aged 18 or over with a history of cellulitis were invited to take part in a survey, qualitative interview, or both.Results: Thirty interviews were conducted between August 2016 and July 2017. Qualitative data highlighted: (1) low awareness of cellulitis prior to first episode, 2) uncertainty around the time of diagnosis, 3) concern/surprise at the severity of cellulitis, 4) perceived insufficient information provision. People were surprised they had never heard of cellulitis and that they had not received advice or leaflets giving self‐care information. Some sought information from the internet and found this confusing. Two hundred and forty surveys were completed (response rate 17%). These showed that, while many participants had received information on the treatment of cellulitis (60.0%, n=144), they often reported receiving no information about causes (60.8%, n=146) or prevention of recurrence (73.3%, n=176).Conclusions: There is a need to provide information for people with cellulitis, particularly around (1) the name of their condition, (2) managing acute episodes and (3) reducing risk of recurrences

Upgrading Milk Productivity of Primiparous Buffaloes Using Glycogenic Precursors; Implications on Milk Production and Blood Biochemical Parameters

This study was performed to explore the effect of drenching propylene glycol (PG) and calcium propionate (CP) as a source of energy to primiparous Egyptian buffalo cows (Bubalus bubalis) on milk production and some blood biochemical parameters. Eighteen primiparous buffalo cows (8 weeks before calving) with an average live body weight (LBW) of 500±25kg and aged 35±5 months were used. Animals were classified to three comparable groups (6, each) based on (LBW), body condition scores and expected calving date. Animals in the 1stgroup served as a control (C), were drenched 3L of saline solution (NaCl 0.9%) without any additives, the animals in the 2nd group (PG) were drenched 300 mL of propylene glycol dissolved in 3L of a saline solution. In the 3rd group (CP), animals were drenched 335g of calcium propionate dissolved in 3L of a saline solution. Milk production and milk composition of primiparous buffalo cows were measured. Blood samples were collected from all buffalos for biochemical analysis. Results showed significant effects on average daily and total milk yield but no significant difference on milk composition. All blood biochemical parameters revealed no significant variation between treated and control groups except for plasma beta-hydroxy butyrate (BHB) and both T3 and T4 hormones concentrations. The overall mean of BHB in treated (PG) and (CP) was also lower (17.67 and 14.67 vs. 26) than control group. Overall mean of T3 concentration hormone was the lowest in control group represented 3.13 vs. 5.28 and 4.99 ng/ml) for (PG) and (CP) treated group. The highest overall mean of T4 concentration hormone was recorded in (CP) treated group represented 19.55 ng/ml. Concisely, the present results indicate that drenching (PG) and (CP) have a positive effect on the productive traits of primiparous Egyptian buffalo cows while, did not affect the blood biochemical parameters

Economic evaluation of the OSAC randomised controlled trial:oral corticosteroids for non-asthmatic adults with acute lower respiratory tract infection in primary care

ObjectiveTo estimate the costs and outcomes associated with treating non-asthmatic adults (nor suffering from other lung-disease) presenting to primary care with acute lower respiratory tract infection (ALRTI) with oral corticosteroids compared with placebo.DesignCost-consequence analysis alongside a randomised controlled trial. Perspectives included the healthcare provider, patients and productivity losses associated with time off work.SettingFifty-four National Health Service (NHS) general practices in England.Participants398 adults attending NHS primary practices with ALRTI but no asthma or other chronic lung disease, followed up for 28 days.Interventions2× 20 mg oral prednisolone per day for 5 days versus matching placebo tablets.Outcome measuresQuality-adjusted life years using the 5-level EuroQol-5D version measured weekly; duration and severity of symptom. Direct and indirect resources related to the disease and its treatment were also collected. Outcomes were measured for the 28-day follow-up.Results198 (50%) patients received the intervention (prednisolone) and 200 (50%) received placebo. NHS costs were dominated by primary care contacts, higher with placebo than with prednisolone (£13.11 vs £10.38) but without evidence of a difference (95% CI £3.05 to £8.52). The trial medication cost of £1.96 per patient would have been recouped in prescription charges of £4.30 per patient overall (55% participants would have paid £7.85), giving an overall mean ‘profit’ to the NHS of £7.00 (95% CI £0.50 to £17.08) per patient. There was a quality adjusted life years gain of 0.03 (95% CI 0.01 to 0.05) equating to half a day of perfect health favouring the prednisolone patients; there was no difference in duration of cough or severity of symptoms.ConclusionsThe use of prednisolone for non-asthmatic adults with ALRTI, provided small gains in quality of life and cost savings driven by prescription charges. Considering the results of the economic evaluation and possible side effects of corticosteroids, the short-term benefits may not outweigh the long-term harms.Trial registration numbersEudraCT 2012-000851-15 and ISRCTN57309858; Pre-results

Effect of oral prednisolone on symptom duration and severity in nonasthmatic adults with acute lower respiratory tract infection: a randomized clinical trial

Importance: Acute lower respiratory tract infection is common and often treated inappropriately in primary care with antibiotics. Corticosteroids are increasingly used but without sufficient evidence. Objective: To assess the effects of oral corticosteroids for acute lower respiratory tract infection in adults without asthma. Design, Setting, and Participants: Multicenter, placebo-controlled, randomized trial (July 2013 to final follow-up October 2014) conducted in 54 family practices in England among 401 adults with acute cough and at least 1 lower respiratory tract symptom not requiring immediate antibiotic treatment and with no history of chronic pulmonary disease or use of asthma medication in the past 5 years. Interventions: Two 20-mg prednisolone tablets (n = 199) or matched placebo (n = 202) once daily for 5 days. Main Outcomes and Measures: The primary outcomes were duration of moderately bad or worse cough (0 to 28 days; minimal clinically important difference, 3.79 days) and mean severity of symptoms on days 2 to 4 (scored from 0 [not affected] to 6 [as bad as it could be]; minimal clinically important difference, 1.66 units). Secondary outcomes were duration and severity of acute lower respiratory tract infection symptoms, duration of abnormal peak flow, antibiotic use, and adverse events. Results: Among 401 randomized patients, 2 withdrew immediately after randomization, and 1 duplicate patient was identified. Among the 398 patients with baseline data (mean age, 47 [SD, 16.0] years; 63% women; 17% smokers; 77% phlegm; 70% shortness of breath; 47% wheezing; 46% chest pain; 42% abnormal peak flow), 334 (84%) provided cough duration and 369 (93%) symptom severity data. Median cough duration was 5 days (interquartile range [IQR], 3-8 days) in the prednisolone group and 5 days (IQR, 3-10 days) in the placebo group (adjusted hazard ratio, 1.11; 95% CI, 0.89-1.39; P = .36 at an α = .05). Mean symptom severity was 1.99 points in the prednisolone group and 2.16 points in the placebo group (adjusted difference, −0.20; 95% CI, −0.40 to 0.00; P = .05 at an α = .001). No significant treatment effects were observed for duration or severity of other acute lower respiratory tract infection symptoms, duration of abnormal peak flow, antibiotic use, or nonserious adverse events. There were no serious adverse events. Conclusions and Relevance: Oral corticosteroids should not be used for acute lower respiratory tract infection symptoms in adults without asthma because they do not reduce symptom duration or severity

Economic evaluation of the OSAC randomised controlled trial: Oral corticosteroids for non-asthmatic adults with acute lower respiratory tract infection in primary care

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ. Objective To estimate the costs and outcomes associated with treating non-asthmatic adults (nor suffering from other lung-disease) presenting to primary care with acute lower respiratory tract infection (ALRTI) with oral corticosteroids compared with placebo. Design Cost-consequence analysis alongside a randomised controlled trial. Perspectives included the healthcare provider, patients and productivity losses associated with time off work. Setting Fifty-four National Health Service (NHS) general practices in England. Participants 398 adults attending NHS primary practices with ALRTI but no asthma or other chronic lung disease, followed up for 28 days. Interventions 2× 20 mg oral prednisolone per day for 5 days versus matching placebo tablets. Outcome measures Quality-adjusted life years using the 5-level EuroQol-5D version measured weekly; duration and severity of symptom. Direct and indirect resources related to the disease and its treatment were also collected. Outcomes were measured for the 28-day follow-up. Results 198 (50%) patients received the intervention (prednisolone) and 200 (50%) received placebo. NHS costs were dominated by primary care contacts, higher with placebo than with prednisolone (£13.11 vs £10.38) but without evidence of a difference (95% CI £3.05 to £8.52). The trial medication cost of £1.96 per patient would have been recouped in prescription charges of £4.30 per patient overall (55% participants would have paid £7.85), giving an overall mean 'profit' to the NHS of £7.00 (95% CI £0.50 to £17.08) per patient. There was a quality adjusted life years gain of 0.03 (95% CI 0.01 to 0.05) equating to half a day of perfect health favouring the prednisolone patients; there was no difference in duration of cough or severity of symptoms. Conclusions The use of prednisolone for non-asthmatic adults with ALRTI, provided small gains in quality of life and cost savings driven by prescription charges. Considering the results of the economic evaluation and possible side effects of corticosteroids, the short-term benefits may not outweigh the long-term harms. Trial registration numbers EudraCT 2012-000851-15 and ISRCTN57309858; Pre-results

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

What treatments are most effective for tinea? [Q&A feature]

In this month’s Acta Eruditorum column, Physician Editor Abby S. Van Voorhees, MD, talks with Dr. Magdy El-Gohary about his recent Cochrane Database of Systematic Reviews article, “Topical Antifungal Treatments for Tinea Cruris and Tinea Corporis.

ASSESSMENT OF DIAGNOSTIC TECHNIQUES OF URINARY TUBERCULOSIS

Khalid Ghaleb a,* , Magdy Afifib, Mohamad El-Gohary c aDepartment of Medical Laboratories, Faculty of Applied Medical Science, King Khalid University, Bisha 551, Saudia Arabia bDepartment of Botany and Microbiology, Faculty of Science, Al-Azhar University, Assuit 71524, Egypt cDepartment of Internal Medicine, Faculty of Medicine, Al-Azhar University, Assuit, Egypt • The corresponding author e-mail: [email protected] Current Tel: 00966595388496 Saudia,  00201119338055 Egypt The place of the study worked : Department of Botany and Microbiology, Faculty of Science, Al-Azhar University, Assuit 71524, Egypt, e-mail: [email protected]  Tel: 00201006554961 Abstract Early diagnosis of active tuberculosis remains an elusive challenge. In addition, one third of the world's population is latently infected with Mycobacterium tuberculosis (Mtb) and up to 10% of infected individuals develop tuberculosis (TB) in their lifetime. In this investigation, the incidence of urinary tuberculosis among renal patients was studied. Three hundreds urine samples were processed for detection of Mtb by Ziehl-Neelson (ZN) smear examination, Lowenstein Jensen (LJ) medium, radiometric BACTEC460 system as well as polymerase chain reaction (PCR) and DNA Enzyme Immunoassay (DEIA) test.  Out of 300 urine samples, 2 were positive by both  ZN smears and LJ medium with incidence rate of 0.66 %, 3 positive samples by BACTEC460 culture system with incidence of 1%. PCR assay gave more positive results than smear and culture examination (i.e. 8 positive samples with incidence  rate of 2.6%).  The specificities were 25% for both ZN smears and LJ medium, 37.5% for BACTEC460 culture system, and 100% for PCR test, while  sensitivities of all assays were 100%. Thus PCR is a rapid and sensitive method for the early diagnosis of urinary tuberculosis.   Keywords: List of abbreviations:Acid Fast Bacilli (AFB)-Base pair (bp)-DNA Enzyme Immunoassay (DEIA)  -Extrapulmonary Tuberculosis (EPTB)-International Union Against Tuberculosis  (IUAT)-Lowenstein Jensen (LJ)-Mycobacterium tuberculosis (Mtb) -Polymerase Chain Reaction (PCR)-Tuberculosis (TB)-Urinary Tuberculosis (UTB-Urogenital Tuberculosis (UGTB)-Ziehl-Neelson (ZN

Transient elastography in patients at risk of liver fibrosis in primary care: a follow-up study over 54 months

Background Liver fibrosis assessment services using transient elastography are growing in primary care. These services identify patients requiring specialist referral for liver fibrosis, and provide an opportunity for recommending lifestyle change. However, there are uncertainties regarding service design, effectiveness of advice given, and frequency of follow-up.Aims To assess: a) effectiveness of standard care lifestyle advice for weight management and alcohol consumption; b) uptake for liver rescan; c) usefulness of a 4.5-year time interval of rescanning in monitoring progression of liver fibrosis. Design and setting Analysis of patient outcomes 4.5 years after first ‘liver service’ attendance that included transient elastography in five GP practices in Southampton, UK. Methods Outcomes included weight, alcohol consumption, rescan uptake, time interval between scans and change in liver fibrosis stage.Results 401 participants were re-contacted. Mean±SD weight loss was 1.2kg±8.4kg (p=0.005), alcohol AUDIT grade increased by 7.8% (p=&lt;0.001). 116/401 participants were eligible for liver rescanning. 59/116 (50.9%) agreed to undergo rescanning. Mean±SD time interval between scans was 53.6±3.4 months. Liver fibrosis progressed from mild (≥6.0kPa-8.1kPa) to significant fibrosis (8.2kPa-9.6kPa) in 3.4% of patients; from mild to advanced fibrosis (9.7kPa-13.5kPa)/cirrhosis (≥13.6kPa) in 15.3% of patients, and did not progress in 81.3%. No baseline factors were independently associated with liver fibrosis progression at follow-up.Conclusion Rescan recall attendance and adherence to lifestyle changes needs improving. Optimum time interval between scans remains uncertain.  After a mean interval of 53.6 months between scans, and with no specific predictors indicated, a substantial minority (18.7%) experienced a deterioration in fibrosis grade. <br/