Adherence to guidelines: A national audit of the management of acute upper gastrointestinal bleeding. The REASON registry

OBJECTIVES:

To assess process of care in nonvariceal upper gastrointestinal bleeding (NVUGIB) using a national cohort, and to identify predictors of adherence to ‘best practice’ standards.

METHODS:

Consecutive charts of patients hospitalized for acute upper gastrointestinal bleeding across 21 Canadian hospitals were reviewed. Data regarding initial presentation, endoscopic management and outcomes were collected. Results were compared with ‘best practice’ using established guidelines on NVUGIB. Adherence was quantified and independent predictors were evaluated using multivariable analysis.

RESULTS:

Overall, 2020 patients (89.4% NVUGIB, variceal in 10.6%) were included (mean [± SD] age 66.3±16.4 years; 38.4% female). Endoscopy was performed in 1612 patients: 1533 with NVUGIB had endoscopic lesions (63.1% ulcers; high-risk stigmata in 47.8%). Early endoscopy was performed in 65.6% and an assistant was present in 83.5%. Only 64.5% of patients with high-risk stigmata received endoscopic hemostasis; 9.8% of patients exhibiting low-risk stigmata also did. Intravenous proton pump inhibitor was administered after endoscopic hemostasis in 95.7%. Rebleeding and mortality rates were 10.5% and 9.4%, respectively. Multivariable analysis revealed that low American Society of Anesthesiologists score patients had fewer assistants present during endoscopy (OR 0.63 [95% CI 0.48 to 0.83), a hemoglobin level <70 g/L predicted inappropriate high-dose intravenous proton pump inhibitor use in patients with low-risk stigmata, and endoscopies performed during regular hours were associated with longer delays from presentation (OR 0.33 [95% CI 0.24 to 0.47]).

CONCLUSION:

There was variability between the process of care and ‘best practice’ in NVUGIB. Certain patient and situational characteristics may influence guideline adherence. Dissemination initiatives must identify and focus on such considerations to improve quality of care.     

Patient satisfaction with medication for gastroesophageal reflux disease: a systematic review

BACKGROUND:

Patient satisfaction is increasingly regarded as an important aspect of measuring treatment success in individuals with gastroesophageal reflux disease (GERD).

OBJECTIVE:

To review how satisfied patients with GERD are with their medication, and to analyze the usefulness of patient satisfaction as a clinical end point by comparing it with symptom improvement.

METHODS:

Systematic searches of the PubMed and EMBASE databases identified clinical trials and patient surveys published between 1966 and 2009.

RESULTS:

Twelve trials reported that 56% to 100% of patients were ‘satisfied’ or ‘very satisfied’ with proton pump inhibitor (PPI) treatment for GERD. Patient satisfaction levels were higher for PPIs than other GERD medications in two trials. The sample-size-weighted average proportion of patients ‘satisfied’ with their PPI after four weeks of treatment in trials was 93% (95% CI 87% to 99%), with 73% (95% CI 62% to 83%) being ‘very satisfied’. In four surveys, the average proportion of patients ‘satisfied’ with their PPI treatment was 82% (95% CI 73% to 90%) and 62% (95% CI 48% to 75%) were ‘very satisfied’. Seven trials found a positive association between patient satisfaction and symptom improvement, and two surveys between satisfaction and improved health-related quality of life. Three trials found that continuous treatment yielded higher rates of satisfaction than on-demand therapy.

CONCLUSIONS:

More than one-half of patients were satisfied with their PPI medication in trials, and more patients were satisfied with PPIs than other medication types. An association between patient satisfaction and symptom resolution was found, suggesting that patient satisfaction is a useful end point for evaluating GERD treatment success.     

Using a ‘no drain’ policy in 342 laparoscopic hepatectomies: which factors predict failure?

Objectives

The aim of this study was to identify factors that predict the failure of a ‘no drain’ policy in laparoscopic hepatectomy.

Methods

Surgical outcomes in 342 consecutive patients undergoing laparoscopic hepatectomy were reviewed. Drains were placed only for the following predefined criteria: (i) intraoperative bile leak; (ii) bilioenteric anastomosis, and (iii) increased risk for postoperative bleeding (‘no drain’ policy). Factors leading to need for postoperative drainage or reoperation were evaluated.

Results

Drains were placed in 44 patients (drainage group). Postoperatively, additional procedures were required in five (11.4%) patients in the drainage group and in 18 (6.0%) patients in the no-drainage group. Multivariate analysis suggested that blood loss of >400 ml [odds ratio (OR) 4.50, 95% confidence interval (CI) 1.41–14.2; P = 0.010] and preoperative chemotherapy (OR = 2.24, 95% CI 0.82–6.48; P = 0.120) may increase the risk for need for postoperative procedures when intraoperative prophylactic drainage is not used.

Conclusions

Prophylactic drainage during liver resection should be considered not only in the presence of uncontrollable bile leak or concern for postoperative bleeding risk, but also in patients who have undergone neoadjuvant chemotherapy and those in whom intraoperative blood loss is >400 ml. Otherwise, a ‘no drain’ policy is safe and would enhance the advantages of minimally invasive liver surgery.     

Patient transitions relevant to individuals requiring ongoing ventilatory assistance: A Delphi study

BACKGROUND:

Various terms, including ‘prolonged mechanical ventilation’ (PMV) and ‘long-term mechanical ventilation’ (LTMV), are used interchangeably to distinguish patient cohorts requiring ventilation, making comparisons and timing of clinical decision making problematic.

OBJECTIVE:

To develop expert, consensus-based criteria associated with care transitions to distinguish cohorts of ventilated patients.

METHODS:

A four-round (R), web-based Delphi study with consensus defined as >70% was performed. In R1, participants listed, using free text, criteria perceived to should and should not define seven transitions. Transitions comprised: T1 – acute ventilation to PMV; T2 – PMV to LTMV; T3 – PMV or LTMV to acute ventilation (reverse transition); T4 – institutional to community care; T5 – no ventilation to requiring LTMV; T6 – pediatric to adult LTMV; and T7 – active treatment to end-of-life care. Subsequent Rs sought consensus.

RESULTS:

Experts from intensive care (n=14), long-term care (n=14) and home ventilation (n=10), representing a variety of professional groups and geographical areas, completed all Rs. Consensus was reached on 14 of 20 statements defining T1 and 21 of 25 for T2. ‘Physiological stability’ had the highest consensus (97% and 100%, respectively). ‘Duration of ventilation’ did not achieve consensus. Consensus was achieved on 13 of 18 statements for T3 and 23 of 25 statements for T4. T4 statements reaching 100% consensus included: ‘informed choice’, ‘patient stability’, ‘informal caregiver support’, ‘caregiver knowledge’, ‘environment modification’, ‘supportive network’ and ‘access to interprofessional care’. Consensus was achieved for 15 of 17 T5, 16 of 20 T6 and 21 of 24 T7 items.

CONCLUSION:

Criteria to consider during key care transitions for ventilator-assisted individuals were identified. Such information will assist in furthering the consistency of clinical care plans, research trials and health care resource allocation.     

Cost comparison analysis of open versus laparoscopic distal pancreatectomy

Background

In comparison with open distal pancreatectomy (ODP), laparoscopic distal pancreatectomy (LDP) is associated with fewer complications and shorter hospital stays, but comparative cost data for the two approaches are limited.

Methods

Records of all distal pancreatectomies carried out from January 2009 to June 2013 were reviewed and stratified according to operative complexity. Patient factors and outcomes were recorded. Total variable costs (TVCs) were tabulated for each patient, and stratified by category [e.g. ‘floor’, ‘operating room’ (OR), ‘radiology’]. Costs for index admissions and 30-day readmissions were compared between LDP and ODP groups.

Results

Of 153 procedures, 115 (70 LDP, 45 ODP) were selected for analysis. The TVC of the index admission was US$3420 less per patient in the LDP group (US$10 480 versus US$13 900; P = 0.06). Although OR costs were significantly greater in the LDP cohort (US$5756 versus US$4900; P = 0.02), the shorter average hospitalization in the LDP group (5.2 days versus 7.7 days; P = 0.01) resulted in a lower overall cost. The total cost of index hospitalization combined with readmission was significantly lower in the LDP cohort (US$11 106 versus US$14 803; P = 0.05).

Conclusions

In appropriately selected patients, LDP is more cost-effective than ODP. The increased OR cost associated with LDP is offset by the shorter hospitalization. These data clarify targets for further cost reductions.     

A promoter mutation in the haemagglutinin segment of influenza A virus generates an effective candidate live attenuated vaccine

Background

Annual seasonal and pandemic influenza vaccines need to be produced in a very tight time frame. Haemagglutinin (HA) is the major immunogenic component of influenza vaccines, and there is a lot of interest in improving candidate vaccine viruses.

Objectives

It has been shown elsewhere that mutations introduced in the non-coding region of influenza genome segments can upregulate protein expression. Our objective was to assess a virus based on the laboratory strain A/PR/8/34 (PR8) containing a modified 3′ non-coding region of RNA segment 4 (haemagglutinin).

Methods

NIBRG-93 was generated using reverse genetics. HA protein expression and growth properties were assessed. The virus phenotype suggested that it could be a candidate for use as a live attenuated vaccine, so in vivo studies were performed to assess its suitability.

Results

NIBRG-93 virus has enhanced haemagglutinin production and is significantly attenuated. Electron microscopy (EM) shows that the modified virus produces a large proportion of ‘virus-like particles’ that consist of budded cell membrane covered in HA but lacking M1 protein. The virus was shown to be attenuated in mice and offered complete protection against lethal challenge.

Conclusions

We demonstrate that NIBRG-93 is an effective live attenuated vaccine virus protecting mice against lethal challenge and reducing virus shedding.     

The determinants of chronic bronchitis in Aboriginal children and youth

BACKGROUND:

There is limited knowledge concerning chronic bronchitis (CB) in Canadian Aboriginal peoples.

OBJECTIVE:

To determine the prevalence (crude and adjusted) of CB and its associated risk factors in Canadian Aboriginal children and youth six to 14 years of age.

METHODS:

Data from the cross-sectional Aboriginal Peoples Survey were analyzed in the present study. Logistic regression analysis was used to determine risk factors influencing the prevalence of CB among Aboriginal children and youth. The balanced repeated replication method was used to compute standard errors of regression coefficients to account for clustering inherent in the study design. The outcome of interest was based on the question: “Have you been told by a doctor, nurse or other health professional that you have chronic bronchitis?” Demographics, environment and population characteristics (predisposing and enabling resources) were tested for an association with CB.

RESULTS:

The prevalence of CB was 3.1% for boys and 2.8% for girls. Other significant risk factors of CB were age (OR 1.38 [95% CI 1.24 to 1.52] for 12 to 14 year olds versus six to eight year olds), income (OR 2.28 [95% CI 2.02 to 2.59] for income category <$25,000/year versus ≥$85,000/year), allergies (OR 1.96 [95% CI 1.78 to 2.16] for having allergies versus no allergies), asthma (OR 7.61 [ 95% CI 6.91 to 8.37] for having asthma versus no asthma) and location of residence (rural/urban and geographical location). A significant two-way interaction between sex and body mass index indicated that the relationship between the prevalence of CB and body mass index was modified by sex.

DISCUSSION:

The prevalence of CB was related to well-known risk factors among adults, including older age and lower annual income.     

Parental perceptions and predictors of consent for school‐located influenza vaccination in urban elementary school children in the United States

Background

School-located influenza vaccination (SLV) programs have the potential to mass-vaccinate all enrolled children, but parental consent is required.

Objective

To examine parental attitudes and determine predictors of parental consent for vaccination of schoolchildren through SLV programs.

Patients/Methods

Surveys were distributed to parents of 4517 children during 2009–2010 (year 1) and 4414 children during 2010–2011 (year 2) in eight elementary schools in conjunction with a SLV program.

Results

Participants included 1259 (27·9%) parents in year 1 and 1496 (33·9%) in year 2. Parental consent for 2009 H1N1, 2009 seasonal, and 2010 seasonal influenza vaccines was obtained from 738 (70·8%), 673 (64·5%), and 1151 (77·2%) respondents, respectively. During the 2009 pandemic, respondents concerned about influenza severity were twice as likely to consent for the 2009 H1N1 vaccination compared to unconcerned respondents (OR 2·04, 95% CI:1·19–3·51). During year 2, factors that predicted parental consent were the perception of high susceptibility to influenza infection (OR 2·19, 95% CI:1·50–3·19) and high benefit of vaccine (OR 2·23, 95% CI:1·47–3·40). In both years, college-educated parents were more likely to perceive vaccine risks (year 1: 83·6 versus 61·5%, P < 0·001 and year 2: 81·1% versus 60·6%, P < 0·001) and less likely to consent for seasonal influenza vaccine (year 1: OR 0·69, 95% CI:0·53–0·89 and year 2: OR 0·61, 95% CI:0·47–0·78) compared to non-college-educated parents.

Conclusions

Parents who appreciate the risks of influenza and benefits of vaccination are more likely to consent for SLV. More research is needed to determine how to address heightened safety concerns among college-educated parents.     

Seroprevalence of antibody to influenza A(H1N1)pdm09 attributed to vaccination or infection,before and after the second (2010) pandemic wave in Australia

Objectives

Historical records of influenza pandemics demonstrate variability in incidence and severity between waves. The influenza A(H1N1)pdm09 pandemic was the first in which many countries implemented strain-specific vaccination to mitigate subsequent seasons. Serosurveys provide opportunity to examine the constraining influence of antibody on population disease experience.

Design

Changes in the proportion of adults seropositive to influenza A(H1N1)pdm09over the 2009/10 (summer) interepidemic period and 2010 (winter) influenza season were measured to determine whether there was a temporal relationship with vaccine distribution and influenza activity, respectively.

Setting

Australia.

Sample

Plasma samples were collected from healthy blood donors from seven cities at the end of the first wave (November 2009), and before (March/April 2010) and after (November 2010) the subsequent influenza season.

Main outcome measures

Haemagglutination inhibition (HI) assays were performed to assess reactivity of plasma against A(H1N1)pdm09, and the proportion seropositive (HI titre ≥ 40) compared over time, by age group and location.

Results

Between the 2009 and 2010 influenza seasons, the seropositive proportion rose from 22% to 43%, an increase observed across all ages and sites. Brisbane alone recorded a significant rise in seropositivity over the 2010 influenza season – from a baseline of 35% to 53%. The seropositive proportion elsewhere was ≥40% pre-season, and did not rise over winter.

Conclusions

A vaccine-associated increase in seropositive proportion preceding the influenza season correlated with low levels of disease activity in winter 2010. These observations support the role of immunisation in mitigating the ‘second wave’ of A(H1N1)pdm09, with timing critical to ensure sustained herd protection.     

Patient satisfaction with the endoscopy experience and willingness to return in a central Canadian health region

OBJECTIVE:

Patient experiences with endoscopy visits within a large central Canadian health region were evaluated to determine the relationship between the visit experience and the patients’ willingness to return for future endoscopy, and to identify the factors associated with patients’ willingness to return.

METHODS:

A self-report survey was distributed to 1200 consecutive individuals undergoing an upper and/or lower gastrointestinal endoscopy at any one of the six hospital-based endoscopy facilities in the region. The Spearman correlation coefficient was used to assess the association between the patients’ overall rating of the visits and willingness to return for repeat procedures under similar medical circumstances. Logistic regression analyses were performed to identify the factors associated with willingness to return for repeat endoscopy and overall satisfaction (rating) of the visit.

RESULTS:

A total of 529 (44%) individuals returned the questionnaire, with 45% rating the visit as excellent and 56% indicating they were extremely likely to return for repeat endoscopy. There was a low moderate correlation between overall rating of the visit and patients’ willingness to return for repeat endoscopy (r=0.30). The factors independently associated with patient willingness to return for repeat endoscopy included perceived technical skills of the endoscopists (OR 2.7 [95% CI 1.3 to 5.5]), absence of pain during the procedure (OR 2.2 [95% CI 1.3 to 3.6]) and history of previous endoscopy (OR 2.4 [95% CI 1.4 to 4.1]). In contrast, the independent factors associated with the overall rating of the visit included information provided pre- and postprocedure, wait time before and on the day of the visit, and the physical environment.

CONCLUSIONS:

To facilitate patient return for needed endoscopy, it is important to assess patients’ willingness to return because positive behavioural intent is not simply a function of satisfaction with the visit.     

Corticosteroid therapy in critical illness due to seasonal and pandemic influenza

BACKGROUND:

Survey data suggest that Canadian intensivists administer corticosteroids to critically ill patients primarily in response to airway obstruction, perceived risk for adrenal insufficiency and hemodynamic instability.

OBJECTIVE:

To describe variables independently associated with systemic corticosteroid therapy during an influenza outbreak.

METHODS:

The present analysis was retrospective cohort study involving critically ill patients with influenza in two Canadian cities. Hospital records were reviewed for critically ill patients treated in the intensive care units (ICUs) of eight hospitals in Canada during the 2008 to 2009 and 2009 to 2010 influenza outbreaks. Abstracted data included demographic information, symptoms at disease onset, chronic comorbidities and baseline illness severity scores. Corticosteroid use data were extracted for every ICU day and expressed as hydrocortisone dose equivalent in mg. Multivariable regression models were constructed to identify variables independently associated with corticosteroid therapy in the ICU.

RESULTS:

The study cohort included 90 patients with a mean (± SD) age of 55.0±17.3 years and Acute Physiology and Chronic Health Evaluation II score of 19.8±8.3. Patients in 2009 to 2010 were younger with more severe lung injury but similar exposure to corticosteroids. Overall, 54% of patients received corticosteroids at a mean daily dose of 343±330 mg of hydrocortisone for 8.5±4.8 days. Variables independently associated with corticosteroid therapy in the ICU were history of airway obstruction (OR 4.8 [95% CI 1.6 to 14.9]) and hemodynamic instability (OR 4.6 [95% CI 1.2 to 17.8]).

CONCLUSION:

Observational data revealed that hemodynamic instability and airway obstruction were associated with corticosteroid therapy in the critical care setting, similar to a recent survey of stated practice. Efforts to determine the effects of corticosteroids in the ICU for these specific clinical situations are warranted.     

Appropriateness of diagnosis of unstable angina pectoris in patients referred for coronary arteriography

BACKGROUND

A diagnosis of unstable angina pectoris (UAP) often carries with it a decision to catheterize the patient promptly. However, UAP remains a clinical diagnosis, based mostly on a patient’s clinical history and electrocardiogram (ECG) findings.

OBJECTIVE

To evaluate whether the diagnosis of UAP is overused in patients referred for coronary arteriography.

METHODS

Ninety-six patients with a diagnosis of UAP who were referred for invasive studies were re-examined clinically before catheterization. Coronarography was independently reviewed for correlation with clinical findings.

RESULTS

Based on the patient’s history and ECG changes, UAP was classified by two independent cardiologists as ‘very likely’ in 58% and 49%, ‘possible’ in 19% and 30%, and of ‘low probability’ in 23% and 21%, respectively. Patients with ‘very likely’ UAP had a high incidence of significant coronary lesions (87% and 96% for each cardiologist) and complex lesions by angiography (41% and 49%, respectively). Patients with a diagnosis of ‘low probability’ UAP had a low incidence of significant coronary lesions (55% for each cardiologist) and a very low incidence of complex angiographic lesions (5% for each cardiologist). Patients with ‘possible’ UAP had intermediate results.

CONCLUSION

Because of a presumptive diagnosis of UAP, approximately 22% of all patients referred for coronarography have no clinical and/or ECG evidence for this diagnosis. The incidence of complex coronary lesions in this group is very low.     

Resident trainees do not affect patient satisfaction in an outpatient gastroenterology clinic: A prospective study conducted in a Canadian gastroenterology clinic

BACKGROUND:

There is little literature regarding how a gastroenterology trainee affects a patient’s interpretation of care during outpatient clinic visits. Improving patient satisfaction is desirable and benefits may include enhanced patient compliance as well as providing trainees with areas for improvement.

OBJECTIVES:

To evaluate patient satisfaction in an outpatient gastroenterology clinic when seen by a trainee and attending physician versus an attending physician alone. The secondary objective was to evaluate physician characteristics that play a role in creating a positive clinical experience.

METHODS:

A randomized prospective survey study was conducted over an 11-month period (July 2012 to June 2013) at St Boniface Hospital (Winnipeg, Manitoba). Two gastroenterology fellows (postgraduate year 4 and 5) and nine internal medicine residents (postgraduate year 1 to 3) comprised the ‘trainee’ role, while three academic clinicians comprised the ‘attending’ role. Patients included individuals seen for an initial consultation and were >18 years of age.

RESULTS:

A total of 211 patients comprised the final study group, with 118 in the attending group and 93 in the trainee group. In univariate analysis, patients more often had a very good experience when seen by an attending physician alone versus a trainee and attending physician (73% versus 56%; P=0.016); however, on multivariate analysis, there was no significant difference in patient satisfaction (OR 0.89; P=0.931). Physician factors found to be associated with high patient satisfaction on multivariate analysis included: addressing all patient concerns (OR 27.56; P=0.021); giving the patient a preliminary diagnosis (OR 78.02; P=0.006); and feeling the physician was thorough (OR 72.53; P=0.029).

CONCLUSIONS:

The present study did not reveal a difference in patient satisfaction if a patient sees an attending physician alone or with a trainee. Moreover, to improve patient satisfaction in a gastroenterology clinic, physicians should address all patient concerns, provide a preliminary diagnosis and appear to be thorough in their assessment. Further work to increase patient awareness on the role of residents in teaching hospitals is warranted to further promote careers in gastroenterology.     

Risk factors and outcomes for pandemic H1N1 influenza compared with seasonal influenza in hospitalized children in China

OBJECTIVE:

To compare clinical features and outcomes of children hospitalized in China with pandemic (p)H1N1 between 2009 and 2010 versus seasonal influenza A between 2008 and 2009.

METHODS:

Systematic review of laboratory-confirmed admissions to the Children’s Hospital, Soochow University (Suzhou, China).

RESULTS:

Seventy-five children younger than 14 years of age were admitted with pH1N1, 70 with H3N2 and three with seasonal H1N1. With pH1N1, the mean age was older (36 months versus seven months), the length of stay was longer (nine days versus seven days), underlying conditions were more common (29% versus 15%), anemia was more common (11% versus 0%) (P<0.05), with trends toward more secondary bacterial pneumonia and intensive care unit care, compared with seasonal influenza. Two of the 75 children with pH1N1 died versus no deaths in children with seasonal influenza. None of the children had received pH1N1, seasonal influenza, conjugated pneumococal or Haemophilus influenzae b vaccines.

CONCLUSION:

In China, children hospitalized with pH1N1 influenza differed from case series in Canada, Argentina and the United States, suggesting that locale, background and health care system influenced the presentation and outcomes of pandemic and seasonal influenza.     

Serological survey of the novel influenza A H1N1 in inner city Winnipeg,Manitoba, 2009

INTRODUCTION:

Little is known about the determinants of pandemic H1N1 (pH1N1) infection in Canada among low-income, inner city populations. To inform future influenza planning, the seroprevalence of pH1N1 antibodies among inner city clinic attendees in Winnipeg (Manitoba) according to sociodemographic and risk factor characteristics were estimated and vaccination rates were explored.

METHODS:

Adults presenting to three inner city community clinics in Winnipeg from October 2009 to December 2009 were recruited as study participants (n=458). A questionnaire was administered to collect demographic, risk factor and symptom information, and a venous blood sample was collected for hemagglutination inhibition assay testing to detect the presence of antibodies against pH1N1.

RESULTS:

Approximately one-half (53%) of the study participants reported an annual household income of <$10,000/year, and 65% identified as Aboriginal. pH1N1 positivity was 5.7% among those enrolled early in the study and 15.5% among those enrolled later in the study. Positivity was higher among participants who were female, Aboriginal and in contact with children ≤5 years of age. The overall pH1N1 vaccination rate was 28%.

DISCUSSION:

pH1N1 positivity was high among low-income adults accessing clinics in Winnipeg’s inner city compared with the general population. Of further concern were the low rates of uptake of both seasonal and pH1N1 influenza vaccinations. When planning for future influenza outbreaks, it is important to incorporate strategies for the prevention, control, and care of influenza among low-income and inner city adults.     

Hepatitis C virus-infected patients are ‘spared’ from the metabolic syndrome but not from insulin resistance. A comparative study of nonalcoholic fatty liver disease and hepatitis C virus-related steatosis

BACKGROUND:

Nonalcoholic fatty liver disease (NAFLD) and chronic hepatitis C feature steatosis and insulin resistance (IR), conditions associated with the metabolic syndrome (MS).

OBJECTIVES:

To assess the prevalence of MS and determinants of IR in patients with NAFLD and chronic hepatitis C.

METHODS:

Ninety-three consecutive patients with NAFLD, 97 with chronic hepatitis C virus (HCV) genotypes 1 and 2, and 182 ‘healthy’ controls without steatosis were enrolled in the present study. The prevalence of MS was assessed by modified Adult Treatment Panel III criteria and IR by the homeostasis model assessment of insulin resistance (HOMA-IR). IR was defined as the 75th percentile of the HOMA-IR of control subjects.

RESULTS:

While the prevalence of IR was similar in NAFLD and HCV-infected subjects (70.0% and 78.7%, respectively), the prevalence of MS was significantly higher in NAFLD patients than in HCV-infected patients (27.9% versus 4.1%) and in controls (5.6%). With multivariate analysis, IR was predicted by body mass index (OR 1.263; 95% CI 1.078 to 1.480) and triglyceridemia (OR 1.011; 95% CI 1.002 to 1.020) in NAFLD and by sex (OR for female sex 0.297; 95% CI 0.094 to 0.940) and fibrosis stage (OR 2.751; 95% CI 1.417 to 5.340) in chronic hepatitis C.

CONCLUSIONS:

IR is independently associated with body mass index and triglyceridemia in NAFLD, sex and fibrosis in chronic HCV infection, and has a higher prevalence in NAFLD and chronic hepatitis C than in controls. However, the frequency of MS in HCV-infected patients, similar to that of controls, is significantly lower than that seen in NAFLD patients. The current diagnostic criteria of MS are more likely to ‘capture’ patients with NAFLD than with chronic hepatitis C, although both groups are insulin resistant.     

Zanamivir versus trivalent split virus influenza vaccine: a pilot randomized trial

Background

Healthcare workers may be exposed to people with respiratory viral infections more often than other working adults. Understanding the risk and the effectiveness of different preventive measures is of great importance.

Objectives

To estimate adherence to prophylactic antiviral medication for a full influenza season, to the compare efficacy of antiviral prophylaxis to that of the seasonal influenza vaccine and to identify exposures that increase risk of acute respiratory illnesses (ARI) in healthy adults.

Methods

Participants were randomized 1:2 to receive the 2008–2009 influenza vaccine or daily prophylaxis with 10 mg of zanamivir during the season. Web-based questionnaires collected information on demographics, symptoms, exposures, medication use and side effects.

Results

Sixty-four healthy adults were recruited in November 2008. Three of 40 active participants discontinued zanamivir due to side effects; the remaining 37 took >85% of scheduled doses for a median of 121 days. Symptomatic, laboratory-confirmed influenza was detected in one person randomized to zanamivir (2·5%) and 2/20 (10%) who received the vaccine (P = 0·25). Forty-seven participants reported 109 episodes of ARI. Factors associated with an ARI were exposure to a spouse (OR 7·2), child (OR 2·4) or patient (OR 2·0) with symptoms of an ARI in the previous 7 days.

Conclusions

Breakthrough influenza infection occurred in both vaccinated participants and those receiving antiviral prophylaxis. Most adults were willing and able to comply with season-long prophylaxis. Report of recent exposure to family members and patients with an ARI increased the risk of developing an ARI in healthy adults.     

Enhanced recovery after pancreatic surgery: a systematic review of the evidence

Background

Enhanced recovery after surgery (ERAS) protocols have been shown to reduce hospital stay without compromising outcomes. Attempts to apply ERAS principles in the context of pancreatic surgery have generated encouraging results. A systematic review of the current evidence for ERAS following pancreatic surgery was conducted.

Methods

A literature search of MEDLINE, CINAHL, EMBASE and the Cochrane Library was performed for articles describing postoperative clinical pathways in pancreatic surgery during the years 2000–2013. The keywords ‘clinical pathway’, ‘critical pathway’, ‘fast-track’, ‘pancreas’ and ‘surgery’ and their synonyms were used as search terms. Articles were selected for inclusion based on predefined criteria and ranked for quality. Details of the ERAS protocols and relevant outcomes were extracted and analysed.

Results

Ten articles describing an ERAS protocol in pancreatic surgery were identified. The level of evidence was graded as low to moderate. No articles reported an adverse effect of an ERAS protocol for pancreatic surgery on perioperative morbidity or mortality. Length of stay (LoS) was decreased and readmission rates were found to be unchanged in six of seven studies that compared these outcomes.

Conclusions

Evidence indicates that ERAS protocols may be implemented in pancreatic surgery without compromising patient safety or increasing LoS. Enhanced recovery after surgery programmes in the context of pancreatic surgery should be standardized based upon the best available evidence, and trials of ERAS programmes involving multiple centres should be performed.