bluuebunny/crossref_metadata_2025 huggingface dataset:
Gabapentin Decreases Morphine Consumption and Improves Functional Recovery following Total Knee Arthroplasty
Authors: Clarke Hance , Pereira Sara , Kennedy Deborah , Gilron Ian , Katz Joel , Gollish Jeffrey , Kay Joseph
Published: March 2016

BACKGROUND: Moderate to severe pain after total knee arthroplasty often interferes with postoperative rehabilitation and delays discharge from hospital. The present study examined the effects of a four‐day postoperative gabapentin (GBP) regimen versus placebo on opioid consumption, pain scores and knee flexion, as well as adverse effects, after total knee arthroplasty.

METHODS: After obtaining research ethics board approval and informed consent, 40 patients were enrolled in a randomized, single‐blind, placebo‐controlled, open‐label study. Patients were assigned to one of five groups – preoperative placebo/postoperative placebo (G1), preoperative GBP 600 mg/postoperative placebo (G2), preoperative GBP 600 mg/postoperative GBP 100 mg three times per day (G3), preoperative GBP 600 mg/postoperative GBP 200 mg three times per day (G4) and preoperative GBP 600 mg/postoperative GBP 300 mg three times per day (G5). Postoperative GBP or placebo was continued for four days after surgery. Two hours before surgery, all patients received celecoxib 400 mg. Based on the above groupings, patients in G1 received placebo medication, whereas patients in G2, G3, G4 and G5 received gabapentin 600 mg 2 h preoperatively. All patients received femoral and sciatic nerve blocks, followed by spinal anesthesia. Beginning in the postanesthetic care unit, all patients received a regimen of celecoxib 200 mg every 12 h for four days and a patient‐controlled morphine analgesia pump for 48 h.

RESULTS: Thirty‐six patients (G1, n=7; G2, n=7; G3, n=8; G4, n=7; G5, n=7) completed the study. Data were analyzed by one‐way ANOVA followed by a contrast comparing patients who received postoperative GBP (G3, G4 and G5) (n=22) with patients who received placebo postoperatively (G1 and G2) (n=14). Patients who received GBP postoperatively used significantly less patient‐controlled morphine analgesia at 24 h, 36 h and 48 h (P<0.05). The postoperative GBP patients had significantly better active assisted knee flexion on postoperative days 2 and 3, with a trend toward better flexion on postoperative day 4. Patients who received GBP postoperatively reported less pruritus than patients who received placebo. There were no differences in pain scores.

CONCLUSIONS: These results support the use of GBP in the acute postoperative period. Further trials are needed to delineate the optimal dose, timing and duration of GBP use following surgery.
An Atypical Presentation of Liver Enzyme Elevation Resulting from Bosentan Use
Authors: Mulchey Kimberley , Bshouty Zoheir
Published: March 2016

Hepatocellular enzyme elevation is a known side effect of both bosentan and atorvastatin. However, a rise in liver enzyme level not characteristic of either agent individually may represent a reaction to their combination or an atypical reaction to bosentan alone.

The present case report describes a patient who had been taking atorvastatin for many years and was started on bosentan for chronic thromboembolic pulmonary hypertension. After 19 weeks of therapy, she developed severe liver enzyme elevation that necessitated the discontinuation of both bosentan and atorvastatin. Although the safety of reintroducing bosentan in such a case is unknown, it was reintroduced in this patient because of the severity of her disease, the demonstrated treatment benefit and the lack of alternative treatment options. On reintroduction of bosentan alone, she again demonstrated significant liver enzyme elevation – this time occurring after only two doses. The present case highlights that bosentan can cause more rapid and severe hepatocellular enzyme elevation than previously believed, thus necessitating more frequent monitoring.
Left out but not Forgotten: Should Closer Attention be Paid to Coinfection with Herpes Simplex Virus Type 1 and HIV?
Authors: Tan Darrell H S , Kaul Rupert , Walsmley Sharon
Published: March 2016

Herpes simplex virus type 1 (HSV‐1) and type 2 (HSV‐2) are among the most common coinfections seen in individuals infected with HIV‐1. Most research on HSV‐HIV coinfection has focused on HSV‐2, and in particular, on its impact on HIV transmission. HSV‐2 is associated with micro‐ and macroulcerations in genital mucosal surfaces, increased numbers of HIV target cells in genital mucosal tissue and increases in plasma HIV viral load of up to 0.5 log10 copies/mL, such that HSV‐2 infection increases the risk of both HIV acquisition and transmission. Because plasma HIV RNA levels are a major determinant of rates of CD4 cell decline, HSV‐2 coinfection may also adversely affect the progression of HIV disease. Anti‐HSV medications have in fact been associated with reciprocal decreases in HIV viral load in short‐term studies. These findings have led to the development of several clinical trials of HSV‐2 suppression as strategies for preventing HIV transmission and slowing the rate of HIV disease progression. HSV‐1 coinfection has largely been ignored from this growing body of research, yet there are several reasons that this coinfection remains an important issue for study. First, the seroprevalence of HSV‐1 is consistently higher than that of HSV‐2 among both HIV‐infected and HIV‐uninfected populations, underscoring the relevance of HSV‐1 coinfection to the majority of HIV‐infected persons. Second, pre‐existing HSV‐1 antibodies in individuals may modulate the course of subsequently acquired HSV‐2 infection; the implications of such changes on HSV‐HIV coinfection remain unexplored. Third, HSV‐1 and HSV‐2 are closely related viruses that share 83% genetic homology. Their virological and pathobiological similarities suggest that their implications on HIV pathogenesis may be similar as well. Finally, HSV‐1 is becoming increasingly relevant because the incidence of genital HSV‐1 has risen. Although genital herpes is traditionally associated with HSV‐2, recent studies have shown that the majority of serologically confirmed primary genital herpes in some settings is attributable to HSV‐1. Because the genital tract is an important site of biological interaction between HSV and HIV, this epidemiological change may be clinically important.
Emergence of and Risk Factors for Ciprofloxacin‐Gentamicin‐Resistant Escherichia coli Urinary Tract Infections in a Region of Quebec
Authors: Pépin Jacques , Plamondon Mireille , Lacroix Caroline , Alarie Isabelle
Published: March 2016

BACKGROUND: An increased incidence of urinary tract infections (UTIs) caused by ciprofloxacin‐gentamicin‐resistant Escherichia coli (CiGREC) has been observed in a tertiary care centre in Sherbrooke, Quebec. The risk factors for such infections remained unclear.

METHODS: To determine risk factors for, and outcomes of, CiGREC UTIs, a case control study was conducted. Between 2000 and 2007, 93 cases and 186 controls were identified using laboratory records of patients with greater than 107 colony‐forming units/L of E coli in a urinary specimen. Cases had E coli with minimum inhibitory concentration to ciprofloxacin of 4 mg/L or greater and minimum inhibitory concentration to gentamicin of 8 mg/L or greater (CiGREC), and controls had E coli with any other susceptibility pattern to ciprofloxacin and gentamicin. Clinical and laboratory data were collected. Adjusted odds ratios (AOR) and their 95% CIs were calculated by logistic regression.

RESULTS: The prevalence of CiGREC increased sixfold during the study period. Risk factors associated with CiGREC UTI were advanced age, male sex, urological abnormality, domicile outside Sherbrooke, living in a nursing home (AOR 11.73; 95% CI 3.70 to 37.15), use of fluoroquinolones (AOR 15.24; 95% CI 5.42 to 42.83) or aminoglycosides (AOR 6.59; 95% CI 1.22 to 35.61) within the previous month, and use of fluoroquinolones during the preceding one to 12 months (AOR 2.45; 95% CI 1.06 to 5.62). Compared with controls, cases were more likely not to receive an active antibiotic as empirical or definitive treatment, and were more likely to relapse.

INTERPRETATION: In the future, it may become necessary to avoid selecting as empirical therapy of urinary tract infection an antibiotic to which the patient has been recently exposed.
Ileocolic Perforation Secondary to Sodium Polystyrene Sulfonate in Sorbitol Use: A Case Report
Authors: Trottier Vincent , Drolet Sébastien , Morcos Mohib W
Published: March 2016

Hyperkalemia is a common condition encountered in medical and surgical patients. It can lead to various complications including cardiac arrhythmias. Sodium polystyrene sulfonate (SPS) in sorbitol is an ion-exchange resin that can be used to treat hyperkalemia. It can be used in enema or in oral form. The present article describes the case of an intensive care unit patient who experienced severe, diffuse, intestinal perforation induced by the use of SPS-sorbitol, requiring multiple laparotomies, followed by a brief review of the relevant literature and recommendations regarding the use of SPS-sorbitol.
Tuberculosis in Children: New diagnostic Blood Tests
Authors: Kakkar F , Allen UD , Ling D , Pai M , Kitai IC
Published: March 2016

The interferon‐gamma‐release assays were developed to overcome the pitfalls and logistic difficulties of the tuberculin skin test (TST) for the diagnosis of latent tuberculosis infection (LTBI). These blood tests measure the in vitro production of interferon‐gamma by sensitized lymphocytes in response to Mycobacterium tuberculosis‐specific antigens. Two interferon‐gamma‐release assays are registered for use in Canada: the QuantiFERON‐TB Gold In‐Tube assay (Cellestis Inc, Australia) and the T.SPOT–TB test (Oxford Immunotec, United Kingdom). Evaluation of these tests has been hampered by the lack of a gold standard for LTBI, and limited paediatric data on their use. It appears that they are more specific than the TST, and may be useful for evaluating TST‐positive patients at low risk of true LTBI. Moreover, they may add sensitivity if used in addition to the TST in immunocompromised patients, very young children and close contacts of infectious adults. A summary of these tests, their limitations and their application to clinical paediatric practice are described.
Long-Term Management of Patients with Celiac Disease: Current Practices of Gastroenterologists in Canada
Authors: Silvester Jocelyn Anne , Rashid Mohsin
Published: March 2016

BACKGROUND: Long-term follow-up of patients with celiac disease is important for monitoring their clinical status, dietary compliance and complications.

AIM: To examine the current practices of Canadian gastroenterologists providing long-term care to patients with celiac disease.

METHODS: All gastroenterologists in Canada (n=585) were surveyed regarding their practice demographics, familiarity with celiac disease practice guidelines, and follow-up clinical examination and investigations.

RESULTS: Of the 585 surveys mailed to gastroenterologists, 567 were expected to be returned. A total of 242 completed surveys (43%) were received. Of these, 237 (184 adult, 51 pediatric and two mixed) had an active practice that included patients with celiac disease. Long-term follow-up care was provided routinely by 76% of respondents. Follow-up consisted of annual clinic visits (67%), dietary review (77%), reinforcement of the need for adherence to a gluten-free diet (90%) and recommending membership in an advocacy group (65%). Physical examination was performed by 78%; most ordered laboratory tests including serology (65%).

Adult gastroenterologists performed routine follow-up intestinal biopsy more often than their pediatric counterparts (46% versus 10%), but performed serology less frequently (48% versus 86%). Pediatric patients were more likely to be followed by a multidisciplinary team. All pediatric gastroenterologists were familiar with at least one celiac disease practice guideline, whereas 15% of adult gastroenterologists were not familiar with any practice guideline. The majority of gastroenterologists who did not routinely provide follow-up expected care to be provided by the patient’s primary physician (86%).

CONCLUSIONS: Most gastroenterologists in Canada who responded to the survey provided long-term follow-up care to patients with celiac disease. The diverse practices reported underscore the need to develop consensus-based guidelines for long-term care of these patients.
Transient Elastography for the Noninvasive Assessment of Liver Fibrosis: A Multicentre Canadian Study
Authors: Myers Robert P , Elkashab Magdy , Ma Mang , Crotty Pam , Pomier-Layrargues Gilles
Published: March 2016

BACKGROUND: Liver stiffness measurement (LSM) using transient elastography (TE) is a promising tool for the noninvasive assessment of hepatic fibrosis.

OBJECTIVES: To determine the feasibility and performance of TE in a North American cohort of patients with chronic liver disease.

METHODS: LSMs were obtained using TE in 260 patients with chronic hepatitis B or C, or nonalcoholic fatty liver disease from four Canadian hepatology centres. The accuracy of TE compared with liver biopsy for the prediction of significant fibrosis (Metavir fibrosis score of F2 or greater), bridging fibrosis (Metavir fibrosis score of F3 or greater) and cirrhosis (Metavir fibrosis score of F4 ) was assessed using area under ROC curves (AUROCs), and compared with the aspartate aminotransferase‐to‐platelet ratio index. The influence of alanine aminotransferase (ALT) levels and other factors on liver stiffness was determined using linear regression analyses.

RESULTS: Failure of TE occurred in 2.7% of patients, while liver biopsies were inadequate for staging in 0.8%. Among the remaining 251 patients, the AUROCs of TE for Metavir fibrosis scores of F2 and F3 or greater, and F4 were 0.74 (95% CI 0.68 to 0.80), 0.89 (95% CI 0.84 to 0.94), and 0.94 (95% CI 0.90 to 0.97), respectively. LSM was more accurate than the aminotransferase‐to‐platelet ratio index for bridging fibrosis (AUROC 0.78) and cirrhosis (AUROC 0.88), but not significant fibrosis (AUROC 0.76). At a cut‐off of 11.1 kPa, the sensitivity, specificity, and positive and negative predictive values for cirrhosis (prevalence 11%) were 96%, 81%, 39% and 99%, respectively. For significant fibrosis (prevalence 53%), a cut‐off of 7.7 kPa was 68% sensitive and 69% specific, and had a positive predictive value of 70% and a negative predictive value of 65%. Liver stiffness was independently associated with ALT, body mass index and steatosis. The optimal LSM cut‐offs for cirrhosis were 11.1 kPa and 11.5 kPa in patients with ALT levels lower than 100 U/L and 100 U/L or greater, respectively. For fibrosis scores of F2 or greater, these figures were 7.0 kPa and 8.6 kPa, respectively.

CONCLUSIONS: The major role of TE is the exclusion of bridging fibrosis and cirrhosis. However, TE cannot replace biopsy for the diagnosis of significant fibrosis. Because liver stiffness may be influenced by significant ALT elevation, body mass index and/or steatosis, tailored liver stiffness cut‐offs may be necessary to account for these factors.
A Randomized Trial of Topical Anesthesia Comparing Lidocaine Versus Lidocaine Plus Xylometazoline for Unsedated Transnasal Upper Gastrointestinal Endoscopy
Authors: Cheung Justin , Goodman Karen J , Bailey Robert , Fedorak Richard N , Morse John , Millan Mario , Guzowski Tom , van Zanten Sander Veldhuyzen
Published: March 2016

BACKGROUND: The optimal topical anesthesia regimen for unsedated transnasal endoscopy is unknown. The addition of a nasal decongestant, such as xylometazoline (X), to a topical anesthestic may improve patient comfort.

OBJECTIVE: To determine the effectiveness of lidocaine (L) versus L plus X (LX) for anesthesia in unsedated transnasal endoscopy.

METHODS: Consecutive participants of the Aklavik Helicobacter pylori project were prospectively randomly assigned to receive LX or L for unsedated transnasal 4.9 mm ultrathin endoscopy. The primary outcome was overall procedure discomfort on a validated 10‐point visual analogue scale (1 = no discomfort, 10 = severe discomfort). Secondary outcomes included pain, endoscope insertion difficulty, gagging, adverse events and encounter times. Results were presented as mean ± SD, difference in mean, 95% CI.

RESULTS: A total of 181 patients were randomly assigned to receive LX (n=94) and L (n=87). Baseline characteristics between the two groups were similar (mean age 40 years, 59% women). Overall, patient procedural discomfort with LX and L were 4.2±2.4 versus 3.9±2.1, respectively (0.29; 95% CI −0.39 to 0.96). Transnasal insertion difficulty was significantly lower with LX than with L (2.4±2.1 versus 3.2±2.8, respectively [−0.80; 95% CI −1.54 to −0.06]). Compared with L, the use of LX was associated with significantly less time needed to apply anesthesia (2.4±1.8 min versus 3.5±2.2 min, respectively [−1.10; 95% CI −1.71 min to −0.50 min]) and less time for insertion (3.2±1.8 min versus 3.9±2.2 min, respectively [−0.70 min; 95% CI −1.30 min to −0.10 min]). Epistaxis was rare but occurred less frequently with LX (1.1%) than with L (4.6%) (P=0.19).

CONCLUSIONS: LX did not improve patient comfort for transnasal endoscopy compared with L alone. However, LX was associated with less difficulty with endoscope transnasal insertion and reduced insertion time. Further studies on the optimal regimen and dosing of anesthesia are required.
Look Out before Polypectomy in Patients with Diverticular Disease – A Case of a Large, Inverted Diverticulum of the Colon Resembling a Pedunculated Polyp
Authors: Paoluzi Omero Alessandro , Tosti Claudio , Andrei Fabio , Stroppa Italo , Pallone Francesco
Published: March 2016

Diverticular disease of the colon may be responsible for abdominal symptoms requiring colonoscopy, which may reveal the presence of concomitant polyps. A polyp found during colonoscopy in patients with colonic diverticular disease may be removed by endoscopic polypectomy with electrosurgical snare, a procedure associated with an incidence of perforation of less than 0.05%. The risk of such a complication may be higher in the event of an inverted colonic diverticulum, which may be misinterpreted as a polypoid lesion at colonoscopy. To date, fewer than 20 cases of inverted colonic diverticula, diagnosed at colonoscopy or following air contrast barium enema, have been reported in the literature. The present report describes a 68-year-old woman who underwent a screening colonoscopy, which revealed a voluminous pedunculated polyp that was recognized to be an inverted giant colonic diverticulum before endoscopic polypectomy.
Rare Lung Diseases III: Pulmonary Langerhans’ Cell Histiocytosis
Authors: Juvet Stephen C , Hwang David , Downey Gregory P
Published: March 2016

Pulmonary Langerhans’ cell histiocytosis (PLCH) is an unusual cystic lung disease that is also characterized by extrapulmonary manifestations. The current review discusses the presenting features and relevant diagnostic testing and treatment options for PLCH in the context of a clinical case. While the focus of the present article is adult PLCH and its pulmonary manifestations, it is important for clinicians to distinguish the adult and pediatric forms of the disease, as well as to be alert for possible extrapulmonary complications. A major theme of the current series of articles on rare lung diseases has been the translation of insights gained from fundamental research to the clinic. Accordingly, the understanding of dendritic cell biology in this disease has led to important advances in the care of patients with PLCH.
Buprenorphine Transdermal System for Opioid Therapy in Patients with Chronic Low Back Pain
Authors: Gordon Allan , Rashiq Saifudin , Moulin Dwight E , Clark Alexander J , Beaulieu André D , Eisenhoffer John , Piraino Paula S , Quigley Patricia , Harsanyi Zoltan , Darke Andrew C
Published: March 2016

OBJECTIVE: The present randomized, double‐blinded, crossover study compared the efficacy and safety of a seven‐day buprenorphine transdermal system (BTDS) and placebo in patients with low back pain of moderate or greater severity for at least six weeks.

METHODS: Prestudy analgesics were discontinued the evening before random assignment to 5 μg/h BTDS or placebo, with acetaminophen 300 mg/codeine 30 mg, one to two tablets every 4 h to 6 h as needed, for rescue analgesia. The dose was titrated to effect weekly, if tolerated, to 10 μg/h and 20 μg/h BTDS. Each treatment phase was four weeks.

RESULTS: Fifty‐three patients (28 men, 25 women, mean [± SD] age 54.5±12.7 years) were evaluable for efficacy (completed two weeks or more in each phase). Baseline pain was 62.1±15.5 mm (100 mm visual analogue scale) and 2.5±0.6 (five‐point ordinal scale). BTDS resulted in lower mean daily pain scores than in the placebo group (37.6±20.7 mm versus 43.6±21.2 mm on a visual analogue scale, P=0.0487; and 1.7±0.6 versus 2.0±0.7 on the ordinal scale, P=0.0358). Most patients titrated to the highest dose of BTDS (59% 20 μg/h, 31% 10 μg/h and 10% 5 μg/h). There were improvements from baseline in pain and disability (Pain Disability Index), Pain and Sleep (visual analogue scale), Quebec Back Pain Disability Scale and Short‐Form 36 Health Survey scores for both BTDS and placebo groups, without significant differences between treatments. While there were more opioid‐related side effects with BTDS treatment than with placebo, there were no serious adverse events. A total of 82% of patients chose to continue BTDS in a long‐term open‐label evaluation, in whom improvements in pain intensity, functionality and quality of life were sustained for up to six months without analgesic tolerance.

CONCLUSION: BTDS (5 μg/h to 20 μg/h) represents a new treatment option for initial opioid therapy in patients with chronic low back pain.
Alcohol Fixation of Induced Sputum Samples for Applications in Rural Communities
Authors: Dorman Sandra C , Bussoli Melanie A , Ritz Stacey A
Published: March 2016

BACKGROUND: Sputum induction is a tool recommended for the assessment of airway inflammation and disease management. Currently, its use is limited because samples need to be processed within 3 h of induction (ie, while cells are viable); therefore, this procedure is unavailable to most clinicians.

OBJECTIVE: To develop a fixation method for induced sputum samples that allows for a delay in processing while maintaining sample integrity and not altering the standard processing method.

METHODS: Sputum samples were collected and split into three portions: a fresh sample processed using the routine method (within 3 h, using dithiothreitol); fixation in alcohol followed by delayed processing using the routine method (within 48 h to 72 h, using dithiothreitol); and fixation in formaldehyde followed by delayed processing using an alternative method (within 48 h to 72 h, using proteolysis). For each method, cytospins were prepared and differential cell counts were performed.

RESULTS: Fixation in alcohol provides accurate measures of eosinophils and macrophages, but not neutrophils. Formaldehyde fixation provides accurate measures of neutrophils and macrophages, but not eosinophils.

DISCUSSION: Alcohol fixation is a superior method for eosinophil quantification. It requires alteration of standardized methods for sputum sample processing and should be recommended for monitoring eosinophilic airway disease in settings where immediate processing of a sputum sample is not possible.
Positive Celiac Disease Serology and Reduced Bone Mineral Density in Adult Women
Authors: Duerksen Donald R , Leslie William D
Published: March 2016

BACKGROUND: Low bone density and osteoporosis have been demonstrated in celiac disease populations in Europe, South America and the United States. Serological testing with tissue transglutaminase (TTG) and immunoglobulin A endomysial (EMA) antibodies is highly specific for celiac disease, while antigliadin antibody (AGA) testing is less specific.

OBJECTIVE: To evaluate the association of celiac serology with reduced bone density in adult women.

METHODS: A clinical database containing all bone density testing data in the province of Manitoba was linked to a database containing all celiac serology data for the province. The study cohort consisted of 376 women older than 20 years of age with bone density measurements preceding initial celiac serology by six months or less. Bone density was assessed in relation to TTG/EMA and AGA seropositivity, and compared with seronegative controls in age‐, height‐ and weight‐adjusted models.

RESULTS: There was significantly lower bone density in TTG/EMA seropositive women than with seronegative controls for all sites tested (lumbar spine, total hip, trochanter, femoral neck; all P<0.05). TTG/EMA seropositive women also had a significantly higher prevalence of osteoporosis (67.7% versus 44.8%; P<0.05). There was lower bone density at the three hip sites (all P<0.05) in AGA seropositive women, but after excluding TTG/EMA seropositive women, isolated AGA seropositivity showed no significant association with any bone density measurements.

CONCLUSION: TTG/EMA seropositivity was associated with lower bone density and a higher prevalence of osteoporosis compared with seronegative controls.
Effect of Hysterectomy on Colonoscopy Completion Rate
Authors: Lacasse Mélanie , Dufresne Geneviève , Jolicoeur Emilie , Rochon Luc , Sabbagh Charles , Deneault Jocelyn , Walsh Valérie , Gaboury Isabelle , Hassard Philip
Published: March 2016

BACKGROUND: Several studies show that colonoscopies are technically more difficult to perform in women than men, especially in women who have undergone abdominal and gynecological surgeries. A review of the literature indicates an increased rate of noncompletion of colonoscopies in most cases; however, no studies have investigated the procedural complication rate, sedation requirements and perception of pain in colonoscopies.

OBJECTIVE: To determine whether women who have undergone a previous hysterectomy have a higher noncompletion rate when undergoing a colonoscopy, and to assess whether there is a higher percentage of complications. Furthermore, the present study also aimed to ascertain whether these women required more sedation and whether their perception of pain is greater than that of women who did not undergo previous abdominal surgeries.

METHODS: The present study was a prospective cohort study of women, 45 to 80 years of age, who underwent colonoscopy (n=508). A total of 229 patients were eligible for the study; they completed a questionnaire, and were subsequently divided into control and hysterectomy groups. Gastroenterologists performed all procedures. After colonoscopy, the patient and endoscopist completed a pain perception questionnaire. Cecal intubation rates were also recorded.

RESULTS: No significant difference for cecal intubation rates were detected between the two groups (95.7% and 98.7% in hysterectomy and control groups, respectively; P=0.176). The crude OR for the success rate was 0.29 (95% CI 0.05 to 1.90). There was no significant difference between groups regarding sedation or the type of colonoscope. No correlation between the gastroenterologists’ evaluation of pain and patients’ pain was observed.

CONCLUSION: Hysterectomy did not significantly diminish the cecal intubation rate, and there was no detectable difference in pain perception or sedative dose. Colonoscopy remains an excellent screening and diagnostic tool for all women.
Thresholds and Tolerance of Physical Pain Among Young Adults Who Self‐Injure
Authors: McCoy Katrina , Fremouw William , McNeil Daniel W
Published: March 2016

Prevalence rates of nonsuicidal self‐injury among college students range from 17% to 38%. Research indicates that individuals with borderline personality disorder who self‐injure sometimes report an absence of pain during self‐injury. Furthermore, self‐injury in the absence of pain has been associated with more frequent suicide attempts. The present study examined pain thresholds and tolerance among 44 college students (11 who engaged in self‐injury and 33 who did not). Pain thresholds and tolerance were measured using an algometer pressure device that was used to produce pain in previous laboratory research. Participants who engaged in self‐injury had a higher pain tolerance than those who did not. In addition, participants who engaged in self‐injury rated the pain as less intense than participants who did not. ANCOVAs revealed that depression was associated with pain rating and pain tolerance.
A Children’s Asthma Education Program: Roaring Adventures of Puff (RAP), Improves Quality of Life
Authors: McGhan Shawna L , Wong Eric , Sharpe Heather M , Hessel Patrick A , Mandhane Puish , Boechler Vicki L , Majaesic Carina , Befus A Dean
Published: March 2016

BACKGROUND: It is postulated that children with asthma who receive an interactive, comprehensive education program would improve their quality of life, asthma management and asthma control compared with children receiving usual care.

OBJECTIVE: To assess the feasibility and impact of ‘Roaring Adventures of Puff’ (RAP), a six‐week childhood asthma education program administered by health professionals in schools.

METHODS: Thirty‐four schools from three health regions in Alberta were randomly assigned to receive either the RAP asthma program (intervention group) or usual care (control group). Baseline measurements from parent and child were taken before the intervention, and at six and 12 months.

RESULTS: The intervention group had more smoke exposure at baseline. Participants lost to follow‐up had more asthma symptoms. Improvements were significantly greater in the RAP intervention group from baseline to six months than in the control group in terms of parent’s perceived understanding and ability to cope with and control asthma, and overall quality of life (P<0.05). On follow‐up, doctor visits were reduced in the control group.

CONCLUSION: A multilevel, comprehensive, school‐based asthma program is feasible, and modestly improved asthma management and quality of life outcomes. An interactive group education program offered to children with asthma at their school has merit as a practical, cost‐effective, peer‐supportive approach to improve health outcomes.
Canadian Clinical Practice Guidelines for Invasive Candidiasis in Adults
Authors: Bow Eric J , Evans Gerald , Fuller Jeff , Laverdière Michel , Rotstein Coleman , Rennie Robert , Shafran Stephen D , Sheppard Don , Carle Sylvie , Phillips Peter , Vinh Donald C
Published: March 2016

Candidemia and invasive candidiasis (C/IC) are life‐threatening opportunistic infections that add excess morbidity, mortality and cost to the management of patients with a range of potentially curable underlying conditions. The Association of Medical Microbiology and Infectious Disease Canada developed evidence‐based guidelines for the approach to the diagnosis and management of these infections in the ever‐increasing population of at‐risk adult patients in the health care system. Over the past few years, a new and broader understanding of the epidemiology and pathogenesis of C/IC has emerged and has been coupled with the availability of new antifungal agents and defined strategies for targeting groups at risk including, but not limited to, acute leukemia patients, hematopoietic stem cell transplants and solid organ transplants, and critical care unit patients. Accordingly, these guidelines have focused on patients at risk for C/IC, and on approaches of prevention, early therapy for suspected but unproven infection, and targeted therapy for probable and proven infection.
The Rate of Prescribing Gastrointestinal Prophylaxis with Either a Proton Pump Inhibitor Or an H2-Receptor Antagonist in Nova Scotia Seniors Starting Nonsteroidal Anti-Inflammatory Drug Therapy
Authors: Superceanu Bogdan , van Zanten Sander Veldhuyzen , Skedgel Chris , Shepherd Michael , Sketris Ingrid
Published: March 2016

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used agents that can cause serious gastrointestinal (GI) side effects. For patients at increased risk of NSAID-related GI complications, prophylaxis with either a nonselective NSAID plus gastroprotective agent (GPA) or, alternatively, therapy with a cyclooxygenase-2 selective inhibitor with or without a GPA such as a proton pump inhibitor (PPI), is recommended.

AIM: To describe the rate, timing and duration of GI prophylaxis in Nova Scotia seniors receiving nonselective NSAIDs.

METHODS: The Nova Scotia Seniors’ Pharmacare Program beneficiaries for the years 1998 to 2002 were studied. A cohort of incident NSAID and GPA users was selected from all nonselective NSAID users (no prescribed NSAID dispensed 12 months before the index month and no GPA dispensed two months before the index prescription). Monthly coprescribing rates were calculated by dividing the number of patients in the cohort using GPAs by the number of NSAID users. GI prophylactic coprescribing was defined as the coprescribing rate present at the first month (index month) of prescribing an NSAID.

RESULTS: The cohort consisted of 12,906 patients. Seventy-five per cent of the nonselective NSAID prescriptions dispensed were for up to two months duration, with only 2.3% longer than one year. GI prophylaxis was given to only 3.8% of patients starting NSAIDs who were not on a GPA in the two months before starting NSAIDs. Of this 3.8%, 92.7% of the patients received H2-receptor antagonists (H2RAs), and 7% received PPIs. The rate of H2RA coprescribing increased with the number of consecutive months on an NSAID from 3.5% in the first month to 24.1% at 48 months. For PPIs, the coprescribing rate increased from 0.3% to 1.9% of all NSAID users in the cohort. The rate of gastroprophylaxis coprescribing for patients receiving NSAIDs did not rise with increasing age.

CONCLUSION: In Nova Scotian seniors using nonselective NSAIDs, the rate of GI prophylaxis was low. Most patients received H2RAs as GPAs despite evidence that they offer insufficient protection.
Wait Times for Sleep Apnea Care in Ontario: A Multidisciplinary Assessment
Authors: Rotenberg Brian W , George Charles F , Sullivan Kevin M , Wong Eric
Published: March 2016

BACKGROUND: Obstructive sleep apnea (OSA) is a highly prevalent disorder that is associated with significant patient morbidity and societal burden. In general, wait times for health care in Ontario are believed to be lengthy; however, many diseases lack specific corroborative wait time data.

OBJECTIVE: To characterize wait times for OSA care in Ontario.

METHODS: Cross-sectional survey. A survey tool was designed and validated to question physicians involved in OSA care about the length of the wait times their patients experience while traversing a simplified model of OSA care. The survey was sent to all otolaryngologists and respirologists in the province, as well as to a random sample of provincial family physicians.

RESULTS: Patients waited a mean of 11.6 months to initiate medical therapy (continuous positive airway pressure), and 16.2 months to initiate surgical therapy. Sleep laboratory availability appeared to be the major restriction in the patient management continuum, with each additional sleep laboratory in a community associated with a 20% decrease in overall wait times. Smaller community sizes were paradoxically associated with shorter wait times for sleep studies (P<0.01) but longer wait times for OSA surgery (P<0.05). Regression analysis yielded an r2of 0.046; less than 5% of the wait time variance could be explained by the simplified model.

CONCLUSION: Patients experienced considerable wait times when undergoing management for OSA. This has implications for both individual patient care and public health in general.
Optimizing Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease – Practical Issues: A Canadian Thoracic Society Clinical Practice Guideline
Authors: Marciniuk Darcy D , Brooks Dina , Butcher Scott , Debigare Richard , Dechman Gail , Ford Gordon , Pepin Veronique , Reid Darlene , Sheel Andrew W , Stickland Micheal K , Todd David C , Walker Shannon L , Aaron Shawn D , Balter Meyer , Bourbeau Jean , Hernandez Paul , Maltais Francois , O’Donnell Denis E , Bleakney Donna , Carlin Brian , Goldstein Roger , Muthuri Stella K
Published: March 2016

Pulmonary rehabilitation (PR) participation is the standard of care for patients with chronic obstructive pulmonary disease (COPD) who remain symptomatic despite bronchodilator therapies. However, there are questions about specific aspects of PR programming including optimal site of rehabilitation delivery, components of rehabilitation programming, duration of rehabilitation, target populations and timing of rehabilitation. The present document was compiled to specifically address these important clinical issues, using an evidence-based, systematic review process led by a representative interprofessional panel of experts.

The evidence reveals there are no differences in major patient-related outcomes of PR between nonhospital- (community or home sites) or hospital-based sites. There is strong support to recommend that COPD patients initiate PR within one month following an acute exacerbation due to benefits of improved dyspnea, exercise tolerance and health-related quality of life relative to usual care. Moreover, the benefits of PR are evident in both men and women, and in patients with moderate, severe and very severe COPD. The current review also suggests that longer PR programs, beyond six to eight weeks duration, be provided for COPD patients, and that while aerobic training is the foundation of PR, endurance and functional ability may be further improved with both aerobic and resistance training.
Lymphoepithelial Cysts of the Pancreas: The Use of Endoscopic Ultrasound-Guided Fine-Needle Aspiration in Diagnosis
Authors: Karim Zamil , Walker Blair , Lam Eric C
Published: March 2016

Lymphoepithelial cysts (LECs) are rare non-neoplastic lesions that can appear as a complex cyst or a mass in the pancreas. Cytology from endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) can be helpful in making a diagnosis with the aim of avoiding unnecessary surgical resection. A case involving a 51-year-old woman with lower abdominal pain who was found to have a multiloculated cystic lesion at the junction of the pancreatic body and tail is described. Cytology from EUS-FNA was consistent with a pancreatic LEC. The lesion was managed conservatively and follow-up imaging of the cyst over the following two years was unchanged. The patient remains clinically well. Cytology from EUS-FNA can help distinguish LECs from cystic neoplasms, thus preventing radical surgical resection of this benign pancreatic cyst.
The Christmas Season as a Risk Factor for Chronic Obstructive Pulmonary Disease Exacerbations
Authors: Johnston Neil W , McIvor Andrew , Reg N Kim Lambert , Greene Justina M , Hussac Pat , de Verdier Maria Gerhardsson , Higenbottam Tim , Lewis Jonathan , Newbold Paul , Herath Athula , Jenkins Martin
Published: March 2016

BACKGROUND: Epidemics of hospitalization for chronic obstructive pulmonary disease (COPD) occur annually during the Christmas holidays, and COPD exacerbations commonly coincide with respiratory viral infections.

OBJECTIVE: To compare the incidence and determinants of COPD exacerbations occurring between the Christmas holiday period and the remainder of the winter season.

METHODS: Seventy-one subjects with COPD of mixed severity faxed daily symptom diaries to a computer monitoring system from December 1, 2006, to April 30, 2007. Possible exacerbations prompted a home visit for assessment, spirometry and specimen collection for virological testing.

RESULTS: Study subjects submitted a total of 95.4% of possible daily symptom diary sheets by fax. Of 114 possible COPD exacerbations detected using the faxed diaries, 110 met the Anthonisen criteria for true exacerbations. A total of 47 exacerbations (mean 6.7/week) occurred during the Christmas holiday period, while 63 exacerbations (mean 4.3/week) occurred during the remainder of winter. Of the Christmas period exacerbations and of those in the balance of winter, 21 (44%) and 20 (32%), respectively, coincided with respiratory viral infections.

CONCLUSIONS: The incidence of COPD exacerbations during the Christmas period was greater than during the rest of winter in 2006/2007 and peaked immediately before Christmas – in contrast to hospital presentation for COPD, which peaked during the Christmas week. No clear role of respiratory viral infections in the increased rate of exacerbations during the Christmas period was established in the present study. COPD patients were highly compliant with daily symptom reporting using faxed daily diaries, which permitted nearly complete detection of all exacerbations that occurred at incidence.
Training the Endoscopy Trainer: From General Principles to Specific Concepts
Authors: Coderre Sylvain , Anderson John , Rostom Alaa , McLaughlin Kevin
Published: March 2016

Endoscopy instruction has progressed a great deal in recent years, evolving from the age-old dictum of ‘see one, do one’ to the current skillful application of sound educational principles. Some of these educational principles are generic and applicable to the teaching of any content at all levels, while others are quite specific to technical skills training. The present review summarizes these important principles under the following headings: creating a learner-centred curriculum; delivering an achievable learning task; and moving from theory to practice. The present article challenges national gastroenterology organizations to embrace these concepts in structured, outcome-based educational programs.
A Descriptive Review of Selected Nonviral Enteric Illnesses Reported in Children in Quebec between 1999 and 2006
Authors: Kaboré Henri , Michel Pascal , Levallois Patrick , Déry Pierre , Payment Pierre , Lebel Germain
Published: March 2016

OBJECTIVE: To review the epidemiology of selected nonviral enteric illnesses reported in children in Quebec between 1999 and 2006.

METHODS: Incidence rates were calculated to describe age, sex, temporal and geographical characteristics of the selected nonviral enteric cases reported in children who were between zero and four years of age. Standard descriptive methods were used to analyze the temporal and geographical distributions of the incidence rates.

RESULTS: A total of 5068 cases were reported. Of these, three pathogens accounted for the majority of the infections: Giardia (32.52%), Salmonella (30.98%) and Campylobacter (30.82%). Salmonella was most frequent in children younger than one year of age, whereas comparable incidence rates for the three pathogens were calculated for children between one and four years of age. For Giardia, the geographical distributions showed that the highest rates were in areas with more than 100,000 inhabitants (except Montreal, Quebec); for Salmonella, the highest rates were in Montreal; and for Campylobacter, the highest rates were in areas with fewer than 10,000 inhabitants. No detectable trends were seen over the study period for the three pathogens. Seasonal summer peaks were noted for Salmonella and Campylobacter, contrasting with late summer to early autumn peaks for Giardia.

CONCLUSION: Findings suggest that Giardia, Salmonella and Campylobacter were the most common causes of nonviral enteric illnesses reported in children in Quebec. Giardia cases seemed to arise from different sources and transmission routes than the other two pathogens. Characteristics specific to Campylobacter infections in children, namely its predominance in areas with low population densities, and to Salmonella infections, namely predominance in the Greater Montreal area, should be further investigated to better guide prevention and control measures.
Solitary Fibrous Tumour of the Pleura: A Case Report
Authors: Rakovich George , Laflamme Maxime , Ouellette Denise , Beauchamp Gilles
Published: March 2016

Solitary fibrous tumours of the pleura are rare pleural neoplasms that are distinct from mesothelioma. Most of them are benign, although some behave aggressively; morphological and pathological features are important in distinguishing them from mesothelioma and in predicting clinical behaviour. Solitary fibrous tumours often grow to a large size before causing symptoms, and are characteristically associated with hypertrophic pulmonary osteoarthropathy in up to 20% of cases. In cases of benign lesions, complete resection is usually curative. A case involving a 62‐year‐old woman who underwent surgical resection of a solitary fibrous tumour of the pleura measuring 25 cm in size is described.
Attentional and Emotional Mechanisms of Pain Processing and Their Related Factors: A Structural Equations Approach
Authors: Huber Claudia , Kunz Miriam , Artelt Cordula , Lautenbacher Stefan
Published: March 2016

BACKGROUND/OBJECTIVE: It is known that maladaptive attentional and emotional mechanisms of pain processing – as indicated by constructs such as pain hypervigilance, pain‐related anxiety and pain catastrophizing – play an important role in the development and maintenance of chronic pain conditions. However, little is known to date about the potential risk factors for these forms of maladaptive processing. The aim of the present study was to shed more light on this issue. A very comprehensive set of predictor variables was examined in healthy pain‐free subjects.

METHOD: Participants were 92 young and healthy subjects (mean [± SD] age 26.99±6.90 years; 47 men, 45 women). Maladaptive attentional and emotional mechanisms of pain processing were assessed by self‐report measures of pain hypervigilance, pain‐related anxiety and pain catastrophizing, as well as by a dot‐probe task. The comprehensive set of predictor variables included measures of affective and bodily distress (depression, anxiety and somatization), experimental pain sensitivity, and cortisol reactivity. Directed relationships were estimated by using structural equation modelling.

RESULTS: Structural equation modelling revealed a significant path from affective and bodily distress to self‐reported maladaptive attentional and emotional pain processing. In contrast, the paths from pain sensitivity and cortisol reactivity did not reach the level of significance.

CONCLUSION: These results support the position that anxiety and depression, as well as somatization, contribute to the aberrance of attentional and emotional mechanisms of pain processing. Surprisingly, the assumption of a close relationship between these maladaptive mechanisms of pain processing and pain sensitivity could not be confirmed.
Gastroscopy Following a Positive Fecal Occult Blood Test and Negative Colonoscopy: Systematic Review and Guideline
Authors: Allard Johane , Cosby Roxanne , Del Giudice M Elisabeth , Irvine E Jan , Morgan David , Tinmouth Jill
Published: March 2016

BACKGROUND: A sizeable number of individuals who participate in population‐based colorectal cancer (CRC) screening programs and have a positive fecal occult blood test (FOBT) do not have an identifiable lesion found at colonoscopy to account for their positive FOBT screen.

OBJECTIVE: To evaluate the evidence and provide recommendations regarding the use of routine esophagogastroduodenoscopy (EGD) to detect upper gastrointestinal (UGI) cancers in patients participating in a population‐based CRC screening program who are FOBT positive and colonoscopy negative.

METHODS: A systematic review was used to develop the evidentiary base and to inform the evidence‐based recommendations provided.

RESULTS: Nine studies identified a group of patients who were FOBT positive and colonoscopy negative. Three studies found no cases of UGI cancer. Four studies reported cases of UGI cancer; three found UGI cancer in 1% or less of the population studied, and one study found one case of UGI cancer that represented 7% of their small subgroup of FOBT‐positive/colonoscopy‐negative patients. Two studies did not provide outcome information that could be specifically related to the FOBT‐positive/colonoscopy‐negative subgroup.

CONCLUSION: The current body of evidence is insufficient to recommend for or against routine EGD as a means of detecting gastric or esophageal cancers for patients who are FOBT positive/colonoscopy negative, in a population‐based CRC screening program. The decision to perform EGD should be individualized and based on clinical judgement.