GI Illness Research Articles

Clinical Predictors of Shigella and Campylobacter Infection in Children in the United States

BackgroundInfectious gastroenteritis is a major cause of morbidity and mortality among children worldwide. While most episodes are self-limiting, for select pathogens such as Shigella and Campylobacter, etiological diagnosis may allow effective antimicrobial therapy and aid public health interventions. Unfortunately, clinical predictors of such pathogens are not well established and are based on small studies using bacterial culture for identification.MethodsWe used prospectively collected data from a multi-center study of pediatric gastroenteritis employing multi-pathogen molecular diagnostics to determine clinical predictors associated with 1) Shigella and 2) Shigella or Campylobacter infection. We used machine learning algorithms for clinical predictor identification, then performed logistic regression on features extracted plus pre-selected variables of interest.ResultsOf 993 children enrolled with acute diarrhea, we detected Shigella spp. in 56 (5.6%) and Campylobacter spp. in 24 (2.4%). Compared with children who had neither pathogen detected (of whom, >70% had ≥1 potential pathogen identified), bloody diarrhea (odds ratio 4.0), headache (OR 2.2), fever (OR 7.1), summer (OR 3.3), and sick contact with GI illness (OR 2.2), were positively associated with Shigella, and out-of-state travel (OR 0.3) and vomiting and/or nausea (OR 0.4) were negatively associated (Table). For Shigella or Campylobacter, predictors were similar but season was no longer significantly associated with infection.ConclusionThese results can create prediction models and assist clinicians with identifying patients who would benefit from diagnostic testing and earlier antibiotic treatment. This may curtail unnecessary antibiotic use, and help to direct and target appropriate use of stool diagnostics.Disclosures A. Leber, BioFIre Diagnostics: Research Contractor and Scientific Advisor, Research support, Speaker honorarium and Travel expenses J. Daly, Biofire: Grant Investigator, Grant recipient R. Selvarangan, BioFire Diagnostics: Board Member and Investigator, Consulting fee and Research grant Luminex Diagnostics: Investigator, Research grant J. Dien Bard, BioFire: Consultant and Investigator, Research grant and Speaker honorarium K. Holmberg, BioFire Diagnostics: Employee, Salary K. Bourzac, BioFire Diagnostics: Employee, Salary K. C. Chapin, BioFire Diagnstics: Investigator, Research support A. Pavia, BioFire Diagnostics: Grant Investigator, Research grant

Online Symptom Checker Accuracy for the Complex HIV and Hepatitis C Population: A Real Life Emergency Room Experience

Introduction: We previously analyzed online patient symptom checkers for both diagnostic and triage accuracy for a barrage of GI illnesses using traditional provided clinical vignettes. We now aim to see whether symptom checkers are feasible diagnostic and triage tools for the complex HIV or Hepatitis C patient, using real-life emergency room (ER) patient encounters. Methods: An ER chart analysis from Sept 2013-Sept 2015 for a 10-day block each month was performed on 8363 patients, searching for “HIV” and “Hepatitis C”. No distinction of lab data, treatment regimen, or active disease was made. Patients who came as a direct transfer, sent from clinic, or unable to consciously make a decision were excluded. Eligible patients included: 90 HIV, 67 HepC, 11 Both (Fig. 1). 5 online symptom checkers were utilized for diagnosis, 3 with triage capabilities.Figure: Baseline demographics.Results: When combining HIV and HepC patients, only a mere 6.0%-11.3% of the symptom checkers had the initial diagnosis listed as the Top1 diagnosis. Between 8.9% and 32.1% had the diagnosis listed in the Top10, with only 8.9%-39.3% having the diagnosis listed at all (Fig. 2). Only about half the time was the triage advice correct (44.6%-53.6%). Each checker did display various strengths and weaknesses in triage capabilities (Fig. 2). Whether the diagnosis was considered GI-based did not affect triage ranking as emergent or non-emergent. However, there were varying results for GI versus non-GI diagnosis accuracy. There remained significant inconsistencies between the five symptom checkers in regards to all diagnostic parameters. A model was built to help predict which variables (race, age, gender, HIV or HepC) would aid in predicting triage and diagnostic results. We did find that a higher number of orders in the ER (labs, meds, Rx given, Imaging, Consultant) did positively correlate with the symptom checker triage output as “Emergent” (p=0.034), further justifying the ER visit.Figure: A.) Diagnostic accuracy for initial diagnosis. B). Diagnostic accuracy for discharge diagnosis. C.) Sensitivity: % Emergent among all predicted as Emergent; Specificity: % Non-Emergent among all predicted as Non-Emergent; POS pred value: % Emergent correctly predicted as Emergent; NEG Pred Value: % Non-Emergent correctly predicted as Non-Emergent; Accuracy: % Correct triage (Emergent as Emergent, Non-Emergent as Non-Emergent).Conclusion: Symptom checker diagnostic and triage capability for complex HIV and HepC patients is quite inferior to prior study analysis of the general patient population. In fact, the substandard accuracy may even be at such dangerous levels to where patients are not being triaged to a safe venue. As this is the first study to utilize real-life emergency room data on a large-scale, part of the results may be linked to real-life, non-textbook, complex clinical vignette patient presentations, something prior studies have failed to analyze.

Effects of sex and early rearing condition on adult behavior, health, and well-being in captive chimpanzees (Pan troglodytes)

Scientific evaluation of management strategies for captive species is part of the establishment of best practices for animal welfare. Here we report the effects of sex, rearing, and a sex-by-rearing interaction on adult, captive chimpanzees’ (Pan troglodytes) behavior, health, well-being, personality, and orientation towards humans based on multiple methods (observation, animal records, and surveys). Chimpanzees raised in three conditions, mother-reared (MR), standard nursery (ST) and an experimental nursery (RC), were assessed approximately 20 years after their differential rearing experiences concluded. Sex had a significant effect on behavior towards conspecifics (aggression [M > F]; affiliation [F > M]), on abnormal behavior (rocking [M > F]), and on likelihood of incurring at least one injury (between ages 6 and 10 [M > F]). Rearing condition had a significant impact on behavior towards humans (negative solicitation [RC = ST > MR = ST]; neutral behavior [RC > ST > MR], yawning (RC = ST > MR = ST), subjective well-being (MR = ST > RC = ST), and on GI illness frequency (RC > ST = MR). Sex interacted with rearing on aggression towards humans (for males, RC > MR = ST), frequency of upper respiratory infection (URI: for males RC > MR = ST)) and likelihood of at least one URI between the ages of 11 and 15 (RC males > ST males). Our findings support the conclusion that there are long-term effects of both early rearing and sex on captive adult chimpanzee welfare.

Utility of Outpatient Syndromic Data for Monitoring Influenza-like Illness

ObjectiveTo explore how outpatient and urgent care syndromic surveillancefor influenza-like illness (ILI) compare with emergency departmentsyndromic ILI and other seasonal ILI surveillance indicators.IntroductionThe North Dakota Department of Health (NDDoH) collectsoutpatient ILI data through North Dakota Influenza-like IllnessNetwork (ND ILINet), providing situational awareness regardingthe percent of visits for ILI at sentinel sites across the state. Becauseof increased clinic staff time devoted to electronic health initiativesand an expanding population, we have found sentinel sites have beenharder to maintain in recent years, and the number of participatingsentinel sites has decreased. Outpatient sentinel surveillance forinfluenza is an important component of influenza surveillance becausehospital and death surveillance does not capture the full spectrum ofinfluenza illness.Syndromic surveillance (SyS) is another possible source ofinformation for outpatient ILI that can be used for situationalawareness during the influenza season; one benefit of SyS is that itcan provide more timely information than traditional outpatient ILIsurveillance [1,2]. The NDDoH collects SyS data from hospitals(emergency department and inpatient visits) and outpatient clinics,including urgent and primary care locations. Visits include chiefcomplaint and/or diagnosis code data. This data is sent to theBioSense 2.0 SyS platform. We compared our outpatient SyS ILI withour ND ILINet and reported influenza cases, and included hospitaland combined SyS ILI for comparison.MethodsWeekly rates from ND ILINet, SyS ILI, and counts of reportedcases from the influenza season (annual weeks 40 through 20) forthe 2014-2015 and 2015-2016 seasons were compiled. Syndromiccategories for outpatient, hospital (emergency department andinpatient), and combined hospital and outpatient data were created,and the BioSense 2.0 definition for ILI was used. These includeddata from 127,050 outpatient and 323,318 hospital visits for2014-15, and 124,597 outpatient and 424,097 hospital visits for2015-16. Because influenza is a reportable condition in North Dakota,case data is routinely used to represent the seasonal influenza trend,and is useful when other respiratory viruses are circulating. A PearsonCorrelation Coefficient was calculated on all variables using SAS 9.4.Alpha was set to 0.05. There was no overlap between the outpatientclinics providing syndromic surveillance data and clinics participatingin ND ILINet.ResultsAll outpatient, hospital, and combined outpatient and hospitalILI rates from SyS data were positively and significantly correlatedwith both ND ILINet rates and influenza case counts (Table 1). Thecorrelation between outpatient SyS ILI rates and traditional influenzaindicators was lower than for hospital SyS ILI rates for both years,with correlation coefficients ranging from 0.38-0.48 and 0.56-0.92,respectively. Generally SyS data was more highly correlated withcase counts than ND ILINET rates. For the 2014-15 season, hospitalSyS data was the most strongly correlated with traditional influenzaindicators. For 2015-16, combined SyS data was the most stronglycorrelated. Visual inspection of the chief complaint data for ILI visitsfound a significant number of gastrointestinal visits that included thephrase “flu-like illness” in both outpatient and hospital SyS data.ConclusionsAlthough correlation coefficients were lower for outpatient SySILI rates, they are significant enough to be included in our ongoinginfluenza surveillance. One possible confounding factor for therelationship between ED surveillance and reported cases is that peoplewith more severe illness may be more likely to be tested for influenza,and may be more likely to seek medical attention at a hospital setting.This may explain why hospital SyS data provided the strongestcorrelation during the 2014-15 season, a season with higher rates ofmore severe illness than 2015-16. The combination of outpatient dataand hospital data provided the strongest correlation for the 2015-16influenza season, indicating the addition of outpatient data, which mayincrease representativeness of ILI data, may be beneficial to SyS ILIsurveillance. We used an existing ILI syndrome from the BioSense2.0 tool, and revising this syndrome may improve correlationsbetween SyS ILI and ND ILINet and case count data. Negation termsto remove visits for GI illness incorrectly referred to as “flu-like”would be one useful change. The nature of visits for influenza atoutpatient clinic versus hospitals is different, and it is possible thismay account for the difference in the strength of correlations betweenthe two data sources. Use of a different ILI syndrome definition foroutpatient SyS data should be investigated.Table 1. Pearson correlation coefficient values for influenza-like illness in threesyndromic surveillance categories compared with ND ILINET and influenzacase counts.

Granulomatous Liver Disease Due to Histoplasma Capsulatum Infection in AIDS Patient

Introduction: Histoplasmosis is endemic mycoses caused by the fungus Histoplasma Capsulatum. It is commonly a pulmonary disease in immunocompetent patients, but it is more likely to be disseminated in AIDS patients. Although gastrointestinal involvement is common in disseminated Histoplasmosis, the clinical manifestations are rare and nonspecific, making the diagnosis difficult. Case presentation: 48 years old female with past medical history of AIDS on antiviral treatment. She was admitted to the hospital due to fever, nausea, vomiting and abdominal pain. Her physical exam showed fever, tachycardia and ill looking. CT abdomen showed diffusely heterogeneous and enlarged liver with multiple hyper-enhancing densities. Subsequent Liver biopsy showed non-necrotizing granulomas, GMS stain was positive for Histoplasmosis. Urine and serum were positive for Histoplasma antigen. Fungal antibody panel was positive for Histoplasma. Intravenous Amphotericin B was initiated for 14 days then she was discharged home in stable condition with long term oral Itraconazole.Figure 1Figure 2Figure 3Clinical Significance: Most patients with disseminated histoplasmosis have underlying conditions that impair their ability to defend against intracellular pathogens. Risk factors includes: immunosuppressive disorders or medications, Extremes of age. Discussion: Gastrointestinal involvement is commonly identified in patients with disseminated Histoplasmosis for whom autopsies were performed but initial presentation as a GI illness is infrequent. Abdominal mass, hepatosplenomegaly and intestinal obstruction are common findings. Lesions of Gastrointestinal Histoplasmosis occur mainly in large intestine and ileocecal area, likely because of the abundance of lymophoid tissue in this area. Pathological examination and fungal cultures of GI tissue are sensitive methods for diagnosis of gastrointestinal Histoplasmosis, but culture may take up to 6 weeks. Urine and blood antigens are also sensitive and rapid diagnostic methods. Conclusion: Clinical outcomes improve significantly with antifungal therapy; therefore, providers need to be aware of varied presentation of disseminated Histoplasmosis, particularly in AIDS patients.High index of suspicion is needed to make the diagnosis of gastrointestinal Histoplasmosis followed by prompt treatment to avoid the high mortality risk associated with disseminated infection. Work up for more common etiologies of GI illness should not delay diagnosis or treatment of Histoplasmosis.

Epidemiologic evaluation of multiple alternate microbial water quality monitoring indicators at three California beaches

IntroductionAdvances in molecular methods provide new opportunities for directly measuring pathogens or host-associated markers of fecal pollution instead of relying on fecal indicator bacteria (FIB) alone for beach water quality monitoring. Adoption of new indicators depends on identifying relationships between either the presence or concentration of the indicators and illness among swimmers. Here we present results from three epidemiologic studies in which a broad range of bacterial and viral indicators of fecal contamination were measured simultaneously by either culture or molecular methods along with Enterococcus to assess whether they provide better health risk prediction than current microbial indicators of recreational water quality. MethodsWe conducted prospective cohort studies at three California beaches -- Avalon Bay (Avalon), Doheny State Beach (Doheny), Surfrider State Beach (Malibu) -- during the summers of 2007, 2008 and 2009. The studies enrolled 10,785 swimmers across the beaches and recorded each swimmer's water exposure. Water and sand samples were collected several times per day at multiple locations at each beach and analyzed for up to 41 target indicators using 67 different methodologies. Interviewers contacted participants by phone 10–14 days later and recorded symptoms of gastrointestinal illness occurring after their beach visit. Regression models were used to evaluate the association between water quality indicators and gastrointestinal illness among swimmers at each beach. ResultsF+ coliphage (measured using EPA Method 1602) exhibited a stronger association with GI illness than did EPA Method 1600 at the two beaches where it was measured, while a molecular method, F+ RNA Coliphage Genotype II, was the only indicator significantly associated with GI illness at Malibu. MRSA, a known pathogen, had the strongest association with GI illness of any microbe measured at Avalon. There were two methods targeting human-associated fecal anaerobic bacteria that were more strongly associated with GI illness than EPA Method 1600, but only at Avalon. No indicator combinations consistently had a higher odds ratio than EPA Method 1600, but one composite indicator, based on the number of pathogens detected at a beach, was significantly associated with gastrointestinal illness at both Avalon and Doheny when freshwater flow was high. DiscussionWhile EPA Method1600 performed adequately at two beaches based on its consistency of association with gastrointestinal illness and the precision of its estimated associations, F+ coliphage measured by EPA Method 1602 had a stronger association with GI illness under high risk conditions at the two beaches where it was measured. One indicator, F+ Coliphage Genotype II was the only indicator significantly associated with GI illness at Malibu. Several indicators, particularly those targeting human associated bacteria, exhibited relationships with GI illness that were equal to or greater than that of EPA Method 1600 at Avalon, which has a focused human fecal source. Our results suggest that site-specific conditions at each beach determine which indicator or indicators best predict GI illness.

Gastric Enterovirus Infection: A Possible Cause of Gastroparesis

Introduction: Gastroparesis (GP) is a debilitating GI disorder with high morbidity, severely impacting patients' quality of life. The most common etiology is idiopathic (40%), which occurs mainly in young or middle-aged women, followed by diabetes-related (30%). Idiopathic GP (IGP) may acutely present after viral-like GI illness, thus speculating that IGP may result from a viral cause. The aim of this study is to present gastric Enterovirus (EV) infection as a possible cause of IGP. Methods: Nine patients referred to our tertiary-care motility center with a diagnosis of GP underwent extensive workup to exclude known causes of GP including endocrine and autoimmune etiologies, and if negative, were diagnosed with IGP. Gastric biopsies from patients who had history of flu-like symptoms or gastroenteritis prior to the onset of GP symptoms were sent for viral immunoperoxidase testing to assess for gastric EV infection (EVMED Research. Lomita, California). Results: Of the 9 patients who had EV testing performed, 8 (89%) were found to be EV positive on gastric biopsies. Seven (88%) were female with a mean age of 44 years. Data on presenting symptoms, extra-intestinal symptoms, and prior nutritional support requirements were catalogued (Table 1). Diagnostics including endoscopy and EV testing results, and EV treatments were recorded (Table 2). 7/8 (88%) EV positive patients received EV treatment with antivirals and/or immune therapies. Of those who completed treatment, 3 (43%) had symptomatic improvement (1 Rx with IVIG alone; 1 Rx with IVIG/Ribavirin/Immunovir/Equilibrant/CoQ-10/Enterogam; and 1 Rx with IVIG/Immunovir/Equilibrant/CoQ-10), 1 (14%) remained stable (Rx with CoQ-10/Naltrexone), and 3 (43%) are currently undergoing therapy. Conclusion: Nine patients who developed GP symptoms after presumed viral infection/symptoms were diagnosed with IGP thereafter. 8/9 were found to have gastric EV infection as a potential etiology of their IGP. EV infection comprises a family of at least 71 small RNA of viruses, including Coxsackievirus groups A&B, Echovirus, Poliovirus, between others but does not isolate one specific virus or strain [MMWR Surveill Summ 2006;55(8):1-20]. 3/4 patients treated with antiviral and/or immune therapies against EV had resolution of their GP symptoms. This is the first study to identify EV as a possible infectious etiology of IGP. Further study of EV as an emerging pathogenic etiology of GP is merited to help treat this debilitating condition.Figure 1Figure 2

Assessing the Potential Impact of the BioSense 24-hour Rule Using NC DETECT ED Data

NC DETECT emergency department (ED) data were analyzed to assess the impact of applying the BioSense 24-hour rule that combines ED visits into a single visit if the patient ID and facility ID are the same and the earliest recorded times occur within the same 24-hour time frame. 4,822,347 unique ED visits from 2013 NC DETECT data were included in this analysis. Applying the 24-hour rule reduced the overall ED visit count in NC by approximately 1.7%. The percentage of ED visits lost was higher for certain types of visits, e.g. behavioral health, healthcare utilization, GI illness and varied significantly across counties in NC.

FRI0223 Development and Validation of Patient-Reported Outcomes Measurement Information System (PROMIS®) Gastrointestinal (GI) Symptom Scales in Systemic Sclerosis

BackgroundThe National Institutes of Health PROMIS® roadmap initiative is a cooperative research program designed to develop, evaluate, and standardize item banks to measure patient-reported outcomes (PROs) across different medical conditions...

Mo1119 What Is the Burden of GI Illness in the United States? It Depends on How You Ask

Background: Statins have been associated with a reduced risk of esophageal adenocarcinoma, however their possible effect on the risk of developing Barrett's esophagus (BE) is unknown. This study evaluated the association between statin use and the risk of BE. Methods: We conducted a case-control study among eligible patients scheduled for elective esophagogastroduodenoscopy (EGD) and a sample of patients eligible for screening colonoscopy recruited from primary care clinics at a single VA center. We compared 303 patients with definitive BE with two separate frequency matched control groups: 303 patients from the primary care group ("primary care controls") and 606 patients from the elective EGD group ("endoscopy controls") with no endoscopic or histopathologic BE. Index date was the earliest BE diagnosis date for cases, and the study EGD date for controls. Use of statins and other lipid lowering medications was ascertained by reviewing filled prescriptions in electronic pharmacy records during a 10-year period before index date, and use before the index date was compared between cases and controls. We calculated odds ratios (OR) and 95% confidence intervals (95% CI) using multivariable logistic regression models adjusting for age, sex, race, GERD symptoms, H. pylori infection, and waist-to-hip ratio (WHR). Results: Most in the cohort were men (97.7%) and white (75.5%). Dispensed prescriptions for statins were identified in 64.6% of subjects, most of whom (94.3%) used simvastatin. The proportion of BE cases (57.4%) with filled statin prescriptions was significantly less than in endoscopy controls (64.9%; p=0.029) and primary care controls (71.3%; p<0.001). Most of the difference was related to a higher proportion of controls having statin prescriptions that were first filled earlier than 5 years before the index date than cases (p=0.001) and prescriptions that lasted for 3-10 years (33.9% vs. 28.1%; p=0.011). Longer durations of statin prescriptions were filled by the combined groups of control subjects than BE cases; mean duration (28.6 months vs. 22.1 months, p=0.001). In multivariable analysis, statin use significantly reduced the risk of BE (adjusted OR, 0.70; 95% CI, 0.52-0.93) compared with the combined control groups. The risk of BE is particularly lower with statin use among patients who were obese (OR, 0.49; 95% CI, 0.31-0.78), or had a high WHR (OR, 0.65; 95% CI, 0.48-0.89). Importantly, we found no significant association between BE and non-statin lipid lowering medications (p=0.452). Most study subjects (91.3%) reported the VA as the primary source for most medications, and 84.6% reported receiving all prescriptions from the VA pharmacy with no significant differences between cases and controls (p=0.618). Conclusion: Statin usemay decrease the risk for BE, especially among patients who are obese or have a highWHR.

Effect of submarine groundwater discharge on bacterial indicators and swimmer health at Avalon Beach, CA, USA

Use of fecal indicator bacteria (FIB) for monitoring beach water quality is based on their co-occurrence with human pathogens, a relationship that can be dramatically altered by fate and transport processes after leaving the human intestine. We conducted a prospective cohort study at Avalon Beach, California (USA), where the indicator relationship is potentially affected by the discharge of sewage-contaminated groundwater and by solar radiation levels at this shallow, relatively quiescent beach. The goals of this study were to determine: 1) if swimmers exposed to marine water were at higher risk of illness than non-swimmers; 2) if FIB measured in marine water were associated with swimmer illness, and; 3) if the associations between FIB and swimmer health were modified by either submarine groundwater discharge or solar radiation levels. There were 7317 individuals recruited during the summers of 2007–08, 6165 (84%) of whom completed follow-up within two weeks of the beach visit. A total of 703 water quality samples were collected across multiple sites and time periods during recruitment days and analyzed for FIB using both culture-based and molecular methods. Adjusted odds ratios (AOR) indicated that swimmers who swallowed water were more likely to experience Gastrointestinal Illness (GI Illness) within three days of their beach visit than non-swimmers, and that this risk was significantly elevated when either submarine groundwater discharge was high (AOR [95% CI]:2.18 [1.22–3.89]) or solar radiation was low (2.45 [1.25–4.79]). The risk of GI Illness was not significantly elevated for swimmers who swallowed water when groundwater discharge was low or solar radiation was high. Associations between GI Illness incidence and FIB levels (Enterococcus EPA Method 1600) among swimmers who swallowed water were not significant when we did not account for groundwater discharge, but were strongly associated when groundwater discharge was high (1.85 [1.06, 3.23]) compared to when it was low (0.77 [0.42, 1.42]; test of interaction: P = 0.03). These results demonstrate the need to account for local environmental conditions when monitoring for, and making decisions about, public health at recreational beaches.The views expressed in this article are those of the authors and do not necessarily reflect the views or policies of the U.S. Environmental Protection Agency.

Probiotic supplementation for respiratory and gastrointestinal illness symptoms in healthy physically active individuals

To examine the effect of supplementation with probiotics on respiratory and gastrointestinal illness in healthy active men and women. A randomised double-blind placebo-controlled trial was conducted. Four hundred and sixty five participants (241 males; age 35 ± 12 y (mean ± SD) and 224 females; age 36 ± 12 y) were assigned to one of three groups: Group 1 - Bifidobacterium animalis subsp. lactis Bl-04 (Bl-04) 2.0 × 10(9)colony forming units per day, CFU per day, Group 2 - Lactobacillus acidophilus NCFM and Bifidobacterium animalis subsp. lactis Bi-07 (NCFM & Bi-07) 5 × 10(9) CFU each per day) or Group 3 - placebo mixed in a drink. The risk of an upper respiratory illness episode was significantly lower in the Bl-04 group (hazard ratio 0.73; 95% confidence interval 0.55-0.95; P = 0.022) compared to placebo. There was no significant difference in illness risk between the NCFM & Bi-07 group (hazard ratio 0.81; 0.62-1.08; P = 0.15) and the placebo group. There was a 0.7 and 0.9 month delay in the median time to an illness episode in the Bl-04 and NCFM & Bi-07 groups respectively compared to placebo (placebo 2.5 months; Bl-04 3.2 months; NCFM & Bi-07 3.4 months). There were insufficient GI illness episodes for analysis. The NCFM & Bi-07 group but not the Bl-04 group undertook significantly more physical activity (8.5%; 6.7%-10%; P < 0.003) than the placebo group. The probiotic Bl-04 appears to be a useful nutritional supplement in reducing the risk of URTI in healthy physically-active adults. Australia New Zealand Clinical Trials Registry: Number ACTRN12611000130965.

Henoch-Schoenlein Purpura Causing GI Bleeding in an Adult

Introduction: Henoch-Schoenlein purpura (HSP) is a systemic leukocytoclastic vasculitis commonly seen in the pediatric population, but can rarely be seen in adults. Gastrointestinal involvement occurs in 85% of cases in adults. Signs and symptoms indicating GI involvement are easily confused with other GI illnesses. Case Presentation: A 61-year-old previously healthy female presented to our institution with one week of progressive symptoms that started with left-sided flank pain and myalgias. Three days prior to admission, she developed a rash that started on her legs and progressed to her arms. One day prior to admission, she developed melena and then frank hematochezia, with new onset of abdominal pain that was in her midline. She had previously had an appendectomy and cholecystectomy. She took no medications. Family history was notable for Crohn's disease in her cousin. She was a former smoker, drank alcohol socially, and had no history of drug abuse. She denied any recent travel history or eating anything out of the ordinary. She had no sick contacts. She was afebrile and tachycardic with a normal blood pressure. She appeared lethargic, had dry mucous membranes and had tenderness to palpation in her upper abdomen. Her skin revealed palpable purpura on her lower extremities and non-palpable purpura and petechiae on her upper extremities. Serum chemistry, liver function tests and lipase were normal. A complete blood count was notable for a white blood count of 19.0 g/dL and hemoglobin of 12.7 g/dL. A computed tomography of the abdomen showed thickening in the proximal ileum suggesting focal enteritis. An upper endoscopy (EGD) was normal. Dermatology performed a skin biopsy, which revealed 1+ perivascular IgA and C5b-9 and trace perivascular IgM in the superficial dermis, consistent with HSP. She was started on prednisone 40 mg and discharged with close follow-up with dermatology and rheumatology. Discussion: HSP is characterized by the tetrad of palpable purpura, GI involvement, arthralgias, and renal disease. Adult cases are uncommon, but will frequently involve the GI tract. GI-related symptoms are not specific and result from immune complex deposition in vessel walls. Hemorrhage, bowel wall edema, and intussusception affect the small bowel most commonly. This case therefore illustrates the importance of keeping in mind systemic disorders such as vasculitides as a source of GI symptoms in the appropriate clinical context. Recognizing the pattern of symptoms and exam findings was critical in guiding appropriate care and preventing unnecessary further diagnostic testing.

ED visits for GI illnesses incur high cost

ED visits for GI illnesses incur high cost

Equivalency of risk for a modified health endpoint: a case from recreational water epidemiology studies.

BackgroundThe United States Environmental Protection Agency (USEPA) and its predecessors have conducted three distinct series of epidemiological studies beginning in 1948 on the relationship between bathing water quality and swimmers’ illnesses. Keeping pace with advances in microbial technologies, these studies differed in their respective microbial indicators of water quality. Another difference, however, has been their specific health endpoints. The latest round of studies, the National Epidemiological Assessment of Recreational (NEEAR) Water studies initiated in 2002, used a case definition, termed “NEEAR GI illness” (NGI), for gastrointestinal illness corresponding closely to classifications employed by contemporary researchers, and to that proposed by the World Health Organization. NGI differed from the previous definition of “highly credible gastrointestinal illness” (HCGI) upon which the USEPA’s 1986 bathing water criteria had been based, primarily by excluding fever as a prerequisite.MethodsIncidence of NGI from the NEEAR studies was compared to that of HCGI from earlier studies. Markov chain Monte Carlo method was used to estimate the respective beta binomial probability densities for NGI and HCGI establish credible intervals for the risk ratio of NGI to HCGI.ResultsThe ratio of NGI risk to that of HCGI is estimated to be 4.5 with a credible interval 3.2 to 7.7.ConclusionsA risk level of 8 HCGI illnesses per 1000 swimmers, as in the 1986 freshwater criteria, would correspond to 36 NGI illnesses per 1000 swimmers. Given a microbial DNA-based (qPCR) water quality vs. risk relationship developed from the NEEAR studies, 36 NGI per 1000 corresponds to a geometric mean of 475 qPCR cell-equivalents per 100 ml.

A descriptive study of reportable gastrointestinal illnesses in Ontario, Canada, from 2007 to 2009

BackgroundGastrointestinal illnesses (GI) continue to pose a substantial burden in terms of morbidity and economic impact in Canada. We describe the epidemiology of reportable GI in Ontario by characterizing the incidence of each reportable GI, as well as associated demographics, clinical outcomes, seasonality, risk settings, and likely sources of infection.MethodsReports on laboratory confirmed cases of amebiasis, botulism, campylobacteriosis, cryptosporidiosis, cyclosporiasis, giardiasis, hepatitis A, listeriosis, paratyphoid fever, salmonellosis, shigellosis, typhoid fever, illness due to verotoxin-producing Escherichia coli (VTEC-illness), and yersiniosis, from January 1, 2007 to December 31, 2009 were obtained from Ontario’s passive reportable disease surveillance system. Cases were classified by history of relevant travel, association with outbreaks, and likely source of infection, obtained through follow-up of reported cases by local health authorities.ResultsThere were 29,897 GI reported by health authorities in Ontario from 2007 to 2009. The most frequently reported diseases were campylobacteriosis (10,916 cases or 36.5% of all GI illnesses) and salmonellosis (7,514 cases, 25.1%). Overall, 26.9% of GI cases reported travel outside of Ontario during the relevant incubation period. Children four years of age and younger had the highest incidence rate for most GI, and significantly more (54.8%, p<0.001) cases occurred among males than females. The most commonly reported sources of infections were food (54.2%), animals (19.8%), and contact with ill persons (16.9%). Private homes (45.5%) and food premises (29.7%) were the most commonly reported exposure settings. Domestic cases of campylobacteriosis, cryptosporidiosis, giardiasis, salmonellosis, and VTEC-illness showed seasonal patterns with incidence peaking in the summer months.ConclusionsReportable GI continues to be a burden in Ontario. Since more than one in four GI cases experienced in Ontario were acquired outside of the province, international travel is an important risk factor for most GI. Because private homes are the most commonly reported risk settings and the main suspect sources of infection are food, animal contact and ill persons, these findings support the continued need for public health food safety programs, public education on safe handling of food and animals, and proper hand hygiene practices.

Migrant workers’ occupation and healthcare-seeking preferences for TB-suspicious symptoms and other health problems: a survey among immigrant workers in Songkhla province, southern Thailand

BackgroundMuch of the unskilled and semi-skilled workforce in Thailand comprises migrant workers from neighbouring countries. While, in principle, healthcare facilities in the host country are open to those migrants registered with the Ministry of Labour, their actual healthcare-seeking preferences and practices, as well as those of unregistered migrants, are not well documented. This study aimed to describe the patterns of healthcare-seeking behaviours of immigrant workers in Thailand, emphasizing healthcare practices for TB-suspicious symptoms, and to identify the role of occupation and other factors influencing these behaviours.MethodsA survey was conducted among 614 immigrant factory workers (FW), rubber tappers (RT) and construction workers (CW), in which information was sought on socio-demography, history of illness and related healthcare-seeking behaviour. Mixed effects logistic regression modeling was employed in data analysis.ResultsAmong all three occupations, self-medication was the most common way of dealing with illnesses, including the development of TB-suspicious symptoms, for which inappropriate drugs were used. Only for GI symptoms and obstetric problems did migrant workers commonly seek healthcare at modern healthcare facilities. For GI illness, FW preferred to attend the in-factory clinic and RT a private facility over government facilities owing to the quicker service and greater convenience. For RT, who were generally wealthier, the higher cost of private treatment was not a deterrent. CW preferentially chose a government healthcare facility for their GI problems. For obstetric problems, including delivery, government facilities were utilized by RT and CW, but most FW returned to their home country. After adjusting for confounding, having legal status in the country was associated with overall greater use of government facilities and being female and being married with use of both types of modern healthcare facility. One-year estimated period prevalence of TB-suspicious symptoms was around 6% among FW but around 27% and 30% in RT and CW respectively. However, CW were the least likely to visit a modern healthcare facility for these symptoms.ConclusionsSelf medication is the predominant mode of healthcare seeking among these migrant workers. When accessing a modern healthcare facility the choice is influenced by occupation and its attendant lifestyle and socioeconomic conditions. Utilization of modern facilities could be improved by reducing the current barriers by more complete registration coverage and better provision of healthcare information, in which local vendors of the same ethnicity could play a useful role. Active surveillance for TB among migrant workers, especially CW, may lead to better TB control.

Statistical Study on Self Medication Pattern in Haryana, India

According to WHO's definition, self medication is “The selection and use of medicines by individuals to treat selfrecognized illnesses or symptoms”. Self-medication includes the use of nonprescription drugs and a range of different alternative medicines such as herbal remedies, food supplements, and traditional products. In most illness episodes, self-medication is the first option which makes self-medication a common practice worldwide. People of all socio-demographic categories practice self-medication. The most frequently self-diagnosed illnesses or symptoms of illnesses were: GI illnesses and headache/fever. Of these more than 30% were less than 24 hours duration and nearly 80% less than seven days duration of illness. The reasons given by respondents for self-diagnosis and self-medication were non-seriousness of the illnesses, for emergency use and prior experience about the illness. Whatever the duration of illnesses and reasons for self-diagnosis, nearly 60% requested drugs by mentioning the names of the drugs and more than one-fifth by telling the symptoms of their illnesses. Requests for antimicrobial drugs were very high for all reported illnesses and very low for ORS.© 2011 IGJPS. All rights reserved.

Outcome of 1st Seizure After Nonfebrile Acute GI Illness

Outcome of 1st Seizure After Nonfebrile Acute GI Illness

The Impact of Mood and Somatization on Quality-of-life in Irritable Bowel Syndrome (IBS)

Purpose: Irritable bowel syndrome (IBS) exerts a negative influence on quality-of-life (QOL) in affected individuals. IBS patients are known to have impairments in QOL comparable to individuals with other chronic GI illnesses, including inflammatory bowel disease and chronic liver disease (El-Serag et al., Aliment Pharmacol Ther 2002). In up to half of IBS patients, co-morbid psychiatric illness (e.g. depression, anxiety, somatization) can be detected; these psychiatric conditions, too, are known to negatively affect QOL. We sought to determine whether the presence of psychiatric co-morbidity further influences QOL while controlling for the effect of bowel symptoms alone in IBS patients. Methods: Consecutive patients presenting for care in a tertiary outpatient GI setting with a diagnosis IBS were recruited to complete several instruments, including: Rome III Research Diagnostic Questions, mood measures (Beck Depression and Anxiety Inventories), the SF-36 health-related QOL index, and the PHQ-15 somatization scale. Bowel symptom severity was assessed using a 10-cm VAS measure, and the number of symptomatic days over the preceding two weeks were recorded. Multivariate linear regression analysis was conducted to assess the independent contribution of demographics, bowel symptoms, and psychiatric measures on QOL. Results: 279 IBS subjects (49.5±14.7 yrs, 219 female) were recruited over a 52-month period. Mean bowel severity score was 6.9±2.6 on VAS scales, with 9.1±4.2 symptomatic days over the past 2 weeks. Mean score for the total SF-36 was 50.9±23.4. Mean BDI and BAI scores were 10.5±8.8 and 12.8±9.6, respectively, corresponding to 79 (28.3%) subjects with depression (BDI ≥14) and 94 (33.7%) with anxiety (BAI ≥16). Mean PHQ-15 scores were 12.8± 5.8, with 128 (25.5%) meeting criteria for ‘high somatization’. In the 146 (52.3%) subjects with ≥ 1 psychiatric comorbidity, poor QOL was noted with significantly lower mean SF-36 scores compared to the remainder (38.3±19.8 vs. 64.7±19.0, p<0.001). In multivariate analysis, poorer QOL was independently predicted by depression (B=-0.45, p<0.001) and somatization (B=-0.30, p<0.001) scores, older age (B=-0.19, p<0.001), and trended toward significance with bowel symptom severity (B=0.-10, p=0.11), but was not related to bowel symptom frequency (B=0.07, p=0.30), gender (B=0.01, p=0.76), or anxiety rating (B=-0.08, p=0.28). Conclusion: Co-existent mood disorders and somatization are common in IBS, and negatively influence QOL independent of bowel symptom severity and frequency. In addition to bowel symptoms, psychiatric comorbidity, particularly depression and somatization, may be equally important therapeutic targets in optimizing the well-being of IBS patients.