bluuebunny/crossref_metadata_2025 huggingface dataset:
Endoscopic Management of Gastric Varices: Efficacy and Outcomes of Gluing with N-Butyl-2-Cyanoacrylate in a North American Patient Population
Authors: Belletrutti PJ , Romagnuolo J , Hilsden RJ , Chen F , Kaplan B , Love J , Beck PL
Published: March 2016

BACKGROUND: Gastric variceal bleeding is associated with significant morbidity and mortality in patients with portal hypertension. Outside of North America, gastric variceal injection of N-butyl-2-cyanoacrylate has been shown to be safe and effective. The majority of studies on this mode of therapy are in Asian populations in which the etiology of portal hypertension differs from North America.

AIM: To assess the safety and efficacy of gastric variceal glue injection in a North American population.

METHODS: Consecutive patients that underwent glue injection of gastric varices in the Calgary Health Region from 2001 to 2006 were assessed.

RESULTS: Thirty-four patients (19 men, 15 women) underwent a total of 47 separate gluing procedures. Of those presenting with active bleeding at endoscopy, immediate hemostasis was achieved in 93.8% of patients. Rebleeding within 48 h of gluing was observed after four procedures. Gastric varices were eradicated in 84.0% of cases. Complications included superior mesenteric vein thrombosis in one patient. Twenty-eight (82.4%) patients were alive at the end of follow-up. The treatment failure-related mortality rate was 2.1%.

CONCLUSIONS: The present study is one of the few to assess the role of gastric variceal gluing in a North American population. Glue injection with cyanoacrylate is safe and effective in the treatment of bleeding gastric varices.
Cryptococcus gattii: An Emerging Cause of Pulmonary Nodules
Authors: Dewar Gary J , Kelly James K
Published: March 2016

BACKGROUND: Since the fall of 1999, a new endemic focus of Cryptococcus gattii serotype B infection has emerged on Vancouver Island (Victoria, British Columbia), with infections occurring in both animals and humans. In the human cases, symptoms have manifested as pulmonary nodules, meningitis or both. This organism has added a new nonmalignant cause of pulmonary nodules to the literature, resulting in a change in the management of these nodules by health care professionals.

METHODS: A search of the number of cases recorded and treated in hospitals of the Vancouver Island Health Authority, along with a review of the literature regarding this emerging organism, was undertaken. The pathology, epidemiology and clinical course of this previously uncommon fungus was determined, and representative cases were chosen for illustration.

RESULTS: More than 130 cases were recorded in the six‐year period from late 1999 to mid‐July 2006. The number of cases increased steadily over this period, but appears to be levelling off. Representative cases with medical imaging, along with photos of the pathology, are included. Recommendations for diagnosis, treatment and follow‐up are outlined.

CONCLUSIONS: The emergence of cryptococcal lung and central nervous system lesions on Vancouver Island have made it important to include travel to or residence of the island as part of the history in patients with pulmonary nodules. A registry of patients from Vancouver Island has been established, and it may be of value to include nonisland patients who are found to be infected with this organism.
Low Prevalence ofHelicobacter PyloriInfection in Canadian Children: A Cross-Sectional Analysis
Authors: Segal Idit , Otley Anthony , Issenman Robert , Armstrong David , Espinosa Victor , Cawdron Ruth , Morshed Muhammad G , Jacobson Kevan
Published: March 2016

BACKGROUND: The incidence and prevalence rates of childhoodHelicobacter pyloriinfection vary greatly by nation, with infection rates of 8.9% to 72.8% reported in developed and developing countries, respectively. To date, few studies have assessed the prevalence ofH pyloriin Canadian children, with studies limited to Aboriginal communities and single tertiary care centres from Ontario and Quebec.

OBJECTIVES: To determine the prevalence ofH pyloriin consecutive children referred to three Canadian tertiary care academic centres for upper gastrointestinal (GI) endoscopy due to upper GI symptoms, and to determine the sensitivity and specificity of the carbon-13-labelled urea breath test, the rapid urease test and theH pyloristool monoclonal antigen test.

RESULTS: Two hundred four patients were recruited. The prevalence ofH pyloriwas 7.1%. Of theH pylori-positive patients, 41.7% were male, with a mean age of 10.3 years. Ethnic minorities accounted for 42% of theH pylori-positive patients. Consistent with previous observations, the sensitivity and specificity of the carbon-13-labelled urea breath test were 1.0 and 0.98, respectively. The sensitivity and specificity of the rapid urease test were 1.0 and 0.99, respectively. Stool samples were collected from 34 patients from one centre, with a sensitivity and specificity of 1.0 and 0.68, respectively. No defining symptoms ofH pyloriinfection were evident and no peptic ulcer disease was demonstrated.

CONCLUSION:H pyloriinfection rates in Canadian children with upper GI symptoms are low, and are lower than those reported for other developed countries. Further studies are required in Canada to determine the prevalence in the general population and specifically in the populations at risk.
Hepatitis A and Hepatitis B Vaccination Responses in Persons with Chronic Hepatitis C Infections: A Review of the Evidence and Current Recommendations
Authors: Buxton Jane A , Kim Jin Hee
Published: March 2016

In persons with chronic hepatitis C virus (HCV) infections, superinfection by hepatitis A virus (HAV) or hepatitis B virus (HBV) can cause serious complications, including fulminating hepatitis or increased severity of hepatitis. Therefore, it is important to adequately protect persons with chronic HCV infections by immunization. Suboptimal response to vaccines has been reported in patients with chronic liver disease. The present article reviews HAV and HBV vaccine responses reported in the literature when administered to individuals with chronic HCV infection, and reviews current national and international recommendations.

RESULTS: Persons with chronic HCV respond well to HAV vaccine, but studies exploring HBV vaccine efficacy in this population have equivocal results. Vaccine schedules and participant characteristics differ among studies, and most do not adjust for confounders. Some studies found no difference in HBV vaccine response between patients with chronic HCV and controls. However, HBV vaccine response was generally reduced in those with cirrhosis and HCV genotype 1. Organizations recommend HAV and HBV vaccines for persons with chronic HCV, but do not suggest alterations in schedule or dose.

RECOMMENDATIONS: Because HAV vaccine response is good and routine laboratory testing may not detect lower levels of vaccine‐induced anti‐HAV, the standard HAV vaccine schedule is recommended without postimmunization testing. HBV vaccine should be administered early in the course of chronic HCV infection because response may be lower in patients with cirrhosis. Reflex testing of anti‐HCV reactive sera for anti‐HAV and hepatitis B surface antibody can facilitate appropriate follow‐up and timely immunization. Determination of postimmunization hepatitis B surface antibody, especially in patients with cirrhosis or genotype 1, will allow HBV vaccine boosters to be offered.
Childhood Asthma Surveillance using Administrative Data: Consistency between Medical Billing and Hospital Discharge Diagnoses
Authors: Labrèche France , Kosatsky Tom , Przybysz Raymond
Published: March 2016

BACKGROUND: The absence of ongoing surveillance for childhood asthma in Montreal, Quebec, prompted the present investigation to assess the validity and practicality of administrative databases as a foundation for surveillance.

OBJECTIVE: To explore the consistency between cases of asthma identified through physician billings compared with hospital discharge summaries.

METHODS: Rates of service use for asthma in 1998 among Montreal children aged one, four and eight years were estimated. Correspondence between the two databases (physician billing claims versus medical billing claims) were explored during three different time periods: the first day of hospitalization, during the entire hospital stay, and during the hospital stay plus a one‐day margin before admission and after discharge (‘hospital stay ± 1 day’).

RESULTS: During 1998, 7.6% of Montreal children consulted a physician for asthma at least once and 0.6% were hospitalized with a principal diagnosis of asthma. There were no contemporaneous physician billings for asthma ‘in hospital’ during hospital stay ± 1 day for 22% of hospitalizations in which asthma was the primary diagnosis recorded at discharge. Conversely, among children with a physician billing for asthma ‘in hospital’, 66% were found to have a contemporaneous in‐hospital record of a stay for ‘asthma’.

CONCLUSIONS: Both databases of hospital and medical billing claims are useful for estimating rates of hospitalization for asthma in children. The potential for diagnostic imprecision is of concern, especially if capturing the exact number of uses is more important than establishing patterns of use.
Pain and Self‐Reported Health in Canadian Children
Authors: van Dijk Adam , McGrath Patricia A , Pickett William , Van Den Kerkhof Elizabeth G
Published: March 2016

BACKGROUND: Despite increasing attention to the epidemiology of pain, relatively little is known about the association between pain and health in children. In particular, no studies have examined this relationship in the general population of children in Canada.

OBJECTIVES: To assess the association between self‐reported pain experiences and health in school children in southeastern Ontario. Health measures included perceived health status, psychological complaints and satisfaction with school.

METHODS: A total of 495 nine‐to 13‐year‐old school children completed the Pain Experience Interview – Short Form and health‐related questions from the Health Behaviour in School‐aged Children questionnaire.

RESULTS: Of the 495 children in the present study, 8% rated their health as ‘fair’ to ‘poor’, 56% reported experiencing at least one of four psychological symptoms more than once a week and 24% said they disliked school. The strongest associations existed between headaches and poor self‐rated health (OR=10.1; 95% CI 1.3 to 78.3), recurrent pain and psychological outcomes (OR=3.6; 95% CI 2.0 to 6.3), and recurrent pain and disliking school (OR=3.6; 95% CI 1.9 to 6.7).

DISCUSSION: These findings indicate that common childhood pains are associated with childhood health. Further studies are needed to assess the causal relationship between pain and health in children, to obtain a more comprehensive understanding of the personal and economic impact of childhood pain, and to monitor changes in the lives of children living with chronic pain.
Hygiene at Work: An Engineering Perspective on the Development of Hygiene Science
Authors: Pityn Peter J
Published: March 2016

The present article examines the work of contemporary hygiene practitioners. Discussion converges from a broad examination of hygiene at work in our society serving the common good to occupational hygiene in the workplace. The article considers the expanding role of hygiene today, juxtaposed against the lack of awareness and perceptions of hygiene. It considers some of the current social challenges facing hygiene, perceptions of risk and problems specifically encountered by occupational hygienists.
Self-Management for People with Inflammatory Bowel Disease
Authors: Saibil Fred , Lai Emily , Hayward Andrew , Yip Jeanne , Gilbert Cameron
Published: March 2016

In North America and the United Kingdom, we are in the age of self-management. Many patients with chronic diseases are ready to participate in the therapeutic decision-making process, and join their physicians in a co-management model. It is particularly useful to consider this concept at a time when physician shortages and waiting times are on the front page every day, with no immediate prospect of relief. Conditions such as diabetes, asthma, chronic obstructive pulmonary disease, recurrent urinary tract infections and others lend themselves to this paradigm of medical care for the informed patient. The present paper reviews some of the literature on self-management for the patient with inflammatory bowel disease (IBD), and provides a framework for the use of self-management in the IBD population, with emphasis on the concept of a patient passport, and the use of e-mail, supported by an e-mail contract, as proposed by the Canadian Medical Protective Association. Examples of specific management strategies are provided for several different IBD scenarios. Eliminating the need for some office visits has clear environmental and economical benefits. Potential negative consequences of this form of patient care are also discussed.
Prevalence of Opioid Dispensings and Concurrent Gastrointestinal Medications in Quebec
Authors: Williams Rachel E , Bosnic Nevzeta , Sweeney Carolyn T , Duncan Ashlee W , Levine Kristen B , Brogan Michael , Cook Suzanne F
Published: March 2016

BACKGROUND: Opioids are frequently prescribed for moderate to severe pain. A side effect of opioid usage is the inhibition of gastrointestinal (GI) motility, known as opioid‐induced bowel dysfunction (OBD). OBD is typically treated prophylactically with laxatives and/or acid suppressants.

AIM: The present study describes the prevalence of outpatient opioid dispensing, opioid patient demographics, and concomitant dispensing of opioids and GI medications in the Quebec Public Prescription Drug Insurance Plan in 2005.

METHODS: Using a retrospective cohort design, opioid dispensings were identified using claims and reimbursement data. Laxative and acid suppressant dispensings were also identified. Concurrent use was defined as having at least one ‘GI medication‐exposed day’ overlapping an ‘opioid‐exposed day’.

RESULTS: More than 11% of the drug plan population was dispensed an opioid in 2005, and dispensings increased with age. Approximately two‐thirds of patients who received an opioid were given codeine. Approximately one‐third of opioid patients were concomitantly dispensed a GI medication, yet only 2% were dispensed a laxative.

CONCLUSIONS: Although the GI side effects of opioids are well known, these side effects appear to increase with age and duration of opioid use. Opioid‐related side effects, particularly OBD, should be effectively managed so as not to lead to the cessation of opioid therapy.
Access to Specialist Gastroenterology Care in Canada: Comparison of Wait Times and Consensus Targets
Authors: Leddin Desmond , Armstrong David , Barkun Alan NG , Chen Ying , Daniels Sandra , Hollingworth Roger , Hunt Richard H , Paterson William G
Published: March 2016

BACKGROUND: Monitoring wait times and defining targets for care have been advocated to improve health care delivery related to cancer, heart, diagnostic imaging, joint replacements and sight restoration. There are few data on access to care for digestive diseases, although they pose a greater economic burden than cancer or heart disease in Canada. The present study compared wait times for specialist gastroenterology care with recent, evidence-based, consensus-defined benchmark wait times for a range of digestive diseases.

METHODS: Total wait times from primary care referral to investigation were measured for seven digestive disease indications by using the Practice Audit in Gastroenterology program, and were benchmarked against consensus recommendations.

RESULTS: Total wait times for 1903 patients who were undergoing investigation exceeded targets for those with probable cancer (median 26 days [25th to 75th percentiles eight to 56 days] versus target of two weeks); probable inflammatory bowel disease (101 days [35 to 209 days] versus two weeks); documented iron deficiency anemia (71 days [19 to 142 days] versus two months); positive fecal occult blood test (73 days [36 to 148 days] versus two months); dyspepsia with alarm symptoms (60 days [23 to 140 days] versus two months); refractory dyspepsia without alarm symptoms (126 days [42 to 225 days] versus two months); and chronic constipation and diarrhea (141 days [68 to 264 days] versus two months). A minority of patients were seen within target times: probable cancer (33% [95% CI 20% to 47%]); probable inflammatory bowel disease (12% [95% CI 1% to 23%]); iron deficiency anemia (46% [95% CI 37% to 55%]); positive occult blood test (41% [95% CI 28% to 54%]); dyspepsia with alarm symptoms (51% [95% CI 41% to 60%]); refractory dyspepsia without alarm symptoms (33% [95% CI 19% to 47%]); and chronic constipation and diarrhea (21% [95% CI 14% to 29%]).

DISCUSSION: Total wait times for the seven indications exceeded the consensus targets; 51% to 88% of patients were not seen within the target wait time. Multiple interventions, including adoption of evidence-based management guidelines and provision of economic and human resources, are needed to ensure appropriate access to digestive health care in Canada. Outcomes can be evaluated by the ‘point-of-care’, practice audit methodology used for the present study.
Review and Clinical Perspectives for the Use of Infliximab in Ulcerative Colitis
Authors: Panaccione Remo , Fedorak Richard N , Aumais Guy , Bernard Edmond-Jean , Bernstein Charles N , Bitton Alain , Croitoru Ken , Dieleman Levinus A , Enns Robert , Feagan Brian G , Franchimont Denis , Greenberg Gordon R , Griffiths Anne-Marie , Marshall John K , Pare Pierre , Patel Sunil , Penner Robert , Render Craig , Seidman Ernest , Steinhart A Hillary
Published: March 2016

Infliximab is a chimeric, monoclonal anti-tumour necrosis factor-alpha antibody. It has been previously demonstrated to be an effective treatment for patients with Crohn’s disease who do not achieve the desired response with conventional treatments. Although the etiology of ulcerative colitis (UC) differs from that of Crohn’s disease, randomized controlled trials have demonstrated that infliximab is also beneficial for the treatment of moderate to severe UC in patients who are either intolerant of or refractory to immunosuppressant agents or steroids, or those who are steroid-dependent. A review of the literature is followed by practical recommendations regarding infliximab that address the needs of clinicians and UC patients. Where there is a lack of evidence-based information, the expert panel provides its combined opinion derived from the members’ clinical experiences.
The Clinical Impact and Cost Implications of Endoscopic Ultrasound on the Use of Endoscopic Retrograde Cholangiopancreatography in a Canadian University Hospital
Authors: Alhayaf Nassir , Lalor Eoin , Bain Vincent , McKaigney John , Sandha Gurpal Singh
Published: March 2016

BACKGROUND: Endoscopic ultrasound (EUS) is a safe alternative to endoscopic retrograde cholangiopancreatography (ERCP) for diagnostic biliary imaging in choledocholithiasis. Evidence linking a decline in diagnostic ERCP with the introduction of EUS in clinical practice is limited.

OBJECTIVE: To assess the clinical impact and cost implications of a new EUS program on diagnostic ERCP at a tertiary referral centre.

PATIENTS AND METHODS: A retrospective review was performed of data collected during the first year of EUS at the University of Alberta Hospital (Edmonton, Alberta). Patients were referred for ERCP because of suspicion of choledocholithiasis based on clinical, biochemical and/or radiological parameters. If they were assessed to have an intermediate probability of choledocholithiasis, EUS was performed first. ERCP was performed if EUS suggested choledocholithiasis, whereas patients were clinically followed for six months if their EUS was normal. Cost data were assessed from a third-party payer perspective, and cost savings were expressed in terms of ERCP procedures avoided.

RESULTS: Over 12 months, 90 patients (63 female, mean age 58 years) underwent EUS for suspected biliary tract abnormalities. EUS suggested choledocholithiasis in 20 patients (22%), and this was confirmed by ERCP in 17 of the 20 patients. EUS was normal in 69 patients, and none underwent a subsequent ERCP during a six-month follow-up period. One patient had pancreatic cancer and did not undergo ERCP. The sensitivity and specificity of EUS for choledocholithiasis were 100% and 96%, respectively. A total of 440 ERCP procedures were performed over the same 12-month period, suggesting that EUS resulted in a 14% reduction in ERCP procedures (70 of 510). There were no complications of EUS. The cost of 90 EUS procedures was $42,840, compared with $108,854 for 70 ERCP procedures. The cost savings for the first year were $66,014.

CONCLUSION: EUS appears to be accurate, safe and cost effective in diagnostic biliary imaging for suspected choledocholithiasis. The impact of EUS is the avoidance of ERCP in selected cases, thereby preventing the risk of complications. Diagnostic ERCP should not be performed in centres and regions with physicians trained in EUS.
Unsedated Transnasal Endoscopy: A Canadian Experience in Daily Practice
Authors: Cho Sarah , Arya Naveen , Swan Katherine , Cirocco Maria , Kandel Gabor , Kortan Paul , Marcon Norman
Published: March 2016

BACKGROUND: Esophagogastroduodenoscopy (EGD) is the most frequently performed diagnostic procedure for upper gastrointestinal disorders. The procedure is routinely performed under conscious sedation in North America. A significant proportion of morbidity and mortality associated with EGD is related to hypoxia due to conscious sedation. The use of sedation is also associated with an increase in cost, loss of work on the day of endoscopy and the need for the patient to be accompanied home after the procedure. Transnasal endoscopy has advantages such as no sedation and less patient monitoring, nursing time and expenses than conventional per oral EGD.

OBJECTIVES: To assess the feasibility and acceptability of unsedated transnasal EGD in daily practice.

METHODS: Patients due to undergo EGD were given a choice of either unsedated transnasal EGD or per oral EGD with sedation. Patients who chose unsedated transnasal EGD had the procedure performed in the office by a senior gastroenterologist with experience in transnasal EGD. All procedures were performed using a small-calibre esophagogastroduodenoscope. All patients were surveyed using a patient satisfaction questionnaire, and were asked to give specific scores in terms of choking sensation, sore throat, nasal discomfort and abdominal discomfort. All variables were assessed by scores between 0 and 10, with 10 indicating the most severe degree of each variable. Any complications were also recorded.

RESULTS: Between March 2002 and August 2003, 231 patients underwent transnasal EGD. The median age of the patients was 57 years (range 15 to 87 years). Complete examinations were possible in 98% of patients. Patients reported a high degree of acceptability (mean score 6.6, range 1 to 10) and low degrees of choking sensation (mean 1.8, range 0 to 10), nasal discomfort (mean 1.7, range 0 to 10), sore throat (mean 0.8, range 0 to 9) and abdominal discomfort (mean 1.1, range 0 to 10). The only complications reported by the patients were epistaxis (n=2, 0.9%) and sinusitis (n=1, 0.4%). Some patients also reported transient light-headedness (n=12, 5%) and mucous discharge (n=2, 0.9%). When asked, 185 patients (88%) stated that they were willing to undergo the same procedure in the future if medically indicated. Of the 84 patients who had conventional EGD under conscious sedation in the past, 52 patients (62%) preferred transnasal EGD without sedation.

CONCLUSIONS: Transnasal EGD is generally well tolerated, feasible and safe. It can be performed with topical anesthesia in an outpatient setting. The low complication rate, high patient satisfaction and potential cost savings make transnasal endoscopy an attractive alternative to conventional EGD to screen patients for upper gastrointestinal tract diseases.
Local Infection after Placement of Percutaneous Endoscopic Gastrostomy Tubes: A Prospective Study Evaluating Risk Factors
Authors: Zopf Y , Konturek P , Nuernberger A , Maiss J , Zenk J , Iro H , Hahn EG , Schwab D
Published: March 2016

BACKGROUND: Due to its high efficacy and technical simplicity, percutaneous endoscopic gastrostomy (PEG) has gained wide-spread use. Local infection, occurring in approximately 2% to 39% of procedures, is the most common complication in the short term. Risk factors for local infection are largely unknown and therefore – apart from calculated antibiotic prophylaxis – preventive strategies have yet to be determined.

OBJECTIVE: To assess the potential patient- and procedure-related risk factors for peristomal infection following PEG tube placement.

METHODS: Potential patient-related (eg, age, sex, diseases, body mass index, concomitant antibiotic therapy) and procedure-related (endoscopist experience, institutional factors, findings on endoscopy) risk factors and their coincidence with local infection, defined as a positive peristomal infection three days after PEG tube placement, were evaluated at two institutions. A standardized antibiotic prophylaxis was not performed. The peristomal infection score was also evaluated in 390 patients.

RESULTS: Using a multivariate binary regression analysis, four risk factors were established as relevant for local infection after PEG: clinical institution (OR 6.69; P=0.0001), size of PEG tubes (15 Fr versus 9 Fr; OR 2.12; P=0.05), experience of the endoscopist (more than 100 investigations versus less than 100 investigations; OR 0.54; P=0.05) and the existence of a malignant underlying disease (OR 2.28; P=0.019).

CONCLUSIONS: Similar to other endoscopic interventions, local infection as a complication of PEG tube placement depends on the experience of the endoscopist. Institutional factors also play a significant role. Additional risk factors include PEG tube size and underlying diseases. These findings indicate that the local infection after PEG tube placement may be influenced by both endoscopy-associated factors and by the underlying disease status of the patient.
Differences in Antimicrobial Susceptibility in Escherichia coli from Canadian Intensive Care Units Based on Regional and Demographic Variables
Authors: Lagacé-Wiens Philippe RS , DeCorby Melanie R , Baudry Patricia J , Hoban Daryl J , Karlowsky James A , the CAN-ICU study group  , Zhanel George G
Published: March 2016

OBJECTIVES: Escherichia coli resistance to antimicrobials varies according to many factors. E coli isolates from Canadian intensive care units (ICUs) were studied to determine the distribution and demographics associated with antimicrobial resistance in this population.

METHODS: The Canadian National Intensive Care Unit (CAN‐ICU) study characterized pathogens isolated in Canadian ICUs from July 2005 to June 2006. E coli susceptibility to 10 antimicrobials was determined and a multivariate logistic regression model was designed to determine whether region, sex, isolation from a sterile site and age (younger than 30 years) were significantly associated with susceptibility to the tested antimicrobials, to multidrug resistance or pan‐susceptibility.

RESULTS: Four hundred ninety‐three E coli isolates, representing 12.6% of all isolates collected in the CAN‐ICU study were examined. Susceptibilities were highest for meropenem and tigecycline (100%), cefepime (98.2%), piperacillin‐tazobactam (97.0%), ceftriaxone (93.1%) and gentamicin (92.3%), and lowest for cefazolin (76.7%), trimethoprim‐sulfamethoxazole (75.7%) and the fluoroquinolones (ciprofloxacin, 78.3%; and levofloxacin, 78.9%). In the multivariate model, fluoroquinolone resistance was lowest in patients younger than 30 years of age. Cefazolin and ceftriaxone susceptibility was lowest in Nova Scotia. Susceptibility to all tested antimicrobials was lowest in Nova Scotia and British Columbia. Isolation from a sterile site was associated with trimethoprim‐sulfamethoxazole, piperacillin‐tazobactam and multidrug resistance.

CONCLUSIONS: E coli antimicrobial susceptibility varies across Canadian ICUs. Age, region and site of infection should be considered when prescribing empirical antimicrobial therapy. For infections caused by or suspected to be caused by E coli, fluoroquinolones, cefazolin and sulfonamides should be avoided due to low susceptibilities. Local antimicrobial prescribing practices, in particular the liberal use of fluoroquinolones and cephalosporins, and inadequate infection control practices are likely reducing susceptibility rates.
Recognizing Immunoglobulin G4-Related Overlap Syndromes in Patients with Pancreatic and Hepatobiliary Diseases
Authors: Montano-Loza Aldo J , Lalor Eoin , Mason Andrew L
Published: March 2016

The first description of autoimmune pancreatitis and elevated serum immunoglobulin-G4 (IgG4) in 2001 heralded further reports of several related autoimmune diseases with raised IgG4 levels. It is now recognized that a spectrum of overlap syndromes associated with increased IgG4 and biopsy evidence of IgG4-producing plasma cells, which has now been convincingly linked with cholangitis, autoimmune hepatitis, Sjögren’s syndrome, nephritis and retroperitoneal fibrosis. Collectively, this disease cluster is referred to as IgG4-related systemic disease. The importance of making the correct diagnosis is underscored by the management of individuals with IgG4-related systemic disease. In the first instance, patients generally have a dramatic response to immunosuppressive therapy, whereas patients with other forms of cholangitis and pancreatitis do not. Also, surgical management of pancreatic malignancy can be avoided once the correct diagnosis of IgG4-related disease has been made. In the present review, an overview of the current information regarding the role of IgG4 and IgG4-positive cells affecting the biliary system, pancreas and liver is provided.
Congenital Short Bowel Syndrome: A Case Report and Review of the Literature
Authors: Hasosah Mohammed , Lemberg Daniel A , Skarsgard Eric , Schreiber Richard
Published: March 2016

Congenital short bowel syndrome (SBS) is a rare condition of the newborn, with several reports demonstrating high mortality. A six-week-old boy presented with chronic diarrhea and failure to thrive. An upper gastrointestinal endoscopy showed a straight duodenum, and multiple small bowel biopsies were histologically normal. An upper gastrointestinal series showed malrotation. At laparotomy, the small bowel was 50 cm in length, confirming the diagnosis of congenital SBS. Parenteral nutrition was initiated and enteral feeding with an amino acid-based formula containing long-chain fatty acids was introduced early and gradually advanced. At the last follow-up examination at 24 months, he was thriving on a regular diet, with normal growth and development. Long-term survival of children with congenital SBS is now possible if enteral feeds are introduced early to promote intestinal adaptation, with subsequent weaning off parenteral nutrition.
Epidemiology and Antifungal Susceptibility of Bloodstream Candida Isolates in Quebec: Report on 453 Cases between 2003 and 2005
Authors: St-Germain Guy , Laverdière Michel , Pelletier René , René Pierre , Bourgault Anne-Marie , Lemieux Claude , Libman Michael
Published: March 2016

BACKGROUND: Between May 2003 and April 2005, a population‐based surveillance of Candida bloodstream infections was conducted in Quebec. A total of 453 episodes of candidemia (464 yeast isolates) from 54 participating hospitals were studied.

RESULTS: The annual incidence rate was three per 100,000 population. Global hospital mortality was 38%. The most common predisposing factors were the presence of an intravascular catheter (80%), use of antibacterial therapy (67%), stay in an intensive care unit (49%), use of parenteral nutrition (32%) and intra‐abdominal surgery (31%). Fluconazole alone or in association with other antifungals was used for treatment in over 80% of cases. Candida albicans comprised 62% of isolates, followed by Candida glabrata (17%), Candida parapsilosis (9%), Candida tropicalis (5%), Candida lusitaniae (3%) and Candida krusei (3%). Of the 288 C albicans isolates, seven (2%) were resistant to flucytosine, one to fluconazole and none to itraconazole or voriconazole. Of the 75 non‐C albicans species isolates with reduced susceptibility to fluconazole (minimum inhibitory concentration [MIC] 16 μg/mL or greater), none were susceptible to itraconazole (MIC 0.12 mg/L or lower), whereas 71 (95%) were susceptible to voriconazole (MIC 1 μg/mL or lower). However, only five of 12 (42%) fluconazole‐resistant isolates were susceptible to voriconazole. Posaconazole, ravuconazole and caspofungin displayed a broad spectrum of activity against these isolates, with MICs of 1 mg/L or lower in 56%, 92% and 100% of isolates, respectively. Overall, a correlation (r2>0.87) was observed among increasing fluconazole MICs and the geometric mean MICs of itraconazole, voriconazole, posaconazole and ravuconazole.

CONCLUSIONS: These surveillance results when compared with those of the 1993 to 1995 survey confirm little variation in the distribution of species causing invasive Candida infection over a 10‐year period in Quebec, as well as the continuous excellent overall in vitro activity of fluconazole.
Five‐Year Follow‐Up of a Cordotomy
Authors: Meeuse Jan J , Vervest Arnoud CM , van der Hoeven Johannes H , Reyners An KL
Published: March 2016

Percutaneous cervical cordotomy is an invasive procedure to treat severe, opioid‐resistant cancer pain. It is usually proposed for patients with a limited life expectancy. As a consequence, objective quantification of the long‐term effects of this procedure is lacking. The present report describes a patient who was treated with a right‐sided percutaneous cervical cordotomy for refractory cancer pain. Afterward, disseminated seminoma was diagnosed, which was cured with chemotherapy. Five years after the procedure, a qualitative and quantitative evaluation of the long‐term effects was performed. Sensory dysfunction was observed in the left side of the body, but no motor neuron or autonomic dysfunction was observed. The influence of these long‐term effects on the patient’s daily activities was limited.
Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease – 2008 Update – Highlights for Primary Care
Authors: O’Donnell Denis E , Hernandez Paul , Kaplan Alan , Aaron Shawn , Bourbeau Jean , Marciniuk Darcy , Balter Meyer , Ford Gordon , Gervais Andre , Lacasse Yves , Maltais Francois , Road Jeremy , Rocker Graeme , Sin Don , Sinuff Tasmin , Voduc Nha
Published: March 2016

Chronic obstructive pulmonary disease (COPD) is a major respiratory illness in Canada that is preventable and treatable but unfortunately remains underdiagnosed. The purpose of the present article from the Canadian Thoracic Society is to provide up-to-date information so that patients with this condition receive optimal care that is firmly based on scientific evidence. Important summary messages for clinicians are derived from the more detailed Update publication and are highlighted throughout the document. Three key messages contained in the update are: use targeted screening spirometry to establish a diagnosis and initiate prompt management (including smoking cessation) of mild COPD; improve dyspnea and activity limitation in stable COPD using new evidence-based treatment algorithms; and understand the importance of preventing and managing acute exacerbations, particularly in moderate to severe disease.
New Diagnostic Techniques for Esophageal Disorders
Authors: Lazarescu A
Published: March 2016

Esophageal disorders are common in the general population and can be associated with significant morbidity. Several new diagnostic techniques for esophageal disorders have become available in recent years. These include capsule pH-metry, high-resolution manometry, impedance combined with either pH-metry or manometry, and high-frequency ultrasound. Capsule pH-metry is useful in children and in patients who cannot tolerate the conventional pH-metry catheter. It has the advantage of not interfering with a patient’s usual meals and activities during the 24 h study. High-resolution manometery is easier to perform and interpret than conventional manometry. This has led to improved diagnosis of various esophageal motility disorders. Impedance measures the movement of liquid and gas in the esophagus. When combined with pH-metry, impedance can confirm that retrograde bolus movement (ie, reflux) is occurring while simultaneously measuring changes in pH levels. It has also highlighted the importance of weakly acidic reflux in patients who do not respond to proton pump inhibitors. Weakly acidic reflux cannot be diagnosed with pH-metry alone. Impedance combined with manometry can determine whether a manometric abnormality leads to abnormal bolus clearance. In the past, this was performed with fluoroscopy, yet impedance is equally effective and does not carry the risk of increased radiation exposure. High-frequency ultrasound is currently a research tool to image the esophageal wall, particulary the two muscle layers, in real time during swallows and at rest. It has broadened our understanding of the pathophysiology of esophageal motility disorders.
Relationship of Child Perceptions of Maternal Pain to Children’s Laboratory and Nonlaboratory Pain
Authors: Evans Subhadra , Tsao Jennie CI , Zeltzer Lonnie K
Published: March 2016

Previous research has established links between parent and child pain. However, little is known about sex‐specific parent‐child pain relationships in a nonclinical population. A sample of 186 children aged eight to 18 years (49% female) provided information on maternal and self bodily pain, assessed by asking children about the presence and location of bodily pain experienced. Children also completed three laboratory pain tasks and reported on cold pressor pain intensity, pressure pain intensity and heat pain intensity. The presence of child‐reported maternal pain was consistently correlated with daughters’ bodily and laboratory pain, but not with sons’ pain in bivariate analyses. Multivariate analyses controlling for child age and maternal psychological distress indicated that children of mothers with bodily pain reported more total bodily pain sites as well as greater pressure and cold pain intensity, relative to children of mothers without bodily pain. For cold pain intensity, these results differed for boys versus girls, in that daughters reporting maternal pain evidenced significantly higher cold pain intensity compared with daughters not reporting maternal pain. No such differences were found for boys. The findings suggest that children’s perceptions of maternal pain may play a role in influencing children’s own experience of pain, and that maternal pain models may affect boys and girls differently.
Cost‐Effectiveness of Continuous Positive Airway Pressure Therapy in Patients with Obstructive Sleep Apnea‐Hypopnea in British Columbia
Authors: Tan MCY , Ayas NT , Mulgrew A , Cortes L , FitzGerald JM , Fleetham JA , Schulzer M , Ryan CF , Ghaeli R , Cooperx P , Marra CA
Published: March 2016

BACKGROUND: Obstructive sleep apnea‐hypopnea (OSAH) is a common disorder characterized by recurrent collapse of the upper airway during sleep. Patients experience a reduced quality of life and an increased risk of motor vehicle crashes (MVCs). Continuous positive airway pressure (CPAP), which is the first‐line therapy for OSAH, improves sleepiness, vigilance and quality of life.

OBJECTIVE: To assess the cost‐effectiveness of CPAP therapy versus no treatment for OSAH patients who are drivers.

METHODS: A Markov decision analytical model with a five‐year time horizon was used. The study population consisted of male and female patients, between 30 and 59 years of age, who were newly diagnosed with moderate to severe OSAH. The model evaluated the cost‐effectiveness of CPAP therapy in reducing rates of MVCs and improving quality of life. Utility values were obtained from previously published studies. Rates of MVCs under the CPAP and no CPAP scenarios were calculated from Insurance Corporation of British Columbia data and a systematic review of published studies. MVCs, equipment and physician costs were obtained from the British Columbia Medical Association, published cost‐of‐illness studies and the price lists of established vendors of CPAP equipment in British Columbia. Findings were examined from the perspectives of a third‐party payer and society.

RESULTS: From the third‐party payer perspective, CPAP therapy was more effective but more costly than no CPAP (incremental cost‐effectiveness ratio [ICER] of $3,626 per quality‐adjusted life year). From the societal perspective, the ICER was similar ($2,979 per quality‐adjusted life year). The ICER was most dependent on preference elicitation method used to obtain utility values, varying almost sixfold under alternative assumptions from the base‐case analysis.

CONCLUSION: After considering costs and impact on quality of life, as well as the risk of MVCs in individuals with OSAH, CPAP therapy for OSAH patients is a highly efficient use of health care resources. Provincial governments who do not provide funding for CPAP therapy should reconsider.
Utilization of Colistin for Treatment of Multidrug‐Resistant Pseudomonas aeruginosa
Authors: Sabuda Deana M , Laupland Kevin , Pitout Johann , Dalton Bruce , Rabin Harvey , Louie Thomas , Conly John
Published: March 2016

BACKGROUND: Colistin is uncommonly used in clinical practice; however, the emergence of multidrug‐resistant organisms has rekindled interest in this potentially toxic therapeutic option. The present study describes the authors’ experience with colistin in the management of patients who were infected with metallo‐beta‐lactamase (MBL)‐producing Pseudomonas aeruginosa within the Calgary Health Region (Calgary, Alberta).

METHOD: Adult patients who received colistimethate sodium (colistin) between January 2000 and December 2005 were identified via pharmacy records, and their charts were reviewed retrospectively. Patients with cystic fibrosis were excluded. Patient demographics, clinical course and relevant laboratory data were extracted.

RESULTS: Twenty‐eight courses of colistin were received by 22 patients. The majority of these treatments were directed at MBL‐producing Pseudomonas. One‐half of the patients received nebulized colistin. Intravenous (IV) colistin was administered to 12 patients for a mean ± SD of 14.7±13.8 days (range 3.7 to 46 days). The highest IV dose used was 125 mg every 6 h or 6 mg/kg/day. Eight of 12 patients (67%) treated with IV colistin responded either fully or partially. Two patients received IV colistin as outpatients. Adverse effects considered to be due to colistin included drug fever, nephrotoxicity and neurotoxicity. Five of nine patients (56%) who had complete data available for evaluation had at least a doubling of creatinine levels from baseline.

CONCLUSION: Patients in the present study received both IV and nebulized colistin for multidrug‐resistant P aeruginosa. The use of IV colistin was associated with a favourable response, but mild nephrotoxicity occurred in two‐third of patients. It was concluded that colistin may be a useful drug when choices are limited.
The Use of Infliximab for Treatment of Hospitalized Patients with Acute Severe Ulcerative Colitis
Authors: Bressler B , Law JK , Al Nahdi Sheraisher N , Atkinson K , Byrne MF , Chung HV , Fishman M , Partovi N , Pearson D , Penner R , Enns RA
Published: March 2016

BACKGROUND/AIM: The use of infliximab in severe ulcerative colitis (UC) is established; however, its role in severe acute UC requires clarification. The present multicentre case series evaluated infliximab in hospitalized patients with steroid-refractory severe UC.

METHODS: Patients from six hospitals were retrospectively evaluated. Data collection included demographics, duration of disease and previous treatments. The primary end point was response to in-hospital infliximab; defined as discharge without colectomy.

RESULTS: Twenty-one patients (median age 26 years) were admitted between May 2006 and May 2008 with severe UC requiring intravenous steroids and given infliximab (median time to infusion eight days). Sixteen (76%) patients were discharged home without colectomy; three of these underwent colectomy at a later date. Of the remaining 13 patients (62%), all but two did not require further courses of steroids; six patients had infliximab as a bridge to azathioprine and seven patients were maintained on regular infliximab. Five patients required in-hospital colectomy after the initial infliximab.

CONCLUSIONS: In this real-life experience of infliximab in patients with steroid-refractory severe UC, infliximab appears to be a viable rescue therapy. The majority of patients were discharged without surgery and 62% maintained response either as a bridge to azathioprine or maintenance infliximab.
A Preliminary Guideline for the Assignment of Methicillin‐Resistant Staphylococcus aureus to a Canadian Pulsed‐Field Gel Electrophoresis Epidemic Type Using spa Typing
Authors: Golding George R , Campbell Jennifer L , Spreitzer Dave J , Veyhl Joe , Surynicz Kathy , Simor Andrew , Mulvey Michael R , Canadian Nosocomial Infection Surveillance Program
Published: March 2016

BACKGROUND: Increasing rates of methicillin‐resistant Staphylococcus aureus (MRSA) infections on a global scale is a major health concern. In Canada, there are 10 known epidemic types of MRSA as determined by pulsed‐field gel electrophoresis (PFGE). Despite the excellent discriminatory power of PFGE, there are several disadvantages of using this technique, such as high degree of labour intensity and the inability to easily develop an MRSA typing database due to the subjective interpretation of results.

OBJECTIVES: The purpose of the present study was to determine whether spa typing, an established DNA sequence‐based typing method, could be used as an alternative to PFGE for the typing of Canadian MRSA (CMRSA) epidemic isolates.

RESULTS: spa types were determined for 1488 CMRSA isolates, and the method was analyzed for its ability to identify and cluster CMRSA1‐10 strains. Minimal spanning tree analysis of 1452 spa types revealed individual clonal clusters for PFGE epidemic types CMRSA1, 2, 7 and 8, but spa typing could not distinguish CMRSA5 from CMRSA9 and CMRSA10, and CMRSA3 from CMRSA4 and CMRSA6. However, specific spa types were generally associated with only one PFGE epidemic type. Based on these results, a spa typing guideline for CMRSA isolates was developed and tested using the first 300 MRSA isolates received in 2007 through the Canadian Nosocomial Infection Surveillance Program.

CONCLUSIONS: The high concordance of spa types with PFGE epidemic types using this guideline demonstrated the feasibility of spa typing as a more rapid and less technically demanding alternative typing method for MRSA in Canada.