Canadian Association of Gastroenterology Communique: After-Hours Endoscopy Cart

Background

Endoscopic procedures performed after-hours often require therapeutic interventions that are technically demanding for the endoscopist. The aim of this position paper is to provide guidance on the minimum standard of equipment that should be available on a mobile endoscopy cart for provision of a safe and effective after-hours emergency endoscopy service. The guidance is based on consensus among academic and community gastroenterologists in Canada.

Methods

A modified Delphi process was used to establish consensus among 9 participants. A list of statements was prepared by an expert panel of endoscopists. The statements were divided into three broad sections for what should be on an after-hours endoscopy cart including medications, nonendoscopic tools and therapeutic/diagnostic equipment. Consensus for being on the endoscopy cart was achieved when 75% or more of voting members indicated ‘agree’.

Results

For nonendoscopic tools, there was agreement for having sterile saline, sterile water, endoscope lubricant, various syringes, bite blocks (paediatric and adult size), a water pump with foot peddle, formalin jars for biopsy specimens, digital photo and printing capability and an overtube. For medications, there was agreement for having hyoscine butylbromide and epinephrine on the cart. For therapeutic/diagnostic tools, there was agreement for having biopsy forceps (standard and jumbo), polypectomy snares, sclerotherapy needles and agent (for a variceal bleed), band ligation kit, multipolar electrocautery probes, heater probe catheter, endoscopic clips, hemostatic powder and retrieval devices.

Interpretation

This position paper provides guidance on the minimum standard of items that should be on an after-hours endoscopy cart. Standardization of equipment may help improve safety and quality of after-hours endoscopic procedures.

Quality and publication success of abstracts of randomized clinical trials in inflammatory bowel disease presented at Digestive Disease Week

BACKGROUND

The incorporation of abstracts from scientific meetings into systematic reviews and practice guidelines may reduce publication bias and delays in implementing therapeutic interventions.

METHODS

All abstracts of Phase III randomized controlled trials in inflammatory bowel disease accepted at Digestive Disease Week (1998-2003) were identified. MedLine, PubMed (1997-current), EMBASE, and Google Scholar were searched for subsequent full publications. Characteristics of methodology and outcomes of the abstracts and articles were analyzed.

RESULTS

The 5-year cumulative publication rate of the 82 eligible abstracts was 78%. Abstracts that presented negative results were less likely to be published than those with positive findings, particularly after the first 2 years (hazard ratio 6.45; 95% confidence interval [CI]: 2.22-18.7) with 5-year cumulative publication rates of (50% versus 91%, respectively, P < 0.001). The median time to publication was longer for negative than positive abstracts (58 versus 26 months, P < 0.001). Abstracts selected for oral presentation were more likely to be published than poster presentations (89% versus 69%; P = 0.03). A change in primary outcome results was observed in 28% (n = 18) of abstracts compared to that in the final publication, and 6% (n = 4) had a statistically significant change resulting in a change of study conclusions.

CONCLUSIONS

Our findings suggest that the use of abstract data would enable detection and mitigation of publication bias. Improving the uniformity and quality of abstract reporting of randomized clinical trials at scientific meetings may facilitate their incorporation in practice guidelines and systematic reviews.

Vertebral artery dissection presenting as a Brown-Séquard syndrome: a case report

INTRODUCTION

Vertebral artery dissection has become increasingly recognized as an important cause of stroke. It usually presents with posterior headache or neck pain followed within hours or days by signs of posterior circulation stroke. To the best of our knowledge, the clinical presentation of a Brown-Séquard syndrome with a vertebral artery dissection has been reported only once before.

CASE PRESENTATION

An otherwise healthy 35-year-old man presented with acute left-sided weakness. He had experienced left-sided posterior neck pain after a 4-hour flight 4 weeks previously. Physical examination was consistent with a left Brown-Séquard syndrome. Magnetic resonance angiography showed evidence of left vertebral artery dissection. He improved after therapy with anticoagulants.

CONCLUSION

We report a case of an unusual presentation of a relatively uncommon condition. This diagnosis should be considered early in relatively young patients with stroke-like symptoms or unexplained neck pain, because missing a dissection can result in adverse outcomes.

Antimicrobials for right-sided endocarditis in intravenous drug users: a systematic review

BACKGROUND

Right-sided endocarditis (RSE) is a serious complication of intravenous drug use. We sought to systematically review the evidence for obtaining clinical cure with antimicrobials in intravenous drug users (IVDUs) with isolated native valve RSE.

SEARCH STRATEGY

We applied broad search strategies in the following databases: MEDLINE (1966-2006), EMBASE (1980-2006) and Cochrane CENTRAL Register (2006, Issue 3). Hand searching was performed on selected peer-reviewed journals and relevant citation lists were screened. No restrictions were set on language and type of publication.

SELECTION CRITERIA

We included randomized controlled trials that evaluated clinical and microbiological cure using single or combination antibiotic regimens for the treatment of isolated native valve bacterial RSE. Clinical and microbiological cure and failure outcomes were evaluated between 2 weeks and 6 months after completion of therapy. Quality assessment of relevant studies was performed using an objective scoring scale.

RESULTS

We identified seven randomized controlled trials, one comparing single antimicrobial therapies, four comparing combination with single therapy and two studies comparing combination therapies. Short-course therapy was present in at least one arm in three studies, but only one study compared short- and long-course therapy. No statistically significant benefit was demonstrated between any antimicrobial therapy and all studies were scored as having a moderate to severe risk of bias.

CONCLUSIONS

Randomized trial evidence does not support one antimicrobial regimen over another in the treatment of RSE in IVDUs.

Sputum versus bronchoscopy for diagnosis of Pseudomonas aeruginosa biofilms in cystic fibrosis

The present authors hypothesised that bronchoscopy with protected specimen brush may sample biofilm-forming bacteria adherent to the airway wall, whereas traditional sputum collection may not. Pseudomonas aeruginosa obtained from sputum, bronchoalveolar lavage and protected brush, taken from the right upper lung bronchus of 12 adult patients with cystic fibrosis, were compared. Retrieved bacteria were genotyped, and grown in planktonic cultures and as biofilms, and susceptibilities to individual antibiotics and to antibiotic combinations were determined. Bacterial cultures obtained using bronchoscopy did not yield any new strains of bacteria that were not also found in sputum. A total of 10 patients (83%) had a single strain of P. aeruginosa found using sputum, bronchoalveolar lavage and protected brush techniques, and two patients (17%) had two strains recovered in sputum, but only one strain was recovered using bronchoscopic techniques. Susceptibility to single antibiotics and to antibiotic combinations were not different between planktonically or biofilm-grown bacteria derived from sputum, as compared to those obtained by bronchoalveolar lavage and protected brush. In conclusion, sputum collection provides as much information as bronchoscopy for characterising the genotype and antibiotic susceptibility of chronic Pseudomonas aeruginosa infection in patients with stable cystic fibrosis.

Adult Cystic Fibrosis Exacerbations and New Strains ofPseudomonas aeruginosa

We hypothesized that in adults with cystic fibrosis, the acquisition of a new strain of Pseudomonas aeruginosa may be associated with a pulmonary exacerbation. Eighty-four patients who were chronically infected with P. aeruginosa were prospectively followed from eight centers over a 26-month period. Patients had sputum cultures performed every 3 months while clinically stable and at the time of an exacerbation. Forty patients (48%) had an exacerbation requiring intravenous antibiotics during the study period, and in 36 of these patients, their P. aeruginosa isolates were genetically typeable by pulsed-field gel electrophoresis. In 34 of the 36 patients (94%), P. aeruginosa recovered during clinical stability and at exacerbation were of the same genotype. In only two patients (6%; 95% confidence interval, 0-18%) was a new P. aeruginosa clone cultured during an exacerbation that had not been cultured during clinical stability. There were no significant differences in antibiotic susceptibilities, measured as mean minimal inhibitory concentrations, for isolates retrieved during clinically stable periods compared with isolates retrieved during exacerbations. We conclude that for the majority of adult patients with cystic fibrosis a new pulmonary exacerbation is not caused by the acquisition of a new strain of P. aeruginosa.

A novel ubiquitin fusion system bypasses the mitochondria and generates biologically active Smac/DIABLO

Smac/DIABLO is a mitochondrial protein that is proteolytically processed and released during apoptosis along with cytochrome c and other proapoptotic factors. Once in the cytosol, Smac protein binds to inhibitors of apoptosis (IAP) proteins and disrupts the ability of the IAPs to inhibit caspases 3, 7, and 9. The requirement for mitochondrial processing and release has complicated efforts to delineate the effect of Smac overexpression and IAP inhibition on cell death processes. In this report, we document a novel expression system using ubiquitin fusions to express mature, biologically active Smac in the cytosol of transfected cells. Processing of the ubiquitin-Smac fusions is rapid and complete and generates mature Smac protein initiating correctly with the Ala-Val-Pro-Ile tetrapeptide sequence that is required for proper function. The biological activity of this exogenous protein was demonstrated by its interaction with X-linked IAP, one of the most potent of the IAPs. The presence of mature Smac was not sufficient to trigger apoptosis of healthy cells. However, cells with excess Smac protein were greatly sensitized to apoptotic triggers such as etoposide exposure. Cancer cells typically display deregulated apoptotic pathways, including Bcl2 overexpression, thereby suppressing the release of cytochrome c and Smac. The ability to circumvent the requirement for mitochondrial processing and release is critical to developing Smac as a possible gene therapy payload in cancer chemosensitization.