bluuebunny/crossref_metadata_2025 huggingface dataset:
Detection of Adult Celiac Disease Using Duodenal Screening Biopsies Over a 30-Year Period
Authors: Freeman Hugh James
Published: March 2016

BACKGROUND: Serological studies suggest that celiac disease may be present in approximately 0.5% to 1% of the North American population. Screening data based on small intestinal biopsy performed during routine endoscopic evaluations are not available.

METHODS: Patients referred between January 1982 and December 2011 for evaluation of gastrointestinal symptoms and requiring elective investigative upper endoscopic evaluation underwent duodenal biopsies to determine whether changes of adult celiac disease were present.

RESULTS: A total of 9665 patients, including 4008 (41.5%) males and 5657 (68.5%) females, underwent elective endoscopies and duodenal biopsies. Of these, 234 (2.4%) exhibited changes of celiac disease including 73 males (1.8%) and 161 females (2.8%). During the first 20 years, the number of biopsy-positive patients in five-year intervals progressively decreased and, subsequently, during the next 10 years, the number progressively increased.

CONCLUSIONS: Celiac disease is far more common in specialist practice than has been suggested in the evaluation of healthy populations using serological screening studies. Endoscopic duodenal biopsy is an important method of identifying underlying celiac disease and should be routinely considered in all patients undergoing an elective endoscopic evaluation. Noninherited factors, possibly environmental, may play a role in the appearance of biopsy-defined celiac disease and alter detection over time.
The Epidemiology of Hepatitis C in a Canadian Indigenous Population
Authors: Uhanova Julia , Tate Robert B , Tataryn Douglas J , Minuk Gerald Y
Published: March 2016

BACKGROUND An estimated 1% to 1.9% of North Americans are infected with the hepatitis C virus (HCV). Although Indigenous peoples are considered to bear the highest burden, there are only limited data regarding the demographic features and epidemiology of hepatitis C in this population.

OBJECTIVES: To document the demographic characteristics, rates of newly diagnosed hepatitis C cases and prevalence of HCV infection in a Canadian First Nations population, and to compare the findings with an infected non-First Nations population.

METHODS: A research database spanning 1991 to 2002 was developed, linking records from multiple clinical and administrative sources. Over a 12-year period, 671 First Nations and 4347 non-First Nations HCV-positive Canadians were identified in the province of Manitoba. Demographics, residence and time trends were compared between infected First Nations and non-First Nations persons.

RESULTS: HCV-infected First Nations individuals were younger (mean [± SD] age 33.0±0.4 years versus 39.7±0.2 years; P<0.0001), more often female (60% versus 40%; P<0.0001) and more often resided in urban centres (73% versus 27%; P<0.001). The rate of newly diagnosed HCV cases was 2.5-fold (91.1 per 100,000 versus 36.6 per 100,000; P<0.000) and prevalence 2.4-fold (801.7 per 100,000 versus 334.8 per 100,000; P<0.000) higher among the First Nations relative to non-First Nations populations.

CONCLUSIONS: The results of the present large population-based study indicate that the First Nations population with hepatitis C is characteristically different from infected non-First Nations persons. The results also describe higher rates of newly diagnosed cases and prevalence of HCV infection in the First Nations population. These findings should serve as an important baseline for future primary prevention and therapeutic intervention strategies in this high-risk population.
Evolution of the COPD Assessment Test Score during Chronic Obstructive Pulmonary Disease Exacerbations: Determinants and Prognostic Value
Authors: Feliz-Rodriguez Darwin , Zudaire Santiago , Carpio Carlos , Martínez Elizabet , Gómez-Mendieta Antonia , Santiago Ana , Alvarez-Sala Rodolfo , García-Río Francisco
Published: March 2016

BACKGROUND: An adequate evaluation of exacerbations is a primary objective in managing patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVES: To define the profile of health status recovery during severe exacerbations of COPD using the COPD Assessment Test (CAT) questionnaire and to evaluate its prognostic value.

METHODS: Forty‐five patients with previous COPD diagnoses who were hospitalized due to severe exacerbation(s) were included in the study. These patients were treated by their respective physicians following current recommendations; health status was assessed daily using the CAT questionnaire. The CAT score, spirometry and recurrent hospitalizations were recorded one and three months after hospital discharge.

RESULTS: Global initiative for chronic Obstructive Lung Disease (GOLD) stage was an independent determinant for increased CAT score during the first days of exacerbation with respect to postexacerbation values. From hospitalization day 5, the CAT score was similar to that obtained in the stable phase. Body mass index, GOLD stage and education level were related to health status recovery pattern. CAT score increase and the area under the curve of CAT recovery were inversely related to the forced expiratory volume in 1 s achieved three months after discharge (r= −0.606; P<0.001 and r= −0.532; P<0.001, respectively). Patients with recurrent hospitalizations showed higher CAT score increases and slower recovery.

CONCLUSIONS: The CAT detects early health status improvement during severe COPD exacerbations. Its initial worsening and recovery pattern are related to lung function and recurrent hospitalizations.
A Case of Vertical Transmission of Chagas Disease Contracted via Blood Transfusion in Canada
Authors: Fearon Margaret A , Scalia Vito , Huang Mary , Dines Irene , Ndao Momar , Lagacé-Wiens Philippe
Published: March 2016

Chagas disease is caused by the protozoan parasite Trypanosoma cruzi and is endemic in many countries in Latin America, where infected bugs of the Triatominea subfamily carry the parasite in the gut and transmit it to humans through fecal contamination of a bite. However, vertical transmission and transmission through blood transfusion and organ transplantation is well documented. Increasing immigration from endemic countries to North America has prompted blood operators, including Canadian Blood Services and Hema Quebec, to initiate blood donor testing for Chagas antibody. In the present report, an unusual case of vertical transmission from a mother, most likely infected through blood transfusion, and detected as part of a concurrent seroprevalence study in blood donors is described.
Percutaneous Liver Biopsy Practice Patterns Among Canadian Hepatologists
Authors: Aljawad Mohammed , Yoshida Eric M , Uhanova Julia , Marotta Paul , Chandok Natasha
Published: March 2016

BACKGROUND: Percutaneous liver biopsy (PLB) is the standard procedure to obtain histological samples essential for the management of various liver diseases. While safe, many hepatologists no longer perform their own PLBs; the reasons for this practice shift are unknown.

OBJECTIVE: To describe the attitudes, practice patterns and barriers to PLB among hepatologists in Canada.

METHODS: A survey was distributed to all hepatologists in Canada.

RESULTS: Thirty-two of 40 (80%) hepatologists completed the survey; the majority of respondents were male (72%) and had been in practice for >5 years in an academic setting. Fifty-six per cent of hepatologists referred all PLBs to radiology, and only 19% of hepatologists reported performing their own PLBs most or all of the time. There were no sex differences nor were there differences based on years in practice. Fifty per cent of respondents who performed PLB routinely used ultrasound, and PLBs are performed in equal frequency in an ambulatory procedure area (50%) versus the endoscopy suite (36%). For almost one-half of hepatologists (47%), their performance of PLBs decreased in the past five years. The majority of respondents at an academic centre (75%) reported access to FibroScan (Echosens, France), and most estimated a resultant 25% to 50% reduction in the need for PLBs. Lack of resources, patient preference and suboptimal reimbursement were the most common reasons cited for not performing PLBs.

CONCLUSION: Most hepatologists in Canada do not perform PLBs to the extent that they did in the past, but refer to radiology. The reasons for this shift in practice include lack of resources, improved perception of safety and patient preference. Where available, FibroScan resulted in a perceived 25% to 50% reduction in required liver biopsies.
Group Interprofessional Chronic Pain Management in the Primary Care Setting: A Pilot Study of Feasibility and Effectiveness in a Family Health Team in Ontario
Authors: Angeles Ricardo N , Guenter Dale , McCarthy Lisa , Bauer Martha , Wolfson Miriam , Chacon Maria , Bullock Lana
Published: March 2016

BACKGROUND: Approximately 18.9% of Canadians live with chronic pain. Primary care reform in Ontario presents unique opportunities to assess approaches to help these patients.

OBJECTIVE: To assess the feasibility of an interprofessional primary care‐based program for patients living with chronic pain, and to examine the potential impact of such a program on quality of life and health resource utilization.

METHODS: >An embedded mixed‐methods evaluation (randomized controlled trial with waiting list control and semistructured interviews) of an eight‐week series of small group sessions exploring multifactoral aspects of pain management was performed. Participants were randomly assigned to early intervention (EI) or delayed intervention (DI) groups. All participants received the intervention; the DI group served as a control group for comparison with the EI group. Outcomes included the Short Form‐36 Health Survey version 2 (SF‐36v2), medication use and health care utilization. Qualitative interviews were conducted to identify areas for program improvement.

RESULTS: A total of 240 patients were recruited and 63 agreed to participate. The mean (± SD) age of the participants was 55±14.1 years and 62.3% were female. There was no significant difference in the mean change in SF‐36v2 summary scores between the EI and DI groups. However, the SF‐36v2 subscale score for bodily pain was significantly improved in the EI group compared with the DI group after six months of observation (mean difference = 13.1 points; P<0.05). There was also significant improvement in this score when both groups were pooled and aggregate preintervention and postintervention scores were compared. There was a significant decrease in the mean number of clinic visits in the six‐month period following the intervention compared with the six‐month period before the intervention (P=0.043).

CONCLUSION: An interprofessional program in primary care for patients living with chronic pain may lead to improvements in quality of life and health resource utilization. The challenges to the feasibility of the program and its evaluation are recruitment and retention of patients, leading to the conclusion that the program, as it was conducted in the present study, is not appropriate for this setting.
Major Care Gaps in Asthma, Sleep and Chronic Obstructive Pulmonary Disease: A Road Map for Knowledge Translation
Authors: Boulet Louis-Philippe , Bourbeau Jean , Skomro Robert , Gupta Samir
Published: March 2016

Large gaps between best evidence‐based care and actual clinical practice exist in respiratory medicine, and carry a significant health burden. The authors reviewed two key care gaps in each of asthma, chronic obstructive pulmonary disease and obstructive sleep apnea. Using the ‘Knowledge‐to‐Action Framework’, the nature of each gap, its magnitude, the barriers that cause and perpetuate it, and past and future strategies that might address the problem were considered. In asthma: disease control is ascertained inadequately, leading to a prevalence of poor asthma control of approximately 50%; and asthma action plans, a key component of asthma management, are provided by only 22% of physicians. In obstructive sleep apnea: disease is under‐recognized, with sleep histories ascertained in only 10% of patients; and Canadian polysomnography wait times remain longer than recommended, leading to unnecessary morbidity and societal cost. In chronic obstructive pulmonary disease: a large proportion of patients seen in primary care remain undiagnosed, mainly due to underuse of spirometry; and <10% of patients are referred for pulmonary rehabilitation, despite strong evidence demonstrating its cost effectiveness. Given the prevalence of these chronic conditions and the size and nature of these gaps, the latter exact an important toll on patients, the health care system and society. In turn, complex barriers at the patient, provider and health care system levels contribute to each gap. There have been few previous attempts to bridge these gaps. Innovative and multifaceted implementation approaches are needed and have the potential to make a large impact on Canadian respiratory health.
Variations in the Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease
Authors: Sandhu Supna K , Chu Jackson , Yurkovich Marko , Harriman David , Taraboanta Catalin , FitzGerald J Mark
Published: March 2016

BACKGROUND: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a significant cause of morbidity and mortality for patients with COPD. AECOPD are the leading cause of hospital admissions in Canada. Although multiple guidelines have been developed for the acute and chronic management of COPD, there are few quality assurance studies investigating adherence to these guidelines.

METHODS: A retrospective chart review of all patients admitted to a tertiary care hospital in 2009 for an AECOPD was performed. Using a standardized data abstraction tool, adherence to current guidelines across different physician groups and patient outcomes were assessed. Particular focus was centred on differences in management across physician groups.

RESULTS: Overall, 293 patients were evaluated. Of these, 82.6% were treated with one or more chronic COPD medication(s) in the community, with only 17.7% of patients treated with a long‐acting inhaled anticholinergic medication. For treatment of AECOPD, 58% of patients received corticosteroids and 84% received antibiotics. Compared with general medicine and the hospitalist service, the respiratory medicine service demonstrated significantly better adherence with current treatment guidelines; however, even this was less than optimal. In addition, there was poor follow‐up of patients cared for outside of the respiratory service.

CONCLUSIONS: The present study identified significant care gaps in the treatment of patients admitted with AECOPD and on their discharge.
Successful Use of Locally Applied Polyhexamethylene Biguanide as an Adjunct to the Treatment Of Fungal Osteomyelitis
Authors: Walls Genevieve , Noonan Lisa , Wilson Elizabeth , Holland David , Briggs Simon
Published: March 2016

Fungal osteomyelitis is rare in immunocompetent patients and is often difficult to cure, even with optimal medical and surgical management. The authors present two cases of fungal osteomyelitis in which the common swimming pool cleaner, polyhexamethylene biguanide, was used successfully as an adjunct to standard surgical and medical treatment. Also presented is a literature review on the use of polyhexamethylene biguanide for this indication. The authors recommend that this safe and well‐tolerated compound be considered as part of the treatment for fungal osteomyelitis.
Rituximab for the Treatment of Patients with Autoimmune Hepatitis Who are Refractory or Intolerant to Standard Therapy
Authors: Burak Kelly W , Swain Mark G , Santodomino-Garzon Tania , Lee Samuel S , Urbanski Stefan J , Aspinall Alexander I , Coffin Carla S , Myers Robert P
Published: March 2016

BACKGROUND: Although most patients with autoimmune hepatitis (AIH) respond to treatment with prednisone and/or azathioprine, some patients are intolerant or refractory to standard therapy. Rituximab is an anti-CD20 monoclonal antibody that depletes B cells and has demonstrated efficacy in other autoimmune conditions.

AIMS: To evaluate the safety and efficacy of rituximab in patients with refractory AIH in an open-label, single-centre pilot study.

METHODS: Six patients with definite, biopsy-proven AIH who failed prednisone and azathioprine treatment received two infusions of rituximab 1000 mg two weeks apart and were followed for 72 weeks.

RESULTS: Rituximab was well tolerated with no serious adverse events. By week 24, mean (± SD) aspartate aminotransferase (AST) levels had significantly improved (90.0±23.3 U/L versus 31.3±4.2 U/L; P=0.03) and mean immunoglobulin G levels had fallen (16.4±2.0 g/L versus 11.5±1.1 g/L; P=0.056). The prednisone dose was weaned in three of four subjects, with one subject flaring after steroid withdrawal. Inflammation grade improved in all four subjects who underwent repeat liver biopsy at week 48. Regulatory T cell levels examined by FoxP3 immunohistochemistry paralleled inflammatory activity and did not increase on follow-up biopsies. There was no significant change in serum chemokine or cytokine levels from baseline to week 24 (n=5), although interferon-gamma-induced protein 10 levels improved in three of five subjects.

CONCLUSIONS: Rituximab was safe, well tolerated and resulted in biochemical improvement in subjects with refractory AIH. These results support further investigation of rituximab as a treatment for AIH.
Improving Access in Gastroenterology: The Single Point of Entry Model for Referrals
Authors: Novak Kerri L , Van Zanten Sander Veldhuyzen , Pendharkar Sachin R
Published: March 2016

In 2005, a group of academic gastroenterologists in Calgary (Alberta) adopted a centralized referral intake system known as central triage. This system provided a single point of entry model (SEM) for referrals rather than the traditional system of individual practitioners managing their own referrals and queues. The goal of central triage was to improve wait times and referral management. In 2008, a similar system was developed in Edmonton at the University of Alberta Hospital (Edmonton, Alberta). SEMs have subsequently been adopted by numerous subspecialties throughout Alberta. There are many benefits of SEMs including improved access and reduced wait times. Understanding and measuring complex patient flow systems is key to improving access, and centralized intake systems provide an opportunity to better understand total demand and system bottlenecks. This knowledge is particularly important for specialties such as gastroenterology (GI), in which demand exceeds supply. While it is anticipated that SEMs will reduce wait times for GI care in Canada, the lack of sufficient resources to meet the demand for GI care necessitates additional strategies.
The Role of Hepatic Expression of STAT1, SOCS3 and PIAS1 in the Response of Chronic Hepatitis C Patients to Therapy
Authors: El-Saadany Sherif , Ziada Dina H , Bassat Hanan El , Farrag Wael , El-Serogy Hesham , Eid Manal , Abdallah Manal , Ghazy Medhat , Salem Hoda A
Published: March 2016

BACKGROUND: The underlying mechanisms of hepatitis C virus (HCV) resistance to treatment are unknown. Signal transducers and activators of transcription (STAT) proteins play a critical role in antiviral defense.

OBJECTIVE: To explore some of the mechanisms of HCV resistance to interferon, the expression of STAT1 and its negative regulators, protein inhibitor of activated STAT (PIAS1) and suppressor of cytokine signalling (SOCS3), in liver tissues of both inteferon responders and nonresponders in chronic HCV patients.

METHODS: Sixty patients were divided into the following groups: group 1a comprised 38 treatment-responder chronic HCV patients; group 1b consisted of 22 treatment-nonresponder chronic HCV patients; and group 2 consisted of six control subjects. Liver biopsies were examined for histological scoring; STAT1, SOCS3 and PIAS1 expression was analyzed using Western blotting methods.

RESULTS: STAT1 expression in the liver tissue of patients in group 1 was significantly increased compared with group 2 patients (P=0.001), while no significant difference in expression was observed between group 1a and group 1b patients (P=0.747). However, phosphorylated STAT1 protein was expressed at a significantly higher level in liver tissue of patients in group 1a compared with patients in group 1b (P=0.001). Western blot analysis of PIAS1 and SOCS3 protein expression in liver tissues from groups 1 and 2 revealed significantly increased expression in group 1 compared with group 2 (P=0.001). In addition, PIAS1 and SOCS3 protein expression was significantly higher in the liver tissues of patients in group 1b compared with patients in group 1a.

CONCLUSION: Levels of STAT1 and/or the protein expression of its negative regulators, PIAS1 and SOCS3, may be a good predictor of response to therapy. These could be used as biomarkers that are easily detected by Western blotting or immunostaining during standard histopathological liver biopsy analysis.
The Impact of Serum Vancomycin Levels and Minimum Inhibitory Concentrations of Methicillin‐Resistant Staphylococcus aureus on Mortality in Patients with Nosocomial Pneumonia
Authors: Machado Denise Pires , Goldani Luciano Z , Paiva Rodrigo Minuto , Aquino Valério Rodrigues , de-Paris Fernanda , Lisboa Thiago , Jung Bruno , dos Santos Rodrigo Pires
Published: March 2016

BACKGROUND: Vancomycin is the treatment of choice for methicillin‐resistant Staphylococcus aureus (MRSA) infections; however, treatment failure is not uncommon, even when the minimum inhibitory concentration (MIC) of the MRSA strain is within the susceptible range for vancomycin.

OBJECTIVE: To describe the relationship between molecular markers such as the mecA and agrII genes, serum vancomycin levels and vancomycin MICs, and the 30‐day mortality rate of patients with nosocomial MRSA pneumonia in an intensive care unit (ICU).

METHODS: The present study was a prospective cohort study including all patients with MRSA hospital‐acquired pneumonia or ventilator‐associated pneumonia who were admitted to the ICU of a tertiary care hospital between June 2009 and December 2011. The MIC for vancomycin was determined using the E‐test and broth microdilution methods. Variables analyzed included age, sex, comorbid conditions, serum vancomycin trough concentration, the Acute Physiology and Chronic Health Evaluation II (APACHE) score and the presence of the agrII gene. The primary outcome was mortality at 30 days.

RESULTS: Thirty‐six (42.4%) patients died within 30 days of the index MRSA culture. A multiple regression analysis that included the variables of MIC (determined using the E‐test or broth microdilution methods), APACHE II score, serum vancomycin level and the presence of agrII revealed that only the APACHE II score was related to the 30‐day mortality rate (P=0.03). Seven patients (9.0%) with isolates exhibiting an MIC ≥1.5 μg/mL according to the E‐test method died, and nine patients (11.6%) survived (P=0.76). Of the patients for whom MICs were determined using the broth microdilution method, 11 (14.1%) patients with MICs of 1.0 μg/mL died, and 16 (20.5%) survived (P=0.92). The median APACHE II score of survivors was 22.5, and the median score of nonsurvivors was 25.0 (P=0.03). The presence of the agrII gene was not related to the 30‐day mortality rate.

CONCLUSIONS: Patients with severe hospital‐acquired pneumonia presented with MRSA isolates with low to intermediate vancomycin MICs in the ICU setting. At the Hospital de Clínicas de Porto Alegre (Porto Alegre, Brazil), the 30‐day mortality rate was high, and was similar among patients with severe hospital‐acquired pneumonia infected with MRSA isolates that exhibited MICs of ≤1.5 μg/mL determined using the E‐test method and ≤1.0 μg/mL determined using the broth microdilution method in those who achieved optimal serum vancomycin levels. The APACHE II scores which provides an overall estimate of ICU mortality were independently associated with mortality in the present study, regardless of the MICs determined. Molecular markers, such as the agrII gene, were not associated with higher mortality in the present study.
Patient Satisfaction with the Endoscopy Experience and Willingness to Return in a Central Canadian Health Region
Authors: Loftus Russell , Nugent Zoann , Graff Lesley A , Schumacher Frederick , Bernstein Charles N , Singh Harminder
Published: March 2016

OBJECTIVE: Patient experiences with endoscopy visits within a large central Canadian health region were evaluated to determine the relationship between the visit experience and the patients’ willingness to return for future endoscopy, and to identify the factors associated with patients’ willingness to return.

METHODS: A self-report survey was distributed to 1200 consecutive individuals undergoing an upper and/or lower gastrointestinal endoscopy at any one of the six hospital-based endoscopy facilities in the region. The Spearman correlation coefficient was used to assess the association between the patients’ overall rating of the visits and willingness to return for repeat procedures under similar medical circumstances. Logistic regression analyses were performed to identify the factors associated with willingness to return for repeat endoscopy and overall satisfaction (rating) of the visit.

RESULTS: A total of 529 (44%) individuals returned the questionnaire, with 45% rating the visit as excellent and 56% indicating they were extremely likely to return for repeat endoscopy. There was a low moderate correlation between overall rating of the visit and patients’ willingness to return for repeat endoscopy (r=0.30). The factors independently associated with patient willingness to return for repeat endoscopy included perceived technical skills of the endoscopists (OR 2.7 [95% CI 1.3 to 5.5]), absence of pain during the procedure (OR 2.2 [95% CI 1.3 to 3.6]) and history of previous endoscopy (OR 2.4 [95% CI 1.4 to 4.1]). In contrast, the independent factors associated with the overall rating of the visit included information provided pre- and postprocedure, wait time before and on the day of the visit, and the physical environment.

CONCLUSIONS: To facilitate patient return for needed endoscopy, it is important to assess patients’ willingness to return because positive behavioural intent is not simply a function of satisfaction with the visit.
Epidemiology and Treatment of Hepatitis C Genotypes 5 and 6
Authors: Al Naamani Khalid , Al Sinani Siham , Deschênes Marc
Published: March 2016

Chronic hepatitis C infection is a major global health problem. The WHO estimates the number of infected people worldwide to be approximately 170 million. The estimated number of hepatitis C virus (HCV)-infected people in Canada is approximately 250,000, with approximately 5000 Canadians newly infected each year. Based on the identification of genomic differences, HCV has been classified into six genotypes; genotype may influence the outcome of antiviral therapy. HCV genotypes 1, 2 and 3 are widely distributed throughout the world and have been the focus of the majority of epidemiological, natural course and treatment studies. Although HCV genotypes 5 and 6 are prevalent in certain geographical areas, they are studied less extensively. HCV genotypes 5 and 6 are uncommon in Canada and account for less than 5% of HCV-infected Canadians. However, immigration and travel can alter the epidemiology of these uncommon genotypes. The present article reviews and summarizes the available data regarding the epidemiology and treatment of HCV genotypes 5 and 6. Genotype 5 is endemic in the northern part of South Africa while genotype 6 is reported primarily in Asia. Available data show that 48 weeks of treatment with a combination of pegylated interferon and ribavirin lead to a higher sustained virological response compared with HCV genotypes 1 and 4. None of the approved direct-acting antiviral agents is currently recommended for the treatment of HCV genotypes 5 or 6.
Use and Nonmedical Use of Prescription Opioid Analgesics in the General Population of Canada and Correlations with Dispensing Levels in 2009
Authors: Shield Kevin D , Jones Wayne , Rehm Jürgen , Fischer Benedikt
Published: March 2016

BACKGROUND: In Canada, harm from nonmedical prescription opioid analgesic (POA) use (NMPOU) has increased in recent years; however, there are limitations to the current estimates of NMPOU. The 2009 Canadian Alcohol and Drug Use Monitoring Survey presents an opportunity to produce more accurate estimates of NMPOU.

OBJECTIVES: To determine the prevalence of POA use, NMPOU and use of pain relievers to ‘get high’, and to assess correlations of these indicators with age, sex and provincial levels of dispensed POAs in Canada in 2009.

METHODS: Data regarding POA use were obtained from the 2009 Canadian Alcohol and Drug Use Monitoring Survey (n=13,032). The amount of POAs dispensed in standardized daily doses was obtained from a representative sample of 2700 retail pharmacies across Canada. Associations among POA use, age, sex and the amount of POAs dispensed were evaluated using regression models. Differences in POA use across provinces were assessed using the Wald test.

RESULTS: In Canada in 2009, the prevalence of POA use was 19.2% (95% CI 18.0% to 20.5%), NMPOU was 4.8% (95% CI 4.1% to 5.5%) and the use of pain relievers to get high was 0.4% (95% CI 0.1% to 0.8%). NMPOU was significantly associated with age. The use of pain relievers to get high varied significantly across provinces, while POA use and NMPOU did not show significant variations. The amount of POAs dispensed per province was not significantly correlated with any type of POA use.

CONCLUSIONS: These findings confirm high POA use and NMPOU across Canada. Research is required to identify determinants of NMPOU.
Macrolide Use in the Treatment of Critically Ill Patients with Pneumonia: Incidence, Correlates, Timing and Outcomes
Authors: Sligl Wendy I , Hoang Holly , Eurich Dean T , Malhotra Atul , Marrie Thomas J , Majumdar Sumit R
Published: March 2016

BACKGROUND: Macrolide antibiotics are commonly used to treat pneumonia despite increasing antimicrobial resistance. Evidence suggests that macrolides may also decrease mortality in severe sepsis via immunomodulatory properties.

OBJECTIVE: To evaluate the incidence, correlates, timing and mortality associated with macrolide‐based treatment.

METHODS: A population‐based cohort of critically ill adults with pneumonia at five intensive care units in Edmonton, Alberta, was prospectively followed over two years. Data collected included disease severity (Acute Physiology and Chronic Health Evaluation [APACHE] II score), pneumonia severity (Pneumonia Severity Index score), comorbidities, antibiotic treatments at presentation and time to effective antibiotic. The independent association between macrolide‐based treatment and 30‐day all‐cause mortality was examined using multivariable Cox regression. A secondary exploratory analysis examined time to effective antimicrobial therapy.

RESULTS: The cohort included 328 patients with a mean Pneumonia Severity Index score of 116 and a mean APACHE II score of 17; 84% required invasive mechanical ventilation. Ninety‐one (28%) patients received macrolide‐based treatments, with no significant correlates of treatment except nursing home residence (15% versus 30% for nonresidents [P=0.02]). Overall mortality was 54 of 328 (16%) at 30 days: 14 of 91 (15%) among patients treated with macrolides versus 40 of 237 (17%) for nonmacrolides (adjusted HR 0.93 [95% CI 0.50 to 1.74]; P=0.8). Patients who received effective antibiotics within 4 h of presentation were less likely to die than those whose treatment was delayed (14% versus 17%; adjusted HR 0.50 [95% CI 0.27 to 0.94]; P=0.03).

CONCLUSIONS: Macrolide‐based treatment was not associated with lower 30‐day mortality among critically ill patients with pneumonia, although receipt of effective antibiotic within 4 h was strongly predictive of survival. Based on these results, timely effective treatment may be more important than choice of antibiotics.
Antibiotic Resistance and Expression Of Resistance‐Nodulation‐Division Pump‐ and Outer Membrane Porin‐Encoding Genes in Acinetobacter Species Isolated from Canadian Hospitals
Authors: Fernando Dinesh , Zhanel George , Kumar Ayush
Published: March 2016

BACKGROUND: Bacterial pathogens belonging to the genus Acinetobacter cause serious infections in immunocompromised individuals that are very difficult to treat due to their extremely high resistance to many antibiotics.

OBJECTIVE: To investigate the role of resistance‐nodulation‐division (RND) pumps and porins in the antibiotic resistance of Acinetobacter species collected from Canadian hospitals.

METHODS: Clinical isolates of Acinetobacter species collected from Canadian hospitals were analyzed for the expression of genes encoding RND pumps (adeB, adeG, adeJ, AciBau_2746 and AciBau_2436) and outer membrane porins (carO, 33 kDa porin and oprD) using quantitative reverse transcription (qRT) polymerase chain reaction. Species identification of the isolates was performed using a multiplex polymerase chain reaction method for gyrB.

RESULTS: The expression of RND pump‐encoding genes was widespread in the clinical isolates of Acinetobacter species, with each of the isolates expressing at least one RND pump. adeG was found to be overexpressed in all of the isolates, while adeB was found to be overexpressed in only two isolates. Among the porin‐encoding genes, the expression of carO was considerably downregulated among the majority of isolates.

CONCLUSION: The present study was the first to analyze the expression of RND pump‐ and porin‐encoding genes in the clinical isolates of Acinetobacter species from Canadian hospitals. The overexpression of genes encoding RND pumps and the downregulation of genes encoding porins was common in clinical isolates of Acinetobacter species from Canadian hospitals, with the AdeFGH pump being the most commonly expressed RND pump.
Infected Pseudoaneurysm of the Superficial Femoral Artery in a Patient with Salmonella enteritidis Bacteremia
Authors: Hussain MA , Roche-Nagle G
Published: March 2016

Mycotic aneurysms, defined as irreversible dilation of an artery due to destruction of the vessel wall by infection, are rare but are associated with a high risk of rupture if not treated promptly. The case of a healthy 52‐year‐old smoker who presented with pyrexia, rigors, night sweats and severe right leg pain with swelling is presented. He was diagnosed with a superficial femoral artery mycotic aneurysm, with Salmonella enteritidis as the causative agent. He was treated with high‐dose antibiotics, local debridement and autologous reconstruction. A high index of suspicion is needed to make the correct diagnosis in these cases. Prompt surgical intervention and antimicrobial therapy are the cornerstones of treatment to reduce the associated high morbidity and mortality.
Prevalence of and Risk Factors for Self‐Reported Chronic Bronchitis in a Canadian Population: The Canadian Community Health Survey, 2007 To 2008
Authors: Karunanayake Chandima , Hagen Briana , Dosman James , Pahwa Punam
Published: March 2016

BACKGROUND: Chronic bronchitis (CB) represents one of the respiratory disease phenotypes that affect the Canadian health care system significantly. Presently, almost 6.5% of total health care costs are related to respiratory diseases.

OBJECTIVE: To determine the prevalence of self‐reported CB and associated risk factors in the Canadian general population.

METHODS: Data regarding individuals ≥12 years of age from the Canadian Community Health Survey, 2007 to 2008, were analyzed. CB was determined through self‐reported health professional diagnosis. Information regarding covariates of importance, such as demographics, lifestyle variables and socioeconomic status, was obtained. A weighted logistic regression analysis was performed with appropriate technique for clustering effects.

RESULTS: The prevalence of self‐reported CB was 2.5%. A greater prevalence of self‐reported CB associated with older age, female sex and white ethnic group was found. There were differences in the prevalence of self‐reported CB among regions of Canada for household income, educational attainment and smoking status.

CONCLUSION: The results suggest an association between ethnicity and the prevalence of CB. The associations between self‐reported CB prevalence and household income, educational attainment and smoking status varied according to region of Canada.
Phenotyping of Chronic Obstructive Pulmonary Disease Using the Modified Bhalla Scoring System for High‐Resolution Computed Tomography
Authors: Tulek Baykal , Kivrak Ali Sami , Ozbek Seda , Kanat Fikret , Suerdem Mecit
Published: March 2016

BACKGROUND: Identifying different phenotypes of chronic obstructive pulmonary disease (COPD) is important for both therapeutic options and clinical outcome of the disease.

OBJECTIVE: To characterize the phenotypes of COPD according to high‐resolution computed tomography (HRCT) findings; and to correlate HRCT scores obtained using the modified Bhalla scoring system with clinical and physiological indicators of systemic inflammation.

METHODS: The present study included 80 consecutive patients with stable COPD. HRCT scans were evaluated by two independent radiologists according to the modified Bhalla scoring system.

RESULTS: Fifty‐four patients exhibited morphological changes on HRCT examination while 26 had no pathological findings. Patients with HRCT findings had lower spirometric measurements and higher levels of inflammation, and reported more exacerbations in the previous year compared with patients with no findings on HRCT. Patients with morphological changes were classified into one of three groups according to their HRCT phenotype(s): emphysema (E) only, E + bronchiectasis (B)/peribronchial thickening (PBT) or B/PBT only. Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, C‐reactive protein (CRP) levels and the number of exacerbations among the groups were significantly different. Pairwise comparisons between the E only and E+B/PBT groups showed significantly lower FVC, FEV1 and FEV1/FVC values, and higher CRP levels and number of exacerbations compared with the B/PBT group. No significant differences were found between the E+B/PBT and the B/PBT groups. An inverse correlation was found between the total HRCT score and FVC, FEV1 and FEV1/FVC; the correlation was positive with CRP level, erythrocyte sedimentation rate and number of exacerbations.

CONCLUSION: The present study exposed the intimate relationship between phenotype(s) characterized by HRCT and scoring for morphological abnormalities; and clinical and functional parameters and inflammatory markers. The inclusion of HRCT among routine examinations for COPD may provide significant benefits both in the management and prognosis of COPD patients.
Airway Pressure Release Ventilation: A Neonatal Case Series and Review of Current Pediatric Practice
Authors: Gupta Shikha , Joshi Vinay , Joshi Preetha , Monkman Shelley , Vallaincourt Kelly , Choong Karen
Published: March 2016

BACKGROUND: The use of airway pressure release ventilation (APRV) in very low birth weight infants is limited.

OBJECTIVE: To report the authors’ institutional experience and to review the current literature regarding the use of APRV in pediatric populations.

METHODS: Neonates <1500 g ventilated using APRV from 2005 to 2006 at McMaster Children’s Hospital (Hamilton, Ontario) were retrospectively reviewed. Publications describing APRV in children from 1987 to 2011 were reviewed.

RESULTS: Five infants, 24 to 28 weeks’ gestational age, were ventilated using APRV. Indications for APRV were refractory hypoxemia (n=3), ventilatory dyssynchrony (n=1) and minimizing sedatives (n=1). All infants appeared to tolerate APRV well with no recorded adverse events. Current pediatric evidence regarding APRV is primarily observational. Published experience reveals that APRV settings in pediatrics often approximate those used in adults, thus deviating from the original guidelines recommended in children. Clinical outcomes, such as oxygenation, ventilation and sedation requirements, are inconsistent.

CONCLUSIONS: APRV is primarily used as a rescue ventilation mode in children. Neonatal evidence is limited; however, the present study indicates that APRV is feasible in very low birth weight infants. There are unique considerations when applying this mode in small infants. Further research is necessary to confirm whether APRV is a safe and effective ventilation strategy in this population.
HIV Disease Progression to CD4 Count <200 Cells/μL and Death in Saskatoon, Saskatchewan
Authors: Konrad Stephanie , Skinner Stuart , Kazadi Germain Bukassa , Gartner Kali , Lim Hyun June
Published: March 2016

OBJECTIVE: To characterize and identify determinants of HIV disease progression among a predominantly injection drug use (IDU) HIV population in the highly active antiretroviral therapy era.

METHODS: The present retrospective study was based on 343 HIV patients diagnosed from 2005 to 2010 from two clinics in Saskatoon, Saskatchewan. Disease progression was defined as the time from diagnosis to immunological AIDS (CD4 count <200 cells/μL) and death. Uni‐ and multivariable Cox proportional hazards models were used.

RESULTS: Of the 343 patients, 79% had a history of IDU, 77% were hepatitis C virus (HCV) coinfected and 67% were of Aboriginal descent. The one‐year and three‐year immunological AIDS‐free probabilities were 78% and 53%, respectively. The one‐year and three‐year survival probabilities were 97% and 88%, respectively. Multicollinearity among IDU, HCV and ethnicity was observed and, thus, separate models were built. HCV coinfection (HR 2.9 [95% CI 1.2 to 6.9]) was a significant predictor of progression to immunological AIDS when controlling for baseline CD4 counts, treatment, age at diagnosis and year of diagnosis. For survival, only treatment use was a significant predictor (HR 0.34 [95% CI 0.1 to 0.8]). HCV coinfection was marginally significant (P=0.067).

CONCLUSION: Baseline CD4 count, HCV coinfection, year of diagnosis and treatment use were significant predictors of disease progression. This highlights the importance of early treatment and the need for targeted interventions for these particularly vulnerable populations to slow disease progression.
Effects of Gabapentin on Pain and Opioid Consumption after Abdominal Hysterectomy
Authors: Frouzanfard Fatemeh , Fazel Mohammed Reza , Abolhasani Azadeh , Fakharian Esmaeil , Mousavi Golmabas , Moravveji Alireza
Published: March 2016

BACKGROUND: Postoperative pain is an important factor affecting anesthesia and surgery.

OBBJECTIVES: The present study assessed the effects of 1200 mg gabapentin, an anticonvulsant drug that acts through voltage‐dependent calcium channels, for the control of postoperative pain in patients undergoing abdominal hysterectomy.

METHODS: Fifty patients undergoing hysterectomy were enrolled in the present study. Subjects received either 1200 mg gabapentin or placebo 2 h before surgery. The amount of morphine consumption and level of postoperative pain at 2 h, 6 h, 12 h and 24 h after surgery were measured.

RESULTS: There were no significant differences in age, duration of surgery and anesthesia, or body mass index between the two groups. The mean intensity of pain in the gabapentin group was significantly lower than in the placebo group. The mean amount of morphine used in the placebo group (5.2±2.8 mg) was significantly higher than in gabapentin group (1.2±0.29 mg; P=0.001). Nausea and vomiting in the placebo group was more common than in the gabapentin group (P=0.001). The time interval for initial ambulation after surgery was significantly shorter in the gabapentin group (12.24±2.18 h) compared with the placebo group (15±3.61 h; P=0.002).

CONCLUSION: 1200 mg gabapentin reduced postoperative pain and the need for opioids, and enabled earlier ambulation of the patient. Significant side effects were not observed.
Streptococcus anginosus Pyogenic Liver Abscess following a Screening Colonoscopy
Authors: Bonenfant Francis , Rousseau Étienne , Farand Paul
Published: March 2016

A previously healthy 58‐year‐old man presented with a septic thrombosis of the right hepatic vein and a pyogenic liver abscess (PLA) one week after undergoing a screening colonoscopy. Blood cultures and a radiological drainage specimen were both positive for Streptococcus anginosus. Evolution was favourable after six weeks of antibiotherapy. To the authors’ knowledge, the present report is the first to describe a PLA following a screening colonoscopy with no intervention. The authors hypothesize that silent microperforations during colonoscopy contributed to the infection. Although 20% to 40% of reported PLA cases are cryptogenic in the literature, it may be because of failure to recognize and report a precipitating factor such as colonoscopy. As more cases similar to the present case are reported, the number of cryptogenic cases may decrease.
Use of Fecal Occult Blood Test in Hospitalized Patients: Survey of Physicians Practicing in a Large Central Canadian Health Region and Canadian Gastroenterologists
Authors: Ip Stephen , Sokoro AbdulRazaq AH , Buchel Al , Wirtzfeld Debrah , Konrad Gerald , Fatoye Tunji , Singh Harminder
Published: March 2016

BACKGROUND: Although the fecal occult blood test (FOBT) was developed for colorectal cancer screening in the outpatient setting, it continues to be used among hospitalized patients. No previous study has evaluated the knowledge, beliefs and attitudes of practicing physicians on the use of FOBT among hospitalized patients and compared practices among physicians with different medical specialty training.

OBJECTIVE: To survey physicians in the Winnipeg Regional Health Authority (WRHA) and Canadian gastroenterologists (GIs) on the use of FOBT in hospitals.

METHODS: A survey was distributed by e-mail to internists (n=198), emergency medicine (EM) physicians (n=118), general surgeons (n=47) and family medicine (FM) physicians with admitting privileges (n=29) in the WRHA. Canadian GIs were surveyed through the membership database of the Canadian Association of Gastroenterology (CAG) (n=449). The survey included items regarding demographics of the respondents and their current use of FOBT in hospitals.

RESULTS: Response rates ranged from 18% among CAG members to 69% among FM physicians in the WRHA. General internal medicine, general surgeon and GI respondents were less likely to order a FOBT and less likely to believe that an FOBT was useful in assessing emergency room or hospitalized patients when compared with FM and EM respondents (P<0.001). The most common indications for ordering a FOBT were black stools and anemia with and without iron deficiency. Two-thirds of EM physicians preferred point-of-care testing rather than laboratory reporting of FOBT.

CONCLUSIONS: The present survey suggests that FOBTs are commonly used in hospitals by EM and FM physicians for indications such as anemia and black stools.