bluuebunny/crossref_metadata_2025 huggingface dataset:
Helicobacter pyloriInfection and Markers of Gastric Cancer Risk in Alaska Native Persons: A Retrospective Case-Control Study
Authors: Keck James W , Miernyk Karen M , Bulkow Lisa R , Kelly Janet J , McMahon Brian J , Sacco Frank , Hennessy Thomas W , Bruce Michael G
Published: March 2016

BACKGROUND: Alaska Native persons experience gastric cancer incidence and mortality rates that are three to four times higher than in the general United States population.

OBJECTIVE: To evaluate pepsinogen I, pepsinogen I/II ratio, anti-Helicobacter pyloriand cytotoxin-associated gene A (CagA) antibody levels, and blood group for their associations with gastric cancer development in Alaska Native people.

METHODS: The present analysis was a retrospective case-control study that matched gastric cancers reported to the Alaska Native Tumor Registry from 1969 to 2008 to three controls on known demographic risk factors forH pyloriinfection, using sera from the Alaska Area Specimen Bank. Conditional logistic regression evaluated associations between serum markers and gastric cancer.

RESULTS: A total of 122 gastric cancer cases were included, with sera predating cancer diagnosis (mean = 13 years) and 346 matched controls. One hundred twelve cases (91.8%) and 285 controls (82.4%) had evidence of previous or ongoingH pyloriinfection as measured by anti-H pyloriantibody levels. Gastric cancer cases had a 2.63-fold increased odds of having positive anti-H pyloriantibodies compared with their matched controls (P=0.01). In a multivariate model, non-cardia gastric cancer (n=94) was associated with anti-H pyloriantibodies (adjusted OR 3.92; P=0.004) and low pepsinogen I level (adjusted OR 6.04; P=0.04). No association between gastric cancer and blood group, anti-CagA antibodies or pepsinogen I/II ratio was found.

CONCLUSION: Alaska Native people with gastric cancer had increased odds of previousH pyloriinfection. Low pepsinogen I level may function as a precancer marker for noncardia cancer.
The Relationship Between Hepatopulmonary Syndrome and Altitude
Authors: Valley Morgan A , Trotter James F , Thomas Deborah , Ginde Adit A , Lowenstein Steven R , Honigman Benjamin
Published: March 2016

BACKGROUND: In a previous small retrospective study, the authors reported that hepatopulmonary syndrome was less common among liver transplant candidates at high-altitude centres compared with low-altitude centres.

OBJECTIVE: To further explore the relationship between hepatopulmonary syndrome and altitude of residence in a larger patient cohort.

METHODS: A cohort of 65,264 liver transplant candidates in the Organ Procurement and Transplantation Network liver database between 1988 and 2006 was analyzed. Hepatopulmonary syndrome diagnosis was determined during a comprehensive evaluation at a liver transplant centre by physicians who were experienced in the diagnosis and treatment of hepatopulmonary syndrome. The altitude of residence was determined for each patient by assigning the mean altitude of the zip code of residence at the time of entry on the wait list. Mean zip code elevation was calculated using the National Elevation Dataset of the United States Geological Survey, which provides exact elevation measurements across the entire country.

RESULTS: Hepatopulmonary syndrome was significantly less common at higher resident altitudes (P=0.015). After adjusting for age, sex and Model for End-Stage Liver Disease score, there was a 46% decrease in the odds of hepatopulmonary syndrome with every increase of 1000 m of resident elevation (OR 0.54 [95% CI 0.33 to 0.89]).

CONCLUSION: There was a negative association between altitude and hepatopulmonary syndrome. One plausible explanation is that the lower ambient oxygen found at higher elevation leads to pulmonary vasoconstriction, which mitigates the primary physiological lesion of hepatopulmonary syndrome, namely, pulmonary vasodilation.
iCanCope with Pain™: User‐Centred Design of a Web‐ and Mobile‐Based Self‐Management Program for Youth with Chronic Pain Based on Identified Health Care Needs
Authors: Stinson Jennifer N , Lalloo Chitra , Harris Lauren , Isaac Lisa , Campbell Fiona , Brown Stephen , Ruskin Danielle , Gordon Allan , Galonski Marilyn , Pink Leah R , Buckley Norman , Henry James L , White Meghan , Karim Allia
Published: March 2016

BACKGROUND: While there are emerging web‐based self‐management programs for children and adolescents with chronic pain, there is currently not an integrated web‐ and smartphone‐based app that specifically addresses the needs of adolescents with chronic pain.

OBJECTIVES: To conduct a needs assessment to inform the development of an online chronic pain self‐management program for adolescents, called iCanCope with Pain™.

METHODS: A purposive sample of adolescents (n=23; 14 to 18 years of age) was recruited from two pediatric chronic pain clinics in Ontario. Interdisciplinary health care providers were also recruited from these sites. Three focus groups were conducted with adolescents (n=16) and one with pediatric health care providers (n=7). Individual adolescent interviews were also conducted (n=7).

RESULTS: Qualitative analysis uncovered four major themes: pain impact; barriers to care; pain management strategies; and transition to adult care. Pain impacted social, emotional, physical and role functioning, as well as future goals. Barriers to care were revealed at the health care system, patient and societal levels. Pain management strategies included support systems, and pharmacological, physical and psychological approaches. Transition subthemes were: disconnect between pediatric and adult systems; skills development; parental role; and fear/anxiety. Based on these identified needs, the iCanCope with Pain™ architecture will include the core theory‐based functionalities of: symptom self‐monitoring; personalized goal setting; pain coping skills training; peer‐based social support; and chronic pain education.

CONCLUSIONS: The proposed iCanCope with Pain™ program aims to address the self‐management needs of adolescents with chronic pain by improving access to disease information, strategies to manage symptoms and social support.
The Real‐Life Effectiveness of Palivizumab for Reducing Hospital Admissions for Respiratory Syncytial Virus in Infants Residing in Nunavut
Authors: Banerji Anna , Panzov Vladimir , Young Michael , Lee Bonita E , Mamdani Muhammad , Giles B Louise , Dennis Marguerite , Morel Johanne , Bisson Danny , Paes Bosco A , Hui Charles , Mahony Jim
Published: March 2016

BACKGROUND/OBJECTIVE: Nunavut has the highest hospitalization rates for respiratory syncytial virus (RSV) worldwide, with rates of 166 per 1000 live births per year <1 year of age. Palivizumab was implemented in Nunavut primarily for premature infants, or those with hemodynamically significant cardiac or chronic lung disease; however, the effectiveness of the program is unknown. The objective of the present multisite, hospital‐based surveillance study was to estimate the effectiveness of palivizumab in infants <6 months of age in Nunavut for the 2009 and 2010 RSV seasons.

METHODS: Infants identified as palivizumab candidates who were <6 months of age were compared with all admissions for lower respiratory tract infection through multisite, hospital‐based surveillance documenting the adequacy of palivizumab prophylaxis, admission for lower respiratory tract infection and the results of RSV testing. The OR for RSV admission in unprophylaxed infants was compared with those who were prophylaxed, and the effectiveness of palivizumab was estimated.

RESULTS: Within the study cohort (n=101) during the two RSV seasons, five of the 10 eligible infants who did not receive adequate prophylaxis were admitted with RSV while two of the 91 infants <6 months of age eligible for palivizumab who were adequately prophylaxed were hospitalized with RSV (OR 22.3 [95% CI 3.8 to 130]; P=0.0005). The estimated effectiveness of palivizumab for the cohort was as high as 96%. Eight eligible infants were missed by the program and did not receive prophylaxis.

CONCLUSION: Palivizumab was highly effective in reducing hospitalizations due to RSV infection in Nunavut. Further efforts need to be made to ensure that all eligible infants are identified.
Examination of Pulse Oximetry Tracings to Detect Obstructive Sleep Apnea in Patients with Advanced Chronic Obstructive Pulmonary Disease
Authors: Scott Adrienne S , Baltzan Marcel A , Wolkove Norman
Published: March 2016

Nocturnal hypoxemia and obstructive sleep apnea (OSA) are common comorbidities in patients with chronic obstructive pulmonary disease (COPD). The authors sought to develop a strategy to interpret nocturnal pulse oximetry and assess its capacity for detection of OSA in patients with stage 3 to stage 4 COPD. A review of consecutive patients with COPD who were clinically prescribed oximetry and polysomnography was conducted. OSA was diagnosed if the polysomnographic apnea‐hypopnea index was >15 events/h. Comprehensive criteria were developed for interpretation of pulse oximetry tracings through iterative validation and interscorer concordance of ≥80%. Criteria consisted of visually identified desaturation ‘events’ (sustained desaturation ≥4%, 1 h time scale), ‘patterns’ (≥3 similar desaturation/saturation cycles, 15 min time scale) and the automated oxygen desaturation index. The area under the curve (AUC), sensitivity, specificity and accuracy were calculated. Of 59 patients (27 male), 31 had OSA (53%). The mean forced expiratory volume in 1 s was 46% of predicted (range 21% to 74% of predicted) and 52% of patients were on long‐term oxygen therapy. Among 59 patients, 35 were correctly identified as having OSA or not having OSA, corresponding to an accuracy of 59%, with a sensitivity and specificity of 59% and 60%, respectively. The AUC was 0.57 (95% CI 0.55 to 0.59). Using software‐computed desaturation events (hypoxemia ≥4% for ≥10 s) indexed at ≥15 events/h of sleep as diagnostic criteria, sensitivity was 60%, specificity was 63% and the AUC was 0.64 (95%CI 0.62 to 0.66). No single criterion demonstrated important diagnostic utility. Pulse oximetry tracing interpretation had a modest diagnostic value in identifying OSA in patients with moderate to severe COPD.
A 47-Year-Old Stem Cell Transplant Recipient with Fever, Cough and Chest Pain
Authors: Salh Omar S , Nadhem Omar N , Thakore Sanket R , Halloush Ruba A , Khasawneh Faisal A
Published: March 2016

Infections and malignancies are among the most serious complications that follow organ or stem cell transplantation. They may have a mild course, and nonspecific and overlapping manifestations. The present article describes a case of symptomatic nodular pulmonary disease that complicated hematopoietic stem cell transplantation. It was diagnosed to be post-transplant lymphoproliferative disorder, a potential sequela of immunosuppression and a very difficult entity to treat in profoundly immunosuppressed patients.
Development and Validation of a Pneumocystis jirovecii Real‐time Polymerase Chain Reaction Assay for Diagnosis of Pneumocystis Pneumonia
Authors: Church Deirdre L , Ambasta Anshula , Wilmer Amanda , Williscroft Holly , Ritchie Gordon , Pillai Dylan R , Champagne Sylvie , Gregson Daniel G
Published: March 2016

BACKGROUND: Pneumocystis jirovecii (PJ), a pathogenic fungus, causes severe interstitial Pneumocystis pneumonia (PCP) among immunocompromised patients. A laboratory‐developed real‐time polyermase chain reaction (PCR) assay was validated for PJ detection to improve diagnosis of PCP.

METHODS: Forty stored bronchoalveolar lavage (BAL) samples (20 known PJ positive [PJ+] and 20 known PJ negative [PJ−]) were initially tested using the molecular assay. Ninety‐two sequentially collected BAL samples were then analyzed using an immunofluorescence assay (IFA) and secondarily tested using the PJ real‐time PCR assay. Discrepant results were resolved by retesting BAL samples using another real‐time PCR assay with a different target. PJ real‐time PCR assay performance was compared with the existing gold standard (ie, IFA) and a modified gold standard, in which a true positive was defined as a sample that tested positive in two of three methods in a patient suspected to have PCP.

RESULTS: Ninety of 132 (68%) BAL fluid samples were collected from immunocompromised patients. Thirteen of 92 (14%) BALs collected were PJ+ when tested using IFA. A total of 40 BAL samples were PJ+ in the present study including: all IFA positive samples (n=13); all referred PJ+ BAL samples (n=20); and seven additional BAL samples that were IFA negative, but positive using the modified gold standard. Compared with IFA, the PJ real‐time PCR had sensitivity, specificity, and positive and negative predictive values of 100%, 91%, 65% and 100%, respectively. Compared with the modified gold standard, PJ real‐time PCR had a sensitivity, specificity, and positive and negative predictive values of 100%.

CONCLUSION: PJ real‐time PCR improved detection of PJ in immunocompromised patients.
A Prospective Study of Percutaneous Vertebroplasty for Chronic Painful Osteoporotic Vertebral Compression Fracture
Authors: Tan Hong-Yu , Wang Li-Min , Zhao Liang , Liu Yi-Lin , Song Rui-Peng
Published: March 2016

BACKGROUND: Percutaneous vertebroplasty (PVP) for patients with chronic painful osteoporotic compression fractures has not been extensively studied.

OBJECTIVE: To prospectively evaluate the efficacy of PVP for patients with chronic painful osteoporotic vertebral compression fractures (VCFs).

METHODS: Sixty‐two consecutive patients with chronic painful osteoporotic VCFs for ≥3 months underwent PVP. All procedures were performed under local anesthesia. The outcomes were pain relief at one week, one month, three months, six months and one year, as measured by visual analogue scale, Oswestry Disability Index, Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) and Roland Morris Disability Questionnaire scores.

RESULTS: The PVP procedures were technically successful and well tolerated in all patients. Sixty‐two patients underwent PVP on 92 vertebrae in 73 procedures three to five days after referral, and no 30‐day mortality was observed. Compared with baseline scores, improvement in visual analogue scale, Oswestry Disability Index, QUALEFFO and Roland Morris Disability Questionnaire scores was significantly greater after PVP at one week (P<0.001), one month (P<0.001), three months (P<0.001), six months (P<0.001) and one year (P<0.001), and the number of patients using drugs for pain treatment was significantly reduced. Five new fractures were reported in five of 62 patients treated with PVP during follow‐up.

CONCLUSION: PVP is effective in patients with chronic painful osteoporotic VCFs. Pain relief after PVP was immediate, was sustained for one year and may be an important factor for reducing persistent pain.
Pulmonary Hemorrhage in Cryoglobulinemia
Authors: Kirkpatrick G , Winstone T , Wilcox P , Van Eeden S
Published: March 2016

Pulmonary manifestations of cryoglobulinemia are uncommon and their clinical behaviour is unpredictable, ranging from mild dyspnea to life‐threatening presentations. A patient with cryoglobulinemia who presented with hypoxic respiratory failure attributed to pulmonary hemorrhage is reported.
The Hepatitis C Genotype 1 Paradox: Cost per Treatment Is Increasing, but Cost per Cure Is Decreasing
Authors: Shafran Stephen D
Published: March 2016

Significant attention has been focused on the perceived increase in the cost of antiviral treatment for hepatitis C genotype 1 infection since the approval of the first direct-acting antiviral agents in 2011. Using Canadian list prices, the present analysis points out a paradox: while the cost per antiviral regimen is increasing, the cost per cure is decreasing, especially with interferon-free therapy. In a publicly funded health care system, the lowest cost per cure is a more valuable measure of value for public money than the cost per regimen.
Self‐Expandable Metallic Stents in Nonmalignant Large Airway Disease
Authors: Fortin Marc , MacEachern Paul , Hergott Christopher A , Chee Alex , Dumoulin Elaine , Tremblay Alain
Published: March 2016

Airway self‐expandable metallic stents (SEMS) were initially studied in malignant airway obstruction; however, their use in benign airway diseases has become progressively more frequent. This may be explained by their ease of insertion compared with silicone stents, which require rigid bronchoscopy for insertion. While initial experience with SEMS in benign disease suggested efficacy and promising short‐term safety profile, long‐term follow‐up revealed significant complication rates. In addition to a high complication rate, the management of these complications is made more difficult by the semipermanent nature of these devices. Reported complications include infection, granulation tissue formation, stent migration, stent fracture, airway perforation and fistula formation, as well as extension of the initial injury, potentially eliminating other therapeutic options such as surgical resection. Therefore, SEMS should only be used in nonmalignant large airway disease as a last resort for patients in whom other endoscopic methods, including silicone stents and dilations, as well as surgical options have failed or are technically not feasible.
The Relationship between Fibromyalgia and Pressure Pain Threshold in Patients with Dyspareunia
Authors: Terzi Hasan , Terzi Rabia , Kale Ahmet
Published: March 2016

OBJECTIVE: To evaluate the number of tender points, pressure pain threshold and presence of fibromyalgia among women with or without dyspareunia.

METHODS: The present cross‐sectional study included 40 patients with dyspareunia and 30 healthy controls. The participants were asked if they had engaged in sexual intercourse during the previous four weeks, and dyspareunia was rated from 0 to 3 based on the Marinoff Dyspareunia Scale. A pressure algometer (dolorimeter) was used to measure the pressure pain threshold. Fibromyalgia was diagnosed based on the 1990 American College of Rheumatology criteria. The depression status of the participants was assessed using the Beck Depression Inventory.

RESULTS: No statistically significant difference was found with regard to age, body mass index, habits (alcohol use and smoking), educational status and occupational status between the two groups. Total myalgic score, total control score and tender point mean pain threshold were significantly lower in the group with dyspareunia. The number of tender points was significantly higher in patients with dyspareunia. The mean Beck Depression Inventory score was 14.7 ±8.4 in the dyspareunia group compared with 11.2 ±7.1 in the control group. Five (12.5%) of the patients with dyspareunia were diagnosed with fibromyalgia, whereas no patients in the control group were diagnosed with fibromyalgia. There was no significant difference between the two groups with regard to the presence of fibromyalgia.

CONCLUSION: The finding of lower pressure pain thresholds and a higher number of tender points among patients with dyspareunia suggests that these patients may have increased generalized pain thresholds. Additional studies involving a larger number of patients are required to investigate the presence of central mechanisms in the pathogenesis of dyspareunia.
Inflammatory Bowel Disease Patients Are Frequently Nonadherent to Scheduled Induction and Maintenance Infliximab Therapy: A Canadian Cohort Study
Authors: Ma Christopher , Evaschesen Chad J , Gracias Grenvil , Huang Vivian W , Fedorak Darryl K , Kroeker Karen I , Dieleman Levinus A , Halloran Brendan P , Fedorak Richard N
Published: March 2016

BACKGROUND: Adherence to maintenance medication regimens in inflammatory bowel disease patients has traditionally been poor. Although infliximab has demonstrated efficacy in inducing and maintaining disease remission, adherence to regularly scheduled infliximab infusions is required to maintain therapeutic trough drug levels and prevent the development of anti-infliximab antibodies.

OBJECTIVES: To characterize patient adherence to regularly scheduled induction and maintenance infliximab infusions.

METHODS: A retrospective cohort study was conducted evaluating adult outpatients with Crohn disease or ulcerative colitis on an induction or maintenance regimen of regularly scheduled infliximab from 2008 to 2010 at the University of Alberta (Edmonton, Alberta). Nonadherence was defined by a discrepancy of >72 h between the scheduled date of infusion and the actual date of administration. Patients were defined as nonadherent if they received <80% of their infliximab infusions per schedule.

RESULTS: A total of 215 patients (173 Crohn disease, 42 ulcerative colitis) met the inclusion criteria. Patients received a median of 12.0 infliximab infusions (interquartile range 7.0 to 13.0) during the study period; 412 induction and 1837 maintenance infliximab infusions were administered. Of 140 patients, 109 (77.9%) were adherent to their infliximab induction regimen, while 68 of 215 (31.6%) were adherent to their infliximab maintenance regimen. One hundred ninety-eight of 215 (92.1%) patients received at least one delayed maintenance infliximab infusion and 20 (10.1%) received maintenance infusions, on average, >1 week late.

CONCLUSIONS: While three-quarters of patients are adherent to infliximab induction therapy, fewer than one-third remained adherent to their scheduled maintenance infliximab regimen.
Biomarkers as Potential Treatment Targets in Inflammatory Bowel Disease: A Systematic Review
Authors: Murdoch Travis B , O’Donnell Sarah , Silverberg Mark S , Panaccione Remo
Published: March 2016

There is increasing interest in the concept of ‘treat-to-target’ in inflammatory bowel disease as a mechanism to standardize management and prevent complications. While clinical, radiographic and endoscopic treatment end points will figure prominently in this promising management paradigm, the role that noninvasive biomarkers will play is currently undefined. The goal of the present systematic review was to investigate the potential value of biomarkers as treatment targets in inflammatory bowel disease, with particular focus on those best studied: serum C-reactive protein (CRP) and fecal calprotectin. In Crohn disease, elevated CRP levels at baseline predict response to anti-tumour necrosis factor agents, and normalization is usually associated with clinical and endoscopic remission. CRP and hemoglobin levels can be used to help predict clinical relapse in the context of withdrawal of therapy. Ultimately, the authors conclude that currently available biomarkers should not be used as treatment targets in inflammatory bowel disease because they have inadequate operational characteristics to make them safe surrogates for clinical, endoscopic and radiographic evaluation. However, CRP and fecal calprotectin are important adjunctive measures that help alert the clinician to pursue further investigation.
Efficacy of an Intrathecal Multidrug Infusion for Pain Control in Older Adults and in End‐Stage Malignancies: A Report of Three Cases
Authors: Abdolmohammadi Sadegh , Hétu Pierre-Olivier , Néron Andrée , Blaise Gilbert
Published: March 2016

The aim of the present study was to explore the effectiveness of an alternative method to manage pain based on a time‐limited intrathecal (IT) infusion of an analgesic medication mixture. Three patients (69, 64 and 94 years of age) with intractable and poorly controlled pain due to bed sores, pelvic metastatic mass, and thoracic vertebra and rib fractures, respectively, were treated. Daily doses of opioids could not be increased due to side effects. An IT catheter (20 G) was placed by percutaneous approach in the lumbar area while advancing toward the thoracic region, and was then tunnelled and fixed subcutaneously. It was connected to an external infusion pump with a mixture of bupivacaine 1 mg/mL, naloxone 0.02 ng/mL, ketamine 100 μg/mL, morphine 0.01 mg/mL and clonidine 0.75 μg/mL. The starting rate was 1 mL/h. The pain was mostly controlled at a rate of <1 mL/h. Opioid consumption was reduced dramatically. The catheter was kept in place for one month in the first and third patients, and for six months in the second patient, until his death. Major side effects, such as hypotension, constipation, muscle weakness, sphincter dysfunction, and cognitive or mood deterioration, were not observed with this approach. One patient experienced a urinary tract infection followed by sepsis and meningitis, which was cured by antibiotics. The catheter was removed in this patient. IT infusion with a low‐concentration multidrug mixture could be considered as an alternative modality for intractable pain relief in older adults or in malignancies.
Prospective Evaluation of Gastric Neurostimulation for Diabetic Gastroparesis in Canada
Authors: Panda Himanish , Mitchell Philip , Curley Michael , Buresi Michelle , Wilsack Lynn , Andrews Christopher N
Published: March 2016

BACKGROUND: The efficacy of gastric neurostimulation therapy for diabetic gastroparesis (GP) in a ‘real-life’ Canadian setting has not been assessed.

AIMS: To assess changes in health-related quality of life (QoL), weekly vomiting frequency (WVF), total symptom score (TSS) and health care utilization 12 months before and after gastric neurostimulator implantation in a diabetic GP cohort.

METHODS: Medication-refractory diabetic GP patients (n=7, four female, mean age 42 years) were prospectively recruited from 2008 to 2012. QoL scores were self-administered and obtained at baseline, 24 and 48 weeks postimplantion. WVF and TSS were assessed similarly. Health care usage, measured as hospitalization frequency and medication cost, was obtained six and 12 months before and after implant. Changes from baseline to six and 12 months for all outcomes were compared.

RESULTS: The mean (± SD) QoL according to EuroQol was significantly better at 24 weeks after the baseline measurement (baseline 29±5, 24 weeks 52±7; P=0.03). The mean improvement in TSS was significantly better at one year postintervention (baseline score 35±5 versus 12 months 27±3; P=0.03). Changes in Short-Form 36 Health Survey and WVF were not significant. Days of GP-related hospitalization were highly variable but decreased from a median of 71 days (range 0 to 227 days) to 29 days (range two to 334 days) one year before and after surgery, respectively (P=0.735). Outpatient medication costs did not decrease to a significant extent.

CONCLUSION: Gastric neurostimulation for diabetic GP appeared to show some beneficial palliative effects overall in the present small open-label series, but the effect is highly variable among patients, and placebo effect cannot be ruled out.
Canada’s National Advisory Committee on Immunization: Celebrating 50 Years
Authors: Desai Shalini , lsmail Shainoor J , Lerch Robert , Warshawsky Bryna F , Gemmill Ian
Published: March 2016

Vaccines have saved more lives than any other innovation in modern medicine. National immunization committees play a vital role in the development of evidence‐based recommendations for the use of vaccines. The present article describes the evolution and work of the National Advisory Committee on Immunization in Canada as the group marks its 50th anniversary. The article also provides insight into the future challenges that the committee is likely to face.
Stakeholder Views Regarding Patient Discharge from Intensive Care: Suboptimal Quality and Opportunities for Improvement
Authors: Li Pin , Boyd Jamie M , Ghali William A , Stelfox Henry T
Published: March 2016

OBJECTIVE: To provide the first description of intensive care unit (ICU) discharge practices from the perspective of Canadian ICU administrators, and ICU providers from Canada, the United States and the United Kingdom.

METHODS: The authors identified 140 Canadian ICUs and administered a survey to ICU administrators (unit manager, director) to obtain an institutional perspective. Also surveyed were members of professional critical care associations in Canada, the United States and the United Kingdom, using membership distribution lists, to obtain a provider perspective.

RESULTS: A total of 118 ICU administrators (114 ICUs [81%]) and 737 ICU providers (denominator unknown) responded to the survey. Administrator and provider respondents reported that ICU physicians are primarily responsible for determining the timing (70% and 77%, respectively) and safety (94% and 96%) for patients discharged from ICU. The majority of respondents indicated that patient summaries (87% and 85%) and medication reconciliation (78% and 79%) were part of their institutions’ discharge process. One‐half of respondents reported the use of discharge protocols, while a minority indicated that checklists (46% and 44%), electronic tools (19% and 28%) or outreach follow‐up (44% and 33%) were used. The majority of respondents rated current ICU discharge practices to be of medium quality (57% and 58% scored 3 on a five‐point scale). Suggested opportunities for improvement included the information provided to patients and families (71% and 59%) and collaboration among hospital units (65% and 66%).

CONCLUSION: Findings from the present study revealed the complexity of the ICU discharge process, considerable practice variation, perception of only medium quality and several proposed opportunities for improvement.
Mild Clinical Behaviour of Crohn Disease in Elderly Patients in a Latin American Country: A Case-Control Study
Authors: Yamamoto-Furusho Jesús K , Sarmiento-Aguilar Andrea
Published: March 2016

BACKGROUND: Crohn disease is characterized by fluctuating clinical behaviour, which is influenced by various factors. There are no data from Latin America that evaluate the clinical behaviour of Crohn disease in elderly patients.

OBJECTIVE: To evaluate the clinical course of elderly onset Crohn disease compared with younger onset in the Mexican population.

METHODS: The present analysis was a case-control study that included 132 patients with a histopathological diagnosis of Crohn disease between 1983 and 2013 in an inflammatory bowel disease clinic of a tertiary care centre. Statistical analysis was performed using SPSS version 17 (IBM Corporation, USA) and descriptive statistics, χ2and Fisher’s exact test for categorical variables and Student’sttest for numerical variables. Univariate and multivariate analysis were performed to identify associated risk factors and OR was calculated.

RESULTS: A total of 132 patients (73 men and 59 women) were divided into two groups according to age at diagnosis: 27 cases (>60 years of age) and 105 controls (≤60 years of age). Factors influencing the clinical course of Crohn disease in the elderly were: female sex (OR 2.55 [95% CI 1.06 to 6.10]; P=0.02); colonic location (OR 0.22 [95% CI 0.03 to 0.89]; P=0.02); mild clinical behaviour of disease (OR 10.08 [95% CI 3.74 to 27.17]; P=0.0001); response to medical treatment (OR 2.85 [95% CI 1.08 to 7.48]; P=0.02); frequent use of sulfasalazine (OR 4.46 [95% CI 1.22 to 16.28]; P=0.03); less use of azathioprine (OR 0.38 [95% CI 0.13 to 1.03]; P=0.04); and long-term remission (OR 4.96 [95% CI 1.70 to 14.48]; P=0.002).

CONCLUSION: Elderly patients with Crohn disease had a mild clinical course characterized by the lack of escalation to immunosuppressive and anti-tumour necrosis factor therapy, as well as long-term remission.
Is There an Association between Symptoms of Anxiety and Depression and Quality of Life in Patients with Chronic Obstructive Pulmonary Disease?
Authors: Parreira Verônica F , Kirkwood Renata N , Towns Megan , Aganon Isabel , Barrett Lauren , Darling Catherine , Lee Michelle , Hill Kylie , Goldstein Roger S , Brooks Dina
Published: March 2016

BACKGROUND: In addition to symptoms, such as dyspnea and fatigue, patients with chronic obstructive pulmonary disease (COPD) also experience mood disturbances.

OBJECTIVE: To explore the relationships between health‐related quality of life measures collected from patients with stable COPD and a commonly used measure of depression and anxiety.

METHODS: The present analysis was a retrospective study of patients with COPD enrolled in a pulmonary rehabilitation program. Hospital Anxiety and Depression Scale (HADS), Chronic Respiratory Disease Questionnaire (CRQ), Medical Research Council dyspnea scale and 6 min walk test data were collected. Statistical analyses were performed using Spearman’s correlations, and categorical regression and categorical principal component analysis were interpreted using the biplot methodology.

RESULTS: HADS anxiety scores retrieved from 80 patients were grouped as ‘no anxiety’ (n=43 [54%]), ‘probable anxiety’ (n=21 [26%]) and ‘presence of anxiety’ (n=16 [20%]). HADS depression scores were similarly grouped. There was a moderate relationship between the anxiety subscale of the HADS and both the emotional function (r=−0.519; P<0.01) and mastery (r=−0.553; P<0.01) domains of the CRQ. Categorical regression showed that the CRQ‐mastery domain explained 40% of the total variation in anxiety. A principal component analysis biplot showed that the highest distance between the groups was along the mastery domain, which separated patients without feelings of anxiety from those with anxiety. However, none of the CRQ domains were able to discriminate the three depression groups.

CONCLUSIONS: The CRQ‐mastery domain may identify symptoms of anxiety in patients with COPD; however, the relationship is not strong enough to use the CRQ‐mastery domain as a surrogate measure. None of the CRQ domains were able to discriminate the three depression groups (no depression, probable and presence); therefore, specific, validated tools to identify symptoms of depression should be used.
Venous Thromboprophylaxis in Gastrointestinal Bleeding
Authors: Malhotra Neel , Chande Nilesh
Published: March 2016

OBJECTIVE: To study the use of venous thromboembolism (VTE) prophylaxis and the incidence of thrombotic events in patients with acute gastrointestinal (GI) bleeding.

METHODS: Individuals admitted with a primary diagnosis of a GI bleed along with any endoscopically confirmed source (over a two-year period) were included. Patient comorbidity and data regarding anticoagulation or antiplatelet agent use before hospitalization were collected, in addition to type of VTE prophylaxis and duration of treatment. The primary end point was the development of VTE (deep vein thrombosis or pulmonary embolism) within one year of presentation.

RESULTS: Data from 504 patients admitted with GI bleeding were eligible for review. The total number of VTE events was 20 (4%) while the mortality rate during hospitalization was 4.6%; 397 patients were not given VTE prophylaxis during their hospitalization. Of the patients who were given VTE prophylaxis, 68 received prophylactic heparin or heparin derivatives during their admission. One hundred sixty-five patients had at least one other significant risk factor for VTE including recent or subsequent surgery, past thrombotic event or malignancy. The incidence of thrombosis in those with significant risk factors for VTE was significantly higher than those without (8.5% versus 1.8%; P=0.0009). Overall, there was no significant difference in thrombotic events between individuals receiving pharmacological prophylaxis (1.2%) and those who did not (2.8%) (P=0.4).

CONCLUSION: Overall, VTE prophylaxis did not significantly affect thrombotic events in patients admitted for an active GI bleed.
An Elderly Long‐Term Care Resident with Crusted Scabies
Authors: Sandre Matthew , Ralevski Filip , Rau Neil
Published: March 2016

Crusted scabies is a highly contagious form of scabies. Altered immune response, nutritional deficiencies and modified host response are all risk factors for crusted scabies. The authors report a case involving a patient found to have a chronic maculopapular, erythematous rash with large hyperkeratotic, white and grey plaques on the soles of both feet. An ultimate diagnosis of crusted scabies was reached after a delay in diagnosis suspected to be caused by the similarity in appearance to more common skin conditions such as psoriasis. After topical permethrin was unsuccessful, intermittent dosing of oral ivermectin resulted in a rapid reduction in cutaneous plaques.
Effects of One-Week Tongue-Task Training on Sleep Apnea Severity: A Pilot Study
Authors: Rousseau Eric , Melo-Silva César Augusto , Gakwaya Simon , Sériès Frédéric
Published: March 2016

The aim of the present study was to assess the effects of one-week tongue-task training (TTT) on sleep apnea severity in sleep apnea subjects. Ten patients with sleep apnea (seven men, mean [± SD] age 52±8 years; mean apnea-hypopnea [AHI] index 20.9±5.3 events/h) underwent 1 h TTT in the authors’ laboratory on seven consecutive days. A complete or limited recording and tongue maximal protruding force were assessed before and after one-week TTT. One-week TTT was associated with a global AHI decrease (pre-TTT: 20.9±5.3 events/h; post-TTT: 16.1±5.1 events/h; P<0.001) and AHI decrease during rapid eye movement sleep (pre-TTT: 32.2±18.4 events/h; post-TTT: 16.7±6.6 events/h; P=0.03), while protruding force remained unchanged. The authors consider these results to be potentially clinically relevant and worthy of further investigation in a large randomized trial.
Dynamic Mechanical Assessment of Muscle Hyperalgesia in Humans: The Dynamic Algometer
Authors: Finocchietti Sara , Graven-Nielsen Thomas , Arendt-Nielsen Lars
Published: March 2016

BACKGROUND: Musculoskeletal pain is often associated with a nonhomogeneous distribution of mechanical hyperalgesia. Consequently, new methods able to detect this distribution are needed.

OBJECTIVE: To develop and test a new method for assessing muscle hyperalgesia with high temporal and spatial resolution that provides complementary information compared with information obtained by traditional static pressure algometry.

METHODS: The dynamic pressure algometer was tested bilaterally on the tibialis anterior muscle in 15 healthy subjects and compared with static pressure algometry. The device consisted of a wheel that was rolled over the muscle tissue with a fixed velocity and different predefined forces. The pain threshold force was determined and pain intensity to a fixed‐force stimulation was continuously rated on a visual analogue scale while the wheel was rolling over the muscle. The pressure pain sensitivity was evaluated before, during, and after muscle pain and hyperalgesia induced unilaterally by either injection of hypertonic saline (0.5 mL, 6%) into the tibialis anterior or eccentric exercise evoking delayed‐onset muscle soreness (DOMS).

RESULTS: The intraclass correlation coefficient was >0.88 for the dynamic thresholds; thus, the method was reliable. Compared with baseline, both techniques detected hyperalgesia at the saline injection site and during DOMS (P<0.05). The dynamic algometer also detected the widespread, patchy distribution of sensitive loci during DOMS, which was difficult to evaluate using static pressure algometry.

DISCUSSION AND CONCLUSION: The present study showed that dynamic pressure algometry is a reliable tool for evaluating muscle hyperalgesia (threshold and pain rating) with high temporal and spatial resolution. It can be applied as a simple clinical bed‐side test and as a quantitative tool in pharmacological profiling studies.
Corticosteroid Therapy in Critical Illness due to Seasonal and Pandemic Influenza
Authors: Yale Philippe , Adhikari Neill KJ , Masse Vincent , Fowler Robert A , Xiong Wei , McGeer Allison , Cann Darlene , Rudnick Wallis , Green Karen , Meade Maureen O , Valiquette Louis , Lamontagne François
Published: March 2016

BACKGROUND: Survey data suggest that Canadian intensivists administer corticosteroids to critically ill patients primarily in response to airway obstruction, perceived risk for adrenal insufficiency and hemodynamic instability.

OBJECTIVE: To describe variables independently associated with systemic corticosteroid therapy during an influenza outbreak.

METHODS: The present analysis was retrospective cohort study involving critically ill patients with influenza in two Canadian cities. Hospital records were reviewed for critically ill patients treated in the intensive care units (ICUs) of eight hospitals in Canada during the 2008 to 2009 and 2009 to 2010 influenza outbreaks. Abstracted data included demographic information, symptoms at disease onset, chronic comorbidities and baseline illness severity scores. Corticosteroid use data were extracted for every ICU day and expressed as hydrocortisone dose equivalent in mg. Multivariable regression models were constructed to identify variables independently associated with corticosteroid therapy in the ICU.

RESULTS: The study cohort included 90 patients with a mean (± SD) age of 55.0±17.3 years and Acute Physiology and Chronic Health Evaluation II score of 19.8±8.3. Patients in 2009 to 2010 were younger with more severe lung injury but similar exposure to corticosteroids. Overall, 54% of patients received corticosteroids at a mean daily dose of 343±330 mg of hydrocortisone for 8.5±4.8 days. Variables independently associated with corticosteroid therapy in the ICU were history of airway obstruction (OR 4.8 [95% CI 1.6 to 14.9]) and hemodynamic instability (OR 4.6 [95% CI 1.2 to 17.8]).

CONCLUSION: Observational data revealed that hemodynamic instability and airway obstruction were associated with corticosteroid therapy in the critical care setting, similar to a recent survey of stated practice. Efforts to determine the effects of corticosteroids in the ICU for these specific clinical situations are warranted.
An Update on the Management of Chronic Hepatitis C: 2015 Consensus Guidelines from the Canadian Association for the Study of the Liver
Authors: Myers Robert P , Shah Hemant , Burak Kelly W , Cooper Curtis , Feld Jordan J
Published: March 2016

Chronic hepatitis C remains a significant medical and economic burden in Canada, affecting nearly 1% of the population. Since the last Canadian consensus conference on the management of chronic hepatitis C, major advances have occurred that warrant a review of recommended management approaches for these patients. Specifically, direct-acting antiviral agents with dramatically improved rates of virological clearance compared with standard therapy have been developed and interferon-free, all-oral antiviral regimens have been approved. In light of this new evidence, an update to the 2012 Canadian Association for the Study of the Liver consensus guidelines on the management of hepatitis C was produced. The present document reviews the epidemiology of hepatitis C in Canada, preferred diagnostic testing approaches and recommendations for the treatment of chronically infected patients with the newly approved antiviral agents, including those who have previously failed peginterferon and ribavirin-based therapy. In addition, recommendations are made regarding approaches to reducing the burden of hepatitis C in Canada.
Preventing Ophthalmia Neonatorum
Authors: Moore Dorothy L , MacDonald Noni E , Canadian Paediatric Society, Infectious Diseases and Immuniz
Published: March 2016

The use of silver nitrate as prophylaxis for neonatal ophthalmia was instituted in the late 1800s to prevent the devastating effects of neonatal ocular infection with Neisseria gonorrhoeae. At that time – during the preantibiotic era – many countries made such prophylaxis mandatory by law. Today, neonatal gonococcal ophthalmia is rare in Canada, but ocular prophylaxis for this condition remains mandatory in some provinces/ territories. Silver nitrate drops are no longer available and erythromycin, the only ophthalmic antibiotic eye ointment currently available for use in newborns, is of questionable efficacy. Ocular prophylaxis is not effective in preventing chlamydial conjunctivitis. Applying medication to the eyes of newborns may result in mild eye irritation and has been perceived by some parents as interfering with mother‐infant bonding. Physicians caring for newborns should advocate for rescinding mandatory ocular prophylaxis laws. More effective means of preventing ophthalmia neonatorum include screening all pregnant women for gonorrhea and chlamydia infection, and treatment and follow‐up of those found to be infected. Mothers who were not screened should be tested at delivery. Infants of mothers with untreated gonococcal infection at delivery should receive ceftriaxone. Infants exposed to chlamydia at delivery should be followed closely for signs of infection.
Empowering Family Physicians to Impart Proper Inhaler Teaching to Patients with Chronic Obstructive Pulmonary Disease and Asthma
Authors: Leung Janice M , Bhutani Mohit , Leigh Richard , Pelletier Dan , Good Cathy , Sin Don D
Published: March 2016

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) and asthma depend on inhalers for management, but critical errors committed during inhaler use can limit drug effectiveness. Outpatient education in inhaler technique remains inconsistent due to limited resources and inadequate provider knowledge.

OBJECTIVE: To determine whether a simple, two‐session inhaler education program can improve physician attitudes toward inhaler teaching in primary care practice.

METHODS: An inhaler education program with small‐group hands‐on device training was instituted for family physicians (FP) in British Columbia and Alberta. Sessions were spaced one to three months apart. All critical errors were corrected in the first session. Questionnaires surveying current inhaler teaching practices and attitudes toward inhaler teaching were distributed to physicians before and after the program.

RESULTS: Forty‐one (60%) of a total 68 participating FPs completed both before and after program questionnaires. Before the program, only 20 (49%) reported providing some form of inhaler teaching in their practices, and only four (10%) felt fully competent to teach patients inhaler technique. After the program, 40 (98%) rated their inhaler teaching as good to excellent. Thirty‐four (83%) reported providing inhaler teaching in their practices, either by themselves or by an allied health care professional they had personally trained. All stated they could teach inhaler technique within 5 min. Observation of FPs during the second session by certified respiratory educators found that none made critical errors and all had excellent technique.

CONCLUSION: A physician inhaler education program can improve attitudes toward inhaler teaching and facilitate implementation in clinical practices.
Staphylococcus pettenkoferi Bacteremia: A Case Report and Review of the Literature
Authors: Hashi Abdulaziz Ahmed , Delport Johannes Andries , Elsayed Sameer , Silverman Michael Seth
Published: March 2016

Staphylococcus pettenkoferi is a relatively recently described coagulase‐negative staphylococci species first described in 2002. Since then, nine additional cases of infection caused by this species have been reported in various countries around the world, including Germany, Belgium, France, South Korea, Italy, Brazil and Mexico. The present report describes a case of S pettenkoferi peripheral line‐associated bacteremia. To our knowledge, the present report is the first description of human infection caused by S pettenkoferi in Canada. The present report also provides an overview of the laboratory detection of uncommon coagulase‐negative staphylococci.