Impetigo. Current etiology and comparison of penicillin, erythromycin, and cephalexin therapies. Topical antibiotic treatment of impetigo with mupirocin. Aggressive pharmacological treatment for reversing malignant bowel obstruction. Treatment of impetigo and ecthyma. A comparison of sulconazole with miconazole. Comparison of mupirocin and erythromycin in the treatment of impetigo. Effectiveness of a clinical practice guideline implementation strategy for patients with anxiety disorders in primary care: cluster randomized trial A multiple imputation strategy for clinical trials with truncation of patient data. A randomized clinical trial of ampicillin, gentamicin and clindamycin versus cefotaxime and clindamycin in children with ruptured appendicitis. The ANTOP study: focal psychodynamic psychotherapy, cognitive-behavioural therapy, and treatment-as-usual in outpatients with anorexia nervosa - a randomized controlled trial Improving pharmacotherapy after myocardial infarction by group academic detailing using feedback data on a patient level. Safety and dose flexibility clinical evaluation of intravesical liposome in patients with interstitial cystitis or painful bladder syndrome. Randomized controlled trial of cognitive behaviour therapy for repeated consultations for medically unexplained complaints: a feasibility study in Sri Lanka. Feasibility, double-blind, randomised, placebo-controlled, multi-centre trial of hand-held NB-UVB phototherapy for the treatment of vitiligo at home (HI-Light trial: Home Intervention of Light therapy) Second European evidence-based consensus on the diagnosis and management of ulcerative colitis part 1: definitions and diagnosis. The microbiology of impetigo in Indigenous children: associations between Streptococcus pyogenes, Staphylococcus aureus,scabies, and nasal carriage ALGOS: the development of a randomized controlled trial testing a case management algorithm designed to reduce suicide risk among suicide attempters Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: diagnosis and treatment.
We attempted to determine the causative bacterial pathogens of impetigo in children in our area , to compare the effectiveness of three frequently used oral antimicrobial treatment regimens , and to correlate the antimicrobial sensitivity of the bacterial isolates with clinical responses to treatment . Seventy-three children with impetigo were r and omly assigned to receive penicillin V potassium or cephalexin monohydrate , both administered in dosages of 40 to 50 mg/kg per day , or erythromycin estolate administered in a dosage of 30 to 40 mg/kg per day . All drugs were given in three divided doses for 10 days . Treatment failure was defined as persistence of lesions 8 to 10 days after initiation of drug therapy as determined by examiners blinded to the treatment therapies . Forty-five ( 62 % ) cultures showed Staphylococcus aureus only , 14 ( 19 % ) showed S aureus and group A beta-hemolytic streptococci , six ( 8 % ) showed group A beta-hemolytic streptococci only , and eight ( 11 % ) showed no growth or other organisms . Treatment failure occurred in six ( 24 % ) of 25 patients treated with penicillin V , one ( 4 % ) of 25 patients treated with erythromycin estolate , and no patients treated with cephalexin . We conclude that S aureus is the most common cause of impetigo in children in our study population , that cephalexin is the most effective treatment , that erythromycin estolate is nearly equally effective and may be preferred on a cost-effectiveness basis , and that penicillin V is inadequate for treatment of this infection Because the effectiveness of topical antimicrobials in the treatment of ecthyma , impetigo , and pyoderma is not well established , the US Food and Drug Administration has recently proposed guidelines for tests of topical antimicrobial efficacy in primary skin infections . The guidelines require both comparison with the agent 's base and microbiologic documentation of efficacy . These guidelines were followed in this double-blind , eight-day evaluation of impetigo/ecthyma treated with mupirocin , a new agent that is only active topically . All cultures , before and after therapy , were taken using swabs dipped in neutralizing broth plus 10 % fetal bovine serum to minimize antimicrobial " carry over " to the culture plate . Staphylococcus aureus , which was isolated from 94 % of the patients before therapy , was eliminated in 88 % of the mupirocin-treated patients and 47 % of the vehicle-treated patients . Group A beta-hemolytic streptococci were eliminated in 100 % of the mupirocin-treated and 0 % of the vehicle-treated patients . To our knowledge , this is the first topical antibacterial treatment for  primary skin infections proved superior to its vehicle using the proposed US Food and Drug Administration guidelines Early and intensive pharmacological treatment not only may reduce gastrointestinal symptoms but also reverse malignant bowel obstruction .  Fifteen consecutive advanced cancer patients with inoperable bowel obstruction received a combination of drugs including metoclopramide , octreotide , dexamethasone and an initial bolus of amidotrizoato .  Recovery of intestinal transit was reported within 1 - 5 days in fourteen patients , who continued this treatment without presenting symptoms of bowel obstruction until death . This case series establishes that the combination of propulsive and antisecretive agents can act synergistically to allow a fast recovery of bowel transit without inducing unpleasant colic . It suggests that the most important mechanism in these circumstances is functional and can be reversible , if an aggressive treatment is initiated early before fecal impaction and edema render bowel obstruction irreversible In a r and omized , double-blind , parallel comparative study of 80 patients , impetigo and ecthyma were treated effectively by sulconazole nitrate 1 % cream and miconazole nitrate 2 % cream applied to lesions twice daily for 14 days . When treatment began , bacterial cultures from all pyodermal lesions yielded Group A beta-hemolytic streptococci or pathogenic staphylococci . Among the 32 sulconazole-treated impetigo patients , bacterial cultures from 26 ( 69 % ) were negative by treatment day 4 , and those from all 32 ( 100 % ) were negative by treatment day 7 ; among the 34 miconazole-treated impetigo patients , cultures from 17 ( 50 % ) were negative by treatment day 4 , cultures from 32 ( 94.1 % ) were negative by treatment day 7 , and cultures from 29 ( 97 % ) were negative by treatment day 14 . Each treatment promptly relieved the pyodermal signs ( crusts , vesicles , pustules , bullae , and exu date ) . Both agents were considered to be safe and effective medications for treating impetigo and ecthyma For the past two decades the accepted treatment of impetigo has been systemic antibiotic therapy , l The recently approved topical antibiotic mupirocin has excellent in vitro activity against Streptococcus pyogenes and Staphylococcus aureus , including multiply resistant strains . Originally called pseudomonic acid A , mupirocin is obtained from submerged fermentation of Pseudomonas fluorescens ; it acts by inhibition of bacterial protein synthesis by inactivation of isoleucyl transfer RNA synthetase . Rapidly inactivated and rapidly excreted when given systemically , mupirocin has been shown to be safe in animal and human trials.2 , 3 Double-blind studies prove mupirocin to be more effective than its polyethylene glycol vehicle for treatment of impetigo.4 , 5 Several nonblind or poorly controlled clinical trials have suggested that mupirocin  's  efficacy is comparable to that of orally administered antibiotics commonly used to treat impetigo , namely , erythromycin , 6 - 1~ ampicillin , 11 and dicloxacillin . 12 We intended to vali date these findings in a double-blind , placebo-controlled study . We further hypothesized that erythromycin would cause more adverse side effects and result in poorer compliance , making mupirocin the preferred medication Background Anxiety is a common mental health problem seen in primary care . However , its management in clinical practice varies greatly . Clinical practice guidelines ( CPGs ) have the potential to reduce variations and improve the care received by patients by promoting interventions of proven benefit . However , uptake and adherence to their recommendations can be low . Method / design This study involves a community based on cluster r and omized trial in primary healthcare centres in the Madrid Region ( Spain ) . The project aims to determine whether the use of implementation strategy ( including training session , information , opinion leader , reminders , audit , and feed-back ) of CPG for patients with anxiety disorders in primary care is more effective than usual diffusion . The number of patients required is 296 ( 148 in each arm ) , all older than 18 years and diagnosed with generalized anxiety disorder , panic disorder , and panic attacks by the Diagnostic and Statistical Manual of Mental Disorders-IV ( DSM-IV ) . They are chosen by consecutive sampling . The main outcome variable is the change in two or more points into Goldberg anxiety scale at six and twelve months . Secondary outcome variables include quality of life ( EuroQol 5D ) , and degree of compliance with the CPG recommendations on treatment , information , and referrals to mental health services . Main effectiveness will be analyzed by comparing the patients percentage improvement on the Goldberg scale between the intervention group and the control group . Logistic regression with r and om effects will be used to adjust for prognostic factors . Confounding factors or factors that might alter the effect recorded will be taken into account in this analysis . Discussion There is a need to identify effective implementation strategies for CPG for the management of anxiety disorders present in primary care . Ensuring the appropriate uptake of guideline recommendations can reduce clinical variation and improve the care patients receive . Trial registration IS RCT N : IS RCT Clinical trials of drug treatments for psychiatric disorders commonly employ the parallel groups , placebo-controlled , repeated measure r and omized comparison . When patients stop adhering to their originally assigned treatment , investigators often ab and on data collection . Thus , non-adherence produces a monotone pattern of unit-level missing data , disabling the analysis by intent-to-treat . We propose an approach based on multiple imputation of the missing responses , using the approximate Bayesian bootstrap to draw ignorable repeated imputations from the posterior predictive distribution of the missing data , stratifying by a balancing score for the observed responses prior to withdrawal . We apply the method and some variations to data from a large r and omized trial of treatments for panic disorder , and compare the results to those obtained by the original analysis that used the st and ard ( endpoint ) method This prospect i ve , r and omized , double-blind study compares the efficacy , safety and cost-effectiveness of ampicillin , gentamicin and clindamycin ( AGC ) or cefotaxime and clindamycin ( CC ) for the treatment of children with complicated appendicitis . Ninety-seven children were r and omized . Forty-seven were assigned to the AGC regimen and 50 received CC . Forty-two patients in the AGC group had an appropriate therapeutic outcome , whereas 48 of 50 children who received CC completed the trial successfully ( p = NS ) . There were no differences between the groups with reference to the duration of antibiotic administration , fever , leukocytosis or length of hospitalization . Complications of therapy were uncommon and neither regimen demonstrated a significant advantage from an economic st and point . We concluded that , in childhood , complicated appendicitis can be treated with either CC or AGC with equal efficacy Background Anorexia nervosa is a serious eating disorder leading to high morbidity and mortality as a result of both malnutrition and suicide . The seriousness of the disorder requires extensive knowledge of effective treatment options . However , evidence for treatment efficacy in this area is remarkably weak . A recent Cochrane review states that there is an urgent need for large , well- design ed treatment studies for patients with anorexia nervosa . The aim of this particular multi-centre study is to evaluate the efficacy of two st and ardized outpatient treatments for patients with anorexia nervosa :  focal psychodynamic ( FPT ) and cognitive behavioural therapy ( CBT ) . Each therapeutic approach is compared to a " treatment-as-usual " control group . Methods / Design 237 patients meeting eligibility criteria are r and omly and evenly assigned to the three groups – two intervention groups ( CBT and FPT ) and one control group . The treatment period for each intervention group is 10 months , consisting of 40 sessions respectively . Body weight , eating disorder related symptoms , and variables of therapeutic alliance are measured during the course of treatment . Psychotherapy sessions are audiotaped for adherence monitoring . The treatment in the control group , both the dosage and type of therapy , is not regulated in the study protocol , but rather reflects the current practice of established outpatient care . The primary outcome measure is the body mass index ( BMI ) at the end of the treatment ( 10 months after r and omization ) . Discussion The study design surmounts the disadvantages of previous studies in that it provides a r and omized controlled design , a large sample size , adequate inclusion criteria , an adequate treatment protocol , and a clear separation of the treatment conditions in order to avoid contamination . Nevertheless , the study has to deal with difficulties specific to the psychopathology of anorexia nervosa . The treatment protocol allows for dealing with the typically occurring medical complications without dropping patients from the protocol . However , because patients are difficult to recruit and often ambivalent about treatment , a drop-out rate of 30 % is assumed for sample size calculation . Due to the ethical problem of denying active treatment to patients with anorexia nervosa , the control group is defined as " treatment-as-usual".Trial registration Current Controlled Trials IS RCT STUDY OBJECTIVE To develop and evaluate a peer review group ( PRG ) meeting using feedback data on a patient level to improve the quality of drug therapy for prevention of recurrent myocardial infa rct ion . DESIGN Prospect i ve follow-up study . DATA SOURCE General practitioners ' computerized patients records ( intervention patients ) and the PHARMO record linkage system  ( controls ) . PATIENTS Forty patients in the intervention group and 1030 control patients ; both groups had documented myocardial infa rct ion . INTERVENTION The intervention , which was based on the principles of group academic detailing , consisted of scoring current cardiovascular treatment on separate forms for each patient , presenting an overview of , and discussing , evidence -based treatment after myocardial infa rct ion , defining the target population , formulating a binding consensus , and identifying patients who were eligible for improvement of pharmacotherapy . MEASUREMENTS AND MAIN RESULTS Drug therapy and adherence to the newly formulated PRG consensus were assessed at baseline and 1 year after the intervention . Of the patients who received the intervention and were not treated according to the PRG consensus at baseline , 40 % received treatment according to the consensus 12 months after the PRG meeting . In the control group , the  proportion of patients was 9.5 % ( prevalence ratio 4.2 , 95 % confidence interval 1.8 - 9.7 ) . CONCLUSION Peer review group meetings can be a valuable tool for improving pharmacotherapy after myocardial infa rct ion To present single institution open-label experience with intravesical liposomes ( LPs ) , a mucosal protective agent , in patients with interstitial cystitis/painful bladder syndrome ( IC/PBS ) and to assess the safety and efficacy on IC/PBS symptoms . A total of 17 symptomatic IC/PBS patients were treated with intravesical LPs ( 80mg/40mL distilled water ) once a week for 4 weeks ( n=12 ) or twice a week treatment for 4 weeks ( n=5 ) . The primary outcome was the change in the O'Leary-Sant Symptom/Problem score and O'Leary-Sant total Score from baseline to Week 4 and Week 8 . Other outcome measurements included the changes in pain scale , urgency scale , voiding log , and patient global assessment . Both weekly and biweekly LP instillation regiments were well tolerated . The incidence of urinary incontinence , retention , or unanticipated adverse changes was not noted at any dose either during the treatment or at the 4-week follow-up . The O'Leary-Sant Symptom/Problem score , O'Leary-Sant total Score , and pain score were significantly improved from baseline at both dose regimens with added benefit with the biweekly regimen . Intravesical LPs treatment is safe and its efficacy has sustained duration . Furthermore large-scale , placebo-controlled studies are warranted to assess the efficacy for this promising new treatment for IC/PBS BACKGROUND Research on the management and the outcome of treatment of medically unexplained symptoms is very limited . Development of simple but effective techniques for treatment and demonstration of their effectiveness when applied in primary health care are needed . METHODS A r and omized controlled trial was carried out with follow-up assessment s at 3 months after baseline assessment s using the  Short Explanatory Model Interview ( SEMI ) , General Health Question naire ( GHQ-30 ) , Bradford Somatic Inventory ( BSI ) and patient satisfaction on a visual analogue scale . The study was carried out in a general out-patient clinic in Sri Lanka . The intervention group received six , 30 min sessions based on the principles of cognitive behavioural therapy over a period of 3 months . The control group received st and ard clinical care . RESULTS Eighty patients out of the 110 patients referred , were eligible . Sixty-eight were r and omly allocated equally to the control and treatment groups . All 34 in the treatment group accepted the treatment offer and 22 completed between three and six sessions . At 3 months , 24 in the treatment and 21 in the control group completed follow-up assessment s. Intention-to-treat analysis revealed significant differences in mean scores of outcome measures ( adjusted for baseline scores ) between control and intervention groups respectively -- complaints 6.1 and 3.8 ( P = 0.001 ) , GHQ 10.4 and 6.3 ( P = 0.04 ) , BSI score 15.6 and 132 ( P < 0 - 01 ) , visits 7.9 and 3.1 ( P = 0.004 ) . CONCLUSIONS Intervention based on cognitive behavioural therapy is feasible and acceptable to patients with medically unexplained symptoms from a general out- patients clinic in Sri Lanka . It had a significant effective in reducing symptoms , visits and distress , and in increasing patient satisfaction Background H and -held NB-UVB units are lightweight devices that may overcome the need to treat vitiligo in hospital-based phototherapy cabinets , allowing early treatment at home that may enhance the likelihood of successful repigmentation . The pilot Hi-Light trial examined the feasibility of conducting a large multi-centre r and omised controlled trial ( RCT ) on the use of such devices by exploring recruitment , adherence , acceptability , and patient education . Methods This was a feasibility , double-blind , multi-centre , parallel group r and omised placebo-controlled trial of h and -held NB-UVB phototherapy for the treatment of vitiligo at home . The overall duration of the trial was seven months ; three months recruitment and four months treatment . Participants were r and omly allocated to active or placebo groups ( 2:1 ratio ) . The primary outcome measure was the proportion of eligible participants who were willing to be r and omised .  The secondary outcomes included proportion of participants expressing interest in the trial and fulfilling eligibility criteria , withdrawal rates and missing data , proportion of participants adhering to and satisfied with the treatment , and incidence of NB-UVB short-term adverse events . Results Eighty-three percent ( 45/54 ) of vitiligo patients who expressed interest in the trial were willing to be r and omised . Due to time and financial constraints , only 29/45 potential participants were booked to attend a baseline hospital visit . All 29 ( 100 % ) potential participants were confirmed as being eligible and were subsequently r and omised . Willingness to participate in the study for General Practice ( family physicians ) surgeries and hospitals were 40 % and 79 % , respectively ; 86 % ( 25/29 ) of patients adhered to the treatment and 65 % ( 7/11 ) of patients in the active group had some degree of repigmentation . Only one patient in the active group reported erythema grade 3 ( 3 % ) . Both devices ( Dermfix 1000 NB-UVB and Waldmann NB-UVB 109 ) were acceptable to participants . Conclusions H and -held NB-UVB devices need evaluation in a large , pragmatic RCT . This pilot trial has explored many of the uncertainties that need to be overcome before embarking on a full scale trial , including the development of a comprehensive training package and treatment protocol . The study has shown strong willingness of participants to be r and omised , very good treatment adherence and repigmentation rates , and provided evidence of feasibility for a definitive trial . Trial registration # # # 1.1 Introduction Ulcerative colitis is a lifelong disease arising from an interaction between genetic and environmental factors , observed predominantly in the developed countries of the world . The precise aetiology is unknown and therefore medical therapy to cure the disease is not yet available . Within Europe there is a North – South gradient , but the incidence appears to have increased in Southern and Eastern countries in recent years.1,2 Patients may live with a considerable symptom burden despite medical treatment ( 66 % describe interference with work and 73 % with leisure activities3 ) in the hope that the aetiology of ulcerative colitis will shortly be revealed and a cure emerge . Although this is conceivable in the next decade , clinicians have to advise patients on the basis of information available today . Despite r and omised trials there will always be many questions that can only be answered by the exercise of judgement and opinion . This leads to differences in practice between clinicians , which may be brought into sharp relief by differences in emphasis between countries . This Consensus endeavours to address these differences . The Consensus is not meant to supersede the guidelines of different countries ( such as those from the UK,4 or Germany,5 ) which reach broadly the same conclusions since they are , after all , based on the same evidence . Rather , the aim of the Consensus is to promote a European perspective on the management of ulcerative colitis ( UC ) and its dilemmas . Since the development of guidelines is an expensive and time-consuming process , it may help to avoid duplication of effort in the future . A European Consensus is also considered important because an increasing number of therapeutic trials recruit from Central and Eastern European countries where practice guidelines have yet to be published . This document up date s the previous European Consensus on the diagnosis and management of UC , and Background Impetigo is caused by both Streptococcus pyogenes and Staphylococcus aureus ; the relative contributions of each have been reported to fluctuate with time and region . While S. aureus is reportedly on the increase in most industrialised setting s , S. pyogenes is still thought to drive impetigo in endemic , tropical regions . However , few studies have utilised high quality microbiological culture methods to confirm this assumption . We report the prevalence and antimicrobial resistance of impetigo pathogens recovered in a r and omised , controlled trial of impetigo treatment conducted in remote Indigenous communities of northern Australia . Methods Each child had one or two sores , and the anterior nares , swabbed . All swabs were transported in skim milk tryptone glucose glycogen broth and frozen at –70 ° C , until plated on horse blood agar . S. aureus and S. pyogenes were confirmed with latex agglutination . Results From 508 children , we collected 872 swabs of sores and 504 swabs from the anterior nares prior to commencement of antibiotic therapy . S. pyogenes and S. aureus were identified together in 503/872 ( 58 % ) of sores ; with an additional 207/872 ( 24 % ) sores having S. pyogenes and 81/872 ( 9 % ) S. aureus , in isolation . Skin sore swabs taken during episodes with a concurrent diagnosis of scabies were more likely to culture S. pyogenes ( OR 2.2 , 95 % CI 1.1 – 4.4 , p = 0.03 ) . Eighteen percent of children  had nasal carriage of skin pathogens . There was no association between the presence of S. aureus in the nose and skin . Methicillin-resistance was detected in 15 % of children who cultured S. aureus from either a sore or their nose . There was no association found between the severity of impetigo and the detection of a skin pathogen . Conclusions S. pyogenes remains the principal pathogen in tropical impetigo ; the relatively high contribution of S. aureus as a co-pathogen has also been confirmed . Children with scabies were more likely to have S. pyogenes detected . While clearance of S. pyogenes is the key determinant of treatment efficacy , co-infection with S. aureus warrants consideration of treatment options that are effective against both pathogens where impetigo is severe and prevalent . Trial registration This trial is registered ; ACTRN12609000858291 Background Suicide attempts ( SA ) constitute a serious clinical problem . People who attempt suicide are at high risk of further repetition . However , no interventions have been shown to be effective in reducing repetition in this group of patients . Methods / Design Multicentre r and omized controlled trial . We examine the effectiveness of « ALGOS algorithm » : an intervention based in a decisional tree of contact type which aims at reducing the incidence of repeated suicide attempt during 6 months . This algorithm of case management comprises the two strategies of intervention that showed a significant reduction in the number of SA repeaters :  systematic telephone contact ( ineffective in first-attempters ) and « Crisis card » ( effective only in first-attempters ) . Participants who are lost from contact and those refusing healthcare , can then benefit from « short letters » or « postcards » . Discussion ALGOS algorithm is easily reproducible and inexpensive intervention that will supply the guidelines for assessment and management of a population sometimes in difficulties with healthcare compliance . Furthermore , it will target some of these subgroups of patients by providing specific interventions for optimizing the benefits of case management strategy .Trial Registration The study was registered with the Clinical Trials.gov Registry ; number : NCT01123174 BACKGROUND Ventilator-associated pneumonia ( VAP ) is an important cause of morbidity and mortality in ventilated critically ill patients . Despite a large amount of research evidence , the optimal diagnostic and treatment strategies for VAP remain controversial . PURPOSE The aim of this study was to develop evidence -based clinical practice guidelines for the diagnosis and treatment of VAP . Data sources include Medline , EMBASE , Cumulative Index to Nursing and Allied Health Literature , and the Cochrane Data base of Systematic Review s and Register of Controlled Trials . STUDY SELECTION The authors systematic ally search ed for all relevant r and omized controlled trials and systematic review s on the diagnosis and treatment of VAP in mechanically ventilated adults that were published from 1980 to October 1 , 2006 . DATA EXTRACTION Independently and in duplicate , the panel critically appraised each published trial . The effect size , confidence intervals , and homogeneity of the results were scored using predefined definitions . The full guideline development panel arrived at a consensus for scores on safety , feasibility , and economic issues . LEVELS OF EVIDENCE Based on the scores for each topic , the following statements of recommendation were used : recommend , consider , do not recommend , and no recommendation because of insufficient or conflicting evidence . DATA SYNTHESIS For the diagnosis of VAP in immunocompetent patients , we recommend that endotracheal aspirates with nonquantitative cultures be used as the initial diagnostic strategy . When there is a suspicion of VAP , we recommend empiric antimicrobial therapy ( in contrast to delayed or culture directed therapy ) and appropriate single agent antimicrobial therapy for each potential pathogen as empiric therapy for VAP . Choice of antibiotics should be based on patient factors and local resistance patterns . We recommend that an antibiotic discontinuation strategy be used in patients who are treated of suspected VAP . For patients who receive adequate initial antibiotic therapy , we recommend 8 days of antibiotic therapy . We do not recommend nebulized endotracheal tobramycin or intratracheal instillation of tobramycin for the treatment of VAP . CONCLUSION We present evidence -based recommendations for the diagnosis and treatment of VAP . Implementation of these recommendations into clinical practice may lessen the morbidity and mortality of patients who develop VAP
This review found limited high- quality evidence to inform the treatment of impetigo .
BACKGROUND Impetigo is a common clinical problem seen in general practice .
Uncertainty exists as to the most effective treatment , or indeed if treatment is necessary .
AIM To determine the most effective treatment for impetigo in a systemically well patient .