bluuebunny/crossref_metadata_2025 huggingface dataset:
A Review of Amoebic Liver Abscess for Clinicians in a Nonendemic Setting
Authors: Wuerz Terry , Kane Jennifer B , Boggild Andrea K , Krajden Sigmund , Keystone Jay S , Fuksa Milan , Kain Kevin C , Warren Ralph , Kempston John , Anderson Joe
Published: March 2016

Amoebic liver abscess (ALA) is an uncommon but potentially life-threatening complication of infection with the protozoan parasiteEntamoeba histolytica. E histolyticais widely distributed throughout the tropics and subtropics, causing up to 40 million infections annually. The parasite is transmitted via the fecal-oral route, and once it establishes itself in the colon, it has the propensity to invade the mucosa, leading to ulceration and colitis, and to disseminate to distant extraintestinal sites, the most common of which is the liver. The authors provide a topical review of ALA and summarize clinical data from a series of 29 patients with ALA presenting to seven hospitals in Toronto, Ontario, a nonendemic setting, over 30 years.
Is There a Role for Bronchial Thermoplasty in the Treatment of Asthma?
Authors: Boulet Louis-Philippe , Laviolette Michel
Published: March 2016

Bronchial thermoplasty is a new technique proposed to improve control of moderate to severe asthma. It delivers thermal energy to the large airways during a bronchoscopy to decrease the amount of bronchial smooth muscle. This intervention has been shown to reduce asthma exacerbations, and improve asthma control and quality of life over a three‐year period without significant complications up to a five‐year period. It could be considered as another option in the treatment of selected patients requiring oral and/or high doses of inhaled corticosteroids to control asthma. It should, however, be performed in specialized centres in patients who understand the potential benefits and side‐effects of this technique. The response to this treatment varies from one patient to another. Consequently, further studies are required to better define the role of this option in the treatment of asthma.
The Determinants of Chronic Bronchitis in Aboriginal Children and Youth
Authors: Hossain Alomgir , Konrad Stephanie , Dosman James A , Senthilselvan Ambikaipakan , McCrosky Jesse , Pahwa Punam
Published: March 2016

BACKGROUND: There is limited knowledge concerning chronic bronchitis (CB) in Canadian Aboriginal peoples.

OBJECTIVE: To determine the prevalence (crude and adjusted) of CB and its associated risk factors in Canadian Aboriginal children and youth six to 14 years of age.

METHODS: Data from the cross-sectional Aboriginal Peoples Survey were analyzed in the present study. Logistic regression analysis was used to determine risk factors influencing the prevalence of CB among Aboriginal children and youth. The balanced repeated replication method was used to compute standard errors of regression coefficients to account for clustering inherent in the study design. The outcome of interest was based on the question: “Have you been told by a doctor, nurse or other health professional that you have chronic bronchitis?” Demographics, environment and population characteristics (predisposing and enabling resources) were tested for an association with CB.

RESULTS: The prevalence of CB was 3.1% for boys and 2.8% for girls. Other significant risk factors of CB were age (OR 1.38 [95% CI 1.24 to 1.52] for 12 to 14 year olds versus six to eight year olds), income (OR 2.28 [95% CI 2.02 to 2.59] for income category <$25,000/year versus ≥$85,000/year), allergies (OR 1.96 [95% CI 1.78 to 2.16] for having allergies versus no allergies), asthma (OR 7.61 [ 95% CI 6.91 to 8.37] for having asthma versus no asthma) and location of residence (rural/urban and geographical location). A significant two-way interaction between sex and body mass index indicated that the relationship between the prevalence of CB and body mass index was modified by sex.

DISCUSSION: The prevalence of CB was related to well-known risk factors among adults, including older age and lower annual income.
Community‐Onset Bloodstream Infection during the ‘After Hours’ Is not Associated with an increased Risk for Death
Authors: Laupland Kevin B , Kibsey Pamela C , Galbraith John C
Published: March 2016

BACKGROUND/OBJECTIVE: Patients admitted to hospital during the ‘after hours’ (weekends and evenings) may be at increased risk for adverse outcome. The objective of the present study was to assess whether community‐onset bloodstream infections presenting in the after hours are associated with death.

METHODS: All patients in the Victoria area of British Columbia, who had first admissions with community‐onset bloodstream infections between 1998 and 2005 were included. The day of admission to hospital, the day and time of culture draw, and all‐cause, in‐hospital mortality were ascertained.

RESULTS: A total of 2108 patients were studied. Twenty‐six per cent of patients were admitted on a weekend. Blood cultures were drawn on a weekend in 27% of cases and, in 43%, 33%, and 25% of cases, cultures were drawn during the day (08:00 to 17:59), the evening (18:00 to 22:59) and night (23:00 to 07:59), respectively. More than two‐thirds (69%) of index cultures were drawn during the after hours (any time Saturday or Sunday and weekdays 18:00 to 07:59). The overall in‐hospital case fatality rate was 13%. No difference in mortality was observed in relation to the day of the week of admission or time period of sampling. After‐hours sampling was not associated with mortality in a multivariable logistic regression model examining factors associated with death.

CONCLUSION: Presentation with community‐onset, bloodstream infection during the after hours does not increase the risk of death.
A Systematic Review of Early Prognostic Factors for Persistent Pain Following Acute Orthopedic Trauma
Authors: Clay Fiona J , Watson Wendy L , Newstead Stuart V , McClure Roderick J
Published: March 2016

Persistent or chronic pain is prevalent in many developed countries, with estimates ranging from 10% to higher than 50%, and is a major economic burden to individuals and societies. However, the variation in pain outcomes after acute orthopedic trauma and treatment confronts treating physicians with uncertainty in providing prognostic advice regarding long‐term recovery. Although several previous reviews have addressed the determinants of chronic pain outcomes secondary to acute trauma, they have primarily focused on specific injury samples and, furthermore, lack consistency with respect to the important prognostic factors, which limits the generalizability of findings. This review, however, aimed specifically to identify the early prognostic factors associated with variation in persistent pain outcomes following acute orthopedic trauma presenting with a spectrum of pathologies.

BACKGROUND: Acute orthopedic trauma contributes substantially to the global burden of disease.

OBJECTIVES: The present systematic review aimed to summarize the current knowledge concerning prognostic factors for the presence of persistent pain, pain severity and pain‐related disability following acute orthopedic trauma involving a spectrum of pathologies to working‐age adults.

METHODS: The Ovid MEDLINE and EMBASE databases were searched for level II prognostic studies published between January 1996 and October 2010. Studies that were longitudinal and reported results with multivariate analyses appropriate for prognostic studies were included. Studies that addressed two specific injury types that have been the subject of previous reviews, namely, injuries to the spinal column and amputations, were excluded.

RESULTS: The searches yielded 992 studies; 10 studies met the inclusion criteria and were rated for methodological quality. Seventeen factors were considered in more than one cohort. There was strong evidence supporting the association of female sex, older age, high pain intensity, preinjury anxiety or depression, and fewer years of education with persistent pain outcomes. There was moderate evidence supporting the association between postinjury depression or anxiety with persistent pain, and that injury severity was not a risk factor for ongoing pain.

CONCLUSION: Many individuals experience persistent pain following acute trauma. Due to the lack of studies, the use of different constructs to measure the same factor and the methodological limitations associated with many of the studies, the present review was only able to reliably identify a limited set of factors that predicted persistent pain. Recommendations for the conduct of future methodologically rigorous studies of persistent pain are provided.
The Effect of Endogenous Angiotensin II on Alveolar Fluid Clearance in Rats with Acute Lung Injury
Authors: Deng Jia , Wang Dao-xin , Deng Wang , Li Chang-yi , Tong Jin
Published: March 2016

BACKGROUND: In acute lung injury (ALI), angiotensin II (Ang II) plays a vital role in the stimulation of pulmonary permeability edema formation through the angiotensin type 1 (AT1) receptor. The effect of Ang II on alveolar fluid clearance (AFC) in ALI remains unknown.

METHODS: Sprague Dawley rats were anesthetized and intratracheally injected with 1 mg/kg lipopolysaccharide (LPS), while control rats received saline. The AT1 receptor antagonist ZD7155 was injected intraperitoneally (10 mg/kg) 30 min before LPS administration. The lungs were isolated for AFC measurement, and alpha‐epithelial sodium channel (ENaC) messenger RNA and protein expression were detected by reverse‐transcription polymerase chain reaction and Western blot.

RESULTS: LPS‐induced ALI caused an increase in Ang II levels in plasma and lung tissue but a decrease in AFC. The time course of Ang II levels paralleled that of AFC. Pretreatment with ZD7155 prevented ALI‐induced reduction of AFC. ZD7155 also reversed the ALI‐induced reduction of beta‐ENaC and gamma‐ENaC levels, and further decreased alpha‐ENaC levels.

CONCLUSIONS: These findings suggest that endogenous Ang II inhibits AFC and dysregulates ENaC expression via AT1 receptors, which contribute to alveolar filling and pulmonary edema in LPS‐induced ALI.
Pain Catastrophizing Predicts Poor Response to Topical Analgesics in Patients with Neuropathic Pain
Authors: Mankovsky Tsipora , Lynch Mary E , Clark AJ , Sawynok J , Sullivan Michael JL
Published: March 2016

The prevalence of neuropathic pain approaches 10% in Canada and the United States. Given the aging population and the increasing survival rates following interventions for neuropathic pain, the prevalence of neuropathic pain conditions is expected to rise significantly over the next 20 years. Although pharmacological interventions represent the dominant treatment approach for neuropathic pain, as many as 50% of patients are partially or completely refractory to the available treatments. Pain catastrophizing has been associated with heightened pain experiences in patients with neuropathic pain conditions; however, the clinical relevance of the relationship between catastrophizing and poor treatment outcomes is, to date, unclear. Accordingly, using a numerical rating scale, this study aimed to examine this relationship in patients with varied neuropathic pain conditions who completed a measure of catastrophizing before initiating a course of topical analgesic.

BACKGROUND: Previous research suggests that high levels of pain catastrophizing might predict poorer response to pharmacological interventions for neuropathic pain.

OBJECTIVE: The present study sought to examine the clinical relevance of the relation between catastrophizing and analgesic response in individuals with neuropathic pain. Clinically meaningful reductions were defined in terms of the magnitude of reductions in pain through the course of treatment, and in terms of the number of patients whose end‐of‐treatment pain ratings were below 4/10.

METHODS: Patients (n=82) with neuropathic pain conditions completed a measure of pain catastrophizing at the beginning of a three‐week trial examining the efficacy of topical analgesics for neuropathic pain.

RESULTS: Consistent with previous research, high scores on the measure of pain catastrophizing prospectively predicted poorer response to treatment. Fewer catastrophizers than noncatastrophizers showed moderate (≥2 points) or substantial reductions in pain ratings through the course of treatment. Fewer catastrophizers than noncatastrophizers achieved end‐of‐treatment pain ratings below 4/10.

CONCLUSIONS: The results of the present study suggest that the development of brief interventions specifically targeting catastrophic thinking might be useful for enhancing the effects of pharmacological interventions for neuropathic pain. Furthermore, failure to account for the level of catastrophizing might contribute to null findings in clinical trials of analgesic medication.
Long-Term Natural History and Complications of Collagenous Colitis
Authors: Freeman Hugh J
Published: March 2016

Microscopic forms of colitis have been described, including collagenous colitis, a possibly heterogeneous disorder. Collagenous colitis most often appears to have an entirely benign clinical course that usually responds to limited treatment. Sometimes significant extracolonic disorders, especially arthritis, spondylitis, thyroiditis and skin disorders, such as pyoderma gangrenosum, dominate the clinical course and influence the treatment strategy. However, rare fatalities have been reported and several complications, some severe, have been attributed directly to the colitis. Toxic colitis and toxic megacolon may develop. Concomitant gastric and small intestinal inflammatory disorders have been described including celiac disease and more extensive collagenous inflammatory disease. Colonic ulceration has been associated with the use of nonsteroidal anti-inflammatory drugs, while other forms of inflammatory bowel disease, including ulcerative colitis and Crohn disease, may evolve directly from collagenous colitis. Submucosal ‘dissection’, colonic fractures, or mucosal tears and perforation, possibly from air insufflation during colonoscopy, have been reported. Similar changes may result from increased intraluminal pressures that may occur during radiological imaging of the colon. Neoplastic disorders of the colon may also occur during the course of collagenous colitis, including colon carcinoma and neuroendocrine tumours (ie, carcinoids). Finally, lymphoproliferative disease has been reported.
Environment and the Inflammatory Bowel Diseases
Authors: Frolkis Alexandra , Dieleman Levinus A , Barkema Herman W , Panaccione Remo , Ghosh Subrata , Fedorak Richard N , Madsen Karen , Kaplan Gilaad G , on behalf of the Alberta IBD Consortium
Published: March 2016

Inflammatory bowel diseases (IBD), which consists of Crohn disease and ulcerative colitis, are chronic inflammatory conditions of the gas-trointestinal tract. In genetically susceptible individuals, the interaction between environmental factors and normal intestinal commensal flora is believed to lead to an inappropriate immune response that results in chronic inflammation. The incidence of IBD have increased in the past century in developed and developing countries. The purpose of the present review is to summarize the current knowledge of the association between environmental risk factors and IBD. A number of environmental risk factors were investigated including smoking, hygiene, microorganisms, oral contraceptives, antibiotics, diet, breast-feeding, geographical factors, pollution and stress. Inconsistent findings among the studies highlight the complex pathogenesis of IBD. Additional studies are necessary to identify and elucidate the role of environmental factors in IBD etiology.
Yoga for Chronic Low Back Pain: A Meta‐Analysis of Randomized Controlled Trials
Authors: Holtzman Susan , Beggs R Thomas
Published: March 2016

OBJECTIVES: To evaluate the efficacy of yoga as an intervention for chronic low back pain (CLBP) using a meta‐analytical approach. Randomized controlled trials (RCTs) that examined pain and/or functional disability as treatment outcomes were included. Post‐treatment and follow‐up outcomes were assessed.

METHODS: A comprehensive search of relevant electronic databases, from the time of their inception until November 2011, was conducted. Cohen’s d effect sizes were calculated and entered in a random‐effects model.

RESULTS: Eight RCTs met the criteria for inclusion (eight assessing functional disability and five assessing pain) and involved a total of 743 patients. At post‐treatment, yoga had a medium to large effect on functional disability (d=0.645) and pain (d=0.623). Despite a wide range of yoga styles and treatment durations, heterogeneity in post‐treatment effect sizes was low. Follow‐up effect sizes for functional disability and pain were smaller, but remained significant (d=0.397 and d=0.486, respectively); however, there was a moderate to high level of variability in these effect sizes.

DISCUSSION: The results of the present study indicate that yoga may be an efficacious adjunctive treatment for CLBP. The strongest and most consistent evidence emerged for the short‐term benefits of yoga on functional disability. However, before any definitive conclusions can be drawn, there are a number of methodological concerns that need to be addressed. In particular, it is recommended that future RCTs include an active control group to determine whether yoga has specific treatment effects and whether yoga offers any advantages over traditional exercise programs and other alternative therapies for CLBP.
Pathogenicity, Host Responses and Implications for Management of EnterohemorrhagicEscherichia coliO157:H7 Infection
Authors: Ho Nathan K , Henry Aleah C , Johnson-Henry Kathene , Sherman Philip M
Published: March 2016

EnterohemorrhagicEscherichia coliserotype O157:H7 is a food- and waterborne pathogen that causes significant morbidity and mortality in both developing and industrialized nations. The present review focuses on the history, epidemiology and evolution of the pathogen; provides a mechanistic overview of major virulence factors (including Shiga toxins, locus of enterocyte effacement pathogenicity island and pO157 plasmid); discusses host immune responses to infection; considers available animal models; and provides an overview of current and potential future management considerations.
Prevalence of Self-Reported Spondyloarthritis Features in a Cohort of Patients with Inflammatory Bowel Disease
Authors: Stolwijk Carmen , Pierik Marieke , Landewé Robert , Masclee Ad , van Tubergen Astrid
Published: March 2016

BACKGROUND: Musculoskeletal symptoms belonging to the spectrum of ‘seronegative spondyloarthritis’ (SpA) are the most common extraintestinal manifestations in patients with inflammatory bowel disease (IBD) and may lead to important disease burden. Patients with suspected SpA should be referred to a rheumatologist for further evaluation.

OBJECTIVE: To investigate the self-reported prevalence of musculoskeletal SpA features in a cohort of patients with IBD and to compare this with actual referrals to a rheumatologist.

METHODS: Consecutive patients with IBD visiting the outpatient clinic were interviewed by a trained research nurse about possible SpA features using a standardized questionnaire regarding the presence or history of inflammatory back pain, peripheral arthritis, enthesitis, dactylitis, psoriasis, uveitis and response to nonsteroidal anti-inflammatory drugs. All patient files were verified for previous visits to a rheumatologist and any rheumatic diagnosis.

RESULTS: At least one musculoskeletal SpA feature was reported by 129 of 350 (36.9%) patients. No significant differences between patients with Crohn disease and ulcerative colitis were found. Review of medical records showed that 66 (51.2%) patients had ever visited a rheumatologist. Axial SpA was diagnosed in 18 (27.3%) patients, peripheral SpA in 20 (30.3%) patients and another rheumatic disorder in 14 (21.2%) patients.

CONCLUSION: Musculoskeletal SpA features are frequently present in patients with IBD. However, a substantial group of patients is not evaluated by a rheumatologist. Gastroenterologists play a key role in early referral of this often debilitating disease.
Safe and Effective Prescription of Exercise in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: Rationale and Methods for an Integrated Knowledge Translation Study
Authors: Camp Pat G , Reid W Darlene , Yamabayashi Cristiane , Brooks Dina , Goodridge Donna , Chung Frank , Marciniuk Darcy D , Neufeld Andrea , Hoens Alison
Published: March 2016

BACKGROUND: Patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) engage in low levels of activity, putting them at risk for relapse and future readmissions. There is little direction for health care providers regarding the parameters for safe exercise during an AECOPD that is effective for increasing activity tolerance before discharge from hospital, especially for patients with associated comorbid conditions.

OBJECTIVE: To report the rationale for and methods of a study to develop evidence‐informed care recommendations that guide health care providers in the assessment, prescription, monitoring and progression of exercise for patients hospitalized with AECOPD.

METHODS: The present study was a multicomponent knowledge translation project incorporating evidence from systematic reviews of exercise involving populations with chronic obstructive pulmonary disease and/or common comorbidities. A Delphi process was then used to obtain expert opinion from clinicians, academics and patients to identify the parameters of safe and effective exercise for patients with AECOPD.

RESULTS: Clinical decision‐making tool(s) for patients and practitioners supported by a detailed knowledge dissemination, implementation and evaluation framework.

CONCLUSION: The present study addressed an important knowledge gap: the lack of availability of parameters to guide safe and effective exercise prescription for hospitalized patients with AECOPD, with or without comorbid conditions. In the absence of such parameters, health care professionals may adopt an ‘activity as tolerated’ approach, which may not improve physical activity levels in their patients. The present study synthesizes the best available evidence and expert opinion, and will generate decision‐making tools for use by patients and their health care providers.
Endoscopy Reporting Standards
Authors: Beaulieu Daphnée , Barkun Alan N , Dubé Catherine , Tinmouth Jill , Hallé Pierre , Martel Myriam
Published: March 2016

OBJECTIVES: The Canadian Association of Gastroenterology (CAG) recently published consensus recommendations for safety and quality indicators in digestive endoscopy. The present article focuses specifically on the identification of key elements that should be found in all electronic endoscopy reports detailing recommendations adopted by the CAG consensus group.

METHODS: A committee of nine individuals steered the CAG Safety and Quality Indicators in Endoscopy Consensus Group, which had a total membership of 35 voting individuals with knowledge on the subject relating to endoscopic services. A comprehensive literature search was performed with regard to the key elements that should be found in an electronic endoscopy report. A task force reviewed all published, full-text, adult and human studies in French or English.

RESULTS: Components to be entered into the standardized report include identification of procedure, timing, procedural personnel, patient demographics and history, indication(s) for procedure, comorbidities, type of bowel preparation, consent for the procedure, pre-endoscopic administration of medications, type and dose of sedation used, extent and completeness of examination, quality of bowel preparation, relevant findings and pertinent negatives, adverse events and resulting interventions, patient comfort, diagnoses, endoscopic interventions performed, details of pathology specimens, details of follow-up arrangements, appended pathology report(s) and, when available, management recommendations. Summary information should be provided to the patient or family.

CONCLUSION: Continuous quality improvement should be the responsibility of every endoscopist and endoscopy facility to ensure improved patient care. Appropriate documentation of endoscopic procedures is a critical component of such activities.
Facilitators and Solutions for Practicing Optimal Guided Asthma Self‐Management: The Physician Perspective
Authors: Lamontagne Alexandrine J , Peláez Sandra , Grad Roland , Blais Lucie , Lavoie Kim L , Bacon Simon L , Guay Hélène , Gauthier Annie , McKinney Martha L , Ernst Pierre , Collin Johanne , Ducharme Francine M
Published: March 2016

OBJECTIVE: To identify key solutions that facilitate the prescription of long‐term asthma controller and provision of written self‐management plans by physicians.

METHODS: One hour individualized semistructured interviews were conducted with physicians. Interviews were transcribed verbatim and analyzed independently by two trained qualitative researchers. A taxonomy of facilitators (contemplated solutions) and experienced solutions was achieved by consensus within the research team.

RESULTS: Forty‐two physicians (family physicians, pediatricians, emergency physicians, pulmonologists and allergists) were interviewed. The 867 facilitators and solutions, grouped in 10 categories, addressed three physician needs: support physicians in delivering optimal care (guideline dissemination, workplace culture, physician training and experience, physician attitudes toward optimal practice, tools and resources supporting physicians’ decision making); assist patients with following recommendations (patient characteristics, experiences and attitudes; physician behaviour; and tools and resources supporting patient self‐management); and offer efficient services (reorganization of care; interprofessional patient management). Suggestions pertaining to the latter two categories were most frequently cited to optimize asthma management and use of self‐management plans (eg, access to self‐management plans; education by allied health care professionals). The most cited suggestions to support prescribing long‐term controller pertained to physician behaviour (eg, involvement in patient education, personalization of prescriptions, feedback to patients of the benefits of long‐term controller). The distribution of facilitators and solutions varied across specialties.

CONCLUSIONS: Physicians proposed multiple facilitators and solutions to support optimal practice, leading to the development of a novel taxonomy. Key suggestions varied across physician specialties and behaviours sought, emphasizing the need to carefully select the most promising knowledge translation interventions.
Feasibility and Success of Hiv Point‐of‐Care Testing in an Emergency Department in an Urban Canadian Setting
Authors: Becker Marissa L , Thompson Laura H , Pindera Carla , Bridger Natalie , Lopez Carmen , Keynan Yoav , Bullard Jared , Van Caseele Paul , Kasper Ken
Published: March 2016

BACKGROUND: Approximately 26% of Canadians living with HIV are unaware of their status. Point‐of‐care (POC) HIV tests have been introduced to simplify and expand HIV testing.

OBJECTIVE: To evaluate the feasibility and acceptability of POC testing in an emergency department (ED) setting in Winnipeg, Manitoba.

METHODS: A cross‐sectional study of unselected adults presenting to the ED at the Health Sciences Centre Hospital (Winnipeg, Manitoba) was performed. Study procedures included pre‐ and post‐test counselling, administration of the INSTI HIV‐1/HIV‐2 Antibody Test (bioLytical Laboratories, Canada) and a brief questionnaire. Venous blood samples were collected from participants for confirmatory testing on all reactive and indeterminate specimens.

RESULTS: In total, 501 adults participated in the study. The majority of participants were younger than 40 years of age, approximately one‐half (48.5%) were women and 53% self‐identified as Aboriginal. Nearly one‐half (49.1%) of the participants had undergone previous HIV testing, although 63% of these tests were performed more than a year earlier. A total of seven individuals tested reactive with the POC test, all of whom were confirmed positive using serological testing (1.4%) and were linked to an HIV specialist within 24 h. Nearly all of the participants (96%) reported satisfaction with the test and believed it belonged in the ED (93%).

CONCLUSIONS: Of the participants tested, 1.4% tested reactive for HIV, which is significantly higher than the reported prevalence in Manitoba and in other similar studies conducted in North America. Furthermore, all individuals were linked to timely care. The present study demonstrated that this particular busy tertiary care ED is an important and feasible location for HIV POC testing.
Biliary Drainage Method and Temporal Trends in Patients Admitted with Cholangitis: A National Audit
Authors: McNabb-Baltar Julia , Trinh Quoc-Dien , Barkun Alan N
Published: March 2016

BACKGROUND: In patients presenting with ascending cholangitis, better outcomes are reported in those undergoing endoscopic retrograde cholangiopancreatography (ERCP) compared with surgical drainage.

OBJECTIVE: To identify factors associated with the type of intervention, and to examine temporal trends in the treatment of ascending cholangitis.

METHODS: Data were extracted from the Nationwide Inpatient Sample. Patients ≥18 years of age with a diagnosis of cholangitis between 1998 and 2009 were selected. Temporal trends were assessed using Poisson regression models. Multivariable models were fitted to predict the likelihood of a patient undergoing ERCP, percutaneous or surgical drainage, or no drainage.

RESULTS: A weighted estimate of 248,942 patients admitted for cholangitis was identified. Overall, 131,052 patients were treated with ERCP (52.6%), 10,486 with percutaneous drainage (4.2%) and 12,460 with surgical drainage (5.0%); 43.0% did not receive drainage during the admission. Temporal trends between 1998 and 2009 showed a decline in surgical and percutaneous drainage, and a rise in ERCP. In multivariable analyses adjusted for clustering, ERCP and percutaneous drainage were more often performed in institutions with a high volume of admissions for cholangitis, those with a greater bed number and hospitals located in urban areas.

CONCLUSION: Over the past decade, the use of surgical and percutaneous drainage has decreased while that of ERCP has risen. Patients treated at institutions with a low volume of admissions for cholangitis, small bed number and in rural areas were less likely to undergo ERCP or percutaneous drainage.
Antimicrobial Resistance and Antimicrobial Use Associated with Laboratory‐Confirmed Cases of Campylobacter Infection in Two Health Units in Ontario
Authors: Deckert Anne E , Reid-Smith Richard J , Tamblyn Susan E , Morrell Larry , Seliske Patrick , Jamieson Frances B , Irwin Rebecca , Dewey Catherine E , Boerlin Patrick , McEwen Scott A
Published: March 2016

AIM: A population‐based study was conducted over a two‐year period in the Perth District (PD) and Wellington‐Dufferin‐Guelph (WDG) health units in Ontario to document antimicrobial resistance and antimicrobial use associated with clinical cases of laboratory‐confirmed campylobacteriosis.

METHODS: Etest (bioMérieux SA, France) was used to determine the minimum inhibitory concentration of amoxicillin/clavulanic acid, ampicillin, chloramphenicol, ciprofloxacin (CIP), clindamycin, erythromycin (ERY), gentamicin, nalidixic acid and tetracycline. Data regarding antimicrobial use were collected from 250 cases.

RESULTS: Of the 250 cases, 165 (65.7%) reported staying home or being hospitalized due to campylobacteriosis. Fifty‐four per cent of cases (135 of 249) reported taking antimicrobials to treat campylobacteriosis. In 115 cases (51.1%), fecal culture results were not used for treatment decisions because they were not available before the initiation of antimicrobial treatment and/or they were not available before the cessation of symptoms. Of the 250 cases, 124 (49.6%) had available Campylobacter isolates, of which 66 (53.2%) were resistant to at least one of the antimicrobials tested. No resistance to ampicillin, chloramphenicol or gentamicin was found in these isolates. Six isolates (4.8%) were resistant to CIP. Two isolates (1.6%) were resistant to ERY; however, no isolates were resistant to both CIP and ERY.

CONCLUSION: Prudent use practices should be promoted among physicians to reduce the use of antimicrobials for the treatment of gastroenteritis in general and campylobacteriosis in particular, as well as to minimize the future development of resistance to these antimicrobials in Campylobacter species.
Current Status of Core and Advanced Adult Gastrointestinal Endoscopy Training in Canada: Survey of Existing Accredited Programs
Authors: Xiong Xin , Barkun Alan N , Waschke Kevin , Martel Myriam ,   the Canadian Gastroenterology Training Program Directors
Published: March 2016

OBJECTIVE: To determine the current status of core and advanced adult gastroenterology training in Canada.

METHODS: A survey consisting of 20 questions pertaining to core and advanced endoscopy training was circulated to 14 accredited adult gastroenterology residency program directors. For continuous variables, median and range were analyzed; for categorical variables, percentage and associated 95% CIs were analyzed.

RESULTS: All 14 programs responded to the survey. The median number of core trainees was six (range four to 16). The median (range) procedural volumes for gastroscopy, colonoscopy, percutaneous endoscopic gastrostomy and sigmoidoscopy, respectively, were 400 (150 to 1000), 325 (200 to 1500), 15 (zero to 250) and 60 (25 to 300). Eleven of 13 (84.6%) programs used endoscopy simulators in their curriculum. Eight of 14 programs (57%) provided a structured advanced endoscopy training fellowship. The majority (88%) offered training of combined endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography. The median number of positions offered yearly for advanced endoscopy fellowship was one (range one to three). The median (range) procedural volumes for ERCP, endoscopic ultrasonography and endoscopic mucosal resection, respectively, were 325 (200 to 750), 250 (80 to 400) and 20 (10 to 63). None of the current programs offered training in endoscopic submucosal dissection or natural orifice transluminal endoscopic surgery.

CONCLUSION: Most accredited adult Canadian gastroenterology programs met the minimal procedural requirements recommended by the Canadian Association of Gastroenterology during core training. However, a more heterogeneous experience has been observed for advanced training. Additional studies would be required to validate and standardize evaluation tools used during gastroenterology curricula.
Diagnosis and Management of the Overlap Syndromes of Autoimmune Hepatitis
Authors: Czaja Albert J
Published: March 2016

BACKGROUND: Autoimmune hepatitis may have cholestatic features that are outside the classical phenotype and that resemble findings in other immune-mediated liver diseases. These cholestatic phenotypes have been designated ‘overlap syndromes’.

OBJECTIVES: To recognize the overlap syndromes in adults and manage them appropriately.

METHODS: The MEDLINE database was reviewed for published experiences from 1984 to 2013.

RESULTS: Patients with autoimmune hepatitis may exhibit features of primary biliary cirrhosis (7% to 13%), primary sclerosing cholangitis (6% to 11%) or a cholestatic syndrome without other diagnostic features (5% to 11%). These mixed phenotypes may represent classical autoimmune hepatitis with atypical features, transition states in the evolution of classical cholestatic syndromes, concurrent separate diseases or pathogenically distinct disorders. The ‘Paris criteria’ have been endorsed for the diagnosis of the overlap syndrome with primary biliary cirrhosis, and treatment with conventional immunosuppressive therapy alone or in combination with low-dose ursodeoxycholic acid can be guided by the serum alkaline phosphatase level. The overlap syndrome with primary sclerosing cholangitis or with cholestasis without diagnostic features is commonly treated with immunosuppressive therapy and ursodeoxycholic acid. Responses are variable and commonly incomplete (20% to 100% improvement) depending on the degree of cholestasis.

DISCUSSION: The overlap syndromes are clinical descriptions rather than pathological entities, and the dominant component of the disease determines its designation and therapy. Cholestatic findings in autoimmune hepatitis influence the response to immunosuppressive therapy.

CONCLUSION: The overlap syndromes must be considered in patients with autoimmune hepatitis and cholestatic findings, concurrent inflammatory bowel disease or steroid-refractory disease.
General Anesthetic Versus Light Sedation: Effect on Pediatric Endoscopy Wait Times
Authors: Edwards Christine , Kapoor Vikram , Samuel Christopher , Issenman Robert , Brill Herbert
Published: March 2016

BACKGROUND: Wait times are an important measure of health care system effectiveness. There are no studies describing wait times in pediatric gastroenterology for either outpatient visits or endoscopy. Pediatric endoscopy is performed under light sedation or general anesthesia. The latter is hypothesized to be associated with a longer wait time due to practical limits on access to anesthesia in the Canadian health care system.

OBJECTIVE: To identify wait time differences according to sedation type and measure adverse clinical outcomes that may arise from increased wait time to endoscopy in pediatric patients.

METHODS: The present study was a retrospective review of medical charts of all patients <18 years of age who had been assessed in the pediatric gastroenterology clinic and were scheduled for an elective outpatient endoscopic procedure at McMaster Children’s Hospital (Hamilton, Ontario) between January 2006 and December 2007. The primary outcome measure was time between clinic visit and date of endoscopy. Secondary outcome measures included other defined waiting periods and complications while waiting, such as emergency room visits and hospital admissions.

RESULTS: The median wait time to procedure was 64 days for general anesthesia patients and 22 days for patients who underwent light sedation (P<0.0001). There was no significant difference between the two groups with regard to the number of emergency room visits or hospital admissions, both pre- and postendoscopy.

CONCLUSIONS: Due to the lack of pediatric anesthetic resources, patients who were administered general anesthesia experienced a longer wait time for endoscopy compared with patients who underwent light sedation. This did not result in adverse clinical outcomes in this population.
Biomarkers in Airway Diseases
Authors: Leung Janice M , Sin Don D
Published: March 2016

The inherent limitations of spirometry and clinical history have prompted clinicians and scientists to search for surrogate markers of airway diseases. Although few biomarkers have been widely accepted into the clinical armamentarium, the authors explore three sources of biomarkers that have shown promise as indicators of disease severity and treatment response. In asthma, exhaled nitric oxide measurements can predict steroid responsiveness and sputum eosinophil counts have been used to titrate anti‐inflammatory therapies. In chronic obstructive pulmonary disease, inflammatory plasma biomarkers, such as fibrinogen, club cell secretory protein‐16 and surfactant protein D, can denote greater severity and predict the risk of exacerbations. While the multitude of disease phenotypes in respiratory medicine make biomarker development especially challenging, these three may soon play key roles in the diagnosis and management of airway diseases.
Dyspnea, Massive Effusion and Lytic Rib Lesion as Initial Presentation of Multiple Myeloma in a Young Man
Authors: AlShati Mohammed H , Kumar Ramesh , Kannan Shreeram
Published: March 2016

Multiple myeloma, a disorder commonly encountered in elderly patients, represents a malignant proliferation of plasma cells that primarily affects bone marrow. Pleural effusion as the presenting manifestation of the disease is uncommon. The authors report a case of multiple myeloma with unusual features presenting at a relatively young age with massive spontaneous hemothorax and multiple thoracic masses completely obscuring rib shadow on plain chest imaging. The patient demonstrated a good response to melphalan chemotherapy without recurrence of effusion or the need for additional chemical or surgical pleural interventions.
Quantitative Sputum Cell Counts to Monitor Bronchitis: A Qualitative Study of Physician and Patient Perspectives
Authors: D’silva Liesel , Neighbour Helen , Gafni Amiram , Radford Katherine , Hargreave Frederick E , Nair Parameswaran
Published: March 2016

Many common diseases affecting the airways are characterized by airway inflammation. The measurement of this inflammation has a significant role in the management of these diseases. Quantitative sputum cell counts provide a measurement of the type and severity of inflammation present. Sputum cell counts are used in routine clinical practice in some centres but their use is not widespread. The present study used a standardized questionnaire to determine both patients’ and physicians’ attitudes toward the use of sputum cell counts. The use of sputum cell counts was well accepted by patients and physicians. Ninety per cent of patients were satisfied with the test. Sixty per cent of family physicians were satisfied with the test and 80% were in favour of it being funded by the government. The authors recommend more widespread use of sputum cell counts to guide the management of airway diseases.
An Intensive Perioperative Regimen of Pregabalin and Celecoxib Reduces Pain and Improves Physical Function Scores Six Weeks after Total Hip Arthroplasty: A Prospective Randomized Controlled Trial
Authors: Carmichael Nicole ME , Katz Joel , Clarke Hance , Kennedy Deborah , Kreder Hans J , Gollish Jeffrey , McCartney Colin JL
Published: March 2016

BACKGROUND: Despite the success of total hip arthroplasty (THA), some patients experience persistent pain and poor function after surgery. Predictors of poor outcomes include the presence of significant pre‐ and postoperative pain. Patients undergoing THA often experience severe, longstanding pain before surgery that may compromise the outcome of the procedure.

OBJECTIVES: To evaluate the effects of administering pregabalin and celecoxib for two weeks before and three weeks after THA in patients with moderate to severe pain before surgery. The aim was to determine whether patients with well‐controlled pain both before surgery and in the acute postoperative period experience less pain and better physical function six weeks after THA.

METHODS: A randomized, double‐blinded, placebo‐controlled pilot study was conducted. Group 1 received pregabalin (75 mg twice per day) and celecoxib (100 mg twice per day) for 14 days before THA and for three weeks after discharge. Group 2 received a placebo for the same duration. All patients received pregabalin and celecoxib 2 h before surgery and while in the hospital.

RESULTS: On the morning of surgery, patients in group 1 reported less pain at rest (mean [± SD] pain intensity measured on a visual analogue scale [VAS] 2.1±1.4) compared with group 2 (3.3±1.9; P=0.04). Patients in group 1 experienced less pain 3 h to 4 h postoperation (P<0.001). There was no difference in morphine consumption between the two groups. Six weeks after THA, movement‐evoked pain was lower in group 1 (VAS 0.8±0.6) compared with group 2 (VAS 2.0±1.3; P=0.01). Group 1 reported better physical function, measured using the Western Ontario and McMaster University Osteoarthritis Index questionnaire score (P=0.04). There was no significant difference in 6 min walk test performance between the two groups.

CONCLUSION: Intensive pain control with pregabalin and celecoxib improves pain and physical function after THA.
Pretreatment Resistance to Hepatitis C Virus Protease Inhibitors Boceprevir/Telaprevir in Hepatitis C Subgenotype 1A-Infected Patients from Manitoba
Authors: Andonov Anton , Kadkhoda Kamran , Osiowy Carla , Kaita Kelly
Published: March 2016

BACKGROUND: Traditional therapy with pegylated interferon and ribavirin combined with the new protease inhibitors boceprevir or telaprevir has demonstrated improved outcomes in hepatitis C virus (HCV)-infected patients. Prevalence data regarding pre-existing drug-resistant variants to these two new virus inhibitors in the Canadian population are not available.

OBJECTIVE: To detect pre-existing mutations conferring resistance to boceprevir and/or telaprevir in Canadian patients infected with HCV genotype 1a.

METHODS: Resistance-associated mutations (RAMs) were evaluated in 85 patients infected with HCV genotype 1a who had not yet received antiviral therapy. TheNS3protease gene was sequenced and common RAMs were identified based on a recently published list.

RESULTS: The overall prevalence of pre-existing RAMs to boceprevir and telaprevir was higher compared with other similar studies. All of the observed RAMs were associated with a low level of resistance. A surprisingly high proportion of patients had the V55A RAM (10.6%). None of the mutations associated with a high level of resistance were observed. The simultaneous presence of two low-level resistance mutations (V36L and V55A) was observed in only one patient. Three other patients had both T54S RAM and V55I mutations, which may require a higher concentration of the protease drugs. The prevalence of various mutations in Aboriginal Canadian patients was higher (37.5%) compared with Caucasians (16.39%) (P=0.038).

CONCLUSIONS: The present study was the first to investigate pre-existing drug resistance to boceprevir/telaprevir in Canadian HCV-infected patients. A relatively high proportion of untreated HCV genotype 1a patients in Manitoba harbour low-level RAMs, especially patients of Aboriginal descent, which may contribute to an increased risk of treatment failure.
Eosinophilia: A Poor Predictor of Strongyloides Infection in Refugees
Authors: Naidu Prenilla , Yanow Stephanie K , Kowalewska-Grochowska Kinga T
Published: March 2016

BACKGROUND: Canada resettles 10,000 to 12,000 refugees annually. Despite this being a highly vulnerable population, there are little Canadian data on subclinical tropical diseases harboured in this population over the past 20 years.

OBJECTIVES: To determine the seroprevalence and predictors of Strongyloides infection in refugees arriving in Edmonton, Alberta.

METHODS: A retrospective chart review of all refugees seen at the New Canadians Clinic between March 2009 and April 2010 was performed. Demographic, symptom and physical examination data were collected from the charts. Laboratory results were obtained from the electronic laboratory records.

RESULTS: A total of 350 subjects were studied. The overall seroprevalence of strongyloidiasis was 4.6%. Equivocal results were found in 6.3%. In the positive group, the majority were male (62.5%); 75% were born in Africa (P=0.004) and 81.2% lived in refugee camps in Africa (P=0.002). Eosinophilia was present in 25% of the positive subjects (P=0.05), in none of the equivocal group and in 8.7% of the negative group.

DISCUSSION: Persistent asymptomatic Strongyloides infection is maintained for years through autoinfection. Traditionally, eosinophilia was used as one of the key tools to diagnose chronic but stable diseases, but it was shown to have a poor predictive value for strongyloidiasis in returning expatriates as well as in those presenting with a disseminated form of the disease. It is important to raise awareness of the severe limitations of eosinophilia as a marker for strongyloidiasis when managing patients who either are immunocompromised, or about to start immunosuppressive therapy.

CONCLUSIONS: The present study indicated that eosinophilia is a poor predictor of seropositivity and, thus, Strongyloides infection. Residence in Africa (birth/refugee camps) proved to be a significantly better predictor of Strongyloides seropositivity.