Updates on the epidemiology, pathogenesis, diagnosis, and management of postinfectious irritable bowel syndrome.

PURPOSE OF REVIEW: With its impact on quality of life and increasing awareness, postinfectious irritable bowel syndrome (PI-IBS) is now gaining attention as one of the major health problems commonly encountered in gastrointestinal practice. Literature investigating the various pathogenic mechanisms involved is rapidly emerging. The objective of the current review is to provide an update on recent evidence published in the past 2 years describing advances in our understanding of the epidemiology, pathogenesis, diagnosis, and treatment of PI-IBS. RECENT FINDINGS: Significant proportion of research in the recent past was preclinical in nature. Epidemiological studies continue to highlight the risk of IBS after infection, with recent studies documenting postprotozoal effects. Advances in pathogenic mechanisms included clinical studies, which documented micro-RNA down-regulation and Peroxiredoxin-1 up-regulation in colonic mucosa of PI-IBS patients. Protease-activated receptor-2 (PAR-2) activation in PI-IBS mice models resulted in increase in epithelial permeability, mucosal inflammation, visceral hypersensitivity. Moxibustion and rifamycin reduced intestinal inflammation by inhibiting cytokine and chemokine release via different mechanisms. Miltefosine reduced mast cell degranulation and TRPV1 activation, thereby reducing visceral hypersensitivity. SUMMARY: At present, generalization of limited diagnostic and therapeutic strategies across a heterogeneous prevalent patient population impedes the ability to provide effective personalized care in PI-IBS. Further development in pathogenesis discovery, diagnostic tool development are needed in order to design well tolerated and effective therapies that guide treatments based on distinct pathways of disease.

Reduction in Resources and Cost for Gastroenteritis Through Implementation of Dehydration Pathway.

OBJECTIVES: Management decisions for patients with gastroenteritis affect resource use within pediatric emergency departments (EDs), and algorithmic care using evidence-based guidelines (EBGs) has become widespread. We aimed to determine if the implementation of a dehydration EBG in a pediatric ED resulted in a reduction in intravenous (IV) fluid administration and the cost of care. METHODS: In a single-center quality improvement initiative between 2010 and 2016, investigators aimed to decrease the percentage of patients with gastroenteritis who were rehydrated with IV fluids. The EBG assigned the patient a dehydration score with subsequent rehydration strategy on the basis of presenting signs and symptoms. The primary outcome was proportion of patients receiving IV fluid, which was analyzed using statistical process control methods. The secondary outcome was cost of the episode of care. Balancing measures included ED length of stay, admission rate, and return visit rate within 72 hours. RESULTS: A total of 7145 patients met inclusion criteria with a median age of 17 months. Use of IV fluid decreased from a mean of 15% to 9% postimplementation. Average episode of care-related health care costs decreased from $599 to $410. For our balancing measures, there were improvements in ED length of stay, rate of admission, and rate of return visits. CONCLUSIONS: Implementation of an EBG for patients with gastroenteritis led to a decrease in frequency of IV administration, shorter lengths of stay, and lower health care costs.

Prevalence and Clinical Management of Non-malarial Febrile Illnesses among Outpatients in the Era of Universal Malaria Testing in Malawi.

Increasing access to rapid diagnostic tests for malaria (mRDTs) has raised awareness of the challenges healthcare workers face in managing non-malarial febrile illnesses (NMFIs). We examined NMFI prevalence, clinical diagnoses, and prescribing practices in outpatient clinics across different malaria transmission settings in Malawi. Standardized facility-based malaria surveillance was conducted at three facilities one of every 4 weeks over 2 years. Information on demographics, presenting symptoms, temperature, clinical diagnosis, and treatment were collected from outpatients presenting with malaria-like symptoms. Of the 25,486 patients with fever, 69% had NMFI. Non-malarial febrile illness prevalence was lower in 5- to 15-year-old patients (55%) than in children < 5 years (72%) and adults > 15 years of age (77%). The most common clinical diagnoses among febrile patients with negative mRDTs in all age-groups and settings were respiratory infections (46%), sepsis (29%), gastroenteritis (13%), musculoskeletal pain (9%), and malaria (5%). Antibiotic prescribing was high in all age-groups and settings. Trimethoprim-sulfamethoxazole (40%) and amoxicillin (29%) were the most commonly prescribed antibiotics and were used for nearly all clinical diagnoses. In these settings with minimal access to diagnostic tools, patients with fever and a negative mRDT received a limited number of clinical diagnoses. Many were likely to be inaccurate and were associated with the inappropriate use of the limited range of available antibiotics. Prescription and diagnostic practices for NMFIs in the facilities require research and policy input. Resource-limited malaria-endemic countries urgently need more point-of-care diagnostic tools and evidence-based diagnosis and treatment algorithms to provide effective and cost-efficient care.

[Management of acute gastroenteritis in children]. / Postepowanie w ostrej biegunce infekcyjnej u dzieci.

Acute gastroenteritis is one of the most common infection among children. An estimated 500 million children suffer from the condition worldwide each year. In developed countries the course of acute infectious diarrhea is relatively mild, symptoms usually resolve spontaneously within few days. Unfortunately high mortality rate is still a heavyweight problem in countries with low economic development. Acute diarrhea is defined as a change of the consistency of stools to loose or liquid and/ or increase of an amount of defecations to more than 3 during a day. Other symptoms of gastroenteritis include fever, nausea and vomiting. The most common cause of AGE are viruses, with rotavirus being the most frequent agent. The diagnose is based on medical interview, that include mainly precise information about duration and characteristic of occurred symptoms and epidemiological data. The most important part of diagnostic and therapeutic management is dehydration's assessment, which determine the severity of AGE and is used as one of the factors that decide about hospital admission. The majority of patients can be treated in an outpatients settings, hospitalization should be reserved for those requiring enteral or parenteral rehydration. Oral rehydration with hypoosmolar fluids is standard first-line treatment. Other effective procedures include administration of probiotics (Lactobacillus GG , Saccharomyces boulardii), racecadotril and diosmectite as antidiarrheals and ondansetron reducing the intensity of nausea and vomiting. Antibiotherapy should be only considered in exceptional situations. Acute diarrhea is commonly known medical problem, which can be easily treated by following simple, well-defined rules.

[Systematic Review of the Burden of Campylobacter-associated Disease]. / Systematischer Review zur Krankheitslast durch Campylobacter spp.

Bacteria of the genus Campylobacter spp. are one of the most common causes of gastroenteritis and can lead to serious sequelae. Several studies have estimated the disease burden of Campylobacter spp. with the quantitative metric of disability-adjusted life years (DALY). The aim of this systematic review is to give an overview of the information available about different countries and periods for which DALYs were calculated and how the different results are comparable. One of the most important transmission pathways for Campylobacter spp. is food. Therefore, special attention was given to studies that only estimated the foodborne disease burden of Campylobacter bacteria. With a systematic search for the period 1/1996-6/2016, one worldwide and 21 country-specific publications of the WHO were identified. Because of the different methods and the quality of the different data sets, the estimated results of all Campylobacter health outcomes of the country-specific studies vary from 0.4 DALYs per 100000 people in France to 109 DALY per population in Poland. The calculation of the attributable foodborne disease burden was based on the estimations of the incidences of all Campylobacter health outcomes with the associated uncertainty for each result. So the estimations of the foodborne disease burden show a large range from 0.5 DALYs per 100000 people in Greek to 21.2 DALYs per 100000 people in New Zealand. This span can only be partially explained by the country-specific variability in the food production, the consumption behavior and the incidence of Campylobacter bacteria.

Assessment of Volume Status and Appropriate Fluid Replenishment in the Setting of Nephrotic Syndrome.

BACKGROUND: When the permeability of the glomerular filtration barrier increases, leading to proteinuria, nephrotic syndrome (NS) occurs. First episodes or relapses of NS can be concurrent with acute gastroenteritis (AGE) infections. This condition can cause further deterioration of the hypovolemic state, as intravascular water is lost through both AGE-related vomiting/diarrhea and NS-related fluid shifting into the interstitium. In this case report, we wish to raise the issues about the difficult management of children presenting with both NS and AGE. CASE REPORT: We report two cases characterized by concurrence of NS and AGE. Despite our intervention, case #1 required dialysis, whereas in the case #2 we restored the patient's liquid homeostasis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: No guidelines helping general physicians in the management of children presenting with both NS and AGE are available in the literature. However, it is common for these patients to seek the first line of treatment at emergency departments. In these patients, restoring the liquid homeostasis is a challenge, but some key points can help the physicians with first-line management: 1) carefully evaluate the signs of hypovolemia (edematous state can be misleading); 2) bear in mind that-in hypovolemic, severely hypoalbuminemic (serum albumin levels < 2 g/dL) NS children-initial fluid administration should be followed by a 20% albumin infusion if oligoanuria persists; intravenous 4.5% albumin may be a valid alternative as a first-line therapy instead of crystalloid and 20% albumin; and 3) pay attention when using furosemide; it should only be administered after albumin infusion or after hypovolemia correction.

Utility of Gastric and Duodenal Biopsies During Follow-up Endoscopy in Children With Eosinophilic Esophagitis.

OBJECTIVES: Eosinophilic esophagitis (EoE) is a chronic antigen-mediated immune disorder of the esophagus. Consensus guidelines recommend obtaining esophageal, gastric, and duodenal biopsies at diagnostic endoscopy when EoE is suspected. The utility of repeated gastric and duodenal biopsies during follow-up endoscopy in patients previously diagnosed with EoE is not established. The aim of the present study was to explore the role of gastric and duodenal biopsies in children with an established diagnosis of EoE undergoing repeat endoscopy to assess histological response to treatment. METHODS: Retrospective chart review of children diagnosed with EoE at a tertiary care center was conducted. A total of 160 patients with EoE with demographic clinical, endoscopic, and histological data at diagnosis and follow-up endoscopy were included. The frequency of gastric and duodenal biopsies at follow-up endoscopy with abnormal histology and their correlation to endoscopic findings was determined. RESULTS: At follow-up endoscopy, 83% (132/160) of patients had gastric and 74% (118/160) had duodenal biopsies. Histology was normal in 81% of gastric and 92% of duodenal biopsies. The most frequent gastric abnormalities were chemical and inactive chronic gastritis. The most frequent duodenal abnormality was villous blunting with increased intraepithelial lymphocytes. Two patients with normal gastric and duodenal histology progressed to eosinophilic gastroenteritis at follow-up endoscopy. CONCLUSIONS: Gastric and duodenal biopsies obtained in EoE patients during follow-up endoscopy show pathology in a minority of patients, increase costs, and may add potential risk of adverse events. Large multicenter, prospective studies of endoscopic practice during follow-up of EoE are warranted to provide evidence supporting best practices.

Low Yield and High Cost of Gastric and Duodenal Biopsies for Investigation of Symptoms of Abdominal Pain During Routine Esophagogastroduodenoscopy.

BACKGROUND: Esophagogastroduodenoscopy (EGD) referrals for symptoms of abdominal pain are common. Current guidelines for dyspepsia recommend biopsies of gastric mucosa for Helicobacter pylori in all patients referred for EGD. Our study aimed to determine the clinical yield and cost-effectiveness of gastric and duodenal biopsy in EGDs performed for abdominal pain. METHODS: Three hundred and ninety-one outpatient EGDs performed at a single academic tertiary care center were studied. For each procedure, endoscopic as well as pathologic findings from the stomach and duodenum were then recorded. Charge of biopsy was calculated using the increased charges for professional fees, forceps, and pathology fees when a biopsy was performed. RESULTS: Gastric biopsies were obtained on 304 EGDs performed with 13 (4.2%) patients diagnosed with H. pylori. In patients with abnormal gastric mucosa on EGD, 11 of 167 (6.5%) were positive for H. pylori compared to 2 of 137 (1.4%) with normal appearing mucosa (p = 0.02). Charge per diagnosis of H. pylori for normal mucosa was calculated to be $43,073. Duodenal biopsies were performed in 263 cases. Celiac disease was diagnosed in 4 of 263 cases (1.5%). Of patients with abnormal duodenal mucosa on EGD, 1 of 36 (2.7%) were positive for celiac disease compared to 3 of 227 (1.3%) with normal mucosa (p = 0.57). Charge per diagnosis of celiac disease for normal mucosa was calculated to be $47,580. CONCLUSION: Routine biopsy during EGD for symptoms of abdominal pain has low yield with high costs. Practice of routine biopsies of normal appearing tissue and the present guidelines should be reconsidered in the investigation of abdominal pain with EGD.

Implementation of clinical decision support in young children with acute gastroenteritis: a randomized controlled trial at the emergency department.

Acute gastroenteritis (AGE) is one of the most frequent reasons for young children to visit emergency departments (EDs). We aimed to evaluate (1) feasibility of a nurse-guided clinical decision support system for rehydration treatment in children with AGE and (2) the impact on diagnostics, treatment, and costs compared with usual care by attending physician. A randomized controlled trial was performed in 222 children, aged 1 month to 5 years at the ED of the Erasmus MC-Sophia Children's hospital in The Netherlands ( 2010-2012). Outcome included (1) feasibility, measured by compliance of the nurses, and (2) length of stay (LOS) at the ED, the number of diagnostic tests, treatment, follow-up, and costs. Due to failure of post-ED weight measurement, we could not evaluate weight difference as measure for dehydration. Patient characteristics were comparable between the intervention (N = 113) and the usual care group (N = 109). Implementation of the clinical decision support system proved a high compliance rate. The standardized use of oral ORS (oral rehydration solution) significantly increased from 52 to 65%(RR2.2, 95%CI 1.09-4.31 p < 0.05). We observed no differences in other outcome measures. CONCLUSION: Implementation of nurse-guided clinical decision support system on rehydration treatment in children with AGE showed high compliance and increase standardized use of ORS, without differences in other outcome measures. What is Known: • Acute gastroenteritis is one of the most frequently encountered problems in pediatric emergency departments. • Guidelines advocate standardized oral treatment in children with mild to moderate dehydration, but appear to be applied infrequently in clinical practice. What is New: • Implementation of a nurse-guided clinical decision support system on treatment of AGE in young children showed good feasibility, resulting in a more standardized ORS use in children with mild to moderate dehydration, compared to usual care. • Given the challenges to perform research in emergency care setting, the ED should be experienced and adequately equipped, especially during peak times.

Complicated norovirus infection and assessment of severity by a modified Vesikari disease score system in hospitalized children.

BACKGROUND: Norovirus (NoV) GII.4 is the most common genotype for norovirus gastroenteritis worldwide. New variants or subgenotypes are continuously emerging, thus posing a serious threat to child health. METHODS: We compared retrospectively the clinical manifestations and complications of norovirus gastroenteritis in children from April, 2004 through December, 2012. NoV variants were analyzed to investigate the association of circulating viral strains with the complications. A modified disease severity score system based on Vesikari score system was devised and to evaluate disease severity. RESULTS: Compared to the outbreak in 2004/2005 winter, significant higher incidence of complications in the later periods are: convulsive disorder (p < 0.001) in 2006/2007 winter gastrointestinal hemorrhage (p = 0.047) and severe abdominal pain or irritability (p = 0.033) in 2008/09/10 winter; gastrointestinal hemorrhage (p = 0.030), severe abdominal pain or irritability (p = 0.014), and prominent hyperthermia (fever >39 °C, p = 0.001) in 2011/2012 winter. GII.4 Den_Haag_2006b, GII.4 2010, GII.4 Sydney 2012, and GII.4 2012b were the predominant strains in the outbreaks after 2006. By the modified severity score system, severe norovirus disease occurred in 28.5 %, 32 %, 33.3 %, and 30.2 % of the patients in the four periods. A longer duration of hospitalization (p = 0.02) were found in those with high score irrespective of the year of admission. CONCLUSIONS: Our study demonstrated NoV outbreaks in northern Taiwan caused by different GII.4 variants that were associated with specific complications and uncommon clinical presentations. A modified severity score system first proposed in this study was able to identify severe cases with a longer hospital stay in NoV-infected children.

Cost-effectiveness of point-of-care testing for dehydration in the pediatric ED.

OBJECTIVES: Acute gastroenteritis (AGE) and subsequent dehydration account for a large proportion of pediatric emergency department (PED) visits. Point-of-care (POC) testing has been used in conjunction with clinical assessment to determine the degree of dehydration. Despite the wide acceptance of POC testing, little formal cost-effective analysis of POC testing in the PED exists. We aim to examine the cost-effectiveness of using POC electrolyte testing vs traditional serum chemistry testing in the PED for children with AGE. METHODS: This was a cost-effective analysis using data from a randomized control trial of children with AGE. A decision analysis model was constructed to calculate cost-savings from the point of view of the payer and the provider. We used parameters obtained from the trial, including cost of testing, admission rates, cost of admission, and length of stay. Sensitivity analyses were performed to evaluate the stability of our model. RESULTS: Using the data set of 225 subjects, POC testing results in a cost savings of $303.30 per patient compared with traditional serum testing from the point of the view of the payer. From the point-of-view of the provider, POC testing results in consistent mean savings of $36.32 ($8.29-$64.35) per patient. Sensitivity analyses demonstrated the stability of the model and consistent savings. CONCLUSIONS: This decision analysis provides evidence that POC testing in children with gastroenteritis-related moderate dehydration results in significant cost savings from the points of view of payers and providers compared to traditional serum chemistry testing.

Semiquantitative fecal calprotectin test in postinfectious and non-postinfectious irritable bowel syndrome: cross-sectional study / Teste calprotectina fecal semiquantitativa na síndrome do intestino irritável pós-infecciosa e não pós-infecciosa: estudo transversal

CONTEXT AND OBJECTIVE:The presence of a certain degree of inflammation in the gut wall is now accepted in irritable bowel syndrome (IBS). Fecal calprotectin is considered to be a reliable test for detecting intestinal inflammation. Our aim was to assess the presence of inflammation in postinfectious IBS (PI-IBS), compared with non-postinfectious IBS (NPI-IBS). A secondary objective was to determine the usefulness of a rapid fecal calprotectin test in inflammatory bowel diseases (IBD).DESIGN AND SETTING:This was a cross-sectional study. Patients with IBS and IBD at a single tertiary gastroenterology center were prospectively included in this study.METHODS:116 patients with Rome III IBS score (76 females; 48 ± 12 years) were investigated; 24 patients (15 females) had PI-IBS. Intestinal inflammation was assessed using the semiquantitative fecal calprotectin test. The results were expressed as T1, T2 or T3 according to the severity of inflammation (< 15 μg/g; 15-60 μg/g; > 60 μg/g). Using the same test, we evaluated 20 patients with IBD (12 males; 47 ± 13 years).RESULTS:None of the patients with IBS had a T2 or T3 positive test. Among PI-IBS patients, 33% had a T1 positive test. Among NPI-IBS patients, 9.8% had a T1 positive test, which was significantly different to PI-IBS. The calprotectin test was positive in all IBD patients: 80% with T3, 10% with T2 and 10% with T1.CONCLUSIONS:Using a semiquantitative test for fecal calprotectin, positive tests were more frequent in PI-IBS patients than in NPI-IBS patients.

CONTEXTO E OBJETIVO:A presença de certo grau de inflamação na parede do intestino é agora aceita na síndrome do intestino irritável (SII). A calprotectina fecal é considerada teste confiável para detectar inflamação intestinal. Nosso objetivo foi avaliar a presença de inflamação na SII pós-infecciosa (SII-PI), em comparação com a SII não pós-infecciosa (SII-NPI). Um objetivo secundário foi determinar a utilidade de um teste rápido fecal da calprotectina em doenças inflamatórias intestinais (DII).TIPO DE ESTUDO E LOCAL:Este foi um estudo transversal. Pacientes com SII e DII em um único centro terciário de gastroenterologia foram prospectivamente incluídos neste estudo.MÉTODOS:116 pacientes com escore Roma III de SII (76 mulheres, 48 ± 12 anos) foram investigados; 24 pacientes (15 mulheres) tinham SII-PI. Inflamação intestinal foi avaliada pelo teste semi-quantitativo de calprotectina fecal. Os resultados foram expressos como T1, T2 ou T3 de acordo com a gravidade da inflamação (< 15 μg/g; 15-60 mg/g; > 60 mg/g). Usando o mesmo teste, foram avaliados 20 pacientes com DII (12 homens, 47 ± 13 anos).RESULTADOS:Nenhum dos pacientes com SII teve um teste positivo T2 ou T3. Na PI-IBS, 33% tiveram um teste positivo T1. Entre os pacientes SII-NPI, teste T1 positivo estava presente em 9,8%, taxa significativamente diferente quando comparada com SII-PI. O teste de calprotectina foi positivo em todos os pacientes com DII: 80% com T3, 10% com T2 e 10% com T1.CONCLUSÕES:Usando teste semi-quantitativo para calprotectina fecal, relatamos positividade em pacientes SII-PI com mais frequência que em pacientes SII-NPI.

Semiquantitative fecal calprotectin test in postinfectious and non-postinfectious irritable bowel syndrome: cross-sectional study.

CONTEXT AND OBJECTIVE: The presence of a certain degree of inflammation in the gut wall is now accepted in irritable bowel syndrome (IBS). Fecal calprotectin is considered to be a reliable test for detecting intestinal inflammation. Our aim was to assess the presence of inflammation in postinfectious IBS (PI-IBS), compared with non-postinfectious IBS (NPI-IBS). A secondary objective was to determine the usefulness of a rapid fecal calprotectin test in inflammatory bowel diseases (IBD). DESIGN AND SETTING: This was a cross-sectional study. Patients with IBS and IBD at a single tertiary gastroenterology center were prospectively included in this study. METHODS: 116 patients with Rome III IBS score (76 females; 48 ± 12 years) were investigated; 24 patients (15 females) had PI-IBS. Intestinal inflammation was assessed using the semiquantitative fecal calprotectin test. The results were expressed as T1, T2 or T3 according to the severity of inflammation (< 15 µg/g; 15-60 µg/g; > 60 µg/g). Using the same test, we evaluated 20 patients with IBD (12 males; 47 ± 13 years). RESULTS: None of the patients with IBS had a T2 or T3 positive test. Among PI-IBS patients, 33% had a T1 positive test. Among NPI-IBS patients, 9.8% had a T1 positive test, which was significantly different to PI-IBS. The calprotectin test was positive in all IBD patients: 80% with T3, 10% with T2 and 10% with T1. CONCLUSIONS: Using a semiquantitative test for fecal calprotectin, positive tests were more frequent in PI-IBS patients than in NPI-IBS patients.

Cost-effectiveness of a pentavalent rotavirus vaccine in Japan.

OBJECTIVE: To evaluate the impact of universal vaccination with a pentavalent rotavirus vaccine (RV5) on the healthcare burden and costs associated with rotavirus gastroenteritis (RGE) in Japan. METHODS: The model included a hypothetical cohort of 1,091,156 children followed for their first 5 years of life. In the absence of universal vaccination, there were 19 deaths, 78,000 hospitalizations, and 678,000 outpatient visits due to RGE. The efficacy of RV5 is based on international clinical trial data, which was similar to the efficacy observed in clinical trials conducted in Japan. The primary outcome measure is the cost per quality-adjusted-life-year (QALY) gained. In the base case, the QALY loss per 1000 RGE episodes included 2.2 for children and 1.8 per parent. RESULTS: Universal vaccination is projected to reduce hospitalizations by 92%, outpatient visits by 74%, and work-loss days by 73%. For the base case analysis, the total vaccination cost was ¥26 billion. The estimated reduction in medical costs was ¥16 billion. Of 2500 QALYs gained with the vaccination program, approximately half are directly attributed to the child. In the base case analysis, the incremental cost-effectiveness ratio (ICER) for vaccination vs. no vaccination is ¥4 million and ¥2 million per quality-adjusted life year (QALY) gained from the healthcare payer and societal perspectives, respectively. The ICERs are ¥8 million and ¥4 million if parental disutilities are excluded. KEY LIMITATION: The QALY decrements for children and parents were evaluated using different instruments, and the QALY decrements do not vary based on episode severity. Given the interdependence between children and their parents, excluding parental disutilities may under-estimate the impact of RGE. CONCLUSION: Universal vaccination with RV5 in Japan is projected to have a substantial public health impact and may be cost-effective from both the payer and societal perspectives if parental disutilities are included in the cost-effectiveness ratios.

The utility of the emergency department observation unit for children with abdominal pain.

OBJECTIVE: This study aimed to determine the outcome of children with unclear etiology for acute abdominal pain admitted to the emergency department observation unit (EDOU). METHODS: This is a retrospective cohort study of children 18 years or younger who presented with acute abdominal pain to a tertiary pediatric ED and were observed in the EDOU. Children with alternative explanations for abdominal pain were excluded. Patients were classified based on disposition, and data were analyzed using χ tests. RESULTS: There were 237 patients included in the study (median age, 9 years; 46% male). Mean length of stay in EDOU was 14.4 hours. Fifty-four percent were evaluated by surgery. Two hundred (84%) were discharged; 37 (16%) were admitted, of whom 22 (9%) underwent surgical intervention (13 appendectomies, 6 ovarian cystectomies, 2 small-bowel obstructions, 1 cholecystectomy). Eight had acute appendicitis on pathology reports. The duration of symptoms, the presence of fever, nausea/vomiting, right-lower-quadrant pain, rebound tenderness, or leukocytosis greater than 10,000 cells/µL did not predict admission. Patients with diarrhea were more likely to be discharged home (P = 0.02). Intravenous hydration (86%) and pain control (63%) were the most common interventions in the EDOU. Abdominal pain not otherwise specified and acute gastroenteritis were the 2 most common discharge diagnoses. Eight (4%) of the 200 discharged patients returned to the ED within 48 hours, and all were discharged home from the ED. CONCLUSIONS: The majority of children admitted to the EDOU with abdominal pain have nonsurgical causes of abdominal pain. The EDOU provides a reasonable alternative for monitoring these patients pending disposition.

Burden of acute gastroenteritis among children younger than 5 years of age--a survey among parents in the United Arab Emirates.

BACKGROUND: Despite its high incidence among children under the age of five, little is known about the burden of pediatric gastroenteritis outside the medical setting. The objective of this study was to describe the burden of acute gastroenteritis among children residing in the United Arab Emirates, including those not receiving medical care. METHODS: A quantitative cross-sectional survey of 500 parents of children under 5 years of age who had suffered from acute gastroenteritis the preceding three months was conducted in the cities of Abu Dhabi and Al Ain. Data collected included respondent characteristics, disease symptoms, medical care sought, and parental expenditures and work loss. Data were analyzed using parametric and non-parametric statistical methods. RESULTS: Vomiting and diarrhea episodes lasted on average between 3 and 4 days. Overall, 87% of parents sought medical care for their children; 10% of these cases required hospitalization with an average length of stay of 2.6 days. When medical care was sought, the average parental cost per gastroenteritis episode was US$64, 4.5 times higher than with home care only (US$14). Nearly 60% of this difference was attributable to co-payments and medication use: 69% of children used oral rehydration solution, 68% antiemetics, 65% antibiotics and 64% antidiarrheals. Overall, 38 parents missed work per 100 gastroenteritis episodes for an average of 1.4 days. CONCLUSIONS: Given its high incidence, pediatric gastroenteritis has an important financial and productivity impact on parents in the United Arab Emirates. To reduce this impact, efforts should be made both to prevent acute gastroenteritis and to optimize its treatment.

Factors influencing hemodialysis and outcome in severe acute renal failure from Ilorin, Nigeria.

The epidemiology of acute renal failure (ARF) varies between nations and even within the same country because of differences in diagnostic criteria, causes, mode of presentation, and cost of therapy. To determine the factors influencing hemodialysis and outcome of severe ARF in Ilorin, Nigeria, we studied ARF patients on hemodialysis in our center between January 1989 and December 2009. There were 138 (58 males and 80 females) patients with age range between 18 and 69 years and a mean of 29.4 ± 11.9 years. Major etiologies of ARF included septicemia, acute glomerulonephritis, septic abortion, herbal remedies, post-partum bleeding, and gastroenteritis. The mean duration of illness and waiting time before dialysis was 11.7 ± 8.14 days and 3.28 ± 1.86 days, respectively. The mean number of dialysis was 2.24 ± 1.13 sessions and 89% of the patients received a maximum of three sessions before recovery. Hypotension, twitching of muscles, and back pains were common intradialysis complications. The factors that influenced hemodialysis and outcome were late presentation, severity of ARF, and financial constraints. The etiological agents are preventable and treatable conditions. The short duration of hospital stay, waiting time before dialysis, and total duration of illness influenced the outcome positively. We strongly recommend early referral of patients with severe ARF to nephrologists for proper management in a bid to reduce mortality from this disease.

Upper gastrointestinal haemorrhage and deprivation: a nationwide cohort study of health inequality in hospital admissions.

OBJECTIVE: Inequalities in health are well recognized in cardiovascular disease and cancer, but in comparison, we have minimal understanding for upper gastrointestinal bleeding. Since furthering our understanding of such inequality signposts preventable disease, we investigated in detail the association between upper gastrointestinal bleeding and socioeconomic status. DESIGN: Population-based cohort study. SETTING: All English National Health Service hospitals. POPULATION: English adult population, 1 January 2001 to 31 December 2007. EXPOSURE MEASURES: Deprivation scores defined according to quintiles of neighbourhood areas ranked by the Indices of Multiple Deprivation for England 2007. OUTCOME MEASURES: Rates of all adult admissions coded with a primary diagnosis of upper gastrointestinal bleed were analysed by deprivation quintile and adjusted for age, sex, region and year using Poisson regression. RESULTS: The annual hospitalization rate for non-variceal haemorrhage was 84.6 per 100,000 population (95% CI 83.5 to 84.1; n=237,145), and for variceal haemorrhage, it was 2.83 per 100,000 population (95% CI 2.87 to 2.99; n=8291). There was a twofold increase in the hospitalization rate ratio for non-variceal haemorrhage from the most deprived areas compared to the least deprived (2.00, 95% CI 1.98 to 2.03). The ratio for variceal haemorrhage was even more pronounced (2.49, 95% CI 2.32 to 2.67). Inequality increased over the study period (non-variceal p<0.0001, variceal p=0.0068), and adjusting for age and sex increased the disparity between deprived and affluent areas. Case fatality did not have a similar socioeconomic gradient. CONCLUSION: Both variceal and non-variceal haemorrhage hospitalization rates increased with deprivation, and there was a similar gradient in all areas of the country and in all age bands. The existence of such a steep gradient suggests that there are opportunities to reduce hospitalizations down to the low rates seen in the most affluent, and thus, there is the potential to prevent almost 10,000 admissions and over 1000 deaths a year.

[Impact of Rotavirus gastroenteritis requiring hospitalization or presenting to emergency room among children less than 5 years in France]. / Impact des gastroentérites à Rotavirus chez les enfants de moins de cinq ans hospitalisés ou consultant en services d'urgences en France.

BACKGROUND: In France, Rotavirus infections are responsible for approximately 300,000 cases of acute gastroenteritis (AGE) in children less than 5 years every year, 138,000 outpatient consultations and 18,000 hospitalizations. Surveillance for Rotavirus Infections in Hospitalized Kids (SHRIK) is a European prospective observational study conducted to assess the burden related to Rotavirus gastroenteritis (RVGE) in these children. METHODS: Patients less than 5 years visiting emergency rooms for AGE (U-AGE), who were hospitalized (H-AGE) or who developed RVGE 48 hours after hospitalization (N-AGE) were included in the study over a year. A stool sample was collected for every child and analyzed by ELISA. RESULTS: Results are presented for patients enrolled in France. A total of 755 eligible patients with AGE were included (357 for U-AGE, 372 for H-AGE and 26 for N-AGE). Among them, the proportion of RVGE was 49.1% (n=114) for U-AGE and 64.4% (n=186) for H-AGE. Most cases of RVGE (89%) involved children less than 2 years. GERV were frequently more severe than GEA non related to Rotavirus (NRVGE), according to the Vesikari scale, (68.4% against 41.9%, P<0.0001). Oral rehydration was performed for nearly 50% of RVGE patients before coming to hospital, versus 36.2% for NRVGE (P<0.002). All RV-positive strains were genotyped: the most frequent strains were G1P[8] (U-AGE, 42%; H-AGE, 46%) and G9P[8] (U-AGE, 38%; H-AGE, 31%). CONCLUSION: SHRIK study followed up all GEA visiting emergency room or requiring hospitalization for one year and showed that the burden of Rotavirus disease is high with a ratio over 70% of all hospital GEA during the winter peak.

Subjective global assessment is not sufficient to screen patients with defective hepatic metabolism.

BACKGROUND AND AIMS: Subjective global assessment (SGA) is useful for screening malnourished patients with several diseases, although it has been indicated to underestimate nutritional status for patients with liver disease. Accordingly, the aim of this study was to examine the usefulness of SGA as a nutritional screening tool for patients with liver disease, compared to patients with gastroenterological disease, without bias of personal ability and experience. METHODS: SGA was performed on 129 of hospitalized patients (86 with liver disease and 43 with gastroenterological disease). Nutritional status was categorized as well-nourished or malnourished status, based on nutritional indicators from laboratory data. RESULTS: The SGA screening ratio (sensitivity) for malnourished patients with liver disease was significantly lower than gastroenterological disease, while specificity or efficiency was not significantly different. In nutritional indicators from laboratory data, the difference between SGA-positive and SGA-negative patients with liver disease was significant but not so remarkable compared with the difference between those with other diseases. The positive number of SGA components per patient for the liver disease group was significantly less than gastroenterological disease group. CONCLUSIONS: SGA for patients with liver diseases was not sufficient as a nutritional screening tool because malnutrition induced by defective hepatic metabolism was not characterized fully.