Treatment of severe, chronic hand eczema: results from a UK-wide survey.

Treatment of severe hand eczema (HE) that is resistant to topical potent corticosteroid treatment is challenging. In 2013, we surveyed 194 UK dermatologists to obtain information about their usual treatment pathways to inform the choice of the comparator in a trial of alitretinoin in severe HE (ALPHA trial); the results indicated that the treatment approaches favoured by UK dermatologists differ. Psoralen combined with ultraviolet A (PUVA) and alitretinoin were identified as the most frequent first-line treatment options for hyperkeratotic HE, whereas oral corticosteroids were identified as the most frequent first-line treatment for vesicular HE, followed by PUVA and alitretinoin. In terms of potential adverse effects of long-term or repeated use, oral steroids and ciclosporin A were reported to cause most concern. There is uncertainty about which treatment gives the best short and long-term outcomes, because of a lack of definitive randomised controlled trials evaluating the effectiveness of different treatment pathways in severe HE.

Future research into the treatment of vitiligo: where should our priorities lie? Results of the vitiligo priority setting partnership.

BACKGROUND: Vitiligo is the most frequent depigmentation disorder of the skin and is cosmetically and psychologically devastating. A recently updated Cochrane systematic review 'Interventions for vitiligo' showed that the research evidence for treatment of vitiligo is poor, making it difficult to make firm recommendations for clinical practice. OBJECTIVES: To stimulate and steer future research in the field of vitiligo treatment, by identifying the 10 most important research areas for patients and clinicians. METHODS: A vitiligo priority setting partnership was established including patients, healthcare professionals and researchers with an interest in vitiligo. Vitiligo treatment uncertainties were gathered from patients and clinicians, and then prioritized in a transparent process, using a methodology advocated by the James Lind Alliance. RESULTS: In total, 660 treatment uncertainties were submitted by 461 participants. These were reduced to a list of the 23 most popular topics through an online/paper voting process. The 23 were then prioritized at a face-to-face workshop in London. The final list of the top 10 treatment uncertainties included interventions such as systemic immunosuppressants, topical treatments, light therapy, melanocyte-stimulating hormone analogues, gene therapy, and the impact of psychological interventions on the quality of life of patients with vitiligo. CONCLUSIONS: The top 10 research areas for the treatment of vitiligo provide guidance for researchers and funding bodies, to ensure that future research answers questions that are important both to clinicians and to patients.

Psychological and educational interventions for atopic eczema in children.

BACKGROUND: Psychological and educational interventions have been used as an adjunct to conventional therapy for children with atopic eczema to enhance the effectiveness of topical therapy. There have been no relevant systematic reviews applicable to children. OBJECTIVES: To assess the effectiveness of psychological and educational interventions in changing outcomes for children with atopic eczema. SEARCH STRATEGY: We searched the Cochrane Skin Group Specialised Register (to September 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2005), MEDLINE (from 1966-2005), EMBASE (from 1980 to week 3, 2005 ), PsycINFO (from 1872 to week 1, 2005). On-line: National Research Register, Meta-register of Controlled Trials, ZETOC alerts, SIGLE (August 2005). SELECTION CRITERIA: RCTs of psychological or educational interventions, or both, used to manage children with atopic eczema. DATA COLLECTION AND ANALYSIS: Two authors independently applied eligibility criteria, assessed trial quality and extracted data. A lack of comparable data prevented data synthesis. MAIN RESULTS: Five RCTs met the inclusion criteria. Some included studies required clearer reporting of trial procedures. Rigorous established outcome measures were not always used. Interventions described in all 5 RCTs were adjuncts to conventional therapy. Four focused on intervention directed towards the parents; data synthesis was not possible. Psychological interventions remain virtually unevaluated by studies of robust design; the only included study examined the effect of relaxation techniques (hypnotherapy and biofeedback) on severity. Three educational studies identified significant improvements in disease severity between intervention groups. A recent German trial evaluated long term outcomes and found significant improvements in both disease severity (3 months to 7 years, p=0.0002, 8 to 12 years, p=0.003, 13 to 18 years, p=0.0001) and parental quality of life (3 months to 7 years, p=0.0001, 8 to 12 years p=0.002), for children with atopic eczema. One study found video-based education more effective in improving severity than direct education and the control (discussion) (p<0.001). The single psychological study found relaxation techniques improved clinical severity as compared to the control at 20 weeks (t=2.13) but this was of borderline significance (p=0.042). AUTHORS' CONCLUSIONS: A lack of rigorously designed trials (excluding one recent German study) provides only limited evidence of the effectiveness of educational and psychological interventions in helping to manage the condition of children with atopic eczema. Evidence from included studies and also adult studies indicates that different service delivery models (multi-professional eczema school and nurse-led clinics) require further and comparative evaluation to examine their cost-effectiveness and suitability for different health systems.

The use of aromatherapy in intrapartum midwifery practice an observational study.

The authors report the process and results of an evaluation of a midwifery aromatherapy service for mothers in labour: This study of 8058 mothers in childbirth, is the largest research initiative in the use of aromatherapy within a health-care setting. The study involved a wide range of participants, from mothers who experienced a low risk, spontaneous labour and birth, to those whose labour was induced, and those who had vaginal operative delivery and Caesarean section. The study-took place over a period of 8 years, which enabled a more challenging test of the effect of aromatherapy on intrapartum midwifery practice and outcomes. In the study a total of 10 essential oils were used, plus a carrier oil, which were administered to the participants via skin absorption and inhalation. The study found little direct evidence that the practice of aromatherapy per se reduces the need for pain relief during labour, or the incidence of operative delivery. But a key finding of this study suggests that two essential oils, clary sage and chamomile are effective in alleviating pain. The evidence from this study suggests that aromatherapy can be effective in reducing maternal anxiety, fear and/or pain during labour. The use of aromatherapy appeared to facilitate a further reduction in the use of systemic opioids in the study centre, from 6% in 1990 to 0.4% in 1997 (per woman). Aromatherapy is an inexpensive care option. In 1997 when 1592 mothers used aromatherapy, the total cost was 769.17 Pounds. The study reports a minimal incidence of associated symptoms. Out of 8058 mothers, 1% (100) recorded an associated symptom. These were mild in nature. The successful model of integrated practice that this aromatherapy study presents, offers a useful example for other units to consider.

An investigation into the use of aromatherapy in intrapartum midwifery practice.

OBJECTIVE: The principal aim of the study was to examine the contribution of aromatherapy to the promotion of maternal comfort during labor and as a tool to improve the quality of midwifery care. DESIGN: Evaluative study. SETTING: Delivery suite in a large British teaching hospital with approximately 6,500 deliveries per annum. SUBJECTS: A total of 8,058 mothers were evaluated between 1990 and 1998. INTERVENTIONS: Women were offered aromatherapy to relieve anxiety, pain, nausea and/or vomiting or to strengthen contractions. Routine data collected on the use of aromatherapy over the period were analyzed. Data from the unit audit were used to provide a comparison group of mothers not given aromatherapy (n = 15,799) from the study center. OUTCOME MEASURES: Outcome measures include mothers' ratings of effectiveness, outcomes of labor, use of pharmacologic pain relief, uptake of intravenous oxytocin, reported associated symptoms, and annual costs. RESULTS: The use of aromatherapy during childbirth was an increasingly popular care option with mothers and midwives. More than 50% of mothers rated it as helpful, and only 14% found it unhelpful. The use of aromatherapy was not confined to low-risk mothers. Sixty percent of the sample were primigravidae, and 32% overall had had their labor induced. The administration of aromatherapy in childbirth did appear to reduce the need for additional pain relief in a proportion of mothers. More than 8% of primigravidae and 18% of multigravidae used no conventional pain relief during labor after using essential oils. During the years of the study, the use of pethidine in the study center declined from 6% to 0.2% of women. The study also showed that aromatherapy may have the potential to augment labor contractions for women in dysfunctional labour. A very low number of associated adverse symptoms were reported (1%). CONCLUSION: This study represents a successful example of the integration of a complementary therapy into mainstream midwifery practice and forms a basis for future research.

Measuring the sleep patterns of older people.

This paper examines a pilot study analysing sleep in nursing care settings. Sleep aids recovery, and affects the quality of life of older people in care settings. Issues are raised about the sleep measurement for research, and feasibility and rigour; new instruments are introduced; the value of self-reported and observed sleep data is discussed and recommendations are made.

The sleep of older people in hospital and nursing homes.

Disturbed sleep can affect personal wellbeing and impede the rehabilitation and recovery of older people from illness. This paper reports the findings of a pilot study which included examination of sleep quality and sleep patterns of older people in community hospital and nursing home settings. A marked proportion of older people reported sleeping well in nursing care settings, and those in nursing homes slept better than those in the community hospital. The main causes of sleep disturbance in both settings were: needing to go to the toilet, noise, pain, and discomfort; a similar pattern was seen across the different settings. No discernible difference was found in quality of sleep and whether patients felt rested or not between those patients on hypnotic medication and those who were not. The implications of the findings for practice and future research are discussed.

Complementary therapies and nursing research: issues and practicalities.

This paper explores the issues which nurses face in attempting to use research-based literature and when conducting research in the field of complementary therapies. Despite the significant interest amongst nurses in using such therapies, there can be difficulties in gaining access to such literature and using it to inform practice. Rising standards of accountability create expectations for nurses to draw on sources of information which inform safe and effective practice. The issue is examined and illustrated by looking at the example of nurses use of essential oils. Strategies are explored to help nurses to practice in an informed way and to engage in research activity in this area. This article is based on a paper given at the Research Council for Complementary Medicine Conference 'Research from Concept to Publication', at the Royal Society of Medicine, London 1993.