bluuebunny/crossref_metadata_2025 huggingface dataset:
The Effects of Mindful Attention on Cold Pressor Pain in Children
Authors: Petter Mark , Chambers Christine T , Chorney Jill MacLaren
Published: March 2016

BACKGROUND: Typical interventions for acute pain in children attempt to reduce pain by directing attention away from pain. Conversely, mindfulness involves devoting attention to one’s experience in an accepting and nonjudgmental way. However, the effect that instructing children to mindfully devote attention to acute pain has on pain outcomes is unknown.

OBJECTIVES: To examine whether mindful attention can help children attend to pain without increasing pain intensity or decreasing pain tolerance; to compare the effects of mindful attention with a well‐established intervention designed to take attention away from pain (guided imagery); and to test whether baseline coping style or trait mindfulness alter the effects of these interventions.

METHODS: A total of 82 children (10 to 14 years of age) completed measures of coping style and trait mindfulness. Participants then received either mindful attention or guided imagery instructions designed to direct attention toward or away from pain, respectively, before participating in a cold pressor task.

RESULTS: The mindful attention group reported more awareness of the physical sensations of pain and thoughts about those sensations. Overall, there were no between‐group differences in measures of pain intensity or pain tolerance during the cold pressor task, and no evidence of an interaction between baseline characteristics of the child and experimental condition.

CONCLUSIONS: Mindful attention was successful in helping children focus attention on experimental pain without increasing pain intensity or decreasing tolerance compared with a well‐established intervention for acute pain reduction.
Liver Transplantation for Alcoholic Liver Disease among Canadian Transplant Centres: A National Study
Authors: Chandok Natasha , Aljawad Mohammed , White Angela , Hernandez-Alejandro Roberto , Marotta Paul , Yoshida Eric M
Published: March 2016

BACKGROUND/OBJECTIVE: Alcoholic liver disease (ALD) is a controversial yet established indication for liver transplantation (LT), and there is emerging evidence supporting a survival benefit in selected patients with severe acute alcoholic hepatitis. The aim of the present survey was to describe policies among Canadian transplant centres for patients with ALD.

METHODS: A survey was distributed to the medical directors of all seven liver transplant centres in Canada.

RESULTS: All seven liver transplant programs in Canada participated in the survey. Every centre requires patients to have a minimum of six months of abstinence from alcohol before listing for LT. Completion of a rehabilitation program is only mandatory in one program; the remaining programs do not mandate this if patients have demonstrated prolonged abstinence, and sufficient insight and social supports. No program considers LT for patients with severe acute alcoholic hepatitis, although six of the seven programs are interested in exploring a national policy. Random alcohol checks for waitlisted patients are performed routinely on patients listed for ALD at only one centre; the remaining centres only perform checks if there is clinical suspicion. In the past five years, the mean (± SD) number of patients per centre with graft dysfunction from recidivism was 10±4.36; a mean of 2.5±4.36 patients per centre developed graft failure.

CONCLUSIONS: With minor exceptions, LT policies for subjects with ALD are uniform across Canadian transplant programs. Presently, no centres perform LT for acute alcoholic hepatitis, although there is broad interest in exploring a national policy. Recidivism resulting in graft loss is a rare phenomenon.
Development and pilot testing of a mobile health solution for asthma self‐management: Asthma action plan smartphone application pilot study
Authors: Licskai Christopher J , Sands Todd W , Ferrone Madonna
Published: March 2016

BACKGROUND: Collaborative self‐management is a core recommendation of national asthma guidelines; the written action plan is the knowledge tool that supports this objective. Mobile health technologies have the potential to enhance the effectiveness of the action plan as a knowledge translation tool.

OBJECTIVE: To design, develop and pilot a mobile health system to support asthma self‐management.

METHODS: The present study was a prospective, single‐centre, nonrandomized, pilot preintervention‐postintervention analysis. System design and development were guided by an expert steering committee. The network included an agnostic web browser‐based asthma action plan smart‐phone application (SPA). Subjects securely transmitted symptoms and peak flow data daily, and received automated control assessment, treatment advice and environmental alerts.

RESULTS: Twenty‐two adult subjects (mean age 47 years, 82% women) completed the study. Biophysical data were received on 84% of subject days (subject day = 1 subject × 1 day). Subjects viewed their action plan current zone of control on 54% and current air quality on 61% of subject days, 86% followed self‐management advice and 50% acted to reduce exposure risks. A large majority affirmed ease of use, clarity and timeliness, and 95% desired SPA use after the study. At baseline, 91% had at least one symptom criterion for uncontrolled asthma and 64% had ≥2, compared with 45% (P=0.006) and 27% (P=0.022) at study close. Mean Asthma Quality of Life Questionnaire score improved from 4.3 to 4.8 (P=0.047).

CONCLUSIONS: A dynamic, real‐time, interactive, mobile health system with an integrated asthma action plan SPA can support knowledge translation at the patient and provider levels.
Burden of Rotavirus Disease: A Population‐Based Study in Eastern Townships, Quebec
Authors: Bernard Sylvain , Valiquette Louis , De Wals Philippe , Nault Vincent , Babakissa Corentin , Cyr Claude , Boileau Thérèse Côté , Gagneur Arnaud
Published: March 2016

BACKGROUND: Since July 2010, the National Advisory Committee on Immunization of Canada has recommended rotavirus vaccination for all healthy infants. However, before implementing this vaccine in routine health programs, Canadian provinces need to establish current epidemiological data on rotavirus‐associated acute gastroenteritis (AGE).

METHODS: A retrospective cohort study of children <5 years of age with AGE from 2002 to 2008 was performed in Eastern Townships, Quebec (population in 2006: 298,780). Data were collected on visits to outpatient clinics, emergency department (ED) visits, hospitalizations (standard and short‐stay units) and nosocomial AGE. The winter residual estimation and Brandt methods were used to estimate the proportion of AGE attributable to rotaviruses.

RESULTS: During the six‐year study period, a total of 1435 hospitalizations, 3631 ED visits and 6220 ambulatory care visits were attributed to AGE. The specific rotavirus burden was estimated to be 449 to 666 for hospitalizations, 1050 to 1361 for ED visits and 1633 to 1687 for outpatient visits. The epidemic curve showed a periodicity with higher incidence in March and April. Short‐stay unit hospitalizations represented 58% of all hospitalizations. The annual incidence rate of rotaviruses was estimated to be 50 to 74 per 10,000 children for hospitalizations, 117 to 152 per 10,000 children for ED visits and 182 to 188 per 10,000 children for outpatient visits.

CONCLUSION: Most available retrospective studies probably underestimate rotavirus‐associated hospitalizations because they do not take into account short‐stay unit hospitalizations. Furthermore, these data on emergency and outpatient visits provide an exhaustive appraisal of the rotavirus burden, which serves as crucial information for the evaluation of immunization programs.
Local and Systemic Oxidative Stress and Glucocorticoid Receptor Levels in Chronic Obstructive Pulmonary Disease Patients
Authors: Zeng Mian , Li Yue , Jiang Yujie , Lu Guifang , Huang Xiaomei , Guan Kaipan
Published: March 2016

BACKGROUND: Previous studies have indicated that oxidative stress plays an important role in the pathogenesis of chronic obstructive pulmonary disease (COPD).

OBJECTIVES: To study local and systemic oxidative stress status in COPD patients, and to clarify the relationship between local and systemic oxidative stress.

METHODS: Lipid peroxide malondialdehyde (MDA), glutathione (GSH), superoxide dismutase (SOD) and GSH peroxidase (GSH-PX) levels in induced sputum and plasma, as well as glucocorticoid receptor (GR) levels in peripheral blood leukocytes were examined in 43 acute exacerbation of COPD patients (group A), 35 patients with stable COPD (group B) and 28 healthy controls (14 smokers [group C]; 14 nonsmokers [group D]).

RESULTS: MDA levels in induced sputum and plasma decreased progressively in groups A to D, with significant differences between any two groups (P<0.001). GSH, SOD and GSH-PX levels in both induced sputum and plasma increased progressively in groups A to D, with significant differences between any two groups (P<0.001). GR levels in peripheral blood leukocytes decreased progressively in groups D to A (all comparisons P<0.001). Pearson analysis revealed strong correlations between MDA, GSH, SOD and GSH-PX levels in plasma and induced sputum. The activity of SOD in plasma and sputum were both positively correlated with GR levels (partial correlation coefficients 0.522 and 0.574, respectively [P<0.001]).

CONCLUSIONS: Oxidative stress levels were elevated in COPD patients. There was a correlation between local and systemic oxidative status in COPD, and between decreased SOD activity and decreased GR levels in COPD patients.
Vaccine Knowledge in Students in Paris, France, and surrounding Regions
Authors: Mellon Guillaume , Rigal Laurent , Partouche Henri , Aoun Olivier , Jaury Philippe , Joannard Nathalie , Guthmann Jean Paul , Cochereau Delphine , Caumes Eric , Bricaire Francois , Salmon-Céron Dominique
Published: March 2016

INTRODUCTION: In France, young adults are legally freed from parental authority at the age of 18 years and are, thus, responsible for their own vaccine record. This young adult population is more frequently exposed to vaccine‐preventable infectious diseases.

OBJECTIVE: To determine the factors associated with students’ knowledge of the interval between two antitetanus boosters and their report of having up‐to‐date vaccinations.

METHODS: In April 2009, a survey was conducted involving a random sample of students between 18 and 25 years of age eating lunch at university dining facilities in Paris and its suburbs (Ile de France).

RESULTS: Among the 677 students approached, 583 agreed to participate. Only 207 (36%) of respondents knew the recommended dosing interval between two doses of tetanus vaccine booster (10 years). The majority of students (69%) reported having up‐to‐date vaccinations. Declaring having up‐to‐date vaccinations was significantly associated with having a general practitioner (OR 3.03 [95% CI 1.69 to 5.55]). Health care students were significantly more likely to know the decennial interval between two antitetanus boosters (OR 2 [95% CI 1.28 to 3.25]). Most of responding students (n=519 [89%]) believed that vaccines were very useful.

CONCLUSIONS: An overall lack of knowledge of vaccines was observed among this student population. Health care providers, such as GPs and university medical practice staff, who interact with these young individuals have an essential role to promote better vaccination coverage in this population.
Melioidosis in a Returned Traveller
Authors: Chagla Zain , Aleksova Natasha , Quirt Jaclyn , Emery Joel , Kraeker Christian , Haider Shariq
Published: March 2016

Melioidosis is an infection endemic to Southeast Asia and Northern Australia, and is associated with significant morbidity and mortality. The present report describes a case of chronic melioidosis in a returning traveller from the Philippines. Clinical suspicion of this illness is warranted in individuals with a history of travel to endemic regions. Safety in handling clinical specimens is paramount because laboratory transmission has been described.
Airway Pressure and Transpulmonary Pressure During High-Frequency Oscillation for Acute Respiratory Distress Syndrome
Authors: Henderson William R , Dominelli Paolo B , Griesdale Donald EG , Talmor Daniel , Sheel A William
Published: March 2016

BACKGROUND: High-frequency oscillation (HFO) is used for the treatment of refractory hypoxic respiratory failure.

OBJECTIVE: To demonstrate that the mean transpulmonary pressure (PL) cannot be inferred from mean airway pressure (mPaw).

METHODS: In seven patients already undergoing HFO for refractory acute respiratory distress syndrome, esophageal pressure (Pes) was measured using an esophageal balloon catheter. Pleural pressure (Ppl) and PLwere calculated from Pes.

MAIN RESULTS: In the seven patients (mean [± SD] age 59±9 years) treated with HFO at 5±1 Hz and amplitude 75±10 cmH2O, the mPaw was 27±6 cmH2O, Ppl was 9±6 cmH2O and PLwas 18±11 cmH2O. Successful catheter placement and measurement of Pes occurred in 100% of subjects. There was no correlation between PLand mPaw. The majority of subjects required hemodynamic support during the use of HFO; the frequency and degree of support during the study period was no different than that before the study.

CONCLUSION: The present report is the first to describe measuring Pes and calculating Ppl during HFO for acute respiratory distress syndrome. While both current guidelines and recent trials have titrated treatment based on mPaw and oxygenation, there is wide variability in PLduring HFO and PLcannot be predicted from mPaw.
The Process of Acceptance among Rheumatoid Arthritis Patients in Switzerland: A Qualitative Study
Authors: Kostova Zlatina , Caiata-Zufferey Maria , Schulz Peter J
Published: March 2016

BACKGROUND: Rheumatoid arthritis (RA) is a chronic, painful disease with many injurious psychological effects. Acceptance is an important component of pain management and is associated with improved quality of life, and lower levels of pain and depression. While studies have begun to identify the stages of acceptance, little is known about factors influencing the ease and speed with which patients pass through these stages.

OBJECTIVE: To explore the main stages through which RA patients pass and the strategies they adopt to learn to live with the pain, and to identify factors shaping patients’ capacities to achieve acceptance.

METHODS: A qualitative study involving 20 semistructured interviews with RA patients in the Italian‐speaking region of Switzerland was conducted. Analysis of the data followed the precepts of grounded theory.

RESULTS: Although the present study revealed that acceptance is not a smooth or linear process, five main stages in patients’ struggles to accommodate the newly imposed limitations were, nonetheless, identified: naming the illness; realizing the illness; resisting the illness; ‘hitting the bottom’; and integrating the illness. Diagnosis proved to be an especially tortuous stage in the case of RA, and the effects of delayed diagnosis continued to be felt during the subsequent stages. Patients’ understanding of the notion of acceptance and the strategies that they used to achieve it were also explored.

CONCLUSIONS: Diagnosis of RA is notoriously difficult. Beyond the clinical difficulties, structural reasons for late diagnosis (symptoms being neglected by patients and medical professionals) were identifed. Delayed diagnosis hindered the acceptance process throughout, and led to more resistant behaviour and to a struggle to achieve the optimal formula for acceptance – accepting the losses of prepain life while still pursuing personal goals.
A rare cause of stridor: Isolated tracheal amyloidosis
Authors: Numbere Numbere K , Grayez Jamal
Published: March 2016

A 50‐year‐old man presented to clinic with a two‐year history of progressive exertional dyspnea and voice hoarseness. This history suggested upper airways obstruction, which was confirmed on computed tomography imaging that revealed extensive thickening of the proximal tracheal wall causing severe luminal narrowing. Bronchoscopic debulking was then performed and the samples obtained confirmed tracheal amyloidoisis. Extensive investigation confirmed that disease was localized solely to the trachea. Ultimately, after multiple discussions, the chosen treatment modality was radiotherapy, which proceeded relatively uneventfully and achieved excellent radiological and clinical response. Although tracheal amyloidosis is rare, it is most commonly observed as part of a multisystem presentation. The present report describes the even more uncommon diagnosis of isolated tracheal amyloidosis and highlights the role of radiotherapy in its management.
Initial Pain Management Plans in Response to Severe Pain Indicators on Oncology Clinic Previsit Questionnaires
Authors: Sanatani Michael S , Kattan Maan , Moulin Dwight E
Published: March 2016

BACKGROUND: The issue of how to address patient pain in the outpatient setting remains challenging. At the London Regional Cancer Program (London, Ontario), patients complete the Edmonton Symptom Assessment System (ESAS) before most visits.

OBJECTIVES:To perform a chart review assessing the frequency and, if applicable, the type of a clinical care plan that was developed if a patient indicated pain ≥7 on a 10‐point scale

METHODS: The charts of 100 eligible sequential outpatient visits were reviewed and the initial pain management approaches were documented.

RESULTS: Between December 2011 and May 2012, visits by 7265 unique patients included 100 eligible visits (pain ≥7 of 10). In 83 cases, active pain management plans, ranging from counselling to hospital admission, were proposed. Active pain management plans were more likely if the cause was believed to be cancer/treatment related: 63 of 65 (96.9%) versus 20 of 35 (57.1%, noncancer/unknown pain cause); P<0.001. There were no differences depending on cancer treatment intent or medical service.

CONCLUSIONS: Active pain management plans were documented in 83% of visits. However, patients who reported severe pain that was assessed as benign or unknown in etiology received intervention less frequently, perhaps indicating that oncologists either consider themselves less responsible for noncancer pain, or believe that pain chronicity may lead to a higher ESAS pain score without indicating a need for acute intervention. Further study is needed to determine the subsequent effect of the care plans on patient‐reported ESAS pain scores at future clinic visits.

Erratum to “Initial Pain Management Plans in Response to Severe Pain Indicators on Oncology Clinic Previsit Questionnaires”dx.doi.org/10.1155/2015/404187
Qualitative Assessment of Pain Management in Patients Undergoing Computed Tomography‐Guided Transthoracic Lung Biopsy
Authors: Wong Erin T , Dunham Carol , Patsios Demetris
Published: March 2016

BACKGROUND: Unpublished questionnaire data collected by the authors’ institution (Toronto General Hospital, Toronto, Ontario) indicates that patients often experience significant pain while undergoing lung biopsy, yet receive only a fraction of the maximum allowable dosage of analgesic.

OBJECTIVES: To qualitatively assess current pain management practices from the patient perspective. Patient education and patient satisfaction were also evaluated.

METHODS: From March through June 2012, participants were contacted via telephone within one week of their procedure until data saturation was reached. The semistructured interviews were based on a study‐specific interview template. Thematic analysis of qualitative study data was used to identify recurring interview topics.

RESULTS: A consecutive sample of 16 outpatients who had undergone image‐guided transthoracic lung biopsy at the authors’ institution were interviewed. None of the study participants reported noteworthy pain associated with the insertion of lung biopsy needles. The most significant pain was caused by positioning within the computed tomography scanner, particularly among participants who were in the prone position. All participants reported high satisfaction with the amount of analgesic received. Potential complications and recovery period details were identified as areas for improved patient education.

CONCLUSIONS: At the authors’ institution, pain associated with lung biopsy needle insertion was well controlled. Positional pain is common for patients required to be in the prone position. Potential solutions include increasing awareness of positional pain and instituting additional supportive equipment.
Safety and Immunogenicity of Two Doses of Quadrivalent Meningococcal Conjugate Vaccine or One Dose of Meningococcal Group C Conjugate Vaccine, both Administered Concomitantly with Routine Immunization to 12‐ to 18‐Month‐Old Children
Authors: Noya Francisco , McCormack Deirdre , Reynolds Donna L , Neame Dion , Oster Philipp
Published: March 2016

OBJECTIVES:To describe the immunogenicity and safety of a two‐dose series of a quadrivalent meningococcal (serogroups A, C, Y and W) polysaccharide diphtheria toxoid conjugate vaccine (MenACYW‐D) administered to toddlers.

METHODS: Children were randomly assigned (1:1) at study entry to receive MenACYW‐D at 12 and 18 months of age (group 1; n=61) or meningococcal serogroup C conjugate vaccine (MCC) at 12 months of age (group 2; n=62). All received routine childhood immunizations. A, C, Y and W antibody titres were measured in group 1 before and one month after the 18‐month MenACYW‐D vaccination and were measured in group 2 at one and seven months post‐MCC vaccination. Antibodies elicited by diphtheria and tetanus toxoids, and acellular pertussis vaccine adsorbed combined with inactivated poliomyelitis vaccine and Haemophilus influenzae b conjugate (DTaP‐IPV‐Hib) vaccine coadministered at the 18‐month vaccination were measured one month later. Safety data were collected.

RESULTS: At 19 months of age, ≥96% in group 1 achieved protective titres for the four meningococcal serogroups after dose 2; 67% in group 2 exhibited protective titres against serogroup C 28 days after MCC vaccination at 12 months of age, declining to 27% seven months later. DTaP‐IPV‐Hib elicited high antibody concentrations/titres in groups 1 and 2, consistent with historical values. The safety profiles after each dose generated no unexpected safety signals; no serious adverse events were related to vaccination.

DISCUSSION: A two‐dose series of MenACYW‐D given concomitantly with a DTaP‐IPV‐Hib booster dose at 18 months of age demonstrated a good immunogenicity and safety profile. A two‐dose series of MenACYW‐D can be used as an alternative to one dose of MCC and provides protection against additional serogroups (NCT ID: NCT01359449).
Colonoscopy Quality Assurance in Ontario: Systematic Review and Clinical Practice Guideline
Authors: Tinmouth Jill , Kennedy Erin B , Baron David , Burke Mae , Feinberg Stanley , Gould Michael , Baxter Nancy , Lewis Nancy
Published: March 2016

Colonoscopy is fundamental to the diagnosis and management of digestive diseases and plays a key role in colorectal cancer (CRC) screening and diagnosis. Therefore, it is important to ensure that colonoscopy is of high quality. The present guidance document updates the evidence and recommendations in Cancer Care Ontario’s 2007 Colonoscopy Standards, and was conducted under the aegis of the Program in Evidence-Based Care. It is intended to support quality improvement for colonoscopies for all indications, including follow-up to a positive fecal occult blood test, screening for individuals who have a family history of CRC and those at average risk, investigation for symptomatic patients, and surveillance of those with a history of adenomatous polyps or CRC. A systematic review was performed to evaluate the existing evidence concerning the following three key aspects of colonoscopy: physician endoscopist training and maintenance of competency; institutional quality assurance parameters; and colonoscopy quality indicators and auditable outcomes. Where appropriate, indicators were designated quality indicators (where there was sufficient evidence to recommend a specific target) and auditable outcomes (insufficient evidence to recommend a specific target, but which should be monitored for quality assurance purposes). The guidance document may be used to support colonoscopy quality assurance programs to improve the quality of colonoscopy regardless of indication. Improvements in colonoscopy quality are anticipated to improve important outcomes in digestive diseases, such as reduction of the incidence of and mortality from CRC.
Quality Indicators for the Assessment and Management of Pain in the Emergency Department: A Systematic Review
Authors: Stang Antonia S , Hartling Lisa , Fera Cassandra , Johnson David , Ali Samina
Published: March 2016

BACKGROUND: Evidence indicates that pain is undertreated in the emergency department (ED). The first step in improving the pain experience for ED patients is to accurately and systematically assess the actual care being provided. Identifying gaps in the assessment and treatment of pain and improving patient outcomes requires relevant, evidence‐based performance measures.

OBJECTIVE: To systematically review the literature and identify quality indicators specific to the assessment and management of pain in the ED.

METHODS: Four major bibliographical databases were searched from January 1980 to December 2010, and relevant journals and conference proceedings were manually searched. Original research that described the development or collection of data on one or more quality indicators relevant to the assessment or management of pain in the ED was included.

RESULTS: The search identified 18,078 citations. Twenty‐three articles were included: 15 observational (cohort) studies; three before‐after studies; three audits; one quality indicator development study; and one survey. Methodological quality was moderate, with weaknesses in the reporting of study design and methodology. Twenty unique indicators were identified, with the majority (16 of 20) measuring care processes. Overall, 91% (21 of 23) of the studies reported indicators for the assessment or management of presenting pain, as opposed to procedural pain. Three of the studies included children; however, none of the indicators were developed specifically for a pediatric population.

CONCLUSION: Gaps in the existing literature include a lack of measures reflecting procedural pain, patient outcomes and the pediatric population. Future efforts should focus on developing indicators specific to these key areas.
Analysis of Cardiopulmonary Stress during Endoscopy: Is Unsedated Transnasal Esophagogastroduodenoscopy Appropriate for Elderly Patients?
Authors: Uchiyama Kazuhiko , Ishikawa Takeshi , Sakamoto Naoyuki , Kajikawa Hirokazu , Takagi Tomohisa , Handa Osamu , Tatsumi Yoshihide , Yagi Nobuaki , Naito Yuji , Itoh Yoshito , Takemura Shuhei
Published: March 2016

BACKGROUND: Transnasal esophagogastroduodenoscopy (EGD) without sedation has been reported to be safe and tolerable. It has recently been used widely in Japan for the detection of upper gastrointestinal disease. Alternatively, transoral examination using a thin endoscope has also been reported to be highly tolerable.

OBJECTIVE: To examine the cardiocirculatory effects of transoral versus transnasal EGD in an attempt to determine the most suitable endoscopic methods for patients ≥75 years of age.

METHODS: Subjects who underwent monitoring of respiratory and circulatory dynamics without sedation during endoscopic screening examinations were enrolled at the New Ooe Hospital (Kyoto, Japan) between April 2008 and March 2009. A total of 165 patients (age ≥75 years) provided written informed consent and were investigated in the present study. Patients were randomly divided into three subgroups: UO group – thin endoscope; SO group – standard endoscope; and UT group – transnasal EGD. Percutaneous arterial blood oxygen saturation, heart rate and blood pressure were evaluated just before EGD and at five time points during EGD. After transnasal EGD, patients who had previously been examined using transoral EGD with a standard endoscope were asked about preferences for their next examination.

RESULTS: There were no statistical differences in the characteristics among the groups. Percutaneous oxygen saturation in the UT group showed a transient drop compared with the SO and UO groups at the beginning of the endoscopic procedure. Heart rate showed no significant differences among the SO, UO and UT groups; Systolic blood pressure in the UO group was lower immediately after insertion compared with the SO and UT groups. The rate pressure product in the UO group was comparable with that in the UT group during endoscopy, and the SO group showed a continuously higher level than the UO and UT groups. More than one-half (54.4%) of patients were ‘willing to choose transnasal EGD for next examination’.

CONCLUSIONS: For elderly patients, unsedated transnasal EGD failed to show an advantage over unsedated standard endoscopy. Transoral thin EGD was estimated to be safe and tolerable.
Does Low‐Level Laser Therapy Enhance The Efficacy of Intravenous Regional Anesthesia?
Authors: Nesioonpour Sholeh , Akhondzadeh Reza , Mokmeli Soheila , Moosavi Shahnam , Mackie Mandana , Naderan Morteza
Published: March 2016

BACKGROUND: The use of intravenous regional anesthesia (IVRA) is limited by pain resulting from the application of tourniquets and postoperative pain.

OBJECTIVE: To assess the efficacy of low‐level laser therapy added to IVRA for improving pain related to surgical fixation of distal radius fractures.

METHODS: The present double‐blinded, placebo‐controlled, randomized clinical trial involved 48 patients who were undergoing surgical fixation of distal radius fractures. Participants were randomly assigned to either an intervention group (n=24), who received 808 nm laser irradiation as 4 J/point for 20 s over ipsilateral three nerve roots in the cervical region corresponding to C5–C8 vertebrae, and 808 nm laser irradiation as 0.1 J/cm2 for 5 min in a tangential scanning mode over the affected extremity; or a control group (n=24), who underwent the same protocol and timing of laser probe application with the laser switched off. Both groups received the same IVRA protocol using 2% lidocaine.

RESULTS: The mean visual analogue scale scores were significantly lower in the laser‐assisted group than in the lidocaine‐only group on all measurements during and after operation (P<0.05). The mean time to the first need for fentanyl administration during the operation was longer in the laser group (P=0.04). The total amount of fentanyl administered to patients was significantly lower in the laser‐assisted group (P=0.003). The laser group needed significantly less pethidine for pain relief (P=0.001) and at a later time (P=0.002) compared with the lidocaine‐only group. There was no difference between the groups in terms of mean arterial pressure and heart rate.

CONCLUSION: The addition of gallium‐aluminum‐arsenide laser irradiation to intravenous regional anesthesia is safe, and reduces pain during and after the operation.
Initial Management of Noncirrhotic Splanchnic Vein Thrombosis: When Is Anticoagulation Enough?
Authors: Ravichandran Pranavi , Croome Kris P , Kovacs Michael J , Lazo-Langner Alejandro , Hernandez-Alejandro Roberto
Published: March 2016

BACKGROUND: The optimal initial treatment of splanchnic vein thrombosis is uncertain. Anticoagulant therapy has been shown to be associated with vessel recanalization and decreased recurrence. Furthermore, information regarding potential predictors of chronic complications is not well understood.

METHODS: A retrospective cohort study involving consecutive patients diagnosed with first-episode noncirrhotic splanchnic vein thrombosis referred to the thrombosis clinic of the authors’ institution between 2008 and 2011 was conducted. Demographic and clinical information was collected. The response to initial anticoagulant therapy was evaluated by determining radiographic recanalization of vessels and clinical resolution (defined as the absence of ongoing splanchnic vein thrombosis symptoms or complications requiring treatment beyond anticoagulant therapy).

RESULTS: Twenty-two patients were included. Anticoagulant therapy alone resulted in vessel recanalization in 41% of patients and 68% achieved clinical resolution. Two patients experienced bleeding events. Factors associated with a lack of clinical resolution included signs of portal hypertension/liver failure on presentation, complete vessel occlusion at diagnosis, presence of a myeloproliferative disorder orJAK2V617Ftyrosine kinase mutation and the absence of a local/transient predisposing factor.

CONCLUSIONS: Anticoagulant therapy appeared to be an effective initial treatment in patients with splanchnic vein thrombosis. Clinical factors may help to identify patients who are at risk for developing complications thus requiring closer monitoring. These findings were limited by the small sample size and need to be explored in larger prospective studies.
Obstructive Sleep Apnea and Driving: A Canadian Thoracic Society and Canadian Sleep Society Position Paper
Authors: Ayas Najib , Skomro Robert , Blackman Adam , Curren Kristen , Fitzpatrick Michael , Fleetham John , George Charles , Hakemi Tom , Hanly Patrick , Li Christopher , Morrison Debra , Series Frédéric
Published: March 2016

Individuals with obstructive sleep apnea (OSA) experience sleep fragmentation and poor sleep quality that results in daytime sleepiness, which impairs performance during driving and leads to an increased risk for collisions. Not surprisingly, observational studies have shown that patients with OSA experience a two- to 10-fold higher risk for collision compared with healthy controls. Although treatment would clearly mitigate these risks, there is no current Canadian position on driving and OSA. This article, the first Canadian position statement addressing the issue, provides an overview of provincial regulations and proposes recommendations with regard to driving in patients with OSA.

Untreated patients with obstructive sleep apnea (OSA) are at increased risk for motor vehicle collisions; however, it is unclear how this should be translated into fitness-to-drive recommendations. Accordingly, the Canadian Thoracic Society (CTS) Sleep Disordered Breathing Clinical Assembly and the Canadian Sleep Society (CSS) assembled a CTS-CSS working group to propose recommendations with regard to driving in patients with OSA.

Recommendations for assessing fitness to drive in noncommercial drivers: 1. Severity of OSA alone is not a reliable predictor of collision risk and, therefore, should not be used in isolation to assess fitness to drive; 2. The severity of sleep apnea should be considered in the context of other factors to assess fitness to drive; 3. The decision to restrict driving is ultimately made by the motor vehicle licensing authority; however, they should take into account the information and recommendations provided by the sleep medicine physician and should follow provincial guidelines; 4. For patients prescribed continuous positive airway pressure (CPAP) therapy, objective CPAP compliance should be documented. Efficacy should also be documented in terms of reversing the symptoms and improvement in sleep apnea based on physiological monitoring; 5. For patients treated with surgery or an oral appliance, verification of adequate sleep apnea treatment should be obtained; and 6. A driver diagnosed with OSA may be recertified as fit to drive based on assessment of symptoms and demonstrating compliance with treatment. The assessment should be aligned with the provincial driver’s license renewal period.

Commercial vehicles: Assessment of fitness to drive should be more stringent for patients operating commercial vehicles. In general, the CTS-CSS working group was in agreement with the Medical Expert Panel recommendations to the Federal Motor Carrier Safety Administration in the United States; these recommendations were adapted for Canadian practitioners.
Pubertal Status Moderates the Association between Mother and Child Laboratory Pain Tolerance
Authors: Tsao Jennie CI , Li Ning , Parker Delana , Seidman Laura C , Zeltzer Lonnie K
Published: March 2016

BACKGROUND:There is limited information regarding the relationship between parent and child responses to laboratory pain induction in the absence of experimental manipulation.

OBJECTIVES: To assess the association between responses to cold and pressure pain tasks in 133 nonclinical mothers and children (mean age 13.0 years; 70 girls), and the moderating effects of child sex and pubertal status on these mother‐child relationships.

METHODS: Mothers and children independently completed the cold and pressure pain tasks. Multiple linear regression analyses examined the association between mothers’ and children’s laboratory pain responses. The moderating effects of child sex and pubertal status were tested in the linear models by examining the interaction among mother laboratory pain responses, and child sex and pubertal status.

RESULTS: Mothers’ cold pain anticipatory anxiety and pressure pain intensity were associated with children’s pressure pain anticipatory anxiety. Mothers’ pressure pain tolerance was associated with children’s pain tolerance for both the cold and pressure pain tasks. Mothers’ cold pain tolerance was associated with children’s pressure pain tolerance. Pubertal status moderated two of the three significant mother‐child pain tolerance relationships, such that the associations held for early pubertal but not for late pubertal children. Sex did not moderate mother‐child pain associations.

CONCLUSIONS: The results indicate that mother‐child pain relationships are centred primarily on pain avoidance behaviour, particularly among prepubertal children. These findings may inform interventions focused on pain behaviours, with a particular emphasis on mothers of prepubertal children, to reduce acute pain responses in their children.
The Effect of Rapid Response Teams on End‐of‐Life Care: A Retrospective Chart Review
Authors: Tam Benjamin , Salib Mary , Fox-Robichaud Alison
Published: March 2016

BACKGROUND: A subset of critically ill patients have end‐of‐life (EOL) goals that are unclear. Rapid response teams (RRTs) may aid in the identification of these patients and the delivery of their EOL care.

OBJECTIVES: To characterize the impact of RRT discussion on EOL care, and to examine how a preprinted order (PPO) set for EOL care influenced EOL discussions and outcomes.

METHODS: A single‐centre retrospective chart review of all RRT calls (January 2009 to December 2010) was performed. The effect of RRT EOL discussions and the effect of a hospital‐wide PPO set on EOL care was examined. Charts were from the Ontario Ministry of Health and Long‐Term Care Critical Care Information Systemic database, and were interrogated by two reviewers.

RESULTS: In patients whose EOL status changed following RRT EOL discussion, there were fewer intensive care unit (ICU) transfers (8.4% versus 17%; P<0.001), decreased ICU length of stay (5.8 days versus 20 days; P=0.08), increased palliative care consultations (34% versus 5.3%; P<0.001) and an increased proportion who died within 24 h of consultation (25% versus 8.3%; P<0.001). More patients experienced a change in EOL status following the introduction of an EOL PPO, from 20% (before) to 31% (after) (P<0.05).

CONCLUSIONS: A change in EOL status following RRT‐led EOL discussion was associated with reduced ICU transfers and enhanced access to palliative care services. Further study is required to identify and deconstruct barriers impairing timely and appropriate EOL discussions.
The Respiratory Presentation of Severe Combined Immunodeficiency in Two Mennonite Children at a Tertiary Centre Highlighting the Importance of Recognizing This Pediatric Emergency
Authors: Lam Simon , Kavadas Fotini D , Haider Seemab , Noseworthy Mary E
Published: March 2016

Severe combined immunodeficiency (SCID) is considered to be a pediatric emergency, with respiratory distress being the most common presenting symptom. The authors present two cases of SCID in children <4 months of age with respiratory distress at a tertiary care centre due to a recently described homozygous CD3 delta mutation found only in the Mexican Mennonite population. Failure to respond to broad‐spectrum antibiotics prompted investigation for possible SCID. Bronchial alveolar lavage fluid from both patients grew Pneumocystis jiroveci, and flow cytometry revealed absent T cells. The CD3 delta gene is believed to be important in T cell differentiation and maturation. The present article reminds pediatricians and pediatric respirologists that the key to diagnosing SCID is to have a high index of suspicion if there is poor response to conventional therapies.
Blockade of Glutamate Release by Botulinum Neurotoxin Type A in Humans: A Dermal Microdialysis Study
Authors: Silva Larissa Bittencourt da , Karshenas Ali , Bach Flemming W , Rasmussen Sten , Arendt-Nielsen Lars , Gazerani Parisa
Published: March 2016

BACKGROUND: The analgesic action of botulinum neurotoxin type A (BoNTA) has been linked to the blockade of peripheral release of neuropeptides and neurotransmitters in animal models; however, there is no direct evidence of this in humans.

OBJECTIVES: To investigate the effect of BoNTA on glutamate release in humans, using an experimental model of pain and sensitization provoked by capsaicin plus mild heat.

METHODS: Twelve healthy volunteers (six men, six women) were pretreated with BoNTA (10 U) on the volar forearm and with a saline control on the contralateral side. Dermal microdialysis was applied one week later to collect interstitial samples before and after the application of a capsaicin patch (8%) plus mild heat (40°C/60 min) to provoke glutamate release, pain and vasodilation. Samples were collected every hour for 3 h using linear microdialysis probes (10 mm, 100 kD). Dialysate was analyzed for glutamate concentration. Pain intensity and skin vasomotor reactions (temperature and blood flow changes) were also recorded.

RESULTS: BoNTA significantly reduced glutamate release compared with saline (P<0.05). The provoked pain intensity was lower in the BoNTA‐pretreated arm (P<0.01). The reduction in pain scores was not correlated with glutamate level. Cutaneous blood flow (P<0.05), but not cutaneous temperature (P≥0.05), was significantly reduced by BoNTA. There was a correlation between glutamate level and skin blood flow (r=0.58/P<0.05) but not skin temperature (P≥0.05). No differences according to sex were observed in any response.

CONCLUSIONS: The present study provided the first direct evidence supporting the inhibitory effect of BoNTA on glutamate release in human skin, which is potentially responsible for some of the analgesic action of BoNTA.
From the Mouth of Babes: Getting Vaccinated Doesn’t Have to Hurt
Authors: Taddio Anna , Ilersich Andrew F , Ilersich Anthony N , Wells Jenny
Published: March 2016

BACKGROUND: Analgesic interventions are not commonly administered during childhood vaccination, despite the fact that two‐thirds of children are afraid of needles and one‐tenth are noncompliant with immunization.

OBJECTIVE: To explore children’s experiences of vaccination and preferences for analgesia.

METHODS: A total of 17 children (four to 14 years of age) at an independent school in Toronto (Ontario) participated in three focus‐group interviews. The majority had previous experience with pain management interventions during vaccination. Thematic content analysis was used to analyze interview transcripts.

RESULTS: The findings were categorized into three main themes: experience of vaccination; roles and responsibilities regarding pain management; and impact of pain management. Children easily recalled previous vaccinations and discussed fear and distress experienced by themselves and others. Children believed that parents and immunizers should prepare them ahead of time and use interventions to manage and monitor pain. They also wanted adults to support their efforts to lead pain management. Children discussed benefits of managing pain, including reduced unnecessary suffering, improved vaccination experience, reduced risk of developing needle fears and reduced noncompliant behaviours. They were knowledgeable about strategies for reducing pain including distraction, topical anesthetics and injection techniques. They contrasted vaccination with and without pain management, and indicated a preference for pain management.

CONCLUSION: Children reported that managing vaccination pain is important and that analgesic interventions should routinely be used. Incorporating pain management in the process of vaccination has the potential to improve children’s experiences with vaccination and promote more positive attitudes and behaviours.
The Relationship Among Psychological Factors, Neglect‐Like Symptoms And Postoperative Pain After Total Knee Arthroplasty
Authors: Hirakawa Yoshiyuki , Hara Michiya , Fujiwara Akira , Hanada Hirofumi , Morioka Shu
Published: March 2016

BACKGROUND: Persistent postoperative pain has a significant relationship with patient health and satisfaction.

OBJECTIVES: To investigate the prevalence and association of neglect‐like symptoms (NLS) and other psychological factors on postoperative pain in patients following total knee arthroplasty (TKA). NLS are defined as the loss of perception of the limb with pain and excessive effort required to move the limb. The authors hypothesized that NLS were an important contributor to postoperative pain.

METHODS: The factors influencing pain were investigated using a longitudinal study with assessments at three and six weeks postsurgery. The relationships among demographic factors (age, body weight, body mass index), psychological factors (State‐Trait Anxiety Inventory and Pain Catastrophizing Scale [PCS]) and NLS with postoperative pain were investigated in 90 patients after TKA. The associations among motor functions (muscle strength of knee extension, range of motion), sensory functions (joint position sense and two‐point discrimination in the thigh) and NLS were also investigated.

RESULTS: At three and six weeks after surgery, 36% and 19% of patients, respectively, experienced NLS. In hierarchical multiple regression analysis, NLS and PCS scores were significantly associated with postoperative pain, while joint position sense and range of motion were significantly associated with NLS.

CONCLUSIONS: These results suggest that facilitation of sensory integration is important in rehabilitation after TKA because NLS appears to result from impaired sensory integration. The association of PCS scores with postoperative pain and NLS suggests the need to provide appropriate postoperative education to reduce persistent negative thoughts regarding future pain.