bluuebunny/crossref_metadata_2025 huggingface dataset:
The Postoperative Pain Assessment Skills Pilot Trial
Authors: McGillion Michael , Dubrowski Adam , Stremler Robyn , Watt-Watson Judy , Campbell Fiona , McCartney Colin , Victor J Charles , Wiseman Jeffrey , Snell Linda , Costello Judy , Robb Anja , Nelson Sioban , Stinson Jennifer , Hunter Judith , Dao Thuan , Promislow Sara , McNaughton Nancy , White Scott , Shobbrook Cindy , Jeffs Lianne , Mauch Kianda , Leegaard Marit , Beattie W Scott , Schreiber Martin , Silver Ivan
Published: March 2016

BACKGROUND/OBJECTIVES: Pain‐related misbeliefs among health care professionals (HCPs) are common and contribute to ineffective postoperative pain assessment. While standardized patients (SPs) have been effectively used to improve HCPs’ assessment skills, not all centres have SP programs. The present equivalence randomized controlled pilot trial examined the efficacy of an alternative simulation method – deteriorating patient‐based simulation (DPS) – versus SPs for improving HCPs’ pain knowledge and assessment skills.

METHODS: Seventy‐two HCPs were randomly assigned to a 3 h SP or DPS simulation intervention. Measures were recorded at baseline, immediate postintervention and two months postintervention. The primary outcome was HCPs’ pain assessment performance as measured by the postoperative Pain Assessment Skills Tool (PAST). Secondary outcomes included HCPs knowledge of pain‐related misbeliefs, and perceived satisfaction and quality of the simulation. These outcomes were measured by the Pain Beliefs Scale (PBS), the Satisfaction with Simulated Learning Scale (SSLS) and the Simulation Design Scale (SDS), respectively. Student’s t tests were used to test for overall group differences in postintervention PAST, SSLS and SDS scores. One‐way analysis of covariance tested for overall group differences in PBS scores.

RESULTS: DPS and SP groups did not differ on post‐test PAST, SSLS or SDS scores. Knowledge of pain‐related misbeliefs was also similar between groups.

CONCLUSIONS: These pilot data suggest that DPS is an effective simulation alternative for HCPs’ education on postoperative pain assessment, with improvements in performance and knowledge comparable with SP‐based simulation. An equivalence trial to examine the effectiveness of deteriorating patient‐based simulation versus standardized patients is warranted.
Conventional Versus Rosemont Endoscopic Ultrasound Criteria for Chronic Pancreatitis: Comparing Interobserver Reliability and Intertest Agreement
Authors: Kalmin Bruce , Hoffman Brenda , Hawes Robert , Romagnuolo Joseph
Published: March 2016

BACKGROUND: The Rosemont criteria (RC) were recently proposed by expert consensus to standardize endoscopic ultrasound (EUS) features and thresholds for diagnosing chronic pancreatitis (CP); however, they are cumbersome and are not validated.

OBJECTIVE: To determine interobserver agreement between RC and conventional criteria (CC), and to assess intertest agreement in the diagnosis of CP.

METHODS: Thirty-six consecutive patients who underwent EUS for abdominal pain or pancreatitis were retrospectively reviewed. Anonymized images were independently chosen as best representations of the pancreatic body and reviewed by three experts who recorded the presence of CC and RC features. Agreement (proportion and kappa statistic) between CC and RC was calculated. Interobserver agreement within the CC and RC was assessed. Secondary comparisons with endoscopic retrograde cholangiopancreatography were made where available.

RESULTS: Using CC, 60 readings (83.3%) were negative for CP, while 12 readings (16.7%) were positive. Using RC, 59 readings (81.9%) were negative for CP, while 13 (18.1%) were positive. The weighted kappa for interobserver agreement for CC (four categories: normal/low probability, indeterminate, high probability or calcific) was 0.50, with 80.0% overall agreement, versus 0.27 and 68.1% for the four RC categories (normal, indeterminate, suggestive of and consistent with). Agreement on a positive diagnosis with CC was 86.1% (P=0.38 [McNemar’s exact test]), with a kappa of 0.47; for RC, agreement was lower at 80.6% (P=0.016 [McNemar’s exact test]), with a kappa of 0.38. For patients who underwent endoscopic retrograde cholangiopancreatography (n=12), false-negative and false-positive rates between CC and RC did not appear to be different.

CONCLUSIONS: The RC do not appear to achieve the goals of improving accuracy and interobserver agreement for diagnosing CP.
Therapeutic Drug Monitoring in the Treatment of Active Tuberculosis
Authors: Babalik Aylin , Mannix Sharyn , Francis Denis , Menzies Dick
Published: March 2016

Therapeutic drug monitoring ensures optimal dosing while aiming to reduce toxicity. However, due to the high costs and complexity of testing, therapeutic drug monitoring is not routinely used in the treatment of individuals with active tuberculosis, despite the efficacy demonstrated in several randomized trials. This study reviewed data spanning five years regarding the frequency of finding low drug levels in patients with tuberculosis, the dosing adjustments that were required to achieve adequate levels and the factors associated with low drug levels.

BACKGROUND: Therapeutic drug monitoring (TDM) is used to optimize dosing that maximizes therapeutic benefit while minimizing toxicity. In the treatment of active tuberculosis (TB), TDM is not routine, yet low levels of anti-TB drugs can be associated with poorer treatment outcomes.

METHODS: In a retrospective case control study, patients with active TB in whom TDM was performed were considered cases and compared with controls who did not undergo TDM, and matched according to year of diagnosis and the results of direct smear microscopy. Medical records were reviewed to abstract demographic, clinical, radiographic and microbiological data including time until smear and culture conversion.

RESULTS: In total, 20 patients were identified in whom TDM was performed, of whom 17 (87%) had at least one low drug concentration. Overall, 27 of 45 (60%) initial drug concentrations were low and resulted in an increased drug dosage. Low drug levels were found in 13 of 15 (87%) isoniazid, four of five (80%) rifabutin and eight of 12 (67%) rifampin measurements, but in only two of 13 (15%) pyrazinamide measurements. Within cases only, the 17 patients with low serum drug levels were significantly more likely to have comorbid illnesses, be smear positive, have lower serum albumin levels and had nonsignificantly longer time to culture conversion, compared with the three cases in whom all drug levels were within therapeutic ranges.

CONCLUSIONS: TB drug levels were frequently below clinically acceptable levels in patients with active TB, particularly in those with HIV infection or other comorbidities. TDM is potentially useful for the treatment of active TB, but is currently underused.
Quality of Internet‐Based Information on Gastrointestinal Diseases
Authors: Tangri Vikram , Chande Nilesh
Published: March 2016

BACKGROUND: The Internet is becoming an increasingly common source of health information for patients.

OBJECTIVE: To examine the quality of gastrointestinal disease‐ and symptom‐related Internet sites that might be searched by patients.

METHODS: A total of 120 websites were evaluated from July to November 2009 using the DISCERN instrument to determine the quality of content of health and treatment information.

RESULTS: There was substantial variability in the quality of Internet resources regarding gastrointestinal diseases and their symptoms. Information‐based and institutional websites were rated highest. Resources related to celiac disease, colon cancer and abdominal pain scored the highest.

CONCLUSIONS: Overall, the quality of web‐based resources was variable. Because patient education is important in the management of gastroenterological diseases, the increasing use of the Internet poses new opportunities and challenges for physicians.
Endoscopic Band Ligation Versus Pharmacological Therapy for Variceal Bleeding in Cirrhosis: A Meta-Analysis
Authors: Li Lan , Yu Chaohui , Li Youming
Published: March 2016

OBJECTIVE: To conduct a meta-analysis of published, full-length, randomized controlled trials evaluating the efficacy of endoscopic band ligation (EBL) versus pharmacological therapy for the primary and secondary prophylaxis of variceal hemorrhage in patients with cirrhosis.

METHODS: Literature searches were conducted using the PubMed, EMBASE and Cochrane Library databases. Eighteen randomized clinical trials that fulfilled the inclusion criteria were further pooled into a meta-analysis.

RESULTS: Among 1023 patients in 12 trials comparing EBL with beta-blockers for primary prevention, there was no significant difference in gastrointestinal bleeding (RR 0.79 [95% CI 0.61 to 1.02]), all-cause deaths (RR 1.06 [95% CI 0.86 to 1.30]) or bleeding-related deaths (RR 0.66 [95% CI 0.38 to 1.16]). There was a reduced trend toward significance in variceal bleeding with EBL compared with beta-blockers (RR 0.72 [95% CI 0.54 to 0.96]). However, variceal bleeding was not significantly different between the two groups in high-quality trials (RR 0.84 [95% CI 0.60 to 1.17]). Among 687 patients from six trials comparing EBL with beta-blockers plus isosorbide mononitrate for secondary prevention, there was no effect on either gastrointestinal bleeding (RR 0.95 [95% CI 0.65 to 1.40]) or variceal bleeding (RR 0.89 [95% CI 0.53 to 1.49]). The risk for all-cause deaths in the EBL group was significantly higher than in the medical group (RR 1.25 [95% CI 1.01 to 1.55]); however, the rate of bleeding-related deaths was unaffected (RR 1.16 [95% CI 0.68 to 1.97]).

CONCLUSIONS: Both EBL and beta-blockers may be considered first-line treatments to prevent first variceal bleeding, whereas beta-blockers plus isosorbide mononitrate may be the best choice for the prevention of rebleeding.
The Metabolic Syndrome Is Associated with Complicated Gallstone Disease
Authors: Ata Naim , Kucukazman Metin , Yavuz Bunyamin , Bulus Hakan , Dal Kursat , Ertugrul Derun Taner , Yalcin Ahmet Arif , Polat Mehmet , Varol Numan , Akin Kadir Okhan , Karabag Aral , Nazligul Yasar
Published: March 2016

BACKGROUND: Gallstone disease (GD) is a common condition worldwide. Several studies demonstrated that the presence of gallstones is strongly associated with cardiovascular disease. The metabolic syndrome is a highly prevalent cardiovascular condition.

OBJECTIVE: To examine the relationship between complicated GD (CGD) and the metabolic syndrome or its components.

METHODS: Two hundred seventeen patients with gallstones were examined. All patients underwent biliary ultrasonography after a complete medical history and laboratory examination. Data collection for the diagnosis of metabolic syndrome included measurements of waist circumference, blood pressure and lipids, and biochemical tests.

RESULTS: Of the 217 patients examined, 115 patients (53%) had CGD and 102 patients (47%) had uncomplicated GD (UCGD). There was a significant difference between the number of patients with large gallstones in the CGD and UCGD groups (n=14 [12%] versus n=2 [2%], respectively; P=0.004). Metabolic syndrome, diabetes mellitus and large waist circumference were more prevalent in the CGD group than in the UCGD group. Homeostatic model assessment of insulin resistance scores were higher in the CGD group than in UCGD group (2.51 [95% CI 0.57 to 23.90] versus 2.20 [95% CI 0.09 to 8.87], respectively; P=0.032). Logistic regression analysis revealed that the presence of metabolic syndrome (OR 1.434; 95% CI 1.222 to 1.846, P=0.014), diabetes mellitus (OR 1.493; 95% CI 1.255 to 1.953; P=0.035) and large gallstones (OR 1.153; 95% CI 1.033 to 1.714; P=0.017) were independent predictors of CGD.

CONCLUSION: Results of the present study demonstrated that metabolic syndrome, diabetes and gallstone size were associated with CGD. Further prospective studies are needed to understand the clinical importance of this association.
Treatment of Neuropathic Pain with 5% Lidocaine‐Medicated Plaster: Five Years of Clinical Experience
Authors: Delorme Claire , Navez Marie L , Legout Valérie , Deleens Rodrigue , Moyse Dominique
Published: March 2016

BACKGROUND: Neuropathic pain is often severe and adversely affects patients’ quality of life.

OBJECTIVE: To perform a retrospective, observational study investigating the efficacy and safety of treating refractory chronic neuropathic pain with 5% lidocaine‐medicated plaster, in patients attending pain centres.

METHODS: Medical records from 467 patients treated with 5% lidocaine‐medicated plaster were evaluated for efficacy (maximum and minimum pain intensities and coanalgesic consumption) and adverse events. Data from an initial assessment and at least one follow‐up visit had to be available, and separate analyses were conducted for the general population and the subpopulation older than 70 years of age.

RESULTS: Of the patients enrolled, 25.0% were older than 70 years of age. While 20.6% had postherpetic neuralgia, 76.3% had other types of peripheral pain. Approximately 78.1% of cases of peripheral neuropathic pain followed surgery, and 23% were post‐traumatic pain. The time from onset to referral was more than one year in two‐thirds of cases. All patients experienced pain of at least moderate severity (mean [± SD] 11‐point numerical rating scale score 5.2±2.4 to 8.2±1.6). Treatment with 5% lidocaine‐medicated plaster reduced pain intensity by more than 50% in 45.5% of patients, and by at least 30% in 82.2%. Of note, the consumption of analgesics and coanalgesics was significantly reduced. Results were similar in both the general population and the subpopulation older than 70 years of age, at high risk and often receiving multiple medications.

CONCLUSIONS: Treatment of refractory neuropathic pain with 5% lidocaine‐medicated plaster clearly demonstrated efficacy and an excellent safety profile in patients with refractory neuropathic pain.
Reactions to a Targeted Intervention to Increase Fecal Occult Blood Testing among Average-Risk Adults Waiting for Screening Colonoscopy
Authors: McGregor S Elizabeth , Ritvo Paul , Tinmouth Jill , Kornblum Ashley , Myers Ronald , Hilsden Robert J , Paszat Lawrence F , Rabeneck Linda
Published: March 2016

BACKGROUND: Increasing demand combined with limited capacity has resulted in long wait times for average-risk adults referred for screening colonoscopy for colorectal cancer. Management of patients on these growing wait lists is an emerging clinical issue.

OBJECTIVE: To inform the content and design of a mailed targeted invitation for patients to undergo annual fecal occult blood testing (FOBT) while awaiting colonoscopy.

METHODS: Focus groups (FGs) with average-risk patients on a wait list for screening colonoscopy at a high-throughput academic outpatient colonoscopy facility were conducted. During each FG session, feedback regarding a range of materials under consideration for the planned intervention was elicited using a semistructured facilitator guide. The FG sessions were recorded and transcribed verbatim, and analyzed using the constant comparative method to identify key themes.

RESULTS: Findings from the three FGs (n=28) suggested that average-risk patients on a wait list for screening colonoscopy would be receptive to a targeted intervention recommending they undergo FOBT while waiting. Participants indicated that the invitation to undergo FOBT was an important acknowledgement that they were on an actively managed list, and that a mechanism to ensure that they were correctly triaged while waiting was in place. Several specific suggestions to improve the design of the targeted intervention were obtained.

CONCLUSIONS: Results of the present study provide useful information for developing effective strategies to manage average-risk individuals facing long wait times for screening colonoscopy.
Integrating Cognitive and Affective Dimensions of Pain Experience into Health Professions Education
Authors: Murinson Beth B , Mezei Lina , Nenortas Elizabeth
Published: March 2016

Pain is prevalent in clinical settings, and yet it is relatively under‐represented in the education of most students in the health professions. Because pain includes both sensory‐discriminative and affective features, teaching students about pain presents unique challenges and opportunities. The present article describes the evolution of a new blueprint for clinical excellence that, among other competencies, incorporates a need for the emotional development of clinical trainees. The framework has been applied to the development and implementation of two new courses in pain. The first course is designed to provide a comprehensive foundation of medical knowledge regarding pain, while integratively introducing students to the affective dimensions of pain. The second course is designed to enhance students’ appreciation for the protean effects of pain through use of the humanities to represent medical experience. It is concluded that, to be most effective, fostering the emotional development of trainees in the health professions necessitates the incorporation of affect‐focused learning objectives, educational tasks and assessment methods.
Heterogeneity of Bronchitis in Airway Diseases in Tertiary Care Clinical Practice
Authors: D’silva Liesel , Hassan Nesreen , Wang Hong-Yu , Kjarsgaard Melanie , Efthimiadis Ann , Hargreave Frederick E , Nair Parameswaran
Published: March 2016

BACKGROUND: Sputum cell counts have identified inflammatory subtypes of bronchitis in relatively small numbers of subjects with asthma, chronic obstructive pulmonary disease (COPD) and chronic cough in research studies. The prevalence of different subtypes of bronchitis in routine clinical practice, however, has not been reported.

OBJECTIVE: To examine the heterogeneity of bronchitis and its relationship to the severity of airflow obstruction.

METHODS: A retrospective cross‐sectional survey based on a computerized database of spontaneous or induced sputum cell counts examined in a large university tertiary respiratory outpatient clinic.

RESULTS: The database contained 4232 consecutive sputum records from 2443 patients with chronic cough (39%), asthma (37%), asthma with COPD (9%), COPD (13%) and bronchiectasis (3%). Total and differential cell counts were obtained from 86% of successful sputum samples. Induced sputum provided more viable samples than spontaneous expectorate. Approximately one‐third of patients with asthma and one‐fifth of patients with COPD experience eosinophilic bronchitis. Asthmatic patients with moderate to severe airflow obstruction had a greater number of sputum eosinophils. There was a significantly higher number of total cell counts and percentage of neutrophils in the sputum of COPD patients with moderate and severe airflow obstruction than in those with mild airflow obstruction.

CONCLUSION: There is heterogeneity in the cellularity of sputum in various airway diseases. Patients with clinically stable airway diseases may have high sputum cell counts. During exacerbations, more patients may experience neutrophilic bronchitis. Severity of airflow obstruction is associated with eosinophilic bronchitis in patients with asthma, and neutrophilic bronchitis in patients with nonasthmatic COPD.
A Curious Lobe
Authors: Chabot-Naud Andréa , Rakovich George , Chagnon Karine , Ouellette Denise , Beauchamp Gilles
Published: March 2016

A case of azygos lobe is presented. An azygos lobe is an accessory lobe of the lung that may occasionally be confused with a pathological process such as a bulla, lung abscess or neoplasm. Its pathogenesis is discussed, as are the characteristic x-ray features that enable an accurate diagnosis.
The Approach to Diagnosis and Treatment of Chronic Constipation: Suggestions for a General Practitioner
Authors: Paré Pierre
Published: March 2016

Chronic constipation is a frequent complaint. Symptoms of obstructive defecation (straining, hard and lumpy stools, or incomplete evacuation) are more frequent and bothersome than the frequency of bowel movements. Patient assessment is clinically based on the presence or absence of red flags. Commonly used therapies (eg, bulk‐forming agents, stool softeners and stimulant laxatives) have only been evaluated in small studies of short duration. Polyethylene glycol was shown to be effective and safe in several rigorous trials with durations of more than one year. New drugs (prucalopride, lubiprostone and linaclotide) were shown to be effective and safe in well‐designed and rigorous studies. Trials conducted in primary care patients are lacking for all therapies. Biofeedback and behavioural therapies are effective, but should be reserved for selected patients after proper diagnostic evaluation. A practical management algorithm is proposed using a multistep approach favouring early introduction of combined therapies and long‐term step‐down strategy to the lowest satisfactory regimen.
A Randomized Controlled Trial of Four Precolonoscopy Bowel Cleansing Regimens
Authors: Kao Dina , Lalor Eoin , Sandha Gurpal , Fedorak Richard N , van der Knoop Bloeme , Doornweerd Stieneke , van Kooten Harmke , Schreuders Eline , Midodzi William , van Zanten Sander Veldhuyzen
Published: March 2016

BACKGROUND: The ideal bowel cleansing regimen for colonoscopy has yet to be determined.

OBJECTIVE: To compare the cleansing efficacy, and patient tolerability and safety of four bowel preparation regimens.

METHODS: A total of 834 patients undergoing outpatient colonoscopy were randomly assigned to one of four regimens: 4 L polyethylene glycol (PEG); 2 L PEG + 20 mg bisacodyl; 90 mL of sodium phosphate (NaP); or two sachets of a commercially available bowel cleansing solution (PSMC) + 300 mL of magnesium citrate (M). The primary outcome measure was cleansing efficacy, which was scored by blinded endoscopists using the Ottawa Bowel Preparation Scale. Secondary outcome measures were bowel preparation quality according to time of colonoscopy, and patient tolerability and safety.

RESULTS: The mean total cleansing score was significantly worse in the NaP group compared with the other three groups (P<0.0001). The mean cleansing scores were worse in patients who underwent morning versus afternoon colonoscopy, a finding that was consistent in all four groups. PSMC + M was the best tolerated regimen. No clinically significant mean changes in creatinine or electrolyte levels were identified, although a significantly higher proportion of patients in the NaP group developed hypokelemia (P<0.0001).

CONCLUSIONS: 2 L PEG + 20 mg bisacodyl, or PSMC + M was as efficacious as 4 L PEG and superior to NaP for bowel cleansing. A short interval between the completion of bowel preparation and the start of colonoscopy (ie, ‘runway time’), irrespective of bowel preparation regimen, appeared to be a more important predictor of bowel cleanliness than the cathartic agents used.
Achromobacter species endocarditis: A Case Report and Literature Review
Authors: Derber Catherine , Elam Kara , Forbes Betty A. , Bearman Gonzalo
Published: March 2016

Endocarditis due to Achromobacter species is a rare, yet serious, endovascular infection. Achromobacter species infective endocarditis is associated with underlying immunodeficiencies or prosthetic heart valves and devices. A case of prosthetic pulmonary valve endocarditis secondary to Achromobacter xylosoxidans subspecies denitrificans is described in the present report. This life‐threatening infection was successfully treated with combined valve replacement and prolonged antibiotic therapy. A Medline/PubMed literature review of Achromobacter endocarditis was also performed. Achromobacter species are an uncommon, yet important, cause of nosocomial endocarditis. Given the significant associated morbidity and mortality, along with a high degree of intrinsic antibiotic resistance, Achromobacter species infective endocarditis remains a clinical treatment challenge.
What is Chronic Constipation? Definition and Diagnosis
Authors: Gray James R
Published: March 2016

Although chronic constipation is a common complaint, there are no ideal biological markers for its diagnosis. Diagnosis rests on individual patient perception or clinical criteria developed by expert consensus. Investigation options are multiple but often not necessary. When selected, investigations are directed at confirming the absence of a primary underlying disease, differentiating or defining an alteration in colonic motility or identifying an anorectal evacuation disorder.
Risk Factors and Complications Following Percutaneous Endoscopic Gastrostomy: A Case Series of 1041 Patients
Authors: Richter-Schrag Hans-Jürgen , Richter Sabine , Ruthmann Olaf , Olschewski Manfred , Hopt Ulrich Theodor , Fischer Andreas
Published: March 2016

BACKGROUND: Most studies exclude patients with severe coagulation disorders or those taking anticoagulants when evaluating the outcomes of percutaneous endoscopic gastrostomy (PEG).

OBJECTIVE: To investigate complications and risk factors of PEG in a large clinical series including patients undergoing antiplatelet and anticoagulant therapy.

METHODS: During a six-year period, 1057 patients referred for PEG placement were prospectively audited for clinical outcome. Exclusion criteria and follow-up care were defined. Complications were defined as minor or severe. Uni- and multivariate analyses were used to evaluate 14 risk factors. No standardized antibiotic prophylaxis was given.

RESULTS: A total of 1041 patients (66% male, 34% female) with the following conditions underwent PEG: neurogenic dysphagia (n=450), cancer (n=385) and others (n=206). No anticoagulants were administered to 351 patients, thrombosis prophylaxis was given to 348 while full therapeutic anticoagulation was received by 313. No increased bleeding risk was associated with patients who had above-normal international normalized ratio values (OR 0.79 [95% CI 0.08 to 7.64]; P=1.00). The total infection rate was 20.5% in patients with malignant disease, and 5.5% in those with nonmalignant disease. Severe complications occurred in 19 patients (bleeding 0.5%, peritonitis 1.3%). Cirrhosis (OR 2.91 [95% CI 1.31 to 6.54]; P=0.008), cancer (OR 2.34 [95% CI 1.33 to 4.12]; P=0.003) and radiation therapy (OR 2.34 [95% CI 1.35 to 4.05]; P=0.002) were significant predictors of post-PEG infection. The 30-day mortality rate was 5.8%. There were no procedure-related deaths.

CONCLUSIONS: Cancer, cirrhosis and radiation therapy were predictors of infection. Post-PEG bleeding and other complications were rare events. Collectively, the data suggested that patients taking concurrent anticoagulants had no elevated risk of post-PEG bleeding.
Management of Pulmonary Embolism with Rheolytic Thrombectomy
Authors: Ferrigno Lisa , Bloch Robert , Threlkeld Judson , Demlow Thomas , Kansal Raman , Karmy-Jones Riyad
Published: March 2016

BACKGROUND: Catheter thrombectomy combining thrombus destruction with local thrombolysis has been used in patients with pulmonary embolism (PE) who are unstable or have significant right heart dysfunction, but have contraindications to systemic thrombolytic therapy.

OBJECTIVES: To assess the outcomes of patients who underwent pulmonary embolectomy using a commercially available thrombectomy device.

METHODS: A retrospective chart review of patients who underwent pulmonary embolectomy between March 2007 and August 2009 was performed. Patients were classified as having clinical massive or submassive PE, and moderate or severe right ventricular dysfunction. Data collected included pre- and postprocedure shock index (heart rate divided by systolic blood pressure) and mean pulmonary artery pressure.

RESULTS: Sixteen patients with a mean (± SD) age of 54.4±15.8 years underwent embolectomy. Five had clinical massive PE (two in cardiogenic shock) and three of 11 submassive cases had severe right ventricular dysfunction. All were deemed to have contraindications to systemic lysis. Both shock index (1.02±33 preintervention versus 0.71±0.2 postintervention [P=0.001]) and mean pulmonary artery pressure (34.5±9.9 mmHg preintervention versus 27.1±7.1 postintervention [P=0.01]) improved. In the massive PE group, one patient died and two survivors experienced retroperitoneal bleeding and transient renal failure. At follow-up (17.3±7.8 months), two patients in the massive PE group demonstrated evidence of mild cor pulmonale.

CONCLUSION: Rheolytic thrombectomy is an effective strategy in managing massive PE, particularly in patients who have well-defined contraindications to systemic lytic therapy. The effectiveness of rheolytic thrombectomy for submassive PE is not as well defined, but warrants a comparison with systemic lytic therapy.
Presentation and Management of Pediatric Orbital Cellulitis
Authors: Fanella Sergio , Singer Alex , Embree Joanne
Published: March 2016

BACKGROUND: Orbital cellulitis is a serious, vision‐threatening infection.

OBJECTIVE: To review the epidemiology and clinical data of pediatric orbital cellulitis in Manitoba.

METHODS: A 12‐year retrospective review was conducted of all children (younger than 18 years of age) with orbital cellulitis admitted to Manitoba’s only tertiary pediatric centre. Admission rates for orbital cellulitis were compared over three distinct time periods, based on licensure and funding levels of the heptavalent pneumococcal conjugate vaccine (PCV7) in Manitoba.

RESULTS: Thirty‐eight patients with orbital cellulitis were identified. Of these, 11% were of Aboriginal ethnicity in contrast with 30% to 40% of children who were admitted for other respiratory illnesses. Subperiosteal abscesses occurred in 31.5%. Only eight patients (21%) required surgery. Follow‐up imaging after presentation usually did not indicate a need for subsequent surgical drainage. The mean number of orbital cellulitis cases per 1000 admissions for the following periods – before PCV7 licensure, after licensure and before full provincial funding, and after licensure and full funding – were 0.39, 0.53 and 0.90, respectively. No significant difference was noted among any of the periods as PCV7 coverage increased.

CONCLUSIONS: The rate of subperiosteal abscesses was lower than other reports. This may be due to the median age at presentation. In contrast to admissions for most other respiratory infections at the Winnipeg Children’s Hospital (Winnipeg, Manitoba), Aboriginal ethnicity was uncommon. Surprisingly, rates of admissions for orbital cellulitis appeared to show an increasing trend with increasing access to PCV7 in Manitoba, although overall the number of cases was very small. Studies into the changing microbiology of orbital cellulitis and sinusitis are warranted.
Cladophialophora bantiana Brain Abscess in an Immunocompetent Patient
Authors: Revankar Sanjay G.
Published: March 2016

Cladophialophora bantiana is a dematiaceous mold with a predilection for causing central nervous system infection, particularly in normal hosts. A case involving a 79‐year‐old immunocompetent woman who presented with left‐sided weakness and a ring‐enhancing brain lesion is reported. She underwent surgical excision, which revealed a brain abscess due to C bantiana. The patient was treated with liposomal amphotericin B for several weeks, then switched to voriconazole and flucytosine, but eventually succumbed to the infection. Therapy is not standardized for this rare mycosis, and mortality remains high, even in immunocompetent patients. Additional studies to understand the pathogenesis of this infection and to improve outcomes are needed.
Adolescents’ Pain Coping Profiles: Expectations for Treatment, Functional Outcomes and Adherence to Psychological Treatment Recommendations
Authors: Claar Robyn Lewis , Simons Laura E
Published: March 2016

OBJECTIVES: To explore how adolescents’ pain coping profiles relate to their expectations regarding psychological treatment recommendations, and to examine patients’ functioning and engagement in psychological treatment three months following a multidisciplinary pain clinic evaluation.

METHODS: Adolescents and their parents completed measures of pain coping strategies, treatment expectations, pain ratings, somatic symptoms, school absences and functional disability. Parents also reported whether patients followed through with psychological treatment recommendations.

RESULTS: Adaptive copers and their parents were more likely to expect psychological treatments to be helpful; however, at follow‐up, there were no significant group differences in patients’ participation in psychological treatment. Patients in both groups experienced significantly lower levels of somatic symptoms and functional disability, and had fewer school absences from the initial evaluation to the follow‐up.

DISCUSSION: The results of the present study identify preliminary clinical implications for the way in which practitioners in multidisciplinary pain clinics present recommendations for psychological treatment to patients and their families.
Pain Education Issues in Developing Countries and Responses to them by the International Association for the Study of Pain
Authors: Bond Michael
Published: March 2016

Unrelieved pain remains a global health problem. There is a major difference between what could be done to relieve pain and what is being done in developing countries – this is known as the ‘treatment gap’. Poor education of health professionals, limited facilities for pain treatment and poor access to drugs for pain relief are contributing factors. While enthusiasm for pain education and clinical training in developing countries has grown, restrictions by governments and health administrations have represented a significant barrier to practice changes. Since 2002, the International Association for the Study of Pain, through its Developing Countries Working Group, has established a series of programs that have resulted in significant improvements in pain education and the clinical management of pain, together with the beginnings of a system of pain centres. These pain centres will act as regional hubs for the future expansion of education and training in pain management in developing countries. Further success will be increased with the demolition of barriers to the treatment of people in pain worldwide.
L’Expression Verbale de la Douleur chez l’Enfant: Comparaison Intermodale entre Sensation de Douleur et Manipulation Tactile
Authors: Bienvenu Margaux , Jacquet Denis , Michelutti Marjolaine , Wood Chantal
Published: March 2016

HISTORIQUE: La présente étude se situe dans le contexte de l’expression verbale de la douleur chez l’enfant. Elle porte plus particulièrement sur la dimension qualitative de la sensation de douleur.

OBJECTIF: Nous cherchons à repérer les particularités de l’expression verbale relativement à l’aspect qualitatif de la douleur.

MÉTHODOLOGIE: La recherche a été menée auprès de 60 patients de quatre à 18 ans ressentant de la douleur, rencontrés dans un hôpital universitaire pédiatrique. Elle confirme en premier lieu l’origine des descripteurs sensoriels de la douleur, qui renvoient aux expériences perceptives passées de l’enfant, non nécessairement liées à la douleur. Ces expériences sont qualifiées de prototypiques, dans la mesure où, bien qu’elles soient liées à des contextes de vie variés, le type de rapport au monde qu’elles provoquent ne varie pas.

RÉSULTATS: Dans ce cadre, le pincement, le tiraillement, le tapement, l’écrasement et l’appuiement, le picotement et le serrement constituent chacune des expériences sensorielles et motrices particulières dont la structure de base ne varie pas d’un contexte à l’autre. En second lieu, les résultats obtenus montrent que dès quatre ans, l’enfant est en mesure de comparer, puis de reconnaître une analogie entre une expérience exclusivement tactile et sa sensation de douleur.

CONCLUSION: Ces résultats mettent en lumière le rôle primordial du raisonnement analogique dans l’expression verbale de la douleur, ce qui amène à affirmer que le niveau de développement cognitif de l’enfant n’est pas une variable a priori déterminante lorsqu’il s’agit de qualifier sa douleur.
Interrelation of Self‐Report, Behavioural and Electrophysiological Measures Assessing Pain‐Related Information Processing
Authors: Dittmar Oliver , Krehl Rüdiger , Lautenbacher Stefan
Published: March 2016

INTRODUCTION: A number of variables reflecting attentional and emotional mechanisms of processing pain‐related information have recently attracted interest, ie, fear of pain, pain catastrophizing, hypervigilance and attentional bias to pain. These variables can be assessed by explicit measures based on conscious self‐report, or by implicit measures assessing mainly preconscious stages of information processing such as behavioural or electrophysiological tests. Convergent validity within implicit measures was assumed to be high, as was the discriminant validity between implicit and explicit measures.

METHOD: In the present study, two implicit measures (the dot‐probe task for pain words and a word‐processing task for pain words allowing event‐related brain potential recordings) and three self‐report measures (Pain Catastrophizing Scale, Pain Anxiety Symptoms Scale, and Pain Hypervigilance and Awareness Questionnaire) were administered to 27 healthy participants.

RESULTS: No significant associations were found between the implicit measures, or between the event‐related brain potentials of pain words and the explicit measures. A single significant positive correlation was found between the dot‐probe pain bias and the Pain Anxiety Symptoms Scale.

CONCLUSION: All variables appeared to be only weakly associated. The attempt to organize the field of variables targeting attentional and emotional mechanisms of processing pain‐related information using concepts such as implicit and explicit measures failed as far as the present test on convergent/discriminant validity proved.
Management and Treatment of Hepatitis B Virus in Patients with Hiv Infection: A Practical Guide for Health Care Professionals
Authors: Klein Marina B. , Baril Jean-Guy , Charron Marc-André , Fortin Claude , Lalonde Richard , Matte Marie-France , Poliquin Marc , Talbot Annie , Therrien Rachel , Tremblay Cécile , Trottier Benoît , Tsarevsky Irina , Villeneuve Jean-Pierre
Published: March 2016

The management and treatment of HIV and hepatitis B virus (HBV)‐coinfected patients present specific challenges for clinicians. The morbidity and mortality related to these concomitant infections are growing concerns, while the use of antiviral drugs effective against both viruses complicates therapeutic decision making. The present document provides guidelines for physicians regarding care and treatment of patients coinfected with HIV and HBV. Primary prevention of HBV in HIV‐positive patients is achieved through appropriate vaccination schedules. Follow‐up before treatment of HBV may include liver biopsy, screening for hepatocellular carcinoma and testing for esophageal varicies in cases of cirrhosis. In HBV‐infected patients requiring treatment, recommendations regarding initiation, duration and choice of first‐line drugs are made. Finally, in the case of resistance, appropriate alternative therapies are necessary.
An Evaluation of the Use of Serum 7-alpha-hydroxycholestenone as a Diagnostic Test of Bile Acid Malabsorption Causing Watery Diarrhea
Authors: Brydon W Gordon , Culbert Pearl , Kingstone Kathleen , Jarvie Ann , Iacucci Marietta , Tenhage Merel , Ghosh Subrata
Published: March 2016

BACKGROUND: Bile acid malabsorption (BAM) is a recognized cause of watery diarrhea, often diagnosed empirically based on clinical response to cholestyramine. The radionuclide selenium-labelled homocholic acid-taurine whole body retention test is expensive, labour intensive and of limited availability.

OBJECTIVE: To report on the clinical performance of serum 7-alpha-hydroxy-4-cholesten-3-one (7HCO) as a test of BAM in adult patients with unexplained diarrhea.

METHODS: Patients with unexplained diarrhea were investigated over a three-year period. Final diagnosis was determined based on medical history and investigations, serum levels of 7HCO and response to cholestyramine. ROC analysis was used to determine the ideal upper reference range cut-off value to optimize sensitivity/specificity for BAM. Time of blood specimen collection was recorded to investigate possible variation in results throughout the working day.

RESULTS: ROC analysis yielded a sensitivity/specificity of 90%/77% for type 1 BAM (ileal disease/resection) and 97%/74% for type 2 BAM (idiopathic) using 30 ng/mL as the upper limit of normal for serum 7HCO when compared with all other patients. Of 813 patients, 196 tested positive. Serum 7HCO levels were significantly higher in blood specimens that were collected between 12:00 and 13:00 (median 24 ng/mL) than in specimens collected between 09:00 and 10:00 (median 17 ng/mL) (P<0.05).

CONCLUSION: Serum 7HCO testing is a simple, sensitive, noninvasive, inexpensive alternative to other more commonly used tests for BAM. Time of specimen collection, however, resulted in small but significant result variations and, although unlikely to have much impact on test value, it should ideally be standardized.
The Influence of Culture on Maternal Soothing Behaviours and Infant Pain Expression in the Immunization Context
Authors: Vinall Jillian , Pillai Riddell Rebecca , Greenberg Saul
Published: March 2016

OBJECTIVE: To investigate how maternal culture (ie, individualist versus collectivist) influences soothing techniques and infant distress.

METHODS: Archival data were analyzed using a subsample of 80 mother‐infant dyads selected from a larger database of infant pain expression.

RESULTS: Mothers belonging to the individualist group used more affection behaviours when attempting to regulate their infants’ distress. No differences were observed in mothers’ touching, holding, rocking, vocalizing, caregiving or distracting their infants. Mothers’ culture did not appear to be related to the level of distress expressed by their infants.

CONCLUSIONS: These results suggest that the similarities in soothing and infant pain expression between individualist and collectivist cultures are more prominent than their differences.
Assessing Inflammatory Bowel Disease-Associated Antibodies in Caucasian and First Nations Cohorts
Authors: Bernstein Charles N , El-Gabalawy Hani , Sargent Michael , Landers Carol J , Rawsthorne Patricia , Elias Brenda , Targan Stephan R
Published: March 2016

BACKGROUND: First Nation populations in Canada have a very low incidence of inflammatory bowel disease (IBD). Based on typical infections in this population, it is plausible that the First Nations react differently to microbial antigens with a different antibody response pattern, which may shed some light as to why they experience a low rate of IBD.

OBJECTIVE: To compare the positivity rates of antibodies known to be associated with IBD in Canadian First Nations compared with a Canadian Caucasian population.

METHODS: Subjects with Crohn’s disease, ulcerative colitis (UC), rheumatoid arthritis (RA) (as an immune disease control) and healthy controls without a personal or family history of chronic immune diseases, were enrolled in a cohort study aimed to determine differences between First Nations and Caucasians with IBD or RA. Serum from a random sample of these subjects (n=50 for each of First Nations with RA, First Nations controls, Caucasians with RA, Caucasians with Crohn’s disease, Caucasians with UC and Caucasians controls, and as many First Nations with either Crohn’s disease or UC as could be enrolled) was analyzed in the laboratory for the following antibodies: perinuclear antineutrophil cytoplasmic antibody (pANCA), and four Crohn’s disease-associated antibodies including anti-Saccharomyces cerevisiae, the outer membrane porin C ofEscherichia coli, I2 – a fragment of bacterial DNA associated withPseudomonas fluorescens, and the bacterial flagellin CBir-1. The rates of positive antibody responses and mean titres among positive results were compared.

RESULTS: For pANCA, First Nations had a positivity rate of 55% in those with UC, 32% in healthy controls and 48% in those with RA. The pANCA positivity rate was 32% among Caucasians with RA. The rates of the Crohn’s disease-associated antibodies for the First Nations and Caucasians were comparable. Among First Nations, up to one in four healthy controls were positive for any one of the Crohn’s disease-associated antibodies. First Nations had significantly higher pANCA titres in both the UC and RA groups than Caucasians

DISCUSSION: Although First Nation populations experience a low rate of IBD, they are relatively responsive to this particular antibody panel.

CONCLUSIONS: The positivity rates of these antibodies in First Nations, despite the low incidence of IBD in this population, suggest that these antibodies are unlikely to be of pathogenetic significance.
Managing Dyspnea in Patients with Advanced Chronic Obstructive Pulmonary Disease: A Canadian Thoracic Society Clinical Practice Guideline
Authors: Marciniuk Darcy D , Goodridge Donna , Hernandez Paul , Rocker Graeme , Balter Meyer , Bailey Pat , Ford Gordon , Bourbeau Jean , O’Donnell Denis E , Maltais Francois , Mularski Richard A , Cave Andrew J , Mayers Irvin , Kennedy Vicki , Oliver Thomas K , Brown Candice ,   Canadian Thoracic Society COPD Committee Dyspnea Expert Working Group
Published: March 2016

Dyspnea is a cardinal symptom of chronic obstructive pulmonary disease (COPD), and its severity and magnitude increases as the disease progresses, leading to significant disability and a negative effect on quality of life. Refractory dyspnea is a common and difficult symptom to treat in patients with advanced COPD. There are many questions concerning optimal management and, specifically, whether various therapies are effective in this setting. The present document was compiled to address these important clinical issues using an evidence-based systematic review process led by a representative interprofessional panel of experts.

The evidence supports the benefits of oral opioids, neuromuscular electrical stimulation, chest wall vibration, walking aids and pursed-lip breathing in the management of dyspnea in the individual patient with advanced COPD. Oxygen is recommended for COPD patients with resting hypoxemia, but its use for the targeted management of dyspnea in this setting should be reserved for patients who receive symptomatic benefit. There is insufficient evidence to support the routine use of anxiolytic medications, nebulized opioids, acupuncture, acupressure, distractive auditory stimuli (music), relaxation, hand-held fans, counselling programs or psychotherapy. There is also no evidence to support the use of supplemental oxygen to reduce dyspnea in nonhypoxemic patients with advanced COPD.

Recognizing the current unfamiliarity with prescribing and dosing of opioid therapy in this setting, a potential approach for their use is illustrated. The role of opioid and other effective therapies in the comprehensive management of refractory dyspnea in patients with advanced COPD is discussed.