bluuebunny/crossref_metadata_2025 huggingface dataset:
Development and Mixed‐Methods Evaluation of a Pain Assessment Video Training Program for Long‐Term Care Staff
Authors: Gagnon Michelle M , Hadjistavropoulos Thomas , Williams Jaime
Published: March 2016

INTRODUCTION: Inadequacies in pain assessment and management in long‐term care have been well documented. Insufficient pain education and inaccurate beliefs about the nature of pain and aging have been identified as possible contributors. The present study addresses the need for improved, efficient and feasible continuing pain education through the use of an assessment training video.

METHODS: A total of 148 long‐term care staff viewed and evaluated the training video. Knowledge changes and pain beliefs were assessed postvideo and at a four‐week follow‐up. Beliefs about pain, as well as pain and aging, were also examined using multivariate procedures to determine whether these variables influenced participants’ evaluation of the video. Focus groups were also conducted, and transcripts were analyzed using thematic content analysis.

RESULTS: Pain assessment knowledge improved postvideo and at the four‐week follow‐up. Participants positively evaluated the content and quality of the video. Individuals who held stronger beliefs (at baseline) about the organic nature of pain provided more positive evaluations. Barriers to implementation of practices in the video identified by the focus groups (and qualitative analysis) included time, workload and resistance to change. Facilitators to implementation included continued management support and observing the benefits to implementation.

DISCUSSION: The present study provides support for the use of video training. However, based on the focus group results, top‐down implementation approaches with ongoing management involvement throughout the implementation process may be needed to achieve sustained changes in pain assessment practices. A model useful for sustained implementation was proposed and discussed, and is hoped to facilitate future research.
A Health Technology Assessment of Transient Elastography in Adult Liver Disease
Authors: Steadman Rodney , Myers Robert P , Leggett Laura , Lorenzetti Diane , Noseworthy Tom , Rose Sarah , Sutherland Lloyd , Clement Fiona
Published: March 2016

BACKGROUND: An estimated one in 10 Canadians have some form of liver disease. The reference standard for staging and monitoring liver fibrosis is percutaneous liver biopsy – an invasive procedure associated with risks and complications. Transient elastography (TE) represents a noninvasive, ultrasound-based alternative.

OBJECTIVE: To assess the efficacy of TE compared with liver biopsy for fibrosis staging in adults with five common types of liver disease: hepatitis B, hepatitis C, nonalcoholic fatty liver disease, cholestatic liver disease and complications post-liver transplantation.

METHODS: A systematic review of published and grey literature from 2001 to June 2011 was conducted. Included were observational studies evaluating the accuracy of TE using liver biopsy as the comparator. An economic model was developed to estimate the cost per correct diagnosis gained with liver biopsy compared with TE. Identification of moderate fibrosis (stages 2 to 4) and cirrhosis (stage 4) were considered.

RESULTS: Fifty-seven studies were included in the review. The diagnostic accuracy of TE for the five clinical subgroups had sensitivities ranging from 0.67 to 0.92 and specificities ranging from 0.72 to 0.95. Liver biopsy was associated with an additional $1,427 to $7,030 per correct diagnosis gained compared with TE. The model was sensitive to the sensitivity and specificity of TE and the prevalence of fibrosis.

CONCLUSIONS: TE is an accurate diagnostic method in patients with moderate fibrosis or cirrhosis. TE is less effective but less expensive than liver biopsy. Systemic implementation of TE should be considered for the noninvasive assessment of liver fibrosis.
Continuing Methadone for Pain in Palliative Care
Authors: Hawley Philippa , Liebscher Ryan , Wilford Jessica
Published: March 2016

BACKGROUND: Methadone is one of the most important medications used for the treatment of refractory pain in the palliative care setting, and is usually initially prescribed by one of a limited number of physicians who have acquired authorization for its use. A lack of authorized physicians able to take over prescribing when the patient is stable is a barrier to accessing methadone for analgesia.

OBJECTIVE: To determine the barriers to family physicians becoming authorized to prescribe methadone for pain in palliative care.

METHODS: A survey exploring the perceived barriers to continuing methadone for pain in palliative care following initial prescription by a specialist was mailed to a randomly selected group of 870 family physicians in British Columbia.

RESULTS: The response rate was 30.9%. Of the 204 responding physicians, 76.1% described themselves as positioned to provide ongoing palliative care to their patients. Within this group, 38 (18.6%) were already authorized to prescribe methadone for pain. The remaining 166 (81.4%) had significant knowledge deficits regarding methadone use in palliative care, but were largely aware of their deficits, and more than one‐half were willing to learn more and to obtain an authorization if requested.

CONCLUSIONS: Responding family physicians had mostly received little education regarding methadone for pain, but were aware of their need for education and were willing to learn. Physicians who had already become authorized were generally satisfied with the process of authorization, and believed the process of education through authorization was appropriate and not onerous.
Clinical Features and Symptom Recovery on a Gluten-Free Diet in Canadian Adults with Celiac Disease
Authors: Pulido Olga , Zarkadas Marion , Dubois Sheila , MacIsaac Krista , Cantin Isabelle , La Vieille Sébastien , Godefroy Samuel , Rashid Mohsin
Published: March 2016

BACKGROUND: Celiac disease can present with mild or nongastrointestinal symptoms, and may escape timely recognition. The treatment of celiac disease involves a gluten-free diet, which is complex and challenging.

OBJECTIVE: To evaluate clinical features and symptom recovery on a gluten-free diet in a Canadian adult celiac population.

METHODS: All adult members (n=10,693) of the two national celiac support organizations, the Canadian Celiac Association andFondation québécoise de la maladie coeliaque,were surveyed using a questionnaire.

RESULTS: A total of 5912 individuals (≥18 years of age) with biopsy-confirmed celiac disease and/or dermatitis herpetiformis completed the survey. The female to male ratio was 3:1, and mean (± SD) age at diagnosis was 45.2±16.4 years. Mean time to diagnosis after onset of symptoms was 12.0±14.4 years. Abdominal pain and bloating (84.9%), extreme weakness/tiredness (74.2%), diarrhea (71.7%) and anemia (67.8%) were the most commonly reported symptoms at the time of diagnosis. Many respondents continued to experience symptoms after being on a gluten-free diet for >5 years. Sex differences were reported in clinical features before diagnosis, recovery after being on gluten-free diet and perceived quality of life, with women experiencing more difficulties than men.

CONCLUSIONS: Delays in diagnosis of celiac disease in Canada remain unacceptably long despite wider availability of serological screening tests. Many patients report continuing symptoms despite adhering to a gluten-free diet for >5 years, with women experiencing more symptoms and a lower recovery rate than men. Awareness of celiac disease needs improvement, and follow-up with a physician and a dietitian is essential for all patients with celiac disease.
What Constitutes a Clinically Important Pain Reduction in Patients after Third Molar Surgery?
Authors: Martin Wilhelmus JJM , Ashton-James CE , Skorpil NE , Heymans MW , Forouzanfar T
Published: March 2016

BACKGROUND: For patients with surgical third molar removal, it is unknown what constitutes a clinically important change in patients’ visual analogue scale (VAS) reports of pain intensity.

OBJECTIVES: To determine what constitutes a clinically important change in pain intensity on a VAS following surgical removal of the third molar.

METHODS: The study population consisted of patients participating in three randomized trials. Patients were asked to rate their pain three times per day over a period of seven days on a 100 mm VAS after surgical removal of the third molar. Global Perceived Effect was measured on day 1 and day 7 and was used as the external criterion for assessing clinically important pain reduction. Global Perceived Effect scores of 6 (‘much improved’) or higher were classified as clinically ‘successful’, and scores of 5 (‘slightly improved’) or below were classified as clinically ‘unsuccessful’. For each trial, the mean absolute and relative changes in VAS scores were calculated for both ‘successful’ and ‘unsuccessful’ treatments. Sensitivity and specificity analyses were performed.

RESULTS: The patients who reported ‘successful’ pain reduction showed a relative pain reduction of ≥69% and an absolute pain reduction >2.5 cm on the VAS, whereas patients who classified their pain reduction as ‘unsuccessful’ had a relative pain reduction of ≥18.5% and an absolute pain reduction <0.5 cm on the VAS. Furthermore, sensitivity and specificity analyses showed that a cut‐off point of ≥50% relative pain reduction exhibited the best balance of sensitivity and specificity.

CONCLUSION: Relative pain reduction of ≥50% and an absolute pain reduction of ≥2.5 cm on the VAS were most accurate in predicting a successful pain reduction after a given treatment.
Patients’ and Professionals’ Views on Managing Fibromyalgia
Authors: Briones-Vozmediano Erica , Vives-Cases Carmen , Ronda-Pérez Elena , Gil-González Diana
Published: March 2016

BACKGROUND: Managing fibromyalgia is a challenge for both health care systems and the professionals caring for these patients, due, in part, to the fact that the etiology of this disease is unknown, its symptoms are not specific and there is no standardized treatment.

OBJECTIVE: The present study examines three aspects of fibromyalgia management, namely diagnostic approach, therapeutic management and the health professional‐patient relationship, to explore specific areas of the health care process that professionals and patients may consider unsatisfactory.

METHODS: A qualitative study involving semistructured interviews with 12 fibromyalgia patients and nine health professionals was performed.

RESULTS: The most commonly recurring theme was the dissatisfaction of both patients and professionals with the management process as a whole. Both groups expressed dissatisfaction with the delay in reaching a diagnosis and obtaining effective treatment. Patients reported the need for greater moral support from professionals, whereas the latter often felt frustrated and of little help to patients. Patients and professionals agreed on one point: the uncertainty surrounding the management of fibromyalgia and, especially, its etiology.

CONCLUSION: The present study contributes to a better understanding regarding why current management of fibromyalgia is neither effective nor satisfactory. It also provides insight into how health professionals can support fibromyalgia patients to achieve beneficial results. Health care services should offer greater support for these patients in the form of specific resources such as fibromyalgia clinics and health professionals with increased awareness of the disease.
Influence of 16S Ribosomal RNA Gene Polymerase Chain Reaction and Sequencing on Antibiotic Management of Bone and Joint Infections
Authors: Alraddadi B , Al-Azri S , Forward KR
Published: March 2016

INTRODUCTION: Amplification of the 16S ribosomal RNA gene by polymerase chain reaction (PCR) followed by analysis of generated sequences can be an important adjunct to conventional cultures.

OBJECTIVE: To determine how the results of this approach influence physicians’ decisions regarding the management of bone and joint infections.

METHOD: Clinical and laboratory findings of patients seen at the Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia) between December 2005 and September 2009 were reviewed. Patients who had negative cultures but likely or possible bone and joint infections were further evaluated using 16S rRNA PCR. The impact of the 16S rRNA PCR result on antibiotic management was evaluated and it was assessed whether untreated patients with negative 16S rRNA PCR subsequently presented with infections, suggesting a false‐negative result.

RESULT: A total of 36 patients (mean age 62 years) were reviewed. Thirty‐two patients were evaluated by infectious disease consultants; of these, 20 were considered likely to have infections. Seventeen patients were admitted with suspected prosthetic joint infections. Twenty‐nine patients received antimicrobial treatment before the sample for the 16S rRNA PCR assay was obtained. Of the 36 patients, 26 (72.2%) were treated appropriately with modifications to their antibiotic regimen in response to the 16S rRNA PCR assay results. Antimicrobials were discontinued for 19 patients based on negative PCR assay and, in seven patients, antibiotics were changed based on a positive result. There were no relapses among patients with negative PCR assay in whom antibiotics were discontinued.

CONCLUSION: 16S ribosomal RNA gene PCR and sequencing is a valuable tool in the guidance of antimicrobial therapy for bone and joint infections.
Severe Airway Injury Due to Alendronate Aspiration
Authors: MacEachern Paul , Brazil Aiden , Tremblay Alain , Stather David R , Chee Alex C , Chou Julie
Published: March 2016

Sequelae of foreign body aspiration can range from clinically silent and asymptomatic to immediate asphyxiation and death. Only two previous cases of bisphosphonate tablet aspiration have been reported. Ulcerative esophagitis, a known adverse effect of oral bisphosphonate formulations, occurs primarily with prolonged exposure of esophageal mucosa to the medication. Little is known about the effects of bisphosphonates on the airway mucosa. The authors present a case involving an 84‐year‐old woman who required multiple bronchoscopic debridements, intubation for airway protection and intensive care unit admission following airway injury believed to be due to delayed recognition of aspiration of an alendronate tablet.
Foreign‐Body Aspiration in the Adult: Presentation and Management
Authors: Bain Alexandra , Barthos Althea , Hoffstein Victor , Batt Jane
Published: March 2016

Nonasphyxiating foreign‐body aspiration in adults can be difficult to diagnose because the symptoms are nonspecific and chest x‐rays may be normal due to organic composition of the foreign bodies. The diagnosis is often made via flexible bronchoscopy; however, debate remains as to whether rigid or flexible bronchoscopy is the optimal method of extraction. The authors describe a patient who was initially referred for assessment of a calcified left mainstem bronchus mass identified only on computed tomography scan of the thorax. The patient underwent flexible bronchoscopy and was discovered to have a bone fragment wedged in the bronchus for a duration of 22 years, which was successfully removed via rigid bronchoscope.
Use of the Alpha-Glucosidase Inhibitor Acarbose in Patients with ‘Middleton Syndrome’: Normal Gastric Anatomy But with Accelerated Gastric Emptying Causing Postprandial Reactive Hypoglycemia and Diarrhea
Authors: Playford Raymond J , Pither Charlotte , Gao Rui , Middleton Stephen J
Published: March 2016

Postprandial reactive hypoglycemia, early satiety and diarrhea are well-recognized side effects following full or partial gastrectomy or gastric bypass. It has only recently been realized, however, that patients with normal gastric anatomy may experience similar symptoms and signs due to primary accelerated gastric emptying (Middleton syndrome). In previous case studies, patients responded well to the use of dietary modification (frequent small-volume meals) alone. The authors describe two patients with this syndrome who continued to experience symptoms of reactive postprandial hypoglycemia despite dietary intervention but became asymptomatic following the addition of the alpha-glucosidase inhibitor acarbose.
Psychiatric Morbidity in Pain Conditions: Results from the Singapore Mental Health Study
Authors: Subramaniam Mythily , Vaingankar Janhavi Ajit , Abdin Edimansyah , Chong Siow Ann
Published: March 2016

BACKGROUND: Chronic pain is a common problem among the general population and has been found to be associated with psychiatric disorders in studies based on both clinical samples and epidemiological surveys.

OBJECTIVES: To establish the prevalence, correlates and comorbidities of chronic pain disorders among the adult population of Singapore.

METHODS: The data used in the present analysis were derived from the Singapore Mental Health Study, a cross‐sectional epidemiological survey of a representative sample of the adult resident population of Singapore. Diagnoses of psychiatric disorders were established using the Composite International Diagnostic Interview version 3.0. A modified version of the Composite International Diagnostic Interview 3.0 checklist of chronic medical disorders was used, in which the chronic medical disorders were reclassified into eight types of physical disorders. Chronic pain disorders included arthritis or rheumatism, back problems including disk or spine problems, and migraine headaches.

RESULTS: The lifetime prevalence estimates for arthritis, back pain and migraine in the Singapore general population were 6.0% (n=282), 7.0% (n=436) and 5.6% (n=446), respectively. After adjusting for sociodemographic factors, comorbid pain disorders and the presence of other chronic physical conditions, migraine remained significantly associated with major depressive disorder (adjusted OR=2.4), generalized anxiety disorder (adjusted OR=3.0) and alcohol use disorders (adjusted OR=2.1), while back pain was significantly associated with major depressive disorder (adjusted OR=2.0).

CONCLUSIONS: The significant association between pain and psychiatric disorders emphasizes the need to screen individuals with chronic pain conditions for psychiatric disorders, particularly depression. There is a need to develop integrated pharmacological and psychological treatments for both conditions.
Population‐Based Surveillance for Hypermucoviscosity Klebsiella pneumoniae Causing Community‐Acquired Bacteremia in Calgary, Alberta
Authors: Peirano Gisele , Pitout Johann DD , Laupland Kevin B , Meatherall Bonnie , Gregson Daniel B
Published: March 2016

The characteristics of hypermucoviscosity isolates among Klebsiella pneumoniae causing community‐acquired bacteremia were investigated. The hypermucoviscous phenotype was present in 8.2% of K pneumoniae isolates, and was associated with rmpA and the K2 serotype; liver abscesses were the most common clinical presentation. The present analysis represents the first population‐based surveillance study of hypermucoviscosity among K pneumoniae causing bacteremia.
Does Pain in Individuals with Multiple Sclerosis Affect Employment? A Systematic Review and Meta‐Analysis
Authors: Shahrbanian Shahnaz , Auais Mohammad , Duquette Pierre , Anderson Katie , Mayo Nancy E
Published: March 2016

BACKGROUND: Individuals with multiple sclerosis (MS) experience some of the highest unemployment rates among all groups of chronic illnesses. Pain has been found to be a common reason for sick leave or early retirement in healthy populations or other groups with chronic illness; however, there is little awareness regarding the effect of pain on the work status of individuals with MS.

OBJECTIVES: To estimate the extent to which individuals with pain differ in employment status compared with those without pain among MS patients.

METHODS: An extensive systematic review of the scientific literature was performed within the framework of the Cochrane Collaboration to identify studies focusing on the effect of pain on employment in individuals with MS. The following databases were searched: PubMed, EMBASE, PsychInfo, Web of Science, MD Consult and Elsevier, and Science Direct. The methodological quality of studies was assessed using the McMaster Critical Review Form.

RESULTS: Ten articles met the inclusion criteria and were included in the systematic review. Of these studies, five that exhibited clinical, methodological and statistical homogeneity were included in the meta‐analysis. The between‐groups (pain + versus pain −) pooled random OR of being employed was 0.7 (strong), and was significantly different from unity (95% CI 0.5 to 0.9; P=0.001).

CONCLUSIONS: The results of the present study indicated that individuals with MS who experience pain were significantly more likely to report a decreased employment rate than individuals with MS who were pain free.

Erratum to “Does Pain in Individuals with Multiple Sclerosis Affect Employment? A Systematic Review and Meta-Analysis”dx.doi.org/10.1155/2013/620869
Late Onset and Persistence of Post‐Traumatic Stress Disorder Symptoms in Survivors of Critical Care
Authors: Khitab Aaron , Reid John , Bennett Vern , Adams G Camelia , Balbuena Lloyd
Published: March 2016

BACKGROUND: Several recent studies have reported that post‐traumatic stress disorder (PTSD) is a frequent occurrence in survivors of an intensive care unit (ICU) admission.

OBJECTIVE: To assess the frequency of PTSD symptoms at three and nine months post‐ICU admission and examine possible risk factors that predispose to the development of PTSD symptoms.

METHOD: Using the following scales: Davidson Trauma Scale, Impact of Event Scale and the Post‐traumatic Symptom Scale, 69 ICU survivors were assessed for PTSD symptoms at three months post‐ICU admission. Of the original 69 patients, 37 completed the same questionnaires at the second follow‐up at nine months post‐ICU admission. Mean symptom levels for avoidance, intrusive thoughts and hyperarousal were calculated, and risk factors for the development of PTSD symptomatology were examined.

RESULTS: Depending on which scale was used, 16% to 33% of ICU survivors met the criteria for PTSD at either three or nine months. Younger age and the use of a prescription psychoactive medication at time of ICU admission were both independently associated with a higher risk of developing PTSD symptoms. Interestingly, symptoms of hyperarousal worsened during the follow‐up interval for female patients, while they remained constant for males.

CONCLUSION: The frequency of PTSD symptoms was high in patients who survived an admission to the ICU. Depending on sex, symptoms may present and evolve differently. The adoption of screening tools and a multicentre ICU database in Canada is recommended to identify patients who are most at risk.
Establishing Intra‐ and Inter‐Rater Agreement of the Face, Legs, Activity, Cry, Consolability Scale for Evaluating Pain in Toddlers During Immunization
Authors: Gomez Rebecca J , Barrowman Nick , Elia Sonja , Manias Elizabeth , Royle Jenny , Harrison Denise
Published: March 2016

BACKGROUND: The Face, Legs, Activity, Cry, Consolability (FLACC) scale is a five‐item tool that was developed to assess postoperative pain in young children. The tool is frequently used as an outcome measure in studies investigating acute procedural pain in young children; however, there are limited published psychometric data in this context.

OBJECTIVE: To establish inter‐rater and intrarater agreement of the FLACC scale in toddlers during immunization.

METHODS: Participants comprised a convenience sample of toddlers recruited from an immunization drop‐in service, who were part of a larger pilot randomized controlled trial. Toddlers were video‐ and audiotaped during immunization procedures. The first rater scored each video twice in random order over a period of three weeks (intrarater agreement), while the second rater scored each video once and was blinded to the first rater’s scores (inter‐rater agreement). The FLACC scale was scored at four time‐points throughout the procedure. Intraclass correlation coefficients were used to assess agreement of the FLACC scale.

RESULTS: Thirty toddlers between 12 and 18 months of age were recruited, and video data were available for 29. Intrarater agreement coefficients were 0.88 at baseline, 0.97 at insertion of first needle, and 0.80 and 0.81 at 15 s and 30 s following the final injection, respectively. Inter‐rater coefficients were 0.40 at baseline, 0.95 at insertion of first needle, and 0.81 and 0.78 at 15 s and 30 s following the final injection, respectively.

CONCLUSIONS: The FLACC scale has sufficient agreement in assessing pain in toddlers during immunizations, especially during the most painful periods of the procedure.
Serum Aspartate Aminotransferase Level and Previous Histopathological Findings Enable Reduction of Protocol Liver Biopsies after Liver Transplantation for Hepatitis C
Authors: Tanaka Tomohiro , Therapondos George , Selzner Nazia , Renner Eberhard L , Lilly Leslie B
Published: March 2016

BACKGROUND: Hepatitis C virus (HCV) infection remains the leading indication for liver transplantation (LT) worldwide. Recurrent hepatitis C following LT is universal, and significant fibrosis (SF, Metavir fibrosis stage ≥2) apparent on protocol biopsy typically prompts antiviral therapy.

OBJECTIVE: To determine the optimal timing of protocol liver biopsies in this setting.

METHODS: A total of 151 patients who underwent LT related to HCV infection between July 2004 and December 2009 were analyzed retrospectively. Data regarding protocol liver biopsies at six, 12 and 24 months post-LT, conventional laboratory parameters and demographic information were obtained.

RESULTS: The 151 patients included in the present study had significantly lower serum aspartate aminotransferase (AST) levels than the four patients who progressed to receive antiviral treatment for SF before six months post-LT (P<0.001). AST level, but not alanine aminotransferase level, histological activity or fibrosis stage at the six-month biopsy was independently associated with the progression to SF at 12 months (P<0.05). However, AST level, histological activity and fibrosis stage at the 12-month biopsy emerged as independent parameters associated with progression to SF at 24 months (P<0.05).

CONCLUSION: The protocol liver biopsy at six months could be eliminated, especially in patients who consistently exhibit low AST levels. Histological activity, the presence or absence of fibrosis, and AST values at the 12-month biopsy may lead to the decision to defer the protocol biopsy at 24 months or result in earlier introduction of antiviral therapy.
A Model of the Costs of Community and Nosocomial Pediatric Respiratory Syncytial Virus Infections in Canadian Hospitals
Authors: Jacobs Philip , Lier Douglas , Gooch Katherine , Buesch Katharina , Lorimer Michelle , Mitchell Ian
Published: March 2016

BACKGROUND: Approximately one in 10 hospitalized patients will acquire a nosocomial infection (NI) after admission to hospital, of which 71% are due to respiratory viruses, including the respiratory syncytial virus (RSV). NIs are concerning and lead to prolonged hospitalizations. The economics of NIs are typically described in generalized terms and specific cost data are lacking.

OBJECTIVE: To develop an evidence‐based model for predicting the risk and cost of nosocomial RSV infection in pediatric settings.

METHODS: A model was developed, from a Canadian perspective, to capture all costs related to an RSV infection hospitalization, including the risk and cost of an NI, diagnostic testing and infection control. All data inputs were derived from published literature. Deterministic sensitivity analyses were performed to evaluate the uncertainty associated with the estimates and to explore the impact of changes to key variables. A probabilistic sensitivity analysis was performed to estimate a confidence interval for the overall cost estimate.

RESULTS: The estimated cost of nosocomial RSV infection adds approximately 30.5% to the hospitalization costs for the treatment of community‐acquired severe RSV infection. The net benefits of the prevention activities were estimated to be equivalent to 9% of the total RSV‐related costs. Changes in the estimated hospital infection transmission rates did not have a significant impact on the base‐case estimate.

CONCLUSIONS: The risk and cost of nosocomial RSV infection contributes to the overall burden of RSV. The present model, which was developed to estimate this burden, can be adapted to other countries with different disease epidemiology, costs and hospital infection transmission rates.
Improving Undergraduate Medical Education about Pain Assessment and Management: A Qualitative Descriptive Study of Stakeholders’ Perceptions
Authors: Tellier Pierre-Paul , Bélanger Emmanuelle , Rodríguez Charo , Ware Mark A , Posel Nancy
Published: March 2016

BACKGROUND: Pain is one of the most common reasons for individuals to seek medical advice, yet it remains poorly managed. One of the main reasons that poor pain management persists is the lack of adequate knowledge and skills of practicing clinicians, which stems from a perceived lack of pain education during the training of undergraduate medical students.

OBJECTIVE: To identify gaps in knowledge with respect to pain management as perceived by students, patients and educators.

METHODS: A qualitative descriptive study was conducted. Data were generated through six focus groups with second‐ and fourth‐year medical students, four focus groups with patients and individual semistructured interviews with nine educators. All interviews were audiotaped and an inductive thematic analysis was performed.

RESULTS: A total of 70 individuals participated in the present study. Five main themes were identified: assessment of physical and psychosocial aspects of pain; clinical management of pain with pharmacology and alternative therapies; communication and the development of a good therapeutic relationship; ethical considerations surrounding pain; and institutional context of medical education about pain.

CONCLUSION: Participating patients, students and pain experts recognized a need for additional medical education about pain assessment and management. Educational approaches need to teach students to gather appropriate information about pain, to acquire knowledge of a broad spectrum of therapeutic options, to develop a mutual, trusting relationship with patients and to become aware of their own biases and prejudice toward patients with pain. The results of the present study should be used to develop and enhance existing pain curricula content.
Disease Burden of Chronic Hepatitis B among Immigrants in Canada
Authors: Wong William WL , Woo Gloria , Heathcote E Jenny , Krahn Murray
Published: March 2016

BACKGROUND: The prevalence of chronic hepatitis B (CHB) infection among immigrants to North America ranges from 2% to 15%, 40% of whom develop advanced liver disease. Screening for hepatitis B surface antigen is not recommended for immigrants.

OBJECTIVE: To estimate the disease burden of CHB among immigrants in Canada using Markov cohort models comparing a cohort of immigrants with CHB versus a control cohort of immigrants without CHB.

METHODS: Markov cohort models were used to estimate life years, quality-adjusted life years and lifetime direct medical costs (adjusted to 2008 Canadian dollars) for a cohort of immigrants with CHB living in Canada in 2006, and an age-matched control cohort of immigrants without CHB living in Canada in 2006. Parameter values were derived from the published literature.

RESULTS: At the baseline estimate, the model suggested that the cohort of immigrants with CHB lost an average of 4.6 life years (corresponding to 1.5 quality-adjusted life years), had an increased average of $24,249 for lifetime direct medical costs, and had a higher lifetime risk for decompensated cirrhosis (12%), hepatocellular carcinoma (16%) and need for liver transplant (5%) when compared with the control cohort.

DISCUSSION: Results of the present study showed that the socio-economic burden of CHB among immigrants living in Canada is sub-stantial. Governments and health systems need to develop policies that promote early recognition of CHB and raise public awareness regarding hepatitis B to extend the lives of infected immigrants.
Comparison of Clinical and Epidemiological Features of Shiga Toxin‐Producing Escherichia coli O157 and Non‐O157 Infections in British Columbia, 2009 to 2011
Authors: Wang Xuetao , Taylor Marsha , Hoang Linda , Ekkert Judi , Nowakowski Craig , Stone Jason , Tone Greg , Trerise Steven , Paccagnella Ana , Wong Titus , Galanis Eleni
Published: March 2016

INTRODUCTION: Shiga toxin‐producing Escherichia coli (STEC) are major foodborne agents that have the potential to cause severe enteric illnesses and large outbreaks worldwide. Several studies found non‐O157 infections to be clinically milder than O157 STEC infections.

OBJECTIVE: To compare the clinical and epidemiological profiles of O157 and non‐O157 STEC human infections in British Columbia (BC).

METHODS: All STEC cases reported in BC from 2009 to 2011 by four local health authorities were included in the study. Cases were classified according to STEC serotype based on laboratory information. Information was gathered via case interview forms. Data analysis included the χ2 test and Mann‐Whitney test; P<0.05 was considered to be statistically significant.

RESULTS: A total of 260 STEC cases were reported, including 154 (59.2%) O157 cases, 63 (24.2%) non‐O157 cases and 43 (16.5%) STEC cases with no serotype identified. Hospitalization rate was higher and duration of hospitalization was significantly longer for O157 cases compared with non‐O157 cases, but other clinical features were not significantly different. Patients with non‐O157 infections were significantly more likely to have travelled outside Canada, less likely to report food exposure at social gatherings and more likely to consume bagged greens and cheese.

DISCUSSION: O157 is the predominant O serotype in BC and appeared to be more clinically severe than non‐O157 STEC infections. However, the true incidence and severity of non‐O157 remain unknown due to our current inability to detect all non‐O157 cases. The present study and the literature suggest the need to identify more predictive virulence factors because serotype does not consistently predict disease severity.
Yield and Cost of Performing Screening Tests for Constipation in Children
Authors: Chogle Ashish , Saps Miguel
Published: March 2016

BACKGROUND: Chronic constipation is one of the most common reasons for pediatric outpatient visits. Clinical guidelines recommend that the work-up for chronic refractory constipation include thyroid function tests, celiac serology, and measurement of calcium and lead levels. Data to justify routine screening of constipated children using these laboratory tests are lacking.

OBJECTIVES: To study the prevalence of celiac disease, hypothyroidism, hypercalcemia and lead poisoning in children with chronic constipation; and to estimate the health care costs of applying the guideline recommendations.

METHOD: Charts of constipated children from 2007 to 2011 were reviewed for the present retrospective cohort study. Results and costs of thyroid function tests, celiac panel, total immunoglobulin (Ig) A, and determination of lead and calcium levels were analyzed.

RESULTS: A total of 7472 children (mean age 7.9 years; 3908 female) were evaluated: 1731 patients were screened for celiac antibodies; 55 had elevated tissue transglutaminase IgA levels and 29 had biopsy-positive celiac disease. Only three celiac patients had constipation as the sole presenting symptom; 1703 patients were screened for total IgA levels; 55 had IgA deficiency and two had biopsy-positive celiac disease; 2332 had free T4 and/or thyroid-stimulating hormone levels; and 14 had hypothyroidism. Only two patients had constipation as the sole presenting symptom; 4651 patients had calcium levels measured, 10 of whom had high levels but normal repeat values. Three patients had normal lead levels. The mean cost per patient was USD$1,014. Total screening cost for all patients was USD$4.7 million.

CONCLUSION: Constipation alone did not increase the likelihood of celiac disease or hypothyroidism above the population prevalence. No benefit of screening for hypercalcemia was found. High health care costs were associated with the use of screening tests for organic constipation.
Employment Prospects and Trends for Gastroenterology Trainees in Canada: A Nationwide Survey
Authors: Razik Roshan , Cino Maria ,   the Canadian Gastroenterology Program Directors, Nguyen Geoffrey C
Published: March 2016

BACKGROUND: Many gastroenterology (GI) trainees face a variety of barriers to stable employment and are finding it increasingly difficult to secure employment in their chosen field.

OBJECTIVE: To elucidate factors that contribute to the burden of unemployment and underemployment, and to examine solutions that may remedy this growing problem in the field of GI.

METHODS: A nationwide survey of current, incoming and recently graduated individuals of GI training programs in Canada was conducted. Trainees in pediatric GI programs and those enrolled in sub-specialty programs within GI were also included.

RESULTS: The response rate was 62%, with 93% of respondents enrolled in an adult GI training program. Many (73%) respondents planned to pursue further subspecialty training and the majority (53%) reported concerns regarding job security after graduation as contributory factors. Only 35% of respondents were confident that they would secure employment within six months of completing their training. Regarding barriers to employment, the most cited perceived reasons were lack of funding (both from hospitals and provincial governments) and senior physicians who continue to practice beyond retirement years. Sixty-nine per cent perceived a greater need for career guidance and 49% believed there were too many GI trainees relative to the current job market in their area. Most residents had a contingency plan if they remained unemployed >18 months, which often included moving to another province or to the United States.

CONCLUSION: GI trainees throughout Canada reported substantial concerns about securing employment, citing national retirement trends and lack of funding as primary barriers to employment. Although these issues are not easily modifiable, certain problems should be targeted including optimizing training quotas, tailoring career guidance to the needs of the population, and emphasizing credentialing and quality control in endoscopy.
Assessing the Subjective and Physiological Effects of Intranasally Administered Crushed Extended‐Release Morphine Formulations with and without a Sequestered Naltrexone Core in Recreational Opioid Users
Authors: Setnik Beatrice , Goli Veeraindar , Levy-Cooperman Naama , Mills Catherine , Shram Megan , Smith Ira
Published: March 2016

OBJECTIVE: To evaluate the pharmacodynamic (PD) effects of morphine sulfate and naltrexone hydrochloride extended‐release (MSN) capsules compared with controlled‐release morphine sulfate (MS) and placebo when crushed and administered intranasally.

METHODS: The present study was a randomized, double‐blinded, placebo‐controlled, single‐dose (30 mg), three‐way crossover study in healthy, nondependent recreational opioid users. PD measures included assessment of subjective drug effects using visual analogue scales (VAS) ranging from 0 to 100 and assessments of pupil diameter. Blood samples were collected for pharmacokinetic analyses.

RESULTS: Both MS and MSN showed significantly higher PD values compared with placebo. MSN showed significantly lower scores for drug liking and high VAS scores on both mean peak effect (Emax) (69.6 and 55.2, respectively) and in area under the effect curve over 2 h (86.3 and 66.7, respectively) following dosing compared with MS (Emax 87.6 and 86.6, respectively; area under the curve over 2 h 120.6 and 132.9, respectively; P<0.001). MSN showed significantly lower Emax for all other positive subjective effects (good drug effects, overall drug liking, and take drug again VAS scores) compared with MS (P<0.001). Peak minimum pupil diameter was significantly larger for MSN than MS (P=0.002). Mean peak plasma concentration (Cmax) and median time to Cmax for morphine following administration of MSN and MS were similar (27.3 ng/mL and 0.57 h versus 27.7 ng/mL and 0.6 h, respectively). Naltrexone mean Cmax was 1497 pg/mL after MSN and median time to Cmax was 0.55 h.

CONCLUSIONS: When crushed and administered intranasally, MSN was associated with significantly lower ratings of drug liking and other positive subjective effects compared with MS.
A Systematic Review and Meta‐Analyses of Nonsucrose Sweet Solutions for Pain Relief in Neonates
Authors: Bueno Mariana , Yamada Janet , Harrison Denise , Khan Sobia , Ohlsson Arne , Adams-Webber Thomasin , Beyene Joseph , Stevens Bonnie
Published: March 2016

BACKGROUND: Sucrose has been demonstrated to provide analgesia for minor painful procedures in infants. However, results of trials investigating other sweet solutions for neonatal pain relief have not yet been synthesized.

OBJECTIVE: To establish the efficacy of nonsucrose sweet‐tasting solutions for pain relief during painful procedures in neonates.

METHOD: The present article is a systematic review and meta‐analyses of the literature. Standard methods of the Cochrane Neonatal Collaborative Review Group were used. Literature searches were reviewed for randomized controlled trials investigating the use of sweet solutions, except sucrose, for procedural pain management in neonates. Outcomes assessed included validated pain measures and behavioural and physiological indicators.

RESULTS: Thirty‐eight studies (3785 neonates) were included, 35 of which investigated glucose. Heel lancing was performed in 21/38 studies and venipuncture in 11/38 studies. A 3.6‐point reduction in Premature Infant Pain Profile scores during heel lances was observed in studies comparing 20% to 30% glucose with no intervention (two studies, 124 neonates; mean difference −3.6 [95% CI −4.6 to −2.6]; P<0.001; I2=54%). A significant reduction in the incidence of cry after venipuncture for infants receiving 25% to 30% glucose versus water or no intervention was observed (three studies, 130 infants; risk difference −0.18 [95% CI −0.31 to −0.05]; P=0.008, number needed to treat = 6 [95% CI 3 to 20]; I2=63%).

CONCLUSIONS: The present systematic review and meta‐analyses demonstrate that glucose reduces pain scores and crying during single heel lances and venipunctures. Results indicate that 20% to 30% glucose solutions have analgesic effects and can be recommended as an alternative to sucrose for procedural pain reduction in healthy term and preterm neonates.
Children and Adolescents with Complex Regional Pain Syndrome: More Psychologically Distressed than Other Children in Pain?
Authors: Logan Deirdre E , Williams Sara E , Carullo Veronica P , Claar Robyn Lewis , Bruehl Stephen , Berde Charles B
Published: March 2016

BACKGROUND: Historically, in both adult and pediatric populations, a lack of knowledge regarding complex regional pain syndrome (CRPS) and absence of clear diagnostic criteria have contributed to the view that this is a primarily psychiatric condition.

OBJECTIVE: To test the hypothesis that children with CRPS are more functionally disabled, have more pain and are more psychologically distressed than children with other pain conditions.

METHODS: A total of 101 children evaluated in a tertiary care pediatric pain clinic who met the International Association for the Study of Pain consensus diagnostic criteria for CRPS participated in the present retrospective study. Comparison groups included 103 children with abdominal pain, 291 with headache and 119 with back pain. Children and parents completed self‐report questionnaires assessing disability, somatization, pain coping, depression, anxiety and school attendance.

RESULTS: Children with CRPS reported higher pain intensity and more recent onset of pain at the initial tertiary pain clinic evaluation compared with children with other chronic pain conditions. They reported greater functional disability and more somatic symptoms than children with headaches or back pain. Scores on measures of depression and anxiety were within normal limits and similar to those of children in other pain diagnostic groups.

CONCLUSIONS: As a group, clinic‐referred children with CRPS may be more functionally impaired and experience more somatic symptoms compared with children with other pain conditions. However, overall psychological functioning as assessed by self‐report appears to be similar to that of children with other chronic pain diagnoses. Comprehensive assessment using a biopsychosocial framework is essential to understanding and appropriately treating children with symptoms of CRPS.
Diffuse Pulmonary Lymphangiomatosis
Authors: Kadakia Kunal C , Patel Sandeep M , Yi Eunhee S , Limper Andrew H
Published: March 2016

Diffuse pulmonary lymphangiomatosis (DPL) is a rare disease characterized by infiltration of the lung, pleura and mediastinum with thin-walled lymphangiomas. DPL can result in mass effect from infiltrative disease, restrictive and obstructive pulmonary physiology, chylous effusions and respiratory failure. The present article discusses clinical, radiographic and pathological features, and treatment options for DPL.
Challenges in the Diagnosis and Management of Autoimmune Hepatitis
Authors: Czaja Albert J
Published: March 2016

BACKGROUND: Autoimmune hepatitis has diverse clinical phenotypes and outcomes that challenge current diagnostic criteria and management algorithms.

OBJECTIVES: To highlight the major difficulties in diagnosis and management, describe the efforts to ease them and encourage further progress in problem solving.

METHODS: The MEDLINE database was reviewed for published experiences from 1984 to 2013.

RESULTS: Acute or acute severe (fulminant) hepatitis, asymptomatic mild disease, and histological findings of centrilobular necrosis or bile duct injury can confound diagnosis and treatment. Continuation of conventional therapy until normal liver test results and liver tissue reduces the frequency of relapse, but does not prevent its occurrence. Problematic patients can be identified using mathematical models, clinical phenotype, serological markers and the speed of improvement after treatment; however, their recognition and treatment are inconsistent. Mycophenolate mofetil can rescue patients with azathioprine intolerance but is less effective for refractory disease. Budesonide in combination with azathioprine can be used frontline, but is effective primarily in noncirrhotic, uncomplicated disease. Molecular and cellular interventions are feasible but largely unevaluated.

DISCUSSION: Resolution of the current challenges requires revision of diagnostic criteria, characterization of biological markers that reflect pathogenic pathways, development of dynamic indexes based on changes in disease behaviour, and introduction of new pharmacological, molecular and cellular interventions that have undergone rigorous evaluation.

CONCLUSION: These challenges reflect important remediable deficiencies in current management.
HIV‐1 Tropism Testing and Clinical Management of CCR5 Antagonists: Quebec Review and Recommendations
Authors: Tremblay Cécile , Hardy Isabelle , Lalonde Richard , Trottier Benoit , Tsarevsky Irina , Vézina Louis-Philippe , Roger Michel , Wainberg Mark , Baril Jean-Guy
Published: March 2016

HIV‐1 tropism assays play a crucial role in determining the response to CCR5 receptor antagonists. Initially, phenotypic tests were used, but limited access to these tests prompted the development of alternative strategies. Recently, genotyping tropism has been validated using a Canadian technology in clinical trials investigating the use of maraviroc in both experienced and treatment‐naive patients. The present guidelines review the evidence supporting the use of genotypic assays and provide recommendations regarding tropism testing in daily clinical management.