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.

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.

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.

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.

Water-based exercise training for chronic obstructive pulmonary disease.

BACKGROUND: Land-based exercise training improves exercise capacity and quality of life in people with chronic obstructive pulmonary disease (COPD). Water-based exercise training is an alternative mode of physical exercise training that may appeal to the older population attending pulmonary rehabilitation programmes, those who are unable to complete land-based exercise programmes and people with COPD with comorbid physical and medical conditions. OBJECTIVES: To assess the effects of water-based exercise training in people with COPD. SEARCH METHODS: A search of the Cochrane Airways Group Specialised Register of trials, which is derived from systematic searches of bibliographic databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, was conducted (from inception to August 2013). Handsearching was done to identify further qualifying studies from reference lists of relevant studies. SELECTION CRITERIA: Review authors included randomised or quasi-randomised controlled trials in which water-based exercise training of at least four weeks' duration was compared with no exercise training or any other form of exercise training in people with COPD. Swimming was excluded. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: Five studies were included with a total of 176 participants (71 people participated in water-based exercise training and 54 in land-based exercise training; 51 completed no exercise training). All studies compared supervised water-based exercise training versus land-based exercise training and/or no exercise training in people with COPD (with average forced expiratory volume in one second (FEV1) %predicted ranging from 39% to 62%). Sample sizes ranged from 11 to 53 participants. The exercise training programmes lasted from four to 12 weeks, and the mean age of participants ranged from 57 to 73 years. A moderate risk of bias was due to lack of reporting of randomisation, allocation and blinding procedures in some studies, as well as small sample sizes.Compared with no exercise, water-based exercise training improved the six-minute walk distance (mean difference (MD) 62 metres; 95% confidence interval (CI) 44 to 80 metres; three studies; 99 participants; moderate quality evidence), the incremental shuttle walk distance (MD 50 metres; 95% CI 20 to 80 metres; one study; 30 participants; high quality evidence) and the endurance shuttle walk distance (MD 371 metres; 95% CI 121 to 621 metres; one study; 30 participants; high quality evidence). Quality of life was also improved after water-based exercise training compared with no exercise (standardised mean difference (SMD) -0.97, 95% CI -0.37 to -1.57; two studies; 49 participants; low quality evidence). Compared with land-based exercise training, water-based exercise training did not significantly change the six-minute walk distance (MD 11 metres; 95% CI -11 to 33 metres; three studies; 62 participants; moderate quality evidence) or the incremental shuttle walk distance (MD 9 metres; 95% CI -15 to 34 metres; two studies; 59 participants; low quality evidence). However, the endurance shuttle walk distance improved following water-based exercise training compared with land-based exercise training (MD 313 metres; 95% CI 232 to 394 metres; two studies; 59 participants; moderate quality evidence). No significant differences were found between water-based exercise training and land-based exercise training for quality of life, as measured by the St George's Respiratory Questionnaire or by three of four domains of the Chronic Respiratory Disease Questionnaire (CRDQ); however, the fatigue domain of the CRDQ showed a statistically significant difference in favour of water-based exercise (MD -3.00; 95% CI -5.26 to -0.74; one study; 30 participants). Only one study reported long-term outcomes after water-based exercise training for quality of life and body composition, and no significant change was observed between baseline results and six-month follow-up results. One minor adverse event was reported for water-based exercise training (based on reporting from two studies; 20 participants). Impact of disease severity could not be examined because data were insufficient. AUTHORS' CONCLUSIONS: There is limited quality evidence that water-based exercise training is safe and improves exercise capacity and quality of life in people with COPD immediately after training. There is limited quality evidence that water-based exercise training offers advantages over land-based exercise training in improving endurance exercise capacity, but we remain uncertain as to whether it leads to better quality of life. Little evidence exists examining the long-term effect of water-based exercise training.

[Pneumoperitoneum after jacuzzi bathing -- an unusual cause for the development of intraperitoneal free air]. / Jacuzzihasználatot követoen kialakult pneumoperitoneum, avagy a szabad hasi levego keletkezésének ritka esete.

Free air within the intraperitoneal cavity most frequently occurs in conjunction with perforation of a hollow viscus and requires urgent surgical intervention. However, approximately 10% of all cases of pneumoperitoneum may not be correlated with disruption of the gastroinestinal tract. In the literature this condition is termed "nonsurgical" (NS) pneumoperitoneum and usually requires conservative management. NS pneumoperitoneum can be classified into the following categories: abdominal, thoracic, gynecologic, and idiopathic. We present a rare case of NS pneumoperitoneum. A 61-year-old woman who underwent a hysterectomy previously is admitted with diffuse abdominal pain without any other symptoms. Chest and abdominal radiographs verified the presence of free air under the diaphragm. We performed an exploration but no evidence of perforated viscus or peritonitis was found. Finally the patient told us that her complaints developed during Jacuzzi usage. We thought therefore that air entered into the intraperitoneal cavity through the vagina by influence of high pressure douche. In the course of postoperative gynecological examination a vaginoperitoneal fistula was detected in the vault which is developed during Jacuzzi usage leading to NS pneumoperitoneum. Essentially, NS pneumoperitoneum usually occurs without signs and symptoms of peritonitis and requires conservative treatment. Detailed physical examination and medical history taking can help to avoid unnecessary surgery in spite of radiological evidence of intraperitoneal free air.

Pedicure-associated rapidly growing mycobacterial infection: an endemic disease.

BACKGROUND: Pedicure-associated nontuberculous mycobacterial furunculosis has been reported in the setting of either outbreaks or sporadic case reports. The epidemiology of these infections is not well understood. METHODS: Systematic surveillance for pedicure-associated nontuberculous mycobacterial furunculosis was conducted in 2 North Carolina counties from 1 January 2005 through 31 December 2008. A subset of implicated nail salons and control salons was inspected and sampled for nontuberculous mycobacteria. RESULTS: Forty cases of suspected or confirmed pedicure-associated nontuberculous mycobacterial furunculosis were reported during the 4-year study period. Furunculosis incidence in the surveillance region was 1.00, 0.96, 0.83, and 0.89 cases per 100,000 population in 2005, 2006, 2007, and 2008, respectively. The responsible organisms primarily belonged to the Mycobacterium chelonae/abscessus group (30 [91%] of 33 isolates). Thirteen implicated salons and 11 control salons were visited and environmentally sampled. An assortment of nontuberculous mycobacteria was cultured from footbaths, but there was no association between the species distribution of the environmental isolates and implication of the salon in human infection. Evidence of suboptimal cleaning (visible debris or surface biofilms) was observed in at least 1 footbath for 11 of 13 implicated salons and 4 of 11 control salons (P = .032). CONCLUSIONS: Pedicure-associated mycobacterial furunculosis was endemic in these 2 North Carolina counties during 2005-2008. Suboptimal footbath cleaning may have contributed to these infections, which suggests straightforward means of potential prevention. The relative rarity of this type of infection in the setting of nearly ubiquitous exposure to these pathogens suggests that as yet undefined host-specific or procedure-related factors may be involved in susceptibility to these infections.