Legionellosis incidents associated with spa pools, England, 2002-2018.

BACKGROUND: Spa pools (SPs) pose risks of Legionella infection for users and bystanders. METHODS: We searched the National Enhanced Legionella Surveillance System for reported SP-associated legionellosis incidents in England between 2002 and 2018 involving at least two cases. RESULTS: For seven legionellosis SP-associated incidents, six were in commercial settings such as hotels. The median number of cases per outbreak was four (range 2-115). CONCLUSION: SP-associated legionellosis incidents were mainly located in commercial settings with a wider range of cases than those recognised in previous publications, reinforcing the need for effective environmental controls for SPs in a range of settings.

Modifiable risk factors for multidrug-resistant Gram-negative infection in critically ill burn patients: a systematic review and meta-analysis.

BACKGROUND: We conducted a systematic review and meta-analysis to identify potentially modifiable risk factors for multidrug-resistant Gram-negative colonization or infection in critically ill burn patients. METHODS: A systematic search was conducted of PubMed, Embase, CINAHL, Web of Science and Central (Cochrane). Risk factors including antibiotic use and hospital interventions were summarized in a random-effects meta-analysis. Risk of publication bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation method and funnel plots. RESULTS: A total of 11 studies met the inclusion criteria. We identified several potentially modifiable risk factors and were able to grade their importance based on effect size. Related to prior antibiotic exposure, extended-spectrum cephalosporins (pooled odds ratio (OR) 7.00, 95% confidence interval (CI) 2.77-17.67), carbapenems (pooled OR 6.65, 95% CI 3.49-12.69), anti-pseudomonal penicillins (pooled OR 4.23, 95% CI 1.23-14.61) and aminoglycosides (pooled OR 4.20, 95% CI 2.10-8.39) were most significant. Related to hospital intervention, urinary catheters (pooled OR 11.76, 95% CI 5.03-27.51), arterial catheters (pooled OR 8.99, 95% CI 3.84-21.04), mechanical ventilation (pooled OR 5.49, 95% CI 2.59-11.63), central venous catheters (pooled OR 4.26, 95% CI 1.03-17.59), transfusion or blood product administration (pooled OR 4.19, 95% CI 1.48-11.89) and hydrotherapy (pooled OR 3.29, 95% CI 1.64-6.63) were most significant. CONCLUSION: Prior exposure to extended-spectrum cephalosporins and carbapenems, as well as the use of urinary catheters and arterial catheters pose the greatest threat for infection or colonization with multidrug-resistant Gram-negative organisms in the critically ill burn patient population.

[Two cases of hot tub lung disease: Environmental investigations]. / Deux cas de pneumopathie d'hypersensibilité du jacuzzi : enquête environnementale.

INTRODUCTION: Hot tub lung is a hypersensitivity pneumonitis (HP) due to exposure to inhaled non-tuberculous mycobacteria, the most frequent being Mycobacterium avium complex (MAC). CASE REPORT: A French couple developed typicalHP in the context of a repeated use of hot tubs. The husband had a severe hypoxemic form whereas his wife had a micronodular form with patchy ground glass on the thoracic scan, with less severe functional impairment. MAC was recovered in the hot tub water, but not in broncho-alveolar lavage fluid, and serologies were negative. Samples taken at home showed unusual exposure to Aureobasidium pullulans and Aspergillus flavus, as well as the presence of potentially responsible domestic molds. Blood precipitins for these microorganisms were identified. The evolution was favorable after removal of the hot tub. CONCLUSIONS: These cases represent two of the typical presentations of hot tub lung, with a possible HP to an antigen other than MAC, which may have been enhanced by chronic exposure to multiple microorganisms.

Occurrence of Antibiotic-Resistant Bacteria in Therapy Pools and Surrounding Surfaces.

The number of patients colonized with antibiotic-resistant bacteria is increasing in health care facilities. Because transmission of antibiotic-resistant bacteria is feared, there exist reports that the affected patients are frequently excluded from hydrotherapy, which is a non-invasive and beneficial treatment used for patients with different diseases. Data from the literature suggest that deficient water disinfection measures exist, which are not always sufficient to kill all released bacteria. If the pool water is not disinfected properly, it may also infect the bathers. Immunocompromised patients are particularly susceptible to be infected with (antibiotic-resistant) bacteria. In order to determine the distribution of antibiotic-resistant bacteria in the pool water treatment system and the pool environment and to estimate the associated transmission risk we analyzed samples from eleven health care facilities. Antibiotic-resistant bacteria were found in the water and surface samples collected. One hundred and two antibiotic-resistant isolates from water samples and 307 isolates from surrounding surfaces were obtained, respectively. The majority of the isolates belonged to non-fermenting Gram-negative rods, like Pseudomonas spp. Some isolates were resistant to a wide range of the tested antibiotics. The results indicate a relation between the number of isolates in water samples and the number of patients using the pools in combination with deficiencies in water treatment. In the pool environment the highest number of isolates was obtained from barefoot areas and floor cleaning equipment.

Acupuncture Combined with Hydrotherapy in Diabetes Patients with Mild Lower-Extremity Arterial Disease: A Prospective, Randomized, Nonblinded Clinical Study.

BACKGROUND The aim of this pragmatic study was to explore the intervention of acupuncture combined with hydrotherapy and perceived effects in type 2 diabetic patients with recently diagnosed, mild, lower-extremity arterial disease (LEAD) in comparison with a control group. MATERIAL AND METHODS One hundred twenty-six diabetes patients who were diagnosed mild LEAD according to ankle-brachial blood pressure index (ABPI) and peripheral neuropathy symptom were randomly assigned to either an experimental (n=64) or control group (n=62). The experimental group attended and completed (1) a 30-min session of acupuncture in certain selected points, and (2) a 30-min hydrotherapy exercise every 2 days for 15 weeks. The outcome parameters were assessed at baseline, after intervention, and at 6-week follow-up. RESULTS The intervention was associated with an improvement in leg flow conductance and partial physical capacities, including chair-sit-and-reach, the walking impairment questionnaire (WIQ), and physical component summary score (PCS), compared to the control group. The treatment benefits were sustained throughout the 6-week follow-up endpoint. There was no difference in fasting glucose levels, Hb1Ac, blood pressure, or BMI after the intervention. At the endpoint of 6-week follow-up, acupuncture plus hydrotherapy appeared to reduce inflammatory response by decreasing IL-6, TNF-α, malondialdehyde, and SOD, and increasing glutathione. CONCLUSIONS Acupuncture plus hydrotherapy, without significant glycemic-controlling effects in the type 2 diabetic patients with mild LEAD, exerts a measurable benefit in disease-specific physical functions and health-related quality of life. Our results suggest that the combined therapy regulates the inflammatory process and oxidative stress and contributes to immune protection.

Use of hydrotherapy during labour: Assessment of pain, use of analgesia and neonatal safety. / Uso de hidroterapia durante el parto: evaluación del dolor, uso de analgesia y seguridad neonatal.

AIM: To evaluate the effectiveness of the use of hydrotherapy in pain perception and requesting analgesia in women who use hydrotherapy during childbirth and to identify possible adverse effects in infants born in water. METHOD: A multicentre prospective cohort study was performed between September 2014 and April 2016. A total of 200 pregnant women were selected and assigned to the hydrotherapy group (HG) or the control group (CG) according to desire and availability of use, data collection started at 5cm dilatation. The instruments used were the numerical rating scale (NRS), use of analgesia, Apgar Test, umbilical cord pH and NICU admission. Participants were distributed into: HG (n=111; 50 water birth) and CG (n=89). RESULTS: Pain at 30 and 90min was lower in the HG than in the CG (NRS 30min 6.7 [SD 1.6] vs 7.8 [SD 1.2] [P<.001] and NRS 90min 7.7 [SD 1.2] vs. 8.9 [SD 1.1] [P<.001]). During the second stage of labour, pain was lower in pregnant women undergoing a water birth (NRS HG 8.2 [SD 1.2], n=50; NRS CG 9.5 [SD 0.5], n=89 [P<.001]). Relative to the use of analgesia, in the CG 30 (33.7%) pregnant women requested epidural analgesia vs. 24 (21.1%) pregnant women in HG (P=.09). The neonatal parameters after water birth were not modified compared to those born out of water. CONCLUSION: The use of hydrotherapy reduces pain during labour, and during second stage in women who undergo a water birth and the demand for analgesia decreases in multiparous pregnant women. No adverse effects were seen in infants born under water.

Role of hydrotherapy in the amelioration of oxidant-antioxidant status in rheumatoid arthritis patients.

AIM: Rheumatoid arthritis (RA) is an inflammatory autoimmune disease. Reactive oxygen species (ROS) are involved in the pathophysiology of RA. Moderate intensity exercises have been reported to have anti-oxidant and anti-inflammatory effects. The aim of this study was to evaluate the effect of hydrotherapy on oxidant-antioxidant status in RA patients. METHODS: Forty RA patients and 30 age- and sex-matched healthy controls were included in this study. RA patients were subdivided into two groups: the first group (n = 20) received treatment with conventional RA drugs, while the second group (n = 20) received hydrotherapy along with the conventional drugs for a period of 12 weeks. Disease Activity Score of 28 joints (DAS-28), ROS level, protein oxidation, lipid peroxidation, DNA damage and the activities of antioxidant enzymes were evaluated before and after 12 weeks of treatment. RESULTS: RA patients showed a significant change in the oxidative stress biomarkers (ROS, P < 0.01; ferric reducing antioxidant potential, P < 0.001; malondialdehyde, P < 0.01; protein carbonyl, P < 0.001; tail length, P < 0.05) and decrease in the activities of anti-oxidant enzymes (superoxide dismutase [SOD], P < 0.01; glutathione peroxidase [GPx], P < 0.001). Conventional drug treatment has not produced any significant change in these parameters. However, cotreatment of drugs with hydrotherapy has decreased protein, lipid and DNA oxidation by increasing the activities of antioxidant enzymes (SOD and GPx). CONCLUSION: Our results indicate that hydrotherapy along with drugs has reduced the severity of disease (DAS-28) by ameliorating the oxidant-antioxidant status in RA patients. Thus, in addition to conventional drugs, RA patients should be advised to have hydrotherapy (moderate intensity exercise) in their treatment regimen.

Cold water immersion: kill or cure?

NEW FINDINGS: What is the topic of this review? This is the first review to look across the broad field of 'cold water immersion' and to determine the threats and benefits associated with it as both a hazard and a treatment. What advances does it highlight? The level of evidence supporting each of the areas reviewed is assessed. Like other environmental constituents, such as pressure, heat and oxygen, cold water can be either good or bad, threat or treatment, depending on circumstance. Given the current increase in the popularly of open cold water swimming, it is timely to review the various human responses to cold water immersion (CWI) and consider the strength of the claims made for the effects of CWI. As a consequence, in this review we look at the history of CWI and examine CWI as a precursor to drowning, cardiac arrest and hypothermia. We also assess its role in prolonged survival underwater, extending exercise time in the heat and treating hyperthermic casualties. More recent uses, such as in the prevention of inflammation and treatment of inflammation-related conditions, are also considered. It is concluded that the evidence base for the different claims made for CWI are varied, and although in most instances there seems to be a credible rationale for the benefits or otherwise of CWI, in some instances the supporting data remain at the level of anecdotal speculation. Clear directions and requirements for future research are indicated by this review.

The Effect of Therapeutic Whirlpool and Hot Packs on Hand Volume During Rehabilitation After Distal Radius Fracture: A Blinded Randomized Controlled Trial.

BACKGROUND: Edema is a possibility with all heating modalities due to the increase in local blood flow caused by vasodilation. Despite the frequent application of superficial heat modalities, their relative effect on hand volume has not been determined for the upper extremity. The objective of this study was to compare the immediate effects of hot packs and whirlpool on hand volume for patients with distal radius fracture (DRF) and to determine whether any changes in volume between these modalities were still present 30 minutes after heat application. Finally, to determine whether there were any differences in volume change between groups after 3 repeated therapy visits. METHODS: Sixty patients with clinically healed DRFs were divided into 2 groups. Half received therapeutic whirlpool at each therapy visit, and the other half received a moist hot pack treatment for 3 consecutive visits. Hand volume was measured before heat, after heat, and at the end of each 30-minute therapy session. RESULTS: There was a significant difference between groups immediately after heat application, as patients in the whirlpool group experienced an initial volume increase greater than those who received a hot pack. When remeasured after a hand therapy session approximately 30 minutes later, this group difference in volume change was no longer significant. The overall change in volume from enrollment in the study to completion of the study 3 weeks later was not statistically different between groups. CONCLUSION: Whirlpool is a potential consideration when selecting a heat modality for patients with DRF.

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.

Effects of Aquatic Intervention on Gross Motor Skills in Children with Cerebral Palsy: A Systematic Review.

AIMS: To review the literature on the effects of aquatic intervention on gross motor skills for children with cerebral palsy (CP). DATA SOURCES: Six databases were searched from inception to January 2016. REVIEW METHODS: Aquatic studies for children aged 1-21 years with any type or CP classification and at least one outcome measuring gross motor skills were included. Information was extracted on study design, outcomes, and aquatic program type, frequency, duration, and intensity. Quality was rated using the Centre of Evidence-Based Medicine: Levels of Evidence and the PEDro scale. RESULTS: Of the 11 studies which met inclusion criteria, only two used randomized control trial design, and the results were mixed. Quality of evidence was rated as moderate to high for only one study. Most studies used quasi-experimental designs and reported improvements in gross motor skills for within group analyses after aquatic programs were held for two to three times per week and lasting for 6-16 weeks. Participants were classified according to the Gross Motor Function Classification System (GMFCS) levels I-V, and were aged 3-21 years. Mild to no adverse reactions were reported. CONCLUSIONS: Evidence on aquatic interventions for ambulatory children with CP is limited. Aquatic exercise is feasible and adverse effects are minimal; however, dosing parameters are unclear. Further research is needed to determine aquatic intervention effectiveness and exercise dosing across age categories and GMFCS levels.

Heated birthing pools as a source of Legionnaires' disease.

In June 2014 Public Health England confirmed a case of Legionnaires' disease (LD) in a neonate following birth at home in a hired birthing pool incorporating a heater and a recirculation pump which had been filled in advance of labour. The case triggered a public health investigation and a microbiological survey of an additional ten heated birthing pools hired or recently hired to the general public across England. The birthing pool used by the parent of the confirmed case was identified as the source of the neonate's infection following detection of Legionella pneumophila ST48 in both patient and environmental samples. Legionella species were detected by quantitative polymerase chain reaction but not culture in a further three pools together with other opportunistic pathogens identified by culture and matrix-assisted laser desorption ionization-time of flight (MALDI-ToF) mass spectrometry. A Patient Safety Alert from NHS England and Public Health England was issued stating that heated birthing pools filled in advance of labour should not be used for home births. This recommendation remains in place. This investigation in conjunction with other recent reports has highlighted a lack of awareness regarding the microbiological safety of heated birthing pools and their potential to be a source of LD and other opportunistic infections. Furthermore, the investigation raised important considerations with regards to microbiological sampling and testing in such incidents. Public health authorities and clinicians should consider LD in the differential diagnosis of severe respiratory infection in neonates within 14 days of a water birth.

Spa therapy for generalized osteoarthritis: an open, observational, preliminary study.

OBJECTIVES: Open, prospective study to evaluate the effect of spa therapy on generalized osteoarthritis (GOA). METHODS: Patients diagnosed as GOA were recruited from a private outpatient clinic. The treatment protocol was designed with 6 different spa modalities, 3 for each consecutive day, during 18 days. Interventions were Berthollet's technique (local mineral water cloud application), peloidotherapy, hydrotherapy, under water /standard (dry) massage, supervised water exercise, bath in hydro-massage pool, bath in tub with hydro-jets, free immersion in mineral water pool. The primary outcome was a clinically relevant improvement in 50% of patients at the end of the treatment. Statistical analyses were based on intention-to-treat method. Health care providers were blinded to the study. RESULTS: Ninety nine patients were included between March 7th-April 29th 2011 and all were analyzed for the primary outcome. Clinically relevant improvement was observed in 61% of the patients at the end of the treatment, and 68% at the 8th month. Patient acceptable symptom state was achieved in 33% of the patients at the 3rd week and 75% at the 8th month and Outcome Measures in Rheumatology-Osteoarthritis Research Society International Criteria (OMERACT-OARSI criteria) response in 41% of the patients at the 3rd week and 19% at the 8th month. Improvement was also observed in other judgment criteria evaluating pain, function and quality of life and continued until the 8th month for some of the parameters. No serious adverse effect was observed. CONCLUSIONS: Spa treatment may improve the clinical status of patients with GOA and seems to be well tolerated.

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.

[Whirlpool-dermatitis with "hot hands"]. / Whirlpool-Dermatitis mit "hot hands".

HISTORY AND ADMISSION FINDINGS: A 15-year-old boy presented with painful nodules on his palms and discrete pustules on the forearm. Two days earlier he had taken a bath in a new whirlpool. INVESTIGATIONS: Bacteriological examination of the pustules revealed Pseudomonas aeruginosa. The cervical and axillary lymph nodes were inconspicuous. TREATMENT AND COURSE: The dermal infection with Pseudomonas aeruginosa was treated with i.v. piperacillin 4 g/tazobactam 0,5 g twice daily. Furthermore, the patient received 400 mg ibuprofen twice daily per os. Seven days later all symptoms had resolved. CONCLUSION: Hot tubs are a potential source of cutaneous infections with the gram-negative rod Pseudomonas aeruginosa. The most common clinical manifestation of these infections is "hot tub- or jacuzzi-folliculitis" with pustules mainly on the trunk and lymphadenopathy. In children and adolescents, the clinical picture may differ, with a predominance of tender reddish nodules on the palms or soles named "hot hand/hot foot syndrome". In general, the first-line antibiotic in an infection with pseudomonas aeruginosa is ciprofloxacin but it is not recommended in children and adolescents.