Acute bacterial gastroenteritis is associated with subsequent post-infectious irritable bowel syndrome (PI-IBS) in adults. Less is known about this relationship in children. In May 2000, contamination of municipal water by Escherichia coli 0157:H7 and Campylobacter species caused a large outbreak of acute gastroenteritis in Walkerton, Ontario. We assessed this association among a cohort of children enrolled in the Walkerton Health Study (WHS).
WHS participants who were under age 16 at the time of the outbreak but who reached age 16 during the 8-year study follow-up were eligible for the pediatric PI-IBS study cohort. Eligibility also required no diagnosis of IBS or inflammatory bowel disease before the outbreak and permanent residency in the Walkerton postal code at the time of the outbreak. Validated criteria were used to classify subjects as having had no gastroenteritis (unexposed controls), self-reported gastroenteritis, or clinically suspected gastroenteritis during the outbreak. From 2002 to 2008, standardized biennial interviews used a modified Bowel Disease Questionnaire to diagnose IBS by Rome I criteria. Risk factors for IBS were identified by logistic regression.
In all, 467 subjects were eligible for the pediatric PI-IBS study cohort (47.1% female; mean age 11.6+/-2.44 years at the time of the outbreak). Of these, 305 were exposed to GE (130 clinically suspected and 175 self-reported) and 162 were unexposed controls. The cumulative incidence of IBS was significantly increased among exposed subjects vs. controls (10.5% vs. 2.5%; odds ratio 4.6, 95% confidence interval (1.6, 13.3)). In an unadjusted risk factor analysis, IBS was associated with a shorter time interval from exposure to assessment of IBS symptoms, female gender, diarrheal illness lasting more than 7 days, weight loss >10 lb, and antibiotic use during the outbreak. In adjusted analyses, both female gender and time interval to assessment of IBS symptoms remained independent predictors of PI-IBS.
Acute bacterial gastroenteritis is associated with subsequent IBS in children as in adults. Risk factors for PI-IBS in children are similar to those identified among adults. Confirmation of these findings in similar cohorts is needed.
We sought to determine the antibiotic susceptibility of organisms causing community-acquired urinary tract infections (UTIs) in adult females attending an urban emergency department (ED) and to identify risk factors for antibiotic resistance.
We reviewed the ED charts of all nonpregnant, nonlactating adult females with positive urine cultures for 2008 and recorded demographics, diagnosis, complicating factors, organism susceptibility, and risk factors for antibiotic resistance. Odds ratios (ORs) and 95% confidence intervals (CIs) for potential risk factors were calculated.
Our final sample comprised 327 UTIs: 218 were cystitis, of which 22 were complicated cases and 109 were pyelonephritis, including 22 complicated cases. Escherichia coli accounted for 82.3% of all UTIs, whereas Staphylococcus saprophyticus accounted for 5.2%. In uncomplicated cystitis, 9.5% of all isolates were resistant to ciprofloxacin and 24.0% to trimethoprim-sulfamethoxazole (TMP-SMX). In uncomplicated pyelonephritis, 19.5% of isolates were resistant to ciprofloxacin and 36.8% to TMP-SMX. In UTI (all types combined), any antibiotic use within the previous 3 months was a significant risk factor for resistance to both ciprofloxacin (OR 3.34, 95% CI 1.16-9.62) and TMP-SMX (OR 4.02, 95% CI 1.48-10.92). Being 65 years of age or older and having had a history of UTI in the previous year were risk factors only for ciprofloxacin resistance.
E. coli was the predominant urinary pathogen in this series. Resistance to ciprofloxacin and TMP-SMX was high, highlighting the importance of relevant, local antibiograms. Any recent antibiotic use was a risk factor for both ciprofloxacin and TMP-SMX resistance in UTI. Our findings should be confirmed with a larger prospective study.
Bovine tuberculosis was eradicated from Sweden after a programme lasting many years. By 1991, no tuberculosis in wildlife had been discovered for 50 years and the last case in cattle had occurred 13 years before. In 1991, the disease was identified in a herd of farmed fallow deer (Dama dama) and over the next three years nine other infected herds were identified. Investigation revealed that all the infected deer were either deer that had been imported into Sweden from the United Kingdom in 1987 or had been in contact with them. Restriction fragment analysis of eight isolates of Mycobacterium bovis from five of the herds showed that the isolates had identical patterns of DNA fragments, which indicated a common source of infection. Among more than 800 isolates of M bovis that have been analysed, these patterns were identical to those of only two previous isolates, both of which came from British deer. These results indicate that the eight Swedish strains of M bovis and the two British strains may have a common source of infection.
The aim of the study was to present a case of clinically diagnosed glomus vagale in a 42-year-old Aboriginal woman treated with external beam radiotherapy and to carry out a review of the published work. The details of presentation, diagnosis, treatment and follow up of the patient are discussed. A review of the published work was carry out using MEDLINE database with respect to aetiology, clinical presentation, diagnosis, treatment and expected outcomes. Glomus vagale tumours are a subtype of paragangliomas of the head and neck derived from extra-adrenal paraganglia of the autonomic nervous system. They are typically slow-growing, benign masses that are often asymptomatic and rarely show signs of hypersecretion. Treatment options include embolization, surgical excision, radiotherapy or surveillance. Radiotherapy is often used for extensive lesions where surgery is considered prohibitively morbid. Following treatment relapse rates are low with the most patients achieving long-term control. Our patient presented with an extensive lesion compressing the wall of the carotid artery and invading the jugular fossa to involve the clivus. Surgery was offered; however, the patient opted for external beam radiotherapy. A dose of 45 Gy in 25 fractions was delivered with 6-MV photons employing a CT-planned, wedge pair technique. Glomus vagale tumours are rare and should be managed in a multidisciplinary head and neck clinic with both surgical and radiation oncology opinions offered. The toxicities and outcomes of both methods should be discussed.
Peptic ulcer disease (PUD) and its complications impose a substantial burden on health care resources. To help identify subpopulations in which preventative measures might achieve maximal cost savings, the authors studied the variation in resource utilization and cost for management of bleeding PUD among demographic subgroups. Resource utilization profiles and direct medical cost estimates were generated for consecutive admissions for bleeding PUD at four hospitals in southern Ontario via chart review and adaptation of an administrative cost database. Multiple linear regression models were developed to identify independent demographic predictors of direct medical case cost and hospital length of stay (LOS). Among 158 admissions, the average LOS and case costs were 5.73 days and $2,953 (Canadian) respectively. Age, comorbid illness, nonsteroidal anti-inflammatory drug use, and the absence of prior PUD or upper gastrointestinal hemorrhage were associated with higher cost in univariate analysis, whereas increasing age and comorbidity predicted LOS. Only age and absence of prior PUD persisted as independent predictors of direct medical cost and LOS in a stepwise multiple linear regression. Costs for managing bleeding PUD vary substantially among demographic subgroups. More careful stratification of treatment costs is needed when economic models of interventions to prevent or to treat PUD are applied to specific subpopulations.
Although postinfectious irritable bowel syndrome (PI-IBS) is a well-recognised complication of acute gastroenteritis, its prognosis remains poorly defined. The natural history of PI-IBS was assessed among participants in the Walkerton Health Study (WHS), which has followed the long-term effects of a large outbreak of acute gastroenteritis related to municipal water contamination in May 2000.
WHS participants were invited to return for annual assessment at a research clinic. Adult residents of Walkerton at the time of the outbreak who enrolled in 2002/2003 and returned for assessment in 2008 were eligible for a PI-IBS study cohort if they had no prior history of IBS or inflammatory bowel disease. A modified Bowel Disease Questionnaire was used to diagnose IBS by Rome I criteria and to identify IBS subtypes.
Of 4561 WHS participants, 2451 returned for their 8 year assessment and 1166 were eligible for the PI-IBS study cohort (688 females, mean age 46.2 years). The prevalence of IBS among 742 eligible subjects who suffered acute gastroenteritis during the outbreak declined from 28.3% after 2-3 years to 15.4% after 8 years, but remained significantly increased compared with controls who did not have acute gastroenteritis (OR 3.12; 95% CI 1.99 to 5.04). Independent risk factors for PI-IBS at 8 years included female gender, younger age, prior anxiety/depression, and fever or weight loss during the acute enteric illness. IBS subtypes were not stable over time.
Acute gastroenteritis can trigger IBS symptoms that persist for at least 8 years. Characteristics of the host and the acute enteric illness can predict the long-term risk of PI-IBS.
To report the findings of a switch from brand-name to generic clozapine in a Canadian outpatient population.
The medical records of 58 outpatients diagnosed with schizophrenia and other psychotic disorders and stabilized on brand-name clozapine therapy were reviewed retrospectively. Patients were switched from brand-name to generic clozapine on their next dispensing supply after September 29, 2003. Data regarding clozapine dose regimens, physicians' visits, hospitalizations, and adverse events were collected from the patients' charts for the 6 months preceding and the 6 months after the switch from brand-name to generic clozapine. Relevant measurement changes in those data associated with the switch are evaluated.
No significant changes in dose, number of physician's visits, or hospitalization rates were observed as a consequence of the switch from brand-name to generic clozapine. In addition, there were no reported increases in the frequency of the most common adverse events, including decreases in white blood cell counts. None of the patients received a "nonrechallengeable" status, and no discontinuation of clozapine therapy occurred for any reason (toxicity or treatment failure) in the 6 months after the formulation switch.
In the current outpatient population, retrospective evaluation of the conversion from brand-name clozapine to the first generic alternative available on the Canadian market did not reveal any significant treatment changes.
Postinfectious irritable bowel syndrome (PI-IBS) is a common clinical phenomenon. To better define its incidence and epidemiology, a large cohort study was initiated after the contamination of a municipal water supply led to a large outbreak of acute Escherichia coli 0157:H7 and Campylobacter jejuni gastroenteritis.
Local residents were invited to undergo structured assessments at research clinics established 2 years after the outbreak. Permanent adult residents with no prior history of inflammatory bowel disease or IBS were eligible. Standardized questionnaires defined past and current health. The cohort was divided into controls without gastroenteritis, subjects with clinically suspected gastroenteritis, and subjects with only self-reported gastroenteritis that could not be substantiated by another source. A modified Bowel Disease Questionnaire identified IBS according to Rome criteria. The incidence and epidemiology of PI-IBS was characterized. Risk factors were assessed using multiple logistic regression.
There were 2069 eligible study participants. Rome I criteria were met by 71 of 701 controls (10.1%) vs 249 of 904 subjects with self-reported gastroenteritis (27.5%) and 168 of 464 subjects with clinically suspected gastroenteritis (36.2%) (all comparisons, P
The purpose of this study was to determine the incidence of postinfectious irritable bowel syndrome (IBS) among community subjects with positive stool studies. This was a prospective cohort study whereby all individuals with stool-positive acute enteric infection (AEI) were recruited from 3 health regions in Ontario, Canada. Each person completed questionnaires regarding preinfectious bowel habit and their bowel habit 3 months postinfection. Manning and Rome I criteria were used to diagnose irritable bowel syndrome. Two hundred thirty-one patients participated. Forty had preexisting IBS and were excluded. Of the remaining 191 patients, 7 developed irritable bowel syndrome, for an incidence of 3.7% (95% confidence interval: 1.0-6.3%). Fever during AEI was the only identifiable risk factor for developing postinfectious IBS (odds ratio, 11.96; P = .02). The incidence of postinfectious IBS in community subjects is 3.7%. Fever during the AEI may be an important risk factor for this condition.
Post-infectious irritable bowel syndrome is a common clinical phenomenon of uncertain aetiology.
To test the association between intestinal permeability and irritable bowel syndrome symptoms 2 years after a large waterborne outbreak of bacterial gastroenteritis.
Consecutive adults with Rome I irritable bowel syndrome and controls without irritable bowel syndrome attending a community clinic were enrolled. Intestinal permeability was measured as the ratio of fractional urinary excretions of lactulose and mannitol, and compared among cases vs. controls and predictors of abnormal intestinal permeability were assessed.
A total of 218 subjects (132 irritable bowel syndrome cases and 86 non-irritable bowel syndrome controls) completed the study protocol. About 27 (12%) had been diagnosed with the irritable bowel syndrome before the outbreak and 115 (53%) had been ill during the outbreak. Lactulose-mannitol ratios were increased among cases vs. controls (Mann-Whitney mean rank 118.8 vs. 95.3, P = 0.007), and cases were more likely to have a ratio >0.020 (P = 0.007). Among cases, those with increased intestinal permeability were more likely to report increased stool frequency. Both irritable bowel syndrome symptoms and male gender, but not diarrhoeal illness during the outbreak, were significant predictors of abnormal permeability.
Irritable bowel syndrome symptoms are associated with a subtle increase in intestinal permeability irrespective of prior gastroenteritis. This may improve understanding of the aetiology of both sporadic and post-infectious irritable bowel syndrome.