bluuebunny/crossref_metadata_2025 huggingface dataset:
Digestive Symptoms in Older Adults: Prevalence and Associations with Institutionalization and Mortality
Authors: AlAmeel Turki , Basheikh Mohammed , Andrew Melissa K
Published: March 2016

BACKGROUND: Digestive symptoms are common in adults. However, little is known about their prevalence in older adults and the association of digestive symptoms with institutionalization and mortality in community-dwelling older adults.

OBJECTIVE: To determine the prevalence of digestive symptoms among older adults in Canada and whether they are associated with increased risk of institutionalization and mortality, independent of the effect of potential confounders.

METHODS: The present study was a secondary analysis of data collected from community-dwelling participants 65 years of age and older in the Canadian Study of Health and Aging. Measures incuded age, sex, presence of digestive symptoms, cognition, impairment in activities of daily living (ADL) and self-reported health. Outcome measures included death or institutionalization over the 10 years of follow-up.

RESULTS: Digestive symptoms were found in 2288 (25.6%) of the 8949 subjects. Those with digestive symptoms were older, with a mean difference in age of six months (P=0.007). Digestive symptoms were more common among women (28.4%) than men (20.3%), among individuals with poor self-reported health and those with an increased number of impairments in their ADLs (P<0.001). The presence of digestive symptoms was associated with higher mortality (HR 1.15 [95% CI 1.05 to 1.25] adjusted for age, sex, cognitive function and ADL impairment); however, this association was not statistically significant after adjusting for self-reported health.

CONCLUSION: Although digestive symptoms were associated with increased mortality independent of age and sex, cognition and function, this association was largely explained by poor self-assessed health. Digestive symptoms were not associated with institutionalization
Evaluation, Modification and Validation of a Set Of Asthma Illustrations in Children with Chronic Asthma in the Emergency Department
Authors: Tulloch Joanie , Vaillancourt Régis , Irwin Danica , Pascuet Elena
Published: March 2016

OBJECTIVES: To test, modify and validate a set of illustrations depicting different levels of asthma control and common asthma triggers in pediatric patients (and/or their parents) with chronic asthma who presented to the emergency department at the Children’s Hospital of Eastern Ontario, Ottawa, Ontario.

METHODS: Semistructured interviews using guessability and translucency questionnaires tested the comprehensibility of 15 illustrations depicting different levels of asthma control and common asthma triggers in children 10 to 17 years of age, and parents of children one to nine years of age who presented to the emergency department. Illustrations with an overall guessability score <80% and/or translucency median score <6, were reviewed by the study team and modified by the study’s graphic designer. Modifications were made based on key concepts identified by study participants.

RESULTS: A total of 80 patients were interviewed. Seven of the original 15 illustrations (47%) required modifications to obtain the prespecified guessability and translucency goals.

CONCLUSION: The authors successfully developed, modified and validated a set of 15 illustrations representing different levels of asthma control and common asthma triggers.

PRACTICE IMPLICATIONS: These illustrations will be incorporated into a child‐friendly asthma action plan that enables the child to be involved in his or her asthma self‐management care.
Canadian Digestive Health Foundation Public Impact Series 4: Celiac Disease in Canada. Incidence, Prevalence, and Direct and Indirect Economic Impact
Authors: Fedorak Richard N , Switzer Connie M , Bridges Ron J
Published: March 2016

The Canadian Digestive Health Foundation initiated a scientific program to assess the incidence, prevalence, mortality and economic impact of digestive disorders across Canada in 2009. The current article presents the updated findings from the study concerning celiac disease.
Genital Herpes in Canada: Deciphering the Hidden Epidemic
Authors: Aslam Mubeen , Kropp Rhonda Y , Jayaraman Gayatri , Dinner Katherine , Wong Thomas , Steben Marc
Published: March 2016

INTRODUCTION: Genital herpes (GH) is the most common cause of genital ulceration, but is not reportable in Canada. Research in the United States has found that less than 10% of seropositive persons reported a diagnosis of GH. The present article investigates the rates of diagnosed cases of GH in Canada from 2002 to 2007.

METHODS: Primary case diagnosis data on GH for the period between 2002 and 2007 were obtained from the Canadian Disease and Therapeutic Index, a proprietary database maintained by Intercontinental Medical Statistics (IMS) Health Canada. Of the 45,000 to 49,000 office‐based physicians in Canada, IMS Health collected diagnosis‐specific prescription diaries from a sample of 652, stratified according to geographic region and representing all major specialties, during this period.

RESULTS: Between 2002 and 2007, there were approximately 84,398 to 122,456 medically attended GH cases annually in Canada. Approximately 74% to 93% of these diagnosed cases made one physician visit per year. The annual rate of medically attended GH cases ranged from 261.2 per 100,000 population to 386.6 per 100,000 population.

DISCUSSION: The present report is the first time that administrative data have been used to estimate the annual rate of medically attended GH cases in Canada. The data include both incident and prevalent cases and are likely an underestimate of the actual number of cases because they only represent diagnosed cases presenting for medical care. Further seroepidemiological and clinical research studies would be helpful to assess the burden of infection and to plan appropriate diagnostic, treatment and preventive counselling services.
Association of Breastfeeding with Asthma in Young Aboriginal Children in Canada
Authors: Ye Ming , Mandhane Piushkumar J , Senthilselvan Ambikaipakan
Published: March 2016

BACKGROUND: Few studies have investigated the factors associated with asthma in young Aboriginal children.

OBJECTIVE: To characterize the association of demographic, environmental and early life factors with asthma in young Aboriginal children in Canada.

METHODS: The 2006 Aboriginal Children’s Survey was conducted among off-reserve Aboriginal children zero to six years of age to obtain information on Aboriginal children’s development and well-being. The prevalence of asthma in Aboriginal children was obtained from the parental report of asthma as diagnosed by a health care professional.

RESULTS: The prevalence of reported asthma among off-reserve Aboriginal children zero to six years of age (n=14,170) was 9.4%. Asthma prevalence in both exclusively breastfed children (6.8%) and ever but not exclusively breastfed children (9.0%) was significantly lower than that in nonbreastfed children (11.0%). In the multiple logistic regression analysis, exclusive breastfeeding was protective of asthma compared with nonbreastfeeding (OR 0.59 [95% CI 0.44 to 0.78]). Older age groups, male sex, having two or more older siblings, low birth weight, day care attendance and ear infection were significant risk factors for asthma.

CONCLUSIONS: The prevalence of asthma among young Aboriginal children zero to six years of age living off reserve was slightly lower than that reported for all other Canadian children. Breastfeeding, especially exclusively breastfeeding, was protective of asthma in Aboriginal children, which is consistent with what has been observed in non-Aboriginal children in Canada. Public health interventions intended for reducing asthma incidence in young Aboriginal children should include breastfeeding promotion programs.
Sternum Length and Rib Cage Dimensions Compared with Bodily Proportions in Adults with Cystic Fibrosis
Authors: Laurin Louis-Philippe , Jobin Vincent , Bellemare François
Published: March 2016

BACKGROUND: A greater structural expansion of the rib cage in females compared with males has been described in cystic fibrosis (CF) patients; however, conflicting data exist as to whether an elongation of the bony ribs and sternum contributes to this expansion.

OBJECTIVES: To compare height‐adjusted anthropometric measures and sternum length between a group of normal subjects and a group of CF patients of both sexes.

METHODS: Anthropometric measurements including body weight, height, upper and lower limb lengths, biacromial distance and pelvic width were measured in the standing position in 30 CF patients (13 males) and 28 normal subjects (14 males). Body surface measurements of anterior‐posterior and lateral diameters of the rib cage at functional residual capacity, and sternum length were also obtained.

RESULTS: Compared with normal subjects, CF patients had lower body weight, shorter standing height and shorter height‐adjusted upper and lower limb lengths. Rib cage diameters were greater in CF patients than in normal subjects of either sex, but height‐adjusted sternum length was not different.

CONCLUSION: Significant differences in bodily proportions were found between normal subjects and CF patients, suggesting a differential growth pattern for the trunk and limbs. However, increased rib cage dimensions with lung hyperinflation and airway obstruction was not associated with an elongation of the sternum.
Characterizing the HIV Epidemic in the Prairie Provinces
Authors: Becker Marissa L , Kasper Ken , Pindera Carla , Cheang Mary , Rodger Debbie , Sanche Stephen , Skinner Stuart , Gill M John
Published: March 2016

BACKGROUND: The numbers and demographics of HIV‐positive patients in care between 2003 and 2007 in the prairie provinces were examined.

METHODS: Estimates of HIV‐positive patients presenting to care between 2003 and 2007 were obtained from four clinic registries in Manitoba, Saskatchewan and southern Alberta. Detailed data were collected from clinical records of new patients in 2007.

RESULTS: By the end of December 2007, 2263 HIV‐positive persons were in care in Manitoba, Saskatchewan and southern Alberta. Males and females accounted for 1674 (74.0%) and 589 of the cases, respectively. Overall, there was a 12% increase per year in new HIV cases to care between 2003 and 2007 (P=0.026), with the rate of increase for males being 60% higher than for females over this time period (P=0.002). In 2007, there were 222 new HIV cases to care (37.4% female). Heterosexual contact was the most common HIV risk, but diversity was seen across sites with frequent injection drug use and men who have sex with men risk in Saskatchewan and southern Alberta, respectively. The Aboriginal population remains heavily over‐represented, with approximately 36.0% of new cases being Aboriginal. Late presentation was common across all care sites, with 35.1% of cases presenting with CD4 counts of less than 200 cells/mm3.

DISCUSSION: Heterosexual risk is the most common risk reported for HIV acquisition, but injection drug use risk remains significant in Saskatchewan. Aboriginals are over‐represented at all sites, and in Saskatchewan accounted for the majority of new cases seen. In contrast to national trends, numbers of new and late diagnoses are increasing in the praire provinces, and this has significant treatment implications and potential public health consequences. Further efforts need to be made to facilitate earlier testing and linkage to care.
Management of Primary Sclerosing Cholangitis: Conventions and Controversies
Authors: Chandok Natasha , Hirschfield Gideon M
Published: March 2016

Primary sclerosing cholangitis (PSC) is a chronic inflammatory cholangiopathy that results in fibrotic strictures and dilations of the intra- and extrahepatic bile ducts. PSC is uncommon, occurs predominantly in males and has a strong association with inflammatory bowel disease. While the pathogenesis of PSC has not been fully elucidated, emerging evidence supports roles for the innate and adaptive immune systems, and genome-wide analyses have identified several genetic associations. Using the best available evidence, the present review summarizes the current understanding of the diagnosis, pathogenesis and management of PSC. Despite its rarity, there is an urgent need for collaborative research efforts to advance therapeutic options for PSC beyond liver transplantation.
The Over-the-Scope Clip System – A Novel Technique for Sastrocutaneous Fistula closure: The first North American Experience
Authors: Kothari Truptesh H , Haber Gregory , Sonpal Niket , Karanth Nithin
Published: March 2016

BACKGROUND: The mainstay of therapy for gastrocutaneous (GC) fistulas has been surgical intervention. However, endoclips are currently used for management of perforations and fistulas but are limited by their ability to entrap and hold the tissue.

OBJECTIVE: To report the first North American experience with a commercially available over-the-scope clip (OTSC) device, a novel and new tool for the endoscopic entrapment of tissue for the closure of fistula and perforations.

METHODS: The present single-centre study was conducted at a tertiary referral academic gastroenterology unit and centre for advanced therapeutic endoscopy and involved patients referred for endoscopic treatment for the closure of a GC fistula. The OTSC device was mounted on the tip of the endoscope and passed into the stomach to the level of the fistula. The targeted site of the fistula was grasped with the tissue anchoring tripod and pulled into the cap with concomitant scope channel suction. Once the tissue was trapped in the cap, a ‘bear claw’ clip was deployed.

RESULTS: The patients recovered with fistula closure. No complication or recurrence was noted. Fistula sizes >1 cm, however, were difficult to close with the OTSC system. The length of stay of the bear claw clip at the fistula site is unpredictable, which may lead to incomplete closure of the fistula.

CONCLUSION: Closure of a GC fistula using a novel ‘bear claw’ clip system is feasible and safe.
Family Caregiver Perspectives on Caring for Ventilator-Assisted Individuals at Home
Authors: Evans Rachael , Catapano Michael , Brooks Dina , Goldstein Roger , Avendano Monica
Published: March 2016

BACKGROUND: The trend of patients who are invasively ventilated to prefer home care is one that benefits both the patient and the health care system. However, this assumes a role for patients’ family members to become informal caregivers.

OBJECTIVE: To explore the impact of caring for a ventilator-assisted individual on informal caregivers.

METHODS: A descriptive design with semistructured caregiver interviews and the Caregiver Burden Inventory were used. Participants were informal caregivers of a family member with a progressive neuromuscular disease on invasive ventilation for at least six months. Transcript coding was performed and regularly reviewed, and recruitment continued until data saturation. Qualitative analysis was based on ‘thematic analysis’.

RESULTS: A total of 21 caregivers were interviewed. Five themes developed: a sense of duty; restriction of day-to-day life; physical and emotional burden; training and education; and the need for more paid support. Caregivers described a sense of duty to take care of loved ones, but suffered a significant restriction of their own time with a negative impact on their physical and mental health. The initial transfer home was highlighted as the most stressful part of the process. The Caregiver Burden Inventory scores supported a high level of burden: median 49 (interquartile range 39.5 to 53.0) of a maximum 96.

CONCLUSION: Homecare for ventilator-assisted individuals with progressive neuromuscular disease causes significant burden to informal care-givers. Approaches to lessen this burden, such as increased paid care, improved professional support and respite care, may enable home ventilation to be a more sustainable modality of care.
Yellow Nails, Lymphedema and Chronic Cough: Yellow Nail Syndrome in an Eight‐Year‐Old Girl
Authors: Siddiq Ishita , Hughes Daniel
Published: March 2016

Yellow nail syndrome is a rare disease and reported mainly in adults. A case of yellow nail syndrome involving an eight‐year‐old girl with associated discoloured yellowish nails on the fingers and toes, lymphedema and chronic cough, and sputum production is reported.
Wait Times for Diagnostic Colonoscopy among Outpatients with Colorectal Cancer: A Comparison with Canadian Association of Gastroenterology Targets
Authors: Sey Michael Sai Lai , Gregor Jamie , Adams Paul , Khanna Nitin , Vinden Chris , Driman David , Chande Nilesh
Published: March 2016

BACKGROUND: Timely access to colonoscopy is a nationally recognized issue in Canada, with previous studies documenting significant wait times for a variety of indications. However, specific wait times for colonoscopy among patients diagnosed with colorectal cancer remain unknown.

METHODS: A review of all outpatient cases of colorectal cancer diagnosed at colonoscopy in London, Ontario, in 2010 was performed. Wait times from the date of referral to colonoscopy were reviewed and compared with maximal wait times established by the Canadian Association of Gastroenterology (CAG) stratified according to indication. Cancer stage at the time of diagnosis was compared with colonoscopy wait times.

RESULTS: A total of 106 colorectal cancer patients meeting the inclusion and exclusion criteria were included in the study. Forty-six per cent of patients waited longer than CAG targets, with a mean (± SD) wait time of 79±101 days. Higher cancer stage was associated with shorter wait time, likely as a result of triaging.

CONCLUSION: Long wait times for diagnostic colonoscopy among patients with colorectal cancer remain an issue, with a significant proportion of cases not meeting maximal CAG wait time targets.
Opioids in Chronic Noncancer Pain: More Faces from the Crowd
Authors: Watson C Peter N
Published: March 2016

BACKGROUND: The use of opioids for chronic noncancer pain (CNCP) remains very controversial. There are several randomized controlled trials, mostly in neuropathic pain, reporting efficacy and safety in the short term, but more long‐term data are needed. Randomized controlled trials may be limited in providing data about the patients who benefit from often high‐dose opioids over the long term. The present article provides details of these patients and adds to a previous case series.

METHODS: The present article contains 17 case reports of 11 CNCP conditions (followed to 2011) selected to illustrate specific issues from a survey of 84 patients with intractable CNCP treated with opioids and followed every three months for a median of 11 years. The previous published survey of this group reported outcomes of pain severity, adverse effects, pain relief, satisfaction, mood, problematic opioid use, tolerance, physical dependency, functional status, health‐related quality of life (HRQL), immune status and sexual function. The outcome measures for that study included a numerical rating scale for pain, the Hospital Anxiety and Depression Scale, the Brief Pain Inventory Interference Scale, the Pain Disability Index and, for HRQL, the Short‐Form Health Survey 12 version 2. Most patients in the total sample reported 50% or greater relief and a moderate improvement in disability. Scores for functional status and HRQL were not severely affected. Problematic use, tolerance and serious adverse effects, including constipation, were not major issues. These selected patient reports were chosen, not to illustrate optimal results, but rather important aspects of the diagnoses, opioids and doses, the paucity of intolerable adverse effects, particular issues (concurrent addiction history, bipolar disorder and combination therapy), disease‐specific and other outcomes and duration of follow‐up with complex pain problems.

RESULTS: Opioids were found to be safe and useful in the long term for these particular patients, as well as in the larger group from which they originated.

INTERPRETATION: These 17 reports of patients with intractable CNCP treated with opioids with some success over many years puts a face on more of the participants in the larger survey of 84 subjects, suggesting that this approach is effective and safe for some patients over many years.
Perceived Injustice Moderates the Relationship between Pain and Depressive Symptoms among Individuals with Persistent Musculoskeletal Pain
Authors: Scott Whitney , Sullivan Michael
Published: March 2016

BACKGROUND: Numerous investigations report that depressive symptoms frequently coexist with persistent pain. However, evidence suggests that symptoms of depression are not an inevitable consequence of pain. Diathesis‐stress formulations suggest that psychological factors interact with the stress of pain to heighten the risk of depressive symptoms. Perceptions of injustice have recently emerged as a factor that may interact with the stress of pain to increase depressive symptoms.

OBJECTIVES: The purpose of the present study was to examine whether perceived injustice moderates the relationship between pain and depressive symptoms.

METHODS: A total of 107 individuals with persistent musculoskeletal pain completed self‐report measures of pain severity, depressive symptoms, perceived injustice and catastrophizing.

RESULTS: A hierarchical regression analysis revealed that the interaction between pain severity and perceived injustice uniquely contributed an additional 6% of the variance to the prediction of depressive symptoms, beyond the main effects of these variables. Post hoc probing indicated that pain was significantly related to depressive symptoms at high, but not low levels of perceived injustice. This finding remained statistically significant even when controlling for pain catastrophizing.

CONCLUSIONS: The results suggest that perceived injustice augments the relationship between pain severity and depressive symptoms. The inclusion of techniques specifically targeting perceptions of injustice may enhance the effectiveness of interventions aimed at reducing symptoms of depression for individuals presenting with strong perceptions of injustice.
The Changing Demographics of Women Living with HIV/AIDS in Southern Alberta from 1982 to 2006
Authors: Hwang Liana , Raffa Jesse , Gill Michael John
Published: March 2016

INTRODUCTION: Women account for a growing proportion of HIV infections in Canada. This has implications with respect to prevention, diagnosis and treatment.

OBJECTIVE: To describe the female population presenting for HIV care in southern Alberta and to examine the impact of opt‐out pregnancy screening.

METHODS: A retrospective review of demographic and clinical characteristics of all patients presenting to the Southern Alberta HIV Clinic (SAC) care program from 1982 to 2006, was performed.

RESULTS: The proportion of newly diagnosed patients who were female increased from 7.5% before 1998 to 21.5% after 1998. Women were more likely to be from vulnerable populations, such as intravenous drug users (31.3% versus 13.7%, P<0.001), aboriginals/Métis (21.5% versus 8.7%, P<0.001), blacks (28.9% versus 4.9%, P<0.001) and immigrants (36.6% versus 14.7%, P<0.001). Heterosexual intercourse was the main risk factor for HIV acquisition (43.7%). Women were less likely than men to have requested HIV testing (20.9% versus 37.8%, P<0.001). Opt‐out pregnancy screening accounted for 12.7% of HIV‐positive tests in women, following its introduction in 1998. Of the women diagnosed by pregnancy screening, 62.1% were from HIV‐endemic countries. There was an association between reason for testing and CD4 count at presentation; women who requested their HIV test had higher median CD4 counts than those diagnosed because of illness (478 cells/mL, interquartile range [IQR]=370 cells/mL versus 174 cells/mL, IQR=328 cells/mL, P<0.001) or pregnancy screening (478 cells/mL, IQR=370 cells/mL versus 271 cells/mL, IQR=256 cells/mL, P=0.001).

CONCLUSIONS: Women were less likely than men to have requested HIV testing and were more likely to be diagnosed by population‐based screening methods. Women, especially vulnerable groups, account for a growing number and proportion of newly diagnosed HIV infections in Alberta. The implications of expanded screening in this population merit further consideration.
Educational Needs of Health Care Providers Working in Long‐Term Care Facilities with Regard to Pain Management
Authors: Tousignant-Laflamme Yannick , Tousignant Michel , Lussier David , Lebel Paule , Savoie Maryse , Lalonde Lyne , Choinière Manon
Published: March 2016

BACKGROUND: The prevalence of chronic pain ranges from 40% to 80% in long‐term care facilities (LTCF), with the highest proportion being found among older adults and residents with dementia. Unfortunately, pain in older adults is underdiagnosed, undertreated, inadequately treated or not treated at all. A solution to this problem would be to provide effective and innovative interdisciplinary continuing education to health care providers (HCPs).

OBJECTIVE: To identify the educational needs of HCPs working in LTCF with regard to pain management.

METHODS: A qualitative research design using the nominal group technique was undertaken. Seventy‐two HCPs (21 physicians/pharmacists, 15 occupational/physical therapists, 24 nurses and 21 orderlies) were recruited from three LTCF in Quebec. Each participant was asked to provide and prioritize a list of the most important topics to be addressed within a continuing education program on chronic pain management in LTCF.

RESULTS: Forty topics were generated across all groups, and six specific topics were common to at least three out of the four HCP groups. Educational need in pain assessment was ranked the highest by all groups. Other highly rated topics included pharmacological treatment of pain, pain neurophysiology, nonpharmacological treatments and how to distinguish pain expression from other behaviours.

CONCLUSION: The present study showed that despite an average of more than 10 years of work experience in LTCF, HCPs have significant educational needs in pain management, especially pain assessment. These results will help in the development of a comprehensive pain management educational program for HCPs in LTCF.
Management of Chronic Hepatitis B: Canadian Association for the Study of the Liver Consensus Guidelines
Authors: Coffin Carla S , Fung Scott K , Ma Mang M
Published: March 2016

Chronic hepatitis B (CHB) is a dynamic disease that is influenced by host and virological factors. The management of CHB has become more complex with the increasing use of long-term oral nucleos/tide analogue antiviral therapies and the availability of novel diagnostic assays. Furthermore, there is often a lack of robust data to guide optimal management such as the selection of therapy, duration of treatment, potential antiviral side effects and the treatment of special populations. In November 2011, the Canadian Liver Foundation and the Canadian Association for the Study of the Liver convened a consensus conference to review the literature and analyze published data, including other international expert guidelines on CHB management. The proceedings of the consensus conference are summarized and provide updated clinical practice guidelines to assist Canadian health care providers in the prevention, diagnosis, assessment and treatment of CHB.
Epigenetics and the Developmental Origins of Inflammatory Bowel Diseases
Authors: Kellermayer Richard
Published: March 2016

The gut microbiota, the intestinal mucosa and the host immune system are among the large biological networks involved in the development of inflammatory bowel disease (IBD), which includes Crohn disease (CD) and ulcerative colitis (UC). Host genetics and environmental factors can significantly modulate the interactive relationships among these biological systems and influence predilection toward IBD. High monozygotic twin discordance rates and the rapid rise in the prevalence of IBD indicate that environmental influences may be as important or even more important in their pathogenesis than genetic susceptibility. However, the nature and timing of environmental factors critical for inducing IBD remain largely unknown. The molecular mechanisms and the key biological component(s) that may be affected by such factors are also in question. Epigenetic changes, such as DNA methylation (the methylation of cytosines followed by a guanine in CpG dinucleotides) can be modified by environmental influences during finite developmental periods and have been implicated in the pathogenesis of IBD. Mucosal DNA methylation can also react to changes in the commensal microbiota, underscoring the intercalating relationships among the large biological systems involved in gastrointestinal disorders. Therefore, transient environmental influences during specific periods of development may induce critical change(s) in an isolated or concomitant fashion within the intestinal biomic networks and lead to increased susceptibility to IBD. The present review focuses on the emerging paradigm shift considering IBD to originate from critical environmental effects during pre- and postnatal development.
Penicillin Susceptibility and Macrolide‐Lincosamide‐Streptogramin B Resistance in Group B Streptococcus Isolates from a Canadian Hospital
Authors: Sherman Kevin , Whitehead Sue , Blondel-Hill Edith , Wagner Ken , Cheeptham Naowarat
Published: March 2016

BACKGROUND: Intrapartum antibiotic prophylaxis (IAP) is recommended for pregnant women who test positive for group B Streptococcus (GBS) in their genitourinary tract to prevent GBS‐induced neonatal sepsis. Penicillin G is used as the primary antibiotic, and clindamycin or erythromycin as the secondary, if allergies exist. Decreased susceptibility to penicillin G has occasionally been reported; however, clindamycin and erythromycin resistance is on the rise and is causing concern over the use of clindamycin and erythromycin IAP.

METHODS: Antibiotic resistance was characterized phenotypically using a D‐Test for erythromycin and clindamycin, while an E‐Test (E‐strip) was used for penicillin G. GBS was isolated from vaginal‐rectal swabs and serologically confirmed using Prolex (Pro‐Lab Diagnostics, Canada) streptococcal grouping reagents. Susceptibility testing of isolates was performed according to the Clinical Laboratory Standards Institute guidelines.

RESULTS: All 158 isolates were penicillin G sensitive. Inducible macrolide‐lincosamide‐streptogramin B (MLSB) resistance was observed in 13.9% of isolates. Constitutive MLSB resistance was observed in 12.7% of isolates. M phenotype resistance was observed in 6.3% of isolates. In total, erythromycin resistance was present in 32.9% of the GBS isolates, while clindamycin resistance was present in 26.6%.

DISCUSSION: The sampled GBS population showed no sign of reduced penicillin susceptibility, with all being well under susceptible minimum inhibitory concentration values. These data are congruent with the large body of evidence showing that penicillin G remains the most reliable clinical antibiotic for IAP. Clindamycin and erythromycin resistance was higher than expected, contributing to a growing body of evidence that suggests the re‐evaluation of clindamycin and erythromycin IAP is warranted.
An Audit of Pain Management Following Pediatric Day Surgery at British Columbia Children’s Hospital
Authors: Shum Serena , Lim Joanne , Page Trish , Lamb Elizabeth , Gow Jennifer , Ansermino J Mark , Lauder Gillian
Published: March 2016

A prospective audit of 225 children was conducted to evaluate current pain management strategies both in‐hospital and at home following day surgery at British Columbia Children’s Hospital (Vancouver, British Columbia). Anesthetic, postanesthetic care unit and surgical day care unit records were collected to generate in‐hospital data. A telephone questionnaire was administered 48 h postdischarge for at home data. Pain reports and scores were significantly higher (P<0.01) at home compared with in‐hospital. Children undergoing certain procedures were more likely to experience significant pain. Although good pain control was commonly achieved after surgery, improvements may be possible by increasing the use of multimodal analgesia, providing standardized written discharge instructions and using surgery‐specific pediatric analgesia guidelines.
Incidence of Severe Pain in Newly Diagnosed Ambulatory Patients with Stage IV Cancer
Authors: Isaac Thomas , Stuver Sherri O , Davis Roger B , Block Susan , Weeks Jane C , Berry Donna L , Weingart Saul N
Published: March 2016

BACKGROUND: Pain is common among cancer patients.

OBJECTIVE: To characterize the incidence of severe pain among newly diagnosed patients with stage IV cancer in ambulatory care.

METHODS: A retrospective cohort of 505 ambulatory oncology patients with newly diagnosed stage IV solid tumours at a comprehensive cancer centre (Dana‐Farber Cancer Institute, Boston, Massachusetts, USA) was followed from January 1, 2004, to December 31, 2006. Pain intensity scores were extracted from electronic medical records. The incidence of severe pain was calculated using the maximum monthly pain scores reported at outpatient visits.

RESULTS: Of the 505 patients included in the present study, 340 (67.3%) were pain‐free at the initial visit, 90 (17.8%) experienced mild pain, 48 (9.5%) experienced moderate pain and 27 (5.4%) experienced severe pain. At least one episode of severe pain within one year of diagnosis was reported by 29.1% of patients. Patients with head and neck, gastrointestinal and thoracic malignancies were more likely to experience severe pain compared with patients with other types of cancer (52.6%, 33.9% and 30.5%, respectively). In the multivariable model, patients whose primary language was not English (OR 2.90 [95% CI 1.08 to 7.80]), patients who reported severe pain at the initial visit (OR 9.30 [95% CI 3.72 to 23.23]) and patients with head and neck (OR 10.17 [95% CI 2.87 to 36.00]) or gastrointestinal (OR 4.05 [95% CI 1.23 to 13.35]) cancers were more likely to report severe pain in the following year.

CONCLUSIONS: The incidence of severe pain was high in ambulatory patients with newly diagnosed stage IV cancer.
A Caenorhabditis elegans Host Model Correlates with Invasive Disease Caused by Staphylococcus aureus Recovered during an Outbreak in Neonatal Intensive Care
Authors: Wu Kaiyu , Simor Andrew E , Vearncombe Mary , McClure Jo-Ann , Zhang Kunyan
Published: March 2016

BACKGROUND: Caenorhabditis elegans has previously been used as a host model to determine the virulence of clinical methicillin‐resistant Staphylococcus aureus isolates. In the present study, methicillin‐susceptible S aureus (MSSA) strains associated with an outbreak in a neonatal intensive care unit (NICU) were investigated using the C elegans model.

METHODS: Two distinct outbreak clones, MSSA type‐C and MSSA type‐G, were identified by pulsed‐field gel electrophoresis in a MSSA outbreak during a seven‐month period in the NICU of the Sunnybrook Health Sciences Centre (Toronto, Ontario). MSSA type‐C was associated with severe infection, while type‐G was associated with less invasive disease. Four representative type‐C isolates, three type‐G and three infant‐colonized isolates unrelated to the outbreak, were sent to Calgary (Alberta), for the double‐blinded virulence tests in the C elegans host model and for further molecular characterization.

RESULTS: The invasive outbreak strains (type‐C) demonstrated highly nematocidal activity, the noninvasive outbreak strains (type‐G) an intermediate virulence, and the outbreak‐unrelated colonization isolates demonstrated avirulence or low virulence in the C elegans model, with mean killing rates of 93.0%, 61.0% and 14.4% by day 9, respectively, for these three group strains. Different group MSSA strains had their own unique genetic profiles and virulence gene profiles, but all isolates within the same group (type‐C or type‐G) shared identical genetic characteristics and virulence gene patterns.

CONCLUSIONS: The present blinded evaluation demonstrated that the nematocidal activities of MSSA strains correlated well with the clinical manifestation in an MSSA outbreak in the NICU, supporting C elegans as a robust host model to study the pathogenesis of S aureus.
Cystic Fibrosis Transmembrane Conductance Regulator Gene Abnormalities in Patients with Asthma and Recurrent Neutrophilic Bronchitis
Authors: Goodwin Jodi , Spitale Naomi , Yaghi Asma , Dolovich Myrna , Nair Parameswaran
Published: March 2016

The present case series describes four patients with asthma, airway hyper‐responsiveness and neutrophilic bronchitis who harboured abnormal cystic fibrosis transmembrance conductance regulator (CFTR) gene mutations. It serves both to alert clinicians to consider CFTR‐related disease in both young and elderly patients with persistent neutrophilic bronchitis, and to highlight the potential utility of future genetic testing for CFTR abnormalities in patients with asthma and recurrent bronchitis or pansinusitis, and the role of nebulized hypertonic saline as a therapeutic option in these patients.
Oscillometric and Spirometric Bronchodilator Response in Preschool Children with and without Asthma
Authors: Shin Youn Ho , Jang Sun Jung , Yoon Jung Won , Jee Hye Mi , Choi Sun Hee , Yum Hye Yung , Warburton David , Han Man Yong
Published: March 2016

BACKGROUND: Bronchodilator responses (BDR) are routinely used in the diagnosis and management of asthma; however, their acceptability and repeatability have not been evaluated using quality control criteria for preschool children.

OBJECTIVES: To compare conventional spirometry with an impulse oscillometry system (IOS) in healthy and asthmatic preschool children.

METHODS: Data from 30 asthmatic children and 29 controls (two to six years of age) who underwent IOS and spirometry before and after salbutamol administration were analyzed.

RESULTS: Stable asthmatic subjects significantly differed versus controls in their spirometry‐assessed BDR (forced expiratory volume in 1 s [FEV1], forced vital capacity and forced expiratory flow at 25% to 75% of forced vital capacity) as well as their IOS‐assessed BDR (respiratory resistance at 5 Hz [Rrs5], respiratory reactance at 5 Hz and area under the reactance curve). However, comparisons based on the area under the ROC curve for ΔFEV1 % initial versus ΔRrs5 % initial were 0.82 (95% CI 0.71 to 0.93) and 0.75 (95% CI 0.62 to 0.87), respectively. Moreover, the sensitivity and specificity for ΔFEV1 ≥9% were 0.53 and 0.93, respectively. Importantly, sensitivity increased to 0.63 when either ΔFEV1 ≥9% or ΔRrs5 ≥29% was considered as an additional criterion for the diagnosis of asthma.

CONCLUSION: The accuracy of asthma diagnosis in preschool children may be increased by combining spirometry with IOS when measuring BDR.
Mechanisms of Reduced Susceptibility to Ciprofloxacin in Escherichia coli Isolates from Canadian Hospitals
Authors: Baudry-Simner Patricia J , Singh Amanpreet , Karlowsky James A , Hoban Daryl J , Zhanel George G , Canadian Antimicrobial Resistance Alliance
Published: March 2016

OBJECTIVE: To determine whether plasmid‐mediated quinolone resistance (PMQR) determinants play a role in the increasing resistance to fluoroquinolones among Escherichia coli isolates in Canadian hospitals, and to determine the mechanisms of reduced susceptibility to ciprofloxacin in a recent collection of 190 clinical E coli isolates.

METHODS: E coli isolates (n=1702) were collected as part of the 2007 Canadian Hospital Ward Antibiotic Resistance Surveillance (CANWARD) study. Antimicrobial susceptibility testing was performed by Clinical and Laboratory Standards Institute (CLSI) broth microdilution. Using a representative subset of isolates (n=190), the mechanisms of reduced susceptibility to ciprofloxacin were detected by polymerase chain reaction and sequencing of the quinolone resistance‐determining regions (QRDR) of chromosomal gyrA and parC genes, and by polymerase chain reaction for the PMQR genes: qnr, aac(6′) Ib-cr and qepA.

RESULTS: 2.1% and 1.1% of E coli harboured aac(6′)Ib-cr and qnrB, respectively. Single amino acid substitutions in the QRDR of gyrA were observed among isolates with ciprofloxacin minimum inhibitory concentrations as low as 0.12 μg/mL. As the ciprofloxacin minimum inhibitory concentration increased to 1 μg/mL (which is still considered to be susceptible by the CLSI), the vast majority of isolates demonstrated both gyrA and parC mutations.

CONCLUSION: PMQR determinants and QRDR mutants among clinical E coli isolates with reduced susceptibility to ciprofloxacin demonstrates the need for increased surveillance and the need to re‐evaluate the current CLSI breakpoints to prevent further development of fluoroquinolone resistance.
Use of Interferon-Gamma Release Assays in a Health Care Worker Screening Program: Experience from a Tertiary Care Centre in the United States
Authors: Joshi Manish , Monson Thomas P , Woods Gail L
Published: March 2016

BACKGROUND: Interferon-gamma release assays including the QuantiFERON-TB Gold In-Tube test (QFT-GIT [Cellestis Ltd, Australia]) may be used in place of the tuberculin skin test (TST) in surveillance programs forMycobacterium tuberculosisinfection control. However, data on performance and practicality of the QFT-GIT in such programs for health care workers (HCWs) are limited.

OBJECTIVES: To assess the performance, practicality and reversion rate of the QFT-GIT among HCWs at a tertiary health care institution in the United States.

METHODS: Retrospective chart review of HCWs at Central Arkansas Veterans Healthcare System (Arkansas, USA) who underwent QFT-GIT testing as a part of their employee screening between November 1, 2008 and October 31, 2009.

RESULTS: QFT-GIT was used to screen 3290 HCWs. The initial QFT-GIT was interpreted as positive for 129 (3.9%) HCWs, negative for 3155 (95.9%) and indeterminate for six (0.2%). Testing with QFT-GIT was repeated in 45 HCWs who had positive results on the initial test. The QFT-GIT reverted to negative in 18 (40.0%) HCWs, all of whom had negative TST status and initial interferon-gamma values of 0.35 IU/mL to 2.0 IU/mL.

CONCLUSIONS: The QFT-GIT test is feasible in large health care setting as an alternative to TST forM tuberculosisinfection screening in HCWs but is not free from challenges. The major concerns are the high number of positive test results and high reversion rates on repeat testing, illustrating poor short-term reproducibility of positive QFT-GIT test results. These results suggest adopting a borderline zone between interferon-gamma values of 0.35 IU/mL to 2.0 IU/mL, and cautious clinical interpretation of values in this range.
Improvements in Pain Outcomes in a Canadian Pediatric Teaching Hospital Following Implementation of a Multifaceted, Knowledge Translation Initiative
Authors: Zhu Lisa M , Stinson Jennifer , Palozzi Lori , Weingarten Kevin , Hogan Mary-Ellen , Duong Silvia , Carbajal Ricardo , Campbell Fiona A , Taddio Anna
Published: March 2016

BACKGROUND: A previous audit performed at a tertiary/quaternary pediatric hospital in Toronto, Ontario, demonstrated suboptimal assessment and treatment of children’s pain. Knowledge translation (KT) initiatives (education, reminders, audit and feedback) were implemented to address identified care gaps; however, the impact is unknown.

OBJECTIVES: To determine the impact of KT initiatives on pain outcomes including process outcomes (eg, pain assessment and management practices) and clinical outcomes (eg, pain prevalence and intensity); and to benchmark additional pain practices, particularly opioid administration and painful procedures.

METHODS: Medical records at The Hospital for Sick Children (Toronto, Ontario) were reviewed on a single day in September 2007. Pain assessment and management practices, and pain prevalence and intensity in the preceding 24 h were recorded on a standardized data collection form. Where possible, pain outcomes were compared with previous audit results.

RESULTS: Records of 265 inpatients were audited. Sixty‐three per cent of children underwent a documented pain assessment compared with 27% in an audit conducted previously (P<0.01). Eighty‐three per cent of children with documented pain received at least one pain management intervention. Overall, 51% of children received pharmacological therapy, and 15% received either a psychological or physical pain‐relieving intervention. Of those assessed, 44% experienced pain in the previous 24 h versus 66% in the previous audit (P<0.01). Fewer children experienced severe pain compared with the first audit (8.7% versus 26.1%; P<0.01). One‐third of children received opioids; 19% of these had no recorded pain assessment. Among 131 children who underwent a painful procedure, 21% had a concurrent pain assessment. Painful procedures were accompanied by a pain‐relieving intervention in 12.5% of cases.

CONCLUSIONS: Following KT initiatives, significant improvements in pain processes (pain assessment documentation and pain management interventions) and clinical outcomes (pain prevalence, pain intensity) were observed. Further improvements are recommended, specifically with respect to procedural pain practices and opioid utilization patterns.
Prion Disease Risk Perception in Canadian Medical Laboratories
Authors: Buxton Jane A , Henry Bonnie , Waheed Aiza , Crabtree Alexis
Published: March 2016

BACKGROUND: There are no national guidelines specific for handling prion‐associated specimens in Canadian medical laboratories. Medical laboratory workers may perceive themselves at risk of prion transmission and, on occasion, decline to process such specimens.

OBJECTIVE: To examine the knowledge, attitudes and reported behaviours of medical laboratory workers in relation to prion disease to understand their risk perception and the need for national laboratory guidelines on prion infection control.

DESIGN: Survey development and cross‐sectional web‐based administration

METHODS: The survey was developed through key informant interviews and a modified Delphi process. Medical laboratory workers across Canada were invited by laboratory managers and national organizations to complete the web‐based survey.

RESULTS: Twelve key informant interviews were performed. Consensus for questionnaire content was reached through two rounds of the Delphi process. Responses were received from 426 Canadian medical laboratory workers; 37% of medical laboratory staff reported processing prion‐associated specimens. Different protocols for specimen processing were followed, and 18% believed they were at risk when processing these specimens. Less than one‐third of those receiving specimens believed they were adequately trained. The mean (±SD) knowledge score was 9.25±4.5/24; individuals who had received training scored significantly higher than those who were untrained (P<0.01). Eighty‐one per cent of respondents would be more comfortable processing specimens if national guidelines existed and were used in their laboratory.

CONCLUSION: There is a high perception of risk and few perceived benefits of processing prion‐associated specimens. National guidelines for prion infection control in medical laboratories and adequate training would enable medical laboratory workers to process these specimens efficiently and confidently.
Meningitis due to Bacillus cereus: A Case Report and Review of the Literature
Authors: Stevens Michael P , Elam Kara , Bearman Gonzalo
Published: March 2016

Bacillus cereus is infrequently associated with invasive central nervous system (CNS) disease. Infection is associated with conditions that lead to reduced host immunity and provide direct access to the CNS, such as spinal anesthesia and ventricular tubes and shunts. A case of ventriculitis secondary to B cereus in a patient receiving intrathecal chemotherapy is reported, along with a review of the current literature. B cereus can colonize medical devices, thus posing a risk for invasive disease. Despite aggressive treatment with broad‐spectrum anti‐infectives, the mortality of CNS invasive B cereus is high. Clinicians should not dismiss Gram‐positive rods resembling Bacillus species from normally sterile sites as contaminants in critically ill patients. Appropriate antibiotic therapy should be promptly initiated to limit morbidity and mortality.