bluuebunny/crossref_metadata_2025 huggingface dataset:
Successful Treatment of Uncomplicated Gonococcal Urethritis in HIV‐Infected Patients with Single‐Dose Oral Cefpodoxime
Authors: Psevdos George , Sharp Victoria
Published: March 2016

Fluoroquinolones are no longer recommended for the treatment of gonococcal infections in the United States. Cephalosporins – ceftriaxone and cefixime – are the treatment of choice, as suggested by the Centers for Disease Control and Prevention (USA). There are limited data on the efficacy of cefpodoxime for the treatment of uncomplicated gonococcal infections. Two cases of HIV‐infected homosexual men who were successfully treated with cefpodoxime for urethritis caused by Neisseria gonorrhoeae are described in the present study.
A Case of Pott’s Disease with Epidural Abscess and Probable Cerebral Tuberculoma following Bacillus Calmette‐Guérin Therapy for Superficial Bladder Cancer
Authors: Josephson Colin B , Al-Azri Saleh , Smyth Daniel J , Haase David , Johnston B Lynn
Published: March 2016

Intravesical Bacillus Calmette‐Guérin (BCG) immunotherapy is an accepted treatment for transitional cell carcinoma of the bladder. Carcinoma in situ of the bladder progresses to invasive muscular disease in approximately 54% of untreated patients, mandating early initiation of therapy once the diagnosis is confirmed. Should BCG treatment fail, an additional course of BCG combined with interferon‐alpha, both administered intravesically, is a promising second‐line immunotherapy. In greater than 95% of patients, BCG is tolerated without significant morbidity or mortality. However, both early (within three months of the original treatment) and late presentations of systemic infection resulting from intravesical BCG treatment have been described. The present study describes the course of a 75‐year‐old man with a late presentation of BCG vertebral osteomyelitis, discitis, epidural abscess, bilateral psoas abscesses and probable cerebral tuberculoma, following treatment regimens of intravesical BCG followed by intravesical BCG plus interferon‐alpha 2b.
Differential Impact of Lactose/Lactase Phenotype on Colonic Microflora
Authors: Szilagyi Andrew , Shrier Ian , Heilpern Debra , Je Jung Sung , Park Sunghoon , Chong George , Lalonde Catherine , Cote Louis-Francois , Lee Byong
Published: March 2016

BACKGROUND: The ability to digest lactose divides the world’s population into two phenotypes that may be risk variability markers for several diseases. Prebiotic effects likely favour lactose maldigesters who experience lactose spilling into their colon.

OBJECTIVE: To evaluate the effects of fixed-dose lactose solutions on fecal bifidobacteria and lactobacilli in digesters and maldigesters, and to determine whether the concept of a difference in ability to digest lactose is supported.

METHODS: A four-week study was performed in 23 lactose mal-digesters and 18 digesters. Following two weeks of dairy food withdrawal, subjects ingested 25 g of lactose twice a day for two weeks. Stool bifidobacteria and lactobacilli counts pre- and postintervention were measured as the primary outcome. For secondary outcomes, total anaerobes, Enterobacteriaceae, beta-galactosidase and N-acetyl-beta-D-glucosaminidase activity in stool, as well as breath hydrogen and symptoms following lactose challenge tests, were measured.

RESULTS: Lactose maldigesters had a mean change difference (0.72 log10colony forming units/g stool; P=0.04) in bifidobacteria counts compared with lactose digesters. Lactobacilli counts were increased, but not significantly. Nevertheless, reduced breath hydrogen after lactose ingestion correlated with lactobacilli (r=−0.5; P<0.001). Reduced total breath hydrogen and symptom scores together, with a rise in fecal enzymes after intervention, were appropriate, but not significant.

CONCLUSIONS: Despite failure to achieve full colonic adaptation, the present study provided evidence for a differential impact of lactose on microflora depending on genetic lactase status. A prebiotic effect was evident in lactose maldigesters but not in lactose digesters. This may play a role in modifying the mechanisms of certain disease risks related to dairy food consumption between the two phenotypes.
Piperacillin‐Associated Pulmonary Infiltrates with Eosinophilia: A Case Report
Authors: Tseng Olivia Ling-I , Kelsall John Thomas , Wilcox Pearce George
Published: March 2016

A case of pulmonary infiltrates with eosinophilia attributed to piperacillin/tazobactam therapy is described. A 54‐year‐old woman was treated for a suspected severe urinary tract infection with piperacillin/tazobactam. Four days later, she developed fever, chills, shortness of breath and intermittent chest pains. Eosinophilia was noted in peripheral blood and, subsequently, on bronchoalveolar lavage. Transbronchial biopsy showed tissue infiltrates with eosinophilia. No evidence of bacterial, fungal and parasitic infection, or vasculitis was observed. Her symptoms and peripheral eosinophilia subsided after drug discontinuation and oral prednisone treatment. Piperacillin is an extended‐spectrum penicillin antibiotic prescribed for moderate to severe infections. The common adverse reactions to piperacillin include nausea, vomiting, diarrhea and rash. Pulmonary infiltrates with eosinophilia is a rare adverse reaction, but one that may result in significant morbidity. Physicians should be aware of this rare but important adverse reaction to piperacillin.
Role of Age at Asthma Diagnosis in the Asthma-Obesity Relationship
Authors: Dogra Shilpa , Baker Joseph , Ardern Chris I
Published: March 2016

OBJECTIVE: To determine whether age at asthma diagnosis has an impact on the previously described relationship between asthma and obesity.

METHODS: Data were provided from Cycle 1.1 (2000/2001) of the Canadian Community Health Survey, a nationally representative health survey that included 6871 participants (2464 males and 4407 females) with asthma. Body mass index was used to categorize participants as normal weight (18.5 kg/m2to 24.9 kg/m2), overweight (25 kg/m2to 29.9 kg/m2) or obese (30 kg/m2or greater). Multivariate logistic regression analyses were used to estimate the odds of overweight and obesity by self-reported age at asthma diagnosis, after accounting for current age and other covariables.

RESULTS: In fully adjusted models, males diagnosed with asthma during adolescence (12 to 20 years of age) were at elevated odds of obesity (OR 1.58; 95% CI 1.03 to 2.43) compared with asthmatic patients diagnosed during childhood (0 to 11 years of age). Women diagnosed with asthma in mid life (21 to 44 years of age) and later life (45 to 64 years of age) were 43% (OR 1.43; 95% CI 1.08 to 1.90) and 56% (OR 1.56; 95% CI 1.00 to 2.44) more likely to be obese than those diagnosed in childhood, respectively.

CONCLUSIONS: The impact of age at asthma diagnosis on the asthma-obesity relationship differed between males and females. However, the identification of high-risk groups of asthmatic patients may strengthen primary prevention strategies for obesity and related comorbidities at multiple levels of influence.
Treatment of Pulmonary Hypertension in Patients with Connective Tissue Disease and Interstitial Lung Disease
Authors: Mittoo Shikha , Jacob Thomas , Craig Andrea , Bshouty Zoheir
Published: March 2016

BACKGROUND: Pulmonary hypertension (PH) in patients with connective tissue disease (CTD) can occur in isolation or concomitantly with interstitial lung disease (ILD). Targeted therapies for PH can mitigate clinical deterioration in CTD patients with isolated PH; however, the effect of these therapies in CTD patients with PH and ILD (CTD-PH-ILD) are poorly characterized.

OBJECTIVE: To investigate outcomes following long-term treatment of PH in patients with CTD-PH-ILD.

METHODS: A retrospective evaluation of 13 CTD-PH-ILD patients who were treated with bosentan, sildenafil or bosentan plus sildenafil, was conducted. Immunosuppressants were prescribed as indicated. Patients underwent pulmonary function testing and assessment of 6 min walk distance at the time of treatment initiation and during follow-up. Patients were followed until time of death, lung transplantation or the end of the study. Kaplan-Meier estimates of survival were calculated and log-rank testing was used to analyze survival differences according to CTD subtype.

RESULTS: Thirteen patients (seven with systemic sclerosis [SSc], four with overlap syndrome, and two with rheumatoid arthritis) were followed for a mean (± SD) duration of 33.8±21.7 months. The survival estimate at a median duration of 34 months was 85%; two patients with SSc died. Mortality rates were greater among patients with SSc versus other CTD subtypes (P=0.04). No changes from baseline to follow-up in mean forced vital capacity or exercise capacity, and no treatment-related toxicity, were observed.

CONCLUSION: Treatment using PH-specific therapies in patients with CTD, PH and ILD was well tolerated. Further studies to investigate the efficacy of PH-specific therapies in CTD-PH-ILD patients are warranted.
Systematic Review of Invasive Acinetobacter Infections in Children
Authors: Hu Jia , Robinson Joan L
Published: March 2016

INTRODUCTION: Clinicians are generally familiar with Acinetobacter as an etiological agent for serious nosocomial infections in intensive care units. However, there are no previous reviews of the full spectrum of invasive infections in children.

METHODS: A systematic review of the literature was completed up to December 2008 for reports of invasive Acinetobacter infections in children.

RESULTS: There were 101 studies that met the inclusion criteria including 18 possible outbreaks, 33 case series and 49 case reports. Suspected outbreaks were concentrated in neonatal intensive care units (16 of 18 outbreaks) and involved bacteremia or meningitis. Proof of isolate clonality or identification of the source of the outbreak was seldom established. Case series were primarily of children younger than five years of age presenting with bacteremia (sometimes multiresistant), meningitis, endocarditis or endophthalmitis, with many community‐acquired infections being reported from India. Case reports consisted of unique presentations of disease or the use of novel therapies. Attributable mortality in the outbreaks and case series combined was 68 of 469 (14.5%).

DISCUSSION: Invasive Acinetobacter infections in children usually manifest as bacteremia, meningitis or both, but can result in a wide variety of clinical presentations. Outbreaks are primarily a problem in newborns with underlying medical conditions. Most reports of community‐acquired infections are from tropical countries. The study of the mechanism of colonization and infection of children in intensive care units and of neonates in tropical countries may provide some insight into prevention of invasive infections.
Wait Times from Presentation to Treatment for Colorectal Cancer: A Population-Based Study
Authors: Singh H , De Coster C , Shu E , Fradette K , Latosinksy S , Pitz M , Cheang M , Turner D
Published: March 2016

BACKGROUND: The wait time from cancer diagnosis to treatment has been a recent focus of cancer care in Canada.

OBJECTIVE: To examine the trends in wait times from patient presentation to treatment (overall health system wait time [OWT]) for colorectal cancer (CRC).

METHODS: Patients with colorectal adenocarcinomas, diagnosed between 2001 and 2005, and their first definitive treatments were identified from the population-based Manitoba Cancer Registry (Winnipeg, Manitoba). By linkage to Manitoba Health and Healthy Living’s administrative databases, a patient’s first gastrointestinal investigation (abdominal radiological imaging, lower gastrointestinal endoscopy or fecal occult blood test) before CRC diagnosis was identified. The index contact with the health care system was estimated from the date of the visit with the physician who ordered the first gastroenterological investigation. The OWT was defined as the time from the index contact to the first treatment, while diagnostic delay was defined as the time from the index contact to the diagnosis of CRC. Multivariate Cox regression analysis was performed to determine independent predictors of OWT.

RESULTS: The OWT was estimated for 2552 cases of CRC over the five years that were examined. The median OWT increased from 61 days in 2001 to 95 days in 2005 (P<0.001). Most of the increase was in diagnostic wait times (median of 44 days in 2001 versus 64 days in 2005 [P<0.001]). Year of diagnosis, older age, urban residence and diagnosis at a teaching facility were independent predictors of OWT.

CONCLUSIONS: The OWT from presentation to treatment of CRC in Manitoba steadily increased between 2001 and 2005, mostly due to diagnostic delays.
Bilateral Killian-Jamieson Diverticula: A Case Report and Literature Review
Authors: Boisvert René D , Bethune Drew CG , Acton David , Klassen Denis R
Published: March 2016

A Killian-Jamieson diverticulum is an outpouching from the lateral wall of the proximal cervical esophagus. These diverticula are rare and are distinct from the more commonly known Zenker’s diverticulum. Literature regarding Killian-Jamieson diverticula and its suggested management is scarce. The present report describes a patient with symptomatic bilateral Killian-Jamieson diverticula. The patient had both diverticula excised and an esophagomyotomy performed. Following surgery, the patient’s symptoms resolved and he recovered well. A literature review and discussion of the etiology, clinical presentation and radiographic findings of Killian-Jamieson diverticulum follow, as do recommendations for clinical management.
Adamantane Resistance in Seasonal Human Influenza A Viruses from Calgary, Alberta (January 2007 to August 2008)
Authors: Pabbaraju Kanti , Wong Sallene , Kits Dmitri K , Fox Julie D
Published: March 2016

The available antivirals for the treatment and prophylaxis of influenza A infections include the adamantanes (amantadine and rimantadine), which are matrix (M2) protein inhibitors, and the neuraminidase inhibitors (oseltamivir and zanamivir). Resistance to the adamantanes is conferred by mutations at amino acid positions 26, 27, 30, 31 or 34 within the M2 protein of influenza A viruses. A significant increase in adamantane resistance has been reported worldwide since 2003, reflected by a similar increase in Canada. The present study reports on the frequency of adamantane resistance in seasonal influenza A viruses in Calgary, Alberta, for the period between January 2007 and August 2008, as an update to the previous report. Positive influenza A samples (221 original patient specimens and 34 isolates obtained by viral culture) were analyzed for changes in the critical amino acid residues of the M2 gene. The amplification and sequencing of regions that confer adamantane resistance directly from RNA extracts of clinical samples (without previous culture) makes this approach a fast and efficient process for monitoring resistance. The results showed that the frequency of resistance varied from 37.5% to 49.2% in circulating influenza A H3N2 virus strains (n=213) between January 2007 and April 2007. The frequency of resistance increased to 100% in May 2007, after which all H3N2 viruses were resistant until the end of the monitoring period. All resistant H3N2 viruses contained the serine to asparagine substitution at amino acid position 31. Resistance was not observed in the H1N1 viruses tested (n=39) within this monitoring period. The level of adamantane resistance in H3N2 viruses continues to remain high since resistant viruses became the prevalent circulating strains in 2005. Recent reports have indicated that the currently circulating swine‐origin influenza A H1N1 subtype viruses are adamantane resistant. It is, thus, important to continue to monitor seasonal influenza A viruses for antiviral resistance markers to ensure optimal prophylaxis and treatment.
The Impact of Patient Education on the Quality of Inpatient Bowel Preparation for Colonoscopy
Authors: Rosenfeld Greg , Krygier Darin , Enns Robert A , Singham Janakie , Wiesinger Holly , Bressler Brian
Published: March 2016

BACKGROUND: For patients requiring colonoscopy while admitted to hospital, achieving adequate cleansing of the colon is often difficult.

OBJECTIVES: To assess the impact of patient education, in the form of both counselling and written instructions, on bowel cleanliness at colonoscopy.

METHODS: A total of 38 inpatients at a tertiary care hospital in Vancouver, British Columbia, who were referred to the gastroenterology service for colonoscopy were enrolled in the present study. Sixteen patients were randomly assigned to the intervention group, while 22 patients comprised the control group. Both groups received a clear liquid diet and 4 L of a commercially available bowel preparation. The intervention group also received a brief counselling session and written instructions outlining the methods and rationale for bowel preparation before colonoscopy. Bowel cleanliness was assessed by the endoscopist using a five‐point rating scale.

RESULTS: The two groups were similar with respect to demographics, the indication for colonoscopy and findings at colonoscopy. The median bowel cleanliness scores in the control group and the enhanced‐instruction group were 3.0 and 2.0, respectively (P=0.001).

CONCLUSION: Patient counselling and written instructions are inexpensive, safe and simple interventions. Such interventions are an effective means of optimizing colonoscopy preparation in the inpatient setting.
Infective Endocarditis: Updated Guidelines
Authors: Allen U
Published: March 2016

The most recent revision of the American Heart Association guidelines on infective endocarditis prophylaxis occurred in 2007. These revisions were based on the fact that current data have brought into question the benefit of previous recommendations for infective endocarditis prophylaxis. It was noted that the bacteremia that occurs following dental procedures represents only a fraction of the episodes of bacteremia that occur with activities of daily living (such as chewing, brushing teeth and other oral hygiene measures). The target groups and the procedures for which prophylaxis is reasonable have been significantly reduced in number. The focus is now on patients who are most likely to have adverse outcomes from infectious endocarditis. The present article is targeted at practicing Canadian physicians and provides the rationale for the current recommendations. In addition to a summary of the indications for prophylaxis, information is provided on the conditions for which prophylaxis is not recommended.
Management of Biliopleural Fistula after Transarterial Chemoembolization of a Liver Lesion
Authors: Butt Amir Shahzad , Mujtaba Ghulam , Anand Sury , Krishnaiah Mahesh
Published: March 2016

A case of a biliopleural fistula with a biloma occurring after superselective hepatic transarterial chemoembolization ablation of a metastatic hepatic carcinoid is described. The presentation was complicated by choledocholithiasis. The biloma was successfully treated with endoscopic drainage.
A 21‐Year‐Old Man with Systemic‐Onset Juvenile Rheumatoid Arthritis, Cough and Progressive Dyspnea
Authors: Leber A , Carette S , Chapman KR , Hwang DM , Singer LG , Marras TK
Published: March 2016

Primary or nonobstructive, endogenous lipoid pneumonia is a rare clinical entity usually associated with an underlying systemic disease. The present report describes a case involving a 21‐year‐old man with systemic‐onset juvenile rheumatoid arthritis who developed primary endogenous lipoid pneumonia. Multiple treatment regimens were attempted; however, definitive management was only achieved through double‐lung transplantation.
Potential Nosocomial Acquisition of Epidemic Listeria monocytogenes Presenting as Multiple Brain Abscesses Resembling Nocardiosis
Authors: Stefanovic Aleksandra , Reid James , Nadon A Celine , Grant Jennifer
Published: March 2016

Listerial brain abscesses are rare, and are found mostly in patients with underlying hematological malignancies or solid‐organ transplants. A case of a patient with Crohn’s disease and multiple brain abscesses involving the left cerebellum and right sylvian fissure is described. The Gram stain and histopathology of the cerebellar abscess revealed Gram‐positive, beaded rods suggestive of Nocardia. However, on culture, Listeria monocytogenes was identified. Listeria may appear Gram‐variable and has been misidentified as streptococci, enterococci and diphtheroids. The present case is the first reported case of L monocytogenes resembling Nocardia on both microbiological and histopathological assessment. Reported cases of listerial brain abscesses are sporadic, while the current case was part of a nationwide listerial outbreak linked to consumption of contaminated deli meats. Broad antimicrobial therapy (including antilisterial coverage) in immunosuppressed patients presenting with brain abscess is crucial, until cultures confirm the identification of the organism.
Social Functioning and Peer Relationships in Children and Adolescents with Chronic Pain: A Systematic Review
Authors: Forgeron Paula A , King Sara , Stinson Jennifer N , McGrath Patrick J , MacDonald Amanda J , Chambers Christine T
Published: March 2016

BACKGROUND: Peer relationships during childhood and adolescence are acknowledged to be negatively impacted by chronic pain; however, to date there has been no synthesis of this literature.

OBJECTIVE: To systematically review existing literature describing the social functioning and peer relationships in children and adolescents with recurrent or continuous chronic pain.

METHODS: Articles on peer relationship factors studied in samples of children and adolescents with chronic pain published in English or French were identified using EMBASE, Medline, CINAHL and PsycINFO. Two independent reviewers performed initial screenings using study titles and abstracts, and reviewed each eligible article in full.

RESULTS: Of 1740 published papers yielded by the search, 42 articles met the inclusion criteria and were included in the present review. Nine studies had peer relationship investigation as the primary purpose of the study; the remaining 33 examined peer relationships as part of a broader study. A range of specific and more general measures was used to examine peer relationships. Across studies, children and adolescents with chronic pain were reported to have fewer friends, be subjected to more peer victimization, and were viewed as more isolated and less likeable than healthy peers.

CONCLUSIONS: Children and adolescents with chronic pain have peer relationship deficiencies. However, the majority of studies to date measure peer relationships as part of a broader study and, thus, little attention has been paid specifically to peer relationships in this group. Additional research examining the quality of peer relationships of children and adolescents with chronic pain, as well as development of measures specifically designed to assess these relationships, is needed.
The Long‐Term Safety and Efficacy of Opioids: A Survey of 84 Selected Patients with Intractable Chronic Noncancer Pain
Authors: Watson C Peter N , Watt-Watson Judy , Chipman Mary
Published: March 2016

BACKGROUND: The use of opioids for chronic noncancer pain (CNCP) remains controversial. Despite a number of randomized controlled trials showing efficacy and safety in the short term, long‐term data are limited.

OBJECTIVE: To survey a selected cohort of patients with intractable CNCP with regard to long‐term efficacy and safety of opioids.

METHODS: The present study reports long‐term results from a survey of 84 patients with CNCP. The majority of patients had neuropathic pain, were treated with opioids and were followed every three months for a median of 8.4 years. Outcomes examined were pain severity, adverse effects, pain relief, satisfaction, mood, problematic opioid use, tolerance, physical dependency, functional status, health‐related quality of life, immune status, sexual function, morbidity and mortality. Measures included a numerical rating scale, the Hospital Anxiety and Depression Scale, Brief Pain Inventory interference scale, Pain Disability Index and Short‐Form Health Survey 12, version 2.

RESULTS AND CONCLUSIONS: Both long‐ and short‐acting opioids were reported to be effective, with few significant long‐term adverse effects in many subjects in the present selected cohort. The majority of patients reported at least 50% or greater pain relief and a moderate improvement in disability. Functional status and health‐related quality of life scores were not severely affected. Problematic opioid use, tolerance and serious adverse effects, including constipation, were not major issues. The authors emphasize that the results obtained in the present selected group may not be generalizable to all CNCP patients in whom opioids are being initiated.
Overexpression of Cyclooxygenase-2 in Noncancerous Liver Tissue Increases the Postoperative Recurrence of Hepatocellular Carcinoma in Patients with Hepatitis B Virus-Related Cirrhosis
Authors: He Yi-Fu , Jin Juan , Wei Wei , Chang Yan , Hu Bing , Ji Chu-Shu , Jia Wei-Dong , Wang Xiao-Qiu , Chen Ke , Chen Jian
Published: March 2016

BACKGROUND: Many previous studies have evaluated the histopathological features of tumours as risk factors for postoperative recurrence in hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC). However, there have been few large studies investigating the relationship between cyclooxygenase-2 (COX-2) expression in non-cancerous regions of the liver and postoperative recurrence in the remnant liver, especially in HBV-related HCC.

OBJECTIVE: To evaluate the significance of COX-2 expression levels in noncancerous liver regions as a prognostic indicator of HCC in patients with HBV-related cirrhosis.

METHODS: A total of 124 patients who underwent curative resection for HCC were reviewed retrospectively. Immunohistochemistry was used to evaluate the expression of COX-2 in noncancerous liver tissue. Clinicopathological variables were compared between patients with high COX-2 expression (n=58 [COX-2-positive group]) and patients with low COX-2 expression (n=66; [COX-2-negative group]). Univariate and multivariate analyses were performed to identify factors that affected disease recurrence.

RESULTS: There was a significant correlation between COX-2 expression and alanine aminotransferase levels and vascular invasion. The recurrence-free survival rates in the COX-2-positive group were significantly lower than the rates in the COX-2-negative group. On multivariate analysis, the overexpression of COX-2 in noncancerous liver regions was found to be an unfavourable prognostic indicator for the recurrence of HCC.

CONCLUSIONS: The results of the current study suggest that over-expression of COX-2 in noncancerous liver regions is an independent and significant indicator predictive of early recurrence of HCC in patients with HBV-related cirrhosis.
Barriers to the Implementation of Practice Guidelines in Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding: A Qualitative Approach
Authors: Hayes Sean M , Murray Suzanne , Dupuis Martin , Dawes Martin , Hawes Ian A , Barkun Alan N
Published: March 2016

BACKGROUND/OBJECTIVE: Guidelines for the management of patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) are inconsistently applied by health care providers, potentially resulting in suboptimal care and patient outcomes. A needs assessment was performed to assess health care providers’ barriers to the implementation of these guidelines in Canada.

METHODS: Semistructured telephone interviews were conducted by trained research personnel with 22 selectively sampled health care professionals actively treating and managing NVUGIB patients, including emergency room physicians (ER), intensivists (ICU), gastroenterologists (GI), gastroenterology nurses and hospital administrators. Participants were chosen from a representative sample of six Canadian community‐ and academic‐based hospitals that participated in a national Canadian audit on the management of NVUGIB.

RESULTS: Participants reported substantive gaps in the implementation of NVUGIB guidelines that included the following: lack of knowledge of the specifics of the NVUGIB guidelines (ER, ICU, nurses); limited belief in the value of guidelines, especially in areas where evidence is lacking (ER, ICU); limited belief in the value of available tools to support implementation of guidelines (GI); lack of knowledge of the roles and responsibilities of health care professions and disciplines, and lack of effective collaboration skills (ER, ICU and GI); variability of knowledge and skills of health care professionals within professions (eg, variability of nurses’ knowledge and skills in endoscopic procedures); and perceived overuse of intravenous proton pump inhibitor treatment, with limited concern regarding cost or side effect implications (all participants).

CONCLUSIONS: In the present study population, ER, ICU and nurses did not adhere to NVUGIB guidelines because they were neither aware of nor familiar with them, whereas the GI lack of adherence to NVUGIB guidelines was influenced more by attitudinal and contextual barriers. These findings can guide the design of multifaceted educational and behavioural interventions when attempting to effectively disseminate existing guidelines, and for guideline implementation into practice.
Endoscopic Mucosal Resection: Early Experience in British Columbia
Authors: Brahmania Mayur , Lam Eric , Telford Jennifer , Enns Robert
Published: March 2016

BACKGROUND: Endoscopic mucosal resection (EMR) has been proposed as a primary method of managing patients with dysplasia‐ or mucosal‐based cancers of the esophagus.

OBJECTIVES: To evaluate the use of EMR for the treatment of Barrett’s esophagus with dysplasia or early adenocarcinoma, assessing efficacy, complication rates and long‐term outcomes.

METHODS: All patients who underwent EMR at St Paul’s Hospital (Vancouver, British Columbia) were reviewed. Eligible patients were assessed with aggressive biopsy protocols. Detected cancers were staged with both endoscopic ultrasound imaging and computed tomography. Appropriate patients were offered EMR using a commercially available mucosectomy device. EMR was repeated at six‐ to eight‐week intervals until complete. Patients with less than one year of follow‐up or who were undergoing other ablative methods were excluded.

RESULTS: Twenty‐two patients (all men) with a mean (± SD) age of 67±10.6 years were identified. The mean duration of gastroesophageal reflux disease was 17 years (range four to 40 years) and all were receiving proton pump inhibitor therapy. The mean length of Barrett’s esophagus was 5.5±3.5 cm. One patient had no dysplasia (isolated nodule), three had low‐grade dysplasia, 15 had high‐grade dysplasia (HGD) and three had adenocarcinoma. A mean of 1.7±0.83 endoscopic sessions were performed, with a mean of 6±5.4 sections removed. Following EMR, three patients developed strictures; two of these patients had pre‐existing strictures and the third required two dilations, which resolved his symptoms. There were no other complications. Three patients underwent esophagectomy. Two had adenocarcinoma or HGD in a pre‐existing stricture. The third patient had an adenocarcinoma not amenable to EMR. One patient with a long segment of Barrett’s esophagus underwent radiofrequency ablation. At a median follow‐up of two years (range one to three years), the remaining 18 patients (82%) had no evidence of HGD or cancer.

CONCLUSION: Most patients with esophageal dysplasia can be managed with EMR. Individuals with pre‐existing strictures require other endoscopic and/or surgical methods to manage their dysplasia or adenocarcinoma.
Wait Times for Gastroenterology Consultation in Canada: The Patients’ Perspective
Authors: Paterson WG , Barkun AN , Hopman WM , Leddin DJ , Paré P , Petrunia DM , Sewitch MJ , Switzer C , van Zanten S Veldhuyzen
Published: March 2016

Long wait times for health care have become a significant issue in Canada. As part of the Canadian Association of Gastroenterology’s Human Resource initiative, a questionnaire was developed to survey patients regarding wait times for initial gastroenterology consultation and its impact. A total of 916 patients in six cities from across Canada completed the questionnaire at the time of initial consultation. Self-reported wait times varied widely, with 26.8% of respondents reporting waiting less than two weeks, 52.4% less than one month, 77.1% less than three months, 12.5% reported waiting longer than six months and 3.6% longer than one year. One-third of patients believed their wait time was too long, with 9% rating their wait time as ‘far too long’; 96.4% believed that maximal wait time should be less than three months, 78.9% believed it should be less than one month and 40.3% believed it should be less than two weeks. Of those working or attending school, 22.6% reported missing at least one day of work or school because of their symptoms in the month before their appointment, and 9.0% reported missing five or more days in the preceding month. A total of 20.2% of respondents reported being very worried about having a serious disease (ie, scored 6 or higher on 7-point Likert scale), and 17.6% and 14.8%, respectively, reported that their symptoms caused major impairment of social functioning and with the activities of daily living. These data suggest that a significant proportion of Canadians with digestive problems are not satisfied with their wait time for gastroenterology consultation. Furthermore, while awaiting consultation, many patients experience an impaired quality of life because of their gastrointestinal symptoms.
What Do the Parents of Children Who Have Chronic Pain Expect from Their First Visit to a Pediatric Chronic Pain Clinic?
Authors: Reid Kathy , Lander Janice , Scott Shannon , Dick Bruce
Published: March 2016

BACKGROUND: Chronic pain in childhood is increasingly recognized as a significant clinical problem. Best‐practice management of pediatric chronic pain in a multidisciplinary pain clinic involves a variety of treatment modalities. It is important that parents of children treated in these settings understand the different treatment options available for their children. By involving parents more effectively, care providers may more efficiently address unmet treatment needs and improve tailoring of treatment programs aimed at increasing function, reducing pain‐related disability and improving quality of life.

OBJECTIVES: To explore the expectations held by parents for their first visit to a pediatric multidisciplinary pain clinic.

METHODS: Fourteen parents completed a paper‐based survey exploring their expectations immediately before their first visit to a multidisciplinary pediatric pain clinic in a tertiary care children’s hospital.

RESULTS: Responses from parents suggest a clear desire for information about the causes of their child’s pain, treatment options available at the pain clinic, effective strategies to enhance children’s ability to cope with pain, and the effects of pain on both body and mood. Most parents rated the various treatment options as important for their child. All parents indicated it was very important to have the pain team ‘be there’ for them.

CONCLUSIONS: These findings indicate that parents want more information about chronic pain and treatment options. Pediatric chronic pain clinics have the ability to assist children with chronic pain and their families considerably by providing information about chronic pain and the various treatment options available to them.
Does Adjuvant Steroid Therapy Post-Kasai Portoenterostomy Improve the Outcome of Biliary Atresia? A Systematic Review and Meta-Analysis
Authors: Sarkhy Ahmed , Schreiber Richard A , Milner Ruth , Barker Collin C
Published: March 2016

BACKGROUND: The role of adjuvant steroid therapy in the postoperative management of patients with biliary atresia (BA) is unclear.

OBJECTIVE: To systematically review the literature and perform a meta-analysis to determine the efficacy of adjuvant steroid therapy post-Kasai portoenterostomy (KP) on BA outcome.

METHODS: A systematic review and meta-analysis of randomized trials and/or observational studies that examined the role of steroids on BA outcomes published between January 1969 and June 2010 was conducted. Studies were identified using the Medline, PubMed, EMBASE and Cochrane databases.

RESULTS: Sixteen observational studies and one randomized controlled trial (RCT) were found. Four of the 16 observational studies (160 participants) and the RCT (73 participants) met the entry criteria and were eligible to be included in the analysis. There was no statistically significant difference in the effect of steroids either on normalizing serum bilirubin levels at six months (pooled OR 1.48 [95% CI 0.67 to 3.28]) or in delaying the need for early liver transplantation (within the first year post-KP (pooled OR 0.59 [95% CI 0.21 to 1.72]).

CONCLUSION: The present meta-analysis did not find a significant effect of steroid over standard therapy, either in normalizing serum bilirubin levels at six months or at delaying the need for early liver transplantation post-KP. RCT studies of sufficient size and comprehensive design using high-dose steroids are needed to determine the effectiveness of steroids on the short and intermediate post-KP outcomes for BA patients.
Acute Liver Failure Caused by ‘Fat Burners’ and Dietary Supplements: A Case Report and Literature Review
Authors: Radha Krishna Y , Mittal V , Grewal P , Fiel MI , Schiano T
Published: March 2016

Globally, people are struggling with obesity. Many effective, non-conventional methods of weight reduction, such as herbal and natural dietary supplements, are increasingly being sought. Fat burners are believed to raise metabolism, burn more calories and hasten fat loss. Despite patient perceptions that herbal remedies are free of adverse effects, some supplements are associated with severe hepatotoxicity. The present report describes a young healthy woman who presented with fulminant hepatic failure requiring emergent liver transplantation caused by a dietary supplement and fat burner containing usnic acid, green tea and guggul tree extracts. Thorough investigation, including histopathological examination, revealed no other cause of hepatotoxicity. The present case adds to the increasing number of reports of hepatotoxicity associated with dietary supplements containing usnic acid, and highlights that herbal extracts from green tea or guggul tree may not be free of adverse effects. Until these products are more closely regulated and their advertising better scrutinized, physicians and patients should become more familiar with herbal products that are commonly used as weight loss supplements and recognize those that are potentially harmful.
Very late‐onset lead‐associated endocarditis
Authors: Cho Min-Soo , Kim Sung-Hwan , Nam Gi-Byoung , Choi Kee-Joon , Kim You-Ho
Published: March 2016

Lead‐associated endocarditis is a serious complication due to device implantation. The present article reports on a case involving a 57‐year‐old man with microbiologically and pathologically confirmed lead‐associated endocarditis caused by Staphylococcus capitis. Transesophageal echocardiography is essential for diagnosis, and treatment usually requires appropriate antibiotics and removal of the lead.
Streptococcus pneumoniae meningitis in Alberta pre‐ and postintroduction of the 7‐valent pneumococcal conjugate vaccine
Authors: Johnstone Jennie , Tyrrell Gregory J. , Marrie Thomas J. , Garg Sipi , Kellner James D. , the Streptococcus pneumoniae Alberta Team (SPAT) group
Published: March 2016

The objective of this study was to describe the epidemiology, clinical characteristics, microbiology and outcomes of patients of all ages with Streptococcus pneumoniae meningitis between 2000 and 2004; two years pre‐ and postintroduction of an S pneumoniae 7‐valent conjugate vaccine program in Alberta in children younger than two years of age. The high mortality rate associated with S pneumoniae meningitis, despite appropriate therapy, suggests that prevention of S pneumoniae meningitis is critical. Despite implementation of a PCV‐7 program in Alberta, rates of S pneumoniae meningitis in children younger than two years of age is still high. Thus, continued research into safe and efficacious vaccines covering a broader range of S pneumoniae serotypes is necessary.

OBJECTIVE: To describe the epidemiology, clinical characteristics, microbiology and outcomes of patients of all ages with Streptococcus pneumoniae meningitis two years pre‐ and postintroduction of a S pneumoniae 7‐valent conjugate vaccine program in Alberta in children <2 years of age.

METHODS: Between 2000 and 2004, all cases of invasive pneumococcal disease in Alberta were identified. From this cohort, patients with S pneumoniae meningitis were identified by chart review. Clinical data, laboratory data and in‐hospital outcomes were collected.

RESULTS: Of the 1768 cases of invasive pneumococcal disease identified between 2000 and 2004, 110 (6.2%) had S pneumoniae meningitis. The overall incidence was 0.7 per 100,000 persons and remained unchanged over the study period. The rate in children <2 years of age appeared to fall over time, from 10.5 per 100,000 persons in 2000 to five per 100,000 persons in 2004, although there was insufficient evidence of a statistically significant time trend within any age group. Overall, the mean age was 30 years and 47% were male. In‐hospital mortality was 20%, ranging from 6% in those ≤2 years of age to 31% for those ≥18 years of age, despite appropriate antimicrobial therapy.

CONCLUSION: The high mortality rate associated with S pneumoniae meningitis suggests that prevention by vaccination is critical. In children <2 years of age, there was a downward trend in the rate of S pneumoniae meningitis after implementation of the S pneumoniae 7‐valent conjugate vaccine program, but rates were still high.
The Impact of Sirolimus on hepatitis C Recurrence after Liver Transplantation
Authors: Asthana Sonal , Toso Christian , Meeberg Glenda , Bigam David L , Mason Andrew , Shapiro AM James , Kneteman Norman M
Published: March 2016

BACKGROUND: While some immunosuppression strategies may accelerate hepatitis C virus (HCV) recurrence after liver transplantation (LT), the impact of sirolimus (SRL) is not known.

OBJECTIVE: To assess the risk of biopsy-proven HCV recurrence and patient survival using known and suspected risk factors for HCV recurrence as covariates.

METHODS: A retrospective analysis of 141 consecutive patients, including 88 who received de novo SRL therapy, who had undergone a first LT for HCV cirrhosis was conducted. Known and suspected risk factor covariates including transplant era, donor and recipient age, Model for End-stage Liver Disease score, cold ischemia time, immunosuppressive drugs and steroid treatment rejection rates were used in the assessment.

RESULTS: Overall, 72.3% of the cohort developed biopsy-proven HCV recurrence. The incidence of HCV recurrence was not significantly different for patients treated with SRL (75% versus 69.8%; P=0.5). There was no difference found for time to recurrence, nor did mean activity or fibrosis scores differ at the time of initial recurrence. However, on follow-up using serial biopsies in patients with recurrence, the mean activity and fibrosis scores were significantly lower in the SRL group. Donor age and acute rejection episodes were the only factors affecting the HCV recurrence rate (expB 1.02 [95% CI 1.01 to 1.03]); P=0.03; and expB 2.8 [95% CI 1.8 to 4.3]; P<0.01], respectively). SRL treatment did not alter patient survival rates. Among patients treated with SRL-based immunosuppression, higher drug area under the curve levels were associated with a trend to lower disease activity and fibrosis at diagnosis; however, higher SRL levels were associated with shorter recurrence-free survival (P=0.038).

CONCLUSION: Results of the present analysis suggest that de novo SRL-based immunosuppression can be safely used in patients undergoing LT for HCV-associated liver disease; however, SRL-based immunosuppression did not significantly affect the timing or severity of post-transplant HCV recurrence. HCV recurrence in SRL-treated patients had lower progressive activity and fibrosis levels on serial biopsy.
Oxygen Desaturation During a 6 Min Walk Test is a Sign of Nocturnal Hypoxemia
Authors: Scott Adrienne S , Baltzan Marcel A , Chan Ryan , Wolkove Norman
Published: March 2016

BACKGROUND/OBJECTIVES: Patients with chronic obstructive pulmonary disease (COPD) may experience sleep disordered breathing with nocturnal desaturation. An exploratory study was performed to determine whether any commonly measured clinical parameters were useful in predicting nocturnal desaturation in patients with COPD. A validation study was subsequently performed to confirm the utility of the parameter identified in the exploratory study as most useful in this regard.

METHODS: A total of 103 (exploratory cohort) and 200 (validation cohort) consecutive patients with COPD admitted for pulmonary rehabilitation were evaluated. Standard outcome measures including nocturnal oximetry and the 6 min walk test (6MWT) on room air with continuous pulse oximetry were assessed. Patients with sleep apnea or those undergoing long‐term oxygen therapy were excluded.

RESULTS: In the exploratory study, the mean (± SD) patient age was 70±9.9 years, with forced expiratory volume in 1 s of 0.76±0.34 L, which was 36±16% of predicted. Body mass index, arterial oxygen tension, oxygen saturation by pulse oximetry at rest and during the 6MWT all demonstrated significant correlations with percentage of time spent with a saturation <90%. When the lowest pulse oximetry during the 6MWT was ≤88%, 10 of 21 patients demonstrated a saturation <90% for at least 30% of sleep time. This measure yielded a positive likelihood ratio of 3.77 (95% CI 1.87 to 7.62) compared with those who did not reach this threshold value. The validation study confirmed similar detection characteristics.

CONCLUSIONS: Results from the present study suggest that monitoring oxygen saturation changes during a 6MWT is useful in helping to identify COPD patients who may experience significant nocturnal desaturation.
The Increasing Prevalence of Clindamycin Resistance in Staphylococcus aureus Isolates in Children with Head and Neck Abscesses
Authors: Alexander Ashlin J. , Richardson Susan E. , Sharma Alok , Campisi Paolo
Published: March 2016

OBJECTIVE: To retrospectively review trends in clindamycin resistance among Staphylococcus aureus head and neck abscesses between January 2000 and June 2008.

METHODS: Between January 2000 and June 2008, inpatient and out‐patient S aureus isolates were reviewed for antibiotic susceptibility. In particular, cultures from 153 abscesses in the head and neck region were assessed for clindamycin and methicillin resistance patterns.

RESULTS: Annual clindamycin resistance rates for all S aureus isolates, and specifically for S aureus head and neck abscesses, revealed concerning levels of clindamycin and methicillin resistance. After 2002, the mean clindamycin resistance rate in head and neck abscesses was approximately 27%. The number of new cases of methicillin‐resistant S aureus per year increased from four cases in 2000 to 44 cases in 2007.

CONCLUSION: Antibiotic resistance should be considered following failed empirical therapy of head and neck abscesses with clindamycin.