bluuebunny/crossref_metadata_2025 huggingface dataset:
Identification of Acute Vaccine‐Preventable Hepatitis in Individuals with Chronic Hepatitis in British Columbia between 1991 and 2007
Authors: Fang Lily , Yu Amanda , Buxton Jane A.
Published: March 2016

BACKGROUND: In British Columbia (BC), hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccines are provincially funded for persons with chronic hepatitis infections. PURPOSE: To assess the effectiveness of BC public health follow‐up of HBV and hepatitis C virus (HCV) cases and immunization policy by determining the number of vaccine‐preventable acute hepatitis infections reported following a chronic HBV or HCV diagnosis, by examining demographic characteristics and by observing temporal trends.

METHODS: All newly identified cases of HAV, HBV and HCV between 1991 and October 2007 were extracted from the BC integrated Public Health Information System and linked to ascertain cases of hepatitis suprainfection.

RESULTS: Between 1991 and October 2007, 30 BC residents with chronic HBV and 104 with HCV were subsequently diagnosed with HAV. Acute HBV was identified in 162 persons previously diagnosed with HCV. Significantly more men than women developed hepatitis suprainfection (P<0.0001), but women were of a younger age when they were diagnosed with HAV (P=0.02) and acute HBV (P=0.0002). HAV suprainfection cases among those with HCV peaked in 1998 at 33 cases and declined to zero cases in 2007. In comparison, HBV suprainfection among individuals with chronic HCV peaked in 1996 at 26 cases and declined to two cases in 2007.

DISCUSSION: Cases of HAV and acute HBV have declined among HCV‐infected individuals. However, despite the availability of publicly funded vaccines for high‐risk groups, a substantial number of acute HBV infections post‐HCV identification are still identified, indicating that follow‐up and vaccination coverage should be improved in these populations.
A Literature Review of Quality in Lower Gastrointestinal Endoscopy from the Patient Perspective
Authors: Sewitch Maida J , Gong Shasha , Dubé Catherine , Barkun Alan , Hilsden Robert , Armstrong David
Published: March 2016

BACKGROUND: Given the limited state of health care resources, increased demand for colorectal cancer (CRC) screening raises concerns about the quality of endoscopy services. Little is known about quality in colonoscopy and endoscopy from the patient perspective.

OBJECTIVE: To systematically review the literature on quality that is relevant to patients who require colonoscopy or endoscopy services.

METHODS: A systematic PubMed search was performed on articles that were published between January 2000 and February 2011. Keywords included “colonoscopy” or “sigmoidoscopy” or “endoscopy” AND “quality”; “colonoscopy” or “sigmoidoscopy” or “endoscopy” AND “patient satisfaction” or “willingness to return”. The included articles were qualitative and quantitative English language studies regarding aspects of colonoscopy and/or endoscopy services that were evaluated by patients in which data were collected within one year of the colonoscopy/endoscopy procedure.

RESULTS: In total, 28 quantitative studies were identified, of which eight (28.6%) met the inclusion criteria (four cross-sectional, three prospective cohort and one single-blinded controlled study). Aspects of quality included comfort, management of pain and anxiety, endoscopy unit staff manner, skills and specialty, procedure and results discussion with the doctor, physical environment, wait times for the appointment and procedure, and discharge. Qualitative studies eliciting the patient perspective on what constituted quality in colonoscopy/endoscopy were not found.

CONCLUSIONS: Factors related to comfort, staff, communication and the service environment were evaluated from the patient perspective using closed-ended questions that were designed by clinicians and researchers. Future research using qualitative methodology to elicit the patient perspective on quality in colonoscopy and/or endoscopy services is needed.
Diagnosis and Pharmacological Management of Small Intestinal Bacterial Overgrowth in Children with Intestinal Failure
Authors: Malik Bushra A , Xie Yuan Y , Wine Eytan , Huynh Hien Q
Published: March 2016

The present article provides a general overview of the possible diagnostic procedures available for the management of small intestinal bacterial overgrowth in pediatric patients with intestinal failure. The focus is to address current diagnostic tools and understand their associated advantages and disadvantages based on a literature search. Culture of small intestinal aspirates, noninvasive breath tests and an emerging interest in quantitative bacterial DNA fingerprinting are discussed. Proper management is critical for preventing the recurrence of small intestinal bacterial overgrowth and its related complications. Antibiotic prophylaxis is one approach to the treatment of bacterial overgrowth in intestinal failure patients. Although treatment trials can be challenging in such a vulnerable population, more investigative clinical studies examining early diagnosis, more effective control of recurrence and the prevention of associated complications must be conducted.
Development and Implementation of a Comprehensive Quality Assurance Program at a Community Endoscopy Facility
Authors: Hilsden Robert J , Rostom Alaa , Dubé Catherine , Pontifex Darlene , McGregor S Elizabeth , Bridges Ronald J
Published: March 2016

Quality assurance (QA) is a process that includes the systematic evaluation of a service, institution of improvements and ongoing evaluation to ensure that effective changes were made. QA is a fundamental component of any organized colorectal cancer screening program. However, it should play an equally important role in opportunistic screening. Establishing the processes and procedures for a comprehensive QA program can be a daunting proposition for an endoscopy unit. The present article describes the steps taken to establish a QA program at the Forzani & MacPhail Colon Cancer Screening Centre (Calgary, Alberta) – a colorectal cancer screening centre and nonhospital endoscopy unit that is dedicated to providing colorectal cancer screening-related colonoscopies. Lessons drawn from the authors’ experience may help others develop their own initiatives. The Global Rating Scale, a quality assessment and improvement tool developed for the gastrointestinal endoscopy services of the United Kingdom’s National Health Service, was used as the framework to develop the QA program. QA activities include monitoring the patient experience through surveys, creating endoscopist report cards on colonoscopy performance, tracking and evaluating adverse events and monitoring wait times.
What Is Nonacid Reflux Disease?
Authors: Storr Martin A
Published: March 2016

Proton pump inhibitors (PPIs) are the gold standard treatment for gastroesophageal reflux disease. In clinical practice, failure of PPIs occurs frequently, and may affect up to 30% of patients in a typical gastroenterology practice. Multichannel impedance monitoring combined with pH monitoring helps to detect nonacid reflux, and if symptoms correlate with these nonacid reflux episodes, nonacid reflux disease can be diagnosed. In contrast to PPIs, reflux inhibitors target transient lower esophageal sphincter relaxations, which are involved in the pathophysiology of reflux disease and may be the appropriate future treatment for nonacid reflux disease. The present article discusses the current understanding of nonacid reflux disease, its diagnosis and treatment.
Using Telehealth Technology to Deliver Pulmonary Rehabilitation to Patients with Chronic Obstructive Pulmonary Disease
Authors: Stickland Michael K , Jourdain Tina , Wong Eric YL , Rodgers Wendy M , Jendzjowsky Nicholas G , MacDonald G Fred
Published: March 2016

BACKGROUND: Pulmonary rehabilitation (PR) is an effective therapeutic strategy to improve health outcomes in patients with chronic obstructive pulmonary disease (COPD); however, there is insufficient PR capacity to service all COPD patients, thus necessitating creative solutions to increase the availability of PR.

OBJECTIVE: To examine the efficacy of PR delivered via Telehealth (Telehealth-PR) compared with PR delivered in person through a standard outpatient hospital-based program (Standard-PR).

METHODS: One hundred forty-seven COPD patients participated in an eight-week rural PR program delivered via Telehealth-PR. Data were compared with a parallel group of 262 COPD patients who attended Standard-PR. Education sessions were administered two days per week via Telehealth, and patients exercised at their satellite centre under direct supervision. Standard-PR patients viewed the same education sessions in person and exercised at the main PR site. The primary outcome measure was change in quality of life as evaluated by the St George’s Respiratory Questionnaire (SGRQ). A noninferiority analysis was performed using both intention-to-treat and per-protocol approaches.

RESULTS: Both Telehealth-PR and Standard-PR resulted in clinically and statistically significant improvements in SGRQ scores (4.5±0.8% versus 4.1±0.6%; P<0.05 versus baseline for both groups), and the improvement in SGRQ was not different between the two programs. Similarly, exercise capacity, as assessed by 12 min walk test, improved equally in both Telehealth-PR and Standard-PR programs (81±10 m versus 82±10 m; P<0.05 versus baseline for both groups).

CONCLUSION: Telehealth-PR was an effective tool for increasing COPD PR services, and demonstrated improvements in quality of life and exercise capacity comparable with Standard-PR.
Bovine Antibody-Based Oral Immunotherapy for Reduction of Intragastric Helicobacter pylori Colonization: A Randomized Clinical Trial
Authors: den Hoed CM , de Vries AC , Mensink PBF , Dierikx CM , Suzuki H , Capelle L , van Dekken H , Ouwendijk R , Kuipers EJ
Published: March 2016

BACKGROUND: Antibiotic-based regimens are frequently used for the treatment of Helicobacter pylori infection. These regimens fail to eradicate H pylori in 15% to 40% of patients, primarily due to antimicrobial resistance and insufficient patient compliance. Effective prevention and eradication of H pylori by passive immunization with orally administered bovine antibodies has been demonstrated in animal studies, and may serve as an alternative therapy in humans.

OBJECTIVE: To study the efficacy and safety of orally administered bovine anti-H pylori antibodies for the reduction of intragastric bacterial load and eradication of H pylori in humans.

METHODS: Dairy cows were immunized against H pylori. After confirmation of the presence of anti-H pylori antibodies in the milk, the milk was subsequently processed into a whey protein concentrate (WPC). In a prospective, double-blind, placebo-controlled randomized clinical trial, H pylori-infected subjects were randomly assigned to treatment with the WPC preparation or placebo. Study medication was continued for 28 days; subjects were followed-up for 56 days.

RESULTS: Of the 30 subjects included, 27 completed the protocol. Of these 27 evaluable subjects, 14 were treated with WPC and 13 with placebo. There was no significant difference in urea breath test decrease between the WPC- and placebo-treated group (P=0.75). H pylori-associated gastritis and density were not significantly reduced in either group after treatment (P>0.05 for all).

CONCLUSION: Bovine antibody-based oral immunotherapy appears to be safe, but does not significantly reduce intragastric H pylori density in humans. Further studies are needed to determine whether WPC treatment has additional value to conventional antibiotic treatment for H pylori.
Moderate and Severe Postendoscopic Retrograde Cholangiopancreatography Pancreatitis Despite Prophylactic Pancreatic Stent Placement: The Effect of Early Prophylactic Pancreatic Stent Dislodgement
Authors: Moffatt Dana C , Kongkam Pradermchai , Avula Haritha , Sherman Stuart , Fogel Evan L , Lehman Glen A
Published: March 2016

BACKGROUND: Placement of prophylactic pancreatic stents (PPS) is a method proven to reduce the rate and severity of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk patients; however, PPS do not eliminate the risk completely. Early PPS dislodgement may occur prematurely and contribute to more frequent or severe PEP.

OBJECTIVE: To determine the effect of early dislodgement of PPS in patients with moderate or severe PEP.

METHOD: A total of 27,176 ERCP procedures from January 1994 to September 2007 for PPS placement in high-risk patients were analyzed. Patient and procedure data were analyzed to assess risk factors for PEP, and to evaluate the severity of pancreatitis, length of hospitalization and subsequent complications. Timing of stent dislodgment was assessed radiographically.

RESULTS: PPS were placed in 7661 patients. Of these, 580 patients (7.5%) developed PEP, which was graded as mild in 460 (6.0%), moderate in 87 (1.1%) and severe in 33 (0.4%). Risk factors for developing PEP were not different in patients who developed moderate PEP compared with those with severe PEP. PPS dislodged before 72 h in seven of 59 (11.9%) patients with moderate PEP and five of 27 (18.5%) patients with severe PEP (P=0.505). The mean (± SD) length of hospitalization in patients with moderate PEP with stent dislodgement before and after 72 h were 7.43±1.46 days and 8.37±1.16 days, respectively (P=0.20). The mean length of hospitalization in patients with severe PEP whose stent dislodged before and after 72 h were 21.6±6.11 and 22.23±3.13 days, respectively (P=0.96).

CONCLUSION: Early PPS dislodgement was associated with moderate and severe PEP in less than 20% of cases and was not associated with a more severe course. Factors other than ductal obstruction contribute to PEP in high-risk patients undergoing ERCP and PPS placement.
Retrospective Analysis of High‐Dose Intrathecal Morphine for Analgesia after Pelvic Surgery
Authors: Rebel Annette , Sloan Paul , Andrykowski Michael
Published: March 2016

BACKGROUND: The effectiveness of intrathecal opioids (ITOs) for postoperative analgesia has been limited by reduced opioid dosing because of opioid‐related side effects, most importantly respiratory depression. To overcome these limitations, high‐dose intrathecal morphine was combined with a continuous intravenous (IV) postoperative naloxone infusion. The aim of the present chart analysis was to investigate the safety and efficacy of high‐dose ITOs combined with IV naloxone compared with IV opioid analgesia alone.

METHODS: A retrospective chart analysis was performed on 121 female patients requiring major pelvic surgery. Ninety‐eight patients received a single injection of high‐dose ITOs before administration of typical general anesthesia, followed by an IV naloxone infusion at 5 μg/kg/h started post‐ITO and continued for 22 h postoperatively. Twenty‐three patients were given IV morphine (IVM) for postoperative analgesia and served as a reference group. Postoperative pain relief, analgesic consumption and ability to ambulate were assessed for 48 h postoperatively. Treatment safety was assessed by monitoring opioid‐related side effects and vital signs. Data are presented as mean ± SD.

RESULTS: Mean ITOs given were morphine 1.1±0.2 mg combined with fentanyl 49±6 μg. The mean worst pain visual analogue scale score in the first 12 h postoperatively was 0.2±0.90 in the ITO group versus 4.3±3.0 in the IVM group (P<0.05). On postoperative day 2, the mean worst pain visual analogue scale score was only 1±1.8 in the ITO group versus 4.1±2.6 in the IVM group (P<0.05). Analgesic requirements were reduced in the ITO group. In the first 24 h, the ITO group used 6.8±10.2 morphine equivalents (mg IV) versus 76.1±44.4 in the IVM group (P<0.05). All patients in the ITO group were able to ambulate in the first 12 h postoperatively compared with 17/23 in the IVM group. There was a higher incidence of opioid‐related sedation in the IVM group. Other opioid‐related side effects were infrequent and minor in both groups.

CONCLUSIONS: High‐dose ITOs combined with a postoperative IV naloxone infusion provided excellent analgesia for major pelvic surgery. The IV naloxone infusion combined with high‐dose ITOs appeared to control opioid side effects without affecting analgesia.
Acute Respiratory Distress following Intravenous Injection of an Oil-Steroid Solution
Authors: Russell Michael , Storck Aric , Ainslie Martha
Published: March 2016

A case of acute respiratory distress and hypoxemia following accidental intravenous injection of an oil-steroid solution in a body builder is presented. Chest roentography at the time of presentation showed diffuse bilateral opacities, and computed tomography revealed predominantly peripheral ground-glass opacifications. The patient’s symptoms gradually improved over 48 h and imaging of the chest was unremarkable one week later. The pathophysiology, diagnosis and treatment of this rare but potentially life-threatening complication of intravenous oil injection are discussed.
Antibodies from a Patient with Type 1 Diabetes and Celiac Disease Bind to Macrophages that Express the Scavenger Receptor CD163
Authors: Sonier Brigitte , Strom Alexander , Wang Gen-Sheng , Patrick Christopher , Crookshank Jennifer A , Mojibian Majid , MacFarlane Amanda J , Scott Fraser W
Published: March 2016

Antibodies against the wheat storage globulin Glo-3A from a patient with both type 1 diabetes (T1D) and celiac disease were enriched to identify potential molecular mimicry between wheat antigens and T1D target tissues. Recombinant Glo-3A was used to enrich anti-Glo-3A immunoglobulin G antibodies from plasma by batch affinity chromatography. Rat jejunum and pancreas, as well as human duodenum and monocytes were probed, and binding was evaluated by immunohistochemistry and confocal microscopy. Glo-3A-enriched antibodies bound to a specific subset of cells in the lamina propria of rat jejunum that co-localized mostly with a marker of resident, alternatively activated CD163-positive (CD163+) macrophages. Blood monocytes and macrophage-like cells in human duodenum were also labelled with the enriched antibodies. Blocking studies revealed that binding to CD163+macrophages was not due to cross-reactivity with anti-Glo-3A antibodies, but rather to non-Glo-3A antibodies co-purified during antibody enrichment. The novel finding of putative autoantibodies against tolerogenic intestinal CD163+macrophages suggests that regulatory macrophages were targeted in this patient with celiac disease and T1D.
Decompression of Multiple Tension Pneumatoceles in a Child Using Computed Tomography‐Guided Percutaneous Catheter Placement
Authors: Ku Shu-Wing , Yu Tak-Ching , Chan Kam-Wai
Published: March 2016

Pneumatoceles can develop as a complication of pneumonia. Air accumulation inside pneumatoceles can produce a pressure effect on surrounding structures. A 15‐month‐old girl who developed multiple tension pneumatoceles secondary to infection caused by pneumococcus is reported. The patient experienced severe cardiorespiratory compromise that was unresponsive to conservative treatment with high‐frequency oscillatory ventilation. The condition was successfully treated with computed tomography‐guided percutaneous catheter placement using a pigtail catheter for decompression. A stepwise approach was adopted for removal of the catheter.
Isolation Prevalence of Pulmonary Nontuberculous Mycobacteria in Ontario in 2007
Authors: Al Houqani Mohammed , Jamieson Frances , Chedore Pamela , Mehta Mauli , May Kevin , Marras Theodore K
Published: March 2016

BACKGROUND: The reported prevalence of pulmonary nontuberculous mycobacteria (NTM) infections is increasing.

OBJECTIVE: To determine the ‘isolation prevalence’ of NTM in 2007 and compare it with previously published research that examined the increasing rates of isolation of NTM from clinical pulmonary specimens between 1997 and 2003.

METHODS: Isolation prevalence was investigated retrospectively by reviewing a cohort of all positive pulmonary NTM culture results from the Tuberculosis and Mycobacteriology Laboratory, Public Health Laboratory (Toronto, Ontario) in 2007, which identifies at least 95% of NTM isolates in Ontario. Isolation prevalence was calculated as the number of persons with a pulmonary isolate in a calendar year divided by the contemporary population and expressed per 100,000 population. Changes in isolation prevalence from previous years were assessed for statistical significance using generalized linear models with a negative binomial distribution.

RESULTS: In 2007, 4160 pulmonary isolates of NTM were collected from 2463 patients. The isolation prevalence of all species (excludingMycobacterium gordonae) was 19 per 100,000 population in 2007 – an increase from previous observations reported for Ontario – corresponding to an average annual increase of 8.5% from 1997 to 2007 (P<0.0001). Average annual increases in isolation prevalence ofMycobacterium aviumcomplex (8.8%, P<0.0001) andMycobacterium xenopi(7.3%, P=0.0005) were largely responsible for the overall increase, while prevalence rates of rapidly growing mycobacteria remained relatively stable.

CONCLUSION: The isolation prevalence of pulmonary NTM continues to increase significantly in Ontario, supporting the belief that pulmonary NTM disease is increasingly common.
Mycobacterial Brain Tuberculomas due to Bacille Calmette‐Guérin Intravesical Chemotherapy for Bladder Cancer: A Case Report and Literature Review
Authors: Golub Vitaly , Malhotra Prashant , Patel Shital
Published: March 2016

Bacille Calmette‐Guérin (BCG) immunotherapy is widely used for the treatment of superficial bladder cancer. The authors believe that the present report is one of the first to document cerebral BCG tuberculoma in a 73‐year‐old immunocompetent man, three years after intra‐vesical BCG immunotherapy. His workup revealed no identifiable extracranial source. He responded well to treatment with rifampin, ethambutol and moxifloxacin.

Patients undergoing intravesical BCG therapy should be closely monitored for the development of this complication. Prolonged antitubercular therapy, possibly including moxifloxacin, appears to be beneficial in the treatment of central nervous system tuberculous infections.
Clinical Parameters Predicting Survival Duration after Hepatectomy for Intrahepatic Cholangiocarcinoma
Authors: Jiang Bei-ge , Ge Rui-liang , Sun Liang-liang , Zong Ming , Wei Gong-tian , Zhang Yong-jie
Published: March 2016

BACKGROUND: Currently, the most effective treatment for intrahepatic cholangiocarcinoma (ICC) is complete hepatic tumour excision.

OBJECTIVE: To identify the clinical parameters associated with survival duration for ICC patients following hepatectomy, and to construct a mathematical model for predicting survival duration.

METHODS: Demographic data and clinical variables for 102 patients diagnosed with ICC, who underwent exploratory laparotomy at a single centre from July 1998 to December 2000 and were followed for an average of 24 months, were collected in 2011. Patients were randomly assigned into training (n=76) and validation (n=26) groups. Univariate and multivariate analyses were performed to identify factors associated with posthepatectomy survival duration.

RESULTS: Univariate analysis revealed that more than three lymph node metastases, a serum carbohydrate antigen 19-9 level >37 U/mL, stage IVa tumours, and intra- or perihepatic metastases were significantly associated with decreased survival duration. Curative resection was significantly associated with increased survival duration. A mathematical model incorporating parameters of age, sex, metastatic lymph node number, curative surgery, carbohydrate antigen 19-9 concentration, alpha-fetoprotein concentration, hepatitis B, TNM stage and tumour differentiation was constructed for predicting survival duration. For a survival duration of less than one year, the model exhibited 93.8% sensitivity, 92.3% total accuracy and a positive predictive value of 93.8%; for a survival duration of one to three years, the corresponding values were 80.0%, 69.2% and 57.1%, repsectively.

CONCLUSIONS: The mathematical model presented in the current report should prove to be useful in the clinical setting for predicting the extent to which curative resection affects the survival of ICC patients, and for selecting optimal postoperative treatment strategies.
Alternative Targets Within the Endocannabinoid System for Future Treatment of Gastrointestinal Diseases
Authors: Schicho Rudolf , Storr Martin
Published: March 2016

Many beneficial effects of herbal and synthetic cannabinoids on gut motility and inflammation have been demonstrated, suggesting a vast potential for these compounds in the treatment of gastrointestinal disorders. These effects are based on the so-called ‘endocannabinoid system’ (ECS), a cooperating network of molecules that regulate the metabolism of the body’s own and of exogenously administered cannabinoids. The ECS in the gastrointestinal tract quickly responds to homeostatic disturbances by de novo synthesis of its components to maintain homeostasis, thereby offering many potential targets for pharmacological intervention. Of major therapeutic interest are nonpsychoactive cannabinoids or compounds that do not directly target cannabinoid receptors but still possess cannabinoid-like properties. Drugs that inhibit endocannabinoid degradation and raise the level of endocannabinoids are becoming increasingly promising alternative therapeutic tools to manipulate the ECS.
Hepatitis B Learning Needs Assessment of Family Medicine Trainees in Canada: Results of a Nationwide Survey
Authors: Sam Justina J , Heathcote E Jenny , Wong David KH , Wooster Douglas L , Shah Hemant
Published: March 2016

BACKGROUND: An estimated 350 million people worldwide have chronic hepatitis B (CHB), which is a major cause of cirrhosis and hepatocellular carcinoma.

OBJECTIVE: To assess the level of knowledge among family medicine trainees regarding the identification and management of CHB.

METHODS: A questionnaire to assess knowledge regarding screening and management of patients with CHB and cirrhosis was developed. The questionnaire was pilot tested among primary care physicians, subsequently revised and distributed to family medicine trainees across Canada through an online survey program (QuestionPro).

RESULTS: A total of 158 trainees completed the questionnaire. Of these, 54% to 56% routinely offered vaccination against hepatitis A or hepatitis B virus (HBV), and 42% regularly screened patients for HBV risk factors. The percentage who recognized the need to screen high-risk populations for CHB, ie, individuals from an HBV-endemic country, men who have sex with men, or intravenous drug users was 73%, 66% and 74%, respectively. While less than 50% of respondents used the appropriate HBV screening tests, 86% to 91% correctly interpreted various HBV serological patterns. Only 3% recognized cirrhosis in our case scenario. Almost 80% of respondents inappropriately preferred prescribing a narcotic or nonsteroidal anti-inflammatory drug over acetaminophen (4%) for pain control in a patient with cirrhosis. While less than 60% recognized HBeAg negative CHB as an indication for referral and treatment, 90% would have referred a patient in the immune-tolerant phase, even though treatment is not indicated.

CONCLUSIONS: Knowledge gaps regarding CHB among family medicine trainees in the areas of primary prevention, disease recognition and management of cirrhosis were identified. Results suggest that opportunities to prevent potentially life-threatening complications are being missed.
Helicobacter pyloriInfection: Is Sequential Therapy Superior to Standard Triple Therapy? A Single-Centre Italian Study in Treatment-Naive and Non-Treatment-Naive Patients
Authors: Urgesi R , Pelecca G , Cianci R , Masini A , Zampaletta C , Riccioni ME , Faggiani R
Published: March 2016

BACKGROUND: Clarithromycin resistance has decreased the eradication rates ofHelicobacter pylori.

AIMS: To determine whether a 10-day course of sequential therapy (ST) is more effective at eradicatingH pyloriinfection than triple therapy (TT) in the first or second line, and to assess side effects and compliance with therapy.

METHODS: One hundred sixty treatment-naive and 40 non-treatment-naive patients who were positive forH pyloriinfection by13C-urea breath test or endoscopy were enrolled. Eighty of 160 patients underwent TT, while 80 of 160 underwent ST with omeprazole (20 mg) plus amoxicillin (1 g) twice/day for five days, followed by omeprazole (20 mg) with tinidazole (500 mg) twice/day and clarithromycin (500 mg) twice/day for five consecutive days.H pylorieradication was evaluated by13C-urea breath test no sooner than four weeks after the end of treatment.

RESULTS: Eradication was achieved in 59 of 80 treatment-naive patients treated with TT (74%), in 74 of 80 patients treated with ST (93%), and in 38 of 40 non-treatment-naive patients (95%). Eradication rates in treatment-naive patients with ST were statistically significantly higher than TT (92.5% versus 73.7%; P=0.0015; OR 4.39 [95% CI 1.66 to 11.58]). Mild adverse effects were reported for both regimens.

CONCLUSIONS: ST appears to be a well-tolerated, promising therapy; however, randomized controlled trials with larger and more diverse sample populations are needed before it can be recommended as a first-line treatment.
Prediction and Prevention of Upper Gastrointestinal Bleeding after Cardiac Surgery: A Case Control Study
Authors: Bhat Mamatha , Larocque Martin , Amorim Marcos , Herba Karl , Martel Myriam , De Varennes Benoît , Barkun Alan
Published: March 2016

BACKGROUND: Gastrointestinal (GI) complications of cardiovascular surgery, particularly bleeding, occur frequently.

OBJECTIVE: To determine factors that predict upper GI bleeding (UGIB) after cardiac surgery to improve prognostication and, thus, outcomes.

METHODS: The present case-control study reviewed institutional records spanning 2002 to 2005 for consecutive patients who developed in-hospital UGIB following cardiovascular surgery. Each case was matched to two to three controls for age, sex and date of hospital admission. Demographics, pharmacotherapy (including use of in-hospital acid suppression), endoscopic findings and outcomes were recorded. After adjustment for possible confounders, including Parsonnet score and demographic parameters, conditional logistic regression analysis identified independent significant predictors of the subsequent development of UGIB.

RESULTS: The study population consisted of 131 cases (mean [± SD] age 68.8±10.2 years, 69.5% male, mean Parsonnet score 24.6±14.2) and 387 matched controls (mean age 68.8±10.8 years, 70.0% male, mean Parsonnet score 20.9±14.2). UGIB events occurred a mean of 10.3±7.7 days after cardiac surgery. Duration of mechanical ventilation (OR 3.01 [95% CI 1.44 to 6.28]), elevation of international normalized ratio (OR 1.91 [95% CI 1.31 to 2.78]) and occurrence ofClostridium difficilecolitis before bleeding (OR 3.15 [95% CI 1.19 to 8.36]) were independent risk factors. Use of histamine type 2 receptor antagonists (H2RAs) (OR 0.65 [95% CI 0.38 to 1.12]) or proton pump inhibitors (PPIs) (OR 0.60 [95% CI 0.27 to 1.32]) demonstrated trends toward protecting against UGIB after cardiac surgery.

CONCLUSIONS: GI bleeding events occurred approximately 10 days after cardiac surgery in patients with a complicated postoperative course. Significant predictors of subsequent bleeding included increased duration of mechanical ventilation and elevation of international normalized ratio; routine acid suppression with PPIs should be considered in such patients.C difficilecolitis also significantly predicted UGIB, and H2RAs should be considered for acid suppression. Neither H2RAs nor PPIs were effective in preventing UGIB, although the small number of patients limits definitive conclusions regarding the role of acid suppression.
Wilson Disease: Canadian Perspectives on Presentation And Outcomes from an Adult Ambulatory Setting
Authors: Moores A , Fox SH , Lang AE , Hirschfield GM
Published: March 2016

BACKGROUND: Wilson disease (WD) is a rare disorder of copper metabolism.

OBJECTIVE: To describe the authors’ clinical experience with a cohort of 48 adult patients followed in an ambulatory setting.

METHODS: A retrospective chart review of patients with a diagnosis of WD was performed.

RESULTS: Fifty-nine charts were identified and 11 were excluded on further review. At diagnosis, 14 patients were asymptomatic, with 13 hepatic, 15 neurological and six mixed hepatic/neurological presentations. Ceruloplasmin levels were low (<0.20 g/L) in 94%, and 24 h urinary copper levels high (>0.60 μmol/L) in 95% of cases. D-penicillamine was the most common initial therapy (48%), with zinc the most common at review (65%). Overall, biopsy and ultrasound reports documented cirrhosis in 53%. Portal hypertension, defined as splenomegaly (>12.0 cm), reversed portal venous flow on ultrasound or varices/gastropathy on endoscopy was seen in 63%. At last review, 39% had elevated aspartate aminotransferase (>34 U/L) and/or alanine aminotransferase levels (>40 U/L). One death and one transplant occurred, while three patients had encephalopathy, two became jaundiced, two developed ascites and one experienced variceal bleed. Of 21 neurological presenting patients, 14 improved compared with baseline, with four making almost complete recovery. Eleven patients experienced documented episodes of neurological decline, including four with non-neurological presentation. Diagnostic magnetic resonance imaging showed basal ganglia (64%), brainstem (64%) abnormalities and atrophy (36%); follow-up showed basal ganglia lesions (50%) and atrophy (55%).

CONCLUSION: WD is a diverse chronic disease with generally favourable outcomes for patients who respond to initial therapy, which can be managed predominantly in an ambulatory setting.
Pain Sensitivity Mediates The Relationship between Stress and Headache Intensity in Chronic Tension‐Type Headache
Authors: Cathcart Stuart , Bhullar Navjot , Immink Maarten , Della Vedova Chris , Hayball John
Published: March 2016

BACKGROUND: A central model for chronic tension‐type headache (CTH) posits that stress contributes to headache, in part, by aggravating existing hyperalgesia in CTH sufferers. The prediction from this model that pain sensitivity mediates the relationship between stress and headache activity has not yet been examined.

OBJECTIVE: To determine whether pain sensitivity mediates the relationship between stress and prospective headache activity in CTH sufferers.

METHOD: Self‐reported stress, pain sensitivity and prospective headache activity were measured in 53 CTH sufferers recruited from the general population. Pain sensitivity was modelled as a mediator between stress and headache activity, and tested using a nonparametric bootstrap analysis.

RESULTS: Pain sensitivity significantly mediated the relationship between stress and headache intensity.

CONCLUSIONS: The results of the present study support the central model for CTH, which posits that stress contributes to headache, in part, by aggravating existing hyperalgesia in CTH sufferers. Implications for the mechanisms and treatment of CTH are discussed.
Venous Thromboembolism in Cirrhosis: A Review of the Literature
Authors: Buresi Michelle , Hull Russell , Coffin Carla S
Published: March 2016

Although hemorrhage has traditionally been regarded as the most significant hemostatic complication of liver disease, there is increasing recognition that hypercoagulability is a prominent aspect of cirrhosis. Identifying markers of coagulability and monitoring anticoagulation therapy in the setting of cirrhosis is problematic. The bleeding risk of venous thromboembolism (VTE) prophylaxis and treatment in patients with chronic liver disease is unclear and there are currently no recommendations to guide practice in this regard. In the present report, the mechanism of coagulation disturbance in chronic liver disease is reviewed with an examination of the evidence for an increased VTE risk in cirrhosis. Finally, the available evidence is assessed for prophylaxis and therapy of VTE in chronic liver disease, and the role it may play in decreasing clinical decompensation and improving survival.
A Canadian Working Group Report on Fecal Microbial Therapy: Microbial Ecosystems Therapeutics
Authors: Allen-Vercoe Emma , Reid Gregor , Viner Norman , Gloor Gregory B , Hota Susy , Kim Peter , Lee Christine , O’Doherty Kieran C , Vanner Stephen J , Weese J Scott , Petrof Elaine O
Published: March 2016

A working group from across Canada comprised of clinician and basic scientists, epidemiologists, ethicists, Health Canada regulatory authorities and representatives of major funding agencies (Canadian Institutes of Health Research and the Crohn’s and Colitis Foundation of Canada) met to review the current experience with fecal microbial therapy and to identify the key areas of study required to move this field forward. The report highlights the promise of fecal microbial therapy and related synthetic stool therapy (together called ‘microbial ecosystems therapeutics’) for the treatment ofClostridium difficilecolitis and, possibly, other disorders. It identifies pressing clinical issues that need to be addressed as well as social, ethical and regulatory barriers to the use of these important therapies.
Active and Uncontrolled Asthma Among Children Exposed to Air Stack Emissions of Sulphur Dioxide from Petroleum Refineries in Montreal, Quebec: A Cross-Sectional Study
Authors: Deger Leylâ , Plante Céline , Jacques Louis , Goudreau Sophie , Perron Stéphane , Hicks John , Kosatsky Tom , Smargiassi Audrey
Published: March 2016

BACKGROUND: Little attention has been devoted to the effects on children’s respiratory health of exposure to sulphur dioxide (SO2) in ambient air from local industrial emissions. Most studies on the effects of SO2have assessed its impact as part of the regional ambient air pollutant mix.

OBJECTIVE: To examine the association between exposure to stack emissions of SO2from petroleum refineries located in Montreal’s (Quebec) east-end industrial complex and the prevalence of active asthma and poor asthma control among children living nearby.

METHODS: The present cross-sectional study used data from a respiratory health survey of Montreal children six months to 12 years of age conducted in 2006. Of 7964 eligible households that completed the survey, 842 children between six months and 12 years of age lived in an area impacted by refinery emissions. Ambient SO2exposure levels were estimated using dispersion modelling. Log-binomial regression models were used to estimate crude and adjusted prevalence ratios (PRs) and 95% CIs for the association between yearly school and residential SO2exposure estimates and asthma outcomes. Adjustments were made for child’s age, sex, parental history of atopy and tobacco smoke exposure at home.

RESULTS: The adjusted PR for the association between active asthma and SO2levels was 1.14 (95% CI 0.94 to 1.39) per interquartile range increase in modelled annual SO2. The effect on poor asthma control was greater (PR=1.39 per interquartile range increase in modelled SO2[95% CI 1.00 to 1.94]).

CONCLUSIONS: Results of the present study suggest a relationship between exposure to refinery stack emissions of SO2and the prevalence of active and poor asthma control in children who live and attend school in proximity to refineries.
It’s a Man’s World: Does Orthotopic Liver Transplantation in the Elderly Male Confer an Additional Risk on Survival?
Authors: Slattery Eoin , Hegarty John E , McCormick P Aiden
Published: March 2016

BACKGROUND: Orthotopic liver transplantation (OLT) in a well-selected population is a highly successful procedure, with one-year survival rates reported to be as high as 90%. Advanced age is considered to be a contraindication. Survival rates in patients >60 years of age appear to be comparable with those of younger patients. However, little objective data exist on the outcomes of patients >65 years of age undergoing OLT.

OBJECTIVE: To review the outcomes of OLT in the Irish National Transplant Unit in patients >65 years of age and to compare outcomes with patients ≤65 years of age. Second, to identify any factors that may provide valuable prognostic information regarding outcomes.

METHOD: Patients >65 years of age who underwent OLT since the inception of the National Liver Unit in 1993 were identified from a prospectively maintained database. Medical records were reviewed. Survival was compared with the overall cohort using the Kaplan-Meier technique. Independent variables between the two groups were assessed using logistic regression analysis.

RESULTS: Between January 1993 and December 2009, 551 patients underwent 639 transplants in the Irish National Liver Transplant Unit. Forty-three transplants were performed in 40 patients >65 years of age. Unadjusted one- and three-year survival rates for the elderly cohort were 77.8% and 64.5%, respectively. This compared with 93% and 85%, respectively, in the unselected cohort. Using Kaplan-Meier analysis, a significant benefit in survival was observed in patients ≤65 years of age (P=0.017). Similarly, when adjusted for sex, a significant difference was noted between the groups. Male patients >65 years of age had poorer survival compared with their female counterparts >65 years of age and all patients ≤65 years of age (P=0.02). There was no significant difference between the groups with respect to preoperative variables such as bilirubin, creatinine and sodium levels, and Model for End-stage Liver Disease score. A significant difference was seen in male patients >65 years of age with more than one comorbidity, compared with female patients and male patients ≤65 years of age.

CONCLUSION: Male sex was associated with poorer survival in patients >65 years of age undergoing OLT. Multiple comorbidities in elderly male patients should be considered a relative contraindication in patients being assessed for OLT.
Validity of Chronic Obstructive Pulmonary Disease Diagnoses in a Large Administrative Database
Authors: Lacasse Yves , Daigle Jean-Marc , Martin Sylvie , Maltais François
Published: March 2016

BACKGROUND: Administrative databases are often used for research purposes, with minimal attention devoted to the validity of the included diagnoses.

AIMS: To determine whether the principal diagnoses of chronic obstructive pulmonary disease (COPD) made in hospitalized patients and recorded in a large administrative database are valid.

METHODS: The medical charts of 1221 patients hospitalized in 40 acute care centres in Quebec and discharged between April 1, 2003 and March 31, 2004, with a principal discharge diagnosis of COPD (International Classification of Diseases, Ninth Revisioncodes 491, 492 or 496) were reviewed. The diagnosis of COPD was independently adjudicated by two pulmonologists using clinical history (including smoking status) and spirometry. The primary outcome measure was the positive predictive value (PPV) of the database for the diagnosis of COPD (ie, the proportion of patients with an accurate diagnosis of COPD corroborated by clinical history and spirometry).

RESULTS: The diagnosis of COPD was validated in 616 patients (PPV 50.4% [95% CI 47.7% to 53.3%]), with 372 patients (30.5%) classified as ‘indeterminate’. Older age and female sex were associated with a lower probability of an accurate diagnosis of COPD. Hospitalization in a teaching institution was associated with a twofold increase in the probability of a correct diagnosis.

CONCLUSIONS: The results support the routine ascertainment of the validity of diagnoses before using administrative databases in clinical and health services research.
Successful Use of Posaconazole to Treat Invasive Cutaneous Fungal Infection in a Liver Transplant Patient on Sirolimus
Authors: Dahlan Randah , Patel Ameen , Haider Shariq
Published: March 2016

Fungi are an important and common cause of cutaneous infections affecting solid organ transplant recipients. These infections can represent a primary site of infection with the potential for dissemination, or a manifestation of metastatic infection. The high morbidity and mortality associated with these infections necessitates urgent therapy with antifungal drugs; however, the interaction between these drugs and immunosuppressive therapies can be a major limitation because of drug toxicity. A case of soft tissue infection of the toe caused by Fusarium chlamydosporum and Candida guilliermondii in a liver transplant patient on sirolimus, who was successfully treated with the new antifungal agent posaconazole, is described. The pharmacokinetic interactions of sirolimus and the new triazoles, and their impact on treatment choices are briefly discussed.
Etiology of Small Bowel Thickening on Computed Tomography
Authors: Finkelstone Lee , Wolf Ellen , Stein Marjorie W
Published: March 2016

BACKGROUND: Abdominal pain is often evaluated using imaging, most often with computed tomography (CT). While CT is sensitive and specific for certain diagnoses, small bowel thickening is a nonspecific finding on CT with a broad differential diagnosis including infection, inflammation, ischemia and neoplasm.

METHOD: A review of medical records of patients who underwent CT scans of the abdomen and pelvis over a one-year period and exhibited small bowel thickening were retrospectively evaluated to determine the final diagnosis.

RESULTS: The etiologies of small bowel thickening on CT were as follows: infection (113 of 446 [25.34%]); reactive inflammation (69 of 446 [15.47%]); primary inflammation (62 of 446 [13.90%]); small bowel obstruction (38 of 446 [8.52%]); iatrogenic (33 of 446 [7.40%]); neoplastic (32 of 446 [7.17%]); ascites (30 of 446 [6.73%]); unknown (28 of 446 [6.28%]); ischemic (24 of 446 [5.38%]); and miscellaneous (17 of 446 [3.81%]).

CONCLUSION: Infectious and inflammatory (primary or reactive) conditions were the most common cause of small bowel thickening in the present series; these data can be used to formulate a more specific differential diagnosis.
Enterocolic Fistula: A Rare Presentation of Cytomegalovirus Infection
Authors: Gill Richdeep S , Taylor Geoffrey , Penner Robert M , Logsetty Sarvesh
Published: March 2016

In the present report, the first reported case of cytomegalovirus (CMV)‐associated enterocolic fistula in an HIV/AIDS patient is described. CMV colitis is the second most common presentation of CMV infection in immunocompromised patients. CMV‐associated enteric fistulae are an exceedingly rare complication, with only four previous cases described: a gastrocolic, an enterocutaneous, a rectovaginal and a colocutaneous fistula. Management of these patient demonstrates the importance of treating the precipitating viral infection before considering surgical intervention of the enterocolic fistula.