bluuebunny/crossref_metadata_2025 huggingface dataset:
Pan-Canadian Respiratory Standards Initiative for Electronic Health Records (PRESTINE): 2011 National Forum Proceedings
Authors: Lougheed M Diane , Minard Janice , Dworkin Shari , Juurlink Mary-Ann , Temple Walley J , To Teresa , Koehn Marc , Van Dam Anne , Boulet Louis-Philippe
Published: March 2016

In a novel knowledge translation initiative, the Government of Ontario’s Asthma Plan of Action funded the development of an Asthma Care Map to enable adherence with the Canadian Asthma Consensus Guidelines developed under the auspices of the Canadian Thoracic Society (CTS). Following its successful evaluation within the Primary Care Asthma Pilot Project, respiratory clinicians from the Asthma Research Unit, Queen’s University (Kingston, Ontario) are leading an initiative to incorporate standardized Asthma Care Map data elements into electronic health records in primary care in Ontario. Acknowledging that the issue of data standards affects all respiratory conditions, and all provinces and territories, the Government of Ontario approached the CTS Respiratory Guidelines Committee. At its meeting in September 2010, the CTS Respiratory Guidelines Committee agreed that developing and standardizing respiratory data elements for electronic health records are strategically important. In follow-up to that commitment, representatives from the CTS, the Lung Association, the Government of Ontario, the National Lung Health Framework and Canada Health Infoway came together to form a planning committee. The planning committee proposed a phased approach to inform stakeholders about the issue, and engage them in the development, implementation and evaluation of a standardized dataset. An environmental scan was completed in July 2011, which identified data definitions and standards currently available for clinical variables that are likely to be included in electronic medical records in primary care for diagnosis, management and patient education related to asthma and COPD. The scan, sponsored by the Government of Ontario, includes compliance with clinical nomenclatures such as SNOMED-CT®and LOINC®. To help launch and create momentum for this initiative, a national forum was convened on October 2 and 3, 2011, in Toronto, Ontario. The forum was designed to bring together key stakeholders across the spectrum of respiratory care, including clinicians, researchers, health informaticists and administrators to explore and recommend a potential scope, approach and governance structure for this important project. The Pan-Canadian REspiratory STandards INitiative for Electronic Health Records (PRESTINE) goal is to recommend respiratory data elements and standards for use in electronic medical records across Canada that meet the needs of providers, administrators, researchers and policy makers to facilitate evidence-based clinical care, monitoring, surveillance, benchmarking and policy development. The focus initially is expected to include asthma, chronic obstructive pulmonary disease and pulmonary function standards elements that are applicable to many respiratory conditions. The present article summarizes the process and findings of the forum deliberations.
The Epidemiology of Chronic Pain in Canadian Men and Women between 1994 and 2007: Results from the Longitudinal Component of the National Population Health Survey
Authors: Reitsma Michelle L , Tranmer Joan E , Buchanan Diane M , VanDenKerkhof Elizabeth G
Published: March 2016

BACKGROUND: The epidemiology of chronic pain is poorly understood due to a paucity of longitudinal studies limiting the ability to develop prevention strategies for a condition resistant to many current therapies.

OBJECTIVES: To identify the incidence of and sociodemographic risk factors for chronic pain in Canadian women and men over a 12‐year period.

METHODS: Using data from the National Population Health Survey, individuals who developed chronic pain, defined as the presence of “usual pain” were identified. The cumulative incidence of chronic pain was calculated separately for men and women followed from 1994 to 2007. Biannual incidence and prevalence estimates of chronic pain were calculated during the same time period. Logistic regression analysis was used to examine predictors of chronic pain in men and women.

RESULTS: The cumulative incidence over the 12‐year period was 35.6% (women 39.0%; men 32.2%). Women had a higher biannual prevalence, but not incidence, of chronic pain compared with men. In women, being older, having lower education and being widowed, separated or divorced, increased the risk of chronic pain. There were no sociodemographic risk factors for chronic pain in men.

CONCLUSION: Women had a higher prevalence – but not incidence – of chronic pain compared with men, indicative of longer duration of illness in women. Risk factors also differed according to sex, supporting current literature reporting potentially different mechanisms for men and women. A better understanding of risk factors is necessary to develop population‐based preventive interventions. The former can only be achieved with population‐based, longitudinal studies.
The Use of Antiviral Drugs for Influenza: Guidance for Practitioners 2012/2013
Authors: Aoki Fred Y , Allen Upton D , Stiver H Grant , Evans Gerald A
Published: March 2016

The present article addresses the use of antiviral drugs in the management of seasonal influenza illness for the 2012/2013 season. It updates the previous document published in 2011 (1). Noteworthy guidance updates since 2011 include the following:

Seasonal influenza in 2012/2013 is predicted to be caused by two human influenza A and one influenza B strain, all of which are anticipated to remain generally susceptible to oseltamivir.

The predicted strains are A/California/7/2009 (H1N1) pdm09‐like, A/Victoria/361/2011 (H3N2)‐like and B/Wisconsin/1/2010‐like (Yamagata lineage). All are included in the seasonal influenza vaccine and are susceptible to oseltamivir.

Swine‐variant H3N2v, which has rarely caused infection in humans exposed to infected swine within the past year in the United States, is susceptible to oseltamivir. It is not included in the current seasonal influenza vaccine.

It is still considered that initiation of antiviral therapy more than 36 h to 48 h after onset of symptoms is beneficial in patients hospitalized with complicated influenza and severe illness.

Oseltamivir continues to be recommended for the treatment of influenza in pregnant women.

The use of antiviral drugs among measures to control outbreaks of influenza in closed facilities such as correctional institutions is now included in the present document.
Ileocolic Mucormycosis – an Unusual Cause of a Mass in the Right Iliac Fossa
Authors: Chethan Kishanchand , Prasad Seetharam , Ramachandra Lingadakai
Published: March 2016

Mucormycosis is a relatively uncommon, aggressive and lethal mycosis. Fungi from the order Mucorales are the etiological agents of mucormycosis. The condition is more common among the immunocompromised, diabetic patients with ketoacidosis and people with iron overload syndromes. Diagnosis of mucormycosis requires a high index of suspicion regarding the possibility of the condition in high‐risk individuals. Timely diagnosis is critical to survival and minimization of morbidity. A favourable outcome is possible only if appropriate treatment is initiated as early as possible. The present article reports a case of ileocolic mucormycosis involving a patient with chronic renal failure and familial hyperuricemia.
Unusual Respiratory Manifestations in Two Young Adults with Duchenne Muscular Dystrophy
Authors: Lemay Julie , Sériès Frédéric , Sénéchal Mario , Maranda Bruno , Maltais François
Published: March 2016

Adult respirologists are often involved in the evaluation and treatment of young adult patients with Duchenne muscular dystrophy. In this context, the most frequent respiratory complication is nocturnal and daytime hypoventilation related to respiratory muscle weakness. The present article describes cases of Duchenne muscular dystrophy involving two brothers, 17 and 19 years of age, respectively, who presented with less frequently reported respiratory complications of their disease: obstructive sleep apnea and Cheyne‐Stokes respiration with central apnea, which were believed to be partially or completely related to congestive cardiomyopathy.
A Cohort Study for the Derivation and Validation of a Clinical Prediction Scale for Hospital-OnsetClostridium difficileInfection
Authors: Chandra Subhash , Latt Nyan , Jariwala Ujjval , Palabindala Venkataraman , Thapa Rameet , Alamelumangapuram Chidamber B , Noel Margarita , Marur Surendra , Jani Niraj
Published: March 2016

OBJECTIVE: To develop and validate a clinical prediction scale for hospital-onsetClostridium difficileinfection (CDI).

METHODS: A community-based, 360-bed hospital located in the suburbs of a metropolitan area in the United States served as the setting for the present retrospective cohort study. The cohort consisted of patients admitted to the adult medical service over a six-year period from October 2005 to September 2011. The cohort was divided into derivation (October 2005 to September 2009) and validation (October 2009 to September 2011) groups. The primary outcome measure was hospital-onset CDIs identified as stool positive forC difficileafter 48 h of hospital admission ordered for new-onset unformed stool by the treating physician.

RESULTS: In the derivation phase, 35,588 patients were admitted to the medical service and 21,541 stayed in hospital beyond 48 h. A total of 266 cases of CDI were identified, 121 of which were hospital onset. The developed clinical prediction scale included the onset of unformed stool (5 points), length of hospital stay beyond seven days (4 points), age >65 years (3 points), long-term care facility residence (2 points), high-risk antibiotic use (1 point) and hypoalbuminemia (1 point). The scale had an area under the receiver operating curve (AUC) of 0.93 (95% CI 0.82 to 0.94) in predicting hospital-onset CDI, with a sensitivity of 0.94 (95% CI 0.88 to 0.97) and a specificity of 0.80 (95% CI 0.79 to 0.80) at a cut-off score of 9 on the scale. During the validation phase, 16,477 patients were admitted, of whom 10,793 stayed beyond 48 h and 58 acquired CDI during hospitalization. The predictive performance of the score was maintained in the validation cohort (AUC 0.95 [95% CI 0.93 to 0.96]) and the goodness-to-fit model demonstrated good calibration.

CONCLUSION: The authors developed and validated a simple clinical prediction scale for hospital-onset CDI. This score can be used for periodical evaluation of hospitalized patients for early initiation of contact precautions and empirical treatment once it is validated externally in a prospective manner.
Alpha-1 Antitrypsin Deficiency Targeted Testing and Augmentation Therapy: A Canadian Thoracic Society Clinical Practice Guideline
Authors: Marciniuk DD , Hernandez P , Balter M , Bourbeau J , Chapman KR , Ford GT , Lauzon JL , Maltais F , O’Donnell DE , Goodridge D , Strange C , Cave AJ , Curren K , Muthuri S ,   Canadian Thoracic Society COPD Clinical Assembly Alpha-1 Antitrypsin Deficiency Expert Working Group
Published: March 2016

Alpha-1 antitrypsin (A1AT) functions primarily to inhibit neutrophil elastase, and deficiency predisposes individuals to the development of chronic obstructive pulmonary disease (COPD). Severe A1AT deficiency occurs in one in 5000 to one in 5500 of the North American population. While the exact prevalence of A1AT deficiency in patients with diagnosed COPD is not known, results from small studies provide estimates of 1% to 5%. The present document updates a previous Canadian Thoracic Society position statement from 2001, and was initiated because of lack of consensus and understanding of appropriate patients suitable for targeted testing for A1AT deficiency, and for the use of A1AT augmentation therapy. Using revised guideline development methodology, the present clinical practice guideline document systematically reviews the published literature and provides an evidence-based update. The evidence supports the practice that targeted testing for A1AT deficiency be considered in individuals with COPD diagnosed before 65 years of age or with a smoking history of <20 pack years. The evidence also supports consideration of A1AT augmentation therapy in nonsmoking or exsmoking patients with COPD (forced expiratory volume in 1 s of 25% to 80% predicted) attributable to emphysema and documented A1AT deficiency (level ≤11 μmol/L) who are receiving optimal pharmacological and nonpharmacological therapies (including comprehensive case management and pulmonary rehabilitation) because of benefits in computed tomography scan lung density and mortality.
Cardiac Device Infection due to Streptococcus pneumoniae
Authors: Liu Theresa T , Nery Pablo B , Birnie David , Jessamine Peter , Suh Kathryn N
Published: March 2016

Cardiac device infections (CDIs) are recognized complications of device implantation. Most CDIs are caused by skin flora but can also result from hematogenous seeding of the device. A case involving Streptococcus pneumoniae CDI, which is rare, potentially vaccine preventable and may not be associated with overt antecedent pneumococcal infection, is reported.
Comparison of Late HIV Diagnosis as a Marker of Care for Aboriginal Versus Non‐Aboriginal People Living with HIV in Ontario
Authors: Jaworsky Denise , Monette LaVerne , Raboud Janet , O’Brien-Teengs Doe , Diong Christina , Blitz Sandra , Rourke Sean B , Loutfy Mona R , OHTN Cohort Study Team
Published: March 2016

BACKGROUND: Studies have found that Aboriginal people living with HIV/AIDS (APHAs) are more likely than non‐APHAs to receive suboptimal HIV care, yet achieve similar clinical outcomes with proper care.

OBJECTIVE: To compare the proportions of individuals diagnosed late with HIV between APHAs and non‐APHAs within the Ontario HIV Treatment Network Cohort Study (OCS).

METHODS: The analysis included OCS participants who completed the baseline visit by November 2009. Two definitions of the outcome of late HIV diagnosis were used: the proportion of participants with an AIDS‐defining illness (ADI) before or within three months of HIV diagnosis; and the proportion of participants with a CD4+ count <200 cells/mL at diagnosis. Logistic regression analysis was used to assess the association between Aboriginal ethnicity and late HIV diagnosis.

RESULTS: APHAs were more likely to be female and have lower income, education and employment. No statistically significant differences were noted in the proportions receiving a late HIV diagnosis defined by ADI (Aboriginal 5.2% versus non‐Aboriginal 6.3%; P=0.40). Multivariate logistic regression analysis revealed a significant association between Aboriginal ethnicity and late HIV diagnosis defined by CD4+ count after adjusting for age and HIV risk factor (OR 1.55; P=0.04).

DISCUSSION: APHAs were more likely to have a CD4+ count <200 cells/mL at diagnosis but had similar clinical outcomes from late diagnosis when defined by ADI. However, differences may be underestimated due to recruitment limitations and selection bias.

CONCLUSION: Additional work is needed to address the socioeconomic and health care needs of APHAs.
Reassessing the Role for Lamivudine in Chronic Hepatitis B Infection: A Four-Year Cohort Analysis
Authors: Shaikh Tahir , Cooper Curtis
Published: March 2016

The data supporting the use of antiviral agents other than lamivudine in the management of patients with hepatitis B virus (HBV) infection are based on highly selected clinical trial populations that may not be representative of typical HBV-infected populations encountered in many clinics. Despite its limitations, however, lamivudine is relatively inexpensive and widely available and, in carefully selected patients, can still be successfully used to achieve long-term HBV suppression. This study investigated the long-term effectiveness of lamivudine in an adherent, frequently monitored, noninvestigational HBV-infected cohort.

BACKGROUND/OBJECTIVES: Lamivudine is readily available and inexpensive. Guidelines recommend other antiviral medications because they achieve superior virological suppression with less resistance. These data are based on clinical trial populations and may not be representative of typical hepatitis B virus (HBV) populations. The authors assessed lamivudine in maintaining long-term viral suppression in an adherent, frequently monitored, noninvestigational HBV-infected population.

METHODS: All HBV patients (n=369) between 2000 and 2010 were evaluated in a retrospective, single-centre study. Virological response was defined by complete suppression of HBV DNA (<400 copies/mL) and was assessed at six to 12 month intervals over four years. Enzymatic and serological outcomes, as well as treatment failures were assessed.

RESULTS: Forty-seven patients (36 men; mean age 44 years, mean alanine aminotransferase level 123 U/L; METAVIR stage 3/4 [n=21], treatment naive [n=41]) received lamivudine 100 mg to 300 mg daily. The mean pretreatment viremia was 5.19 log10copies/mL, and was above the limit of detection (>6.91 log10copies/mL) in 11 patients (23%). The mean (± SD) dosing duration was 32±22 months. Virological suppression was achieved in 45 (96%) patients. Mean viremia declined to 3.06 log10copies/mL (n=27) and 2.68 log10copies/mL (n=18) at 12 and 48 months, respectively, with 78% and 88% with undetectable viremia at these time points, respectively. The mean alanine aminotransferase level declined to 31 U/L and 36 U/L at 12 and 48 months, respectively. Seven of 13 (54%) hepatitis B e antigen-positive patients seroconverted. The treatment failure rate was 11%.

CONCLUSIONS: In a selected group of HBV patients, successful long-term viremia suppression was achieved with low treatment failure rates. With strict dosing adherence and monitoring for virological breakthrough, sustained virological suppression can be reliably achieved with lamivudine in carefully selected patients.
A Meta-Analysis of Nutritional Supplementation for Management of Hospitalized Alcoholic Hepatitis
Authors: Antar Ramy , Wong Phil , Ghali Peter
Published: March 2016

BACKGROUND: Alcoholic liver disease (ALD) is associated with a high risk of morbidity and mortality. Malnutrition accompanies this condition and may be both a consequence of and contributor to the pathology. Many trials have investigated the benefits of providing supplemental nutrition in the management of patients with ALD. The present study is a meta-analysis of the available evidence.

METHOD: A meta-analysis of randomized controlled studies comparing nutritional supplementation plus a normal hospital diet versus diet alone.

RESULTS: Seven randomized controlled studies including 262 patients with ALD were identified. Pooled analysis revealed no statistical difference in mortality between groups given special nutritional therapy versus a normal balanced diet (OR 0.80 [95% CI 0.42 to 1.52]). In addition, nutrition did not significantly improve ascites (OR 1.29 [95% CI 0.52 to 3.20]) or any biochemical parameters. However, encephalopathy showed a significant improvement or resolution (OR 0.24 [95% CI 0.06 to 0.93]).

CONCLUSION: Nutritional supplementation provided no mortality benefit in patients with ALD, and neither ascites nor biochemical parameters significantly improved. However, encephalopathy was significantly ameliorated and, therefore, nutritional supplementation should be encouraged in that setting.
An Update on the Management of Chronic Hepatitis C: Consensus Guidelines from the Canadian Association for the Study of the Liver
Authors: Myers Robert P , Ramji Alnoor , Bilodeau Marc , Wong Stephen , Feld Jordan J
Published: March 2016

Chronic hepatitis C remains a significant medical and economic burden in Canada, affecting nearly 1% of the population. Since the last consensus conference on the management of chronic hepatitis C, major advances have warranted a review of recommended management approaches for these patients. Specifically, direct-acting antiviral agents with dramatically improved rates of virological clearance compared with standard therapy have been developed, and several single nucleotide polymorphisms associated with an increased probability of spontaneous and treatment-induced viral clearance have been identified. In light of this new evidence, a consensus development conference was held in November 2011; the present document highlights the results of the presentations and discussions surrounding these issues. It reviews the epidemiology of hepatitis C in Canada, preferred diagnostic testing approaches and recommendations for the treatment of chronically infected patients with the newly approved protease inhibitors (boceprevir and telaprevir), including those who have previously failed pegylated interferon and ribavirin therapy. In addition, recommendations are made regarding approaches to reducing the burden of hepatitis C in Canada.
Functional Abdominal Pain in Childhood: Background Studies and Recent Research Trends
Authors: Levy Rona L , van Tilburg Miranda AL
Published: March 2016

The present review summarizes many of the major research trends investigated in the past five years regarding pediatric functional abdominal pain, and also summarizes the primary related findings from the authors’ research program. Specific areas discussed based on work within the authors’ group include familial illness patterns, genetics, traits, and mechanisms or processes related to abdominal pain. Topics covered from research published in the past five years include prevalence and cost, longitudinal follow‐up, overlap with other disorders, etiology and mechanisms behind functional abdominal pain and treatment studies. It is hoped that findings from this work in abdominal pain will be interpreted as a framework for understanding the processes by which other pain phenomena and, more broadly, reactions to any physical state, can be developed and maintained in children. The present article concludes with recommendations for clinical practice and research.
Health Care Professionals’ Pain Narratives in Hospitalized Children’s Medical Records. Part 1: Pain Descriptors
Authors: Rashotte Judy , Coburn Geraldine , Harrison Denise , Stevens Bonnie J , Yamada Janet , Abbott Laura K , the CIHR Team in Children’s Pain
Published: March 2016

BACKGROUND: Although documentation of children’s pain by health care professionals is frequently undertaken, few studies have explored the nature of the language used to describe pain in the medical records of hospitalized children.

OBJECTIVES: To describe health care professionals’ use of written language related to the quality and quantity of pain experienced by hospitalized children.

METHODS: Free‐text pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized on 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was used.

RESULTS: Pain narratives were documented a total of 5390 times in 1518 of the 3822 children’s medical records (40%). Overall, word choices represented objective and subjective descriptors. Two major categories were identified, with their respective subcategories of word indicators and associated cues: indicators of pain, including behavioural (eg, vocal, motor, facial and activities cues), affective and physiological cues, and children’s descriptors; and word qualifiers, including intensity, comparator and temporal qualifiers.

CONCLUSIONS: The richness and complexity of vocabulary used by clinicians to document children’s pain lend support to the concept that the word ‘pain’ is a label that represents a myriad of different experiences. There is potential to refine pediatric pain assessment measures to be inclusive of other cues used to identify children’s pain. The results enhance the discussion concerning the development of standardized nomenclature. Further research is warranted to determine whether there is congruence in interpretation across time, place and individuals.
Assessment of Pain Response in Capsaicin‐Induced Dynamic Mechanical Allodynia Using a Novel and Fully Automated Brushing Device
Authors: du Jardin Kristian G , Gregersen Lise S , Røsland Turid , Uggerhøj Kathrine H , Petersen Lars J , Arendt-Nielsen Lars , Gazerani Parisa
Published: March 2016

BACKGROUND: Dynamic mechanical allodynia is traditionally induced by manual brushing of the skin. Brushing force and speed have been shown to influence the intensity of brush‐evoked pain. There are still limited data available with respect to the optimal stroke number, length, force, angle and speed. Therefore, an automated brushing device (ABD) was developed, for which brushing angle and speed could be controlled to enable quantitative assessment of dynamic mechanical allodynia.

OBJECTIVES: To compare the ABD with manual brushing using capsaicin‐induced allodynia, and to investigate the role of stroke angle and speed on pain intensity.

METHODS: Experimental dynamic mechanical allodynia was induced by an intradermal injection of capsaicin (100 μg) into the volar forearm of 12 healthy, male volunteers. Dynamic mechanical allodynia was rated on a 10 cm visual analogue scale (VAS) after each set of strokes at angles of 30°, 60° and 90° with speeds of 17 mm/s, 21 mm/s and 25 mm/s for each angle. A two‐way ANOVA with repeated measures was performed to assess the influence of brushing parameters. To evaluate test‐retest reliability, Bland‐Altman 95% limits of agreement, including a coefficient of repeatability and an intraclass correlation coefficient (ICC), were determined.

RESULTS: The angle and speed exhibited a significant impact on pain intensity (P<0.001 and P<0.015, respectively). Post hoc analysis showed that the highest pain intensity was recorded with an angle of 30° regardless of brushing speed. The ABD demonstrated superior test‐retest reliability (coefficient of repeatability = 1.9 VAS; ICC=0.91) compared with manual brushing (coefficient of repeatability = 2.8 VAS; ICC=0.80; P<0.05). The most reliable combination of parameters (coefficient of repeatability = 1.3 VAS; ICC=0.97) was an angle of 60° and a speed of 21 mm/s.

CONCLUSIONS: A controlled, automatic brushing method can be used for quantitative investigations of allodynic reactions, and is more reliable for quantitative assessment of dynamic mechanical allodynia compared with traditional manual brushing.
Methicillin‐Resistant Staphylococcus aureus Colonization among Medical Residents
Authors: Trépanier Pascale , Tremblay Claude , Ruest Annie
Published: March 2016

BACKGROUND: Medical residents may be at risk of becoming colonized by methicillin‐resistant Staphylococcus aureus (MRSA) during their training. The occupational risk of this specific population is unknown. Furthermore, there are no data regarding MRSA colonization among health care professionals in Quebec.

OBJECTIVE: To determine the MRSA colonization rate in Laval University (Quebec City, Quebec) medical residents and compare it with the MRSA colonization rate of a control group.

METHODS: A controlled cross‐sectional study of MRSA prevalence among medical residents of Laval University was performed. The control group consisted of Laval University undergraduate medical students without previous clinical rotations in their curriculum. After informed consent was obtained, participants were screened for MRSA with a nasal swab in both anterior nares. They also completed a questionnaire regarding relevant risk factors and demographic data.

RESULTS: A total of 250 residents of all residency levels from medical and surgical specialties and 247 controls were recruited between February and April 2010. One case of MRSA colonization was detected among the residents and none in the control group (prevalence of 0.4% versus 0.0%; P=1.00).

DISCUSSION: MRSA nasal carriage was very low among Laval University residents. This may reflect the decreasing rate of health care‐associated MRSA in Quebec City. Young age and good health may also explain this low risk. The strict infection control policies for MRSA patients (including cohorting, use of gloves, gown and patient‐dedicated equipment) may also contribute to prevent MRSA transmission.

CONCLUSIONS: Medical residents in Quebec City appeared to be at very low risk of contracting MRSA through professional activities.
Community‐Associated Methicillin‐Resistant Staphylococcus aureus in Northwest Ontario: A Five‐Year Report of Incidence and Antibiotic Resistance
Authors: Muileboom Jill , Hamilton Marsha , Parent Karen , Makahnouk Donna , Kirlew Michael , Saginur Raphael , Lam Freda , Kelly Len
Published: March 2016

BACKGROUND: The incidence of community‐associated methicillin‐resistant Staphylococcus aureus (CA‐MRSA) is traditionally high in remote areas of Canada with large Aboriginal populations. Northwestern Ontario is home to 28,000 First Nations people in more than 30 remote communities; rates of CA‐MRSA are unknown.

OBJECTIVE: To determine the CA‐MRSA rates and antibiotic susceptibilities in this region.

METHODS: A five‐year review of laboratory and patient CA‐MRSA data and antibiotic susceptibility was undertaken.

RESULTS: In 2012, 56% of S aureus isolates were CA‐MRSA strains, an increase from 31% in 2008 (P=0.06). Reinfection rates have been increasing faster than new cases and, currrently, 25% of infections are reinfections. CA‐MRSA isolates continue to be susceptible to many common antibiotics (nearly 100%), particularly trimethoprim/sulfamethoxazole, clindamycin and tetracycline. Erythromycin susceptibility stands at 58%.

DISCUSSION: Rates of CA‐MRSA, as a percentage of all S aureus isolates, were higher than those reported in other primary care series. The infection rate per 100,000 is one the highest reported in Canada. Antibiotic susceptibilities were unchanged during the study period; the 99% susceptibility rate to clindamycin differs from a 2010 Vancouver (British Columbia) study that reported only a 79% susceptibility to this antibiotic.

CONCLUSION: There are very high rates of CA‐MRSA infections in northwestern Ontario. Disease surveillance and ongoing attention to antibiotic resistance is important in understanding the changing profile of MRSA infections. Social determinants of health, specifically improved housing and sanitation, remain important regional issues.
The Ethics of Canadian Entry‐To‐Practice Pain Competencies: How Are We Doing?
Authors: Watt-Watson Judy , Peter Elizabeth , Clark A John , Dewar Anne , Hadjistavropoulos Thomas , Morley-Forster Pat , O’Leary Christine , Raman-Wilms Lalitha , Unruh Anita , Webber Karen , Campbell-Yeo Marsha
Published: March 2016

BACKGROUND: Although unrelieved pain continues to represent a significant problem, prelicensure educational programs tend to include little content related to pain. Standards for professional competence strongly influence curricula and have the potential to ensure that health science students have the knowledge and skill to manage pain in a way that also allows them to meet professional ethical standards.

OBJECTIVES: To perform a systematic, comprehensive examination to determine the entry‐to‐practice competencies related to pain required for Canadian health science and veterinary students, and to examine how the presence and absence of pain competencies relate to key competencies of an ethical nature.

METHODS: Entry‐to‐practice competency requirements related to pain knowledge, skill and judgment were surveyed from national, provincial and territorial documents for dentistry, medicine, nursing, pharmacy, occupational therapy, physiotherapy, psychology and veterinary medicine.

RESULTS: Dentistry included two and nursing included nine specific pain competencies. No references to competencies related to pain were found in the remaining health science documents. In contrast, the national competency requirements for veterinary medicine, surveyed as a comparison, included nine pain competencies. All documents included competencies pertaining to ethics.

CONCLUSIONS: The lack of competencies related to pain has implications for advancing skillful and ethical practice. The lack of attention to pain competencies limits the capacity of health care professionals to alleviate suffering, foster autonomy and use resources justly. Influencing professional bodies to increase the number of required entry‐to‐practice pain competencies may ultimately have the greatest impact on education and practice.
Integrated Interdisciplinary Care for Patients with Chronic Obstructive Pulmonary Disease Reduces Emergency Department Visits and Admissions: A Quality Assurance Study
Authors: Dajczman Esther , Robitaille Chantal , Ernst Pierre , Hirsch Andrew Michael , Wolkove Norman , Small David , Bianco Judy , Stern Hartley , Palayew Mark
Published: March 2016

BACKGROUND: Dedicated programs for the management of chronic obstructive pulmonary disease (COPD) can reduce hospitalizations and improve quality of life.

OBJECTIVE: To investigate whether health care utilization could be reduced by a newly developed integrated, interdisciplinary initiative that included a COPD nurse navigator who educates patients and families, transitions patients through various points of care and integrates services.

METHODS: The present quality assurance, pre‐post study included patients followed by a COPD nurse navigator from January 25, 2010 to November 5, 2011. Information regarding emergency department visits and hospitalizations, including lengths of stay, were obtained from hospital databases. Diagnoses were classified as respiratory or nonrespiratory, and used primary and secondary hospitalization diagnoses to identify acute exacerbations of COPD (AECOPD). Paired sign tests were performed.

RESULTS: The sample consisted of 202 patients. Following nurse navigator intervention, significantly more patients experienced a decrease in the number of respiratory‐cause emergency department visits (P<0.05), number of respiratory hospitalizations (P<0.001), total hospital days for respiratory admissions (P<0.001), number of hospitalizations with AECOPD (P<0.001) and total hospital days for admissions with AECOPD (P<0.001). Financial modelling estimated annual savings in excess of $260,000.

CONCLUSION: The present quality assurance study indicated that the implementation of an integrated interdisciplinary program for the care of patients with COPD can improve patient outcomes despite the tendency of COPD to worsen over time.
Physician Variability in Treating Pain and Irritability of Unknown Origin in Children with Severe Neurological Impairment
Authors: Siden Harold B , Carleton Bruce C , Oberlander Tim F
Published: March 2016

BACKGROUND: Pain and irritability of unknown origin (PIUO) is a challenging problem for nonverbal children with severe neurological impairments. PIUO is not associated with an identifiable source of nociceptive‐inflammatory or neuropathic pain.

OBJECTIVE: To assess how physicians use pharmacotherapy to treat PIUO, and to report a pilot study of a standardized approach to investigating and treating PIUO.

METHOD: Part 1 of the present study involved independently presenting a case vignette of a patient with PIUO to six experienced physicians who care for children with neurological impairments. They were asked for medication choices and sequences to empirically treat PIUO. Part 2 was a pilot study of a PIUO protocol. Patients followed a standard pathway for PIUO, referred to as the pathway for unknown pain (PUP). The initial drug sequence for the PUP was based on Part 1.

RESULTS: In Part 1, physicians responding to the case vignette listed eight medications (atypical antipsychotics, benzodiazepines, gabapentin, methadone, opioids, selective serotonin reuptake inhibitors, tramadol and tricylic antidepressants) and eight empiric drug sequences. In Part 2, eight children with PIUO (six to 17 years of age; five females, three males) were enrolled in a pilot clinic. Only two had been fully evaluated for nociceptive‐inflammatory pain sources before enrollment. At the end of the pilot study, four patients were clinically improved and only three required a study medication.

DISCUSSION AND CONCLUSION: Even experienced physicians do not agree on a common approach for medical treatment of PIUO. A standardized pathway is feasible and readily implemented. The proposed PUP has the potential to address PIUO and be the basis for future intervention studies.
Evaluation of MRSASelect™ Chromogenic Medium for the Early Detection of Methicillin‐Resistant Staphylococcus aureus from Blood Cultures
Authors: Manickam Kanchana , Walkty Andrew , Lagacé-Wiens Philippe RS , Adam Heather , Swan Barbara , McAdam Brenda , Pieroni Peter , Alfa Michelle , Karlowsky James A
Published: March 2016

INTRODUCTION: Staphylococcus aureus bacteremia is associated with considerable morbidity and mortality. In theory, reducing the turnaround time in reporting of methicillin‐resistant S aureus (MRSA) among patients with bactermia could assist with the rapid optimization of antimicrobial therapy.

OBJECTIVE: To evaluate the sensitivity and specificity of MRSASelect (Bio‐Rad Laboratories, USA), a chromogenic medium, in the early detection of MRSA from blood cultures growing Gram‐positive cocci in clusters, and to confirm that routine use of this medium would, in fact, reduce turnaround time for MRSA identification.

METHODS: The present study was conducted at three microbiology laboratories in Manitoba. Between April 2010 and May 2011, positive blood cultures with Gram‐positive cocci in clusters visualized on Gram stain were subcultured to both MRSASelect and routine media. MRSA isolates were identified using conventional microbiological methods from routine media and using growth with the typical colony morphology (pink colony) on MRSASelect medium.

RESULTS: A total of 490 blood cultures demonstrating Gram‐positive cocci in clusters on Gram stain were evaluated. S aureus was recovered from 274 blood cultures, with 51 S aureus isolates (51 of 274 [18.6%]) identified as MRSA. MRSASelect medium had a sensitivity of 98%, a specificity of 100%, a positive predictive value of 100% and a negative predictive value of 99.8% for the recovery and identification of MRSA directly from positive blood culture bottles. In addition, use of MRSASelect medium was found to improve turnaround time in the detection of MRSA by almost 24 h relative to conventional methods.

DISCUSSION: These data support the utility of MRSASelect medium for the rapid identification of MRSA from positive blood cultures. Further clinical studies are warranted to determine whether the improvement in turnaround time will result in a measurable reduction in suboptimal antimicrobial therapy and/or improvement in patient outcome.
Peripheral Blood Leukocytes and Serum Nested Polymerase Chain Reaction Are Complementary Methods for Monitoring Active Cytomegalovirus Infection in Transplant Patients
Authors: Andrade PD , Fioravanti MT , Anjos EBV , De Oliveira C , Albuquerque DM , Costa SCB
Published: March 2016

BACKGROUND: Human cytomegalovirus is an important cause of morbidity and mortality in immunocompromised patients. Qualitative polymerase chain reaction (PCR) has proven to be a sensitive and effective technique in defining active cytomegalovirus infection, in addition to having low cost and being a useful test for situations in which there is no need for quantification. Real‐time PCR has the advantage of quantification; however, the high cost of this methodology makes it impractical for routine use.

OBJECTIVE: To apply a nested PCR assay to serum (sPCR) and to evaluate its efficiency to diagnose active cytomegalovirus infection compared with PCR of peripheral blood leukocytes (L‐PCR).

METHODS: Samples of 37 patients were prospectively evaluated. An internal control was created and applied to sPCR to exclude false‐negative results.

RESULTS: In total, 21 patients (57%) developed active cytomegalovirus infection. After analyzing the two methods for the diagnosis of active infection, higher sensitivity and negative predictive value of the L‐PCR versus sPCR (100% versus 62%), and higher specificity and positive predictive value of sPCR versus L‐PCR (81% versus 50% and 72%, respectively) were observed. Discordant results were observed in 11 patients who were L‐PCR‐positive but sPCR‐negative for active cytomegalovirus infection, five of whom developed clinical symptoms of cytomegalovirus. Clinical symptoms were observed in 14 patients, 12 of whom were diagnosed with active infection by nested L‐PCR (P=0.007) and seven by nested sPCR (P=0.02). Higher specificity and a positive predictive value for sPCR were observed.

CONCLUSION: Nested L‐PCR and sPCR were considered to be complementary methods for the diagnosis and management of symptomatic cytomegalovirus infection.
Colorectal Cancer Surveillance after Index Colonoscopy: Guidance from the Canadian Association of Gastroenterology
Authors: Leddin Desmond , Enns Robert , Hilsden Robert , Fallone Carlo A , Rabeneck Linda , Sadowski Daniel C , Singh Harminder
Published: March 2016

BACKGROUND: Differences between American (United States [US]) and European guidelines for colonoscopy surveillance may create confusion for the practicing clinician. Under- or overutilization of surveillance colonoscopy can impact patient care.

METHODS: The Canadian Association of Gastroenterology (CAG) convened a working group (CAG-WG) to review available guidelines and provide unified guidance to Canadian clinicians regarding appropriate follow-up for colorectal cancer (CRC) surveillance after index colonoscopy. A literature search was conducted for relevant data that postdated the published guidelines.

RESULTS: The CAG-WG chose the 2012 US Multi-Society Task Force (MSTF) on Colorectal Cancer to serve as the basis for the Canadian position, primarily because the US approach was the simplest and comprehensively addressed the issue of serrated polyps. Aspects of other guidelines were incorporated where relevant. The CAG-WG recommendations differed from the US MSTF guidelines in three main areas: patients with negative index colonoscopy should be followed-up at 10 years using any of the appropriate screening tests, including colonos-copy, for average-risk individuals; among patients with >10 adenomas, a one-year interval for subsequent colonoscopy is recommended; and for long-term follow-up, patients with low-risk adenomas on both the index and first follow-up procedures can undergo second follow-up colonos-copy at an interval of five to 10 years.

DISCUSSION: The CAG-WG adapted the US MSTF guidelines for colonoscopy surveillance to the Canadian health care environment with a few modifications. It is anticipated that the present article will provide unified guidance that will enhance physician acceptance and encourage appropriate utilization of recommended surveillance intervals.
The Second Canadian Symposium on Hepatitis C Virus: A Call to Action
Authors: Grebely Jason , Bilodeau Marc , Feld Jordan J , Bruneau Julie , Fischer Benedikt , Raven Jennifer F , Roberts Eve , Choucha Norma , Myers Rob P , Sagan Selena M , Wilson Joyce A , Bialystok Frank , Tyrrell D Lorne , Houghton Michael , Krajden Mel ,   on behalf of the National CIHR Research Training Program in Hepatitis C
Published: March 2016

In Canada, hepatitis C virus (HCV) infection results in considerable morbidity, mortality and health-related costs. Within the next three to 10 years, it is expected that tolerable, short-duration (12 to 24 weeks) therapies capable of curing >90% of those who undergo treatment will be approved. Given that most of those already infected are aging and at risk for progressive liver disease, building research-based interdisciplinary prevention, care and treatment capacity is an urgent priority. In an effort to increase the dissemination of knowledge in Canada in this rapidly advancing field, the National CIHR Research Training Program in Hepatitis C (NCRTP-HepC) established an annual interdisciplinary Canadian Symposium on Hepatitis C Virus. The first symposium was held in Montreal, Quebec, in 2012, and the second symposium was held in Victoria, British Columbia, in 2013. The current article presents highlights from the 2013 meeting. It summarizes recent advances in HCV research in Canada and internationally, and presents the consensus of the meeting participants that Canada would benefit from having its own national HCV strategy to identify critical gaps in policies and programs to more effectively address the challenges of expanding HCV screening and treatment.
Do We EradicateHelicobacter pyloriin Hospitalized Patients with Peptic Ulcer Disease?
Authors: Wong Frank , Ou George , Svarta Sigrid , Kwok Ricky , Donaldson Kieran , Frenette Joe , Enns Robert
Published: March 2016

BACKGROUND:Helicobacter pyloriinfection is the most common chronic infection in humans. It is a major contributor to the cause of duodenal and gastric ulcers worldwide. Its eradication has been shown to reduce rates ofH pylori-related ulcers as well as other complications such as gastric cancer.

OBJECTIVE: To determine the rate of appropriate treatment in patients following a diagnosis ofH pyloriinfection on biopsy during esophagoduodenoscopy for upper gastrointestinal bleeding over a four-year period at a tertiary centre in Vancouver, British Columbia. Also evaluated was the rate of eradication confirmation using the urea breath test.

METHODS: A retrospective review of 1501 inpatients who underwent esophagoduodenoscopy for upper gastrointestinal bleeding (January 2006 to December 2010) was undertaken. Patients who were biopsy stain positive forH pyloriwere selected for drug review either via a provincial database (PharmaNet) or via records from patients’ family practitioners. Data were also obtained via two provincial laboratories that perform the urea breath test to determine the rates of confirmation of eradication.

RESULTS: Ninety-eight patients had biopsy-provenH pylori. The mean (± SD) age was 56.13±17.9 years and 65 were male. Data were not available for 22 patients; the treatment rate was 52.6% (40 of 76). Of those treated, 12 patients underwent a post-treatment urea breath test for eradication confirmation.

CONCLUSION: There was substantial discrepancy between the number of diagnosedH pyloriinfections and the rate of treatment as well as confirmation of eradication. Numerous approaches could be taken to improve treatment and eradication confirmation.