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New onset fever, abdominal pain, confusion, or other signs or symptoms of infection in a cirrhotic patient should prompt an evaluation of the ascitic fluid for spontaneous bacterial peritonitis SBP.Iodine, low quality of data for the high and low dosage subgroups was observed, Reference 75, with a little sum when the persistence is distended, one must rate down the quality one point on the four-point scale ranging from "high" to "very low".
This leaflet was last revised in. For each individual criterion not met, or after careful benefit-risk evaluation when other treatments cannot be used.
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The Canadian regulations governing NHP are separate from the regulations governing prescription drugs. The more serious the health claim being made on the label, the higher the required level of evidence.
Several meta-analyses and reviews have evaluated the clinical effectiveness of probiotics in the prevention or treatment of symptoms for a variety of gastrointestinal diseases, such as lactose intolerance, irritable bowel syndrome, antibiotic-associated diarrhea, and those due to Helicobacter pylori and Clostridium difficile infections Reference 77, Reference 79-81.
However, only a few randomized controlled studies have examined the use of probiotics in the prevention of TD with an outcome showing significant effects Reference 82-86; and only one of four meta-analyses showed a significant pooled effect Reference 79, Reference 87-89.
Furthermore, it is difficult to interpret the findings because of the differing probiotic species, formulations and dosages used in the studies, and due to methodological problems within the studies themselves i.
Of the various probiotic species studied, Saccharomyces boulardii Reference 84, Reference 85 and Lactobacillus rhamnosus GG Reference 82, Reference 83, both of which are stable at room temperature when lyophilized Reference 87, appeared to be the most promising for prevention of TD with no significant side effects.
Evidence related to the preventive effects of prebiotics and synbiotics for TD is also limited Reference 90-92. Variability in the study designs prevented comparisons as each study evaluated a different compound and used differing dosages and duration of treatment.
Efficacy The pooled results from three randomized controlled trials RCTs Reference 94-96, as well as results from one Cochrane review Reference 97, found no increased benefit for the oral cholera vaccine for preventing an episode of TD during travel when compared to those vaccinated with a placebo Reference iii.
Additionally, these studies found no difference in effect for prevention of TD related to ETEC when compared to placebo. Lower confidence in estimate of effect can primarily be attributed to an ambiguous, potentially non-standard definition of TD in one study Reference 94, as well as a non-standard immunization protocol in one of the other studies Reference 95.
Two other observational studies found no difference in effect Reference 101, Reference 102.
However, these five observational studies were not included in the assessment due to serious limitations with the selection of the comparison group: those who were not vaccinated had either refused vaccination or were not referred for vaccination because they were judged to be engaging in types of travel at lower risk for cholera and thus by extrapolation also potentially at lower risk for TD.
In both cases, this presents important differences in risk profile between the vaccinated and non-vaccinated groups which quite probably biased the results.
This indication is largely based on a field study conducted in an endemic population with a primary outcome of ETEC diarrhea Reference 103. This study was considered in the review of the evidence but was excluded from the analysis given that it was not conducted in a traveller population that is potentially exposed to a broad spectrum of TD-causing bacteria.
Harms We were unable to assess with GRADE the safety of the inactivated oral cholera vaccines due to insufficient detail provided on adverse events.