Background: Tropospheric winds from northeastern China have been linked to fluctuations in Kawasaki disease (KD) cases in Japan. These winds may carry aerosols that trigger KD in genetically susceptible children. We investigated whether reduced numbers of KD cases were linked to large scale circulation patterns affecting the U.S. West Coast. Methods: KD cases with either date of onset of fever or date of hospitalization (PHIS, Pediatric Health Information System) were obtained from 5 sites from Seattle to San Diego from 1995-2014. Six days were subtracted from date of hospitalization to approximate date of onset. For each site, periods from December-March were identified for which there were no KD cases for an interval of ≥10 days, called “KD dry spells”. Daily NCEP-NCAR atmospheric Reanalysis 700hPa height anomalies were used to represent the atmospheric circulation. Results: From 27-48 dry spells were defined for each site. Composites of atmospheric circulation from Day -20 to Day +10 relative to first day of a dry spell were created for each study site. The atmospheric circulation preceding the KD dry spell featured a higher than normal pressure center (results in weakened onshore flow) either offshore over the North Pacific or directly over the site. The circulation anomalies were statistically significant, and unlikely to have occurred by chance. The dry spell pattern intensified and persisted over several days. The strongest anomalous atmospheric circulation (and associated blocked wind flow) occurred between Day -6 to -1 relative to the start of the dry spell. A similar pattern was shared by 4 of the 5 sites. One site featured strong high pressure anomalies > 6 days before the KD dry spells, but only a weak anomaly in the Day -6 to-1 interval preceding the dry spell. Conclusion: This analysis reinforces results from previous studies of KD case fluctuations in Japan wherein anomalous KD activity was associated with particular wind flow patterns. The circulation patterns associated with the West Coast KD “dry spells” suggest that reduced wind flow from the North Pacific results in reduced KD occurrences. These results support the hypothesis that a KD agent is transported by winds, possibly from a shared source region with transport of the agent across the Pacific.
Purpose: To compare adenoma detection rates (ADRs) between patients undergoing colonoscopy after colonic lavage with sodium phosphate solution vs a pegylated electrolyte lavage solution, and subsequently characterize the pathology based on degree of severity. Methods: One thousand consecutive colonoscopies were studied for each bowel lavage group, with retrospective analysis to determine ADR and further characterize pathology. One group underwent pre-colonoscopy lavage with sodium phosphate solution and the other with a pegylated electrolyte lavage solution. All colonoscopies were performed by the same five endoscopists in one University practice group. Comparisons were made of colon cancer detection rates, and ADR with characterization of adenomas greater than or less than 1 cm. Statistical analysis included T test, Chi-square multivariant analysis and Odds ratios. Results: Please see table below. Sodium phosphate lavage solution group = NaP. Pegylated electrolyte lavage solution group = PEG. Conclusion: Bowel lavage preparation with sodium phosphate solution resulted in a significantly higher Adenoma Detection Rate and identified more patients overall with adenomas, compared to bowel lavage with a pegylated electrolyte lavage solution. However, there was no difference in the detection of significant pathology, as defined by adenomas >9 mm or neoplastic lesions. We feel that it is important to recognize that pegylated electrolyte lavage solutions perform as well as the sodium phosphate solutions in the detection of significant pathology, given the concerns regarding nephrotoxicity risks with sodium phosphate.
This qualitative study examined multiple perspectives of participants who experienced a Victim–Offender Mediation (VOM) program in a Midwestern city in the United States. Of particular interest are the roles and skills of mediators. Data consisted of 34 face‐to‐face interviews with 37 participants including adult crime victims, juvenile offenders and their parents, mediators and representatives from referring agencies. Insider perspectives regarding the roles and skills of the mediators in restorative processes were revealed through personal stories. Although the majority of the participants reported that the roles and skills of mediators were consistent with restorative justice principles, this exploratory study also revealed that some roles and skills exhibited by mediators were inconsistent with restorative justice values, which shows the variance of 'real world' restorative justice. Recommendations are made to promote mediators' roles and skills that are compatible with restorative justice principles.
Purpose: We report a 49-year-old woman with long-standing steroid dependant ulcerative colitis, who developed transfusion dependent hematochezia. Her history was significant for Ulcerative Colitis for 17 years with no resections. She had been steroid dependent for over a year and had previously been diagnosed with low-grade dysplasia. She presented with 3 days of abdominal pain and hematochezia with fever. She presented with a HCT of 24 despite transfusion and was transferred to our institution for emergent colectomy. Her stool culture and Clostridium difficile were negative. Preoperative colonoscopy revealed mild acute inflammatory colitis with chronic inflammatory changes and numerous punched out ulcers. Biopsies showed viral inclusions and serologic studies all suggested recent CMV infection. Low-grade dysplasia was also found on biopsies throughout the colon. The patient was started on intravenous gangcyclovir, was slowly tapered from steroids and started 6-MP. Over six weeks her symptoms improved with intravenous gancyclovir and a colectomy was avoided. Repeat colonoscopy at 8 weeks showed near total eradication of the CMV and complete resolution of the low-grade dysplasia. The patient had no further episodes of hematochezia and had normalization of her HCT. Cytomegalovirus (CMV) colitis has been reported in patients with underlying inflammatory bowel disease. Previous prospective studies have shown higher rates of CMV infection in steroid resistant ulcerative colitis. CMV colitis and ulcerative colitis can both present clinically with hematochezia and can be difficult to differentiate by endoscopic evaluation. Inflammatory changes secondary to CMV infection can confuse the diagnosis of low-grade dysplasia on biopsy. CMV colitis is a potentially treatable cause of colitis and should be excluded in patients contemplating colectomy for low-grade dysplasia or refractory hematochezia in steroid dependent ulcerative colitis. CMV infection should be excluded prior to advancing immunosuppressive therapy in steroid refractory cases. Analysis of blood for cytomegalovirus culture and serology should be obtained to corroborate biopsy results.
Introduction: MALT lymphoma is a cancer of gastrointestinal mucosa associated with H. Pylori infection. Less than 1% of MALT lymphoma occur in the esophagus. Esophageal MALT lymphoma has previously been treated with radiation therapy. We describe a case of Endoscopic Mucosal Resection as therapy for the treatment of esophageal MALT lymphoma confined to the mucosa. Case: A 38 year old female presented with 3 months of GERD symptoms despite treatment with a variety of medications. She denied hematemesis, melena, hematochezia or unintended weight loss. She denied alcohol or tobacco use. Her family history is significant for a father with colon polyps. Physical exam was unremarkable. Laboratory analysis: WBC 8, HCT 43, Plts 275, K 4.0, Cr 0.7, LFT normal. H. Pylori IgG Negative. An EGD was performed that demonstrated a 4.4 mm*1.8 mm nodule 4 cm above the GE junction. Biopsies of the nodule demonstrated lymphoma. Gastric biopsies demonstrated no evidence of H. Pylori or malignancy. EUS demonstrated a hypoechoic lesion with 2 mm of depth localized to the mucosa. CT scan showed no evidence of lymphadenopathy or other disease. The nodule was removed with an EMR technique. It was first raised with 10 cc of normal saline. An oblique 16 mm hard EMR cap was attached to a single channel therapeutic endoscope and the nodule was removed using a snare. Histopathology showed extranodal monoclonal kappa restricted marginal cell lymphoma with normal surrounding mucosa. Immunohistochemistry demonstrated: LCA+/CD20+/CD79a+ Bcle-2 staining demonstrated residual reactive germinal center. Discussion: Extranodal MALT lymphomas arise in mucosal organs of the gastrointestinal tract, usually in the stomach and colon. H. Pylori infection is the usual underlying etiology of MALT lymphoma in the stomach and eradication of H. Pylori is the initial treatment of choice for gastric MALT lymphoma. This patient demonstrated no evidence of H. Pylori infection on either gastric biopsy or serology. MALT lymphoma in the esophagus is very rare. MALT lymphomas are confined to the primary site and tend to disseminate slowly. There have been two previously documented cases of MALT lymphoma arising in the esophagus. In these reports EMR has been demonstrated to be an effective technique to remove MALT lymphoma that has not invaded the muscularis. Complete removal of esophageal MALT lymphoma with EMR precludes further treatment with radiation therapy.
Purpose: A 28 year-old female with an eight-year history of Crohn's Disease complicated by multiple small bowel obstructions and fistulectomies was referred to our office for a second opinion regarding leg pain requiring narcotics. She presented with a three-year history of constant bilateral lower extremity pain radiating from the knees, along the tibia to the dorsum of her feet. Her symptoms increased with weight bearing and were not altered by passive motion. She denied joint swelling, erythema, warmth or rash. She had daily, semi-formed bowel movements without cramping or evidence of bleeding. Her history was significant for Crohn's Disease requiring multiple partial small bowel resections and endometriosis. Family history was noncontributory. Medications included Mesalamine 1 gm Q. I.D, but she had previously been treated with 6-MP and three doses of Infliximab, with no effect on her leg pain. To explore a possible diagnosis of Crohn's associated tenosynovitis she was referred to Rheumatology. Her Vitamin D level was checked and was 26 (normal 20–100) and a bone scan demonstrated abnormal increased uptake in both tibia. An endoscopy performed for persistent anemia showed normal appearing mucosa without scalloping, but small intestinal biopsy noted marked villous blunting and increased intraepithelial lymphocytes. Her TTG IgG level was elevated at 122 (<20) and IgA 90 Crohn's disease and Celiac Sprue are both chronic immune mediated inflammatory processeswhich can cause malabsorption and Vitamin D deficiency. Both disease processes can effect the proximal bowel and can also result in an anemia. Here we report a case of celiac sprue disease presenting as Vitamin D deficiency in a patient with concomitant Crohn's disease. Previous prospective analysis have found small but increased prevalence of concomitant celiac disease with Crohn's Disease. Bone pain is a described presenting symptom of Celiac Disease secondary to Vitamin D deficiency In patients with bone pain and a history Crohn's Disease, consideration should be given to the presence of concomitant celiac sprue and Vitamin D deficiency.
This guide shows readers how to achieve BS7750 quickly and easily. It provides clear ideas for planning and implementing environmental management and demonstrates to readers how to identify problems their organisations face. When objectives have been achieved it illustrates to readers how to assess the implementation. Author played a key role in developing BS7750. Includes checklists and action points in each chapter helping readers quickly and easily assess their organisation. Provides practical communication hints in each chapter. It is aimed at managers with responsibility for business practices, processes, procedures and projects that have impact on the environment and at managers responsible for implementing environmental management systems.
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