bluuebunny/crossref_metadata_2025 huggingface dataset:
Treatment of Chronic Phantom Limb Pain Using a Trauma‐Focused Psychological Approach
Authors: de Roos C , Veenstra AC , de Jongh A , den Hollander-Gijsman ME , van der Wee NJA , Zitman FG , van Rood YR
Published: March 2016

BACKGROUND: Chronic phantom limb pain (PLP) is a disabling chronic pain syndrome for which regular pain treatment is seldom effective. Pain memories resulting from long‐lasting preamputation pain or pain flashbacks, which are part of a traumatic memory, are reported to be powerful elicitors of PLP.

OBJECTIVE: To investigate whether a psychological treatment directed at processing the emotional and somatosensory memories associated with amputation reduces PLP.

METHODS: Ten consecutive participants (six men and four women) with chronic PLP after leg amputation were treated with eye movement desensitization and reprocessing (EMDR). Pain intensity was assessed during a two‐week period before and after treatment (mean number of sessions = 5.9), and at short‐ (three months) and long‐term (mean 2.8 years) follow‐up.

RESULTS: Multivariate ANOVA for repeated measures revealed an overall time effect (F[2, 8]=6.7; P<0.02) for pain intensity. Pairwise comparison showed a significant decrease in mean pain score before and after treatment (P=0.00), which was maintained three months later. All but two participants improved and four were considered to be completely pain free at three months follow‐up. Of the six participants available at long‐term follow‐up (mean 2.8 years), three were pain free and two had reduced pain intensity.

CONCLUSIONS: These preliminary results suggest that, following a psychological intervention focused on trauma or pain‐related memories, substantial long‐term reduction of chronic PLP can be achieved. However, larger outcome studies are required.
Effects of a Short Course of Inhaled Corticosteroids in Noneosinophilic Asthmatic Subjects
Authors: Lemière Catherine , Tremblay Caroline , FitzGerald Mark , Aaron Shawn D , Leigh Richard , Boulet Louis-Philippe , Martin James G , Nair Parameswaran , Olivenstein Ronald , Chaboillez Simone
Published: March 2016

BACKGROUND: Noneosinophilic asthma has been regarded as a distinct phenotype characterized by a poor response to inhaled corticosteroids (ICS).

OBJECTIVE: To determine whether noneosinophilic, steroid‐naive asthmatic subjects show an improvement in asthma control, asthma symptoms and spirometry after four weeks of treatment with ICS, and whether they further benefit from the addition of a long‐acting beta‐2 agonists to ICS.

METHODS: A randomized, double‐blind, placebo‐controlled, multicentre study comparing the efficacy of placebo versus inhaled fluticasone propionate 250 μg twice daily for four weeks in mildly uncontrolled, steroid‐naive asthmatic subjects with a sputum eosinophil count ≤2%. This was followed by an open‐label, four‐week treatment period with fluticasone propionate 250 μg/salmeterol 50 μg, twice daily for all subjects.

RESULTS: After four weeks of double‐blind treatment, there was a statistically significant and clinically relevant improvement in the mean (± SD) Asthma Control Questionnaire score in the ICS‐treated group (n=6) (decrease of 1.0±0.5) compared with the placebo group (n=6) (decrease of 0.09±0.4) (P=0.008). Forced expiratory volume in 1 s declined in the placebo group (−0.2±0.2 L) and did not change in the ICS group (0.04±0.1 L) after four weeks of treatment (P=0.02). The open‐label treatment with fluticasone propionate 250 μg/salmeterol 50 μg did not produce additional improvements in those who were previously treated for four weeks with inhaled fluticasone alone.

CONCLUSION: A clinically important and statistically significant response to ICS was observed in mildly uncontrolled noneosinophilic asthmatic subjects.
Epidemiology and Burden of Chronic Constipation
Authors: Pinto Sanchez Maria Ines , Bercik Premysl
Published: March 2016

Chronic constipation is an important component of clinical gastroenterology practice worldwide. Based on the definition, either self‐reported or using Rome criteria, chronic constipation can affect from 2% to 27% of the population. Constipation is physically and mentally troublesome for many patients, and can significantly interfere with their daily living and well‐being. Although only a proportion of patients with constipation seek medical care, most of them use prescribed or over‐the‐counter medication to improve their condition. The health care costs of constipation are significant as evidenced by the hundreds of million dollars spent yearly on laxatives alone. Because constipation is more common in older patients and life expectancy is increasing, an increase in the prevalence of constipation is expected in the years to come, with the associated impact on quality of life and socioeconomic burden.
Treatment of Gastric Epithelial Tumours by Endoscopic Submucosal Dissection Using an Insulated‐Tip Diathermic Knife
Authors: Hua Xu Li , Bo Qian Jun , Gen Gu Liu , Fei Lu , Min Wang Ya , Ming Li Yu , Sheng Lu Hua
Published: March 2016

BACKGROUND: Endoscopic submucosal dissection (ESD) is a promising technique for the treatment of large, pre‐ and early malignant gastrointestinal lesions.

OBJECTIVE: To assess the rates of en bloc resection, incidence of complications, procedure times and therapeutic outcomes of ESD using an insulated‐tip diathermic knife; and to investigate predictors of these outcomes based on the final pathological features of biopsy specimens.

METHODS: One hundred twenty patients with endoscopically suspected gastric epithelial tumours who were treated with ESD from January 2006 to December 2009 were evaluated.

RESULTS: The mean diameter of the gastric epithelial tumours in the present cohort was 1.88 cm. The mean diameter of the resected specimens was 3.33 cm. The en bloc resection rate was 90% (108 of 120). The median length of the operation was 64.6 min. The bleeding and perforation complication rates were 5.0% (six of 120) and 2.5% (three of 120), respectively. Of 10 gastric tumours initially diagnosed as adenocarcinoma on biopsy, four were found to be low‐grade dysplasia and six were found to be high‐grade dysplasia after resection and final pathological examination. A total of 112 (93.33%) patients underwent curative treatment, eight patients (6.67%) underwent noncurative treatment with ESD, and two patients (1.67%) experienced local recurrence and subsequently underwent surgery.

CONCLUSIONS: ESD is a promising local curative treatment option for gastric epithelial tumours, but still carries the risks of bleeding and/or perforation. Differences in the interpretation of histological results among different pathologists and/or between biopsy specimens before ESD and the en bloc tissue specimens after ESD will result in discrepancies.
Home Mechanical Ventilation: A Canadian Thoracic Society Clinical Practice Guideline
Authors: McKim Douglas A , Road Jeremy , Avendano Monica , Abdool Steve , Côté Fabien , Duguid Nigel , Fraser Janet , Maltais François , Morrison Debra L , O’Connell Colleen , Petrof Basil J , Rimmer Karen , Skomro Robert ,   Canadian Thoracic Society Home Mechanical Ventilation Committee
Published: March 2016

Increasing numbers of patients are surviving episodes of prolonged mechanical ventilation or benefitting from the recent availability of user-friendly noninvasive ventilators. Although many publications pertaining to specific aspects of home mechanical ventilation (HMV) exist, very few comprehensive guidelines that bring together all of the current literature on patients at risk for or using mechanical ventilatory support are available. The Canadian Thoracic Society HMV Guideline Committee has reviewed the available English literature on topics related to HMV in adults, and completed a detailed guideline that will help standardize and improve the assessment and management of individuals requiring noninvasive or invasive HMV. The guideline provides a disease-specific review of illnesses including amyotrophic lateral sclerosis, spinal cord injury, muscular dystrophies, myotonic dystrophy, kyphoscoliosis, post-polio syndrome, central hypoventilation syndrome, obesity hypoventilation syndrome, and chronic obstructive pulmonary disease as well as important common themes such as airway clearance and the process of transition to home. The guidelines have been extensively reviewed by international experts, allied health professionals and target audiences. They will be updated on a regular basis to incorporate any new information.
Duloxetine Contributing to a Successful Multimodal Treatment Program for Peripheral Femoral Neuropathy and Comorbid ‘Reactive Depression’ in an Adolescent
Authors: Kachko Ludmyla , Ben Ami Shiri , Liberman Alon , Birk Einat , Kronenberg Sefi
Published: March 2016

In the United States, duloxetine has been approved for the treatment of major depressive disorder, diabetic peripheral neuropathic pain and fibromyalgia in the adult population. Data regarding the use of duloxetine in the pediatric population, however, are very limited. Femoral nerve injury is a rare complication of cardiac catheterization. In the case described, duloxetine contributed to a successful multimodal treatment program for peripheral neuropathic pain due to femoral neuropathy in an adolescent with ‘reactive depression’ and conversion symptoms. To the best of the authors’ knowledge, the present article is only the third such report on this dual use of duloxetine in children and adolescents, and the first report of such treatment following femoral neuropathy induced by cardiac catheterization.
Antiretroviral therapy for adults infected with HIV: Guidelines for health care professionals from the Quebec HIV care committee
Authors: Rouleau Danielle , Fortin Claude , Trottier Benoît , Lalonde Richard , Lapointe Normand , Côté Pierre , Routy Jean-Pierre , Matte Marie-France , Tsarevsky Irina , Baril Jean-Guy , for the Comité consultatif sur la prise en charge clinique d
Published: March 2016

The appropriate use of antiretrovirals reduces morbidity and mortality caused by HIV infection. The present article provides health care professionals with a practical guide for the use of antiretrovirals. Therapy should be initiated based predominantly on clinical presentation and CD4 count, and should consist of three active drugs or at least two active drugs when this is not possible, as in cases of some treatment‐experienced patients. This is the most effective way to achieve long‐term suppression of viral replication. Selection of individual drugs in the regimen should consider the weight of the evidence supporting these choices, as well as their tolerability profiles and ease of use, the patients’ comorbidities and treatment history. Treatment interruption is not recommended, either in aviremic patients or in those who have experienced virological failure. Instead, the therapeutic regimen should be adjusted to minimize side effects, promote adherence and suppress viral replication.
Examination of Migraine Management in Emergency Departments
Authors: Nijjar Satnam S , Pink Leah , Gordon Allan S
Published: March 2016

BACKGROUND: Despite advances in treatment, patients with migraine have been underdiagnosed and undertreated, specifically in emergency departments. In addition, great variability exists with respect to the diagnosis, management and treatment of migraine patients in emergency departments. In particular, migraine‐specific treatments, including serotonin receptor agonists, appear to be rarely used.

OBJECTIVE: To examine the diagnosis and management of migraine patients within Ontario emergency departments.

METHODS: A prospective survey was designed to inquire how emergency physicians diagnose and manage patients with migraine. Questions focused on the use of serotonin receptor agonists, the rationale behind their use or nonuse, and acute headache protocols. The survey also inquired about the use of International Classification Of Headache Disorders‐2 criteria in diagnosing migraine by emergency physicians, medication prescribed on discharge, and referrals made to outpatient specialists. These surveys were distributed to and anonymously completed by emergency physicians in several departments in Ontario.

RESULTS: Migraine‐specific treatments were underused in emergency departments. Furthermore, many departments lacked headache protocols and, often, migraine‐specific treatment was not included in the few departments with protocols.

CONCLUSIONS: Diagnosis and management of migraines can be improved within emergency departments, and patients can be more effectively channelled toward appropriate outpatient care.
Comparing the Efficacy of Biofeedback and Balloon‐Assisted Training in the Treatment of Dyssynergic Defecation
Authors: Pourmomeny Abbs Ali , Emami Mohammad Hassan , Amooshahi Mahboobeh , Adibi Peyman
Published: March 2016

BACKGROUND: Dyssynergic defecation does not respond appropriately to routine treatments for constipation. Recently, research has shown that biofeedback therapy is useful in anorectal dyssynergia.

OBJECTIVE: To compare two treatment modalities for patients experiencing dyssynergic defecation.

METHODS: Sixty‐five subjects with dyssynergic defecation were recruited and randomly allocated to one of two treatment groups: balloon defecation training and biofeedback therapy. In the first group, a balloon was inserted into the rectum and inflated by water injection so that the patient experienced the sensation of a full rectum and, thus, the need to defecate. The patient was subsequently asked to reject the balloon. In the biofeedback group, the pen electrode of an electromyographic biofeedback device was inserted into the rectum, with the patient subsequently being asked to increase abdominal pressure and relax the rectal muscles accordingly.

RESULTS: The findings showed a reduction in constipation in both groups. The ability to reject the balloon (volume and time) was significantly better in postintervention measurements; however, better results were found in the biofeedback arm of the study. Patient satisfaction after treatment reached 52% with balloon training and 79% in the biofeedback group. Reports of incomplete evacuation and the need for digit use during defecation remained constant after treatment in balloon‐trained patients.

CONCLUSION: Biofeedback training appeared to be superior to balloon defecation training and resulted in measurable changes in subjective and objective variables of dyssynergia.
Current States of Opinion and Future Directions on the Epidemiology of Sex Differences in Human Pain
Authors: Vigil Jacob M
Published: March 2016

One of the most commonly neglected findings in the human pain literature is the observation of sex differences in the mechanisms that support the phenotypic expression of pain. The present commentary describes an assessment of the prevalence of observed sex differences in various pain processes, and of how expert pain researchers interpret the epidemiology and, hence, the proximate and ultimate causes of such differences. Forty‐two pain investigators completed an anonymous survey on the epidemiology of sex differences in the human pain experience. Investigator responses indicated that sex differences are pervasive across various areas of pain research, that sex differences are particularly pronounced in the area of situational influences on pain behaviors, and that contemporary pain researchers largely disagree on the epidemiology of, and hence, proximate and ultimate causes of the differences. The relevance of social situational factors on sex differences in pain behaviours is discussed in the context of evolutionary, developmental, social psychology and pain sensory systems that may function, in part, for regulating interpersonal intimacy.
Evaluating Pain Education Programs: An Integrated Approach
Authors: Dubrowski Adam , Morin Marie-Paule
Published: March 2016

Evaluation of educational programs and assessment of learning are essential to maintain high‐standard health science education, which includes pain education. Current models of program evaluations applied to the education of the health professions, such as the Kirkpatrick model, are mainly outcome based. More recently, efforts have been made to examine other process‐based models such as the Context Input Process Product model. The present article proposes an approach that integrates both outcome‐ and process‐based models with models of clinical performance assessment to provide a deeper understanding of a program function. Because assessment instruments are a critical part of program evaluation, it is suggested that standardization and rigour should be used in their selection, development and adaptation. The present article suggests an alternative to currently used models in pain education evaluation.
Post Hoc Analyses of Data from a 90‐Day Clinical Trial Evaluating the Tolerability and Efficacy of Tapentadol Immediate Release and Oxycodone Immediate Release for the Relief of Moderate to Severe Pain in Elderly and Nonelderly Patients
Authors: Vorsanger Gary , Xiang Jim , Biondi David , Upmalis David , Delfgaauw Jacqueline , Allard René , Moskovitz Bruce
Published: March 2016

OBJECTIVE: To evaluate the tolerability and efficacy of tapentadol immediate release (IR) and oxycodone IR for relief of moderate to severe pain in elderly and nonelderly patients.

METHODS: Post hoc data analyses were conducted on a 90‐day randomized, phase 3, double‐blind, flexible‐dose study (ClinicalTrials.gov: NCT00364546) of adults with moderate to severe lower back pain or osteoarthritis pain who received tapentadol IR 50 mg or 100 mg, or oxycodone HCl IR 10 mg or 15 mg every 4 h to 6 h as needed for pain relief. Treatment‐emergent adverse events and study discontinuations were recorded.

RESULTS: Data from 849 patients randomly assigned (4:1 ratio) to treatment with a study drug (tapentadol IR [n=679] or oxycodone IR [n=170]) were analyzed according to age (younger than 65 years of age [nonelderly], or 65 years of age or older [elderly]) and treatment group. Among elderly patients, incidences of constipation (19.0% versus 35.6%) and nausea or vomiting (30.4% versus 51.1%) were significantly lower with tapentadol IR versus oxycodone IR (all P<0.05). Initial onsets of nausea and constipation occurred significantly later with tapentadol IR versus oxycodone IR (both P≤0.031). Tapentadol IR‐treated elderly patients had a lower percentage of days with constipation than oxycodone IR‐treated patients (P=0.020). For tapentadol IR‐ and oxycodone IR‐treated elderly patients, respectively, incidences of study discontinuation due to gastrointestinal treatment‐emergent adverse events were 15.8% and 24.4% (P=0.190). Tapentadol IR and oxycodone IR provided similar pain relief, with no overall age‐dependent efficacy differences (mean pain scores [11‐point numerical rating scale] decreased from 7.0 and 7.2 at baseline, to 4.9 and 5.2 at end point, respectively).

CONCLUSIONS: Tapentadol IR was safe and effective for the relief of lower back pain and osteoarthritis pain in elderly patients, and was associated with a better gastrointestinal tolerability profile than oxycodone IR.
Direct Costs of Occupational Asthma due to Sensitization in Quebec (1988 to 2002): Revisited
Authors: Malo Jean-Luc , Zunzunegui Maria-Victoria , L’Archevêque Jocelyne , Cardinal Shélanie , Ghezzo Heberto
Published: March 2016

BACKGROUND: In a previous study, the authors assessed direct costs for occupational asthma (OA) in a random sample of eight to 10 accepted claims per year for OA between 1988 and 2002. Compensation for loss of income (CLI) was found to be significantly higher for men and for OA caused by low-molecular-weight agents.

OBJECTIVES AND METHODS: To identify sociodemographic factors that modulate CLI, the dossier of each claimant in the previous study was re-examined.

RESULTS: Higher CLI costs were directly related to the duration of CLI (over which loss of income was reimbursed) (r=0.65). Costs of CLI were higher in patients 30 years of age or older at diagnosis, married subjects and individuals who were offered early retirement or were enrolled in an active interventional rehabilitation program. Higher CLI costs in men, but not in women, were associated with the following sociodemographic factors: older age, different rehabilitation program (early retirement and active program versus no specific program) and married status. Older age was found to be significant in the multivariate analysis performed for men. The cost of CLI was higher in workers with OA caused by low-molecular-weight agents. Although proportionally fewer men and younger workers were affected with OA caused by low-molecular-weight agents, the longer duration of CLI for this category of agent could explain the higher costs.

CONCLUSION: Higher costs for CLI were associated in men (but not women) with older age, married status and type of rehabilitation program (early retirement and active rehabilitation). Higher costs of CLI for OA caused by low-molecular-weight agents were associated with a longer duration of CLI per se, and not with sociodemographic factors.
Innovation and Design of a Web‐Based Pain Education Interprofessional Resource
Authors: Lax Leila , Watt-Watson Judy , Lui Michelle , Dubrowski Adam , McGillion Michael , Hunter Judith , MacLennan Cameron , Knickle Kerry , Robb Anja , Lapeyre Jaime
Published: March 2016

INTRODUCTION: The present article describes educational innovation processes and design of a web‐based pain interprofessional resource for prelicensure health science students in universities across Canada. Operationalization of educational theory in design coupled with formative evaluation of design are discussed, along with strategies that support collaborative innovation.

METHODS: Educational design was driven by content, theory and evaluation. Pain misbeliefs and teaching points along the continuum from acute to persistent pain were identified. Knowledge‐building theory, situated learning, reflection and novel designs for cognitive scaffolding were then employed. Design research principles were incorporated to inform iterative and ongoing design.

RESULTS: An authentic patient case was constructed, situated in inter‐professional complex care to highlight learning objectives related to pre‐operative, postoperative and treatment up to one year, for a surgical cancer patient. Pain mechanisms, assessment and management framed content creation. Knowledge building scaffolds were used, which included video simulations, embedded resources, concurrent feedback, practice‐based reflective exercises and commentaries. Scaffolds were refined to specifically support knowledge translation. Illustrative commentaries were designed to explicate pain misbeliefs and best practices. Architecture of the resource was mapped; a multimedia, interactive prototype was created. This pain education resource was developed primarily for individual use, with extensions for interprofessional collective discourse.

DISCUSSION: Translation of curricular content scripts into representation maps supported the collaborative design process by establishing a common visual language. The web‐based prototype will be formatively and summatively evaluated to assess pedagogic design, knowledge‐translation scaffolds, pain knowledge gains, relevance, feasibility and fidelity of this educational innovation.
Primary Care Physicians’ Perceptions of the Challenges and Barriers in the Timely Diagnosis, Treatment and Management of Fibromyalgia
Authors: Hadker Nandini , Garg Suchita , Chandran Arthi B , Crean Sheila M , McNett Michael , Silverman Stuart L
Published: March 2016

OBJECTIVES: To describe beliefs and practice patterns of primary care physicians (PCPs) providing fibromyalgia (FM) care, and to characterize differences between PCPs who report being able to provide timely and beneficial care versus the remaining PCPs.

METHODS: A mixed‐methods approach including surveys followed by semi‐structured focus groups among United States‐based PCPs in seven cities was used. Post hoc, a composite threshold of timely and beneficial care, defined as PCPs reports of at least one‐half of their patients achieving an ‘acceptable’ quality of life within one to four office visits after diagnosis, was created to compare subgroups.

RESULTS: Forty‐six per cent of PCPs reported some uncertainty when diagnosing FM. PCPs reported personally treating approximately two‐thirds of their patients (63%), and reported an average of three dosage titrations. In a post hoc exploratory analysis, 42.5% of PCPs met a composite threshold of self‐reported timely and beneficial FM care. These PCPs reported fewer office visits to confirm an FM diagnosis (2.7 versus 4.0 visits [P<0.01]) and more patients with ‘significant improvement’ (38% versus 23% [P<0.01]) after six months of treatment compared with the remaining PCPs.

CONCLUSIONS: Physicians self‐reported an inadequacy in diagnosing, treating and managing patients with FM in current practice. A subset of PCPs, however, perceived an ability to reach a definitive diagnosis and initiate treatment plans relatively sooner than the other respondents. If the perception of this subset can be confirmed with objective clinical outcomes, and these behaviours modelled, steps could be taken to improve FM care within the broader PCP setting.
Evaluation of the Iconic Pain Assessment Tool by a Heterogeneous Group of People in Pain
Authors: Lalloo Chitra , Henry James L
Published: March 2016

The Iconic Pain Assessment Tool (IPAT) is a novel web‐based instrument for the self‐report of pain quality, intensity and location in the form of a permanent diary. Originally designed for people with central poststroke pain, the tool is being adapted for a larger, more diverse patient population. The present study aimed to collect evaluative feedback on the IPAT from a heterogeneous sample of individuals with chronic pain. The specific study aims were to evaluate participant comfort with the tool including enjoyment, ease of use and comfort with the electronic medium; to assess perceived value of the tool for communicating pain quality, intensity and location; to gauge participant intent to share their pain diaries with others and use the tool on a regular basis to track their pain over time; to assess the perceived descriptiveness of current IPAT icons and the numerical rating scale; and to identify strengths and weaknesses of the tool to refine the existing prototype.

Written and verbal feedback from individuals with a variety of chronic pain conditions (n=23) were collected in the context of these objectives. Overall, the IPAT was positively endorsed by this heterogeneous sample of people in pain. The authors concluded that the IPAT is a user‐friendly instrument that has the potential to help people express, document and share their personal experience with chronic pain.
Do All Hemochromatosis Patients Have the Same Origin? A Pilot Study of Mitochondrial DNA and Y-DNA
Authors: Symonette Caitlin J , Adams Paul C
Published: March 2016

BACKGROUND: Mitochondrial DNA (mtDNA) and Y-DNA analysis have been widely used to predict ancestral origin. Genetic anthropologists predict that human civilizations may have originated in central Africa one to two million years previously. Primary iron overload is not a common diagnosis among indigenous people of northern Africa, but hereditary hemochromatosis is present in approximately one in 200 people in northern Europe. MtDNA analysis has the potential to determine whether contemporary hemochromatosis patients have an ancient ancestral linkage.

METHODS: DNA was obtained from buccal smears for mtDNA and Y-DNA analysis. Y-DNA analysis included examination of 20 short tandem repeat markers on the Y chromosome. Analysis of mtDNA involved sequencing of theHVR-1genetic sequence (nucleotides 16001 to 16520) and was compared with the Cambridge Reference Sequence. MtDNA ancestral haplotypes were predicted from the analysis of the HVR-1 sequence.

RESULTS: Twenty-six male C282Y homozygotes were studied. There were 28 polymorphisms present in the HVR-1 sequence of these participants. The most common polymorphism was present at position 16519 in 15 participants and at position 16311 in eight participants. There were 12 different ancestral haplotypes predicted by mtDNA analysis, with the K haplotype being present in five participants. Y-DNA analysis revealed eight different haplotypes, with R1b being found in 11 of the 26 participants.

CONCLUSION: Analysis of mtDNA and Y-DNA in 26 hemochromatosis patients suggested that they did not all originate from the same ancestral tribe in Africa. These findings were consistent with the theory that the original hemochromatosis mutation occurred after migration of these ancestral people to central Europe, possibly 4000 years previously.
Canadian Thoracic Society 2011 Guideline Update: Diagnosis and Treatment of Sleep Disordered Breathing
Authors: Fleetham John , Ayas Najib , Bradley Douglas , Fitzpatrick Michael , Oliver Thomas K , Morrison Debra , Ryan Frank , Series Frederic , Skomro Robert , Tsai Willis ,   The Canadian Thoracic Society Sleep Disordered Breathing Committee
Published: March 2016

The Canadian Thoracic Society (CTS) published an executive summary of guidelines for the diagnosis and treatment of sleep disordered breathing in 2006/2007. These guidelines were developed during several meetings by a group of experts with evidence grading based on committee consensus. These guidelines were well received and the majority of the recommendations remain unchanged. The CTS embarked on a more rigorous process for the 2011 guideline update, and addressed eight areas that were believed to be controversial or in which new data emerged. The CTS Sleep Disordered Breathing Committee posed specific questions for each area. The recommendations regarding maximum assessment wait times, portable monitoring, treatment of asymptomatic adult obstructive sleep apnea patients, treatment with conventional continuous positive airway pressure compared with automatic continuous positive airway pressure, and treatment of central sleep apnea syndrome in heart failure patients replace the recommendations in the 2006/2007 guidelines. The recommendations on bariatric surgery, complex sleep apnea and optimum positive airway pressure technologies are new topics, which were not covered in the 2006/2007 guidelines.
Assessing Response to Therapy in Idiopathic Pulmonary Arterial Hypertension: A Consensus Survey of Canadian Pulmonary Hypertension Physicians
Authors: Borrie Adrienne E , Ostrow David N , Levy Robert D , Swiston John R
Published: March 2016

BACKGROUND: Many treatment options are now available for patients with idiopathic pulmonary arterial hypertension (IPAH). Data regarding the optimal combination of therapies are lacking, as is consensus on how to assess response to therapy and when to change therapeutic regimens.

OBJECTIVES: To gather the opinions of Canadian pulmonary hypertension (PH) experts regarding standard practice in the care of IPAH patients after therapy is initiated.

METHODS: Canadian PH physicians were surveyed using short questionnaires to assess their opinions and practices in the care of IPAH patients. A Delphi forecasting approach was used to gain consensus among Canadian physicians on the most important clinical parameters to consider when assessing patients after the initiation of therapy.

RESULTS: Twenty-six of 37 Canadian PH experts who were invited to participate completed the study. All endorsed the use of combination therapy for IPAH patients despite the lack of universal provincial coverage for this approach. By consensus, WHO functional class, 6 min walk distance and hospitalization for right heart failure were the most important clinical parameters. The most highly rated physical examination parameters were jugular venous pressure, peripheral edema, the presence of ascites and body weight.

CONCLUSIONS: The overall approach to care of IPAH patients is similar across PH centres in Canada. A limited number of clinical and physical examination parameters were considered to be most important to reassess patients after therapy is initiated. These parameters, along with definition of threshold values, will facilitate the development of standard practice guidelines for IPAH patients in Canada.
A Bibliometric Analysis of Digestive Health Research in Canada
Authors: Tuitt Désirée , Knight Frank , Lipman Tara
Published: March 2016

Measurement of the impact and influence of medical/scientific journals, and of individual researchers has become more widely practiced in recent decades. This is driven, in part, by the increased availability of data regarding citations of research articles, and by increased competition for research funding. Digestive disease research has been identified as a particularly strong discipline in Canada. The authors collected quantitative data on the impact and influence of Canadian digestive health research. The present study involved an analysis of the research impact (Hirsch factor) and research influence (Influence factor) of 106 digestive health researchers in Canada. Rankings of the top 25 researchers on the basis of the two metrics were dominated by the larger research groups at the University of Toronto (Toronto, Ontario), McMaster University (Hamilton, Ontario), and the Universities of Calgary (Calgary, Alberta) and Alberta (Edmonton, Alberta), but with representation by other research groups at the Universities of Manitoba (Winnipeg, Manitoba), Western Ontario (London, Ontario) and McGill University (Montreal, Quebec). Female and male researchers had similar scores for the two metrics, as did basic scientists versus clinical investigators. Strategic recruitment, particularly of established investigators, can have a major impact on the ranking of research groups. Comparing these metrics over different time frames can provide insights into the vulnerabilities and strengths of research groups.
Unrelieved Pain: A Crisis
Authors: Sessle Barry J
Published: March 2016

Despite many recent advances in the past 40 years in the understanding of pain mechanisms, and in pain diagnosis and management, considerable gaps in knowledge remain, with chronic pain present in epidemic proportions in most countries. It is often unrelieved and is associated with significant socioeconomic burdens. Several opportunities and approaches to address this crisis are identified in the present article. Most crucial is the need to increase pain awareness, enhance pain education, improve access to pain care and increase pain research resources. Given the variability among countries in health care policies and programs, resources and educational programs, many of the approaches and strategies outlined will need to be tailored to each country’s socioeconomic and educational situation.
Chronic Constipation: Current Management and Challenges
Authors: Storr Martin
Published: March 2016

Many challenges are associated with the diagnosis and management of patients with chronic constipation. Some of these challenges arise from the currently incomplete understanding of what causes constipation and from the difficulties in diagnosing and classifying the heterogeneous group of patients with chronic constipation. Despite the availability of different treatment options for constipation, an unmet need for drugs in the treatment of patients with chronic constipation remains. This holds especially true for patients who fail an initial treatment. With promising novel drugs either close to approval for the Canadian market or on the horizon, many of these unmet needs may be addressed. The present supplement to The Canadian Journal of Gastroenterology provides an educational overview of the current understanding of the diagnosis, epidemiology, pathophysiology and management of chronic constipation, and summarizes current treatment options in light of current and newly available drugs.
Description of Two NewABCB11Mutations Responsible for Type 2 Benign Recurrent Intrahepatic Cholestasis in a French-Canadian Family
Authors: Beauséjour Yannick , Alvarez Fernando , Beaulieu Martin , Bilodeau Marc
Published: March 2016

Benign recurrent intrahepatic cholestasis is a rare clinical entity that is caused by mutations in the canalicular transport genes. The present report describes two individuals from the same family whose symptoms were typical of the clinical characteristics of type 2 benign recurrent intrahepatic cholestasis. Sequencing of theABCB11gene revealed two previously unreported mutations that predict the absence of expression of the protein. The clinical presentation of the current cases are discussed, as are the differential diagnosis and genetic characteristics of the hereditary cholestatic disorders, overemphasizing the possibility of making a definite genetic diagnosis.
Mortality among Subjects with Chronic Obstructive Pulmonary Disease or Asthma at Two Respiratory Disease Clinics in Ontario
Authors: Finkelstein Murray M , Chapman Kenneth R , McIvor R Andrew , Sears Malcolm R
Published: March 2016

BACKGROUND: Chronic obstructive pulmonary disease (COPD) and asthma are common; however, mortality rates among individuals with these diseases are not well studied in North America.

OBJECTIVE: To investigate mortality rates and risk factors for premature death among subjects with COPD.

METHODS: Subjects were identified from the lung function testing databases of two academic respiratory disease clinics in Hamilton and Toronto, Ontario. Mortality was ascertained by linkage to the Ontario mortality registry between 1992 and 2002, inclusive. Standardized mortality ratios were computed. Poisson regression of standardized mortality ratios and proportional hazards regression were performed to examine the multivariate effect of risk factors on the standardized mortality ratios and mortality hazards.

RESULTS: Compared with the Ontario population, all‐cause mortality was approximately doubled among subjects with COPD, but was lower than expected among subjects with asthma. The risk of mortality in patients with COPD was related to cigarette smoking, to the presence of comorbid conditons of ischemic heart disease and diabetes, and to Global initiative for chronic Obstructive Lung Disease severity scores. Individuals living closer to traffic sources showed an elevated risk of death compared with those who lived further away from traffic sources.

CONCLUSIONS: Mortality rates among subjects diagnosed with COPD were substantially elevated. There were several deaths attributed to asthma among subjects in the present study; however, overall, patients with asthma demonstrated lower mortality rates than the general population. Subjects with COPD need to be managed with attention devoted to both their respiratory disorders and related comorbidities.
Long‐Term Impact of Bronchopulmonary Dysplasia on Pulmonary Function
Authors: Landry Jennifer S , Chan Tiffany , Lands Larry , Menzies Dick
Published: March 2016

BACKGROUND: Bronchopulmonary dysplasia (BPD) and the long‐term respiratory consequences of prematurity are unfamiliar to adult respirologists and remain under‐recognized entities to adult caregivers. In Canada, the incidence of preterm births and its main chronic respiratory complication, BPD, have increased over the past 25 years.

OBJECTIVE: To describe the posthospitalization morbidity, medication use, health care use and pulmonary function tests of a large cohort of individuals with preterm birth complicated by BPD.

METHODS: A retrospective review of the hospital records of 322 preterm infants with BPD was conducted. Outcome variables were compared across levels of disease severity. Differences between groups were tested with one‐way ANOVA for continuous variables and the Mantel‐Haenszel χ2 test for ordinal variables.

RESULTS: Outcomes after the initial hospitalization that were associated with the initial severity of BPD were as follows: hospital readmissions in the first two years of life, the presence of developmental delay, forced expiratory volume in 1 s and forced vital capacity on pulmonary function tests in patients between eight and 15 years of age.

CONCLUSION: Initial BPD severity was an important predictor of pulmonary function abnormality and health care use during childhood.
Province‐wide Adenovirus Type 3 Outbreak with Severe Cases in New Brunswick
Authors: Girouard Gabriel , Garceau Richard , Thibault Louise , Bourque Christine , Bastien Nathalie , Li Yan
Published: March 2016

Adenovirus is a commonly isolated virus in clinical samples. Life‐threatening infections, although rare, are described worldwide. An epidemic spread of an adenovirus type 3 strain occurred in the province of New Brunswick during the fall of 2008 to the winter of 2009; it resulted in three severely ill patients, with one fatality. Adenovirus should be considered as a cause of severe community‐acquired viral pneumonia, especially when the influenza test is negative.
Autophagy: A Primer for the Gastroenterologist/Hepatologist
Authors: Sokollik Christiane , Ang Michelle , Jones Nicola L
Published: March 2016

Autophagy is a conserved cellular pathway that maintains intracellular homeostasis by degrading proteins and cytosolic contents of eukaryotic cells. Autophagy clears misfolded and long-lived proteins, damaged organelles and invading microorganisms from cells, and provides nutrients and energy in response to exposure to cell stressors such as starvation. Defective autophagy has recently been linked to a diverse range of disease processes of relevance to gastroenterologists and hepatologists including Crohn’s disease, pancreatitis, hepatitis and cancer. The present article provides an overview of the autophagy pathway and discusses gastrointestinal disease processes in which alterations in autophagy have been implicated. The clinical significance of autophagy as a potential therapeutic option is also discussed.
The Value of Repeat Clostridium difficile Toxin Testing during and after an Outbreak of C difficile‐Associated Diarrhea
Authors: Dylewski Joseph
Published: March 2016

BACKGROUND: The recent increase in Clostridium difficile‐associated diarrhea (CDAD) has led to questions about the reproducibility and sensitivity of C difficile toxin testing (CDTT). While there have been recommendations to repeat CDTT following a negative result, previous studies have failed to show a benefit. However, no studies were performed during an outbreak of CDAD. The value of repeat CDTT after an initial negative result in patients tested during and after an outbreak of CDAD is reported in the present study, as well as the reproducibility of CDTT when multiple samples are received and tested on the same day.

METHODS: The results of CDTT, performed using a cell cytotoxicity assay between April 1, 2001, and March 31, 2008, were retrieved and searched for patients who had repeat samples tested after an initial negative result. The result and the number of days after a negative result were determined using the date of the most recent negative test. The cumulative positivity rate was calculated by adding all of the repeat positive test results for the days in question and dividing by the total number of tests performed during that time.

RESULTS: A total of 8661 patients submitted 14,991 stool specimens for CDTT during the study period. There were 3095 samples that tested positive (20.6%) for the toxin. The results were divided into two time periods to reflect the CDAD outbreak, which began in April 2002: period 1 (outbreak) was from April 1, 2002, to March 31, 2006, and period 2 was from April 1, 2006, to March 31, 2008. The rate of positivity was 24.2% during period 1, and 11.6% during period 2 (P<0.001). Repeat CDTT was performed 619 times on samples received on the same day as the initial specimen, and only three (0.5%) were discordant. A total of 1630 samples were retested within one to seven days of a negative result, and 103 (6.3%) tested positive (7.8% period 1 and 2.9% period 2; P=0.002). The likelihood of a positive result on repeat testing in the first three days after a negative result was low (0.9%, 7% and 4%, respectively). The cumulative positivity for repeat testing performed in the first three days was 0.9%, 3.3% and 3.5%, respectively, and did not differ significantly at day 3 during the period of high CDTT positivity (P=0.110).

CONCLUSIONS: The value of repeat CDTT, performed using a cell cytotoxicity assay, was low in the first three days after an initial negative result and was unchanged during a CDAD outbreak.
Predicting, Treating and Preventing Postoperative Recurrence of Crohn’s Disease: The State of the Field
Authors: Borowiec Anna M , Fedorak Richard N
Published: March 2016

The majority of patients diagnosed with Crohn’s disease eventually require surgical intervention. Unfortunately, postsurgical remission tends to be short lived; a significant number of patients experience clinical relapse and many require additional operations. The pathogenesis of this postoperative recurrence is poorly understood and, currently, there are no reliable tools to predict when and in whom the disease will recur. Furthermore, the postoperative prophylaxis profiles of available Crohn’s disease therapeutic agents such as 5-aminosalicylates, immunomodulators, steroids and probiotics have been disappointing. Recently, the combination of antibiotics and azathioprine in selected high-risk patients has demonstrated some potential for benefit. The goal of the present article is to provide a coherent summary of previous and new research to guide clinicians in managing the challenging and complex problem of postoperative Crohn’s disease recurrence.
Laboratory Diagnosis of Syphilis: A Survey to Examine the Range of Tests Used in Canada
Authors: Tsang Raymond SW. , Radons Sandra Michelle , Morshed Muhammad , on behalf of the Syphilis Laboratory Task Group of the Canad
Published: March 2016

Laboratory diagnosis of syphilis has undergone major changes in the past decade with the introduction of immunoassays and recombinant Treponema pallidum antigens as screening tools for syphilis infection. To address this change in laboratory practice, a national syphilis laboratory working group was established with members from the Public Health Agency of Canada, provincial public health laboratories across the country as well as sexually transmitted infection researchers, clinicians and epidemiologists. This working group aims to examine how the use of newer immunoassays will affect syphilis diagnosis, surveillance and disease management. To provide a baseline for this work, an e‐mail survey was conducted in the fall of 2009 to determine current laboratory practices for syphilis diagnosis in Canada. The most commonly used tests were rapid plasma reagin, enzyme immunoassay, T pallidum passive particle agglutination, venereal disease research laboratory, fluorescent treponemal antibody absorption, line immunoassay and polymerase chain reaction with 92%, 36%, 32%, 20%, 12%, 12% and 12% of the responding laboratories reporting using these tests, respectively. The ultimate goal of this working group will be to update laboratory guidelines for the diagnosis of syphilis, and to identify syphilis surveillance and research priorities in Canada.