Gastroenterologists release new safety guidelines
Crohn’s disease, which affects the large and small intestines, is even more common in Canada and affects about 234 per 100,000 people, with an incidence of 13.4 per 100,000 each year. By comparison, ulcerative colitis prevalence is 58 to 157 per 100,000 in Northern Europe and about 167 per 100,000 for an area of Minnesota. Crohn’s disease prevalence ranges from 27 to 48 per 100,000 in Northern Europe to 144 per 100,000 in an area of Minnesota. Some Third World nations and areas in tropical latitudes have still lower rates. Although the reasons for these differences remain unclear, the hygiene hypothesis may help explain the distribution in Canada, said Richard Fedorak, M.D., of the University of Alberta in Edmonton, a co-author. “If you live in an environment that’s too clean or too sterile as a child your intestines are not exposed to bacteria of the same types and numbers you would be exposed to in a tropical area,” he said. which is especially true for Canada because much of the country has cold winters with little bacterial activity in the soil. Then if the genetic triggers are present, “your intestine is not able to tolerate bacteria as you get older and starts to destroy itself,” he added. Supporting this speculation, the researchers discovered differences among provinces: Nova Scotia in the Maritimes consistently had the highest rates of ulcerative colitis (19.2 incidence and 247.9 prevalence per 100,000) and Crohn’s disease (20.2 incidence and 318.5 per 100,000), Following closely is Alberta, with ulcerative colitis incidence of 11.0 and prevalence of 185.0 per 100,000 and Crohn’s disease incidence of 16.5 and prevalence of 283.0 per 100,000, and Manitoba had likewise high rates of ulcerative colitis (15.4 incidence and 248.6 prevalence per 100,000) and Crohn’s disease (15.4 incidence and 271.4 prevalence per 100,000); Whereas British Columbia, on the west coast, consistently had much lower rates of both ulcerative colitis (9.9 incidence and 162.1 prevalence per 100,000) and Crohn’s disease (8.8 incidence and 160.7 prevalence per 100,000). British Columbia proved to be an outlier, particularly for Crohn’s disease perhaps because of its milder winters, more precipitation, and “because its population ethnic make-up is somewhat different from the rest of Canada,” the researchers wrote. Much of British Columbia’s immigration in the past 20 years has been from Asia, they said.
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Although the Canadian Association of Gastroenterology has guidelines around credentials and training, there was a void in other areas. “If one looks at the sort of totality of endoscopy service delivery, particularly from a patient point of view — which is access to services, rapid access, high quality services, feedback, and an ability to respond to how they perceive endoscopy service delivery — then there really was nothing in place,” said Dr. David Armstrong, chair of the endoscopy committee and the consensus guideline committee. Endoscopy is used to detect or screen for a number of diseases and involves examining the colon or digestive tract using a long, thin tube with a light and camera attached. Last October, about 6,800 Ottawa residents were sent letters from public health officials after it was found that a non-hospital clinic wasn’t following some procedures involving cleaning and infection prevention. The letters indicated the patients might have been exposed to hepatitis B, hepatitis C or HIV. Armstrong said he likes to think the presence of these guidelines would have made a difference in the Ottawa situation. “That’s really because one of the challenges for endoscopy — and it’s in and out of hospitals — has been that if there isn’t a framework to say how things should be monitored and how they should be delivered, it’s difficult to know how much or how closely to monitor things, and what actually are the standards,” Armstrong said in an interview from Hamilton, where he’s an associate professor of medicine at McMaster University. “So I think guidelines that say what should be monitored and what processes have to be in place really from a patient point of view and knowledge that there are tools available to monitor the way that services are delivered and to use as a basis for quality improvement programs would have made a big difference.” Armstrong indicated that it used to be felt that washing the scope and then doing a manual cleaning was sufficient. “And the trouble is there are times when that isn’t sufficient. It’s also important to ensure that all of the endoscopy manufacturers’ instructions and the automatic cleaning equipment instructions are followed, that there’s regular checks of the equipment and the water supply and the filtration and everything else.” It’s something of an undertaking, he noted.