March 15, 2009
Some people go off food when they’re unwell, others take to their beds. I think I’ve discovered a new phenomenon which has yet to be documented in any medical journal. Whenever I succumb to an infection in my head, I lose all appetite for blogging. To understand this, you have to realise that the blogsphere represents the outside world, a world which crumples at my feet each time illness strikes. The battle of the bugs continues…
St. Valentine’s Day marked the beginning of this particular episode. I woke with a severe headache and as the day wore on, pain and pressure started to build behind my right eye. My GP prescribed a tetracycline antibiotic, Doxycycline which has been the stalwart of my treatment in recent years. My symptoms subsided but a week later, my right eye began to close over with swelling and the pain and pressure returned in my head. On account of my previous history, I was seen urgently by a specialist. A swab ruled out MRSA but this new resistance to Doxycycline, was a definite cause for concern. I was started on a cephalosporin antibiotic, Keftid which seemed to work well so after two weeks the dose was reduced with the plan that I would continue on it long term to break the cycle of chronic infection. That plan fell apart when another bacterial superinfection took hold last week. The headaches gradually returned and my life ground to a halt once more. This time my GP prescribed a different cephalosporin antibiotic, Suprax which I’m happy to report, appears to be taking hold. The headaches have eased and so has the sense of despondency which accompanied them. Where to from here? Who knows but for today anyhow, I’m happy to have had my world open up again. On I march.
While on the subject of nasty bugs, one of my regular readers kindly sent me details of a worrying outbreak of the Norovirus (Winter Vominting Bug) in Limerick. This highly infectious virus is usually found in our hospitals and can be potentially dangerous in the very young or old. The outbreak occurred on a college campus which has been temporarily closed while infection control measures are implemented by the HSE. See press release.
It seems that healthcare associated infections (HCAIs) are no longer confined to hospitals. The bugs are marching on.
19 Comments | antibiotics, chronic illness, HCAI, health, HSE, infection control, MRSA | Tagged: bacterial superinfection, nasal swab, Norovirus | Permalink
Posted by Steph
July 12, 2008
Did you know that hand washing is an effective way to prevent MRSA contamination and infection? According to a recent survey, the main source of the public’s information about MRSA, is through the media. The results of the survey have shown that there is a clear need to further educate the public on how to prevent the spread of infection. You can find a report here in The Irish Times online. Ever since my own brush with MRSA, I’ve tried to make it my business to become better informed about infection control and to spread the word.
MRSA is a subject close to the heart of The Biopsy Report. Consistently, the top posts on this blog are the ones which contain information on MRSA. The most frequently used search engine terms all refer to queries about MRSA. Terms such as “boils on butt”, “do you have mrsa forever”, “antibiotic resistance”, “chances of mrsa recurrence”, “superbug news”, “what is difference between mrsa and C Diff” and “mrsa nasal swab”, appear regularly and show that there is a huge hunger out there for more information on MRSA. Two funny search terms which appeared recently were “mrsa bed and breakfast” and “steph and staph infection together.” The mind boggles to think what was going through the minds of those people?
There is no doubt that infection control would benefit from greater public awareness. The media coverage of MRSA is far from an ideal source of information because of a tendency towards a sensationalist approach. We need a well-orchestrated campaign to combat the spread of MRSA and where better to start than online. Spread the word, not the germs.
22 Comments | Clostridium difficile, handwashing, health, infection control, Irish Times, MRSA, Staph A | Tagged: nasal swab | Permalink
Posted by Steph
May 4, 2008
Steph’s back! And so is Staph. I had a bit of blip with my health last week but I’m back on form again. At first, there was concern that it might be the unwelcome return of the superbug, MRSA. As it turns out, I have a nasty Staphylococcus aureus (Staph A) infection in my head but luckily, I have a non-resistant version of this bacterium which is very treatable. The problem I now face is finding a way to effectively eradicate this bug from my system.
It’s just over a year since I had surgery to stamp out a chronic osteomyelitis in my skull which had resulted from an MRSA wound infection following previous surgery. A few months later, I started to develop minor sinus infections and was reassured when laboratory tests showed that I was only positive for the more common form of the Staph aureus bug rather than it’s resistant form, MRSA. This bacterium is commonly found on the skin and in the nose of healthy people but it is not harmful unless it gets into the bloodstream. Approximately 20–30% of the general population are ‘Staph carriers’. I was treated with an sensitive antibiotic but the minor infections still continued to occur. Last November, I developed a nasty infection in my hand which turned out to be another Staph A infection. I was treated aggressively with oral antibiotics for 3 weeks and commenced a 6-month decontamination programme with the application of a topical antibiotic ointment to the inside of my nose. This process would appear to have failed as last week, nasal swabs and blood tests showed that the infection in my head is due to a heavy growth of Staph aureus. This latest development is worrying as it confirms that I am again systemically infected with this bacterium. I have responded well to a tetracycline antibiotic so there is no immediate cause for concern.
The reality is that Staph aureus is everywhere. It may well be that I have just been unlucky to have been contaminated/infected on several different occasions. My own theory is that my immune system has been weakened following intensive antibiotic treatment for MRSA and it has become a breeding ground for opportune bacteria like Staph aureus. The problem now is how to find a way to shake off this damned bug before it gets an even greater hold on my system. I cannot afford to let things go wrong with my head again. My GP has gone away to think about the options over the weekend. If anyone reading this has any knowledge on how best to proceed, I would be eternally grateful for your advice. I intend to win this battle.
When I became generally unwell last week and my head started to hurt, I lost all enthusiasm for blogging. I deserted the blogosphere but it didn’t desert me. My new-found blogging friends reached out and gave me the support and encouragement needed to get back on track. Thanks guys! I’m really, really grateful. Blogging – Yes! it’s the way to go!
24 Comments | antibiotics, chronic frontal sinus infection, health, MRSA, Steph's Story, superbugs, Uncategorized | Tagged: infection, nasal swab | Permalink
Posted by Steph
April 29, 2008
I’ve been tagged by Mousie. Now Mousie’s not someone you mess about with as one day you may end up on a trolley in her A&E Dept and that’s when you’ll be glad you did as she asked! Having said that, I’ve never been good at obeying rules so I’m going to do my own thing with this meme. If you want to see how it should have been done, pop on over to Mousethinks and, be impressed.
I’ve been asked to share some facts about myself, some random, some weird. As the theme of this blog is medical/health-related, I’m going to stick with my medical misadventures. Here goes!
I am a twin. My mother spent the final month of her pregnancy in a small nursing home, on strict bed rest. My twin brother arrived into this world 20 minutes ahead of me but he arrived so quickly, my mother never made it to the delivery room. They tried to transfer my mother immediately afterwards but I decided to arrive while she was on the stairs. She was rushed back to her bed just in time for my delivery. In all the excitement, my brother got forgotten and was later rescued from under the bedclothes. That all happened 50 years ago last May.
I once smashed my big toe when my ‘hot jar’ landed on it. When I was a little girl, we didn’t have the luxury of rubber hot water bottles. I had a heavy ceramic jar filled with hot water, with a large ceramic screw lid on top and it was used to take the chill off the bed as our house had no central heating at that stage. Anyway I managed to drop this thing on my foot one day causing my toe to bleed profusely. I can recall having my foot immersed in a basin of hot water (with Dettol) and watching the water turn bright red. I also remember my Dad giving me a piggy back every day into school. A few week’s later I felt something peculiar in my sock and found a discarded toe nail.
During my college days, I was the proud owner of a gold Yamaha 50cc motorbike having worked for a whole summer in a German canning factory, to fund it. One dark wet winter’s evening on driving home, an oncoming car suddenly turned across my path without warning, at a road junction. In that split second, I had a clear choice. 1) to crash into the side of the car or 2) to take evasive action and swerve into the path of oncoming traffic. I chose to hit the car and I can still recall the ‘thump’ and the sensation of being catapulted through the air, over the roof of the car. I was lucky in that I survived and was carted off to hospital by ambulance but I lost my dear bike that night. It took many years before I rid myself of the nickname, Evel Knievel.
Those of you who have read this blog before will know that I have an inherited connective tissue disorder (EDS) which leaves me prone to joint laxity. I’m right-handed and so my right shoulder takes the brunt if/when I have a fall. After several dislocations it eventually got to the stage where I needed surgery to stabilise my right shoulder joint. The surgeon carried out a ‘Putti-Platt’ procedure to shorten the ligaments and prevent further dislocation. Now no matter how hard I try, I cannot rotate my right arm outwards (no external rotation) to reach things on my right side. Think about this, the next time you reach for your driver’s seat belt.
And that’s as far as I got last night before I became all tagged out and went to bed feeling rotten. I’ve not been feeling well since last Friday having woken with marked congestion in my nasopharynx (area behind nose and above soft palate) but with no sign of a cold or sore throat. The congestion continued over the weekend and I began to feel like I was fighting a viral infection. My husband had to abandon the bed by Sunday night as loud snoring prevented him from getting any decent sleep. Yesterday, the congestion moved on up into my forehead and overnight it turned into a fulminating infection with pus literally bubbling over in my head. With my past history, I cannot afford to take risks so I headed to the doctor first thing this morning to get nasal swabs taken before starting on an antibiotic. So my medical misadventures are ongoing. I’m going to call it a day now as my head feels like it’s been taken over by aliens. I’m not going to tag anyone with this meme for fear it may be infectious. Enjoy the lucky escape!
9 Comments | antibiotics, connective tissue, EDS, hospital, hospital trolley, medical | Tagged: ambulance, dislocation, infection, ligaments, nasal swab | Permalink
Posted by Steph
December 6, 2007
Today I returned to the private specialist to have two stitches in my hand removed. I waited one hour to be seen, had one stitch removed during a very brief consultation and was then charged €150 for this pleasure. And to cap it all, I’ve been asked to return next week to have the last stitch removed. Can you believe it?
I’m still angry about this check-up. I arrived five minutes early for my appointment but had to wait until four people ahead of me had been seen. When I was eventually called in to the doctor’s room, I received no apology for the delay and this did not impress me. I had a punch biopsy performed on an infected lesion a week ago and was asked to return to get the biopsy report and to have the stitches removed. Only one stitch was taken out today – the specialist felt that the wound hadn’t fully healed thanks to my history of Ehlers-Danlos syndrome (EDS). I was surprised by this as my hand looked pretty good to me but I didn’t argue.
The only good bit of news today was that the biopsy report showed the lesion to be non-malignant. The not-so-good news was that the swabs taken one week ago, show that I remain colonised (in my nose) as well as infected (in the hand) by the Staphylococcus aureus bacteria. I’m all too familiar with Staph aureus having fought a long battle with it in the past, with infection due to MRSA, the antibiotic resistant strain of this bacteria. About 20-30% of the population are colonised with Staph A at any given time but unless they become infected by it, it does not pose a problem. A swab taken two weeks ago established that my present infection is sensitive to penicillin thankfully and I’ve been undergoing treatment with an appropriate oral antibiotic since then. I now also have to begin a de-colonisation treatment which involves using an antibiotic nasal ointment for the next year.
I think what bugged me the most about today was the sheer arrogance of it all. I’m well used to delays in doctors’ clinics and I don’t have a problem with this as long as I receive a simple apology. I can appreciate that doctors are very busy people but that doesn’t excuse bad manners. My consultation was very rushed lasting just 5 minutes or less, and I was given little or no opportunity to discuss anything. When I was asked to return in another week’s time for follow-up, I presumed that there would be no charge for today’s consultation. Not only did I presume wrong, I was asked to pay the same amount as I paid for the initial consultation two weeks ago. Usually a lesser charge is made for a return visit. And as if to rub salt into the wound, I also had to pay double the car park fee thanks to the long wait to be seen.
Now, I’ve seen many doctors over the years but I’ve never, ever felt as ripped off as I did today. I despair if this is the sort of health service we can anticipate when/if our Minister for Health gets her wish to privatise healthcare in this country. I did not settle today’s bill on principle and instead offered to pay next week when my treatment has been completed. The doctor’s secretary was not amused and insisted I took away a bill showing that €150 was still due for ‘Con 2’. I sure felt conned alright! You have to realise that the specialist will also be handsomely paid by my insurance company for carrying out the biopsy as a day procedure. It looks as if consultation no. 3 may well result in another charge and I’m suspicious now that this may be the real reason for why the final stitch wasn’t removed today. I think I’ll ring in the morning and query whether or not there’ll be another charge. If this is the case, then I might have to remove my own stitch and treat myself to some retail therapy instead.
My Christmas wish is that one day I’ll be able to wave goodbye to ‘Staph’ and resort back to being just plain old Steph.
14 Comments | antibiotics, biopsy, Health Service, medical, Minister for Health, MRSA, patient's story, Steph's Story | Tagged: check-up, nasal swab | Permalink
Posted by Steph
November 29, 2007
So the saga continues with an infected lesion on the back of my hand. The infection has responded well to a heavy dose of antibiotics over the past week and the lesion has reduced to a fraction of it’s original size. However the centre of it remains incredibly painful to touch, as I discovered to my cost when I caught my hand briefly on the edge of a cardboard box. Ouch!
Yesterday I attended a day centre at the hospital to have the lesion biopsied. I was somewhat surprised to have a repeat swab taken from the lesion and another one from my nose before a punch biopsy was performed on my hand. Local anaesthetic was first injected around the lesion to numb the area and then under sterile conditions, a 5mm diameter chunk of tissue was removed for analysis. I felt no pain whatsoever though the wound spurted copious amounts of blood and the surgeon had his work cut out trying to stem the flow. Two stitches were inserted to close the wound and then a pressure bandage was applied to ensure that no further bleeding occurred. With my history of having the connective tissue disorder, Ehlers-Danlos syndrome (EDS), extra caution is needed following surgery due to skin fragility and poor wound healing. Unfortunately, my hands do indeed suffer from delayed healing and so special care is required to prevent infection. I was sent home with antiseptic cream, spare dressings and instructions to return in a week’s time to have the stitches removed, and to receive the biopsy report. I was also given a prescription for a further week’s supply of the oral antibiotic (Flucloxacillin) plus an antibiotic ointment (Bactroban) to be applied to the inside of my nose. My legacy of previous MRSA infection seems to follow me everywhere though I suppose I should be grateful that every precaution is taken to ensure there is no return of this unwelcome superbug.
As procedures go, yesterday was plain sailing. I had a somewhat disturbed night due to discomfort in my hand but it’s no big deal. The best bit of all yesterday was that I received strict instructions to avoid doing washing-up. My only regret is that I didn’t succeed in getting this in writing 😉
The Biopsy Report now awaits the biopsy report.
14 Comments | antibiotics, biopsy, EDS, medical, MRSA, patient's story, Steph's Story, superbugs, surgeons | Tagged: legacy, nasal swab | Permalink
Posted by Steph
September 14, 2007
Anyone who’s ever tested positive for an MRSA infection will know what I’m talking about here. I’m curious to know when if ever, you can be declared free of this dreaded superbug? The standard procedure seems to be to aim for three consecutive negative screening swabs. Is this really enough to give you the green light for all-clear? Or does a requisite time-frame have to elapse before a recurrence/repeat recurrence can be ruled out? It’s been my own personal experience to discover that the medical profession does not seem to want to know or care about the reality of recurrence. Once you’ve been labelled with an MRSA status, it seems that you are forever more to be viewed as a ‘threat’ to mankind and believe me, it produces some ‘interesting’ reactions.
A close friend of mine (with a very good sense of humour) was admitted to hospital this week to have some neurosurgery performed on his back. He recounted to me the following discussion which took place between him and the admissions nurse.
Question: Have you ever had an MRSA infection?
Answer: No, but I have a good friend who has.
Question: Have you been in close contact with your friend?
Answer: Yes, but if you mean have we had sex – the answer is No! (Ha!Ha!)
Question: (asked with zero humour) Have you been in recent contact?
Answer: Yes, I have – our families meet regularly.
The interrogation terminated at this stage and my friend was then subjected to a full screening for MRSA prior to his surgery. He rang me this evening to tell me what had happened and we shared a good laugh about it together. I have had two reactions to this scenario.
Firstly, it’s good to know that patients are being screened whenever there is any doubt about the possibility of MRSA contamination. However I’d like to point out that the logic for screening in this instance seems to have been as a safety precaution for the hospital rather than for the patient. My friend was admitted on the day of his surgery and therefore the result of the screening would not have been known prior to his operation. Secondly, my friend was not asked for any details about my present status. It seemed to be a case of “once an MRSA risk – always an MRSA risk”.
My situation is that I contracted MRSA osteomyelitis of the frontal bone of the skull following surgery two years ago. I underwent intensive intra-venous antibiotic therapy to eradicate the infection and eventually got the all-clear some three months later following repeated MRSA screening. However my MRSA infection recurred ‘out of the blue’ nine months later and required further intensive antibiotic treatment plus extensive surgery to remove the diseased bone. I have not had any screening since the most recent surgery and yet it appears that I am still to be tarnished with the same ‘leper’ status acquired two years ago. I have been subjected to many strange reactions over the years. I’m aware that a huge amount of ignorance exists around having a positive MRSA status and therefore I can laugh at the consequences – I’ve no doubt that others are hurt and offended by the reaction received. There is a question that remains unanswered here however – “when can someone who has a history of recurrence of MRSA infection, be considered to be risk free?”. I’ve never been able to elicit a confident reply to this question from the medics. I suppose it’s a bit like the uncertainty faced by people who’ve survived cancer – no doctor can tell them with utter confidence that they will remain free of the disease. My conscience has taught me to stay clear of anyone who has had recent surgery or is immuno-compromised and I also avoid newborn babies for the same reason. I otherwise go about life quite normally without undue worries. However, the legacy lives on and I’d love someone to be able to tell me that I can leave it all behind.
Have you got any views on this?
82 Comments | infection control, medical, MRSA, patient's story, Steph's Story, superbugs, surgery | Tagged: legacy, nasal swab | Permalink
Posted by Steph
August 30, 2007
I heard an item on the radio this morning concerning an article written by the journalist Kevin Myers, in today’s Irish Independent. In this piece he refers to the perfect contours of the late Princess Diana’s nose which, when combined with her appealing eyes, made her into a real photogenic beauty. It started me thinking about the contours of my own nose and forehead which have been altered by recent surgery. My medical history is complex – I’ve had a lot of surgery, in various specialities and have the surgical scars to show for it – but none of these compare to living with a slight facial disfigurement.
I was admitted to an NHS hospital in northern England earlier this year to undergo a complex operation at a specialist Head & Neck surgical unit. This surgery is unavailable in Ireland unfortunately. I have a long history of serious sinus infection which has necessitated regular surgical intervention and intensive antibiotic treatment over the years. As a result of this, I now also (surprise, surprise) have a history of recurrent MRSA infection. The MRSA presented itself as orbital cellulitis following my last episode of frontal sinus surgery and this infection manifested into chronic osteomyelitis in the frontal bone of my skull. All surgical efforts to establish drainage from the frontal sinus had failed and despite intensive antibiotic treatment, I continued to develop abscesses in the bone close to the base of my brain. As this had an associated risk of developing into a brain abscess/septic meningitis, I was referred to the UK for assessment. Here I was advised that the most effective way to stamp out chronic osteomyelitis would be to have all the infected/dead bone removed, and an operation called the ‘Riedel procedure’ was recommended. I was fully informed that there would be a cosmetic disfigurement post-operatively and having considered my predicament very carefully, I finally agreed to proceed.
My little friend, the superbug, is thankfully still responsive to a tetracycline antibiotic, Vibramycin (Doxycycline), and this enabled me to obtain the requisite ‘all-clear’ from MRSA screening prior to the surgery. The operation itself went very well and was completed in just under four hours. My head was opened from ear to ear (zig-zag coronal incision), my ‘face’ was peeled back to the bridge of my nose and the anterior and inferior walls (bone) of both frontal sinuses were removed completely leaving a large hollow in my forehead. The margins of the frontal sinus along with the supraorbital rims were then ‘chamfered’ (planed) to make a gentle curve rather than a sharp step out of this hollow. This allows the soft tissue of the face to fall in and line the vacated frontal sinus area and improves the cosmetic defect which results from the procedure. My ‘face’ was then put back where it belongs and the coronal incision was stapled together before a pressure bandage was applied with a drain in situ to minimise haematoma formation. I had no post-operative complications other than vomiting copious amounts of blood when in the recovery room – this had drained into my stomach during the surgery. Ten days later when I had the staples (59 of them) removed from my scalp, the incision was healing beautifully and I was well on the way to making a good recovery.
That all happened five months ago and I remain free of infection. The post-operative numbness of my scalp has almost resolved though it has left behind an unpleasant neuralgia which requires medication. The surgery has left a definite legacy – a facial cosmetic defect. The bridge of my nose ends abruptly where the large hollow begins in my forehead. I’ve got used to seeing my new ‘look’ in the mirror although photographs still tend to take me aback. I’ve also had to get used to having conversations with people, usually strangers whose eyes are firmly fixed on my forehead while they try to work out what’s happened to the contours of my face. I’ve had a few tactless comments but nothing that humour can’t handle. You have to keep things in perspective – I’ve been given a second chance at life – not everyone gets that chance. My surgeon has offered re-constructive surgery (a split calvarial bone graft/titanium plate) in the future but for the moment anyhow I’ve no wish to go there and certainly no wish to invite further trouble. And anyway, I’m proud of my war wound – my husband refers to it as the ‘bomb crater’- it was a hard fought battle and I’ve come through it still smiling 😀
I’ve just gotta face it – I’ll never be a Princess Di. But then, that’s life!
12 Comments | antibiotics, chronic frontal sinus infection, medical, MRSA, NHS, patient's story, riedel's procedure, Steph's Story, superbugs, surgery | Tagged: anatomy, avoiding eye contact, nasal swab, Princess Diana, RTE Radio | Permalink
Posted by Steph
June 18, 2007
We all know at this stage that infection control is a big problem in Irish hospitals. Outbreaks of MRSA and many other dangerous infections are on the increase. Huge investment is now required in the health service to bring about radical change in the control of infection. Here is my list of things-to-do for Mary Harney now that she’s back (where she wants to be) as our Minister for Health. This is not rocket science. These are obvious changes that could be put in place if only the funding was made available.
1. Practice preventative medicine – provide mandatory testing for MRSA colonisation for all patients being admitted to hospital. The present system for testing nasal swabs takes too long for results to be processed (2-3 days). A faster, but more expensive testing mechanism is available and could be used for all patients being admitted through A&E.
2. Microbiology is a key component of infection control. Many more microbiology staff are required and lab facilities need to be urgently expanded and updated.
3. Improve basic hygiene practice by staff on the wards – provide alcohol gel dispensers beside every bed, more hand washing facilities needed for everyone, improve cleaning of equipment etc.
4. Reduce the bed occupancy rate to less than 80% – in Ireland it’s over 100% most of the time (is it any wonder the nurses are moaning about their job lot!) – more beds in public hospitals are needed now.
5. Provide proper isolation facilities for infected patients – it’s like a bad joke the way the situation is being managed at the moment.
6. Clean hospitals = cost-effective health care. Our hospitals are filthy! Stop the present practice of sub-contracting the cleaning of our hospitals to outside agencies. Each hospital needs to take back responsibility for it’s own state of affairs.
7. And please stop messing around with plans for a 2-tier health system and get working on a 1st class health system for everyone!
Leave a Comment » | 2-tier health system, Co-Located Hospitals, handwashing, Health Service, infection control, medical, Minister for Health, MRSA, nursing | Tagged: nasal swab | Permalink
Posted by Steph
June 1, 2007
MRSA: My Room Shared with Aliens! This is a follow-on from Part 1 of my story yesterday.
Part 2: Admission to Hospital
I was admitted to hospital in July 2005 to have an operation (external frontoethmoidectomy) carried out for the fifth time (also had numerous previous nasal endoscopic surgeries), to open up the frontal sinus above one eye to drain an abscess in the bone close to the base of my brain. I was also to have a new channel created (drilled through bone) in my skull with a stent inserted to hold open this area for the purpose of aeration and drainage. The surgery was long, but uncomplicated and I made a good recovery. About three weeks later my post-op pain began to worsen over a period of days and a hot painful swelling developed around both eyes with an unmerciless headache. I was re-admitted to hospital via A&E where a nasal swab was taken before I was transferred to a ward. In my innocence about MRSA in those days, I reckoned that the swab was just a routine procedure and thought no more about it. Four days later, after numerous different combinations of antibiotics had been administered through an IV line to little effect, my infection was still very much on the march. It was like sharing my body with an alien. Every time I slept, even if only dozing for minutes, the swelling would move around my eyes and I’d awake with a visibly different appearance, and feeling really awful. I became exhausted from lack of sleep and so when I was moved from a noisy 5-bed ward into a tiny single en suite room, I really thought that things were looking up. How wrong I was to be proved!
Read Part 3 tomorrow!
5 Comments | a lonely journey, MRSA, patient's story, Steph's Story | Tagged: nasal swab | Permalink
Posted by Steph