bluuebunny/crossref_metadata_2025 huggingface dataset:
A One-Year Economic Evaluation of Six Alternative Strategies for the Management of Uninvestigated Upper Gastrointestinal Symptoms in Canadian Primary Care
Authors: Barkun Alan N , Crott Ralph , Fallone Carlo A , Kennedy Wendy A , Lachaine Jean , Levinton Carey , Armstrong David , Chiba Naoki , Thomson Alan , van Zanten Sander Veldhuyzen , Sinclair Paul , Escobedo Sergio , Chakraborty Bijan , Smyth Sandra , White Robert , Kalra Helen , Nevin Krista
Published: March 2016

BACKGROUND: The cost-effectiveness of initial strategies in managing Canadian patients with uninvestigated upper gastrointestinal symptoms remains controversial.

OBJECTIVE: To assess the cost-effectiveness of six management approaches to uninvestigated upper gastrointestinal symptoms in the Canadian setting.

METHODS: The present study analyzed data from four randomized trials assessing homogeneous and complementary populations of Canadian patients with uninvestigated upper gastrointestinal symptoms with comparable outcomes. Symptom-free months, quality-adjusted life-years (QALYs) and direct costs in Canadian dollars of two management approaches based on the Canadian Dyspepsia Working Group (CanDys) Clinical Management Tool, and four additional strategies (two empirical antisecretory agents, and two prompt endoscopy) were examined and compared. Prevalence data, probabilities, utilities and costs were included in a Markov model, while sensitivity analysis used Monte Carlo simulations. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were determined.

RESULTS: Empirical omeprazole cost $226 per QALY ($49 per symptom-free month) per patient. CanDys omeprazole and endoscopy approaches were more effective than empirical omeprazole, but more costly. Alternatives using H2-receptor antagonists were less effective than those using a proton pump inhibitor. No significant differences were found for most incremental cost-effectiveness ratios. As willingness to pay (WTP) thresholds rose from $226 to $24,000 per QALY, empirical antisecretory approaches were less likely to be the most cost-effective choice, with CanDys omeprazole progressively becoming a more likely option. For WTP values ranging from $24,000 to $70,000 per QALY, the most clinically relevant range, CanDys omeprazole was the most cost-effective strategy (32% to 46% of the time), with prompt endoscopy-proton pump inhibitor favoured at higher WTP values.

CONCLUSIONS: Although no strategy was the indisputable cost-effective option, CanDys omeprazole may be the strategy of choice over a clinically relevant range of WTP assumptions in the initial management of Canadian patients with uninvestigated dyspepsia.
A Qualitative Systematic Review of Head‐to‐Head Randomized Controlled Trials of Oral Analgesics in Neuropathic Pain
Authors: Watson C Peter N , Gilron Ian , Sawynok Jana
Published: March 2016

BACKGROUND: Neuropathic pain (NP) encompasses many difficult‐to‐treat disorders. There are few head‐to‐head, comparative, randomized controlled trials (RCTs) of drugs for NP in different analgesic categories, or of different drugs within a category, despite many placebo‐controlled RCTs for individual agents. Well‐designed head‐to‐head comparative trials are an effective way to determine the relative efficacy and safety of a new drug.

OBJECTIVE: To perform a systematic review of head‐to‐head RCTs of oral analgesics in NP.

METHODS: A systematic review of RCTs involving NP patients was performed, of which head‐to‐head comparative trials were selected. Reference lists from published systematic reviews were searched. These studies were rated according to the Jadad scale for quality.

RESULTS AND CONCLUSIONS: Twenty‐seven such trials were identified. Seventeen were comparisons of different analgesics, and 10 were of different drugs within an analgesic class. Important information was obtained about the relative efficacy and safety of drugs in different categories and within a category. Some significant differences between active treatments were reported. Trial inadequacies were identified. More and improved head‐to‐head RCTs are needed to inform clinical choices.
Endoscopic Sealing of Bronchopleural Fistulas with Submucosal Injection of a Tissue Expander: A Novel Technique
Authors: García-Polo Cayo , León-Jiménez Antonio , López-Campos Jose Luis , Arnedillo Aurelio , González-Moya Enrique , Fernández-Berni Juan José , Gómez Juan Manuel
Published: March 2016

The occurrence of a bronchopleural fistula (BPF) continues to represent a challenging management problem, and is associated with high morbidity and mortality. A novel and successful technique that uses submucosal injection of a tissue expander for bronchoscopic occlusion of BPFs has been designed. This method may be used either alone or in combination with bronchoscopic instillation of n‐butyl‐cyanoacrylate glue. The occlusion technique is described, with a presentation of two patients who were successfully treated with this method. The submucosal injection of a tissue expander is an effective, economical and minimally invasive technique for managing BPFs.
Autoantibodies and Liver Disease: Uses and Abuses
Authors: Zeman Marilyn V , Hirschfield Gideon M
Published: March 2016

Confirming whether a patient has autoimmune liver disease is challenging, given its varied presentation and complex definitions. In the continued absence of pathognomonic serum markers, diagnosis requires evaluation of laboratory investigations and, frequently, a liver biopsy – all of which need to be interpreted in the correct clinical context, with an emphasis on exclusion of viral infections, drug toxicity and metabolic disease. However, clear diagnosis is important for appropriate and timely therapy. Autoantibodies remain important tools for clinicians, and were the first proposed serological markers to aid in differentiating viral from chronic autoimmune hepatitis. Their presence is occasionally considered to be synonymous with autoimmune liver disease – a misinterpretation of their clinical significance. The present article summarizes the serum autoantibodies currently investigated in clinical and research practice, along with a description of their value in adult chronic liver diseases, with an emphasis on their appropriate use in the diagnosis and management of patients with autoimmune liver disease.
The Epworth Sleepiness Scale: Self‐Administration Versus Administration by the Physician, and Validation of a French Version
Authors: Kaminska Marta , Jobin Vincent , Mayer Pierre , Amyot Robert , Perraton-Brillon Mélanie , Bellemare François
Published: March 2016

BACKGROUND/OBJECTIVES: The Epworth Sleepiness Scale (ESS) measures sleepiness and is used for, among others, patients with obstructive sleep apnea (OSA). The questionnaire is usually self‐administered, but may be physician administered. The aim was to compare the two methods of administration and to validate a French version.

METHODS: Consecutive patients presenting to the sleep clinic at a tertiary care centre completed a self‐administered questionnaire containing the ESS. During the medical interview the same day, one of three pulmonologists who specialized in sleep medicine administered the ESS. Correlations with the apnea‐hypopnea index and mean sleep latencies were used to assess construct validity, while results of previous self‐administered ESS questionnnaires in untreated and recently treated OSA patients were used to test reproducibility and longitudinal construct validity, respectively.

RESULTS: In OSA patients, the ESS weakly correlated with the apnea‐hypopnea index (r=0.224; P=0.05; n=120) and negatively with mean sleep latency. For untreated patients (test‐retest), the mean (± SD) average score was unchanged (10.3±6.0 to 10.8±6.5; P=0.35; n=56) after a median of seven months. With continuous positive airway pressure use, the mean score decreased from 12.4±6.8 to 7.6±5.0 after 40.2 months (P<0.0001; n=68). For all subjects, the ESS score obtained by the physician was less than that of the self‐administered result (9.4±5.9 versus 8.5±5.8; P<0.0001 [paired t test]; n=188).

CONCLUSIONS: In a sleep clinic population, the French version of the ESS performed similarly to the English version. However, the systematic underscoring during physician administration may be important to consider in the research setting if questionnaire administration methods are not consistent.
Postoperative Self‐Report of Pain in Children: Interscale Agreement, Response to Analgesic, and Preference for a Faces Scale and a Visual Analogue Scale
Authors: de Tovar Clément , von Baeyer Carl L , Wood Chantal , Alibeu Jean-Pierre , Houfani Malik , Arvieux Charles
Published: March 2016

OBJECTIVE: To augment available validation data for the Faces Pain Scale – Revised (FPS‐R) and to assess interscale agreement and preference in comparison with the Coloured Analogue Scale (CAS) in pediatric acute pain.

METHOD: The present prospective, multicentre study included 131 inpatients five to 15 years of age (mean age 8.8 years; 56% male) seen in postoperative recovery. They provided CAS and FPS‐R pain scores before and after administration of analgesic medication. Nurses and physicians used the same tools as observational scales. Children and health care providers indicated which scale they preferred.

RESULTS: FPS‐R scores for the intensity of postoperative pain correlated highly with the corresponding CAS scores in all age groups (0.66 ≤ r ≤ 0.88). There were no significant mean differences in any age group between the scales. Scores on the two scales differed by 2/10 or less in 81% to 91% of children, depending on age. Both scales demonstrated expected changes in postoperative pain following administration of an analgesic. Scores at the upper end point were given by approximately 20% of children five to six years of age on both scales, compared with 2% to 9% in the older age groups. Health care providers’ observational ratings were significantly lower than self‐ratings. The FPS‐R was preferred over the CAS by most children in all age groups and both sexes. Global satisfaction of the health care providers was similar for both tools.

DISCUSSION: These results support the use of the FPS‐R for most children five years of age or older in the postoperative period. Further research is needed to identify young children, particularly those younger than seven years of age, who have difficulty with self‐report tools, and to establish methods for training them in the reliable use of these measures.
Cannabinoid Hyperemesis
Authors: Sullivan Stephen
Published: March 2016

Cannabinoid hyperemesis syndrome is characterized by chronic, heavy use of cannabis, recurrent episodes of severe nausea and intractable vomiting, and abdominal pain. Temporary relief of symptoms is achieved by taking a hot bath or shower, and resolution of the problem when cannabis use is stopped. Failure to recognize the syndrome leads to misdiagnoses such as psychogenic vomiting, the cyclic vomiting syndrome, an eating disorder or ‘drug‐seeking behaviour’, and may lead to extensive, expensive and unproductive investigations, psychiatric referrals and ineffective treatments. Other than stopping cannabis use, there is no proven treatment. Why a substance known for its antiemetic properties should cause such a syndrome is unknown.
Calcified Cavitating Mesenteric Lymph Node Syndrome: Case Presentation and Literature Review
Authors: Keer Dipinder S , Jeon Paul , Borgaonkar Mark R , Potoczny Stefan
Published: March 2016

Cavitating mesenteric lymph node syndrome (CMLNS) is a rare complication of celiac disease. Globally, only 36 cases of CMLNS have been reported to date. The present article reports an incidence of its unique pathology and possible complications of celiac disease, followed by a review of the syndrome. A case involving a 51-year-old man with celiac disease who was referred to hospital because of a non-tender abdominal mass is described. Plain film x-ray of the abdomen revealed fine curvilinear calcifications in the left lower quadrant. A complex, cystic-appearing, lobulated mass with somewhat echogenic walls most consistent with calcifications was revealed on subsequent ultrasound (US) imaging. Colour Doppler imaging showed no evidence of vascularity within the lesion. Computed tomography (CT) imaging showed a thin rim of calcification in the walls of multiple cystic components. Enhanced magnetic resonance (MR) imaging revealed a mixed solid and cystic multiloculated mass, with fat-fluid layers originating from the root of the small bowel mesentery. A CT-guided biopsy was performed. The fine-needle aspirate revealed calcified matter with no associated cellular material. No malignant cells were seen; CMLNS was established as the diagnosis. To the authors’ knowledge, there are no previous reports in the literature describing the finding of rim calcification on US or MR imaging in the setting of CMLNS. CMLNS is an important diagnosis to consider, particularly in patients with a history of celiac disease. The finding of rim calcification on US in the setting of cavitating mesenteric adenopathy should prompt further diagnostic imaging studies such as CT or MR imaging. These may lead to additional pathology studies such as a CT-guided biopsy to further characterize the lesion at the cellular level, to investigate potential malignancy and to further guide follow-up and patient management.
Recurrent Abdominal Pain and Weight Loss in an Adolescent: Celiac Artery Compression Syndrome
Authors: Gander Sarah , Mulder Daniel J , Jones Sarah , Ricketts John D , Soboleski Don A , Justinich Christopher J
Published: March 2016

Celiac artery compression syndrome is a rare cause of abdominal pain and weight loss, likely caused by compression of the celiac artery or plexus by the median arcuate ligament. A case of celiac artery compression syndrome in a 17‐year‐old male patient with severe postprandial pain and weight loss is described. Imaging techniques such as computed tomography, angiography and Doppler ultrasound identified the abnormality, which was corrected by laparoscopic surgery.
Ranking in Canadian Gastroenterology Residency Match: What Do Residents and Program Directors Want?
Authors: Khan Khurram J , Levstik Mark A
Published: March 2016

BACKGROUND: Matching to a gastroenterology (GI) fellowship position in Canada is increasingly competitive.

OBJECTIVE: To identify factors that determine how residents rank programs across the country, and how program directors rank their applicants.

METHODS: Using input from several current GI trainees and former program directors, two separate surveys were developed. An online survey was sent one month after the match to every resident matched to an adult GI program in the 2007 match. A separate online survey was simultaneously sent to all program directors of 14 accredited GI programs in Canada. Two subsequent cohorts (2008 and 2009) of matched residents were surveyed during the annual GI fellow endoscopy course at McMaster University (Hamilton, Ontario).

RESULTS: The overall response rate was 64 of 91 (70%) for residents and 11 of 15 (73%) for program directors (one program had codirectors). Using a five-point Likert scale for rating the importance of various factors influencing their decision, residents from three years ranked the following factor as most important: suitable location for spouse/partner/family (median score = 5). The overall least important factor was an opportunity for pediatric elective (median score = 2). Using the same scale, program directors ranked the following factors as most important (median score = 5) in ranking residents to their program: the ability to get along with others, outstanding reference letters, exceptional curriculum vitae and applying to only one specialty.

CONCLUSIONS: Several factors important for GI applicants and program directors were identified, as well as a few less-important factors. Based on these results, GI training programs can more effectively market their programs to applicants in the future, and residents applying to GI programs can strengthen their applications in the ever competitive match process.
Health Care Costs Associated with Hepatitis C: A Longitudinal Cohort Study
Authors: Krajden Mel , Kuo Margot , Zagorski Brandon , Alvarez Maria , Yu Amanda , Krahn Murray
Published: March 2016

BACKGROUND: Disease-specific estimates of medical costs are important for health policy decision making.

OBJECTIVE: To identify predictors of health care costs associated with hepatitis C virus (HCV) seropositivity across disease phases.

METHODS: HCV laboratory tests from the BC Centre for Disease Control were linked to administrative data pertaining to health services and drugs dispensed to estimate costs among case subjects and controls. The case group comprised HCV seropositive individuals (n=20,001), and the control group comprised single-tested, HCV seronegative persons (n=70,752) identified between January 1997 and December 2004. Subject observation time was assigned to the three following disease phases: initial phase (after diagnosis), late phase (late-stage liver disease) and predeath phase (12 months before death). Case subjects and controls were matched for age, sex and a propensity score within each phase to determine the net cost attributable to HCV seropositivity, and were adjusted for demographic and clinical factors.

RESULTS: Costs increased with disease progression, with hospitalization being the highest cost component in all phases. Initial and late phase net costs (2005 Canadian dollars) were $1,850 and $6,000 per patient per year, respectively. Costs among case subjects were driven by age, comorbidities, mental illness, illicit drug use and HIV coinfection. While predeath case subject and control costs were virtually the same, costs were high and case subjects died at a younger age.

CONCLUSION: HCV seropositivity is associated with increased medical costs driven by viral sequelae and medicosocial vulnerabilities (ie, mental illness, illicit drug use and HIV coinfection). Cost mitigation and health outcome improvements will require broad-based prevention programming to reduce vulnerabilities and HCV treatment to prevent disease progression, respectively.
Mesalazine in Inflammatory Bowel Disease: A Trendy Topic Once Again?
Authors: Iacucci Marietta , de Silva Shanika , Ghosh Subrata
Published: March 2016

5‐aminosalicylic acid (5‐ASA) preparations (eg, mesalazine, mesalamine) are well‐established preparations used in the management of inflammatory bowel disease. These drugs are most useful for the treatment of mild to moderate flares of ulcerative colitis and, especially, for maintenance of remission. Although most gastroenterologists are very familiar with these drugs, the interest in these drugs has undergone a resurgence, with new preparations offering convenience and high dosage, while preserving their customary safety. New dosage regimens are likely to become standard practice in the near future. There is also considerable interest in chemoprevention of colorectal cancer in the context of inflammatory bowel disease, and the role of long‐term maintenance therapy with 5‐ASAs in achieving such chemoprevention. A mechanism of action for such chemoprevention has been provided by the agonism of the peroxisome proliferator‐activated receptor‐gamma by 5‐ASA, which unifies its efficacy as an anti‐inflammatory and chemopreventive agent. In the future, even more effective agents based on 5‐ASA are expected, based on more powerful agonism of peroxisome proliferator‐activated receptor‐gamma; 5‐ASA preparations have become ‘trendy’ again.
Familial Interstitial Pulmonary Fibrosis: A Large Family with Atypical Clinical Features
Authors: Chibbar Ranji , Gjevre John A , Shih Francis , Neufeld Heather , Lemire Edmond G , Fladeland Derek A , Cockcroft Donald W
Published: March 2016

A large kindred of familial pulmonary fibrosis is reported. Six members from the first two generations of this particular kindred were described more than 40 years previously; six more individuals from the third and fourth generations have also been evaluated. The proband, now 23 years of age, has mild disease; the other 11 documented affected family members all died from their disease at an average age of 37 years (range 25 to 50 years). The pathology was that of usual interstitial pneumonia, as is typical in idiopathic pulmonary fibrosis. However, the initial radiographic pattern in many of these individuals was upper lobe and nodular and, along with the young age, was atypical for idiopathic pulmonary fibrosis. Several genetic abnormalities have been associated with familial pulmonary fibrosis. The present study examined the genes coding for surfactant protein-C, ATP-binding cassette protein A3 and telomerase, and found no abnormalities.
Relapse of Multiple Myeloma Presenting with Biliary Obstruction
Authors: Coss Alan , Zhou Chen , Byrne Michael F , Weiss Alan A
Published: March 2016

Pancreatic infiltration is a rare feature of multiple myeloma. A case of a 74‐year‐old man presenting with symptomatic biliary obstruction two years after the original diagnosis of myeloma is described. Confirmation of pancreatic infiltration with myeloma cells was performed by endoscopic ultrasound‐guided fine‐needle aspiration. Biliary stenting was performed at endoscopic retrograde cholangiopancreatography. Resolution of the pancreatic mass and the associated biliary stricture was observed after radiation and chemotherapy.
The Trajectory of Chronic Pain: Can a Community‐Based Exercise/Education Program Soften the Ride?
Authors: Dubin Ruth , King-VanVlack Cheryl
Published: March 2016

The entire primary care record of six patients attending a community‐based education/exercise self‐management program for chronic noncancer pain (YMCA Pain Exercise/Education Program [Y‐PEP]) was reviewed. Medical visits, consultations and hospital admissions were coded as related or unrelated to their pain diagnoses. Mood disruption, financial concerns, conflicts with employers/insurers, analgesic doses, medication side effects and major life events were also recorded. The ‘chronic pain trajectory’ resembled a roller coaster with increased health care visits at the time of initial injuries and during ‘crises’ (reinjury, conflict with insurers/employers, failed back‐to‐work attempts and life events). Visits decreased when conflicts were resolved. Analgesic doses increased during ‘crises’ but did not fall after resolution. After attending Y‐PEP, health care use fell for four of six patients and two returned to work. Primary care physicians need to recognize the functional limitations and psychosocial complications experienced by their chronic pain patients. A program such as Y‐PEP may promote active self‐management strategies resulting in lowered health care use.
Rescue Therapy Using a Rifabutin‐Based Regimen is Effective for Cure of Helicobacter pylori Infection
Authors: van Zanten Sander Veldhuyzen , Desai Snehal , Best Linda , Cooper-Lesins Geraldine , Malatjalian Dickran , Haldane David , Peltekian Kevork
Published: March 2016

OBJECTIVE: To evaluate the efficacy of rescue therapy using rifabutin, amoxicillin and a proton pump inhibitor (PPI) in the eradication of Helicobacter pylori in patients who have failed at least one course of PPI‐based triple therapy.

METHODS: The present study was a single‐centre case series of 16 consecutive patients who had received at least one course of standard eradication therapy. Pretreatment evaluation included endoscopy with biopsies for histology and culture for H pylori infection. Treatment consisted of a one‐week regimen containing a PPI twice daily, amoxicillin (A) 1 g twice daily and rifabutin (R) 300 mg once daily (PPI‐AR). Post‐treatment evaluation consisted of a repeat endoscopy with biopsy for histology and culture, or a validated urea breath test at least four weeks after treatment was completed. Pretreatment antibiotic susceptibility to metronidazole, clarithromycin and A was evaluated using a validated epsilometer test.

RESULTS: Of the 16 patients, four had previously received one course of triple therapy, 10 had received two courses and two had received more than two courses. The overall success rate of PPI‐AR was 63% (10 of 16). Resistance to A was 0% (0 of 13), metronidazole 77% (10 of 13), clarithromycin 70% (seven of 10), and both metronidazole and clarithromycin 60% (six of 10). There was no correlation between resistance patterns and cure rate.

CONCLUSIONS: An R‐containing regimen such as PPI‐AR is a viable option as rescue therapy for H pylori infection.
A Research Synthesis of Therapeutic Interventions for Whiplash‐Associated Disorder (WAD): Part 2 – Interventions for Acute WAD
Authors: Teasell Robert W , McClure J Andrew , Walton David , Pretty Jason , Salter Katherine , Meyer Matthew , Sequeira Keith , Death Barry
Published: March 2016

Whiplash‐associated disorder (WAD) represents a significant public health problem, resulting in substantial social and economic costs throughout the industrialized world. While many treatments have been advocated for patients with WAD, scientific evidence supporting their effectiveness is often lacking. A systematic review was conducted to evaluate the strength of evidence associated with various WAD therapies. Multiple databases (including Web of Science, EMBASE and PubMed) were searched to identify all studies published from January 1980 through March 2009 that evaluated the effectiveness of any clearly defined treatment for acute (less than two weeks), subacute (two to 12 weeks) or chronic (more than 12 weeks) WAD. The present article, the second in a five‐part series, evaluates the evidence for interventions initiated during the acute phase of WAD. Twenty‐three studies that met the inclusion criteria were identified, 16 of which were randomized controlled trials with ‘fair’ overall methodological quality (median Physiotherapy Evidence Database score of 5.5). For the treatment of acute WAD, there was strong evidence to suggest that not only is immobilization with a soft collar ineffective, but it may actually impede recovery. Conversely, although exercise programs, active mobilization and advice to act as usual all appeared to improve recovery, it is not clear which of these interventions was the most effective. While there was also evidence supporting the use of pulsed electromagnetic field therapy and methylprednisolone infusion, the evidence was insufficient to establish the effectiveness of either of these treatments. Based on current evidence, activation‐based therapy is recommended for the treatment of acute WAD; however, additional research is required to determine the relative effectiveness of various exercise/mobilization programs.
Sellar Inflammatory Mass with Inflammatory Bowel Disease
Authors: Freeman Hugh J , Maguire John
Published: March 2016

Inflammatory bowel disease may be associated with different intracranial disorders. An inflammatory sellar mass is very rare but includes a variety of noninfectious causes including lymphocytic hypophysitis, granulomatous inflammation and Wegener’s granulomatosis. A 32-year-old man was diagnosed with an inflammatory sellar mass associated with an extensive colonic inflammatory process clinically characteristic of Crohn’s disease. The concurrent onset of these inflammatory disorders in distinctly separate sites may reflect their common embryological origin or represent an unusual form of metastatic Crohn’s disease. Further studies are needed to determine if less overt or focal sellar inflammatory processes occur in inflammatory bowel disease, particularly in Crohn’s disease because their occurrence may be critically relevant for long-term management.
Use of Complementary and Alternative Medicine in Children with Asthma
Authors: Torres-Llenza Vanessa , Bhogal Sanjit , Davis Michael , Ducharme Francine M
Published: March 2016

BACKGROUND: Because of the potential risk of interaction with, and underuse of, conventional medications, it is important to document the prevalence of the use of complementary and alternative medicines (CAMs) in asthmatic children.

OBJECTIVE: To ascertain the prevalence and type of CAMs, and to identify factors associated with their use.

METHODS: A cross-sectional survey of children who presented to the Asthma Centre of The Montreal Children’s Hospital (Montreal, Quebec) between 1999 and 2007 was conducted. At the initial consultation, parents completed a questionnaire inquiring, in part, about CAM use. Computerized health records provided information regarding patient characteristics and their condition.

RESULTS: The median age of the 2027 children surveyed was 6.1 years (interquartile range 3.3 to 10.5 years); 58% were male and 59% of children had persistent asthma. The prevalence of CAM use was 13% (95% CI 12% to 15%). Supplemental vitamins (24%), homeopathy (18%) and acupuncture (11%) were the most commonly reported CAMs. Multivariable logistic regression analysis confirmed the association of CAM use with age younger than six years (OR 1.86; 95% CI 1.20 to 2.96), Asian ethnicity (OR 1.89; 95% CI 1.01 to 3.52), episodic asthma (OR 1.88; 95% CI 1.08 to 3.28) and poor asthma control (OR 1.98; 95% CI 1.80 to 3.31).

CONCLUSION: The prevalence of reported CAM use among Quebec children with asthma remained modest (13%), with vitamins, homeopathy and acupuncture being the most popular modalities. CAM use was associated with preschool age, Asian ethnicity, episodic asthma and poor asthma control.
Factors Associated with the Progression of Fibrosis on Liver Biopsy in Alaska Native and American Indian Persons with Chronic Hepatitis C
Authors: Livingston Stephen E , Deubner Heike , Bruden Dana L , McMahon Brian J , Homan Chriss E , Townshend-Bulson Lisa J , Bruce Michael G , Hennessy Thomas W , Williams James L , Gretch David R
Published: March 2016

BACKGROUND: Various factors influence the development and rate of fibrosis progression in chronic hepatitis C virus (HCV) infection.

OBJECTIVES: To examine factors associated with fibrosis in a long-term outcomes study of Alaska Native/American Indian persons who underwent liver biopsy, and to examine the rate of fibrosis progression in persons with subsequent biopsies.

METHODS: A cross-sectional analysis of the demographic, inflammatory and viral characteristics of persons undergoing liver biopsy compared individuals with early (Ishak fibrosis score of lower than 3) with those with advanced (Ishak score of 3 or greater) fibrosis. Persons who underwent two or more biopsies were analyzed for factors associated with fibrosis progression.

RESULTS: Of 253 HCV RNA-positive persons who underwent at least one liver biopsy, 76 (30%) had advanced fibrosis. On multivariate analysis, a Knodell histological activity index score of 10 to 14 and an alpha-fetoprotein level of 8 ng/mL or higher were found to be independent predictors of advanced liver fibrosis (P<0.0001 for each). When surrogate markers of liver inflammation (alanine aminotransferase, aspartate aminotransferase/alanine aminotransferase ratio and alpha-fetoprotein) were removed from the model, type 2 diabetes mellitus (P=0.001), steatosis (P=0.03) and duration of HCV infection by 10-year intervals (P=0.02) were associated with advanced fibrosis. Among 52 persons who underwent two or more biopsies a mean of 6.2 years apart, the mean Ishak fibrosis score increased between biopsies (P=0.002), with progression associated with older age at initial biopsy and HCV risk factors.

CONCLUSIONS: The presence of type 2 diabetes mellitus, steatosis and duration of HCV infection were independent predictors of advanced fibrosis in the present cohort, with significant fibrosis progression demonstrated in persons who underwent serial biopsies.
Cholangiocarcinoma: Has There been Any Progress?
Authors: Meza-Junco Judith , Montano-Loza Aldo J , Ma Mang , Wong Winnie , Sawyer Michael B , Bain Vincent G
Published: March 2016

Cholangiocarcinoma is the second most common primary hepatic tumour after hepatocellular carcinoma. Primary sclerosing cholangitis is one of the most commonly recognized risk factors for cholangiocarcinoma; however, approximately 90% of patients have no identifiable risk factors. Extrahepatic type is its most common presentation. Cholangiocarcinoma is considered to be a devastating disease, with a poor survival rate and few therapeutic options. Although surgical resection has been considered the best treatment option for localized cholangiocarcinoma, local recurrences of this cancer are very common, and imply persistent micrometastatic disease in lymph nodes or at surgical margins, even after extended surgical resection. Consequently, the five-year survival rate after attempted curative resection is only 20% to 40%. Early studies of liver transplantation for cholangiocarcinoma did not show a survival benefit and, currently, this tumour is considered to be an absolute contraindication for liver transplantation in most transplant centres worldwide. Recently, neoadjuvant chemoradiation in combination with liver transplantation for highly selected patients with cholangiocarcinoma has shown impressive results, with five-year survival rates at approximately 76% to 82% – similar to other standard indications for liver transplantation, such as hepatocellular carcinoma or hepatitis C-induced cirrhosis. However, this success of liver transplantation applies to only a subset of patients and most of the data originated from a single centre. Wider application of this strategy, especially for patients with potentially resectable disease, will require validation by other centres.
Predictors of Serious Complications Associated with Lower Gastrointestinal Endoscopy in a Major City-Wide Health Region
Authors: Singh Harminder , Penfold Robert B , De Coster Carolyn , Au Wendy , Bernstein Charles N , Moffatt Michael
Published: March 2016

BACKGROUND: There are limited data regarding complications associated with colonoscopy and flexible sigmoidoscopy in usual clinical practice in Canada.

OBJECTIVE: To determine the risk factors for lower gastrointestinal (GI) endoscopy-associated complications in usual clinical practice.

METHODS: All outpatient lower GI endoscopies performed in Winnipeg (Manitoba) between April 1, 2004 and March 31, 2006, were identified from the provincial physicians’ claims database. All subsequent hospital admissions within 30 days that documented potential complications associated with lower GI endoscopies were identified from the electronic hospital discharges database and reviewed. Multivariate generalized estimating equation regression analysis was performed to determine independent factors (patient, endoscopist and procedure) associated with the risk of developing complications.

RESULTS: There were 29,990 outpatient lower GI endoscopies performed in Winnipeg during the years studied. Seventy-seven (0.26%) procedures were associated with complications requiring hospitalization within 30 days of the index procedure. Stricture dilation (rate ratio [RR] 23.14; 95% CI 6.70 to 76.51), polypectomy (RR 5.93; 95% CI 3.66 to 9.62), increasing patient age (for each year increase in age, RR 1.03; 95% CI 1.01 to 1.05) and performance of endoscopy by low-volume endoscopists (fewer than 200 procedures per year, RR 2.28; 95% CI 1.18 to 4.42) and family physicians (RR 2.23; 95% CI 1.39 to 3.58) were independently associated with complications.

CONCLUSIONS: The results of the present study suggest that increasing patient age, complex procedures and performance of the index procedure by low-volume endoscopists are independent risk factors for lower GI endoscopy-associated complications in usual clinical practice. This suggests that it may be time to consider implementing minimum volume requirements for endoscopists performing non-screening lower GI endoscopies.
Efficacy and Safety of a Novel Pegylated Interferon Alpha-2a in Egyptian Patients with Genotype 4 Chronic Hepatitis C
Authors: Taha Alaa Awad , El-Ray Ahmad , El-Ghannam Maged , Mounir Bahaa
Published: March 2016

BACKGROUND: Hepatitis C virus (HCV) genotype 4 is a common infection in Egypt and is the leading cause of liver disease.

OBJECTIVE: To study the efficacy and safety of a novel 20 kD pegylated interferon alpha-2a derived fromHansenula polymorphain combination with ribavirin for the treatment of Egyptian patients with genotype 4 chronic hepatitis C (CHC).

METHODS: One hundred seven patients with genotype 4 CHC were involved in the present study. Liver biopsy was performed in all patients. All patients received a fixed weekly dose of 160 μg of a novel pegylated interferon in combination with ribavirin in standard and adjusted doses. Serum HCV RNA levels were assessed by a real-time sensitive polymerase chain reaction assay at four, 12, 48 and 72 weeks after the start of therapy. Patients demonstrating an early virological response (EVR) completed a 48-week course of treatment.

RESULTS: The overall sustained virological response (SVR) was 60.7%. The SVR in patients with a rapid virological response was significantly higher (91.7%) than in patients with complete EVR (67.74%) (P=0.033) and partial EVR (56.14%) (P=0.003). SVR was also significantly higher in patients with a low degree of liver fibrosis according to Metavir score (F1 and F2) (67.57%) compared with those with a high degree of liver fibrosis (F3 and F4) (45.45%) (P=0.017). The baseline viral load had no impact on SVR in the present series nor were any serious adverse events reported.

CONCLUSION: The novel pegylated interferon alpha-2a assessed in the present study was effective for the treatment of patients with genotype 4 CHC, and was safe and well tolerated.
Risk of Coinfection with Chlamydia trachomatis and Neisseria Gonorrhoeae in Nova Scotia
Authors: Forward Kevin R
Published: March 2016

BACKGROUND: The frequency of Chlamydia trachomatis and Neisseria gonorrhoeae coinfection can vary depending on their individual incidence and prevalence rates.

OBJECTIVE: To determine the frequency of C trachomatis and N gonorrhoeae coinfections by evaluating the results of testing in 2007 and 2008 to better inform testing and treatment decisions.

METHODS: Specimens from the same patient submitted on the same day served as the basis for the present study. The age, sex and the source of the specimen were also linked to the accession number. Infection and coinfection rates were analyzed in both males and females.

RESULTS: Concurrent testing was performed on 41,567 female specimens and 1827 male specimens, of which, 1495 female samples (3.6%) tested positive for C trachomatis infection and 88 (0.2%) tested positive for N gonorrhoeae infections. Only 31 females were coinfected; however, for those between 11 and 25 years of age, 25 of 61 females (40.1%) with N gonorrhoeae infection also tested positive for C trachomatis infection; conversely, 25 of 1248 females (2.0%) with C trachomatis infection also tested positive for N gonorrhoeae infection. For males, 213 (11.7%) tested positive for C trachomatis infection, and 59 (3.2%) tested positive for N gonorrhoeae infection. In 30 males with N gonorrhoeae between 11 and 25 years of age, and 149 males with C trachomatis, eight coinfections were observed (26.7% and 5.3%, respectively). Of those older than 25 years of age, only five of 905 men and six of 19,465 women were coinfected. None of the 10,935 women who were 30 years of age or older had coinfections.

CONCLUSION: The N gonorrhoeae coinfection rate in males with C trachomatis may justify empirical antimicrobials; however, in females, the proportion of coinfected may not justify empirical treatment for N gonorrhoeae infection when the C trachomatis test is positive and N gonorrhoeae testing has not been performed.
Systemic Therapy of New World Cutaneous Leishmaniasis: A Case Report and Review Article
Authors: Abadir Amir , Patel Ameen , Haider Shariq
Published: March 2016

Cutaneous leishmaniasis is a disease endemic to Central and South America, Mexico and the Caribbean, and affects millions of people. As travel to these regions becomes more common, cutaneous leishmaniasis is becoming a disease of increasing importance in the developed world. However, disease recognition and access to appropriate therapy for cutaneous leishmaniasis remains a challenge in North America. The present article reports a case of cutaneous leishmaniasis in a Canadian man following a trip to Costa Rica. Species‐specific diagnosis was confirmed by polymerase chain reaction analysis of a skin biopsy, which was positive for Leishmania panamensis. After failing a course of itraconazole, the patient was successfully treated with sodium stibogluconate, despite significant barriers to administering this therapy, and the paucity of data regarding its efficacy and tolerability. The pathophysiology, diagnosis and systemic treatment of cutaneous leishmaniasis, as well as its emerging presence in the developed world, are reviewed.
A Patient with an Aberrant Pulmonary Blood Supply and Recurrent Infection
Authors: Pescarus Radu , Rakovich George , Ouellette Denise , Beauchamp Gilles
Published: March 2016

A case of intralobar pulmonary sequestration presenting with recurrent episodes of infection is reported. Pulmonary sequestration is a rare congenital malformation characterized by accessory lung tissue with no direct connection to the tracheobronchial tree and is supplied by an aberrant systemic artery. The aberrant artery is key to both diagnosis and treatment. The correct diagnosis may be suspected on clinical grounds and should be confirmed by identifying the lesion and aberrant artery on imaging studies. Surgical resection is curative, taking particular care not to injure the aberrant artery, which may result in devastating intraoperative hemorrhage.
Spontaneous Rupture of the Spleen Associated with Legionella Pneumonia
Authors: Casanova-Roman Manuel , Casas Javier , Sanchez-Porto Antonio , Nacle Belen
Published: March 2016

Spontaneous rupture of the spleen associated with Legionella pneumonia is a rare and life‐threatening complication; only three cases have been reported to date. The authors describe a case of a 47‐year‐old man who presented with pneumonia and abdominal pain. He underwent a splenectomy, and was successfully treated with clarithromycin and levofloxacin.
Endoscopic Assessment of Children with Esophageal Atresia: Lack of Relationship of Esophagitis and Esophageal Metaplasia to Symptomatology
Authors: Castilloux Julie , Soglio Dorothée Bouron-Dal , Faure Christophe
Published: March 2016

BACKGROUND: Late complications of esophageal atresia (EA), particularly esophagitis and Barrett’s esophagus, are increasingly being recognized. With the exception of patients with dysphagia associated with esophageal stricture, it is unknown whether patient symptomatology can predict endoscopic findings.

METHODS: Data regarding the digestive symptoms of patients who were referred to the EA multidisciplinary clinic from October 2005 to October 2008, and underwent upper gastrointestinal endoscopic evaluation, were systematically collected. Macroscopic and histological findings were analyzed. Endoscopy was considered normal if no esophagitis, intestinal metaplasia or gastric metaplasia (GM) was discerned.

RESULTS: Sixty‐three patients underwent endoscopy. Eighteen had dysphagia related to an esophageal stricture needing dilation and were subsequently excluded from the analysis. Forty‐five patients (26 girls) with a median age of 7.3 years (range 0.4 to 17.9 years) were evaluated. Twenty‐six patients (58%) were normal at endoscopy, 14 patients (31%) had esophagitis and 16 patients (36%) had GM. No intestinal metaplasia or adenocarcinoma was detected. Six patients with abnormal endoscopy results were asymptomatic. No correlation between digestive symptoms and endoscopy results was found.

CONCLUSION: The present cross‐sectional study showed that symptomatology was not predictive of abnormal endoscopy in EA patients. Esophagitis or GM may be discovered, even in the absence of symptoms, suggesting that physicians cannot rely solely on symptomatology to accurately evaluate the extent of these esophageal complications in this population.
Poststroke Pain – but Multiple Pain Mechanisms
Authors: Chari Vinjamuri , Tunks Eldon
Published: March 2016

A 42‐year‐old man presented with acute left hemiplegia due to a right frontotemporal hemorrhagic stroke and left‐sided pain. While the initial presentation suggested central poststroke pain, subsequent investigations also implicated heterotopic ossification of the left hip and amplification of previous low back pain by the new central pain. While heterotopic ossification has been commonly associated with brain injury, spinal cord injury or osseous injury, it is only rarely associated with stroke. Poststroke pain may be multifactorial, and discovering the pain mechanisms has important implications for treatment.
Congenital Cytomegalovirus Infection in High‐Risk Canadian Infants: Report of a Pilot Screening Study
Authors: Vaudry Wendy , Rosychuk Rhonda J , Lee Bonita E , Cheung Po Yin , Pang XL , Preiksaitis Jutta K
Published: March 2016

OBJECTIVES: Congenital cytomegalovirus (cCMV) is the most common congenital infection; however, the epidemiology in Canada has not been recently examined. The present prospective study pilots tools for a population‐based study of cCMV infection in Canada by determining the maternal seroprevalence and risk factors, the clinical characteristics and the incidence of cCMV using a variety of diagnostic tests in a cohort of high‐risk infants in northern Alberta.

METHODS: All infants born at the Royal Alexandra Hospital in Edmonton, Alberta, from June 1, 2003, to May 31, 2004, were screened for the study. Eligible infants were those with very low birth weights (VLBWs) or small for gestational age (SGA). Maternal CMV serostatus was determined, and chart review and parental interviews were completed. Neonatal urine and throat cultures, and polymerase chain reaction (PCR) were performed. Dried blood spots (DBS) were tested for CMV by PCR.

RESULTS: In total, 213 infants were eligible for the study. Of these, 137 entered the study (79 VLBW and 58 SGA). Some families were not contacted for participation in the study due to neonatal deaths or early discharge. The mean age of the mothers was 27.6 years; 68% of the mothers were Caucasian and 16% were Aboriginal. The maternal CMV seroprevalence was 55%. Seropositivity was significantly associated with ethnicity (First Nations [100%]; Caucasian [34%]) and country of birth (outside Canada [94%]; Canadian born [45%]). The rate of cCMV was two in 137 (1.5%), with a rate of one in 79 (1.3%) for the VLBW infants and one in 58 (1.7%) for the SGA infants. Both had positive throat or urine specimens, but only the symptomatic infant was positive on DBS.

CONCLUSIONS: A cCMV screening program should be universal and routine to successfully screen all newborns. Maternal CMV seropositivity varies widely within the Canadian population. In the present pilot study, DBS PCR was not a sensitive screening tool and throat swab was the best screening specimen.
Gastrointestinal Schwannoma: An Unusual Colonic Lesion Mimicking Adenocarcinoma
Authors: Wilde Brent K , Senger Jenna-Lynn , Kanthan Rani
Published: March 2016

Gastrointestinal schwannoma is a rare, benign pathological entity that can mimic colonic adenocarcinoma and cause diagnostic dilemmas for treatment. A case of a 68‐year‐old woman with colonic adenocarcinoma who was discovered to have an incidental synchronous bowel lesion that proved to be a gastrointestinal schwannoma and not a synchronous adenocarcinoma is described. Gastrointestinal schwannomas are uncommon in the colorectal region; they are most often located in the stomach. These spindle cell lesions are distinct from gastrointestinal stromal tumours because the tumour cells have a distinct immunophenotype, with strong diffuse positivity for S‐100, glial fibrillary acidic protein and vimentin, and corroborative negative staining of CD34, CD117 and smooth muscle markers. Accurate diagnosis and recognition of this benign entity is, therefore, of immense clinicopathological value for accurate planning of therapeutic strategies.