bluuebunny/crossref_metadata_2025 huggingface dataset:
Major Depressive Disorder and Sleep Disturbance in Patients with Chronic Pain
Authors: Emery Patricia C , Wilson Keith G , Kowal John
Published: March 2016

BACKGROUND: Disturbed sleep is a common problem in both chronic pain and major depressive disorder (MDD). Moreover, many patients with chronic pain are depressed.

OBJECTIVES: To examine the effects of depression on the sleep behaviour of chronic pain patients by comparing patients who did or did not meet diagnostic criteria for MDD.

METHODS: A total of 60 patients with chronic musculoskeletal pain underwent structured diagnostic interviews for MDD and insomnia, and completed questionnaires assessing pain severity, disability, sleep quality, beliefs and attitudes about sleep, and sleep hygiene. For four consecutive days, they also completed a sleep diary, and reported on sleep hygiene practices and presleep arousal.

RESULTS: Thirty‐three patients (55%) met diagnostic criteria for MDD, most of whom (n=32 [97%]) also fulfilled criteria for insomnia disorder. Insomnia was also common among patients without MDD (21 of 27 [78%]). Participants with MDD had higher self‐reports of pain, disability, dysfunctional beliefs about sleep, and, on a prospective basis, greater presleep arousal and poorer sleep hygiene. However, diary assessments of specific sleep parameters (eg, sleep onset latency, total sleep time, sleep efficiency) did not differ between the groups.

DISCUSSION: Chronic pain patients with comorbid MDD exhibited more dysfunctional beliefs about sleep, poorer sleep hygiene practices and greater presleep arousal; however, diary‐recorded sleep characteristics may not differ from those of patients without MDD. Chronic pain itself may disturb sleep so extensively that MDD introduces little additive effect.

CONCLUSION: MDD in chronic pain may be related to the cognitive and behavioural aspects of insomnia, rather than to an incremental disturbance in the initiation or maintenance of sleep.
Patient Transitions Relevant to Individuals Requiring Ongoing Ventilatory Assistance: A Delphi Study
Authors: Rose Louise , Fowler Robert A , Goldstein Roger , Katz Sherri , Leasa David , Pedersen Cheryl , McKim Douglas , the CANuVENT Group
Published: March 2016

BACKGROUND: Various terms, including ‘prolonged mechanical ventilation’ (PMV) and ‘long‐term mechanical ventilation’ (LTMV), are used interchangeably to distinguish patient cohorts requiring ventilation, making comparisons and timing of clinical decision making problematic.

OBJECTIVE: To develop expert, consensus‐based criteria associated with care transitions to distinguish cohorts of ventilated patients.

METHODS: A four‐round (R), web‐based Delphi study with consensus defined as >70% was performed. In R1, participants listed, using free text, criteria perceived to should and should not define seven transitions. Transitions comprised: T1 – acute ventilation to PMV; T2 – PMV to LTMV; T3 – PMV or LTMV to acute ventilation (reverse transition); T4 – institutional to community care; T5 – no ventilation to requiring LTMV; T6 – pediatric to adult LTMV; and T7 – active treatment to end‐of‐life care. Subsequent Rs sought consensus.

RESULTS: Experts from intensive care (n=14), long‐term care (n=14) and home ventilation (n=10), representing a variety of professional groups and geographical areas, completed all Rs. Consensus was reached on 14 of 20 statements defining T1 and 21 of 25 for T2. ‘Physiological stability’ had the highest consensus (97% and 100%, respectively). ‘Duration of ventilation’ did not achieve consensus. Consensus was achieved on 13 of 18 statements for T3 and 23 of 25 statements for T4. T4 statements reaching 100% consensus included: ‘informed choice’, ‘patient stability’, ‘informal caregiver support’, ‘caregiver knowledge’, ‘environment modification’, ‘supportive network’ and ‘access to interprofessional care’. Consensus was achieved for 15 of 17 T5, 16 of 20 T6 and 21 of 24 T7 items.

CONCLUSION: Criteria to consider during key care transitions for ventilator‐assisted individuals were identified. Such information will assist in furthering the consistency of clinical care plans, research trials and health care resource allocation.
Canadian consensus statement on HIV and its transmission in the context of criminal law
Authors: Loutfy Mona , Tyndall Mark , Baril Jean-Guy , Montaner Julio SG , Kaul Rupert , Hankins Catherine
Published: March 2016

INTRODUCTION: A poor appreciation of the science related to HIV contributes to an overly broad use of the criminal law against individuals living with HIV in cases of HIV nondisclosure.

METHOD: To promote an evidence‐informed application of the law in Canada, a team of six Canadian medical experts on HIV and transmission led the development of a consensus statement on HIV sexual transmission, HIV transmission associated with biting and spitting, and the natural history of HIV infection. The statement is based on a literature review of the most recent and relevant scientific evidence (current as of December 2013) regarding HIV and its transmission. It has been endorsed by >70 additional Canadian HIV experts and the Association of Medical Microbiology and Infectious Disease Canada.

RESULTS: Scientific and medical evidence clearly indicate that HIV is difficult to transmit during sex. For the purpose of informing the justice system, the per‐act possibility of HIV transmission through sex, biting or spitting is described along a continuum from low possibility, to negligible possibility, to no possibility of transmission. This possibility takes into account the impact of factors such as the type of sexual acts, condom use, antiretroviral therapy and viral load. Dramatic advances in HIV therapy have transformed HIV infection into a chronic manageable condition.

DISCUSSION: HIV physicians and scientists have a professional and ethical responsibility to assist those in the criminal justice system to understand and interpret the science regarding HIV. This is critical to prevent miscarriage of justice and to remove unnecessary barriers to evidence‐based HIV prevention strategies.
Impaired Modulation of Pain in Patients with Postherpetic Neuralgia
Authors: Pickering Gisèle , Pereira Bruno , Dufour Elodie , Soule Sylvie , Dubray Claude
Published: March 2016

BACKGROUND: The efficiency of inhibitory pain descending pathways (evaluated using conditioned pain modulation [CPM]) has not been studied in postherpetic neuralgia (PHN).

OBJECTIVE: To compare CPM in PHN patients with healthy controls.

METHODS: Nine PHN patients and nine control individuals were matched according to age and sex. Amplitudes of cortical thermal‐evoked potentials were recorded on the surface of the scalp; clinical pain and thermal pain were evaluated on a 0 to 10 numerical rating scale, at baseline and at intervals during the 6 min after CPM (elicited by a cold pressor test, 8°C). A battery of cognitive tests was performed. Amplitude differences, percentages and related areas under the curve (AUCCPM) were calculated and all data were compared between both groups; P<0.05 was considered to be statistically significant.

RESULTS: AUCCPM0–6 min was significantly lower in PHN patients compared with controls (−39±51 μV/min versus −144±66 μV/min; P=0.0012) and correlated (P=0.04) with clinical pain intensity. Pain ratings before CPM were similar in both groups but were significantly lower in the control group 3 min after the cold pressor test. Cognitive test results were not significantly different.

CONCLUSION: Psychophysical and electrophysiological approaches have shown that patients with PHN exhibit a deficiency of pain inhibition modulation, which could signal a predisposing factor to developing chronic pain. This deficiency was not linked to the cognitive performance but rather to subtle in situ cognitivoemotional adaptations, which remain to be investigated.
Critical Care Trainees’ Career Goals and Needs: A Canadian Survey
Authors: St-Onge Maude , Mandelzweig Keren , Marshall John C , Scales Damon C , Granton John
Published: March 2016

BACKGROUND: For training programs to meet the needs of trainees, an understanding of their career goals and expectations is required.

OBJECTIVES: Canadian critical care medicine (CCM) trainees were surveyed to understand their career goals in terms of clinical work, research, teaching, administration and management; and to identify their perceptions regarding the support they need to achieve their goals.

METHODS: The online survey was sent to all trainees registered in a Canadian adult or pediatric CCM program. It documented the participants’ demographics; their career expectations; the perceived barriers and enablers to achieve their career goals; and their perceptions relating to their chances of developing a career in different areas.

RESULTS: A response rate of 85% (66 of 78) was obtained. The majority expected to work in an academic centre. Only approximately one-third (31%) estimated their chances of obtaining a position in CCM as >75%. The majority planned to devote 25% to 75% of their time performing clinical work and <25% in education, research or administration. The trainees perceived that there were limited employment opportunities. Networking and having specialized expertise were mentioned as being facilitators for obtaining employment. They expressed a need for more protected time, resources and mentorship for nonclinical tasks during training.

CONCLUSION: CCM trainees perceived having only limited support to help them to achieve their career goals and anticipate difficulties in obtaining successful employment. They identified several gaps that could be addressed by training programs, including more mentoring in the areas of research, education and administration.
Management of Thrombocytopenia in Advanced Liver Disease
Authors: Gangireddy VGR , Kanneganti PC , Sridhar S , Talla S , Coleman T
Published: March 2016

Thrombocytopenia (defined as a platelet count <150×109/L) is a well-known complication in patients with liver cirrhosis and has been observed in 76% to 85% of patients. Significant thrombocytopenia (platelet count <50×109/L to 75×109/L) occurs in approximately 13% of patients with cirrhosis. Thrombocytopenia can negatively impact the care of patients with severe liver disease by potentially interfering with diagnostic and therapeutic procedures. Multiple factors can contribute to the development of thrombocytopenia including splenic platelet sequestration, immunological processes, bone marrow suppression by chronic viral infection, and reduced levels or activity of the hematopoietic growth factor thrombopoietin. The present review focuses on the etiologies and management options for severe thrombocytopenia in the setting of advanced liver disease.
Missed Opportunities for Prevention of Perinatal Transmission of Hepatitis B: A Retrospective Cohort Study
Authors: van Schalkwyk Julie , Nourmoussavi Melica , Massey Andrea , Gustafson Reka , Brodkin Elizabeth , Petric Martin , Krajden Mel , Dobson Simon , Buxton Jane , Bigham Mark , Pick Neora , Schreiber Richard , Sherlock Christopher H , Money Deborah , Yoshida Eric M
Published: March 2016

BACKGROUND: Perinatal transmission of hepatitis B virus (HBV) can occur despite postexposure prophylaxis (PEP). Recent literature suggests that antiviral treatment during pregnancy when maternal HBV DNA levels are elevated can further decrease vertical transmission. However, HBV DNA screening is not routinely performed antenatally.

OBJECTIVE: To determine the rates of HBV prevalence and perinatal transmission in an antenatal cohort.

METHODS: A retrospective review of public health records (December 2008 to December 2010) was performed for both mothers and newborns.

RESULTS: A total of 725 mother-infant pairs were included. Of these, 574 of 715 (80%) women had antenatal hepatitis B e antigen (HBeAg) testing performed, and 127 of 574 (22%) were HBeAg positive (HBeAg+). Of babies born to hepatitis B surface antigen-positive (HBsAg+) mothers, only 573 of 725 (79%) received complete PEP. In addition, 172 of 725 (24%) infants did not receive post-PEP blood testing or were lost to follow-up. Of the 552 infants with results available, seven cases (1.3%) of mother-to-child HBV transmission were observed, six of which involved infants born to HBeAg+ women.

CONCLUSIONS: Our findings suggest that routine HBeAg screening could identify a subset of mother-infant pairs among HBsAg+ pregnant women who are at higher risk for vertical HBV transmission. Determination of viral load in expectant HBeAg+ mothers may provide more precise insight into HBV transmission to their infants.
New Insights into the Pathophysiology of Mild Chronic Obstructive Pulmonary Disease
Authors: Guenette Jordan A
Published: March 2016

The classification of mild chronic obstructive pulmonary disease (COPD) requires a postbronchodilator forced expiratory volume in 1 s (FEV1) to forced vital capacity ratio <0.7 and an FEV1 ≥80% predicted. Given their relatively well‐preserved spirometry, some have argued that respiratory symptoms in patients with mild COPD are unlikely to be related to pulmonary function abnormalities and that early detection of COPD is a ‘waste of resources’. Despite this viewpoint, there is emerging clinical and physiological evidence of peripheral airway dysfunction, diminished quality of life and reduced physical activity levels, and increased mortality, hospitalizations, dyspnea and exercise intolerance in patients with mild COPD compared with healthy controls. The purpose of the present focused review was to summarize recent research regarding the pathophysiology and treatment of mild COPD.
Hospitalized Children Continue to Report Undertreated and Preventable Pain
Authors: Birnie Kathryn A , Chambers Christine T , Fernandez Conrad V , Forgeron Paula A , Latimer Margot A , McGrath Patrick J , Cummings Elizabeth A , Finley G Allen
Published: March 2016

BACKGROUND: Published reports of substantial rates of moderate to severe pediatric inpatient pain tend to overlook lower‐intensity pain that may be clinically significant.

OBJECTIVE: To document the prevalence of clinically significant pain in pediatric inpatients by considering the pain threshold at which each child desires intervention, and to assess sources of pain, pain assessment and intervention, and relationships among demographic and medical variables to reported pain.

METHODS: Inpatients or their parents on four hospital units during four nonconsecutive days were eligible for inclusion. Interviews (76 parents; 31 patients) captured experiences of 107 inpatients (three weeks to 18 years of age) including current, worst and usual pain, pain treatment thresholds, sources of pain and help received during the previous 24 h. A chart review provided data regarding demographic and medical variables, and pain assessment and management.

RESULTS: In total, 94% of patients experienced pain. The prevalence of clinically significant pain was 8% (current), 62% (worst) and 24% (usual). Current and worst pain was primarily procedural, and usual pain was primarily disease related. On average, patients had 4.03 documented pain assessments over 24 h. Caregiver responses (eg, reassurance) and nonpharmacological interventions were frequently reported (>90%) but infrequently documented (<50%); 66% of patients received pharmacological interventions. Younger patients received fewer pain assessments and opioids. Patients with clinically significant usual pain were more likely to have undergone surgery, and receive more pain assessments and interventions.

CONCLUSIONS: While recent studies suggest reduced pain in pediatric inpatients, the present findings reveal a continued high frequency of undertreated pain. High rates of procedural pain are preventable and should be targeted given the underutilization of pain management strategies.
Exploring the Associations between Sleep Problems and Chronic Musculoskeletal Pain in Adolescents: A Prospective Cohort Study
Authors: Harrison Lee , Wilson Sue , Munafò Marcus R
Published: March 2016

BACKGROUND: The prevalence of musculoskeletal chronic pain in adolescents is estimated to be approximately 4% to 40%. The development of musculoskeletal pain during teenage years could have a marked impact on physical, psychological and social well‐being.

OBJECTIVE: To examine whether sleep problems during adolescence are associated with musculoskeletal pain, particularly chronic regional pain and chronic widespread pain.

METHODS: Using data from the Avon Longitudinal Study of Children, the relationship between sleep problems at 15 years of age and the presence of chronic regional and widespread pain at 17 years of age was explored. Pain data were not available at 15 years of age. A total of 2493 participants with complete data were identified. Relationships among sleep problems and musculoskeletal pain were examined using logistic regression. ORs were calculated after adjusting for sex, ethnicity, socioeconomic position and depression (15 years of age).

RESULTS: Sleep disturbance (usually wakes up more than two or three times), difficulties with hypersomnolence and poor subjective sleep perception were associated with the presence of both musculoskeletal regional and widespread pain. Finally, using ordered logistic regression, poor subjective sleep perception was also found to be associated with greater pain severity in participants with chronic musculoskeletal regional and widespread pain.

DISCUSSION: The results of the present study suggest an association between sleep problems during adolescence and the presence of musculoskeletal pain at a later stage. These findings are consistent with adult literature suggesting a link between sleep problems and musculoskeletal pain. Given these associations, sleep problems in adolescence may be an important risk factor for musculoskeletal pain.
A Presentation of Massive Hemoptysis in a Patient with Churg‐Strauss Syndrome
Authors: Hikmat Fadi , Pearse David B , Damarla Mahendra
Published: March 2016

Given that Churg‐Strauss syndrome is a systemic small‐vessel vasculitis, it is not usually considered in patients who present with massive hemoptysis, which is typically caused by bronchiectasis, cancer or, in some cases, aberrant bronchial arteries. This article, however, describes a novel case involving a 50‐year‐old Churg‐Strauss patient who presented with sudden‐onset massive hemoptysis. Details of the physical examination, laboratory investigations and several imaging studies, including computed tomography, bronchoscopy and three‐dimensional imaging, are presented.

Churg‐Strauss syndrome (CSS) is a systemic small‐vessel vasculitis. When involving the lungs, small‐vessel vasculitides typically cause capillaritis, leading to diffuse alveolar hemorrhage and submassive hemoptysis. In contrast, massive hemoptysis primarily originates from the bronchial arteries; therefore, small‐vessel vasculitis is not considered when a patient presents with massive hemoptysis. The authors describe a patient with CSS who presented with the novel finding of massive hemoptysis. Computed tomography scans lacked alveolar infiltrates and bronchoalveolar lavage lacked hemosiderin‐laden macrophages. Bronchoscopy demonstrated a raised mucosal lesion in the right mainstem bronchus and computed tomography angiogram revealed aberrant dilated bronchial arteries underlying the same region, suggesting this as the source of the hemoptysis. To the authors’ knowledge, the present report describes the first reported case of CSS to present with massive hemoptysis with likely involvement of the bronchial arterial circulation. CSS should be considered in patients with unexplained massive hemoptysis.
Bringing Psychosocial Support to Headache Sufferers Using Information and Communication Technology: Lessons Learned from Asking Potential Users What they Want
Authors: Huguet Anna , Stinson Jennifer , MacKay Bonnie , Watters Carolyn , Tougas Michelle , White Meghan , McGrath Patrick J
Published: March 2016

BACKGROUND: Headaches are a major concern for which psychosocial interventions are recommended. However, headache sufferers do not always have ready access to these interventions. Technology has been used to improve access, especially in young people.

OBJECTIVES: To examine user preferences to inform the development of an Internet‐based psychosocial intervention including smartphone technology, referred to as the Wireless Headache Intervention.

METHODS: The methodology followed a participatory design cycle, including 25 headache sufferers (14 to 28 years of age) who informed the prototype design. All participants were familiar with smartphones and the Internet. Through two iterative cycles of focus groups stratified according to age, qualitative data were collected by asking user preferences for the different planned components of the intervention (ie, smartphone pain diary, Internet‐based self‐management treatment, social support) and other relevant aspects (ie, smartphone versus computer delivery, and ways of reaching target audience). NVivo 8 with content analysis was used to analyze data and reflect themes as guided by the thematic survey.

RESULTS: Participants reported a preference for completing the smart‐phone pain diary on a daily basis. Participants believed that the program should facilitate easy access to information regarding headaches and management strategies. They also wanted access to other headache sufferers and experts. Participants believed that the program should be customizable and interactive. They reinforced the need and value of an integrated smartphone and Internet‐based application.

CONCLUSIONS: The results provide insight into a participatory design to guide design decisions for the type of intervention for which success relies largely on self‐motivation. The results also provide recommendations for design of similar interventions that may benefit from the integration of mobile applications to Internet‐based interventions. The present research contributes to the theoretical frameworks that have been formulated for the development of Internet‐based applications.
A Survey of Perceptions and Practices of Complementary Alternative Medicine among Canadian Gastroenterologists
Authors: Gallinger Zane , Bressler Brian , Devlin Shane M , Plamondon Sophie , Nguyen Geoffrey C
Published: March 2016

BACKGROUND: Despite a high prevalence of complementary alternative medicine (CAM) use among inflammatory bowel disease (IBD) patients, there is a dearth of information about the attitudes and perceptions of CAM among the gastroenterologists who treat these patients.

OBJECTIVE: To characterize the beliefs, perceptions and practices of gastroenterologists toward CAM use in patients with IBD.

METHODS: A web-based survey was sent to member gastroenterologists of the Canadian Association of Gastroenterology. The survey included multiple-choice and Likert scale questions that queried physician knowledge and perceptions of CAM and their willingness to discuss CAM with patients.

RESULTS: Fifty-three per cent of respondents considered themselves to be IBD subspecialists. The majority (86%) of gastroenterologists reported that less than one-half of their patient population had mentioned the use of CAM. Only 8% of physicians reported initiating a conversation about CAM in the majority of their patient encounters. Approximately one-half (51%) of respondents were comfortable with discussing CAM with their patients, with lack of knowledge being cited as the most common reason for discomfort with the topic. Most gastroenterologists (79%) reported no formal education in CAM. While there was uncertainty as to whether CAM interfered with conventional medications, most gastroenterologists believed it could be effective as an adjunct treatment.

CONCLUSION: Our findings demonstrate that gastroenterologists were hesitant to initiate discussions about CAM with patients. Nearly one-half were uncomfortable or only somewhat comfortable with the topic, and most may benefit from CAM educational programs. Interestingly, most respondents appeared to be receptive to CAM as adjunct therapy alongside conventional IBD treatment.
Practice and Documentation of Performance of Colonoscopy in a Central Canadian health Region
Authors: Singh Harminder , Kaita Lisa , Taylor Gerry , Nugent Zoann , Bernstein Charles
Published: March 2016

OBJECTIVE: To evaluate the reporting and performance of colonoscopy in a large urban centre.

METHODS: Colonoscopies performed between January and April 2008 in community hospitals and academic centres in the Winnipeg Regional Health Authority (Manitoba) were identified from hospital discharge databases and retrospective review of a random sample of identified charts. Information regarding reporting of colonoscopies (including bowel preparation, photodocumentation of cecum/ileum, size, site, characteristics and method of polyp removal), colonoscopy completion rates and follow-up recommendations was extracted. Colonoscopy completion rates were compared among different groups of physicians.

RESULTS: A total of 797 colonoscopies were evaluated. Several deficiencies in reporting were identified. For example, bowel preparation quality was reported in only 20%, the agent used for bowel preparation was recorded in 50%, photodocumentation of colonoscopy completion in 6% and polyp appearance (ie, pedunculated or not) in 34%, and polyp size in 66%. Although the overall colonoscopy completion rate was 92%, there was a significant difference among physicians with varying medical specialty training and volume of procedures performed. Recommendations for follow-up procedures (barium enema, computed tomography colonography or repeat colonoscopy) were recorded for a minority of individuals with reported poor bowel preparation or incomplete colonoscopy.

CONCLUSIONS: The present study found many deficiencies in reporting of colonoscopy in typical, city-wide clinical practices. Colonoscopy completion rates varied among different physician specialties. There is an urgent need to adopt standardized colonoscopy reporting systems in everyday practice and to provide feedback to physicians regarding deficiencies so they can be rectified.
Chronic Hepatitis C in Western Canada: A Survey of Practice Patterns among Gastroenterologists in Alberta and British Columbia
Authors: Pai Rohit , Ramji Alnoor , Lee Samuel S , Wong Winnie W , Yoshida Eric M
Published: March 2016

OBJECTIVE: To survey gastroenterologists in British Columbia and Alberta with regard to awareness of chronic hepatitis C virus (HCV) management and practice patterns among physicians who treat and do not treat HCV-infected patients.

METHODS: An anonymous two-page mail survey was distributed to actively practicing adult gastroenterologists in British Columbia and Alberta. Among physicians who treated HCV patients, respondents answered assessment of fibrosis pretreatment, measurement of rapid virological response, prescription of protease inhibitors (PIs), barriers to using these agents and referral patterns. For those who did not treat HCV, referral of patients for treatment and to whom was assessed.

RESULTS: Seventy-seven of 166 individuals completed the survey (46% response rate). Most (49%) practiced in academic or large community (42%) settings. Chronic liver disease comprised <25% of individual practice in 71%. Forty-eight (62%) treated HCV and two-thirds prescribed a PI. Barriers to prescription included unfamiliarity (six of 16), lack of allied health (five of 16) and few suitable patients (seven of 16). Pretreatment liver biopsy was performed by 33% (16 of 48) and 69% (33 of 48) used noninvasive measures. Rapid virological response was measured in 83% (40 of 48). Referral patterns changed in 46% (22 of 48) of physicians who treated HCV. All respondents who did not treat HCV referred patients for consideration, with 90% (26 of 29) made to hepatologists.

CONCLUSIONS: Chronic liver disease comprised <25% of practice in the majority of surveyed respondents. Among those who treated HCV, one-third have not prescribed a PI. Barriers to prescription and referral pattern changes are noted by those currently treating patients with HCV infection.
Colon Capsule Endoscopy: Detection of Colonic Polyps Compared with Conventional Colonoscopy and Visualization of Extracolonic Pathologies
Authors: Hagel Alexander F , Gäbele Erwin , Raithel Martin , Hagel Wolfgang H , Albrecht Heinz , de Rossi Thomas M , Singer Christine , Schneider Thomas , Neurath Markus F , Farnbacher Michael J
Published: March 2016

BACKGROUND: Conventional colonoscopy (CC) is the gold standard for diagnostic examination of the colon. However, the overall acceptance of this procedure is low due to patient fears of complications or embarrassment. Colon capsule endoscopy (CCE) represents a minimally invasive, patient-friendly procedure that offers complete visualization of the entire intestine.

OBJECTIVE: To assess the PillCam Colon 2 (Given Imaging Ltd, Israel) capsule with regard to feasibility, sensitivity and specificity for the detection of colonic pathologies and additional recorded extracolonic findings.

METHODS: CCE was performed before CC in patients indicated for CC for known or suspected colonic disease. The results of both techniques were compared with regard to polyp detection. Additionally, bowel preparation and extracolonic pathologies were analyzed.

RESULTS: Twenty-four patients (mean age 51.1 years) were included in the analysis. Visualization of the colon was complete in 23 CCs and 17 CCEs. No adverse events or major technical failures occurred. CC detected 47 polyps and CCE detected 43 polyps of any size (per-finding sensitivity 90.9%, specificity 67.6%). The accuracy of CCE in detecting polyp carriers was 81.5% (per-patient analysis). On average, the colon was adequately cleansed in 90.1% of patients. CCE identified esophageal, gastric and small bowel pathologies in seven (24%), nine (38%) and 14 (58%) patients, respectively.

CONCLUSIONS: CCE proved to be technically feasible and safe. Acceptable sensitivity and moderate specificity levels in polyp detection were recorded. Bowel preparation was adequate in most patients. Because extracolonic pathologies were effectively visualized, new indications for the PillCam Colon 2 may be defined.
Variation in Outpatient Oral Antimicrobial Use Patterns among Canadian Provinces, 2000 to 2010
Authors: Glass-Kaastra Shiona K , Finley Rita , Hutchinson Jim , Patrick David M , Weiss Karl , Conly John
Published: March 2016

BACKGROUND: The volume and patterns of antimicrobial drug use are key variables to consider when developing guidelines for prescribing, and programs to address stewardship and combat the increasing prevalence of antimicrobial resistant pathogens. Because drug programs are regulated at the provincial level, there is an expectation that antibiotic use may vary among provinces.

OBJECTIVE: To assess these potential differences according to province and time.

METHODS: Provincial antimicrobial prescribing data at the individual drug level were acquired from the Canadian Integrated Program for Antimicrobial Resistance Surveillance for 2000 to 2010. Data were used to calculate two yearly metrics: prescriptions per 1000 inhabitant‐days and the average defined daily doses per prescription. The proportion of liquid oral prescriptions of total prescriptions was also calculated as a proxy measure for the proportion of prescriptions given to children versus adults. To assess the significance of provincial antimicrobial use, linear mixed models were developed for each metric, accounting for repeated measurements over time.

RESULTS: Significant differences among provinces were found, as well as significant changes in use over time. Newfoundland and Labrador was found to have significantly higher prescribing rates than all other provinces (P<0.001) in 2010, as well as the mean of all other provinces (P<0.001). In contrast, Quebec exhibited significantly lower prescribing than all other provinces (P<0.001 for all provinces except British Columbia, where P=0.024) and the mean of all other provinces (P<0.001).

DISCUSSION/CONCLUSION: Reports of reductions in antimicrobial use at the Canadian level are promising, especially prescribing to children; however, care must be taken to avoid the pitfall of the ecological fallacy. Reductions are not consistent among the provinces or among the classes of antimicrobial drugs dispensed in Canada.
Deferred Consent in a Minimal‐Risk Study Involving Critically Ill Subarachnoid Hemorrhage Patients
Authors: Topolovec-Vranic Jane , Santos Marlene , Baker Andrew J , Smith Orla M , Burns Karen EA
Published: March 2016

INTRODUCTION: Alterations from first‐party and surrogate decision‐maker consent can enhance the feasibility of research involving critically ill patients.

OBJECTIVE: To describe the use of a deferred‐consent model to enable participation of critically ill patients in a minimal‐risk biomarker study.

METHODS: A prospective observational study was conducted in which serum biomarker samples were collected three times daily over the first 14 days following aneurysmal subarachnoid hemorrhage. Sample collection was initiated on intensive care unit admission and consent was obtained when research personnel could approach the patient or the patient’s surrogate decision maker.

RESULTS: Twenty‐seven patients were eligible for the study, of whom only five were capable of providing informed consent. Full consent was obtained for 21 (78%) patients through self‐ (n=4) and surrogate (n=17) consent. Partial consent or refusal (only permitting the collection of blood samples as a part of routine care or use of data) occurred in three patients. Among the 22 consents sought from surrogates, three (11%) refused participation. The refusals included the sickest patients in the cohort. Once consent was provided, no patient or surrogate withdrew consent before study completion.

DISCUSSION: Use of a deferred consent model enabled participation of critically ill patients in a minimal‐risk biomarker study with no withdrawals.

CONCLUSIONS: Further research and enhanced awareness of the potential utility of hybrid models, including deferred consent in addition to patient or surrogate consent, in the conduct of low‐risk and minimally interventional time‐sensitive studies of critically ill patients are required.
The Efficacy of a Multidisciplinary Group Program for Patients with Refractory Chronic Pain
Authors: Inoue Masayuki , Inoue Shinsuke , Ikemoto Tatsunori , Arai Young-Chang P , Nakata Masatoshi , Miyazaki Atsuko , Nishihara Makoto , Kawai Takashi , Hatakeyama Noboru , Yamaguchi Setsuko , Shimo Kazuhiro , Miyagawa Hirofumi , Hasegawa Tomomi , Sakurai Hiroki , Hasegawa Yoshinobu , Ohmichi Yusuke , Ushida Takahiro
Published: March 2016

BACKGROUND: Chronic pain is a major problem because it can result in not only a reduction in activities of daily living and quality of life but also requires initiation of social assistance. Seeking only to eliminate pain itself would appear to be too narrow an objective, in addition to often being unachievable; therefore, a multifaceted, comprehensive approach with multiple objectives is needed.

OBJECTIVE: To describe the effects of a program (the ‘Chronic Pain Class’) offering cognitive behavioural therapy to small groups of individuals with refractory chronic pain in Japan. Exercise was an important feature of the program.

METHODS: A total of 46 patients who were experiencing treatment difficulties and decreased activity participated in the program. The programs were conducted in groups of five to seven patients who met weekly for nine weeks. Weekly sessions, which were approximately 2 h in duration, combined lectures with exercise. Several measures related to pain and physical function were administered at the beginning and the conclusion of the program.

RESULTS: Nine patients dropped out during the program. A number of measures (eg, pain intensity, disability, catastrophizing thoughts) showed significant improvements after intervention (P<0.002 after Bonferroni correction). Furthermore, most measures of physical function showed substantial improvement, especially seated forward bends, zig‐zag walking, self‐care and 6 min walk test (P<0.001).

CONCLUSION: The results of the present study provide evidence that a combination of cognitive behavioural therapy and exercise should be recommended to patients with refractory chronic pain.
Physician Global Assessments or Blood tests do not Predict Mucosal Disease Activity in Ulcerative Colitis
Authors: Brahmania Mayur , Bernstein Charles N
Published: March 2016

BACKGROUND: Mucosal healing has been proposed as the therapeutic end point in the treatment of patients with ulcerative colitis (UC).

OBJECTIVE: To investigate the relationship between physician global assessment (PGA) and laboratory blood tests (complete blood count, ferritin, C-reactive protein, albumin) and endoscopic findings in UC to determine whether they could be adequate surrogates for endoscopy.

METHODS: A retrospective chart review of patients known to have UC from July 2008 to November 2012 was performed at the Health Sciences Centre, Winnipeg, Manitoba. Patients included individuals with UC who underwent colonoscopy within one month of clinic assessment. Blood tests were standard at the time of colonoscopy. Patients presenting through the emergency department, those with colonoscopies performed outside the authors’ institution, or whose colonoscopies and clinical assessments were undertaken more than one month apart were excluded. The PGA was used to determine disease activity in patients before colonoscopy. The Ulcerative Colitis Endoscopic Index of Severity, a validated scoring system to rate endoscopic disease severity in ulcerative colitis, was adapted.

RESULTS: A total of 154 patients (mean [± SD] age 44±15.7 years) with UC were identified including 82 (53%) men. Mean hemoglobin level was 139 g/L, mean platelet level was 296×109/L, mean ferritin level was 102 μg/L, mean C-reactive protein level was 10 mg/L and mean albumin level was 40 g/L. Using endoscopy as the ‘gold standard’ for assessing UC activity (moderate-severe), abnormalities in laboratory parameters and PGA were both highly specific but not sensitive for identifying individuals with at least moderately active endoscopic disease. The PGA had higher positive and negative predictive values than the laboratory parameters.

CONCLUSION: Neither blood tests nor PGA could replace endoscopy for assessing mucosal healing. When patients experienced active symptoms and abnormal serum markers, they were highly likely to have abnormal endoscopy. However, inactive symptoms or normal laboratory values did not preclude having active endoscopic disease.
Invasive Amoebiasis: A Review ofEntamoebaInfections Highlighted with Case Reports
Authors: Skappak Christopher , Akierman Sarah , Belga Sara , Novak Kerri , Chadee Kris , Urbanski Stefan J , Church Deirdre , Beck Paul L
Published: March 2016

Entamoeba histolyticainfections of the gastrointestinal tract are common in the developing world but rare in North America. The authors present two cases: one involving an individual who had not travelled to an endemic area and another involving an individual who was born in Bulgaria. Both presented with severe abdominal pain and diarrhea. Endoscopic assessment revealed scattered colonic ulcerations and one patient was found to have a liver abscess on imaging. Stool ova and parasite studies were negative in both cases and both were diagnosed on review of colonic biopsies. On review of allEntamoebacases in the Calgary Health Zone (Alberta), ova and parasite analysis found an average of 63.7Entamoebacases per year and a pathology database review revealed a total of seven cases of invasiveE histolytica(2001 to 2011). Both patients responded well to antibiotic therapy.E histolyticashould be considered in new-onset colitis, especially in individuals from endemic areas.
A confusing Case – Weissella confusa Prosthetic Joint Infection: A Case Report and Review of the Literature
Authors: Medford Richard , Patel Samir N , Evans Gerald A
Published: March 2016

The authors describe the first case of Weissella confusa infection of a prosthetic joint. Identification of the pathogen required 16S ribosomal RNA sequencing of isolates obtained on two separate occasions during the assessment of an elderly woman with a painful, swollen knee following total knee arthroplasty. A review of reported human infections due to W confusa are summarized, and risk factors and pitfalls in the application of empirical antimicrobial therapy pending definitive microbiological identification are discussed.
Restauration Fonctionnelle du Rachis : Effet du Niveau Initial de Douleur sur Les Performances des Sujets Lombalgiques Chroniques
Authors: Caby Isabelle , Olivier N , Mendelek F , Kheir R Bou , Vanvelcenaher J , Pelayo P
Published: March 2016

BACKGROUND: Chronic low back pain is a persistent lumbar pain of multifactorial origin. The initial pain level remains poorly used to analyze and compare responses in low back pain patients in a reconditioning program.

OBJECTIVE: To assess and evaluate the responses of subjects with very painful chronic low back pain in a dynamic and intensive care program.

METHODS: A total of 134 patients with chronic low back pain were included in a spine functional restoration program for five weeks. The subjects were classified into two groups by level of pain: a group experiencing severe pain (n=28) and a group experiencing mild to moderate pain (n=106). All subjects received identical support consisting primarily of physiotherapy, occupational therapy, cardiovascular and muscular reconditioning as well as psychological counselling. The physical parameters (flexibility, muscular strength) and psychological (quality of life) were measured before (T0) and after the program (T5sem).

RESULTS: All physical and functional performances of the subjects with severe pain were lower and the impact of back pain on quality of life for these subjects was increased. All significant differences at T0 between the two groups were no longer present at T5sem.

DISCUSSION: Muscular atrophy is more important in subjects with severe pain at T0. The intense pain would cause kinesiophobia and central inhibition in chronic low back pain. The analgesic effects of the spine functional restoration program allowed subjects to obtain similar physical, functional and psychological performances at the end of the five weeks of support.

CONCLUSIONS: Patients with very painful chronic low back pain respond favourably to the dynamic and intensive program. The intensity of low back pain had no effect on responses to the program. The spine functional restoration program enables patients to better manage their pain, whatever its level.
Real‐Time Polymerase Chain Reaction for Microbiological Diagnosis of Parapneumonic Effusions in Canadian Children
Authors: Pernica Jeffrey M , Moldovan Ioana , Chan Francis , Slinger Robert
Published: March 2016

BACKGROUND: Community‐acquired pneumonia (CAP) complicated by parapneumonic effusion/empyema is an infectious syndrome commonly encountered by physicians caring for children in Canada.

OBJECTIVE: To investigate the incremental benefit of novel molecular testing for the microbiological diagnosis of pediatric CAP complicated by parapneumonic effusion/empyema in Canada.

METHODS: A convenience sample of pleural fluid from 56 children who had been admitted to hospital in Ontario with CAP complicated by parapneumonic effusion between 2009 and 2011 was examined. Multiple uniplex real‐time polymerase chain reaction (PCR) testing was performed on these pleural fluids and compared with traditional culture‐based testing of blood and pleural fluid samples.

RESULTS: Molecular methods detected a pathogen in 82% of cases, whereas traditional cultures of blood and pleural fluids detected a pathogen in only 25%. The majority of parapneumonic effusions were associated with pneumococcal infection; Streptococcus pneumoniae was detected in 62% of the samples using molecular methods but in only 14% of samples using culture‐based methods. Streptococcus pyogenes, detected in 16% of samples using PCR, was the second most common pathogen found. No patients were found to have empyema caused by Staphylococcus aureus.

DISCUSSION: The results showed that multiple uniplex real‐time PCR performed substantially better than traditional culture methods for microbiological diagnosis of CAP complicated by effusion/ empyema. S pneumoniae and S pyogenes were found to be responsible for the majority of infections. The approach detected pathogens in a similar proportion of pleural fluid samples as previously reported nested PCR assays; furthermore, the real‐time closed‐well approach also minimized the risk of nonspecificity due to cross‐contamination relative to nested PCR.

CONCLUSIONS: Real‐time PCR for the detection of bacterial DNA in pleural fluids has the potential to better define the microbiological cause of pediatric CAP. This approach could help clinicians provide targeted antimicrobial therapy.
Improving Medical Communication: Skills for a Complex (And Multilingual) Clinical World
Authors: Brindley Peter G , Smith Katherine E , Cardinal Pierre , LeBlanc Francois
Published: March 2016

It has been reported that suboptimal communication represents the largest source of preventable error during acute medical care. Because a significant proportion of ongoing care relies heavily on verbal communication, it is incumbent on clinicians to develop, hone and maintain these skills in the interests of their patients and, at the same time, contribute to a more reliable and patient-focused health care system. This review briefly discusses why communication matters, practical strategies from both inside and outside clinical medicine, the implications of poor translation and the state of medical communication in Canada.
Idiopathic Pulmonary Fibrosis: New Insights to Functional Characteristics at Diagnosis
Authors: Cortes-Telles Arturo , Forkert Lutz , O’Donnell Denis E , Morán-Mendoza Onofre
Published: March 2016

BACKGROUND: The lung function of patients with idiopathic pulmonary fibrosis (IPF) has not been characterized in detail.

OBJECTIVE: To characterize the heterogeneous physiological abnormalities that exist in patients with IPF during their initial clinical evaluation.

METHODS: Lung function tests from 93 patients, performed within six months of the initial diagnosis of IPF, were obtained from a referral pulmonary function laboratory at a tertiary care hospital in Canada. A restrictive pattern was defined as total lung capacity (TLC) <95th percentile of predicted value. Patients with obstructive lung disease, lung cancer, emphysema and other restrictive lung diseases were excluded.

RESULTS: On diagnosis, 73% of patients with IPF had a restrictive pattern, with a mean TLC of 72% of predicted. Mean forced vital capacity (FVC) was 71% and 44% of patients had an FVC <95th percentile. Mean diffusing capacity for carbon monoxide (DLco) was 60% and DLco/alveolar volume (VA) 92% of predicted. Increased severity of restriction – based on TLC – was associated with lower DLco (74% of predicted in mild restriction and 39% of predicted in severe restriction) and higher forced expiratory volume in 1 s (FEV1)/FVC ratio (82% of predicted in mild restriction and 90% of predicted in severe restriction) but not with age (76 years in mild restriction and 69 years in severe restriction). Regardless of severity of restriction, the average DLco/VA (≥86% of predicted) remained within normal limits.

CONCLUSIONS: One in four patients with IPF had normal TLC and more than one‐half had a normal FVC during initial evaluation. As the severity of the restriction increased, FEV1/FVC increased, DLco decreased but DLco/VA remained normal.