bluuebunny/crossref_metadata_2025 huggingface dataset:
Barriers to the Recognition and Reporting of Occupational Asthma by Canadian Pulmonologists
Authors: Parhar Anu , Lemiere Catherine , Beach Jeremy R
Published: March 2016

BACKGROUND: Occupational asthma is a common, but probably under-recognized problem.

OBJECTIVE: To identify the factors that suggest work-related asthma when a pulmonologist encounters an adult patient with new-onset asthma, and to identify the barriers to recognizing and reporting such cases.

METHODS: A postal questionnaire was sent to all pulmonologists in Canada. The questionnaire asked participants to respond to several questions about recognizing, diagnosing and reporting occupational asthma. Answers were scored using visual analogue scales.

RESULTS: A total of 201 eligible responses were received from 458 pulmonologists. Pulmonologists identified that the most important factor in initially considering the role of work in occupational asthma was having seen others affected at the same workplace, or exposed to the same agent. Important perceived barriers to considering a diagnosis of occupational asthma were physicians’ low awareness, lack of knowledge and time. The most important barriers to reporting cases were the pulmonologists’ perceived patient concerns regarding job security and income. Quebec pulmonologists generally perceived barriers to recognizing and reporting occupational asthma to be less important, and believed that the use of specific inhalation challenge was more important in considering a diagnosis.

CONCLUSIONS: Pulmonologists most readily recognized occupational asthma caused by a substance or process that they previously encountered as a possible cause of asthma. Time constraints and knowledge may hamper their ability to recognize occupational asthma. Concerns regarding the effect of the diagnosis on the patient’s job and income may discourage reporting.
Validation of the MediByte® Type 3 Portable Monitor Compared with Polysomnography for Screening of Obstructive Sleep Apnea
Authors: Driver Helen S , Pereira Effie J , Bjerring Kathryn , Toop Fern , Stewart Steven C , Munt Peter W , Fitzpatrick Michael F
Published: March 2016

BACKGROUND: Portable monitors are increasingly being used as a diagnostic screening tool for obstructive sleep apnea (OSA), and in‐laboratory validation of these devices with polysomnography (PSG) is required.

OBJECTIVE: To assess the reliability of the MediByte (Braebon Medical Corporation, Canada) type 3 screening device compared with overnight PSG.

METHODS: To cover a range of OSA severity, a consecutive series of patients wore the screening device while simultaneously undergoing PSG. Data acquired from the screener and PSG were blinded and scored separately. The number of apneas and hypopneas per hour were calculated using recording time (respiratory disturbance index [RDI]) for the MediByte device, and sleep time (apnea‐hypopnea index [AHI]) for PSG.

RESULTS: Data from 73 patients with a mean age of 53 years and body mass index of 32.2 kg/m2 showed high measurement association between the RDI and AHI, with a Pearson correlation of 0.92, accounting for 85% of the variance. Based on Bland‐Altman measurement agreement, the mean difference between the RDI and AHI (−5.9±11.2 events/h) indicated screener under‐reporting. For an AHI of greater than 15 events/h, the sensitivity and specificity of the screener was 80% and 97%, respectively; for an AHI of greater than 30 events/h, the positive predictive value was 100%, while the negative predictive value was 88%.

CONCLUSION: The MediByte device accurately identified patients without OSA and had a high sensitivity for moderate‐to‐severe OSA.
Development of Transient Peanut Allergy Following Lung Transplantation: A Case Report
Authors: Bhinder Sacha , Heffer Matthew J , Lee Jason K , Chaparro Cecilia , Tarlo Susan M
Published: March 2016

A 47‐year‐old woman underwent bilateral lung transplantation for nonspecific interstitial pneumonitis and received donor lungs from a 12‐year‐old patient with a known peanut allergy. Post‐transplant, the patient experienced four anaphylaxis‐like reactions. A skin prick test to peanut was initially positive; however, it steadily declined over serial assessments and reverted to negative one year post‐transplant. The patient subsequently had a negative oral peanut challenge. Transfer of food allergy post‐transplantation is theorized to occur via transfer of donor B lymphocytes producing peanut‐specific immunoglobulin E into the circulation of the recipient. An alternate mechanism proposes passive transfer of immunoglobulin E‐sensitized mast cells and/or basophils within the transplanted tissue that subsequently migrate into recipient tissues. The gradual decline in the magnitude of the peanut skin prick test and its return to negative over the course of one year supports the gradual depletion of sensitized cells in the recipient (B lymphocytes and, possibly, mast cells), and supports the initial passive transfer of sensitized cells from donor tissue during transplantation. This should be considered when donor organs are obtained from allergic individuals.
Changes in Perceived Pain Severity during Interdisciplinary Treatment for Chronic Pain
Authors: Kowal John , Wilson Keith G , Geck Celia M , Henderson Peter R , D’Eon Joyce L
Published: March 2016

Biopsychosocial approaches to the treatment of chronic pain are founded on the principles of cognitive behavioural therapy, the basic aims of which are, among others, to identify and modify beliefs, decrease pain‐related fear and avoidance of activity, and to teach adaptive coping strategies. To determine whether functional outcomes in multiple domains are improved in such settings, this retrospective study investigated patients’ reports of increased pain severity while participating in an interdisciplinary cognitive behavioural therapy‐oriented outpa‐tient treatment program.
Emotional and Neurobehavioural Status in Chronic Pain Patients
Authors: Shuchang He , Mingwei He , Hongxiao Jia , Si Wu , Xing Yang , Antonius Daniel , Opler Mark GA
Published: March 2016

OBJECTIVE: To investigate the emotional and neurobehavioural status of patients suffering from chronic pain.

METHODS: Fifteen male patients with chronic lower back pain and 15 healthy control subjects were studied for approximately six months. Pain was measured using a visual analogue scale. The WHO Neurobehavioral Core Test Battery (NCTB) was used to assess neurobehavioural effects of environmental and occupational exposures.

RESULTS: Visual analogue scale results demonstrated a modest range of reported pain (mean [± SD] 62.0±10.8) in chronic pain patients, whereas control subjects reported no measurable pain. With the NCTB, it was found that scores of negative mood state, including anger‐hostility, depression‐dejection, fatigue‐inertia and tension‐anxiety in pain patients were significantly higher than scores in the control subjects. By contrast, scores of positive mood state (vigour‐activity) in chronic pain patients were lower than those in the control group. The NCTB scores of the Santa Ana Dexterity and Pursuit Aiming II tests in chronic lower back pain patients were lower than those of the control group. Scores for other NCTB sub‐tests, including the Digit Span, Benton Visual Retention and Digit Symbol tests, were not significantly different compared with controls.

CONCLUSIONS: Chronic lower back pain patients had more negative mood and less positive mood than controls. These patients also demonstrated neuromotor deficits in coordination and reaction time. Further studies are required to examine possible neurological mechanisms and research potential intervention strategies for patients suffering from chronic pain.
Predictors of Respiratory Symptoms in a Rural Canadian Population: A Longitudinal Study of Respiratory Health
Authors: Karunanayake Chandima P , Rennie Donna C , Pahwa Punam , Chen Yue , Dosman James A
Published: March 2016

BACKGROUND: Predictors of new and long‐term respiratory symptoms for rural residents are not well defined.

OBJECTIVE: To identify early predictors of respiratory symptoms in a rural community population.

METHODS: The study population consisted of 871 adults living in the rural community of Humboldt, Saskatchewan, who participated in two cross‐sectional respiratory studies conducted in 1993 and 2003. Questionnaire information obtained at both time points included respiratory symptoms (cough, phlegm and wheeze), history of allergy, smoking, and information regarding home and farm environments. Transitional modelling, in which measurement in a longitudinal sequence is described as a function of previous outcomes, was used to predict later outcomes of cough, phlegm and wheeze. Asymptomatic individuals in 1993 were assessed to determine factors associated with the development of symptoms during the study period.

RESULTS: The prevalences of cough, phlegm and wheeze in 1993 were 16.1%, 18.1% and 25.5%, respectively. Change in symptoms over time was significant for cough, phlegm and wheeze. The adjusted ORs (95% CI) from separate transitional models for each respiratory outcome in 1993 that predicted the same symptom in 2003 were 6.32 (4.02 to 9.95) for cough, 14.36 (9.01 to 22.89) for phlegm and 6.40 (4.40 to 9.32) for wheeze. For asymptomatic individuals in 1993, home dampness, allergic reaction to inhaled allergens and cigarette smoking were major risk factors associated with respiratory symptoms that were reported in 2003.

CONCLUSION: The presence of previous respiratory symptoms, allergies and environmental exposures can predict the occurrence of future respiratory symptoms in adults.
Representations of OxyContin in North American Newspapers and Medical Journals
Authors: Whelan Emma , Asbridge Mark , Haydt Susan
Published: March 2016

Following the approval of OxyContin (Purdue Pharma, Canada) for medical use, the media began to report the use of OxyContin as a street drug, representing the phenomenon as a social problem. Meanwhile, the pain medicine community has criticized the inaccurate and one‐sided media coverage of the OxyContin problem. The authors of this study aimed to contribute to an understanding of both sides of this controversy by analyzing the coverage of OxyContin in newspapers and medical journals. The analyses revealed inconsistent messages about the drug from physicians in the news media and in medical journals, which has likely contributed to the drug’s perception as a social problem. The authors suggest ways to address the lack of medical consensus surrounding OxyContin. The results of this study may help resolve the concerns and conflicts surrounding this drug and other opioids.

BACKGROUND: There are public concerns regarding OxyContin (Purdue Pharma, Canada) and charges within the pain medicine community that media coverage of the drug has been biased.

OBJECTIVE: To analyze and compare representations of OxyContin in medical journals and North American newspapers in an attempt to shed light on how each contributes to the ‘social problem’ associated with OxyContin.

METHODS: Using searches of newspaper and medical literature databases, two samples were drawn: 924 stories published between 1995 and 2005 in 27 North American newspapers, and 197 articles published between 1995 and 2007 in 33 medical journals in the fields of addiction/substance abuse, pain/anesthesiology and general/internal medicine. The foci, themes, perspectives represented and evaluations of OxyContin presented in these texts were analyzed statistically.

>RESULTS: Newspaper coverage of OxyContin emphasized negative evaluations of the drug, focusing on abuse, addiction, crime and death rather than the use of OxyContin for the legitimate treatment of pain. Newspaper stories most often conveyed the perspectives of law enforcement and courts, and much less often represented the perspectives of physicians. However, analysis of physician perspectives represented in newspaper stories and in medical journals revealed a high degree of inconsistency, especially across the fields of pain medicine and addiction medicine.

CONCLUSION: The prevalence of negative representations of OxyContin is often blamed on biased media coverage and an ignorant public. However, the proliferation of inconsistent messages regarding the drug from physicians plays a role in the drug’s persistent status as a social problem.
Exploring the Association Between Pain Intensity and Facial Display in Term Newborns
Authors: Schiavenato Martin , Butler-O’Hara Meggan , Scovanner Paul
Published: March 2016

BACKGROUND: Facial expression is widely used to judge pain in neonates. However, little is known about the relationship between intensity of the painful stimulus and the nature of the expression in term neonates.

OBJECTIVES: To describe differences in the movement of key facial areas between two groups of term neonates experiencing painful stimuli of different intensities.

METHODS: Video recordings from two previous studies were used to select study subjects. Four term neonates undergoing circumcision without analgesia were compared with four similar male term neonates undergoing a routine heel stick. Facial movements were measured with a computer using a previously developed ‘point‐pair’ system that focuses on movement in areas implicated in neonatal pain expression. Measurements were expressed in pixels, standardized to percentage of individual infant face width.

RESULTS: Point pairs measuring eyebrow and eye movement were similar, as was the sum of change across the face (41.15 in the circumcision group versus 40.33 in the heel stick group). Point pair 4 (horizontal change of the mouth) was higher for the heel stick group at 9.09 versus 3.93 for the circumcision group, while point pair 5 (vertical change of the mouth) was higher for the circumcision group (23.32) than for the heel stick group (15.53).

CONCLUSION: Little difference was noted in eye and eyebrow movement between pain intensities. The mouth opened wider (vertically) in neonates experiencing the higher pain stimulus. Qualitative differences in neonatal facial expression to pain intensity may exist, and the mouth may be an area in which to detect them. Further study of the generalizability of these findings is needed.
Improving the Usefulness of the Multidimensional Pain Inventory
Authors: McKillop Jeffrey M , Nielson Warren R
Published: March 2016

BACKGROUND: The Multidimensional Pain Inventory (MPI) is a reliable and valid self‐report instrument that measures the impact of pain on an individual’s life, quality of social support and general activity. Criticism of the MPI has focused on this instrument’s internal structure and the stability of its classification taxonomy.

OBJECTIVES: To determine whether empirical summary scales could be developed for the MPI based on a large sample of respondents diagnosed with fibromyalgia syndrome. It was hypothesized that summary scales would improve the psychometric quality of the MPI and increase the stability of respondents’ taxonomy profiles across time.

METHODS: Respondents completed the MPI on two occasions before their admission to a multidisciplinary pain management program.

RESULTS AND CONCLUSIONS: Based on principal components analysis, three summary scales were developed that reflected level of impairment, social support and activity. Summary scales possessed good psychometric qualities and, when cluster analyzed, replicated the MPI taxonomy. Exploratory analyses of the MPI taxonomy revealed that goodness‐of‐fit values generally became less reliable as respondent profiles approached the overall sample mean. When the relative distance between respondents fit to taxonomy profiles and the distance from the sample mean was considered, profile stability using summary scales was predicted with good precision. These results suggest that summary scales may enhance the usefulness of the MPI, and that the traditional method of determining profile fit within the MPI is not stable and needs to be reconsidered.
Chiropractic Treatment for Gastrointestinal Problems: A Systematic Review of Clinical Trials
Authors: Ernst E
Published: March 2016

Many chiropractors believe that chiropractic treatments are effective for gastrointestinal disorders. The aim of the present systematic review was to critically evaluate the evidence from controlled clinical trials supporting or not supporting this notion. Six electronic databases were searched for relevant studies. No limits were applied to language or publication date. Prospective, controlled, clinical trials of any type of chiropractic treatment for any type of gastrointestinal problem, except infant colic, were included. Only two trials were found – one was a pilot study, and the other had reached a positive conclusion; however, both had serious methodological flaws. There is no supportive evidence that chiropractic is an effective treatment for gastrointestinal disorders.
Association between Proximity to Major Roads and Sputum Cell Counts
Authors: Wallace Julie , D’silva Liesel , Brannan John , Hargreave Frederick E , Kanaroglou Pavlos , Nair Parameswaran
Published: March 2016

BACKGROUND: Air pollution caused by motor vehicle emissions has been associated with exacerbations of obstructive airway diseases; however, the nature of the resulting bronchitis has not been quantified.

OBJECTIVE: To examine whether proximity to major roads or highways is associated with an increase in sputum neutrophils or eosinophils, and to evaluate the effect of proximity to roads on spirometry and exacerbations in patients with asthma.

METHODS: A retrospective study of 485 sputum cell counts from patients attending a tertiary chest clinic in Hamilton, Ontario, identified eosinophilic or neutrophilic bronchitis. Patients’ residences were geocoded to the street network of Hamilton using geographic information system software. Associations among bronchitis, lung function, and proximity to major roads and highways were examined using multinomial logistic and multivariate linear regression analyses adjusted for patient age, smoking status and corticosteroid medications.

RESULTS: Patients living within 1000 m of highways showed an increased risk of bronchitis (OR 3.8 [95% CI 1.0 to 13.7]; P<0.05), particularly neutrophilic bronchitis (OR 4.7 [95% CI 1.2 to 18.7]; P<0.05) as well as an increased risk of an asthma diagnosis (OR 1.9 [95% CI 1.0 to 3.4]; P<0.05). Patients living within 300 m of a major road were at increased risk for an asthma exacerbation (OR 1.9 [95% CI 1.5 to 15.5]; P<0.01) and lower lung function, particularly in women (P=0.036).

CONCLUSION: In patients with airway diseases, living close to a highway or major road was associated with neutrophilic bronchitis, an increased risk of asthma diagnosis, asthma exacerbations and lower lung function.
Update on Anal Fistulae: Surgical Perspectives for the Gastroenterologist
Authors: Tabry Helena , Farrands Paul A
Published: March 2016

Anal fistulae are common and debilitating; they are characterized by severe pain and discharge. They arise following infection near the anal canal, or as a primary event from an abscess in the abdomen, fistulating into the vagina or perianal skin. The term ‘cryptoglandular’ is given to abscesses arising from the anal glands.

For many years, the treatment of choice was to lay open the fistula; however, this risks causing incontinence with potentially devastating consequences. Alternative surgical treatments include setons, fibrin glue, collagen plugs and flaps to cover the internal fistula opening. These have achieved varying degrees of success, as will be discussed. The present review also discusses anal fistulae in light of much recently published literature. Currently, anal fistulae remain challenging and require specialist expertise; however, new treatment options are on the horizon.
Sensitivity to Pain Traumatization: A Higher‐Order Factor Underlying Pain‐Related Anxiety, Pain Catastrophizing and Anxiety Sensitivity among Patients Scheduled for Major Surgery
Authors: Kleiman Valery , Clarke Hance , Katz Joel
Published: March 2016

BACKGROUND: The present article addresses two related developments in the psychology of pain, and integrates them into a coherent framework to better understand the relationship between pain and trauma. The first is an emerging conceptualization regarding the nature of the hierarchical organization of major pain‐related anxiety constructs. The second is the theoretical rationale and empirical evidence linking pain and symptoms of post‐traumatic stress disorder.

OBJECTIVES: To explore the underlying hierarchical factor structure of commonly used pain‐related anxiety measures including the Pain Anxiety Symptoms Scale (PASS‐20), the Pain Catastrophizing Scale (PCS), and the Anxiety Sensitivity Index (ASI); and to relate this structure to post‐traumatic stress disorder in patients scheduled for major surgery.

METHODS: Measures were completed by 444 patients scheduled to undergo major surgery. Exploratory factor analysis and subsequent higher‐order analysis using the Schmid‐Leiman transformation were conducted to investigate the underlying factor structure of the ASI, the PCS and the PASS‐20.

RESULTS: Twenty items from the ASI, the PASS‐20 and the PCS loaded exclusively on one higher‐order factor. The authors suggest the term ‘sensitivity to pain traumatization’ (SPT) for the underlying construct based in part on the strong, significant positive correlation between SPT scores and scores on the Post‐traumatic Stress Disorder Checklist – Civilian Version. Finally, the total SPT score was significantly higher for patients with a history of pain than for those without a history of pain, both before surgery and one year after surgery. SPT describes the propensity to develop anxiety‐related somatic, cognitive, emotional and behavioural responses to pain that resemble features of a traumatic stress reaction. Together, the results of the present study provide preliminary evidence for the construct validity of SPT.
Timing and Frequency of Bowel Activity in Patients Ingesting Sodium Picosulphate/Magnesium Citrate and Adjuvant Bisacodyl for Colon Cleansing Before Colonoscopy
Authors: Vanner Stephen , Hookey Lawrence C
Published: March 2016

BACKGROUND: Despite the wealth of research investigating bowel cleansing efficacy, there are very little data on the timing or frequency of bowel movements after each agent is ingested.

OBJECTIVE: To examine the effect of each component of a three-day combined sodium picosulphate/magnesium citrate (PSLX) and bisacodyl regimen on the timing and frequency of bowel activity in patients undergoing colonoscopy.

METHODS: Outpatients booked for colonoscopy were asked to complete a diary of their bowel preparation that tracked the timing of bowel movements. Bowel preparation quality was assessed using the Ottawa Bowel Preparation Scale. Bowel activity was compared with baseline and correlated with colon cleansing. Subgroup analysis was performed examining the effect of timing of the procedure and split-dose regimens.

RESULTS: One hundred patients undergoing colon cleansing received bisacodyl 10 mg at 17:00 three days and two days before the day of colonoscopy. In one group, both sachets of PSLX were given the night before colonoscopy, while the second group, whose colonoscopies were scheduled after 11:00, ingested one sachet the night before and the second sachet at 06:00 on the day of colonoscopy. Patients had a mean of 1.7 bowel movements per day in the seven days before starting the cleansing regimen. Both doses of bisacodyl tablets resulted in a significant increase in the mean number of bowel movements compared with baseline (3.3/day first dose; 3.8/day second dose [P=0.03 and 0.001, respectively]). Each dose of PSLX also resulted in a significant increase in bowel movement frequency compared with baseline, with means of 4.4, 6.3 and 4.5 bowel movements after each dose. The mean time to the final bowel movement following the second sachet of PSLX was 8.9 h when taken the night before, and 3.9 h when taken the morning of the procedure. Bowel preparation quality significantly correlated with bowel frequency when total bowel movements were considered and when only the effects of bisacodyl were accounted for (P<0.01 for each).

DISCUSSION: These data demonstrate that the addition of bisacodyl before PSLX ingestion has a significant additive effect on bowel frequency and correlates with bowel cleansing quality. The timing of the resulting bowel movements have practical implications for sleep and travel times to endoscopy suites.
Presentation and Treatment of Monozygotic Twins with Congenital Central Hypoventilation Syndrome
Authors: Amin Reshma , Riekstins Andrea , Al-Saleh Suhail , Massicotte Colin , Coates Allan L , MacLusky Ian
Published: March 2016

Congenital central hypoventilation syndrome is a rare genetic disorder characterized by hypoventilation during sleep secondary to a blunted response to hypercapnia and hypoxia. The current case report describes developmentally normal four-year-old monozygotic twin boys who presented in infancy with variable presentations and clinical severity of congenital central hypoventilation syndrome. Both were managed with noninvasive positive pressure ventilation.
Primary Peritonitis due to Group A Streptococcus in a Previously Healthy Pediatric Patient
Authors: Holden R , Wilmer A , Kollman T
Published: March 2016

Primary peritonitis remains a rare disease in otherwise healthy children, with group A Streptococcus (GAS) being a particularly unusual cause. A case involving a 14‐year‐old girl, who presented with an ‘acute abdomen’ and was taken to the operating room for urgent laparoscopy, is reported. Abdominal and pelvic structures were only minimally inflamed, as was the appendix. Peritoneal fluid and blood cultures both grew pure cultures of GAS. The patient’s course was complicated by streptococcal toxic shock syndrome. She fortunately made a full recovery. The present report highlights the diagnostic and treatment dilemmas associated with GAS primary peritonitis.
Genetic and Antigenic Analysis of Invasive Serogroup C Neisseria meningitidis in Canada: A Decrease in the Electrophoretic Type (Et)‐15 Clonal Type and an Increase in the Proportion of Isolates Belonging to the Et‐37 (But Not Et‐15) Clonal Type During the Period from 2002 to 2009
Authors: Zhou Jianwei , Jamieson Frances , Dolman Sharon , Hoang Linda MN , Rawte Prasad , Tsang Raymond SW
Published: March 2016

BACKGROUND: Serogroup C meningococcal disease has been endemic in Canada since the early 1990s, with periods of hyperendemic disease documented in the past two decades. The present study characterized invasive serogroup C meningococci in Canada during the period from 2002 to 2009.

METHODS: Serogroup C meningococci were serotyped using monoclonal antibodies. Their clonal types were identified by either multilocus enzyme electrophoresis or multilocus sequence typing.

RESULTS: The number of invasive serogroup C Neisseria meningitidis isolates received at the National Microbiology Laboratory (Winnipeg, Manitoba) for characterization has dropped from a high of 173 isolates in 2001 to just 17 in 2009, possibly related to the introduction of the serogroup C meningococcal conjugate vaccine. Before 2006, 80% to 95% of all invasive serogroup C meningococci belonged to the electrophoreic type (ET)‐15 clonal type, and the ET‐37 (but not ET‐15) type only accounted for up to 5% of all isolates. However, beginning in 2006, the percentage of the ET‐15 clonal type decreased while the ET‐37 (but not ET‐15) type increased from 27% in 2006 to 52% in 2009. The percentage of invasive serogroup C isolates not belonging to either ET‐15 or ET‐37 also increased. Most ET‐15 isolates expressed the antigenic formula of C:2a:P1.7,1 or C:2a:P1.5. In contrast, the ET‐37 (but not ET‐15) isolates mostly expressed the antigens of C:2a:P1.5,2 or C:2a:P1.2.

CONCLUSION: A shift in the antigenic and clonal type of invasive serogroup C meningococi was noted. This finding suggests vigilance in the surveillance of meningoccocal disease is warranted.
Pregnancy Following Liver Transplantation: Review of Outcomes and Recommendations for Management
Authors: Parhar Kuljit S , Gibson Paul S , Coffin Carla S
Published: March 2016

Liver transplantation is considered to be the treatment of choice for end-stage liver disease and its success has led to an increase in the number of female liver transplant recipients who are of childbearing age. Several key issues that are noted when counselling patients who are considering pregnancy following liver transplantation include the optimal timing of pregnancy, optimal contraception methods and the management of immunosuppression during pregnancy. The present review summarizes the most recent literature so that the clinician may address these issues with their patient and enable them to make informed decisions about pregnancy planning. The authors review recent studies examining maternal and fetal outcomes, and the rates of complications including risk of graft rejection. Subsequently, the authors provide recommendations for counselling prospective mothers and the management of the pregnant liver transplant recipient.
An Audit of Influenza Vaccination Status in Adults with Inflammatory Bowel Disease
Authors: Narula Neeraj , Dhillon Amit S , Chauhan Usha , Marshall John K
Published: March 2016

BACKGROUND Several guidelines recommend influenza vaccination for high-risk patients, including those on immune-suppressing medications (IS).

OBJECTIVE: To assess the vaccination status and immunization history of an outpatient inflammatory bowel disease (IBD) population for H1N1 and seasonal influenza.

RESULTS: Among 250 patients, 104 (41.6%) had been immunized against H1N1 and 62 (24.8%) against seasonal influenza, and 158 (63.2%) were taking IS (azathioprine, 6-mercaptopurine, infliximab, adalimumab, methotrexate, cyclosporine or prednisone). Among subjects on IS, the presence of comorbidities warranting vaccination was associated with higher likelihood of H1N1 immunization (62.5% versus 35.8%; P=0.022) but not of seasonal influenza vaccination (25.0% versus 17.2%; P=0.392). Among patients without comorbidities warranting vaccination, IS was associated with a decreased likelihood of vaccination against seasonal influenza (17.2% versus 30.7%; P=0.036) but not H1N1 (35.8% versus 41.3%; P=0.46). The frequency of H1N1 vaccination was significantly higher among patients who visited a general practitioner at least once yearly (45.7% versus 20%; P=0.0027), with a similar trend for seasonal influenza vaccination (27.1% versus 12.5%; P=0.073). Among 91 patients on IS who declined vaccination, 39.6% reported fear of immediate side effects, 29.7% reported concerns about developing serious medical complications, 15.4% reported concerns about activating IBD and 15.4% were not aware that vaccination was indicated.

CONCLUSIONS: Current strategies for vaccinating IBD patients on IS are inadequate. Primary care provider education, incentive programs and regular primary care contact may improve immunization uptake.
Pulmonary Involvement in Brucellosis
Authors: Uluğ Mehmet , Can-Uluğ Nuray
Published: March 2016

BACKGROUND: Brucellosis is a zoonotic disease caused by a Gram‐negative bacillus of the Brucella genus with multisystem involvement, primarily affecting the reticuloendothelial system, joints, heart and kidneys. Although the disease can be spread by inhalation, pulmonary involvement is rare.

OBJECTIVE: To report a case of brucellosis with pulmonary involvement.

CASE PRESENTAION: A previously healthy 36‐year‐old woman was admitted with complaints of fever, weakness, night sweats, dry cough and bilateral chest pain. She hed been diagnosed with pneumonia 20 days previously and was started on a course of ampicillin for 14 days, with no response. Her chest auscultation revealed diminished breath sounds and scattered crackles and rhonchi over the inferior zone of the right hemithorax. Wright and Coombs testing resulted in titres of 1:1280 and 1:640, respectively. Chest radiography revealed an area of confluent lobar consolidation in the right lower lobe. Treatment was started with a six‐week course of oral doxycycline 200 mg/day and rifampicin 600 mg/day. This treatment regimen rapidly improved the patient’s condition. Follow‐up after one year showed no residual effects from the infection.

CONCLUSION: Pulmonary involvement is a rare event in the course of brucellosis, but the rate could be higher than currently estimated. In endemic regions, brucellosis should be considered as a causative agent in patients with pulmonary symptoms.
Survey of Perceptions and Practices among Canadian Gastroenterologists regarding the Prevention of Venous Thromboembolism for Hospitalized Inflammatory Bowel Disease Patients
Authors: Razik Roshan , Bernstein Charles N , Sam Justina , Thanabalan Reka , Nguyen Geoffrey C
Published: March 2016

BACKGROUND: Patients with inflammatory bowel disease (IBD) who are hospitalized with disease flares are known to be at an increased risk of venous thromboembolism (VTE). This is a preventable complication; however, there is currently no standardized approach to the prevention and management of VTE.

OBJECTIVES: To characterize the opinions and general prophylaxis patterns of Canadian gastroenterologists and IBD experts.

METHODS: A survey questionnaire was sent to Canadian gastroenterologists affiliated with a medical school or IBD referral centre. Participants were required to be practicing physicians who had completed all of their training and had been involved in the care of IBD patients within the previous 12 months. Various clinical scenarios were presented and demographic data were solicited.

RESULTS: The majority of respondents were practicing in an academic setting (95%) and considered themselves to be IBD experts or subspecialists (71%). Eighty-three per cent reported providing VTE prophylaxis most, if not all of the time, and most (96%) used pharmacological prophylaxis alone, usually heparin or one of its analogues. There was less consistency among respondents with respect to whether IBD patients in remission, but admitted for another condition, should be given prophylaxis. There was also less agreement regarding the duration of anticoagulation in patients with confirmed VTE.

CONCLUSION: There was a general consensus among academic gastroenterologists that IBD inpatients are at an increased risk for VTE and would benefit from VTE prophylaxis. However, areas of uncertainty still exist and the IBD community would benefit from evidence-based clinical practice guidelines to standardize the management of this important problem.
Canadian Thoracic Society 2012 Guideline Update: Diagnosis and Management of Asthma in Preschoolers, Children and Adults: Executive Summary
Authors: Lougheed M Diane , Lemiere Catherine , Ducharme Francine M , Licskai Chris , Dell Sharon D , Rowe Brian H , FitzGerald Mark , Leigh Richard , Watson Wade , Boulet Louis-Philippe ,   Canadian Thoracic Society Asthma Clinical Assembly
Published: March 2016

BACKGROUND: In 2010, the Canadian Thoracic Society (CTS) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older, and adults, including an updated Asthma Management Continuum. The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline update process, focusing, in this first iteration, on topics of controversy and/or gaps in the previous guidelines.

METHODS: Four clinical questions were identified as a focus for the updated guideline: the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy; the initiation of adjunct therapy to inhaled corticosteroids (ICS) for uncontrolled asthma; the role of a single inhaler of an ICS/long-acting beta2-agonist combination as a reliever, and as a reliever and a controller; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan. The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics. In addition, literature searches were performed to identify relevant systematic reviews and randomized controlled trials. The panel formally assessed and graded the evidence, and made 34 recommendations.

RESULTS: The updated guideline recommendations outline a role for inclusion of assessment of sputum eosinophils, in addition to standard measures of asthma control, to guide adjustment of controller therapy in adults with moderate to severe asthma. Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations. New recommendations for the adjustment of controller medication within written action plans are provided. Finally, priority areas for future research were identified.

CONCLUSIONS: The present document is an executive summary of the first update of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee’s new guideline development process. Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide updates reflecting new evidence.
Caulobacter Species as a Cause of Postneurosurgical Bacterial Meningitis in a Pediatric Patient
Authors: Bridger Natalie , Walkty Andrew , Crockett Maryanne , Fanella Sergio , Nichol Kim , Karlowsky James A
Published: March 2016

Caulobacter species have been rarely found to be a cause of human infection. A case of probable Caulobacter species meningitis occurring postneurosurgery in a pediatric patient is reported in the present article. Gram stain and colony morphology of the isolate were not consistent with the identification provided by commercial phenotypic identification systems. The present case illustrates the need to reconcile conflicting phenotypic test results using 16S ribosomal DNA sequencing.
Development of an Electronic Database for Acute Pain Service Outcomes
Authors: Love Brandy L , Jensen Louise A , Schopflocher Donald , Tsui Ban CH
Published: March 2016

From mitigating complications during hospital stay to reducing the incidence of chronic pain, improving pain management positively impacts short‐ and long‐term outcomes of treatment. Quality assurance has become the focus of many health care programs in an effort to confront the challenges presented by pain and its management. The analysis of treatment strategies and patient responses form the basis of a reflective, evidence‐based practice, which can raise awareness of about the importance of adequate pain management. The capabilities of an electronic database can be exploited to organize large amounts of data, which can then be used to characterize symptoms and analyze treatment responses. However, the types of data to collect, the burden of data collection on workers, and costs must be considered before implementing an electronic database for research and/or everyday practice. This study tested the relevance and usability of an electronic database in an acute pain service by assessing several variables important to database development and evaluation.

BACKGROUND: Quality assurance is increasingly important in the current health care climate. An electronic database can be used for tracking patient information and as a research tool to provide quality assurance for patient care.

OBJECTIVE: An electronic database was developed for the Acute Pain Service, University of Alberta Hospital (Edmonton, Alberta) to record patient characteristics, identify at‐risk populations, compare treatment efficacies and guide practice decisions.

METHOD: Steps in the database development involved identifying the goals for use, relevant variables to include, and a plan for data collection, entry and analysis. Protocols were also created for data cleaning quality control. The database was evaluated with a pilot test using existing data to assess data collection burden, accuracy and functionality of the database.

RESULTS: A literature review resulted in an evidence‐based list of demographic, clinical and pain management outcome variables to include. Time to assess patients and collect the data was 20 min to 30 min per patient. Limitations were primarily software related, although initial data collection completion was only 65% and accuracy of data entry was 96%.

CONCLUSIONS: The electronic database was found to be relevant and functional for the identified goals of data storage and research.
Thermodilution and Fick Cardiac Outputs Differ: Impact on Pulmonary Hypertension Evaluation
Authors: Fares Wassim H , Blanchard Sarah K , Stouffer George A , Chang Patricia P , Rosamond Wayne D , Ford Hubert James , Aris Robert M
Published: March 2016

BACKGROUND: The relationship between thermodilution and indirect Fick cardiac output determination methods has not been well described.

OBJECTIVE: To describe the relationship between these two cardiac output determination methods in patients evaluated for pulmonary hypertension and to highlight potential clinical implications.

METHODS: A retrospective review of charts of all adult patients who underwent a right heart catheterization (RHC) between January 1, 2007 and November 10, 2010, and participated in the pulmonary hypertension program of the pulmonary division at an academic institution was conducted. For validation, the charts of all patients who underwent RHC during the same period within the cardiology division were reviewed.

RESULTS: A total of 198 patients underwent 213 RHCs, 79 (40%) of whom had pulmonary arterial hypertension, were included. Forty‐three per cent of patients had >20% difference between thermodilution and Fick. The average difference (thermodilution − Fick ±SD) was −0.39±2.03 L/min (n=213; P=0.006). There was no significant difference in bias or variability between thermodilution and Fick among patients with tricuspid regurgitant jet velocity (TRJ) of <3 m/s versus those with TRJ >3 m/s (−0.41±2.10 L/min versus −0.36±1.93 L/min, respectively; P=0.87). In a multivariable analysis, the thermodilution‐Fick difference increased with age (P=0.001).

DISCUSSION: The presence of such discrepancy in 36% of patients evaluated for heart failure and/or heart transplant validated the results. In total, 37% of the 1315 procedures (213 performed by pulmonologists and 1102 performed by cardiologists) had a difference of >20% between thermodilution and Fick.

CONCLUSION: Significant discrepancy exists between thermodilution and indirect Fick methods. This discrepancy potentially impacts pulmonary arterial hypertension prognostication and diagnosis, and is independent of TRJ.
Prevalence of High Epworth Sleepiness Scale Scores in a Rural Population
Authors: Pahwa P , Karunanayake CP , Hagel L , Gjevre JA , Rennie D , Lawson J , Dosman JA
Published: March 2016

BACKGROUND: Increased daytime sleepiness is an important symptom of obstructive sleep apnea (OSA). OSA is frequently underdiagnosed, and the Epworth Sleepiness Scale (ESS) can be a useful tool in alerting physicians to a potential problem involving OSA.

OBJECTIVE: To measure the prevalence and determinants of daytime sleepiness measured using the ESS in a rural community population.

METHODS: A community survey was conducted to examine the risk factors associated with ESS in a rural population in 154 households comprising 283 adults. Questionnaire information was obtained regarding physical factors, social factors, general medical history, family medical history, ESS score, and self-reported height and weight. Multivariable binary logistic regression analysis based on the generalized estimating equations approach to account for clustering within households was used to predict the relationship between a binary ESS score outcome (normal or abnormal) and a set of explanatory variables.

RESULTS: The population included 140 men (49.5%) and 143 women (50.5%) with an age range of 18 to 97 years (mean [± SD] 52.0±14.9 years). The data showed that 79.2% of the study participants had an ESS score in the normal range (0 to 10) and 20.8% had an ESS score >10, which is considered to be abnormal or high sleepiness. Multivariable regression analysis revealed that obesity was significantly associated with an abnormal or high sleepiness score on the ESS (OR 3.40 [95% CI 1.31 to 8.80).

CONCLUSION: High levels of sleepiness in this population were common. Obesity was an important risk factor for high ESS score.
The Interaction among Insulin Resistance, Liver Fibrosis and Early Virological Response in Egyptian Patients with Chronic Hepatitis C
Authors: Ziada Dina H , El Saadany Sherif , Enaba Mohamed , Ghazy Medhat , Hasan Azza
Published: March 2016

BACKGROUND: Hepatitis C virus (HCV) infection may induce insulin resistance (IR) irrespective of the severity of liver disease, and there is evidence of a central role for IR in failure to achieve sustained virological response (SVR) in HCV patients.

OBJECTIVE: To assess IR as a predictor of the severity of hepatic fibrosis in Egyptian HCV patients, and its effect on early viral kinetics and virological response to HCV therapy.

METHODS: A total of 140 chronic HCV patients were divided into two groups according to the homeostasis model assessment-IR (HOMA-IR). Group 1 consisted of 48 chronic HCV patients with HOMA-IR ≥2, and group 2 consisted of 92 chronic HVC patients without IR (HOMA IR <2). All patients were treated with combination therapy (pegylated interferon-alpha 2a plus ribavirin) for 48 weeks and studied for viral kinetics throughout the period of therapy.

RESULTS: The study revealed that older age, higher body mass index and HOMA-IR≥2 were significantly associated with advanced fibrosis. Rapid virological response, complete early virological response and SVR were significantly lower in the IR-HCV group compared with the non-IR-HCV group. Univariate and multivariate analyses revealed that older age, fibrosis (F≥3), high viral load (>600,000 IU/mL) and HOMA-IR ≥2 were significantly associated with a lack of viral kinetics as well as SVR. However, HOMA-IR ≥2 was the main independent variable associated with lack of SVR. On the other hand, body mass index, plasma insulin level and HOMA-IR decreased significantly compared with starting levels in patients who achieved SVR. This suggests a cause and effect relationship between HCV infection and IR.

CONCLUSION: IR in chronic HCV patients is associated with progressive fibrosis and slow viral kinetics, and could be a predictor for lack of rapid and early virological response. Therefore, HOMA-IR levels should be measured and improved before starting antiviral treatment.
Culture‐Negative Endocarditis Diagnosed Using 16S DNA Polymerase Chain Reaction
Authors: Duffett Stephen , Missaghi Bayan , Daley Peter
Published: March 2016

16S DNA polymerase chain reaction (PCR) is a molecular amplification technique that can be used to identify bacterial pathogens in culture‐negative endocarditis. Bacterial DNA can be isolated from surgically excised valve tissue or from blood collected in EDTA vials. Use of this technique is particularly helpful in identifying the bacterial pathogen in cases of culture‐negative endocarditis. A case involving a 48‐year‐old man who presented with severe aortic regurgitation and a four‐month prodrome of low‐grade fever is reported. Blood and valve tissue cultures following valve replacement were negative. A valve tissue sample was sent for investigation with 16S DNA PCR, which successfully identified Streptococcus salivarius and was interpreted as the true diagnosis. A review of the literature suggests that 16S DNA PCR from valve tissue is a more sensitive diagnostic test than culture. It is also extremely specific, based on a sequence match of at least 500 base pairs.