bluuebunny/crossref_metadata_2025 huggingface dataset:
Usefulness and Impact on Management of Positive and Negative Capsule Endoscopy
Authors: Chami George , Raza Mamoon , Bernstein Charles N
Published: March 2016

OBJECITIVE: To determine the usefulness of positive and negative capsule endoscopies (CEs), and the impact of each on short- and long-term patient management.

METHODS: Medical records were reviewed for 70 consecutive CE patients. Based on outcomes from referring physicians, it was determined whether CE was useful, partially useful or not useful at all in the overall patient management, and whether CE assisted in providing a diagnosis, and impacted on short-term long-term management.

RESULTS: CE indications included overt bleeding (37%), occult bleeding (20%), iron deficiency (17%), abdominal pain and weight loss (13%), assessing the extent of or confirming a diagnosis of Crohn’s disease (9%) and screening for familial adenomatous polyposis (4%). Positive studies were seen in 58% of overt bleeds, 50% of occult bleeds, 33% of iron deficiencies and 33% of Crohn’s diseases. Overall, 28 studies (40%) were positive studies and 42 (60%) were negative studies. CE aided in diagnosis in 11 of 28 (39%) positive and 12 of 42 (29%) negative studies (P=0.35). Positive and negative CEs had an impact on short-term management in 12 of 28 (43%) versus 18 of 42 (43%) cases, respectively (P=1.0), and on long-term management in 14 of 28 (50%) versus 15 of 42 (36%) cases, respectively (P=0.23). For positive and negative studies, respectively, CE was considered useful in 12 of 28 (43%) versus 15 of 42 (36%) cases (39% overall), partially useful in 10 of 28 (36%) versus 10 of 42 (24%) cases (28% overall), and not useful at all in six of 28 (21%) versus 17 of 42 (40%) cases (33% overall).

CONCLUSIONs: Although a negative CE may aid in making a definitive diagnosis in only 29% of patients, its effect on management and overall usefulness is similar to that of a positive CE. A physician’s decision on whether to order CE should not be based solely on the pretest probability of a positive examination but also on the clinical utility of a negative study.
Infection Control During Gastrointestinal Endoscopy
Authors: Nelson Douglas B , Adams Paul C
Published: March 2016

Dr Douglas Nelson is a staff physician in the department of gastroenterology at the Minneapolis VA Medical Center (Minnesota, USA) and a Professor of Medicine at the University of Minnesota (USA). He has written numerous articles on the subject of infection control during gastrointestinal endoscopy, and was the lead author of the "Multi-society guideline for reprocessing flexible gastrointestinal endoscopes" (1).
Sputum Neutrophilia Can Mask Eosinophilic Bronchitis During Exacerbations
Authors: D’silva Liesel , Allen Christopher J , Hargreave Frederick E , Parameswaran Krishnan
Published: March 2016

BACKGROUND: Exacerbations of airway disease are eosinophilic, neutrophilic, both or neither. The primary objective of the present study was to identify whether the treatment of a neutrophilic bronchitis can unmask an associated eosinophilia.

METHODS: A retrospective survey of 2160 consecutive sputum cell counts from 1343 patients with airway disease was conducted to identify patients with an isolated neutrophilic bronchitis, which was defined as a sputum total cell count of greater than or equal to 12×106 cells/g of sputum and a proportion of neutrophils of 80% or greater. The characteristics of the patients who subsequently demonstrated sputum eosinophilia (3% or greater) within eight weeks of resolving the neutrophilia were compared with the patients who subsequently did not have sputum eosinophilia.

RESULTS: Two hundred thirty‐seven patients had 273 neutrophilic exacerbations. The sputum was re‐examined within eight weeks in 65 patients (27.4%), of whom 38 (58.5%) had resolution of the neutrophilic bronchitis after treatment with an antibiotic. Of these 38 patients, 13 (34%) showed eosinophilia.

CONCLUSIONS: A neutrophilic exacerbation of airway disease was observed to mask sputum eosinophilia in one‐third of patients who had sputum cell counts available before and after antibiotic therapy. Hence, the absence of sputum eosinophilia during an infective exacerbation should not be used as an indication to reduce the dose of corticosteroids. To optimize therapy, repeat sputum cell count measurements are recommended after antibiotic treatment before changing corticosteroid treatment.
A Randomized Controlled Trial to Assess the Efficacy of Tiotropium in Canadian Patients with Chronic Obstructive Pulmonary Disease
Authors: Chan Charles KN , Maltais François , Sigouin Chris , Haddon Jennifer M , Ford Gordon T , on behalf of the SAFE Study Group
Published: March 2016

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) who smoke have a greater annual rate of decline in forced expiratory volume in 1 s (FEV1) than those patients who have stopped smoking.

OBJECTIVES: To assess the effect of tiotropium on pre‐dose (trough) FEV1 in patients with COPD followed in Canada.

METHODS: A total of 913 patients were randomly assigned to receive either tiotropium 18 μg once daily (n=608) or placebo (usual care minus inhaled anticholinergics) (n=305) for 48 weeks in the present randomized, double‐blind, parallel‐group study. The effect of tiotropium on measurements of lung function (FEV1, FEV6 and forced vital capacity), symptoms, health‐related quality of life (St George’s Respiratory Questionnaire) and exacerbations were examined.

RESULTS: Tiotropium improved trough FEV1 in both current and ex‐smokers compared with placebo. Baseline FEV1 in smokers and ex‐smokers was 1.03 L and 0.93 L, respectively (P<0.001). At week 48, the mean difference between the tiotropium and placebo groups was 0.14±0.04 L (P<0.001) in the smoker group and 0.08±0.02 L (P<0.0001) in the ex‐smoker group. Tiotropium also significantly improved trough forced vital capacity and FEV6 compared with placebo throughout the treatment period (P<0.05, for all). Furthermore, tiotropium significantly improved the St George’s Respiratory Questionnaire total score compared with placebo at week 48 (40.9 versus 43.7 units, P<0.005).

CONCLUSIONS: Compared with the placebo group, tiotropium provides sustained improvements in lung function in patients with COPD, with improvements for smokers and ex‐smokers.
Persistent Urethritis and Prostatitis Due to Trichomonas vaginalis: A Case Report
Authors: Abdolrasouli Alireza , Amin Abolghasem , Baharsefat Manouchehr , Roushan Azita , Mofidi Shamseddin
Published: March 2016

The present report describes a case of persistent urethritis accompanied by prostatitis due to Trichomonas vaginalis in a young male patient. The importance of the laboratory diagnosis of trichomoniasis in persistent or recurrent urethritis (ie, testing samples from multiple sites) is highlighted, with the aim of improving the clinical recognition of this pathogen.
Cost‐Effectiveness of Various Diagnostic Approaches for Occupational Asthma
Authors: Kennedy Wendy A , Girard Frédéric , Chaboillez Simone , Cartier André , Côté Johanne , Hargreave Frederick , Labrecque Manon , Malo Jean-Luc , Tarlo Susan M , Redlich Carrie A , Lemière Catherine
Published: March 2016

BACKGROUND: Diagnosis of occupational asthma (OA) by specific inhalation challenge (SIC) can be costly and is not always available. The use of sputum testing to avoid this in some patients may be a more cost‐effective alternative.

OBJECTIVES: To compare the cost‐effectiveness of SIC with serial measurements of sputum cell counts (sputum testing) and peak expiratory flow (PEF) monitoring.

METHODS: Clinical data and testing costs for OA in 49 patients were collected during a previously published trial, modelled and compared using TreeAge Pro. Clinical outcome was the percentage of accurately diagnosed patients, using SIC as the gold standard. The PEF approach used the most accurate assessment of five experts who were blinded to SIC results. Differences in the proportion of eosinophils during periods on and off work were used for the sputum testing approach and in PEF/sputum for the combined approach. Unit costs were estimated from charges in Canadian hospitals. Data were analyzed by one‐way and two‐way analyses, and by probabilistic sensitivity analysis using a Monte Carlo simulation technique.

RESULTS: The PEF approach had an estimated accuracy of 52% and cost $365 per patient tested. Compared with PEF monitoring, sputum testing was more accurate and cost an estimated $255 for each additional OA patient correctly diagnosed. SIC costs per additional correct diagnosis were $11,032 compared with sputum testing and $6,458 compared with PEF monitoring. The combined PEF/sputum testing approach was not cost‐effective in the base case analysis, but cannot be excluded according to probabilistic sensitivity analyses.

CONCLUSIONS: Although SIC remains the reference test to diagnose OA, when this test is not available, sputum testing is a cost‐effective alternative to PEF for diagnosis of OA.
Pulmonary Hyalinizing Granuloma in HIV/AIDS
Authors: Liu Theresa , Kyrollos Maggy , Kravcik Stephen
Published: March 2016

A 55‐year‐old man who was recently diagnosed with HIV/AIDS developed multiple bilateral pulmonary nodules after starting highly active antiretroviral therapy. Workup confirmed the diagnosis of pulmonary hyalinizing granuloma. This is the first described case of pulmonary hyalinizing granuloma in HIV/AIDS, and may represent a rare form of immune reconstitution inflammatory syndrome.
Nonsurgical Management of Severe Esophageal and Gastric Injury Following Alkali Ingestion
Authors: Abaskharoun Ramy D , Depew William T , Hookey Lawrence C
Published: March 2016

The ingestion of caustic substances may result in significant gastrointestinal injury. Endoscopy can play a major role in the initial evaluation and subsequent therapy of such injuries. The case of a 50-year-old man who ingested an alkaline floor stripper is described, including the endoscopic management of esophageal and pyloric strictures, with good functional results. The role of endoscopy, steroids and acid suppression in the management of such patients is also explored.
Diagnostic Value of Peripheral Lymph Node Biopsy in Sarcoidosis: A Report of 67 Cases
Authors: Yanardag Halil , Caner Metin , Papila Irfan , Uygun Sedat , Demirci Sabriye , Karayel Tuncer
Published: March 2016

A peripheral lymph node (PLN) 1 cm or greater was found in 79 of 546 sarcoidosis patients (14.5%) between 1972 and 2005. Seventy‐two of the 79 sarcoidosis patients had a lymph node biopsy performed. Sixty‐seven of these biopsy specimens were histologically diagnosed as sarcoidosis, whereas five patients had a reactive adenopathy. For patients with histological diagnosis of sarcoidosis, localizations of the biopsies were as follows: cervical (n=21), supra‐clavicular (n=20), inguinal (n=11), axillary (n=8), epitrochlear (n=5) and submandibular (n=2). At the time of biopsy, 12 patients had stage 0 disease, 37 patients had stage I disease, 14 patients had stage II disease and four patients had stage III disease. Skin involvement (16.4%) was the most frequently observed type of organ involvement in patients who had enlarged PLNs due to sarcoidosis. In the presence of an enlarged PLN in sarcoidosis, biopsy had a greater diagnostic value compared with other methods, as well as having a relatively low cost (approximately US$120) in Turkey. No procedure‐related complications were observed. In conclusion, it is recommended that PLNs be thoroughly examined when sarcoidosis is suspected. If an enlarged PLN is found, biopsy should be routinely performed because it is an easy, convenient and practical method, with a low complication risk and a high sensitivity.
Prevalence of Screening in Patients Newly Diagnosed with Colorectal Cancer in Ontario
Authors: Taylor Chelsea , Schultz Susan E , Paszat Lawrence F , Bondy Susan , Rabeneck Linda
Published: March 2016

OBJECTIVES: The primary objective was to determine the proportion of individuals with a new diagnosis of colorectal cancer (CRC) in Ontario in whom the cancer was screen detected. The secondary objectives were to determine the cancer stage at diagnosis and the indications for the procedure in patients who received their first colonoscopy.

PATIENTS AND METHODS: Individuals admitted to a hospital with a new diagnosis of CRC were randomly selected after stratifying by hospital type (teaching or community). The Canadian Institute for Health Information’s Discharge Abstract Database was used to identify individuals with a first diagnosis of CRC during calendar year (CY) 2000, and Ontario Health Insurance Plan data were used to identify people 50 to 74 years of age who had their first colonoscopy during CY 2000. Up to 20 individuals were selected for each group (CRC or colonoscopy) in each of seven randomly selected community hospitals and three randomly selected teaching hospitals. Data were abstracted from the hospital charts.

RESULTS: The hospital charts of 152 patients with a new diagnosis of CRC were examined. Of the 133 patients in whom screening status could be determined, eight had screen-detected cancers (6.0%). Of the 99 patients (65% of the sample) in whom stage could be determined, 43 (43.4%) had advanced disease (tumour-node-metastasis stage III or IV) at diagnosis. The hospital charts of 184 patients who underwent their first colonoscopy were examined. Of the 175 patients in whom the indication for colonoscopy could be determined, 45 underwent the procedure for screening purposes, 10 were for diagnostic workup of anemia and 120 for evaluation of symptoms.

CONCLUSIONS: The low proportion (6%) of screen-detected CRC and the high proportion of patients (43.4%) with advanced disease at diagnosis reflect the lack of an organized screening program.
Complementary and Alternative Medicine Use by Patients Chronically Infected with Hepatitis C Virus
Authors: White Colin P , Hirsch Gerilynn , Patel Sunil , Adams Fatin , Peltekian Kevork M
Published: March 2016

Complementary and alternative medicine (CAM) is becoming increasingly popular in North America. The use of CAM is also popular in patients with chronic liver disease but is not well documented. The extent of use of CAM in chronic hepatitis C virus (HCV) infected patients was determined, and the demographic and clinical data between users and nonusers of CAM was compared.

Seventy-six patients (30% female) with chronic HCV were interviewed. The mean age was 43±8 years. Current use of CAM for HCV was reported by 35 of 76 patients (46%). Eighteen of 76 patients within this group used herbal supplements (24%). The most commonly used herb wasSilybum marianum(milk thistle), reported by 10 of 76 patients (13.2%). Commonly reported benefits of CAM use included reduction in fatigue, boost in the immune system and improved gastrointestinal function. No adverse effects of CAM use were reported. In the present study, four of 18 patients (22%) with chronic liver disease taking herbal therapies were on herbs that increased bleeding time.

The use of CAM in chronic HCV patients is significant. Patients should be asked specifically about their use of CAM. CAM use may have implications affecting conventional treatment and management of HCV.
Methicillin‐Resistant Staphylococcus aureus: A Public Health Issue with Economic Consequences
Authors: Goetghebeur Mireille , Landry Pierre-Alexandre , Han Donald , Vicente Colin
Published: March 2016

BACKGROUND: Methicillin‐resistant Staphylococcus aureus (MRSA) has become endemic worldwide in hospitals, and community‐associated MRSA is spreading into the community at large.

OBJECTIVES: To estimate the current cost of MRSA in Canada and to assess the magnitude of this public health issue.

METHODS: An extensive review of the literature was conducted to gather epidemiology, health care resource utilization and cost data for MRSA in Canadian settings. The current MRSA burden was estimated using available cost data and the most recent epidemiology data.

RESULTS: The rate of MRSA in Canadian hospitals increased from 0.46 to 5.90 per 1000 admissions between 1995 and 2004, while community‐associated MRSA continued to spread into the community. Patients harbouring MRSA required prolonged hospitalization (average 26 days of isolation per patient), special control measures, expensive treatments and extensive surveillance. Total cost per infected MRSA patient averaged $12,216, with hospitalization being the major cost driver (81%), followed by barrier precautions (13%), antimicrobial therapy (4%) and laboratory investigations (2%). The most recent epidemiological data, combined with available cost data, suggest that direct health care cost attributable to MRSA in Canada, including cost for management of MRSA‐infected and‐colonized patients and MRSA infrastructure, averaged $82 million in 2004 and could reach $129 million in 2010.

CONCLUSION: MRSA is a costly public health issue that needs to be tackled if the growing burden of this disease in Canadian hospitals and in the community is to be limited.
Canadian Pediatric Gastroenterology Workforce: Current Status, Concerns and Future Projections
Authors: Morinville Véronique , Drouin Éric , Lévesque Dominique , Espinosa Victor M , Jacobson Kevan
Published: March 2016

BACKGROUND: There is concern that the Canadian pediatric gastroenterology workforce is inadequate to meet health care demands of the pediatric population. The Canadian Association of Gastroenterology Pediatric Committee performed a survey to determine characteristics and future plans of the Canadian pediatric gastroenterology workforce and trainees.

METHODS: Estimates of total and pediatric populations were obtained from the 2001 Census of Population, Statistics Canada (with estimates to July 1, 2005). Data on Canadian pediatric gastroenterologists, including clinical full-time equivalents, sex, work interests, opinions on workforce adequacy, retirement plans, fellowship training programs and future employment plans of fellows, were gathered through e-mail surveys and telephone correspondence in 2005 and 2006.

RESULTS: Canada had an estimated population of 32,270,507 in 2005 (6,967,853 people aged zero to 17 years). The pediatric gastroenterology workforce was estimated at 9.2 specialists per million children. Women accounted for 50% of the workforce. Physician to pediatric population ratios varied, with Alberta demonstrating the highest and Saskatchewan the lowest ratios (1:69,404 versus 1:240,950, respectively). Between 1998 and 2005, Canadian pediatric gastroenterology fellowship programs trained 65 fellows (65% international trainees). Twenty-two fellows (34%) entered the Canadian workforce.

CONCLUSIONS: The survey highlights the variable and overall low numbers of pediatric gastroenterologists across Canada, an increasingly female workforce, a greater percentage of part-time physicians and a small cohort of Canadian trainees. In conjunction with high projected retirement rates, greater demands on the work-force and desires to partake in nonclinical activities, there is concern for an increasing shortage of pediatric gastroenterologists in Canada in future years.
Usefulness of Pulsed‐Field Gel Electrophoresis in Tracking Two Outbreaks of Invasive Meningococcal Disease Serogroup C in British Columbia
Authors: Quan Grahame , Gilbert Mark , David Samara T , Rahim Tazim , Adie Kathy , Shaw Carol , McNabb Alan , Isaac-Renton Judy , Patrick David M
Published: March 2016

Two major outbreaks of invasive meningococcal disease serogroup C (IMD‐C) were identified in British Columbia between 2000 and 2004. Pulsed‐field gel electrophoresis (PFGE) and porA gene sequencing of all retained IMD‐C isolates were used to assess correlations between genotypes and epidemiological patterns. PFGE patterns of IMD‐C genotypes correlated with epidemiological patterns between 2000 and 2004 in British Columbia, and demonstrated that PFGE can identify outbreak‐related cases. Both IMD‐C outbreaks correlated with a respective PFGE pattern. PFGE analysis demonstrated that the 2004 British Columbia outbreak strain in men who have sex with men was closely related to the 2001 Abbotsford outbreak strain. PorA sequencing data indicated low diversity of class 1 outer membrane proteins in British Columbia, and did not correlate with epidemiological trends. There was a trend for outbreak‐associated PFGE types to demonstrate higher case fatality rates.
Survey of the Practice of Spinal Cord Stimulators and Intrathecal Analgesic Delivery Implants for Management of Pain in Canada
Authors: Peng Philip WH , Fedoroff Ingrid , Jacques Line , Kumar Krishna
Published: March 2016

BACKGROUND: In 2006, the Canadian Neuromodulation Society was formed. The present survey characterizes the practice of spinal cord stimulator (SCS) and intrathecal analgesic delivery pump (IADP) implantation for pain management in different centres across Canada.

METHOD: A structured questionnaire was designed to examine the funding source, infrastructure and patient screening process in different centres implanting SCSs and IADPs. Centres that performed more than 10 implants per year were surveyed. The survey was centre‐based, ie, each centre received one questionnaire regardless of the number of staff involved in neuromodulation practice.

RESULTS: Fourteen centres were identified and 13 responded. Implantation of SCS and IADP was performed in 12 and 10 centres, respectively. In most centres, failed back surgery syndrome was the most frequent indication for SCS and IADP implantation. For SCS, all centres always performed a trial; the majority used percutaneous electrode (83%) before the SCS implantation. Routine psychological screening was performed in 25% of centres before any SCS trial procedure. For IADP, all centres performed a trial injection or infusion before implantation. Five centres (50%) performed psychological screening in almost all patients. Continuous infusion techniques were the most popular (50%) used for the trial.

CONCLUSION: The present survey provides a ‘snapshot’ of the practice of SCS and IADP implantation in Canada. A review of SCS and IADP trials indicated that Canadian practices are mostly, but not always, consistent with those elsewhere.
Endoscopic pH Monitoring for Patients with Suspected or Refractory Gastroesophageal Reflux Disease
Authors: Turner Brian G , Saltzman John R , Hua Ling , Maurer Rie , Feldman Natan , Carr-Locke David L , Burakoff Robert , Liu Julia J
Published: March 2016

BACKGROUND: Wireless pH studies can offer prolonged pH monitoring, which may potentially facilitate the diagnosis and management of patients with gastroesophageal reflux disease (GERD). The aim of the present study was to evaluate the detection rate of abnormal esophageal acid exposure using prolonged pH monitoring in patients with suspected or refractory GERD symptoms.

METHODS: Patients undergoing prolonged ambulatory pH studies for the evaluation of GERD-related symptoms were assessed. Patients with a known diagnosis of GERD were tested on medical therapy, while patients with suspected GERD were tested off therapy. The wireless pH capsules were placed during upper endoscopy 6 cm above the squamocolumnar junction.

RESULTS: One hundred ninety-one patients underwent a total of 198 pH studies. Fifty ambulatory pH studies (25%) were excluded from the analysis: 27 patients (14%) had insufficient data capture (less than 18 h on at least one day of monitoring), 15 patients had premature capsule release (7%), seven were repeat studies (3.5%) and one had intolerable pain requiring capsule removal (0.5%). There were 115 patients undergoing pH studies who were off medication, and 33 patients were on therapy. For the two groups of patients, results were as follows: 32 (28%) and 22 (67%) patients with normal studies on both days; 58 (50%) and five (15%) patients with abnormal studies on both days; 18 (16%) and three (9%) patients with abnormal studies on day 1 only; and seven (6%) and three (9%) patients with abnormal studies on day 2 only, respectively.

CONCLUSIONS: Prolonged 48 h pH monitoring can detect more abnormal esophageal acid exposure but is associated with a significant rate of incomplete studies.
Validation of the 30 Second Asthma Test™ as a Measure of Asthma Control
Authors: Ahmed Sara , Ernst Pierre , Tamblyn Robyn , Colman Neil
Published: March 2016

BACKGROUND: The primary objective of asthma management is to help patients establish and maintain optimal disease control. Simple and efficient tools are needed to assess patient‐reported symptoms so that they can be used with or without airway function to evaluate asthma control.

OBJECTIVE: The objective of the present study was to evaluate the validity of The 30 Second Asthma Test (GlaxoSmithKline Inc, Canada), based on the Canadian Asthma Guidelines, by estimating its relationship with criterion measures of control.

RESULTS: The discriminative and diagnostic validity of The 30 Second Asthma Test™ was examined in a sample of 81 patients with a confirmed diagnosis of asthma. Based on a cut‐off score of two or greater on The 30 Second Asthma Test™, the overall agreement with specialist ratings was 65%, and 58% with per cent predicted forced expiratory volume in 1 s. The 30 Second Asthma Test™ scores distinguished between groups of patients who were classified based on the change in intensity of therapy.

CONCLUSION: The results support the use of The 30 Second Asthma Test™ as a brief screening tool for asthma control.
The Epic of Phage Therapy
Authors: Dublanchet Alain , Bourne Shawna
Published: March 2016

The present report describes the presentation given by Dr Alain Dublanchet at the Stanier/Oxford Hygiene Symposium, held in Oxford, England, on November 10, 2004. Dr Dublanchet′s lecture, entitled ‘The epic of phage therapy’, provided a sequential account of the use of phage as an antimicrobial from its discovery to its rise and fall and current rediscovery.
Hospital‐Acquired Phaeohyphomycosis Due to Exserohilum rostratum in a Child with Leukemia
Authors: Saint-Jean Maude , St-Germain Guy , Laferrière Céline , Tapiero Bruce
Published: March 2016

The present study describes a case of cutaneous phaeohyphomycosis caused by Exserohilum rostratum in a child undergoing treatment for leukemia. The infection was possibly due to contaminated intravenous dressings and was successfully treated with surgical excision combined with liposomal amphotericin B. Consequently, new infection control policies have been implemented at CHU Sainte‐Justine (Montreal, Quebec).
Contributing to Communicable Diseases Intelligence Management in Canada: CACMID Meeting, March 2007, Halifax, Nova Scotia
Authors: Mukhi Shamir , Aramini Jeff , Kabani Amin
Published: March 2016

In the spring of 2003, the Public Health Agency of Canada (then, Health Canada) partnered with several provincial/territorial and regional public health stakeholders to improve pan‐Canadian public health surveillance, communications and response through the application of new technologies. This resulted in the creation of the Canadian Network for Public Health Intelligence (CNPHI), a comprehensive framework of applications and resources designed to fill critical gaps in Canada′s national public health infostructure. Over the past four years, the CNPHI has evolved into Canada′s only pan‐Canadian public health information management system. With over 2000 registered users, the current CNPHI environment consists of more than 30 integrated applications and systems that can be loosely categorized into four functional groups: data exchange; data analysis and integration; communication, collaboration and coordination; and knowledge management. Despite poor data repositories, legacy information management systems, and the lack of standards and agreements, the CNPHI has demonstrated that much can be accomplished in these areas. Over the next decade, significant barriers impeding additional advances will be bridged through the implementation of the Electronic Health Record, and through ongoing efforts to address gaps in standards, and data‐ and information‐sharing agreements. Together with new technologies coming on‐line, opportunities to further enhance public health surveillance and response will be limited only by one′s imagination.
Reproducibility of Wireless Capsule Endoscopy in the Investigation of Chronic Obscure Gastrointestinal Bleeding
Authors: Christodoulou Dimitrios , Haber Gregory , Beejay Umar , Tang Shou-jiang , Zanati Simon , Petroniene Rima , Cirocco Maria , Kortan Paul , Kandel Gabor , Tatsioni Athina , Tsianos Epameinondas , Marcon Norman
Published: March 2016

BACKGROUND: Capsule endoscopy (CE) is a valuable tool in the diagnostic evaluation of obscure gastrointestinal bleeding, but limited information is available on the reproducibility of CE findings.

OBJECTIVE: To compare two successive CE studies with push enteroscopy (PE) in patients presenting with chronic obscure gastrointestinal bleeding.

METHODS: A prospective study was conducted. Ten patients (seven men and three women) with chronic obscure gastrointestinal bleeding and no contraindications for CE were eligible and completed the trial. For each patient, the first capsule was administered on day 1, the second capsule was administered on day 2 and PE was performed on day 3. Endoscopists were blinded to the capsule findings. Capsule findings were assessed independently by two investigators blinded to PE findings.

RESULTS: A potential small intestinal bleeding source was found in 60% of the patients when all the studies were combined. A bleeding source was found in four patients in both CE studies. The second CE also identified a bleeding source in a fifth patient. Interobserver agreement by kappa analysis was 0.642 to 1.000 (P≤0.05) for the CE studies. PE identified a potential small bowel bleeding site in four patients, including one patient who had negative CE studies.

CONCLUSIONS: This study confirmed the reproducibility of CE findings on successive studies. Some patients did not have a source of bleeding in the small intestine, and all studies found this.
Times have Changed – Is it Time to Consider Restructuring the CAG?
Authors: Paterson William G
Published: March 2016

Following the 2005 annual general meeting of the Canadian Association of Gastroenterology (CAG) where certain proposals for CAG bylaw revisions were tabled, the CAG Board decided to create an ad hoc committee to take a more comprehensive look at restructuring the CAG management, which in turn would result in proposals for bylaw amendments. A committee consisting of William Paterson, Des Leddin, Ronald Bridges, Mary Perdue, John Wallace and Paul Sinclair was formed. This committee endorsed the need to make fundamental changes in the structure of the CAG management to streamline the operations of the organization and better achieve its strategic goals. It was further agreed that the process for implementing change must involve broad consultation with the CAG Board and the membership. The present document represents the first step in this consultative process.
Comparison of Canadian Versus American Emergency Department Visits for Acute Asthma
Authors: Rowe Brian H , Bota Gary W , Clark Sunday , Camargo Carlos A , on behalf of the Multicenter Airway Research Collaboration i
Published: March 2016

BACKGROUND: Acute asthma is a common emergency department (ED) presentation in both Canada and the United States.

OBJECTIVE: To compare ED asthma management and outcomes between Canada and the United States.

MEHODS: A prospective cohort study of 69 American and eight Canadian EDs was conducted. Patients aged two to 54 years who presented with acute asthma underwent a structured ED interview and telephone follow‐up two weeks later.

RESULTS: A total of 3031 patients were enrolled. Canadian patients were more likely to be white (89% versus 22%; P<0.001), have health insurance (100% versus 69%; P<0.001) and identify a primary care provider (89% versus 64%; P<0.001) than American patients. In addition, Canadian patients were more likely to be using inhaled corticosteroids (63% versus 44%; P<0.001) and had higher initial peak expiratory flow (61% versus 48%; P<0.001). In the ED, Canadians received fewer beta‐agonist (one versus two; P<0.001) and more anticholinergic (two versus one; P<0.001) treatments in the first hour; use of systemic corticosteroids was similar (60% versus 68%; P=0.13). Canadians were less likely to be hospitalized (11% versus 21%; P=0.02). Corticosteroids were prescribed similarly at discharge (60% versus 69%; P=0.13); however, Canadians were discharged more commonly on inhaled corticosteroids (63% versus 11%; P<0.001) and relapses were similar.

CONCLUSIONS: Canadian patients with acute asthma have fewer barriers to primary care and are more likely to be on preventive medications, both before the ED visit and following discharge. Admissions rates are higher in the United States; however, relapse after discharge is similar between countries. These findings highlight the influences of preventive practices and heath care systems on ED visits for asthma.
Admission is not Always Necessary for Patients with Community‐Acquired Pneumonia in Risk Classes IV and V Diagnosed in the Emergency Room
Authors: Marrie TJ , Huang JQ
Published: March 2016

OBJECTIVE: To determine the factors that allow patients with community‐acquired pneumonia who are at high risk of mortality (risk classes IV and V) to be treated at home.

DESIGN: A prospective, observational study.

SETTING: Six hospitals and one free‐standing emergency room in Edmonton, Alberta.

PARTICIPANTS: The present study included 2354 patients in risk classes IV and V who had a diagnosis of pneumonia made by an emergency room physician or an internist.

MEASUREMENTS: Symptoms, signs and laboratory findings, as well as outcome measures of length of stay and mortality.

RESULTS: Of the total study group, 319 of the patients (13.5%) were treated on an ambulatory basis. Factors predictive of admission were definite or possible pneumonia on chest radiograph as read by a radiologist, functional impairment, altered mental status, substance abuse, psychiatric disorder, abnormal white blood cell count, abnormal lymphocyte count, oxygen saturation less than 90% and antibiotic administration in the week before admission. If chest pain was present, admission was less likely. Only two of the 319 patients required subsequent admission (both had positive blood cultures) and only two died.

CONCLUSIONS: A substantial number of patients in risk classes IV and V can be safely treated at home. Factors that help clinicians to select this subset of patients are discussed.
Ventilation and Perfusion Lung Scintigraphy of Allergen‐Induced Airway Responses in Atopic Asthmatic Subjects
Authors: Parameswaran Krishnan , Knight Andrew C , Keaney Niall P , Williams E David , Taylor Ian K
Published: March 2016

BACKGROUND: Both ventilation (V) and perfusion (Q) of the lungs are altered in asthma, but their relationships with allergen‐induced airway responses and gas exchange are not well described.

METHODS: The effects of aerosolized allergen provocation of V/Q abnormalities in nonsmoking, male atopic asthmatics (six dual responders and two isolated early responders) were compared with measurements of airflow limitation (forced expiratory volume in 1 s [FEV1]), gas exchange (arterial oxygen saturation, arterial oxygen partial pressure and alveolar‐arterial oxygen gradient) and airway reactivity (provocative concentration of histamine causing a decrease of 20% in FEV1). V and Q lung scans at 30 min and 6 h following allergen challenge and changes in all variables were compared with prechallenge data. Digital image data were registered to baseline scans, and quantitative comparisons of changes made were supported by qualitative assessments of the images.

RESULTS: All subjects showed evidence of impaired gas exchange, as reflected by lowered arterial oxygen tension and widened alveolar arterial oxygen gradients. Baseline V/Q scans were abnormal, and there were allergen‐induced changes in V and Q at 30 min, with scans at 6 h showing additional changes in Q, particularly in dual responders. Allergen‐induced gas trapping was evident at 30 min and was sustained at 6 h.

CONCLUSIONS: Regional patterns of V and Q derived from lung scintigraphy showed a wider range of disturbances than were indicated by the magnitude of airflow limitation and arterial hypoxemia following allergen provocation, and they remained abnormal despite normalization of FEV1. Imaging of regional abnormalities of gas exchange may be relevant in the evaluation of patients with asthma.
The Effect of Biliary Sphincterotomy on Serum Cholesterol Levels in Postcholecystectomy Patients: A Pilot Study
Authors: Alazmi Waleed M , Fogel Evan L , Watkins James L , McHenry Lee , Sherman Stuart , Lehman Glen A
Published: March 2016

BACKGROUND: Cholesterol, in the form of bile salts, is reabsorbed from the small intestine via the enterohepatic circulation. Biliary sphincterotomy increases the delivery of bile to the terminal ileum. If the absorptive capacity is exceeded, cholesterol excretion may increase, resulting in a decrease in serum cholesterol levels and improvement in serum lipid profiles.

AIM: To determine the effect of biliary sphincterotomy on serum cholesterol levels in patients without biliary obstruction.

PATIENTS AND METHODS: Postcholecystectomy patients with type III biliary sphincter of Oddi dysfunction (disabling pancreatobiliary-type pain with normal liver function tests and bile duct diameter) who underwent biliary sphincterotomy were identified retrospectively from the endoscopic retrograde cholangiopancreatography database. Baseline (pre-endoscopic retrograde cholangiopancreatography) laboratory investigations (including cholesterol) were obtained for all patients. The effect of sphincterotomy on total cholesterol levels was noted in all patients who returned for subsequent procedures (temporary pancreatic stent removal or evaluation of recurrent symptoms), and also in the subgroup of patients with baseline hypercholesterolemia (higher than 5.18 mmol/L).

RESULTS: In the present pilot study, the performance of biliary sphincterotomy was associated with a reduction in total serum cholesterol levels in postcholecystectomy patients without biliary obstruction. This was statistically significant in patients with a baseline cholesterol level higher than 5.18 mmol/L. A possible effect on low-and high-density lipoprotein concentrations was not evaluated. The influence of dietary changes and exercise were not accounted for.

CONCLUSION: A prospective, controlled study involving a larger series of patients is required to determine whether biliary sphincterotomy lowers cholesterol levels and improves lipid profiles.
The Diagnosis of Genital Herpes – Beyond Culture: An Evidence‐Based Guide for the Utilization of Polymerase Chain Reaction and Herpes Simplex Virus Type‐Specific Serology
Authors: Ratnam S , Severini A , Zahariadis G , Petric M , Romanowski B
Published: March 2016

Accurate identification of persons with genital herpes is necessary for optimal patient management and prevention of transmission. Because of inherent inaccuracies, clinical diagnosis of genital herpes should be confirmed by laboratory testing for the causative agents herpes simplex virus type 1 (HSV‐1) and HSV type 2 (HSV‐2). Further identification of the HSV type is valuable for counselling on the natural history of infection and risk of transmission. Laboratory methods include antigen detection, culture, polymerase chain reaction (PCR) and conventional and type‐specific serology (TSS). PCR has, by far, the greater sensitivity and should be the test of choice for symptomatic cases. HSV‐2 TSS is indicated for patients with genital lesions in whom antigen detection, culture or PCR fail to detect HSV, and for patients who are asymptomatic but have a history suggestive of genital herpes. HSV‐2 TSS is further indicated for patients infected with HIV. HSV‐2 TSS along with HSV‐1 TSS may be considered, as appropriate, in evaluating infection and/or immune status in couples discordant for genital herpes, women who develop their first clinical episode of genital herpes during pregnancy, asymptomatic pregnant women whose partners have a history of genital herpes or HIV infection, and women contemplating pregnancy or considering sexual partnership with those with a history of genital herpes. The above should be performed in conjunction with counselling of infected persons and their sex partners.
Nursing Staff Knowledge and Beliefs about Pain in Elderly Nursing Home Residents with Dementia
Authors: Zwakhalen Sandra MG , Hamers Jan PH , Peijnenburg Rieneke HA , Berger Martijn PF
Published: March 2016

BACKGROUND: Aging is known to be associated with a high prevalence (up to 80%) of persistent pain among residents of nursing homes. However, even with high pain prevalence rates, nursing home residents are at risk for undertreatment. Knowledge deficits and beliefs among nurses influence staff behaviour in pain assessment and management.

OBJECTIVES: To develop a psychometrically sound questionnaire and to gather information about knowledge and beliefs of nursing staff regarding various aspects of pain in elderly patients with dementia. In addition, the differences among several categories of nurses (based on educational level and work experience) with respect to beliefs about pain were investigated.

METHODS: Participants were 123 staff members of psychogeriatric wards in two nursing homes in the Netherlands (mean of 11.4 years of experience). Their results were compared with those of two groups of nurses, one consisting of 25 registered nurse PhD students in nursing science and the other consisting of 20 trainee pain nurse specialists.

RESULTS: The main findings indicate that nursing home staff respondents showed knowledge deficits about several aspects of pain, even though they were satisfied about the way pain was assessed and treated at their wards. Specific knowledge deficits were found regarding pain treatment and medication in elderly nursing home residents. Staff educational level seemed to influence their beliefs and knowledge about pain in elderly nursing home patients.
Who Provides Gastrointestinal Endoscopy in Canada?
Authors: Hilsden Robert J , Tepper Joshua , Moayyedi Paul , Rabeneck Linda
Published: March 2016

PURPOSE: To determine who provides gastrointestinal endoscopy in Canada and to understand provincial and regional differences in endoscopy providers.

METHODS: Aggregate physician sociodemographic and activity data for 2002 were obtained from the Canadian Institute of Health Information’s National Physician Database. Physicians were classified as gastroenterologists, general surgeons and others.

RESULTS: In 2002, 1444 physicians, including 735 surgeons, 551 gastroenterologists and 158 others, performed at least 100 colonoscopies or 100 gastroscopies. Gastroenterologists performed 53% of all colonoscopies and 59% of all gastroscopies. Gastroenterologists were the primary providers of colonoscopies in large urban areas, whereas surgeons were the primary providers in smaller urban and rural areas. An average of 317 colonoscopies were performed by surgeons, 516 by gastroenterologists and 203 by other physicians. The proportion of surgeon colonoscopists in each province ranged from 47% to 71%.

CONCLUSIONS: Surgeons and gastroenterologists are the major providers of gastrointestinal endoscopy in Canada, but the distribution of these providers among provinces and urban and rural areas varies. Although surgeon endoscopists are more numerous, on average, they perform fewer procedures annually than internists.
Elastography in Hepatology
Authors: Abenavoli Ludovico , Corpechot Christophe , Poupon Raoul
Published: March 2016

A common characteristic of all chronic liver diseases is the occurrence and progression of fibrosis toward cirrhosis. Consequently, liver fibrosis assessment plays an important role in hepatology. Besides its importance for prognosis, determining the level of fibrosis reveals the natural history of the disease and the risk factors associated with its progression, to guide the antifibrotic action of different treatments. Currently, in clinical practice, there are three available methods for the evaluation of liver fibrosis: liver biopsy, which is still considered to be the ‘gold standard’; serological markers of fibrosis and their mathematical combination – suggested in recent years to be an alternative to liver biopsy – and, more recently, transient elastography (TE). TE is a new, simple and noninvasive method used to measure liver stiffness. This technique is based on the progressing speed of an elastic shear wave within the liver. Currently, there are only a few studies that have evaluated TE effectiveness in chronic liver diseases, mostly in patients infected with the hepatitis C virus. Further studies are needed in patients with chronic liver disease, to assess the effectiveness of the fibrosis treatment.
A Randomized, Double‐Blind, Placebo‐Controlled Clinical Trial Using a Low‐Frequency Magnetic Field in the Treatment of Musculoskeletal Chronic Pain
Authors: Thomas Alex W , Graham Karissa , Prato Frank S , McKay Julia , Forster Patricia Morley , Moulin Dwight E , Chari Sesh
Published: March 2016

Exposure to a specific pulsed electromagnetic field (PEMF) has been shown to produce analgesic (antinociceptive) effects in many organisms. In a randomized, double‐blind, sham‐controlled clinical trial, patients with either chronic generalized pain from fibromyalgia (FM) or chronic localized musculoskeletal or inflammatory pain were exposed to a PEMF (400 μT) through a portable device fitted to their head during twice‐daily 40 min treatments over seven days. The effect of this PEMF on pain reduction was recorded using a visual analogue scale. A differential effect of PEMF over sham treatment was noticed in patients with FM, which approached statistical significance (P=0.06) despite low numbers (n=17); this effect was not evident in those without FM (P=0.93; n=15). PEMF may be a novel, safe and effective therapeutic tool for use in at least certain subsets of patients with chronic, nonmalignant pain. Clearly, however, a larger randomized, double‐blind clinical trial with just FM patients is warranted.
A Review of Current Issues Underlying Colon Cleansing before Colonoscopy
Authors: Hookey Lawrence C , Vanner Stephen
Published: March 2016

The present review examines four current issues related to the efficacy, patient tolerance and safety of the following bowel cleansing agents: oral sodium phosphate (NaP), polyethylene glycol (PEG) and magnesium citrate (Pico-Salax, Ferring Pharmaceuticals Inc, Canada), an agent recently made available in Canada. MedLine and PubMed databases were systematically searched to identify studies related to the efficacy of altered PEG solutions combined with adjunct treatments; the efficacy, tolerability and safety of Pico-Salax; the association between nephrocalcinosis, and chronic renal failure and oral NaP use; and the role of diet. Although lower volume PEG solutions combined with adjuvant agents were generally associated with better patient tolerance, their efficacy was varied and interpretation of this end point is complicated by study design issues. There are very few reported studies of Pico-Salax, and as a result, there are insufficient data to draw conclusions about the efficacy of this agent. The available data suggest that Pico-Salax may be better tolerated by patients, than oral NaP and PEG solutions. There is a paucity of hemodynamic monitoring data pre- and postadministration, but the available data suggests that this small-volume osmotic agent could cause subclinical contraction of the intravascular space. Recent case reports suggest an association between nephrocalcinosis and oral NaP ingestion, but to date, these reports have been confined to a single centre. Preliminary studies suggest that this is not a widespread problem, but more studies are needed. There are only a few studies examining diet and patient tolerability, but they do suggest that diet may be liberalized with some cleansing regimens to enhance tolerability without decreasing efficacy. The present review highlights current controversies and advances in colon cleansing before colonoscopy, and also identifies areas for further study.