bluuebunny/crossref_metadata_2025 huggingface dataset:
Psychometric Evaluation and Refinement of the Pain Response Preference Questionnaire
Authors: McWilliams Lachlan A , Kowal John , Sharpe Donald , Dick Bruce D
Published: March 2016

BACKGROUND: The Pain Response Preference Questionnaire (PRPQ) assesses preferences regarding pain‐related social support. The initial factor analytical study of the PRPQ produced four empirically supported scales labelled Solicitude, Management, Encouragement and Suppression. A second study produced similar findings, but suggested that the Management and Encouragement scales be combined into a single scale labelled Activity Direction.

OBJECTIVES: To use factor analytical methods to evaluate these competing configurations of the PRPQ (ie, three versus four scales) and to further refine the measure. The ability of the PRPQ scales to account for pain severity and disability ratings was also evaluated.

METHODS: Chronic pain patients (n=201) completed the PRPQ along with the Pain Catastrophizing Scale (PCS) and self‐reports of pain severity and disability.

RESULTS: Confirmatory factor analysis indicated that both models tested provided a poor fit to the data. A follow‐up exploratory factor analysis was used to further refine the PRPQ scales and resulted in scales labelled Solicitude, Encouragement and Suppression. Supportive of the potential clinical utility of the PRPQ, Suppression was positively associated with pain severity and Solicitude was positively associated with disability. These two scales were also positively associated with the PCS. Supportive of the incremental validity of the PRPQ, a multiple regression analysis indicated that the Solicitude scale accounted for unique variance in disability ratings beyond that accounted for by demographic/clinical variables and the PCS.

CONCLUSIONS: The PRPQ has promise as a clinical assessment measure and for advancing research examining the interpersonal context of pain.
Institutional Care for Long‐Term Mechanical Ventilation in Canada: A National Survey
Authors: Rose Louise , McKim Douglas , Katz Sherri , Leasa David , Nonoyama Mika , Pedersen Cheryl , Avendano Monica , Goldstein Roger
Published: March 2016

INTRODUCTION: No national Canadian data define resource requirements and care delivery for ventilator‐assisted individuals (VAIs) requiring long‐term institutional care. Such data will assist in planning health care services to this population.

OBJECTIVE: To describe institutional and patient characteristics, prevalence, equipment used, care elements and admission barriers for VAIs requiring long‐term institutional care.

METHODS: Centres were identified from a national inventory and snowball referrals. The survey weblink was provided from December 2012 to April 2013. Weekly reminders were sent for six weeks.

RESULTS: The response rate was 84% (54 of 64), with 44 adult and 10 pediatric centres providing data for 428 VAIs (301 invasive ventilation; 127 noninvasive ventilation [NIV]), equivalent to 1.3 VAIs per 100,000 population. An additional 106 VAIs were on wait lists in 18 centres. More VAIs with progressive neuromuscular disease received invasive ventilation than NIV (P<0.001); more VAIs with chronic obstructive pulmonary disease (P<0.001), obesity hypoventilation syndrome (P<0.001) and central hypoventilation syndrome (P=0.02) required NIV. All centres used positive pressure ventilators, 21% diaphragmatic pacing, 15% negative pressure and 13% phrenic nerve stimulation. Most centres used lung volume recruitment (55%), manually (71%) and mechanically assisted cough (55%). Lack of beds and provincial funding were common admission barriers.

CONCLUSIONS: Variable models and care practices exist for institutionalized care of Canadian VAIs. Patient prevalence was 1.3 per 100,000 Canadians.
Making an Accurate Diagnosis of Chronic Hypersensitivity Pneumonitis
Authors: Johannson Kerri A , Ryerson Christopher J
Published: March 2016

Chronic hypersensitivity pneumonitis (HP) arises from repeated exposure to causative antigens. Although HP can be challenging to diagnose, it is important to differentiate from idiopathic pulmonary fibrosis and idiopathic non‐specific interstitial pneumonia. HP has a unique management approach and portends a unique prognosis. The present article summarizes the recent published literature on chronic HP and highlights the features that may be helpful in distinguishing it from other chronic interstitial lung diseases.
What to Do with All of These Lung Nodules?
Authors: Rozenberg Dmitry , Shapera Shane
Published: March 2016

Caplan syndrome is a rare entity that is specific to rheumatoid arthritis and presents with multiple, well‐defined necrotic nodules in patients with occupational dust exposure. The present report describes a case of Caplan syndrome involving a 71‐year‐old man with a known diagnosis of seropositive rheumatoid arthritis who presented to the authors’ centre with a five‐year history of multiple, bilateral cavitary lung nodules with mild dyspnea on exertion. He was an ex‐smoker (30 pack‐years) and had previously worked with silica. The case highlights the clinical, radiological and pathological features of this syndrome and outlines the importance of considering a broad differential in the management of pulmonary nodules, especially in patients with rheumatoid arthritis.
Exploring Anthropometric and Laboratory Differences in Children of Varying Ethnicities with Celiac Disease
Authors: Rajani Seema , Alzaben Abeer , Shirton Leanne , Persad Rabindranath , Huynh Hien Q , Mager Diana R , Turner Justine M
Published: March 2016

BACKGROUND: Celiac disease (CD) is a common autoimmune disorder with an increasing prevalence, including in ethnic minorities.

OBJECTIVE: To report the frequency of CD diagnosis in ethnic minorities presenting to a Canadian pediatric celiac clinic and to determine whether ethnic differences exist at diagnosis or follow-up.

METHODS: Patients with biopsy-proven CD diagnosed at a multidisciplinary celiac clinic between 2008 and 2011 were identified through the clinic database. Data at referral, and six-month and 12-month follow-ups were collected. These included demographics, self-reported ethnicity, symptoms, anthropometrics and laboratory investigations, including serum immunoglobulin antitissue transglutaminase (aTTG).

RESULTS: A total of 272 patients were identified; 80% (n=218) were Caucasian (group 1) and 20% (n=54) were other ethnicities. South Asians (group 2) comprised 81% (n=44) of the minority population. No differences in age or sex were found between the two groups. Group 1 patients presented more often with gastrointestinal symptoms (71% versus 43%; P<0.001), while patients in group 2 presented more often with growth concerns (21% versus 68%; P<0.001). At diagnosis, serum aTTG level was consistently lower in group 1 compared with group 2 (367 IU/mL versus 834 IU/mL; P=0.030). Both groups reported symptom improvement at six months and one year. At the end of one year, aTTG level was more likely to be normal in group 1 compared with group 2 (64% versus 29%; P<0.001).

CONCLUSION: Although they represent a minority group, South Asian children comprised a significant proportion of CD patients presenting to a Canadian celiac clinic. South Asian children were more likely to present with growth concerns, which has important implications for timely diagnosis in this population. In addition, the apparent delay in normalization of aTTG levels suggests that careful follow-up and culturally focused education supports should be developed for South Asian children with CD.
Overview of Four Prescription Monitoring/Review Programs in Canada
Authors: Furlan Andrea D , MacDougall Peter , Pellerin Denise , Shaw Karen , Spitzig Doug , Wilson Galt , Wright Janet
Published: March 2016

BACKGROUND: Prescription monitoring or review programs collect information about prescription and dispensing of controlled substances for the purposes of monitoring, analysis and education. In Canada, it is the responsibility of the provincial institutions to organize, maintain and run such programs.

OBJECTIVE: To describe the characteristics of four provincial programs that have been in place for >6 years.

METHODS: The managers of the prescription monitoring/review programs of four provinces (British Columbia, Alberta, Saskatchewan and Nova Scotia) were invited to present at a symposium at the Canadian Pain Society in May 2012. In preparation for the symposium, one author collected and summarized the information.

RESULTS: Three provinces have a mix of review and monitoring programs; the program in British Columbia is purely for review and education. All programs include controlled substances (narcotics, barbiturates and psychostimulants); however, other substances are differentially included among the programs: anabolic steroids are included in Saskatchewan and Nova Scotia; and cannabinoids are included in British Columbia and Nova Scotia. Access to the database is available to pharmacists in all provinces. Physicians need consent from patients in British Columbia, and only professionals registered with the program can access the database in Alberta. The definition of inappropriate prescribing and dispensing is not uniform. Double doctoring, double pharmacy and high‐volume dispensing are considered to be red flags in all programs.

CONCLUSIONS: There is variability among Canadian provinces in managing prescription monitoring/review programs.
Physicians’ Practices for Diagnosing Liver Fibrosis in Chronic Liver Diseases: A Nationwide, Canadian Survey
Authors: Sebastiani Giada , Ghali Peter , Wong Philip , Klein Marina B , Deschenes Marc , Myers Robert P
Published: March 2016

OBJECTIVE: To determine practices among physicians in Canada for the assessment of liver fibrosis in patients with chronic liver diseases.

METHODS: Hepatologists, gastroenterologists, infectious diseases specialists, members of the Canadian Gastroenterology Association and/or the Canadian HIV Trials Network who manage patients with liver diseases were invited to participate in a web-based, national survey.

RESULTS: Of the 237 physicians invited, 104 (43.9%) completed the survey. Routine assessment of liver fibrosis was requested by the surveyed physicians mostly for chronic hepatitis C (76.5%), followed by autoimmune/cholestatic liver disease (59.6%) and chronic hepatitis B (52.9%). Liver biopsy was the main diagnostic tool for 46.2% of the respondents, Fibroscan (Echosens, France) for 39.4% and Fibrotest (LabCorp, USA) for 7.7%. Etiology-specific differences were observed: noninvasive methods were mostly used for hepatitis C (63% versus 37% liver biopsy) and hepatitis B (62.9% versus 37.1% liver biopsy). For 42.7% of respondents, the use of noninvasive methods reduced the need for liver biopsy by >50%. Physicians’ characteristics associated with higher use of noninvasive methods were older age and being based at a university hospital or in private practice versus community hospital. Physicians’ main concerns regarding noninvasive fibrosis assessment methods were access/availability (42.3%), lack of guidelines for clinical use (26.9%) and cost/lack of reimbursement (14.4%).

CONCLUSIONS: Physicians who manage patients with chronic liver diseases in Canada require routine assessment of liver fibrosis stage. Although biopsy remains the primary diagnostic tool for almost one-half of respondents, noninvasive methods, particularly Fibroscan, have significantly reduced the need for liver biopsy in Canada. Limitations in access to and availability of the noninvasive methods represent a significant barrier. Finally, there is a need for clinical guidelines and a better reimbursement policy to implement noninvasive tools to assess liver fibrosis.
Canadian Association of Gastroenterology Policy on the Application for, and Implementation of, Clinical Practice Guidelines
Authors: Singh Harminder , Leontiadis Grigorios I , Hookey Lawrence , Enns Robert , Bistritz Lana , Rioux Louis-Charles , Hope Louise , Sinclair Paul
Published: March 2016

An important mandate of the Canadian Association of Gastroenterology (CAG), as documented in the Association’s governance policies, is to optimize the care of patients with digestive disorders. Clinical practice guidelines are one means of achieving this goal. The benefits of timely, high-quality and evidenced-based recommendations include:

Enhancing the professional development of clinical members through education and dissemination of synthesized clinical research;

Improving patient care provided by members by providing focus on quality and evidence;

Creating legislative environments that favour effective clinical practice;

Enhancing the clinical care provided to patients with digestive disease by nongastroenterologists; and

Identifying areas that require further information or research to improve clinical care.

The present document provides the foundation required to ensure that clinical practice guidelines produced by the CAG are necessary, appropriate, credible and applicable. These recommendations should be adhered to as closely as possible to obtain CAG endorsement.
PredictingC282YHomozygote Genotype for Hemochromatosis Using Serum Ferritin and Transferrin Saturation Values from 44,809 Participants of the HEIRS Study
Authors: Lim Andrew , Speechley Mark , Adams Paul C
Published: March 2016

INTRODUCTION: The simultaneous interpretation of serum ferritin level and transferrin saturation has been used as a clinical guide to diagnose genetic hemochromatosis. The Hemochromatosis and Iron Overload Screening (HEIRS) Study screened 101,168 North American participants for serum ferritin level and transferrin saturation, andC282Ygenotyping for theHFEgene.

METHODS: Logistic regression involving a subsample of Caucasians (n=44,809) was used to predict individual probabilities ofHFE C282Yhomozygosity using serum ferritin and transferrin saturation values. Men (n=17,323) and women (n=27,486) were analyzed separately. Regression equations were evaluated using area under the curve from ROC analysis and variance explained by Nagelkerke’s pseudo R-squared. An Android smartphone App and website application were developed to provide physicians with easy access to predictingC282Yhomozygosity of theHFEgene.

RESULTS: The logistic equation had an area under the ROC curve of 0.91 for men and 0.89 for women. The pseudo R-squared was 0.44 for men and 0.34 for women. An example analysis was a Caucasian man with a transferrin saturation of 50% and a ferritin level of 500 µg/L, who had a 1.3% (95% CI 1.1% to 8.8%) probability of being aC282Yhomozygote.

CONCLUSIONS: A large primary care-based sample of 44,809 participants contributed to the development of a new computer/smartphone tool that predicts the probability of being aC282Yhomozygote of theHFEgene from serum ferritin and transferrin saturation values.
The 3rd Canadian Symposium on Hepatitis C Virus: Expanding Care in the Interferon-Free Era
Authors: MacParland Sonya A , Bilodeau Marc , Grebely Jason , Bruneau Julie , Cooper Curtis , Klein Marina , Sagan Selena M , Choucha Norma , Balfour Louise , Bialystok Frank , Krajden Mel , Raven Jennifer , Roberts Eve , Russell Rodney , Houghton Michael , Tyrrell D Lorne , Feld Jordan J
Published: March 2016

Hepatitis C virus (HCV) currently infects approximately 250,000 individuals in Canada and causes more years of life lost than any other infectious disease in the country. In August 2011, new therapies were approved by Health Canada that have achieved higher response rates among those treated, but are poorly tolerated. By 2014/2015, short-course, well-tolerated treatments with cure rates >95% will be available. However, treatment uptake is poor due to structural, financial, geographical, cultural and social barriers. As such, ‘Barriers to access to HCV care in Canada’ is a crucial topic that must be addressed to decrease HCV disease burden and potentially eliminate HCV in Canada. Understanding how to better care for HCV-infected individuals requires integration across multiple disciplines including researchers, clinical services and policy makers to address the major populations affected by HCV including people who inject drugs, baby boomers, immigrants and Aboriginal and/or First Nations people. In 2012, the National CIHR Research Training Program in Hepatitis C organized the 1st Canadian Symposium on Hepatitis C Virus (CSHCV) in Montreal, Quebec. The 2nd CSHCV was held in 2013 in Victoria, British Columbia. Both symposia were highly successful, attracting leading international faculty with excellent attendance leading to dialogue and knowledge translation among attendees of diverse backgrounds. The current article summarizes the 3rd CSHCV, held February 2014, in Toronto, Ontario.
Geographical Variation and Factors Associated with Colorectal Cancer Mortality in a Universal Health Care System
Authors: Torabi Mahmoud , Green Christopher , Nugent Zoann , Mahmud Salaheddin M , Demers Alain A , Griffith Jane , Singh Harminder
Published: March 2016

OBJECTIVE: To investigate the geographical variation and small geographical area level factors associated with colorectal cancer (CRC) mortality.

METHODS: Information regarding CRC mortality was obtained from the population-based Manitoba Cancer Registry, population counts were obtained from Manitoba’s universal health care plan Registry and characteristics of the area of residence were obtained from the 2001 Canadian census. Bayesian spatial Poisson mixed models were used to evaluate the geographical variation of CRC mortality and Poisson regression models for determining associations with CRC mortality. Time trends of CRC mortality according to income group were plotted using joinpoint regression.

RESULTS: The southeast (mortality rate ratio [MRR] 1.31 [95% CI 1.12 to 1.54) and southcentral (MRR 1.62 [95% CI 1.35 to 1.92]) regions of Manitoba had higher CRC mortality rates than suburban Winnipeg (Manitoba’s capital city). Between 1985 and 1996, CRC mortality did not vary according to household income; however, between 1997 and 2009, individuals residing in the highest-income areas were less likely to die from CRC (MRR 0.77 [95% CI 0.65 to 0.89]). Divergence in CRC mortality among individuals residing in different income areas increased over time, with rising CRC mortality observed in the lowest income areas and declining CRC mortality observed in the higher income areas.

CONCLUSIONS: Individuals residing in lower income neighbourhoods experienced rising CRC mortality despite residing in a jurisdiction with universal health care and should receive increased efforts to reduce CRC mortality. These findings should be of particular interest to the provincial CRC screening programs, which may be able to reduce the disparities in CRC mortality by reducing the disparities in CRC screening participation.
Personalized Genetic Testing and Norovirus Susceptibility
Authors: Prystajecky Natalie , Brinkman Fiona SL , Auk Brian , Isaac-Renton Judith L , Tang Patrick
Published: March 2016

BACKGROUND: The availability of direct‐to‐consumer personalized genetic testing has enabled the public to access and interpret their own genetic information. Various genetic traits can be determined including resistance to norovirus through a nonsense mutation (G428A) in the FUT2 gene. Although this trait is believed to confer resistance to the most dominant norovirus genotype (GII.4), the spectrum of resistance to other norovirus strains is unknown. The present report describes a cluster of symptomatic norovirus GI.6 infection in a family identified to have norovirus resistance through personalized genetic testing.

CASE PRESENTATION: In January 2013, four members of a family determined by a direct‐to‐consumer genetic test to be homozygous for the norovirus resistance trait (A/A genotype for single nucleotide polymorphism rs601338) developed symptoms consistent with acute viral gastroenteritis. Stool and vomitus samples were submitted for enteric viral pathogen testing. Samples were positive for norovirus GI.6 in three of the four cases.

CONCLUSIONS: The present report is the first to describe norovirus GI.6 infection in patients with the G428A nonsense mutation in FUT2; this cluster of cases suggests that the G428A mutation in FUT2 may not confer resistance to norovirus GI.6. Direct‐to‐consumer genetic testing is empowering members of the public to identify novel associations with their genetic traits. Expert consultation is important for the interpretation of personalized genetic test results, and follow‐up laboratory testing can confirm any potentially novel associations.
Outcomes of Pediatric Laparoscopic Fundoplication: A Critical Review of the Literature
Authors: Martin Kathryn , Deshaies Catherine , Emil Sherif
Published: March 2016

BACKGROUND/OBJECTIVE: Laparoscopic fundoplication for gastroesophageal reflux disease (GERD) is one of the most common procedures performed in children. A critical literature review was performed to evaluate the level and quality of evidence supporting the efficacy of this procedure.

METHODS: Systematic reviews of the EMBASE, PubMed and CENTRAL databases were conducted to retrieve all articles published over a 15-year period (1996 to 2010) reporting medium- to long-term outcomes (minimum six months follow-up) of laparoscopic fundoplication for the treatment of pediatric GERD. Articles were critically appraised using the Newcastle-Ottawa quality assessment scale and the Cochrane risk of bias assessment tool. Extracted outcomes included GERD recurrence, need for reoperation, postoperative morbidity and mortality.

RESULTS: A total of 5302 articles were retrieved. Thirty-six studies met inclusion and exclusion criteria, including five prospective (level 2b), four retrospective comparative (level 3b) and 27 case series (level 4). No studies compared laparoscopic fundoplication with medical treatment. Thirty-six per cent of studies did not describe the symptoms used to suspect GERD; 11% did not disclose the diagnostic modalities used; and 41% did not report the findings of diagnostic modalities. Only 17% of studies provided a definition of recurrence, and only 14% attempted to control for confounding variables. The follow-up intervals were inconsistently reported, ranging between two months and nine years. Significant heterogeneity among studies limited the ability to pool outcomes. Mean (± SD) recurrence rates varied between 0% and 48±19.6% of patients. Reoperation was required in 0.69±0.95% to 17.7±8.4% of patients. Mortality ranged between 0% and 24±16.7%.

CONCLUSION: The level and quality of the evidence supporting laparoscopic fundoplication are extremely poor. Higher-quality data are required before the procedure can be considered to be an effective intervention in the treatment of pediatric GERD.
Similarities and Differences Between Asthma Health Care Professional and Patient Views Regarding Medication Adherence
Authors: Peláez Sandra , Bacon Simon L , Aulls Mark W , Lacoste Guillaume , Lavoie Kim L
Published: March 2016

BACKGROUND: The recent literature has reported disparate views between patients and health care professionals regarding the roles of various factors affecting medication adherence.

OBJECTIVE: To examine the perspectives of asthma patients, physicians and allied health professionals regarding adherence to asthma medication.

METHODOLOGY: A qualitative, multiple, collective case study design with six focus‐group interviews including 38 participants (13 asthma patients, 13 pulmonologist physicians and 12 allied health professionals involved in treating asthma patients) was conducted.

RESULTS: Patients, physicians and allied health professionals understood adherence to be an active process. In addition, all participants believed they had a role in treatment adherence, and agreed that the cost of medication was high and that access to the health care system was restricted. Major disagreements regarding patient‐related barriers to medication adherence were identified among the groups. For example, all groups referred to side effects; however, while patients expressed their legitimate concerns, health care professionals believed that patients’ opinions of medication side effects were based on inadequate perceptions.

CONCLUSION: Differences regarding medication adherence and barriers to adherence among the groups examined in the present study will provide insight into how disagreements may be translated to overcome barriers to optimal asthma adherence. Furthermore, when designing an intervention to enhance medication adherence, it is important to acknowledge that perceptual gaps exist and must be addressed.
Rates of Minor Adverse Events and Health Resource Utilization Postcolonoscopy
Authors: Azalgara Vladimir Marquez , Sewitch Maida J , Joseph Lawrence , Barkun Alan N
Published: March 2016

BACKGROUND: Little is known about minor adverse events (MAEs) following outpatient colonoscopies and associated health care resource utilization.

OBJECTIVE: To estimate the rates of incident MAE at two, 14 and 30 days postcolonoscopy, and associated health care resource utilization. A secondary aim was to identify factors associated with cumulative 30-day MAE incidence.

METHODS: A longitudinal cohort study was conducted among individuals undergoing an outpatient colonoscopy at the Montreal General Hospital (Montreal, Quebec). Before colonoscopy, consecutive individuals were enrolled and interviewed to obtain data regarding age, sex, comorbidities, use of antiplatelets/anticoagulants and previous symptoms. Endoscopy reports were reviewed for intracolonoscopy procedures (biopsy, polypectomy). Telephone or Internet follow-up was used to obtain data regarding MAEs (abdominal pain, bloating, diarrhea, constipation, nausea, vomiting, blood in the stools, rectal or anal pain, headaches, other) and health resource use (visits to emergency department, primary care doctor, gastroenterologist; consults with nurse, pharmacist or telephone hotline). Rates of incident MAEs and health resources utilization were estimated using Bayesian hierarchical modelling to account for patient clustering within physician practices.

RESULTS: Of the 705 individuals approached, 420 (59.6%) were enrolled. Incident MAE rates at the two-, 14- and 30-day follow-ups were 17.3% (95% credible interval [CrI] 8.1% to 30%), 10.5% (95% CrI 2.9% to 23.7%) and 3.2% (95% CrI 0.01% to 19.8%), respectively. The 30-day rate of health resources utilization was 1.7%, with 0.95% of participants seeking the services of a physician. No predictors of the cumulative 30-day incidence of MAEs were identified.

DISCUSSION: The incidence of MAEs was highest in the 48 h following colonoscopy and uncommon after two weeks, supporting the Canadian Association of Gastroenterology’s recommendation for assessment of late complications at 14 days. Predictors of new onset of MAEs were not identified, but wide CrIs did not rule out possible associations. Although <1% of participants reported consulting a physician for MAEs, this figure may represent a substantial number of visits given the increasing number of colonoscopies performed annually.

CONCLUSION: Postcolonoscopy MAEs are common, occur mainly in the first two weeks postcolonoscopy and result in little use of health resources.
Pharmacological Management of Chronic Neuropathic Pain: Revised Consensus Statement from the Canadian Pain Society
Authors: Moulin DE , Boulanger A , Clark AJ , Clarke H , Dao T , Finley GA , Furlan A , Gilron I , Gordon A , Morley-Forster PK , Sessle BJ , Squire P , Stinson J , Taenzer P , Velly A , Ware MA , Weinberg EL , Williamson OD
Published: March 2016

BACKGROUND: Neuropathic pain (NeP), redefined as pain caused by a lesion or a disease of the somatosensory system, is a disabling condition that affects approximately two million Canadians.

OBJECTIVE: To review the randomized controlled trials (RCTs) and systematic reviews related to the pharmacological management of NeP to develop a revised evidence‐based consensus statement on its management.

METHODS: RCTs, systematic reviews and existing guidelines on the pharmacological management of NeP were evaluated at a consensus meeting in May 2012 and updated until September 2013. Medications were recommended in the consensus statement if their analgesic efficacy was supported by at least one methodologically sound RCT (class I or class II) showing significant benefit relative to placebo or another relevant control group. Recommendations for treatment were based on the degree of evidence of analgesic efficacy, safety and ease of use.

RESULTS: Analgesic agents recommended for first‐line treatments are gabapentinoids (gabapentin and pregabalin), tricyclic antidepressants and serotonin noradrenaline reuptake inhibitors. Tramadol and controlled‐release opioid analgesics are recommended as second‐line treatments for moderate to severe pain. Cannabinoids are now recommended as third‐line treatments. Recommended fourth‐line treatments include methadone, anticonvulsants with lesser evidence of efficacy (eg, lamotrigine, lacos‐amide), tapentadol and botulinum toxin. There is support for some analgesic combinations in selected NeP conditions.

CONCLUSIONS: These guidelines provide an updated, stepwise approach to the pharmacological management of NeP. Treatment should be individualized for each patient based on efficacy, side‐effect profile and drug accessibility, including cost. Additional studies are required to examine head‐to‐head comparisons among analgesics, combinations of analgesics, long‐term outcomes and treatment of pediatric, geriatric and central NeP.
Safety and Efficacy of Hemospray®in Upper Gastrointestinal Bleeding
Authors: Yau Alan Hoi Lun , Ou George , Galorport Cherry , Amar Jack , Bressler Brian , Donnellan Fergal , Ko Hin Hin , Lam Eric , Enns Robert Allan
Published: March 2016

BACKGROUND: Hemospray (Cook Medical, USA) has recently been approved in Canada for the management of nonvariceal upper gastrointestional bleeding (UGIB).

OBJECTIVE: To review the authors’ experience with the safety and efficacy of Hemospray for treating UGIB.

METHODS: A retrospective chart review was performed on patients who required endoscopic evaluation for suspected UGIB and were treated with Hemospray.

RESULTS: From February 2012 to July 2013, 19 patients (mean age 67.6 years) with UGIB were treated with Hemospray. A bleeding lesion was identified in the esophagus in one (5.3%) patient, the stomach in five (26.3%) and duodenum in 13 (68.4%). Bleeding was secondary to peptic ulcers in 12 (63.2%) patients, Dieulafoy lesions in two (10.5%), mucosal erosion in one (5.3%), angiodysplastic lesions in one (5.3%), ampullectomy in one (5.3%), polypectomy in one (5.3%) and an unidentified lesion in one (5.3%). The lesions showed spurting hemorrhage in four (21.1%) patients, oozing hemorrhage in 11 (57.9%) and no active bleeding in four (21.1%). Hemospray was administered as monotherapy in two (10.5%) patients, first-line modality in one (5.3%) and rescue modality in 16 (84.2%). Hemospray was applied prophylactically to nonbleeding lesions in four (21.1%) patients and therapeutically to bleeding lesions in 15 (78.9%). Acute hemostasis was achieved in 14 of 15 (93.3%) patients. Rebleeding within seven days occurred in seven of 18 (38.9%) patients. Potential adverse events occurred in two (10.5%) patients and included visceral perforation and splenic infarct. Mortality occurred in five (26.3%) patients but the cause of death was unrelated to gastrointestinal bleeding with the exception of one patient who developed hemoperitoneum.

CONCLUSIONS: The high rates of both acute hemostasis and recurrent bleeding suggest that Hemospray may be used in high-risk cases as a temporary measure or a bridge toward more definitive therapy.
Knowledge, Attitudes and Beliefs about Chronic Noncancer Pain in Primary Care: a Canadian Survey of Physicians and Pharmacists
Authors: Lalonde Lyne , Leroux-Lapointe Vincent , Choinière Manon , Martin Elisabeth , Lussier David , Berbiche Djamal , Lamarre Diane , Thiffault Robert , Jouini Ghaya , Perreault Sylvie
Published: March 2016

BACKGROUND: Primary care providers’ knowledge, attitudes and beliefs (KAB) regarding chronic noncancer pain (CNCP) are a barrier to optimal management.

OBJECTIVES: To evaluate and identify the determinants of the KAB of primary care physicians and pharmacists, and to document clinician preferences regarding the content and format of a continuing education program (CEP).

METHOD: Physicians and pharmacists of 486 CNCP patients participated. Physicians completed the original version of the KnowPain‐50 questionnaire. Pharmacists completed a modified version. A multivariate linear regression model was developed to identify the determinants of their KAB.

RESULTS: A total of 137 of 387 (35.4%) physicians and 110 of 278 (39.5%) pharmacists completed the survey. Compared with the physicians, the pharmacists surveyed included more women (64% versus 38%) and had less clinical experience (15 years versus 26 years). The mean KnowPain‐50 score was 69.3% (95% CI 68.0% to 70.5%) for physicians and 63.8% (95% CI 62.5% to 65.1%) for pharmacists. Low scores were observed on all aspects of pain management: initial assessment (physicians, 68.3%; pharmacists, 65.4%); definition of treatment goals and expectations (76.1%; 61.6%); development of a treatment plan (66.4%; 59.0%); and reassessment and management of longitudinal care (64.3%; 53.1%). Ten hours of reported CEP sessions increased the KAB score by 0.3 points. All clinicians considered a CEP for CNCP to be essential. Physicians preferred an interactive format, while pharmacists had no clear preferences.

CONCLUSION: A CEP to improve primary care providers’ knowledge and competency in managing CNCP, and to reduce false beliefs and inappropriate attitudes regarding CNCP is relevant and perceived as necessary by clinicians.
Evaluation of Amplification Targets for the Specific Detection of Bordetella pertussis Using Real‐Time Polymerase Chain Reaction
Authors: Hasan Mohammad Rubayet , Tan Rusung , Al-Rawahi Ghada N , Thomas Eva , Tilley Peter
Published: March 2016

BACKGROUND:
Bordetella pertussis infections continue to be a major public health challenge in Canada. Polymerase chain reaction (PCR) assays to detect B pertussis are typically based on the multicopy insertion sequence IS481, which offers high sensitivity but lacks species specificity.

METHODS: A novel B pertussis real‐time PCR assay based on the porin gene was tested in parallel with several previously published assays that target genes such as IS481, ptx‐promoter, pertactin and a putative thialase. The assays were evaluated using a reference panel of common respiratory bacteria including different Bordetella species and 107 clinical nasopharyngeal specimens. Discrepant results were confirmed by sequencing the PCR products.

RESULTS: Analytical sensitivity was highest for the assay targeting the IS481 element; however, the assay lacked specificity for B pertussis in the reference panel and in the clinical samples. False‐positive results were also observed with assays targeting the ptx‐promoter and pertactin genes. A PCR assay based on the thialase gene was highly specific but failed to detect all reference strains of B pertussis. However, a novel assay targeting the porin gene demonstrated high specificity for B pertussis both in the reference panel and in clinical samples and, based on sequence‐confirmed results, correctly predicted all B pertussis‐positive cases in clinical samples. According to Probit regression analysis, the 95% detection limit of the new assay was 4 colony forming units/reaction.

CONCLUSION: A novel porin assay for B pertussis demonstrated superior performance and may be useful for improved molecular detection of B pertussis in clinical specimens.
Poor ‘Real-Life’ Negative Predictive Value of Cross-Sectional Imaging in Obstructive Jaundice
Authors: Brunson Brian A , Hawes Robert , Hoffman Brenda , Vela Stacie , Romagnuolo Joseph
Published: March 2016

BACKGROUND: Cross-sectional imaging remains the first-line test for obstructive jaundice despite high miss rates for pancreatobiliary tumours. Improvements in resolution and slice thickness of spiral computed tomography/magnetic resonance imaging/magnetic resonance cholangiopancreatography promised to increase accuracy.

OBJECTIVE: To assess whether the post-test probability of neoplasm is truly altered by the presence or absence of a mass on computed tomography/magnetic resonance imaging in obstructive jaundice.

METHODS: The institutional endoscopic ultrasound (EUS) database was retrospectively reviewed to stratify patients presenting to EUS over a two-year period for obstructive jaundice (suspicious for malignancy) according to their pre-EUS imaging results. The primary analysis involved the calculation of the positive predictive value and negative predictive value (NPV) of imaging with 95% binomial CIs. Test performance of EUS/fine-needle aspiration (FNA) was also calculated. Final diagnosis was determined by positive cytology/histology; negative EUS was supplemented by clinical follow-up.

RESULTS: The positive predictive value (n=51) and NPV (n=53) of pre-EUS imaging was 98% (95% CI 90% to 100%) and 9% (95% CI 3% to 21%), respectively (accuracy 53%), with post-test suspicion of malignancy similar between imaging-positive and -negative groups. EUS demonstrated a mass in 96% of imaging-positive cases versus 85% in imaging-negative cases (exact P=0.09). Malignant or suspicious FNA cytology was obtained with EUS in 92% of the imaging-positive group, and 62% of the imaging-negative group (75% of subgroup with FNA) (P<0.001).

CONCLUSION: Lack of a definite mass on pre-EUS imaging had low NPV, and was clearly not sufficiently accurate or reassuring in this clinical setting. In suspicious obstructive jaundice, EUS with FNA has a high diagnostic yield regardless of the findings of pre-EUS cross-sectional imaging and, as such, EUS may be a more reasonable first-line test in this high-suspicion setting.
Bacteremia Caused by Eggerthella lenta in an Elderly Man with a Gastrointestinal Malignancy: A Case Report
Authors: Wong Davie , Aoki Fred , Rubinstein Ethan
Published: March 2016

Eggerthella lenta is an anaerobic, Gram‐positive bacillus commonly found in the human digestive tract. Occasionally, it can cause life‐threatening infections. Bacteremia due to this organism is always clinically significant and is associated with gastrointestinal diseases and states of immune suppression. The authors report a case involving an elderly man with a newly diagnosed gastrointestinal malignancy who developed bacteremia caused by E lenta, treated successfully using empirical therapy with vancomycin and piperacillin‐tazobactam, followed by directed therapy with metronidazole once the identity and antibiotic susceptibility of the organism was established. The present case reinforces the connection between E lenta bacteremia with gastrointestinal malignancy and highlights the importance of searching for a source of bacteremia due to this organism.
Atypical Distribution of Inflammation in Newly Diagnosed Ulcerative Colitis is not Rare
Authors: Park Sang Hyoung , Yang Suk-Kyun , Park Soo-Kyung , Kim Jong Wook , Yang Dong-Hoon , Jung Kee Wook , Kim Kyung-Jo , Ye Byong Duk , Byeon Jeong-Sik , Myung Seung-Jae , Kim Jin-Ho
Published: March 2016

BACKGROUND: Appendiceal orifice inflammation (AOI) is a common ‘skip lesion’ in patients with ulcerative colitis (UC). However, other skip lesions are less well known.

OBJECTIVE: To evaluate the atypical distribution of UC lesions, other than AOI, in terms of their frequency, pattern, risk factors and prognostic implications.

METHODS: A retrospective analysis of colonoscopic findings and clinical course of 240 adult UC patients who were initially diagnosed at Asan Medical Center (Seoul, South Korea) was performed.

RESULTS: Of 240 patients, 46 (19.2%) showed an atypical distribution of lesions at initial colonoscopy: eight (3.3%) had rectal sparing (segmental-type UC); and 38 (15.8%) had patchy/segmental skip lesions other than AOI. Skip lesions were detected more frequently in proximal segments of the colon than in distal segments (P=0.001). An atypical distribution was more common in patients with AOI (31.3%) than in those without AOI (10.6%; P<0.001). The clinical course of patients with an atypical distribution was not different from that of patients with a typical distribution in terms of remission, relapse, disease extension, colectomy and mortality. In addition, of the 36 patients with an atypical distribution of lesions at diagnosis who underwent follow-up colonoscopy, 24 (66.7%) demonstrated a typical distribution of lesions.

CONCLUSIONS: Patchy/segmental skip lesions and rectal sparing occur not infrequently in adult patients with newly diagnosed, untreated UC. As such, these features alone should not be considered to be definitive evidence against a diagnosis of UC. There does not appear to be a prognostic implication of an atypical distribution of lesions.
Pulsed Radiofrequency Treatment of Complex Regional Pain Syndrome: A Case Series
Authors: Djuric Vlad
Published: March 2016

BACKGROUND: Various forms of sympathetic chain neurolysis (sympathectomy) have, at one time or another, held promise as effective treatment options for complex regional pain syndrome (CRPS). Complications, such as worsening pain and the development of new pain syndromes, have prevented sympathectomy from emerging as a standard intervention. In an effort to avoid poor outcomes associated with neurolysis, pulsed radiofrequency (PRF) has been proposed as a potential treatment alternative for a number of chronic neuropathic pain states, including some forms of CRPS.

METHODS: The present report describes three cases in which patients diagnosed with lower extremity CRPS type I obtained substantial and lasting intervals of pain relief following PRF of the lumbar sympathetic chain. Over a period of four years, 14 fluoroscopically guided procedures using PRF lesioning of the lumbar sympathetic chain at L2, L3 and L4 were performed in three individuals with CRPS type I of the lower limb. Outcome measures included pre‐ and post‐treatment self‐reported pain and medication requirements.

RESULTS: Substantial pain relief (>50%) was achieved in 91.7% of PRF applications at three months and 83.3% at six months, with some treatments resulting in persistent relief well beyond 12 months. Medication use decreased to a comparable degree, with discontinuation of opiates after all but three treatments.

CONCLUSIONS: PRF lesioning of the lumbar sympathetic chain can be an effective treatment for patients with CRPS type I of the lower extremity, with the potential to provide ≥6 months of substantial pain relief.
Differential Prescribing of Opioid Analgesics According to Physician Specialty for Medicaid Patients with Chronic Noncancer Pain Diagnoses
Authors: Ringwalt Chris , Gugelmann Hallam , Garrettson Mariana , Dasgupta Nabarun , Chung Arlene E , Proescholdbell Scott K , Skinner Asheley Cockrell
Published: March 2016

BACKGROUND: Despite >20 years of studies investigating the characteristics of patients seeking or receiving opioid analgesics, research characterizing factors associated with physicians’ opioid prescribing practices has been inconclusive, and the role of practitioner specialty in opioid prescribing practices remains largely unknown.

OBJECTIVE: To examine the relationships between physicians’ and other providers’ primary specialties and their opioid prescribing practices among patients with chronic noncancer pain (CNCP).

METHODS: Prescriptions for opioids filled by 81,459 Medicaid patients with CNCP in North Carolina (USA), 18 to 64 years of age, enrolled at any point during a one‐year study period were examined. χ2 statistics were used to examine bivariate differences in prescribing practices according to specialty. For multivariable analyses, maximum‐likelihood logistic regression models were used to examine the effect of specialty on prescribing practices, controlling for patients’ pain diagnoses and demographic characteristics.

RESULTS: Of prescriptions filled by patients with CNCP, who constituted 6.4% of the total sample of 1.28 million individuals, 12.0% were for opioids. General practitioner/family medicine specialists and internists were least likely to prescribe opioids, and orthopedists were most likely. Across specialties, men were more likely to receive opioids than women, as were white individuals relative to other races/ethnicities. In multivariate analyses, all specialties except internal medicine had higher odds of prescribing an opioid than general practitioners: orthopedists, OR 7.1 (95% CI 6.7 to 7.5); dentists, OR 3.5 (95% CI 3.3 to 3.6); and emergency medicine physicians, OR 2.7 (95% CI 2.6 to 2.8).

CONCLUSIONS: Significant differences in opioid prescribing practices across prescriber specialties may be reflective of differing norms concerning the appropriateness of opioids for the control of chronic pain. If so, sharing these norms across specialties may improve the care of patients with CNCP.
Relationship between Bone Mineral Density and the Frequent Administration of Epidural Steroid Injections in Postmenopausal Women with Low Back Pain
Authors: Kim Sungyun , Hwang Byeongmun
Published: March 2016

BACKGROUND: Epidural steroid injection (ESI) is one of the most common nonsurgical treatments for low back pain. In general, corticosteroid therapy often results in bone loss and osteoporosis. In previous studies, bone mineral density (BMD) was evaluated after epidural injections of relatively small numbers and relatively low total doses of corticosteroids. However, the relationship between BMD and multiple ESIs remains to be elucidated.

OBJECTIVE: To explore the relationship between BMD and multiple ESIs in postmenopausal women with low back pain.

METHODS: Medical records of postmenopausal women with low back pain treated with or without ESIs were reviewed. BMD was measured in the lumbar spine, femoral neck and total femur after the treatments. A total of 71 patients were divided into two groups: group 1 included patients who had received non‐ESI medications; and group 2 included those who had received ESIs >10 times, with a cumulative administered triamcinolone dose >200 mg.

RESULTS: Patients in group 2 showed lower BMD in the femoral neck and total femur. However, no significant intergroup differences in the BMD of the lumbar spine were observed. The prevalences of osteoporosis and osteopenia in the lumbar spine and femoral neck were significantly higher in group 2; these patients also had lower femoral neck BMD Z‐scores.

CONCLUSIONS: Multiple ESIs (approximately 14 injections with a cumulative triamcinolone dose of approximately 400 mg) can reduce BMD in postmenopausal women with low back pain.