bluuebunny/crossref_metadata_2025 huggingface dataset:
Intracerebral Abscess: A Complication of Severe Cystic Fibrosis Lung Disease
Authors: Fenton Mark E , Cockcroft Donald W , Gjevre John A
Published: March 2016

Intracerebral abscess is an uncommon complication of severe cystic fibrosis lung disease. The present report describes a case of fatal multiple intracerebral abscesses in a patient with a severely bronchiectatic, nonfunctioning right lung and chronic low‐grade infection. The patient was previously turned down for pneumonectomy. Intracerebral abscess in cystic fibrosis and the potential role of pneumonectomy in the present patient are discussed.
Access to Specialist Gastroenterology Care in Canada: The Practice Audit in Gastroenterology (PAGE) Wait Times Program
Authors: Armstrong David , Barkun Alan NG , Chen Ying , Daniels Sandra , Hollingworth Roger , Hunt Richard H , Leddin Desmond
Published: March 2016

BACKGROUND: Canadian wait time data are available for the treatment of cancer and heart disease, as well as for joint replacement, cataract surgery and diagnostic imaging procedures. Wait times for gastroenterology consultation and procedures have not been studied, although digestive diseases pose a greater economic burden in Canada than cancer or heart disease.

METHODS: Specialist physicians completed the practice audit if they provided digestive health care, accepted new patients and recorded referral dates. For patients seen for consultation or investigation over a one-week period, preprogrammed personal digital assistants were used to collect data including the main reason for referral, initial referral and consultation dates, procedure dates (if performed), personal and family history, and patient symptoms, signs and test results. Patient triaging, appropriateness of the referral and timeliness of care were noted.

RESULTS: Over 10 months, 199 physicians recorded details of 5559 referrals, including 1903 visits for procedures. The distribution of total wait times (from referral to procedure) nationally was highly skewed at 91/203 days (median/75th percentile), with substantial interprovincial variation: British Columbia, 66/185 days; Alberta, 134/284 days; Ontario, 110/208 days; Quebec, 71/149 days; New Brunswick, 104/234 days; and Nova Scotia, 42/84 days. The percentage of physicians by province offering average-risk screening colonoscopy varied from 29% to 100%.

DISCUSSION: Access to specialist gastroenterology care in Canada is limited by long wait times, which exceed clinically reasonable waits for specialist treatment. Although exhibiting some methodological limitations, this large practice audit sampling offers broadly generalized results, as well as a means to identify barriers to health care delivery and evaluate strategies to address these barriers, with the goals of expediting appropriate care for patients with digestive health disorders and ameliorating the personal and societal burdens imposed by digestive diseases.
S100 Calgranulin Proteins S100A8, S100A9 and S100A12 are Expressed in the Inflamed Gastric Mucosa ofHelicobacter Pylori-Infected Children
Authors: Leach Steven T , Mitchell Hazel M , Geczy Carolyn L , Sherman Philip M , Day Andrew S
Published: March 2016

The expression of the inflammatory S100 calgranulin proteins (S100A8, S100A9 and S100A12) in normal andHelicobacter pylori-infected gastric mucosa of children were examined. S100A8, S100A9 and S100A12, which were virtually absent in normal gastric mucosa, were highly expressed inH pylori-infected mucosa. This expression correlated with the severity of gastritis (r=0.9422, P<0.05). S100 calgranulins may be involved in bacterial-induced gastritis and may limit bacterial growth.
Early Experience with Unsedated Ultrathin 4.9 mm Transnasal Gastroscopy: A Pilot Study
Authors: Cheung Justin , Bailey Robert , van Zanten Sander Veldhuyzen , McLean Ross , Fedorak Richard N , Morse John , Millan Mario , Guzowski Tom , Goodman Karen J , for the CANHelp working group
Published: March 2016

BACKGROUND: Unsedated transnasal gastroscopy is a technique with unverified clinical advantages.

OBJECTIVE: To evaluate the efficacy and procedure times with transnasal gastroscopy by physicians with no previous experience in transnasal endoscopy.

METHODS: Unsedated transnasal gastroscopy using 4.9 mm ultrathin transnasal gastroscopes with randomization to two different biopsy forceps was prospectively evaluated during a single day in January 2008. The outcomes included patient tolerance (scale: 1, no discomfort; 10, severe discomfort), physician technical assessment (1, excellent; 10, very poor), gastric biopsy quality, adverse events and procedure times.

RESULTS: Twenty patients underwent transnasal gastroscopy. Nineteen patients (95%) successfully completed transnasal gastroscopy. The patient-reported mean (± SD) overall discomfort level during the procedure was 4.0±1.9 compared with a physician-estimated level of 3.2±1.7 (P=0.04). Only 10% (n=2) reported they would have preferred sedated over unsedated gastroscopy. Mean total encounter time from anesthesia to discharge was 33.5±9.3 min. The time from anesthesia to insertion was 7.0±5.3 min and from room exit to discharge 6.2±2.9 min. No patients who had gastric biopsies taken (zero of 14) had any of unacceptable quality. The only adverse event was distressing sensations (dyspnea, dizziness) in one patient that started during pre-endoscopy anesthetic application, persisting postendoscopy, but without any abnormalities in vital signs.

CONCLUSION: Assuming the adverse event was a rare reaction, early experience with unsedated ultrathin transnasal gastroscopy was an efficient, effective and well-tolerated procedure for evaluation of the upper gastrointestinal tract.
Towards Excellence in Asthma Management: Final Report of an Eight‐Year Program Aimed at Reducing Care Gaps in Asthma Management in Quebec
Authors: Boulet Louis-Philippe , Dorval Eileen , Labrecque Manon , Turgeon Michel , Montague Terrence , Thivierge Robert L
Published: March 2016

BACKGROUND AND OBJECTIVES: Asthma care in Canada and around the world persistently falls short of optimal treatment. To optimize care, a systematic approach to identifying such shortfalls or ‘care gaps’, in which all stakeholders of the health care system (including patients) are involved, was proposed.

METHODS: Several projects of a multipartner, multidisciplinary disease management program, developed to optimize asthma care in Quebec, was conducted in a period of eight years. First, two population maps were produced to identify regional variations in asthma‐related morbidity and to prioritize interventions for improving treatment. Second, current care was evaluated in a physician‐patient cohort, confirming the many care gaps in asthma management. Third, two series of peer‐reviewed outcome studies, targeting high‐risk populations and specific asthma care gaps, were conducted. Finally, a process to integrate the best interventions into the health care system and an agenda for further research on optimal asthma management were proposed.

RESULTS: Key observations from these studies included the identification of specific patterns of noncompliance in using inhaled corticosteroids, the failure of increased access to spirometry in asthma education centres to increase the number of education referrals, the transient improvement in educational abilities of nurses involved with an asthma hotline telephone service, and the beneficial effects of practice tools aimed at facilitating the assessment of asthma control and treatment needs by general practitioners.

CONCLUSIONS: Disease management programs such as Towards Excellence in Asthma Management can provide valuable information on optimal strategies for improving treatment of asthma and other chronic diseases by identifying care gaps, improving guidelines implementation and optimizing care.
Direct Costs of Occupational Asthma in Quebec between 1988 and 2002
Authors: Malo Jean-Luc , L’Archevêque Jocelyne , Ghezzo Heberto
Published: March 2016

BACKGROUND: Forty to 70 cases of occupational asthma due to sensitization to an agent present in the workplace are accepted each year by the Commission de la santé et de la sécurité du travail, the Quebec medicolegal agency.

OBJECTIVES AND METHODS: In a random sample of eight to 10 accepted claims per year from 1988 to 2002, the direct costs of compensation for loss of income (CLI) and compensation for functional impairment (CFI), as well as the associations of these costs with selected variables, were assessed.

RESULTS: Mean costs (presented as Canadian dollars ×103) of CLI, CFI and total were 72.5, 11.7 and 92.8, respectively, while the median costs were 40.7, 7.6 and 61.3 for CLI, CFI and total, respectively. Median CLI costs were significantly higher in men than women (69.9 versus 13.1), workers aged 40 years or older versus those younger than 40 years (90.1 versus 27.4), workers with occupational asthma due to workplace exposure to low versus high molecular weight agents (51.2 versus 38.6), and workers taking inhaled steroids at diagnosis (92 versus 52) and reassessment (81 versus 35). Median CFI costs were also higher in those requiring retraining (10.4) and taking early retirement (61.8) than workers who stayed with the same employer but in a different job (5.4). Median CFI costs were significantly higher for individuals being treated with inhaled steroids at the time of diagnosis (14.0 versus 5.2) and reassessment (13 versus 6), and for those left with bronchial hyperresponsiveness (9.5 versus 0.8) related to forced expiratory volume in 1 s and forced expiratory volume in 1 s/forced vital capacity.

CONCLUSION: Age, sex, nature of occupational agent, treatment with inhaled steroids and type of rehabilitation all affect CLI, whereas lung function status at baseline and reassessment is related to CFI.
Procedural Skills Education – Colonoscopy as a Model
Authors: Raman Maitreyi , Donnon Tyrone
Published: March 2016

Traditionally, surgical and procedural apprenticeship has been an assumed activity of students, without a formal educational context. With increasing barriers to patient and operating room access such as shorter work week hours for residents, and operating room and endoscopy time at a premium, alternate strategies to maximizing procedural skill development are being considered. Recently, the traditional surgical apprenticeship model has been challenged, with greater emphasis on the need for surgical and procedural skills training to be more transparent and for alternatives to patient-based training to be considered. Colonoscopy performance is a complex psychomotor skill requiring practioners to integrate multiple sensory inputs, and involves higher cortical centres for optimal performance. Colonoscopy skills involve mastery in the cognitive, technical and process domains. In the present review, we propose a model for teaching colonoscopy to the novice trainee based on educational theory.
Sarcoidosis Complicated by Cirrhosis and Hepatopulmonary Syndrome
Authors: Gupta Samir , Faughnan Marie E , Prud’homme Gerald J , Hwang David M , Munoz David G , Kopplin Peter
Published: March 2016

Sarcoidosis is a multisystem disorder commonly affecting the lungs, but also the liver, with cirrhosis and portal hypertension occurring in fewer than 1% of cases. Although hepatopulmonary syndrome (HPS) is seen in 15% to 20% of patients with cirrhosis of varying causes, it has rarely been associated with sarcoidosis. Also, although a brain abscess is not uncommon in patients with discrete pulmonary arteriovenous malformations, it is rarely seen in patients with the much smaller intrapulmonary vascular dilations that characterize HPS. A patient with an unusual series of uncommon sarcoidosis complications, including cirrhosis with HPS, brain abscess and finally Nocardia meningitis, is reported. The possibility of HPS should be considered in sarcoidosis patients with liver involvement, if gas‐exchange abnormalities are out of proportion to the degree of lung involvement. These patients may also be susceptible to a cerebral abscess by paradoxical embolization, and to opportunistic infections due to cirrhosis.
Increasing the Use of Anti‐Inflammatory Agents for Acute Asthma in the Emergency Department: Experience with an Asthma Care Map
Authors: Rowe Brian H , Chahal Anthony M , Spooner Carol H , Blitz Sandra , Senthilselvan Ambikaipakan , Wilson Deborah , Holroyd Brian R , Bullard Michael
Published: March 2016

PURPOSE: Acute asthma is a common emergency department (ED) presentation and variation in its management is well recognized. The present study examined the use of an asthma care map (ACM) in one Canadian ED to improve adherence to acute asthma guidelines, emphasizing the use of systemic corticosteroids (SCSs) and inhaled corticosteroids (ICSs).

METHODS: Three time periods were studied: the 15 months before ACM introduction (PRE), the 15 months following a three‐month introduction of the ACM (POST1) and the 18 months after POST1 (POST2). Randomly selected patient charts from each period were included from patients who were 18 to 60 years of age and presented with a primary diagnosis of acute asthma. A priori criteria were established to determine the degree of completion and success of the ACM. Primary outcomes included documentation, use of SCSs in the ED, and prescription of SCSs and ICSs at ED discharge.

RESULTS: A total of 387 patient charts were included (PRE, n=150; POST1, n=150; POST2, n=87). Patient characteristics in the three groups were similar; however, patients in POST1 and POST2 showed higher use of newer agents than those in the PRE group. Overall, more women (n=209; 54%) than men were seen; the mean age was 32.4 years. The care map was used in 67% of cases during POST1 and 70% during POST2. The use of peak expiratory flow (PEF) was high during the PRE, POST1 and POST2 periods (91%, 89% and 91%, respectively); however, documentation of other markers of severity increased in the POST periods. Use of SCSs occurred earlier (P<0.01) and more often (57% PRE, 68% POST1 and 75% POST2; P<0.01) in the POST1,2 periods than the PRE period. There was a significant increase in use of SCSs on discharge (55% PRE, 66% POST1 and 69% POST2; P<0.05), and prescription of ICSs significantly increased (24% PRE, 45% POST1 and 61% POST2; P<0.001) in the POST1,2 periods. Discharge with‐out any corticosteroids decreased over the three periods (32% PRE, 21% POST1 and 17% POST2; P<0.05). The length of stay in the ED increased over the study periods (181 min PRE, 209 min POST1 and 265 min POST2; P<0.01) and admissions were infrequent (9% PRE, 13% POST1 and 6% POST2; P=0.50).

CONCLUSIONS: The present study provides evidence that the standardized ED ACM was widely accepted, improved chart documentation, improved some aspects of ED care and increased prescribing of discharge preventive medications.
Sex Differences in Parent and Child Pain Ratings during an Experimental Child Pain Task
Authors: Moon Erin C , Chambers Christine T , Larochette Anne-Claire , Hayton Kelly , Craig Kenneth D , McGrath Patrick J
Published: March 2016

Research in the field of pediatric pain has largely ignored the role of fathers in their children’s pain experiences. The first objective of the present study was to examine the effect of the presence of mothers versus fathers on children’s subjective ratings, facial expressions and physiological responses to acute pain. The second objective was to examine whether child and parent sex influence parents’ proxy ratings of their children’s pain. The final objective was to compare levels of agreement between mothers’ and fathers’ assessments of their children’s pain. Participants included 73 children (37 boys, 36 girls), four to 12 years of age, along with 32 fathers and 41 mothers. Children undertook the cold pressor pain task while observed by one of their parents. During the task, the children’s heart rates and facial expressions were recorded. Children provided self‐reports and parents provided proxy reports of child pain intensity using the seven‐point Faces Pain Scale. Neither child nor parent sex had a significant impact on children’s subjective reports, facial expressions or heart rates in response to acute pain. Fathers gave their sons higher pain ratings than their daughters, whereas mothers’ ratings of their sons’ and daughters’ pain did not differ. Kappa statistics and t tests revealed that fathers tended to be more accurate judges of their children’s pain than mothers. Overall, this research highlights the importance of examining both parent and child sex differences in pediatric pain research.
Fever in Returning Travellers Due to a Noninfectious Disease: Two Case Reports
Authors: Miller Saul , Gabel Kevin , Lee Christine H
Published: March 2016

Each year, increasing numbers of people from developed countries travel to developing countries. It is not rare for these travellers to experience illness during or following their trips. It has been estimated that fever is present in 25% of those who seek medical attention following travel. In the majority of cases, the focus of the investigations centre around an infectious etiology, which can lead to a delay in establishing the noninfectious cause of fever. Two cases of fever, which were due to a noninfectious disease, are reported in returning travellers.
Pneumoscrotum after Colonoscopy
Authors: Singh Sandeep , Thakur Manika
Published: March 2016

Pneumoscrotum is an unusual problem that is very rarely associated with gastrointestinal endoscopy procedures. It has been reported to occur after colonoscopy and polypectomy. The present paper describes the case of an 81-year-old man with benign pneumoscrotum that formed after polypectomy at the site of a previous rectal polyp. The pneumoscrotum was managed with conservative treatment.
VSL#3 Probiotic Upregulates Intestinal Mucosal Alkaline Sphingomyelinase and Reduces Inflammation
Authors: Soo Isaac , Madsen Karen L , Tejpar Qassim , Sydora Beate C , Sherbaniuk Richard , Cinque Benedetta , Di Marzio Luisa , Cifone Maria Grazia , Desimone Claudio , Fedorak Richard N
Published: March 2016

BACKGROUND: Alkaline sphingomyelinase, an enzyme found exclusively in bile and the intestinal brush border, hydrolyzes sphingomyelin into ceramide, sphingosine and sphingosine-1-phosphate, thereby inducing epithelial apoptosis. Reduced levels of alkaline sphingomyelinase have been found in premalignant and malignant intestinal epithelia and in ulcerative colitis tissue. Probiotic bacteria can be a source of sphingomyelinase.

OBJECTIVE: To determine the effect of VSL#3 probiotic therapy on mucosal levels of alkaline sphingomyelinase, both in a mouse model of colitis and in patients with ulcerative colitis.

METHODS: Interleukin-10 gene-deficient (IL10KO) and wild type control mice were treated with VSL#3 (109colony-forming units per day) for three weeks, after which alkaline sphingomyelinase activity was measured in ileal and colonic tissue. As well, 15 patients with ulcerative colitis were treated with VSL#3 (900 billion bacteria two times per day for five weeks). Alkaline sphingomyelinase activity was measured through biopsies and comparison of ulcerative colitis disease activity index scores obtained before and after treatment.

RESULTS: Lowered alkaline sphingomyelinase levels were seen in the colon (P=0.02) and ileum (P=0.04) of IL10KO mice, as compared with controls. Treatment of these mice with VSL#3 resulted in upregulation of mucosal alkaline sphingomyelinase activity in both the colon (P=0.04) and the ileum (P=0.01). VSL#3 treatment of human patients who had ulcerative colitis decreased mean (± SEM) ulcerative colitis disease activity index scores from 5.3±1.8946 to 0.70±0.34 (P=0.02) and increased mucosal alkaline sphingomyelinase activity.

CONCLUSION: Mucosal alkaline sphingomyelinase activity is reduced in the intestine of IL10KO mice with colitis and in humans with ulcerative colitis. VSL#3 probiotic therapy upregulates mucosal alkaline sphingomyelinase activity.
Mathematical Assessment of Canada’s Pandemic Influenza Preparedness Plan
Authors: Gumel Abba B , Nuño Miriam , Chowell Gerardo
Published: March 2016

OBJECTIVE: The presence of the highly pathogenic avian H5N1 virus in wild bird populations in several regions of the world, together with recurrent cases of H5N1 influenza arising primarily from direct contact with poultry, have highlighted the urgent need for prepared‐ness and coordinated global strategies to effectively combat a potential influenza pandemic. The purpose of the present study was to evaluate the Canadian pandemic influenza preparedness plan.

PATIENTS AND METHODS: A mathematical model of the transmission dynamics of influenza was used to keep track of the population according to risk of infection (low or high) and infection status (susceptible, exposed or infectious). The model was parametrized using available Canadian demographic data. The model was then used to evaluate the key components outlined in the Canadian plan.

RESULTS: The results indicated that the number of cases, mortalities and hospitalizations estimated in the Canadian plan may have been underestimated; the use of antivirals, administered therapeutically, prophylactically or both, is the most effective single intervention followed by the use of a vaccine and basic public health measures; and the combined use of pharmaceutical interventions (antivirals and vaccine) can dramatically minimize the burden of the pending influenza pandemic in Canada. Based on increasing concerns of Oseltamivir resistance (wide‐scale implementation), coupled with the expected unavailability of a suitable vaccine during the early stages of a pandemic, the present study evaluated the potential impact of non‐pharmaceutical interventions (NPIs) which were not emphasized in the current Canadian plan. To this end, the findings suggest that the use of NPIs can drastically reduce the burden of a pandemic in Canada.

CONCLUSIONS: A deterministic model was designed and used to assess Canada’s pandemic preparedness plan. The study showed that the estimates of pandemic influenza burden given in the Canada pandemic preparedness plan may be an underestimate, and that Canada needs to adopt NPIs to complement its preparedness plan.
Pain Characteristics of Adults 65 Years of Age and Older Referred to a Tertiary Care Pain Clinic
Authors: Mailis-Gagnon Angela , Nicholson Keith , Yegneswaran Balaji , Zurowski Mateusz
Published: March 2016

BACKGROUND: Reports indicate that characteristics of older adults with chronic pain may be different than those of younger persons.

OBJECTIVE: To study the pain characteristics of older patients presenting to a tertiary pain clinic for the first time.

METHODS: Age, sex and relative contributions of biomedical versus psychosocial variables contributing to chronic pain were investigated in patients 65 years of age and older, in comparison with younger patients, from a sample of 1242 consecutive new patients attending a tertiary care pain clinic. The presence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision somatoform pain disorders were defined, using an explicated method of ascertaining the biomedical and psychological variables underlying the pain complaints.

RESULTS: The older patients (14.7% of the total sample) had relatively more physical problems (concordant with their complaints) but fewer psychological factors contributing to disability than the younger pain patients. Musculoskeletal and neuropathic disorders affected 40.7% and 35.2% of the older patients, respectively, while several patients had more than one painful disorder. Musculoskeletal problems were more prevalent in the women, and neuropathic problems were more prevalent in the men.

CONCLUSIONS: The older pain patients are a distinct group. Factors affecting the delayed presentation of older pain patients to the pain clinic and limitations of the present study are discussed.
Acute Exacerbation of Chronic Obstructive Pulmonary Disease: Influence of Social Factors in Determining Length of Hospital Stay and Readmission Rates
Authors: Wong Alyson WM , Gan Wen Q , Burns Jane , Sin Don D , van Eeden Stephan F
Published: March 2016

BACKGROUND: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is the leading reason for hospitalization in Canada and a significant financial burden on hospital resources. Identifying factors that influence the time a patient spends in the hospital and readmission rates will allow for better use of scarce hospital resources.

OBJECTIVES: To determine the factors that influence length of stay (LOS) in the hospital and readmission for patients with AECOPD in an inner‐city hospital.

METHODS: Using the Providence Health Records, a retrospective review of patients admitted to St Paul’s Hospital (Vancouver, British Columbia) during the winter of 2006 to 2007 (six months) with a diagnosis of AECOPD, was conducted. Exacerbations were classified according to Anthonisen criteria to determine the severity of exacerbation on admission. Severity of COPD was scored using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. For comparative analysis, severity of disease (GOLD criteria), age, sex and smoking history were matched.

RESULTS: Of 109 admissions reviewed, 66 were single admissions (61%) and 43 were readmissions (39%). The number of readmissions ranged from two to nine (mean of 3.3 readmissions). More than 85% of admissions had the severity of COPD equal to or greater than GOLD stage 3. The significant indicators for readmission were GOLD status (P<0.001), number of related comorbidities (OR 1.47, 95% CI 1.10 to 1.97; P<0.009) and marital status (single) (OR 4.18, 95% CI 1.03 to 17.02; P<0.046). The requirement for social work involvement during hospital admission was associated with a prolonged LOS (P<0.05).

CONCLUSIONS: The results of the present study show that disease severity (GOLD status) and number of comorbidities are associated with readmission rates of patients with AECOPD. Interestingly, social factors such as marital status and the need for social work intervention are also linked to readmission rates and LOS, respectively, in patients with AECOPD.
Gastroenterology Fellowship Training: Approaches to Curriculum Assessment and Evaluation
Authors: Raman Maitreyi , Shaffer Eldon , Lockyear Jocelyn
Published: March 2016

BACKGROUND: Medical education requires ongoing curriculum development and evaluation to incorporate new knowledge and competencies. The Kern model of curricular development is a generic model to guide curriculum design, whereas the Royal College of Physicians and Surgeons of Canada (RCPSC) has a specific model for curriculum development through its accreditation structure.

OBJECTIVE: To apply the Kern model to an assessment of a residency program in gastroenterology.

METHODS: A case study was used, which is a method of qualitative research designed to help researchers understand people and the societal contexts in which they live.

RESULTS: The six steps involved in the Kern model of curricular development include problem identification; needs assessment; establishing objectives; establishing educational strategies; implementation; and evaluation. The steps of the RCPSC model of curriculum development include establishing an administrative structure for the program; objectives; structure and organization of the program; resources; clinical, academic and scholarly content of the program; and evaluation. Two differences between the models for curriculum development include the ability of the Kern model to conduct problem identification and learner needs assessment. Identifying problems that exist suggests a need for an educational program, such as the long wait times for gastroenterology referrals. Assessing learner needs allows for the development of a tailored curriculum for the trainee.

CONCLUSIONS: The Kern model and RCPSC model for curriculum development are complementary. Consideration by the RCPSC should be provided to add the missing elements of curriculum design to the accreditation structure for completeness.
Percutaneous Endoscopic Gastrostomy in Children
Authors: El-Matary Wael
Published: March 2016

Percutaneous endoscopic gastrostomy has been a valuable tool in nutritional rehabilitation since its inception in 1980. Although it was originally described in children, a large sector of the adult population is dependant on it for nutritional support. Percutaneous endoscopic gastrostomy tube insertion is generally a safe procedure. Nevertheless, variable incidence rates of complications have been reported. The present review highlights the up-to-date indications, contraindications and complications of percutaneous endoscopic gastrostomy in children, along with a discussion of issues that need further exploring through future research.
Pneumatosis Intestinalis in a Patient with Chronic Bronchiectasis
Authors: Doumit Maya , Saloojee Nav , Seppala Richard
Published: March 2016

Pneumatosis intestinalis has been described in association with many gastrointestinal tract disorders including infection, ischemia and obstruction. It has also been described in patients with chronic obstructive pulmonary disease, connective tissue disorders, organ transplantation, leukemia and various states of immunodeficiency. In the present paper, the case of a 66-year-old woman with chronic bronchiectasis who subsequently developed pneumatosis intestinalis is described.
Helicobacter PyloriInfection in Canada’s Arctic: Searching for the Solutions
Authors: Cheung Justin , Goodman Karen , Munday Rachel , Heavner Karen , Huntington Janis , Morse John , van Zanten Sander Veldhuyzen , Fedorak Richard N , Corriveau Andre , Bailey Robert J , for the CANHelp working group
Published: March 2016

The Canadian NorthHelicobacter pylori(CANHelp) working group is a team composed of investigators, health officials and community leaders from Alberta and the Northwest Territories. The group’s initial goals are to investigate the impact ofH pyloriinfection on Canada’s Arctic communities; subsequent goals include identifying treatment strategies that are effective in this region and developing recommendations for health policy aimed at management ofH pyloriinfection. The team’s investigations have begun with the AklavikH pyloriProject in the Aboriginal community of Aklavik, Northwest Territories.
Autoimmune Hepatitis in a North American Aboriginal/First Nations Population
Authors: Minuk GY , Liu S , Kaita K , Wong S , Renner E , Rempel J , Uhanova J
Published: March 2016

North American Aboriginal populations are at increased risk for developing immune-mediated disorders, including autoimmune hepatitis. In the present study, the demographic, clinical, biochemical, serological, radiological and histological features of autoimmune hepatitis were compared in 33 First Nations (FN) and 150 predominantly Caucasian, non-FN patients referred to an urban tertiary care centre. FN patients were more often female (91% versus 71%; P=0.04), and more likely to have low serum albumin (69% versus 36%; P=0.0006) and elevated bilirubin (57% versus 35%; P=0.01) levels on presentation compared with non-FN patients. They also had lower hemoglobin, and complement levels, more cholestasis and higher serum immunoglobulin A levels than non-FN patients (P=0.05 respectively). Higher histological grades of inflammation and stages of fibrosis, and more clinical and radiological evidence of advanced liver disease were observed in FN patients, but the differences failed to reach statistical significance. The results of the present study suggest that in addition to being more common, autoimmune hepatitis may be more severe in FN populations, compared with predominantly Caucasian, non-FN populations.
Incidence and Survival for Gastric and Esophageal Cancer Diagnosed in British Columbia, 1990 to 1999
Authors: Bashash Morteza , Shah Amil , Hislop Greg , Brooks-Wilson Angela , Le Nhu , Bajdik Chris
Published: March 2016

BACKGROUND: Geographical variation and temporal trends in the incidence of esophageal and gastric cancers vary according to both tumour morphology and organ subsite. Both diseases are among the deadliest forms of cancer. The incidence and survival rates for gastric and esophageal carcinoma in British Columbia (BC) between 1990 and 1999 are described.

METHODS: Incidence data for the period 1990 to 1999 were obtained from the BC Cancer Registry. Age-adjusted incidence and survival rates were computed by anatomical subsite, histological type and sex. All rates were standardized to the 1996 Canadian population. The estimated annual percentage change (EAPC) was used to measure incidence changes over time. Kaplan-Meier curves were used to show survival rates, and log-rank tests were used to test for differences in the curves among various groups.

RESULTS: Between 1990 and 1999, 1741 esophageal cancer cases and 3431 gastric cancer cases were registered in BC. There was an increase in the incidence of adenocarcinoma of the esophagus over time (EAPC=9.6%) among men, and of gastric cardia cancer among both women (EAPC=9.2%) and men (EAPC=3.8%). Patients with proximal gastric (cardia) cancer had significantly better survival rates than patients with cancer in the lower one-third of the esophagus. Among gastric cancers, patients with distal tumours had a significantly better survival rate than patients with proximal tumours.

DISCUSSION: The incidences of proximal gastric cancer and esophageal adenocarcinoma are increasing, and their survival patterns are different. Examining these cancers together may elucidate new etiological and prognostic factors.
Comparison of Canadian versus United States Emergency Department Visits for Chronic Obstructive Pulmonary Disease Exacerbation
Authors: Rowe Brian H , Cydulka Rita K , Tsai Chu-Lin , Clark Sunday , Sinclair Douglas , Camargo Carlos A
Published: March 2016

INTRODUCTION: Despite the frequency of emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) exacerbation, little is known about practice variation in EDs.

OBJECTIVES: To examine the differences between Canadian and United States (US) COPD patients, and the ED management they receive.

METHODS: A prospective multicentre cohort study was conducted involving 29 EDs in the US and Canada. Using a standard protocol, consecutive ED patients with COPD exacerbations were interviewed, their charts reviewed and a two‐week telephone follow‐up completed. Comparisons between Canadian and US patients, as well as their treatment and outcomes, were made. Predictors of antibiotic use were determined by multivariate logistic regression.

RESULTS: Of 584 patients who had physician‐diagnosed COPD, 397 (68%) were enrolled. Of these, 63 patients (16%) were from Canada. Canadians were older (73 years versus 69 years; P=0.002), more often white (97% versus 65%; P<0.001), less educated (P=0.003) and more commonly insured (P<0.001) than the US patients. US patients more commonly used the ED for their usual COPD medications (17% versus 3%; P=0.005). Although Canadian patients had fewer pack‐years of smoking (45 pack‐years versus 53 pack‐years; P=0.001), current COPD medications and comorbidities were similar. At ED presentation, Canadian patients were more often hypoxic and symptomatic. ED treatment with inhaled beta‐agonists (approximately 90%) and systemic corticosteroids (approximately 65%) were similar; Canadians received more antibiotics (46% versus 25%; P<0.001) and other treatments (29% versus 11%; P=0.002). Admission rates were similar in both countries (approximately 65%), although Canadian patients remained in the ED longer than the US patients (10 h versus 5 h, respectively; P<0.001).

CONCLUSIONS: Overall, patients with acute COPD in Canada and the US appear to have similar history, ED treatment and outcomes; however, Canadian patients are older and receive more aggressive treatment in the ED. In both countries, the prolonged length of stay and high admission rate contribute to the ED overcrowding crisis facing EDs.
Predicting the Success of Endoscopic Transpapillary Gallbladder Drainage for Patients with Acute Cholecystitis During Pretreatment Evaluation
Authors: Ogawa Osamu , Yoshikumi Hiroki , Maruoka Naotaka , Hashimoto Yusuke , Kishimoto Yui , Tsunamasa Watanabe , Kuroki Yuichiro , Yasuda Hiroshi , Endo Yutaka , Inoue Kazuaki , Yoshiba Makoto
Published: March 2016

INTRODUCTION: Although endoscopic transpapillary gallbladder drainage (ETGBD) has been reported to be an effective treatment for acute cholecystitis, technical difficulties have precluded more widespread use of this technique. Case evaluations that can predict the occurrence of such difficulties should increase the acceptance of ETGBD for acute cholecystitis treatment.

OBJECTIVE: To establish a pretreatment evaluation protocol for patients with acute cholecystitis.

METHODS: Eleven patients with acute cholecystitis who received ETGBD in 2003 or 2004 were enrolled in the present retrospective study. The frequency of success, complications and overall effectiveness of ETGBD for treatment of cholecystitis were measured. Factors that could affect ETGBD success, including clinical and laboratory parameters, and gallbladder ultrasonograms, were also evaluated.

RESULTS: ETGBD was successful in seven of 11 patients (success rate 63.6%). All seven patients who underwent ETGBD successfully were afebrile and asymptomatic within a few days. No clinical or laboratory variables were significantly associated with the success of ETGBD. In contrast, ultrasonographic measures of gallbladder minor-axis length and wall thickness in successful cases were significantly shorter (27.4 mm versus 38.0 mm; P=0.008) and thinner (4.2 mm versus 9.0 mm; P=0.041) relative to unsuccessful cases.

CONCLUSIONS: Ultrasonographic measures of gallbladder minor-axis length and wall thickness can serve as important predictors of ETGBD technical difficulties during pretreatment evaluation of patients with acute cholecystitis.
Wait Time for Endoscopic Evaluation at a Canadian Tertiary Care Centre: Comparison with Canadian Association of Gastroenterology Targets
Authors: Yu Derek , Hopman Wilma M , Paterson William G
Published: March 2016

BACKGROUND: In recent years, there has been considerable concern regarding wait times for Canadian health care, which led the Canadian Association of Gastroenterology (CAG) to develop specific wait time targets.

OBJECTIVES: To quantify wait times for endoscopic procedures at a tertiary care centre and correlate these with clinical presentation, impact on quality of life (QOL) and final diagnosis; and to determine how well the CAG wait time targets are being met.

METHODS: Patients completed a 12-item questionnaire regarding wait times and their impact on QOL. A blind review was performed of the endoscopic results, with a specific focus on correlating wait time with a final diagnosis of serious and treatable diseases.

RESULTS: The average total wait time for the 417 participants in the present study was 229 days; 78.6% did not meet CAG wait time targets. The wait time for screening colonoscopy was longer, and the proportion of patients meeting wait time targets was significantly smaller, than for patients referred with iron deficiency anemia or a positive fecal occult blood test result. The 41 patients deemed to have a high-impact diagnosis established by endoscopy had a median wait time of 115 days, and only 23.5% met wait time targets. Overall, 38.4% of patients believed that their wait was too long, 13.9% missed school or work in the preceding month because of gastrointestinal symptoms and 23% reported being very worried about having a serious disease.

CONCLUSIONS: The majority of patients waiting for endoscopy did not meet CAG wait time targets, with the screening colonoscopy group faring the worst. Many of these patients await a definitive diagnosis of serious diseases that negatively impact QOL.
Influence of Current or Former Smoking on Asthma Management and Control
Authors: Boulet Louis-Philippe , FitzGerald J Mark , McIvor R Andrew , Zimmerman Sabrina , Chapman Kenneth R
Published: March 2016

BACKGROUND: In patients with asthma, smoking has been associated with accelerated decline in pulmonary function, poor disease control and reduced responsiveness to corticosteroids.

OBJECTIVE: To assess the influence of current and former smoking on self‐reported asthma control and health care use in a large population of asthma patients.

METHODS: The present analysis was conducted following a telephone survey of adult Canadians aged 18 to 54 years who had physician‐diagnosed asthma and a smoking history of less than 20 pack‐years.

RESULTS: Of 893 patients, 268 were former smokers and 108 were current smokers. Daytime and nighttime symptoms, absenteeism from work or school, emergency care use for asthma in the past year, and use of a short‐acting bronchodilator without controller medication were reported more frequently by current smokers than non‐smokers and former smokers. Former smokers were not significantly different from nonsmokers with respect to most asthma outcomes.

CONCLUSIONS: Current smokers with asthma show evidence of poorer asthma control and greater acute care needs than lifelong nonsmokers or former smokers. These observations stress the importance of smoking cessation to help achieve asthma control.
Evaluation of Oral Cannabinoid-Containing Medications for the Management of Interferon and Ribavirin-Induced Anorexia, Nausea and Weight Loss in Patients Treated for Chronic Hepatitis C Virus
Authors: Costiniuk Cecilia T , Mills Edward , Cooper Curtis L
Published: March 2016

OBJECTIVES: The systemic and cognitive side effects of hepatitis C virus (HCV) therapy may be incapacitating, necessitating dose reductions or abandonment of therapy. Oral cannabinoid-containing medications (OCs) ameliorate chemotherapy-induced nausea and vomiting, as well as AIDS wasting syndrome. The efficacy of OCs in managing HCV treatment-related side effects is unknown.

METHODS: All patients who initiated interferon-ribavirin therapy at The Ottawa Hospital Viral Hepatitis Clinic (Ottawa, Ontario) between August 2003 and January 2007 were identified using a computerized clinical database. The baseline characteristics of OC recipients were compared with those of nonrecipients. The treatment-related side effect response to OC was assessed by χ2analysis. The key therapeutic outcomes related to weight, interferon dose reduction and treatment outcomes were assessed by Student’sttest and χ2analysis.

RESULTS: Twenty-five of 191 patients (13%) initiated OC use. Recipients had similar characteristics to nonrecipients, aside from prior marijuana smoking history (24% versus 10%, respectively; P=0.04). The median time to OC initiation was seven weeks. The most common indications for initiation of OC were anorexia (72%) and nausea (32%). Sixty-four per cent of all patients who received OC experienced subjective improvement in symptoms. The median weight loss before OC initiation was 4.5 kg. A trend toward greater median weight loss was noted at week 4 in patients eventually initiating OC use (−1.4 kg), compared with those who did not (−1.0 kg). Weight loss stabilized one month after OC initiation (median 0.5 kg additional loss). Interferon dose reductions were rare and did not differ by OC use (8% of OC recipients versus 5% of nonrecipients). The proportions of patients completing a full course of HCV therapy and achieving a sustained virological response were greater in OC recipients.

CONCLUSIONS: The present retrospective cohort analysis found that OC use is often effective in managing HCV treatment-related symptoms that contribute to weight loss, and may stabilize weight decline once initiated.
High-Resolution Esophageal Manometry: A Time Motion Study
Authors: Sadowski Daniel C , Broenink Linda
Published: March 2016

INTRODUCTION: High-resolution manometry (HRM) of the esophagus is a new technique that provides a more precise assessment of esophageal motility than conventional techniques. Because HRM measures pressure events along the entire length of the esophagus simultaneously, clinical procedure time should be shorter because less catheter manipulation is required. According to manufacturer advertising, the new HRM system is more accurate and up to 50% faster than conventional methods.

OBJECTIVE: To test the hypothesis that clinical testing with HRM requires less procedural time than a standard water perfusion (WP) method.

METHODS: Forty-one consecutive patients were studied (20 underwent WP and 21 underwent HRM). Using time-motion analysis, the start and end times for each task associated with performing the study were recorded. Patient discomfort and study quality were also assessed by using five- and four-point qualitative scales, respectively.

RESULTS: Total procedure time was reduced on average by 25.6% in the HRM group (from 41.8 minutes with WP to 30.7 minutes with HRM, P<0.05). There was no significant difference in the discomfort scores reported by the study subjects and no difference in study quality.

CONCLUSIONS: HRM requires less time to complete than conventional manometry and should therefore shorten the wait-times of patients scheduled for esophageal manometry and have a significant impact on the cost of performing this commonly used clinical investigation.
The Stretta Procedure Versus Proton Pump Inhibitors and Laparoscopic Nissen Fundoplication in the Management of Gastroesophageal Reflux Disease: A Cost-Effectiveness Analysis
Authors: Comay Dan , Adam Viviane , da Silveira Eduardo B , Kennedy Wendy , Mayrand Serge , Barkun Alan N
Published: March 2016

BACKGROUND: The Stretta procedure is an endoscopic therapy for gastroesophageal reflux disease.

OBJECTIVE: To evaluate the cost-effectiveness of the Stretta procedure and that of competing strategies in the long-term management of gastroesophageal reflux disease.

METHODS: A Markov model was designed to estimate costs and health outcomes in Canadian patients with gastroesophageal reflux disease over five years, from a Ministry of Health perspective. Strategies included the use of daily proton pump inhibitors (PPIs), laparoscopic Nissen fundoplication (LNF) and the Stretta procedure. Probabilities and utilities were derived from the literature. Costs are expressed in 2006 Canadian dollars. Units of effectiveness were symptom-free months (SFMs) and quality-adjusted life years (QALYs), using a five-year time horizon.

RESULTS: In the analysis that used SFMs, the strategy using PPIs exhibited the lowest costs ($40 per SFM) and the greatest number of SFMs, thus dominating both the LNF and Stretta systems. But the cost-effectiveness analysis using QALYs as the measure of effectiveness showed that PPIs presented the lowest cost-effectiveness ratio, while both the LNF and Stretta strategies were associated with very high incremental costs (approximately $353,000 and $393,000, respectively) to achieve an additional QALY. However, the PPI strategy did not dominate the two other strategies, which were associated with better effectiveness.

CONCLUSIONS: If SFMs are used as the measure of effectiveness, PPIs dominate the Stretta and LNF strategies. However, if QALYs are used, the PPIs still present the lowest cost and LNF gives the best effectiveness. Regardless of the units of effectiveness or utility used in the present cost analysis, an approach of prescribing PPIs appears to be the preferred strategy.