ObjectiveTo explore and categorise the state of existing literature for national programmes designed to affirm or establish the continuing competence of physicians.DesignScoping review.Data ...sourcesMEDLINE, ERIC, Sociological Abstracts, web/grey literature (2000–2014).SelectionIncluded when a record described a (1) national-level physician validation system, (2) recognised as a system for affirming competence and (3) reported relevant data.Data extractionUsing bibliographic software, title and abstracts were reviewed using an assessment matrix to ensure duplicate, paired screening. Dyads included both a methodologist and content expert on each assessment, reflective of evidence-informed best practices to decrease errors.Results45 reports were included. Publication dates ranged from 2002 to 2014 with the majority of publications occurring in the previous six years (n=35). Country of origin—defined as that of the primary author—included the USA (N=32), the UK (N=8), Canada (N=3), Kuwait (N=1) and Australia (N=1). Three broad themes emerged from this heterogeneous data set: contemporary national programmes, contextual factors and terminological consistency. Four national physician validation systems emerged from the data: the American Board of Medical Specialties Maintenance of Certification Program, the Federation of State Medical Boards Maintenance of Licensure Program, the Canadian Revalidation Program and the UK Revalidation Program. Three contextual factors emerged as stimuli for the implementation of national validation systems: medical regulation, quality of care and professional competence. Finally, great variation among the definitions of key terms was identified.ConclusionsThere is an emerging literature focusing on national physician validation systems. Four major systems have been implemented in recent years and it is anticipated that more will follow. Much of this work is descriptive, and gaps exist for the extent to which systems build on current evidence or theory. Terminology is highly variable across programmes for validating physician competence and fitness for practice.
Background & Aims: Infection of the lymphatic system by hepatitis C virus (HCV) appears to be an intrinsic characteristic of chronic hepatitis C (CHC) and low-level (occult) HCV infection, but the ...subsets of immune cells involved were not defined. The aim of this study was to characterize HCV replication status and to assess virus compartmentalization in CD4+ and CD8+ T lymphocytes, B cells, and monocytes in CHC, and silent infection persisting after resolution of hepatitis C. Methods: Immune cell subtypes isolated from 7 patients with CHC and 7 individuals with occult infection were analyzed for HCV-RNA–positive and –negative strands and, in selected cases, nonstructural protein 5A display and HCV variants. Results: All subtypes of immune cells investigated support HCV replication in both forms of infection, although significant differences were found between patients, and virus loads in the cells were greater in CHC than in occult infection. Although HCV RNA occurred at a comparable frequency in all cell subtypes in CHC, monocytes contained the greatest loads. In contrast, B cells tended to carry the highest virus quantities in occult infection, whereas monocytes appeared to be the least frequently infected. Detection of HCV nonstructural protein 5A and HCV variants that were not found in plasma confirmed virus replication in different immune cell types. Conclusions: This work documents that the immune system supports HCV replication regardless of clinical appearance of infection and identifies immune cells that are reservoirs of HCV in symptomatic and occult infections.
Idiopathic small-bowel and colonic varices are a rare source of bleeding from the gastrointestinal tract. To date there are only eight published case series of familial idiopathic small-bowel and ...colonic varices. We present a case series detailing three affected siblings who presented with significant lower gastrointestinal bleeding and had multiple varices on endoscopy and imaging. Though not confirmed, consanguinity in the parents suggests an autosomal recessive mode of inheritance. We summarize the literature to date and describe our institution's experience of endoscopy, diagnostic imaging, and treatment in these patients.
Severe congenital neutropenia type 4 (SCN4) is an autosomal recessive disorder caused by mutations in the third subunit of the enzyme glucose-6-phosphatase (G6PC3). Its core features are congenital ...neutropenia and a prominent venous skin pattern, and affected individuals have variable birth defects. Oculocutaneous albinism type 4 (OCA4) is caused by autosomal recessive mutations in SLC45A2.
We report a sister and brother from Newfoundland, Canada with complex phenotypes. The sister was previously reported by Cullinane et al., 2011. We performed homozygosity mapping, next generation sequencing and conventional Sanger sequencing to identify mutations that cause the phenotype in this family. We have also summarized clinical data from 49 previously reported SCN4 cases with overlapping phenotypes and interpret the medical histories of these siblings in the context of the literature.
The siblings' phenotype is due in part to a homozygous mutation in G6PC3, c.829C > T, p.Gln277X. Their ages are 38 and 37 years respectively and they are the oldest SCN4 patients published to date. Both presented with congenital neutropenia and later developed Crohn disease. We suggest that the latter is a previously unrecognized SCN4 manifestation and that not all affected individuals have an intellectual disability. The sister also has a homozygous mutation in SLC45A2, which explains her severe oculocutaneous hypopigmentation. Her brother carried one SLC45A2 mutation and was diagnosed with "partial OCA" in childhood.
This family highlights that apparently novel syndromes can in fact be caused by two known autosomal recessive disorders.
1 Molecular Virology and Hepatology Research, Division of Basic Medical Science, Faculty of Medicine, Health Sciences Centre, Memorial University, St John's, Newfoundland, Canada A1B 3V6
2 Liver ...Unit, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
3 Gastroenterology Unit, General Hospital, Faculty of Medicine, Memorial University, St John's, Newfoundland, Canada
4 Discipline of Laboratory Medicine, Faculty of Medicine, Memorial University, St John's, Newfoundland, Canada
Correspondence Tomasz I. Michalak timich{at}mun.ca
Considering growing evidence indicating that hepatitis C virus (HCV) replicates in lymphoid cells, establishment of a reliable and sensitive method for detection of HCV in these cells may provide means for monitoring the infection and the efficacy of sterilizing antiviral therapy. In this study, conditions for ex vivo augmentation and detection of the HCV genome in peripheral blood mononuclear cells (PBMCs) from patients with chronic hepatitis C (CHC) or after a sustained virological response (SVR) to antiviral treatment were assessed. Following stimulation with combinations of mitogens and/or cytokines, PBMCs and, in certain cases, affinity-purified T and B cells were examined for HCV positive- and negative-strand RNA by using RT-PCR followed by nucleic acid hybridization, while the presence of viral NS3 protein was determined by flow cytometry. HCV RNA augmentation was assessed by quantification of Southern and dot-blot hybridization signals. The results showed that treatment of peripheral lymphoid cells with mitogens stimulating T- and B-cell proliferation and with cytokines supporting their growth significantly increased HCV RNA detection in patients with both CHC and SVR. This enhancement was up to 100-fold for the HCV genome and fivefold for the NS3 protein compared with untreated cells. In conclusion, HCV RNA can be readily detected in circulating lymphoid cells in progressing hepatitis C and following SVR after ex vivo cell stimulation. As such, this method offers a new investigative tool to study HCV lymphotropism and to monitor virus presence during the course of HCV infection.
Competency-based medical education (CBME) is as important in continuing professional development (CPD) as at any other stage of a physician's career. Principles of CBME have the potential to ...revolutionize CPD. Transitioning to CBME-based CPD will require a cultural change to gain commitment from physicians, their employers and institutions, CPD providers, professional organizations, and medical regulators. It will require learning to be aligned with professional and workplace standards. Practitioners will need to develop the expertise to systematically examine their own clinical performance data, identify performance improvement opportunities and possibilities, and develop a plan to address areas of concern. Health care facilities and systems will need to produce data on a regular basis and to develop and train CPD educators who can work with physician groups. Stakeholders, such as medical regulatory authorities who are responsible for licensing physicians and other standard-setting bodies that credential and develop maintenance-of-certification systems, will need to change their paradigm of competency enhancement through CPD.
The present paper is an update to and extension of the previous systematic review on the primary care management of patients with uninvestigated dyspepsia (UD). The original publication of the ...clinical management tool focused on the initial four- to eight-week assessment of UD. This update is based on new data from systematic reviews and clinical trials relevant to UD. There is now direct clinical evidence supporting a test-and-treat approach in patients with nondominant heartburn dyspepsia symptoms, and head-to-head comparisons show that use of a proton pump inhibitor is superior to the use of H2-receptor antagonists (H2RAs) in the initial treatment of Helicobacter pylori-negative dyspepsia patients. Cisapride is no longer available as a treatment option and evidence for other prokinetic agents is lacking. In patients with long-standing heartburn-dominant (ie, gastroesophageal reflux disease) and nonheartburn-dominant dyspepsia, a once-in-a-lifetime endoscopy is recommended. Endoscopy should also be considered in patients with new-onset dyspepsia that develops after the age of 50 years. Conventional nonsteroidal anti-inflammatory drugs, acetylsalicylic acid and cyclooxygenase-2-selective inhibitors can all cause dyspepsia. If their use cannot be discontinued, cotherapy with either a proton pump inhibitor, misoprostol or high-dose H2RAs is recommended, although the evidence is based on ulcer data and not dyspepsia data. In patients with nonheartburn-dominant dyspepsia, noninvasive testing for H pylori should be performed and treatment given if positive. When starting nonsteroidal anti-inflammatory drugs for a prolonged course, testing and treatment with H2RAs are advised if patients have a history of previous ulcers or ulcer bleeding.
The NS-Plus automated analyzer and fecal immunochemical testing (FIT) testing system (Alfresa Pharma) was evaluated for use in Newfoundland and Labrador's provincial colorectal cancer (CRC) screening ...program.
Various method performance characteristics were evaluated including the sample stability. The sensitivity for detecting neoplastic lesions was evaluated in 249 patients scheduled for colonoscopy. Each patient collected up to 2 samples for both guaiac based testing (Hemoccult ® SENSA; gFOBT) and FIT using the NS-plus system (cutoff=20μg Hb/g feces or 100μg Hb/L) over 2days. Data was analyzed comparing 1- and 2-day testing strategies.
The analyzer showed acceptable linearity, precision, and accuracy. The collection device maintained acceptable sample stability for at least 7days at: 37°C, room temperature (~23°C), 4–8°C, and −20°C. The 2-day sampling strategy identified 30% (21 of 69) of all neoplastic lesions (low and high grade adenomas and CRC) including 2 of 4 high-grade adenomas and 2 of 2 CRCs. The single day strategy identified the same high-grade adenomas and CRCs but fewer low-grade adenomas (23% of all neoplasia). Reducing the screening cutoff to the estimated 95th percentile of FIT results in the healthy adult population (10μg Hb/g feces), detected all high-grade adenomas in the 2-day strategy.
The NS Plus automated analyzer system detects clinically significant neoplasms and shows acceptable performance for use in a CRC screening program with the potential for gains in sensitivity by modifying the number of days of screening or through lowering the cutoff.
► We examine NS Plus automated analyzer system for cancer screening program. ► Collection vials maintain acceptable sample stability for at least 7days. ► Lowering cutoff or increasing screening days increases sensitivity for neoplasm. ► The NS Plus automated analyzer system detects clinically significant neoplasm.
To assess process of care in nonvariceal upper gastrointestinal bleeding (NVUGIB) using a national cohort, and to identify predictors of adherence to 'best practice' standards.
Consecutive charts of ...patients hospitalized for acute upper gastrointestinal bleeding across 21 Canadian hospitals were reviewed. Data regarding initial presentation, endoscopic management and outcomes were collected. Results were compared with 'best practice' using established guidelines on NVUGIB. Adherence was quantified and independent predictors were evaluated using multivariable analysis.
Overall, 2020 patients (89.4% NVUGIB, variceal in 10.6%) were included (mean ± SD age 66.3±16.4 years; 38.4% female). Endoscopy was performed in 1612 patients: 1533 with NVUGIB had endoscopic lesions (63.1% ulcers; high-risk stigmata in 47.8%). Early endoscopy was performed in 65.6% and an assistant was present in 83.5%. Only 64.5% of patients with high-risk stigmata received endoscopic hemostasis; 9.8% of patients exhibiting low-risk stigmata also did. Intravenous proton pump inhibitor was administered after endoscopic hemostasis in 95.7%. Rebleeding and mortality rates were 10.5% and 9.4%, respectively. Multivariable analysis revealed that low American Society of Anesthesiologists score patients had fewer assistants present during endoscopy (OR 0.63 95% CI 0.48 to 0.83), a hemoglobin level <70 g⁄L predicted inappropriate high-dose intravenous proton pump inhibitor use in patients with low-risk stigmata, and endoscopies performed during regular hours were associated with longer delays from presentation (OR 0.33 95% CI 0.24 to 0.47).
There was variability between the process of care and 'best practice' in NVUGIB. Certain patient and situational characteristics may influence guideline adherence. Dissemination initiatives must identify and focus on such considerations to improve quality of care.
To provide Canadian primary care physicians with an evidence-based clinical management tool, including diagnostic and treatment recommendations, for patients who present with uninvestigated ...dyspepsia. The management tool has 5 key decision steps addressing the following: (1) evidence that symptoms originate in the upper gastrointestinal tract, (2) presence of alarm features, (3) use of nonsteroidal anti-inflammatory drugs (NSAIDs), (4) dominant reflux symptoms and (5) evidence of Helicobacter pylori infection. All patients over 50 years of age who present with new-onset dyspepsia and patients who present with alarm features should receive prompt investigation, preferably by endoscopy. The management options for patients with uninvestigated dyspepsia who use NSAIDs regularly are: (1) to stop NSAID therapy and assess symptomatic response, (2) to treat with NSAID prophylaxis if NSAID therapy cannot be stopped or (3) to refer for investigation. Gastroesophageal reflux disease can be diagnosed clinically if the patient's dominant symptoms are heartburn or acid regurgitation, or both; these patients should be treated with acid suppressive therapy. The remaining patients should be tested for H. pylori infection, and those with a positive result should be treated with H. pylori-eradication therapy. Those with a negative result should have their symptoms treated with optimal antisecretory therapy or a prokinetic agent. VALIDATION AND EVIDENCE: Evidence for resolution of the dyspepsia symptoms was the main outcome measure. Supporting evidence for the 5 steps in the management tool and the recommendations for treatment were graded according to the strength of the evidence and were endorsed by consensus of committee members. If no randomized controlled clinical trials were available, the recommendations were based on the best available evidence. Evidence was obtained from MEDLINE searches for pertinent articles published from 1966 to October 1999. The searches focused on dyspepsia, diagnosis and treatment. Additional articles were retrieved through a manual search of bibliographies and abstracts from international gastroenterology conferences.
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