bluuebunny/crossref_metadata_2025 huggingface dataset:
Prognosis of Gastric Cancer Patients with Node-Negative Metastasis following Curative Resection: Outcomes of the Survival and Recurrence
Authors: Deng Jingyu , Liang Han , Sun Dan , Zhang Rupeng , Zhan Hongjie , Wang Xiaona
Published: March 2016

BACKGROUND: The purpose of the present study was to provide valuable prognostic information on lymph node-negative gastric cancer patients following curative resection.

METHODS: Data from 112 lymph node-negative gastric cancer patients who underwent curative resection were reviewed to identify the independent factors of overall survival and recurrence.

RESULTS: The five-year survival rate of lymph node-negative gastric cancer patients was 85.7%, and recurrence was identified in 25 patients after curative surgery. The five-year survival rate of lymph node-negative gastric cancer patients was higher than that of lymph node-positive gastric cancer patients (P<0.001). Recurrence in lymph node-negative gastric cancer patients was less than that of lymph node-positive gastric cancer patients (P=0.001). The median survival after recurrence of lymph node-negative gastric cancer patients was longer than that of lymph node-positive gastric cancer patients (P=0.021). Using multivariate analyses, the following results were determined for lymph node-negative gastric cancer patients: sex, operative type and the presence of serosal involvement were independent factors of overall survival; and lymphadenectomy, number of dissected nodes and the presence of serosal involvement were independent factors of recurrence.

CONCLUSIONS: The prognosis of lymph node-negative gastric cancer patients was better than that of lymph node-positive gastric cancer patients. Male sex, subtotal gastrectomy and nonserosal involvement should be considered to be the favourable predictors of postoperative long-term survival of lymph node-negative gastric cancer patients. Conversely, limited lymphadenectomy, few dissected nodes and serosal involvement should be considered to be risk factors of postoperative recurrence of lymph node-negative gastric cancer patients.
Exercise and Inflammatory Bowel Disease
Authors: Narula Neeraj , Fedorak Richard N
Published: March 2016

Crohn’s disease and ulcerative colitis are both idiopathic inflammatory bowel diseases (IBDs) that affect 0.5% of Canadians. As yet, there is no known cure for either disease, and symptoms are treated with an array of medicines. The objective of the present review was to present the role of exercise and its impact on all facets of IBD. Exercise has been speculated to be protective against the onset of IBD, but the literature is inconsistent and weak. Preliminary studies reveal that exercise training may be beneficial to reduce stress and symptoms of IBD. Current research also recommends exercise to help counteract some IBD-specific complications by improving bone mineral density, immunological response, psychological health, weight loss and stress management ability. However, the literature advises that some patients with IBD may have limitations to the amount and intensity of exercise that they can perform. In summary, exercise may be beneficial to IBD patients, but further research is required to make a convincing conclusion regarding its role in the management of IBD and to help establish exercise regimens that can account for each IBD patient’s unique presentation.
Opposing Trends in the Prevalence of Health Professional‐Diagnosed Asthma by Sex: A Canadian National Population Health Survey Study
Authors: Ghosh S , Pahwa P , Rennie D , McDuffie HH
Published: March 2016

BACKGROUND: The prevalence of asthma is on the rise worldwide, with large variations in prevalence existing between and within countries. Little is known regarding the variation in asthma prevalence in adults living in rural and urban settings.

OBJECTIVES: Using questionnaire data from the Canadian National Population Health Survey, the prevalence of asthma at four time periods (1994/1995 [cycle 1], 1996/1997 [cycle 2], 1998/1999 [cycle 3] and 2000/2001 [cycle 4]) was compared between rural and urban populations stratified by sex, smoking status and age group. Asthma was defined as a positive response to the question: “Do you have asthma diagnosed by a health professional?”

METHODS: To account for the complexity of the survey design, the bootstrap method was used to calculate prevalences and 95% CIs.

RESULTS: Overall, the prevalence of asthma increased from 7.3% (cycle 1) to 7.5% (cycle 4). After stratifying by sex, the asthma prevalence decreased among men, but in women, there was a steady increase. Asthma prevalence increased for both the rural population and the urban population. After stratifying each cycle by sex and location (rural or urban), both rural and urban men showed a decrease in asthma prevalence. On dividing according to age groups (0 to 14 years, 15 to 34 years, 35 to 64 years, and 65 years and older), the prevalence of asthma was greatest in the 15‐ to 34‐year age group of urban and rural women.

CONCLUSIONS: Asthma prevalence increased among rural and urban women. The prevalence of asthma was highest among female smokers and male nonsmokers when stratified by smoking status. Based on these findings, the rate of increase in asthma prevalence is different for men and women.
Review of the Literature on the Psychoemotional Reality of Women with Vulvodynia: Difficulties Met and Strategies Developed
Authors: Cantin-Drouin Maude , Damant Dominique , Turcotte Daniel
Published: March 2016

BACKGROUND: Within the past three decades, increased attention has been placed on the study of vulvodynia ‐ an unexplained chronic vulvular discomfort felt without any related pathology. In addition to its physical implications, vulvodynia has a psychosocial dimension.

OBJECTIVE: The purpose of the current article is to present a review of the literature on the psychoemotional reality of women with vulvodynia.

METHOD: A systematic literature review was conducted in the main social sciences databases, such as Dissertation Abstracts, Current Contents and PsycINFO.

RESULTS: Although some discrepancies were found in study results, the review of the literature revealed that women with vulvodynia are often confronted with identity and psychological difficulties, which are, in turn, influenced by social standards regarding sexuality and femininity. To cope with these difficulties, women develop different strategies to decrease the stress related to pain and enhance their psychological well‐being.

CONCLUSION: The psychological and relational difficulties experienced by women with vulvodynia are not only due to the physical pain but also to the meaning they attribute to it, often influenced by social expectations related to heterosexuality and femininity. Hence, it is important to assist these women by increasing their knowledge on the psychosocial aspects of their experience while taking into account influences from the social context.
Use of Oral Miltefosine for Cutaneous Leishmaniasis in Canadian Soldiers Returning from Afghanistan
Authors: Keynan Yoav , Larios Oscar E , Wiseman Marni C , Plourde Marie , Ouellette Marc , Rubinstein Ethan
Published: March 2016

Old world cutaneous leishmaniasis (CL) is caused by Leishmania major and Leishmania tropica, and is endemic to several Asian and Middle‐Eastern countries where the rates of infection can be substantial. CL is one of the most common vector‐transmitted parasitic infections in Afghanistan. Six cases of CL in Canadian soldiers returning from Afghanistan are reported in the present study. Their lesions did not improve with fluconazole therapy, and the organism demonstrated in vitro resistance. Oral miltefosine seemed effective.
Neurological Disorders in Adult Celiac Disease
Authors: Freeman Hugh J
Published: March 2016

Celiac disease may initially present as a neurological disorder. Alternatively, celiac disease may be complicated by neurological changes. With impaired nutrient absorption, different deficiency syndromes may occur and these may be manifested clinically with neurological changes. However, in patients with deficiency syndromes, extensive involvement of the small intestine with celiac disease is often evident. There are a number of reports of celiac disease associated with neuropathy, ataxia, dementia and seizure disorder. In these reports, there is no clear relationship with nutrient deficiency and a precise mechanism for the neurological changes has not been defined. A small number of patients have been reported to have responded to vitamin E administration, but most do not. In some, gluten antibodies have also been described, especially in those with ataxia, but a consistent response to a gluten-free diet has not been defined. Screening for celiac disease should be considered in patients with unexplained neurological disorders, including ataxia and dementia. Further studies are needed, however, to determine if a gluten-free diet will lead to improvement in the associated neurological disorder.
Fibrosing Mediastinitis: Successful Stenting of the Pulmonary Artery
Authors: Thiessen Rennae , Matzinger Fred , Seely Jean , Aina Rima , MacLeod Peter
Published: March 2016

Fibrosing mediastinitis is a rare benign condition, which can cause compression of the pulmonary or systemic vessels, tracheobronchial tree, coronary arteries or esophagus, leading to disabling clinical symptoms and even death. The case of a 26‐year‐old woman who presented with dyspnea is described. She was found to have 80% stenosis of the right pulmonary artery secondary to fibrosing mediastinitis. The stenosis was managed successfully with an endovascular Palmaz‐Schatz stent, and the patient remains symptom‐free 10 years later.
Pain Catastrophizing Scale for Francophone Adolescents: A Preliminary Validation
Authors: Tremblay Isabelle , Beaulieu Yves , Bernier Annie , Crombez Geert , Laliberté Simon , Thibault Pascal , Velly Ana M , Sullivan Michael JL
Published: March 2016

BACKGROUND: In adults, it is well known that high levels of pain catastrophizing are related to increased pain and disability as well as to heightened anxiety and depression. However, due to the lack of a measure of pain catastrophizing adapted for francophone adolescents, little is known about the role of catastrophizing in this population.

OBJECTIVES: To adapt the French version of the Pain Catastrophizing Scale (PCS) and to examine the psychometric properties and factorial structure of the PCS for Francophone Adolescents (PCS‐Ado).

METHODS: The French version of the PCS was modified by a group of experts. The format of the questions was modified to be appropriate for adolescents aged between 12 and 18 years. To assess the psychometric properties of the PCS‐Ado, 345 adolescents completed the PCS‐Ado and questionnaires measuring depression, anxiety and intensity of pain. Twelve to 16 weeks later, participants completed the questionnaires again to examine the test‐retest reliability of the PCS‐Ado.

RESULTS: Results revealed a three‐factor solution similar to the original PCS. In addition, results revealed that PCS‐Ado had good internal consistency (PCS‐Ado total: 0.85; rumination: 0.72; magnification: 0.66; helplessness: 0.74), and high test‐retest reliability (r=0.73). Finally, significant correlations among catastrophizing, depression, anxiety and pain intensity support the construct validity of the PCS‐Ado.

CONCLUSIONS: The results suggest that the PCS‐Ado is valid and reliable with francophone adolescents. Further research is required to assess the validity of the PCS‐Ado in clinical settings.
Bacterial Skin and Soft Tissue Infections in Adults: A Review of Their Epidemiology, Pathogenesis, Diagnosis, Treatment and Site Of Care
Authors: Ki Vincent , Rotstein Coleman
Published: March 2016

Skin and soft tissue infections (SSTIs) involve microbial invasion of the skin and underlying soft tissues. They have variable presentations, etiologies and severities. The challenge of SSTIs is to efficiently differentiate those cases that require immediate attention and intervention, whether medical or surgical, from those that are less severe. Approximately 7% to 10% of hospitalized patients are affected by SSTIs, and they are very common in the emergency care setting. The skin has an extremely diverse ecology of organisms that may produce infection. The clinical manifestations of SSTIs are the culmination of a two‐step process involving invasion and the interaction of bacteria with host defences. The cardinal signs of SSTIs involve the features of inflammatory response, with other manifestations such as fever, rapid progression of lesions and bullae. The diagnosis of SSTIs is difficult because they may commonly masquerade as other clinical syndromes. To improve the management of SSTIs, the development of a severity stratification approach to determine site of care and appropriate empirical treatment is advantageous. The selection of antimicrobial therapy is predicated on knowledge of the potential pathogens, the instrument of entry, disease severity and clinical complications. For uncomplicated mild to moderate infections, the oral route suffices, whereas for complicated severe infections, intravenous administration of antibiotics is warranted. Recognition of the potential for resistant pathogens causing SSTIs can assist in guiding appropriate selection of antibiotic therapy.
Genotypic Investigation of Clostridium difficile in Prince Edward Island
Authors: Martin H , Abbott LP , Low DE , Willey B , Mulvey M , Weese J Scott
Published: March 2016

Clostridium difficile is an important cause of disease in Canada; however, little information is available about the disease in the Maritime provinces. The objective of the present study was to characterize C difficile isolates obtained from people hospitalized with C difficile infection in Prince Edward Island. One hundred twenty‐six C difficile ELISA toxin‐positive stool samples were obtained and cultured using an enrichment protocol. C difficile was isolated from 105 of 126 (83%) samples. Twenty‐two different ribotypes were identified. The most common ribotype, ribotype W, was a North American pulsotype 2 (NAP2), toxinotype 0 strain, which represented 18% of isolates. The next most common ribotype was a NAP1, toxinotype III strain, which accounted for 11% of isolates. Ribotype 027/NAP1 only accounted for five (4.7%) isolates. Forty‐five per cent of isolates possessed genes encoding production of binary toxin. Three different ribotypes, all NAP1, toxinotype III strains, had a frameshift mutation in the tcdC gene (Δ117), while one isolate (ribotype 078, NAP4, toxinotype V) had a truncating mutation (C184T) in the tcdC gene.
Pediatric Infective Endocarditis: Has Staphylococcus aureus Overtaken Viridans Group Streptococci as the Predominant Etiological Agent?
Authors: Alshammary Aisha , Hervas-Malo Marilou , Robinson Joan L
Published: March 2016

BACKGROUND: Viridans group streptococci (VGS) have traditionally been the most common etiological agents of infective endocarditis (IE). Advances in cardiovascular surgery and the increasing use of long‐term central venous catheters may have altered the epidemiology of pediatric IE.

METHODS: A chart review of children younger than 17 years of age with IE was completed at the Stollery Children’s Hospital (Edmonton, Alberta) between 1985 and 2004. The literature was reviewed to look for changes over time in the most common etiological agents of pediatric IE.

RESULTS: There were 31 cases of definite IE and nine cases of possible IE at the Stollery Children’s Hospital, 19 of which were nosocomial. Thirty cases (75%) had congenital heart disease. The etiological agents were Staphylocccus aureus (n=16), VGS (n=5), coagulase‐negative staphylococci (n=3), enterococcus (n=3), other streptococci (n=8), Enterobacter cloacae (n=1) and Stenotrophomonas maltophilia (n=1), while three cases were culture negative. Two deaths were due to S aureus IE. Review of the literature identified an increasing number of case series in which S aureus was the predominant etiological agent, but VGS still predominated in some recent series.

CONCLUSION: Congenital heart disease remains the primary risk factor for pediatric IE. Prospective population‐based studies are required to determine whether S aureus has become the predominant pathogen.
Use of Allopurinol with Low-Dose 6-Mercaptopurine in Inflammatory Bowel Disease to Achieve Optimal Active Metabolite Levels: A Review of Four Cases and the Literature
Authors: Witte Todd N , Ginsberg Allen L
Published: March 2016

BACKGROUND: At least one-third of patients with inflammatory bowel disease do not respond or are intolerant to therapy with 6-mercaptopurine (6-MP). A subgroup fails to attain optimal levels of 6-thioguanine nucleotide (6-TGN) and instead shunts to 6-methylmercaptopurine nucleotide (6-MMPN).

PATIENTS AND METHODS: A retrospective chart review was conducted, and four patients are described who had been previously unable to achieve optimal 6-TGN metabolite levels until allopurinol was added to their treatment.

RESULTS: All four patients achieved optimal 6-TGN levels and undetectable 6-MMPN with a mean 6-MP dose of 0.49 mg/kg. Three achieved steroid-free clinical remission. Two of those three patients had normalization of liver enzymes; one patient had baseline normal liver enzymes despite an initial 6-MMPN level of 27,369 pmol/8×108red blood cells. Two patients experienced reversible leukopenia.

CONCLUSIONS: Combination allopurinol and low-dose 6-MP is an effective means to achieve optimal metabolite levels and steroid-free clinical remission in previously refractory patients. Caution is advised.
Latent Lymphocytic Enterocolitis Associated with Celiac Disease Manifesting after Resection for Colon Cancer: Case Report and Review of the Literature
Authors: Tangri Vikram , Driman David K , Chande Nilesh
Published: March 2016

Lymphocytic colitis, a cause of chronic watery diarrhea, is histologically characterized by increased intraepithelial lymphocytosis. Studies have associated this disorder with celiac disease, although there are no reports of patients with both lymphocytic colitis and colon cancer. The present case report describes a patient with lymphocytic colitis, which manifested five years after he presented with a cecal adenocarcinoma, and three years following a diagnosis of celiac disease. Pathological review of his initial resection specimen demonstrated lymphocytic enterocolitis, indicating a five-year latency in the presentation of this disease.
Once‐Daily, Controlled‐Release Tramadol and Sustained‐Release Diclofenac Relieve Chronic Pain due to Osteoarthritis: A Randomized Controlled Trial
Authors: Beaulieu André D , Peloso Paul M , Haraoui Boulos , Bensen William , Thomson Glen , Wade John , Quigley Patricia , Eisenhoffer John , Harsanyi Zoltan , Darke Andrew C
Published: March 2016

OBJECTIVE: The present study was a randomized, parallel, double‐blind comparison between controlled‐release (CR) tramadol and sustained‐release (SR) diclofenac in patients with chronic pain due to osteoarthritis of the hips and/or knees.

METHODS: Patients with at least moderate pain intensity, and having received analgesics over the past three months, underwent a two‐to seven‐day washout of current analgesics before initiation of 200 mg CR tramadol or 75 mg SR diclofenac. During the eight‐week study, patients returned to the clinic biweekly. CR tramadol doses were titrated to a maximum of 200 mg, 300 mg or 400 mg per day. SR diclofenac doses were titrated to 75 mg or 100 mg once daily, or 75 mg twice a day based on pain relief and the presence of side effects. For rescue analgesic, patients took acetaminophen as needed, up to 650 mg three times a day.

RESULTS: Forty‐five patients on CR tramadol and 52 patients on SR diclofenac were evaluable. Significant improvements from prestudy treatment were shown for visual analogue scale pain (P=0.0001), stiffness (P<0.0005) and physical function (P=0.0001) scores for both treatments. There were no significant differences between the two treatments in the Western Ontario and McMaster Universities subscales, overall pain, pain and sleep, or the clinical effectiveness evaluation. Overall incidence of adverse events was similar in both groups, with more opioid‐related adverse events with CR tramadol, and two serious adverse events occurring with the use of SR diclofenac.

CONCLUSIONS: CR tramadol is as effective as SR diclofenac in the treatment of pain due to knee or hip osteoarthritis, with the potential for fewer of the serious side effects that characterize nonsteroidal anti‐inflammatory drug administration.
Pearls and Pitfalls in the Diagnosis of Adult Celiac Disease
Authors: Freeman Hugh J
Published: March 2016

In adults with diarrhea or suspected malabsorption, a diagnosis of celiac disease requires that two criteria be fulfilled: first, a demonstration of typical pathological changes of untreated disease in biopsies from the proximal small bowel; and second, evidence should exist that clinical (and/or pathological) changes are gluten-dependent, most often as an unequivocal response to a gluten-free diet. Pathological abnormalities of celiac disease may include severe (‘flat’) or variably severe (mild or moderate) small bowel mucosal architectural abnormalities that are associated with both epithelial cell and lymphoid cell changes, including intraepithelial lymphocytosis. Architectural changes tend to be most severe in the duodenum and proximal jejunum and less severe, or absent, in the ileum. These findings, while characteristic of celiac disease, are not specific because several other conditions can produce similar changes. Some serological assays (eg, tissue transglutaminase antibody assays) are very useful screening tools in clinical practice because of their high specificity and sensitivity, but these do not provide a definitive diagnosis. The most critical step in the diagnosis of celiac disease is the demonstration of its gluten-dependent nature. The clinical response to gluten restriction in celiac disease is usually reflected in the resolution of diarrhea and weight gain. Normalization of biopsy changes can be first shown in the most distal intestinal sites of involvement, and later, sometimes only after prolonged periods (months to years) in the duodenum. Rarely, recurrent (or refractory) celiac disease may occur after an initial gluten-free diet response. Finally, some with ‘sprue-like intestinal disease’ cannot be classified because a diet response fails to occur. This may be a heterogeneous group, although some are eventually found to have a malignant lymphoma.
Clinical Manifestations of Hemochromatosis inHFEC282Y Homozygotes Identified by Screening
Authors: McLaren Gordon D , McLaren Christine E , Adams Paul C , Barton James C , Reboussin David M , Gordeuk Victor R , Acton Ronald T , Harris Emily L , Speechley Mark R , Sholinsky Phyliss , Dawkins Fitzroy W , Snively Beverly M , Vogt Thomas M , Eckfeldt John H ,   for the Hemochromatosis and Iron Overload Screening (HEIRS) Study Research Investigators
Published: March 2016

BACKGROUND: Patients with hemochromatosis may suffer organ damage from iron overload, often with serious clinical consequences.

OBJECTIVE: To assess prevalences of self-reported symptoms and clinical signs and conditions in persons homozygous for the hemochromatosis gene (HFE)mutation (C282Y) identified by screening.

METHODS: Participants were adults 25 years of age or older enrolled in the Hemochromatosis and Iron Overload Screening (HEIRS) Study. C282Y homozygotes (n=282) were compared with control participants without theHFEC282Y or H63D alleles (ie, wild type/wild type; n=364).

RESULTS: Previously diagnosed C282Y homozygotes and newly diagnosed homozygotes with elevated serum ferritin levels had higher prevalences of certain symptoms such as chronic fatigue (OR 2.8; 95% CI 1.34 to 5.95, and OR 2.0; 95% CI 1.07 to 3.75, respectively), and had more hyperpigmentation on physical examination (OR 4.7; 95% CI 1.50 to 15.06, and OR 3.7; 95% CI 1.10 to 12.16, respectively) and swelling or tenderness of the second and third metacarpophalangeal joints (OR 4.2; 95% CI 1.37 to 13.03, and OR 3.3; 95% CI 1.17 to 9.49, respectively) than control subjects. Joint stiffness was also more common among newly diagnosed C282Y homozygotes with elevated serum ferritin than among control subjects (OR 2.7; 95% CI 1.38 to 5.30). However, the sex- and age-adjusted prevalences of self-reported symptoms and signs of liver disease, heart disease, diabetes and most other major clinical manifestations of hemochromatosis were similar in C282Y homozygotes and control subjects.

CONCLUSIONS: Some symptoms and conditions associated with hemochromatosis were more prevalent among C282Y homozygotes identified by screening than among control subjects, but prevalences of most outcomes were similar in C282Y homozygotes and controls in this primary care-based study.
Dicrocoelium DendriticumInfection in a Patient with Crohn’s Disease
Authors: Schweiger Franzjosef , Kuhn Magdalena
Published: March 2016

Infection withDicrocoelium dendriticumin humans is rarely reported in the medical literature. This liver fluke, which commonly infects ruminants, has a complex life cycle with two intermediate hosts – the land snail and the ant. True human infection occurs by ingestion of the second intermediate host, but spurious infections have occurred after consumption of undercooked animal liver. The present report describes a patient with active Crohn’s disease whose stool containedD dendriticumeggs. A brief discussion of the medical literature is presented.
Ulcerative Colitis and Sweet’s Syndrome: A Case Report and Review of the Literature
Authors: Ali Massud , Duerksen Donald R
Published: March 2016

A 47-year-old man with a history of ulcerative colitis on prednisone and azathioprine was admitted to the hospital with a four-day history of fever, skin rash, arthralgias and leukocytosis. A skin biopsy demonstrated neutrophilic infiltration of the dermis that was consistent with Sweet’s syndrome. He improved after several days with an increase in his prednisone and azathioprine. Sweet’s syndrome is a rare cutaneous manifestation of inflammatory bowel disease, with approximately 40 cases reported in the literature. In a previously reported case of a patient with ulcerative colitis-associated Sweet’s syndrome who was on azathioprine at the time of the skin eruption, the azathioprine was stopped, raising the possibility of drug-induced Sweet’s syndrome. In the present case, the azathioprine was actually increased with complete resolution of the skin manifestations. This would support the theory that immunosuppressive therapy is the mainstay of therapy for this condition. In conclusion, Sweet’s syndrome is a neutrophilic dermatosis that is rarely associated with ulcerative colitis. It may occur while on immunosuppressive therapy and responds to an intensification of immunosuppression.
Human Granulocytic Anaplasmosis: First Reported Case in Canada
Authors: Parkins Michael D , Church Deirdre L , Jiang Xiu Yan , Gregson Daniel B
Published: March 2016

Human granulocytic anaplasmosis (HGA) is a tick‐borne rickettsial infection of peripheral blood neutrophils caused by Anaplasma phagocytophilum. While this infection is increasingly recognized as endemic throughout much of the United States, no Canadian cases have been previously described, despite the agent being identified in Canadian ticks. Herein we present a case of HGA acquired in an urban Alberta centre. Canadian physicians must be aware of the possibility of tick‐borne rickettsial diseases as etiology of fever in individuals presenting with leukopenia/lymphopenia, thrombocytopenia and elevated transaminases during periods of tick activity. Prompt recognition and treatment are important in minimizing resultant morbidity and mortality.
Does Classification of Persons with Fibromyalgia into Multidimensional Pain Inventory Subgroups Detect Differences in Outcome after a Standard Chronic Pain Management Program?
Authors: Verra Martin L , Angst Felix , Brioschi Roberto , Lehmann Susanne , Keefe Francis J , Staal J Bart , de Bie Rob A , Aeschlimann André
Published: March 2016

INTRODUCTION: The present study aimed to replicate and validate the empirically derived subgroup classification based on the Multidimensional Pain Inventory (MPI) in a sample of highly disabled fibromyalgia (FM) patients. Second, it examined how the identified subgroups differed in their response to an intensive, interdisciplinary inpatient pain management program.

METHODS: Participants were 118 persons with FM who experienced persistent pain and were disabled. Subgroup classification was conducted by cluster analysis using MPI subscale scores at entry to the program. At program entry and discharge, participants completed the MPI, Medical Outcomes Study Short Form‐36, Hospital Anxiety and Depression Scale and Coping Strategies Questionnaire.

RESULTS: Cluster analysis identified three subgroups in the highly disabled sample that were similar to those described by other studies using less disabled samples of FM. The dysfunctional subgroup (DYS; 36% of the sample) showed the highest level of depression, the interpersonally distressed subgroup (ID; 24%) showed a modest level of depression and the adaptive copers subgroup (AC; 38%) showed the lowest depression scores in the MPI (negative mood), Medical Outcomes Study Short Form‐36 (mental health), Hospital Anxiety and Depression Scale (depression) and Coping Strategies Questionnaire (catastrophizing). Significant differences in treatment outcome were observed among the three subgroups in terms of reduction of pain severity (as assessed using the MPI). The effect sizes were 1.42 for DYS, 1.32 for AC and 0.62 for ID (P=0.004 for pairwise comparison of ID‐AC and P=0.018 for ID‐DYS).

DISCUSSION: These findings underscore the importance of assessing individuals’ differences in how they adjust to FM.
Survival in Cystic Neoplasms of the Pancreas
Authors: Cadili Ali , Bazzerelli Amy , Garg Sipi , Bailey Robert
Published: March 2016

BACKGROUND: The natural history of pancreatic cystic neoplasms remains poorly understood despite growing evidence on the subject. Pancreatic cysts display a wide spectrum of pathological phenotypes, each associated with a different prognostic implication. Many pancreatic cysts are of undetermined malignant potential at presentation and remain so until surgically resected. While the survival rates of patients with malignant cysts are known to be poor, survival rates in patients with undetermined pancreatic cysts are unknown.

OBJECTIVE: To identify the factors associated with survival in a group of patients diagnosed with a pancreatic cyst(s).

METHODS: The present study was a retrospective multicentre review of pancreatic cystic neoplasms. All patients with a diagnosis of a neoplastic pancreatic cyst from 1994 to 2003 were identified at five different institutions in Edmonton, Alberta. The data collected included patient age, sex, imaging modality, cyst location, cyst size, number of cysts, comorbid illnesses, history of upper abdominal surgery, previous cancer, previous or concurrent metastases, symptoms (pain, upper gastrointestinal bleeding, signs of biliary obstruction, nausea/vomiting), remarkable radiological features, elevated amylase or lipase, type of pancreatic surgery, final pathology (benign or malignant) and overall survival. Survival models were used to assess whether any covariates were predictors of the survival time. Patient data were plotted using the Kaplan-Meier method. The resulting plot was used to calculate survival in the cohort.

RESULTS: In total, 64 patients were identified as having neoplastic pancreatic cysts from 1994 to 2003 at the five institutions. The median overall patient survival time was 86 months. The median age at diagnosis for the patient population was 73 years, with 40 patients being women. Univariate analysis revealed that the risk of death was associated with patient age, sex and history of major comorbid illness. Multivariate models identified increased patient age and male sex as the factors that correlated most strongly with decreased overall survival.

CONCLUSION: Overall survival in patients with neoplastic pancreatic cysts is determined by patient factors (ie, age and sex) rather than factors descriptive of the cyst such as size and morphology. No conclusions could be made regarding the relationship between cyst pathology and patient survival.
Pandemic Influenza is a Strong Motivator for Participation in Vaccine Clinical Trials among HIV‐Positive Canadian Adults
Authors: Kiberd MB , Cooper C , Slaunwhite JM , Halperin B , Haase D , McNeil SA
Published: March 2016

BACKGROUND: HIV‐positive patients represent an immunosuppressed population at risk for severe influenza. In the event of a pandemic, such as 2009 H1N1, rapid implementation of vaccine clinical trials in target populations will be critical. In the present paper, knowledge and attitudes of HIV‐positive adults regarding seasonal/pandemic influenza vaccination were evaluated, and facilitators and barriers to participation in vaccine clinical trials were explored.

METHODS: A validated, 70‐item, self‐administered questionnaire was distributed to all HIV patients presenting for routine follow‐up at eight Canadian Institutes of Health Research Canadian HIV Trials Network (CTN) sites from October 2008 to February 2009, as well as all participants in CTN trial 237. This study has representation from all Canadian provinces.

RESULTS: In total, 610 HIV‐positive adults responded (298 CTN 237 participants; 312 non‐CTN 237 participants). Most reported receiving influenza vaccine last season (83% of CTN 237 participants versus 83% non‐CTN 237 participants; P not significant) and most would receive a pandemic influenza vaccine if offered (76% versus 73%; P not significant). A majority believed that it was important to include HIV patients in vaccine clinical trials (65% versus 53%; P<0.001) and would agree to participate in trials of a pandemic vaccine if invited (86% versus 51%; P≤0.0001). Predictors of willingness to participate in a pandemic vaccine trial were ‘desire to be protected from pandemic flu’, OR 4.5 (95% CI 2 to 8) and ‘desire to help others’, OR 2.3 (95% CI 1.3 to 4.5). ‘Fear of needles’, OR 0.49 (95% CI 0.1 to 1.5) and ‘need for extra blood tests’, OR 0.49 (95% CI 0.2 to 1.4) were key barriers to participation.

CONCLUSION: Most HIV‐positive Canadian adults surveyed receive influenza vaccination. Protection from pandemic influenza is considered important and is a motivator for receiving influenza vaccine and future trial participation. Modifiable barriers to these objectives identified in the present study should be the focus of efforts to increase influenza immunization in this population.
Incidence of Duodenal Ulcers and Gastric Ulcers in a Western Population: Back to Where It Started
Authors: Groenen Marcel JM , Kuipers Ernst J , Hansen Bettina E , Ouwendijk Rob J Th
Published: March 2016

BACKGROUND/OBJECTIVES: As recently as 40 years ago, a decline in the incidence of peptic ulcers was observed. The discovery of Helicobacter pylori had a further major impact on the incidence of ulcer disease. Our aim was to evaluate the trends in the incidence and bleeding complications of ulcer disease in the Netherlands.

METHODS: From a computerized endoscopy database of a district hospital, the data of all patients who underwent upper gastrointestinal endoscopy from 1996 to 2005 were analyzed. The incidence of duodenal and gastric ulcers, with and without complications, were compared over time.

RESULTS: Overall, 20,006 upper gastrointestinal endoscopies were performed. Duodenal ulcers were diagnosed in 696 (3.5%) cases, with signs of bleeding in 158 (22.7%). Forty-five (6.5%) of these ulcers were classified as Forrest I and 113 (16.2%) as Forrest II. Gastric ulcers were diagnosed in 487 cases (2.4%), with signs of bleeding in 60 (12.3%). A Forrest 1 designation was diagnosed in 19 patients (3.9%) and Forrest 2 in 41 patients (8.4%). The incidence of gastric ulcers was stable over time, while the incidence of duodenal ulcers declined.

CONCLUSIONS: The incidence of duodenal ulcer disease in the Dutch population is steadily decreasing over time. Test and treatment regimens for H pylori have possibly contributed to this decline. With a further decline in the prevalence of H pylori, the incidence of gastric ulcers is likely to exceed the incidence of duodenal ulcers in the very near future, revisiting a similar situation that was present at the beginning of the previous century.
Canadian Association of Gastroenterology Clinical Practice Guidelines: The Use of Tumour Necrosis Factor-Alpha Antagonist Therapy in Crohn’s Disease
Authors: Sadowski Daniel C , Bernstein Charles N , Bitton Alain , Croitoru Ken , Fedorak Richard N , Griffiths Anne , the CAG Crohn’s Consensus Group
Published: March 2016

BACKGROUND: Guidelines regarding the use of infliximab in Crohn’s disease were previously published by the Canadian Association of Gastroenterology in 2004. However, recent clinical findings and drug developments warrant a review and update of these guidelines.

OBJECTIVE: To review and update Canadian guidelines regarding the use of tumour necrosis factor-alpha antibody therapy in both luminal and fistulizing Crohn’s disease.

METHODS: A consensus group of 25 voting participants developed a series of recommendation statements that addressed pertinent clinical questions and gaps in existing knowledge. An iterative voting and feedback process was used in advance of the consensus meeting in conjunction with a systematic literature review to refine the voting statements. These statements were brought to a formal consensus meeting held in Montreal, Quebec (March 2008), wherein each statement underwent discussion, reformulation, voting and subsequent revision until group consensus was obtained (at least 80% agreement).

OUTCOME: The 47 voting statements addressed three themes: induction therapy, maintenance therapy and safety issues. As a result of the iterative process, 23 statements achieved consensus and were submitted for publication.

CONCLUSION: In the past five years, tumour necrosis factor-alpha antagonist therapy has become a cornerstone in the management of moderate-to-severe Crohn’s disease refractory to conventional treatment algorithms. The evidentiary base supporting the use of these drugs in Crohn’s disease is substantial and strengthened by results from long-term clinical and molecular studies. However, significant gaps in knowledge exist, particularly with regard to treatment failure. Confidence in the safety of these drugs is increasing, provided that therapy is administered in a clinical setting in which potential complications can be readily recognized and treated.
Prevalence and Correlates of Pain in the Canadian National Palliative Care Survey
Authors: Wilson Keith G , Chochinov Harvey Max , Allard Pierre , Chary Srini , Gagnon Pierre R , Macmillan Karen , De Luca Marina , O’Shea Fiona , Kuhl David , Fainsinger Robin L
Published: March 2016

BACKGROUND: Pain is a common problem for people with cancer who are nearing the ends of their lives.

OBJECTIVE: In the present multicentre Canadian study of palliative cancer care, the prevalence of pain, its perceived severity and its correlates across a range of physical, social, psychological, and existential symptoms and concerns were examined.

METHODS: Semistructured interviews were conducted with 381 patients. In addition to inquiring about pain, the interview also assessed 21 other symptoms and concerns, and collected information about demographic characteristics, functional status and medication use.

RESULTS: Pain of any intensity was reported by 268 (70.3%) participants, although for 139 (36.5%), the severity was rated as minimal or mild. For 129 (33.9%) individuals, pain was reported as moderate to extreme, and considered by the respondents to be an important ongoing problem. Patients who reported moderate to extreme pain were younger than other participants, but had lower functional status and a shorter median survival duration. They were more likely than other participants to be treated with opioid medications (P<0.001) and, less reliably, with benzodiazepines (P=0.079). Compared with participants with no, minimal or mild pain, those with moderate to extreme pain had a higher prevalence of distressing problems on 11 of 21 other symptoms and concerns. The strongest correlations were with general malaise (rho = 0.44), suffering (rho = 0.40), nausea (rho = 0.34), weakness (rho = 0.31), drowsiness (rho = 0.29) and anxiety (rho = 0.29).

CONCLUSIONS: Pain continues to be a difficult problem for many patients who are receiving palliative cancer care, particularly younger individuals who are nearing death.
The Impact of Misdiagnosing Celiac Disease at a Referral Centre
Authors: Biagi Federico , Bianchi Paola I , Campanella Jonia , Zanellati Giovanni , Corazza Gino R
Published: March 2016

In the past few years, the number of celiac disease diagnoses not confirmed at the Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, a tertiary referral centre, was particularly high. Therefore, a decision was made to investigate the reasons why these diagnoses were wrong and by whom they had been made. The clinical histories of all celiac patients referred to the centre were re-evaluated. Between December 1998 and January 2007, 614 patients who were diagnosed at other institutions and presumed to be affected by celiac disease attended the tertiary referral outpatient clinic. The histological and serological results allowed for confirmation the diagnosis in 434 patients. In the remaining 180 patients, the initial diagnosis of celiac disease could not be confirmed; therefore, the patients were re-investigated. After re-evaluation, the diagnosis of celiac disease was confirmed in only 61 of these 180 cases. The reasons for incorrect initial diagnosis were analyzed. A mere 80% correct diagnosis rate is a very disappointing result. Although it should be obvious that celiac disease must be investigated with duodenal biopsies and celiac antibody testing, this well-known strategy is not always followed, probably resulting in an incorrect diagnosis.
A Double‐Blind, Randomized, Controlled Trial of Topical Polysporin Triple Compound Versus Topical Mupirocin for the Eradication of Colonization with Methicillin‐Resistant Staphylococcus aureus in a Complex Continuing Care Population
Authors: O’Grady S , Hirji Z , Pejcic-Karapetrovic B , Fung S , Dedier H , Takata-Shewchuk J , Zhang K , Conly J
Published: March 2016

BACKGROUND: Intranasal mupirocin or Polysporin Triple (PT) ointment (polymyxin B, bacitracin, gramicidin), in combination with chlorhexidine body washes, have been used for eradicating methicillin‐resistant Staphylococcus aureus (MRSA), but no comparative studies have been done.

METHODS: A double‐blind, randomized, controlled clinical trial to compare the efficacy of mupirocin versus PT ointment in combination with chlorhexidine body washes in eradicating MRSA carriage was conducted. Asymptomatic MRSA carriers, medically stable and at least 18 years of age who were patients on medical wards, received twice daily application of either mupirocin or PT ointment to the anterior nares plus once daily 2% chlorhexidine body washes for seven days. Follow‐up swabs from multiple sites using broth enrichment were conducted at 48 h, and one, two, four, eight and 12 weeks.

RESULTS: Of 103 patients eligible for analysis (54 mupirocin; 49 PT), no significant differences between the two groups with respect to baseline demographics, risk factors for MRSA or MRSA colonization sites were noted. At 48 h, 35 of 54 (65%) patients in the mupirocin group versus 15 of 49 (31%) in the PT group (P=0.001) were found to be MRSA negative at all sites. Significant differences were observed at one and two weeks but were not maintained at other intervals. In those with complete microbiological follow‐up, MRSA eradication at all sites occurred in 12 of 39 (30.8%) mupirocin‐ and one of 36 (2.8%) PT‐treated patients (P=0.001).

CONCLUSION: Both agents demonstrated poor efficacy and PT was significantly less efficacious than mupirocin at 12 weeks in eradicating MRSA from all sites.
Amiodarone Pulmonary Toxicity
Authors: Wolkove Norman , Baltzan Marc
Published: March 2016

Amiodarone is an antiarrhythmic agent commonly used to treat supraventricular and ventricular arrhythmias. This drug is an iodine‐containing compound that tends to accumulate in several organs, including the lungs. It has been associated with a variety of adverse events. Of these events, the most serious is amiodarone pulmonary toxicity. Although the incidence of this complication has decreased with the use of lower doses of amiodarone, it can occur with any dose. Because amiodarone is widely used, all clinicians should be vigilant of this possibility. Pulmonary toxicity usually manifests as an acute or subacute pneumonitis, typically with diffuse infiltrates on chest x‐ray and high‐resolution computed tomography. Other, more localized, forms of pulmonary toxicity may occur, including pleural disease, migratory infiltrates, and single or multiple nodules. With early detection, the prognosis is good. Most patients diagnosed promptly respond well to the withdrawal of amiodarone and the administration of corticosteroids, which are usually given for four to 12 months. It is important that physicians be familiar with amiodarone treatment guidelines and follow published recommendations for the monitoring of pulmonary as well as extrapulmonary adverse effects.
A Survey of Prelicensure Pain Curricula in Health Science Faculties in Canadian Universities
Authors: Watt-Watson Judy , McGillion M , Hunter J , Choiniere M , Clark AJ , Dewar A , Johnston C , Lynch M , Morley-Forster P , Moulin D , Thie N , von Baeyer CL , Webber K
Published: March 2016

OBJECTIVE: The present exploratory, descriptive study aimed to determine the designated time for mandatory pain content in curricula of major Canadian universities for students in health science and veterinary programs before being licensed.

METHOD: Major Canadian university sites (n=10) were chosen where health science faculties included at least medicine (n=10) and nursing (n=10); many also included dentistry (n=8), pharmacy (n=7), physical therapy (n=8) and/or occupational therapy (n=6). These disciplines provide the largest number of students entering the workforce but are not the only ones contributing to the health professional team. Veterinary programs (n=4) were also surveyed as a comparison. The Pain Education Survey, developed from previous research and piloted, was used to determine total mandatory pain hours.

RESULTS: The majority of health science programs (67.5%) were unable to specify designated hours for pain. Only 32.5% respondents could identify specific hours allotted for pain course content and/or additional clinical conferences. The average total time per discipline across all years varied from 13 h to 41 h (range 0 h to 109 h). All veterinary respondents identified mandatory designated pain content time (mean 87 h, range 27 h to 200 h). The proportion allotted to the eight content categories varied, but time was least for pain misbeliefs, assessment and monitoring/follow‐up planning.

CONCLUSIONS: Only one‐third of the present sample could identify time designated for teaching mandatory pain content. Two‐thirds reported ‘integrated’ content that was not quantifiable or able to be determined, which may suggest it is not a priority at that site. Many expressed a need for pain‐related curriculum resources.