SummaryProton‐pump inhibitor failure has become a common clinical dilemma in gastrointestinal clinics and has been increasingly encountered at the primary care level as well. Underlying mechanisms are diverse and may overlap. Most patients who have proton‐pump inhibitor failure are likely to originate from the non‐erosive reflux disease phenotype. Currently, available diagnostic modalities provide limited clues to the exact underlying cause. Treatment relies primarily on escalating dosing of proton‐pump inhibitors. However, new insights into the pathophysiology of proton‐pump inhibitor failure are likely to provide alternative therapeutic options.

Background Small intestinal bacterial overgrowth (SIBO) is an under-recognized diagnosis with important clinical implications when untreated. However, optimal treatment regimen remains unclear. Aim Systematic review and meta-analysis to compare clinical effectiveness of antibiotic therapies for treatment of symptomatic patients with documented SIBO. Methods Four databases were searched to identify clinical trials comparing effectiveness of: (1) different antibiotics, (2) different doses of the same antibiotic, and (3) antibiotics compared with placebo. Data were independently extracted according to predetermined inclusion and exclusion criteria. Study quality was independently assessed. Primary outcome was normalization of post-treatment breath testing. Secondary outcome was post-treatment clinical response. Results Of 1,356 articles identified, ten met inclusion criteria. Rifaximin was the most commonly studied antibiotic (8 studies) with overall breath test normalization rate of 49.5% (95% CI 44.0–55.1). Antibiotic efficacy varied by antibiotic regimen and dose. Antibiotics were more effective than placebo, with a combined breath test normalization rate of 51.1% (95% CI 46.7–55.5) for antibiotics compared with 9.8% (95% CI 4.6–17.8) for placebo. Meta-analysis of 4 studies favored antibiotics over placebo for breath test normalization with odds ratio 2.55 (95% CI 1.29–5.04). Clinical response was heterogeneously evaluated among six studies, but tended to correlate with breath test normalization. Conclusions Antibiotics appear to be more effective than placebo for breath test normalization in patients with symptoms attributable to SIBO, and breath test normalization may correlate with clinical response. Studies were limited by modest quality, small sample size, and heterogeneous design. Additional higher-quality clinical trials of SIBO therapy are warranted.

Aim: Cognitive load theory (CLT) is of increasing interest to health professions education researchers. CLT has intuitive applicability to workplace settings, yet how CLT should inform teaching, learning, and research in health professions workplaces is unclear. Method: To map the existing literature, we performed a scoping review of studies involving cognitive load, mental effort and/or mental workload in professional workplace settings within and outside of the health professions. We included actual and simulated workplaces and workplace tasks. Result: Searching eight databases, we identified 4571 citations, of which 116 met inclusion criteria. Studies were most often quantitative. Methods to measure cognitive load included psychometric, physiologic, and secondary task approaches. Few covariates of cognitive load or performance were studied. Overall cognitive load and intrinsic load were consistently negatively associated with the level of experience and performance. Studies consistently found distractions and other aspects of workplace environments as contributing to extraneous load. Studies outside the health professions documented similar findings to those within the health professions, supporting relevance of CLT to workplace learning. Conclusion: The authors discuss implications for workplace teaching, curricular design, learning environment, and metacognition. To advance workplace learning, the authors suggest future CLT research should address higher-level questions and integrate other learning frameworks.

SUMMARYBackground: Therapeutic trials with high-dose lansoprazole and omeprazole have been shown to be sensitive clinical tools for diagnosing patients with gastro-oesophageal reflux disease-related non-cardiac chest pain. Aim: To determine the clinical value of a therapeutic trial of high-dose rabeprazole over 7 days in detecting patients with gastro-oesophageal reflux disease-related non-cardiac chest pain. Methods: Double-blind, randomized, placebo-controlled, crossover study. Patients referred by a cardiologist after a comprehensive cardiac work-up were enrolled into the study. Oesophageal mucosal disease was determined by upper endoscopy and 24-h oesophageal pH monitoring assessed acid exposure. Patients were then randomized to either placebo or rabeprazole 20 mg am and 20 mg pm for 7 days. After a washout period of 1 week, patients crossed over to the other arm of the study for an additional 7 days. Patients completed a daily diary

The CLIC measures three types of cognitive load during colonoscopy training. Evidence of validity is provided. Although CLIC items relate to colonoscopy, the development process we detail can be used to adapt the instrument for use in other learning settings in medical education.

SummarySevoflurane, desflurane and isoflurane were compared using a circle system in 97 patients undergoing short surgical procedures. Using initial high flows, the time intervals to equilibration between inspired and end-expired agent concentrations were measured; equilibration was defined as F E = F I 0:8. The mean (SD) times obtained for sevoflurane, desflurane and isoflurane were 8.2 (2.1) min, 3.8 (0.7) min and 19.7 (6.5) min, respectively. These times were significantly different from each other (p < 0:0001). After equilibration total flows were reduced to 500 ml.min ÿ 1 ; at these flows the initial decline in end-expired agent concentration was minimal with desflurane, intermediate with sevoflurane and greatest with isoflurane. Both desflurane and sevoflurane are appropriate for efficient use of the circle system during short anaesthetics.Keywords Anaesthetics, volatile; sevoflurane, desflurane, isoflurane. Equipment; breathing systems, circle, closed. ...................................................................................... Correspondence to: Dr N. Soni Accepted: 17 November 1996 In contrast to other anaesthetic breathing systems in common use, the circle system has the unique advantage of permitting anaesthesia with low fresh gas flows, thereby conferring physiological, economic and environmental benefits [1, 2]. In clinical practice, the important considerations when using circle systems are firstly the initial period of high gas inflow required to denitrogenate the lungs and attain an adequate alveolar anaesthetic concentration and subsequently the effective maintenance of this concentration during low flows. There is no general agreement as to what constitutes an adequate alveolar concentration before flows can be reduced. Low-flow anaesthesia is commonly instituted only after about 20 min at high flows, but this precludes the efficient use of the circle system for the large proportion of anaesthetics which are of short duration. (The term 'efficient' refers to a low value for the ratio of fresh gas flow to expired minute volume. This is obtained by flows classified minimal (250-500 ml.min ÿ 1 ) or low (500-1000 ml.min ÿ 1 ), using the terminology proposed by Simionescu [3].It has been shown that, when desflurane is used in the circle system, an adequate alveolar concentration, as indicated by end-expired (F E 0 ) desflurane concentration, is rapidly achieved [4]. This allows reduction of fresh gas flow after a very short time, with the end-expired desflurane concentration effectively maintained at flows of 500 ml.min ÿ 1 . In contrast, isoflurane takes longer for endexpired and inspired (F I ) concentrations to equilibrate [4], and after flow reduction end-expired isoflurane concentrations are poorly maintained. Sevoflurane has not been studied in this context, although its physical properties [5] suggest that it should behave similarly to desflurane. This study compares sevoflurane, desflurane and isoflurane for efficient use of the circle system during short anaesthetics. Me...

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