bluuebunny/crossref_metadata_2025 huggingface dataset:
Clostridium difficileInfection Worsens the Prognosis of Ulcerative Colitis
Authors: Negrón María E , Barkema Herman W , Rioux Kevin , De Buck Jeroen , Checkley Sylvia , Proulx Marie-Claude , Frolkis Alexandra , Beck Paul L , Dieleman Levinus A , Panaccione Remo , Ghosh Subrata , Kaplan Gilaad G
Published: March 2016

BACKGROUND: The impact ofClostridium difficileinfections among ulcerative colitis (UC) patients is well characterized. However, there is little knowledge regarding the association betweenC difficileinfections and postoperative complications among UC patients.

OBJECTIVE: To determine whetherC difficileinfection is associated with undergoing an emergent colectomy and experiencing postoperative complications.

METHODS: The present population-based case-control study identified UC patients admitted to Calgary Health Zone hospitals for a flare between 2000 and 2009.C difficiletoxin tests ordered in hospital or 90 days before hospital admission were provided by Calgary Laboratory Services (Calgary, Alberta). Hospital records were reviewed to confirm diagnoses and to extract clinical data. Multivariate logistic regression analyses were performed among individuals tested forC difficileto examine the association betweenC difficileinfection and emergent colectomy and diagnosis of any postoperative complications and, secondarily, an infectious postoperative complication. Estimates were presented as adjusted ORs with 95% CIs.

RESULTS:C difficilewas tested in 278 (58%) UC patients and 6.1% were positive.C difficileinfection was associated with an increased risk for emergent colectomy (adjusted OR 3.39 [95% CI 1.02 to 11.23]). Additionally, a preoperative diagnosis ofC difficilewas significantly associated with the development of postoperative infectious complications (OR 4.76 [95% CI 1.10 to 20.63]).

CONCLUSION:C difficilediagnosis worsened the prognosis of UC by increasing the risk of colectomy and postoperative infectious complications following colectomy. Future studies are needed to explore whether early detection and aggressive management ofC difficileinfection will improve UC outcomes.
Severe Asthma Associated with Myasthenia Gravis
Authors: Satkunam Natasha , Siddiqi Zaeem A , Vethanayagam Dilini
Published: March 2016

Severe asthma constitutes a subgroup of approximately 10% of all asthma cases. Approximately one‐half of these individuals have a refractory form of the disease in which atopy and T‐helper cell 2‐skewed immunological response may not be as closely linked to the disease as in other phenotypes of asthma. This suggests that not all asthma is explained by a T‐helper cell 2‐skewed immunological response, and that other immunological mechanisms may be important in this category of nonatopic asthma. The authors present a case involving a 55‐year‐old Caucasian man with nonatopic, adult‐onset asthma, nonsteroidal anti‐inflammatory drug sensitivity and idiopathic urticaria. This individual presented two years following his initial asthma diagnosis with diplopia and mild ptosis, and was subsequently diagnosed with seropositive myasthenia gravis.
Identification and Validation of Nebulized Aerosol Devices for Sputum Induction
Authors: Davidson Warren J , Dennis John , The Stephanie , Litoski Belinda , Pieron Cora , Leigh Richard
Published: March 2016

BACKGROUND: Induced sputum cell counts are a noninvasive and reliable method for evaluating the presence, type and degree of airway inflammation in patients with asthma. Currently, standard nebulizer devices used for sputum induction in multiple patients are labelled as single-patient devices by the manufacturer, which conflicts with infection prevention and control requirements. As such, these devices cannot feasibly be used in a clinical sputum induction program. Therefore, there is a need to identify alternative nebulizer devices that are either disposable or labelled for multi-patient use.

OBJECTIVE: To apply validated rigorous, scientific testing methods to identify and validate commercially available nebulizer devices appropriate for use in a clinical sputum induction program.

METHODS: Measurement of nebulized aerosol output and size for the selected nebulizer designs followed robust International Organization for Standardization methods. Sputum induction using two of these nebulizers was successfully performed on 10 healthy adult subjects. The cytotechnologist performing sputum cell counts was blinded to the type of nebulizer used.

RESULTS: The studied nebulizers had variable aerosol outputs. The AeroNeb Solo (Aerogen, Ireland), Omron NE-U17 (Omron, Japan) and EASYneb II (Flaem Nuova, Italy) systems were found to have similar measurements of aerosol size. There was no significant difference in induced sputum cell results between the AeroNeb Solo and EASYneb II devices.

DISCUSSION: There is a need for rigorous, scientific evaluation of nebulizer devices for clinical applications, including sputum induction, for measurement of cell counts.

CONCLUSION: The present study was the most comprehensive analysis of different nebulizer devices for sputum induction to measure cell counts, and provides a framework for appropriate evaluation of nebulizer devices for induced sputum testing.
Can We Improve Parents’ Management of their Children’S Postoperative Pain at Home?
Authors: Chorney Jill MacLaren , Twycross Alison , Mifflin Katherine , Archibald Karen
Published: March 2016

BACKGROUND: Thousands of children undergo surgery each year, and a shift toward same‐day surgeries and decreased lengths of hospital stay results in parents being increasingly responsible for their child’s postoperative care. Recent studies have tested interventions designed to improve parent management of their children’s postoperative pain at home, but progress in this area has been limited by a lack of synthesis of these findings.

OBJECTIVE: To conduct a systematic review of interventions aimed at improving parent management of children’s postoperative pain at home.

METHODS: Articles evaluating interventions to improve management of their children’s postoperative pain were identified using a library scientist‐designed search strategy applied in EMBASE, PubMed, CINAHL and PsycINFO. Two independent raters assessed each study for eligibility and extracted data.

RESULTS: Of the 147 articles identified for the review, eight met the inclusion criteria. Interventions included pain education, training in pain assessment, education on distraction, instruction in around‐the‐clock dosing and nurse coaching. Overall, results of comparisons of pain intensity and analgesic administration were modest. The intervention with the largest effect size was instruction in around‐the‐clock dosing, either alone or in combination with nurse coaching. Results of studies investigating pain assessment, pain education and distraction trials revealed small to medium effect sizes.

CONCLUSIONS: Results of trials investigating interventions to improve parent management of their children’s postoperative pain at home were modest. Future studies should further examine barriers and facilitators to pain management to design more effective interventions.
Defining Quality Indicators for Best-Practice Management of Inflammatory Bowel Disease in Canada
Authors: Nguyen Geoffrey C , Devlin Shane M , Afif Waqqas , Bressler Brian , Gruchy Steven E , Kaplan Gilaad G , Oliveira Liliana , Plamondon Sophie , Seow Cynthia H , Williams Chadwick , Wong Karen , Yan Brian M , Jones Jennifer
Published: March 2016

BACKGROUND: There is a paucity of published data regarding the quality of care of inflammatory bowel disease (IBD) in Canada. Clinical quality indicators are quantitative end points used to guide, monitor and improve the quality of patient care. In Canada, where universal health care can vary significantly among provinces, quality indicators can be used to identify potential gaps in the delivery of IBD care and standardize the approach to interprovincial management.

METHODS: The Emerging Practice in IBD Collaborative (EPIC) group generated a shortlist of IBD quality indicators based on a comprehensive literature review. An iterative voting process was used to select quality indicators to take forward. In a face-to-face meeting with the EPIC group, available evidence to support each quality indicator was presented by the EPIC member aligned to it, followed by group discussion to agree on the wording of the statements. The selected quality indicators were then ratified in a final vote by all EPIC members.

RESULTS: Eleven quality indicators for the management of IBD within the single-payer health care system of Canada were developed. These focus on accurate diagnosis, appropriate and timely management, disease monitoring, and prevention or treatment of complications of IBD or its therapy.

CONCLUSIONS: These quality indicators are measurable, reflective of the evidence base and expert opinion, and define a standard of care that is at least a minimum that should be expected for IBD management in Canada. The next steps for the EPIC group involve conducting research to assess current practice across Canada as it pertains to these quality indicators and to measure the impact of each of these indicators on patient outcomes.
Management of the Pregnant Inflammatory Bowel Disease Patient on Antitumour Necrosis Factor Therapy: State of the Art and Future Directions
Authors: Leung Yvette PY , Panaccione Remo , Ghosh Subrata , Seow Cynthia H
Published: March 2016

Antitumour necrosis factor (anti-TNF) therapy has been a major advance in the treatment of inflammatory bowel disease (IBD) by improving rates of mucosal healing, steroid-free remission, and decreasing rates of hospitalization and surgery. Because IBD affects women in their reproductive years, clinicians have and will continue to be asked in the future about the safety profile of these agents and their potential impact on pregnancy, the developing fetus and newborn. Immunoglobulin G transfer from the mother to fetus begins in the second trimester, with an elevation starting at 22 weeks of gestation and the largest amount transferred in the third trimester. Although research investigating the long-term outcomes of children exposed to anti-TNF therapy in utero is limited, there is no known adverse effect on either pregnancy or newborn outcomes including infectious complications with this class of drugs. The World Congress of Gastroenterology consensus statement on biological therapy for IBD considered infliximab and adalimumab to be low risk and compatible with use during conception and during pregnancy in at least the first two trimesters. Based on a clinical algorithm used at the University of Calgary Pregnancy and IBD clinic (Calgary, Alberta), recommendations have been provided on the management of pregnant patients on anti-TNF therapy, particularly with regard to third-trimester dosing, taking into account disease characteristics of individual patients. When educated about the safety of anti-TNF therapy during pregnancy, patients often choose to continue on therapy during the third trimester.
Micafungin Compared with Caspofungin for the Treatment of Febrile Episodes in Neutropenic Patients with Hematological Malignancies: A Retrospective Study
Authors: Shalhoub Sarah , Wang Luchen , Ching Arthur , Husain Shahid , Rotstein Coleman
Published: March 2016

BACKGROUND: Invasive fungal infections are associated with morbidity and mortality in neutropenia secondary to hematological malignancies. Empirical antifungal agents are used to reduce their consequences. Caspofungin is the only echinocandin approved for this indication. Micafungin was compared with caspofungin for the treatment of patients with hematological malignancies and prolonged neutropenia.

METHODS: A retrospective cohort study was conducted involving patients who had hematological malignancies with profound neutropenia for a minimum of 10 days, and received empirical micafungin or caspofungin for a minimum of five days, between April 2005 and November 2009. Successful outcome was based on a composite end point: survival for a minimum of seven days following antifungal cessation, successful treatment of baseline fungal infection, absence of adverse events and absence of breakthrough fungal infection. Fungal infections were defined according to revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC‐MSG) criteria, with modification of the diagnostic imaging criteria.

RESULTS: Micafungin had similar overall success to caspofungin (60.4% [29 of 48] versus 57.3% [47 of 82], respectively; P=0.729). Survival was higher in the micafungin group compared with the caspofungin group (100% [48 of 48] versus 89% [73 of 82]; P=0.02). No baseline invasive fungal infections were identified in the micafungin group, compared with three proven infections treated successfully with caspofungin (3.7%; P=0.18). Three proven breakthrough infections were observed in the micafungin group (three of 48 [27.3%]) compared with none in the caspofungin group (zero of 82; P=0.02).

CONCLUSION: Micafungin has similar efficacy to caspofungin as empirical antifungal therapy in febrile neutropenic patients with hematological malignancies. Verification of these results in a prospective trial is warranted.
Identifying Factors Associated with Changes in CD4+ Count in HIV‐Infected Adults in Saskatoon, Saskatchewan
Authors: Hunt Kelsey , Mondal Prosanta , Konrad Stephanie , Skinner Stuart , Gartner Kali , Lim Hyun J
Published: March 2016

OBJECTIVE: To assess the impact of clinical and social factors unique to HIV‐infected adults in Saskatoon, Saskatchewan, regarding the rate of CD4+ count change, and to identify factors associated with a risk of CD4+ count decline.

METHODS: A retrospective longitudinal cohort study from medical chart reviews at two clinics was conducted in Saskatoon. Univariate and multivariate linear mixed effects models were used to assess the impact of selected factors on CD4+ count change.

RESULTS: Four hundred eleven HIV‐infected patients were identified from January 1, 2003 to November 30, 2011. Two hundred eighteen (53%) were male, mean (± SD) age was 35.6 ±10.1 years, 257 (70.8%) were First Nations or Métis, 312 (80.2%) were hepatitis C virus (HCV) coinfected and 300 (73.3%) had a history of injection drug use (IDU). In univariate models, age, ethnicity, HCV, IDU, antiretroviral therapy and social assistance were significant. Using ethnicity, HCV and IDU, three multivariate models (models 1, 2, 3) were built due to high correlation. First Nations or Métis ethnicity, HCV coinfection and a history of IDU were associated with significantly lower CD4+ counts in multivariate models. Older age and social assistance were associated with significantly lower CD4+ counts in models 1 and 3. Age was marginally significant in model 2 (P=0.055). Not prescribed antiretroviral therapy was associated with a significantly negative CD4+ count slope in all multivariate models.

CONCLUSION: The unique epidemiology of this HIV‐infected population may be contributing to CD4+ count change. Increased attention and resources focused on this high‐risk population are needed to prevent disease progression and to improve overall health and quality of life.
Noninvasive Methods, including Transient Elastography, for the Detection of Liver Disease in Adults with Cystic Fibrosis
Authors: Sadler Matthew D , Crotty Pam , Fatovich Linda , Wilson Stephanie , Rabin Harvey R , Myers Robert P
Published: March 2016

BACKGROUND: Liver disease is the third leading cause of mortality in patients with cystic fibrosis (CF). However, detection of CF-associated liver disease (CFLD) is challenging.

OBJECTIVE: To evaluate the diagnostic performance of noninvasive methods for the detection of CFLD with a focus on transient elastography (TE).

METHODS: Patients at the Adult CF Clinic of Calgary and Southern Alberta (n=127) underwent liver stiffness measurement (LSM) by TE using the FibroScan (FS, Ecosens, France) M probe; aspartate amino-transferase to platelet ratio index (APRI) and FibroTest (FT) scores were also calculated. The diagnostic performance of these tools for the detection of CFLD (defined as two or more the following criteria: abnormal liver biochemistry, hepatomegaly or sonographic abnormalities other than steatosis) were compared using the area under ROC curves.

RESULTS: Forty-seven percent of the cohort was male. The median age was 27 years (interquartile range [IQR] 22 to 37 years) and body mass index 21 kg/m2(IQR 19 kg/m2to 23 kg/m2); 25% of patients were on ursodeoxycholic acid and 12% had undergone lung transplantation. The prevalence of CFLD was 14% (n=18). FS was successful in all patients; one (0.8%) patient had poorly reliable results (IQR/M >30% and LSM ≥7.1kPa). Compared with patients without CFLD (n=109), individuals with CFLD had higher median LSM according to FS (3.9 kPa [IQR 3.4 to 4.9 kPa] versus 6.4 kPa [IQR 4.4 to 8.0 kPa]), APRI (0.24 [IQR 0.17 to 0.31] versus 0.50 [IQR 0.22 to 1.18]) and FT scores (0.08 [IQR 0.05 to 1.5] versus 0.18 [IQR 0.11 to 0.35]; all P<0.05). Area under ROC curve for FS, APRI and FT for the detection of CFLD were 0.78 (95% CI 0.65 to 0.92), 0.72 (95% CI 0.56 to 0.87) and 0.76 (95% CI 0.62 to 0.90) (P not significant). At a threshold of >5.2 kPa, the sensitivity, specificity, positive and negative predictive values of LSM according to FS for detecting CFLD were 67%, 83%, 40% and 94%, respectively.

CONCLUSIONS: FS, APRI and FT were useful noninvasive methods for detecting CFLD in adults.
Do Photographic Images of Pain Improve Communication during Pain Consultations?
Authors: Padfield Deborah , Zakrzewska Joanna M. , de C Williams Amanda C
Published: March 2016

BACKGROUND: Visual images may facilitate the communication of pain during consultations.

OBJECTIVES: To assess whether photographic images of pain enrich the content and/or process of pain consultation by comparing patients’ and clinicians’ ratings of the consultation experience.

METHODS: Photographic images of pain previously co‐created by patients with a photographer were provided to new patients attending pain clinic consultations. Seventeen patients selected and used images that best expressed their pain and were compared with 21 patients who were not shown images. Ten clinicians conducted assessments in each condition. After consultation, patients and clinicians completed ratings of aspects of communication and, when images were used, how they influenced the consultation.

RESULTS: The majority of both patients and clinicians reported that images enhanced the consultation. Ratings of communication were generally high, with no differences between those with and without images (with the exception of confidence in treatment plan, which was rated more highly in the image group). However, patients’ and clinicians’ ratings of communication were inversely related only in consultations with images. Methodological shortcomings may underlie the present findings of no difference. It is also possible that using images raised patients’ and clinicians’ expectations and encouraged emotional disclosure, in response to which clinicians were dissatisfied with their performance.

CONCLUSIONS: Using images in clinical encounters did not have a negative impact on the consultation, nor did it improve communication or satisfaction. These findings will inform future analysis of behaviour in the video‐recorded consultations.
Canadian Public Health Laboratory Network laboratory Guidelines for the Use of Point‐of‐Care Tests for the Diagnosis of Syphilis in Canada
Authors: Singh Ameeta E , Chernesky Max A , Morshed Muhammad , Wong Tom
Published: March 2016

Syphilis point‐of‐care tests (POCT) are widely available in developing countries enabling early diagnosis, treatment and support. The majority of commercially available tests use treponemal antigens and the presence of antibodies does not distinguish between current and past infection, which may lead to unnecessary antibiotic use and stigmatization of having a current STI. In hard‐to‐reach populations, the benefits may outweigh the risks. Available studies show reasonable performance of POCT with median sensitivity of 86%, specificity of 99% and positive predictive values >80% when prevalence was >0.3%. Although no syphilis POCT are approved in Canada at this time, a single study in an outreach setting in Alberta showed limited benefit due to a high prevalence of previous infection but more studies are needed. Newer dual tests employing treponemal and nontreponemal antigens look promising.
A Novel Pain Interprofessional Education Strategy for Trainees: Assessing Impact on Interprofessional Competencies and Pediatric Pain Knowledge
Authors: Hunter Judith P. , Stinson Jennifer , Campbell Fiona , Stevens Bonnie , Wagner Susan J. , Simmons Brian , White Meghan , van Wyk Margaret
Published: March 2016

BACKGROUND: Health care trainees/students lack knowledge and skills for the comprehensive clinical assessment and management of pain. Moreover, most teaching has been limited to classroom settings within each profession.

OBJECTIVES: To develop and evaluate the feasibility and preliminary outcomes of the ‘Pain‐Interprofessional Education (IPE) Placement’, a five‐week pain IPE implemented in the clinical setting. The utility (content validity, readability, internal consistency and practical considerations) of the outcome measures was also evaluated.

METHODS: A convenience sample of 21 trainees from eight professions was recruited over three Pain‐IPE Placement cycles. Pre‐ and postcurriculum assessment included: pain knowledge (Pediatric Pain Knowledge and Attitudes Survey), IPE attitudes (Interdisciplinary Education Perception Scale [IEPS]) and IPE competencies (Interprofessional Care Core Competencies Global Rating Scales [IPC‐GRS]), and qualitative feedback on process/acceptability.

RESULTS: Recruitment and retention met expectations. Qualitative feedback was excellent. IPE measures (IEPS and IPC‐GRS) exhibited satisfactory utility. Postcurriculum scores improved significantly: IEPS, P<0.05; IPC‐GRS constructs, P<0.01; and competencies, P<0.001. However, the Pediatric Pain Knowledge and Attitudes Survey exhibited poor utility in professions without formal pharmacology training. Scores improved in the remaining professions (n=14; P<0.01).

DISCUSSION: There was significant improvement in educational outcomes. The IEPS and IPC‐GRS are useful measures of IPE‐related learning. At more advanced training levels, a single pain‐knowledge questionnaire may not accurately reflect learning across diverse professions.

CONCLUSION: The Pain‐IPE Placement is a successful collaborative learning model within a clinical context that successfully changed interprofessional competencies. The present study represents a first step at defining and assessing change in interprofessional competencies gained from Pain‐IPE.
Patient Preference and Willingness to Pay for Transient Elastography versus Liver Biopsy: A Perspective from British Columbia
Authors: Kan Victoria Y , Azalgara Vladimir Marquez , Ford Jo-Ann E , Kwan WC Peter , Erb Siegfried R , Yoshida Eric M
Published: March 2016

BACKGROUND: The cost of liver biopsy (LB) is publicly funded in British Columbia, while the cost of transient elastography (FibroScan [FS], Echosens, France) is not. Consequently, there is regional variation regarding FS access and monitoring of liver disease progression.

OBJECTIVE: To evaluate patient preference for FS versus LB and to assess the willingness to self-pay for FS.

METHODS: Questionnaires were distributed in clinic and via mail to LB-experienced and LB-naive patients who underwent FS at Vancouver General Hospital, Vancouver, British Columbia.

RESULTS: The overall response rate was 76%. Of the 422 respondents, 205 were LB-experienced. The mean age was 53.5 years, 50.2% were male, 54.7% were Caucasian, 38.2% had hepatitis C and 26.3% had an annual household income >$75,000. Overall, 95.4% of patients preferred FS to LB. FS was associated with greater comfort than LB, with the majority reporting no discomfort during FS (84.1% versus 7.8% for LB), no discomfort after (96.2% versus 14.6% LB) and no feelings of anxiety after FS explanation (78.2% versus 12.7% LB). FS was also associated with greater speed, with the majority reporting short test duration (97.2% versus 48.3% LB) and short wait for the test result (95.5% versus 30.2% LB). Most (75.3%) respondents were willing to self-pay for FS, with 26.3% willing to pay $25 to $49. Patients with unknown liver disease preferred LB (OR [FS preference] 0.20 [95% CI 0.07 to 0.53]).

CONCLUSIONS: FS was the preferred method of assessing liver fibrosis among patients, with the majority willing to self-pay. To ensure consistency in access, provincial funding for FS is needed. However, LB remains the procedure of choice for individuals with an unknown diagnosis.
Usefulness of Previous Methicillin‐resistant Staphylococcus aureus Screening Results in Guiding Empirical Therapy for S Aureus Bacteremia
Authors: Bai Anthony D , Burry Lisa , Showler Adrienne , Steinberg Marilyn , Ricciuto Daniel , Fernandes Tania , Chiu Anna , Raybardhan Sumit , Tomlinson George A , Bell Chaim M , Morris Andrew M
Published: March 2016

BACKGROUND: Staphylococcus aureus bacteremia (SAB) is an important infection. Methicillin‐resistant S aureus (MRSA) screening is performed on hospitalized patients for infection control purposes.

OBJECTIVE: To assess the usefulness of past MRSA screening for guiding empirical antibiotic therapy for SAB.

METHODS: A retrospective cohort study examined consecutive patients with confirmed SAB and previous MRSA screening swab from six academic and community hospitals between 2007 and 2010. Diagnostic test properties were calculated for MRSA screening swab for predicting methicillin resistance of SAB.

RESULTS: A total of 799 patients underwent MRSA screening swabs before SAB. Of the 799 patients, 95 (12%) had a positive and 704 (88%) had a negative previous MRSA screening swab. There were 150 (19%) patients with MRSA bacteremia. Overall, previous MRSA screening swabs had a positive likelihood ratio of 33 (95% CI 18 to 60) and a negative likelihood ratio of 0.45 (95% CI 0.37 to 0.54). Diagnostic accuracy differed depending on mode of acquisition (ie, community‐acquired, nosocomial or health care‐associated infection) (P<0.0001) and hospital (P=0.0002). At best, for health care‐associated infection, prior MRSA screening swab had a positive likelihood ratio of 16 (95% CI 9 to 28) and a negative likelihood ratio of 0.27 (95% CI 0.17 to 0.41).

CONCLUSIONS: A negative prior MRSA screening swab cannot reliably rule out MRSA bacteremia and should not be used to guide empirical antibiotic therapy for SAB. A positive prior MRSA screening swab greatly increases likelihood of MRSA, necessitating MRSA coverage in empirical antibiotic therapy for SAB.
Impact on Health‐Related Quality of Life and Costs of Managing Chronic Neuropathic Pain in Academic Pain Centres: Results from a One‐Year Prospective Observational Canadian Study
Authors: Tarride J-E , Moulin DE , Lynch M , Clark AJ , Stitt L. , Gordon A , Morley-Forster PK , Nathan H , Smyth C , Toth C , Ware MA
Published: March 2016

BACKGROUND: The management of chronic pain, including neuropathic pain (NeP), is a major public health issue. However, there is a paucity of data evaluating pain management strategies in real‐life settings.

OBJECTIVE: To inform policy makers about the economic value of managing chronic NeP in academic centres by conducting a subeconomic assessment of a Canadian multicentre cohort study aimed at determining the long‐term outcomes of the management of chronic NeP in academic pain centres. Specific questions regarding the economic value of this type of program were answered by a subset of patients to provide further information to policy makers.

METHODS: Baseline demographic information and several pain‐related measurements were collected at baseline, three, six and 12 months in the main study. A resource use questionnaire aimed at determining NeP‐related costs and the EuroQoL‐5 Dimension were collected in the subset study from consenting patients. Statistical analyses were conducted to compare outcomes over time and according to responder status.

RESULTS: A total of 298 patients were evaluated in the present economic evaluation. The mean (± SD) age of the participants was 53.7±14.0 years, and 56% were female. At intake, the mean duration of NeP was >5 years. Statistically significant improvements in all pain and health‐related quality of life outcomes were observed between the baseline and one‐year visits. Use decreased over time for many health care resources (eg, visits to the emergency room decreased by one‐half), which resulted in overall cost savings.

CONCLUSION: The results suggest that increased access to academic pain centres should be facilitated in Canada.
E‐Cigarette Use in Patients Receiving Home Oxygen Therapy
Authors: Lacasse Yves , Légaré Martin , Maltais François
Published: March 2016

Current smokers who are prescribed home oxygen may not benefit from the therapy. In addition to being an obvious fire hazard, there is some evidence that the physiological mechanisms by which home oxygen is believed to operate are inhibited by smoking. Although their effectiveness is yet to be demonstrated, electronic cigarettes (e‐cigarettes) are often regarded as an aid to smoking cessation. However, several burn accidents in e‐cigarette smokers receiving home oxygen therapy have also been reported, leading Health Canada to release a warning of fire risk to oxygen therapy patients from e‐cigarettes. It is the authors’ position that patients receiving oxygen should definitely not use e‐cigarettes. The authors provide suggestions for addressing the delicate issue of home oxygen therapy in current cigarette and/or e‐cigarette smokers.
Grey Zones in the Diagnosis of Adult Migraine without Aura Based on the International Classification of Headache Disorders‐Iii Beta: Exploring the Covariates of Possible Migraine without Aura
Authors: Ozge Aynur , Aydinlar Elif , Tasdelen Bahar
Published: March 2016

BACKGROUND: Exploring clinical characteristics and migraine covariates may be useful in the diagnosis of migraine without aura.

OBJECTIVE: To evaluate the diagnostic value of the International Classification of Headache Disorders (ICHD)‐III beta‐based diagnosis of migraine without aura; to explore the covariates of possible migraine without aura using an analysis of grey zones in this area; and, finally, to make suggestions for the final version of the ICHD‐III.

METHODS: A total of 1365 patients (mean [± SD] age 38.5±10.4 years, 82.8% female) diagnosed with migraine without aura according to the criteria of the ICHD‐III beta were included in the present tertiary care‐based retrospective study. Patients meeting all of the criteria of the ICHD‐III beta were classified as having full migraine without aura, while those who did not meet one, two or ≥3 of the diagnostic criteria were classified as zones I, II and III, respectively. The diagnostic value of the clinical characteristics and covariates of migraine were determined.

RESULTS: Full migraine without aura was evident in 25.7% of the migraineurs. A higher likelihood of zone I classification was shown for an attack lasting 4 h to 72 h (OR 1.560; P=0.002), with pulsating quality (OR 4.096; P<0.001), concomitant nausea/vomiting (OR 2.300; P<0.001) and photophobia/phonophobia (OR 4.865; P<0.001). The first‐rank determinants for full migraine without aura were sleep irregularities (OR 1.596; P=0.005) and periodic vomiting (OR 1.464; P=0.026). However, even if not mentioned in ICHD‐III beta, the authors determined that motion sickness, abdominal pain or infantile colic attacks in childhood, associated dizziness and osmophobia have important diagnostic value.

CONCLUSIONS: In cases that do not fulfill all of the diagnostic criteria although they are largely consistent with the characteristics of migraine in clinical terms, the authors believe that a history of infantile colic; periodic vomiting (but not periodic vomiting syndrome); recurrent abdominal pain; the presence of motion sickness or vertigo, dizziness or osmophobia accompanying the pain; and comorbid atopic disorder are characteristics that should to be discussed and considered as additional diagnostic criteria (covariates) in the preparation of the final version of ICHD‐III.
An unusual Case of Meningitis
Authors: Pond Eric DR , El-Bailey Sameh , Webster Duncan
Published: March 2016

Pasteurella multocida is a rare cause of bacterial meningitis. A 56‐year‐old man with several pets developed a profoundly decreased level of consciousness following left tympanomastoidectomy. Lumbar puncture produced cerebrospinal fluid with the typical findings of meningitis (low glucose, high protein, high leukocytes). Cultures from the cerebrospinal fluid and a swab of the left ear revealed Gram‐negative coccobacillus identified as P multocida. The organism was sensitive to ceftriaxone, ampicillin and penicillin, and a 14‐day course of intravenous penicillin was used as definitive treatment, resulting in full recovery. Although rare, P multocida should be considered as a potential cause of meningitis in patients with animal exposure, particularly in the setting of recent cranial surgery.
The Effects of Outdoor Air Pollution on the Respiratory Health of Canadian Children: A Systematic Review of Epidemiological Studies
Authors: Rodriguez-Villamizar Laura A , Magico Adam , Osornio-Vargas Alvaro , Rowe Brian H
Published: March 2016

BACKGROUND: Outdoor air pollution is a global problem with serious effects on human health, and children are considered to be highly susceptible to the effects of air pollution.

OBJECTIVE: To conduct a comprehensive and updated systematic review of the literature reporting the effects of outdoor air pollution on the respiratory health of children in Canada.

METHODS: Searches of four electronic databases between January 2004 and November 2014 were conducted to identify epidemiological studies evaluating the effect of exposure to outdoor air pollutants on respiratory symptoms, lung function measurements and the use of health services due to respiratory conditions in Canadian children. The selection process and quality assessment, using the Newcastle‐Ottawa Scale, were conducted independently by two reviewers.

RESULTS: Twenty‐seven studies that were heterogeneous with regard to study design, population, respiratory outcome and air pollution exposure were identified. Overall, the included studies reported adverse effects of outdoor air pollution at concentrations that were below Canadian and United States standards. Heterogeneous effects of air pollutants were reported according to city, sex, socioeconomic status and seasonality. The present review also describes trends in research related to the effect of air pollution on Canadian children over the past 25 years.

CONCLUSION: The present study reconfirms the adverse effects of outdoor air pollution on the respiratory health of children in Canada. It will help researchers, clinicians and environmental health authorities identify the available evidence of the adverse effect of outdoor air pollution, research gaps and the limitations for further research.
Improving Public Health Policy through Infection Transmission Modelling: Guidelines for Creating a Community of Practice
Authors: Moghadas Seyed M , Haworth-Brockman Margaret , Isfeld-Kiely Harpa , Kettner Joel
Published: March 2016

BACKGROUND: Despite significant research efforts in Canada, real application of modelling in public health decision making and practice has not yet met its full potential. There is still room to better address the diversity of the Canadian population and ensure that research outcomes are translated for use within their relevant contexts.

OBJECTIVES: To strengthen connections to public health practice and to broaden its scope, the Pandemic Influenza Outbreak Research Modelling team partnered with the National Collaborating Centre for Infectious Diseases to hold a national workshop. Its objectives were to: understand areas where modelling terms, methods and results are unclear; share information on how modelling can best be used in informing policy and improving practice, particularly regarding the ways to integrate a focus on health equity considerations; and sustain and advance collaborative work in the development and application of modelling in public health.

METHOD: The Use of Mathematical Modelling in Public Health Decision Making for Infectious Diseases workshop brought together research modellers, public health professionals, policymakers and other experts from across the country. Invited presentations set the context for topical discussions in three sessions. A final session generated reflections and recommendations for new opportunities and tasks.

CONCLUSIONS: Gaps in content and research include the lack of standard frameworks and a glossary for infectious disease modelling. Consistency in terminology, clear articulation of model parameters and assumptions, and sustained collaboration will help to bridge the divide between research and practice.
Perspectives, Perceptions and Experiences in Postoperative Pain Management in Developing Countries: A Focus Group Study Conducted in Rwanda
Authors: Johnson Ana P , Mahaffey Ryan , Egan Rylan , Twagirumugabe Theogene , Parlow Joel L
Published: March 2016

BACKGROUND: Access to postoperative acute pain treatment is an important component of perioperative care and is frequently managed by a multidisciplinary team of anesthesiologists, surgeons, pharmacists, technicians and nurses. In some developing countries, treatment modalities are often not performed due to scarce health care resources, knowledge deficiencies and cultural attitudes.

OBJECTIVES: In advance of a comprehensive knowledge translation initiative, the present study aimed to determine the perspectives, perceptions and experiences of anesthesia residents regarding postoperative pain management strategies.

METHODS: The present study was conducted using a qualitative assessment strategy in a large teaching hospital in Rwanda. During two sessions separated by seven days, a 10‐participant semistructured focus group needs analysis was conducted with anesthesia residents at the Centre Hospitalier Universitaire de Kigali (Kigali, Rwanda). Field notes were analyzed using interpretative and descriptive phenomenological approaches. Participants were questioned regarding their perspectives, perceptions and experiences in pain management.

RESULTS: The responses from the focus groups were related to five general areas: general patient and medical practice management; knowledge base regarding postoperative pain management; pain evaluation; institutional/system issues related to protocol implementation; and perceptions about resource allocation. Within these areas, challenges (eg, communication among stakeholders and with patients) and opportunities (eg, on‐the‐job training, use of protocols, routine pain assessment, participation in resource allocation decisions) were identified.

CONCLUSIONS: The present study revealed the prevalent challenges residents perceive in implementing postoperative pain management strategies, and offers practical suggestions to overcoming them, primarily through training and the implementation of practice recommendations.
Implementation of a Targeted Screening Program to Detect Airflow Obstruction Suggestive of Chronic Obstructive Pulmonary Disease within a Presurgical Screening Clinic
Authors: Robitaille Chantal , Dajczman Esther , Hirsch Andrew M , Small David , Ernst Pierre , Porubska Dana , Palayew Mark
Published: March 2016

BACKGROUND: Targeted spirometry screening for chronic obstructive pulmonary disease (COPD) has been studied in primary care and community settings. Limitations regarding availability and quality of testing remain. A targeted spirometry screening program was implemented within a presurgical screening (PSS) clinic to detect undiagnosed airways disease and identify patients with COPD/asthma in need of treatment optimization.

OBJECTIVE: The present quality assurance study evaluated airflow obstruction detection rates and examined characteristics of patients identified through the targeted screening program.

METHODS: The targeted spirometry screening program was implemented within the PSS clinic of a tertiary care university hospital. Current or ex‐smokers with respiratory symptoms and patients with a history of COPD or asthma underwent prebronchodilator spirometry. History of airways disease and smoking status were obtained during the PSS assessment and confirmed through chart reviews.

RESULTS: After exclusions, the study sample included 449 current or ex‐smokers. Abnormal spirometry results were found in 184 (41%) patients: 73 (16%) had mild, 93 (21%) had moderate and 18 (4%) had severe or very severe airflow obstruction. One hundred eighteen (26%) new cases of airflow obstruction suggestive of COPD were detected. One‐half of these new cases had moderate or severe airflow obstruction. Only 34% of patients with abnormal spirometry results had reported a previous diagnosis of COPD. More than one‐half of patients with abnormal spirometry results were current smokers.

CONCLUSIONS: Undiagnosed airflow obstruction was detected in a significant number of smokers and ex‐smokers through a targeted screening program within a PSS clinic. These patients can be referred for early intervention and secondary preventive strategies.
Polyethylene Glycol versus sodium picosulfalte Bowel Preparation in the Setting of a Colorectal Cancer Screening Program
Authors: Kherad Omar , Restellini Sophie , Martel Myriam , Barkun Alan N
Published: March 2016

BACKGROUND: Adequate bowel preparation for colonoscopy is an important predictor of colonoscopy quality.

OBJECTIVE: To determine the difference in terms of effectiveness between different existing colon cleansing products in the setting of a colorectal cancer screening program.

METHODS: The records of consecutive patients who underwent colonoscopy at the Montreal General Hospital (Montreal, Quebec) between April 2013 and April 2014 were retrospectively extracted from a dedicated electronic digestive endoscopic institutional database.

RESULTS: Overall, 2867 charts of patients undergoing colonoscopy were assessed, of which 1130 colonoscopies were performed in a screening setting; patients had adequate bowel preparation in 90%. Quality of preparation was documented in only 61%. Bowel preparation was worse in patients receiving sodium picosulfate (PICO) alone compared with polyethylene glycol, in a screening setting (OR 0.3 [95% CI 0.2 to 0.6]). Regardless of the preparation type, the odds of achieving adequate quality cleansing was 6.6 for patients receiving a split-dose regimen (OR 6.6 [95% CI 2.1 to 21.1]). In multivariable analyses, clinical variables associated with inadequate bowel preparation in combined population were use of PICO, a nonsplit regimen and inpatient status. The polyp detection rate was very high (45.6%) and was correlated with withdrawal time.

CONCLUSION: Preparation quality needs to be more consistently included in the colonoscopy report. Split-dose regimens increased the quality of colon cleansing across all types of preparations and should be the preferred method of administration. Polyethylene glycol alone provided better bowel cleansing efficacy than PICO in a screening setting but PICO remains an alternative in association with an adjuvant.
Lung Transplantation from Donors after Circulatory Death Using Portable Ex Vivo Lung Perfusion
Authors: Bozso Sabin , Vasanthan Vishnu , Luc Jessica GY , Kinaschuk Katie , Freed Darren , Nagendran Jayan
Published: March 2016

BACKGROUND: Donation after circulatory death is a novel method of increasing the number of donor lungs available for transplantation. Using organs from donors after circulatory death has the potential to increase the number of transplants performed.

METHODS: Three bilateral lung transplants from donors after circulatory death were performed over a six‐month period. Following organ retrieval, all sets of lungs were placed on a portable ex vivo lung perfusion device for evaluation and preservation.

RESULTS: Lung function remained stable during portable ex vivo perfusion, with improvement in partial pressure of oxygen/fraction of inspired oxygen ratios. Mechanical ventilation was discontinued within 48 h for each recipient and no patient stayed in the intensive care unit longer than eight days. There was no postgraft dysfunction at 72 h in two of the three recipients. Ninety‐day mortality for all recipients was 0% and all maintain excellent forced expiratory volume in 1 s and forced vital capacity values post‐transplantation.

CONCLUSION: The authors report excellent results with their initial experience using donors after circulatory death after portable ex vivo lung perfusion. It is hoped this will allow for the most efficient use of available donor lungs, leading to more transplants and fewer deaths for potential recipients on wait lists.
Multidrug‐Resistant Tuberculosis: Treatment and Outcomes of 93 Patients
Authors: Brode Sarah K , Varadi Robert , McNamee Jane , Malek Nina , Stewart Sharon , Jamieson Frances B , Avendano Monica
Published: March 2016

BACKGROUND: Tuberculosis (TB) remains a leading cause of death worldwide and the emergence of multidrug‐resistant TB (MDR TB) poses a threat to its control. There is scanty evidence regarding optimal management of MDR TB. The majority of Canadian cases of MDR TB are diagnosed in Ontario; most are managed by the Tuberculosis Service at West Park Healthcare Centre in Toronto. The authors reviewed 93 cases of MDR TB admitted from January 1, 2000 to December 31, 2011.

RESULTS: Eighty‐nine patients were foreign born. Fifty‐six percent had a previous diagnosis of TB and most (70%) had only pulmonary involvement. Symptoms included productive cough, weight loss, fever and malaise. The average length of inpatient stay was 126 days. All patients had a peripherally inserted central catheter for the intensive treatment phase because medications were given intravenously. Treatment lasted for 24 months after bacteriologic conversion, and included a mean (± SD) of 5±1 drugs. A successful outcome at the end of treatment was observed in 84% of patients. Bacteriological conversion was achieved in 98% of patients with initial positive sputum cultures; conversion occurred by four months in 91%.

CONCLUSIONS: MDR TB can be controlled with the available anti‐TB drugs.