bluuebunny/crossref_metadata_2025 huggingface dataset:
The Role of Rapid Endoscopy for High-Risk Patients with Acute Nonvariceal Upper Gastrointestinal Bleeding
Authors: Targownik Laura E , Murthy Sanjay , Keyvani Leila , Leeson Shauna
Published: March 2016

BACKGROUND: Performance of endoscopy within 24 h is recommended for patients with acute nonvariceal upper gastrointestinal bleeding (ANVUGIB). It is unknown whether performing endoscopy early within this 24 h window is beneficial for clinically high-risk patients.

METHODS: A retrospective review was performed to identify patients presenting to two tertiary care centres with ANVUGIB and either systolic blood pressure lower than 100 mmHg or heart rate greater than 100 beats/min on presentation between 1999 and 2004. Patients receiving endoscopy within 6 h (rapid endoscopy [RE]) were compared with patients undergoing endoscopy between 6 h and 24 h (early endoscopy [EE]). The primary outcome measure was the development of any adverse bleeding outcome (rebleeding, surgery for control of bleeding, in-hospital mortality or readmission within 30 days for ANVUGIB).

RESULTS: There were 169 patients who met the entry criteria (77 RE patients and 92 EE patients). There was no significant difference in the development of any adverse bleeding outcomes between RE and EE patients (25% RE versus 23% EE, difference between groups 2%, 95% CI −9% to 13%). Transfusion requirements and length of hospital stay also did not differ between the comparator groups. RE was not associated with fewer adverse outcomes, even after adjusting for confounders.

CONCLUSION: For clinically high-risk ANVUGIB patients, performing endoscopy within 6 h of presentation is no more effective than performing endoscopy between 6 h and 24 h after presentation. The role of RE in high-risk ANVUGIB patients requires further delineation in a prospective fashion.
The Systematic Evaluation of Instruments Designed to Assess Pain in Persons with Limited Ability to Communicate*
Authors: Aubin Michèle , Giguère Anik , Hadjistavropoulos Thomas , Verreault René
Published: March 2016

Chronic pain is often underdetected and undertreated in long‐term care facilities. The use of self‐report measures of pain (such as the visual analogue scale) is often problematic for older adults residing in long‐term care because of the high prevalence of visual and auditory deficits and severe cognitive impairment. Observational measures of pain have been developed to address this concern. A systematic grid designed to assess the properties of existing observational measures of pain was used for seniors with dementia. The grid focused on the evaluation of content validity (12 items), construct validity (12 items), reliability (13 items) and clinical utility (10 items). Among the 24 instruments that were evaluated, several were deemed to be promising in the assessment of pain among older persons with severe dementia. Nonetheless, additional research is needed before their routine integration in the practices of long‐term care settings.
The Burden of Pneumococcal Disease in the Canadian Population Before Routine Use of the Seven‐Valent Pneumococcal Conjugate Vaccine
Authors: Morrow Adrienne , De Wals Philippe , Petit Geneviève , Guay Maryse , Erickson Lonny James
Published: March 2016

BACKGROUND: In the United States, implementation of the seven‐valent conjugate vaccine into childhood immunization schedules has had an effect on the burden of pneumococcal disease in all ages of the population. To evaluate the impact in Canada, it is essential to have an estimate of the burden of pneumococcal disease before routine use of the vaccine.

METHODS: The incidence and costs of pneumococcal disease in the Canadian population in 2001 were estimated from various sources, including published studies, provincial databases and expert opinion.

RESULTS: In 2001, there were 565,000 cases of pneumococcal disease in the Canadian population, with invasive infections representing 0.7%, pneumonia 7.5% and acute otitis media 91.8% of cases. There were a total of 3000 deaths, mainly as a result of pneumonia and largely attributable to the population aged 65 years or older. There were 54,330 life‐years lost due to pneumococcal disease, and 37,430 quality‐adjusted life‐years lost due to acute disease, long‐term sequelae and deaths. Societal costs were estimated to be $193 million (range $155 to $295 million), with 82% borne by the health system and 18% borne by families. Invasive pneumococcal infections represented 17% of the costs and noninvasive infections represented 83%, with approximately one‐half of this proportion attributable to acute otitis media and myringotomy.

CONCLUSIONS: The burden of pneumococcal disease before routine use of the pneumococcal conjugate vaccine was substantial in all age groups of the Canadian population. This estimate provides a baseline for further analysis of the direct and indirect impacts of the vaccine.
Referring Patients to Nurses: Outcomes and Evaluation of a Nurse Flexible Sigmoidoscopy Training Program for Colorectal Cancer Screening
Authors: Dobrow Mark J , Cooper Mary Anne , Gayman Karen , Pennington Jason , Matthews Joanne , Rabeneck Linda
Published: March 2016

Colorectal cancer is a significant health burden. Several screening options exist that can detect colorectal cancer at an early stage, leading to a more favourable prognosis. However, despite years of knowledge on best practice, screening rates are still very low in Canada, particularly in Ontario. The present paper reports on efforts to increase the flexible sigmoidoscopy screening capacity in Ontario by training nurses to perform this traditionally physician-performed procedure. Drawing on American, British and local experience, a professional regulatory framework was established, and training curriculum and assessment criteria were developed. Training was initiated at Princess Margaret Hospital and Sunnybrook and Women’s College Health Sciences Centre in Toronto, Ontario. (During the study, Sunnybrook and Women’s College Health Sciences Centre was deamalgamated into two separate hospitals: Women’s College Hospital and Sunnybrook Health Sciences Centre.) Six registered nurses participated in didactic, simulator and practical training. These nurses performed a total of 77 procedures in patients, 23 of whom had polyps detected and biopsied. Eight patients were advised to undergo colonoscopy because they had one or more neoplastic polyps. To date, six of these eight patients have undergone colonoscopy, one patient has moved out of the province and another patient is awaiting the procedure. Classifying the six patients according to the most advanced polyp histology, one patient had a negative colonoscopy (no polyps found), one patient’s polyps were hyperplastic, one had a tubular adenoma, two had advanced neoplasia (tubulovillous adenomas) and one had adenocarcinoma. All these lesions were excised completely at colonoscopy. Overall, many difficulties were anticipated and addressed in the development of the training program; ultimately, the project was affected most directly by challenges in encouraging family physicians to refer patients to the program. As health human resource strategies continue to evolve, it is believed that lessons learned from experience make an important contribution to the knowledge of how nontraditional health services can be organized and delivered.
Refractory Crohn’s Disease of the Vulva Treated with Infliximab: A Case Report
Authors: Makhija Sapna , Trotter Martin , Wagner Elizabeth , Coderre Sylvain , Panaccione Remo
Published: March 2016

Crohn’s disease (CD) is a chronic relapsing and remitting inflammatory disorder of the gastrointestinal tract. The common presentation includes abdominal pain, abdominal cramping and diarrhea. Many patients may exhibit systemic symptoms of fever and weight loss. Approximately 20% to 40% of patients will experience extraintestinal manifestations that involve the eyes, skin and joints. Women may experience a variety of gynecological manifestations, including vulvovaginal involvement, which is often not recognized and also difficult to treat. A case of refractory vulvovaginal CD is presented and the literature of gynecological manifestations of CD and its treatment are reviewed.
Chronic Pain in Canada: Have We Improved Our Management of Chronic Noncancer Pain?
Authors: Boulanger Aline , Clark Alexander J , Squire Pamela , Cui Edward , Horbay GLA
Published: March 2016

BACKGROUND: Chronic noncancer pain (CNCP) is a global issue, not only affecting individual suffering, but also impacting the delivery of health care and the strength of local economies.

OBJECTIVES: The current study (the Canadian Chronic Pain Study II [CCPSII]) was designed to assess any changes in the prevalence and treatment of CNCP, as well as in attitudes toward the use of strong analgesics, compared with a 2001 study (the CCPSI), and to provide a snapshot of the current standards of care for pain management in Canada.

METHODS: Standard, computer‐assisted telephone interview survey methodology was applied in two segments, ie, a general population survey and a survey targeting randomly selected primary care physicians (PCPs) who treat moderate to severe CNCP.

RESULTS AND DISCUSSION: The patient‐reported prevalence of CNCP within Canada has not markedly changed since 2001 but the duration of suffering has decreased. There have been minor changes in regional distribution and generally more patients receive medical treatment, which includes prescription analgesics. Physicians continue to demonstrate opiophobia in their prescribing practices; however, although this is lessened relating to addiction, abuse remains an important concern to PCPs. Canadian PCPs, in general, are implementing standard assessments, treatment approaches, evaluation of treatment success and tools to prevent abuse and diversion, in accordance with guidelines from the Canadian Pain Society and other pain societies globally, although there remains room for improvement and standardization.
Impact of a Provincial Asthma Guidelines Continuing Medical Education Project: The Ontario Asthma Plan of Action’s Provider Education in Asthma Care Project
Authors: Lougheed M Diane , Moosa Dilshad , Finlayson Shelagh , Hopman Wilma M , Quinn Mallory , Szpiro Kim , Reisman Joseph
Published: March 2016

BACKGROUND: The Ontario Ministry of Health and Long‐Term Care funded the Ontario Lung Association to develop and implement a continuing medical education program to promote implementation of the Canadian asthma guidelines in primary care.

OBJECTIVES: To determine baseline knowledge, preferred learning format, satisfaction with the program and reported impact on practice patterns.

METHODS: A 3 h workshop was developed that combined didactic presentations and small group case discussions. Outcome measures included a workshop evaluation, baseline assessment of asthma management knowledge and three‐month postreflective evaluations.

RESULTS: One hundred thirty‐seven workshops were delivered to 2783 primary care providers (1313 physicians, 1470 allied health) between September 2002 and March 2005. Of the 2133 participants, 1007 physicians and 1126 allied health professionals submitted workshop evaluations. Most (98%) of the attendees indicated they would recommend the workshop to a colleague. The majority preferred the combination of didactic lecture plus interactive case discussions. A subset of physicians provided consent to use these data for research (n=298 pediatric and 288 adult needs assessments; n=349 postreflective evaluations). Important needs identified included appropriate medication for chronic asthma and development of written action plans. On the postreflective evaluations, 88.7% remained very satisfied, 95.5% reported increased confidence, 91.9% reported an influence on practice and 67.2% reported using a written action plan.

CONCLUSIONS: This continuing medical education program addresses identified needs of primary care providers. Participants reported improvements in asthma care, including prescribing practices, use of spirometry and written action plans. Similar programs should be considered as part of multifaceted asthma guidelines dissemination and implementation initiatives in other provinces and nationally.
Treatment of Candiduria with Micafungin: A Case Series
Authors: Lagrotteria Danny , Rotstein Coleman , Lee Christine H
Published: March 2016

There has been a gradual increase in the incidence of non‐Candida albicans‐related nosocomial infections. Candida glabrata urinary tract infections have increased in frequency, and treating these infections can be difficult because the organism may be resistant to fluconazole. A newer antifungal agent, micafungin, which belongs in the class of echinocandins, provides an alternative and effective therapy against C glabrata. The present report describes three cases of C glabrata‐associated urinary tract infections successfully treated with micafungin. To the authors’ knowledge, this is the first report of successful treatment of C glabrata and azole‐resistant C albicans‐associated urinary tract infection with an echinocandin.
Factors Associated with Spontaneous Clearance of Hepatitis C Virus among Illicit Drug Users
Authors: Grebely Jason , Raffa Jesse D , Lai Calvin , Krajden Mel , Conway Brian , Tyndall Mark W
Published: March 2016

BACKGROUND: Spontaneous clearance of hepatitis C virus (HCV) occurs in approximately 25% of individuals.

METHODS: To better understand the characteristics associated with clearance, the present study evaluated HCV clearance in a community-based cohort study. The Community Health and Safety Evaluation project recruited 3553 individuals via community organizations and door-to-door canvassing of a random sample of single occupancy hotels in the community to monitor uptake of health services and to estimate the incidence of communicable infections. Cohort data were linked with longitudinal laboratory databases, including HCV antibody and polymerase chain reaction assay results.

RESULTS: Overall, 762 individuals had HCV antibody and RNA testing performed between 1999 and 2005. Spontaneous HCV clearance was observed in 179 individuals (23.5%), while HCV persistence was observed in 583 individuals (76.5%). The ability to develop protective immunity against HCV, as demonstrated by viral clearance, occurred more often in individuals of Aboriginal ethnicity (adjusted OR [AOR] 2.9, 95% CI 2.0 to 4.3; P<0.001) and female individuals (AOR 1.6, 95% CI 1.1 to 2.4; P=0.01). The rate of spontaneous HCV clearance was reduced in individuals using any type of illicit drugs (AOR 0.54, 95% CI 0.29 to 1.00; P=0.05) and those with HIV coinfection (AOR 0.58, 95% CI 0.38 to 0.88; P=0.01). Of 218 HIV-infected subjects, 48 of 51 (94%) in whom the order of HCV and HIV infection was established were infected with HCV a median of 2.4 years (range 0.2 to 10 years) before becoming infected with HIV.

CONCLUSIONS: Aboriginal ethnicity and female sex were associated with increased rates of HCV clearance, while HIV coinfection and illicit drug use were associated with increased HCV persistence.
Recommendations on Chronic Constipation (Including Constipation Associated with Irritable Bowel Syndrome) Treatment
Authors: Paré Pierre , Bridges Ronald , Champion Malcolm C , Ganguli Subhas C , Gray James R , Irvine E Jan , Plourde Victor , Poitras Pierre , Turnbull Geoffrey K , Moayyedi Paul , Flook Nigel , Collins Stephen M
Published: March 2016

While chronic constipation (CC) has a high prevalence in primary care, there are no existing treatment recommendations to guide health care professionals. To address this, a consensus group of 10 gastroenterologists was formed to develop treatment recommendations. Although constipation may occur as a result of organic disease, the present paper addresses only the management of primary CC or constipation associated with irritable bowel syndrome. The final consensus group was assembled and the recommendations were created following the exact process outlined by the Canadian Association of Gastroenterology for the following areas: epidemiology, quality of life and threshold for treatment; definitions and diagnostic criteria; lifestyle changes; bulking agents and stool softeners; osmotic agents; prokinetics; stimulant laxatives; suppositories; enemas; other drugs; biofeedback and behavioural approaches; surgery; and probiotics. A treatment algorithm was developed by the group for CC and constipation associated with irritable bowel syndrome. Where possible, an evidence‐based approach and expert opinions were used to develop the statements in areas with insufficient evidence. The nature of the underlying pathophysiology for constipation is often unclear, and it can be tricky for physicians to decide on an appropriate treatment strategy for the individual patient. The myriad of treatment options available to Canadian physicians can be confusing; thus, the main aim of the recommendations and treatment algorithm is to optimize the approach in clinical care based on available evidence.
Severe Chronic Cough after Lap‐Band Gastric Surgery
Authors: Nemni Jacqueline
Published: March 2016

Respirologists are often consulted in cases of chronic cough. Most patients have diagnoses of asthma, upper airway cough or gastroe‐sophageal reflux disease. The present case describes a newly recognized cause of a cough in a patient who had undergone laparoscopic adjustable gastric banding for weight loss. The cough was persistent and severe for several months, and did not respond to any therapeutic interventions. Imaging studies were not helpful in making the diagnosis, which was confirmed by deflating the Lap‐Band, thereby eliminating the cough.

As more patients undergo bariatric surgery, physicians must anticipate and be familiar with potential complications.
Association between Leptin, Metabolic Factors and Liver Histology in Patients with Chronic Hepatitis C
Authors: Myers Robert P , Messous Djamila , Poynard Thierry , Imbert-Bismut Francoise
Published: March 2016

BACKGROUND: Steatosis is common in hepatitis C virus (HCV)-infected patients and likely accelerates fibrosis progression. Leptin, the peptide product of the obesity gene (ob), has been implicated in hepatic fibrogenesis; circulating levels of leptin correlate with body fat mass. The objective of the present study was to determine the clinical and histological correlates of serum leptin in HCV-infected patients, and to determine its utility in predicting liver histological lesions.

PATIENTS AND METHODS: In 62 patients with chronic HCV, serum leptin was measured using a commercially available immunoassay. Associations between leptin, metabolic parameters, and severe hepatic fibrosis (stages 2 to 4) and steatosis (30% or greater) were determined. The utility of leptin in predicting liver histology was determined using receiver operating characteristic (ROC) curves.

RESULTS: The median body mass index (BMI) was 23.2 kg/m2(range 17.7 kg/m2to 35.6 kg/m2); 16% of patients (n=10) had HCV genotype 3. Severe fibrosis and steatosis were present in 23% and 13% of patients, respectively. Leptin was strongly correlated with the BMI, and its levels were higher in women. BMI-corrected leptin levels were not independently associated with severe fibrosis but were significantly associated with steatosis (OR of 1.07; 95% CI 1.01 to 1.04). On it own, leptin was poorly predictive of severe steatosis (area under the ROC curve was 0.64; 95% CI 0.42 to 0.87). However, its accuracy improved with the addition of HCV genotype (area under the ROC curve was 0.86; 95% CI 0.72 to 1.00; P=0.07).

CONCLUSIONS: As observed in the non-HCV setting, serum leptin correlates with BMI; higher leptin levels are found in women than men with chronic HCV. Serum leptin is a poor predictor of HCV-related fibrosis but may play a role in predicting steatosis when combined with HCV genotype.
Acute Esophageal Necrosis and Low-Flow State
Authors: Burtally Ahmad , Gregoire Philippe
Published: March 2016

Acute esophageal necrosis (AEN), also called black esophagus, is quite exceptional. Endoscopic findings show circumferential black discolouration of the esophagus with or without exudates. The etiology of AEN is presently unknown and is assumed to be multifactorial. Distal esophageal involvement with proximal extension ending sharply at the gastroesophageal junction is the most common presentation. The present case report describes the clinical and endoscopic evolution of black esophagus observed in a patient with significant peripheral vascular disease, who was presented to the intensive care unit at the Hopital Saint-Francois d’Assise (Quebec City, Quebec). Through an extensive review of the literature, common underlying clinical conditions of patients diagnosed with AEN have been identified.
Recent insights into the cellular mechanisms of acute pancreatitis
Authors: Cosen-Binker Laura I , Gaisano Herbert Y
Published: March 2016

In acute pancreatitis, initiating cellular events causing acinar cell injury includes co-localization of zymogens with lysosomal hydrolases, leading to premature enzyme activation and pathological exocytosis of zymogens into the interstitial space. This is followed by processes that accentuate cell injury; triggering acute inflammatory mediators, intensifying oxidative stress, compromising the microcirculation and activating a neurogenic feedback. Such localized events then progress to a systemic inflammatory response leading to multiorgan dysfunction syndrome with resulting high morbidity and mortality. The present review discusses some of the most recent insights into each of these cellular processes postulated to cause or propagate the process of acute pancreatitis, and also the role of alcohol and genetics.
Hepatic Portal Venous Gas: A Report of Two Cases and a Review of the Epidemiology, Pathogenesis, Diagnosis and Approach to Management
Authors: Alqahtani Saleh , Coffin Carla S , Burak Kelly , Chen Fred , MacGregor John , Beck Paul
Published: March 2016

BACKGROUND: Hepatic portal venous gas (HPVG) is a rare condition that occurs when intraluminal gas and/or gas produced by intestinal bacteria enters the portal venous circulation. The most common precipitating factors include ischemia, intra-abdominal abscesses and inflammatory bowel disease. However, HPVG has recently been recognized as a rare complication of endoscopic and radiological procedures. Earlier studies advised immediate surgical intervention, but according to current recommendations, in some settings, HPVG can be managed conservatively. The present study reports two cases of HPVG; one that occurred following colonoscopy in a patient with severe Crohn’s disease and one in a patient with graft-versus-host disease.

METHODS: The epidemiology, pathogenesis, diagnosis and management of HPVG are reviewed. Two case reports are presented, followed by the development of a management algorithm.

RESULTS: Of the two patients that developed HPVG, one was an outpatient undergoing a colonoscopy for assessment of Crohn’s disease activity and the other was an inpatient with graft-versus-host disease. Once the diagnosis of HPVG was made, both patients were managed conservatively with antibiotic therapy and management of their underlying disease.

CONCLUSIONS: HPVG can occur in the setting of severe gastrointestinal disease states and following endoscopic procedures. It is critical that gastroenterologists are aware of the differential diagnosis, pathogenesis, diagnostic approach and management of HPVG.
Do Physician Recommendations for Colorectal Cancer Screening Differ by Patient Age?
Authors: Sewitch Maida J , Fournier Caroline , Dawes Martin , Yaffe Mark , Snell Linda , Roper Mark , Zanelli Patrizia , Pavilanis Alan
Published: March 2016

Colorectal cancer screening is underutilized, resulting in preventable morbidity and mortality. In the present study, age-related and other disparities associated with physicians’ delivery of colorectal cancer screening recommendations were examined. The present cross-sectional study included 43 physicians and 618 of their patients, aged 50 to 80 years, without past or present colorectal cancer. Of the 285 screen-eligible patients, 45% received a recommendation. Multivariate analyses revealed that, compared with younger nonde-pressed patients, older depressed patients were less likely to receive fecal occult blood test recommendations, compared with no recommendation (OR=0.31, 95% CI 0.09 to 1.02), as well as less likely to receive colonoscopy recommendations, compared with no recommendation (OR=0.14; 95% CI 0.03 to 0.66). Comorbidity and marital status were associated with delivery of fecal occult blood test and colonoscopy recommendations, respectively, compared with no recommendation. In summary, patient age and other characteristics appeared to influence physicians’ delivery of colorectal cancer screening and choice of modality.
Fourteen-Year Study of Hospital Admissions for Diverticular Disease in Ontario
Authors: Warner Eiran , Crighton Eric J , Moineddin Rahim , Mamdani Muhammad , Upshur Ross
Published: March 2016

BACKGROUND: Diverticular disease is one of the most common gastrointestinal conditions affecting the Canadian population, yet very little is known about its epidemiology.

OBJECTIVE: The aim of the present study was to measure the rate of hospital admission for diverticular disease by age and sex over a 14-year period in the population of Ontario.

PATIENTS AND METHODS: The present study was a retrospective, population-based cohort study of all hospital admissions for diverticular disease from 1988 to 2002.

RESULTS: There were 133,875 hospital admissions during the period. Admission rates increased with age, and women were admitted at higher rates than men across all age groups.

CONCLUSION: Diverticular disease is an important cause of gastrointestinal morbidity. As the population ages, a rise in the incidence of diverticular disease can be anticipated. Future studies to explain sex difference in admissions are required.
Impact of Pharmaceutical Industry Versus University Sponsorship on Survey Response: A Randomized Trial among Canadian Hepatitis C Care Providers
Authors: Myers Robert P , Shaheen Abdel Aziz M , Lee Samuel S
Published: March 2016

BACKGROUND: Surveys originating from universities appear to have higher response rates than those from commercial sources. In light of the growing scrutiny placed on physician-industry relations, the present study aimed to determine the impact of the pharmaceutical industry versus university sponsorship on response to a postal survey completed by Canadian hepatitis C virus (HCV) care providers.

PATIENTS AND METHODS: In the present controlled trial, 229 physicians and nurses involved in HCV treatment were randomly assigned to receive a survey with sponsorship from a pharmaceutical company or university. The primary outcome was the proportion of completed surveys returned. The secondary outcomes included the response rate after the first mailing and the number of days taken to respond.

RESULTS: One hundred fifteen participants were randomly assigned to receive the pharmaceutical industry survey and 114 were assigned to receive the university survey. The final response rate was 72.9% (167 of 229), which did not differ between the industry and university groups (RR=0.91; 95% CI 0.78 to 1.07). Nurses (OR=2.20; 95% CI 1.08 to 4.48) and participants from an academic centre (OR=3.14; 95% CI 1.64 to 6.00) were more likely to respond. The response rate after the first mailing (RR=0.85; 95% CI 0.68 to 1.07) and the median number of days taken to respond (21 days in both groups; P=0.20) did not differ between the industry and university groups.

CONCLUSIONS: Pharmaceutical industry sponsorship does not appear to negatively impact response rates to a postal survey completed by Canadian HCV care providers.
Characterization of Pulmonary Rehabilitation Programs in Canada in 2005
Authors: Brooks Dina , Sottana Rebecca , Bell Barbara , Hanna Mary , Laframboise Lisanne , Selvanayagarajah Sugi , Goldstein Roger
Published: March 2016

BACKGROUND: Pulmonary rehabilitation (PR) is recognized as the prevailing standard of care for patients with chronic respiratory conditions. National surveys of PR programs provide important information regarding the structure, content and organization of these programs.

OBJECTIVE: To conduct a national survey to characterize adult PR across Canada, in terms of program distribution, utilization, content and outcome measures.

METHODS: A cross‐sectional descriptive study in which questionnaires were mailed to PR programs connected with hospitals or identified through the Canadian Lung Association was performed.

RESULTS: Of the 98 PR programs identified, over 90% of patients in the programs had chronic obstructive pulmonary disease (COPD) and 57% of the programs were outpatient. Inpatient programs accounted for only 10% of the total. The main program components included supervised lower extremity strength (77%), cycle (72%) and treadmill (70%) training, education (75%) and breathing retraining (68%). Over 80% of patients completed their programs and 90% of patients were enrolled in a follow‐up component. Physical therapists, dieticians, respiratory therapists and respirologists were the most commonly identified health care providers. The most commonly used outcome measures were the 6 min walk test and disease‐specific quality of life questionnaires.

CONCLUSION: There were similarities in program format, content, staffing, follow‐up and funding among Canadian PR programs. The marked shortfall between the national PR capacity and the prevalence of COPD meant that only 1.2% of the COPD population had access to PR.
Pain Assessment in a Geriatric Psychiatry Program
Authors: Stolee Paul , Hillier Loretta M , Esbaugh Jacquelin , Bol Nancy , McKellar Laurie , Gauthier Nicole , Gibson Maggie C
Published: March 2016

BACKGROUND: The assessment of pain in older persons with psychiatric illness is particularly challenging for health care professionals. There are few well‐tested pain assessment tools for this population.

OBJECTIVES: A study was conducted to explore pain assessment and management issues in geriatric psychiatry.

METHODS: Seventy‐four staff members of a geriatric psychiatry service at Regional Mental Health Care London, St Joseph’s Health Care London, London, Ontario completed a survey to assess current pain assessment and management practice for geriatric psychiatry patients, and to identify indicators used to assess pain in this population. The results of the survey were later shared with members of the program’s pain management team in a focus group discussion to explore opportunities on how to transfer these findings into clinical practice.

RESULTS: The majority of survey respondents (91.8%) agreed that pain assessment and management could be improved for patients; only 14.9% reported that there was a consistent approach to pain management. Misconceptions and attitudes about pain, lack of easily administered pain tools, inconsistent monitoring of pain, and lack of documentation of pain symptoms and indicators were identified as significant barriers to optimal pain management for their patients. A number of behaviours indicative of pain were identified but emphasis was placed on recognition of changes from usual behaviour.

CONCLUSIONS: The findings of the present study highlight the need for a comprehensive, practical and consistent approach to pain assessment and management, and provide insight into the critical components, including behavioural indicators, that could be incorporated into a pain protocol to be used with this population.
Phage as an Antimicrobial Agent: D’herelle’s Heretical Theories and Their Role in the Decline of Phage Prophylaxis in the West
Authors: Fruciano Dottore Emiliano , Bourne Shawna
Published: March 2016

The present report describes the presentation given by medical historian Dottore Emiliano Fruciano at the Stanier/Oxford Hygiene Symposium, held in Oxford, England, on November 10, 2004. Dr Fruciano′s lecture, entitled “The failure of d’Herelle′s project to consolidate the value of phage in the prevention and prophylaxis of infectious pathologies”, provided a historical synthesis of the events that led to the dismissal of the amazing discoveries of Félix d’Herelle. The present article chronicles the profound works of d’Herelle, from spectacular scientific, commercial and political successes to complete obscurity. The impact of social perspectives on the outcomes of critical scientific research is revealed in this poignant account.
The Emergence of Extensively Drug‐Resistant Tuberculosis (TB): TB/HIV Coinfection, Multidrug‐Resistant TB and the Resulting Public Health Threat from Extensively Drug‐Resistant TB, Globally and in Canada
Authors: Alexander Paul E , De Prithwish
Published: March 2016

Resistance to anti‐tuberculosis (TB) drugs continues to present a major challenge to global public health. Resistance usually develops due to inadequate TB management, including improper use of medications, improper treatment regimens and failure to complete the treatment course. This may be due to an erratic supply or a lack of access to treatment, as well as to patient noncompliance. However, the emergence and transmission of drug‐resistant TB, including the recently detected extensively drug resistant TB (XDR‐TB), is driven, in part, by the synergistic relationship between TB and HIV (TB/HIV coinfection). There is evidence that persons infected with HIV are more likely to experience XDR‐TB. XDR‐TB is virtually untreatable with available TB medications. XDR‐TB presents a grave global public health threat, particularly in high HIV prevalence settings. The present commentary discusses the current status of XDR‐TB and draws attention to the urgency in addressing this problem, for both the global and Canadian public health networks. XDR‐TB and the apparent XDR‐TB and HIV association warrants further study.
Achieving Organizational Change in Pediatric Pain Management
Authors: Dowden Stephanie , McCarthy Maria , Chalkiadis George
Published: March 2016

BACKGROUND: Pain in hospitalized children is often under‐treated. Little information exists to guide the process of organizational change with a view to improving pain management practices.

OBJECTIVES: To describe the process and results of a hospital‐wide review of pain management practices designed to identify deficiencies in service provision and recommend directions for change in a pediatric hospital.

DESIGN: Prospective consultation of the clinical staff of a specialist pediatric hospital, using qualitative research methodology involving semistructured individual and group interviews. Recommendations based on the interview findings were made by a hospital‐appointed working party.

RESULTS: A total of 454 staff (27% of all clinical staff) from a variety of professional backgrounds, representing almost every hospital unit or department, were interviewed. Procedural and persistent (chronic) pain was identified as the area needing the most improvement. Barriers to improving pain management included variability in practice, outmoded beliefs and inadequate knowledge, factors which were seen to contribute to a culture of slow or no change. Recommendations of the working party and changes achieved after the review are described.

CONCLUSION: The review process identified deficiencies in the management of pain in children, and barriers to its effective management. With institutional support, the present review has guided improvement.
Regard sur les Lazarets en Terre Canadienne
Authors: Milot Jean
Published: March 2016

Puisant dans les nombreuses références qu’offrent les publications médicales canadiennes du milieu du XIXe siècle à nos jours, l’auteur fait découvrir l’existence de lazarets en terre canadienne, décrit l’impact de la maladie sur les conditions vie des lépreux qui y étaient confinés et en souligne les contrecoups tant sur le plan physique et psychologique que social. Il présente un bref aperçu de la maladie, ses symptômes, ses signes ainsi que ses complications oculaires et rappelle les premiers moyens thérapeutiques à base d’huile de chaulmoogra introduits dans la colonie de Tracadie vers 1901. Il illustre son propos en évoquant la vie dans les lazarets de l’île de Sheldrake (1844–1848) et de Tracadie (1848–1965) au Nouveau‐Brunswick, puis dans ceux des îles D’Arcy (1891–1924) et de Bentinck (1924–1957) en Colombie‐Britannique.
Does a Rapid Decline in the Hematological and Biochemical Parameters Induced by Interferon and Ribavirin Combination Therapy for the Hepatitis C Virus Predict a Sustained Viral Response?
Authors: Turbide Christian , Soulellis Constantine A , Deschênes Marc , Hilzenrat Nir
Published: March 2016

BACKGROUND AND OBJECTIVES: To analyze whether rapid myelosuppression and a decrease in alanine aminotransferase (ALT) induced by standard interferon (IFN) and ribavirin (RBV) combination therapy predict a sustained viral response (SVR) in hepatitis C virus patients.

PATIENTS AND METHODS: Data from 111 patients (mean age 48.1 years) with chronic hepatitis C virus were retrospectively analyzed. All patients were treated with the same initial doses of IFN and RBV combination therapy. The following laboratory values were measured at baseline, and then at weeks 2, 4, 8, 12 and 24 of treatment: hemoglobin, white blood cells (WBCs), neutrophils, platelets and ALT. A delta value was then calculated for each interval from baseline (baseline values minus two weeks, etc). The delta value of each variable was then compared between the responders and nonresponders using Wilcoxon’s signed rank test.

RESULTS: Sixty patients (54%) achieved an SVR. There were no significant differences between the responder and nonresponder groups for baseline variables. The delta value of ALT was the only significant marker in the prediction of an SVR. The mean ± SD delta values for the ALT at week 2 of treatment were 71±92 U/L and 44±85 U/L for the responders and nonresponders, respectively (P<0.0046). At week 4, the values were 101±96 U/L and 84±100 U/L for the responders and nonresponders, respectively (P<0.0154). The decline was then calculated for the ALT as a percentage decrease from baseline: at weeks 2 and 4, the decreases were 64% and 66%, respectively, for the responders, and 43% and 41%, respectively, for the nonresponders. At week 2, the delta values for WBC count were found to be significant in predicting failure to achieve an SVR, with mean ± SD delta values of 0.85× 109/L±1.48× 109/L and 1.53× 109/L±2.16× 109/L for the responders and nonresponders, respectively (P<0.0173). The same trend emerged at two weeks for neutrophils: 0.72× 109/L±1.33× 109/L for the responders and 1.02× 109/L±1.20× 109/L for the nonresponders (P<0.0150). The delta values were insignificant for hemoglobin, lowest hemoglobin values and platelets.

CONCLUSIONS: The decline rates of ALT from baseline to week 2 and 4 of IFN and RBV combination therapy are good predictors of an SVR. A significant drop in WBC and neutrophil values is a predictor of failure to achieve an SVR. The hemoglobin, platelets and lowest hemoglobin values failed to predict an SVR.
A Review of Systematic Reviews on Pain Interventions in Hospitalized Infants
Authors: Yamada Janet , Stinson Jennifer , Lamba Jasmine , Dickson Alison , McGrath Patrick J , Stevens Bonnie
Published: March 2016

BACKGROUND: Hospitalized infants undergo multiple, repeated painful procedures. Despite continued efforts to prevent procedural pain and improve pain management, clinical guidelines and standards frequently do not reflect the highest quality evidence from systematic reviews.

OBJECTIVE: To critically appraise all systematic reviews on the effectiveness of procedural pain interventions in hospitalized infants.

METHODS: A structured review was conducted on published systematic reviews and meta‐analyses of pharmacological and nonpharmacological interventions of acute procedural pain in hospitalized infants. Searches were completed in the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, CINAHL and PsycINFO. Two reviewers independently selected articles for review and rated the methodological quality of the included reviews using a validated seven‐point quality assessment measure. Any discrepancies were resolved by a third reviewer.

RESULTS: Of 1469 potential systematic reviews on interventions for painful procedures in hospitalized infants, 11 high‐quality reviews were included in the analysis. Pharmacological interventions supported by research evidence included premedication for intubation, dorsal penile nerve block and EMLA (AstraZeneca Canada, Inc) for circumcision, and sucrose for single painful procedures. Non‐nutritive sucking, swaddling, holding, touching, positioning, facilitative tucking, breast feeding and supplemental breast milk were nonpharmacological interventions supported for procedural pain.

CONCLUSION: There is a growing number of high‐quality reviews supporting procedural pain management in infants. Ongoing research of single, repeated and combined pharmacological and nonpharmacological interventions is required to provide the highest quality evidence to clinicians for decision‐making on optimal pain management.
Asthma Counselling Targeted to Removal of Domestic Animals
Authors: Hagan Louise , Valois Pierre , Patenaude Hélène , Boutin Hélène , Boulet Louis-Philippe , Lafrenière France
Published: March 2016

OBJECTIVES: To create and evaluate the efficacy of a short individualized educational intervention program, based on Prochaska’s transtheoretical model, for a six‐month period in a population of adult asthma patients living with domestic animals but sensitized to these pets.

METHODS: A randomized, controlled study using a pretested questionnaire was conducted at three different times (pretest, and at three and six months postintervention).

RESULTS: Eleven members (29%) of the intervention group and eight members (21%) of the control group removed their pets within six months (χ2=3.23; P>0.35). The two groups showed similar improvements in their perception of the benefits of pet removal and in their level of belief that they could do it. The experimental group showed a greater improvement in knowledge acquisition about asthma and allergies than the control group (P<0.05). Both experimental and standard educational interventions were effective in facilitating progression through the stages of behavioural change.

CONCLUSION: Overall, the results do not support the utility of behavioural change educational intervention, tailored to the transtheoretical model stage of the individual, in the context of convincing patients to remove their pets from their homes. However, the decision‐making aid appears to be helpful in raising awareness of the problem of asthma and allergy in the patient, and in developing appropriate knowledge.
Cost‐Effectiveness of Combination Therapy for Chronic Obstructive Pulmonary Disease
Authors: Chuck Anderson , Jacobs Philip , Mayers Irvin , Marciniuk Darcy
Published: March 2016

BACKGROUND: There is evidence that combination therapy (CT) in the form of long‐acting beta2‐agonists (LABAs) and inhaled corticosteroids can improve lung function for patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVE: To determine the cost‐effectiveness of using CT in none, all or a selected group of COPD patients.

METHODS: A Markov model was designed to compare four treatment strategies: no use of CT regardless of COPD severity (patients receive LABA only); use of CT in patients with stage 3 disease only (forced expiratory volume in 1 s [FEV1] less than 35% of predicted); use of CT in patients with stages 2 and 3 disease only (FEV1 less than 50% of predicted); and use of CT in all patients regardless of severity of COPD. Estimates of mortality, exacerbation and disease progression rates, quality‐adjusted life years (QALYs) and costs were derived from the literature. Three‐year and lifetime time horizons were used. The analysis was conducted from a health systems perspective.

RESULTS: CT was associated with a cost of $39,000 per QALY if given to patients with stage 3 disease, $47,500 per QALY if given to patients with stages 2 and 3 disease, and $450,333 per QALY if given to all COPD patients. Results were robust to various assumptions tested in a Monte Carlo simulation.

CONCLUSION: Providing CT for COPD patients in stage 2 or 3 disease is cost‐effective. The message to family physicians and specialists is that as FEV1 worsens and reaches 50% of predicted values, CT is recommended.
Helicobacter PyloriInfection in Canadian and Related Arctic Aboriginal Populations
Authors: Goodman Karen J , Jacobson Kevan , van Zanten Sander Veldhuyzen
Published: March 2016

In 2006, the Canadian Helicobacter Study Group identified Aboriginal communities among Canadian population groups most at risk ofHelicobacter pylori-associated disease. The objective of this systematic review was to summarize what is known about theH pylori-associated disease burden in Canadian and related Arctic Aboriginal populations to identify gaps in knowledge. Six health literature databases were systematically searched to identify reports onH pyloriprevalence in Canadian population groups, or any topic related toH pyloriin Canadian Aboriginals, Alaska Natives or Aboriginals of other Arctic regions. Identified reports were organized by subtopic and summarized in narrative form. Key data from studies ofH pyloriprevalence in defined populations were summarized in tabular form. A few Arctic Aboriginal communities were represented in the literature: two Canadian Inuit; one Canadian First Nation; two Greenland Inuit; one Russian Chutkotka Native; and several Alaska Native studies. These studies uniformly showed elevatedH pyloriprevalence; a few studies also showed elevated occurrence ofH pylori-related diseases and high rates of treatment failure. Based on the evidence, it would be warranted for clinicians to relax the criteria for investigatingH pyloriand related diseases in patients from Arctic Aboriginal communities, and to pursue post-therapy confirmation of eradication. Additional community-based research is needed to develop public health policies for reducingH pylori-associated health risks in such communities.
Endoscopist-Administered Propofol: A Retrospective Safety Study
Authors: Morse John WI , Fowler Sharyle A , Morse Amy L
Published: March 2016

BACKGROUND: Propofol is an anesthetic agent that is commonly used for conscious sedation. Propofol has advantages as a sedative agent for endoscopic procedures including rapid onset, short half-life and rapid recovery time. However, concerns exist regarding the potential for respiratory depression, hypotension, perforation due to deep sedation and the need for monitoring by an anesthetist. Propofol has been used under endoscopist supervision at the Stanton Territorial Hospital in Yellowknife, Northwest Territories since 1996 (approximately 7000 cases).

METHODS: A retrospective chart review of endoscopic procedures conducted at the Stanton Territorial Hospital between January 1996 and May 2007 was performed. A random sample of 680 procedures was reviewed from a total of 6396 procedures.

RESULTS: The mean (± SD) baseline systolic blood pressure (SBP) was 122.8±17.0 mmHg. The mean lowest SBP was 101.7±14.5 mmHg. The mean absolute drop in SBP was 21.1±16.7 mmHg, with a mean per cent drop of 16.3%±11.7%. Eighty-eight patients (12.9%) developed transient hypotension (SBP lower than 90 mmHg). All patients regained normal blood pressure spontaneously on repeated measurement. No patients required intravenous fluid resuscitation. The mean O2saturation was 96.4%±2.1%. One patient (0.1%) transiently desaturated (O2saturation 89%), but recovered spontaneously on repeat measurement with no intervention. No procedures were aborted for patient safety. There were no major complications, including perforation or death. There was one mucosal tear during nontherapeutic colonoscopy (0.1%).

CONCLUSIONS: Propofol can be safely administered in a community hospital setting under endoscopist supervision, with no additional support or monitoring.