bluuebunny/crossref_metadata_2025 huggingface dataset:
Central Poststroke Pain: An Abstruse Outcome
Authors: Henry James L , Lalloo Chitra , Yashpal Kiran
Published: March 2016

Central poststroke pain (CPSP), formerly known as thalamic pain syndrome of Déjerine and Roussy, is a central neuropathic pain occurring in patients affected by stroke. It is one manifestation of central pain, which is broadly defined as central neuropathic pain caused by lesions or dysfunction in the central nervous system. Thalamic pain was first described 100 years ago by Déjerine and Roussy and has been described as “among the most spectacular, distressing, and intractable of pain syndromes”. CPSP is characterized by constant or intermittent pain and is associated with sensory abnormalities, particularly of thermal sensation. While the pain is frequently described as burning, scalding, or burning and freezing, other symptoms are usually vague and hard to characterize, making an early diagnosis particularly difficult. In fact, those who develop CPSP may no longer be under the care of health care professionals when their symptoms begin to manifest, resulting in misdiagnosis or a significant delay before treatment begins. Diagnosis is further complicated by cognitive and speech limitations that may occur following stroke, as well as by depression, anxiety and sleep disturbances. Patients may also exhibit spontaneous dysesthesia and the stimulus‐evoked sensory disturbances of dysesthesia, allodynia and hyperalgesia. The present study offers a historical reference point for future clinical and basic research into this elusive type of debilitating pain.
Lidocaine Infusion as a Rescue Analgesic in the Perioperative Setting
Authors: Clarke C , McConachie I , Banner R
Published: March 2016

In the present case series, three patients for whom regional anesthesia may have been the optimum technique for controlling postoperative pain are discussed. However, due to prevailing circumstances, regional anesthesia could not be provided. An intravenous infusion of lidocaine at 4 mg/min was administered perioperatively as an alternative ‘rescue’ analgesic technique. This infusion rate, based on previous extensive pharmacokinetic studies, is widely considered to be safe. Postoperative pain was lower than expected for the type of surgery. Anecdotal experience suggests that hospital length of stay may also be reduced, with both patient and economic benefits.
Fatal Hemorrhage from a Gastroaortic Fistula Secondary to Gastric Ulceration Associated with Nissen Fundoplication and Nonsteroidal Anti-Inflammatory Drug Use
Authors: Manduch Marsoh , Rossiter John P , Depew William T , Mercer C Dale , Hurlbut David J
Published: March 2016

Acute gastrointestinal hemorrhage from a gastroaortic fistula in the gastric fundoplication pouch is a rare complication of Nissen fundoplication. The present case reports a gastroaortic fistula secondary to gastric ulceration associated with prior Nissen fundoplication and nonsteroidal anti-inflammatory drug use. A 55-year-old man presented with massive hematemesis and died of exsanguination during emergency laparotomy. Recognition of factors that predispose a patient to gastric ulceration after fundoplication, including nonsteroidal anti-inflammatory drug use, is critical to arouse the high index of suspicion required to diagnose and manage this life-threatening complication.
Fatal Disseminated Trichosporon asahii Infection in a Child with Acute Lymphoblastic Leukemia
Authors: Thibeault Roseline , Champagne Martin , de Repentigny Louis , Fournet Jean-Christophe , Tapiero Bruce , Moghrabi Albert , Ovetchkine Philippe
Published: March 2016

Few cases of Trichosporon species infection have been reported in children. The present report describes a case of fatal disseminated Trichosporon asahii infection in a child treated for relapsed leukemia. Voriconazole has previously shown promising activity in vitro, and has been used successfully in the treatment of T asahii infections. The patient died five days after voriconazole treatment was started, and the autopsy revealed widespread systemic dissemination to all organs.
Primary sclerosing cholangitis
Authors: Silveira Marina G , Lindor Keith D
Published: March 2016

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by inflammation and fibrosis of the bile ducts, resulting in end-stage liver disease and reduced life expectancy. PSC primarily affects young and middle-aged men, often in association with underlying inflammatory bowel disease. The etiology of PSC includes immune-mediated components and elements of undefined nature. A cholestatic picture of liver biochemistries with elevations in serum alkaline phosphatase, nonspecific autoantibodies such as perinuclear antineutrophilic antibody, antinuclear antibodies and smooth muscle antibodies, and diffuse multifocal biliary strictures, resulting in a ‘beaded’ appearance on radiographic studies, are the hallmarks of the disease. No effective medical therapy is currently available, although clinical studies are in progress. Ursodeoxycholic acid at high doses (28 mg/kg/day to 30 mg/kg/day) is the most promising agent but is unproven so far. Liver transplantation is currently the only life-extending therapy for patients with end-stage disease, although recurrent disease can be observed in the transplanted liver. The multiple complications of PSC include pruritus, fatigue, vitamin deficiencies, metabolic bone disease, peristomal varices, bacterial cholangitis, dominant biliary strictures, gallbladder stones and polyps, and malignancy, particularly cholangiocarcinoma, which is the most lethal complication of PSC.
Probiotic Products in Canada with Clinical Evidence: What Can Gastroenterologists Recommend?
Authors: Reid Gregor , Anukam Kingsley , Koyama Tara
Published: March 2016

Probiotics, defined as ‘live microorganisms, which when administered in adequate amounts, confer a health benefit on the host’, are finally becoming an option for gastroenterologists in Canada, after being available for many years in Japan, Europe and the United States of America. Unfortunately, Health Canada and the US Food and Drug Administration have not controlled the use of the term ‘probiotic’ or put into place United Nations and World Health Organization guidelines. The net result is that a host of products called ‘probiotics’ are available but are not truly probiotic. The aim of the present review was to discuss the rationale for probiotics in gastroenterology, and specifically examine which products are options for physicians in Canada, and which ones patients might be using. It is hoped that by clarifying what probiotics are, and the strengths and limitations of their use, specialists will be better placed to make recommendations on the role of these products in patient care. In due course, more clinically documented probiotics will emerge, some with therapeutic effects based on a better understanding of disease processes.
Diagnosis of Multidrug‐Resistant Tuberculosis and Extensively Drug‐Resistant Tuberculosis: Current Standards and Challenges
Authors: Migliori Giovanni Battista , Matteelli Alberto , Cirillo Daniela , Pai Madhukar
Published: March 2016

INTRODUCTION: The emergence of multidrug‐resistant tuberculosis (MDR‐TB) and, more recently, extensively drug‐resistant TB (XDR‐TB) is widely considered a serious threat to global TB control. Over 400,000 new cases of MDR‐TB occur each year and, although their rates are currently unknown, XDR‐TB cases have been detected in every country where there is capacity to detect them (including Canada).

METHODS: The present article provides a narrative overview of the various diagnostic options available for XDR‐TB, including conventional tools and newer rapid tests for drug resistance. Available data suggest that automated liquid cultures are highly accurate and their use is rapidly expanding. Newly developed phenotypic tests include TK Medium (Salubris Inc, USA), microscopic‐observation drug‐susceptibility assay, FASTPlaque‐Response bacteriophage assay (Biotec Laboratories Ltd, UK), colorimetric redox indicator methods and the microcolony method. These tests are usually cheaper but not always simple to perform, with some requiring high standards of biosafety and quality control. Among the newly developed phenotypic methods, reverse hybridization‐based assays, referred to as line probe assays, represent a useful tool because of their superior accuracy and cost‐effectiveness.

CONCLUSIONS: To effectively address the threats of MDR‐TB and XDR‐TB, global initiatives are required to scale‐up culture and drug susceptibility testing capacities, especially in high‐burden countries where such capacity is scarce. In parallel, efforts are needed to expand the use of novel and emerging technologies (ie, molecular diagnostics) for the rapid determination of drug resistance.
Second‐Hand Smoke Exposure in Canada: Prevalence, Risk Factors, and Association with Respiratory And Cardiovascular Diseases
Authors: Vozoris Nicholas , Lougheed M Diane
Published: March 2016

OBJECTIVES: The aims of the present study were to estimate the prevalence of second‐hand smoke exposure in Canada, to identify sociodemographic risk factors for second‐hand smoke exposure, and to examine the relationship between second‐hand smoke exposure and respiratory and cardiovascular diseases.

METHODS: Data from the 2000/2001 Statistics Canada Canadian Community Health Survey (n=130,880, aged 12 years or older) were analyzed. Second‐hand smoke exposure was based on self‐report within the past month. The presence of chronic health conditions was also based on self‐report. Because ex‐smokers would be expected a priori to have poorer health than never‐smokers, the analysis was stratified by previous smoking status.

RESULTS: Approximately 25% of never‐smokers and 30% of ex‐smokers self‐reported recent second‐hand smoke exposure. The following factors were identified as risk factors for second‐hand smoke exposure: men; residences in Quebec, Atlantic Canada and the Territories; younger ages; nonimmigrant status; low education and income levels; social assistance receipt; and households without children younger than 12 years of age. After controlling for potential confounders, both never‐ and ex‐smokers exposed to second‐hand smoke had significantly higher odds of self‐reporting asthma (20% to 30%) and chronic bronchitis (50%) than those not exposed to secondhand smoke. Among ex‐smokers, those exposed to second‐hand smoke also had significantly higher odds of self‐reporting hypertension (20%) than those not exposed to second‐hand smoke. No associations were observed between second‐hand smoke exposure and emphysema or heart disease.

CONCLUSIONS: Self‐reported recent second‐hand smoke exposure in Canada in 2000/2001 was high, and was associated with asthma, chronic bronchitis and hypertension in never‐ and ex‐smokers. Potential causal associations and public health implications warrant additional research.
Barriers to Hepatitis C Virus Treatment in a Canadian HIV-Hepatitis C Virus Coinfection Tertiary Care Clinic
Authors: McLaren Meaghan , Garber Gary , Cooper Curtis
Published: March 2016

BACKGROUND: Despite demonstrated efficacy in HIV-hepatitis C virus (HCV) coinfection, not all patients initiate, complete or achieve success with HCV antiviral therapy.

PATIENTS AND METHODS: All HIV-HCV coinfected patient consults received at The Ottawa Hospital Viral Hepatitis Clinic (Ottawa, Ontario) between June 2000 and September 2006 were identified using a clinical database. A descriptive analysis of primary and contributing factors accounting for why patients did not initiate HCV therapy, as well as the therapeutic outcomes of treated patients, was conducted.

RESULTS: One hundred two consults were received. Sixty-seven per cent of patients did not initiate HCV therapy. The key primary reasons included: HIV therapy was more urgently needed (22%), loss to follow-up (12%), patients were deemed unlikely to progress to advanced liver disease (18%) and patient refusal (12%). Many patients had secondary factors contributing to the decision not to treat, including substance abuse (23%) and psychiatric illness (14%). Overall, 59% of untreated patients (40 of 68) were eventually lost to follow-up. Thirty-three per cent of referred patients started HCV therapy. Twenty-seven of 42 courses (64%) were interrupted prematurely for reasons such as virological nonresponse (48%), psychiatric complications (10%) and physical side effects (7%). Of all treatment recipients, 12 of 42 full courses of therapy were completed and three remained on HCV medication. Overall, eight of the 102 coinfected patients studied (8%) achieved a sustained virological response.

DISCUSSION: Not all HIV-HCV coinfected patients who are deemed to be in need of HCV treatment are initiating therapy. Only a minority of patients who do receive treatment achieve success. Implementation of HIV treatment, patient retention, attention to substance abuse and mental health care should be the focus of efforts designed to increase HCV treatment uptake and success. This can be best achieved within a multidisciplinary model of health care delivery.
Fibromyalgia: Presentation and Management with a Focus on Pharmacological Treatment
Authors: Sumpton Janice E , Moulin Dwight E
Published: March 2016

Fibromyalgia is a condition with widespread muscle pain. Prevalence studies showed that 2% to 7% of the population have fibromyalgia, which affects approximately one million Canadians. Fibromyalgia is most common in women, but it also involves men and children. As with most chronic illnesses, the causes of fibromyalgia are unknown. However, recent research supports underlying abnormalities in the central nervous system, which supports fibromyalgia as a chronic disease state and valid clinical entity. Pain is the primary symptom, often accompanied by overwhelming fatigue, sleep dysfunction and cognitive impairment. In 1990, the American College of Rheumatology developed diagnostic criteria for the diagnosis of fibromyalgia. Lifestyle changes, including pacing of activities and aerobic exercise, are very important in managing fibromyalgia symptoms. Emotional and behavioural therapy can also be helpful. Controlled trials of antidepressants, gabapentinoids, tramadol, zopiclone and sodium oxybate have shown effectiveness in fibromyalgia patients. Pregabalin and duloxetine were recently approved in the United States. Effective management of fibromyalgia is complex and requires a multidisciplinary treatment approach. Response and tolerance of different therapeutic interventions vary from patient to patient. Recent advances in the pathophysiology of fibromyalgia offer hope for new and improved therapies in the management of this disabling condition.
Montelukast as Add‐On Therapy with Inhaled Corticosteroids or Inhaled Corticosteroids and Long‐Acting Beta‐2‐Agonists in the Management of Patients Diagnosed with Asthma and Concurrent Allergic Rhinitis (The RADAR Trial)
Authors: Keith Paul K , Koch Caroline , Djandji Michel , Bouchard Jacques , Psaradellis Eliofotisti , Sampalis John S , Schellenberg R Robert , McIvor R Andrew
Published: March 2016

OBJECTIVE: To evaluate the effectiveness of montelukast as add‐on therapy for patients diagnosed with asthma and concurrent allergic rhinitis who remain uncontrolled while receiving inhaled corticosteroid (ICS) monotherapy or ICS/long‐acting beta‐2‐agonist (LABA) therapy in a community practice setting.

DESIGN: An eight‐week, multicentre, open‐label, observational study. Patients were 15 years of age or older and, while treated with an ICS or ICS/LABA, had allergic rhinitis and uncontrolled asthma symptoms by at least two criteria as per the Canadian Asthma Consensus Guidelines. The primary outcome measure was the percentage of patients with controlled asthma symptoms after eight weeks of treatment with montelukast 10 mg once daily added to ICS or ICS/LABA therapy.

RESULTS: In total, 1004 patients participated in the survey phase of the study. Of these patients, 319 continued in the treatment phase and 301 (94.4%) completed the eight‐week assessment. At baseline, all patients had uncontrolled asthma symptoms based on the Canadian Asthma Consensus Guidelines; at the eight‐week assessment, 229 patients (76.1%) achieved asthma control. According to the Asthma Control Questionnaire (as determined by scores of 0.75 or less), 164 patients (54.7%) achieved well‐controlled asthma at week 8. The mean (± SD) Asthma Control Questionnaire score decreased from 2.03±0.80 to 0.92±0.80 (P<0.001) for all patients, representing a clinically significant improvement. A statistically and clinically significant reduction in the overall Mini Rhinitis Quality of Life Questionnaire score was achieved with a decrease from 2.57±1.20 to 1.12±1.00 (–1.45±1.35; P<0.001). Patient and physician satisfaction rates with montelukast add‐on therapy were also significantly increased when compared with baseline treatment.

CONCLUSION: Montelukast add‐on therapy is effective for managing asthma and allergic rhinitis symptoms in patients who were previously uncontrolled with ICS or ICS/LABA treatment.
Nocardia Farcinica Lung Abscess Presenting in the Context of Advanced HIV Infection: Spontaneous Resolution in Response to Highly Active Antiretroviral Therapy Alone
Authors: King Arienne S , Castro Jose G , Dow Gordon CK
Published: March 2016

A 43‐year‐old man, known to be HIV‐positive, presented with a six‐week history of symptoms including cough, hemoptysis, anterior chest pain, fever and wasting. His CD4 cell count was 46 cells/μL, and his chest x‐ray showed a cavitating lesion in the left upper lobe. Sputum culture was positive for Nocardia farcinica. His infection resolved following initiation of antiretroviral therapy. Nocardia is an uncommon opportunistic pathogen in patients with HIV infection and is usually associated with advanced CD4 depletion, cavitary pneumonia, metastatic infection and high mortality. The impact of antiretroviral therapy on Nocardia infection in the setting of HIV has not been clearly elucidated. The current report is the first to present a case in which a complete clinical cure of Nocardia pneumonia has been documented, primarily in response to highly active antiretroviral therapy alone.
The Efficacy of Tiotropium as a Steroid‐Sparing Agent in Severe Asthma
Authors: Kapoor Anmol S , Olsen Sharla-Rae , O’Hara Cindy , Puttagunta Lakshmi , Vethanayagam Dilini
Published: March 2016

People with severe asthma account for 5% to 10% of all asthmatic patients; however, this small group uses the majority of health care resources. Novel methods are needed to cope with the burden that this minority of patients places on the health care system. A severe asthma clinic patient, who was monitored through the University of Alberta’s Virtual Asthma Clinic (Edmonton, Alberta) is presented. Despite optimization of his disease and individualized asthma education (provided by a certified asthma educator), the patient remained on oral glucocorticosteroids (OGS) to control his disease. Following optimization and stabilization, a further reduction in the dose of his OGS by the addition of the long‐acting anticholinergic agent tiotropium bromide, was demonstrated. The role of tiotropium as a potential ‘steroid‐sparing agent’ in severe refractory asthma is discussed, noting that if patients who are on OGS are not monitored for active inflammation, they may overuse the amount of prescribed systemic steroids, which can result in long‐term steroid‐related sequelae.
Catastrophizing and Depressive Symptoms as Prospective Predictors of Outcomes Following Total Knee Replacement
Authors: Edwards Robert R , Haythornthwaite Jennifer A , Smith Michael T , Klick Brendan , Katz Jeffrey N
Published: March 2016

Several recent reports suggest that pain‐related catastrophizing is a risk factor for poor acute pain outcomes following surgical interventions. However, it has been less clear whether levels of catastrophizing influence longer‐term postoperative outcomes. Data were analyzed from a relatively small number (n=43) of patients who underwent total knee replacement and were followed for 12 months after their surgery. Previous research has suggested that high levels of both catastrophizing and depression are associated with elevated acute postoperative pain complaints among patients undergoing knee surgery. In this sample, catastrophizing and depression at each of the assessment points were studied as prospective predictors of pain (both global pain ratings and pain at night) at the subsequent assessment point over the course of one year. The predictive patterns differed somewhat across measures of pain reporting; depressive symptoms were unique predictors of greater global pain complaints, while catastrophizing was a specific and unique predictor of elevated nighttime pain. While surgical outcomes following total knee replacement are, on average, quite good, a significant minority of patients continue to experience long‐term pain. The present findings suggest that high levels of catastrophizing and depression may promote enhanced pain levels, indicating that interventions designed to reduce catastrophizing and depressive symptoms may have the potential to further improve joint replacement outcomes.
Hepatocellular Carcinoma with Cutaneous Metastases
Authors: Rueben Suzanne , Owen David , Lee Patricia , Weiss Alan
Published: March 2016

Two cases of cutaneous metastases from hepatocellular carcinoma (HCC) are reported. Both patients had been diagnosed with HCC at least one year before the appearance of skin lesions. The lesions presented as small reddish nodules in both patients, with a large additional vascular lesion in one of the patients. Cutaneous metastases from HCC are very rare. However, these two cases suggest that patients with HCC and presenting with skin nodules should have biopsies performed to confirm the diagnosis.
The Role of Iron in the Pathophysiology and Treatment of Chronic Hepatitis C
Authors: Price Leslie , Kowdley Kris V
Published: March 2016

Increased hepatic iron content may be observed in patients with chronic hepatitis C infection, and may contribute to disease severity. The presence of hemochromatosis gene mutations is associated with increased hepatic iron accumulation and may lead to accelerated disease progression. Hepatic iron depletion has been postulated to decrease the risk of hepatocellular carcinoma in patients with cirrhosis due to chronic hepatitis C. It is possible that iron depletion stabilizes or improves liver histology and slows disease progression in these individuals. The present article reviews the prevalence and risk factors for hepatic iron overload in chronic hepatitis C, with emphasis on the available data regarding the efficacy of iron depletion in the treatment of this common liver disease.
Variation in Physician Reimbursement for Endoscopy across Canada
Authors: Roth Lee S , Adams Paul C
Published: March 2016

BACKGROUND: Endoscopy accounts for a significant proportion of income for physicians practicing gastroenterology. Fees are set provincially, and the consistency with regard to compensation for colonoscopy and gastroscopy across the provinces has yet to be established.

OBJECTIVE: To compare and contrast provincial endoscopy fees across Canada and internationally.

METHODS: Provincial and territorial ministries responsible for health care were contacted for their most current fee schedule. This was reviewed, and the billing amounts for colonoscopy and endoscopy collected. International contacts were made with regard to rates outside of Canada.

RESULTS: The mean (± SD) national fee for gastroscopy was $114.19±$31.47 per procedure, with a range of $52.50 to $156.10. Physician billing nationally averaged $170.99±$33.49 per colonoscopy procedure, with a range of $105.00 to $223.00. The province of Quebec provided the least amount of compensation for both procedures, and the province of Nova Scotia provided the most for both procedures.

CONCLUSION: Physician fees for gastroscopy and colonoscopy vary widely among the provinces, and, on average, seem to be less than international rates.
Assessing the Educational Needs of Canadian Gastroenterologists and Gastroenterology Nurses: Challenges to Optimal Care in Crohn’s Disease
Authors: Dupuis Martin , Marshall John K , Hayes Sean M , Cytryn Kayla , Murray Suzanne
Published: March 2016

OBJECTIVE: A national needs assessment of Canadian gastroenterologists and gastroenterology nurses was undertaken to determine the perceived and unperceived educational and performance barriers to caring for patients with Crohn’s disease (CD).

METHODS: A triangulated, mixed-method approach (qualitative and quantitative) was used to determine the nature and extent of knowledge gaps and barriers in the care of patients with CD.

RESULTS: Qualitative interviews were conducted with nine gastroenterologists, four gastroenterology nurses and nine patients with CD. Based on this exploratory research, a survey was designed and launched nationally (37 gastroenterologists, 36 gastroenterology nurses). Findings indicated that Canadian gastroenterologists and gastroenterology nurses lacked clarity regarding their roles and responsibilities across the continuum of CD care, and face communication gaps within the health care team, undermining their effectiveness. Gastroenterologists identified challenges in optimal diagnosis due to unclear testing and diagnostic criteria. They recognized knowledge gaps when treating patient subgroups and in prescribing biological therapies. Furthermore, gastroenterologists self-identified gaps in skill, knowledge, and confidence in monitoring disease progression and effectively assessing response to therapy. When managing patients with CD, gastroenterologists expressed challenges with patient issues outside their domain of medical expertise, particularly with the skills needed to facilitate effective patient communication and education that would enhance adherence to recommended treatments.

CONCLUSIONS: Educational initiatives should address diagnostic and treatment guidelines, as well as enhancement of clinical performance gaps in health care team processes and the patient-professional therapeutic relationship. To impact care and patient outcomes, these initiatives must be relevant to clinical practice settings and applicable to the practice context.
Physical Therapy Practice Patterns in Acute Exacerbations of Chronic Obstructive Pulmonary Disease
Authors: Harth Leslie , Stuart Jennifer , Montgomery Catherine , Pintier Karol , Czyzo Susan , Hill Kylie , Goldstein Roger , Brooks Dina
Published: March 2016

BACKGROUND AND OBJECTIVE: The importance of the multidisciplinary approach to the management of chronic obstructive pulmonary disease is increasingly emphasized. The present study aimed to examine the current practice patterns of physical therapists involved in the management of patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease.

METHOD: A self‐administered postal survey was distributed to the rehabilitation departments of all Canadian acute care hospitals with more than 250 beds. The survey addressed patient assessment, treatment, education and discharge planning for intensive care unit and/or ward admissions.

RESULTS: In total, 66% of hospitals (n=109) participated in the study, with provincial representation mainly from Ontario (n=36 [33%]) and Quebec (n=36 [33%]). Assessment and treatment techniques did not differ greatly between the ward and the intensive care unit. Assessment focused on patient observation, pulse oximetry and auscultation, and was reported to be used ‘always or frequently’ by 76%, 76% and 69% of respondents, respectively. Less than 18% of respondents used a measure of functional capacity, and health‐related quality of life measures were rarely used. Treatment focused on ambulatory techniques, with 78% and 75% of respondents using mobility and transfer training ‘always or frequently’, respectively. The most common educational topics were breathing exercises and positioning, which were addressed by 68% and 67% of respondents, respectively.

CONCLUSION: Patient assessment focused on physical impairments, with little use of measures of function or health‐related quality of life, whereas treatment focused on mobility, with a lesser focus on airway clearance. Further study is needed to identify the factors that impact these practice patterns.
Autistic Enterocolitis: Fact or Fiction?
Authors: Galiatsatos Polymnia , Gologan Adrian , Lamoureux Esther
Published: March 2016

Autism spectrum disorder refers to syndromes of varying severity, typified by impaired social interactions, communicative delays and restricted, repetitive behaviours and interests. The prevalence of autism spectrum disorders has been on the rise, while the etiology remains unclear and most likely multifactorial. There have been several reports of a link between autism and chronic gastrointestinal symptoms. Endoscopy trials have demonstrated a higher prevalence of nonspecific colitis, lymphoid hyperplasia and focally enhanced gastritis compared with controls. Postulated mechanisms include aberrant immune responses to some dietary proteins, abnormal intestinal permeability and unfavourable gut microflora. Two autism spectrum disorder patients with chronic intestinal symptoms and abnormal endoscopic findings are described, followed by a review of this controversial topic.
Colon Cleansing before Colonoscopy: Does Oral Sodium Phosphate Solution Still Make Sense?
Authors: Rex Douglas K , Vanner Stephen J
Published: March 2016

Oral sodium phosphate (NaP) solution has been withdrawn from the market in the United States but remains available for over-the-counter purchase for bowel preparation for colonoscopy in Canada. The present review summarizes recent data regarding the renal toxicity of oral NaP as well as its efficacy and tolerability relative to other preparations. Given the availability of effective alternatives to NaP solution, its use for colonoscopy preparation in Canada should be limited. Candidate patients for oral NaP solution should be assessed for eligibility and preparation instructions should adhere to the current recommendations for maximizing the safety of oral NaP.
Does Smoking Reduce Infliximab’s Effectiveness against Crohn’s Disease?
Authors: Narula Neeraj , Fedorak Richard N
Published: March 2016

Crohn’s disease (CD) is an idiopathic inflammatory bowel disease and has no known cure. CD symptoms are treated using an array of medicines, including biological agents such as infliximab. However, infliximab therapy is expensive; therefore, identifying variables that can help predict response to infliximab is worthwhile. The present article reviews the impact of tobacco smoking on the efficacy of infliximab in CD. Earlier studies have speculated that smoking has a negative effect on the response to infliximab in CD, but the current literature is largely unable to identify a significant relationship between the two. Although smoking is known to have a negative effect on the course of CD, as well as other organ systems, presently, a CD patient’s smoking status should not influence treatment decisions regarding infliximab therapy.
Clinicopathological Features Associated with Lymph Node Metastasis in Early Gastric Cancer: Analysis of a Single-Institution Experience in China
Authors: Shen Lizong , Huang Yiming , Sun Maocai , Xu Hao , Wei Wei , Wu Wenxi
Published: March 2016

BACKGROUND: An accurate assessment of potential lymph node metastasis is an important issue for the appropriate treatment of early gastric cancer. Minimizing the number of invasive procedures used in cancer therapy is critical for improving the patient’s quality of life.

OBJECTIVE: To evaluate the clinicopathological features associated with lymph node metastasis of early gastric cancer in patients from a single institution in China.

METHODS: A retrospective review of data from 410 patients surgically treated for early gastric cancer at the First Affiliated Hospital (Nanjing, China) between 1998 and 2007, was conducted. The clinicopathological variables associated with lymph node metastasis were evaluated.

RESULTS: Lymph node metastasis was observed in 12.20% of patients. The macroscopic type, tumour size, location in the stomach, depth of gastric carcinoma infiltration, and presence of vascular or lymphatic invasion showed a positive correlation with the incidence of lymph node metastasis by univariate analysis. Multivariate analyses revealed histological classification, macroscopic type, tumour size, depth of gastric carcinoma infiltration, and the presence of vascular or lymphatic invasion to be significantly and independently related to lymph node metastasis. The depth of gastric carcinoma infiltration was the strongest predictive factor for lymph node metastasis. For intramucosal cancer, tumour size was the unique risk factor for lymph node metastasis. For submucosal cancer, histological classification and tumour size were independent risk factors for lymph node metastasis.

CONCLUSIONS: Histological classification, macroscopic type, tumour size, depth of gastric carcinoma infiltration, and the presence of vascular or lymphatic invasion are independent risk factors for lymph node metastasis in patients with early gastric cancer in China. Minimal invasive treatment, such as endoscopic mucosal resection, may be possible for highly selected cancers.
Disseminated Herpes Simplex Virus Type 1 Primary Infection in a Healthy Individual
Authors: Boivin Guy , Malette Brigitte , Goyette Nathalie
Published: March 2016

BACKGROUND: Primary herpes simplex virus (HSV) infection usually involves one mucosal region.

OBJECTIVE: To describe an unusual disseminated HSV‐1 infection involving two mucosal sites in a healthy man.

RESULTS: Primary HSV infection involved oral and genital mucosa and was associated with viremia, hepatitis and rash. Phylogenetic analysis of genital and oral viruses revealed that the patient was infected by a single HSV‐1 strain.

CONCLUSION: Use of polymerase chain reaction detection techniques for HSV may identify viremic patients in the absence of obvious immunosuppression.
Ultra Low‐Dose Naloxone and Tramadol/Acetaminophen in Elderly Patients Undergoing Joint Replacement Surgery: A Pilot Study
Authors: Imasogie Ngozi N , Singh Sudha , Watson James T , Hurley Debbie , Morley-Forster Patricia
Published: March 2016

OBJECTIVE: A pilot study was conducted to assess whether both the rationale and feasibility exist for future randomized clinical trials to evaluate the combined use of naloxone infusion and tramadol/acetaminophen as opioid‐sparing drugs in elderly patients undergoing lower extremity joint replacement surgery.

DESIGN: Ten patients 70 years of age or older undergoing either total knee (n=7) or total hip (n=3) arthroplasty were treated prospectively. Each patient received two tablets of tramadol/acetaminophen (Tramacet; Janssen‐Ortho Inc, Canada) preoperatively and every 6 h postoperatively, as well as a naloxone infusion started preoperatively at 0.25 μg/kg/h and continued up to 48 h postoperatively. In addition, standard intraoperative care was provided with 0.2 mg of intrathecal morphine, 1.4 mL of 0.75% bupivacaine, and an intra‐articular infiltration of 100 mL of 0.3% ropivacaine and 30 mg of ketorolac, as well as standard postoperative morphine via patient‐controlled analgesia orders and celecoxib 200 mg twice daily for five days.

OUTCOME MEASURES: Compared with seven historical controls, also 70 years of age or older, who had undergone either a total knee (n=4) or total hip (n=3) arthroplasty, postoperative opioid use was reduced by 80%. Except for transient nausea and vomiting in 40% and 20% of patients, respectively, the 10 patients on tramadol/acetaminophen and naloxone tolerated the new regimen without difficulty.

CONCLUSION: Consequently, a randomized, double‐blinded clinical trial comparing standard therapy versus standard therapy plus these two drugs seems warranted. In such a trial, it would require approximately 20 subjects per treatment arm to detect a 80% decrease in morphine use.
Gastric Intramural Hematoma: A Case Report and Literature Review
Authors: Dhawan Vivek , Mohamed Ahmed , Fedorak Richard N
Published: March 2016

Intramural hematoma of the gastrointestinal tract is an uncommon occurrence, with the majority being localized to the esophagus or duodenum. Hematoma of the gastric wall is very rare, and has been described most commonly in association with coagulopathy, peptic ulcer disease, trauma, and amyloid-associated microaneurysms. A case of massive gastric intramural hematoma, secondary to anticoagulation therapy, and a gastric ulcer that was successfully managed with conservative therapy, is presented. A literature review of previously reported cases of gastric hematoma is also provided.
Reliability of Temporal Summation and Diffuse Noxious Inhibitory Control
Authors: Cathcart Stuart , Winefield Anthony H , Rolan Paul , Lushington Kurt
Published: March 2016

BACKGROUND: The test‐retest reliability of temporal summation (TS) and diffuse noxious inhibitory control (DNIC) has not been reported to date. Establishing such reliability would support the possibility of future experimental studies examining factors affecting TS and DNIC. Similarly, the use of manual algometry to induce TS, or an occlusion cuff to induce DNIC of TS to mechanical stimuli, has not been reported to date. Such devices may offer a simpler method than current techniques for inducing TS and DNIC, affording assessment at more anatomical locations and in more varied research settings.

METHOD: The present study assessed the test‐retest reliability of TS and DNIC using the above techniques. Sex differences on these measures were also investigated.

RESULTS: Repeated measures ANOVA indicated successful induction of TS and DNIC, with no significant differences across test‐retest occasions. Sex effects were not significant for any measure or interaction. Intraclass correlations indicated high test‐retest reliability for all measures; however, there was large interindividual variation between test and retest measurements.

CONCLUSION: The present results indicate acceptable within‐session test‐retest reliability of TS and DNIC. The results support the possibility of future experimental studies examining factors affecting TS and DNIC.
Inflammatory Bowel Disease and Pregnancy: Evidence, Uncertainty and Patient Decision-Making
Authors: Habal Flavio M , Kapila Varun
Published: March 2016

Inflammatory bowel disease (IBD) often affects women during their child-bearing years. Management of a pregnant IBD patient, or a patient contemplating pregnancy, poses unique challenges and can be quite daunting. Knowledge of the basic interplay among disease, normal host physiology and pregnancy is vital to managing these patients. One of the most important advances in the management of IBD over the past decade has been the finding that normal pregnancy outcomes can be achieved when a woman enters the pregnancy in remission. New insights into the safety of a wider spectrum of drugs in these patients has allowed for increased success in IBD management. The evidence supporting medical interventions including biological therapy such as antibodies to tumour necrosis factor agents is reviewed. Once the treating physician understands this complex relationship, management of the pregnant IBD patient can often become a rewarding experience.
Sensorineural Hearing Loss and Celiac Disease: A Coincidental Finding
Authors: Volta Umberto , Ferri Gian Gaetano , De Giorgio Roberto , Fabbri Angela , Parisi Claudia , Sciajno Laura , Castellari Alessandra , Fiorini Erica , Piscaglia Maria , Barbara Giovanni , Granito Alessandro , Pirodda Antonio
Published: March 2016

BACKGROUND: Celiac disease (CD) can be associated with a variety of extraintestinal manifestations, including neurological diseases. A new neurological correlation has been found between CD and sensorineural hearing loss (SNHL).

OBJECTIVE: To verify the association between SNHL and CD, and to establish whether the neurological hearing impairment in CD is related to nonorgan-specific and antineuronal antibodies, as well as the presence of autoimmune disorders.

METHODS: A sample of 59 consecutive biopsy- and serologically proven CD patients were studied. Among CD patients, 11 were newly diagnosed and 48 were on a gluten-free diet. Hearing function was assessed by audiometric analysis in all CD patients as well as in 59 age- and sex-matched controls. Patients were tested for a panel of immune markers including nonorgan-specific autoantibodies and antineuronal antibodies.

RESULTS: SNHL was detected in five CD patients (8.5%) and in two controls (3.4%). In one patient, the SNHL was bilateral, whereas the remaining four had a monolateral impairment. The prevalence of SNHL was not significantly different between CD patients and controls. At least one of the antibodies tested for was positive in two of the five CD patients with SNHL and in 12 of the 54 CD patients without SNHL. Antineuronal antibodies to central nervous system antigens were consistently negative in the five CD patients with SNHL. Only one of the five CD patients with SNHL had Hashimoto thyroiditis.

CONCLUSIONS: SNHL and CD occur coincidentally. Hearing function should be assessed only in CD patients with clinical signs of hearing deficiency.
Celiac and Perigastric Lymph Node Metastasis of Prostate Cancer Diagnosed with Endoscopic Ultrasound-Guided Fine-Needle Aspiration
Authors: Attila Tan , Ricketts-Loriaux Reva , Sauer David A , Faigel Douglas O
Published: March 2016

Endoscopic ultrasound has been used to diagnose and stage gastrointestinal and nongastrointestinal tumours. To our knowledge, the present report describes the first case of celiac and perigastric lymph node metastasis of prostate cancer diagnosed with endoscopic ultrasound-guided fine-needle aspiration.
Time to Endoscopy and Outcomes in Upper Gastrointestinal Bleeding
Authors: Sarin Nitin , Monga Neerav , Adams Paul C
Published: March 2016

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a common problem associated with significant morbidity and mortality. Previous studies show that immediate endoscopies do not affect outcomes in patients; however, endoscopic interventions have evolved. The present retrospective review of endoscopies performed at a large teaching hospital assessed the timing of endoscopy with respect to the morbidity and mortality of UGIB.

METHODS: Diagnostic billing codes were used to assess all inpatients of gastroenterologists at the University Hospital of the London Health Sciences Centre, London, Ontario, from July 2004 to June 2006, using a centralized data recording system. Time to endoscopy (within 6 h, 6 h to 24 h and beyond 24 h) were compared for the outcomes of mortality, need for surgery and transfusion requirements.

RESULTS: From July 2004 to June 2006, there were 502 upper endoscopies performed for the indication of suspected UGIB and 375 for overt acute nonvariceal UGIB. Approximately 10% of cases revealed variceal bleeding. When comparing endoscopy within 6 h with endoscopy at 6 h to 24 h, there were no significant differences in mortality, need for surgery (OR 3.6 and 2.8, respectively, compared with endoscopy beyond 24 h) or transfusion requirements. Even when assessing the group that received endoscopic hemostasis, time to endoscopy was not associated with better outcomes. Multivariate analysis did not demonstrate any advantages for early endoscopy (less than 6 h) compared with endoscopy within 24 h.

CONCLUSIONS: Most patients with acute gastrointestinal bleeding can be effectively managed with endoscopy within 24 h.
Bone Mineral Densities in Individuals with Gilbert’s Syndrome: A Cross-Sectional, Case-Control Pilot Study
Authors: Minuk GY , Greenberg R , Uhanova J , Hawkins K , Leslie WD
Published: March 2016

BACKGROUND: Unconjugated bilirubin inhibits osteoblastic proliferative activity in vitro, raising the possibility that Gilbert’s syndrome (GS) patients are at increased risk of osteoporosis.

OBJECTIVES: To compare bone mineral density (BMD), serum parathyroid hormone (PTH), C-telopeptide (CTX) and osteocalcin levels in GS subjects versus matched controls in a cross-sectional, case-control study.

METHODS: BMD determinations were obtained with central dual-energy x-ray absorptiometry. Serum PTH, CTX and osteocalcin levels were measured by enzyme immunoassay.

RESULTS: A total of 17 GS and 30 control subjects were studied. Overall, there were no significant differences in BMD, PTH, CTX or osteocalcin levels between the two groups. However, when older (older than 40 years of age) and younger (40 years of age and younger) cohorts were considered separately, the older GS cohort had significantly decreased total hip BMD, T scores and Z scores, and femoral neck BMD, T scores and Z scores (P<0.005 for each parameter, respectively) compared with older control subjects. Serum osteocalcin levels were lower in the older versus younger GS cohort (P=0.006). An inverse correlation existed between all subjects’ serum unconjugated bilirubin levels and total body BMD determinations (r=−0.42; P=0.04). On univariate analysis, the association between serum unconjugated bilirubin and total body BMD was not significant (P=0.066), nor was serum unconjugated bilirubin identified as a risk factor for low BMD when entered into multivariate analyses.

CONCLUSIONS: The results of the present pilot study warrant further research involving larger numbers of subjects and longitudinal measurements to determine whether GS is associated with decreased BMD, particularly in older GS subjects.
Does Routine Pain Assessment Result in Better Care?
Authors: Hadjistavropoulos Thomas , MacNab Ying C , Lints-Martindale Amanda , Martin Ronald , Hadjistavropoulos Heather
Published: March 2016

BACKGROUND: Although a variety of national organizations such as the Canadian Pain Society, the American Pain Society and the Joint Commission on Accreditation of Health Care Organizations have advanced the idea that pain should be assessed on a routine basis, there is little evidence that systematic pain assessment information is used routinely by clinicians even when it is readily available.

OBJECTIVE: To determine whether systematic pain assessment information alters medical practitioners’ clinical practices.

METHODS: A population of seniors with complex medical problems who were evaluated by case coordinators was studied. Case coordinators were assigned to either an experimental or control patient assessment condition. Control condition patients were assessed as usual. In the experimental condition, a psychometrically valid pain assessment battery as well as the Geriatric Depression Scale – Short Form (because depression and chronic pain are frequently comorbid) were integrated into the routine case coordination assessment. A summary of the results of the depression and pain assessments was subsequently sent to physicians via mail and fax. Patients were also given copies of the assessment summaries and were asked to discuss these with their physicians. Physicians’ medication prescriptions were monitored over time through the database of the provincial ministry of health.

RESULTS: At the end of the study, no significant differences between experimental and control patients were found with respect to medications prescribed or patient self‐reports of pain. Nonetheless, there was a significant relationship between Geriatric Depression Scale – Short Form scores and pain medications prescribed for patients in the experimental condition. Moreover, indexes of overall pain intensity did not change significantly over time.

CONCLUSIONS: The findings do not support the idea that the availability of systematic pain assessment information leads to change in clinician’s medication practices. As such, educational interventions and public policy initiatives are needed to ensure that treatment providers do not only gather but also use pain assessment information.