bluuebunny/crossref_metadata_2025 huggingface dataset:
Pulmonary Rehabilitation in Canada: A Report from the Canadian Thoracic Society COPD Clinical Assembly
Authors: Camp Pat G , Hernandez Paul , Bourbeau Jean , Kirkham Ashley , Debigare Richard , Stickland Michael K , Goodridge Donna , Marciniuk Darcy D , Road Jeremy D , Bhutani Mohit , Dechman Gail
Published: March 2016

BACKGROUND: Pulmonary rehabilitation (PR) is a recommended intervention in the management of individuals with chronic lung disease. It is important to study the characteristics and capacity of programs in Canada to confirm best practices and identify future areas of program improvement and research.

OBJECTIVE: To identify all Canadian PR programs, regardless of setting, and to comprehensively describe all aspects of PR program delivery. The present article reports the results of the survey related to type of program, capacity and program characteristics.

METHODS: All hospitals in Canada were contacted to identify PR programs. A representative from each program completed a 175-item online survey encompassing 16 domains, 10 of which are reported in the present article.

RESULTS: A total of 155 facilities in Canada offered PR, of which 129 returned surveys (83% response rate). PR programs were located in all provinces, but none in the three territories. Most (60%) programs were located in hospital settings, 24% were in public health units and 8% in recreation centres. The national capacity of programs was estimated to be 10,280 patients per year, resulting in 0.4% of all Canadians with chronic obstructive pulmonary disease (COPD) and 0.8% of Canadians with moderate to severe COPD having access to PR. COPD, interstitial lung disease, and asthma were the most common diagnoses of patients. The majority of programs had at least four health care professionals involved; 9% had only one health care professional involved.

CONCLUSION: The present comprehensive survey of PR in Canada reports an increase in the number of programs and the total number of patients enrolled since the previous survey in 2005. However, PR capacity has not kept pace with demand, with only 0.4% of Canadians with COPD having access.
New-Onset Atrial Fibrillation in Critically Ill Patients
Authors: Sibley Stephanie , Muscedere John
Published: March 2016

New-onset atrial fibrillation is a common problem in critically ill patients, with reported incidence ranging from 5% to 46%. It is associated with significant morbidity and mortality. The present review summarizes studies investigating new-onset atrial fibrillation conducted in the critical care setting, focusing on the etiology, management of the hemodynamically unstable patient, rate versus rhythm control, ischemic stroke risk and anticoagulation. Recommendations for an approach to management in the intensive care unit are drawn from the results of these studies.
Recent Advances in the Recognition and Management of Eosinophilic Esophagitis
Authors: Eustace Gregory , Gui Xianyong , Iacucci Marietta
Published: March 2016

The incidence and recognition of eosinophilic esophagitis is increasing. Pathophysiological understanding of eosinophilic esophagitis is improving and an immunological reaction to ingested food is likely to play a significant role. Patients present with dysphagia and food bolus obstruction. Both histological and endoscopic criteria have been developed and validated. Dietary therapy, topical steroid therapy, proton pump inhibitors and endoscopic dilation are the main approaches to therapy; however, novel targeted therapies are being developed. Among the food items commonly implicated are wheat, dairy, nuts, soy, shellfish and eggs. A multidisciplinary approach to management in dedicated clinics may yield the best results.
Observer trait anxiety is associated with response bias to patient facial pain expression independent of pain catastrophizing
Authors: Rash Joshua A , Prkachin Kenneth M , Campbell Tavis S
Published: March 2016

Nonverbal communication, such as facial expression, is an important component of the communication of pain to an observer. One factor that influences pain perception by an observer is characteristics specific to the observer themselves (ie, ‘top‐down’ characteristics). The authors of this article aimed to assess how anxiety in the observer affects their ability to rate a sufferer’s pain, controlling for pain catastrophizing.

BACKGROUND: Top‐down characteristics of an observer influence the detection and estimation of a sufferer’s pain. A comprehensive understanding of these characteristics is important because they influence observer helping behaviours and the sufferer’s experience of pain.

OBJECTIVES: To examine the hypothesis that individuals who score high in trait anxiety would perceive more intense pain in others, as indicated by a larger negative response bias, and that this association would persist after adjusting for pain catastrophizing.

METHODS: Healthy young adult participants (n=99; 50 male) watched videos containing excerpts of facial expressions taken from patients with shoulder pain and were asked to rate how much pain the patient was experiencing using an 11‐point numerical rating scale. Sensitivity and response bias were calculated using signal detection methods.

RESULTS: Trait anxiety was a predictor of response bias after statistically adjusting for pain catastrophizing and observer sex. More anxious individuals had a proclivity toward imputing greater pain to a sufferer.

CONCLUSIONS: Individuals scoring higher on trait anxiety were more likely to impute pain to a sufferer. Anxious caregivers may be better able to respond with appropriate intervention once pain behaviour is detected, or they may exacerbate symptoms by engaging in excessive palliative care and solicitous behaviour.
A Study Investigating the Association of Dermatological and Infusion Reactions to Infliximab and Infliximab Trough Levels
Authors: Huang Vivian Wai-Mei , Dhami Neil , Fedorak Darryl , Prosser Connie , Shalapay Carol , Kroeker Karen Ivy , Halloran Brendan Phillip , Dieleman Levinus Albert , Fedorak Richard Neil
Published: March 2016

BACKGROUND: Although infliximab is an effective therapy for inflammatory bowel disease (IBD), it is associated with dermatological events and infusion reactions. It is not known whether a relationship between these adverse events (AEs) and infliximab trough levels (ITLs) exists.

OBJECTIVES: To report the prevalence of infliximab-associated AEs in IBD patients receiving stable maintenance infliximab therapy, and to correlate ITLs with dermatological and infusion reactions to infliximab.

METHODS: Adult IBD patients receiving stable maintenance infliximab therapy were recruited from the University of Alberta Infusion Clinic (Edmonton, Alberta). ITLs were measured in blood samples collected before infusion, and the patients’ records were reviewed for dermatological and infusion reactions to infliximab.

RESULTS: One-quarter (18 of 71 [25.4%]) of patients experienced dermatological or infusion reactions to infliximab: nine (12.7%) dermatological events and nine (12.7%) infusion reactions. The median ITL was similar among patients with and without these AEs (7.2 μg/mL [interquartile range (IQR) 2.0 μg/mL to 13.3 μg/mL] versus 6.6 μg/mL [IQR 3.2 μg/mL to 12.7 μg/mL]; P=0.648). The median ITL of patients who experienced infusion reactions (2.0 μg/mL [IQR 0.1 μg/mL to 5.7 μg/mL]) was lower than that of patients who experienced no such AEs (6.6 μg/mL [IQR 3.2 μg/mL to 12.7 μg/mL]; P=0.008]) and lower than that of patients who experienced dermatological AEs (13.3 μg/mL [IQR 8.8 μg/mL to 17.4 μg/mL]; P<0.001).

CONCLUSION: One-quarter of IBD outpatients receiving stable maintenance infliximab therapy experienced dermatological and infusion reactions. Low ITLs were correlated with infusion reactions, and normal or high ITLs with dermatological events.
Resident Trainees Do Not Affect Patient Satisfaction in an Outpatient Gastroenterology Clinic: A Prospective Study Conducted in a Canadian Gastroenterology Clinic
Authors: Brahmania Mayur , Young Madison , Muthiah Chetty , Ilnyckyj Alexandra , Duerksen Donald , Moffatt Dana C
Published: March 2016

BACKGROUND: There is little literature regarding how a gastroenterology trainee affects a patient’s interpretation of care during outpatient clinic visits. Improving patient satisfaction is desirable and benefits may include enhanced patient compliance as well as providing trainees with areas for improvement.

OBJECTIVES: To evaluate patient satisfaction in an outpatient gastroenterology clinic when seen by a trainee and attending physician versus an attending physician alone. The secondary objective was to evaluate physician characteristics that play a role in creating a positive clinical experience.

METHODS: A randomized prospective survey study was conducted over an 11-month period (July 2012 to June 2013) at St Boniface Hospital (Winnipeg, Manitoba). Two gastroenterology fellows (postgraduate year 4 and 5) and nine internal medicine residents (postgraduate year 1 to 3) comprised the ‘trainee’ role, while three academic clinicians comprised the ‘attending’ role. Patients included individuals seen for an initial consultation and were >18 years of age.

RESULTS: A total of 211 patients comprised the final study group, with 118 in the attending group and 93 in the trainee group. In univariate analysis, patients more often had a very good experience when seen by an attending physician alone versus a trainee and attending physician (73% versus 56%; P=0.016); however, on multivariate analysis, there was no significant difference in patient satisfaction (OR 0.89; P=0.931). Physician factors found to be associated with high patient satisfaction on multivariate analysis included: addressing all patient concerns (OR 27.56; P=0.021); giving the patient a preliminary diagnosis (OR 78.02; P=0.006); and feeling the physician was thorough (OR 72.53; P=0.029).

CONCLUSIONS: The present study did not reveal a difference in patient satisfaction if a patient sees an attending physician alone or with a trainee. Moreover, to improve patient satisfaction in a gastroenterology clinic, physicians should address all patient concerns, provide a preliminary diagnosis and appear to be thorough in their assessment. Further work to increase patient awareness on the role of residents in teaching hospitals is warranted to further promote careers in gastroenterology.
Safety and effectiveness of the herpes zoster vaccine to prevent postherpetic neuralgia: 2014 Update and consensus statement from the Canadian Pain Society
Authors:   Canadian Pain Society Study Day participants
Published: March 2016

The Canadian Pain Society (CPS) hosted its first Study Day in Toronto in July 2014, attended by experts in various fields of pain management and research (listed below). The aim was to review the National Advisory Committee on Immunization guidelines and to prepare a CPS position statement concerning the use of the zoster vaccine in Canada.
Trichosporon asahii Infection after Total Knee Arthroplasty: A Case Report and Review of the Literature
Authors: Zuo Qiang , Dong Lele , Mu Weidong , Zhou Lingyun , Hu Tongping , Zhang Hua
Published: March 2016

Reports of fungal infection after total knee arthroplasty are extremely rare. In most reports, the infecting organism is a Candida species. The present report describes a case involving a 73‐year‐old immunocompetent woman who underwent total knee arthroplasty and presented one month later with signs of prosthetic infection. She underwent joint debridement and the fluid was sent for culture and sensitivity testing. The culture showed growth of Trichosporon asahii. The patient was administered intravenous and intra‐articular injections of amphotericin B, followed by antifungal treatment with voriconazole for one year. At 26 months of follow‐up, there was no evidence of infection and the patient was ambulating with a walker. To the authors’ knowledge, the present case is the first report of T asahii infection following knee replacement. Early detection, prompt institution of the appropriate antibiotics and regular follow‐up are recommended.
A Multidimensional Approach to the Management of Severe Asthma: Inflammometry, Molecular Microbiology and Bronchial Thermoplasty
Authors: Cox Conor , Kjarsgaard Melanie , Surette Michael G , Cox P Gerard , Nair Parameswaran
Published: March 2016

The authors illustrate the merits of identifying the components of diseases (eg, bronchitis and airway hyper‐responsiveness) that contribute to exacerbations in the management of a patient with severe asthma. Quantitative cell counts in sputum identified a neutrophilic – as opposed to eosinophilic – bronchitis that enabled a stepwise weaning of prednisone. Molecular microbiology and extended culture methods identified anaerobes and other airway microbiome that helped to guide the use of antibiotics. Further control of asthma was achieved by performing bronchial thermoplasty.
Blastomycosis in Northwestern Ontario, 2004 to 2014
Authors: Dalcin Daniel , Ahmed Syed Zaki
Published: March 2016

Blastomycosis is an invasive fungal disease caused by Blastomyces dermatitidis and the recently discovered Blastomyces gilchristii. The medical charts of 64 patients with confirmed cases of blastomycosis in northwestern Ontario during a 10‐year period (2004 to 2014) were retrospectively reviewed. The number of patients diagnosed with blastomycosis in Ontario was observed to have increased substantially compared with before 1990, when blastomycosis was removed from the list of reportable diseases. Aboriginals were observed to be disproportionately represented in the patient population. Of the patients whose smoking status was known, 71.4% had a history of smoking. 59.4% of patients had underlying comorbidities and a higher comorbidity rate was observed among Aboriginal patients. The case‐fatality rate from direct complications of blastomycosis disease was calculated to be 20.3%; this case‐fatality rate is the highest ever to be reported in Canada and more than double that of previously published Canadian studies. The clinical characteristics of 64 patients diagnosed with blastomycosis are summarized.
Prevalence of Antimicrobial Use in a Network of Canadian Hospitals in 2002 and 2009
Authors: Taylor Geoffrey , Gravel Denise , Saxinger Lynora , Bush Kathryn , Simmonds Kimberley , Matlow Anne , Embree Joanne , Le Saux Nicole , Johnston Lynn , Suh Kathryn N , Embil John , Henderson Elizabeth , John Michael , Roth Virginia , Wong Alice , The Canadian Nosocomial Infection Surveillance Program
Published: March 2016

BACKGROUND: Increasing antimicrobial resistance has been identified as an important global health threat. Antimicrobial use is a major driver of resistance, especially in the hospital sector. Understanding the extent and type of antimicrobial use in Canadian hospitals will aid in developing national antimicrobial stewardship priorities.

METHODS: In 2002 and 2009, as part of one‐day prevalence surveys to quantify hospital‐acquired infections in Canadian Nosocomial Infection Surveillance Program hospitals, data were collected on the use of systemic antimicrobial agents in all patients in participating hospitals. Specific agents in use (other than antiviral and antiparasitic agents) on the survey day and patient demographic information were collected.

RESULTS: In 2002, 2460 of 6747 patients (36.5%) in 28 hospitals were receiving antimicrobial therapy. In 2009, 3989 of 9953 (40.1%) patients in 44 hospitals were receiving antimicrobial therapy (P<0.001). Significantly increased use was observed in central Canada (37.4% to 40.8%) and western Canada (36.9% to 41.1%) but not in eastern Canada (32.9% to 34.1%). In 2009, antimicrobial use was most common on solid organ transplant units (71.0% of patients), intensive care units (68.3%) and hematology/oncology units (65.9%). Compared with 2002, there was a significant decrease in use of first‐and second‐generation cephalosporins, and significant increases in use of carbapenems, antifungal agents and vancomycin in 2009. Piperacillin‐tazobactam, as a proportion of all penicillins, increased from 20% in 2002 to 42.8% in 2009 (P<0.001). There was a significant increase in simultaneous use of >1 agent, from 12.0% of patients in 2002 to 37.7% in 2009.

CONCLUSION: From 2002 to 2009, the prevalence of antimicrobial agent use in Canadian Nosocomial Infection Surveillance Program hospitals significantly increased; additionally, increased use of broad‐spectrum agents and a marked increase in simultaneous use of multiple agents were observed.
Empyema Caused by Clostridium bifermentans: A Case Report
Authors: Edagiz Safa , Lagace-Wiens Phil , Embil John , Karlowsky James , Walkty Andrew
Published: March 2016

A case of pneumonia with associated empyema caused by Clostridium bifermentans is described. C bifermentans is an anaerobic, spore‐forming, Gram‐positive bacillus. This organism is infrequently reported as a cause of infection in humans, and older publications tended to regard it as nonpathogenic. However, in more recent reports, C bifermentans has been documented as a cause of septic arthritis, osteomyelitis, soft tissue infection, abdominal infections, brain abscess, bacteremia and endocarditis. The present case is the third reported case of empyema caused by C bifermentans, and it serves to further define the spectrum of illness due to this uncommon organism.
A Cluster of Bacillus cereus Bacteremia Cases among Injection Drug Users
Authors: Benusic Michael A , Press Natasha M , Hoang Linda MN , Romney Marc G
Published: March 2016

Bacillus cereus is a ubiquitous spore‐forming organism that is infrequently implicated in extraintestinal infections. The authors report three cases of B cereus bacteremia among injection drug users presenting within one month to an urban tertiary care hospital. Treatment with intravenous vancomycin was successful in all three cases. While temporal association suggested an outbreak, molecular studies of patient isolates using pulsed‐field gel electrophoresis did not suggest a common source. A review of the association of B cereus infections with heroin use and treatment of this pathogen is provided.
Plasma Leptin Concentrations and Esophageal Hypomotility in Obese Patients
Authors: Côté-Daigneault Justin , Poitras Pierre , Rabasa-Lhoret Rémi , Bouin Mickael
Published: March 2016

BACKGROUND: Although esophageal hypomotility is prevalent in obese patients, its cause remains unknown. Leptin, a hormone derived from adipose tissue, may be involved in this phenomenon because it has been shown to decrease gastric and intestinal motility in animals. It has been hypothesized that elevated plasma leptin concentration is a risk factor for esophageal dysmotility in obese patients.

OBJECTIVE: To determine whether plasma leptin concentrations are higher in obese patients with esophageal hypomotility than in obese patients with a normal motility profile.

METHOD: Fasting plasma leptin concentration (assessed by radioimmuoassay) was measured in all patients who were included in a study protocol investigating esophageal manometry before bariatric surgery. The patients completed standardized surveys regarding epidemiological data, upper gastrointestinal symptoms, medical history and medication(s). Basal levels of leptin, as well as corrected leptin scores adjusted for sex and body mass index, were compared in patients with and without esophageal dysmotility.

RESULTS: Nine patients without dysmotility and eight with dysmotility were included. Both groups were comparable with regard to age (42±9 versus 38±9 years), sex (78% versus 75% women) and body mass index (49±10 kg/m2versus 42±7 kg/m2). There were no significant differences regarding medication(s) and comorbidities between the two groups. When compared with normal predicted values, the corrected leptin scores were 30% higher in patients with dysmotility than in the control group with normal motility (P≤0.05).

CONCLUSION: Obese patients with esophageal dysmotility exhibited elevated plasma leptin concentrations, suggesting a role for leptin in promoting esophageal hypomotility.
Gestion de la douleur chronique par les infirmières des Groupes de médecine de famille
Authors: Bergeron Dave A , Bourgault Patricia , Gallagher Frances
Published: March 2016

INTRODUCTION: Thousands of people treated in primary care are currently experiencing chronic pain (CP), for which management is often inadequate. In Quebec, nurses in family medicine groups (FMGs) play a key role in the management of chronic health problems.

OBJECTIVE: The present study aimed to describe the activities performed by FMG nurses in relation to CP management and to describe barriers to those activities.

METHOD: A descriptive correlational cross‐sectional postal survey was used. The accessible population includes FMG nurses on the Ordre des infirmières et infirmiers du Québec list. All nurses on the list who provided consent to be contacted at home for research purposes were contacted. A self‐administered postal questionnaire (Pain Management Activities Questionnaire) was completed by 53 FMG nurses.

RESULTS: Three activities most often performed by nurses were to establish a therapeutic relationship with the client; discuss the effectiveness of therapeutic measures with the physician; and conduct personalized teaching for the patient. The average number of individuals seen by interviewed nurses that they believe suffer from CP was 2.68 per week. The lack of knowledge of possible interventions in pain management (71.7%) and the nonavailability of information on pain management (52.8%) are the main barriers perceived by FMG nurses.

CONCLUSION: FMG nurses are currently performing few activities in CP management. The nonrecognition of CP may explain this situation.
Withdrawing Versus not Offering Cardiopulmonary Resuscitation: Is There a Difference?
Authors: Oczkowski Simon JW , Rochwerg Bram , Sawchuk Corey
Published: March 2016

Conflict between substitute decision makers (SDMs) and health care providers in the intensive care unit is commonly related to goals of treatment at the end of life. Based on recent court decisions, even medical consensus that ongoing treatment is not clinically indicated cannot justify withdrawal of mechanical ventilation without consent from the SDM. Cardiopulmonary resuscitation (CPR), similar to mechanical ventilation, is a life‐sustaining therapy that can result in disagreement between SDMs and clinicians. In contrast to mechanical ventilation, in cases for which CPR is judged by the medical team to not be clinically indicated, there is no explicit or case law in Canada that dictates that withholding/not offering of CPR requires the consent of SDMs. In such cases, physicians can ethically and legally not offer CPR, even against SDM or patient wishes. To ensure that nonclinically indicated CPR is not inappropriately performed, hospitals should consider developing ‘scope of treatment’ forms that make it clear that even if CPR is desired, the individual components of resuscitation to be offered, if any, will be dictated by the medical team’s clinical assessment.
Investigation of Occupational Asthma: Do Clinicians Fail to Identify rRelevant Occupational Exposures?
Authors: de Olim Carlo , Bégin Denis , Boulet Louis-Philippe , Cartier André , Gérin Michel , Lemière Catherine
Published: March 2016

BACKGROUND: Specific inhalation challenges (SIC) enable the identification of the agent responsible of occupational asthma (OA). A clinician may fail to identify a specific agent in the workplace, which may potentially lead to a misdiagnosis. The expert assessment method performed by an occupational hygienist has been used to evaluate occupational exposures in epidemiological studies.

OBJECTIVE: The broad aim of the present study was to evaluate the contribution of an expert assessment performed by an occupational hygienist to the diagnosis of OA. The specific aim was to compare work‐place exposures identified by an occupational hygienist and by chest physicians in subjects with positive SICs and subjects with asthma, but with a negative SIC.

METHODS: SICs were performed in 120 cases: 67 were positive and 53 were negative. A clinician assessed occupational exposures to sensitizers during a routine clinical evaluation preceding the performance of the SIC. An expert assessment of occupational exposures was performed by an occupational hygienist blind to the result of the SIC.

RESULTS: The occupational hygienist identified the causal agent in 96.7% of the 61 cases of positive SIC. In 33 (62.3%) cases of negative SICs, the occupational hygienist identified ≥1 sensitizing agent(s) that had not been identified by the clinician.

CONCLUSION: The hygienist identified the causal agent in almost all subjects with OA. In contrast, the clinician failed to identify potential exposures to sensitizers in >60% of the negative SIC subjects, which may have resulted in some subjects being misdiagnosed as not having OA.
The Role of Empirical Albendazole Treatment in Idiopathic Hypereosinophilia ‐ A Case Series
Authors: Vaisben Eleonora , Brand Ronen , Kadakh Anas , Nassar Faris
Published: March 2016

Hypereosinophilia is usually defined as a blood eosinophil count >1500/μL. A broad variety of conditions are associated with hypereosinophilia. The present report describes three cases of hypereosinophilia, in which a thorough history, physical examination, laboratory and imaging investigations were unable to detect any abnormalities. Albendazole was empirically administered in all three cases, with complete normalization of eosinophil counts thereafter. Empirical treatment with albendazole for patients presenting with hypereosinophilia should be strongly considered.
Family Presence during Resuscitation: A Canadian Critical Care Society Position Paper
Authors: Oczkowski Simon JW , Mazzetti Ian , Cupido Cynthia , Fox-Robichaud Alison E
Published: March 2016

BACKGROUND: Recent evidence suggests that patient outcomes are not affected by the offering of family presence during resuscitation (FPDR), and that psychological outcomes are neutral or improved in family members of adult patients. The exclusion of family members from the resuscitation area should, therefore, be reassessed.

OBJECTIVE: The present Canadian Critical Care Society position paper is designed to help clinicians and institutions decide whether to incorporate FPDR as part of their routine clinical practice, and to offer strategies to implement FPDR successfully.

METHODS: The authors conducted a literature search of the perspectives of health care providers, patients and families on the topic of FPDR, and considered the relevant ethical values of beneficence, nonmaleficence, autonomy and justice in light of the clinical evidence for FPDR. They reviewed randomized controlled trials and observational studies of FPDR to determine strategies that have been used to screen family members, select appropriate chaperones and educate staff.

RESULTS: FPDR is an ethically sound practice in Canada, and may be considered for the families of adult and pediatric patients in the hospital setting. Hospitals that choose to implement FPDR should develop transparent policies regarding which family members are to be offered the opportunity to be present during the resuscitation. Experienced chaperones should accompany and support family members in the resuscitation area. Intensive educational interventions and increasing experience with FPDR are associated with increased support for the practice from health care providers.

CONCLUSIONS: FPDR should be considered to be an important component of patient and family‐centred care.
Gaps in the Inpatient Management of Chronic Obstructive Pulmonary Disease Exacerbation and Impact of An Evidence-Based Order Set
Authors: Kitchlu Abhijat , Abdelshaheed Tamer , Tullis Elizabeth , Gupta Samir
Published: March 2016

BACKGROUND: Evidence-based, guideline-recommended practices improve multiple outcomes in patients admitted with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), but are incompletely implemented in actual practice. Admission order sets with evidence-based diagnostic and therapeutic guidance have enabled quality improvement and guideline implementation in other conditions.

OBJECTIVE: To characterize the magnitude of care gaps and the effect of order sets on quality of care in patients with AECOPD.

METHODS: The authors prospectively designed a standardized chart review protocol to document process of care and health care utilization before and after implementation of AECOPD order sets at an academic hospital in Toronto, Ontario.

RESULTS: A total of 243 total AECOPD admissions and multiple important care gaps were identified. There were 74 admissions in the pre-order set period (January to June 2009) and 169 in the order set period (October 2009 to September 2010). The order set was used in 78 of 169 (46.2%) admissions. In the order set period, we observed improvements in respiratory therapy educational referrals (five of 74 [6.8%] versus 48 of 169 [28.4%]; P<0.01); venous thromboembolism prophylaxis prescriptions (when indicated) (15 of 68 [22.1%] versus 100 of 134 [74.6%]; P<0.01); systemic steroid prescriptions (55 of 74 (74.3%) versus 151 of 169 [89.4%]; P<0.01]); and appropriate antibiotic prescriptions (nine of 24 [37.5%] versus 61 of 88 [69.3%]; P<0.01). The mean (± SD) length of stay also decreased from 6.5±7.7 days before order sets to 4.1±5.0 days with order sets (P=0.017).

CONCLUSIONS: Care gaps in inpatient AECOPD management were large and evidence-based order sets may improve guideline adherence at the point of care. Randomized trials including patient outcomes are required to further evaluate this knowledge translation intervention.
Canadian Public Health Laboratory Network Laboratory Guidelines for Congenital Syphilis and Syphilis Screening in Pregnant Women in Canada
Authors: Singh Ameeta E , Levett Paul N , Fonseca Kevin , Jayaraman Gayatri C , Lee Bonita E
Published: March 2016

Despite universal access to screening for syphilis in all pregnant women in Canada, cases of congenital syphilis have been reported in recent years in areas experiencing a resurgence of infectious syphilis in heterosexual partnerships. Antenatal screening in the first trimester continues to be important and should be repeated at 28 to 32 weeks and again at delivery in women at high risk of acquiring syphilis. The diagnosis of congenital syphilis is complex and is based on a combination of maternal history and clinical and laboratory criteria in both mother and infant. Serologic tests for syphilis remain important in the diagnosis of congenital syphilis and are complicated by the passive transfer of maternal antibodies which can affect the interpretation of reactive serologic tests in the infant. All infants born to mothers with reactive syphilis tests should have nontreponemal tests (NTT) and treponemal tests (TT) performed in parallel with the mother’s tests. A fourfold or higher titre in the NTT in the infant at delivery is strongly suggestive of congenital infection but the absence of a fourfold or greater NTT titre does not exclude congenital infection. IgM tests for syphilis are not currently available in Canada and are not recommended due to poor performance. Other evaluation in the newborn infant may include long bone radiographs and cerebrospinal fluid tests but all suspect cases should be managed in conjunction with sexually transmitted infection and/or pediatric experts.
Evolution of Thoracic Surgery in Canada
Authors: Deslauriers Jean , Griffith Pearson F , Nelems Bill
Published: March 2016

BACKGROUND: Canada’s contributions toward the 21st century’s practice of thoracic surgery have been both unique and multilayered. Scattered throughout are tales of pioneers where none had gone before, where opportunities were greeted by creativity and where iconic figures followed one another.

OBJECTIVE: To describe the numerous and important achievements of Canadian thoracic surgeons in the areas of surgery for pulmonary tuberculosis, thoracic oncology, airway surgery and lung transplantation.

METHOD: Information was collected through reading of the numerous publications written by Canadian thoracic surgeons over the past 100 years, interviews with interested people from all thoracic surgery divisions across Canada and review of pertinent material form the archives of several Canadian hospitals and universities.

RESULTS: Many of the developments occurred by chance. It was the early and specific focus on thoracic surgery, to the exclusion of cardiac and general surgery, that distinguishes the Canadian experience, a model that is now emerging everywhere. From lung transplantation in chimera twin calves to ex vivo organ preservation, from the removal of airways to tissue regeneration, and from intensive care research to complex science, Canadians have excelled in their commitment to research. Over the years, the influence of Canadian thoracic surgery on international practice has been significant.

CONCLUSIONS: Canada spearheaded the development of thoracic surgery over the past 100 years to a greater degree than any other country. From research to education, from national infrastructures to the regionalization of local practices, it happened in Canada.
Scoliosis and Bronchial Obstruction
Authors: Qiabi Mehdi , Chagnon Karine , Beaupré Alain , Hercun Julian , Rakovich George
Published: March 2016

Severe scoliosis may have a significant effect on respiratory function. The effect is most often restrictive due to severe anatomical distortion of the chest, leading to reduced lung volumes, limited diaphragmatic excursion and chest wall muscle inefficiency. Bronchial compression by the deformed spine may also occur but is more unusual. Management options include a conservative approach using bracing and physiotherapy in mild cases, as well as surgical correction of the scoliosis in more severe cases. Bronchial stenting has also been used successfully as an alternative to surgical correction, and in cases in which spinal surgery was either unsuccessful or not feasible. The authors present a case involving a 52‐year‐old woman who exhibited symptomatic compression of the bronchus intermedius by severe residual scoliosis despite previous corrective surgery. She was treated with an indwelling bronchial stent.
A 14-Day Course of Triple Therapy is Superior to a 10-Day Course for the Eradication ofHelicobacter pylori: A Canadian Study Conducted in a ‘Real World’ Setting
Authors: Chen Yen-I , Fallone Carlo A
Published: March 2016

BACKGROUND: SuccessfulHelicobacter pylorieradication with the traditional seven-day course of proton pump inhibitor (PPI) triple therapy is declining. Prolonging therapy to either 10 or 14 days is associated with better eradications rates.

OBJECTIVE: To compare the effectiveness of 14-day course of triple therapy versus a 10-day course in the treatment ofH pyloriin Canada.

METHODS: Consecutive treatment-naive patients with clinical indications forH pylorieradication underwent either a 10-day course or a 14-day course of traditional PPI triple therapy depending on the date of the office visit (an odd date received the 10-day course, whereas an even date received the 14-day treatment).H pylorieradication was ascertained via urea breath test or gastric biopsies performed ≥4 weeks after completion of therapy. Analyses were by both intention to treat and per-protocol.

RESULTS: A total of 83 patients were included in the study (31 in the 10-day group and 52 in the 14-day group). In the intention-to-treat analysis, eradication rates were 82.7% (95% CI 70% to 92%) versus 45.2% (95% CI 27% to 64%), favouring the 14-day treatment (P<0.001). Similarly, in the per-protocol analysis, eradication rates were 91.5% (95% CI 80% to 98%) versus 63.6% (95% CI 41% to 83%), favouring the 14-day arm (P=0.01). Adverse events and compliance were not significantly different between the two groups.

CONCLUSION: A 14-day course of standard PPI triple therapy was superior to a shorter-duration therapy and should be included as a first-line regimen forH pylorieradication in Canada. The 10-day course of treatment did not achieve an acceptable eradication rate and should no longer be used in this country.
Transient Elastography in Canada: Current State and Future Directions
Authors: Aljawad Mohammed , Sirpal Sanjeev , Yoshida Eric M , Chandok Natasha
Published: March 2016

BACKGROUND: Transient elastography (TE) is a safe and effective technology to noninvasively assess hepatic fibrosis in patients with numerous liver conditions. TE is not readily available to all Canadians, and data regarding how this technology is incorporated into clinical practice are lacking.

OBJECTIVE: To describe TE practices in Canada, and to identify strategies to optimize access and usage.

METHODS: All Canadian centres with TE devices were invited to complete a survey after obtaining purchasing data from the national distributor of the device. Descriptive statistics were generated.

RESULTS: Forty-two devices were available in Canada as of January 2015. Seventy-one percent are used in academic settings, 74% are hospital based and 26% are in private clinics. The test is performed by trained nurses in 48% of centres, physicians in 19%, technicians in 9.5% and by any member of the health care team in 19%. Nineteen percent of centres provide satellite clinics to perform the test. While the majority of the centres perform the test at no additional cost to patients, 29% charge a variable fee.

CONCLUSION: In Canada, most TE devices are used in academic and/or hospital-based settings, thus limiting access to this technology to many patients. A sizeable minority of centres mandate patients pay variable out-of-pocket fees. Satellite clinics offered by some centres could increase access, but are not widespread. The lack of uniformity with TE practices in Canada suggests that a national policy is needed.
Canadian Public Health Laboratory Network Laboratory Guidelines for the Use of Direct Tests to Detect Syphilis in Canada
Authors: Tsang Raymond SW , Morshed Muhammad , Chernesky Max A , Jayaraman Gayatri C , Kadkhoda Kamran
Published: March 2016

Treponema pallidum subsp. pallidum and/or its nucleic acid can be detected by various methods such as microscopy, rabbit infectivity test or polymerase chain reaction (PCR) tests. The rabbit infectivity test for T. pallidum, although very sensitive, has been discontinued from most laboratories due to ethical issues related to the need for animal inoculation with live T. pallidum, the technically demanding procedure and long turnaround time for results, thus making it impractical for routine diagnostic use. Dark‐field and phase‐contrast microscopy are still useful at clinic‐ or hospital‐based laboratories for near‐bedside detection of T. pallidum in genital, skin or mucous lesions although their availability is decreasing. The lack of reliable and specific anti‐T. pallidum antibodies and its inferior sensitivity to PCR may explain why the direct fluorescent antibody test for T. pallidum is not widely available for clinical use. Immunohistochemical staining for T. pallidum also depends on the availability of specific antibodies, and the method is only applicable for histopathological examination of biopsy and autopsy specimens necessitating an invasive specimen collection approach. With recent advances in molecular diagnostics, PCR is considered to be the most reliable, versatile and practical for laboratories to implement. In addition to being an objective and sensitive test for direct detection of Treponema pallidum subsp. pallidum DNA in skin and mucous membrane lesions, the resulting PCR amplicons from selected gene targets can be further characterized for antimicrobial (macrolide) susceptibility testing, strain typing and identification of T. pallidum subspecies.
Social Network Investigation of a Syphilis Outbreak in Ottawa, Ontario
Authors: D’Angelo-Scott H , Cutler J , Friedman D , Hendriks A , Jolly AM
Published: March 2016

BACKGROUND: The incidence of syphilis in Ottawa, Ontario, has risen substantially since 2000 to six cases per 100,000 in 2003, again to nine cases per 100,000 in 2007, and recently rose to 11 cases per 100,000 in 2010. The number of cases reported in the first quarter of 2010 was more than double that in the first quarter of 2009.

OBJECTIVE: In May 2010, the Ontario Ministry of Health and Long Term Care requested the assistance of the Field Epidemiology Program to describe the increase in infectious syphilis rates and to identify social network sources and prevention messages.

METHODS: Syphilis surveillance data were routinely collected from January 1, 2009 to July 15, 2010, and social networks were constructed from an enhanced social network questionnaire. Univariate comparisons between the enhanced surveillance group and the remaining cases from 2009 on non‐normally distributed data were conducted using Kruskal‐Wallis tests and χ2 tests.

RESULTS: The outbreak cases were comprised of 89% men. Seventeen of the 19 most recent cases consented to answer the questionnaire, which revealed infrequent use of condoms, multiple sex partners and sex with a same‐sex partner. Information regarding social venues where sex partners were met was plotted together with sexual partnerships, linking 18 cases and 40 contacts, representing 37% of the outbreak population and connecting many of the single individuals and dyads.

CONCLUSION: Uncovering the places sex partners met was an effective proxy measure of high‐risk activities shared with infected individuals and demonstrates the potential for focusing on interventions at one named bar and one Internet site to reach a high proportion of the population at risk.
Sepsis due to Erysipelothrix rhusiopathiae in a Patient with Chronic Lymphocytic Leukemia Associated with Bronchopneumonia due to PSeudomonas aeruginosa And Escherichia coli: A Case Report
Authors: Bîrlutiu Victoria
Published: March 2016

INTRODUCTION: The present report describes a case of sepsis due to Erysipelothrix rhusiopathiae in a patient with B‐cell chronic lymphocytic leukemia with no animal exposure, associated with concomitant bronchopneumonia due to Pseudomonas aeruginosa and Escherichia coli.

CASE PRESENTATION: A 54‐year‐old Caucasian man presented to an emergency room with a three‐day history of chest pain, fever, cough with purulent sputum, chills and dyspnea. The patient had associated erythematous papules on the chest and enlarged axillary, submandibular, pectoral and supraclavicular lymph nodes, which regressed under treatment with penicillin. The patient was found to have sepsis without endocarditis caused by E rhusiopathiae, associated with bronchopneumonia that was induced by a double Gram‐negative infection.

CONCLUSIONS: The underlying‐B cell chronic lymphocytic leukemia may have favoured the development of bacteremia due to E rhusiopathiae, which occurred subsequent to glossitis in an immunocompromised host being treated with methylprednisolone and cladribine.
Does the Level of Reproductive Knowledge Specific to Inflammatory Bowel Disease Predict Childlessness among Women with Inflammatory Bowel Disease?
Authors: Huang Vivian W , Chang Hsiu-Ju , Kroeker Karen I , Goodman Karen J , Hegadoren Kathleen M , Dieleman Levinus A , Fedorak Richard N
Published: March 2016

BACKGROUND: Women with inflammatory bowel disease (IBD) may choose to remain childless due to a lack of IBD-specific reproductive knowledge.

OBJECTIVES: To examine the effects of IBD-specific reproductive knowledge and discussion of family planning with a physician on childlessness among women with IBD.

METHODS: Female IBD patients 18 to 45 years of age completed the Crohn’s and Colitis Pregnancy Knowledge questionnaire (CCPKnow), and answered questions regarding reproductive history, plans to have children and discussion of family planning with a physician. CCPKnow scores were grouped according to poor (0 to 7), adequate (8 to 10), good (11 to 13) and very good (14 to 17).

RESULTS: Of 434 eligible women, 248 (57.1%) completed the questionnaires. Of these 248 women, 51.6% were childless and, among these, 12.9% were voluntarily childless and 12.1% were trying to become pregnant. Childless women had a lower median CCPKnow score than women with children (6.0 versus 8.0; P=0.001). After adjusting for current age and marital status, each one point increase in the CCPKnow score corresponded to 8% lower odds of childlessness (OR 0.92 [95% CI 0.86 to 0.99]), 9% lower odds of voluntary child-lessness (OR 0.91 [95% CI 0.79 to 1.0]) and 20% higher odds of trying to become pregnant (OR 1.2 [95% CI 1.0 to 1.4]). Discussion of family planning with a gastroenterologist corresponded to 72% lower odds of a poor CCPKnow score (OR 0.28 [95% CI 0.15 to 0.53]) and of voluntary childlessness (OR 0.28 [95% CI 0.057 to 1.3]).

CONCLUSION: In the present study, higher IBD-specific reproductive knowledge lowered the odds of childlessness among women with IBD. Discussion of family planning with a physician was associated with higher CCPKnow scores and lower odds of voluntary childlessness.
Parents’ and Adolescents’ Willingness to be Vaccinated Against Serogroup B Meningococcal Disease during a Mass Vaccination in Saguenay–Lac‐St‐Jean (Quebec)
Authors: Dubé Eve , Gagnon Dominique , Hamel Denis , Belley Sylvie , Gagné Hélène , Boulianne Nicole , Landry Monique , Bettinger Julie A
Published: March 2016

A mass vaccination campaign with the 4CMenB vaccine (Bexsero®; Novartis Pharmaceutical Canada Inc) was launched in a serogroup B endemic area in Quebec. A telephone survey was conducted to assess parental and adolescent opinions about the acceptability of the vaccine. Intent to receive the vaccine or vaccine receipt was reported by the majority of parents (93%) and adolescents (75%). Meningitis was perceived as being a dangerous disease by the majority of parents and adolescents. The majority of respondents also considered the 4CMenB vaccine to be safe and effective. The main reason for positive vaccination intention or behaviour was self‐protection, while a negative attitude toward vaccination in general was the main reason mentioned by parents who did not intend to have their child vaccinated. Adolescents mainly reported lack of interest, time or information, and low perceived susceptibility and disease severity as the main reasons for not intending to be vaccinated or not being vaccinated.
Bacterial Communities in Neonatal Feces are Similar to Mothers’ Placentae
Authors: Dong Xu-Dong , Li Xiao-Ran , Luan Jian-Jun , Liu Xiao-Feng , Peng Juan , Luo Yi-Yong , Liu Chen-Jian
Published: March 2016

BACKGROUND: The gut microbiota plays an important role in human health. It is essential to understand how the composition of the gut microbiota in neonates is established.

OBJECTIVES: To investigate the nature of the microbial community in the first feces of newborn infants compared with the mothers’ placentae and vaginas.

METHODS: One infant who was delivered via Cesarean section was compared with an infant who was delivered vaginally. Bar‐coded pyro‐sequencing of 16S ribosomal RNA genes was used to investigate the bacterial community composition and structure of each site.

RESULTS: Neonatal feces of both infants had similar bacterial communities, and they were similar to the mother’s placenta regardless of the method of delivery. The vaginal bacterial community differed between the two mothers, but not different sites within the vagina. The bacteria in the neonatal feces and the mothers’ placentae demonstrated considerably higher diversity compared with the vaginas. The family Lactobacillaceae dominated in the vaginal samples, while the most abundant family in the fecal and placental samples was Micrococcineae.

CONCLUSIONS: These results may provide new directions for the study of infant gut microbial formation.