Children with medical complexity: a scoping review of interventions to support caregiver stress.

BACKGROUND: Caring for children with chronic and complex medical needs places extraordinary stress on parents and other family members. A scoping review was undertaken to identify and describe the full range of current interventions for reducing caregiver stress. METHODS: Applying a broad definition of caregiver stress, a systematic search of three scientific databases (CINAHL, Embase and Ovid Medline), a general internet search and hand searching of key peer-reviewed articles were conducted. Inclusion criteria were as follows: (i) published in English between 2004-2016; (ii) focused on familial caregivers, defined as parents, siblings or extended family; (iii) targeted children/youth with medical complexity between the ages of 1-24 years; and (iv) described an intervention and impact on caregiver stress. Data on type of intervention, study design and methods, measures and overall findings were extracted. RESULTS: Forty-nine studies were included from a list of 22 339 unique titles. Six domains of interventions were found: care coordination models (n = 23); respite care (n = 8); telemedicine (n = 5); peer and emotional support (n = 6); insurance and employment benefits (n = 4); and health and related supports (n = 3). Across studies, there was a wide variety of designs, outcomes and measures used. CONCLUSIONS: Positive findings of reductions in caregiver stress were noted within an emerging body of evidence on effective interventions for families of children with medical complexity. A commonality across domains was a significant focus on streamlining services and reducing the burden of care related to varied pressures experienced, including time, finances, care needs and service access, among others. There was non-conclusive evidence however around which of the six identified intervention domains or combination thereof are most effective for reducing stress. These promising findings demonstrate that stress reduction is possible with the right support and that multiple interventions may be effective in reducing burdens of care experienced by families of children with medical complexity.

The ASSURE study: HIV-1 suppression is maintained with bone and renal biomarker improvement 48 weeks after ritonavir discontinuation and randomized switch to abacavir/lamivudine + atazanavir.

OBJECTIVES: HIV treatment guidelines endorse switching or simplification of antiretroviral therapy in therapy-experienced patients with suppressed viraemia; ritonavir discontinuation may also enhance tolerability and reduce long-term adverse events (AEs). This open-label, multicentre, noninferiority study enrolled HIV-1-infected, treatment-experienced adults with confirmed HIV-1 RNA ≤ 75 HIV-1 RNA copies/mL currently receiving tenofovir/emtricitabine + atazanavir/ritonavir (TDF/FTC + ATV/r) for ≥ 6 months with no reported history of virological failure. METHODS: Participants were randomized 1:2 to continue current treatment or switch to abacavir/lamivudine + atazanavir (ABC/3TC + ATV). Endpoints included the proportion of participants with HIV-1 RNA < 50 copies/mL by time to loss of virological response (TLOVR), AEs, fasting lipids, and inflammatory, coagulation, bone and renal biomarkers. RESULTS: After 48 weeks, 76% (152 of 199) of ABC/3TC + ATV-treated and 79% (77 of 97) of TDF/FTC + ATV/r-treated participants had HIV-1 RNA < 50 copies/mL (TLOVR; P = 0.564). Other efficacy analyses yielded similar results. Rates of new grade 2-4 AEs were 45% in both groups, but an excess of hyperbilirubinaemia made the rate of treatment-emergent grade 3-4 laboratory abnormalities higher with TDF/FTC + ATV/r (36%) compared with ABC/3TC + ATV (19%). Most fasting lipid levels remained stable over time; high-density lipoprotein (HDL) cholesterol increased modestly in ABC/3TC + ATV-treated participants. Bone and renal biomarkers improved significantly between baseline and week 48 in participants taking ABC/3TC + ATV and were stable in participants taking TDF/FTC + ATV/r. No significant changes occurred in any inflammatory or coagulation biomarker within or between treatment groups. CONCLUSIONS: The ABC/3TC + ATV treatment-switch group had similar viral suppression rates up to 48 weeks to the TDF/FTC + ATV/r comparator group, with lower rates of moderate- to high-grade hyperbilirubinaemia and improvements in bone and renal biomarkers.

Risk factors for non-Escherichia coli community-acquired bacteriuria.

PURPOSE: Urinary tract infection (UTI) is one of the most common bacterial infections, with Escherichia coli causing up to 80 % of community-acquired bacteriuria (CA-Bu). The epidemiology and pathogenesis of E. coli have been intensively studied, yet, less is known about risk factors for CA-Bu due to other uropathogens. The purpose of this study was to clarify the latest knowledge. METHODS: A clinical epidemiological study among adult ambulatory patients was conducted. During November 2009, all urine cultures sent to our Microbiology Laboratory were evaluated, including demographic characteristics of the patients, underlying diseases and antibiotic treatment. Data were analysed by the SPSS statistical package. RESULTS: During the study period, 4,653 cultures were sent for evaluation. Of the 1,047 (22.5 %) that were positive, 838 were included in the study; 82.5 % were from females. E. coli was the most common pathogen, comprising 58.6 % of all positive cultures. By multivariate analysis, five independent risk factors were associated with non-E. coli CA-Bu: presence of foreign body in the urinary tract [odds ratio (OR) 5.8], nitrite urine test negative (OR 3.2), male gender (OR 2.5), normal erythrocyte count in urine test (OR 1.5) and recurrent UTI in the past year (OR 1.5). CONCLUSIONS: For adult outpatients presenting with CA-Bu, five independent factors suggesting the involvement of uropathogens other than E. coli were identified. These should be taken into consideration when empiric antibiotic treatment is prescribed.

Mycobacterium marinum skin infections. Report of 31 cases and review of the literature.

BACKGROUND: Mycobacterium marinum is a rare cause of skin infections, and its treatment has been based primarily on the personal experience and preferences of individual investigators without the benefit of large studies. METHODS: Thirty-one patients with confirmed M marinum infection were identified at 33 Kaiser Permanente Northern California Region medical centers by microbiologic records, and their charts were reviewed. RESULTS: The upper extremity was affected in 90% of cases, and lymphatic or local spread was seen during the initial examination or during observation in 25 patients (81%). Granuloma was present in 22 (63%) of 35 biopsy specimens, and staining for acid-fast bacteria yielded positive results in two of 22 specimens. Cure or improvement occurred in 22 (81%) of 27 patients in whom outcome could be evaluated. Treatment with ethambutol plus rifampin appeared more successful (effective in five [100%] of five cases) than minocycline treatment (effective in 10 [71%] of 14 cases), although not significantly so (P = .28). Adverse reactions, most of which were gastrointestinal, occurred in five patients (18%). CONCLUSION: Ethambutol plus rifampin appears more useful than minocycline in treating cutaneous M marinum infection. This result remains to be confirmed by larger clinical studies, which may be difficult because this infection is relatively rare.

Decision-making speed in HIV-1 infection: a preliminary report.

OBJECTIVES: To test the efficacy of reaction time measures derived from cognitive psychology as measures of subclinical cognitive slowing in individuals with HIV-1 infection. DESIGN: Cognitive slowing is the primary deficit in AIDS dementia. One measure of cognitive slowing is decision-making speed, the discrepancy between simple and choice reaction times, which represents an index of central information processing time. METHODS: Nineteen HIV-seropositive and 13 control subjects performed a detection and decision task in a reaction time procedure. All subjects were administered measures of simple and choice reaction time, a control measure of rate of verbal encoding, and measures of psychological distress. RESULTS: Compared with controls, both symptomatic and asymptomatic HIV-seropositive subjects had significantly longer decision times, but performed the control task of rate of encoding normally. Simple reaction times correlated significantly with depression scores, but choice reaction times were unrelated to psychological distress. CONCLUSIONS: The results support mental slowing as the initial cognitive disturbance of HIV-1 infection and emphasize potential use of reaction times as markers of central nervous system involvement in HIV-1 infection.

Perinephric abscess. Modern diagnosis and treatment in 47 cases.

The records of 47 patients with a perinephric abscess diagnosed from 1975 to 1986 at 8 San Francisco Bay Area hospitals were reviewed. The mean age was 51 years. Fifty-five percent were females and 45%, males. The left kidney was affected in 47% of cases, the right kidney in 40%, both in 4%, and a transplanted pelvic kidney in 9%. Fever (55%), chills or diaphoresis (47%), flank pain (40%), abdominal pain (40%), and nausea or vomiting (32%) were the most common presenting symptoms. About half the patients had symptoms for 1 week or less and 12% had no symptoms. Fever was documented before diagnosis in 88% of patients. Abdominal mass (13%) or tenderness (49%), and flank mass (9%) or tenderness (42%) were seen less frequently, and 11% of patients did not have fever, flank, or abdominal findings. The most frequent underlying conditions included previous urologic surgery (45%), previous urinary tract infection (38%), diabetes mellitus (36%), and urinary tract stones (36%). Cultures of perinephric abscesses yielded gram-negative aerobes in 52% of patients, primarily Escherichia coli. Staphylococcus aureus was isolated in 26% of patients and anaerobes in 17%. A single pathogen was isolated in 71% and multiple isolates in 29%. Of interest and great potential therapeutic importance was culture of anaerobes, primarily Bacteroides spp. in 17%, Enterococcus spp. in 7%, and Candida albicans in 7%. Positive blood and urine cultures identified perinephric abscess organisms exactly in 58% and 37% of cases, respectively. Routine laboratory tests such as the white blood cell count and urinalysis were insensitive and non-specific for perinephric abscess. Leukocytosis and anemia at admission were seen in slightly more than half of the patients. For radiologic diagnosis, computerized tomographic scanning was most helpful. Ultrasound and intravenous pyelography were falsely negative in about one-third of cases. Mortality (13%) was low in this series when compared with earlier studies, and probably reflects modern medical care. Six patients (13%) died during hospitalization, 2 of whom had diagnosis of PNA established only at autopsy. Drainage of the perinephric abscess was carried out by open surgical drainage in 64% of patients, percutaneous drainage in 19%, and both in 13%. The initial procedure, whether open surgical drainage or percutaneous catheter drainage, was usually successful. Late complications included nephrocutaneous fistulas in 3 patients and disseminated candidiasis in 1 patient.

Atypical presentations of Pneumocystis carinii pneumonia in patients receiving inhaled pentamidine prophylaxis.

Inhaled pentamidine is used commonly to prevent Pneumocystis carinii pneumonia (PCP) in patients with advanced human immunodeficiency virus infection. Case reports indicate that PCP can recur in patients who receive inhaled pentamidine and that clinical features may be atypical. To determine the magnitude of this problem, we reviewed retrospectively the medical records of patients with proven PCP during a 30-month period at two hospitals. Four (31 percent) of 13 patients with previous PCP who received inhaled pentamidine prophylaxis had recurrent P carinii infection, including one patient with widely metastatic extrapulmonary disease. Chest roentgenographic findings included cavities, pneumothoraces, bilateral and upper lobe interstitial infiltrates, and pleural effusion. False-negative bronchoalveolar lavage and induced sputum examinations were frequent. We conclude that recurrent PCP in patients maintained on a regimen of inhaled pentamidine prophylaxis occurs frequently, causes chest roentgenographic abnormalities other than interstitial infiltrates, and may be difficult to diagnose. Clinicians who choose to use this effective and convenient mode of prophylaxis should be aware of the problems attendant to its use.

Home intravenous antibiotic therapy programme, 1999.

OBJECTIVES: To evaluate the cost-effectiveness and safety of the Home Intravenous Antibiotic Therapy (HIAT) program in the district of Haifa and Western Galilee in Northern Israel. METHODS: We checked all the medical records of all the patients who had been treated at home with intravenous antibiotics during 1999. We reviewed the mean clinical diagnosis, aetiological agent, type of antibiotic given, complications and cost evaluation. RESULTS: During 1999, 250 patients received 284 courses of HIAT. The total duration of treatments was 3404 days; 61% of the patients were referred from clinical departments from one of the medical centres in our area. Soft-tissue infections and osteomyelitis were the most common clinical diagnoses at 40%. Pseudomonas aeruginosa was the most frequent pathogen presented and Ceftazidine the most common antimicrobial agent prescribed. The HIAT program saved $815 000 during 1999. Only minor complications were present. CONCLUSIONS: HIAT is effective, safe, comfortable for the patients, and has an important economical impact.

Posthospital care for older people: a collaborative solution.

This collaborative model of "short-term, long-term care" (Brody, 1987) for older persons returning home after a hospital stay involved three hospitals, a senior center, and an Area Agency on Aging. The program provided short-term (up to 6 weeks) case management and nonmedical, supportive services to elderly individuals, in their own homes, immediately following discharge from acute-care hospitals. Client satisfaction was high, costs were moderate, and only one-third of the clients required formal services after 6 weeks. The program was discontinued due to lack of funding.

[Hospital-at-home as a solution for the treatment requirements of acute exacerbation in multiple sclerosis].

Cooperation between the Multiple Sclerosis center at the Carmel medical center and the Hospital-at-Home (H.H) department of the continuing care unit in the Haifa and Western Galilee district of the Clalit Health Services has made it possible to give methylprednisolone intravenously to Multiple Sclerosis (M.S) patients during an acute exacerbation of the disease, in their home. In this study, we describe the joint work of the two centers. We have summarized 30 treatment courses given to 26 patients in their homes, following referral by the M.S. center, in the year 1999. The aims of the study included assessing satisfaction, safety and cost-effectiveness in a treatment course in the HH framework, as compared to the same treatment being conducted in the framework of hospitalization in various neurological departments, as was done in the past in the same group of patients. The expenses involved in HH for this group of patients were only 14% of the parallel treatment in the hospital (a savings of 86%). The treatment has proven to be extremely safe. There were no side-effects that required returning patients to the hospital, and the treatment was given in conditions of maximum comfort for the patient and his family. A telephone survey was conducted, which compared the satisfaction with the HH treatment, and the burden caused the patient's family to prior hospitalization for the same treatment. For all of the parameters examined, greater satisfaction was distinctly proven in the HH treatment. In light of these findings, we can conclude that giving methylprednisolone intravenously to M.S patients during an acute exacerbation, in the HH framework, is a safe and cost effective treatment, preferred by the patient and his family.

Seasonal variation in Escherichia coli bloodstream infections in northern Israel.

Seasonal variation in the infection rate with certain Gram-negative organisms has been previously described, but few studies have been published regarding Escherichia coli. The aim of this study was to investigate the incidence rate of E. coli bloodstream infection (BSI) and the association with temperature in different seasons in the Yizrael Valley. Positive blood cultures sent to the microbiology laboratory of Ha'Emek Medical Centre over a period of 8 years (January 2001 to December 2008) were included. The mean monthly temperature in the Yizrael Valley in the same period was compared with the monthly E. coli BSI rate. We divided the year into three periods: winter (December to February: mean temperature <15°C), transitional (March, April and November: mean temperature 15-19°C) and summer (May to October: mean temperature ≥20°C). In addition, we correlated the mean monthly antibiotic use in the same period measured as total defined daily doses for the whole regional population with E. coli BSI. During the study period, 2810 BSIs were recorded (35%E. coli). In 67.4% of the cases of E. coli bacteraemia, the source was urinary tract infection. The crude incidence of E. coli BSI was 4.1/1000 admissions. There was no difference in the number of cultures/month (mean: 29 ± 6). However, E. coli BSI was 19% and 21% more frequent in summer than in the transitional and winter seasons, respectively (p 0.01). The antibiotic consumption was significantly higher in the winter period. We found significantly higher rates of E. coli BSI in the summer period. Host, bacterial and ecological factors, together with high consumption of antibiotics during the winter season, could partially explain these findings.

Mannose-binding lectin in pre-menopausal women with recurrent urinary tract infections.

Mannose-binding lectin (MBL) comprises an oligomeric serum protein that is a member of the collectin class of the C-type lectin superfamily. Its deficiency is genetically determined and confers predisposition to recurrent infections as well as increased infection severity. This correlation has been demonstrated in recurrent furunculosis caused by Staphylococcus aureus, and in pneumococcal and Candida infections. The present study aimed to determine whether there is a correlation between MBL serum levels and recurrent urinary tact infections (UTI) in pre-menopausal women. The present aged-matched double-blind controlled study was conducted in 100 pre-menopausal adult women: 50 who suffered from recurrent UTI and 50 without UTI. The MBL concentration was measured in a single serum sample from each patient using an enzyme-linked immunosorbent assay. MBL serum levels [median (range)] were 2500 (4-12,000) ng/mL and 2105 (4-22,800) ng/mL for the research and control groups, respectively. The results from the two groups were compared and were not statistically different (p 0.4). According to these results, MBL serum levels are not associated with an increased risk for recurrent UTI in pre-menopausal women.

Candida albicans septic arthritis and osteomyelitis of the sternoclavicular joint in a patient with human immunodeficiency virus infection.

A 52-year-old intravenous drug user, seropositive for human immunodeficiency virus, developed Candida albicans fungemia and septic phlebitis due to an infected peripheral plastic intravenous catheter. Amphotericin B produced quick resolution of fungemia and systemic toxicity, but in the midst of treatment, after 647 mg of amphotericin B, he developed sternoclavicular osteomyelitis and arthritis due to Candida albicans. He responded well to surgical debridement and continuance of antifungal therapy. This is the only case to our knowledge of Candida albicans arthritis and osteomyelitis occurring either in a patient infected with human immunodeficiency virus or in the sternoclavicular joint.

Mycobacterium fortuitum infection in a patient with a penile prosthesis. Case report.

A 47-year-old male with a Mentor penile prosthesis presented with purulent drainage eight months after implantation. In addition to other organisms, routine cultures from the implant site yielded Mycobacterium fortuitum, an association never reported previously in the literature. Infection resolved with removal of the implant and antibiotic therapy.

Epstein-Barr virus causing encephalitis in an elderly woman.

Although infectious mononucleosis commonly afflicts young persons, it is now being described more frequently in the elderly. Neurologic manifestations are uncommon, and encephalitis is rare, especially in elderly patients. We have reported a case of acute Epstein-Barr virus infection causing acute encephalitis in a 64-year-old woman. Despite the severity of encephalitis, the patient recovered fully after several weeks.

Carumonam versus ceftazidime for urinary tract infections.

Carumonam is a new monobactam antibiotic with potent activity against gram-negative aerobes. To study the efficacy and safety of carumonam for treatment of complicated and uncomplicated urinary tract infections, 54 patients were randomized to therapy with either carumonam or ceftazidime. Of 42 patients who could be evaluated, 82% of the carumonam-treated patients and 80% of the ceftazidime-treated patients were cured clinically. At 5 to 9 days posttherapy, microbiologic criteria indicated that 13 carumonam-treated patients (48%) and 8 ceftazidime-treated patients (53%) were cured. Patients with indwelling bladder catheters at the end of therapy had a markedly worse microbiologic outcome than those without catheters. Enterococcus sp. reinfection was common in both groups. Possible adverse clinical and laboratory reactions occurred in six carumonam-treated patients (21%) and four ceftazidime-treated patients (27%). Most reactions occurred at the end of therapy and resolved with discontinuation of the study drug. In this small study, carumonam appeared as safe and as effective as ceftazidime for the treatment of complicated and uncomplicated urinary tract infections.

Osteomyelitis of the jaw in patients infected with the human immunodeficiency virus.

Eight patients with osteomyelitis of the jaw were identified at two county hospitals over a 4-year period. Three patients (37.5%) were found to be HIV-seropositive, including two patients not previously known to be HIV-seropositive. Signs and symptoms of infection were similar in both groups of patients, and commonly included fever, pain, and swelling. Radiographs showed specific findings of osteomyelitis in one of three HIV-seropositive patients and four of four seronegative patients with chronic jaw infection. HIV-seropositive patients appeared to have a worse clinical outcome than their seronegative counterparts. We conclude that osteomyelitis of the jaw may be the presenting manifestation of HIV infection, and that careful attention and close follow-up should be applied to such patients because of their poor overall clinical response.

Pneumococcal bacteremia as a marker for human immunodeficiency virus infection in patients without AIDS.

We retrospectively reviewed medical records of all adult patients with blood cultures positive for Streptococcus pneumoniae to determine the number of HIV seropositive patients in whom S pneumoniae bacteremia was the presenting manifestation. We also compared the clinical presentation, laboratory data, and outcome of pneumococcal bacteremia in patients who were HIV seropositive with patients with no risk factors for HIV infection. All adult patients with blood cultures positive for S pneumoniae from January 1987 through April 1989 at two acute care general hospitals in northern California were identified by review of microbiology data. One hospital served veterans, the other the indigent of a suburban area. Six (15%) of 41 patients with pneumococcal bacteremia were HIV seropositive; five were not known to be HIV seropositive before the onset of bacteremia, and the sixth was asymptomatic with respect to HIV infection. No patient with AIDS had pneumococcal bacteremia. HIV seropositive patients were significantly younger, had significantly fewer underlying diseases, and had fewer complications of pneumococcal bacteremia than bacteremic patients with no risk factors for HIV infection. Patients with pneumococcal bacteremia should be evaluated for HIV infection, especially in the absence of other underlying diseases that predispose to pneumococcal bacteremia.