Xiaoqing Xue

Latitude, sunshine, and human lactase phenotype distributions may contribute to geographic patterns of modern disease: the inflammatory bowel disease model

Countries with high lactase nonpersistence (LNP) or low lactase persistence (LP) populations have lower rates of some “western” diseases, mimicking the effects of sunshine and latitude. Inflammatory bowel disease (IBD), ie, Crohn’s disease and ulcerative colitis, is putatively also influenced by sunshine. Recent availability of worldwide IBD rates and lactase distributions allows more extensive comparisons. The aim of this study was to evaluate the extent to which modern day lactase distributions interact with latitude, sunshine exposure, and IBD rates. National IBD rates, national distributions of LP/LNP, and population-weighted average national annual ultraviolet B exposure were obtained, estimated, or calculated from the literature. Negative binomial analysis was used to assess the relationship between the three parameters and IBD rates. Analyses for 55 countries were grouped in three geographic domains, ie, global, Europe, and non-Europe. In Europe, both latitude and ultraviolet B exposure correlate well with LP/LNP and IBD. In non-Europe, latitude and ultraviolet B exposure correlate weakly with LP/LNP, but the latter retains a more robust correlation with IBD. In univariate analysis, latitude, ultraviolet B exposure, and LP/LNP all had significant relationships with IBD. Multivariate analysis showed that lactase distributions provided the best model of fit for IBD. The model of IBD reveals the evolutionary effects of the human lactase divide, and suggests that latitude, ultraviolet B exposure, and LP/LNP mimic each other because LP/LNP follows latitudinal directions toward the equator. However, on a large scale, lactase patterns also follow lateral polarity. The effects of LP/LNP in disease are likely to involve complex interactions.

Patient Needs, Required Level of Care, and Reasons Delaying Hospital Discharge for Nonacute Patients Occupying Acute Hospital Beds

Abstract: This study aims to determine the proportion of nonacute patients occupying acute care beds and to describe their needs, the appropriate level of alternative care, and reasons preventing discharge. Data from 952 patients hospitalized in an acute care unit for 30 days were obtained from their medical charts and by consulting with the medical team at two tertiary teaching hospitals. Among them, 333 (35%) were determined nonacute on day 30 of hospitalization. According to the Appropriateness Evaluation Protocol (AEP), 55% had no medical, nursing, or patient needs. Among nonacute patients with AEP needs, 88% were related to nursing/life‐support services and 12% related to patient condition factors. Regarding alternative level of care, 186 (56%) were waiting for out‐of‐hospital resources, of which 36% were waiting for palliative care, 33% for long‐term care, 18% for rehabilitation, and 12% for home care. For the remaining 147 (44%) nonacute patients, the alternative resources remained undetermined although acute care was no longer required. Main reasons preventing discharge included unavailability of alternative resources, ongoing assessment to determine appropriate resources, ongoing process with community care, and family/patient education/counseling. Available subacute facilities and community‐based care would liberate acute care beds and facilitate their appropriate use.

What is the Impact of the Implementation of an Evidence Based ProceduralSedation Protocol in the Emergency Department

Background: Procedural sedation and analgesia (PSA) enables emergency physicians to provide pain and anxiety relief for many procedures. However, PSA introduces an independent risk factor and requires continuous monitoring. Recently, we applied the principles of knowledge translation (KT) to develop and implement a PSA protocol in our ED. Objectives: To evaluate the impact of a PSA protocol developed and implemented using KT principles on changes in ED physician practices with respect to length of monitoring time in resuscitation area, complication rate, medication types and doses. Methods: Design: Pre- Post retrospective chart review. Setting: Adult tertiary-care academic centre. Participants: Patients who underwent PSA in the ED as per physician billing code from September 2008 to August 2010. The Pre protocol implementation was from Sept 2008 to Aug 2009 and the Post was from Sept 2009 to Aug 2010. One of the authors (NM) reviewed all charts and recorded patient information such as sociodemographics, past medical history, allergies, monitoring time, complications, medication and doses. Pre and post periods information was compared using two-sample T-test and Chi-square test as appropriate. Results: There were 318 billing codes for PSA from September 2008 to August 2010 of which the 150 occurred during the Pre protocol period and 134 during the Post protocol implementation period. Excluded were 34 patients due to lack of documentation. There were no statistical differences in Pre vs. Post for baseline characteristics (mean age+standard deviation (52+20 vs. 53+22 years), male gender (54% vs. 53%), with a past medical history (36% vs. 47%) and allergies (16% vs. 15.7%)). As well no differences in outcomes with respect to complication rate (7.4% vs. 9.9%) and medication types (70% vs. 65% Ketafol, 23% vs. 23% propofol) and doses used. However, monitoring time in minutes recorded from time of first medication given until patient was moved out of resuscitation area was significantly reduced during the Post period (Pre period: mean 49 (95% CI: 42-56) versus Post period: mean 19 (95% CI: 17-21). Conclusion: The implementation of the PSA protocol using KT principles resulted in a significant and important decrease in monitoring time required for PSA thus liberating important resources in busy EDs.

Hospital stay on acute care units for non-acute reasons Effects of patient pre-hospitalization and admission factors

This study identifies patient risk factors present prior to an acute hospitalization that are associated with occupying acute care beds for non-acute reasons on the 30th day of a hospitalization. Data from 952 adult patients were obtained, among which 333 (35%) were evaluated as non-acute on their 30th day. Inability to move in and out of the bed, cognitive impairment, receiving home or community healthcare services prior to hospitalization, unavailable family resources, a secondary diagnosis within the mental and behavioural category, and age ≥75 years were found to increase the risk of occupying acute care beds for non-acute reasons, while patients with a feeding tube were less likely to be non-acute at day 30.

Evaluation of a fecal immunochemistry test prior to colonoscopy for outpatients with various indications

Background Stool tests can predict advanced neoplasms prior to colonoscopy. Results of immunochemical stool tests to predict findings at colonoscopy for various indications are less often reported. We compared pre-colonoscopy stool tests with findings in patients undergoing colonoscopy for different indications. Patients and methods Charts of patients undergoing elective or semi-urgent colonoscopy were reviewed. Comparison of adenoma detection rates and pathological findings was made between prescreened and non-prescreened, and between stool-positive and stool-negative cases. Demographics, quality of colonoscopy, and pathological findings were recorded. Odds ratios (ORs) and 95% confidence intervals (CIs) were assessed. Statistical significance was accepted at p≤0.05. Results Charts of 325 patients were reviewed. Among them, stool tests were done on 144 patients: 114 were negative and 30 were positive. Findings were similar in the pretest and non-pretest groups. Detection of advanced adenomas per patient was higher in the stool-positive group compared to the stool-negative group (23.4% vs 3.5%, p=0.0016, OR =7.6 [95% CI: 2–29.3]). Five advanced adenomas (without high-grade dysplasia or adenocarcinoma) and several cases of multiple adenomas were missed in the negative group. Sensitivity and specificity for advanced polyps was 63.6% and 82.7%, respectively. The negative predictive value was 96.5%. Male gender was independently predictive of any adenoma. Conclusion The stool immunochemical test best predicted advanced neoplasms and had a high negative predictive value in this small cohort. Whether this test can be applied to determine the need for colonoscopy in groups other than average risk would require more studies.