bluuebunny/crossref_metadata_2025 huggingface dataset:
A Review of 11 Years of Stenotrophomonas maltophilia Blood Isolates at a Tertiary Care Institute in Canada
Authors: Naidu Prenilla , Smith Stephanie
Published: March 2016

BACKGROUND: Stenotrophomonas maltophilia has emerged as a significant nosocomial pathogen with increasing resistance to trimethoprim/sulphamethoxazole (TMP/SMX), the current drug of choice for treatment.

OBJECTIVES: To describe the microbiological and clinical characteristics of S maltophilia bloodstream infections (BSIs) over an 11‐year period at a tertiary care centre in Canada.

METHODS: All adult S maltophilia BSIs from 1999 to 2009 in a 750‐bed tertiary care teaching hospital (University of Alberta Hospital, Edmonton, Alberta) were identified through the infection control nosocomial infection surveillance program. Demographic and clinical data were extracted from the infection control database and from patient charts. Microbiological data were confirmed through the laboratory information system.

RESULTS: Twenty‐five episodes of S maltophilia BSI (0.9% of all BSIs) involving 24 patients were identified between 1999 and 2009. The patient age range was 18 to 83 years (average 45.7 years). The majority were men (14 of 24 [58.3%]). The mean length of hospital stay was 83.3 days (range eight to 310 days). The rate of S maltophilia BSIs per 1000 admissions ranged from 0.04 to 0.22 (average 0.09). Greater than one‐half of the episodes (13 of 25 [52%]) were admitted to the intensive care unit before BSI onset. Laboratory data were available for 24 of the 25 isolates. Polymicrobial infections were present in 11 of 24 (45.8%) patients. Resistance to TMP/SMX occurred in 8.3% of all infections. Fifteen per cent of isolates were resistant to ticarcillin/clavulanate. Mortality attributed to bacteremia was 16.7%.

CONCLUSIONS: In the University of Alberta Hospital, the rate of S maltophilia BSI remains low and constant, and TMP/SMX remains the drug of choice for treatment.
Atypical Lung Parenchymal Bronchogenic Cyst Complicated by Tuberculosis Infection
Authors: Chu Haiqing , Yi Xianghua , Zhao Lan , Gui Tao , Fang Xia , Sun Xiwen
Published: March 2016

A bronchogenic cyst (BC) is a rare congenital lesion that may cause life‐threatening organ compression in children, but is generally asymptomatic in adults unless there are other complications. In the present report, a 34‐year‐old woman in whom a BC was complicated by tuberculosis infection is described. Due to the small size of the BC, it was asymptomatic and could not be diagnosed until she was treated with antituberculosis medications.
The Utility of Xenon-133 Liver Scan in the Diagnosis and Management of Nonalcoholic Fatty Liver Disease
Authors: Al-Busafi Said A , Ghali Peter , Wong Philip , Novales-Diaz Javier A , Deschênes Marc
Published: March 2016

Nonalcoholic fatty liver disease (NAFLD) encompasses a wide spectrum of liver damage and is the most common cause of chronic liver diseases in Western countries. Although a relatively common condition affecting approximately 20% of the general population, NAFLD is especially prevalent in obese individuals, a figure likely to rise as obesity rates in Western countries continue to increase. Liver biopsy remains the gold standard diagnostic method; however, its invasive nature, among other factors, has prompted the need to develop less invasive, alternative methods to quantify hepatic fat and determine disease severity. Xenon-133 liver scanning is one such method that has been in use for more than 10 years in the evaluation of patients with suspected NAFLD. This study compared Xenon-133 liver scan with other currently used, invasive and noninvasive methods of liver assessment.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is an important and common condition affecting approximately 20% of the general population. Given the limitation of radiological investigations, diagnosis often requires a liver biopsy.

OBJECTIVE: To compare Xenon-133 (Xe-133) liver scanning with ultrasonography in the diagnosis of NAFLD.

METHODS: From January 2003 to February 2007, 258 consecutive patients with suspected NAFLD underwent Xe-133 liver scanning at Royal Victoria Hospital (Montreal, Quebec). Of these, 43 patients underwent ultrasonography and liver biopsy for the evaluation of NAFLD. Patients with other liver diseases and significant alcohol consumption were excluded. Two nuclear medicine physicians assessed liver Xe-133 uptake and measured the grade of steatosis using a standardized protocol. The degree of steatosis was determined from biopsy specimens assessed by two hepatopathologists.

RESULTS: NAFLD was identified by liver biopsy in 35 of 43 patients (81.4%). Xe-133 scan demonstrated 94.3% sensitivity (95% CI 81.4% to 98.4%) and 87.5% specificity (95% CI 52.9% to 99.4%) for the presence of NAFLD. The positive and negative predictive values for detection of steatosis by Xe-133 scan were 97.1% (95% CI 85.1% to 99.8%) and 77.8% (95% CI 45.3% to 93.7%), respectively. The positive and negative likelihood ratios were 7.54 (95% CI 1.20 to 47.26) and 0.07 (95% CI 0.02 to 0.26), respectively. Two patients with NAFLD (5.7%) who had a negative Xe-133 scan result had histologically mild steatosis (<10%). The grade of steatosis on liver biopsy was highly correlated with the results of the Xe-133 scan (r=0.87; P<0.001). The sensitivity and specificity of ultrasound in diagnosing steatosis were 62.9% and 75%, respectively.

CONCLUSION: Xe-133 liver scan proved to be a safe, reliable, non-invasive method for diagnosing and quantifying hepatic steatosis, and was superior to ultrasound.
Pulmonary Alveolar Proteinosis
Authors: Patel Sandeep M , Sekiguchi Hiroshi , Reynolds Jordan P , Krowka Michael J
Published: March 2016

Pulmonary alveolar proteinosis (PAP) is a disease of alveolar accumulation of phospholipoproteinaceous material that results in gas exchange impairment leading to dyspnea and alveolar infiltrates. There are three forms of PAP: congenital, acquired and idiopathic; of which the latter two are predominant in the adult population. Previous case studies have found that the acquired form can be secondary to various autoimmune, infectious, malignant and environmental etiologies. Recent advances in the understanding of the pathophysiology of PAP demonstrate that the idiopathic form is due to antigranulocyte macrophage‐colony stimulating factor antibodies. Therapeutic targets that replace granulocyte macrophage colony stimulating factor or remove these antibodies are being actively developed. The current standard of care is to perform whole lung lavage on these patients to clear the alveolar space to help improve respiratory physiology. A case of PAP is reported, followed by a literature review on the diagnosis and management of this rare condition with the aim of increasing awareness among physicians when treating patients who present with alveolar infiltrates.
Herpes Simplex Virus Type 1 is the Leading Cause of Genital Herpes in New Brunswick
Authors: Garceau Richard , Leblanc Danielle , Thibault Louise , Girouard Gabriel , Mallet Manon
Published: March 2016

INTRODUCTION: Little is known about the role of herpes simplex virus (HSV) type 1 (HSV1) in the epidemiology of genital herpes in Canada. Data on herpes viral cultures for two consecutive years obtained from L’Hôpital Dr GL Dumont, which performs all the viral culture testing in New Brunswick, were reviewed. It was hypothesized that HSV1 was the main cause of genital herpes in New Brunswick.

METHODS: Samples of genital origin sent to the laboratory for HSV culture testing between July 2006 and June 2008 were analyzed. Samples from an unspecified or a nongenital source were excluded from analysis. Multiple positive samples collected from the same patient were pooled into a single sample.

RESULTS: HSV was isolated from 764 different patients. HSV1 was isolated in 62.6% of patients (male, 55%; female, 63.8%). HSV1 was isolated in 73.2% of patients 10 to 39 years of age and in 32% of patients ≥40 years of age. The difference in rates of HSV1 infection between the 10 to 39 years of age group and the ≥40 years of age group was statistically significant (P<0.001 [χ2]). In a similar Canadian study performed in Nova Scotia, HSV1 was recovered in 53.7% of positive cultures (male, 36.7%; female, 58.1%). The rates of HSV1 infection reported by this study and the present study were significantly different (P<0.001 [χ2] for male, P=0.012 for female).

CONCLUSION: In New Brunswick, HSV1 is the dominant type of HSV isolated in samples collected from a genital site. Significant rate differences were demonstrated between the groups 10 to 39 years of age and ≥40 years of age.
Pediatric Fear‐Avoidance Model of Chronic Pain: Foundation, Application and Future Directions
Authors: Asmundson Gordon JG , Noel Melanie , Petter Mark , Parkerson Holly A
Published: March 2016

The fear‐avoidance model of chronic musculoskeletal pain has become an increasingly popular conceptualization of the processes and mechanisms through which acute pain can become chronic. Despite rapidly growing interest and research regarding the influence of fear‐avoidance constructs on pain‐related disability in children and adolescents, there have been no amendments to the model to account for unique aspects of pediatric chronic pain. A comprehensive understanding of the role of fear‐avoidance in pediatric chronic pain necessitates understanding of both child/adolescent and parent factors implicated in its development and maintenance. The primary purpose of the present article is to propose an empirically‐based pediatric fear‐avoidance model of chronic pain that accounts for both child/adolescent and parent factors as well as their potential interactive effects. To accomplish this goal, the present article will define important fear‐avoidance constructs, provide a summary of the general fear‐avoidance model and review the growing empirical literature regarding the role of fear‐avoidance constructs in pediatric chronic pain. Assessment and treatment options for children with chronic pain will also be described in the context of the proposed pediatric fear‐avoidance model of chronic pain. Finally, avenues for future investigation will be proposed.
Validation of a New Questionnaire with Generic and Disease-Specific Qualities: The Mcgill Copd Quality of Life Questionnaire
Authors: Pakhale Smita , Wood-Dauphinee Sharon , Spahija Adriana , Collet Jean-Paul , Maltais François , Bernard Sarah , Baltzan Marc , Rouleau Michel , Bourbeau Jean ,   for the Respiratory Health Network of the FRSQ
Published: March 2016

BACKGROUND: A validated health-related quality of life questionnaire in chronic obstructive pulmonary disease (COPD) with advantages of both generic- and disease-specific questionnaires is needed to capture patients’ perspectives of severity and impact of the disease. The McGill COPD questionnaire was created to include these advantages in English and French. It assesses three domains: symptoms, physical function and feelings with 29 items (12 from the 36-item Short-Form Health Survey with 17 from the previously developed COPD-specific module).

OBJECTIVE: To evaluate the psychometric properties of this newly developed hybrid questionnaire in subjects with COPD.

METHODS: Data from a multicentre, prospective cohort study involving four hospitals with COPD subjects undergoing pulmonary rehabilitation were used. Patient evaluations included health-related quality of life (the new McGill COPD questionnaire, the St Georges Respiratory Questionnaire and the 36-item Short-Form Health Survey) and pulmonary function tests pre-and postrehabilitation. Reliability, validity and responsiveness were tested.

RESULTS: The study included 246 COPD subjects (111 females) with a mean age of 66 years, 87% ex- and 8% current smokers (mean 61 pack-years) and mean forced expiratory volume in 1 s of 1.12 L (Global initiative for chronic Obstructive Lung Disease stages: 2, 27%; 3, 33%; and 4, 37%). Missing data were <2% and floor and ceiling effects were <5%. Internal consistency (Cronbach’s alpha) was 0.68 to 0.82. Test-retest reliability (intracorrelation coefficients) ranged from 0.74 to 0.96 for the sub-scales, and 0.95 for the total score. Correlation with the St George’s Respiratory Questionnaire was moderately high (r=− 0.88 [95% CI −0.91 to −0.84]), consistent with the a priori hypothesis for convergent validity. The effect size was 0.33 (pre-postrehabilitation mean score difference = 6), suggesting a small to moderate change.

CONCLUSIONS: The new McGill COPD questionnaire showed high internal consistency, test-retest reliability, validity and moderate responsiveness in COPD subjects.
Awareness of Postpolypectomy Surveillance Guidelines: A Nationwide Survey of Colonoscopists in Canada
Authors: van Kooten Harmke , de Jonge Vincent , Schreuders Eline , Nicolaas Jerome Sint , van Leerdam Monique E , Kuipers Ernst J , van Zanten Sander JO Veldhuyzen
Published: March 2016

Several studies have demonstrated that screening asymptomatic, average-risk individuals and those at increased risk can reduce colorectal cancer mortality. Adherence to postpolypectomy surveillance guidelines becomes increasingly important amid the increasing demands for colonoscopy because suboptimal compliance can lead to unnecessary risks and the ineffective use of resources. However, performing too many surveillance colonoscopies, or at intervals that are too short, may hinder access to endoscopic procedures and decrease the cost effectiveness of colorectal cancer screening programs. Two reasons appear to be primarily responsible for nonadherence to postpolypectomy guidelines: lack of awareness or familiarity, and disagreement with the guidelines. Accordingly, this study aimed to determine the awareness of postpolypectomy guidelines among members of the Canadian Association of Gastroenterology, and the factors associated with physicians’ choices to deviate from them.

INTRODUCTION: Due to the increasing demand for colonoscopy, adherence to postpolypectomy surveillance guidelines is important. Suboptimal compliance can lead to unnecessary risks and ineffective use of resources.

OBJECTIVE: To determine the awareness of and adherence to postpolypectomy surveillance guidelines among members of the Canadian Association of Gastroenterology (CAG).

METHODS: A survey describing 14 clinical cases was mailed to all physician members (n=411) of the CAG. Respondents were required to recommend a surveillance interval and a reason for his or her choice.

RESULTS: A total of 150 colonoscopists (37%) completed the survey. Adherence to the guidelines varied from 23% to 96% per clinical scenario (median 63%). Recommended surveillance intervals were too short in 0% to 60% of the different cases (median 8%). The recommended interval was most often (60%) too short for a patient with one tubular adenoma with high-grade dysplasia. Surveillance intervals were too long in 4% to 75% of the cases (median 9%). The recommended interval was most often too long in a patient with a villous adenoma 15 mm in size and removed piecemeal (75%). Most often, recommendations were reported to be based on guidelines (median 74%; range 31% to 94%). However, in nine of 14 cases, more than 10% (median 18%; range 12% to 38%) of the respondents stated that their recommendation was based on guidelines, but did not provide the appropriate surveillance interval.

CONCLUSIONS: Compliance to colonoscopy surveillance guidelines is suboptimal and reflects both overuse and underuse. The results show that awareness about the content of guidelines needs to be raised and strategies implemented to increase adherence.
Patients Undergoing Colorectal Cancer Screening Underestimate Their Cancer Risk and Delay Presentation for Screening
Authors: Wang Haili , Gies Nicholas , Wong Clarence , Sadowski Dan , Moysey Barbara , Fedorak Richard N
Published: March 2016

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer in Canada. Screening guidelines recommend that first-time screening should occur at 50 years of age for average-risk individuals and at 40 years of age for those with a family history of CRC.

OBJECTIVE: To examine whether persons with a positive CRC family history were achieving screening at 40 years of age and whether average-risk persons were achieving screening at 50 years of age.

METHODS: The present study was a cross-sectional analysis of subjects who entered a colon cancer screening program and were undergoing CRC screening for the first time.

RESULTS: A total of 778 individuals were enrolled in the present study: 340 (174 males) with no family history of CRC, and 438 (189 males) with a positive family history of CRC. For the group with a positive family history, the mean (± SD) age for primary screening was 54.4±8.5 years, compared with 58.2±6.4 years for the group with no family history. On average, those with a positive family history initiated screening 3.8 years (95% CI 2.8 to 4.8; P<0.05) earlier than those without. Adenoma polyp detection rate for the positive family history group was 20.8% (n=91) compared with 23.5 % (n=80) for the group with no family history.

CONCLUSIONS: Individuals with a positive CRC family history are initiating screening approximately four years earlier than those without a family history; nevertheless, both groups are undergoing screening well past current guideline recommendations.
Executive and Attentional Functions in Chronic Pain: Does Performance Decrease with Increasing Task Load?
Authors: Oosterman Joukje M , Derksen Laura C , van Wijck Albert JM , Kessels Roy PC , Veldhuijzen Dieuwke S
Published: March 2016

BACKGROUND: Diminished executive function and attentional control has been reported in chronic pain patients. However, the precise pattern of impairment in these aspects of cognition in chronic pain remains unclear. Moreover, a decline in psychomotor speed could potentially influence executive and attentional control performance in pain patients.

OBJECTIVE: To examine different aspects of executive and attentional control in chronic pain together with the confounding role of psychomotor slowing.

METHODS: Neuropsychological tests of sustained attention, planning ability, inhibition and mental flexibility were administered to 34 participants with chronic pain and 32 control participants.

RESULTS: Compared with the controls, participants with chronic pain took longer to complete tests of sustained attention and mental flexibility, but did not perform worse on inhibition or planning tasks. The decreased performance on the mental flexibility task likely reflects a reduction in psychomotor speed. The pattern of performance on the sustained attention task reveals a specific decline in attention, indicated by a disproportionate decline in performance with an increase in task duration and by increased fluctuations in attention during task performance. No additional effect was noted of pain intensity, pain duration, pain catastrophizing, depressive symptoms, reduced sleep because of the pain or opioid use.

CONCLUSIONS: Executive and attention functions are not uniformly affected in chronic pain. At least part of the previously reported decline in executive function in this group may reflect psychomotor slowing. Overall, limited evidence was found that executive and attention performance is indeed lower in chronic pain. Therefore, it can be concluded that in chronic pain sustained attention performance is diminished while mental flexibility, planning and inhibition appear to be intact.
Recent Immigrants Show improved Clinical Outcomes at a Tertiary Care HIV Clinic
Authors: Raboud Janet , Blitz Sandra , Antoniou Tony , Loutfy Mona , Walmsley Sharon
Published: March 2016

BACKGROUND: In recent years, the proportion of patients attending tertiary care HIV clinics who are recent immigrants to Canada has increased dramatically.

METHODS: Among patients first seen at the Toronto Hospital Immunodeficiency Clinic (Toronto, Ontario) between January 1, 2000 and August 31, 2009, the time to death from the first positive HIV test was compared between individuals who had immigrated to Canada within 10 years of their first visit and individuals who were either Canadian‐born or who had immigrated more than 10 years before their first clinic visit. In addition, for the antiretroviral‐naive patients in these two groups who initiated combination antiretroviral therapy, the time to and the duration of virologic suppression were compared.

RESULTS: In a multivariable proportional hazards (PH) model, recent immigrant status was associated with decreased mortality (HR 0.11, P=0.03) after adjusting for age, CD4 count and the risk factor for men having sex with men. In multivariable PH models, recent female immigrants achieved virologic suppression more quickly (HR 1.51, P=0.02), while male immigrants (HR 1.14, P=0.44) and female nonimmigrants (HR 0.90, P=0.61) had similar times to virologic suppression as male nonimmigrants, respectively, after adjusting for the year of and viral load at combination antiretroviral therapy initiation. When pregnant women were removed from the analysis, there were no significant differences in the rates of virologic rebound according to sex or immigration status.

DISCUSSION: Despite the perceived barriers of newcomers to Canada, mortality was lower among recent immigrants and virologic suppression was achieved more quickly in recent female immigrants.
Inflammatory Bowel Disease: A Canadian Burden of Illness Review
Authors: Rocchi Angela , Benchimol Eric I , Bernstein Charles N , Bitton Alain , Feagan Brian , Panaccione Remo , Glasgow Kevin W , Fernandes Aida , Ghosh Subrata
Published: March 2016

BACKGROUND: Inflammatory bowel diseases (IBD) – Crohn’s disease (CD) and ulcerative colitis (UC) – significantly impact quality of life and account for substantial costs to the health care system and society.

OBJECTIVE: To conduct a comprehensive review and summary of the burden of IBD that encompasses the epidemiology, direct medical costs, indirect costs and humanistic impact of these diseases in Canada.

METHODS: A literature search focused on Canadian data sources. Analyses were applied to the current 2012 Canadian population.

RESULTS: There are approximately 233,000 Canadians living with IBD in 2012 (129,000 individuals with CD and 104,000 with UC), corresponding to a prevalence of 0.67%. Approximately 10,200 incident cases occur annually. IBD can be diagnosed at any age, with typical onset occurring in the second or third decade of life. There are approximately 5900 Canadian children <18 years of age with IBD. The economic costs of IBD are estimated to be $2.8 billion in 2012 (almost $12,000 per IBD patient). Direct medical costs exceed $1.2 billion per annum and are driven by cost of medications ($521 million), hospitalizations ($395 million) and physician visits ($132 million). Indirect costs (society and patient costs) total $1.6 billion and are dominated by long-term work losses of $979 million. Compared with the general population, the quality of life patients experience is low across all dimensions of health.

CONCLUSIONS: The present review documents a high burden of illness from IBD due to its high prevalence in Canada combined with high per-patient costs. Canada has among the highest prevalence and incidence rates of IBD in the world. Individuals with IBD face challenges in the current environment including lack of awareness of IBD as a chronic disease, late or inappropriate diagnosis, inequitable access to health care services and expensive medications, diminished employment prospects and limited community-based support.
Different Screening Definitions have Little Impact on Polypectomy Rate Estimates
Authors: Jiang Mengzhu , Sewitch Maida J , Joseph Lawrence , Barkun Alan N
Published: March 2016

BACKGROUND: Polypectomy rate is a surrogate quality indicator for screening colonoscopy. Various methods for identifying screening colonoscopies have been used and it is unclear how different definitions affect the estimated polypectomy rate.

OBJECTIVE: To estimate polypectomy rates and how they vary according to the definition of a screening colonoscopy, using patient- and endoscopist-reported indications.

METHODS: A cross-sectional analysis of endoscopists and their patients 50 to 75 years of age who underwent colonoscopy was conducted. Based on questionnaire responses, four patient indications were derived: perceived screening; perceived nonscreening; medical history indicating nonscreening; and combination of the three indications. Endoscopist indication was derived from a questionnaire completed immediately after colonoscopy. Polypectomy status was obtained from provincial physician billing records. Polypectomy rates were computed, while accounting for physician and hospital level clustering, using all four patient indications, endoscopist indication, and the agreement between patient and endoscopist indications. The effect of indications on polypectomy rate was estimated adjusting for age, sex and family history of colorectal cancer.

RESULTS: A total of 2134 patients and 45 endoscopists were included. The proportion of colonoscopies classified as screening according to the nine indications ranged from 32.2% to 70.9%. Polypectomy rates ranged between 22.6% and 26.2% for screening colonoscopy, and between 27.1% and 30.8% for nonscreening colonoscopy. Adjusted ORs for indication ranged between 0.74 and 0.94.

DISCUSSION: Although the proportion of colonoscopies identified as screening varied considerably among the indications, the estimated polypectomy rates were similar.

CONCLUSION: The findings suggest that the way screening is defined does not greatly affect the estimates of polypectomy rate.
Knowledge Brokering: An Innovative Model for Supporting Evidence‐Informed Practice in Respiratory Care
Authors: Hoens Alison M , Reid W Darlene , Camp Pat G
Published: March 2016

The process of adopting research findings in the clinical setting is challenging, regardless of the area of practice. One strategy to facilitate this process is the use of knowledge brokering. Knowledge brokers (KBs) are individuals who work to bridge the gap between researchers and knowledge users. In the health care setting, KBs work closely with clinicians to facilitate enhanced uptake of research findings into clinical practice. They also work with researchers to ensure research findings are translatable and meaningful to clinical practice. The present article discusses a KB’s role in a respiratory care setting. Working closely with both researchers and clinicians, the KB has led teams in the process of conceptualizing, developing, testing, disseminating and evaluating several projects related to respiratory care, including projects related to mobility in critical care settings and acute exacerbations of chronic obstructive pulmonary disease; inspiratory muscle training; and the use of incentive spirometry in postsurgical populations. The KB role has provided an important communication link between researcher and knowledge user that has facilitated evidence‐informed practice to improve patient care.
The Impact Of Body Mass Index On Inpatient‐ Versus Outpatient‐Treated Chronic Obstructive Pulmonary Disease Exacerbations
Authors: Jacob Ariane , Laurin Catherine , Lavoie Kim L , Moullec Gregory , Boudreau Maxine , Lemière Catherine , Bacon Simon L
Published: March 2016

BACKGROUND: Increased body weight has been associated with worse prognoses for many chronic diseases; however, this relationship is less clear in patients with chronic obstructive pulmonary disease (COPD), with underweight patients experiencing higher morbidity than normal or overweight patients.

OBJECTIVE: To assess the impact of body mass index (BMI) on the risk for COPD exacerbations.

METHODS: The present study included 115 patients with stable COPD (53% women; mean [± SD] age 67±8 years). Height and weight were measured to calculate BMI. Patients were followed for a mean of 1.8±0.8 years to assess the prospective risk of inpatient‐treated exacerbations and outpatient‐treated exacerbations, all of which were verified by chart review.

RESULTS: Cox regression models revealed that underweight patients were at greater risk for inhospital‐treated exacerbations (RR 2.93 [95% CI 1.27 to 6.76) relative to normal weight patients. However, overweight (RR 0.59 [95% CI 0.33 to 1.57) and obese (RR 0.99 [95% CI 0.53 to 1.86]) patients did not differ from normal weight patients. All analyses were adjusted for age, sex, length of diagnosis, smoking pack‐years, forced expiratory volume in 1 s, and time between recruitment and last exacerbation. BMI did not influence the risk of out‐of‐hospital exacerbations.

CONCLUSIONS: The present study showed that underweight patients were at greater risk for inhospital exacerbations. However, BMI did not appear to be a risk factor for out‐of‐hospital exacerbations. This suggests that the BMI‐exacerbation link may differ according to the nature of the exacerbation, the mechanisms for which are not yet known.
A Randomized Controlled Trial Comparing Sequential with Triple Therapy forHelicobacter pyloriin an Aboriginal Community in the Canadian North
Authors: Morse Amy L , Goodman Karen J , Munday Rachel , Chang Hsiu-Ju , Morse John , Keelan Monika , Geary Janis , van Zanten Sander Veldhuyzen , CAN Help Working Group
Published: March 2016

BACKGROUND:Helicobacter pyloriinfection occurs more frequently in Arctic Aboriginal settings than elsewhere in North America and Europe. Research aimed at reducing health risks fromH pyloriinfection has been conducted in the Aboriginal community of Aklavik, Northwest Territories.

OBJECTIVE: To compare the effectiveness of the Canadian standard therapy with an alternative therapy for eliminatingH pyloriinfection in Aklavik.

METHODS: Treatment-naiveH pylori-positive individuals were randomly assigned to a 10-day regimen (oral twice-daily doses) with rabeprazole (20 mg): standard triple therapy (proton pump inhibitor, added clarithromycin [500 mg] and amoxicillin [1 g] [PPI-CA]); sequential therapy (ST) added amoxicillin (1 g) on days 1 to 5, and metronidazole (500 mg) and clarithromycin (500 mg) on days 6 to 10. Participants with clarithromycin-resistantH pyloriwere randomly assigned to ST or quadruple therapy. Treatment effectiveness was estimated as per cent (95% CI) with a negative urea breath test at least 10 weeks after treatment.

RESULTS: Of 104 (53 PPI-CA, 51 ST) randomized participants, 89 (49 PPI-CA, 40 ST) had post-treatment results. Per-protocol treatment effectiveness was 59% (95% CI 45% to 73%) for PPI-CA and 73% (95% CI 58% to 87%) for ST. Based on intention to treat, effectiveness was 55% (95% CI 41% to 69%) for PPI-CA and 57% (95% CI 43% to 71%) for ST. Of 77 participants (43 PPI-CA, 34 ST) with 100% adherence, effectiveness was 63% (95% CI 43% to 82%) for PPI-CA and 81% (95% CI 63% to 99%) for ST.

CONCLUSIONS: While additional evidence is needed to confirm that ST is more effective for Arctic Aboriginal communities than the Canadian standardH pyloritreatment, these results show standard PPI-CA treatment to be inadequate for communities such as Aklavik.
The Analgesic Efficacy of Intra‐Articular Acetaminophen in an Experimental Model of Carrageenan‐Induced Arthritis
Authors: Arun Oguzhan , Canbay Ozgur , Celebi Nalan , Sahin Altan , Konan Ali , Atilla Pergin , Aypar Ulku
Published: March 2016

BACKGROUND: Acetaminophen is one of the most common drugs used for the treatment of pain and fever.

OBJECTIVES: To examine the effects of intra‐articular (IA) acetaminophen on carrageenan‐induced arthritic pain‐related behaviour and spinal c‐Fos expression in rats.

METHODS: The present study was performed using 20 Sprague Dawley rats. Forty microlitres of IA 0.9% NaCl was injected in the control group, and 40 μL of IA carrageenan was injected in the carrageenan group. One hour after carrageenan injection, 400 μg of IA acetaminophen was injected in the IA acetaminophen group, and 400 μg of intraperitoneal (IP) acet‐aminophen was injected in the IP acetaminophen group. One day before injection, and 4 h and 8 h after injection, diameters of both knee joints, motility of the rat, paw loading and joint mobility were assessed. After the rats were euthanized, L3 and L4 spinal segments were excised for c‐Fos assessment.

RESULTS: IA acetaminophen decreased both the severity and distribution of c‐Fos expression. IP acetaminophen decreased only the distribution of c‐Fos expression. IA acetaminophen decreased knee diameter at 8 h. IA and IP acetaminophen increased rat motility and paw loading scores. Joint mobility scores of IP acetaminophen were similar to saline at 8 h.

CONCLUSIONS: Results of the present study indicate an analgesic and/or possible anti‐inflammatory effect of IA acetaminophen and provide further evidence on the efficacy of systemic acetaminophen injection in reducing arthritic pain.
In a ‘Real-World’, Clinic-Based Community Setting, Sorafenib Dose of 400 mg/day is as Effective as Standard Dose of 800 mg/day in Patients with Advanced Hepatocellular Carcimona, with Better Tolerance and Similar Survival
Authors: Shingina Alexandra , Hashim Al Moutaz , Haque Mazhar , Suen Michael , Yoshida Eric M , Gill Sharlene , Donnellan Fergal , Weiss Alan A
Published: March 2016

BACKGROUND: Sorafenib, an oral multityrosine kinase inhibitor, has been approved for treatment of unresectable hepatocellular carcinoma (HCC). British Columbia (BC) was the first province in Canada to provide drug coverage for sorafenib.

OBJECTIVE: To review the BC experience with sorafenib to assess its effectiveness and tolerance in a ‘real-world’ clinical setting.

METHODS: A retrospective clinic chart review identified 99 patients referred to the BC Cancer Agency from 2008 to 2010 with a diagnosis of HCC who qualified for treatment with sorafenib.

RESULTS: Therapy with sorafenib was initiated and continued at a reduced dosage of 400 mg/day in 66 of 99 patients, with 22 patients requiring further dose reduction. Full- and reduced-dose group patients had similar baseline characteristics, except for a higher proportion of female patients (P=0.02) and individuals with alcoholic liver disease (P=0.04) in the full-dose group. The incidence of any grade of adverse effects was higher in the full-dose group (94% versus 77% in the reduced-dose group; P=0.04). Dose reduction rates were significantly higher in the full-dose group, occurring in 66% versus 24% of reduced-dose group patients (P=0.001). The overall survival rates were similar between the two groups: 7.8 months versus 7.1 months in full- versus reduced-dose groups (P=0.14), as were radiological progression rates and alpha-fetoprotein levels.

CONCLUSIONS: In a review of 99 patients in a ‘real-world’ community setting, a sorafenib dose of 400 mg/day was better tolerated and had similar efficacy compared with a sorafenib dose of 800 mg/day with respect to survival and outcomes.
Immunoglobulin G4-Related Pancreatic and Biliary Diseases
Authors: Al-Dhahab Hisham , McNabb-Baltar Julia , Al-Busafi Said , Barkun Alan N
Published: March 2016

BACKGROUND: Autoimmune pancreatitis and autoimmune cholangitis are new clinical entities that are now recognized as the pancreaticobiliary manifestations of immunoglobulin (Ig) G4-related disease.

OBJECTIVE: To summarize important clinical aspects of IgG4-related pancreatic and biliary diseases, and to review the role of IgG4 in the diagnosis of autoimmune pancreatitis (AIP) and autoimmune cholangitis (AIC).

METHODS: A narrative review was performed using the PubMed database and the following keywords: “IgG4”, “IgG4 related disease”, “autoimmune pancreatitis”, “sclerosing cholangitis” and “autoimmune cholangitis”. A total of 955 articles were retrieved; of these, 381 contained relevant data regarding the IgG4 molecule, pathogenesis of IgG-related diseases, and diagnosis, management and long-term follow-up for patients with AIP and AIC. Of these 381 articles, 66 of the most pertinent were selected.

RESULTS: The selected studies demonstrated the increasing clinical importance of both AIP and AIC, which can mimic pancreatic cancer and cholangiocarcinoma, respectively. IgG4 titration in tissue or blood cannot be used alone to diagnose all IgG4-related diseases; however, it is often a useful adjunct to clinical, radiological and histological features. AIP and AIC respond to steroids; however, relapse is common and long-term maintenance treatment often required.

CONCLUSIONS: A review of the diagnosis and management of both AIC and AIP is timely and pertinent to clinical practice because the amount of information regarding these conditions has increased substantially in the past few years, resulting in significant impact on the clinical management of affected patients.
Diffuse Intrapulmonary Neuroendocrine Cell Hyperplasia
Authors: McGuire Anna L , Maziak Donna E , Sekhon Harman S
Published: March 2016

Diffuse intrapulmonary neuroendocrine cell hyperplasia is a rare, potential precursor lesion to typical pulmonary carcinoid tumours. Fewer than 50 cases have been reported in the literature. Their pathogenesis, clinical significance and management is controversial. A patient who presented with diffuse intrapulmonary neuroendocrine cell hyperplasia associated with a primary typical carcinoid tumour of the lung is reported.
Diagnostic Value of Stool Dna Testing for Multiple Markers Of Colorectal Cancer and Advanced Adenoma: A Meta-Analysis
Authors: Yang Hua , Xia Bing-Qing , Jiang Bo , Wang Guozhen , Yang Yi-Peng , Chen Hao , Li Bing-Sheng , Xu An-Gao , Huang Yun-Bo , Wang Xin-Ying
Published: March 2016

BACKGROUND AND OBJECTIVES: The diagnostic value of stool DNA (sDNA) testing for colorectal neoplasms remains controversial. To compensate for the lack of large-scale unbiased population studies, a meta-analysis was performed to evaluate the diagnostic value of sDNA testing for multiple markers of colorectal cancer (CRC) and advanced adenoma.

METHODS: The PubMed, Science Direct, Biosis Review, Cochrane Library and Embase databases were systematically searched in January 2012 without time restriction. Meta-analysis was performed using a random-effects model using sensitivity, specificity, diagnostic OR (DOR), summary ROC curves, area under the curve (AUC), and 95% CIs as effect measures. Heterogeneity was measured using the χ2test and Q statistic; subgroup analysis was also conducted.

RESULTS: A total of 20 studies comprising 5876 individuals were eligible. There was no heterogeneity for CRC, but adenoma and advanced adenoma harboured considerable heterogeneity influenced by risk classification and various detection markers. Stratification analysis according to risk classification showed that multiple markers had a high DOR for the high-risk subgroups of both CRC (sensitivity 0.759 [95% CI 0.711 to 0.804]; specificity 0.883 [95% CI 0.846 to 0.913]; AUC 0.906) and advanced adenoma (sensitivity 0.683 [95% CI 0.584 to 0.771]; specificity 0.918 [95% CI 0.866 to 0.954]; AUC 0.946) but not for the average-risk subgroups of either. In the methylation subgroup, sDNA testing had significantly higher DOR for CRC (sensitivity 0.753 [95% CI 0.685 to 0.812]; specificity 0.913 [95% CI 0.860 to 0.950]; AUC 0.918) and advanced adenoma (sensitivity 0.623 [95% CI 0.527 to 0.712]; specificity 0.926 [95% CI 0.882 to 0.958]; AUC 0.910) compared with the mutation subgroup. There was no significant heterogeneity among studies for subgroup analysis.

CONCLUSION: sDNA testing for multiple markers had strong diagnostic significance for CRC and advanced adenoma in high-risk subjects. Methylation makers had more diagnostic value than mutation markers.
Asthma Education Program for First Nations Children: An exemplar of the Knowledge‐to‐Action Framework
Authors: Douglas Maureen L , McGhan Shawna L , Tougas Danielle , Fenton Nancy , Sarin Christopher , Latycheva Oxana , Befus A Dean
Published: March 2016

BACKGROUND: The prevalence of asthma in Aboriginal children is 6% to 14%. Gaps in knowledge regarding asthma and its management exist in First Nations (FN) communities, and culturally relevant education and resources are required. Studies have recommended that the children’s asthma education program, the ‘Roaring Adventures of Puff’, be modified through partnership with FN communities to be culturally appropriate.

OBJECTIVE: To adapt this knowledge tool and design an effective implementation process for FN knowledge users (children with asthma and care providers), guided by the Canadian Institutes of Health Research knowledge translation framework.

METHODS: The problem was identified, knowledge was identified/reviewed/selected (literature review); knowledge was adapted to the local context (FN working and advisory groups); barriers to knowledge use were assessed (by knowledge users); and interventions were selected, tailored and implemented (modified curricula and the creation of a new activity book and web‐based resources, and regional coordinators, asthma educator mentors and community teams were recruited).

RESULTS: Major outcomes were the adapted tools and blueprints for tailoring implementation. Additional outcomes were preliminary observations and outputs from the iterative processes, including information about local context and barriers. Specific additions were roles for community members supported by asthma educators (applying FN teaching models and addressing health care demands); relevant triggers (addressing knowledge gaps); and FN images and stories, themes of circle, sacred teachings, nature and family/elders (culture and addressing low reading levels).

CONCLUSION: The framework model provides a logical, valuable tool for adapting a knowledge tool and implementation process to new knowledge users. Future research should measure uptake, effect on health outcomes of FN asthma sufferers and sustainability.
The Appropriateness of Surveillance Colonoscopy Intervals after Polypectomy
Authors: Schreuders Eline , Nicolaas Jerome Sint , de Jonge Vincent , van Kooten Harmke , Soo Isaac , Sadowski Daniel , Wong Clarence , van Leerdam Monique E , Kuipers Ernst J , van Zanten Sander JO Veldhuyzen
Published: March 2016

BACKGROUND: Adherence to surveillance colonoscopy guidelines is important to prevent colorectal cancer (CRC) and unnecessary workload.

OBJECTIVE: To evaluate how well Canadian gastroenterologists adhere to colonoscopy surveillance guidelines after adenoma removal or treatment for CRC.

METHODS: Patients with a history of adenomas or CRC who had surveillance performed between October 2008 and October 2010 were retrospectively included. Time intervals between index colonoscopy and surveillance were compared with the 2008 guideline recommendations of the American Gastroenterological Association and regarded as appropriate when the surveillance interval was within six months of the recommended time interval.

RESULTS: A total of 265 patients were included (52% men; mean age 58 years). Among patients with a normal index colonoscopy (n=110), 42% received surveillance on time, 38% too early (median difference = 1.2 years too early) and 20% too late (median difference = 1.0 year too late). Among patients with nonadvanced adenomas at index (n=96), 25% underwent surveillance on time, 61% too early (median difference = 1.85) and 14% too late (median difference = 1.1). Among patients with advanced neoplasia at index (n=59), 29% underwent surveillance on time, 34% too early (median difference = 1.86) and 37% later than recommended (median difference = 1.61). No significant difference in adenoma detection rates was observed when too early surveillance versus appropriate surveillance (34% versus 33%; P=0.92) and too late surveillance versus appropriate surveillance (21% versus 33%; P=0.11) were compared.

CONCLUSION: Only a minority of surveillance colonoscopies were performed according to guideline recommendations. Deviation from the guidelines did not improve the adenoma detection rate. Interventions aimed at improving adherence to surveillance guidelines are needed.
Postoperative Delirium in the Intensive Care Unit Predicts Worse Outcomes in Liver Transplant Recipients
Authors: Lescot Thomas , Karvellas Constantine J , Chaudhury Prosanto , Tchervenkov Jean , Paraskevas Steven , Barkun Jeffrey , Metrakos Peter , Goldberg Peter , Magder Sheldon
Published: March 2016

BACKGROUND: Delirium is common in intensive care unit patients and is associated with worse outcome.

OBJECTIVE: To identify early risk factors for delirium in patients admitted to the intensive care unit following orthotopic liver transplantation (OLT).

METHODS: An observational study of patients admitted to the intensive care unit from January 2000 to May 2010 for elective or semi-elective OLT was conducted. The primary end point was delirium in the intensive care unit. Pre- and post-transplantation and intraoperative factors potentially associated with this outcome were examined.

RESULTS: Of the 281 patients included in the study, 28 (10.03%) developed delirium in the intensive care unit at a median of two days (interquartile range one to seven days) after OLT. According to multivariate analysis, independent risk factors for delirium were intraoperative transfusion of packed red blood cells (OR 1.15 [95% CI 1.01 to 1.18]), renal replacement therapy during the pretransplantation period (OR 13.12 [95% CI 2.82 to 72.12]) and Acute Physiologic and Health Evaluation (APACHE) II score (OR per unit increase 1.10 [95% CI 1.03 to 1.29]). Using Cox proportional hazards models adjusted for baseline covariates, delirium was associated with an almost twofold risk of remaining in hospital, a fourfold increased risk of dying in hospital and an almost threefold increased rate of death by one year.

CONCLUSION: Intraoperative transfusion of packed red blood cells, pretransplantation renal replacement therapy and APACHE II score are predictors for the development of delirium in intensive care unit patients post-OLT and are associated with increased hospital lengths of stay and mortality.
Improving the Quality of Colonoscopy Bowel Preparation Using an Educational Video
Authors: Prakash Sateesh R , Verma Siddharth , McGowan John , Smith Betsy E , Shroff Anjali , Gibson Gregory H , Cheng Michael , Lowe Douglas , Gopal Kavitha , Mohanty Smruti R
Published: March 2016

Colonoscopy is the preferred modality for colon cancer screening. A successful colonoscopy requires proper bowel preparation. Adequate bowel preparation continues to remain a limiting factor. One hundred thirty-three patients scheduled for an outpatient colonoscopy were prospectively randomized in a single-blinded manner to video or nonvideo group. In addition to written bowel preparation instructions, patients in the video group viewed a brief instructional video. Quality of colon preparation was measured using the Ottawa Bowel Preparation Quality scale, while patient satisfaction with preparation was evaluated using a questionnaire. Statistical analyses were used to evaluate the impact of the instructional colonoscopy video. There were significant differences in the quality of colonoscopy preparation between the video and the nonvideo groups. Participants who watched the video had better preparation scores in the right colon (P = 0.0029), mid-colon (P = 0.0027), rectosigmoid (P = 0.0008), fluid content (P = 0.03) and aggregate score (median score 4 versus 5; P = 0.0002). There was no difference between the two groups with regard to patient satisfaction. Income, education level, sex, age and family history of colon cancer had no impact on quality of colonoscopy preparation or patient satisfaction. The addition of an instructional bowel preparation video significantly improved the quality of colon preparation.
Discordant Diagnosis of Malaria in a Family of Child Refugees from Sierra Leone
Authors: Yanow Stephanie K , Gregson Daniel , Chawla Rupesh
Published: March 2016

The clinical presentation and diagnosis of malaria involving a family with seven children who arrived in Canada as refugees is reported. Discrepancies in front‐line testing using microscopy and rapid diagnostic tests compared with confirmatory testing using real‐time polymerase chain reaction in this cluster of symptomatic and asymptomatic patients were identified.