bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessing Pain in Children with Intellectual Disabilities
Authors: Breau Lynn M , Burkitt Chantel
Published: March 2016

Children with intellectual and developmental disabilities suffer more often from pain than their typically developing peers. Their pain can be difficult to manage, and assessment is often complicated by their limited communication skills, multiple complex pain problems and the presence of maladaptive behaviours. However, current research does provide some guidance for assessing their pain. Although self‐report is an alternative for a small number of higher‐functioning children, observational measures have the most consistent evidence to support their use at this time. For this reason, the Non‐communicating Children’s Pain Checklist – Postoperative Version is recommended for children and youth 18 years of age or younger. However, other measures should be consulted for specific applications. Changes in function and maladaptive behaviour should also be considered as possible reflections of pain. In addition, children’s coping skills should be considered because improving these may reduce the negative impact of pain.
Tuberculosis Screening and Active Tuberculosis among HIV‐Infected Persons in a Canadian Tertiary Care Centre
Authors: Brassard Paul , Hottes Travis Salway , Lalonde Richard G , Klein Marina B
Published: March 2016

RATIONALE: HIV infection increases the risk of reactivation of latent tuberculosis (TB). The present study evaluates how latent TB is detected and treated to determine the effectiveness of screening in HIV‐infected patients with diverse risk profiles.

METHOD: A retrospective medical record database review (1988 to 2007) was conducted at a tertiary care HIV clinic. The proportion of patients receiving tuberculin skin tests (TSTs) and the rate of active TB at each stage of screening and prevention were estimated. Predictors of receiving a TST at baseline, testing positive by TST and developing active TB were evaluated.

RESULTS: In the present study, 2123 patients were observed for a total of 9412 person‐years. Four hundred seventy‐six (22.4%) patients were tested by TST within 90 days of first clinic visit. Having a first clinic visit during the highly active antiretroviral therapy era (OR 3.64; 95% CI 2.66 to 4.99), country of birth (ORs: Africa 3.11, Asia 2.79, Haiti 3.14, and Latin America and the Caribbean 2.38), time between HIV diagnosis and first visit (OR per one‐year change 0.97; 95% CI 0.94 to 0.99) and previous antiretroviral exposure (OR 0.61; 95% CI 0.45 to 0.81) were independent predictors of receiving a TST at baseline. Of the 17 patients who developed active TB during follow‐up, nine (53%) had no documented TSTs at baseline or during follow‐up. Forty‐one per cent of all TB patients and 56% of TB patients who were not screened were born in Canada.

CONCLUSION: The administration of TSTs to newly diagnosed HIV patients was inconsistent and differential according to country of birth, among other factors, resulting in missed opportunities for TB prevention.
An Evaluation of Procedural Training in Canadian Respirology Fellowship Programs: Program Directors’ and Fellows’ Perspectives
Authors: Stather David Ryan , Jarand Julie , Silvestri Gerard A , Tremblay Alain
Published: March 2016

BACKGROUND: In recent years, there has been a rapid growth in diagnostic and therapeutic procedures performed by respirologists.

OBJECTIVES: To assess the number and type of procedures performed in Canadian respirology training programs, for comparison with the American College of Chest Physicians minimum competency guidelines, and to assess fellow satisfaction with procedural training during their fellowships.

METHODS: Internet‐based surveys of Canadian respirology fellows and respirology fellowship program directors were conducted.

RESULTS: Response rates for program director and respirology fellow surveys were 71% (10 of 14) and 62% (41 of 66), respectively. Thirty‐eight per cent of respirology fellows reported the presence of an interventional pulmonologist at their institution. Flexible bronchoscopy was the only procedure reported by a large majority of respirology fellows (79.5%) to meet American College of Chest Physicians recommendations (100 procedures). As reported by respirology fellows, recommended numbers of procedures were met by 59.5% of fellows for tube thoracostomy, 21% for transbronchial needle aspiration and 5.4% for closed pleural biopsy. Respirology fellows in programs with an interventional pulmonologist were more likely to have completed some form of additional interventional bronchoscopy training (80% versus 32%; P=0.003), had increased exposure to and expressed improved satisfaction with training in advanced diagnostic and therapeutic procedures, but did not increase their likelihood of achieving recommended numbers for any procedures.

CONCLUSIONS: Canadian respirology fellows perform lower numbers of basic respiratory procedures, other than flexible bronchoscopy, than that suggested by the American College of Chest Physicians guidelines. Exposure and training in advanced diagnostic and therapeutic procedures is minimal. A concerted effort to improve procedural training is required to improve these results.
Gastropulmonary Fistula after Bariatric Surgery
Authors: Doumit Maya , Doumit Gaby , Shamji Farid M , Gregoire Sylvie , Seppala Richard E
Published: March 2016

The Roux-en-Y gastric bypass is one of the most common operations for morbid obesity. Although rare, gastropulmonary fistulas are an important complication of this procedure. There is only one recently reported case of this complication. The present report describes the serious nature of this complication in a patient after an uneventful laparoscopic gastric bypass surgery.
The Use of Endoscopic Ultrasonography and Other Imaging Modalities in the Preoperative Staging of Rectal Villous Tumours: A Case of Overstaging by Magnetic Resonance Imaging
Authors: Buresi Michelle , Zandieh Iman , Nagy Alexander G , Spielmann Audrey , Yee William C , Weiss Alan A , Yoshida Eric M
Published: March 2016

A case of a 60-year-old man with recurrent rectal villous adenoma is described. Preoperative staging with endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) revealed very discordant results. EUS showed a tumour present in the mucosa with no submucosal invasion, while MRI revealed invasion of the muscularis propria consistent with an invasive stage T2 carcinoma. Based on the MRI findings, the patient underwent a low anterior resection of the tumour. The surgical pathology specimen revealed a villous adenoma with low-grade dysplasia but no carcinoma and no extension into the muscularis propria. The present case highlights the uncertainty that currently exists as to which imaging modality provides the greatest accuracy in the staging of rectal cancer and in guiding the type of surgical procedure performed. Two recent meta-analyses and a systematic review of the literature point to EUS as the imaging modality of choice for determining muscularis propria and perirectal tissue invasion, as well as nodal involvement.
Catheter‐Related Right Atrial Thrombus and Pulmonary Embolism: A Case Report and Systematic Review of the Literature
Authors: Burns Karen EA , McLaren Andrew
Published: March 2016

Central venous catheters (CVCs) are commonly used in clinical practice. One of the foremost complications associated with their use is the potential for symptomatic or asymptomatic thrombosis. CVC thrombosis, in turn, may not only result in vascular and catheter occlusion but also infection, pulmonary embolism, and formation of right heart thromboemboli. Thrombi within cardiac chambers are associated with an increased risk of mortality due to their potential for embolization to the pulmonary vasculature. We describe the case of a 77‐year‐old man, who was successfully thrombolyzed following detection of a right atrial thrombus and hemodynamically significant pulmonary embolism resulting from thrombus formation on the tip of a peripherally inserted central catheter (PICC). The present article is the first report of a PICC‐related right atrial thrombus in an adult treated with thrombolysis. A systematic review of the literature suggests that the true incidence of this complication may be underestimated because the diagnosis may not be considered in asymptomatic and symptomatic patients, or may be missed by transthoracic echocardiography. The present case highlights the importance of maintaining a high index of suspicion for thromboembolic complications and heparin‐induced thrombocytopenia in patients with CVCs or a PICC. It also underscores the important role of transesophageal echocardiography and thrombolysis in the diagnosis and management, respectively, of right heart thromboemboli with associated pulmonary embolism.
Work‐Related Asthma: A Case‐Based Guide
Authors: Tarlo Susan M , Cartier André , Lemière Catherine , on behalf of the Canadian Thoracic Society Asthma Committee
Published: March 2016

Work‐related asthma is common yet underdiagnosed. It is a significant cause of morbidity and socioeconomic loss. Diagnosis is often difficult, and requires a strong index of suspicion and careful investigation. The Canadian Thoracic Society has endorsed the recent American College of Chest Physicians consensus statement on work‐related asthma. The present document illustrates the advised approach to diagnosis and management of work‐related asthma using case‐based examples of occupational asthma and work‐exacerbated asthma. The main statements of advice from the American College of Chest Physicians consensus statement are reproduced with permission.
Transdermal Nitroglycerin as an Adjuvant to Patient‐Controlled Morphine Analgesia after Total Knee Arthroplasty
Authors: Orbach-Zinger Sharon , Lenchinsky Artium , Paul-Kesslin Lesley , Velks Steven , Salai Moses , Eidelman Leonid A
Published: March 2016

BACKGROUND: Nitroglycerin (NTG) has been shown to be a useful adjunct for pain treatment without increasing adverse side effects. The effects of NTG on postoperative morphine consumption after knee replacement were evaluated.

METHODS: After undergoing total knee replacement, patients receiving patient‐controlled morphine analgesia were randomly assigned to receive either an NTG or a placebo patch. The blinded investigator assessed each patient using a visual analogue scale at rest and while moving, as well as the patient’s morphine requirements, sedation score, sleep quality, nausea and vomiting, vital signs and postoperative bleeding.

RESULTS: Two of the patients in the NTG group suffered postoperative myocardial infarctions after removal of the patch. Because of these two serious adverse effects, the study was stopped prematurely. In the subset of patients studied, NTG conferred no advantage over placebo in pain control (visual analogue scale at rest or during movement) and in satisfaction scores.

CONCLUSIONS: The use of NTG patches conferred no advantage over the use of placebo in patients receiving patient‐controlled morphine analgesia after total knee replacement. Two myocardial infarcts occurred in this group. Therefore, the safety of postoperative NTG patch use for pain control must be questioned.
Recurrent Obscure Gastrointestinal Bleeding: Dilemmas and Success with Pharmacological Therapies. Case Series and Review
Authors: Almadi Majid , Ghali Peter M , Constantin Andre , Galipeau Jacques , Szilagyi Andrew
Published: March 2016

The present article describes three difficult cases of recurrent bleeding from obscure causes, followed by a review of the pitfalls and pharmacological management of obscure gastrointestinal bleeding. All three patients underwent multiple investigations. An intervening complicating diagnosis or antiplatelet drugs may have compounded long-term bleeding in two of the cases. A bleeding angiodysplasia was confirmed in one case but was aggravated by the need for anticoagulation. After multiple transfusions and several attempts at endoscopic management in some cases, long-acting octreotide was associated with decreased transfusion requirements and increased hemoglobin levels in all three cases, although other factors may have contributed in some. In the third case, however, the addition of low-dose thalidomide stopped bleeding for a period of at least 23 months.
Patient Satisfaction with Colonoscopy: A Literature Review and Pilot Study
Authors: Chartier Lucas , Arthurs Erin , Sewitch Maida J
Published: March 2016

BACKGROUND: Current guidelines recommend that colonoscopic colorectal cancer screening be undertaken every 10 years after the age of 50 years. However, because the procedure does not meet criteria that promote screening uptake, patient satisfaction with colonoscopy may encourage repeat screening.

OBJECTIVE: To systematically review the literature and conduct a pilot study of patient satisfaction with the colonoscopy experience.

METHODS: All cohort studies from January 1997 to August 2008 in the MEDLINE database that measured either patient satisfaction with colonoscopy, patient willingness to return for colonoscopy under the same conditions or patient preference for colonoscopy compared with other large bowel procedures were identified. The search was supplemented by journal citation lists in the retrieved articles.

RESULTS: Of the 29 studies identified, 15 met the inclusion criteria. Consistently, the vast majority of patients (approximately 95%) were very satisfied with their colonoscopy experience. Patient satisfaction was similar for screening and nonscreening colonoscopy. Patient willingness to return for the procedure ranged from 73% to 100%. Of the five studies that examined modality preference, three studies reported the majority of patients preferred colonography to colonoscopy and two studies reported the reverse. Our pilot study findings mirrored those of other studies that were conducted in the United States. The major limitation of the included studies was that patients who were most dissatisfied may have gone elsewhere to have their colonoscopy.

CONCLUSIONS: Patients were very satisfied with colonoscopy. The majority were willing to return for repeat testing under the same conditions, and colonoscopy was not preferred over other modalities. However, studies were limited by methodological shortcomings.
Comparison of Per Cent Predicted and Percentile Values for Pulmonary Function Test Interpretation
Authors: Pakhale Smita , Bshouty Zoheir , Marras Theodore K
Published: March 2016

BACKGROUND: Pulmonary function tests (PFTs) are commonly interpreted as a fraction of predicted normal values, with an abnormal test often defined as less than 80% or greater than 120% of the predicted value. However, recommendations of the American Thoracic Society/European Respiratory Society suggest using a percentile‐based approach to define an abnormal test (less than the fifth or greater than the 95th percentiles).

OBJECTIVE: To compare PFT values obtained by the per cent predicted method with the percentile‐based method for lung function parameters.

METHODS: Full PFTs performed between January 2000 and July 2004, at the Health Sciences Centre (Winnipeg, Manitoba) were analyzed. Using the Crapo and Gutierrez equations, per cent predicted and percentile values were calculated. An abnormal test was defined as less than 80% or greater than 120% of predicted (per cent predicted method) or as less than the fifth or greater than the 95th percentiles (percentile method). Using the percentile method as reference standard, the diagnostic test characteristics of the per cent predicted method were calculated.

RESULTS: The full PFTs of 2176 men and 1658 women were analyzed using the Crapo and Gutierrez equations. The mean (± SD) age of all subjects was 52±15 years. Per cent agreement between the two tests was more than 94% for all parameters except for reduced residual volume (88%). Per cent predicted methods had suboptimal sensitivity for abnormal total lung capacity (88% to 89%), increased residual volume (83% to 89%) and reduced diffusion capacity (89% with Crapo equations). Suboptimal specificity (83% to 86%) was observed for decreased residual volume.

CONCLUSION: The results of the per cent predicted and percentile‐based approaches for PFT interpretation were similar for the majority of lung function parameters. These two methods can be used interchangeably for spirometry. However, caution may be warranted in relying solely on per cent predicted methods for assessing lung volume or diffusion capacity.
Spontaneous Clearance of Hepatitis C after Liver and Renal Transplantation
Authors: Dale CH , Burns P , McCutcheon M , Hernandez-Alejandro R , Marotta PJ
Published: March 2016

Spontaneous clearance of hepatitis C virus (HCV) is rare in immunocompromised patients, such as those who have undergone organ transplantation. It has been recognized that patients receiving liver transplantation for HCV-related disease have decreased graft and patient survival compared with those transplanted for other etiologies. There is a growing trend toward treating HCV recurrence aggressively after liver transplantation. For other organ transplant recipients with concurrent HCV, treatment is not often an option, given the high rates of graft rejection and loss secondary to interferon and its immunomodulatory effects. Although spontaneous clearance of HCV has been reported in recipients of solitary liver and renal transplants, a common factor arising in these cases has been previous exposure to interferon. To date, no reports of spontaneous clearance of HCV RNA have been reported in a multiorgan transplant recipient. A case of spontaneous clearance of HCV RNA in an immunocompromised patient, within five months of simultaneous liver and kidney retransplantation is described. Importantly, this patient had no previous exposure to interferon.
Successful Treatment of a Prosthetic Joint Infection due to Mycobacterium abscessus
Authors: Petrosoniak Andrew , Kim Paul , Desjardins Marc , Lee B Craig
Published: March 2016

Prosthetic joint infection due to Mycobacterium abscessus is uncommon and optimal therapy remains poorly defined. Following a two‐stage revision, clinical and microbiological cure was achieved in a patient with a M abscessus‐infected total hip arthroplasty. A prolonged course of directed antibacterial therapy comprising clarithromycin and cefoxitin coupled with the application of amikacin‐impregnated cement likely contributed to the successful outcome.
Recurrent Acute Pancreatitis Secondary to a Duodenal Duplication Cyst in an Adult. A Case Report and Literature Review
Authors: Salemis Nikolaos S , Liatsos Christos , Kolios Michail , Gourgiotis Stavros
Published: March 2016

Duodenal duplication cysts are rare congenital abnormalities that are most commonly diagnosed in infancy and childhood. However, in rare cases, the lesion can remain asymptomatic until adulthood. An extremely rare case of a previously healthy adult patient with recurrent acute pancreatitis, who was diagnosed with a duodenal duplication cyst is presented. At laparotomy, a duplication cyst measuring 4.8 cm × 4 cm × 4 cm was found adjacent to the ampulla of Vater. A partial cyst excision and marsupialization into the duodenal lumen was performed. The patient is healthy and asymptomatic four years after surgery. The present case illustrates the necessity of considering a duodenal duplication cyst in the differential diagnosis of recurrent acute pancreatitis in previously healthy adults.
All That Bleeds Is Not Infliximab-Refractory Ulcerative Colitis
Authors: Law JK , Salh B , Yoshida EM
Published: March 2016

The role of biological agents in moderate to severe ulcerative colitis has been shown to be effective in the induction of clinical remission. However, the role of infliximab therapy for induction of remission in patients with fulminant colitis is debatable. A case of a hospitalized patient with a new diagnosis of severe ulcerative colitis refractory to intravenous steroids is presented. The patient was treated with infliximab and discharged with clinical remission, but subsequently presented back to hospital with a lower gastrointestinal hemorrhage.
End‐Of‐Life Care for Persons with Advanced Chronic Obstructive Pulmonary Disease: Report of a National Interdisciplinary Consensus Meeting
Authors: Goodridge DM , Marciniuk DD , Brooks D , van Dam A , Hutchinson S , Bailey P , Baxter S , Dorasamy P , Dumont S , Hassan S , Hernandez P , Kerigan A , Rocker G , Wilson D , Young J
Published: March 2016

While systemic shortcomings in meeting the needs of individuals with progressive chronic illnesses at the end of life have been well documented, there is growing interest in improving both care and quality of life for persons with advanced chronic obstructive pulmonary disease (COPD). For instance, the American Thoracic Society has issued an official statement on palliative care for patients with respiratory diseases, affirming that the prevention, relief, reduction and soothing of symptoms “without affecting a cure” must become an integral component of standard care. A recent Medline search located 1015 articles related to palliative or end‐of‐life care for people with COPD published between 2001 and 2008, compared with only 336 articles published before 2001. To address the needs of Canadian patients, an interdisciplinary consensus meeting, funded by the Canadian Institutes of Health Research and supported by the Canadian Thoracic Society, the Canadian Respiratory Health Professionals and the Canadian Lung Association was convened in Toronto, Ontario, on November 22, 2008, to begin examining the quality of end‐of‐life care for individuals with COPD in Canada. The present report summarizes the background to and outcomes of this consensus meeting.
A Research Synthesis of Therapeutic Interventions for Whiplash‐Associated Disorder: Part 1 – Overview and Summary
Authors: Teasell Robert W , McClure J Andrew , Walton David , Pretty Jason , Salter Katherine , Meyer Matthew , Sequeira Keith , Death Barry
Published: March 2016

Whiplash‐associated disorder (WAD) represents a significant public health problem, resulting in a substantial socioeconomic burden throughout the industrialized world, wherever costs are documented. While many treatments have been advocated for patients with WAD, scientific evidence of their effectiveness is often lacking. A systematic review was conducted to evaluate the strength of evidence supporting various WAD therapies. Multiple databases (including Web of Science, EMBASE and PubMed) were searched to identify all studies published from January 1980 through March 2009 that evaluated the effectiveness of any clearly defined treatment for acute (less than two weeks), subacute (two to 12 weeks) or chronic (longer than 12 weeks) WAD. The present article, the first in a five‐part series, provides an overview of the review methodology as well as a summary and discussion of the review’s main findings. Eighty‐three studies met the inclusion criteria, 40 of which were randomized controlled trials. The majority of studies (n=47) evaluated treatments initiated in the chronic stage of the disorder, while 23 evaluated treatments for acute WAD and 13 assessed therapies for subacute WAD. Exercise and mobilization programs for acute and chronic WAD had the strongest supporting evidence, although many questions remain regarding the relative effectiveness of various protocols. At present, there is insufficient evidence to support any treatment for subacute WAD. For patients with chronic WAD who do not respond to conventional treatments, it appears that radiofrequency neurotomy may be the most effective treatment option. The present review found a relatively weak but growing research base on which one could make recommendations for patients at any stage of the WAD continuum. Further research is needed to determine which treatments are most effective at reducing the disabling symptoms associated with WAD.
A Research Synthesis of Therapeutic Interventions for Whiplash‐Associated Disorder (WAD): Part 3 – Interventions for Subacute WAD
Authors: Teasell Robert W , McClure J Andrew , Walton David , Pretty Jason , Salter Katherine , Meyer Matthew , Sequeira Keith , Death Barry
Published: March 2016

Whiplash‐associated disorder (WAD) represents a significant public health problem, resulting in substantial social and economic costs throughout the industrialized world. While many treatments have been advocated for patients with WAD, scientific evidence supporting their effectiveness is often lacking. A systematic review was conducted to evaluate the strength of evidence associated with various WAD therapies. Multiple databases (including Web of Science, EMBASE and PubMed) were searched to identify all studies published from January 1980 through March 2009 that evaluated the effectiveness of any clearly defined treatment for acute (less than two weeks), subacute (two to 12 weeks) or chronic (longer than 12 weeks) WAD. The present article, the third in a five‐part series, evaluates the evidence for interventions initiated during the subacute phase of WAD. Thirteen studies that met the inclusion criteria were identified, six of which were randomized controlled trials with ‘good’ overall methodology (median Physiotherapy Evidence Database score of 6). Although some evidence was identified to support the use of interdisciplinary interventions and chiropractic manipulation, the evidence was not strong for any of the evaluated treatments. There is a clear need for further research to evaluate interventions aimed at treating patients with subacute WAD because there are currently no interventions satisfactorily supported by the research literature.
Factors Associated with Colonoscopy Performed in Nonhospital Settings
Authors: Alharbi Othman , Rabeneck Linda , Paszat Lawrence F , Wijeysundera Duminda N , Sutradhar Rinku , Yun Lingsong , Vinden Christopher M , Tinmouth Jill
Published: March 2016

BACKGROUND: Colonoscopy is being increasingly performed in facilities outside of hospitals. Regulation of these facilities is variable, and concerns regarding the quality of procedures in nonhospital (NH) settings have been raised. Further study is needed to better understand endoscopic practice in these facilities.

OBJECTIVES: To describe NH-based colonoscopy practice in Ontario from 1993 to 2005, and to identify patient (age, sex, income quintile and comorbidity) and physician (specialty and colonoscopy volume) factors associated with this practice.

METHODS: The present study was a population-based, cross-sectional analysis using health administrative data from Ontario adults who underwent at least one outpatient colonoscopy between 1993 and 2005. A total of 1,240,781 patients underwent 1,917,714 colonoscopies. The main outcome measure was the receipt of colonoscopy in an NH facility.

RESULTS: An increase in NH-based colonoscopy from 10.0% in 1993 to 15.1% in 2005 (P<0.0001) was found. In the multivariate model, younger, healthier men living in higher income areas were significantly more likely to undergo NH-based colonoscopy. Surgeons and other practitioners (eg, nongastroenterologists and noninternists) were significantly more likely to practice in NH settings. Physicians in the highest colonoscopy volume quintile were 25 times more likely to practice in NH settings than those in the lowest volume quintile (P<0.0001).

CONCLUSION: Rates of NH-based colonoscopy are rising in Ontario. High-volume endoscopists and surgeons are most likely to practice in NH settings. Given its increasing use, further study of the practice and the regulation of NH colonoscopy is warranted.
Diagnostic Performance of Gastric Imprint Smear for Determination ofHelicobacter pyloriInfection
Authors: Al-Ali J , Al-Asfar F , Dhar R , Dhar PM , Kapila K
Published: March 2016

BACKGROUND: Despite the availability of several methods (invasive and noninvasive) for the diagnosis ofHelicobacter pyloriinfection, no test is considered to be the ‘gold standard’. Endoscopy-based tests are regarded as the reference method in most studies.

OBJECTIVE: To evaluate the diagnostic performance of imprint cytology smears of antral biopsies compared with Gram-stained smears, the rapid urease test and culture methods, separately and in combination.

METHODS: Antral biopsies were obtained from consecutive patients undergoing upper gastrointestinal endoscopy at a single centre. The biopsies were examined for the presence ofH pyloriby Gram-stained smear, the rapid urease test, culture methods and imprint cytology smear.

RESULTS: A total of 273 biopsies were studied. All tests were positive in 36% of the patients. Of 252 biopsies tested, 73% were positive using the imprint cytology technique. Using Gram-stained smear, the rapid urease test and culture methods individually, the sensitivity and specificity of imprint cytology smears for the detection ofH pyloriwere found to be 92.7% and 50%; 92.7% and 49%; and 92.4% and 38.5%, respectively. Combining the three microbiological methods resulted in a sensitivity of 92.1%, a specificity of 51.0% and an efficiency of 71.7% for imprint cytology smears.

CONCLUSIONS: Endoscopic examination provides useful clinical information. Imprint gastric cytology can be used as a rapid test to establish the diagnosis ofH pyloriinfection at the time endoscopy is performed, enabling the endoscopist to start treatment with immediate effect.
Admissions to Canadian Hospitals for Acute Asthma: A Prospective, Multicentre Study
Authors: Rowe Brian H , Villa-Roel Cristina , Abu-Laban Riyad B , Stenstrom Rob , Mackey Duncan , Stiell Ian G , Campbell Sam , Young Bryan
Published: March 2016

BACKGROUND:

Asthma exacerbations constitute one of the most common causes of emergency department (ED) attendance in most developed countries. While severe asthma often requires hospitalization, variability in admission practices has been observed.

OBJECTIVE:

To describe the factors associated with admission to Canadian hospitals for acute asthma after ED treatment.

METHODS:

Subjects 18 to 55 years of age treated for acute asthma in 20 Canadian EDs prospectively underwent a structured ED interview (n=695) and telephone interview two weeks later.

RESULTS:

The median age of the patients was 30 years, and the majority were women (62.8%). The admission rate was 13.1% (95% CI 10.7% to 15.8%). Admitted patients were older, more often receiving oral or inhaled corticosteroids at presentation, and more frequently receiving systemic corticosteroids and magnesium sulphate in the ED. Similar proportions received beta‐2 agonists and/or ipratropium bromide within 1 h of arrival. On multivariable analyses, factors associated with admission included age, previous admission in the past two years, more than eight beta‐2 agonist puffs in the past 24 h, a Canadian Triage and Acuity Score of 1 to 2, a respiratory rate of greater than 22 breaths/min and an oxygen saturation of less than 95%.

CONCLUSION:

The admission rate for acute asthma from these Canadian EDs was lower than reported in other North American studies. The present study provides insight into practical factors associated with admission for acute asthma and highlights the importance of history and asthma severity markers on ED decision making. Further efforts to standardize ED management and expedite admission decision‐making appear warranted.
Lung Atelectasis Secondary to Massive Esophageal Dilation in a Patient With Scleroderma
Authors: St-Arnaud Charles , Bouchard Nicole , Lanthier Luc
Published: March 2016

Esophageal dilation is a rare complication of scleroderma and CREST syndrome. A case of atelectasis secondary to right inferior bronchus compression by a massively dilated esophagus is described. The authors are unaware of any previous cases of atelectasis secondary to esophageal dilation in scleroderma.
Intermittent Obstruction Resulting from Multiple Intestinal Webs
Authors: Prabhu Kristel Lobo , Enns Robert , Brown Carl J
Published: March 2016

Intestinal webs are a rare cause of bowel obstruction. A case of a 32‐year‐old man with multiple intestinal webs causing intermittent, partial bowel obstruction is described. The webs were initially detected with capsule endoscopy. The patient was treated with intraoperative endoscopy and balloon dilation. At early follow‐up, no recurrence of his symptoms was evident.
Risk Factors and Outcomes for the Development of Malignancy in Lung and Heart‐Lung Transplant Recipients
Authors: Metcalfe Michael J , Kutsogiannis Demetrios J , Jackson Kathy , Oreopoulous Antigone , Mullen John , Modry Denis , Weinkauf Justin , Lien Dale C , Stewart Ken C
Published: March 2016

BACKGROUND: Many factors may limit survival from lung and heart‐lung transplantation, including malignancy.

OBJECTIVE: To investigate factors associated with the development of malignancy following transplantation and its effect on survival by retrospectively reviewing a population of lung transplant recipients.

METHODS: Data from 342 consecutive lung transplant patients were collected. Results were analyzed by fitting variables into a multivariate logistic regression model predicting the development of post‐transplant malignancies. Covariates were selected based on crude associations that reached a level of significance at P≤0.10. Length of survival was analyzed using the Kaplan‐Meier method.

RESULTS: Fifty‐eight subjects developed post‐transplant malignancies, which were the cause of death of 14 patients. Twenty‐one patients had a pretransplant malignancy, of whom six developed a malignancy post‐transplant – of these, two were fatal recurrences. No risk factors were significantly associated with all forms of post‐transplant malignancy. When adjusted for age at transplantation and donor smoking history, Epstein‐Barr virus seropositivity at the time of transplant was significantly associated with a reduced risk of a post‐transplant lymphoproliferative disorder (OR 0.17; 95% CI 0.05 to 0.59). The median survival time in individuals without a post‐transplant malignancy was significantly shorter than in those with a post‐transplant malignancy (P=0.018 Wilcoxon [Breslow]). This may be secondary to the length of time required to develop malignancy and the fact that not all malignancies that developed were fatal. The median time to develop malignancy was greater than two years. In addition, the 14 patients who died as a result of their malignancy had a significantly shorter survival time than the 44 who died because of nonmalignant causes (P<0.001).

CONCLUSIONS: Malignancy was not associated with an overall decrease in survival time when compared with those who did not develop a malignancy. Risk factors specific for the development of malignancies remain difficult to specify.
Prophylactic Positive End‐Expiratory Pressure and Postintubation Hemodynamics: An Interventional, Randomized Study
Authors: Lesur Olivier , Remillard Marie-Anaïs , St-Pierre Catherine , Falardeau Simon
Published: March 2016

OBJECTIVE: To investigate the hemodynamic and outcome effects of implementing prophylactic positive end‐expiratory pressure (PEEP) versus zero end‐expiratory pressure (ZEEP) in patients during the postintubation period in the emergency setting.

METHODS: The present study was a prospective, single‐centre, interventional, single‐blinded randomized trial performed in a 16‐bed medical intensive care unit. The study cohort consisted of consecutive patients who urgently required intubation. During the postintubation period, patients received either 5 cmH2O PEEP or ZEEP. The primary aim was to assess the variation in mean arterial pressure (MAP) from baseline up to 90 min postintubation. The secondary aim was to determine the mean duration of intubation, level of MAP support after intubation and 28‐day mortality.

RESULTS: Seventy‐five consecutive patients with similar mean (± SD) baseline characteristics and preintubation MAP (76±18 mmHg in the ZEEP group and 78.5±23 mmHg in the PEEP group, P=Not significant [NS]) were studied. The final analysis was performed in 33 patients in the ZEEP group and 30 patients in the PEEP group. Regarding outcome measures following intubation, delta MAP (ie, the difference between the lowest MAP values from baseline) was not differentially affected in either group (P=NS); the mean durations of intubation were similar (ZEEP 9.2±8.5 days versus PEEP 9.2±8.8 days, P=NS); 28‐day mortality was not discriminative (ZEEP 14 of 33, PEEP nine of 30; P=NS); and levels of MAP support after intubation were comparable between the two groups.

CONCLUSION: In the present trial, there was no evidence that implementing a prophylactic PEEP of 5 cmH2O adversely affects short‐term hemodynamics or outcome in medical intensive care patients during the postintubation period.
Endoscopic Management of Gastric Variceal Bleeding with Cyanoacrylate Glue Injection: Safety and Efficacy in a Canadian Population
Authors: Al-Ali Jaber , Pawlowska Monika , Coss Alan , Svarta Sigrid , Byrne Michael , Enns Robert
Published: March 2016

BACKGROUND: Gastric variceal bleeding (GVB) is a major cause of morbidity and mortality among patients with portal hypertension. Endoscopic band ligation and standard sclerotherapy have been used but have significant limitations. Decompression through transjugular intrahepatic portosystemic shunt insertion has been shown to be effective. Gastric variceal injection therapy with a commercially available cyanoacrylate glue is less invasive than transjugular intrahepatic portosystemic shunt insertion and has recently been shown to be effective for acute hemostasis.

OBJECTIVE: To assess the immediate and long-term outcomes of cyanoacrylate glue injection therapy for GVB.

METHODS: A retrospective chart review was conducted to identify patients treated with cyanoacrylate injection for GVB at two tertiary care hospitals over a period of six years. The outcomes assessed included complications, acute hemostasis, rebleeding rate and all-cause mortality.

RESULTS: Thirty-seven patients (60% men) underwent cyanoacrylate glue injections for GVB. The median follow-up period was 14 months and included 29 patients (eight were lost to follow-up). Initial hemostasis was achieved in 35 patients (95%). No significant complications from cyanoacrylate injection were observed. Early rebleeding was rare (8%) and late rebleeding occurred in only 28% of patients. The all-cause mortality rate was 28.6% during the median follow-up period.

CONCLUSION: The data suggest that cyanoacrylate injection therapy is safe and effective for the prevention of short- and long-term bleeding from gastric varices. Furthermore, although these patients had significant comorbid disease, survival in the follow-up time period was greater than 70%.
Ceftobiprole: First Reported Experience in Osteomyelitis
Authors: MacDonald A , Dow G
Published: March 2016

A 74‐year‐old man with long‐standing diabetes presented with advanced infection of the right forefoot associated with septic arthritis and osteomyelitis involving the second and third metatarsophalangeal joints. Polymicrobial infection, which included methicillin‐resistant Staphylococcus aureus, was documented. First‐line antibiotic therapy, which included vancomycin, was not tolerated. A durable cure was obtained following a six‐week course of intravenous ceftobiprole medocaril combined with local surgery. The present report is the first to administer intravenous ceftobiprole medocaril to a patient with methicillin‐resistant S aureus‐associated septic arthritis and osteomyelitis.
Opportunity Costs of Gastrointestinal Endoscopic Training in Canada
Authors: Depew WT , Hookey LC , Vanner SJ , Louw JA , Lowe CE , Ropeleski MJ , Beyak MJ , Lazarescu A , Paterson WG
Published: March 2016

BACKGROUND: No data exist to define the opportunity costs related to instruction in endoscopic procedures in Royal College of Physicians and Surgeons of Canada-accredited teaching centres. Academic and institutional administrators expect staff to achieve acceptable performance standards. There is a need to measure some of the effects of training activity in the establishment of such standards.

OBJECTIVE: To measure the effect of resident training in colonoscopy on real procedure times and, as a secondary goal, to estimate procedural losses related to the process of training.

METHODS: Real procedure times for ambulatory colonoscopy in a single academic, hospital-based endoscopy unit were documented. Times for certified endoscopy instructors functioning solo were compared with times for procedures involving trainees at several levels of colonoscopic experience. Procedural reductions associated with resident training were estimated based on the parameters derived from the results. The analysis was executed retrospectively using prospectively collected data.

RESULTS: Resident training prolonged procedure times for ambulatory colonoscopy by 50%. The trainee effect was consistent, although variable in degree, among a variety of endoscopy instructors. Such increased procedure times have the potential to reduce case throughput and endoscopist remuneration.

CONCLUSIONS: Resident training in colonoscopy in a Canadian certified training program has significant negative effects on case throughput and endoscopist billings. These factors should be considered in any assessment of performance in similar training environments.
Comparing Patient and Endoscopist Perceptions of the Colonoscopy Indication
Authors: Sewitch Maida J , Stein Dara , Joseph Lawrence , Bitton Alain , Hilsden Robert J , Rabeneck Linda , Paszat Lawrence , Tinmouth Jill , Cooper Mary Anne
Published: March 2016

BACKGROUND: Determining whether a colonoscopy is performed for screening or nonscreening purposes can facilitate clinical practice and research. However, there is no simple method to determine the colonoscopy indication using patient medical files or health administrative databases.

OBJECTIVE: To determine patient‐endoscopist agreement on the colonoscopy indication.

METHODS: A cross‐sectional study was conducted among staff endoscopists and their patients at seven university‐affiliated hospitals in Montreal, Quebec. The study participants were 50 to 75 years of age, they were able to understand English or French, and were about to undergo colonoscopy. Self‐ (endoscopist) and interviewer‐administered (patient) questionnaires ascertained information that permitted classification of the colonoscopy indication. Patient colonoscopy indication was defined as the following: perceived screening (routine screening, family history, age); perceived nonscreening (follow‐up); medical history that implied nonscreening; and a combination of the three preceding indications. Agreement between patient and endoscopist indications was measured using concordance and Kappa statistic.

RESULTS: In total, 702 patients and 38 endoscopists participated. The three most common reasons for undergoing colonoscopy were routine screening/regular check‐up (33.8%), follow‐up to a previous problem (30.2%) and other problem (24.6%). Concordance (range 0.79 to 0.85) and Kappa (range 0.58 to 0.70) were highest for perceived nonscreening colonoscopy. Recent large bowel symptoms accounted for 120 occurrences of disagreement in which the patient perceived a nonscreening colonoscopy while the endoscopist perceived a screening colonoscopy.

CONCLUSIONS: Patient self‐report may be an acceptable means for rapidly assessing whether a colonoscopy is performed for screening or nonscreening purposes. Delivery of patient‐centred care may help patients and endoscopists reach a shared understanding of the reason for colonoscopy.
The Role of Garlic in Hepatopulmonary Syndrome: A Randomized Controlled Trial
Authors: De Binay K , Dutta Deep , Pal Subrata K , Gangopadhyay Subhabrata , Das Baksi Sumanta , Pani Adyapad
Published: March 2016

BACKGROUND: Increased nitric oxide production in cirrhosis has been commonly implicated in the genesis of hepatopulmonary syndrome (HPS). Initial studies suggested that garlic, a constituent of the daily diet, may have a role in the treatment of HPS by altering nitric oxide production.

OBJECTIVE: To evaluate the effects of oral garlic supplementation on arterial blood gas parameters, and overall morbidity and mortality in patients with HPS.

METHODS: Twenty-one and 20 HPS patients were randomly assigned to receive either oral garlic supplementation or placebo, respectively, and were evaluated monthly over a period of nine to 18 months.

RESULTS: After nine months, garlic supplementation was associated with a 24.66% increase in baseline arterial oxygen levels (83.05 mmHg versus 66.62 mmHg; P<0.001), compared with only a 7.37% increase (68.75 mmHg versus 64.05 mmHg; P=0.02) among subjects in the placebo group. There was also a 28.35% decrease in alveolar-arterial oxygen gradient (21.35 mmHg versus 29.77 mmHg; P<0.001) among patients with HPS who received garlic, in contrast with only a 10.73% decrease (29.11 mmHg versus 32.61 mmHg; P=0.12) among those in the placebo group. After nine months, the arterial oxygen level was significantly higher (83.05 mmHg versus 68.75 mmHg; P<0.001) and the alveolar-arterial oxygen gradient was significantly lower (21.35 mmHg versus 29.11 mmHg; P<0.001) among patients receiving garlic compared with those receiving placebo. Reversal of HPS was observed in 14 of 21 patients (66.67%) on garlic supplementation (intent-to-treat analysis) and in one of 20 patients (5%) on placebo. Two of 21 patients undergoing garlic supplementation died during follow-up in contrast to seven of 20 patients who were on placebo.

CONCLUSIONS: Garlic supplementation may be beneficial in patients with HPS for the reversal of intrapulmonary shunts as well as reducing hypoxemia and mortality.
Fibromyalgia and the Therapeutic Relationship: Where Uncertainty Meets Attitude
Authors: Hayes Sean M , Myhal Genevieve C , Thornton John F , Camerlain Monique , Jamison Cynthia , Cytryn Kayla N , Murray Suzanne
Published: March 2016

BACKGROUND: Fibromyalgia remains underdiagnosed and suboptimally treated even though it affects an estimated 3.3% of Canadians. The present study examines knowledge and attitudinal challenges affecting optimal care.

METHODS: A mixed‐methods approach was employed. Discussion groups, semistructured interviews and a quantitative online survey (five‐point scale) were conducted (June 2007 to January 2008). Participants included 189 general practitioners (GPs) and 139 specialists (anesthesiologists, neurologists, physiatrists, psychiatrists and rheumatologists) distributed across Canada. Participants included 18 patients to enrich the scope of the findings.

RESULTS: GPs reported insufficient knowledge and skill in diagnosing fibromyalgia, with not all believing it to be a diagnosable condition (mean 3.74/5). Twenty‐three per cent of GPs and 12% of specialists characterized fibromyalgia patients as malingerers. They further reported a lack of knowledge and skill in treating fibromyalgia (mean 2.73/5), including the pain, sleep disorders and mood disorders related to the condition (mean 3.32/5). Specialists shared these challenges, although to a lesser degree – “We are not trained to treat distress and suffering” (Specialist). Attitudinal issues centred around frustration (mean 3.91/5) and negative profiling of fibromyalgia patients (mean 3.06/5 and 1.99/5).

CONCLUSIONS: Findings revealed the presence of GP attitudinal and confidence challenges in caring for fibromyalgia patients. As care of fibromyalgia patients moves to general practices, these fundamental competencies must be addressed to assure that all patients receive the quality of care necessary to manage their disease and to empower physicians to be more professionally effective. As stated by one patient, “Why are we being penalized for having this disability?”