bluuebunny/crossref_metadata_2025 huggingface dataset:
Cyclosporine in the Management of Esophageal Lichen Planus
Authors: Chaklader M , Morris-Larkin C , Gulliver W , McGrath J
Published: March 2016

Lichen planus (LP) is an uncommon disorder of unknown etiology, mostly affecting patients in their fifth and sixth decade of life. It is believed to be an autoimmune process involving T cells directed against basal keratinocytes. It affects the skin, nails, oral pharynx and genitals. Esophageal involvement is quite rare and can cause strictures, ulcerations and squamous cell cancer. The present article describes the case of a 54-year-old woman who was referred for assessment of dysphagia that initially occurred with solids, which then progressed to soft foods but spared liquids. The patient reported a weight loss of 9.1 kg. An esophagogastroduodenoscopy was performed and she was subsequently diagnosed with pill esophagitis. At the same time, she was also diagnosed with oral LP, with no involvement of the esophagus. She was treated with a proton pump inhibitor that resolved her gastrointestinal symptoms. The symptoms returned one year later and a repeat esophagogastroduodenoscopy revealed white plaques due to LP. She was treated with intermittent glucocorticoids. Diagnosis of esophageal LP is crucial for the proper treatment. Some patients may require systemic immunosuppression and mechanical dilation to prevent weight loss. Surveillance endoscopies should be performed to monitor for squamous cell cancer. Cyclosporine has been used for genital and oral LP, but the present case is the first in which it has been used successfully to treat esophageal LP.
Evaluation of Tumour Necrosis Factor‐Alpha and Interleukin‐1beta in an Experimental Pyelonephritis Model Induced with Planktonic and Biofilms Cells of Pseudomonas aeruginosa
Authors: Mittal Rahul , Sharma Saroj , Chhibber Sanjay , Harjai Kusum
Published: March 2016

Urinary tract infections may induce severe inflammation, transient impairment in renal function and scar formation, ranging in severity from acute symptomatic pyelonephritis to chronic pyelonephritis, and have the potential to lead to renal failure and death. In the present study, the relationship between production of tumour necrosis factor‐alpha (TNF‐α), interleukin‐1beta (IL‐1β), neutrophil recruitment, bacterial colonization and tissue damage was investigated using a mouse model of acute ascending pyelonephritis induced with planktonic and biofilm cells of Pseudomonas aeruginosa. Neutrophil influx correlated with rise in TNF‐α and IL‐1β, indicating an association between these cytokines and neutrophil infiltration. However, biofilm cells of P aeruginosa induced higher levels of TNF‐α and IL‐1β leading to higher neutrophil infiltration causing tissue damage, assessed in terms of malondialdehyde, lactate dehydrogenase and glutathione content, which may have contributed to bacterial persistence compared with their planktonic counterparts. The results of the present investigation suggest that exaggerated cytokine production during P aeruginosa‐induced pyelonephritis causes tissue damage operative through neutrophil recruitment leading to bacterial persistence in host tissues. The findings of the present study may be relevant for the better understanding of disease pathophysiology and for the future developments of preventive strategies against pyelonephritis based on anti‐inflammatory intervention.
Vitamin D Deficiency and Chronic Lung Disease
Authors: Gilbert Christopher R , Arum Seth M , Smith Cecilia M
Published: March 2016

Vitamin D deficiency is increasingly being recognized as a prevalent problem in the general population. Patients with chronic lung diseases such as asthma, cystic fibrosis, chronic obstructive lung disease and interstitial pneumonia appear to be at increased risk for vitamin D deficiency for reasons that are not clear.

Several studies indicate that vitamin D possesses a range of anti‐inflammatory properties and may be involved in processes other than the previously believed functions of calcium and phosphate homeostasis. Various cytokines, cellular elements, oxidative stress and protease/antiprotease levels appear to affect lung fibroproliferation, remodelling and function, which may be influenced by vitamin D levels. Chronic lung diseases such as asthma and chronic obstructive lung disease have also been linked to vitamin D on a genetic basis. This immune and genetic influence of vitamin D may influence the pathogenesis of chronic lung diseases. A recent observational study notes a significant association between vitamin D deficiency and decreased pulmonary function tests in a large ambulatory population.

The present review will examine the current literature regarding vitamin D deficiency, its prevalence in patients with chronic lung disease, vitamin D anti‐inflammatory properties and the role of vitamin D in pulmonary function.
The Quality of Screening Colonoscopies in an Office-Based Endoscopy Clinic
Authors: Bair Douglas , Pham Joe , Seaton M Bianca , Arya Naveen , Pryce Michelle , Seaton Trevor L
Published: March 2016

BACKGROUND: Wait times for hospital screening colonoscopy have increased dramatically in recent years, resulting in an increase in patient referrals to office-based endoscopy clinics. There is no formal regulation of office endoscopy, and it has been suggested that the quality of service in some office locations may be inferior to hospital procedures.

OBJECTIVE: To compare the quality of office-based screening colonos-copies at a clinic in Oakville, Ontario, with published benchmarks for cecal intubation, withdrawal times, polyp detection, adenoma detection, cancer detection and patient complications.

METHODS: Demographic information on consecutive patients and colonoscopy reports by all nine gastroenterologists at the Oakville Endoscopy Centre between August 2006 and December 2007 were prospectively obtained.

RESULTS: A total of 3741 colonoscopies were analyzed. The mean age of patients was 57.1 years and 51.9% were women. The cecal intubation rate was 98.98% with an average withdrawal time of 9.75 min. A total of 3857 polyps were retrieved from 1725 patients (46.11%), and 1721 adenomas were detected in 953 patients (25.47%). A total of 126 patients (3.37%) had advanced polyps and 18 (0.48%) were diagnosed with colon cancer. One patient (0.027%) had a colonic perforation and two patients had postpolypectomy bleeding (0.053%). These results meet or exceed published benchmarks for quality colonoscopy.

CONCLUSIONS: The Oakville Endoscopy Centre data demonstrate that office-based colonoscopies, performed by well-trained physicians using adequate sedation and hospital-grade equipment, result in outcomes at least equal to or better than those of published academic/community hospital practices and are therefore a viable option for the future of screening colonoscopy in Canada.
Cryptococcemia Resulting in an Incomplete Abortion in an HIV‐Positive Patient
Authors: Rahimi Kurosh , Chetty Runjan , Clarke Blaise
Published: March 2016

Exotic infections and unusual presentations are the norm in immunocompromised patients. An unusual case of cryptococcemia resulting in a miscarriage is reported. This was the first presentation of the disease and the sentinel infection in the patient who was found to be HIV positive. Histological evaluation of the dilation and curettage specimen showed numerous typical organisms of cryptococcus present within the products of conception. There was a focal granulomatous response to the organisms. An accompanying cryptococcal endometritis was not noted. Other concomitant infections were not seen.
Fulminant Legionellosis in Two Patients Treated with Infliximab for Crohn’s Disease: Case Series and Literature Review
Authors: Hofmann Adam , Beaulieu Yanick , Bernard Francis , Rico Philippe
Published: March 2016

Two cases of fulminant pulmonary legionellosis, complicated by prolonged intensive care unit stays and acute respiratory distress syndrome, and who were recently treated with infliximab for Crohn’s disease, are described. A review of the literature revealed three additional cases in patients with inflammatory bowel disease, and a total of 22 cases ofLegionella pneumophilapneumonia in the context of treatment with antitumour necrosis (TNF)-alpha medications. The median age of the patients was 49 years, and men and women were affected equally. The case fatality rate was 14% (three of 22). Early recognition and treatment of this anti-TNF-alpha-related complication would likely result in reduced mortality and morbidity. Physicians prescribing anti-TNF-alpha drugs should be aware of this association.
Screening for Iron Overload: Lessons from the HEmochromatosis and IRon Overload Screening (HEIRS) Study
Authors: Adams Paul C , Barton James C , McLaren Gordon D , Acton Ronald T , Speechley Mark , McLaren Christine E , Reboussin David M , Leiendecker-Foster Catherine , Harris Emily L , Snively Beverly M , Vogt Thomas , Sholinsky Phyliss , Thomson Elizabeth , Dawkins Fitzroy W , Gordeuk Victor R , Eckfeldt John H
Published: March 2016

BACKGROUND: The HEmochromatosis and IRon Overload Screening (HEIRS) Study provided data on a racially, ethnically and geographically diverse cohort of participants in North America screened from primary care populations.

METHODS: A total of 101,168 participants were screened by testing forHFEC282Y and H63D mutations, and measuring serum ferritin concentration and transferrin saturation. In the present review, lessons from the HEIRS Study are highlighted in the context of the principles of screening for a medical disease as previously outlined by the World Health Organization.

RESULTS: Genetic testing is well accepted, with minimal risk of discrimination. Transferrin saturation has high biological variability and relatively low sensitivity to detectHFEC282Y homozygotes, which limits its role as a screening test. Symptoms attributable toHFEC282Y homozygosity are no more common in individuals identified by population screening than in control subjects.

CONCLUSIONS: Generalized population screening in a primary care population as performed in the HEIRS Study is not recommended. There may be a role for focused screening in Caucasian men, with some debate regarding genotyping followed by phenotyping, or phenotyping followed by genotyping.
Improvement in Health‐Related Quality of Life After Lung Transplantation
Authors: Santana Maria-Jose , Feeny David , Jackson Katherine , Weinkauf Justin , Lien Dale
Published: March 2016

BACKGROUND/OBJECTIVE: Traditional survival outcomes do not reflect the effects on the health‐related quality of life (HRQL) of patients. HRQL following lung transplantation has not been studied systematically. The Health Utilities Index (HUI) is a family (HUI2 and HUI3) of measures of HRQL that has not been previously used to assess HRQL in lung transplantation. The objective of the present study was to assess the impact of lung transplantation on patient’s HRQL using the HUI.

METHODS: A total of 43 patients completed a battery of questionnaires before lung transplantation, and at three months and six months after lung transplantation. The 15‐item questionnaire (HUI2 and HUI3) was used. Overall scores were based on a conventional scale (0.00 = dead, 1.00 = perfect health). Mental health was assessed by the Hospital Anxiety and Depression Scale. Adherence to medication and exercise were assessed by Morisky’s and Godin’s questionnaires, respectively.

RESULTS: Sixty‐five per cent of the patients were men, with a mean age of 53 years (range 18 to 67 years). The mean overall HUI3 score for the lung transplant candidates (0.57) was much lower than for the lung transplant recipients (0.82) at six months post‐transplantation. This difference was clinically important and statistically significant (P<0.05 [paired ttest, degrees of freedom (df) = 35]). Differences in mean Hospital Anxiety and Depression Scale scores after transplantation were statistically significant (P<0.05 [paired t test, df=35]). After six months, transplant recipients were more adherent to medication (P<0.05 [χ2 test, df=1]). Recipients were able to increase the duration of exercise at all levels of intensity.

CONCLUSION: Lung transplantation improved the patients’ HRQL and adherence to medication. Anxiety levels persisted six months after transplantation but depression levels had decreased significantly.
Putting Pain Assessment into Practice: Why Is It so Painful?
Authors: Franck Linda S , Bruce Elizabeth
Published: March 2016

OBJECTIVE: To explore some of the reasons for poor compliance with the use of standardized pain assessment tools in clinical practice, despite numerous guidelines and standards mandating their use.

METHODS: First, a review of research and clinical audit literature on the effects of standardized pain assessment tools on patient or process outcomes was conducted, and findings were critiqued. Second, a synthesis of recent literature on the biopsychosocial mechanisms of human detection and recognition of pain in others was presented. Third, the implications for pain assessment in pediatric clinical settings were discussed.

RESULTS: There is a lack of good‐quality evidence for the efficacy, effectiveness or cost‐benefit of standardized pain assessment tools in relation to pediatric patient or process outcomes. Research suggests that there may be greater variability than previously appreciated in the ability and motivation of humans when assessing pain in others. It remains unknown whether pain detection skills or motivation to relieve pain in others can be improved or overcome by standardized methods of pain assessment.

DISCUSSION: Further research is needed to understand the intra‐ and interpersonal dynamics in clinical assessment of pain in children and to test alternative means of achieving diagnosis and treatment of pain. Until this evidence is available, guidelines recommending standardized pain assessment must be clearly labelled as being based on principles or evidence from other fields of practice, and avoid implying that they are ‘evidence based’.
The Potential Impact of Contemporary Developments in the Management of Patients with Gastroesophageal Reflux Disease Undergoing an Initial Gastroscopy
Authors: Salem Suhail B , Kushner Yael , Marcus Victoria , Mayrand Serge , Fallone Carlo A , Barkun Alan N
Published: March 2016

BACKGROUND: Recent developments may alter the approach to patients presenting with gastroesophageal reflux disease (GERD)-like symptoms. A newly proposed Montreal consensus definition of Barrett’s esophagus includes all types of esophageal columnar metaplasia, with or without intestinal-type metaplasia. There is also increasing recognition of eosinophilic esophagitis (EE) in patients with GERD-like symptoms.

OBJECTIVE: To quantify the impact of these developments on a multiphysician general gastroenterology practice in a tertiary care medical centre.

METHODS: Medical charts of all patients having an initial gastroscopy for GERD-like symptoms over a one-year period were reviewed retrospectively, and audits of their endoscopic images and esophageal biopsies were performed.

RESULTS: Of the 353 study participants, typical symptoms of heartburn and acid reflux were present in 87.7% and 23.2%, respectively. Less commonly, patients presented with atypical symptoms (eg, dysphagia in 9.4%). At endoscopy, 26% were found to have erosive esophagitis and 12% had endoscopically suspected esophageal metaplasia. Histological evaluation was available for 65 patients. Ten of the 65 biopsied patients (15%) met traditional criteria for Barrett’s esophagus (ie, exhibiting intestinal-type metaplasia), whereas 49 (75%) fulfilled the newly proposed consensus definition of Barrett’s esophagus. Five patients (7.7%) met the study criteria for EE (more than 20 eosinophils per high-power field), four of whom had not been previously recognized.

CONCLUSIONS: Among patients presenting with GERD-like symptoms, the prevalence of Barrett’s esophagus may increase markedly if the Montreal definition is adopted. In addition, growing awareness of EE may lead to an increase in the prevalence of this diagnosis. Prospective studies of the management implications of these findings are warranted.
Investigating and Treating Fecal Incontinence: When and How
Authors: Lazarescu Adriana , Turnbull Geoffrey K , Vanner Stephen
Published: March 2016

Fecal incontinence is a common disorder in our aging population and can have profound effects on patient’s well-being. The present review examines the current understanding of fecal incontinence and provides a practical approach to the investigation and management of this condition. A special emphasis is placed on specialized testing, focusing on indications and impact on guiding management.
A Study of the Prevalence of Cytotoxic and Non‐Cytotoxic Klebsiella oxytoca Fecal Colonization in Two Patient Populations
Authors: Smith Stephen A , Campbell Sarah J , Webster Duncan , Curley Michael , Leddin Desmond , Forward Kevin R
Published: March 2016

BACKGROUND: Klebsiella oxytoca is a cause of antibiotic‐associated hemorrhagic colitis. Few reports of the occurrence of K oxytoca within stool exist and there is no gold standard method for its isolation.

METHODS: MacConkey agar was modified to culture K oxytoca. Ampicillin was added and adonitol was substituted for lactose. Rectal swabs from 200 patients being screened for vancomycin‐resistant enterococci (VRE) and stool specimens from 429 patients who tested negative for Clostridium difficile cytotoxin were cultured. K oxytoca isolates were evaluated for cytotoxicity to HEp‐2 cells. Available charts of K oxytoca‐positive patients and a convenience sample of 93 K oxytoca‐negative patients who underwent testing for C difficile cytotoxicity were reviewed retrospectively for documentation of bloody stool.

RESULTS: K oxytoca was isolated from 14 of 200 patients (7.0%) being screened for VRE; only one of the 14 isolates (7.1%) was cytotoxic. The organism was isolated from 42 of 429 patients (9.8%) tested for C difficile cytotoxicity; 10 isolates (23.8%) were cytotoxic. Differences in isolation and cytotoxicity rates between groups were not statistically significant. Two of 13 (15.4%) K oxytoca‐positive patients screened for VRE, three of 27 (11.1%) K oxytoca‐positive patients tested for C difficile cytotoxicity, and 11 of 93 (11.8%) patients from the convenience sample had documented bloody stool.

CONCLUSIONS: A medium that greatly facilitates isolation of K oxytoca was developed. Occurrence of K oxytoca colonization was similar in the two patient populations studied and isolation of cytotoxic K oxytoca was not usually associated with hematochezia. Current understanding of the occurrence and causality of antibiotic‐associated hemorrhagic colitis is insufficient for clinical laboratories to begin culturing K oxytoca and testing for cytotoxicity.
Prevention ofClostridium difficileInfection withSaccharomyces boulardii: A Systematic Review
Authors: Tung Jennifer M , Dolovich Lisa R , Lee Christine H
Published: March 2016

BACKGROUND:Clostridium difficileis a major cause of antibioticassociated diarrhea within the hospital setting. The yeastSaccharomyces boulardiihas been found to have some effect in reducing the risk ofC difficileinfection (CDI); however, its role in preventive therapy has yet to be firmly established.

OBJECTIVE: To review the effectiveness ofS boulardiiin the prevention of primary and recurrent CDI. Benefit was defined as a reduction of diarrhea associated withC difficile. Risk was defined as any adverse effects ofS boulardii.

METHODS: A literature search in MEDLINE, EMBASE, CINAHL and the Cochrane Library was performed. Included studies were English language, randomized, double-blind placebo controlled trials evaluatingS boulardiiin CDI prevention.

RESULTS: Four studies were reviewed. Two studies investigated the prevention of recurrence in populations that were experiencing CDI at baseline. One trial showed a reduction of relapses in patients experiencing recurrent CDI (RR=0.53; P<0.05). The other demonstrated a trend toward reduction of CDI relapse in the recurrent treatment group of patients receiving high-dose vancomycin (RR=0.33; P=0.05). Two other studies examined primary prevention of CDI in populations that had been recently prescribed antibiotics. These studies lacked the power to detect statistically significant differences. Patients on treatment experienced increased risk for thirst and constipation.

CONCLUSION:S boulardiiseems to be well tolerated and may be effective for secondary prevention in some specific patient populations with particular concurrent antibiotic treatment. Its role in primary prevention is poorly defined and more research is required before changes in practice are recommended.
Is the presence ofHelicobacter pyloriin the Dental Plaque of Patients with Chronic Periodontitis a Risk Factor for Gastric Infection?
Authors: Al Asqah Mohammed , Al Hamoudi Nawaf , Anil Sukumaran , Al jebreen Abdulrahman , Al-hamoudi Waleed Khalid
Published: March 2016

BACKGROUND:Helicobacter pyloriis considered to be a pathogen responsible for gastritis and peptic ulcers, and a risk factor for gastric cancer. A periodontal pocket in the teeth of individuals with chronic periodontitis may function as a reservoir forH pylori.

OBJECTIVE: The present study was undertaken to evaluate whether the presence ofH pyloriin the dental plaque of patients with and without periodontitis correlates with gastric involvement.

METHODS: A total of 101 patients with dyspepsia were included in the present study. Subjects were divided into periodontitis and non-periodontitis groups. For the detection ofH pyloriin dental plaque, samples were collected from two teeth using a periodontal curette. Subgingival plaque was obtained by inserting two sterile paper points into periodontal pockets for 20 s. This was followed by an upper gastrointestinal endoscopy and antral biopsies.

RESULTS: Sixty-five per cent of patients had dental plaque positive forH pyloriand more than 50% harboured the bacteria in their stomach. Periodontitis patients had a significantly higher percentage ofH pyloriin their dental plaque (79% versus 43%; P<0.05) and the stomach (60% versus 33%; P<0.05) than patients with no periodontitis. Additionally, 78% of patients from the periodontitis group versus only 30% from the nonperiodontitis group had a positive test result for the coexistence ofH pyloriin both dental plaque and the stomach.

CONCLUSION: Patients with poor oral hygiene have a higher prevalence ofH pyloriin dental plaque and in the stomach. This finding suggests that the oral cavity may be a reservoir forH pylori,and potentially a source of transmission or reinfection.
Identifying Patients with Physician‐Diagnosed Asthma in Health Administrative Databases
Authors: Gershon Andrea S , Wang Chengning , Guan Jun , Vasilevska-Ristovska Jovanka , Cicutto Lisa , To Teresa
Published: March 2016

BACKGROUND: Asthma imposes a heavy and expensive burden on individuals and populations. A population‐based surveillance and research program based on health administrative data could measure and study the burden of asthma; however, the validity of a health administrative data diagnosis of asthma must first be confirmed.

OBJECTIVE: To evaluate the accuracy of population‐based provincial health administrative data in identifying adult patients with asthma for ongoing surveillance and research.

METHODS: Patients from randomly selected primary care practices were assigned to four categories according to their previous diagnoses: asthma, chronic obstructive pulmonary disease, related respiratory conditions and nonasthma conditions. In each practice, 10 charts from each category were randomly selected, abstracted, then reviewed by a blinded expert panel who identified them as asthma or nonasthma. These reference standard diagnoses were then linked to the patients’ provincial records and compared with health administrative algorithms designed to identify asthma. Analyses were performed using the concepts of diagnostic test evaluation.

RESULTS: A total of 518 charts, including 160 from individuals with asthma, were reviewed. The algorithm of two or more ambulatory care visits and/or one or more hospitalization(s) for asthma in two years had a sensitivity of 83.8% (95% CI 77.1% to 89.1%) and a specificity of 76.5% (95% CI 71.8% to 80.8%).

CONCLUSION: Definitions of adult asthma using health administrative data are sensitive and specific for identifying adults with asthma. Using these definitions, cohorts of adults with asthma for ongoing population‐based surveillance and research can be developed.
Closure of a Nonhealing Gastrocutaneous Fistula Using Argon Plasma Coagulation and Endoscopic Hemoclips
Authors: Hameed H , Kalim S , Khan YI
Published: March 2016

A case in which a gastrocutaneous fistula developed after percutaneous endoscopic gastrostomy tube placement is presented. The fistula was first managed conservatively, then was closed by argon plasma coagulation and hemoclip placement. The patient was observed and was discharged once the gastrocutaneous fistula closed.
Epidemiology of Enteric Disease in C‐EnterNet’s Pilot Site – Waterloo Region, Ontario, 1990 to 2004
Authors: Keegan Victoria A , Majowicz Shannon E , Pearl David L , Marshall Barbara J , Sittler Nancy , Knowles Lewinda , Wilson Jeffery B
Published: March 2016

OBJECTIVE: The objective of the present study was to describe the epidemiology of reportable enteric illness in Ontario’s Waterloo region, including comparing calculated incidence rates with published rates, and adjusting for under‐reporting to determine the number of community cases, where published data were available.

METHODS: Descriptive analyses were performed on reportable disease data for 13 enteric diseases collected in the Waterloo region from 1990 to 2004. Poisson and negative binomial regression analyses were used to investigate differences in incidence rates among age, sex, the 15 years of data and seasons. Disease‐specific incidence rates were calculated and compared with the literature, where possible. Under‐reporting ratios from the literature were applied to estimate the number of cases of campylobacteriosis, nontyphoidal salmonellosis and verotoxigenic Escherichia coli infection at the community level.

RESULTS: Over the study period, the average annual age‐ and sex‐adjusted incidence rates per 100,000 population were highest for campylobacteriosis (49.69 cases), followed by giardiasis (31.87 cases) and nontyphoidal salmonellosis (25.97 cases). The incidence of most enteric illnesses peaked in the summer. The highest incidence occurred in young children, followed by adults in their 20s. Diarrhea (85.4%) was the most frequently reported symptom, food (57.4%) was the most commonly reported probable source, and home (41.7%) and travel (37.0%) were the two most frequently reported risk settings.

CONCLUSIONS: Enteric illness was a significant health burden in the Waterloo region from 1990 to 2004. Because reportable disease data are subject to under‐reporting, it is likely that the true burden is greater than estimated in the present study.
Predictive Factors for Local Recurrence and Incomplete Resection of Early Gastric Cancer Treated by Endoscopic Resection: A Western Experience
Authors: Hondo Fábio Yuji , Maluf-Filho Fauze , Kishi Humberto Setsuo , Uemura Ricardo Sato , Okawa Luciano , Cecconello Ivan , Sakai Paulo
Published: March 2016

BACKGROUND: Early gastric cancer (EGC) is defined as adenocarcinoma limited to the mucosa or submucosa regardless of lymph node involvement. Local EGC recurrence rates have been described in up to 6% of cases.

OBJECTIVES: To evaluate predictive factors for incomplete resection and local recurrence of EGC treated by endoscopic mucosal resection (EMR) that was followed up for at least one year.

METHODS: From June 1994 to December 2005, 46 patients with EGC underwent EMR. Possible predictive factors for incomplete endoscopic resection and local recurrence were identified by medical chart analysis. Demographic, endoscopic and histopathological data were retrospectively evaluated. EMR was considered complete or incomplete. Patients from the complete resection group were divided into subgroups (with and without local EGC recurrence).

RESULTS: Complete resection was possible in 36 cases (76.6%). Predictive factors for incomplete resection were tumour location (P=0.035), histological type (P=0.021), lesion size (P=0.022) and number of resected fragments (P=0.013). On multivariate analysis, undifferentiated histological type (OR 0.8; 95% CI 0.036 to 0.897) and number of resected fragments (OR 7.34; 95% CI 1.266 to 42.629) were independent predictive factors for incomplete resection. In the complete resection group, a larger lesion size was associated with a higher the number of resected fragments (P=0.018). Local recurrence occurred in nine cases (25%). Use of the cap technique was the only predictive factor for local recurrence in five of seven cases (71.4%) (P=0.006).

CONCLUSIONS: A larger lesion size was associated with a higher number of resected fragments. Undifferentiated adenocarcinoma and piecemeal resection were predictive factors for incomplete resection. Technique type was a predictive factor for local EGC recurrence.
Trends in Nosocomial Bloodstream Infections following Health Care Restructuring in Alberta between 1999 and 2005
Authors: Lee Mao-Cheng , Saxinger Lynora , Forgie Sarah E , Taylor Geoffrey
Published: March 2016

OBJECTIVE: A previous study at the University of Alberta Hospital/Stollery Children’s Hospital in Edmonton, Alberta, revealed an increase in hospital‐acquired bloodstream infection (BSI) rates associated with an increase in patient acuity during a period of public health care delivery restructuring between 1993 and 1996. The present study assessed trends in BSIs since the end of the restructuring.

DESIGN: Prospective surveillance for BSIs was performed using Centers for Disease Control and Prevention (USA) criteria for infection. BSI cases between January 1, 1999, and December 31, 2005, were reviewed. Available measures of patient volumes, acuity and BSI risk factors between 1999 and 2005 were also reviewed from hospital records.

SETTING: The University of Alberta Hospital/Stollery Children’s Hospital (617 adult and 139 pediatric beds, respectively).

PATIENTS: All pediatric and adult patients admitted during the above‐specified period with one or more episodes of BSIs.

RESULTS: There was a significant overall decline in the BSI number and rate over the study period between 1999 and 2005. The downward trend was widespread, involving both adult and pediatric populations, as well as primary and secondary BSIs. During this period, the number of hospital‐wide and intensive care unit admissions, intensive care unit central venous catheter‐days, total parenteral nutrition days and number of solid‐organ transplants were either unchanged or increased. Gram‐positive bacterial causes of BSIs showed significant downward trends, but Gram‐negative bacterial and fungal etiologies were unchanged.

CONCLUSIONS: These data imply that, over time, hospitals can gradually adjust to changing patient care circumstances and, in this example, control infectious complications of health care delivery.
Management and Prevention of Herpes Zoster: A Canadian Perspective
Authors: Boivin Guy , Jovey Roman , Elliott Catherine T , Patrick David M
Published: March 2016

Varicella‐zoster virus reactivation leads to herpes zoster – the main complication of which is postherpetic neuralgia (PHN). Rapid antiviral therapy initiated within 72 h of rash onset has been shown to accelerate rash healing, reduce the duration of acute pain and, to some extent, attenuate the development and duration of PHN. Other adjunctive therapies such as analgesics, antidepressants and some anticonvulsants are frequently required in the management of severe PHN. A live, attenuated zoster vaccine has been recently shown to significantly decrease herpes zoster incidence, PHN and the overall burden of illness when administered to adults older than 60 years of age. This new prophylactic modality has been reported to be cost‐effective in the Canadian context, especially in the 60‐ to 75‐year‐old age group.
Managing Low Back Pain in the Primary Care Setting: The Know‐Do Gap
Authors: Scott N Ann , Moga Carmen , Harstall Christa
Published: March 2016

OBJECTIVE: To ascertain knowledge gaps in the diagnosis and treatment of acute and chronic low back pain (LBP) in the primary care setting to prepare a scoping survey for identifying knowledge gaps in LBP management among Alberta’s primary care practitioners, and to identify potential barriers to implementing a multidisciplinary LBP guideline.

METHODS: English language studies, published from 1996 to 2008, comparing the clinical practice patterns of primary care practitioners with guideline recommendations were identified by systematically searching literature databases, the websites of various health technology assessment agencies and libraries, and the Internet. Data were synthesized qualitatively.

RESULTS: The literature search identified 14 relevant studies. Knowledge gaps were reported among various primary care practitioner groups in the assessment of red flags, use of diagnostic imaging, provision of advice regarding sick leave and continuing activity, administration of some medications (muscle relaxants, oral steroids and opioids) and recommendation of particular treatments (acupuncture, physiotherapy, spinal manipulation, traction, ultrasound, transcutaneous electrical nerve stimulation and spinal mobilization).

CONCLUSIONS: A know‐do gap clearly exists among primary care practitioners with respect to the diagnosis and treatment of LBP. The information on know‐do gaps will be used to construct a survey tool for unearthing the local knowledge gaps extant among Alberta’s primary care practitioners, and to develop a dissemination strategy for a locally produced multidisciplinary LBP guideline, with the aim of ensuring that the know‐do gaps inherent within each primary practice discipline are specifically targeted.
Primary Pulmonary Hodgkin’s Lymphoma
Authors: Lluch-Garcia R , Briones-Gomez A , Castellano E Monzó , Sanchez-Toril F , Lopez A , Brotons B
Published: March 2016

A 21-year-old man presented to hospital with a two-month history of productive cough with no other symptoms. Radiology revealed a cavitating lesion in the left upper lobe for which a variety of diagnoses were considered. A biopsy revealed primary pulmonary Hodgkin’s lymphoma. Primary pulmonary Hodgkin’s lymphoma is an uncommon initial presentation; lung lesions usually occur later in the course of the disease. Following diagnosis, the patient began chemotherapy and full remission was achieved.
Unilateral Re‐Expansion Pulmonary Edema following Treatment of Pneumothorax with Exceptionally Massive Sputum Production, followed by Circulatory Collapse
Authors: Komatsu Teruya , Shibata Sumiya , Seo Ryutaro , Tomii Keisuke , Ishihara Kyousuke , Hayashi Takurou , Takahashi Yutaka
Published: March 2016

A case of a 61‐year‐old man who developed ipsilateral re‐expansion pulmonary edema after pleural drainage for a right pneumothorax is described. The patient’s chest x‐ray revealed a totally collapsed right lung. After insertion of a chest drainage tube, he began to produce a moderate amount of serous, yellowish sputum. Despite continuous positive airway pressure support, his dyspnea gradually worsened and his oxygenation could not be maintained; therefore, to improve his hypoxemic state, intubation was necessary. His chest x‐ray following chest tube insertion showed ipsilateral diffuse infiltrates. These radiographic and physical findings were consistent with re‐expansion pulmonary edema. The present case was complicated by extreme hypotension and tachycardia due to massive fluid loss. His condition gradually improved with invasive mechanical ventilation. Re‐expansion pulmonary edema is an uncommon complication of pleural drainage for pneumothorax, and therapy is supportive. In the present case, the exceptional severity of the pulmonary edema, as well as its general concept, is reviewed in accordance with other relevant literature.
Adherence to Pediatric Asthma Guidelines in the Emergency Department: A Survey of Knowledge, Attitudes and Behaviour among Health Care Professionals
Authors: Bhogal Sanjit K , Bourbeau Jean , McGillivray David , Benedetti Andrea , Bartlett Susan J , Ducharme Francine M
Published: March 2016

BACKGROUND: Despite strong evidence for using clinical care pathways to manage acute pediatric asthma, adherence remains suboptimal.

OBJECTIVES: To elicit information from health care professionals regarding their knowledge, attitudes and use of a care pathway for acute childhood asthma.

METHODS: A cross-sectional, self-administered survey of physicians, nurses and respiratory therapists who worked in the emergency department at the Montreal Children’s Hospital (Montreal, Quebec) from August to December 2007 was conducted. The survey assessed knowledge, attitude toward and agreement with the care pathway, as well as its use four years after its implementation.

RESULTS: Of the 128 health care professionals surveyed, 72 (56%) responded. Of these, 99% reported being familiar with the pathway, more than 90% agreed with its use for mild and moderate asthma, while 79% agreed with its use for severe asthma. For 99% of health care professionals, the advantages of using the pathway outweighed the disadvantages; however, 64% admitted to making variations to the pathway. Although 92% of respondents reported that they were quite comfortable with using the asthma severity Pediatric Respiratory Assessment Measure, only 53% and 36% correctly identified the severity score cut-offs for moderate and severe asthma, respectively. Seventeen per cent of respondents underestimated the delay of onset of action of oral corticosteroids, while 36% of physicians incorrectly believed that a higher than necessary dose was recommended for ipratropium bromide.

CONCLUSIONS: Results of the survey confirmed that the health care professionals queried had a positive attitude toward the pediatric asthma care pathway. Knowledge gaps and the balance between standardization versus individualization of care may be key elements to explain suboptimal adherence to the pathway.
Canadian Consensus Guidelines for the Optimal Use of Maraviroc in the Treatment of HIV‐Infected Adults
Authors: Rachlis Anita , Harris Marianne , Lalonde Richard , Shafran Stephen D , Tremblay Cécile , Wainberg Mark A , Walmsley Sharon
Published: March 2016

BACKGROUND AND OBJECTIVES: A Canadian group, consisting of six physicians and an HIV researcher with significant experience and knowledge in HIV management, reviewed the available data and developed guidelines for Canadian health care providers (who treat HIV infection) on the appropriate use of maraviroc (UK‐427,857) in HIV‐infected adults.

METHODS: Evidence from the published literature and conference presentations, as well as the expert opinions of the group members were considered and evaluated to develop the recommendations. Feedback on the draft recommendations was obtained from this core group, as well as from four other physicians across Canada with expertise in HIV treatment and experience with the use of maraviroc. The final recommendations represent the core group’s consensus agreement once all feedback was considered.

RESULTS/CONCLUSIONS: Recommendations were developed to guide physicians and other health care providers in the optimal use of maraviroc. The recommendations were considered in light of the fact that the decision to include maraviroc in an antiretroviral regimen depends not only on issues that concern all antiretroviral agents, such as efficacy, safety, resistance and drug interactions, but also on the issue of viral tropism, which is unique to maraviroc and other CCR5 inhibitors.
Airway Remodelling in Asthma: From Benchside to Clinical Practice
Authors: Bergeron Céline , Tulic Meri K , Hamid Qutayba
Published: March 2016

Airway remodelling refers to the structural changes that occur in both large and small airways relevant to miscellaneous diseases including asthma. In asthma, airway structural changes include subepithelial fibrosis, increased smooth muscle mass, gland enlargement, neovascularization and epithelial alterations. Although controversial, airway remodelling is commonly attributed to an underlying chronic inflammatory process. These remodelling changes contribute to thickening of airway walls and, consequently, lead to airway narrowing, bronchial hyper-responsiveness, airway edema and mucous hypersecretion. Airway remodelling is associated with poor clinical outcomes among asthmatic patients. Early diagnosis and prevention of airway remodelling has the potential to decrease disease severity, improve control and prevent disease expression. The relationship between structural changes and clinical and functional abnormalities clearly deserves further investigation. The present review briefly describes the characteristic features of airway remodelling observed in asthma, its clinical consequences and relevance for physicians, and its modulation by therapeutic approaches used in the treatment of asthmatic patients.
Eosinophilic Esophagitis: Clinical Features, Endoscopic Findings and Response to Treatment
Authors: Enns Robert , Kazemi Pooya , Chung Wiley , Lee Mitchell
Published: March 2016

Eosinophilic esophagitis (EE) is a motility disorder of the esophagus that typically presents with dysphagia. The objective of the present study was to explore patient characteristics, clinical and endoscopic features, and response to treatment of patients with EE. Patients were selected retrospectively based on a review of biopsy results from previous endoscopies performed between 2004 and 2008. A total of 54 patients (41 men and 13 women) with biopsy‐proven EE were included in the study. Further information regarding the patients’ clinical and endoscopic features, and response to treatment were obtained through chart reviews and patient telephone interviews. The mean age of the patients at symptom onset was 30 years. All patients complained of dysphagia, 81% had a history of bolus obstruction, 43% had a history of asthma and 70% had a history of environmental allergies. Thirty‐three per cent had a family history of asthma, while 52% had a family history of food or seasonal allergies. The most common endoscopic findings were rings and/or corrugations, which were found in 63% of patients. Swallowed fluticasone therapy resulted in symptom resolution in 74% of patients; however, 79% of these patients relapsed after discontinuing fluticasone therapy and required repeat treatments. Esophageal dilation was complication free and resulted in improvement in 80% of patients. However, 83% of those reporting improvement relapsed within one year. The clinical and endoscopic findings were similar to those found in the literature, with most patients requiring ongoing, repeated therapies. Further studies are needed to assess the safety and efficacy of treatment modalities ideally suited to patients with EE.
Cognitive and School Functioning in Children and Adolescents with Chronic Pain: A Critical Review
Authors: Dick Bruce D , Riddell Rebecca Pillai
Published: March 2016

Cognitive function is a critical factor related to a child’s overall developmental trajectory. There is increasing evidence that chronic pain disrupts cognitive function in adults. Little is known about the nature or impact of cognitive disruption in children and adolescents with chronic pain. The present review examines the current literature related to cognitive function in children and adolescents with chronic pain, implications of these findings and future research directions. Nine studies on this topic were found, with a relatively recent increase in publications related to school attendance and subjective studies of school performance. The studies that were found on this topic suggested that chronic pain affects cognitive function in children but the scope of these effects on children’s function and developmental trajectories is not yet clear. While methodological issues surely make it difficult to study cognitive function in children with chronic pain, the potential gains from such research warrant a pursuit of such work. Much remains to be studied on this important topic.
Direct Health Care Costs Associated with Asthma in British Columbia
Authors: Sadatsafavi Mohsen , Lynd Larry , Marra Carlo , Carleton Bruce , Tan Wan C , Sullivan Sean , FitzGerald J Mark
Published: March 2016

BACKGROUND: A better understanding of health care costs associated with asthma would enable the estimation of the economic burden of this increasingly common disease.

OBJECTIVE: To determine the direct medical costs of asthma‐related health care in British Columbia (BC).

METHODS: Administrative health care data from the BC Linked Health Database and PharmaNet database from 1996 to 2000 were analyzed for BC residents five to 55 years of age, including the billing information for physician visits, drug dispensations and hospital discharge records. A unit cost was assigned to physician/emergency department visits, and government reimbursement fees for prescribed medications were applied. The case mix method was used to calculate hospitalization costs. All costs were reported in inflation‐adjusted 2006 Canadian dollars.

RESULTS: Asthma resulted in $41,858,610 in annual health care‐related costs during the study period ($331 per patient‐year). The major cost component was medications, which accounted for 63.9% of total costs, followed by physician visits (18.3%) and hospitalization (17.8%). When broader definitions of asthma‐related hospitalizations and physician visits were used, total costs increased to $56,114,574 annually ($444 per patient‐year). There was a statistically significant decrease in the annual per patient cost of hospitalizations (P<0.01) over the study period. Asthma was poorly controlled in 63.5% of patients, with this group being responsible for 94% of asthma‐related resource use.

CONCLUSION: The economic burden of asthma is significant in BC, with the majority of the cost attributed to poor asthma control. Policy makers should investigate the reason for lack of proper asthma control and adjust their policies accordingly to improve asthma management.
Counselling by Primary Care Physicians May Help Patients with Heartburn-Predominant Uninvestigated Dyspepsia
Authors: Paré Pierre , Math Joanna Lee M , Hawes Ian A
Published: March 2016

OBJECTIVE: To determine whether strategies to counsel and empower patients with heartburn-predominant dyspepsia could improve health-related quality of life.

METHODS: Using a cluster randomized, parallel group, multicentre design, nine centres were assigned to provide either basic or comprehensive counselling to patients (age range 18 to 50 years) presenting with heartburn-predominant upper gastrointestinal symptoms, who would be considered for drug therapy without further investigation. Patients were treated for four weeks with esomeprazole 40 mg once daily, followed by six months of treatment that was at the physician’s discretion. The primary end point was the baseline change in Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire score.

RESULTS: A total of 135 patients from nine centres were included in the intention-to-treat analysis. There was a statistically significant baseline improvement in all domains of the QOLRAD questionnaire in both study arms at four and seven months (P<0.0001). After four months, the overall mean change in QOLRAD score appeared greater in the comprehensive counselling group than in the basic counselling group (1.77 versus 1.47, respectively); however, this difference was not statistically significant (P=0.07). After seven months, the overall mean baseline change in QOLRAD score between the comprehensive and basic counselling groups was not statistically significant (1.69 versus 1.56, respectively; P=0.63).

CONCLUSIONS: A standardized, comprehensive counselling intervention showed a positive initial trend in improving quality of life in patients with heartburn-predominant uninvestigated dyspepsia. Further investigation is needed to confirm the potential benefits of providing patients with comprehensive counselling regarding disease management.