bluuebunny/crossref_metadata_2025 huggingface dataset:
Adaptation of the Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) into French‐Canadian and English‐Canadian
Authors: Coffin Donna , Duval Karine , Martel Simon , Granton John , Lefebvre Marie-Claude , Meads David M , Twiss James , McKenna Stephen P
Published: March 2016

BACKGROUND: The Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) is the first disease‐specific instrument for assessing patient‐reported symptoms, functioning and quality of life (QoL) in pulmonary arterial hypertension (PAH).

OBJECTIVES: To create and validate French‐Canadian (FC) and English‐Canadian (EC) language versions of the CAMPHOR.

METHODS: A translation panel (for the FC version) and lay panels (for both versions) were convened to adapt the questionnaires (dual‐panel methodology). Subsequently, these new questionnaires were field‐tested in 15 FC PAH and 15 EC PAH patients. Finally, in a postal validation study, the new language versions of the CAMPHOR underwent psychometric evaluation in 41 FC and 52 EC PAH patients to test for reliability and validity.

RESULTS: The FC and EC field‐test interview participants found the questionnaires relevant, comprehensible and easy to complete. Psychometric analyses showed that the FC and EC adaptations were successful. High test‐retest coefficients for the scales after controlling for change in respondent’s QoL (FC: 0.92 to 0.96; EC: 0.85 to 0.99) indicated a high degree of reliability. The FC and EC CAMPHOR scales had good internal consistency (Cronbach’s alpha coefficients 0.90 to 0.92 and 0.88 to 0.92, respectively). Predicted correlations with the Nottingham Health Profile provided evidence of the construct validity of the FC and EC scales. The FC and EC adaptations also showed known groups validity.

CONCLUSIONS: The FC and EC adaptations of the CAMPHOR have been shown to be reliable and valid for measures of health‐related QoL and QoL in PAH, and thus can be recommended for use in clinical studies and routine practice in PAH.
Nonsurgical Management of an Impacted Mechanical Lithotriptor with Fractured Traction Wires: Endoscopic Intracorporeal Electrohydraulic Shock Wave Lithotripsy Followed by Extra-Endoscopic Mechanical Lithotripsy
Authors: Attila Tan , May Gary R , Kortan Paul
Published: March 2016

In a patient with a mid-common bile duct stone, the traction wires of a mechanical lithotriptor snapped, resulting in lithotriptor basket impaction. Simultaneous occurrence of these two potential complications of endoscopic stone extraction is very rarely reported. Extracorporeal shock wave lithotripsy failed to fragment the stone entrapped within the impacted basket. Endoscopic intracorporeal electrohydraulic shock wave lithotripsy successfully fragmented the stone under direct visualization through a cholangioscope. The entrapped stone within the basket could subsequently be pulled into the supra-ampullary bile duct for the final fragmentation with an extra-endoscopic mechanical lithotriptor cable. The present report is the first to describe a safe and effective use of endoscopic intracorporeal electrohydraulic shock wave lithotripsy followed by extra-endoscopic mechanical lithotripsy in the management of an impacted lithotriptor basket.
Association between Proton Pump Inhibitors and Respiratory Infections: A Systematic Review and Meta-Analysis of Clinical Trials
Authors: Sultan Nabil , Nazareno Jose , Gregor James
Published: March 2016

BACKGROUND: Proton pump inhibitors (PPIs) have become the mainstay of treatment for and prevention of many serious gastrointestinal diseases. Laboratory and clinical evidence suggests that the increase in gastric pH caused by PPIs may be linked to increased bacterial colonization of the stomach and may predispose patients to an increased risk for respiratory infections.

OBJECTIVE: To examine the association between PPI treatment and respiratory infections.

METHODS: A literature search was conducted using PubMed, MEDLINE and Cochrane databases of randomized, placebo-controlled trials evaluating the efficacy of PPIs. Studies that listed and quantified the specific adverse events of ‘respiratory infection’ or ‘upper respiratory infection’ (or equivalent), and compared their rates between PPIs and placebo were included. The χ2analysis was used to calculate the significance of association in individual studies and a meta-analysis of the selected studies was performed.

RESULTS: Of 7457 studies initially identified and 70 relevant randomized, controlled trials (RCTs) selected, seven studies met the inclusion criteria. A total of 16 comparisons for χ2analysis were possible given the multiple dosage arms used in several studies. PPIs included in the studies were esomeprazole, rabeprazole, pantoprazole and omeprazole. More than one-half of the studies showed a trend toward an association between PPI use and respiratory infections, although the majority of the studies failed to show a significant correlation. A single study using high-dose esomeprazole (40 mg) showed a significant association – 4.3% rate of respiratory infections in the active group compared with 0% in the placebo group (P<0.05). Meta-analysis showed a trend toward an association between PPIs and respiratory infections, although it failed to reach significance (OR 1.42, 95% CI 0.86 to 2.35; P=0.17).

CONCLUSION: Although a trend was evident in both a χ2analysis of individual studies and a meta-analysis, the present review and meta-analysis failed to show a conclusive association between PPIs and respiratory infections. Very few RCTs actively sought out respiratory infections, which excluded the majority of RCTs identified. A well-structured, placebo-controlled prospective study would be needed to determine whether a true association between PPIs and respiratory infections exists.
Posaconazole: A New Agent for the Prevention and Management of Severe, Refractory or Invasive Fungal Infections
Authors: Page Andrea V , Liles W Conrad
Published: March 2016

Posaconazole is the newest antifungal agent to be approved for use in Canada. With excellent in vitro activity against a broad spectrum of yeasts and filamentous fungi, as well as having a well‐tolerated oral formulation, posaconazole offers many potential advantages. Of particular interest are its seemingly lower potential for cross‐resistance with other azoles and its activity (unique among oral antifungal agents) against the zygomycetes. As the incidence of both common and uncommon fungal infections increases commensurate with the growing population of immunocompromised individuals, posaconazole may ultimately become an important therapeutic option. The present article reviews the in vitro and in vivo data describing its activity, and focuses on both the proven and the potential clinical applications of this new triazole agent.
Antimicrobial Stewardship in Acute Care Centres: A Survey of 68 Hospitals in Quebec
Authors: Nault Vincent , Beaudoin Mathieu , Thirion Daniel JG , Gosselin Michel , Cossette Benoit , Valiquette Louis
Published: March 2016

BACKGROUND: Antimicrobial stewardship programs (ASPs) and quantitative monitoring of antimicrobial use are required to ensure that antimicrobials are used appropriately in the acute care setting, and have the potential to reduce costs and limit the spread of antimicrobial‐resistant organisms and Clostridium difficile. Currently, it is not known what proportion of Quebec hospitals have an ASP and/or monitor antimicrobial use.

OBJECTIVES: To determine what proportion of Quebec hospitals have an ASP, and what is the nature of such a program.

METHODS: A detailed questionnaire was sent to the pharmacy directors of all acute care hospitals in the province of Quebec. Information was collected on antimicrobial surveillance; antimicrobial stewardship and resource allocation to these areas were assessed.

RESULTS: Questionnaires were completed for 68 of 81 (84%) hospitals contacted. ASPs were identified at 50 (74%) hospitals, but only 20 (29%) of hospitals had a quantitative antimicrobial surveillance program (QASP) in 2006. Academic centres (P=0.03) and hospitals with over 200 beds (P=0.02) were more likely to have a QASP. Even among hospitals with an ASP, 18% had less than one full‐time pharmacist for a QASP.

CONCLUSIONS: Over one‐quarter of Quebec hospitals do not have an ASP, and few hospitals in Quebec are currently evaluating their use of antimicrobials on a quantitative basis. In some cases, the lack of a QASP may be due to the allocation of insufficient pharmaceutical resources to antimicrobial stewardship (ie, less than one full‐time pharmacist).
Endoscopic Transcolonic Catheter-Free Pelvic Abscess Drainage
Authors: Alis Halil , Soylu Aliye , Dolay Kemal , Aygun Ersan
Published: March 2016

Natural orifice transluminal endoscopic surgery is a novel therapeutic method in development that uses different routes of surgical approach. The use of various methods, instruments and accessories during this procedure are currently being investigated. A case of appendicitis-related intra-abdominal abscess that was resolved by a transcolonic endoscopic approach using a wide-channel colonoscope with the help of precut and standard sphincterotome without radiological percutaneous drainage is presented.
Esophageal pH Testing in Patients Refractory to Proton Pump Inhibitor Therapy
Authors: MacKalski Barbara A , Ilnyckyj Alexandra
Published: March 2016

BACKGROUND: Proton pump inhibitors (PPIs) are the most potent drugs available for the management of gastroesophageal reflux disease (GERD). Ambulatory 24 h pH monitoring is often recommended for patients experiencing symptoms despite PPI therapy. Recent pivotal data suggest that pH studies are predictably normal in this setting, casting doubt on the clinical utility of the current practice.

OBJECTIVE: To describe 24 h pH findings in patients referred by gastrointestinal specialists for the indication of GERD refractory to PPI therapy.

METHODS: A retrospective review was performed, examining all patients undergoing ambulatory esophageal pH monitoring at the St Boniface General Hospital Motility Laboratory, between January 2002 and June 2005. Tests performed in patients clinically suspected of having GERD who were not responding to PPI therapy formed the study group. pH data were analyzed for the total, upright and supine periods. Abnormal reflux parameters were defined by applying three criteria: DeMeester score greater than 14.72; pH less than 4.0 more than 5.5% of the total time, more than 8.3% of the time upright or more than 3% of the time in the supine position; and pH less than 4.0 for more than 1.6% of the total time.

RESULTS: A total of 417 patients underwent pH monitoring during the time of the review. One hundred seven patients (mean age 51.7 years; 37 men and 70 women) met study criteria. Sixty-eight (63.6%) were referred by a gastroenterologist and 39 (36.4%) were referred by a gastroenterologist surgeon. Sixty-one patients were on twice-daily PPIs and 46 were on once-daily dosing. Using the most stringent pH criteria, namely criteria 2, pH readings were abnormal in 30% of patients on once-daily PPIs and in 25% of patients on twice-daily dosing. The prevalence of abnormal pH readings were even higher if criteria 1 or 3 were applied.

CONCLUSIONS: In a patient population assessed by a specialist as having clinically suspected GERD that is not responding to PPI therapy, a substantial number of patients will have abnormal esophageal pH test results. The role of pH testing in the algorithm of GERD is evolving; however, our data suggests that an abandonment of pH testing is premature.
Spinal Epidural Abscess – A Rare Complication of Inflammatory Bowel Disease
Authors: Brown Carl J , Jaffer Hussein , Jaffer Nasir , Burul Claude , McLeod Robin S
Published: March 2016

Spinal epidural abscess is an uncommon but highly morbid illness. While it usually afflicts older, immunocompromised patients, this condition has been reported as a result of intestinal perforation in the setting of inflammatory bowel disease. Two cases of spinal epidural abscess in patients with inflammatory bowel disease are reported: one in a patient with Crohn’s disease and one in a patient with ulcerative colitis after restorative proctocolectomy.
Effects of Aerobic Exercise Training and Irbesartan on Blood Pressure and Heart Rate Variability in Patients with Chronic Obstructive Pulmonary Disease
Authors: Marquis Karine , Maltais François , Lacasse Yves , Lacourcière Yves , Fortin Claudette , Poirier Paul
Published: March 2016

BACKGROUND AND OBJECTIVES: The present pilot study was undertaken to evaluate the efficacy of an aerobic exercise training (AET) program alone or combined with an antihypertensive agent (irbesartan) to reduce blood pressure (BP) and enhance heart rate variability (HRV) in chronic obstructive pulmonary disease patients.

METHODS: Twenty‐one patients were randomly assigned to a double‐blind treatment with exercise and placebo (n=11) or exercise and irbesartan (n=10). Subjects underwent 24 h BP monitoring and 24 h electrocardiographic recording before and after the 12‐week AET. HRV was investigated using three indexes from the power spectral analysis and three indexes calculated from the time domain. The AET program consisted of exercising on a calibrated ergocycle for 30 min three times per week. Five patients in the placebo group were excluded during follow‐up because they were not compliant.

RESULTS: There was no change in 24 h systolic and diastolic BP before (130±14 mmHg and 70±3 mmHg, respectively) and after (128±8 mmHg and 70±8 mmHg, respectively) exercise training in the placebo group, whereas in the irbesartan group systolic and diastolic BP decreased from 135±9 mmHg and 76±9 mmHg to 126±12 mmHg and 72±8 mmHg, respectively (P<0.02). There were no changes in HRV parameters in either group.

CONCLUSIONS: The present study suggests that a 12‐week AET program is not associated with a significant reduction in BP or enhancement in HRV, whereas an AET program combined with irbe‐sartan is associated with a reduction in 24 h BP.
Residual Hemothorax after Chest Tube Placement Correlates with Increased Risk of Empyema Following Traumatic Injury
Authors: Karmy-Jones Riyad , Holevar Michele , Sullivan Ryan J , Fleisig Ani , Jurkovich Gregory J
Published: March 2016

BACKGROUND: Empyema complicates tube thoracostomy following trauma in up to 10% of cases. Studies of potential risk factors of empyema have included use of antibiotics, site of injury and technique of chest tube placement. Residual fluid has also been cited as a risk factor for empyema, although the imaging technique to identify this varies.

OBJECTIVE: To determine whether residual hemothorax detected by chest x‐ray (CXR) after one or more initial chest tubes predicts an increased risk of empyema.

METHODS: A study of patients admitted to two level I trauma centres between January 7, 2004, and December 31, 2004, was conducted. All patients who received a chest tube in the emergency department, did not undergo thoracotomy within 24 h, and survived more than two days were followed. Empyema was defined as a pleural effusion with positive cultures, and a ratio of pleural fluid lactate dehydrogenase to serum lactate dehydrogenase greater than 0.6 in the setting of elevated leukocyte count and fever. Factors analyzed included the presence of retained hemothorax on CXR after the most recent tube placement in the emergency room, age, mechanism of injury and injury severity score.

RESULTS: A total of 102 patients met the criteria. Nine patients (9%) developed empyema: seven of 21 patients (33%) with residual hemothorax developed empyema versus two of 81 patients (2%) without residual hemothorax developed empyema (P=0.001). Injury severity score was significantly higher in those who developed empyema (31.4±26) versus those who did not (22.6±13; P=0.03).

CONCLUSIONS: The presence of residual hemothorax detected by CXR after tube thoracostomy should prompt further efforts, including thoracoscopy, to drain it. With increasing injury severity, there may be increased benefit in terms of reducing empyema with this approach.
Double-Balloon Enteroscopy following Capsule Endoscopy in the Management of Obscure Gastrointestinal Bleeding: Outcome of a Combined Approach
Authors: Kamalaporn Patarapong , Cho Sarah , Basset Nancy , Cirocco Maria , May Gary , Kortan Paul , Kandel Gabor , Marcon Norman
Published: March 2016

BACKGROUND: There is no consensus on the relative accuracy of capsule endoscopy (CE) versus double-balloon enteroscopy (DBE) to investigate obscure gastrointestinal bleeding (GIB). CE is less invasive, but DBE more directly examines the small bowel, and allows tissue sampling plus therapeutic intervention.

OBJECTIVES: To evaluate the yield and outcome of DBE following CE in patients with obscure GIB.

METHODS: After DBE became readily available at the Centre for Therapeutic Endoscopy and Endoscopic Oncology (St Michael’s Hospital, Toronto, Ontario), all patients with obscure GIB seen from December 2002 to June 2007 were evaluated identically, first with CE, then with DBE (some with further interventions). Findings, adverse outcomes and interventions are reported.

RESULTS: Fifty-one patients (25 women) with a mean (range) age of 64.1 years (34 to 83 years) are reported. Eight patients underwent DBE twice, for a total of 59 DBEs. Fourteen patients had overt GIB and the median (range) number of red blood cell unit transfusions was 10 (0 to 100). The positive findings for each type of lesion were compared in these 51 patients: angiodysplasia (CE 64.7% and DBE 61%, P=0.3), ulcers (CE 19.6% and DBE 18.6%, P=0.5), bleeding lesions (CE 43.1% and DBE 15.3%, P=0.0004) and mass (CE 10.2% and DBE 8.5%, P=0.5). DBE provided the advantage of therapeutic intervention: argon plasma coagulation (33 of 59 DBEs), clipping (two of 59), both argon plasma coagulation and clipping (three of 59), polypectomy (two of 59), tattooing (52 of 59) and biopsies (11 of 59). DBE detected lesions not seen by CE in 21 patients; lesions were treated in 18 patients. However, CE detected 31 lesions not seen by DBE. No major complications occurred with either examination.

CONCLUSION: Overall detection rates for both techniques are similar. Each technique detected lesions not seen by the other. These data suggest that CE and DBE are complementary and that both evaluate obscure GIB more fully than either modality alone.
Cost Analysis of Monitoring Asthma Treatment using Sputum Cell Counts
Authors: D’silva Liesel , Gafni Amiram , Thabane Lehana , Jayaram Lata , Hussack Pat , Hargreave Frederick E , Nair Parameswaran
Published: March 2016

BACKGROUND: In a four‐centre trial, the use of sputum cell counts (sputum strategy [SS]) to guide treatment had resulted in fewer and less severe exacerbations without the need for a higher corticosteroid dose, compared with the use of symptoms and spirometry (clinical strategy [CS]).

OBJECTIVE: To compare the cost of the SS with the CS in the treatment of patients with moderate to severe asthma.

METHODS: In 39 patients (19 in the SS, 20 in the CS) from one of the centres, the cost (third‐party payer) of the two treatment strategies was compared. Resource use data were collected using a structured questionnaire. Corresponding unit costs in 2006 Canadian dollars were obtained.

RESULTS: The clinical characteristics of the patients were similar to the study population at the four centres. In the SS, the number of visits to a family physician for health disorders indirectly related to asthma (P=0.003) and the amount of inhaled long‐acting beta‐agonists (P=0.007) were less than that of the CS. While the total estimated median cost per patient for spirometry ($393; range $299 to $487) was less than that for sputum induction ($1,008; range $907 to $1,411), the total cost of the SS ($2,265; range $1,466 to $4,347) was less than that of the CS ($3369; range $2208 to $3927) (P=0.216). This cost difference was due to lower costs of physician and hospital visits and services (P=0.078), of inhaled short‐acting bronchodilators (P=0.067), of long‐acting beta‐agonists (P=0.002) and of inhaled corticosteroids (P=0.064) in the SS.

CONCLUSION: In patients with moderate to severe asthma, the use of sputum cell counts to guide treatment is more effective and is likely to be less costly than management using symptoms and spirometry.
DSM‐IV‐TR “Pain Disorder Associated with Psychological Factors” as a Nonhysterical Form of Somatization
Authors: Aragona Massimiliano , Tarsitani Lorenzo , De Nitto Serena , Inghilleri Maurizio
Published: March 2016

BACKGROUND: Elevated Minnesota Multiphasic Personality Inventory (MMPI) scores on the hysteria (Hy) scale are reported in several forms of pain. Previous results were possibly biased by diagnostic heterogeneity (psychogenic, somatic and mixed pain syndromes included in the same index sample) or Hy heterogeneity (failure to differentiate Hy scores into clinically meaningful sub‐scales, such as admission of symptoms [Ad] and denial of symptoms [Dn]).

METHODS: To overcome this drawback, 48 patients diagnosed as having a Diagnostic and Statistical Manual of Mental Disorders, 4th edn, Text Revision (DSM‐IV‐TR) diagnosis of “pain disorder associated with psychological factors” were compared with 48 patients experiencing somatic pain excluding psychological factors, and 42 somatic controls without pain.

RESULTS: MMPI Hy and hypochondriasis (Hs) scores were significantly higher in the pain disorder group than in control groups, who scored similarly. MMPI correction (K) scores and Dn scores were similar in the three groups, whereas Ad was significantly higher in the pain disorder group and lower and similar in the two control groups, respectively. In the pain disorder group, Ad and Dn were negatively correlated, whereas in control groups they were unrelated.

CONCLUSIONS: These findings suggest that whereas a pattern of high Hs and Hy scores together with a normal K score might characterize patients with a pain disorder associated with psychological factors, elevated Hy scores per se do not indicate hysterical traits. In the pain disorder group, elevated Hy scores reflected the Ad subscale alone, indicating a strikingly high frequency of distressing somatic symptoms. They tend not to repress or deny the emotional malaise linked to symptoms, as the hysterical construct expects. The pain disorder designation should be considered a nonhysterical form of somatization.
Depression Augments Activity‐Related Pain in Women but not in Men with Chronic Musculoskeletal Conditions
Authors: Adams Heather , Thibault Pascal , Davidson Nicole , Simmonds Maureen , Velly Ana , Sullivan Michael JL
Published: March 2016

OBJECTIVES: The primary objective of the present study was to examine the role of sex as a moderator of the relation between depression and activity‐related pain.

METHODS: The study sample consisted of 83 participants (42 women, 41 men) with musculoskeletal conditions. Participants were asked to lift a series of 18 canisters that varied in weight (2.9 kg, 3.4 kg and 3.9 kg) and distance from the body. Participants were asked to rate their pain while they lifted each canister and estimate the weight of the canisters.

RESULTS: Consistent with previous research, the relations among depression, pain intensity and disability were stronger for women than for men. ANOVA revealed that depression was associated with more intense activity‐related pain in women only. For both women and men, the intensity of pain increased with each trial, although the weight of the objects lifted remained constant. Neither sex nor depression had an effect on participants’ weight estimates.

CONCLUSIONS: The present discussion addresses the mechanisms through which depression may differentially affect pain in women and men. It also addresses the potential clinical implications of pain‐augmenting effects of depression in women.
Efficacy of Argon Plasma Coagulation Compared with Topical Formalin Application for Chronic Radiation Proctopathy
Authors: Alfadhli AA , Alazmi WM , Ponich T , Howard JM , Prokopiw I , Alaqeel A , Gregor JC
Published: March 2016

BACKGROUND: Chronic radiation proctopathy (CRP) is a troublesome complication of radiotherapy to the pelvis for which current treatment modalities are suboptimal. Currently, the application of formalin to the rectal mucosa (AFR) and thermal ablation with argon plasma coagulation (APC) are the most promising options.

OBJECTIVE: To compare the efficacy and safety of AFR with APC for CRP.

PATIENTS AND METHODS: Records of 22 patients (male to female ratio, 19:3; mean age, 74 years) who received either APC or AFR for chronic hematochezia caused by CRP, and who were evaluated and treated between May 1998 and April 2002, were reviewed. Complete evaluations were made three months after completion of each therapeutic modality. Patients were considered to be responders if there was a 10% increase in hemoglobin from baseline or complete normalization of hemoglobin (male patients, higher than 130 g/L; female patients, higher than 115 g/L) without the requirement for blood transfusion.

RESULTS: The mean hemoglobin level before therapy was 107 g/L. Patients received an average of 1.78 sessions for APC and 1.81 sessions for AFR. Eleven patients (50%) were treated with APC alone, eight patients (36%) with AFR alone and three (14%) with both modalities (two with AFR followed by APC, and one with APC followed by AFR). Eleven of 14 patients (79%) in the APC group were responders, compared with three of 11 patients (27%) in the AFR group (P=0.017). In the APC group, seven of 11 responders required only a single session, while in the AFR group, only one patient responded after a single session. Adverse events (nausea, vomiting, flushing, abdominal cramps, rectal pain and fever) occurred in two patients after APC and in nine patients after AFR (P=0.001). In the APC group, the mean hemoglobin level increase was 20 g/L at three months follow-up, compared with 14 g/L in the AFR group.

CONCLUSION: This retrospective study suggests that APC is more effective and safe than topical AFR to control hematochezia caused by CRP. Further studies are needed to confirm this observation.
Role of Plasmapheresis in the Treatment of Severe Pruritus in Pregnant Patients with Primary Biliary Cirrhosis: Case Reports
Authors: Alallam Alallam , Barth David , Heathcote E Jenny
Published: March 2016

BACKGROUND: Primary biliary cirrhosis (PBC) may be associated with pruritus and, when present, may be accentuated during pregnancy. Several therapeutic modalities have been used to control itching caused by cholestasis, with variable responses. Drug therapies are ill-advised, particularly in early pregnancy. Plasmapheresis has been successful in controlling pruritus in patients with cholestasis. The use of plasmapheresis to alleviate severe life-threatening pruritus during pregnancy is reported in two patients with PBC.

CASE PRESENTATIONS: Two patients with PBC presented during their second trimester of pregnancy with severe pruritus that did not respond to the anion exchange resin cholestyramine. Their symptoms were disabling to the point that one patient had suicidal ideation. Given the severity of their symptoms, multiple sessions of plasmapheresis were instituted with good control of pruritus. Both patients tolerated the procedure well and delivered healthy babies.

CONCLUSION: Plasmapheresis is a relatively safe and rapidly effective treatment for severe pruritus during pregnancy in patients with PBC.
Empyema: An Increasing Concern in Canada
Authors: Finley Christian , Clifton Joanne , FitzGerald J Mark , Yee John
Published: March 2016

BACKGROUND: Empyema is a suppurative infection of the pleural space. Without prompt treatment, it can result in significant hospital stays, more invasive treatments as it progresses, and substantial morbidity and mortality.

OBJECTIVES: The primary objective of the present study was to evaluate whether there has been an increasing incidence of empyema in Canada. A secondary objective was to investigate whether this increase disproportionately affects any age group.

METHODS: The Discharge Abstract Database of the Canadian Institute for Health Information was used to evaluate national empyema data.

RESULTS: There were 11,294 patients identified with empyema over the nine‐year period of the present study, of whom 31% were women. The mean (± SD) length of stay was stable throughout the study at 21.82±33.88 days, and 63.4% were discharged home. The incidence rate ratio (IRR) was defined as the ratio of the incidence rate of medical empyema in 2003 divided by the incidence rate in 1995. Medical empyema increased significantly (IRR 1.30, 95% CI 1.20 to 1.41; P<0.001), as did empyema of unknown cause (IRR 1.29, 95% CI 1.08 to 1.54; P=0.005), while surgical empyema did not appear to increase (IRR 1.17, 95% CI 0.97 to 1.43; P=0.114). A Poisson regression showed an increase in the indirect age‐standardized IRR during the study period (IRR 1.025, 95% CI 1.018 to 1.032; P<0.001). The IRR for patients younger than 19 years of age from 1995 to 2003 was 2.20 (95% CI 1.56 to 3.10), while the IRR in patients older than 19 years was 1.23 (95% CI 1.14 to 1.34).

CONCLUSIONS: The present study demonstrates the increasing rate of empyema in Canada and shows a change in pattern of disease. The disproportionate rate change in the pediatric population suggests a high‐risk group that needs to be addressed. In the adult population, while cause is unknown, it is necessary to continually educate front‐line physicians to confront both the increased burden of this disease, caused by an aging population, and the underlying increasing rate of empyema in Canada.
Chronic Pain Assessment: A Seven‐Factor Model
Authors: Davidson Megan A , Tripp Dean A , Fabrigar Leandre R , Davidson Paul R
Published: March 2016

BACKGROUND: There are many measures assessing related dimensions of the chronic pain experience (eg, pain severity, pain coping, depression, activity level), but the relationships among them have not been systematically established.

OBJECTIVE: The present study set out to determine the core dimensions requiring assessment in individuals with chronic pain.

METHODS: Individuals with chronic pain (n=126) completed the Beck Anxiety Inventory, Beck Depression Inventory, Beck Hopelessness Scale, Chronic Pain Coping Index, Multidimensional Pain Inventory, Pain Catastrophizing Scale, McGill Pain Questionnaire – Short Form, Pain Disability Index and the Tampa Scale of Kinesiophobia.

RESULTS: Before an exploratory factor analysis (EFA) of the nine chronic pain measures, EFAs were conducted on each of the individual measures, and the derived factors (subscales) from each measure were submitted together for a single EFA. A seven‐factor model best fit the data, representing the core factors of pain and disability, pain description, affective distress, support, positive coping strategies, negative coping strategies and activity.

CONCLUSIONS: Seven meaningful dimensions of the pain experience were reliably and systematically extracted. Implications and future directions for this work are discussed.
Clinical Manifestations and Treatment of Adult‐Onset Asthma and Periocular Xanthogranuloma
Authors: Cavallazzi Rodrigo , Hirani Amyn , Vasu Tajender S , Sergott Robert C , Bilyk Jurij R , Eagle Ralph C , Weibel Sandra
Published: March 2016

BACKGROUND: Adult‐onset asthma and periocular xanthogranuloma is an uncommon and recently described disease. Little is known about the condition because only a few case reports and series are available.

OBJECTIVE/METHODS: To describe the clinical manifestations, lung physiology, and response to systemic treatment of three patients with adult‐onset asthma and periocular xanthogranuloma, followed by a review of the literature.

RESULTS: Three men, with an age at diagnosis ranging from 48 to 51 years, presented with right periorbital swelling, asthma and chronic rhinosinusitis. The patients’ lung physiology was consistent with airway obstruction. Diagnosis was established by periorbital biopsy. All patients received oral corticosteroids for their periorbital swelling, without significant clinical response. Two patients received oral methotrexate, with nearly complete resolution of periorbital swelling. A third patient received oral azathioprine, without clinical response. The three patients had improvement of their asthma with inhaled steroids/long‐acting bronchodilator, and immunosuppressive medication.

CONCLUSION: A triad consisting of periorbital swelling, asthma and chronic rhinosinusitis should raise the suspicion of adult‐onset asthma and periocular xanthogranuloma. Oral methotrexate should be considered as an alternative to corticosteroids in the treatment of this disorder.
Effects of Virtual Reality Immersion and Audiovisual Distraction Techniques for Patients with Pruritus
Authors: Leibovici Vera , Magora Florella , Cohen Sarale , Ingber Arieh
Published: March 2016

BACKGROUND: Virtual reality immersion (VRI), an advanced computer‐generated technique, decreased subjective reports of pain in experimental and procedural medical therapies. Furthermore, VRI significantly reduced pain‐related brain activity as measured by functional magnetic resonance imaging. Resemblance between anatomical and neuroendocrine pathways of pain and pruritus may prove VRI to be a suitable adjunct for basic and clinical studies of the complex aspects of pruritus.

OBJECTIVES: To compare effects of VRI with audiovisual distraction (AVD) techniques for attenuation of pruritus in patients with atopic dermatitis and psoriasis vulgaris.

METHODS: Twenty‐four patients suffering from chronic pruritus – 16 due to atopic dermatitis and eight due to psoriasis vulgaris – were randomly assigned to play an interactive computer game using a special visor or a computer screen. Pruritus intensity was self‐rated before, during and 10 min after exposure using a visual analogue scale ranging from 0 to 10. The interviewer rated observed scratching on a three‐point scale during each distraction program.

RESULTS: Student’s t tests were significant for reduction of pruritus intensity before and during VRI and AVD (P=0.0002 and P=0.01, respectively) and were significant only between ratings before and after VRI (P=0.017). Scratching was mostly absent or mild during both programs.

CONCLUSIONS: VRI and AVD techniques demonstrated the ability to diminish itching sensations temporarily. Further studies on the immediate and late effects of interactive computer distraction techniques to interrupt itching episodes will open potential paths for future pruritus research.
Risk Factors and Outcomes Associated with Chronic Obstructive Pulmonary Disease Exacerbations Requiring Hospitalization
Authors: Bahadori Katayoun , FitzGerald J Mark , Levy Robert D , Fera Tharwat , Swiston John
Published: March 2016

BACKGROUND: Acute respiratory exacerbations are the most frequent cause of medical visits, hospitalization and death for chronic obstructive pulmonary disease (COPD) patients and, thus, exert a significant social and economic burden on society.

OBJECTIVE: To identify the risk factors associated with hospital readmission(s) for acute exacerbation(s) of COPD (AECOPD).

METHODS: A review of admission records from three large urban hospitals in Vancouver, British Columbia, identified 310 consecutive patients admitted for an AECOPD between April 1, 2001, and December 31, 2002. Logistic regression analysis was performed to identify risk factors for readmissions following an AECOPD.

RESULTS: During the study period, 38% of subjects were readmitted at least once. The mean (± SD) duration from the index admission to the first readmission was 5±4.08 months. Comparative analysis among the three hospitals identified a significant difference in readmission rates (54%, 36% and 18%, respectively). Logistic regression analysis revealed that preadmission home oxygen use (OR 2.55; 95%CI 1.45 to 4.42; P=0.001), history of a lung infection within the previous year (OR 1.73; 95% CI 1.01 to 2.97; P=0.048), other chronic respiratory disease (OR 1.78; 95% CI 1.06 to 2.99; P=0.03) and shorter length of hospital stay (OR 0.97; 95% CI 0.945 to 0.995; P=0.021) were independently associated with frequent readmissions for an AECOPD.

CONCLUSIONS: Hospital readmission rates for AECOPD were high. Only four clinical factors were found to be independently associated with COPD readmission. There was significant variability in the readmission rate among hospitals. This variability may be a result of differences in the patient populations that each hospital serves or may reflect variability in health care delivery at different institutions.
A Noninvasive Imaging Technique to Evaluate Therapeutic Efficacy after Injection of n-Butyl-2-cyanoacrylate Tissue Adhesive into Gastric Varices: A Case Report
Authors: Spier Bret J , Taylor Andrew J , Pfau Patrick R , Said Adnan , Gopal Deepak V
Published: March 2016

A novel use of multidetector computed tomographic intravenous (MDCT IV) portography in the evaluation of gastric varices treated with tissue adhesive is described. A 55-year-old man presented with upper gastrointestinal hemorrhage as a result of bleeding gastric varices. The patient was stabilized and the gastric varices were treated with n-butyl-2-cyanoacrylate (two injections, total 7.5 mL). MDCT IV portography performed after injection revealed thrombosis of all but one of the submucosally based gastric varices. The endoscopist who performed repeat endoscopy three weeks later was then able to direct therapy at the remaining patent submucosally based gastric varix. This represents the first reported use of MDCT IV portography in the evaluation of treatment adequacy in a patient with gastric varices treated with n-butyl-2-cyanoacrylate.
Does Onsite Cytotechnology Evaluation Improve the Accuracy of Endoscopic Ultrasound-Guided Fine-Needle Aspiration Biopsy?
Authors: Alsohaibani Fahad , Girgis Safwat , Sandha Gurpal Singh
Published: March 2016

BACKGROUND: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the preferred modality for the cytological diagnosis of various cancers. Onsite cytopathology interpretation is not available in most centres.

OBJECTIVE: To assess whether the the adequacy of tissue sampling assessed by an onsite cytotechnologist improves the diagnostic accuracy of EUS-FNA.

METHODS: The present study is a retrospective review of all patients undergoing solid mass EUS-FNA between September 2005 and August 2007. Patients in group I (September 2005 to August 2006) had cytology slides prepared by an endoscopy nurse. Patients in group II (September 2006 to August 2007) had cytology slides prepared, stained and assessed for adequacy of tissue sampling by a cytotechnologist in the endoscopy suite. The final cytopathological diagnosis (definitely positive, definitely negative or inconclusive) was compared between the two groups.

RESULTS: A total of 49 EUS-FNA procedures were performed in 47 patients in group I and 60 EUS-FNA procedures in 55 patients in group II. Pancreatic masses were the most common target site in both groups. The total number of needle passes was 105 in group I (mean 2.14 passes per patient; range one to five needle passes) and 158 in group II (mean 2.63 passes per patient; range one to four needle passes). The difference in the number of needle passes was not statistically significant between groups. The final diagnosis was definite in 53% in group I compared with 77% in group II (P=0.01). The percentage of inconclusive diagnoses was 47% in group I and 23% in group II (P=0.001).

CONCLUSION: Onsite cytotechnologist interpretation of adequacy of tissue sampling significantly improves the diagnostic yield of EUS-FNA. This appears to be independent of the total number of needle passes undertaken for tissue sampling.
Assessment of Chronic Pain in Children: Current Status and Emerging Topics
Authors: Palermo Tonya Mizell
Published: March 2016

The present paper reviews the current status of research on assessment of chronic pain in children and adolescents, primarily in the context of treatment outcome research. Two specific primary aims are addressed. First, the degree of attention devoted to several major domains of chronic pain assessment (pain, physical functioning, role functioning, sleep and emotional functioning) is summarized, highlighting areas where further instrument development and validation are needed. Second, sensitivity of instruments within these domains is presented using data from clinical trials of psychological therapies aimed at treatment of chronic pain in children and adolescents. Findings demonstrate that although there has been recent progress in developing and validating a range of measures of pain‐related outcomes, as of yet, very few clinical trials have included any outcomes other than pain intensity. Moreover, in randomized controlled trials where physical, role or emotional functioning outcomes have been included, there have been limited positive findings. The present paper lists some challenges and future directions in assessment of physical and role functioning, including highlighting emerging methodologies for assessment of physical activity and function in children with chronic pain. Clinical implications of integrating assessment tools into clinical practice are discussed. In conclusion, progress in developing and validating specific tools to assess important outcome domains in chronic pain has been realized. Opportunities exist for further measurement validation in most domains, and further theory‐driven treatment research to match goals of the treatment with specific interventions and outcomes.
Role for Endovascular Therapy in Chronic Mesenteric Ischemia
Authors: Loffroy Romaric , Steinmetz Eric , Guiu Boris , Molin Valérie , Kretz Benjamin , Gagnaire Alice , Bouchot Olivier , Cercueil Jean-Pierre , Brenot Roger , Krausé Denis
Published: March 2016

Chronic mesenteric ischemia is a rare condition that is caused by stenosis or occlusion of the mesenteric arteries and usually manifests as abdominal pain. While surgical revascularization has been the standard treatment for symptomatic patients, recent advances in interventional devices and techniques have made endovascular treatment feasible and effective. Percutaneous transluminal angioplasty with stent placement is now recognized as a minimally invasive means of obtaining good long-term results with an acceptable recurrence rate; consequently, the technique is suggested for the primary treatment of chronic mesenteric ischemia. The present article discusses the indications and principles of endovascular treatment, and reviews the literature, with emphasis on short- and long-term outcomes, particularly morbidity and mortality rates.
Assessment and Management of Patients with Chronic Cough by Certified Respiratory Educators: A Randomized Controlled Trial
Authors: Field Stephen K , Conley Diane P , Thawer Amin M , Leigh Richard , Cowie Robert L
Published: March 2016

BACKGROUND: The value of other health care professionals is increasingly being recognized to compensate for the shortage of physicians in Canada. Chronic cough is one of the most common reasons for consultation with a respirologist. In the present study, a prospective, randomized, controlled study was undertaken to determine whether Certified Respiratory Educators (CREs) could manage screened patients with chronic cough as effectively as respirologists.

METHODS: An eight‐week, prospective, parallel‐design, randomized, controlled trial of the management of chronic cough patients was conducted. Patients were screened to exclude those with potentially life‐threatening conditions. The primary outcome was the number of patients whose cough resolved or subjectively improved.

RESULTS: A total of 198 patients were randomly assigned, and eight‐week data were available on 151 patients. Mean age of the patients was 49.8±13.4 years, 70.2% were female and median cough duration was 16 months. The screening process was effective and referral wait times decreased from a median of two months to less than four weeks (P<0.0001). The educators averaged 4.9 contacts per patient compared with 2.7 by the physicians over the eight‐week study period (P<0.0001). Most patients had had multiple therapeutic trials before referral. Cough resolved or improved in two‐thirds of the patients at eight weeks; however, more patients showed improvement in the educator arm than in the physician arm, P<0.02. Cough‐specific quality of life improved similarly in the two study arms at eight weeks (physician arm: 61.5±14.1 to 52.6±14.4, P<0.0001; CRE arm: 58.1±14.9 to 50.0±15.8, P=0.0003).

CONCLUSIONS: CREs can safely and effectively assess, as well as appropriately treat, screened patients with chronic cough with a resultant reduction in wait times.
The Diagnostic Value of Double-Balloon Enteroscopy in Children with Small Bowel Disease: Report of 31 Cases
Authors: Liu Wei , Xu Chundi , Zhong Jie
Published: March 2016

BACKGROUND AND OBJECTIVE: Before the introduction of double-balloon enteroscopy (DBE), it was impossible to visualize the entire small bowel. Its diagnostic yield has been assessed in adults, but not yet in children. The present retrospective study evaluated the diagnostic usefulness and safety of DBE in children with suspected small bowel disease.

METHODS: Between June 2003 and June 2007, 31 patients (19 boys and 12 girls, age range three to 14 years) with suspected small bowel disease underwent DBE after receiving negative evaluations using other diagnostic modalities.

RESULTS: There were no severe complications. In two patients, the entire small bowel was viewed using oral and anal approaches, and for the remaining 29 patients, only one approach was used. The sites of disease in were identified in 25 of 31 cases (80.65%). The bleeding source was found in 21 of 27 patients with obscure gastrointestinal bleeding (diagnostic rate of 77.78%). Different diseases were identified in four children with chronic diarrhea.

CONCLUSION: DBE is a safe and effective method to diagnose patients with suspected small bowel disorders.
Treating Stress‐Related Pain with the Flotation Restricted Environmental Stimulation Technique: Are There Differences between Women and Men?
Authors: Bood Sven Å , Kjellgren Anette , Norlander Torsten
Published: March 2016

The aim of the present study was to explore, for the first time, sex differences among patients diagnosed with stress‐related pain before and after flotation restricted environmental stimulation technique (REST) treatment, delivered 12 times during seven weeks. The present study included 88 patients (69 women, 19 men) from three different studies (post hoc analysis). They had been diagnosed by a physician as having chronic stress‐related muscle tension pain. The analyses indicated that the flotation‐REST treatment had beneficial effects on stress, anxiety, depression, sleep quality and pain and that there were few sex differences. Women were more depressed than men before treatment, but after treatment there was no difference between sexes. However, there was a sex difference in the ability to endure experimentally induced pain, suggesting that men exhibited greater endurance both before and after the flotation‐REST treatment. The results also showed, for the first time, that both sexes improved their ability to endure experimentally induced pain (higher scores for upper pain threshold) following the successful flotation‐REST pain treatment.