bluuebunny/crossref_metadata_2025 huggingface dataset:
The Relationship Between Pain and Eating among Overweight and Obese Individuals with Osteoarthritis: An Ecological Momentary Study
Authors: Choi Karmel W , Somers Tamara J , Babyak Michael A , Sikkema Kathleen J , Blumenthal James A , Keefe Francis J
Published: March 2016

BACKGROUND: Osteoarthritis (OA) patients who are overweight or obese report higher levels of pain compared with their normal‐weight OA counterparts. Evidence suggests that overweight or obese OA patients also experience pain relief from eating foods high in calories, fat or sugar. Eating to alleviate pain may be problematic because it can lead to additional weight gain, which may contribute to heightened pain.

OBJECTIVES: To investigate the relationship between pain and food intake using ecological momentary assessments in a sample of 71 over‐weight and obese OA patients.

METHODS: Participants completed two consecutive days of diary entries in which they recorded their levels of pain, mood and food intake throughout the day. Data were analyzed using generalized estimating equations that modelled pain as a predictor of calorie, fat and sugar intake. All models were adjusted for sex, body mass index, negative mood, time and treatment history.

RESULTS: Pain significantly predicted calorie (Z=2.57; P=0.01) and fat intake (Z=1.99; P=0.05).

CONCLUSIONS: Using ecological momentary assessments as a novel approach, the present study provides preliminary data supporting a relationship between pain and food intake among overweight and obese OA patients. Continued advances in our understanding of the relationship between pain and eating behaviour may help to optimize intervention strategies for these patients.
Impact of Excessive Daytime Sleepiness on The Safety and Health of Farmers in Saskatchewan
Authors: King Nathan , Pickett William , Hagel Louise , Lawson Josh , Trask Catherine , Dosman James A
Published: March 2016

BACKGROUND: Sleep disorders may negatively impact the health and well‐being of affected individuals. The resulting sleepiness and impaired cognitive functioning may also increase the risks for injury.

OBJECTIVE: To examine the relationship between daytime sleepiness, defined as an Epworth Sleepiness Scale score >10, and self‐reported sleep apnea, as potential determinants of farming‐related injury and self‐perceived physical health.

METHODS: Phase 2 of the Saskatchewan Farm Injury Cohort Study (2013) involved a baseline survey that included 2849 individuals from 1216 farms. A mail‐based questionnaire was administered to obtain self‐reports regarding sleep, demographics, farm injuries and general physical health. Multilevel logistic regression was used to quantify relationships between excessive daytime sleepiness and health.

RESULTS: The prevalence of excessive daytime sleepiness was 15.1%; the prevalence of diagnosed sleep apnea was 4.0%. Sleepiness was highest in the 60 to 79 (18.7%) and ≥80 (23.6%) years of age groups, and was higher in men (19.0%) than in women (9.3%). Injuries were reported by 8.4% of individuals, and fair or poor health was reported by 6.2%. Adjusting for confounding, individuals with excessive daytime sleepiness appeared more likely to experience a farming‐related injury (OR 1.34 [95% CI 0.92 to 1.96]) and were more likely to report poorer physical health (OR 2.19 [95% CI 1.45 to 3.30]) than individuals with normal daytime sleepiness.

CONCLUSION: Excessive daytime sleepiness, a potentially treatable condition, appeared to be common in farmers and to negatively affect their health. Sleep disorder diagnosis and treatment programs did not appear to be used to their full potential in this population.
A 29‐Year‐Old Man with Hospital‐Acquired Cavitary Pneumonia
Authors: Mehmood Mansoor , Halloush Ruba A , Khasawneh Faisal A
Published: March 2016

Mucormycosis is an infection that can manifest in many forms and is an emerging complication in several health care procedures. Portals of entry can be attributed to surgical procedures and medical devices such as chest tubes; however, the skin and gastrointestinal tract are the most common sites of infection and outbreaks have been traced to adhesive bandages, wooden tongue depressors and ostomy bags. This article describes the presentation, work‐up, diagnosis and treatment of an East Asian immigrant who was admitted with acute hypoxemic respiratory failure.

Cavitary lung processes pose a formidable diagnostic challenge. Causes vary widely and include cavitary pneumonia, vasculitis and malignancy. In some cases, patient history and basic work‐up may yield a diagnosis, but in others, an extensive work‐up, including tissue biopsy, may be necessary to establish the cause. The authors present a case of cavitary pneumonia that complicated an open lung biopsy. It developed in the hospital and was caused by mucormycosis, a potential emerging infection causing health care‐associated infections.
Systematic Review of Stimulant and Nonstimulant Laxatives for the Treatment of Functional constipation
Authors: Paré Pierre , Fedorak Richard N
Published: March 2016

BACKGROUND: Constipation is an uncomfortable and common condition that affects many, irrespective of age. Since 1500 BC and before, health care practitioners have provided treatments and prevention strategies to patients for chronic constipation despite the significant variation in both medical and personal perceptions of the condition.

OBJECTIVE: To review relevant research evidence from clinical studies investigating the efficacy and safety of commercially available pharmacological laxatives in Canada, with emphasis on studies adopting the Rome criteria for defining functional constipation.

SEARCH METHODS: PubMed, Medline, Embase and Evidence-Based Medicine Reviews databases were searched for blinded or randomized clinical trials and meta-analyses assessing the efficacy of nonstimulant and stimulant laxatives for the treatment of functional constipation.

RESULTS: A total of 19 clinical studies and four meta-analyses were retrieved and abstracted regarding study design, participants, interventions and outcomes. The majority of studies focused on polyethylene glycol compared with placebo. Both nonstimulant and stimulant laxatives provided better relief of constipation symptoms than placebo according to both objective and subjective measures. Only one study compared the efficacy of a nonstimulant versus a stimulant laxative, while only two reported changes in quality of life. All studies reported minor side effects due to laxative use, regardless of treatment duration, which ranged from one week to one year. Laxatives were well tolerated by both adults and children.
Diffuse Pulmonary Ossification as a Rare Cause of Interstitial Lung Disease
Authors: Burkett Andrew , Coffey Niamh , Voduc Nha
Published: March 2016

Diffuse pulmonary ossification (DPO) is a rare form of interstitial lung disease. The present article describes a case of DPO in an elderly man who presented with progressive dyspnea on exertion and an isolated reduction in diffusing capacity for carbon monoxide. DPO may occur as sequelae of mitral stenosis, left heart failure, idiopathic pulmonary fibrosis, recurrent aspiration pneumonia, solid organ transplant, adult respiratory distress syndrome or may arise idiopathically. In the absence of other findings of interstitial lung disease, a lung biopsy is unlikely to be helpful in the management of these patients.
Breakthrough Pain in Patients with Controlled or Uncontrolled Pain: An Observational Study
Authors: Gatti Antonio , Gentili Marta , Baciarello Marco , Lazzari Marzia , Marzi Rossella , Palombo Elisa , Sabato Alessandro F , Fanelli Guido
Published: March 2016

BACKGROUND: Breakthrough pain (BTP) is traditionally defined as a pain exacerbation in patients with chronic controlled pain. However, this definition has recently been challenged.

OBJECTIVES: To evaluate the prevalence of unsatisfactory control in patients with chronic cancer pain, and investigate the frequency and intensity of BTP episodes.

METHODS: A total of 665 patients with chronic cancer pain attending 21 pain therapy units in Italy were evaluated for baseline pain intensity and number of BTP episodes over a 30‐day period. All patients started, continued or modified treatment for BTP at enrollment, according to medical judgment.

RESULTS: The number of BTP events was higher in patients with uncontrolled baseline pain, although the intensity and duration of episodes were similar. In patients with uncontrolled baseline pain, the number of events decreased with time and reached values comparable with those reported in patients with controlled pain. Both the intensity of the pain and the duration of the BTP events exhibited similar values in the two groups at all time points, following increased monitoring and the prescription of analgesic medication.

CONCLUSION: Patients with uncontrolled baseline pain experienced BTP flares with higher frequency, but similar intensity and duration with respect to patients with controlled pain at baseline. Notably, a close follow‐up and adequate management of the BTP episodes led to an improvement of BTP in the observed patients.
Pain Patients and Who they Live with: A Correlational Study of Coresidence Patterns and Pain Interference
Authors: Vigil Jacob M , Pendleton Patricia , Coulombe Patrick , Vowles Kevin E , Alcock Joe , Smith Bruce W
Published: March 2016

BACKGROUND: Mixed associations have been observed between various aspects of ‘social support’ and patient pain experiences

OBJECTIVE: To explore the possibility that more basic social factors, namely coresidence patterns, may be associated with variability in patient pain experiences.

METHODS: Relationships between coresidence partners and self‐reported pain that interferes with activities were examined in a large representative sample of home health care patients (n=11,436; age range 18 to 107 years, mean [± SD] age 66.3±16.1 years; 55% females).

RESULTS: After controlling for sex, age and behavioural risks, compared with living alone, coresidence with an intimate affiliate (eg, spouse, relative) predicted greater pain interference (Cohen’s d = 0.10 to 1.72), and coresidence with a less intimate type of affiliate (eg, friend, paid help) predicted lower pain interference (Cohen’s d = −0.21 tö0.83). In general, however, coresidence patterns accounted for small proportions of variance in pain interference, and the magnitudes of these effects varied widely according to patients’ sex, age and diagnosis.

DISCUSSION: The findings suggest that fundamental components of patient’s home‐living environment may be associated with potential costs and benefits related to clinically relevant pain functioning for some subgroups of patients.

CONCLUSION: Further research that incorporates quantitative and qualitative assessments of patient pain functioning is warranted to better understand how objective and subjective characteristics of patients’ home‐living environment may inform the development of more individualized pain treatment options for patients with differing social circumstances.
Osteomyelitis Due to Multiple Carbapenemase‐Producing Gram‐Negative Bacteria: The First Case Report of a GES‐13‐Producing Pseudomonas aeruginosa Isolate in Canada
Authors: Sepehri Shadi , Poliquin Guillaume , Alfattoh Nora , Boyd David , Mulvey Michael , Denisuik Andrew , Fanella Sergio , Karlowsky James , Walkty Andrew
Published: March 2016

A case of osteomyelitis in an infant following a burn injury sustained in Pakistan caused by a GES‐13‐producing Pseudomonas aeruginosa (the first reported in Canada) and an OXA‐48 producing Klebsiella pneumoniae is described. The present case serves to highlight the importance of international travel as a risk factor for infection with carbapenemase‐producing bacteria and the challenges in the laboratory detection of these organisms.
Assessment of Factors Affecting the Difficulty of Caudal Epidural Injections in Adults Using Ultrasound
Authors: Kim Young Hoon , Park Hue Jung , Cho Sungkun , Moon Dong Eon
Published: March 2016

BACKGROUND: In unaided caudal epidural block (CEB), incorrect needle insertion has been reported to occur in 15% to 38% of attempts.

OBJECTIVE: To statistically analyze the anatomical variables affecting difficult CEB using ultrasonographic measurement.

METHODS: Preprocedural ultrasonography was performed and the following measurements were obtained in 146 patients: the distance from the skin to the apex of the sacral hiatus; the depth of the sacral canal at the apex of the sacral hiatus; the length of the sacrococcygeal ligament between the apex of the sacral hiatus and sacral base; the distance from the skin to the apex of the sacral cornu; and the distance between the apexes of bilateral cornua. One clinician, unaware of the ultrasonographic findings, performed the injections using the landmark technique. The procedures were videotaped and were subsequently reviewed by an independent investigator.

RESULTS: The means (± SDs) of the abovementioned measurements were 12.1±3.7 mm, 6.1±2.1 mm, 25.9±7.4 mm, 10.0±4.0 mm and 16.4±3.2 mm, respectively. Injections failed in 16 (11%) patients and were defined as difficult in 21 (14.4%) patients. The depth of the sacral canal at the apex of sacral hiatus (P<0.001) and the length of the sacrococcygeal ligament between the apex of the sacral hiatus and sacral base (P=0.001) were significant predictors of difficult CEB. Of all patients, 85.7% and 75.2% were correctly classified as difficult or not difficult, respectively. The cutoff values of the depth of the sacral canal at the apex of the sacral hiatus and the length of the sacrococcygeal ligament between the apex of the sacral hiatus and the sacral base to predict a difficult CEB were 3.7 mm and 17.6 mm, respectively.

CONCLUSIONS: Both the depth of the sacral canal at the apex of the sacral hiatus and the length of the sacrococcygeal ligament between the apex of the sacral hiatus and sacral base are significant variables affecting the difficulty of the CEB.
Do Obstructive Sleep Apnea Syndrome Patients Underestimate Their Daytime Symptoms before Continuous Positive Airway Pressure Treatment?
Authors: Leclerc Gabrielle , Lacasse Yves , Page Diane , Sériès Frédéric
Published: March 2016

BACKGROUND: Daytime somnolence is an important feature of the obstructive sleep apnea (OSA) hypopnea syndrome and is usually subjectively assessed using the Epworth Sleepiness Scale (ESS).

OBJECTIVE: To compare the scores of the ESS and different domains of the Quebec Sleep Questionnaire (QSQ) assessed before and after the first months of continuous positive airway pressure (CPAP) treatment, as well as retrospectively without treatment.

METHODS: The ESS score and domain scores of the QSQ were obtained before and after a three‐month period of CPAP treatment using a retrospective assessment of the pretreatment scores in 76 untreated OSA patients.

RESULTS: Fifty‐two patients completed the study. The ESS and QSQ scores significantly improved following CPAP therapy. Retrospective evaluation of the ESS score was significantly worse than pre‐ and post‐treatment values (mean [± SD] pretreatment score 11.0±4.8; retrospective pretreatment score 13.5±5.1). Such differences were not observed in any domain of the QSQ, including the domain assessing hypersomnolence.

CONCLUSION: OSA patients underestimated their sleepiness according to the most widely used instrument to assess hypersomnolence. This finding may not be observed with other methods used to assess OSA‐related symptoms such as quality of life questionnaires.
Training Highly Qualified Health Research Personnel: The Pain in Child Health Consortium
Authors: von Baeyer Carl L , Stevens Bonnie J , Chambers Christine T , Craig Kenneth D , Finley G Allen , Grunau Ruth E , Johnston C Celeste , Riddell Rebecca Pillai , Stinson Jennifer N , Dol Justine , Campbell-Yeo Marsha , McGrath Patrick J
Published: March 2016

BACKGROUND AND OBJECTIVES: Pain in Child Health (PICH) is a transdisciplinary, international research training consortium. PICH has been funded since 2002 as a Strategic Training Initiative in Health Research of the Canadian Institutes of Health Research, with contributions from other funding partners and the founding participation of five Canadian universities. The goal of PICH has been to create a community of scholars in pediatric pain to improve child health outcomes.

METHODS: Quantitative analyses enumerated PICH faculty, trainees, training activities and scientific outputs. Interviews with PICH stakeholders were analyzed using qualitative methods capturing perceptions of the program’s strengths, limitations, and opportunities for development and sustainability.

RESULTS: PICH has supported 218 trainee members from 2002 through 2013, from 14 countries and more than 16 disciplines. The faculty at the end of 2013 comprised nine co‐principal investigators, 14 Canadian coinvestigators, and 28 Canadian and international collaborators. Trainee members published 697 peer‐reviewed journal articles on pediatric pain through 2013, among other research dissemination activities including conference presentations and webinars. Networks have been established between new and established researchers across Canada and in 13 other countries. Perceptions from stakeholders commended PICH for its positive impact on the development of pediatric pain researchers. Stakeholders emphasized skills and abilities gained through PICH, the perceived impact of PICH training on this research field, and considerations for future training in developing researchers in pediatric pain.

CONCLUSIONS: PICH has been successfully developing highly qualified health research personnel within a Canadian and international community of pediatric pain scholarship.
Use of Fecal Occult Blood Testing in Hospitalized Patients: Results of an Audit
Authors: Ip Stephen , Sokoro AbdulRazaq AH , Kaita Lisa , Ruiz Claudia , McIntyre Elaine , Singh Harminder
Published: March 2016

BACKGROUND: The fecal occult blood test (FOBT), widely used as a colorectal cancer screening tool, continues to be used in hospitalized patients. However, the utility of this test for hospitalized patients is unclear.

OBJECTIVE: To assess FOBT use in a large urban regional health authority.

METHODS: Reports of all FOBTs performed between April 1, 2011 and March 30, 2012 from two academic and four community hospitals in Winnipeg (Manitoba) were extracted. Of 650 hospitalizations with a positive FOBT result and 1254 with a negative FOBT result, random samples of 230 and 97 charts, respectively, were reviewed. Information including demographics, admission diagnos(es), indication(s) for ordering the FOBT and clinical management was extracted.

RESULTS: Thirty-four percent (650 of 1904) of hospitalizations with an FOBT had a positive FOBT result. Family medicine physicians ordered approximately one-half of the reviewed FOBTs. The most common indication for ordering an FOBT was anemia. Of those with a positive FOBT, 66% did not undergo further gastrointestinal investigations. Of those with a positive FOBT and overt gastrointestinal bleeding and/or melena who underwent endoscopy, 60% had their endoscopy performed before the FOBT result being reported while 38% underwent their endoscopy ≥3 days after the stool sample was collected. There were minimal differences in clinical practices between academic and community hospitals.

CONCLUSIONS: The present study suggests that FOBT results in hospitalized patients may have little beneficial impact on clinical management. Hospital laboratories may be better served in directing resources to other tests.
Mortality Related to Coagulase‐Negative Staphylococcal Bacteremia in Febrile Neutropenia: A Cohort Study
Authors: Rosa Regis G , dos Santos Rodrigo P , Goldani Luciano Z
Published: March 2016

BACKGROUND: Coagulase‐negative staphylococci (CoNS) are currently the most common isolates recovered from the blood of patients with cancer and febrile neutropenia (FN).

OBJECTIVES:To assess the mortality associated with bloodstream infections (BSIs) caused by CoNS in cancer patients with FN.

METHODS: A prospective cohort study was conducted in a single tertiary hospital from October 2009 to August 2011. Follow‐ups were performed on all of the adult patients who were admitted to the hematology ward with cancer and FN. Bacteremia caused by CoNS was defined as two positive results of two independent cultures. Twenty‐eight days after the onset of FN, the mortality rates of the patients with BSIs caused by CoNS were compared with those of patients with BSIs caused by other pathogens.

RESULTS: A total of 169 subjects were evaluated. During the study period, 78 patients with BSIs were documented. Twenty‐three BSIs (29.4%) were a result of CoNS. CoNS‐induced bacteremia resulted in lower 28‐day mortality compared with bacteremia caused by other pathogens (4.3% versus 32.7%; log‐rank P=0.009). In a Cox proportional hazards regression analysis, BSIs caused by CoNS were independently associated with lower mortality (HR 0.09 [95% CI 0.01 to 0.74]).

CONCLUSIONS:In adult patients with cancer and FN, BSIs caused by CoNS were associated with lower mortality compared with BSIs caused by other pathogens.
Patient Versus Parental Perceptions about Pain and Disability in Children and Adolescents with a Variety of Chronic Pain Conditions
Authors: Vetter Thomas R , Bridgewater Cynthia L , Ascherman Lee I , Madan-Swain Avi , McGwin Gerald L
Published: March 2016

BACKGROUND: Cross‐informant variance is often observed in patient self‐reports versus parent proxy reports of pediatric chronic pain and disability.

OBJECTIVE: To assess the relationship and merit of the child versus parent perspective.

METHODS: A total of 99 patients (eight to 17 years of age [mean 13.2 years]; 71% female, 81% Caucasian) and parents completed the Pediatric Pain Questionnaire and Functional Disability Inventory at their initial clinic visit. Patients’ and parents’ pain intensity and disability scores were analyzed using an intraclass correlation coefficient (ICC), Wilcoxon signed‐rank test, Bland‐Altman plot and Spearman’s correlation coefficient. The association between clinical/demographic variables and differences in patient/parent pain intensity and disability scores was assessed using multivariable regression.

RESULTS: There was significant agreement between patients’ self‐reports and parents’ proxy reports of their child’s pain intensity (ICC=0.52; P<0.001) and disability (ICC=0.57; P=0.004) at the individual level. There were no significant group differences in patient versus parent‐proxy pain intensity scores (P=0.40) and disability scores (P=0.54). The difference between patient and parent‐proxy pain intensity was associated with patients’ self‐reported pain intensity (P<0.001). The difference between patient and parent‐proxy disability was associated with patient’s self‐reported pain disability (P<0.001). Bland‐Altman plots revealed major inter‐rater variation in the Pediatric Pain Questionnaire and Functional Disability Inventory across their score ranges. A significant relationship (r=0.38; P<0.001) was observed between patients’ self‐reported pain intensity and disability.

CONCLUSIONS: While equal merit should ideally be given to pediatric chronic pain patients’ self‐reports and their parents’ proxy reports of pain intensity and disability, it would appear that, as needed, pediatric patients or parents can offer a clinically valid, single clinical perspective.
Association Between Proton Pump Inhibitor Use and Spontaneous Bacterial Peritonitis in Cirrhotic Patients with Ascites
Authors: Ratelle Mélissa , Perreault Sylvie , Villeneuve Jean-Pierre , Tremblay Lydjie
Published: March 2016

BACKGROUND: There are data suggesting a link between proton pump inhibitor (PPI) use and the development of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites; however, these data are controversial.

OBJECTIVE: To assess whether the use of PPIs in cirrhotic patients with ascites is associated with an increased risk for SBP.

METHODS: A retrospective case-control study (June 2004 to June 2010) was conducted at theCentre Hospitalier de l’Université de Montréalin Montreal, Quebec. Fifty-one cirrhotic patients admitted with paracentesis-proven SBP (≥250 neutrophils/mm3), occurring within seven days of hospital admission, met the inclusion criteria. These patients were matched 1:2 (for age, Child-Pugh class and year of admission) with 102 comparable cirrhotic patients with ascites who were admitted for conditions other than SBP.

RESULTS: Patients with SBP had a significantly higher rate of pre-hospital PPI use (60.8%) compared with cirrhotic patients without SBP (42.2%; P=0.03). On multivariate analysis, PPI use was the only factor independently associated with SBP (OR 2.09 [95% CI 1.04 to 4.23]; P=0.04). Thirty-five (35%) patients in both groups had no documented indication for PPI use in their charts. Forty-five percent of the remaining cirrhotic patients with SBP had an inappropriate indication, as defined in the protocol, for PPI use compared with 25% of controls.

CONCLUSIONS: Cirrhotic patients with SBP were twice as likely to have taken PPIs than patients without SBP. These findings reinforce the association between PPI use and SBP observed in other studies. A high percentage of cirrhotic patients were taking a PPI without any documented indication.
Hepatitis B and Hepatitis C Viral Infections in Patients with Chronic Lymphocytic Leukemia
Authors: Minuk Gerald Y , Lerner Betty , Gibson Spencer B , Johnston James B , Uhanova Julia , Andonov Anton , Wu Jun
Published: March 2016

BACKGROUND: Whether chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections contribute to the pathogenesis and/or course of chronic lymphocytic leukemia is unclear.

OBJECTIVE: To document the prevalences of HBV and HCV infections in chronic lymphocytic leukemia patients, and to determine whether infected patients experience more aggressive disease than those without infection.

METHODS: Patient sera were screened for antibodies to HBV core antigen and HCV (anti-HCV) using ELISA; both sera and peripheral blood lymphocytes were further tested (regardless of antibody results) for HBV-DNA and HCV-RNA using real-time polymerase chain reaction. Prognostic markers for chronic lymphocytic leukemia included Rai stage,IgVHmutational status, β2-microglobulin levels, Zap-70 and CD38 status.

RESULTS: Fourteen of 222 (6.3%) chronic lymphocytic leukemia patients and two of 72 (2.8%) healthy controls tested positive for previous or ongoing HBV infection (OR 2.4 [95% CI 0.5 to 7.7]; P=0.25) while four of 222 (1.8%) chronic lymphocytic leukemia patients and one of 72 (1.4%) controls tested positive for HCV markers (OR 1.3 [95% CI 0.2 to 6.4]; P=0.81). The levels and distribution of the various indicators of aggressive chronic lymphocytic leukemia disease were similar among HBV- and HCV-infected and uninfected patients. Survival times were also similar. Occult HBV and HCV infection (HBV-DNA or HCV-RNA positive in the absence of diagnostic serological markers) were uncommon in chronic lymphocytic leukemia patients (0.5% and 1.8%, respectively).

CONCLUSIONS: The results of the present study do not support the hypothesis that HBV or HCV infections play an important role in the pathogenesis or course of chronic lymphocytic leukemia.
Patient-Reported Outcome Measures in Inflammatory Bowel Disease
Authors: El-Matary Wael
Published: March 2016

Patient-reported outcome measures (PROMs) are increasingly used in both research and clinical health settings. With the recent development of United States Food and Drug Administration guidance on PROMs, more attention is being devoted to their role and importance in health care. Several methodological challenges in the development, validation and implementation of PROMs must be resolved to ensure their appropriate utilization and interpretation. The present review discusses recent developments and updates in PROMs, with specific focus on the area of inflammatory bowel disease.
Clinical and Economic Consequences of Vancomycin and Fidaxomicin for the Treatment of Clostridium difficile Infection in Canada
Authors: Wagner Monika , Lavoie Louis , Goetghebeur Mireille
Published: March 2016

BACKGROUND:
Clostridium difficile infection (CDI) represents a public health problem with increasing incidence and severity.

OBJECTIVE: To evaluate the clinical and economic consequences of vancomycin compared with fidaxomicin in the treatment of CDI from the Canadian health care system perspective.

METHODS: A decision‐tree model was developed to compare vancomycin and fidaxomicin for the treatment of severe CDI. The model assumed identical initial cure rates and included first recurrent episodes of CDI (base case). Treatment of patients presenting with recurrent CDI was examined as an alternative analysis. Costs included were for study medication, physician services and hospitalization. Cost effectiveness was measured as incremental cost per recurrence avoided. Sensitivity analyses of key input parameters were performed.

RESULTS: In a cohort of 1000 patients with an initial episode of severe CDI, treatment with fidaxomicin led to 137 fewer recurrences at an incremental cost of $1.81 million, resulting in an incremental cost of $13,202 per recurrence avoided. Among 1000 patients with recurrent CDI, 113 second recurrences were avoided at an incremental cost of $18,190 per second recurrence avoided. Incremental costs per recurrence avoided increased with increasing proportion of cases caused by the NAP1/B1/027 strain. Results were sensitive to variations in recurrence rates and treatment duration but were robust to variations in other parameters.

CONCLUSIONS: The use of fidaxomicin is associated with a cost increase for the Canadian health care system. Clinical benefits of fidaxomicin compared with vancomycin depend on the proportion of cases caused by the NAP1/B1/027 strain in patients with severe CDI.
Desquamative Interstitial Pneumonitis in a Healthy Non-Smoker: A Rare Diagnosis
Authors: Kroll Ryan R , Flood Diane A , Srigley John
Published: March 2016

This article reports a rare condition first described in 1965 and is most commonly associated with smoking and certain occupations. Onset of nonspecific symptoms is typically insidious and, while bloodwork and imaging may be valuable, tissue sampling is required for diagnosis. Desquamative interstitial pneumonitis most commonly affects tobacco smokers in their fourth or fifth decades of life; this article, however, describes the condition in a 27-year-old who worked in a potato chip factory.

Desquamative interstitial pneumonitis is an interstitial lung disease most commonly associated with smoking. It causes respiratory symptoms including indolent cough and dyspnea. Characteristic findings on computed tomography include bilateral ground-glass opacities, septal thickening and preserved structure. Diagnosis is made by tissue sampling, which classically demonstrates alveolar macrophages, and thickened alveolar septa with an eosinophilic infiltrate lined with hyperplastic type II pneumocytes. Treatment is immune suppression with steroids or other agents, and avoiding the causal agent. The case reported describes a 27-year-old woman with no smoking history who worked in a potato chip factory, presenting with cough, dyspnea and dizziness. The patient had characteristic findings on imaging and was diagnosed via biopsy with desquamative interstitial pneumonitis. She improved clinically with reduced exposure and steroid therapy. While food production workers are at risk for respiratory illness, there are no reported cases of desquamative interstitial pneumonitis in this setting.
Computer-Based Virtual Reality Colonoscopy Simulation Improves Patient-Based Colonoscopy Performance
Authors: McIntosh Keith S , Gregor James C , Khanna Nitin V
Published: March 2016

BACKGROUND: Colonoscopy simulators that enable one to perform computer-based virtual colonoscopy now exist. However, data regarding the effectiveness of this virtual training are limited.

OBJECTIVE: To determine whether virtual reality simulator training translates into improved patient-based colonoscopy performance.

METHODS: The present study was a prospective controlled trial involving 18 residents between postgraduate years 2 and 4 with no previous colonoscopy experience. These residents were assigned to receive 16 h of virtual reality simulator training or no training. Both groups were evaluated on their first five patient-based colonoscopies. The primary outcome was the number of proctor ‘assists’ required per colonoscopy. Secondary outcomes included insertion time, depth of insertion, cecal intubation rate, proctor- and nurse-rated competence, and patient-rated pain.

RESULTS: The simulator group required significantly fewer proctor assists than the control group (1.94 versus 3.43; P≤0.001), inserted the colonoscope further unassisted (43 cm versus 24 cm; P=0.003) and there was a trend to intubate the cecum more often (26% versus 10%; P=0.06). The simulator group received higher ratings of competence from both the proctors (2.28 versus 1.88 of 5; P=0.02) and the endoscopy nurses (2.56 versus 2.05 of 5; P=0.001). There were no significant differences in proctor-, nurse- or patient-rated pain, or attention to discomfort.

CONCLUSIONS: Computer-based colonoscopy simulation in the initial stages of training improved novice trainees’ patient-based colonoscopy performance.
Marijuana Use in Hepatitis C Infection does not Affect Liver Biopsy Histology or Treatment Outcomes
Authors: Liu Theresa , Howell Glen T , Turner Lucy , Corace Kimberley , Garber Gary , Cooper Curtis
Published: March 2016

BACKGROUND: Marijuana smoking is prevalent among hepatitis C virus-infected patients. The literature assessing the influence of marijuana on liver disease progression and hepatitis C virus antiviral treatment outcomes is conflicting.

METHODS: The authors evaluated hepatitis C virus RNA-positive patients followed at The Ottawa Hospital Viral Hepatitis Clinic (Ottawa, Ontario) from 2000 to 2009. Using The Ottawa Hospital Viral Hepatitis Clinic database and charts, information regarding demographics, HIV coinfection, alcohol use, liver biopsy results, treatment outcomes and self-reported marijuana use was extracted. Biopsy characteristics and hepatitis C virus antiviral treatment outcomes were assessed for association with categorized marijuana use by adjusted logistic regression; covariates were specified according to clinical relevance a priori.

RESULTS: Information regarding marijuana use was available for 550 patients, 159 (28.9%) of whom were using marijuana at the time of first assessment. Biopsy fibrosis stage and marijuana use data were available for 377 of these 550 (F0-2=72.3%). Overall, marijuana use did not predict fibrosis stage, inflammation grade or steatosis. Sustained virological response and marijuana use data were available for 359 of the 550 cohort participants; a total of 211 (58.8%) achieved a sustained virological response. Marijuana use was not associated with premature interruption of therapy for side effects, the likelihood of completing a full course of therapy or sustained virological response.

CONCLUSION: Marijuana use did not influence biopsy histology or alter key hard outcomes of hepatitis C virus antiviral therapy.
Radiofrequency Ablation for Chronic Low Back Pain: A Systematic Review of Randomized Controlled Trials
Authors: Leggett Laura E , Soril Lesley JJ , Lorenzetti Diane L , Noseworthy Tom , Steadman Rodney , Tiwana Simrandeep , Clement Fiona
Published: March 2016

BACKGROUND: Radiofrequency ablation (RFA), a procedure using heat to interrupt pain signals in spinal nerves, is an emerging treatment option for chronic low back pain. Its clinical efficacy has not yet been established.

OBJECTIVE: To determine the efficacy of RFA for chronic low back pain associated with lumbar facet joints, sacroiliac joints, discogenic low back pain and the coccyx.

METHODS: A systematic review was conducted. Medline, EMBASE, PubMed, SPORTDiscus, CINAHL and the Cochrane Library were searched up to August 2013. Abstracts and full‐text articles were reviewed in duplicate. Included articles were sham‐controlled randomized controlled trials (RCTs), assessed the efficacy of RFA, reported at least one month of follow‐up and included participants who had experienced back pain for at least three months. Data were extracted in duplicate and quality was assessed using the Cochrane Risk of Bias tool. Due to heterogeneity, as well as a lack of reported mean differences and SDs, meta‐analysis was not possible using these data.

RESULTS: The present systematic review retrieved 1063 abstracts. Eleven sham‐controlled RCTs were included: three studies involving discogenic back pain; six studies involving lumbar facet joint pain; and two studies involving sacroiliac joint pain. No studies were identified assessing the coccyx. The evidence supports RFA as an efficacious treatment for lumbar facet joint and sacroiliac joint pain, with five of six and both of the RCTs demonstrating statistically significant pain reductions, respectively. The evidence supporting RFA for the treatment of discogenic pain is mixed.

CONCLUSIONS: While the majority of the studies focusing on lumbar facet joints and sacroiliac joints suggest that RFA significantly reduces pain in short‐term follow‐up, the evidence base for discogenic low back pain is mixed. There is no RCT evidence for RFA for the coccyx. Future studies should examine the clinical significance of the achieved pain reduction and the long‐term efficacy of RFA.
Characterization of Methicillin‐Resistant Staphylococcus aureus Isolates from Patients with Persistent or Recurrent Bacteremia
Authors: Wong Henry , Watt Christine , Elsayed Sameer , John Michael , Johnson Glen , Katz Kevin , Krajden Sigmund , Lee Christine , Mazzulli Tony , Ostrowska Krystyna , Richardson David , Toye Baldwin , Vermeiren Christie , Yamamura Deborah , Simor Andrew E
Published: March 2016

BACKGROUND: Methicillin‐resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI) are associated with considerable morbidity and mortality, especially with persistent (PB) or recurrent bacteremia (RB).

OBJECTIVE: To determine the frequency of PB and RB in patients with MRSA BSI, and to characterize the isolates from these patients.

METHODS: Surveillance for MRSA BSI was performed for one year in 13 Canadian hospitals. PB was defined as a positive blood culture that persisted for ≥7 days; RB was defined as the recurrence of a positive blood culture ≥14 days following a negative culture. Isolates were typed using pulsed‐field gel electrophoresis (PFGE). Vancomycin susceptibility was determined using Etest.

RESULTS: A total of 183 patients with MRSA BSI were identified; 14 (7.7%) had PB and five (2.7%) had RB. Ten (5.5%) patients were known to have infective endocarditis, and five of these patients had PB or RB. Initial and subsequent MRSA isolates from patients with PB and RB had the same PFGE type. There were no significant differences in the distribution of PFGE types in patients with PB or RB (37% CMRSA‐2/USA100; 37% CMRSA‐10/USA300) compared with that in other patients (56% CMRSA‐2/USA100; 32% CMRSA‐10/USA300). All isolates were susceptible to vancomycin, but patients with PB or RB were more likely to have initial isolates with vancomycin minimum inhibitory concentration = 2.0 μg/mL (26% versus 10%; P=0.06).

CONCLUSIONS: Persistent or recurrent MRSA bacteremia occurred in 10.4% of patients with MRSA BSIs. Initial isolates from patients with persistent or recurrent MRSA BSIs were more likely to exhibit reduced susceptibility to vancomcyin, but were not associated with any genotype.
Chronic Q fever: An ongoing challenge in diagnosis and management
Authors: Das Ira , Guest Nicola , Steeds Richard , Hewins Peter
Published: March 2016

Chronic Q fever is a potentially fatal disease. The current difficulty in the diagnosis of this condition is discussed in the present article. A 51‐year‐old woman with a history of aortic valve replacement presented with complaints of feeling generally unwell, pyrexia and occasional unproductive cough over a period of several weeks. Phase 1 immunoglobulin G titre to Coxiella burnetii was initially detected at a low level (1:320, detected using immunofluorescence) and was not considered to be significant according to the modified Duke criteria. Later in the course of her illness, the patient’s antibody titre rose to a high level (1:1280). The issues regarding current laboratory diagnosis and management of Q fever are discussed. Chronic Q fever can be associated with an inadequate serological response. Close follow‐up of cases is essential. The recommended serological criteria for the diagnosis of Q fever endocarditis needs to be revisited.
Le Domaine des Co‐infections et des Maladies Concomitantes du Réseau Canadien pour les Essais VIH des IRSC : Lignes Directrices Canadiennes pour la Prise en Charge et le Traitement de la Co‐Infection par le VIH et l’Hépatite C chez les Adultes
Authors: Hull Mark , Giguère Pierre , Klein Marina , Shafran Stephen , Tseng Alice , Côté Pierre , Poliquin Marc , Cooper Curtis
Published: March 2016

HISTORIQUE: De 20 % à 30 % des Canadiens qui vivent avec le VIH sont co‐infectés par le virus de l’hépatite C (VHC), lequel est responsable d’une morbidité et d’une mortalité importantes. La prise en charge du VIH et du VHC est plus complexe en raison de l’évolution accélérée de la maladie hépatique, du choix et des critères d’initiation de la thérapie antirétrovirale et du traitement anti‐VHC, de la prise en charge de la santé mentale et des toxicomanies, des obstacles socioéconomiques et des interactions entre les nouvelles thérapies antivirales à action directe du VHC et les antirétroviraux

OBJECTIF: Élaborer des normes nationales de prise en charge des adultes co‐infectés par le VHC et le VIH dans le contexte canadien.

MÉTHODOLOGIE: Le Réseau canadien pour les essais VIH des Instituts de recherche en santé du Canada a réuni un groupe d’experts possédant des compétences cliniques en co‐infection par le VIH et le VHC pour réviser les publications à jour ainsi que les lignes directrices et les protocoles en place. Après une vaste sollicitation afin d’obtenir des points de vue, le groupe de travail a approuvé des recommandations consensuelles, qu’il a caractérisées au moyen d’une échelle de qualité des preuves fondée sur la classe (bienfaits par rapport aux préjudices) et sur la catégorie (degré de certitude).

RÉSULTATS: Toutes les personnes co‐infectées par le VIH et le VHC devraient subir une évaluation en vue de recevoir un traitement du VHC. Les personnes qui ne sont pas en mesure d’entreprendre un traitement du VHC devraient être soignées pour le VIH afin de ralentir l’évolution de la maladie hépatique. La norme de traitement du VHC de génotype 1 est un régime comprenant de l’interféron pégylé et de la ribavirine dosée en fonction du poids, associés à un inhibiteur de la protéase du VHC. Pour les génotypes 2 ou 3, une bithérapie classique est recommandée pendant 24 semaines s’il y a clairance virologique à la semaine 4 ou, pour les génotypes 2 à 6, à 48 semaines. On peut envisager de reporter le traitement chez les personnes ayant une maladie hépatique légère. Le VIH ne devrait pas être considéré comme un obstacle à la transplantation hépatique chez les patients co‐infectés.

EXPOSÉ: Les recommandations ne se substituent pas au jugement clinique personnel.
Pulmonary Ossification Syndrome in a Patient with Chronic Thromboembolic Pulmonary Hypertension
Authors: Rajwani Noreen Amirali , Puttagunta Lakshmi , Barrie James , Kalluri Meena
Published: March 2016

First described more than 150 years ago, diffuse pulmonary ossification is a rare disease that can be idiopathic or secondary to an underlying chronic disorder. Commonly under-recognized and challenging to diagnose, clinical, radiographic and functional tests are often necessary. Given the increasing prevalence of chronic lung disease in the aging population, it is likely the pulmonary ossification will be encountered in clinics more often. This article describes the diagnosis of the condition in a 51-year-old man.

Pulmonary ossification syndrome is a rare disease characterized by bone tissue formation in the lung parenchyma with or without bone marrow elements. This disorder, often under-recognized, can be idiopathic or secondary to an underlying chronic disorder such as chronic thromboembolic pulmonary hypertension. The pathogenesis involves tissue injury and an alkaline environment in which the precipitation of calcium salts enables alkaline phosphatase activity. This activates profibrogenic cytokines that convert fibroblasts into osteoblasts. Diagnosis can prove challenging and is based on clinical, radiographic and functional tests, and by tissue biopsy. Achieving an accurate and timely diagnosis is essential to avoid erroneous treatments due to misdiagnosis and to expand knowledge of its progression, prognosis and treatment. As the population and prevalence of chronic lung disease increases, it is likely that physicians will encounter more cases of pulmonary ossification.
The Feasibility and Reliability of Transient Elastography Using Fibroscan®: A Practice Audit of 2335 Examinations
Authors: Pang Jack XQ , Pradhan Faruq , Zimmer Scott , Niu Sophia , Crotty Pam , Tracey Jenna , Schneider Christopher , Heitman Steven J , Kaplan Gilaad G , Swain Mark G , Myers Robert P
Published: March 2016

BACKGROUND: Liver stiffness measurement (LSM) using transient elastography is widely used in the management of patients with chronic liver disease.

OBJECTIVES: To examine the feasibility and reliability of LSM, and to identify patient and operator characteristics predictive of poorly reliable results.

METHODS: The present retrospective study investigated the frequency and determinants of poorly reliable LSM (interquartile range [IQR]/median LSM [IQR/M] >30% with median liver stiffness ≥7.1 kPa) using the FibroScan (Echosens, France) over a three-year period. Two experienced operators performed all LSMs. Multiple logistic regression analyses examined potential predictors of poorly reliable LSMs including age, sex, liver disease, the operator, operator experience (<500 versus ≥500 scans), FibroScan probe (M versus XL), comorbidities and liver stiffness. In a subset of patients, medical records were reviewed to identify obesity (body mass index ≥30 kg/m2).

RESULTS: Between July 2008 and June 2011, 2335 patients with liver disease underwent LSM (86% using the M probe). LSM failure (no valid measurements) occurred in 1.6% (n=37) and was more common using the XL than the M probe (3.4% versus 1.3%; P=0.01). Excluding LSM failures, poorly reliable LSMs were observed in 4.9% (n=113) of patients. Independent predictors of poorly reliable LSM included older age (OR 1.03 [95% CI 1.01 to 1.05]), chronic pulmonary disease (OR 1.58 [95% CI 1.05 to 2.37), coagulopathy (OR 2.22 [95% CI 1.31 to 3.76) and higher liver stiffness (OR per kPa 1.03 [95% CI 1.02 to 1.05]), including presumed cirrhosis (stiffness ≥12.5 kPa; OR 5.24 [95% CI 3.49 to 7.89]). Sex, diabetes, the underlying liver disease and FibroScan probe were not significant. Although reliability varied according to operator (P<0.0005), operator experience was not significant. In a subanalysis including 434 patients with body mass index data, obesity influenced the rate of poorly reliable results (OR 2.93 [95% CI 0.95 to 9.05]; P=0.06).

CONCLUSIONS: FibroScan failure and poorly reliable LSM are uncommon. The most important determinants of poorly reliable results are older age, obesity, higher liver stiffness and the operator, the latter emphasizing the need for adequate training.