bluuebunny/crossref_metadata_2025 huggingface dataset:
A Cross-Sectional Analysis of Acute Hepatitis B Virus Reported to the Vancouver Coastal Health Authority from 2000 to 2003
Authors: Leung Yvette , Ip Chan Jessica , Yoshida Eric , Wu Hong-Xing , Daly Patricia C
Published: March 2016

BACKGROUND: Acute hepatitis B virus (HBV) transmission remains a significant public health problem despite effective vaccination and prophylaxis strategies. Vancouver, British Columbia, has a large ethnic community from endemic areas, which may further impact on the epidemiology of acute HBV. A cross-sectional study of factors associated with acute HBV cases reported to the Vancouver Coastal Health Authority (Vancouver, British Columbia) from 2000 to 2003 is reported.

METHODS: New seropositive cases of hepatitis B surface antigen were reported to the Vancouver Coastal Health Authority Office of Communicable Disease Control. Patients meeting both clinical and laboratory criteria for acute HBV were interviewed by telephone for demographic and risk behaviour information. Risk behaviours within the last six months before disease onset were ranked on efficiency of transmission in a mutually exclusive risk category.

RESULTS: There were 78 patients of identified acute HBV in Vancouver from 2000 to 2003. The overall incidence rate was 3.38 per 100,000 person years. Outside of Canada, Asia was the most common place of birth (29.5%). The three most frequently identified risk factors were men who have sex with men (21.9%), heterosexual activity with two or more partners (14.0%) and intravenous drug use (14.0%). Sexual contact with an HBV carrier was identified in 9.4% of patients.

CONCLUSIONS: Sexual transmission is a major mode in the spread of HBV in Vancouver. Existing public education, surveillance and vaccination strategies for HBV need to be strengthened to address those engaging in risky behaviours.
Increasing Incidence of Adenocarcinoma of the Gastroesophageal Junction and Distal Stomach in Canada – An Epidemiological Study from 1964 to 2002
Authors: Parfitt Jeremy R , Miladinovic Zoran , Driman David K
Published: March 2016

BACKGROUND: The increasing incidence of esophageal and proximal gastric (cardia) adenocarcinoma and the decreasing incidence of distal gastric (antropyloric) adenocarcinoma has been documented in several populations. The aim of the present study was to examine incidence trends of these neoplasms in Ontario, Canada’s most populous province, over a 39-year period.

METHODS: Analyses were based on data obtained from the Ontario Cancer Registry of Cancer Care Ontario. Number of cases and rates per 100,000, age-adjusted to the 1996 Canadian standard, were obtained for all esophageal and gastric carcinoma cases reported between 1964 and 2002. Rates were grouped into five-year periods to analyze trends over the 39-year period. Point and 95% CI estimates of average annual percentage change in incidence rates were calculated with a log-linear regression model.

RESULTS: The incidence of adenocarcinoma of the distal esophagus increased in men and women (average annual increase of 9.5% in men; 4.3% in women). The incidence of adenocarcinoma of the cardia increased in men and women (average annual increase of 7.3% in men; 5.8% in women). The incidence of antropyloric adenocarcinoma increased in men and women (average annual increase of 4.4% in men; 5.3% in women). The incidence of esophageal squamous cell carcinoma remained stable.

CONCLUSIONS: There has been a significant increase in the incidence of adenocarcinoma around the gastroesophageal junction in men over the 39-year study period. The increase in incidence of distal gastric adenocarcinoma is unexpected and may relate to a reclassification phenomenon, immigration trends in Ontario and a rising incidence of diffuse/signet ring cell adenocarcinoma.
Rupture, Invasion and Inflammatory Destruction of the Intestinal Barrier by Shigella: The Yin and Yang of Innate Immunity
Authors: Sansonetti Philippe J
Published: March 2016

Shigella is a Gram‐negative bacterial species of the family Enterobacteriaceae that causes bacillary dysentery in humans. This acute colitis reflects the capacity of the microorganism to disrupt, invade and cause the inflammatory destruction of the intestinal epithelium. The pathogenesis of the Shigella infection can be seen as a disruption of the homeostatic balance that protects the gut against inflammation in the presence of its commensal flora. This provides the unified view that enteroinvasive pathogens allow for the identification of key signalling molecules and pathways involved in the regulation of intestinal inflammation, and more generally, in the regulation of the innate and adaptive immune response.
Pneumonia Severity Index in the Immunocompromised
Authors: Sanders Kevin M , Marras Theodore K , Chan Charles KN
Published: March 2016

BACKGROUND: The pneumonia severity index (PSI) accounts for many comorbidities, but not immunosuppression.

OBJECTIVES: To document the utility of the PSI to predict mortality in immunocompromised patients (IP) with community‐acquired pneumonia (CAP).

METHODS: Charts of 284 patients with immunosuppression and CAP were reviewed, and these patients were compared with a contemporary sample of non‐IP with CAP. The ability of the PSI to predict mortality was assessed by using multiple logistic regression. Discrimination of the PSI was studied by using the concordance index.

RESULTS: Thirty‐nine of 284 IP died. Mortality varied according to the etiology of the immunosuppression. Patients with HIV, solid organ transplantation or treatment with immunosuppressive drugs (n=118) had a low in‐hospital mortality (4.3%) and were classified as low risk. IP with hematological malignancies, chemotherapy, chest radiation or marrow transplantation (n=166) had a high mortality (20%) and were classified as high risk. Compared with non‐IP, low‐risk IP had similar PSI‐controlled mortality (OR=0.9, P=0.80), whereas high‐risk IP had significantly greater mortality (OR=2.8, P<0.0001). The concordance index revealed similar discrimination for the PSI in low‐risk IP (0.77) and in non‐IP (0.7), but inferior discrimination in high‐risk patients (0.6).

CONCLUSIONS: Patients with CAP and immunosuppression can be divided into low‐risk and high‐risk groups. The low‐risk IP have mortality similar to non‐IP and can be risk stratified by using the PSI.
Prenatal Screening for HIV in Nova Scotia: Survey of Postpartum Women and Audit of Current Prenatal Screening Practices
Authors: Downing Mark , Youden Laura , Halperin Beth A , Scott Heather , Smith Bruce , Halperin Scott A
Published: March 2016

BACKGROUND: Current guidelines for screening for HIV infections in Nova Scotia recommend an opt‐in approach in which patients are counselled and consent to testing. The objectives of the present study were to measure adherence to these recommendations, to explore women′s knowledge, attitudes, beliefs and behaviours concerning HIV screening, and to compare these results with prenatal screening practices for rubella, hepatitis B and group B streptococcus.

METHODS: All women who gave birth consecutively during a seven‐week period were recruited. Study participants were interviewed to determine their knowledge, attitudes and beliefs concerning prenatal screening. Hospital and laboratory records were reviewed for information concerning prenatal screening and perinatal treatment to audit screening practices.

RESULTS: A total of 279 patients were enrolled in the study, representing 58% of those eligible. The HIV screening rate was 72%, compared with 95% for rubella, 89% for hepatitis B and 24% for group B streptococcus. Of the participants tested for HIV, 80% were aware of being tested. Of all the study participants, 17% indicated having received pretest counselling about HIV, 56% volunteered to be tested for HIV, 78% received the test results, and 3.8% received post‐test counselling. More participants preferred an opt‐out approach to HIV screening (50%), where testing is routinely performed on everyone, rather than the opt‐in approach (43%). Participants displayed a similar preference for screening for the other infections.

INTERPRETATION: HIV prenatal testing rates in Nova Scotia are comparable with those of other provinces that recommend an opt‐in approach, but are lower than testing rates for opt‐out programs. Most study participants were not screened using the recommended opt‐in approach.
Recurrent Hepatitis C Post-Transplantation: Where Are We Now and Where Do We Go From Here? A Report from the Canadian Transplant Hepatology Workshop
Authors: Watt Kymberly DS , Burak Kelly , Deschênes Marc , Lilly Les , Marleau Denis , Marotta Paul , Mason Andrew , Peltekian Kevork M , Renner Eberhard L , Yoshida Eric M ,   for the Canadian Transplant Hepatology Outcomes Research Network
Published: March 2016

Approximately 400 liver transplants are performed in Canada every year and close to 6000 per year in the United States. Forty per cent to 45% of all liver transplants are performed for patients with underlying hepatitis C virus (HCV)-related liver disease. These patients have a different natural history, new complication risks and different treatment efficacy than nontransplant HCV patients. Every effort must be made to identify those patients at highest risk for progressive liver disease post-transplant. Recurrent HCV is an Achilles’ heel to transplant hepatology. The true natural history of this disease is only starting to unravel and many questions remain unanswered on the optimal management of these patients after liver transplantation. The present report summarizes the literature and ongoing research needs that are specific to HCV-related liver transplantation.
Transjugular Intrahepatic Portosystemic Shunt before Abdominal Surgery in Cirrhotic Patients: A Retrospective, Comparative Study
Authors: Vinet Evelyne , Perreault Pierre , Bouchard Louis , Bernard Denis , Wassef Ramses , Richard Carole , Létourneau Richard , Pomier-Layrargues Gilles
Published: March 2016

Surgery in cirrhotic patients is associated with high morbidity and mortality related to portal hypertension and liver insufficiency. Therefore, preoperative portal decompression is a logical approach to facilitate abdominal surgery and hopefully to improve postoperative survival. The present study evaluated the clinical outcomes of 18 patients (mean age 58 years) with cirrhosis (seven alcoholics and 11 nonalcoholics) who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement before antrectomy (n=5), colectomy (n=10), small-bowel resection (n=1), pancreatectomy (n=1) and nephrectomy (n=1). TIPS was performed a mean (± SD) of 72±21 days before surgery and induced a marked mean decrease in portohepatic gradient from 21.4±3.9 mmHg to 8.4±3.4 mmHg. Cirrhotic patients (n=17) who underwent elective abdominal surgery without preoperative TIPS placement were used as the control group. Both groups were matched for age, etiology of cirrhosis, indications for surgery, type of surgery and coagulation parameters. The mean Pugh score was significantly higher in the TIPS group (7.7 versus 6.2). No significant differences were observed for operative blood loss, postoperative complications, duration of hospitalization and one-month (83% versus 88%) or one-year (54% versus 63%) cumulative survival rate. Analysis using the Cox proportional hazards model showed that neither TIPS placement nor preoperative Pugh score were independent predictors for survival. The present study suggests that preoperative TIPS placement does not improve postoperative evolution after abdominal surgery in cirrhotic patients with good or moderately impaired liver function.
The Utility of Serum Receptor-Binding Cancer Antigen Expressed on Siso Cells in Gastrointestinal Tract Cancers
Authors: Çoban Şahin , Özkan Hasan , Köklü Seyfettin , Yüksel Osman , Koçkar Muhammed Cem , Akar Tarik , Örmeci Necati
Published: March 2016

BACKGROUND: Receptor-binding cancer antigen expressed on SiSo cells (RCAS1) is a novel tumour marker that has been described in various kinds of cancer. The majority of observations include immunohistochemical studies; however, there are not enough data about the utility of this antigen as a serum tumour marker and its tumour specificity.

AIM: To measure the serum levels of RCAS1 in patients with gastrointestinal (GI) tract cancers and compare them with other GI tract tumour markers.

PATIENTS AND METHODS: Sera collected from patients with GI cancers (14 esophagus, 32 gastric and 36 colon) and from healthy volunteers (30 individuals) were analyzed for RCAS1 and compared with carcinoembryonic antigen (CEA) and cancer antigen 19-9. The relationship between serum RCAS1, tumour stage and tumour grade was also evaluated.

RESULTS: Mean serum RCAS1 level was higher in patients with GI tract cancers compared with the control group (P=0.001). Among GI tract cancers, RCAS1 had lowest and highest sensitivity for esophagus and colon cancer diagnosis, respectively. Serum RCAS1 had a higher sensitivity for malignancy, except in the colon, and lower specificity in all groups compared with CEA. In comparison with cancer antigen 19-9, serum RCAS1 was more sensitive but less specific for all GI cancer groups. Mean serum RCAS1 levels were not statistically significant among histopathological tumour types (P>0.05). Although serum RCAS1 levels were significantly higher in cases with lymph node involvement compared with lymph node-negative cases (P=0.009), there was no difference between cases with and without serosal involvement, vascular invasion and distant metastasis; no correlation was found between tumour size and RCAS1 levels.

CONCLUSIONS: RCAS1 may be used and combined with CEA as a tumour marker in GI tract cancers.
Escherichia Coli: From Genome Sequences to Consequence
Authors: Pallen Mark
Published: March 2016

The present article summarizes a presentation given by Professor Mark Pallen of the School of Medicine at the University of Birmingham (Birmingham, United Kingdom) for the Fourth Stanier Lecture held in Regina, Saskatchewan, on November 9, 2004. Professor Pallen′s lecture, entitled ′Escherichia coli: From genome sequences to consequences′, provides a summary of the important discoveries of his team of research scientists in the area of genetic sequencing and variations in phenotypic expression.
A Case of Rectal Dieulafoy’s Ulcer and Successful Endoscopic Band Ligation
Authors: Yoshikumi Yukako , Mashima Hirosato , Suzuki Junko , Yamaji Yutaka , Okamoto Makoto , Ogura Keiji , Kawabe Takao , Omata Masao
Published: March 2016

Dieulafoy’s ulcer is a rare cause of gastrointestinal bleeding. The lesion is usually located in the stomach, although it may occur anywhere in the gastrointestinal tract. A 44-year-old man was admitted to hospital due to cerebral infarction. On the 23rd day of hospitalization, he showed massive hematochezia. He underwent an urgent colonoscopy. There was a visible protuberant vessel without significant ulceration at the fundus of the rectum, consistent with a Dieulafoy’s ulcer. It was treated by endoscopic hemoclipping. However, rebleeding occurred three times despite repeated hemoclipping. Finally, endoscopic band ligation was successfully performed to achieve permanent hemostasis. Endoscopic band ligation is an effective treatment for bleeding rectal Dieulafoy’s ulcer.
Rofecoxib-Induced Hepatotoxicity: A Forgotten Complication of the Coxibs
Authors: Yan Brian , Leung Yvette , Urbanski Stefan J , Myers Robert P
Published: March 2016

Rofecoxib is a member of the coxib family of nonsteroidal anti-inflammatory drugs that selectively inhibit cyclooxygenase-2. Although the coxibs are generally well-tolerated, rofecoxib was recently withdrawn from the market due to concerns regarding cardiovascular safety. Rare cases of hepatic injury attributable to the coxibs have been reported. In the present study, two additional cases of severe hepatotoxicity are described in patients with cholestatic symptoms and abnormal liver biochemistry, shortly following the initiation of rofecoxib for arthritic complaints. In both cases, liver histology was compatible with drug-induced hepatotoxicity, and rapid clinical and biochemical improvements were observed following rofecoxib discontinuation. With new coxibs and expanding indications on the horizon, physicians in all areas of practice must be aware of this disorder and consider it in any patient who develops hepatic dysfunction after taking a coxib.
Blood Serum Levels of Proinflammatory Cytokines in Patients with Different Degrees of Biliary Pancreatitis
Authors: Panek Józefa , Karcz Danuta , Pieton Richard , Zasada Jakub , Tusinski Marcin , Dolecki Miroslaw , Winiarski Marek
Published: March 2016

BACKGROUND: Proinflammatory cytokines play a fundamental role in the local and systemic inflammatory responses in the initial stages of acute biliary pancreatitis (ABP) and in the development of severe forms of the disease.

OBJECTIVES: The aim of the present study was to assess the systemic release of proinflammatory cytokines and to characterize differences between patients with mild ABP (MABP) and severe ABP (SABP)

PATIENTS AND METHODS: In the current study, 54 patients with MABP were compared with 14 patients with SABP. Serum levels of tumour necrosis factor-alpha, interleukin (IL)-1ß, IL-6, IL-8 and IL-12p40 were measured every second day after admission for one week.

RESULTS: The tumour necrosis factor-alpha level was similar in all days of analysis in patients with MABP but was lower compared with SABP patients. The level of IL-1ß was higher at admission in patients with MABP. The level of IL-6 peaked on admission day in both groups, but in patients with SABP, the obtained values were higher. The level of IL-8 on admission day was slightly higher in patients with MABP and systematically decreased when measured on the following days (the third, fifth and seventh days of the study). An increased level of IL-8 during the third, fifth and seventh days of the investigation was seen in SABP patients. The level of IL-12p40 was slightly higher in patients with MABP on the day of admission.

CONCLUSIONS: The levels of some proinflammatory cytokines are higher in patients with SABP than in patients with MABP. The most consistent difference between the two groups was that the levels of IL-6 were significantly higher in patients with SABP throughout the study. Serum concentration of IL-6 may be helpful as a marker of severity and outcome of ABP.
Gastric Calcifying Fibrous Tumour
Authors: Attila Tan , Chen Dean , Gardiner Geoffrey W , Ptak Theadore W , Marcon Norman E
Published: March 2016

Intramucosal gastric tumours are most commonly found to be gastrointestinal stromal tumours or leiomyomas (smooth muscle tumours); however, a variety of other uncommon mesenchymal tumours can occur in the stomach wall. A rare benign calcifying fibrous tumour is reported and the endoscopic appearance, ultrasound findings and morphology are documented. A review of the literature found only two similar cases.
Gastrointestinal Stromal Tumours: Consensus Statement on Diagnosis and Treatment
Authors: Blackstein Martin E , Blay Jean-Yves , Corless Christopher , Driman David K , Riddell Robert , Soulières Denis , Swallow Carol J , Verma Shailendra ,   on behalf of the Canadian Advisory Committee on GIST
Published: March 2016

In the multidisciplinary management of gastrointestinal stromal tumours (GISTs), there is a need to coordinate the efforts of pathology, radiology, surgery and oncology. Surgery is the mainstay for resectable nonmetastatic GISTs, but virtually all GISTs are associated with a risk of metastasis. Imatinib 400 mg/day with or without surgery is the recommended first-line treatment for recurrent or metastatic GIST; a higher dose may be considered in patients who progress, develop secondary resistance or present with specific genotypic characteristics. Adjuvant or neoadjuvant imatinib is not advised for resectable non-metastatic GISTs. Neoadjuvant imatinib may be considered when surgery would result in significant morbidity or loss of organ function. Follow-up computed tomography imaging is recommended every three to six months for at least five years. Patients with metastatic disease should be continued on imatinib due to the high risk of recurrence on discontinuation of therapy. Treatment should be continued until there is progression or intolerable adverse effects. If dose escalation with imatinib fails, a clinical trial with novel agents alone or in combination may be considered. The present recommendations were developed at a surgical subcommittee meeting and a subsequent full Advisory Committee meeting held in Toronto, Ontario, in April 2005, under the sponsorship of Novartis Pharmaceuticals Canada Inc.
Action Plans in Asthma
Authors: Beauchesne Marie-France , Levert Valérie , Tawil Miray El , Labrecque Manon , Blais Lucie
Published: March 2016

BACKGROUND: Action plans are recommended for most patients with persistent asthma to reduce the morbidity associated with this chronic disease. Unfortunately, despite these recommendations, this tool remains underused.

METHODS: The authors conducted a descriptive study at the asthma clinic of a tertiary care centre to determine the number of asthmatic patients presenting to a respiratory physician (new reference or follow‐up visit) who possessed an individualized, written action plan, and to evaluate the patients’ level of confidence and perceived efficacy toward their plans. In addition, for all patients in the study, the level of confidence in and the perceived efficacy of three different action plans (two traditional tools versus a simplified tool) were compared.

RESULTS: A total of 92 asthmatic patients were included in the study. Overall, 46% of the patients possessed an action plan. The patients’ average level of confidence and perceived efficacy toward their action plans were high (4.1 out of five and 3.3 out of four, respectively). When the three different action plans were compared, the level of confidence in and perceived efficacy of the traditional tools were similar, both being superior to the simplified tool.

CONCLUSION: The number of asthmatic patients who presented to the asthma clinic and who possessed an action plan was higher than the reported Canadian mean of 10%; however, most of the patients were treated by specialized respiratory physicians, which may explain this improvement. Considering that most patients with persistent asthma should have an individualized, written action plan, the present study confirms that this tool is still not used for all asthmatic patients.
Depression and Cigarette Smoking Independently Relate to Reduced Health-Related Quality of Life among Canadians Living with Hepatitis C
Authors: Balfour Louise , Cooper Curtis , Kowal John , Tasca Giorgio A , Silverman Amy , Kane Marie , Garber Gary
Published: March 2016

BACKGROUND: Many people living with chronic viral hepatitis C (HCV) report reduced health-related quality of life. The relative contribution of behavioural, psychosocial and HCV disease factors to reduction in HCV health-related quality of life is not well understood. The objectives of the present study were to compare standardized health-related quality of life scores between Canadian HCV patients and age-matched Canadian and American norms, and to examine the relative contribution of biopsychosocial variables (ie, cigarette smoking, alcohol intake and depression) to health-related quality of life scores among Canadian HCV patients.

METHODS: HCV RNA-positive patients were recruited during their first visit to the Ottawa Hospital Viral Hepatitis Clinic (Ottawa, Ontario). A questionnaire assessing health behaviours, health-related quality of life and depressed mood was completed. Data on liver studies, liver biopsy findings and HIV serostatus were also collected.

RESULTS: A total of 123 participants (71% men) ranging from 20 to 67 years of age were evaluated. All had compensated liver function. Patients reported significantly lower health-related quality of life compared with age-matched Canadian and American normative samples. In a series of hierarchical multiple regression models, depression and smoking were independently related to compromised health-related quality of life scores, even after controlling for sociodemographic variables and health behaviours.

DISCUSSION: These results highlight the value of adopting a biopsychosocial model of HCV care. Depressed mood and smoking behaviour should be evaluated in HCV patients. Empirically validated psychological and pharmacological treatments for depression and smoking cessation may improve health-related quality of life in HCV infected patients.
Retractile Mesenteritis Presenting as Protein-Losing Gastroenteropathy
Authors: Rajendran Bahe , Duerksen Donald R
Published: March 2016

Retractile mesenteritis is a rare, idiopathic condition characterized by nonspecific inflammation of the mesenteric adipose tissue. The majority of patients present with abdominal pain and/or a palpable mass. In the present report, a 68-year-old man with peripheral edema and mild hypoalbuminemia is presented. Protein-losing gastroenteropathy was confirmed with an abnormal stool alpha1-antitrypsin clearance test and retractile mesenteritis was diagnosed at laparoscopy. This rare condition may respond to therapy with corticosteroids, azathioprine, cyclophosphamide, colchicine, progesterone, tamoxifen or thalidomide. Gastroenterologists should consider the diagnosis of protein-losing enteropathy in patients who present with unexplained peripheral edema or hypoalbuminemia. The test of choice to confirm this diagnosis is the stool alpha1-antitrypsin clearance test.
The Effect of Information Level and Coping Style on Pain and Anxiety in Needle Liver Biopsy
Authors: Hilzenrat Nir , Yesovitch Rose , Shrier Ian , Stavrakis Maria , Deschênes Marc
Published: March 2016

Biopsy of the liver is an important diagnostic procedure. The procedure is invasive and may be painful for patients. Sedative drugs are not used because the associated drop in blood pressure mimics hemorrhage, a major complication of the procedure. Cognitive and behavioural techniques have been used to decrease stress in patients undergoing other medical procedures. In the present study, it is postulated that providing procedural and sensory information may reduce patient anxiety levels. Patient coping styles were evaluated and anxiety and pain levels were assessed by using a visual analogue scale. Subjects were randomly assigned to one of two groups. The control group received basic information about the procedure. The experimental group received the same basic information followed by more detailed educational information. Subjects also filled out the Krantz Health Opinion Survey, a short questionnaire used to classify coping styles as either information-seeking or information-avoiding. Seventy-five subjects (38 control and 37 experimental) with similar demographics were included in the present study. No significant differences were found in anxiety levels or pain levels 30 min and 6 h postbiopsy. There was also no significant difference between groups once coping style was added into the analysis. The study failed to show any advantage in providing additional information to subjects before liver biopsy, regardless of coping style.
The Pharmacotherapy of Chronic Pain: A Review
Authors: Lynch Mary E , Watson C Peter N
Published: March 2016

The past two decades have contributed a large body of preclinical work that has assisted in our understanding of the underlying pathophysiological mechanisms that cause chronic pain. In this context, it has been recognized that effective treatment of pain is a priority and that treatment often involves the use of one or a combination of agents with analgesic action. The current review presents an evidence‐based approach to the pharmacotherapy of chronic pain. Medline searches were done for all agents used as conventional treatment in chronic pain. Published papers up to June 2005 were included. The search strategy included randomized, controlled trials, and where available, systematic reviews and meta‐analyses. Further references were found in reference sections of papers located using the above search strategy. Agents for which there were no controlled trials supporting efficacy in treatment of chronic pain were not included in the present review, except in cases where preclinical science was compelling, or where initial human work has been positive and where it was thought the reader would be interested in the scientific evidence to date.
Preservation of Pleural Integrity during Coronary Artery Bypass Surgery Affects Respiratory Functions and Postoperative Pain: A Prospective Study
Authors: Oz Bilgehan Savas , Iyem Hikmet , Akay Hakki Tankut , Yildirim Vedat , Karabacak Kubilay , Bolcal Cengiz , Demirkiliç Ufuk , Tatar Harun
Published: March 2016

OBJECTIVE: To evaluate the role of preserved pleural integrity in postoperative pain and respiratory functional status in patients undergoing coronary revascularization.

METHODS: Two hundred forty patients undergoing on‐pump coronary artery bypass grafting between March 2004 and February 2005 were included in the present study. The patients were prospectively randomized and divided into either an opened pleura (OP) group (n=120, patients with an OP) or a closed pleura (CP) group (n=120, patients whose pleural integrity was preserved). Preoperative patient characteristics were similar. Postoperative respiratory functions were compared between the groups by chest x‐rays, respiratory functional tests and arterial blood gas analyses. Postoperative pain was compared by using a multidimensional pain score. All the tests were examined by the same blinded clinician.

RESULTS: The mean age of the patients was 60.4±8.8 years. Postoperative bleeding and the duration of hospital stay were markedly higher in the OP group than in the CP group. The incidences of atelectasis and pleural effusion were also significantly higher in the OP group (P<0.01). Respiratory functions and postoperative pain scores were better in the CP group (P<0.01 and P=0.008, respectively).

CONCLUSIONS: Preserving pleural integrity has beneficial effects on the respiratory functions and postoperative pain after coronary revascularization. The preservation of pleural integrity results in better respiratory function, decreased hospital stay and cost, and as a consequence, a better surgical outcome.
Emergency Management of Bleeding Esophageal Varices: Drugs, Bands or Sleep?
Authors: Yan Brian M , Lee Samuel S
Published: March 2016

Variceal bleeding is a severe complication of cirrhosis leading to significant morbidity and mortality. Treatment of acute variceal bleeding has improved dramatically since the era of the mechanical balloon tamponade. These advances include endoscopic band ligation or sclerotherapy, and vasoactive pharmacological options such as somatostatin, octreotide, vasopressin and terlipressin. Evidence from a multitude of clinical trials and meta-analyses comparing endoscopic and pharmacological treatments suggests near equivalence in efficacy for initial hemostasis, mortality and rate of rebleeding. This raises the question of whether on-call gastroenterologists should be performing emergency endoscopic treatment in the middle of the night or start pharmacological treatment and delay endoscopy until optimal patient and working conditions the next morning. The present review analyzes the available comparative data between endoscopic and pharmacological treatment options. Although the literature cannot yet definitively answer the question posed, the authors suggest that delaying endoscopic treatment until the next morning may be the most reasonable practical approach.
Recurrent Respiratory Papillomatosis Causing Chronic Stridor and Delayed Speech in an 18-Month-Old Boy
Authors: Alharbi Adel , Drummond Derek , Pinto Alfredo , Kirk Valerie
Published: March 2016

Recurrent respiratory papillomatosis is a relatively uncommon disease that presents clinically with symptoms ranging from hoarseness to severe dyspnea. Human papilloma virus types 6 and 11 are important in the etiology of papillomas and are most probably transmitted from mother to child during birth. Although spontaneous remission is frequent, pulmonary spread and/or malignant transformation resulting in death has been reported. CO2laser evaporation of papillomas and adjuvant drug therapy using lymphoblastoid interferon-alpha are the most common treatments. However, several other treatments have been tried, with varying success. In the present report, a case of laryngeal papillomatosis presenting with chronic stridor and delayed speech is described.
Paper Stamp Checklist Tool Enhances Asthma Guidelines Knowledge and Implementation by Primary Care Physicians
Authors: Renzi PM , Ghezzo H , Goulet S , Dorval E , Thivierge RL
Published: March 2016

BACKGROUND: The Canadian Clinical Practice Guidelines (CPGs) for the management of asthmatic patients were last published in 1999, with updates in 2001 and June 2004. Large disparities exist in the implementation of these guidelines into clinical practice.

OBJECTIVE: The present study evaluated the knowlege of Quebec‐based primary care physicians regarding the CPGs, as well as patient outcomes before and after introducing physicians to a new clinical tool – a memory aid in the form of a self‐inking paper stamp checklist summarizing CPG criteria and guidelines for assessing asthmatic patient control and therapy. The primary objective of the present study was to assess whether the stamp would improve physicians’ knowledge of the CPGs, and as a secondary objective, to assess whether it would decrease patient emergency room visits and hospitalizations.

METHODS: A prospective, randomized, controlled study of 104 primary care physicians located in four Quebec regions was conducted. Each physician initially responded to questions on their knowledge of the CPGs, and was then randomly assigned to one of four groups that received information about the CPGs while implementing an intervention (the stamp tool) aimed at supporting their decision‐making process at the point of care. Six months later, the physicians were retested, and patient outcomes for approximately one year were obtained from the Régie de l’assurance maladie du Québec.

RESULTS: The stamp significantly improved physicians’ knowledge of the CPGs in all Quebec regions tested, and reduced emergency room visits and hospitalizations in patients who were followed for at least one year.

CONCLUSION: A paper stamp summarizing CPGs for asthma can be used effectively to increase the knowledge of physicians and to positively affect patient outcomes.
Altered Respiratory Physiology in Obesity
Authors: Parameswaran Krishnan , Todd David C , Soth Mark
Published: March 2016

The major respiratory complications of obesity include a heightened demand for ventilation, elevated work of breathing, respiratory muscle inefficiency and diminished respiratory compliance. The decreased functional residual capacity and expiratory reserve volume, with a high closing volume to functional residual capacity ratio of obesity, are associated with the closure of peripheral lung units, ventilation to perfusion ratio abnormalities and hypoxemia, especially in the supine position. Conventional respiratory function tests are only mildly affected by obesity except in extreme cases. The major circulatory complications are increased total and pulmonary blood volume, high cardiac output and elevated left ventricular end‐diastolic pressure. Patients with obesity commonly develop hypoventilation and sleep apnea syndromes with attenuated hypoxic and hypercapnic ventilatory responsiveness. The final result is hypoxemia, pulmonary hypertension and progressively worsening disability. Obese patients have increased dyspnea and decreased exercise capacity, which are vital to quality of life. Decreased muscle, increased joint pain and skin friction are important determinants of decreased exercise capacity, in addition to the cardiopulmonary effects of obesity. The effects of obesity on mortality in heart failure and chronic obstructive pulmonary disease have not been definitively resolved. Whether obesity contributes to asthma and airway hyper‐responsiveness is uncertain. Weight reduction and physical activity are effective means of reversing the respiratory complications of obesity.
New Treatment Strategies against Hepatitis C Viral Infection
Authors: Bilodeau Marc , Lamarre Daniel
Published: March 2016

Treatment of hepatitis C virus infection is currently based on a combination of pegylated interferon and ribavirin. Because efficacy of this therapy remains suboptimal and side effects sometimes problematic, major efforts have been put forward by scientists and the pharmaceutical industry to develop alternative treatments for this chronic infection. Over the past few years, clinical studies performed with some of these new agents have been presented at major international meetings. The present paper aims to review the rationale underlying the development of these new forms of treatment as well as the current available data concerning their clinical efficacy.
Alemtuzumab and Natalizumab: The Monoclonal Antibody Story Continues
Authors: Johnston BL , Conly JM
Published: March 2016

In the July/August 2006 issue of this journal, the infectious complications associated with the use of infliximab, etanercept and adalimumab were reviewed (1). These represent only three of the many monoclonal antibodies either licensed or in clinical trials for therapeutic use in cancer and autoimmune disease or to prevent rejection in both solid organ and hematopoietic stem cell transplantation. While most of these agents have not been associated with increased infection rates, alemtuzumab and natalizumab have gained particular attention related to either the frequency or type of infection seen in some individuals who have received them.
Health Care Utilization and Changes in Health Status Over Time for Migraineurs
Authors: Chuck Anderson , Jacobs Philip , Ohinmaa Arto , Schopflocher Donald , Rashiq Saifudin , Feroe Raquel
Published: March 2016

BACKGROUND: Determining how migraineurs manage their condition from the viewpoint of health resource utilization (including both medical and personal resources) may provide insights that could lead to more effective care strategies.

OBJECTIVES: To determine the relative importance of modifiable health‐influencing activities for migraineurs, and to compare the effects of these activities between migraineurs and nonmigraineurs in the general population.

METHODS: Linear regression analysis was applied to all persons older than 19 years of age with migraine in the Canadian Community Health Survey Cycle 1.1. The dependent variable was reported health status change over time. Explanatory variables were a series of health care utilization, health behaviour and background control variables.

RESULTS: Results showed that health status was positively associated with higher levels of physical activity and negatively associated with smoking for both migraineurs and nonmigraineurs, even when controlling for all other variables.

CONCLUSION: By modifying controllable resources and behaviours, the reported health status of migraineurs can be improved as effectively as nonmigraineurs.
Antibiotic Availability and the Prevalence of Pediatric Pneumonia During a Physicians’ Strike
Authors: Crocker Ken , Cramer Benvon , Hutchinson James M
Published: March 2016

BACKGROUND: Antibiotics are widely believed to be overpre‐scribed for pediatric respiratory infections, yet there are few data available on the effect of a sudden decrease in antibiotic availability on pediatric infectious disease.

OBJECTIVE: To determine whether the prevalence of radiographically diagnosed pneumonia changed over a period of decreased physician access and decreased antibiotic availability.

DESIGN: A retrospective study was performed which reviewed the number of pediatric respiratory antibiotic prescriptions over a period which included a physicians’ strike. The study examined whether antibiotic availability had been affected by the strike. Pediatric chest radiograph reports were reviewed for the same period to determine whether changes in antibiotic availability had affected the prevalence of radiographically diagnosable pneumonias among children presenting to a pediatric emergency room.

RESULTS: While prescriptions for antibiotics fell by a minimum estimate of 28% during the strike, there was no change in the frequency of radiographic diagnoses of pneumonia.

CONCLUSIONS: Respiratory antibiotics appear to be available in the community in excess of the amount required to control pneumonia. A 28% decrease in antibiotic availability did not result in a significant increase in respiratory disease.
Cancer Pain and Depression: A Systematic Review of Age‐Related Patterns
Authors: Gagliese Lucia , Gauthier Lynn R , Rodin Gary
Published: March 2016

BACKGROUND: Pain is a common and debilitating symptom experienced by cancer patients of all ages. Cancer pain is associated with elevated levels of depression; however, age‐related patterns in this relationship remain unclear. This information is important to provide effective palliation of pain and depression to the growing numbers of older cancer patients.

OBJECTIVE: To provide a systematic review of the literature regarding age‐related patterns in the intensity or prevalence of depression among cancer patients with pain.

METHODS: Medical and psychological literature databases were searched to identify eligible studies. The methodological quality and outcomes of the studies were compiled and systematically reviewed.

RESULTS: Five articles, describing four studies, met the inclusion and exclusion criteria. Due to high levels of cross‐study methodological variability, a qualitative review was undertaken. Three of the four studies did not find evidence for age‐related patterns in depression. The fourth study found that depression increased with age.

CONCLUSION: The weight of the evidence suggests that younger and older cancer patients with pain report comparable levels of depression. However, this conclusion remains preliminary due to the methodological limitations of the available studies. Research is needed to more adequately address this important issue.
Clinical Onset of Celiac Disease after an Episode ofCampylobacter jejuniEnteritis
Authors: Verdu EF , Mauro M , Bourgeois J , Armstrong D
Published: March 2016

The present report describes a young woman with no previous gastrointestinal complaints who was initially diagnosed with postinfective irritable bowel syndrome (IBS) after a confirmed case ofCampylobacter jejunienteritis. However, because of persistent diarrhea, new-onset bloating and the development of iron and vitamin deficiencies, serological markers for celiac disease (CD) were evaluated. A positive tissue transglutaminase immunoglobulin A antibody test and repeat endoscopy with duodenal biopsy showing a Marsh IIIa lesion confirmed the diagnosis of CD. Infectious gastroenteritis is a well-established risk factor for the development of IBS, and there is recent evidence that it could play a role in the initiation and exacerbation of inflammatory bowel disease. The present case suggests that the clinical expression of CD can be unmasked by an acute gastrointestinal infection and supports the hypothesis that environmental factors other than gliadin may play a role in the clinical onset of CD in a genetically susceptible host. The increasing availability of serological testing and upper endoscopy has led to increasingly frequent diagnoses of CD and recognition that it may mimic IBS. The present case findings suggest that CD should be considered in the differential diagnosis of persistent IBS-like symptoms after an episode of infectious gastroenteritis.
Management of Solitary 1 cm to 2 cm Liver Nodules in Patients with Compensated Cirrhosis: A Decision Analysis
Authors: Bremner Karen E , Bayoumi Ahmed M , Sherman Morris , Krahn Murray D
Published: March 2016

OBJECTIVES: Current guidelines, based on expert opinion, recommend that suspected 1 cm to 2 cm hepatocellular carcinoma (HCC) detected on screening be biopsied and, if positive, treated (eg, resection or transplantation). Alternative strategies are immediate treatment or observation until disease progression occurs.

METHODS: A Markov decision model was developed that compared three management strategies – immediate resection, biopsy and resection if positive, and ultrasound surveillance every three months until disease progression – for a single 1 cm to 2 cm liver nodule suspicious for HCC following ultrasound screening and computed tomography confirmation. The cohort included 55-year-old patients with compensated cirrhosis and no significant comorbidities. The model used in the present study incorporated the probabilities of false-positive and false-negative results, needle-track seeding, HCC recurrence, cirrhosis progression and death. The quality-adjusted life expectancy (LE) and the unadjusted LE were evaluated and the model’s strength was assessed with sensitivity analyses.

RESULTS: In the base case analysis, biopsy, resection and surveillance yielded an unadjusted LE of 60.5, 59.7 and 56.6 months, respectively, and a quality-adjusted LE of 46.6, 45.6 and 43.8 months, respectively. In probabilistic sensitivity analyses, biopsy was the preferred strategy 69.5% of the time, resection 30.5% of the time and surveillance never. Resection was the optimal decision if the sensitivity of biopsy was very low (less than 0.45) or if the accuracy of the imaging tests resulted in a high percentage of HCC-positive patients (greater than 76%) in the screened cohort, as with expert interpretation of triphasic computed tomography.

CONCLUSIONS: The present model suggests that biopsy is the preferred management strategy for these patients. When postimaging probability of HCC is high or pathology expertise is lacking, resection is the best alternative. Surveillance is never the optimal strategy.
Treatment Strategy: Role of Enfuvirtide in Managing Treatment‐Limiting Side Effects
Authors: Tsoukas Christos
Published: March 2016

Side effects can limit the options available to physicians for the treatment of HIV infection. Management of these side effects is essential, to avoid cessation of treatment. The entry inhibitor enfuvirtide can be useful as one of three active agents in an HIV treatment regimen as a way to both reduce treatment‐limiting side effects and provide an efficacious agent for viral control. In the present case, the patient had a problematic and lengthy treatment history, with numerous concomitant conditions. His latest regimen, which includes an agent in a new drug class (enfuvirtide), has maintained HIV suppression while minimizing toxicity.