bluuebunny/crossref_metadata_2025 huggingface dataset:
Molecular Identification and Susceptibility Pattern of Clinical Nocardia Species: Emergence of Nocardia crassostreae as an Agent of Invasive Nocardiosis
Authors: Taj-Aldeen Saad J , Deshmukh Anand , Doiphode Sanjay , Abdul Wahab Atqah , Allangawi Mona , AlMuzrkchi Ahmed , Klaassen Corné H , Meis Jacques F
Published: March 2016

BACKGROUND: Nocardia species are rare, opportunistic organisms that cause disease in both immunocompetent and immunocompromised individuals.

OBJECTIVE: To investigate the clinical presentations of various Nocardia infections based on the 16S ribosomal RNA gene of the isolate, as well as related risk factors and susceptibility patterns to antimicrobial agents

METHODS: Thirteen patients with a diagnosis of nocardiosis were included in the present study. Seven Nocardia species were identified by 16S ribosomal RNA. Susceptibility testing was performed using six antimicrobial agents.

RESULTS: Five patients were immunocompromised, and eight were immunocompetent with predisposing factors including cystic fibrosis, tuberculosis and ophthalmic infections. Nocardia caused pulmonary infections in eight patients (61.5%), invasive systemic infections in three patients (23%) and local (ophthalmic) infections in two patients (15.4%). In the patients with pulmonary disease, nocardiosis was caused by six species (Nocardia cyriacigeorgica, Nocardia otitidiscaviarum, Nocardia farcinica, Nocardia carnea, Nocardia testacea and Nocardia asiatica). The seventh species identified in the present study was Nocardia crassostreae.

DISCUSSION: N crassostreae is a multidrug‐resistant organism that was reported to be an emerging human pathogen causing invasive nocardiosis in a patient with non‐Hodgkin’s lymphoma. N farcinica was isolated from blood in a patient with breast cancer. None of the Nocardia isolates were resistant to linezolid. One N otitidiscaviarum isolate was a multidrug‐resistant organism. All patients in the present study were treated with the appropriate antibiotics and their condition resolved without further sequelae.

CONCLUSIONS: The present study is the first report on N crassostreae as a human pathogen. The detection of multidrug‐resistant species necessitate molecular identification and susceptibility testing, and should be performed for all Nocardia infections. Nocardiosis manifests various clinical features depending on the Nocardia species and underlying conditions.
Low Seroconversion after One Dose of AS03‐Adjuvanted H1N1 Pandemic Influenza Vaccine in Solid‐Organ Transplant Recipients
Authors: Resende Mariangela R , Husain Shahid , Gubbay Jonathan , Singer Lianne , Cole Edward , Renner Eberhard L , Rotstein Coleman
Published: March 2016

BACKGROUND: Immunocompromised individuals are more susceptible to complications produced by influenza infection. As a result, solid‐organ transplant (SOT) recipients were targeted as a priority group to receive AS03‐adjuvanted H1N1 influenza vaccine during 2009.

OBJECTIVE: To evaluate seroconversion after one dose of adjuvanted pandemic influenza H1N1 (pH1N1) vaccine in SOT recipients.

METHODS: Adult SOT recipients were enrolled to receive one 3.75 μg dose of adjuvanted pH1N1 vaccine. Serological status was tested using a hemagglutination inhibition assay before and two and four weeks postvaccination.

RESULTS: The five SOT recipients (one liver, two kidney and two lung transplants) had a median age of 50 years (range 36 to 53 years), and three were male, who were a median time of three years (range two months to 15 years) post‐transplant. All patients were on a double or triple immunosuppressive regimen. The prevaccination pH1N1 titre was 1:10 in four patients and 1:40 in one patient. Seroprotection was observed only in one patient, with a rise in titre from 1:40 at baseline to 1:320 at both two and four weeks after vaccination. This lung transplant recipient had documented previous infection with pH1N1.

CONCLUSION: Results of the present small study call into question whether one dose of adjuvanted pH1N1 vaccine can provide seroprotection in SOT recipients.
Validation and Evaluation of Two Observational Pain Assessment Tools in a Trauma and Neurosurgical Intensive Care Unit
Authors: Topolovec-Vranic Jane , Gélinas Celine , Li Yangmei , Pollmann-Mudryj Mary Ann , Innis Jennifer , McFarlan Amanda , Canzian Sonya
Published: March 2016

BACKGROUND: Studies have demonstrated that patients in the intensive care unit experience high levels of pain. While many of these patients are nonverbal at some point during their stay, there are few valid tools available to assess pain in this group.

OBJECTIVES: To evaluate the validity and clinical utility of two pain assessment tools, the revised Adult Non‐Verbal Pain Scale (NVPS‐R) and the Critical Care Pain Observation Tool (CPOT), in a trauma and neurosurgical patient population.

METHODS: Patients were assessed using the NVPS‐R and CPOT by trained intensive care unit nurses (n=23) and research assistants before, during and after two procedures: turning of the patient (nociceptive procedure) and noninvasive blood pressure cuff inflation (non‐nociceptive procedure). Communicative patients were also asked to report their level of pain during each assessment.

RESULTS: A total of 66 patients (34 communicative, 32 noncommunicative) were included in the study. CPOT and NVPS‐R scores increased significantly when participants were exposed to turning, but not during noninvasive blood pressure measurement (repeated measures ANOVA: CPOT, F=5.81, P=0.019; NVPS‐R, F=5.32, P=0.025) supporting discriminant validity. CPOT and NVPS‐R scores were significantly higher during the turning procedure for patients who had indicated that they were in pain versus those who were not, indicating criterion validity. Inter‐rater reliability was generally higher for the CPOT than NVPS‐R. Nurses rated the feasibility of the two tools as comparable but provided higher ratings of acceptability for the CPOT.

CONCLUSIONS: While the present study supports the use of the CPOT and the NVPS‐R with critically ill trauma and neurosurgical patients, further research should explore the role of vital signs in pain.
An Assessment of the Effects of Iyengar Yoga Practice on the Health‐Related Quality of Life of Patients with Chronic Respiratory Diseases: A Pilot Study
Authors: Santana Maria-Jose , S-Parrilla Julia , Mirus Judith , Loadman Martha A , Lien Dale C , Feeny David
Published: March 2016

OBJECTIVE: To assess the effects of an Iyengar yoga program (IYP) on patients with chronic respiratory diseases.

METHODS: Patients attending lung transplant clinics in a tertiary institution were invited to participate in a two‐phase, 12‐week IYP that included 2 h biweekly classes. Doctors completed a formal physical and clinical assessment on candidates before enrollment. Patients with New York Association Class III or IV, or dyspnea grade IV were excluded. At baseline and at the end of 12‐weeks, patients completed the Hospital Anxiety and Depression Scale (HADS), Chronic Respiratory Questionnaire (CRQ) and Health Utilities Index (HUI). Medication(s), 6 min walk test results and other clinical parameters were also recorded. Patients recorded the effects of the IYP on their daily living in journals. Nonparametric and qualitative methods were used to analyze the data.

RESULTS: Twenty‐five patients diagnosed with pulmonary arterial hypertension and chronic obstructive pulmonary disease (mean age 60 years) were invited to participate. At the end of the 12‐week period, changes in HADS anxiety and CRQ fatigue scores were statistically significant (P<0.05) and changes in HUI ambulation, pain, emotion and overall score were clinically important. The content of the journals revealed patients’ improvement in breathing capacity, mobility, energy, sleep and included positive feedback such as: “increased tidal volume with slowing expiration”, “I have an overall feeling of wellbeing” and “excellent amount of energy”.

CONCLUSIONS: The findings suggest that yoga has significant potential to produce benefits. Potential benefits will be further explored in a national multisite study.
Sarcoidosis with Major Airway, Vascular and Nerve Compromise
Authors: Sekiguchi Hiroshi , Suzuki Jun , Utz James P
Published: March 2016

The present report describes a 60‐year‐old Caucasian woman who presented with progressive dyspnea, cough and wheeze. A computed tomography scan of the chest showed innumerable bilateral inflammatory pulmonary nodules with bronchovascular distribution and a mediastinal and hilar infiltrative process with calcified lymphadenopathy leading to narrowing of lobar bronchi and pulmonary arteries. An echocardiogram revealed pulmonary hypertension. Bronchoscopy showed left vocal cord paralysis and significant narrowing of the bilateral bronchi with mucosal thickening and multiple nodules. Transbronchial biopsy was compatible with sarcoidosis. Despite balloon angioplasty of the left lower lobe and pulmonary artery, and medical therapy with oral corticosteroids, her symptoms did not significantly improve. To the authors’ knowledge, the present report describes the first case of pulmonary sarcoidosis resulting in major airway, vascular and nerve compromise due to compressive lymphadenopathy and suspected concurrent granulomatous infiltration. Its presentation mimicked idiopathic mediastinal fibrosis.
The Utility of Thiopurine Methyltransferase Enzyme Testing in Inflammatory Bowel Disease
Authors: Chisick Laura , Oleschuk Curtis , Bernstein Charles N
Published: March 2016

OBJECTIVE: To assess the levels of red blood cell thiopurine methyltransferase (TPMT) in subjects with inflammatory bowel disease (IBD) and to determine how these levels impacted thiopurine dosing and leukopenia over the first six months of therapy.

METHODS: A retrospective chart review was performed on all adult IBD patients (n=423, 88.2% Caucasian) who had TPMT levels measured by 11 participating gastroenterologists in Manitoba between 2008 and 2010. In addition to descriptive data, white blood cell count, dose and reason for discontinuation were analyzed for the first six months of therapy. Patients receiving ≥2.0 mg/kg of azathioprine (AZA) or ≥1.0 mg/kg of 6-mercapatopurine were considered to be ‘substantially’ dosed.

RESULTS: Of the 423 patients, 8.3% had intermediate levels and 93.4% had normal levels of TPMT. Only one subject had a low level. A total of 216 patients had sufficient data to be included for full analysis. Patients with intermediate TPMT levels were generally started at lower doses of thiopurine than patients with normal TPMT levels (mean [± SD] 1.0±0.6 mg/kg versus 1.8±0.5 mg/kg). Of the subjects with normal TPMT levels, only 37.8% were dosed with ≥2.0 mg/kg of AZA. Each month, approximately 5% of subjects were leukopenic. These subjects received a mean overall AZA dose of 1.9±0.3 mg/kg and had a mean white blood cell count of 3.8±0.4×109/L.

CONCLUSIONS: Normal TPMT levels did not prevent the development of leukopenia, although life-threatening leukopenia was rare. Physicians are not using TPMT levels to substantially dose thiopurines at the outset, which may limit the speed at which adequate doses are reached to facilitate remission.
Infant Pain Regulation as an Early Indicator of Childhood Temperament
Authors: Stevens Sara A , Racine Nicole , Riddell Rebecca Pillai , Horton Rachel , Garfield Hartley , Greenberg Saul
Published: March 2016

BACKGROUND: There is considerable variability in infants’ responses to painful stimuli, including facial and vocal expressions. This variability in pain‐related distress response may be an indicator of temperament styles in childhood.

OBJECTIVE: To examine the relationships among immunization pain outcomes (pain reactivity, pain regulation and parent ratings of infant pain) over the first year of life and parent report of early temperament.

METHODS: A subset of parent‐infant dyads in an ongoing Canadian longitudinal cohort was studied. Infant pain behaviours were coded using the Modified Behavior Pain Scale. Parental judgments of infant pain were recorded using the Numeric Rating Scale. Infant temperament was measured using the Infant Behaviour Questionnaire‐Revised. Correlational analyses and multiple regressions were conducted.

RESULTS: Multiple regressions revealed that the 12‐month regulatory pain scores predicted parent ratings of the Negative Affectivity temperament dimension at 14 months of age. Parent ratings of infant pain at 12 months of age predicted parent ratings of the Orienting/Affiliation temperament dimension, with sex differences observed in this substrate.

CONCLUSION: Pain‐related distress regulation at one year of age appears to be a novel indicator of parent report of temperament ratings. Pain outcomes in the first six months of life were not related to parent temperament ratings.
Open-Access Colonoscopy in Ontario: Associated Factors and Quality
Authors: Hadlock Shane , Rabeneck Linda , Paszat Lawrence F , Sutradhar Rinku , Wilton Andrew S , Tinmouth Jill
Published: March 2016

BACKGROUND Open-access (OA) colonoscopy may increase efficiency and decrease wait times; however, because the patient is seen for the first time at the endoscopy appointment, previous processes, such as information about the procedure, preparation and appropriate triage, may be suboptimal.

OBJECTIVE: To identify factors associated with OA colonoscopy and to determine the relationship between OA colonoscopy and an important quality measure, incomplete colonoscopy.

METHODS: A population-based analysis of all adult outpatients undergoing a first-time colonoscopy between 1997 and 2007 in Ontario was performed. Colonoscopy was considered to be OA if there were no visits in the preceding five years with the physician performing the colonoscopy. Using logistic regression, patient, physician and institution factors associated with OA colonoscopy were identified. Using propensity score matching, the relationship between OA colonoscopy and incomplete colonoscopy in 2006 was examined.

RESULTS: A total of 1,079,259 colonoscopies were performed. Of these, 14% were OA in 1997 compared with 26% in 2007. Patients 50 to 69 years of age, those from higher-income neighbourhoods and those with less comorbidity were more likely to undergo OA colonoscopy. The odds of receiving OA colonoscopy were six times greater in a nonhospital clinic compared with a community hospital. Colonoscopy was more likely to be complete if the procedure was OA (OR 1.3 [95% CI 1.2 to 1.4]; P<0.0001).

CONCLUSIONS: Rates of OA colonoscopy have increased substantially since 1997. Institution type was most strongly associated with OA colonoscopy. Colonoscopy completeness, a recognized quality indicator, does not appear to be compromised by OA colonoscopy.
A Qualitative Review of the Psychometric Properties and Feasibility of Electronic Headache Diaries for Children and Adults: Where We Are and Where We Need to Go
Authors: Stinson Jennifer N , Huguet Anna , McGrath Patrick , Rosenbloom Brittany , Soobiah Charlene , White Meghan , Coburn Geraldine
Published: March 2016

BACKGROUND: While paper headache pain diaries have been used to determine the effectiveness of headache treatments in clinical trials, recent advances in information and communication technologies have resulted in the burgeoning use of electronic diaries (e‐diaries) for headache pain.

OBJECTIVE: To qualitatively review headache e‐diaries, assess their measurement properties, examine measurement components and compare these components with recommended reporting guidelines.

METHODS: The databases Medline, the Cumulative Index to Nursing and Allied Health Literature, Embase, PsychInfo, the Education Resources Information Centre and ISI Web of Science were searched for self‐report headache e‐diaries for children and adults. A total of 21 publications that involved e‐diaries were found; five articles reported on the development of an e‐diary and 16 used an e‐diary as an outcome measure in randomized controlled trials or observational studies. The diary measures’ components, features and psychometric properties, as well as the quality of evidence of their psychometric properties, were evaluated.

RESULTS: Five headache e‐diaries met the a priori criteria and were included in the final analysis. None of these e‐diaries had well‐developed evidence of reliability and validity. Three e‐diaries showed evidence of feasibility. E‐diaries with ad hoc measures developed by the study investigators were most common, with little to no supportive evidence of reliability and/or validity. Compliance with the reporting guidelines was variable, with only one‐half of the e‐diaries measuring the recommended primary outcome of headache frequency.

CONCLUSIONS: Specific recommendations regarding the development (including essential components) and testing of headache e‐diaries are discussed. Further research is needed to strengthen the measurement of headache pain in clinical trials using headache e‐diaries.
Does Vigilance to Pain Make Individuals Experts in Facial Recognition of Pain?
Authors: Baum Corinna , Kappesser Judith , Schneider Raphaela , Lautenbacher Stefan
Published: March 2016

BACKGROUND: It is well known that individual factors are important in the facial recognition of pain. However, it is unclear whether vigilance to pain as a pain‐related attentional mechanism is among these relevant factors.

OBJECTIVES: Vigilance to pain may have two different effects on the recognition of facial pain expressions: pain‐vigilant individuals may detect pain faces better but overinclude other facial displays, misinterpreting them as expressing pain; or they may be true experts in discriminating between pain and other facial expressions. The present study aimed to test these two hypotheses. Furthermore, pain vigilance was assumed to be a distinct predictor, the impact of which on recognition cannot be completely replaced by related concepts such as pain catastrophizing and fear of pain.

METHODS: Photographs of neutral, happy, angry and pain facial expressions were presented to 40 healthy participants, who were asked to classify them into the appropriate emotion categories and provide a confidence rating for each classification. Additionally, potential predictors of the discrimination performance for pain and anger faces – pain vigilance, pain‐related catastrophizing, fear of pain – were assessed using self‐report questionnaires.

RESULTS: Pain‐vigilant participants classified pain faces more accurately and did not misclassify anger as pain faces more frequently. However, vigilance to pain was not related to the confidence of recognition ratings. Pain catastrophizing and fear of pain did not account for the recognition performance.

CONCLUSIONS: Moderate pain vigilance, as assessed in the present study, appears to be associated with appropriate detection of pain‐related cues and not necessarily with the overinclusion of other negative cues.
Long-Term Follow-Up of Patients with Malignant Pedunculated Colon Polyps after Colonoscopic Polypectomy
Authors: Freeman Hugh James
Published: March 2016

BACKGROUND: Previously published studies have suggested that patients with resected colon cancer have an increased risk for early metachronous colon cancer. Current screening guidelines recommend intense surveillance by colonoscopy for the initial five years after the initial colon cancer has been resected. Information regarding endoscopically removed malignant polyps is limited.

METHODS: In the present study, 25 consecutive patients (14 male, 11 female) with malignant pedunculated colon polyps treated with snare cautery polypectomy were followed for more than one decade up to 20 years. Five patients required an additional resection to ensure that removal of the original cancer was complete. Annual colonoscopies were planned for five years. If an adenoma was detected in the fifth year, colonoscopy was performed annually until no adenomas were detected. Otherwise, colonoscopy was planned every three years after five years.

RESULTS: In the present study, there was no mortality from colon cancer and no patient developed either recurrent colon cancer or an early metachronous colon cancer during the initial five-year period of surveillance. Two patients (one male, one female) ultimately developed late cecal cancers almost one decade after the original colon cancers were resected. One had an early stage cancer that was resected, while the other had an infiltrating mucinous carcinoma complicating a small tubulovillous adenoma with extension to a single lymph node. After surgical removal and adjuvant chemotherapy, no further neoplastic disease has been detected.

CONCLUSIONS: Overall, patients with malignant pedunculated polyps do extremely well if appropriately managed at the time of the initial polypectomy. Short-term outcomes after removal of a malignant polyp(s) appear to be similar to those with a nonmalignant polyp. However, late metachronous colon cancer may still occur. Long-term follow-up should be considered in each patient, assuming reasonable life expectancy, because risk of additional adenomas and metachronous colon cancer persists even after the initial five years of currently recommended surveillance. Patients with resected malignant polyps may represent a special patient subgroup that requires surveillance for more extended periods than current guidelines have recommended.
Toy‐Mediated Distraction: Clarifying the Role of Distraction Agent and Preneedle Distress in Toddlers
Authors: Hillgrove-Stuart Jessica , Pillai Riddell Rebecca , Horton Rachel , Greenberg Saul
Published: March 2016

BACKGROUND: Distraction has recently gained attention as a technique that may help reduce acute pain in infants and toddlers; however, results remain equivocal. It appears that these mixed results stem from a variety of methodological differences with regard to how distraction is implemented.

OBJECTIVES: To offer more definitive conclusions regarding the efficacy and mechanisms of distraction for pain management during infancy. Specifically, the goal was to examine whether the agent of distraction (ie, the specific person conducting the distraction) and preneedle distress behaviours impact the efficacy of distraction when toddlers were held by parents.

METHODS: A total of 99 toddlers were randomly assigned to one of three conditions (typical care, research assistant‐directed distraction or parent‐directed distraction). Toddler distress behaviours were assessed pre‐ and postneedle. Toddlers were further grouped according to distress behaviours preneedle (low/no distress versus high distress). Parental soothing behaviours were also assessed as a manipulation check.

RESULTS: Toddler postneedle pain did not significantly differ among groups. However, toddlers who were distressed preneedle displayed significantly more pain postneedle, regardless of the treatment group. There were no significant interactions between treatment group and preneedle distress behaviours.

CONCLUSIONS: These results suggest that, when being held by a parent, distraction using a toy does not result in lower pain scores in the context of immunization, regardless of who offers the distraction. Furthermore, these findings raise the notion that if clinicians ensured toddlers were regulated before attempting an immunization, postneedle pain may be significantly reduced.
Drugs for Chronic Pain in Children: A Commentary on Clinical Practice and the Absence of Evidence
Authors: Grégoire Marie-Claude , Finley G Allen
Published: March 2016

Pediatric chronic pain is widespread, under‐recognized and undertreated. Best management usually involves a multimodal approach coordinated by a multidisciplinary team. The present commentary specifically discusses common pharmacological approaches to chronic pain in children, identifies gaps in knowledge and suggests several research directions that would benefit future clinical care.
Twenty-Four Hour Noninvasive Ventilation in Duchenne Muscular Dystrophy: A Safe Alternative to Tracheostomy
Authors: McKim Douglas A , Griller Nadia , LeBlanc Carole , Woolnough Andrew , King Judy
Published: March 2016

BACKGROUND: Almost all patients with Duchenne muscular dystrophy (DMD) eventually develop respiratory failure. Once 24 h ventilation is required, either due to incomplete effectiveness of nocturnal noninvasive ventilation (NIV) or bulbar weakness, it is common practice to recommend invasive tracheostomy ventilation; however, noninvasive daytime mouthpiece ventilation (MPV) as an addition to nocturnal mask ventilation is also an alternative.

METHODS: The authors’ experience with 12 DMD patients who used 24 h NIV with mask NIV at night and MPV during daytime hours is reported.

RESULTS: The mean (± SD) age and vital capacity (VC) at initiation of nocturnal (only) NIV subjects were 17.8±3.5 years and 0.90±0.40 L (21% predicted), respectively; and, at the time of MPV, 19.8±3.4 years and 0.57 L (13.2% predicted), respectively. In clinical practice, carbon dioxide (CO2) levels were measured using different methods: arterial blood gas analysis, transcutaneous partial pressure of CO2and, predominantly, by end-tidal CO2. While the results suggested improved CO2levels, these were not frequently confirmed by arterial blood gas measurement. The mean survival on 24 h NIV has been 5.7 years (range 0.17 to 12 years). Of the 12 patients, two deaths occurred after 3.75 and four years, respectively, on MPV; the remaining patients continue on 24 h NIV (range two months to 12 years; mean 5.3 years; median 3.5 years).

CONCLUSIONS: Twenty-four hour NIV should be considered a safe alternative for patients with DMD because its use may obviate the need for tracheostomy in patients with chronic respiratory failure requiring more than nocturnal ventilation alone.
Cancer‐Related Pain in Older Adults Receiving Palliative Care: Patient and Family Caregiver Perspectives on the Experience of Pain
Authors: McPherson Christine J , Hadjistavropoulos Thomas , Lobchuk Michelle M , Kilgour Kelly N
Published: March 2016

BACKGROUND: Despite an emphasis on pain management in palliative care, pain continues to be a common problem for individuals with advanced cancer. Many of those affected are older due to the disproportionate incidence of cancer in this age group. There remains little understanding of how older patients and their family caregivers perceive patients’ cancer‐related pain, despite its significance for pain management in the home setting.

OBJECTIVES: To explore and describe the cancer pain perceptions and experiences of older adults with advanced cancer and their family caregivers.

METHODS: A qualitative descriptive approach was used to describe and interpret data collected from semistructured interviews with 18 patients (≥65 years of age) with advanced cancer receiving palliative care at home and their family caregivers.

RESULTS: The main category ‘Experiencing cancer pain’ incorporated three themes. The theme ‘Feeling cancer pain’ included the sensory aspects of the pain, its origin and meanings attributed to the pain. A second theme, ‘Reacting to cancer pain’, included patients’ and family caregivers’ behavioural, cognitive (ie, attitudes, beliefs and control) and emotional responses to the pain. A third theme, ‘Living with cancer pain’ incorporated individual and social‐relational changes that resulted from living with cancer pain.

CONCLUSIONS: The findings provide an awareness of cancer pain experienced by older patients and their family caregivers within the wider context of ongoing relationships, increased patient morbidity and other losses common in the aged.
A Pilot Study Examining the Relationship among Crohn Disease Activity, Glucagon-Like Peptide-2 Signalling and Intestinal Function in Pediatric Patients
Authors: Sigalet David L , Kravarusic Dragan , Butzner Decker , Hartmann Bolette , Holst Jens J , Meddings Jon
Published: March 2016

BACKGROUND/OBJECTIVES: The relationship between the enteroendocrine hormone glucagon-like peptide 2 (GLP-2) and intestinal inflammation is unclear. GLP-2 promotes mucosal growth, decreases permeability and reduces inflammation in the intestine; physiological stimulation of GLP-2 release is triggered by nutrient contact. The authors hypothesized that ileal Crohn disease (CD) affects GLP-2 release.

METHODS: With ethics board approval, pediatric patients hospitalized with CD were studied; controls were recruited from local schools. Inclusion criteria were endoscopy-confirmed CD (primarily of the small intestine) with a disease activity index >150. Fasting and post-prandial GLP-2 levels and quantitative urinary recovery of orally administered 3-O-methyl-glucose (active transport) and lactulose/mannitol (passive) were quantified during the acute and remission phases.

RESULTS: Seven patients (mean [± SD] age 15.3±1.3 years) and 10 controls (10.3±1.6 years) were studied. In patients with active disease, fasting levels of GLP-2 remained stable but postprandial levels were reduced. Patients with active disease exhibited reduced glucose absorption and increased lactulose/mannitol recovery; all normalized with disease remission. The change in the lactulose/mannitol ratio was due to both reduced lactulose and increased mannitol absorption.

CONCLUSIONS: These findings suggest that pediatric patients with acute ileal CD have decreased postprandial GLP-2 release, reduced glucose absorption and increased intestinal permeability. Healing of CD resulted in normalization of postprandial GLP-2 release and mucosal functioning (nutrient absorption and permeability), the latter due to an increase in mucosal surface area. These findings have implications for the use of GLP-2 and feeding strategies as a therapy in CD patients; further studies of the effects of inflammation and the GLP-2 axis are recommended.
Loud Snoring is A Risk Factor for Occupational Injury in Farmers
Authors: Dosman James A , Hagel Louise , Skomro Robert , Sun Xiaoqun , Day Andrew G , Pickett William
Published: March 2016

BACKGROUND: Loud snoring is a common symptom in the general population. The evidence-based literature indicates that snoring may be associated with sleep fragmentation and sleep apnea, which may affect cognitive function and predispose to occupational injury. High rates of occupational injury occur on farms and may be related to personal and health factors. Thus, loud snoring may not be a trivial symptom and should be considered as important in medical assessments.

METHODS: A prospective cohort study was conducted in Saskatchewan. Baseline questionnaires were completed for 5502 individuals by representatives from 2390 farms. Sleep patterns at baseline were categorized as the following: no reported sleep disorders; physician-diagnosed sleep apnea (treatment unknown); and loud snoring. Survival analyses were used to relate sleep patterns with subsequent injury.

RESULTS: A total of 6.7% (369 of 5502) of participants reported a possible sleep disorder. Of these, 69.4% (256 of 369) reported loud snoring only. Loud snoring was only associated with a consistent increase in risk (eg, HR 1.45 [95 CI 1.07 to 1.99 for work-related injury]) for five farm injury outcomes. Relationships between physician-diagnosed sleep apnea and time to first injury were not significant, presumably because a diagnosis of sleep apnea implied treatment for sleep apnea.

DISCUSSION: Sleep disorders are an important potential risk factor for occupational injury on farms. Substantial proportions of farm residents report loud snoring and this is related to subsequent injury. Some of these cases may represent sleep fragmentation or undiagnosed obstructive sleep apnea. Identification and clinical management of sleep disorders related to snoring should be part of health assessments conducted by physicians.
Health Care Professionals’ Pain Narratives in Hospitalized Children’S Medical Records. Part 2: Structure and Content
Authors: Rashotte Judy , Harrison Denise , Coburn Geraldine , Yamada Janet , Stevens Bonnie J , the CIHR Team in Children’s Pain
Published: March 2016

BACKGROUND: Although clinical narratives – described as free‐text notations – have been noted to be a source of patient information, no studies have examined the composition of pain narratives in hospitalized children’s medical records.

OBJECTIVES: To describe the structure and content of health care professionals’ narratives related to hospitalized children’s acute pain.

METHODS: All pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized in 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was performed.

RESULTS: Three major structural elements with their respective categories and subcategories were identified: information sources, including clinician, patient, parent, dual and unknown; compositional archetypes, including baseline pain status, intermittent pain updates, single events, pain summation and pain management plan; and content, including pain declaration, pain assessment, pain intervention and multidimensional elements of care.

CONCLUSIONS: The present qualitative analysis revealed the multidimensionality of structure and content that was used to document hospitalized children’s acute pain. The findings have the potential to inform debate on whether the multidimensionality of pain narratives’ composition is a desirable feature of documentation and how narratives can be refined and improved. There is potential for further investigation into how health care professionals’ pain narratives could have a role in generating guidelines for best pain documentation practice beyond numerical representations of pain intensity.
Bile Acid Malabsorption in Chronic Diarrhea: Pathophysiology and Treatment
Authors: Barkun Alan , Love Jonathan , Gould Michael , Pluta Henryk , Steinhart A Hillary
Published: March 2016

BACKGROUND: Bile acid malabsorption (BAM) is a common but frequently under-recognized cause of chronic diarrhea, with an estimated prevalence of 4% to 5%.

METHODS: The published literature for the period 1965 to 2012 was examined for articles regarding the pathophysiology and treatment of BAM to provide an overview of the management of BAM in gastroenterology practice.

RESULTS: BAM is classified as type 1 (secondary to ileal dysfunction), type 2 (idiopathic) or type 3 (secondary to gastrointestinal disorders not associated with ileal dysfunction). The estimated prevalence of BAM is >90% in patients with resected Crohn disease (CD) and 11% to 52% of unresected CD patients (type 1); 33% in diarrhea-predominant irritable bowel syndrome (type 2); and is a frequent finding postcholecystectomy or postvagotomy (type 3). Investigations include BAM fecal bile acid assay, 23-seleno-25-homo-tauro-cholic acid (SeHCAT) testing and high-performance liquid chromatography of serum 7-α-OH-4-cholesten-3-one (C4), to determine the level of bile acid synthesis. A less time-consuming and expensive alternative in practice is an empirical trial of the bile acid sequestering agent cholestyramine. An estimated 70% to 96% of chronic diarrhea patients with BAM respond to short-course cholestyramine. Adverse effects include constipation, nausea, borborygmi, flatulence, bloating and abdominal pain. Other bile acid sequestering agents, such as colestipol and colesevelam, are currently being investigated for the treatment of BAM-associated diarrhea.

CONCLUSIONS: BAM is a common cause of chronic diarrhea presenting in gastroenterology practice. In accordance with current guidelines, an empirical trial of a bile acid sequestering agent is warranted as part of the clinical workup to rule out BAM.
Treatment of Chronic Hepatitis C Infection among Current And Former Injection Drug Users within a Multidisciplinary Treatment Model at a Community Health Centre
Authors: Newman Adam I , Beckstead Shelley , Beking David , Finch Susan , Knorr Tina , Lynch Carol , MacKenzie Meredith , Mayer Daphne , Melles Brenda , Shore Ron
Published: March 2016

The aim of the present prospective observational study was to assess uptake and success of hepatitis C virus (HCV) treatment among a group of former and current injection drug users with chronic HCV infection at the Street Health Centre in Kingston, Ontario. The Street Health Centre offers hepatitis C education, assessment and treatment within a multidisciplinary, integrated and collaborative treatment model of care delivered by primary care professionals. The study enrolled a convenience sample of 34 patients. Seventy per cent of study patients had no postsecondary education, 85% were unemployed and one-third were unstably housed. A majority of study patients self-reported mental health problems. Of the 14 patients who initiated antiviral treatment in the study period, eight (57%) achieved sustained virological response. Regardless of virological outcome, patients who initiated treatment showed positive trends toward increased social and psychiatric stability, and decreases in high-risk behaviours. These results suggest that not only is successful treatment of chronic HCV infection in current and former injection drug users with concurrent psychiatric disorders possible, but the benefits of such treatment delivered in a community-based, multidisciplinary, primary care model may extend beyond narrowly defined virological outcomes.
Endoscopic Submucosal Dissection in the Colorectum: Feasibility in the Canadian Setting
Authors: Iacucci Marietta , Eustace Gregory , Uraoka Toshio , Saito Yutaka , Gasia Miriam Fort , Love Jon , Yahagi Naohisa
Published: March 2016

Endoscopic submucosal dissection is a minimally invasive endoscopic technique for the removal of gastrointestinal tumours that is increasingly being used for colonic neoplasms to spare resection of colon in selected patients. Colonic endoscopic submucosal dissection is technically challenging and was initially pioneered in Japan but increasingly used in selected western centres. Its use in Canada is currently limited, and the authors review the challenges and opportunities, in addition to the unique training infrastructure required to practice the procedure under supervision. Specific tools are required to perform endoscopic submucosal dissection and meticulous attention to detail is essential. The authors provide a combined Japanese and Canadian perspective to this technique, and discuss training and performance of endoscopic submucosal dissection as well as potential indications.
Establishing a Normal Range for Induced Sputum Cell Counts in Western Canada
Authors: Davidson Warren J , The Stephanie , Leigh Richard
Published: March 2016

BACKGROUND: Induced sputum cell counts are a noninvasive, reliable method for evaluating the presence, type and degree of airway inflammation. Whether current reference values for induced sputum cell counts are applicable in other induced‐sputum laboratories, particularly those in Western Canada or at elevated altitude, is not clear.

OBJECTIVES: To describe the normal range of induced sputum cell counts in healthy adults in Western Canada.

METHODS: A total of 105 healthy nonsmoking adults with normal bronchial responsiveness and no history of lung disease proceeded with sputum induction. Sputum samples were fixed in formalin.

RESULTS: Sixty‐nine subjects were included in the final analyses. The mean ± SD and median (interquartile range) of the cell counts, respectively, were: total cell count 2.453±2.108, 2.000 (2.512); neutrophils 1.212±1.491, 0.721 (1.016); eosinophils 0.034±0.069, 0.005 (0.043); macrophages 1.050±1.213, 0.696 (1.005); lymphocytes 0.057±0.161, 0.001 (0.049); and bronchial epithelial cells 0.041±0.126, 0.000 (0.027). The respective differential cell percentages were: neutrophils 50.3±23.5, 51.9 (32); eosinophils 1.4±2.3, 0.3 (2); macrophages 43±22.8, 39.3 (32); lymphocytes 2.6±5.2, 0.4 (2.5); and bronchial epithelial cells 2.2±4.8, 0.0 (2.9). Bland‐Altman analysis and intraclass correlation coefficients revealed excellent interobserver agreement for measurement of sputum cell types.

DISCUSSION: The range of induced sputum cell counts performed in a laboratory in Western Canada in healthy nonsmoking adult subjects was described; cellular distributions were similar to previous studies. This was also the first description of normal values for formalin‐fixed induced sputum samples.

CONCLUSIONS: These results confirm that current reference values for induced sputum are generalizable across different laboratories, including those in Western Canada and those at elevated altitude, and are also generalizable to formalin‐fixed samples, allowing use in the broader Canadian asthma population.
A Delphi Study to Identify Indicators of Poorly Managed Pain for Pediatric Postoperative and Procedural Pain
Authors: Twycross Alison M , Chorney Jill MacLaren , McGrath Patrick J , Finley G Allen , Boliver Darlene M , Mifflin Katherine A
Published: March 2016

BACKGROUND: Adverse health care events are injuries occurring as a result of patient care. Significant acute pain is often caused by medical and surgical procedures in children, and it has been argued that undermanaged pain should be considered to be an adverse event. Indicators are often used to identify other potential adverse events. There are currently no validated indicators for undertreated pediatric pain.

OBJECTIVES: To develop a preliminary list of indicators of undermanaged pain in hospitalized pediatric patients.

METHODS: The Delphi technique was used to survey experts in pediatric pain management and quality improvement. The first round used an electronic questionnaire to ask: “In your opinion, what indicators would signify that acute pain in a child has not been adequately controlled?” Responses were grouped together in semantically similar themes, providing a list of possible adverse event indicators. Using this list, an electronic questionnaire was developed for round 2 asking respondents to indicate the importance of each potential indicator.

RESULTS: All but one indicator achieved a level of consensus ≥70%. Separate indicators emerged for postoperative and procedural pain. An additional distinction was made between indicators that could be identified by chart review and those requiring observation of practice and assessment from the child or parent.

DISCUSSION: The adverse care indicators developed in the present study require further refinement. There is a need to test their clinical usability and to determine whether these indicators actually identify undermanaged pain in clinical practice. The present study is an important first step in identifying undermanaged pain in hospital and treating it as an adverse event.

CONCLUSION: The adverse care indicators developed in the present study are the first step in conceptualizing mismanaged pain as an adverse event.
Patient-Identified Quality Indicators for Colonoscopy Services
Authors: Sewitch Maida J , Dubé Catherine , Brien Stephanie , Jiang Mengzhu , Hilsden Robert J , Barkun Alan N , Armstrong David
Published: March 2016

BACKGROUND: Current quality improvement tools for endoscopy services, such as the Global Rating Scale (GRS), emphasize the need for patient-centred care. However, there are no studies that have investigated patient expectations and/or perceptions of quality indicators in endoscopy services.

OBJECTIVES: To identify quality indicators for colonoscopy services from the patient perspective; to rate indicators of importance; to determine factors that influence indicator ratings; and to compare the identified indicators with those of the GRS.

METHODS: A two-phase mixed methods study was undertaken in Montreal (Quebec), Calgary (Alberta) and Hamilton (Ontario) among patients ≥18 years of age who spoke and read English or French. In phase 1, focus group participants identified quality indicators that were then used to construct a survey questionnaire. In phase 2, survey questionnaires, which were completed immediately after colonoscopy, prompted respondents to rate the 20 focus group-derived indicators according to their level of importance (low, medium, high) and to list up to nine additional items. Multiple logistic regression analysis was used to determine the factors that influenced focus group-derived indicator ratings. Patient-identified indicators were compared with those used in the GRS to identify novel indicators.

RESULTS: Three quality indicator themes were identified by 66 participants in 12 focus groups: communication, comfort and service environment. Of the 828 surveys distributed, 402 (48.6%) were returned and 65% of focus group-derived indicators were rated highly important by at least 55% of survey respondents. Indicator ratings differed according to age, sex, site and perceived colorectal cancer risk. Of the 29 patient-identified indicators, 17 (58.6%) were novel.

CONCLUSIONS: Patients identified 17 novel quality indicators, suggesting that patients and health professionals differ in their perspectives with respect to quality in colonoscopy services.
Relationship between the Number of Positive Fecal Occult Blood Tests and the Diagnostic Yield of Colonoscopy
Authors: Muinuddin Ahmad , Aslahi Ramona , Hopman Wilma M , Paterson William G
Published: March 2016

BACKGROUND: In 2007, Ontario launched a colon cancer screening program for average-risk individuals based on biennial fecal occult blood tests (FOBTs) on three fecal samples, followed by colonoscopy for individuals who tested positive.

OBJECTIVE: To determine whether >1 positive screening FOBT was predictive of finding advanced neoplasia at colonoscopy.

METHODS: A retrospective chart review of outpatient colonoscopic procedures performed at Hotel Dieu Hospital (Kingston, Ontario) in the first two years of the colon cancer screening program was conducted, focusing on endoscopic and pathological findings.

RESULTS: Of 5556 individuals undergoing colonoscopy, 346 were referred for positive FOBT. Overall, 41 (11.8%) patients with a positive FOBT had colon cancer. In 16 (4.6%) cases, the number of positive FOBTs was not reported. For the 330 individuals in whom the number of positive tests was specified, 198, 71 and 61 cases had one, two and three positive results, respectively. Cancer was found at colonoscopy in 11 (5.6%), 11 (15.5%) and 18 (29.5%) of individuals with one, two and three positive FOBT results, respectively (OR 3.0 [95% CI 1.2 to 7.3] and 6.5 [95% CI 2.8 to 15.0] for two or three positive FOBTs compared with one; P=0.015 and P<0.001, respectively). High-risk adenomas (>1 cm in diameter, villous component and/or high-grade dysplasia) were found in 41 (20.8%), 29 (42.0%) and 25 (41.0%) individuals with one, two and three positive FOBTs, respectively (OR 2.8 [95% CI 1.5 to 5.0] and 2.4 [95% CI 1.3 to 4.5] for two or three positive FOBTs compared with one; P=0.001 and P=0.006, respectively).

CONCLUSIONS: The diagnostic yield of colonoscopy varied directly with the number of positive FOBTs. This information may be useful in assigning scheduling priority for patients with positive FOBTs.
Summary of Guidelines for Infection Prevention and Control for Flexible Gastrointestinal Endoscopy
Authors: Hookey Lawrence , Armstrong David , Enns Rob , Matlow Anne , Singh Harminder , Love Jonathan
Published: March 2016

BACKGROUND: High-quality processes to ensure infection prevention and control in the delivery of safe endoscopy services are essential. In 2010, the Public Health Agency of Canada and the Canadian Association of Gastroenterology (CAG) developed a Canadian guideline for the reprocessing of flexible gastrointestinal endoscopy equipment.

METHODS: The CAG Endoscopy Committee carefully reviewed the 2010 guidelines and prepared an executive summary.

RESULTS: Key elements relevant to infection prevention and control for flexible gastrointestinal endoscopy were highlighted for each of the recommendations included in the 2010 document. The 2010 guidelines consist of seven sections, including administrative recommendations, as well as recommendations for endoscopy and endoscopy decontamination equipment, reprocessing endoscopes and accessories, endoscopy unit design, quality management, outbreak investigation and management, and classic and variant Creutzfeldt-Jakob Disease.

DISCUSSION: The recommendations for infection prevention and control for flexible gastrointestinal endoscopy are intended for all individuals with responsibility for endoscopes in all settings where endoscopy is performed.