bluuebunny/crossref_metadata_2025 huggingface dataset:
Cerebral Near‐Infrared Spectroscopy as a Measure of Nociceptive Evoked Activity in Critically III Infants
Authors: Ranger Manon , Johnston Celeste C , Limperopoulos Catherine , Rennick Janet E , du Plessis Adre J
Published: March 2016

Due to the subtlety or absence of predictable, objective signs of pain in critically ill infants, health care professionals must often rely on observations of behavioural or nonspecific physiological signals. Although parameters such as heart rate or blood pressure could be regarded as relatively more objective or quantifiable measures than behavioural signals, they are often unstable and generally nonspecific. However, reducing inaccuracies in pain assessment and misinterpretation of pain intensity may be facilitated by new techniques that shed light on the cerebral responses to pain that could be measured directly. Near‐infrared spectroscopy is one such technique that has been used to detect subtle changes in the concentrations of oxygenated and deoxygenated hemoglobin in the brains of preterm and term infants in response to stressful and/or painful stimuli. Following a review of cortical pain responses, this article provides an overview of near‐infrared spectroscopy technology and its use in functional activation studies in critically ill infants, and its potential applications in clinical settings and pain research.

Signs of pain may be subtle or absent in a critically ill infant. The complex nature of pain may further obscure its identification and measurement. Because the use of monitoring and neuroimaging techniques has become more common in pain research, an understanding of these specialized technologies is important. Near‐infrared spectroscopy (NIRS) is a noninvasive technique for monitoring tissue hemodynamics and oxygenation. There are indications that NIRS is capable of detecting the cerebral hemodynamic changes associated with sensory stimuli, including pain, in infants. These developments suggest that NIRS may play an important role in research focusing on pain perception in critically ill infants. The present review briefly describes the cortical responses to noxious stimuli, which parallel cerebral hemodynamic responses to various stimuli. This is followed by an overview of NIRS technology including a summary of the literature on functional studies that have used NIRS in infants. Current NIRS techniques have well‐recognized limitations that must be considered carefully during the measurement and interpretation of the signals. Nonetheless, until more advanced NIRS techniques emerge, the current devices have strengths that should be exploited.
Coagulability in Obstructive Sleep Apnea
Authors: Liak Christina , Fitzpatrick Michael
Published: March 2016

BACKGROUND: Obstructive sleep apnea (OSA) is a common disorder that affects both quality of life and cardiovascular health. The causal link between OSA and cardiovascular morbidity/mortality remains elusive. One possible explanation is that repeated episodes of nocturnal hypoxia lead to a hypercoagulable state that predisposes patients to thrombotic events. There is evidence supporting a wide array of hematological changes that affect hemostasis (eg, increased hematocrit, blood viscosity, platelet activation, clotting factors and decreased fibrinolytic activity).

OBJECTIVE: To provide a comprehensive review of the current evidence associating OSA with increased coagulability, and to highlight areas for future research.

METHODS: Keyword searches in Ovid Medline were used to identify relevant articles; all references in the articles were searched for relevant titles. The Web of Science was used to identify articles citing the relevant articles found using the Ovid Medline search. All original peer‐reviewed articles, meta‐analyses and systematic reviews regarding the pertinent topics between 1990 and present were selected for review.

RESULTS: Hematocrit, blood viscosity, certain clotting factors, tissue factor, platelet activity and whole blood coagulability are increased in patients with OSA, while fibrinolysis is impaired.

CONCLUSION: There is considerable evidence that OSA is associated with a procoagulant state. Several factors are involved in the procoagulant state associated with OSA. There is a need for adequately powered clinical studies involving well‐matched control groups to address potential confounding variables, and to accurately delineate the individual factors involved in the procoagulant state associated with OSA and their response to treatment.
A Concise Review of Hepatitis C in Heart and Lung Transplantation
Authors: Kim Edward , Ko Hin Hin , Yoshida Eric M
Published: March 2016

Hepatitis C (HCV) infection is prevalent in recipients of, and candidates for, solid organ transplants. The outcomes of HCV infection in cardiac and lung transplant recipients have yet to be clearly established, and future prospective studies are needed. In the absence of safe and effective antiviral treatment for HCV infection in heart and lung transplant recipients, the management of these patients remains a challenge and must be considered on an individual basis. Interferon therapy for HCV before transplantation appears to improve outcomes; however, post-transplant interferon therapy in the cardiac and pulmonary transplant setting may be associated with an increased risk of graft rejection. Given the paucity of information regarding HCV treatment in these transplant recipients, and with appropriate concerns that graft loss from rejection may not be amenable to a second transplant (given the scarcity of suitable cadaveric organs), multicentre, randomized controlled trials are needed to determine the optimal approach for treatment of HCV infection in this population.
Unusual Case of Colonized Pacemaker Lead Presenting with Endocarditis, Hemoptysis and Tricuspid Valve Stenosis
Authors: Morin Jean-Francois , Sheppard Richard , Chamoun Patrick
Published: March 2016

The present report is the first to describe a case of hemoptysis caused by an endocardial pacemaker lead. In addition, the patient presented with endocarditis and tricuspid valve stenosis. Aggressive treatment consisted of surgical extraction of two pacemaker leads and one pacemaker battery, replacement of the tricuspid valve and implantation of a DDD‐R epicardial pacemaker.
Liver Transplant Outcomes in a Canadian First Nations Population
Authors: Zhang M , Uhanova J , Minuk GY
Published: March 2016

BACKGROUND: A higher incidence of autoimmune disorders may predispose First Nations (FN) individuals to higher rates and more severe episodes of rejection, graft loss and mortality following liver transplantation for advanced liver disease.

METHODS: A retrospective review of patient outcomes in a single centre providing long-term follow-up care for FN and non-FN patients transplanted for advanced liver disease was conducted.

RESULTS: A total of 20 FN and 129 non-FN charts were available for review. FN subjects were younger at transplantation (mean [± SD] age 32.4±4.1 years versus 46.3±1.4 years; P=0.00005), less often male (35% versus 58%; P=0.05), more commonly transplanted for autoimmune hepatitis (30% versus 4.7%; P=0.006), less often from urban residences (25% versus 74%; P=0.0001) and less compliant with medical care (20% versus 80%; P=0.007). After a mean follow-up period of 11.0±1.5 years and 8.4±0.5 years in FN and non-FN subjects, respectively, the incidence and severity of rejection, graft and patient survival were similar between cohorts.

CONCLUSION: Although demographic profiles, nature of the underlying disease and compliance differed, the rates and severity of rejection, graft and patient survival were similar in FN and non-FN patients who underwent liver transplantation for advanced liver disease.
Desquamative Interstitial Pneumonitis and Systemic Lupus Erythematosus
Authors: Esmaeilbeigi Faranak , Juvet Stephen , Hwang David , Mittoo Shikha
Published: March 2016

Desquamative interstitial pneumonia (DIP) is a rare form of interstitial lung disease (ILD) commonly found among healthy smokers. ILD is a rare manifestation of systemic lupus erythematosus (SLE), and typically associated with a histopathological pattern of nonspecific interstitial pneumonia (NSIP). The present article describes an unusual case of DIP in a non‐smoking patient with SLE presenting as NSIP. DIP can occur in the context of SLE in patients with a negative smoking history, and clinicians should consider lung biopsy to correctly classify ILD with unusual presentation on computed tomography scan.
The Role of Torovirus in Nosocomial Viral Gastroenteritis at a Large Tertiary Pediatric Centre
Authors: Gubbay JB , Al-Rezqi A , Hawkes M , Williams L , Richardson SE , Matlow A
Published: March 2016

OBJECTIVE: To describe the viral etiology and epidemiology of nosocomial viral gastroenteritis (NVG) at a tertiary care pediatric hospital and identify any changes over the past two decades.

METHODS: Retrospective review of all patients with laboratory‐confirmed NVG at The Hospital for Sick Children (Toronto, Ontario), from January 1, 2004, to December 31, 2005.

RESULTS: One hundred forty‐two episodes of NVG were found among 133 patients, occurring in 0.48 of 100 admissions. The median age was two years; 42% were <1 year of age and 41% were immunocompromised. The most commonly detected pathogen was torovirus (67% of episodes), followed by rotavirus (19%) and adenovirus (9%). Seventy‐five cases (53%) were epidemiologically linked in 32 separate clusters (median cluster size two, range two to four). The NVG rate fell from 0.63 of 100 to 0.22 of 100 admissions after March 2005 (P<0.001) when enhanced infection control precautions were instituted in response to an outbreak of vancomycin‐resistant Enterococcus.

CONCLUSIONS: Torovirus remains the most commonly identified cause of NVG at The Hospital for Sick Children. Most NVG cases were epidemiologically linked, and a significant reduction in cases occurred after the institution of enhanced infection control practices following an outbreak of vancomycin‐resistant Enterococcus. Improved education and surveillance for NVG should lead to further reduction in this problem.
Helicobacter pyloriin First Nations and Recent Immigrant Populations in Canada
Authors: Jones Nicola L , Chiba Naoki , Fallone Carlo , Thomson Alan , Hunt Richard , Jacobson Kevan , Goodman Karen
Published: March 2016

The diminishing prevalence ofHelicobacter pyloriinfection among most segments of the Canadian population has led to changes in the etiologies and patterns of associated upper gastrointestinal diseases, including fewer peptic ulcers and their complications. Canadian Aboriginals and recent immigrants are among populations in which the prevalence ofH pyloriinfection remains high and, therefore, the health risks imposed byH pyloriremain a significant concern. Population-based strategies forH pylorieradication in groups with a low prevalence of infection are unlikely to be cost effective, but such measures are attractive in groups in which the prevalence rates of infection remain substantial. In addition to a lower prevalence of peptic ulcers and dyspepsia, the public health value of eradication may be particularly important if this leads to a reduction in the prevalence of gastric cancer in high prevalence groups. Therefore The Canadian Helicobacter Study Group held a conference that brought together experts in the field to address these issues, the results of which are reviewed in the present article. Canadians with the highest prevalence ofH pyloriinfection are an appropriate focus for considering the health advantages of eradicating persistent infection. In Canadian communities with a high prevalence of bothH pyloriand gastric cancer, there remains an opportunity to test the hypothesis thatH pyloriinfection is a treatable risk factor for malignancy.
Diagnostic yield of Capsule Endoscopy in the Setting of Iron Deficiency Anemia without Evidence of Gastrointestinal Bleeding
Authors: Tong Jessica , Svarta Sigrid , Ou George , Kwok Ricky , Law Joanna , Enns Robert
Published: March 2016

BACKGROUND: The diagnostic yield of capsule endoscopy (CE) in the setting of iron deficiency anemia (IDA) without evidence of occult/overt bleeding has been questioned. Often, these patients have nongastrointestinal causes of iron deficiency but undergo CE to exclude a potential small bowel source.

OBJECTIVE: To assess the diagnostic yield of CE, the characteristics predicting positive results, the presumed etiology of IDA in negative/normal CE and patient management after CE.

METHODS: A retrospective review of 934 patients who underwent CE between December 2001 and February 2010 was conducted. All patients had undergone previous negative endoscopic examinations before CE. Patients with IDA but no evidence of overt/occult bleeding were separated into three categories based on CE findings: group A – positive; group B – negative/normal; and group C – incomplete/indeterminate.

RESULTS: A total of 101 capsules in 97 patients were evaluated. Group A had 25 subjects with positive findings on CE, 18 of whom were managed supportively. Group B consisted of 69 subjects with negative/normal CE, 60 of whom were treated supportively. Group C consisted of three subjects with incomplete CE results.

CONCLUSION: In patients with IDA without evidence of gastrointestinal bleeding, CE had a low diagnostic yield (25.7%), which increased to 45.5% after adjusting for low dietary iron intake and menorrhagia. However, CE did not alter management in most patients regardless of findings, and many of the lesions requiring intervention were within reach of standard endoscopes. No predictor of positive results was found. In this patient population, careful history taking and thorough endoscopy could improve CE utilization, although its value is still relatively limited.
Coagulase‐Negative Staphylococcus, Catheter‐Related, Bloodstream Infections and their Association with Acute Phase Markers of Inflammation in the Intensive Care Unit: An Observational Study
Authors: Rewa Oleksa , Muscedere John , Reynolds Steve , Jiang Xuran , Heyland Daren K
Published: March 2016

OBJECTIVE: To examine the relationship between the isolation of coagulase‐negative Staphylococcus in blood cultures and acute phase markers of inflammation.

METHODS: The present study was a prospective observational analysis conducted at three medical/surgical intensive care units (ICUs) involving adult patients with an expected ICU stay of more than 24 h duration.

RESULTS: Of the 598 patients enrolled, 573 developed suspected bloodstream infection and 434 (72.6%) had blood cultures sent 24 h after ICU admission; 142 were excluded due to positive cultures from other sites. Of the remaining 292 patients, 31 (10.7%) grew coagulase‐negative Staphylococcus, 59 (20.2%) grew known pathogenic organisms and 202 (69.2%) did not grow any organisms in their blood cultures. Twenty‐five patients without suspicion of infection served as the control group. Interleukin (IL)‐6, procalcitonin (PCT) and C‐reactive protein (CRP) levels were highest among the known pathogen group (IL‐6 271.8 U/L, PCT 4.6 U/L and CRP 164 mg/L), were similar between the coagulase‐negative Staphylococcus and negative culture groups (IL‐6 67.0 U/L versus 61.4 U/L [P=1.00]; PCT 1.0 U/L versus 0.9 U/L [P=0.80]; and CRP 110 mg/L versus 103 mg/L [P=0.75]), and were lowest in the control group (IL‐6 31.0 U/L, PCT 0.2 U/L and CRP 41.0 mg/L). In the coagulase‐negative Staphylococcus group, patients who died by day 28 had increased inflammatory bio‐marker levels compared with survivors, although the differences were not statistically significant.

CONCLUSIONS: Coagulase‐negative Staphylococcus isolated from blood cultures were associated with lower levels of inflammation compared with bloodstream infections due to known pathogens and were comparable with levels in patients with negative cultures.
Genetic Testing for Respiratory Disease: Are We There Yet?
Authors: Paré Peter D
Published: March 2016

The human genome project promised a revolution in health care – the development of ‘personalized medicine’, where knowledge of an individual’s genetic code enables the prediction of risk for specific diseases and the potential to alter that risk based on preventive measures and lifestyle modification. The present brief review provides a report card on the progress toward that goal with respect to respiratory disease. Should generalized population screening for genetic risk factors for respiratory disease be instituted? Or not?
Assessment and Management of Pain in Juvenile Idiopathic Arthritis
Authors: Stinson Jennifer N , Luca Nadia JC , Jibb Lindsay A
Published: March 2016

Juvenile idiopathic arthritis (JIA) is a common chronic childhood illness. Pain is the most common and distressing symptom of JIA. Pain has been found to negatively impact all aspects of functioning, including physical, social, emotional and role functions. Children with arthritis continue to experience clinically significant pain despite adequate doses of disease‐modifying antirheumatic drugs and anti‐inflammatory agents. The present article reviews the prevalence and nature of pain in JIA, the biopsychosocial factors that contribute to the pain experience, current approaches to assessing pain in this population, and ways of managing both acute and persistent pain using pharmacological, physical and psychological therapies. Finally, new approaches to delivering disease self‐management treatment for youth with JIA using the Internet will be outlined.
Development and Validation of an Administrative Case Definition for Inflammatory Bowel Diseases
Authors: Rezaie Ali , Quan Hude , Fedorak Richard N , Panaccione Remo , Hilsden Robert J
Published: March 2016

BACKGROUND: A population-based database of inflammatory bowel disease (IBD) patients is invaluable to explore and monitor the epidemiology and outcome of the disease. In this context, an accurate and validated population-based case definition for IBD becomes critical for researchers and health care providers.

METHODS: IBD and non-IBD individuals were identified through an endoscopy database in a western Canadian health region (Calgary Health Region, Calgary, Alberta). Subsequently, using a novel algorithm, a series of case definitions were developed to capture IBD cases in the administrative databases. In the second stage of the study, the criteria were validated in the Capital Health Region (Edmonton, Alberta).

RESULTS: A total of 150 IBD case definitions were developed using 1399 IBD patients and 15,439 controls in the development phase. In the validation phase, 318,382 endoscopic procedures were searched and 5201 IBD patients were identified. After consideration of sensitivity, specificity and temporal stability of each validated case definition, a diagnosis of IBD was assigned to individuals who experienced at least two hospitalizations or had four physician claims, or two medical contacts in the Ambulatory Care Classification System database with an IBD diagnostic code within a two-year period (specificity 99.8%; sensitivity 83.4%; positive predictive value 97.4%; negative predictive value 98.5%). An alternative case definition was developed for regions without access to the Ambulatory Care Classification System database. A novel scoring system was developed that detected Crohn disease and ulcerative colitis patients with a specificity of >99% and a sensitivity of 99.1% and 86.3%, respectively.

CONCLUSION: Through a robust methodology, a reproducible set of criteria to capture IBD patients through administrative databases was developed. The methodology may be used to develop similar administrative definitions for chronic diseases.
Interferon‐Gamma Release Assays Are a Better Tuberculosis Screening Test for Hemodialysis Patients: A Study and Review of the Literature
Authors: Grant J , Jastrzebski J , Johnston J , Stefanovic A , Jastrabesky J , Elwood K , Roscoe D , Balshaw R , Bryce E
Published: March 2016

Diagnosing latent tuberculosis (TB) infection (LTBI) in dialysis patients is complicated by poor response to tuberculin skin testing (TST), but the role of interferon‐gamma release assays (IGRAs) in the dialysis population remains uncertain. Seventy‐nine patients were recruited to compare conventional diagnosis (CD) with the results of two IGRA tests in a dialysis unit. Combining TST, chest x‐ray and screening questionnaire results (ie, CD) identified 24 patients as possible LTBI. IGRA testing identified 22 (QuantiFERON Gold IT, Cellestis, USA) and 23 (T‐spot.TB, Oxford Immunotec, United Kingdom) LTBI patients. IGRA and CD correlated moderately (κ=0.59). IGRA results correlated with history of TB, TB contact and birth in an endemic country. TST was not helpful in identifying LTBI patients in this population. The tendency for IGRAs to correlate with risk factors for TB, active TB infection and history of TB argues for their superiority over TST in dialysis patients. There was no superiority of one IGRA test over another.
Current Considerations in Direct Percutaneous Endoscopic Jejunostomy
Authors: Zhu Yanfei , Shi Liping , Tang Hao , Tao Guoqing
Published: March 2016

For patients who are unable to meet their nutritional needs orally, enteral feeding via a percutaneous approach has become the mainstay of therapy. However, traditional enteral feeding methods, such as percutaneous endoscopic gastrostomy, may not be viable options for patients with severe gastroparesis or gastric outlet obstruction. Direct percutaneous endoscopic jejunostomy (DPEJ) is an enteral access method that was first described more than 20 years ago and has gained popularity among gastroenterologists. This review discusses the indications for and contraindications to DPEJ, the procedure, the application of DPEJ in specific subsets of patients with gastrointestinal disorders, and presents a brief tabular summary of complications and success rates of DPEJ in case series published since 2000.

BACKGROUND: Direct percutaneous endoscopic jejunostomy (DPEJ) is a well-known approach to deliver postpyloric enteral nutritional support to individuals who cannot tolerate gastric feeding. However, it is technically difficult, and some case series have reported significant procedural failure rates. The present article describes current indications, successes and complications of DPEJ placement

METHODS: A MEDLINE database search was performed to identify relevant articles using the key words “direct percutaneous endoscopic jejunostomy”, “percutaneous endoscopic gastrostomy”, and “percutaneous endoscopic gastrostomy with a jejunal extension tube”. Additional articles were identified by a manual search of the references cited in the key articles obtained in the primary search.

RESULTS: DPEJ is gradually becoming more common in the treatment of patients who cannot tolerate gastric feeding. Differences in patient selection and technique modifications may contribute to the various success rates reported. Failure is most often due to inadequate transillumination or gastroduodenal obstruction. Currently, there are limited data to evaluate the safety and effectiveness of DPEJ.

CONCLUSION: The clinical use of DPEJ is increasing. With appropriate care and expertise, DPEJ may prove to be reliable and safe.
Mycobacterium marinum Infection from Sea Monkeys
Authors: LeBlanc Jaclyn , Webster Duncan , Tyrrell Gregory J , Chiu Isabelle
Published: March 2016

A case of cutaneous Mycobacterium marinum infection acquired from Artemia nyos (sea monkeys) is presented. The infection was unresponsive to initial antimicrobial therapies. A biopsy of a lesion revealed granulomatous inflammation with cultures that subsequently grew M marinum. A three‐month course of clarithromycin provided complete resolution.
Incomplete Colonoscopy: Maximizing Completion Rates of Gastroenterologists
Authors: Brahmania Mayur , Park Jei , Svarta Sigrid , Tong Jessica , Kwok Ricky , Enns Robert
Published: March 2016

BACKGROUND Cecal intubation is one of the goals of a quality colonoscopy; however, many factors increasing the risk of incomplete colonoscopy have been implicated. The implications of missed pathology and the demand on health care resources for return colonoscopies pose a conundrum to many physicians. The optimal course of action after incomplete colonoscopy is unclear.

OBJECTIVES: To assess endoscopic completion rates of previously incomplete colonoscopies, the methods used to complete them and the factors that led to the previous incomplete procedure.

METHODS: All patients who previously underwent incomplete colonoscopy (2005 to 2010) and were referred to St Paul’s Hospital (Vancouver, British Columbia) were evaluated. Colonoscopies were re-attempted by a single endoscopist. Patient charts were reviewed retrospectively.

RESULTS: A total of 90 patients (29 males) with a mean (± SD) age of 58±13.2 years were included in the analysis. Thirty patients (33%) had their initial colonoscopy performed by a gastroenterologist. Indications for initial colonoscopy included surveillance or screening (23%), abdominal pain (15%), gastrointestinal bleeding (29%), change in bowel habits or constitutional symptoms (18%), anemia (7%) and chronic diarrhea (8%). Reasons for incomplete colonoscopy included poor preparation (11%), pain or inadequate sedation (16%), tortuous colon (30%), diverticular disease (6%), obstructing mass (6%) and stricturing disease (10%). Reasons for incomplete procedures in the remaining 21% of patients were not reported by the referring physician. Eighty-seven (97%) colonoscopies were subsequently completed in a single attempt at the institution. Seventy-six (84%) colonoscopies were performed using routine manoeuvres, patient positioning and a variable-stiffness colonoscope (either standard or pediatric). A standard 160 or 180 series Olympus gastroscope (Olympus, Japan) was used in five patients (6%) to navigate through sigmoid diverticular disease; a pediatric colonoscope was used in six patients (7%) for similar reasons. Repeat colonoscopy on the remaining three patients (3%) failed: all three required surgery for strictures (two had obstructing malignant masses and one had a severe benign obstructing sigmoid diverticular stricture).

CONCLUSION: Most patients with previous incomplete colonoscopy can undergo a successful repeat colonoscopy at a tertiary care centre with instruments that are readily available to most gastroenterologists. Other modalities for evaluation of the colon should be deferred until a second attempt is made at an expert centre.
Patient Characteristics and Outcomes of a Provincial Prolonged‐Ventilation Weaning Centre: A Retrospective Cohort Study
Authors: Rose Louise , Fraser Ian M
Published: March 2016

BACKGROUND: Growing numbers of critically ill patients require prolonged mechanical ventilation and experience difficulty with weaning. Specialized centres may facilitate weaning through focused interprofessional expertise with an emphasis on rehabilitation.

OBJECTIVE: To characterize the population of a specialized prolonged‐ventilation weaning centre (PWC) in Ontario, and to report weaning, mobility, discharge and survival outcomes.

METHODS: Data from consecutively admitted patients were retrospectively extracted from electronic and paper medical records by research staff and verified by the primary investigator.

RESULTS: From January 2004 to March 2011, 144 patients were admitted: 115 (80%) required ventilator weaning, and 29 (20%) required tracheostomy weaning or noninvasive ventilation. Intensive care unit length of stay before admission was a median 51 days (interquartile range [IQR] 35 to 86 days). Of the patients admitted for ventilator weaning, 76 of 115 (66% [95% CI 55% to 75%]) achieved a 24 h tracheostomy mask trial in a median of 15 days (IQR eight to 25 days). Weaning success, defined as no further ventilation for seven consecutive days, was achieved by 61 patients (53% [95% CI 44% to 62%]) in a median duration of 62 days (IQR 46 to 95 days) of ventilation, and 14 days (IQR nine to 29 days) after PWC admission. Seventeen patients died during admission. Of the 91 patients discharged from the PWC for one year, 43 (47.3% [95% CI 37.3% to 57.4%]) survived; of the 78 discharged for two years, 27 (34.6% [95% CI 25.0% to 45.7%]) were alive; of the 53 discharged for three years, 19 (35.9% [95% CI 24.3% to 49.3%]) were alive; and seven of 22 (31.8% [95% CI 16.4% to 52.7%]) survived to five years.

CONCLUSIONS: Weaning success was moderate despite a prolonged intensive care unit stay before admission, but was comparable with studies reporting weaning outcomes from centres in other countries. Few patients survived to five years.
Clinical Presentation of Patients with Aseptic Meningitis, Factors Influencing Treatment and Hospitalization, and Consequences of Enterovirus Cerebrospinal Fluid Polymerase Chain Reaction Testing
Authors: Patriquin Glenn , Hatchette Jill , Forward Kevin
Published: March 2016

INTRODUCTION: Clinical and laboratory features of enteroviral meningitis may overlap with those of bacterial meningitis. In the present retrospective review, we compared features of enteroviral (EV)‐positive and ‐negative patients to determine those that were most influential in admission, discharge and in anti‐infective administration.

METHODS: Data were analyzed from the records of 117 pediatric and adult patients who underwent cerebrospinal fluid (CSF) EV testing over a three‐year period.

RESULTS: The oldest EV‐positive patient was 34 years of age and the occurrence of the disease was highly seasonal. EV‐positive patients were more likely to report fever, rash, photophobia, short onset and exposure to an ill contact. A positive polymerase chain reaction (PCR) result was associated with relatively short hospitalization. Seizure and neurological symptoms were more strongly associated with a negative PCR test result. CSF characteristics did not discriminate well between patients with positive and negative PCR tests. Patients with imperfect Glasgow Coma Scores or with neurological symptoms were more likely to be admitted to hospital than those without. Fever and recent onset predicted determinants of anti‐infective use.

CONCLUSION: The present retrospective study confirms previous reports regarding seasonality and the young age of positive patients. Factors that indicate nonenteroviral etiology were appropriately also those that influenced hospitalization. Patients with EV meningitis were likely to be treated with empirical anti‐infectives, and a substantial proportion continued to take antibiotics for more than 24 h after receiving the positive EV PCR test result.
Optimizing Hepatitis C Therapy in HIV/hepatitis C Virus (HCV) Coinfected Patients: Analysis of HCV Viral Kinetics on Treatment
Authors: James Paul Damien , Wong David KH
Published: March 2016

INTRODUCTION: Hepatitis C virus (HCV) infection is potentially curable, but the sustained virological response (SVR) has been shown to be lower in patients coinfected HIV. A single‐centre experience treating individuals with HCV and HIV coinfection is reported.

METHODS: Twenty‐one patients who received standard doses of pegylated interferon with weight‐based dosing of ribavirin (mean 14.3 mg/kg) were retrospectively reviewed. Qualitative HCV polymerase chain reaction (PCR) was performed prospectively every four weeks if the patient remained HCV PCR positive. All patients with HCV genotype 1 were treated for 48 weeks. Patients with genotype 2 or 3 were treated for 24 weeks and 32 weeks to 36 weeks if their HCV RNA level was undetectable after four weeks (RVR4) or eight weeks (RVR8) of therapy, respectively. If RVR8 was not achieved, the treatment was continued for 48 weeks.

RESULTS: There were no dropouts or dose reductions within the first 12 weeks of treatment. SVR status was available for 20 patients and adequate serum for viral kinetics analyses was available for 17 patients. Eighty per cent of the patients achieved SVR (50% genotype 1; 100% genotypes 2 and 3). The week 8 viral load remained elevated for all genotype 1 nonresponders.

DISCUSSION: High effectiveness rates were seen, particularly in patients with HCV genotype 2 and 3 who were treated for shorter durations. HCV viral loads after eight weeks of therapy helped distinguish patients with HCV genotype 1 who would respond to therapy.
Anxiety and Functional Disability in a Large Sample of Children and Adolescents with Chronic Pain
Authors: Simons Laura E , Sieberg Christine B , Claar Robyn Lewis
Published: March 2016

BACKGROUND: Anxiety is the most common psychiatric condition in children and adolescents, and is linked to significant disruptions across domains of function. Due to the avoidant nature of anxiety and pain‐related disability, studying anxiety symptoms in children with chronic and recurrent pain conditions is important.

OBJECTIVES: To examine anxiety symptoms in a large cohort of children and adolescents evaluated for complex chronic and recurrent pain conditions.

METHODS: Through retrospective chart review, data on anxiety, pain and functional disability were collected from 655 children evaluated at a multidisciplinary pain clinic over a three‐year period.

RESULTS: Approximately 11% of children and adolescents reported clinically elevated anxiety symptoms, with elevated levels across dimensions of anxiety ranging from 14% (social anxiety, worry) to 27% (physiological). In addition, a notable 31% of the sample potentially minimized their anxiety by responding in a socially desirable manner. Anxiety was linearly associated with greater pain‐related functional disability, but was not directly correlated with pain. Moderation analyses revealed that at low levels of worry, higher levels of pain were associated with greater functional disability, whereas at high levels of worry, pain no longer predicted the level of functional disability.

CONCLUSIONS: These findings document the prevalence of anxiety in children and adolescents with chronic pain, and also extend recent studies examining the complex relationships among pain, anxiety and pain‐related disability.
Invasive Bacillus cereus Infection in a Renal Transplant Patient: A Case Report and Review
Authors: John Susan , Neary John , Lee Christine H
Published: March 2016

Bacillus cereus is a common cause of gastrointestinal diseases. The majority of individuals with B cereus‐related food poisoning recover without any specific treatment. It can, however, rarely cause invasive disease in immunocompromised patients.
Does Pain Necessarily Have an Affective Component? Negative Evidence from Blink Reflex Experiments
Authors: Horn Claudia , Blischke Yvonne , Kunz Miriam , Lautenbacher Stefan
Published: March 2016

The experience of pain can be described using two dimensions – sensory and affective‐motivational – of which the affective‐motivational component is strongly modulated by context and the cognitive appraisal of pain. In pain research, the sensory component is commonly represented by ratings of pain intensity, while the affective component is represented by ratings of pain unpleasantness. However, there is evidence to suggest that test subjects tend to judge pain intensity different from unpleasantness whenever separate scales for both dimensions are presented concurrently. This study used a startle reflex as an objective measure of affective response to stimuli of varying intensities to determine whether the affective component can be abolished when predictable stimulation paradigms are applied.

BACKGROUND: Experimental pain research has shown that the affective component of pain is influenced strongly by situational characteristics; affective pain processing appears to be particularly pronounced in situations that provoke a feeling of uncertainty and uncontrollability.

OBJECTIVES: To determine whether the affective component of pain can be completely abolished if a ‘safe’, particularly predictable stimulation paradigm is applied.

METHOD: Forty healthy volunteers recruited at the University of Bamberg (Bamberg, Germany) were assessed in two experiments. Tonic contact heat stimuli staged in three intensities (warmth, heat and pain) relative to the individual pain threshold was applied; these were predictable with regard to intensity and course, and the subjects had easy access to control. The startle reflex was assessed as an objective measure of affective response. In addition, the subjects provided unpleasantness ratings. To compare these results to a gold standard for affective response, affective pictures taken from the International Affective Picture System were presented during temperature stimulation in the second experiment.

RESULTS: Both experiments showed no potentiation of the startle reflex under painful heat stimulation compared with the two nonpainful stimulus intensities (heat and warmth), although the painful stimulation was clearly rated as more unpleasant.

CONCLUSIONS: Results suggest that it is possible to develop a ‘safe’ noxious stimulus, which is rated as clearly unpleasant, but lacks physiological indication of negative affect. This divergence might be explained by subjective ratings being influenced by the instructions. The possibility of reducing the pain affect by suggesting ‘safety’ may be of therapeutic interest.
The Coincidence of Necrotizing Enterocolitis and Rotavirus Infections and Potential Associations with Cytokines
Authors: Sızmaz Efsun , Satar Mehmet , Özlü Ferda , Yaman Akgün , Yıldızdaş Hacer Yapıcıoğlu , Özcan Kenan
Published: March 2016

BACKGROUND: Necrotizing enterocolitis (NEC) is the most common gastrointestinal disease in neonatal intensive care units. Although the pathogenesis of NEC remains unclear, evidence suggests that infections, especially bacterial infections, may play an important role. Viral infections may also result in NEC. Several outbreaks of NEC associated with rotaviruses have been described previously.

OBJECTIVE: To investigate the association between rotavirus (RV) and serum interleukin (IL)‐6 and IL‐8 levels in infants with NEC.

METHODS: RV infections were prospectively studied using antigen detection in the stools of 31 infants with NEC. Additionally, serum levels of IL‐6, IL‐8 and tumour necrosis factor‐alpha were tested using micro‐ELISA at 0 h and 48 h after diagnosis of NEC.

RESULTS: Fecal specimens from 13 infants were positive, while fecal specimens from 18 infants were negative for RV according to antigen detection (RV+ and RV− groups, respectively). The mortality rate and the severity of NEC were not significantly different between the RV+ and RV− groups. IL‐6 levels at 0 h and 48 h after diagnosis of NEC in RV+ infants were lower compared with RV− infants, while IL‐8 levels were greater at 0 h and 48 h after diagnosis of NEC in RV+ infants compared with RV− infants.

CONCLUSION: A high prevalence of RV infection in neonates with NEC was found. Decreased IL‐6 levels and increased IL‐8 and tumour necrosis factor‐alpha levels in RV+ neonates with NEC suggests a role for RV in NEC.
Small Bowel Enteroscopy
Authors: Teshima Christopher W , May Gary
Published: March 2016

Over the past decade, the advent of capsule endoscopy and balloon-assisted enteroscopy has revolutionized the approach to small intestinal diseases. The small bowel is no longer out of reach, and has fallen within the diagnostic and therapeutic realm of the gastrointestinal endoscopist. Double-balloon enteroscopy was the first type of balloon-assisted endoscopy and is the method for which there are the most data. Single-balloon enteroscopy has since been introduced as an alternative balloon-assisted method, followed more recently by the development of spiral overtube-assisted enteroscopy. The purpose of the present article is to review these methods of small bowel enteroscopy and to discuss the latest developments. While the investigation of small bowel diseases cannot be addressed without considering the central role of capsule endoscopy, a detailed assessment is beyond the scope of the present article, and capsule endoscopy will only be discussed as it pertains to enteroscopy.
Implementation of a Multidisciplinary Team Approach and Fish Oil Emulsion Administration in the Management of Infants with Short Bowel Syndrome and Parenteral Nutrition-Associated Liver Disease
Authors: Sant’Anna Ana MGA , Altamimi Eyad , Clause Rose-Frances , Saab Joanne , Mileski Heather , Cameron Brian , Fitzgerald Peter , Sant’Anna Guilherme M
Published: March 2016

OBJECTIVE: To describe the authors’ experience with the implementation of a multidisciplinary approach and use of fish oil emulsion (FOE) in the management of infants with short bowel syndrome (SBS) and parenteral nutrition-associated liver disease (PNALD).

METHODS: Between August 2006 and June 2009, four cases of SBS and severe PNALD were managed by the team using specifically developed protocols. The FOE was initiated if serum direct bilirubin levels were ≥100 μmol/L. To quantify the degree of exposure to high serum direct bilirubin levels over time, the area under the curve (AUC) for each patient was calculated before and after initiation of FOE. Linear regression analyses were performed to evaluate correlations between the AUC, duration of cholestasis and initiation of FOE.

RESULTS: All patients survived and no complications were observed during the study period. After the first patient, FOE was initiated progressively earlier, but poor correlation between the AUC before and after its introduction was observed (r2=0.41924). However, there was strong correlation between the duration of PNALD before FOE initiation and time to resolution (r2=0.72133): the earlier the FOE was initiated, the shorter the time to resolution.

CONCLUSION: The authors report a positive experience with the implementation of a multidisciplinary approach and the use of FOE in infants with SBS and severe PNALD. The earlier the FOE was initiated during the cholestatic process, the shorter the time to resolution. The present study is a hypothesis generator, raising the question of whether an earlier introduction of this particular therapy can effectively shorten the cholestasis process in these patients.
Economic Evaluation of Posaconazole Versus Standard Azole Therapy as Prophylaxis against Invasive Fungal Infections in Patients with Prolonged Neutropenia in Canada
Authors: Tahami Monfared Amir A , O’Sullivan Amy K , Rotstein Coleman , Papadopoulos George
Published: March 2016

INTRODUCTION: Posaconazole prophylaxis in high‐risk neutropenic patients prevents invasive fungal infection (IFI). An economic model was used to assess the cost effectiveness of posaconazole from a Canadian health care system perspective.

METHODS: A decision‐analytic model was developed based on data from a randomized trial comparing posaconazole with standard azole (fluconazole or itraconazole) therapy. The model was extrapolated to a lifetime horizon using one‐month Markov cycles; lifetime survival was specific to the underlying disease. Drug and treatment costs associated with IFI were estimated using published literature. The model was used to estimate total costs, IFIs avoided, life‐years gained and the incremental cost‐effectiveness ratio of posaconazole versus standard azole therapy, in 2007 Canadian dollars.

RESULTS: Based on the clinical trial data, posaconazole was associated with fewer cases of IFI (0.05 versus 0.11; P=0.003), increased life‐years (2.52 years versus 2.43 years) and slightly lower costs ($6,601 versus $7,045) per patient relative to standard azole therapy over a lifetime horizon. Higher acquisition costs for posaconazole were offset by IFI‐associated inpatient costs for those prophylaxed with standard azoles. Probabilistic sensitivity analysis indicated a 59% probability that posaconazole was cost‐saving versus standard azole therapy and a 96% probability that the incremental cost‐effectiveness ratio for posaconazole was at or below the $50,000 per life‐year saved threshold.

DISCUSSION: In Canada, posaconazole appears to be cost‐saving relative to standard azole therapy in IFI prevention among high‐risk neutropenic patients.
Cost Comparison of Linezolid Versus Vancomycin for Treatment of Complicated Skin and Skin‐Structure Infection Caused by Methicillin‐Resistant Staphylococcus aureus in Quebec
Authors: Pettigrew Martine , Thirion Daniel JG , Libman Michael , Zanotti Giovanni
Published: March 2016

BACKGROUND: In Canada, complicated skin and skin‐structure infection (cSSSI) caused by methicillin‐resistant Staphylococcus aureus (MRSA) is usually treated with antibiotics in hospital, with a follow‐up course at home for stable patients. The cost implications of using intravenous and oral linezolid instead of intravenous vancomycin in Canadian clinical practice have not been examined.

OBJECTIVES: To evaluate the potential treatment cost impact for the Quebec health care system of linezolid versus vancomycin for MRSA‐related cSSSI therapy, using a net impact analysis approach.

METHODS: Health care resource use associated with linezolid and vancomycin therapy was estimated for patients in Quebec, based on expert opinion. Costs were assigned to health care resources (antibiotics, medical supplies, laboratory testing and health care professional time) based on unit prices. The base‐case analysis assumed 14 days of antibiotic treatment for both agents; five days in hospital followed by nine days at home. Therapy duration, length of inpatient treatment and discharge rates were varied in sensitivity analyses.

RESULTS: Antibiotic costs were higher for linezolid than for vancomycin, for both inpatient ($874 versus $144, respectively) and outpatient therapy ($1,356 versus $1,242, respectively). Compared with vancomycin, lower costs for antibiotic preparation, administration and monitoring of linezolid offset drug acquisition costs. Total treatment costs were $3,850 for linezolid versus $5,189 for vancomycin. Results were sensitive to the number of treatment days spent at home and the discharge rate.

CONCLUSION: Using linezolid instead of vancomycin to treat MRSA‐related cSSSI, for hospital and home courses combined, may reduce health care resource utilization and costs in Quebec.