bluuebunny/crossref_metadata_2025 huggingface dataset:
Workshops to Disseminate the Canadian Thoracic Society Guidelines for Chronic Obstructive Pulmonary Disease to Health Care Professionals in Ontario: Impact on Knowledge, Perceived Health Care Practices and Participant Satisfaction
Authors: Moosa Dilshad , Blouin Maria , Hill Kylie , Goldstein Roger
Published: March 2016

BACKGROUND: The Canadian Thoracic Society (CTS) has developed a clinical practice guideline (CPG) regarding the management of patients with chronic obstructive pulmonary disease (COPD). Implementation of this CPG in the primary care setting requires an effective dissemination strategy.

OBJECTIVES: To examine the change in knowledge, participant satisfaction and perceived changes in clinical practice among health care professionals working in the primary care setting following attendance at a workshop to disseminate the CTS CPG for COPD.

METHODS: A 2.5 h workshop was conducted in three community health sites within Ontario. Each workshop comprised a didactic presentation and interactive case study discussions. Before, and one month following the workshop, a structured knowledge assessment questionnaire was administered. A structured satisfaction questionnaire and evaluative form that examined the impact of the workshop on the clinical management of COPD patients were administered immediately and three months following completion of the workshop, respectively.

RESULTS: Sixty‐nine participants attended the workshop. The mean score for the structured knowledge assessment questionnaire increased from 8.5±2.7 to 10.6±2.0 following the workshop (P=0.008). Eighty‐nine per cent and 96% of participants indicated that they would recommend the workshop to a colleague and had greater confidence in their management of COPD patients, respectively. Following attendance of the workshop, 73%, 69% and 46% described increased patient education, patient monitoring and the use of objective testing in clinical practice, respectively.

CONCLUSIONS: Workshop attendance was associated with high levels of satisfaction and important self‐reported changes in clinical practice, which may reflect improved knowledge of the CTS CPG for COPD.
Liver Biopsies for Chronic Hepatitis C: Should Nonultrasound-Guided Biopsies Be Abandoned?
Authors: Flemming Jennifer A , Hurlbut David J , Mussari Ben , Hookey Lawrence C
Published: March 2016

BACKGROUND/OBJECTIVE: Liver biopsy has been the gold standard for grading and staging chronic hepatitis C virus (HCV)-mediated liver injury. Traditionally, this has been performed by trained practitioners using a nonimage-guided percutaneous technique at the bedside. Recent literature suggests an expanding role for radiologists in obtaining biopsies using an ultrasound (US)-guided technique. The present study was undertaken study to determine if the two techniques produced liver biopsy specimens of similar quality and hypothesized that at our institution, non-US-guided percutaneous liver biopsies for HCV would be of higher quality than US-guided specimens.

METHODS: Liver biopsies from 100 patients with chronic HCV infection (50 consecutive US-guided and 50 consecutive non-US-guided), were retrospectively identified using a hospital histopathology database. All original biopsy slides were coded and prospectively reanalyzed by a single hepatopathologist who was blinded to the technique used in obtaining the biopsy. Additionally, all liver biopsies for chronic HCV infection completed at the centre from 1998 to 2007 were identified and the technique used was recorded. Biopsy quality was determined primarily by the number of complete portal tracts (CPTs) identifiable in the slides. The total length of specimen and the degree of fragmentation were secondary outcome measures.

RESULTS: There was a slight difference observed between the US-guided and non-US-guided groups in mean age (46.3 years versus 42.5 years, repectively; P=0.018) but no differences in sex, presence of cirrhosis, bilirubin, creatinine, international normalized ratio, and grade or stage of disease. Biopsies obtained using the US-guided technique produced higher quality specimens than the non-US-guided technique based on our primary outcome of number of CPTs in the biopsy (11.8 versus 7.4; P<0.001). US-guided specimens also were longer (24.4 mm versus 19.7 mm; P=0.001), had less fragmentation (P=0.016), and a higher overall histopathological quality assessment (P=0.026) than the non-US-guided biopsies. However, there was no significant difference between the two groups in the ability to grade and stage the disease (96% US-guided versus 90% in non-US-guided (P=0.20). Over a 10-year period, 763 biopsies for chronic HCV infection were identified with an obvious trend toward the increased use of US-guided technique observed at 2% in 1998 to 85% in 2007.

CONCLUSIONS: US-guided liver biopsies for chronic HCV are the most common method of obtaining specimens at the Kingston General Hospital, Kingston, Ontario, and are of higher quality than non-US-guided specimens. However, there is no significant difference in the two techniques in the ability to grade and stage chronic HCV.
Douleurs et conflits : Approche comparative et implications pour la qualité des soins en fin de vie
Authors: Mpinga Emmanuel Kabengele , Verloo Henk , Rapin Charles-Henri , Chastonay Philippe
Published: March 2016

Are conflicts to an organization what pain is to an organism?

OBJECTIVES: To explore the similarities and the differences between pain and conflicts in palliative care settings, and to better understand the potential importance of conflicts in end of life quality of care.

METHODS: Comparative and reflective methods focusing on how conflicts and pain are taken care of in health structures.

RESULTS: Pain and conflicts present numerous similarities such as identity, typology, prevalence, warning function, economic and social costs, denial, occultation and hurdles to appropriate management. Differences also exist regarding pain – there are prevention programs on local and international levels; there are specific research and training programs; and there is also some social visibility. This does not yet exist on a larger scale regarding conflicts.

CONCLUSION: Decision makers at clinical and public health levels should probably push to label conflicts as indicators of quality of care and develop appropriate health policy programs.
A Multicentre, Observational Study of Sodium Picosulfate and Magnesium Citrate as a Precolonoscopy Bowel Preparation
Authors: Love Jonathan , Bernard Edmond-Jean , Cockeram Alan , Cohen Lawrence , Fishman Martin , Gray James , Morgan David
Published: March 2016

BACKGROUND: Sodium picosulfate with magnesium citrate (PSMC) has been available as a precolonoscopy bowel preparation in Canada since 2005. A high patient acceptability and preference appears to have contributed to its wide adoption across the country. Despite its frequent use, there are relatively few published studies of this product, especially reports regarding its use in routine clinical practice. Moreover, to date, there have been no Canadian studies of any kind.

OBJECTIVE: To conduct a preliminary evaluation of PSMC by prospectively collecting data describing its effectiveness.

METHODS: In the present multicentre, observational study, sequential patients used PSMC according to each institution’s standard colonoscopy protocol. Differences in bowel cleansing protocols included dose timing, fluid intake, dietary restrictions and administration of bisacodyl. During colonoscopy, preparation quality was rated separately for the right and left sides of the colon.

RESULTS: Of the 613 patients entered, 606 were evaluable for efficacy. For the right and left colon, respectively, 93.0% and 96.2% of preparations were rated either ‘excellent’ or ‘adequate’. In the 334 patients who received adjunctive bisacodyl and the 272 patients who did not, the results were similar: for the right and left colon, 92.3% and 97.1% of those who did not, and 93.4% and 95.7% of those who did receive bisacodyl, respectively, were rated either ‘excellent’ or ‘adequate’.

CONCLUSIONS: Despite the differences in bowel cleansing protocols used at each hospital (including an additional laxative), PSMC consistently yielded a high percentage of positive ratings for efficacy.
Best Practices for Smoking Cessation Interventions in Primary Care
Authors: McIvor Andrew , Kayser John , Assaad Jean-Marc , Brosky Gerald , Demarest Penny , Desmarais Philippe , Hampson Christine , Khara Milan , Pathammavong Ratsamy , Weinberg Robert
Published: March 2016

BACKGROUND: In Canada, smoking is the leading preventable cause of premature death. Family physicians and nurse practitioners are uniquely positioned to initiate smoking cessation. Because smoking is a chronic addiction, repeated, opportunity‐based interventions are most effective in addressing physical dependence and modifying deeply ingrained patterns of beliefs and behaviour. However, only a small minority of family physicians provide thorough smoking cessation counselling and less than one‐half offer adjunct support to patients.

OBJECTIVE: To identify the key steps family physicians and nurse practitioners can take to strengthen effective smoking cessation interventions for their patients.

METHODS: A multidisciplinary panel of health care practitioners involved with smoking cessation from across Canada was convened to discuss best practices derived from international guidelines, including those from the United States, Europe, and Australia, and other relevant literature. The panellists subsequently refined their findings in the form of the present article.

RESULTS: The present paper outlines best practices for brief and effective counselling for, and treatment of, tobacco addiction. By adopting a simple series of questions, taking 30 s to 3 min to complete, health care professionals can initiate smoking cessation interventions. Integrating these strategies into daily practice provides opportunities to significantly improve the quality and duration of patients’ lives.

CONCLUSION: Tobacco addiction is the most important preventable cause of morbidity and mortality in Canada. Family physicians, nurse practitioners and other front‐line health care professionals are well positioned to influence and assist their patients in quitting, thereby reducing the burden on both personal health and the public health care system.
Alexithymia and Fear of Pain Independently Predict Heat Pain Intensity Ratings among Undergraduate University Students
Authors: Katz Joel , Martin Andrea L , Pagé M Gabrielle , Calleri Vincent
Published: March 2016

BACKGROUND: Alexithymia is a disturbance in awareness and cognitive processing of affect that is associated with over‐reporting of physical symptoms, including pain. The relationship between alexithymia and other psychological constructs that are often associated with pain has yet to be evaluated.

OBJECTIVES: The present study examined the importance of alexithymia in the pain experience in relation to other integral psychological components of Turk’s diathesis‐stress model of chronic pain and disability, including fear of pain, anxiety sensitivity, pain avoidance and pain catastrophizing.

METHODS: Heat pain stimuli, using a magnitude estimation procedure, and five questionnaires (Anxiety Sensitivity Index, Fear of Pain Questionnaire III, Pain Catastrophizing Scale, avoidance subscale of the Pain Anxiety Symptoms Scale‐20 and Toronto Alexithymia Scale‐20) were administered to 67 undergraduate students (44 women) with a mean (± SD) age of 20.39±3.77 years.

RESULTS: Multiple linear regression analysis revealed that sex, fear of pain and alexithymia were the only significant predictors of average heat pain intensity (F[6, 60]=5.43; R2=0.35; P=0.008), accounting for 6.8%, 20.0% and 9.6% of unique variance, respectively. Moreover, the difficulty identifying feelings and difficulty describing feelings subscales, but not the externally oriented thinking subscale of the Toronto Alexithymia Scale‐20 significantly predicted average heat pain intensity.

CONCLUSIONS: Individuals with higher levels of alexithymia or increased fear of pain reported higher average pain intensity ratings. The relationship between alexithymia and pain intensity was unrelated to other psychological constructs usually associated with pain. These findings suggest that difficulties with emotion regulation, either through reduced emotional awareness via alexithymia or heightened emotional awareness via fear of pain, may negatively impact the pain experience.
Primary Sternal Tuberculosis Osteomyelitis: A Case Report and Discussion
Authors: Vasa Miten , Ohikhuare Christine , Brickner Leslea
Published: March 2016

As immigration to the United States from countries endemic for tuberculosis (TB) increases, the incidence of pulmonary and extrapulmonary TB disease may increase. Primary tuberculous sternal osteomyelitis is one form of extrapulmonary TB that is exceedingly rare throughout the world, and falls under the differential diagnosis for chest wall masses. Management involves standard antituberculous therapy with antibiotics similar to treating other forms of extrapulmonary TB, as well as consideration of surgical intervention depending on the extent of osteomyelitis. A typical case of primary sternal TB osteomyelitis is reported, and the epidemiology, differential diagnosis, clinical manifestations and management are reviewed.
Renal Effects of Long-Term Treatment with 5-Aminosalicylic Acid
Authors: Patel Harshna , Barr Aiala , Jeejeebhoy Khursheed N
Published: March 2016

BACKGROUND: A number of case reports link the use of 5-aminosalicylic acid (5-ASA) to interstitial nephritis in patients with inflammatory bowel disease (IBD).

OBJECTIVE: To investigate whether the long-term use of 5-ASA has harmful effects on renal function in patients with IBD.

METHODS: A retrospective analysis of 171 consecutive outpatients with Crohn’s disease or ulcerative colitis was conducted. Serum creati-nine levels and body weight were measured before and after treatment to calculate the creatinine clearance (CrCl) rate.

RESULTS: In 171 patients (93 women, 78 men), the mean (± SD) dose of 5-ASA was 3.65±0.85 g/day with a cumulative dose of 11±7.7 kg over an interval of 8.4±5.9 years. Serum creatinine concentrations increased from 76.8 μmol/L to 88.7 μmol/L (n=171; P<0.0001) and the CrCl rate fell significantly from 104.6 mL/min to 93.1 mL/min (n=81; P<0.0001). There was one case of interstitial nephritis reported. Treatment groups included mesalamine (74.3%), sulfasalazine (15.2%) and combination (sulfalsalazine/mesalamine [10.5%]) with treatment durations of 7.2±4.5, 12.3±8.7 and 11.2±6.7 years, respectively. The duration of treatment was the most important covariate for change in CrCl and when analyzed by treatment group, those treated with sulfasazine had a strong correlation (r=−0.54, P=0.0145), while nonsignificant in the mesalamine group (r=0.06, P=0.7017). The decline in CrCl was negatively correlated with the pretreatment CrCl rate (r=−0.34; P=0.0024) and positively correlated with the mean daily dose of 5-ASA (r=0.32; P=0.0034).

CONCLUSION: The present study is the first to demonstrate a significant dose- and treatment duration-dependant decline in CrCl. The risks need to be further evaluated because 5-ASA is widely used for long-term maintenance therapy in patients with IBD.
Clozapine-Induced Fatal Fulminant Hepatic Failure: A Case Report
Authors: Chang Albert , Krygier Darin S , Chatur Nazira , Yoshida Eric M
Published: March 2016

Fulminant hepatic failure (FHF) refers to the rapid development of severe acute liver injury with impaired synthetic function and encephalopathy in a person who previously had a normal liver or had well-compensated liver disease. The potential causes of FHF are numerous, but viral or toxin-induced hepatitis are the most common. Clozapine-induced hepatotoxicity has rarely been reported in the literature, occurs via an unknown mechanism and results in liver biochemical abnormalities that are usually of no clinical significance. In approximately 30% to 50% of patients treated with clozapine, there is an asymptomatic rise in serum aminotransaminase levels; however, there are no current guidelines for routine monitoring of liver function tests and liver enzymes during its use. Fatal fulminant hepatitis has only been reported in three patients receiving clozapine. A case of fatal FHF that occurred in a schizophrenic woman who began clozapine therapy shortly before her illness developed is described.
Acetylsalicylic Acid Use in Patients with Acute Myocardial Infarction and Peptic Ulcer Bleeding
Authors: Cheung Justin , Rajala Jennifer , Moroz Daniel , Zhu Qiaohao , Stamm Michael , Sandha Gurpal Singh
Published: March 2016

BACKGROUND: Acetylsalicylic acid (ASA) is used in the treatment of acute myocardial infarction (AMI) but is also a risk factor for peptic ulcer disease (PUD) bleeding.

OBJECTIVE: To determine the factors associated with continued ASA use in patients with AMI who develop PUD bleeding.

METHODS: AMI patients who developed PUD bleeding during the same hospitalization at two tertiary care hospitals in Edmonton, Alberta, between January 1999 and December 2006, were evaluated retrospectively. Multivariate analysis was used to determine predictors of the primary outcome of continued ASA use during PUD bleeding.

RESULTS: A total of 102 patients were analyzed. Thirty-eight patients (37%) were continued on ASA, while 64 (63%) had ASA discontinued during their hospitalization. On multivariate regression analysis, significant predictors of continued ASA use included low-risk ulcer stigmata on endoscopy (OR 3.7; 95% CI 1.4 to 10.2; P=0.01) and AMI requiring coronary intervention (OR 8.2; 95% CI 2.1 to 32.1; P=0.002). The mean (± SD) blood transfusion requirement was 3.9±3.6 units. The 30-day rebleeding and mortality rates were 14% and 14%, respectively.

CONCLUSIONS: The continued use of ASA during AMI and PUD bleeding was variable. However, patients with low-risk ulcers and those who received coronary intervention were more likely to have ASA continued during PUD bleeding. Further studies evaluating the gastrointestinal risk of immediate ASA use in AMI with acute PUD bleeding are required.
Learning the Lessons of Antitumour Necrosis Factor Therapy-Associated Psoriasis
Authors: Shale Matt , Ghosh Subrata
Published: March 2016

Psoriasis or psoriasiform skin lesions, as an adverse effect of treatment with antitumor necrosis factor antibody therapy, have been described relatively recently. Patients with these lesions have no personal or family history of psoriasis. In a small number of cases, an association withChlamydiahas been suggested. The skin lesions may disappear on discontinuation of therapy or, in the majority of cases, even if antitumor necrosis factor antibody therapy is continued. Therefore, withdrawal of therapy is generally not required for this adverse effect but referral to a dermatologist may be desirable for confirmation of diagnosis and treatment.
Multiple Cavitating Nodules in a Renal Transplant Recipient
Authors: Olsen Sharla-Rae J , Bhutani Mohit
Published: March 2016

Pulmonary nodules are common following solid organ transplantation and vary in etiology. Nodules with central cavitation are most likely to be of infectious origin in the post‐transplant population. A novel presentation of post‐transplant lymphoproliferative disorder manifesting as multiple cavitating pulmonary nodules is described. The patient, a 45‐year‐old female renal transplant recipient, presented with constitutional symptoms and a chest x‐ray showing multiple bilateral cavitating lesions. A computed tomography scan confirmed innumerable, randomly dispersed, cavitating nodules in the lung parenchyma. Multiple large hypodense lesions were identified in the liver and spleen. The appearance of the native and transplanted kidneys was normal. A liver biopsy identified an Epstein‐Barr virus‐negative, diffuse, large B cell lymphoma. Repeat imaging after treatment with a cyclophosphamide, hydroxydaunorubicin, oncovin and prednisone/prednisolone regimen demonstrated dramatic resolution of all lesions. The present case represents a unique radiographic presentation of post‐transplant lymphoproliferative disorder not previously reported in the literature.
Intrathecal Infusions for Intractable Cancer Pain: A Qualitative Study of the Impact on a Case Series of Patients and Caregivers
Authors: Hawley Philippa , Beddard-Huber Elizabeth , Grose Cameron , McDonald William , Lobb Daphne , Malysh Louise
Published: March 2016

BACKGROUND: The need for intrathecal infusion in a palliative care setting is infrequent. Despite established efficacy, safety and cost effectiveness, this is considered an ‘extraordinary measure’ in Canada. Patients requiring this approach are not typical palliative care patients, having shorter and more uncertain life expectancies.

OBJECTIVES: The present study is a qualitative exploration of the impact of intrathecal pump implantation on cancer patients, and also the impact of the intervention on the staff caring for those patients.

METHODS: Palliative care unit patients who received an implanted intrathecal pump or dome catheter for intractable cancer pain participated in multiple semistructured interviews. Doctors and nurses caring for each patient were also interviewed. Interviews were recorded and analyzed for themes. The study terminated when saturation was reached.

RESULTS: Six patients participated, with up to three interviews each. Twenty‐four staff interviews took place. Patients’ hopes and expectations were not always fully met, but the infusions had a profound positive effect on quality of life. Patients expressed anxiety about dependence on the device, and also on a few highly skilled individuals. Staff interviews revealed a significant impact on the ‘culture’ of the palliative care unit. Clear communication of the rationale for infusion was very important, as was regular education about infusion management.

CONCLUSIONS: Implanted intrathecal infusion devices are a necessary part of a tertiary level cancer pain management service for the unfortunate minority with intractable pain. Practical recommendations for care are made for palliative care programs contemplating offering intrathecal infusions.
The Nature and Causes of Chronic Obstructive Pulmonary Disease: A Historical Perspective
Authors: Warren C Peter W
Published: March 2016

Chronic obstructive pulmonary disease (COPD) is the currently favoured name for the diseases formerly known as emphysema and bronchitis. COPD has been recognized for more than 200 years. Its cardinal symptoms are cough, phlegm and dyspnea, and its pathology is characterized by enlarged airspaces and obstructed airways. In the 19th century, the diagnosis of COPD depended on its symptoms and signs of a hyperinflated chest, and reduced expiratory breath sounds. The airflow obstruction evident on spirometry was identified in that century, but did not enter into clinical practice. Bronchitis, and the mechanical forces required to overcome its obstruction, was believed to be responsible for emphysema, although the inflammation present was recognized. The causes of bronchitis, and hence emphysema, included atmospheric and domestic air pollution, as well as dusty occupations. Cigarette smoking only became recognized as the dominant cause in the 20th century. The lessons learned of the risks for COPD in 19th‐century Britain are very pertinent to the world today.
Assessing Pain by Facial Expression: Facial Expression as Nexus
Authors: Prkachin Kenneth M
Published: March 2016

The experience of pain is often represented by changes in facial expression. Evidence of pain that is available from facial expression has been the subject of considerable scientific investigation. The present paper reviews the history of pain assessment via facial expression in the context of a model of pain expression as a nexus connecting internal experience with social influence. Evidence about the structure of facial expressions of pain across the lifespan is reviewed. Applications of facial assessment in the study of adult and pediatric pain are also reviewed, focusing on how such techniques facilitate the discovery and articulation of novel phenomena. Emerging applications of facial assessment in clinical settings are also described. Alternative techniques that have the potential to overcome barriers to the application of facial assessment arising out of its resource‐intensiveness are described and evaluated, including recent work on computer‐based automatic assessment.
Longstanding Eosinophilic Gastroenteritis of More Than 20 Years
Authors: Freeman Hugh J
Published: March 2016

Eosinophilic gastroenteritis (EGE) is an eosinophil-predominant inflammatory process that may be detected in endoscopic gastric or intestinal biopsies. The long-term natural history and effects of EGE treatment are not known. A 44-year-old man with abdominal pain was treated with oral ketotifen and followed for more than 20 years. Ketotifen provided symptomatic benefit, with prompt clinical relapse if the drug was discontinued. However, despite the use of ketotifen, the endoscopic abnormalities persisted and appeared to progress. Gastric body and antral mucosal folds appeared thickened, erythematous and friable, with minimal erosive change. Later, even during long asymptomatic periods suggesting clinical ‘remission’, inflammatory polypoid change, previously described in children with EGE, developed with mucosal ‘pock-marking’ and apparent scarring. Ketotifen treatment does not appear to prohibit or reverse the inflammatory process in the gastric mucosa in EGE, although long-term effects of steroids may be avoided. In the future, treatment of EGE may involve monoclonal antibody agents that target the specific biological effects of the eosino-phil, apparently central to this unusual inflammatory process.
Diagnostic Algorithm Using a Sensitive Broth Culture Method for Detection of Clostridium difficile Toxin from Stool Samples
Authors: Bayardelle Paul
Published: March 2016

BACKGROUND: The two‐step glutamate dehydrogenase antigencytotoxicity neutralization assay algorithm has been found to be reliable for the diagnosis of toxigenic Clostridium difficile. However, the high sensitivity of the screening method is compromised by the relative low sensitivity of the second step, the direct cytotoxin neutralization assay (DCNA) using a fecal filtrate. The objective of the present study was to compare the DCNA with an indirect cytotoxin neutralization assay (ICNA).

METHODS: For ICNA, the cytotoxin B of C difficile was obtained from a broth culture of the stools and neutralized according to a standard cytotoxin assay using MRC‐5 fibroblast cells.

RESULTS: A total of 923 stool specimens from adults were tested during a three‐month period from June to August 2008. The prevalence of toxigenic C difficile was 13.5%. The sensitivity of the two‐step algorithm was 88%. With the ICNA, 12% toxigenic C difficile were detected that were missed by DCNA.

CONCLUSIONS: The use of broth for the ICNA is convenient, and results in increased sensitivity of detection of toxigenic C difficile. It can be implemented in routine diagnosis.
Montelukast as Add‐On Therapy to Inhaled Corticosteroids in the Management of Asthma (The SAS Trial)
Authors: FitzGerald J Mark , Foucart Sylvain , Coyle Stephen , Sampalis John , Haine Denis , Psaradellis Eliofotisti , McIvor R Andrew
Published: March 2016

AIM: To evaluate the effectiveness of montelukast as add‐on therapy for asthmatic patients who remain uncontrolled with low, moderate or high doses of inhaled corticosteroid monotherapy.

DESIGN: An eight‐week, multicentre, open‐label, observational study.

RESULTS: Of 320 patients enrolled, 288 (90.0%) completed the study. Of patients who had uncontrolled asthma symptoms (Canadian Asthma Consensus Guidelines Update, 2003) but were controlled according to the Asthma Control Questionnaire (ACQ score of less than 1.5), 93.9% maintained asthma control at week 8. Of patients with uncontrolled asthma at baseline for both definitions, 63.5% achieved asthma control by week 8. The mean ± SD ACQ score decreased from 1.13±0.28 to 0.57±0.50 (P<0.001) for controlled patients at baseline and from 2.38±0.73 to 1.03±0.80 (P<0.001) for patients who were uncontrolled at baseline, each representing a clinically significant improvement.

CONCLUSION: Montelukast add‐on therapy is an effective alternative to inhaled corticosteroid monotherapy.
Comparison of Chromoendoscopy and Conventional Endoscopy in the Detection of Premalignant Gastric Lesions
Authors: Taghavi Seyed Alireza , Membari Mohammed Ebrahim , Eshraghian Ahad , Dehghani Seyed Moshen , Hamidpour Lelah , Khademalhoseini Farnaz
Published: March 2016

BACKGROUND: Diagnosis and localization of intestinal metaplasia and early gastric cancer is problematic because of the lack of any tell-tale gross endoscopic signs.

OBJECTIVE: To compare the efficacy of chromoendoscopy with conventional endoscopy for the detection of gastric premalignant lesions (intestinal metaplasia).

METHOD: Thirty-three patients in whom previous routine endoscopic biopsies showed intestinal metaplasia were enrolled in a prospective study. Each patient underwent a two-step endoscopy procedure: conventional endoscopy and chromoendoscopy using methylene blue. Biopsies were taken during each step and were studied by an expert pathologist. Presence of intestinal metaplasia was considered a positive result.

RESULTS: Considering the presence of intestinal metaplasia anywhere in the stomach as a positive result, 13 patients were diagnosed with intestinal metaplasia using both endoscopic methods, while eight patients had positive results using chromoendoscopy without any metaplastic changes detected with the conventional method (P=0.003). One patient showed positive biopsies with the conventional method while the pathology report showed no positive biopsies using the chromoendoscopy method. The number of positive biopsies from the antrum, body and fundus were 18, 15 and seven, respectively, using chromoendoscopy, and 10, four and two, respectively, from the same sites using conventional endoscopy.

CONCLUSION: The present study demonstrated that chromoendoscopy is superior to conventional endoscopy for the detection of metaplastic changes and its use can be suggested for the screening of early malignancies of the stomach.
Pancreatic Pseudocyst with Fistula to the Common Bile Duct Resolved by Combined Biliary and Pancreatic Stenting – A Case Report and Literature Review
Authors: Ali Jaber A Al , Chung Henry , Munk Peter L , Byrne Michael F
Published: March 2016

Pancreatic pseudocysts develop in 10% to 20% of patients with chronic pancreatitis, and can cause a variety of complications such as infection, bleeding or development of fistulae. However, fistulous communication with the common bile duct is very rare. The present report describes an unusual case of a patient with a large, symptomatic pancreatic pseudocyst with a fistula to the common bile duct that was treated successfully by combined biliary and pancreatic stenting.
Sociocultural Factors That Potentially Affect the Institution of Prevention and Treatment Strategies for Hepatitis B in Chinese Canadians
Authors: Wu Harry , Yim Colina , Chan Alex , Ho Michael , Heathcote Jenny
Published: March 2016

BACKGROUND: Despite the availability of screening for chronic hepatitis B (CHB) infection and effective treatments now available, many at-risk individuals fail to seek appropriate medical attention.

OBJECTIVE: To identify the barriers to care for CHB infection in a Chinese Canadian community.

METHODS: A survey conducted in English or Chinese collected information from individuals with CHB infection that evaluated the level of understanding and identified the barriers that may prevent Chinese patients from undergoing monitoring, screening and/or treatment for CHB infection.

RESULTS: Among the 204 patients enrolled, common misconceptions were that sharing food transmits hepatitis B and that patients with severe disease are always symptomatic. Patients with a better understanding of hepatitis B were better educated, younger and were being followed at a tertiary care centre (P<0.01 for all). Prominent barriers to health care were time, inconvenience and language difficulties. Patients under the care of family physicians who had extended office hours were less likely to cite time (P=0.06) and distance (P=0.05) as barriers.

CONCLUSION: Patient misconceptions that severe liver disease due to hepatitis B infection is symptomatic may factor into the unwillingness to spare the time and undergo the inconvenience associated with regular medical follow-up. Implementation of programs that increase awareness of the silent progression of CHB infection and provide culturally responsive clinics, better able to work within patients’ time constraints may improve Chinese patients’ access to health care.
The Identification of Lynch Syndrome in British Columbia
Authors: Cremin Carol M , Armstrong Linlea , Gill Sharlene , Huntsman David , Bajdik Chris
Published: March 2016

OBJECTIVE: To determine the prevalence of Lynch syndrome mutations in a Canadian hereditary cancer clinic population, and to determine the effectiveness of the program’s referral criteria and testing algorithm.

METHODS: A retrospective chart review of all patients who were referred for and received genetic counselling at the BC Cancer Agency’s Hereditary Cancer Program for a family history of colon cancer from August 1, 2004, to September 1, 2006, was performed. Charts were reviewed for referral criteria met, cancer history, whether testing was offered and the outcome of testing.

RESULTS: Lynch syndrome was confirmed or highly suspected in 14.3% of index test patients (eight of 56) by the identification of a deleterious mutation or variant likely to be deleterious in either of thehMLH1orhMSH2mismatch repair genes. In the program, the two most effective criteria were a personal diagnosis of two or more primary Lynch syndrome-related cancers (one diagnosed at younger than 50 years of age) or two first-degree relatives with a Lynch syndrome-related cancer (both diagnosed at younger than 50 years of age). The respective positive predictive values of these two criteria were calculated to be 66.7% (95% CI 40% to 93%) and 58.3% (95% CI 30.4% to 86.2%).

CONCLUSIONS: The Hereditary Cancer Program developed and successfully implemented an approach that selected individuals at risk for Lynch syndrome with a significant pretest probability of mutation of 14.3%. Improved ascertainment of families with Lynch syndrome will require greater physician awareness of referral criteria, program advances in the testing algorithm and a population-based approach to screening incident colon cancers.
Adherence to Guidelines for Surveillance Colonoscopy in Patients with Ulcerative Colitis at a Canadian Quaternary Care Hospital
Authors: Kottachchi Dan , Yung Derek , Marshall John K
Published: March 2016

BACKGROUND: Patients with ulcerative colitis (UC) are at high risk of colonic dysplasia. Therefore, surveillance colonoscopy to detect early dysplasia has been endorsed by many professional organizations.

OBJECTIVES: To determine whether gastroenterologists at Hamilton Health Sciences (Hamilton, Ontario) adhere to recommendations for UC surveillance issued by the Canadian Association of Gastroenterology and to retrospectively assess the incidence and type of dysplasia found and the subsequent outcome of patients with dysplasia (ie, colorectal cancer [CRC], colectomy, dysplasia recurrence).

METHODS: A retrospective chart review of all patients with UC undergoing colonoscopy screening at Hamilton Health Sciences from January 1980 to January 2005, was performed. Patients were classified by the extent of colonic disease: limited left-sided colitis (LSC), pancolitis and any disease extent with concurrent primary sclerosing cholangitis.

RESULTS: A total of 141 patients fulfilled eligibility criteria. They underwent 921 endoscopies, including 453 for surveillance, which were performed by 20 endoscopists. Overall, screening was performed on 90% of patients, and surveillance at the appropriate time in 74%. There was a statistically significant increase in the mean number of biopsies per colonoscopy after the guidelines were published (P<0.01 for all categories). Colonic dysplasia was detected in 24 of 141 patients (17.0%), with 17 of 24 (70.8%) found at surveillance. Two patients (8.3%) had CRC successfully treated. The average age of patients with dysplasia was 56.1 years, with a mean disease duration of 10.9 years in LSC versus 11.8 years in pancolitis (P not significant). Colectomy was not recommended for any patient with flat dysplasia. No patients progressed to high-grade dysplasia or CRC. Patients with pancolitis had a higher incidence of neoplasia (21% [18 of 86]) than patients with LSC (12% [6 of 49]; P=0.24). Forty-one patients (29.5%) had at least one hyperplastic or inflammatory polyp.

CONCLUSIONS: For the majority of patients who underwent surveillance colonoscopies, their procedures were performed within the recommended time intervals, and biopsy compliance has improved. Dysplasia tended to arise after approximately 10 years of disease duration and in middle age, with flat dysplasia being rare. Interventions resulted in no dysplasia progressing to CRC, implying successful prevention.
The Effect of Weekend versus Weekday Admission on Outcomes of Esophageal Variceal Hemorrhage
Authors: Myers Robert P , Kaplan Gilaad G , Shaheen Abdel Aziz M
Published: March 2016

BACKGROUND: Hospital staffing is often lower on weekends than weekdays, and may contribute to higher mortality in patients admitted on weekends. Because esophageal variceal hemorrhage (EVH) requires complex management and urgent endoscopic intervention, limitations in physician expertise and the availability of endoscopy on weekends may be associated with increased EVH mortality.

OBJECTIVE: To assess the differences in mortality, hospital length of stay (LOS), and costs between patients admitted on weekends versus patients who were admitted on weekdays.

METHODS: The United States Nationwide Inpatient Sample database was used to identify patients hospitalized for EVH between 1998 and 2005. Differences in mortality, LOS, and costs between patients admitted on weekends and weekdays were evaluated using regression models with adjustment for patient and clinical factors, including the timing of endoscopy.

RESULTS: Between 1998 and 2005, 36,734 EVH admissions to 2207 hospitals met the inclusion criteria. Compared with patients admitted on weekdays, individuals admitted on the weekend were slightly less likely to undergo endoscopy on the day of admission (45% versus 43%, respectively; P=0.01) and by the second day (81% versus 75%; P<0.0001). However, mortality (11.3% versus 10.8%; P=0.20) and the requirement for endoscopic therapy (70% versus 69%; P=0.08) or portosystemic shunt insertion (4.4% versus 4.7%; P=0.32) did not differ between weekend and weekday admissions. After adjusting for confounding factors, including the timing of endoscopy, the risk of mortality was similar between weekend and weekday admissions (OR 1.05; 95% CI 0.97 to 1.14). Although LOS was similar between groups, adjusted hospital charges were 4.0% greater (95% CI 2.3 to 5.8%) for patients hospitalized on the weekend.

CONCLUSIONS: In patients with EVH, admission on the weekend is associated with a small delay in receiving endoscopic intervention, but no difference in mortality or the requirement for portosystemic shunt insertion. The weekend effect observed for some medical and surgical conditions does not apply to patients with EVH.
Severe Skin Rash Associated with Atazanavir
Authors: Walkty Andrew , Smith Dick , Lopko Bernie , Kasper Ken
Published: March 2016

Three cases of severe rash associated with the use of atazanavir are described. In all cases, the rash was maculopapular and pruritic. Rash onset occurred eight to 11 days after initiation of therapy, and resolved with atazanavir discontinuation. Clinicians prescribing atazanavir should be aware of this potential adverse effect.
Risk Factors for and Outcomes Associated with Clinical Isolates of Escherichia coli and Klebsiella Species Resistant to Extended‐Spectrum Cephalosporins among Patients Admitted to Canadian Hospitals
Authors: Ofner-Agostini Marianna , Simor Andrew , Mulvey Michael , McGeer Alison , Hirji Zahir , McCracken Melissa , Gravel Denise , Boyd David , Bryce Elizabeth
Published: March 2016

BACKGROUND: Clinical features associated with Gram‐negative bacterial isolates with extended‐spectrum beta‐lactamase (ESBL)‐ and AmpC‐mediated resistance identified in Canadian hospitals is largely unknown. The objective of the present study was to determine the demographics, risk factors and outcomes of patients with ESBL‐ or AmpC‐mediated resistant organisms in Canadian hospitals.

METHODS: Patients with clinical cultures of Escherichia coli or Klebsiella species were matched with patients with a similar organism but susceptible to third‐generation cephalosporins. Molecular identification of the AmpC or ESBL was determined using a combination of polymerase chain reaction and sequence analysis. Univariate and multivariate logistic regression analysis was performed to identify variables associated with becoming a case.

RESULTS: Eight Canadian hospitals identified 106 cases (ESBL/AmpC) and 106 controls. All risk factors identified in the univariate analysis as a predictor of being an ESBL/AmpC cases at the 0.20 P‐value were included in the multivariate analysis. No significant differences in outcomes were observed (unfavourable responses 17% versus 15% and mortality rates 13% versus 7%, P not significant). Multivariate logistic regression found an association of becoming an ESBL/AmpC case with: previous admission to a nursing home (OR 8.28, P=0.01) or acute care facility (OR 1.96, P=0.03), length of stay before infection (OR 3.05, P=0.004), and previous use of first‐generation cephalosporins (OR 2.38, P=0.02) or third‐generation cephalosporins (OR 4.52, P=0.01). Appropriate antibiotics were more likely to be given to controls (27.0% versus 13.3%, P=0.05) and number of days to appropriate antibiotics was longer for cases (median 2.8 days versus 1.2 days, P=0.05).

CONCLUSION: The importance of patient medical history, present admission and antibiotic use should be considered for all E coli or Klebsiella species patients pending susceptibility testing results.
Research Funding for Pain in Canada
Authors: Lynch Mary E , Schopflocher Donald , Taenzer Paul , Sinclair Caitlin
Published: March 2016

Chronic pain is an escalating public health problem. There are inadequate resources to assist patients suffering with pain in Canada. Therefore, it is important that research examining novel and appropriate treatment for chronic pain is conducted. To determine the current level of research funding for pain in Canada, the Canadian Pain Society conducted a survey. Of 79 active researchers performing pain‐related studies, 65 received funding in the past five years amounting to a total of approximately $80.9 million. This is less than 1% of the total funding from the Canadian Institutes of Health Research and 0.25% of the total funding for health research.
Pulmonary Vein Stenosis: Case Report and Literature Review
Authors: Amin R , Kwon S , Moayedi Y , Sweezey N
Published: March 2016

BACKGROUND: Pulmonary vein stenosis is a rare cause of pulmonary hypertension, with variable onset and presentation. One or more of the four pulmonary veins can be primarily or secondarily affected. A five‐month‐old girl presented with respiratory distress, lethargy and cyanosis requiring intubation.

METHODS: Echocardiography showed right ventricular dilation, a right ventricular systolic pressure of 97 mmHg, decreased ejection fraction and turbulent flow at the left atrium. Cardiac catheterization revealed stenosis of the left‐sided pulmonary veins, for which she underwent a Coles procedure.

RESULTS: Postoperatively, there was a transient improvement in the patient’s pulmonary hypertension but she subsequently deteriorated. Her prognosis was considered bleak, and a decision was made with the family to withdraw care.

CONCLUSION: Pulmonary vein stenosis is a rare cause of pulmonary hypertension, and is associated with significant morbidity and mortality. Surgical intervention may be of benefit in selected cases. It stands to reason that any treatment will have the best chance of success if completed before the pulmonary hypertension becomes fixed. Early diagnosis depends on a high index of clinical suspicion.
Short- and Long-Term Results of Transcatheter Embolization for Massive Arterial Hemorrhage from Gastroduodenal Ulcers Not Controlled by Endoscopic Hemostasis
Authors: Loffroy Romaric , Guiu Boris , Mezzetta Lise , Minello Anne , Michiels Christophe , Jouve Jean-Louis , Cheynel Nicolas , Rat Patrick , Cercueil Jean-Pierre , Krausé Denis
Published: March 2016

BACKGROUND AND AIM: Severe bleeding from gastrointestinal ulcers is a life-threatening event that is difficult to manage when endoscopic treatment fails. Transcatheter embolization has been suggested as an alternative treatment in this situation. The present study reports on the efficacy and long-term outcomes of transcatheter embolization after failed endoscopic treatments were assessed in high-operative-risk patients.

METHODS: A retrospective review of 60 consecutive emergency embolization procedures in hemodynamically unstable patients (41 men, 19 women; mean [±SD] age 69.4±15 years) was conducted. Patients were referred for selective angiography between 1999 and 2008 after failed endoscopic treatment of massive bleeding from gastrointestinal ulcers. Mean follow-up was 22 months.

RESULTS: Embolization was feasible and successful in 57 patients. Sandwich coiling of the gastroduodenal artery was used in 34 patients, and superselective occlusion of the terminal feeding artery (with glue, coils or gelatin particles) was used in 23 patients. Early rebleeding occurred in 16 patients and was managed with endoscopy (n=8), reembolization (n=3) or surgery (n=5). No major embolization-related complications occurred. Sixteen patients died within 30 days after embolization (including three who died from rebleeding) and 11 died thereafter. No late bleeding recurrences were reported.

CONCLUSIONS: Selective angiographic embolization is safe and effective for controlling life-threatening bleeding from gastroduodenal ulcers. The procedure usually obviates the need for emergency surgery in these high-risk patients. Survival depends chiefly on underlying conditions.
Research Preparedness Paves the Way to Respond to Pandemic H1N1 2009 Influenza Virus
Authors: French Michelle B , Loeb Mark B , Richardson Carol , Singh Bhagirath
Published: March 2016

The international community has been preparing for an influenza pandemic because of the threat posed by H5N1 avian influenza. Over the past several years, Canada has dedicated funding to boost capacity for research, and public health and health care system readiness and response in the event of a pandemic. The current H1N1/09 influenza pandemic is now testing our readiness. From a research perspective, the present commentary discusses how have we prepared, along with the research gaps. We conclude that: sources of pandemics are not always predictable; investment in the past few years has paid off in a rapid response to pandemic H1N1/09 virus in Canada; and research to meet the challenges of infectious diseases has to be done on an ongoing long‐term basis, and its funding has to be flexible, available and predictable to maintain capacity and expertise. In addition, new vaccine technologies are needed to develop and produce vaccines for public health emergencies in a timely fashion.