bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical Recommendations for the Use of Recombinant Human Erythropoietin in Patients with Hepatitis C Virus Being Treated with Ribavirin
Authors: Sherman Morris , Cohen Lawrence , Anne Cooper Mary , Elkashab Magdy , Feinman Victor , Fletcher David , Girgrah Nigel , Heathcote Jenny , Levstik Mark , McNaull William B , Wong David , Wong Florence , Yim Colina
Published: March 2016

Today, combination antiviral therapy with pegylated interferon-alpha and ribavirin (RBV) allows many patients infected with hepatitis C virus (HCV) to achieve a sustained virological response, which is equivalent to cure. Data also support the clinical benefit of combination antiviral therapy in patients coinfected with HCV and HIV, and in patients who have received a liver transplant.

Antiviral therapy with pegylated interferon-alpha and RBV is, however, associated with a high incidence and significant magnitude of anemia. This anemia may have several mechanisms, including bone marrow suppression and hemolysis. In addition, patients coinfected with HIV may have both pre-existing and RBV-associated anemia. Management of anemia in patients with HCV through RBV dose reduction or treatment discontinuation may compromise the effectiveness of treatment, because studies have demonstrated that treatment adherence or maintenance of antiviral therapy dose is an important predictor of sustained virological response.

Anemia associated with combination antiviral therapy in patients with HCV is frequently associated with an inadequate or blunted endogenous erythropoietin response. Accumulating evidence now supports the use of recombinant human erythropoietin (rHuEpo) to manage anemia in these patients, with the objective of maintaining the RBV dose, but clinical standards are lacking. The present article reviews the data relevant to the use of rHuEpo in this patient population and proposes a set of clinical practice standards to assist clinicians in selecting patients for rHuEpo and in implementing rHuEpo therapy effectively.
Dermatomyositis Associated with Celiac Disease: Response to a Gluten-Free Diet
Authors: Song Min Soo , Farber David , Bitton Alain , Jass Jeremy , Singer Michael , Karpati George
Published: March 2016

The association between dermatomyositis and celiac disease in children has been well documented. In the adult population, however, the association has not been clearly established. A rare case of concomitant dermatomyositis and celiac disease in a 40-year-old woman is presented. After having been diagnosed with dermatomyositis and iron deficiency anemia, this patient was referred to the gastroenterology clinic to exclude a gastrointestinal malignancy. Blood tests revealed various vitamin deficiencies consistent with malabsorption. The results of gastroscopy with duodenal biopsy were consistent with celiac disease. After she was put on a strict gluten-free diet, both nutritional deficiencies and the dermatomyositis resolved. The patient’s human leukocyte antigen haplotype study was positive for DR3 and DQ2, which have been shown to be associated with both juvenile dermatomyositis and celiac disease. It is suggested that patients with newly diagnosed dermatomyositis be investigated for concomitant celiac disease even in the absence of gastrointestinal symptoms.
First Canadian Reports of Cervical Adenitis due to Mycobacterium malmoense and a 10‐Year Review of Nontuberculous Mycobacterial Adenitis
Authors: McCrossin Chris , Mailman Tim
Published: March 2016

The present report reviews a decade of experience with nontuberculous mycobacterial adenitis at a pediatric referral centre, noting that patients are often subjected to multiple ineffective antibiotic courses, and that delays in diagnosis and referral for appropriate therapy are common. Notable clinical features include a mean age of presentation of 3.4 years, a male‐to‐female ratio of 1:1.5 and a gradual onset of painless, unilateral cervical adenopathy. Fever was absent in most patients (77%), and the disease failed to respond to antistaphylococcal antibiotics. The mean time to correct diagnosis was longer than three months (15 weeks). The clinical features of the disease are highlighted and presented with a practical diagnostic approach to the child with subacute/chronic adenitis. New molecular diagnostic tools and emerging mycobacteria are discussed, including the first reports of Mycobacterium malmoense adenitis in Canada.
Predictors of Antiviral Therapy in a Post-Transfusion Cohort of Hepatitis C Patients
Authors: Witkos Maciej , Yi Qi-Long , Heathcote Jenny , Kapral Moira K , Krahn Murray D
Published: March 2016

INTRODUCTION: In the past, antiviral therapy has been given to 15% to 30% of patients infected with hepatitis C virus (HCV). The efficacy of therapy has recently improved with the addition of ribavirin and pegylated interferon. The aim of the present study was to identify the clinical, socioeconomic and health-system predictors of antiviral treatment for HCV.

METHODS: A retrospective analysis of compensation claims data of patients who acquired HCV through blood transfusions between 1986 and 1990 was performed. The patients consisted of 2456 Canadian HCV-positive individuals. The authors reviewed narrative comments from physicians, and constructed univariate and multivariate logistic regression models, using receipt of antiviral therapy with interferon or interferon/ribavirin as the primary outcome.

RESULTS: Of the 2456 patients, approximately 30% appeared to be eligible, but only 16% received treatment. Univariate analyses suggested that the disease severity, age, HIV status and province of residence were associated with the likelihood of receiving treatment (P<0.01). The final, multivariable model indicated that in patients with HCV: intermediate disease severity (eg, fibrosis, P<0.0001); middle age (P<0.0001); HIV-negative status (P<0.0001); and province of residence (Quebec, P<0.0001; and Saskatchewan, P<0.0001) were independent predictors of treatment. Narrative comments of physicians emphasized the importance of age, HIV status and patient preferences in clinical decision-making.

DISCUSSION: Given the efficacy and cost-effectiveness of current antiviral therapy, treatment rates of HCV patients may be suboptimal. Further work is required to understand barriers to treatment related to geography, organization of medical care, age, medical provider and patient preferences.
A Patient with Microcytic Anemia and Fever
Authors: Bhatia Sacha , Kuriya Bindee , Stroud Lynfa , Rachlis Anita , Adhikari Neill KJ
Published: March 2016

A 62‐year‐old man with a history of mechanical aortic valve insertion and ascending aorta replacement in 1997 presented to his family doctor in August 2004 with a two‐week history of melena after recently returning from a six‐month vacation in Mexico. The patient had no other abdominal complaints. He took warfarin but did not take nonsteroidal anti‐inflammatory agents, acetylsalicylic acid or alcohol. The patient had no history of liver or peptic ulcer disease. He had lost 7 kg over the past month, but did not complain of fever or night sweats. On physical examination, vital signs were normal, the second heart sound was mechanical, and there were no abnormal findings. Laboratory investigations showed a borderline microcytic anemia (hemoglobin 76 g/L; mean corpuscular volume 79 fL; mean corpuscular hemoglobin concentration 323 g/L), a therapeutic international normalized ratio (2.6) and an elevated creatinine level (112 µmol/L). His stool was positive for occult blood, although the ferritin level was high (623 µg/L). Other routine blood work was normal. The patient was admitted to hospital for investigation of the anemia.
Central Venous Catheter‐Associated Bloodstream Infections in Hemodialysis Patients: Another Patient Safety Bundle?
Authors: Johnston B Lynn , Conly John M
Published: March 2016

In a previous issue of The Canadian Journal of Infectious Diseases & Medical Microbiology, we reviewed the ′Safer Healthcare Now!′ campaign′s focus on reducing central venous catheter (CVC)‐associated bloodstream infections (BSIs) as a way of improving patient safety (1). This initiative is focused on preventing CVC‐associated BSIs in intensive care units. However, other patient groups are also at risk for CVC‐related BSIs, suggesting that there are other individuals who would benefit from preventive efforts. A 1996 hospital‐wide survey of nosocomial bacteremia in an Israeli university hospital (2) found that 9% of infected patients were on chronic hemodialysis. Surveillance in 73 hospitals in England between 1997 and 2001 found a CVC BSI rate of 21/1000 nephrology patients at risk who were hospitalized in teaching hospitals (3). This rate was similar to that found in special care neonatal units, although not quite one‐half that of patients in a general intensive care unit. In a population‐based survey performed in the Calgary Health Region from 2000 to 2002 (4), hemodialysis (HD) posed the greatest risk (RR 208.7; 95% CI 142.9 to 296.3) for acquiring severe BSI.
A Comparison between the Strep a Rapid Test Device and Conventional Culture for the Diagnosis of Streptococcal Pharyngitis
Authors: Forward Kevin R , Haldane David , Webster Duncan , Mills Carolyn , Brine Cheryl , Aylward Diane
Published: March 2016

BACKGROUND: Rapid antigen detection tests are frequently used to diagnose pharyngitis due to Streptococcus pyogenes. Because a large number of kits are available commercially, performance characteristics may vary considerably. The present study evaluated one such kit currently in use in Canadian laboratories for which published evaluations are not available.

OBJECTIVE: To evaluate the performance characteristics of the Strep A Rapid Test Device (SARTD) (Nova Century Scientific Inc, Canada).

METHODS: Pharyngeal swabs from 818 patients with suspected streptococcal pharyngitis were tested. Swabs were initially inoculated onto the surface of a blood agar plate and then used to perform the rapid antigen test. The test was performed in accordance with the product monograph. Beta‐hemolytic colonies were identified as S pyogenes using conventional means.

RESULTS: Four hundred ninety specimens were obtained from children and 328 from adults. S pyogenes was recovered from 171 (21%) patients. The SARTD detected S pyogenes antigens in 123 of 171 specimens from which S pyogenes was isolated on culture; the screen was negative in 610 of 647 specimens from which cultures were negative. The positive and negative predictive values of the SARTD were 76.9% and 92.7%, respectively.

CONCLUSIONS: The SARTD was much less sensitive (72%) than was suggested in the product monograph (90%). Laboratories should vigorously evaluate such products in‐house, optimize specimen collection and transport, and choose more sensitive kits for use.
Where Have all the Antibiotics Gone?
Authors: Davies Julian
Published: March 2016

The discovery of antibiotics some 60 years ago was anticipated to herald the end of infectious diseases. However, microbial evolution and genetic jugglery have dispelled this notion; the constant increase in the appearance of resistant strains has not been matched by the introduction of new therapeutic agents. On the contrary, the dire need for novel antibiotics has coincided with a reduction in antibiotic discovery programs in the pharmaceutical industry. As a result, the treatment of microbial diseases has reached a point where many infections are essentially untreatable by the antimicrobial agents currently available. At the present time, numerous initiatives are being undertaken by physicians and by governments in an attempt to redress this situation. In addition, alternative approaches to antibiotics for the treatment of infectious diseases are being explored intensively.
Hydrogen Breath Test for Diagnosis of Lactose Malabsorption: The Importance of Timing and the Number of Breath Samples
Authors: Di Camillo Mauro , Marinaro Vanessa , Argnani Fiorenza , Foglietta Tiziana , Vernia Piero
Published: March 2016

BACKGROUND: The hydrogen breath test (H2BT) is the most widely used procedure in the diagnostic workup of lactose malabsorption and lactose intolerance.

AIM: To establish whether a simplified two-or three-sample test may reduce time, costs and staff resources without reducing the sensitivity of the procedure.

PATIENTS AND METHODS: Data from 1112 patients (292 men, 820 women) with a positive 4 h, nine-sample H2BT were retrospectively analyzed. Patients were stratified according to the degree of lactose malabsorption, the occurrence and type of symptoms. Loss of sensitivity in the procedure was evaluated taking into account two-sample tests (0 min and 120 min or 0 min and 210 min) or three-sample tests (0 min, 120 min and 180 min or 0 min, 120 min and 210 min).

RESULTS: Using a two-sample test (0 min and 120 min or 0 min and 210 min) the false-negative rate was 33.4% and 22.7%, respectively. With a three-sample test (0 min, 120 min and 180 min or 0 min, 120 min or 210 min), lactose malabsorption was diagnosed in 91.2% (1014 of 1112) patients and in 96.1% (1068 of 1112) patients, respectively. Of 594 patients with abdominal symptoms, 158 (26.6%) and 73 (12.2%) would have false-negative results with 0 min and 120 min or 0 min and 210 min two-sample tests, respectively. The three-sample tests, 0 min, 120 min and 180 min or 0 min, 120 min and 210 min, have a false-negative rate of 5.9% and 2.1%, respectively.

CONCLUSIONS: A three-sample H2BT is time-and cost-sparing without significant loss of sensitivity for the diagnosis both of lactose malabsorption and lactose intolerance.
Prevalence and Determinants of Pain and Pain‐Related Disability in Urban and Rural Settings in Southeastern Ontario
Authors: Tripp Dean A , VanDenKerkhof Elizabeth G , McAlister Margo
Published: March 2016

BACKGROUND: Canadian chronic pain prevalence estimates range from 11% to 66%, are affected by sampling and measurement bias, and largely represent urban settings.

OBJECTIVES: To estimate chronic pain prevalence and factors associated with pain in southeastern Ontario, a region with a larger rural than urban residence.

METHODS: A systematic sampling with a random start was used to contact households. A telephone‐administered questionnaire using the Graded Chronic Pain Scale, with questions on health care and medication use, health status, depression and demographics, was administered to consenting adults (18 to 94 years of age; mean age 50.2±16.6 years).

RESULTS: The response rate was 49% (1067 of 2167), with 76% reporting some pain over the past six months. Low pain intensity with low pain interference prevalence was 34% (grade I), high pain intensity with low pain interference was 26% (grade II), and high pain intensity with high pain interference was 17% (grades III and IV). Of those reporting pain, 49% reported chronic pain (ie, pain for a minimum of 90 days over the past six months) representing 37% of the sample. Being female, unmarried, lower income, poorer self‐reported health status and rural residence were associated with increasing pain. Once depression was considered in this pain analysis, residence was no longer significant. Lower rates of health care utilization were reported by rural residents. In those reporting the highest pain grades, poor health, greater medication and health care use, depression and more pain sites were associated with higher odds for pain‐related disability.

CONCLUSION: There is an elevated prevalence of pain in this almost equally split rural/urban region. Further examination of health care utilization and depression is suggested in chronic pain prevalence research.
A Recurrent Headache
Authors: Dylewski Joe
Published: March 2016

Case Presentation A 43‐year‐old man presented to the emergency room in September 2004 with a two‐day history of increasing headache, myalgias and low‐grade fever. No family members had been ill recently and he denied having nausea or diarrhea. On examination, he was nontoxic, with a temperature of 37.5¡ãC, pulse of 90 beats/min and blood pressure of 146/84 mmHg. Skin rashes were not present, and the neck was supple. The patient claimed that he seldom had headaches but that he had been hospitalized in England 15 years ago for viral meningitis. He remembered receiving antibiotics at the time despite being told it was a viral meningitis. The patient underwent a computed tomography scan of the brain, which was normal, followed by a lumbar puncture. The opening pressure was not recorded, but there were 23x106/L polymorphonuclear cells and 308x106/L lymphocytes in the cerebrospinal fluid (CSF). The CSF protein was elevated at 1.26 g/L (N¡Ü0.45), with a CSF glucose of 2.9 mmol/L compared with a serum value of 5.3 mmol/L. The peripheral white blood cell count was 10.5x109/L, with 8.0x109/L neutrophils.
Spontaneous Intramural Esophageal Hematoma: Case Report and Review
Authors: Cheung Justin , Müller Nestor , Weiss Alan
Published: March 2016

Intramural esophageal hematoma is a rare form of esophageal injury. The presenting symptoms are nonspecific. Esophagogastroscopy and computed tomography scan are usually needed to establish the diagnosis of intramural esophageal hematoma. Presented here is a patient with spontaneous intramural esophageal hematoma who was successfully treated with conservative measures.
Central Venous Catheter‐Associated Blood Stream Infections Occurring in Canadian Intensive Care Units: A Six‐Month Cohort Study
Authors: Holton Donna , Paton Shirley , Conly John , Embree Joanne , Taylor Geoffrey , Thompson William , Canadian Nosocomial Infection Surveillance Program
Published: March 2016

OBJECTIVE: To determine the rate and risk factors associated with central venous catheter (CVC)‐associated bloodstream infections (BSIs) in Canadian intensive care units (ICUs).

DESIGN: A prospective, active six‐month cohort with a nested case‐control study.

SETTING: Forty‐one ICUs located in 19 Canadian hospitals.

METHODS: Data were collected using a standardized format on all CVCs and patients when a CVC was inserted for more than 48 h. Results of microbiological studies and therapeutic interventions were recorded when a BSI occurred.

RESULTS: There were 182 BSIs from 3696 CVC insertions in 2531 patients. Coagulase‐negative staphylococci were responsible for 73% of the BSIs. Mean rates of CVC‐associated BSIs per 1000 CVC days were 6.9, 6.8 and 5.0 in adult, neonatal and pediatric ICUs, respectively. Significant factors associated with BSI included duration of CVC insertion (OR=1.2, 95% CI 1.1 to 1.3), receiving total parenteral nutrition (OR=4.1, 95% CI 1.2 to 14.3) and having one or more CVCs (OR=3.1, 95% CI 1.5 to 6.5). In the case‐control study, 80% of the variance in a backward elimination logistic regression analysis was explained by duration of CVC insertion (OR=1.2 per day), receiving chemotherapy (OR=6.1), more than one CVC insertion during the study (OR=3.5), insertion of a CVC with two or more lumens (OR=2.3), using the CVC to administer total parenteral nutrition (OR=1.6) and having a surgical wound other than a clean wound (OR=1.6).

CONCLUSION: The present study identified risk factors explaining 80% of the variance associated with BSIs and is one of the largest reports on the rate of CVC‐associated BSIs occurring in the ICU setting.
Maternal Infectious Diseases, Antimicrobial Therapy or Immunizations: Very few Contraindications to Breastfeeding
Authors: Macdonald Noni E
Published: March 2016

The Canadian Paediatric Society recommends exclusive breastfeeding as the optimal method of infant feeding for the first six months of life for healthy, term infants (1). There are many benefits associated with breastfeeding, including nutritional, immunological, psychological, developmental, environmental, social, economic and health (eg, decrease in infectious diseases) (2‐4). To promote, protect and support breastfeeding, every effort must be made to minimize contraindications to breastfeeding, particularly unnecessary ones. The present article summarizes the maternal infectious diseases in which continuing breastfeeding is recommended, the very few infectious diseases in which it is not recommended, the rare instances in which maternal antimicrobial therapy indicates a caution for breastfeeding, and the continuation of breastfeeding when a mother or her infant is receiving a routine recommended immunization.
Survey of Clinical Nutrition Practices of Canadian Gastroenterologists
Authors: Singh Harminder , Duerksen Donald R
Published: March 2016

OBJECTIVE: Nutrition education is a required part of gastrointestinal training programs. The involvement of gastroenterologists in clinical nutrition once their training has been completed is unknown. The aim of the present study was to determine the practice pattern of gastroenterologists in clinical nutrition and their perceived adequacy of nutrition training during their gastroenterology (GI) fellowship.

METHODS: The Canadian Association of Gastroenterology mailed a survey to all of its 463 Canadian clinician members and 88 trainee members. Components of the survey included knowledge of nutritional assessment and total parenteral nutrition, involvement in a nutrition support service, physician involvement in nutritional assessment and nutrition support teams, obesity management, insertion of gastrostomy (G) tubes and management of tube-related complications, and adequacy of training in clinical nutrition.

RESULTS: Sixty per cent (n=279) of the Canadian Association of Gastroenterology clinicians and 38% (n=33) of the fellows responded. Of the clinicians, 80% were practicing adult gastroenterologists with the following demographics: those practicing full time in academic centres (42%), community practice (45%), completed training in the last 10 years (32%) and those that completed training in the United States (14%). Although only 6% had a primary focus of nutrition in their GI practices, 65% were involved in nutrition support (including total parenteral nutrition), 74% placed G tubes and 68% managed at least one of the major complications of G tube insertion. Respondents felt a gastroenterologist should be the physician’s consultant on nutrition support services (89%). Areas of potential inadequate training included nutritional assessment, indications for nutrition support, management of obesity and management of G tube-related complications. The majority of clinicians (67%) and trainees (73%) felt that nutrition training in their GI fellowship was underemphasized.

CONCLUSIONS: The majority of Canadian gastroenterologists are involved in nutrition support. However, this survey demonstrated that nutritional training is underemphasized in most training programs. It is important for GI fellowship programs to develop standardized nutrition training that prepares trainees for their practice.
Exposure to a Specific Pulsed Low‐Frequency Magnetic Field: A Double‐Blind Placebo‐Controlled Study of Effects on Pain Ratings in Rheumatoid Arthritis and Fibromyalgia Patients
Authors: Shupak Naomi M , McKay Julia C , Nielson Warren R , Rollman Gary B , Prato Frank S , Thomas Alex W
Published: March 2016

BACKGROUND: Specific pulsed electromagnetic fields (PEMFs) have been shown to induce analgesia (antinociception) in snails, rodents and healthy human volunteers.

OBJECTIVE: The effect of specific PEMF exposure on pain and anxiety ratings was investigated in two patient populations.

DESIGN: A double‐blind, randomized, placebo‐controlled parallel design was used.

METHOD: The present study investigated the effects of an acute 30 min magnetic field exposure (less than or equal to 400 μTpk; less than 3 kHz) on pain (McGill Pain Questionnaire [MPQ], visual analogue scale [VAS]) and anxiety (VAS) ratings in female rheumatoid arthritis (RA) (n=13; mean age 52 years) and fibromyalgia (FM) patients (n=18; mean age 51 years) who received either the PEMF or sham exposure treatment.

RESULTS: A repeated measures analysis revealed a significant pre‐post‐testing by condition interaction for the MPQ Pain Rating Index total for the RA patients, F(1,11)=5.09, P<0.05, estimate of effect size = 0.32, power = 0.54. A significant pre‐post‐effect for the same variable was present for the FM patients, F(1,15)=16.2, P<0.01, estimate of effect size = 0.52, power =0.96. Similar findings were found for MPQ subcomponents and the VAS (pain). There was no significant reduction in VAS anxiety ratings pre‐ to post‐exposure for either the RA or FM patients.

CONCLUSION: These findings provide some initial support for the use of PEMF exposure in reducing pain in chronic pain populations and warrants continued investigation into the use of PEMF exposure for short‐term pain relief.
Pharmacological Therapy of Vascular Malformations of the Gastrointestinal Tract
Authors: Szilagyi Andrew , Ghali Maged P
Published: March 2016

Vascular malformation (AVM) in the gastrointestinal tract is an uncommon, but not rare, cause of bleeding and iron deficiency anemia, especially in an aging population. While endoscopic coagulative therapy is the method of choice for controlling bleeding, a substantial number of cases require additional therapy. Adjunctive or even primary phamacotherapy may be indicated in recurrent bleeding. However, there is little evidence-based proof of efficacy for any agent. The bulk of support is derived from anecdotal reports or case series. The present review compares the outcome of AVM after no intervention, coagulative therapy or focus on pharmacological agents. Most of the literature encompasses two common AVMs, angiodysplasia and hereditary hemorrhagic telangiectasia. Similarly, the bulk of information evaluates two therapies, hormones (estrogen and progesterone) and the somatostatin analogue octreotide. Of these, the former is the only therapy evaluated in randomized trials, and the results are conflicting without clear guidelines. The latter therapy has been reported only as case reports and case series without prospective trials. In addition, other anecdotally used medications are discussed.
Liver Transplant Candidate Unsuitability: A Review of the British Columbia Experience
Authors: Alali Jaber , Ramji Alnoor , Ho Jin K , Scudamore Charles H , Erb Siegfried R , Cheung Elsie , Kopit Bina , Bannon Clare A , Chung Stephen W , Soos John G , Buczkowski Andrezj K , Brooks Eileen M , Steinbrecher Urs P , Yoshida Eric M
Published: March 2016

BACKGROUND: Every centre has contraindications to liver transplantation and declares patients unsuitable for medical or nonmedical reasons. To date, there has been no published review of any centre’s experience.

METHODS: A retrospective chart review was completed from 1997 to 2001, inclusive of all patients referred for liver transplant to the British Columbia Transplant Society who were declared unsuitable for transplantation, as well as the reasons for unsuitability.

RESULTS: One hundred fifty patients were considered to be unsuitable for transplantation. During this period, 167 transplants were performed and 737 patients were referred for candidacy. Data were missing on three patients; analysis was performed on the remaining 147. Patients’ ages ranged from 15 to 72 years, and 33.3% were female. The most common primary liver disease was hepatitis C (n=53, 35%), followed by alcoholic liver disease (n=35, 24%) and autoimmune liver diseases (n=23, 16%). Medical contraindications constituted 74 patients (49.0%) and the most common reasons for unsuitability were no need of a liver transplant (29 patients [39%]), exclusion due to hepatoma or extrahepatic malignancy (20 patients [27%]) and multisystem failure (12 patients [16%]). Nonmedical contraindications constituted 73 patients. Failure to meet minimal alcohol criteria comprised the largest group (n=39, 53.4%) followed by inadequate social support (n=12, 16.4%), failure to follow up medical assessment (n=10, 13.7%) and drug abuse (n=6, 8.2%).

CONCLUSIONS: Although many patients were declined for transplantation, the proportion is relatively small compared with the number of referred patients. Nonmedical reasons, including failure to meet alcohol criteria and lack of social support, remain a significant reason for unsuitability in British Columbia. Community intervention before transplant referral is recommended.
Colistin: The phoenix Arises
Authors: Conly JM , Johnston BL
Published: March 2016

The polymyxins were discovered in the 1940s and represent a group of closely related polypeptide antibiotics obtained from Bacillus polymyxa, which was originally isolated from soil (1,2). Although they have been used extensively worldwide in topical otic and ophthalmic solutions for decades, the intravenous formulations were gradually abandoned in most parts of the world in the early 1980s because of the reported high incidence of nephrotoxicity (3‐5). As a result, the use of polymyxin preparations has been mainly restricted to the treatment of lung infections due to multidrug‐resistant (MDR) gram‐negative bacteria in patients with cystic fibrosis (6,7). The emergence of bacteria resistant to most classes of commercially available antibiotics and the shortage of novel antimicrobial agents with activity against gram‐negative microorganisms have led to the reemergence of polymyxins as a valuable addition to the therapeutic armamentarium. It was thus considered timely to review colistin and its emerging role in managing infections due to MDR gram‐negative bacteria.
Nonalcoholic Fatty Liver Disease: A Clinical Approach and Review
Authors: Raman Maitreyi , Allard Johane
Published: March 2016

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of incidental elevation of liver enzymes in North America and Europe. Risk factors for NAFLD include body mass index of 25 kg/m2or greater, central obesity and diabetes mellitus. The spectrum of disease is variable, ranging from simple steatosis with benign prognosis, to non-alcoholic steatohepatitis and cirrhosis, conferring increase in morbidity and mortality. The primary abnormality or ‘first hit’ in patients with NAFLD is insulin resistance leading to hepatic steatosis. The second hit involves multiple proinflammatory cytokines resulting in non-alcoholic steatohepatitis. Treatment is aimed at aggressive risk factor control and weight loss. Currently, there are no pharmacological agents recommended in the treatment of NAFLD, although preliminary studies suggest promising agents in the future.
Learning from Mistakes
Authors: Nicolle LE
Published: March 2016

In the present issue of the Journal, Patrick and his colleagues (pages 330‐336) describe an episode in the summer of 2003, immediately following the severe acute respiratory syndrome (SARS) epidemic, when an outbreak of respiratory illness occurred in a long‐term care facility in Vancouver, and was initially reported by the National Microbiology Laboratory (NML) to be SARS. The local laboratories did not support the diagnosis and, subsequently, the NML diagnosis was acknowledged to be incorrect. The misdiagnosis, however, had an immediate negative impact by suggesting that SARS continued to be transmitted in Canada, raising the spectre of social and economic impacts recently experienced by Toronto. The episode also had a longer term negative impact on national and international perceptions of the reliability of the Canadian laboratory. Thus, a critical review of this episode to understand what happened and to avoid future errors is appropriate. Dr Patrick and his coauthors, including those from the NML, are to be congratulated for presenting this information to the Canadian infectious diseases and public health communities.
Syndromic Surveillance of Norovirus Using over the Counter Sales of Medications related to Gastrointestinal Illness
Authors: Edge Victoria L , Pollari Frank , King Lai , Michel Pascal , McEwen Scott A , Wilson Jeffrey B , Jerrett Michael , Sockett Paul N , Martin S Wayne
Published: March 2016

OBJECTIVE: To assess whether over‐the‐counter (OTC) sales of gastrointestinal illness (GI)‐related medications are associated with temporal trends of reportable community viral, bacterial and parasitic infections.

METHODS: The temporal patterns in weekly and seasonal sales of nonprescription products related to GI were compared with those of reportable viral, bacterial and parasitic infections in a Canadian province.

RESULTS: Temporal patterns of OTC product sales and Norovirus activity were similar, both having highest activity in the winter months. In contrast, GI cases from both bacterial and parasitic agents were highest from late spring through to early fall.

CONCLUSIONS: Nonprescription sales of antidiarrheal and antinauseant products are a good predictor of community Norovirus activity. Syndromic surveillance through monitoring of OTC product sales could be useful as an early indicator of the Norovirus season, allowing for appropriate interventions to reduce the number of infections.
The Link Between Obesity and Asthma: A Canadian Perspective
Authors: Boulet Louis-Philippe , Cormiers Annick Des
Published: March 2016

Asthma is considered to be more prevalent in obese subjects, and a possible causal link between these two entities has been suggested. In the present study, various observations on this relationship were reviewed, and an analysis of data obtained from the 2000 to 2001 Canadian Community Health Survey on the prevalence of self‐reported asthma, medication use and allergy, according to body weight, was reported. Asthma medication use and self‐reported asthma were more prevalent in the obese population, particularly in women. Mean body mass index was higher in the asthmatic population compared with the nonasthmatic population. Self‐reported nonfood‐related allergies were higher in the more obese subjects in the general population, but the prevalence of allergy was not different in obese asthmatic subjects compared with nonobese asthmatic subjects. Smoking did not seem to influence the relationship between asthma and body mass index. Further research should investigate the mechanisms by which obesity may influence the prevalence of asthma or asthma‐like symptoms.
Methicillin‐Resistant Staphylococcus aureus in a Canadian Intensive Care Unit: Delays in Initiating Effective Therapy Due to the Low Prevalence of Infection
Authors: Sligl Wendy , Taylor Geoffrey , Gibney RT Noel , Rennie Robert , Chui Linda
Published: March 2016

INTRODUCTION: Methicillin‐resistant Staphylococcus aureus (MRSA) infection in intensive care units (ICUs) has increased dramatically in prevalence in recent years, and is associated with increased morbidity, mortality and cost of care. The aim of the present study was to describe the epidemiology and outcomes of MRSA infection in the general systems ICU at the University of Alberta Hospital in Edmonton, Alberta.

METHODS: A retrospective cohort analysis of patients infected with MRSA in a general systems ICU was conducted from January 1, 1997, to August 15, 2005.

RESULTS: Forty‐six cases of MRSA were identified, of which 36 (78.3%) were infected. The most common admitting diagnoses included respiratory failure (41.7%) and sepsis or septic shock (36.1%). Infection was hospital acquired in 58.3% of cases (10 cases ICU acquired), with a median time to infection of 11 days. The most common sites of infection were the respiratory tract, skin and blood. Median lengths of stay were 13 days in the unit and 27 days in‐hospital. Crude mortality was 55.6%. Time to appropriate antimicrobial treatment was delayed in 80.5% of patients. Four prototypical Canadian MRSA (CMRSA) strains were identified by pulsed‐field gel electrophoresis. Hospital‐acquired strains were predominantly CMRSA‐2 (59%), indicating that this clone circulates at the University of Alberta Hospital.

CONCLUSIONS: MRSA infection remains uncommon at the University of Alberta Hospital, resulting in delays in instituting appropriate antimicrobial therapy. To date, only a few community‐acquired strains have been noted. ICU acquisition of MRSA remains rare, with only 10 cases over the past nine years. The majority of hospital‐acquired strains were CMRSA‐2.
Microbiological Guideline Values for Recreational Bathing in Canada: Time for Change?
Authors: Lévesque Benoit , Gauvin Denis
Published: March 2016

Recreational bathing is an activity practiced by thousands of Canadians every year. While its health benefits are numerous, bathing in polluted water can also be a source of health problems. These problems are generally nonspecific and are difficult to detect through usual health monitoring systems. Most involve ear and eye ailments, febrile respiratory illness and, particularly, gastroenteritis. In 1992, Health Canada recommended microbiological guideline values for recreational water quality. The values are based on the presence of fecal indicator bacteria, namely, enterococci for marine water, and Escherichia coli or fecal coliforms for fresh water. In marine water, the guideline value is set at 35 enterococci/100 mL, while in fresh water, the standard is 200 E coli/100 mL or 200 fecal coliforms/100 mL when experience demonstrates that over 90% of the fecal coliforms are E coli. Notwithstanding certain variances, many Canadian provinces apply these guidelines. However, in Ontario, the guideline is 100 E coli/100 mL. Over the past several years, many epidemiological studies, including randomized clinical trials, have examined the relationship between bathing in polluted water and ensuing health problems. On review of this literature, the Canadian guideline values for marine water seems appropriate, but scientific evidence argues toward lowering the Canadian guideline values for fresh water to 100 E coli/100 mL, in line with the standard currently in effect in Ontario.
Data Equivalency of an Interactive Voice Response System for Home Assessment of Back Pain and Function
Authors: Shaw William S , Verma Santosh K
Published: March 2016

BACKGROUND: Interactive voice response (IVR) systems that collect survey data using automated, push‐button telephone responses may be useful to monitor patients’ pain and function at home; however, its equivalency to other data collection methods has not been studied.

OBJECTIVES: To study the data equivalency of IVR measurement of pain and function to live telephone interviewing.

METHODS: In a prospective cohort study, 547 working adults (66% male) with acute back pain were recruited at an initial outpatient visit and completed telephone assessments one month later to track outcomes of pain, function, treatment helpfulness and return to work. An IVR system was introduced partway through the study (after the first 227 participants) to reduce the staff time necessary to contact participants by telephone during nonworking hours.

RESULTS: Of 368 participants who were subsequently recruited and offered the IVR option, 131 (36%) used IVR, 189 (51%) were contacted by a telephone interviewer after no IVR attempt was made within five days, and 48 (13%) were lost to follow‐up. Those with lower income were more likely to use IVR. Analysis of outcome measures showed that IVR respondents reported comparatively lower levels of function and less effective treatment, but not after controlling for differences due to the delay in reaching non‐IVR users by telephone (mean: 35.4 versus 29.2 days).

CONCLUSIONS: The results provided no evidence of information or selection bias associated with IVR use; however, IVR must be supplemented with other data collection options to maintain high response rates.
Preoperative Alpha-Fetoprotein Slope is Predictive of Hepatocellular Carcinoma Recurrence after Liver Transplantation
Authors: Han Kathy , Tzimas George N , Barkun Jeffrey S , Metrakos Peter , Tchervenkov Jean I , Hilzenrat Nir , Wong Phil , Deschênes M
Published: March 2016

BACKGROUND: Liver transplantation (LT) offers a possible cure for patients with hepatocellular carcinoma (HCC) and cirrhosis. However, tumour progression while on the waiting list and tumour recurrence after LT are common. The prognostic significance of various pre- and postoperative variables were investigated in regard to tumour recurrence, with an emphasis on the slope of preoperative serum alpha-fetoprotein (AFP) levels.

PATIENTS AND METHODS: Data from 48 patients who had HCC diagnosed preoperatively and underwent LT at the McGill University Health Centre (Montreal, Quebec) were reviewed retrospectively, and possible risk factors for tumour recurrence were examined.

RESULTS: Univariate analysis revealed a positive correlation between the preoperative AFP slope and vascular invasion (P = 0.045), total tumour diameter at explant (P = 0.040), Cancer of the Liver Italian Program score (P = 0.017) and recurrence-free survival (P = 0.028). Of the preoperative variables examined, only the preoperative AFP slope was identified as an independent predictor of tumour recurrence by multivariate analysis. Receiver operating characteristic analysis showed that the best discriminant cut-off value, calculated as the value of the maximized likelihood ratio, was preoperative AFP slope greater than 50 µg/L per month. At this cut-off, sensitivity was 36%, and specificity was 97%. Patients with a preoperative AFP slope greater than 50 µg/L per month had a much worse one-year recurrence-free survival rate than those with a preoperative AFP slope 50 µg/L per month or less (40% versus 90%, P < 0.001).

CONCLUSIONS: These results suggest that the preoperative AFP slope is an important predictor of HCC recurrence after LT and should be examined in future studies of patients receiving LT for HCC.
Improvement of Lumbar Bone Mass after Infliximab Therapy in Crohn’s Disease Patients
Authors: Mauro Marina , Radovic Vladimir , Armstrong David
Published: March 2016

BACKGROUND: Patients with Crohn’s disease (CD) have a high risk of developing osteoporosis, but the mechanisms underlying bone mass loss are unclear. Elevated proinflammatory cytokines, such as tumour necrosis factor-alpha (TNFα), have been implicated in the pathogenesis of bone resorption.

AIM: To assess whether suppression of TNFα with infliximab treatment has a beneficial effect on lumbar bone mass.

METHODS: Adult CD patients who had received infliximab treatment, and who underwent lumbar densitometric evaluation before and during treatment, were selected. Adult CD patients who had never received infliximab treatment were selected as controls. Information regarding age, sex, weight, duration of CD, use of glucocorticoids and bisphosphonates, and signs of disease activity between both densitometric measurements were collected.

RESULTS: Data from 45 patients were analyzed. The control group (n=30, mean [± SD] 26.7±9 years of age) had a significantly higher increase in body weight between both evaluations (6.26%±8%) than the infliximab group (n=15, 30.6±13 years), which had an increase of 0.3%±7.4%. There was a strong correlation between the final weight and lumbar bone mineral content (BMC) in both groups. The infliximab group had a significant increase in lumbar bone area (4.15%±6.6%), BMC (12.8%±13.6%) and bone mineral density (8.13%±7.7%) between both evaluations (interval 22.6±11 months) compared with the control group. The increase in BMC in patients who had received infliximab treatment was significant when compared with control patients who had received glucocorticoids (n=8) or had evidence of disease activity (n=13).

CONCLUSION: Infliximab therapy improved lumbar bone mass independent of nutritional status. This finding suggests that TNFα plays a role in bone loss in CD.
Colonic Malakoplakia in a Liver Transplant Recipient
Authors: Kim Peter TW , Davis Jennifer E , Erb Siegfried R , Yoshida Eric M , Steinbrecher Urs P
Published: March 2016

Malakoplakia is a rare inflammatory condition seen in transplant patients. There are two previously reported cases of malakoplakia involving the gastrointestinal tract in liver transplant patients. The present paper reports a case of colonic malakoplakia in a 58-year-old woman, a liver transplant recipient who was receiving immunosuppressive drugs. She presented with chronic diarrhea while on tacrolimus. There was no history of antecedent infection. Colonoscopy showed patchy mucosal edema, but no discrete yellow plaques or nodules. The diagnosis was made by colon biopsies, which showed chronic inflammation with many histiocytes containing Michaelis-Gutmann bodies. Although rare, malakoplakia is one of many potential causes of diarrhea in a transplant patient. The present case indicates that malakoplakia may be associated with chronic diarrhea, even if there are no macroscopic lesions seen during colonoscopy.
Pregabalin‐Induced Remission in a 62‐Year‐Old Woman with a 20‐Year History of Vulvodynia
Authors: Jerome Laurence
Published: March 2016

A case of a 62‐year‐old woman presenting with a 20‐year history of vulvodynia previously unresponsive to medical treatment is described. The epidemiology, phenomenology and medical management of vulvodynia is reviewed. The case presentation illustrates the role of pregabalin in successful medical management of this chronic pain disorder, as well as the management of common psychiatric morbidities associated with this condition.
An Assessment of Endoscopic and Concomitant Management of Acute Variceal Bleeding at a Tertiary Care Centre
Authors: Singh H , Targownik LE , Ward G , Minuk GY , Bernstein CN
Published: March 2016

BACKGROUND: Several therapies have been demonstrated to be beneficial in the management of acute variceal bleeding (AVB). The aim of the present study was to characterize the use of these therapies at a Canadian tertiary care centre.

PATIENTS AND METHODS: A comprehensive chart review was performed to assess the management of all adult cirrhotic patients with AVB who were admitted to a university-affiliated, tertiary care centre between April 2001 and March 2004.

RESULTS: A total of 81 AVB patients were identified with a mean age of 53.7±13.2 years and a median model for end-stage liver disease score of 14. Endoscopy was performed within 8.2±7.6 h of admission. Variceal banding was performed for 87% of patients with esophageal varices, which were the most common source of bleeding (80%). Octreotide was used in 82% of patients for a mean duration of 74.3±35.4 h; prophylactic antibiotics were used in 25% of patients and beta-blockers were used in 24% of patients without any contraindications. Follow-up endoscopy was arranged for 46 of 71 (65%) survivors. Prophylactic antibiotic use was associated with the presence of ascites, while beta-blockers were used more often in the last year of the study.

CONCLUSIONS: There is a disconnection between the use of evidence-based recommendations and routine clinical practices in the management of AVB. Deficiencies identified include the lack of use of prophylactic antibiotics and beta-blockers, variable use of octreotide and inadequate follow-up recommendations. There is a need to identify measures to improve the process of care for patients with AVB which would ensure optimal management of these patients.