bluuebunny/crossref_metadata_2025 huggingface dataset:
Mode of Transmission, Rather than the Hepatitis C Virus, as a Major Determinant of Poor Interpersonal Relationships in Patients with Chronic Hepatitis C
Authors: La Thuy Phuong , Deschênes Marc
Published: March 2016

BACKGROUND: Recent studies have demonstrated that patients with the hepatitis C virus (HCV) have significant neurocognitive impairment.

OBJECTIVE: To assess whether chronic HCV infection impacts on patient marital status, living arrangement and employment.

METHODS: The charts of patients with chronic hepatitis C and hepatitis B were reviewed.

RESULTS: The mean (± SD) age of the 129 patients with the hepatitis B virus (HBV) was 46±15 years and that of the 428 patients with HCV was 48±15 years. Sixty-seven per cent of HBV patients were men, compared with 68% of HCV patients. Eighty per cent of HCV patients were Caucasian, compared with 44% of patients with HBV. The main modes of transmission were intravenous drug use (37%) and transfusion of blood products (37%) for HCV, compared with country of origin (76%) for HBV. There were no differences in marital status rates between HBV- and HCV-infected patients (HBV – married (73%), single (21%) and divorced (6%); and HCV – married (66%), single (23%) and divorced (10%); P=0.20). HCV patients lived alone more often than HBV patients (HBV – 13%, HCV – 22%; P=0.03). There was no difference in overall employment rate between HCV and HBV patients (81% versus 87%; P=0.15). Though there may not have been overall differences between HCV and HBV marital status and employment status, there were differences in the HCV subgroups. These subgroup differences were discovered in the multivariate analysis; mode of transmission was identified as the only predictor of the patients’ marital status and employment status.

CONCLUSIONS: The most important determinant of interpersonal relationships was the mode of transmission of the viral hepatitis rather than the type of viral infection: past intravenous drug users had lower level relationships.
Increased Risk of Colorectal Cancer in Ulcerative Colitis Patients Diagnosed after 40 Years of Age
Authors: Karvellas Constantine J , Fedorak Richard N , Hanson John , Wong Clarence KW
Published: March 2016

BACKGROUND: The association between ulcerative colitis (UC) and colorectal cancer (CRC) is well established. Retrospective data show a 5.4% CRC incidence rate among patients with pancolitis and suggest that cancer surveillance should be provided to patients following eight to 10 years of extensive UC.

AIM: To identify premalignant risk factors for UC patients and to determine whether current recommendations for cancer surveillance need reviewing.

PATIENTS AND METHODS: A retrospective audit was conducted of adult patients with UC who were diagnosed with CRC between 1991 and 2002 in five hospitals in Edmonton, Alberta.

RESULTS: Thirty-one cases of CRC (68% male) were identified. In this group, the mean ages at diagnosis were 44.4 years for UC patients and 60.1 years for CRC patients. For patients in whom the initial data of diagnosis of UC could be determined (n=29), the median duration of UC at the time of CRC diagnosis was 16 years. Patients diagnosed with UC after 40 years of age (n=15, mean age 64 years) progressed more rapidly to CRC than patients diagnosed before 40 years of age (n=14, mean age 23 years). The median durations of UC before development of CRC were 22 years and 10 years, respectively, for patients with a diagnosis of UC before and after 40 years of age (OR 11.5, 95% CI 2.41 to 20.16; P=0.00029). Only four patients (13%) were enrolled in an appropriate cancer-screening program. Nine of these UC patients (29%) who were older than 40 years of age developed CRC before the 10-year point.

CONCLUSIONS: In the present study, patients diagnosed with UC after 40 years of age developed CRC more rapidly than those diagnosed before 40 years of age. This finding suggests that patients who are diagnosed with UC after 40 years of age should undergo CRC surveillance earlier than current recommendations.
Health Care‐Associated Staphylococcus aureus Pneumonia
Authors: Webster Duncan , Chui Linda , Tyrrell Gregory J , Marrie Thomas J
Published: March 2016

INTRODUCTION: While Staphylococcus aureus is an uncommon but serious cause of traditional community‐acquired pneumonia (CAP), it is a predominant cause of nosocomial pneumonia in addition to the unique clinical entity of health care‐associated pneumonia (HCAP). A cohort of bacteremic S aureus pneumonia cases was reviewed to determine the role of HCAP among the cohort, and to assess for differences between CAP and HCAP.

PATIENTS AND METHODS: Bacteremic S aureus pneumonia cases were identified from a prospective study of all patients diagnosed with CAP who presented to hospitals in Edmonton, Alberta, between November 2000 and November 2002. These cases were subsequently reviewed retrospectively. Demographic, clinical and microbiological data were obtained, and patients were classified as having CAP or HCAP. Relatedness of isolates was determined by pulsed‐field gel electrophoresis analysis in conjunction with epidemiological information.

RESULTS: There were 28 cases of bacteremic S aureus pneumonia identified. Fifty‐seven per cent were reclassified as having HCAP, and 43% remained classified as having CAP. The CAP cohort was significantly younger than the HCAP cohort (mean age 49.0±23.7 years versus 67.8±18.6 years; P=0.035) with higher rates of intravenous drug use (50% versus 0%; P=0.002). Long‐term care facility residence (44%) was common in the HCAP cohort. The HCAP cohort presented with more severe illness, having a higher mean pneumonia severity index score (143.1±41.1 versus 98.2±54.6; P=0.028), and despite fewer embolic complications, there was a trend toward a significantly higher mortality rate (31% versus 0%; P=0.052). Two community‐acquired isolates cultured in the setting of intravenous drug use were methicillin‐resistant, and no isolates were positive for Panton‐Valentine leukocidin. There was evidence of relatedness involving 44% of the HCAP isolates by pulsed‐field gel electrophoresis analysis.

CONCLUSION: HCAP accounts for a significant number of cases that, when using traditional definitions, would be classified as CAP. Severity of illness and mortality was excessive within the HCAP group. There was evidence of relatedness and spread of common strains in the HCAP cohort. The present study supports recommendations for treatment guidelines directed toward the entity of HCAP and the empirical coverage of S aureus among certain high‐risk groups.
Catamenial Hemoptysis and Pneumothoraces in a Patient with Cystic Fibrosis
Authors: Parker Chris M , Nolan Robert , Lougheed M Diane
Published: March 2016

Hemoptysis or pneumothorax that recurs with the onset of menses is strongly suggestive of thoracic endometriosis syndrome (TES). TES is a rare disorder, with relatively few cases reported in the literature. A 32‐year‐old woman with cystic fibrosis, who over a period of several months had experienced recurrent catamenial hemoptysis and pneumothoraces, including an episode of life‐threatening hemoptysis that coincided with menstruation, is presented. Thoracic computed tomography and magnetic resonance imaging scans, as well as a bronchosopic evaluation that demonstrated endobronchial lesions that disappeared after menses, support the diagnosis of TES in the present patient. The patient was treated empirically with danazol and subsequently underwent a successful double‐lung transplantation. Danazol was discontinued postoperatively, and she was started on an oral contraceptive. Eighteen months post‐transplant, she has not experienced a recurrence of her catamenial symptoms, despite having resumed a regular menstrual cycle.
Two Sisters with Idiopathic Pulmonary Hemosiderosis
Authors: Gencer Mehmet , Ceylan Erkan , Bitiren Muharrem , Koc Ahmet
Published: March 2016

Idiopathic pulmonary hemosiderosis (IPH) is a rare cause of diffuse alveolar hemorrhage with unknown etiology. In the present report, the presentations of two sisters are described: one sister had IPH, eosinophilia and a high serum immunoglobulin E (IgE) level; and the other had IPH, pneumothorax, eosinophilia and a high serum IgE level. Both cases had quite unusual presentations. The first patient was 23 years of age, and had suffered from dry cough and progressive dyspnea for four years. Her hemoglobin level was 60 g/L, total serum IgE level was 900 U/mL and eosinophilia was 9%. Her chest radiography revealed diffuse infiltration. She died due to respiratory failure. The second patient was 18 years of age. She had also suffered from dry cough and gradually increasing dyspnea for two years. She had partial pneumothorax in the right lung and diffuse infiltration in other pulmonary fields on chest radiography. Her hemoglobin level was 99 g/L, total serum IgE level was 1200 U/mL and eosinophilia was 8%. IPH was diagnosed by open lung biopsy. All these findings suggested that familial or allergic factors, as well as immunological factors, might have contributed to the etiology of IPH.
Asthma is not Enough: Continuation of Smoking Among Parents with an Asthmatic Child
Authors: Liem Joel J , Kozyrskyj Anita L , Benoit Cecilia M , Becker Allan B
Published: March 2016

BACKGROUND: Ideally, on diagnosis of asthma in a child, parents are counselled to decrease environmental tobacco smoke exposure to their children.

OBJECTIVE: To determine whether a diagnosis of asthma in children altered parental smoking behaviour toward a reduction in environmental tobacco smoke exposure.

METHODS: In 2002/2003, a survey was sent to 12,556 households with children born in 1995 in Manitoba. Parents were asked whether their seven‐year‐old child had asthma, and whether smokers were present in the home in 1995 and/or currently. The likelihood (OR) of a change in parental smoking behaviour was determined according to the presence of asthma in their child, a family history of asthma, the location of residence (rural or urban) and their socioeconomic status.

RESULTS: A total of 3580 surveys (28.5%) were returned. The overall prevalence of parental smoking in 1995 and 2002/2003 was 32.2% and 23.4%, respectively (31.9%/23.2% and 32.3%/23.6% in rural and urban environments, respectively). In 2002/2003, the prevalence of parental smoking in homes with asthmatic children was 29.8%. Parents were not more likely to quit smoking (OR=1.01, 95% CI 0.66 to 1.54) or smoke outside (OR=1.02, 95% CI 0.56 to 1.83) if their child developed asthma. Parental smoking behaviour (quit smoking or smoked outside) did not change if there was a positive family history of asthma (OR=1.04, 95% CI 0.78 to 1.37), if they lived in a rural or urban location (OR=0.94, 95% CI 0.71 to 1.23), or if they were from a low‐ or high‐income household (OR=1.12, 95% CI 0.85 to 1.47).

CONCLUSIONS: The likelihood of altering parental smoking behaviour occurred independently of a diagnosis of asthma in their child, a family history of asthma, the location of residence and their socioeconomic status.
New Endoscopic Techniques for Obscure Gastrointestinal Bleeding
Authors: Ouden Henk den , van Tuyl SAC , Groenen Marcel , Stolk Mark FJ , Kuipers Ernst J
Published: March 2016

The case of a postmenopausal woman with a congenital aortic stenosis is presented. She presented with severe iron deficiency anemia. After negative extensive gastrointestinal analysis, she was treated with octreotide for six months. After cessation of octreotide, anemia rapidly recurred. A second capsule endoscopy and a double balloon enteroscopy were performed, and an intestinal vascular malformation was found. After surgical segment resection, the patient had stable, normal levels of hemoglobin and no complaints after 14 months of follow-up.
Endoscopy by Nonphysicians
Authors: Gossman Elaine R
Published: March 2016

In 1945, Henry J Kaiser organized a group of physicians to provide health care for shipyard workers and their families. His foundation, Kaiser Permanente (USA), has developed into a prepaid health plan facility serving 8.4 million members in nine states and in Washington, DC, within the United States. It aspires to provide high quality, affordable, integrated health care within an organized, efficient system. A focus on preventive care in a cost-effective manner is a high priority. The Kaiser Permanente northwest region (covering northwest Oregon and southwest Washington) serves nearly one-half of a million members. Our region has utilized nurse practitioners (NPs) and physician assistants (PAs) (allied health care providers) in a variety of capacities for many years. The present paper reviews the background and current status of their role in endoscopy.
Low Risk of Irritable Bowel Syndrome afterClostridium difficileInfection
Authors: Piche Thierry , Vanbiervliet Geoffroy , Pipau Fernand Girard , Dainese Raffaella , Hébuterne Xavier , Rampal Patrick , Collins Stephen M
Published: March 2016

OBJECTIVE: The incidence of postinfectious irritable bowel syndrome (IBS) ranges between 4% and 32% of individuals after bacterial or parasitic infection. This study analyzed IBS symptoms in hospitalized patients three months after a symptomaticClostridium difficileinfection.

PATIENTS AND METHODS: All patients with a proven, symptomaticC difficileinfection identified in the department of bacteriology over a four-month period were considered for enrolment. Patients were excluded in cases of pre-existing IBS or other organic gastrointestinal diseases. Patients completed both modified Talley and Rome II questionnaires within five days of clinical improvement with metronidazole and at three months postinfection, when stools were cultured andC difficiletoxins were examined to exclude ongoing infection.

RESULTS: Twenty-three patients were evaluated three months after infection withC difficile. Just after infection, 15 patients were symptom free, whereas eight patients exhibited symptoms suggestive of IBS. Three months after infection, 22 patients remained symptom free, whereas one patient presented with symptoms indicative of IBS. That female patient had a prolonged infection without vomiting.

CONCLUSIONS: We have shown that while transient functional bowel disorder occurred in 34.7% of patients (eight of 23 patients) recently infected withC difficile, only 4.3% of patients (one of 23 patients) had symptoms indicative of IBS after three months (ie, postinfectious IBS). Because an age-related reduction in immune responsiveness has been documented, it can be speculated that the low incidence of postinfectious IBS may be explained by the older age of the study population. Therefore, it cannot be excluded that the findings may be different in younger patients.
Catheter-Directed Middle Hemorrhoidal Artery Embolization for Life-Threatening Rectal Bleeding
Authors: Syed Mubin I , Chaudhry Najeeb , Shaikh Azim , Morar Kamal , Mukerjee Kumar , Damallie Earl
Published: March 2016

Over the past 10 years, arteriography has become a well-established technique for the diagnosis of acute lower gastrointestinal bleeding, but not particularly for rectal bleeding. However, to the authors’ knowledge, the technique of middle hemorrhoidal artery embolization has rarely been reported in the literature. In the present report, three patients with life-threatening rectal bleeding are presented, which was controlled by superselective embolization of the middle hemorrhoidal artery or selective embolization of the internal iliac artery as a last resort.
Safety and Immunogenicity of a Fully Liquid Vaccine Containing Five‐Component Pertussis‐Diphtheria‐Tetanus‐Inactivated Poliomyelitis‐Haemophilus influenzae Type B Conjugate Vaccines Administered at Two, Four, Six and 18 Months of Age
Authors: Gold Ronald , Barreto Luis , Ferro Santiago , Thippawong John , Guasparini Roland , Meekison William , Russell Margaret , Mills Elaine , Harrison Dana , Lavigne Pierre
Published: March 2016

OBJECTIVE: The safety, immunogenicity and lot consistency of a fully liquid, five‐component acellular pertussis combination vaccine, comprised of diphteria, tetanus and acellular pertussis, inactivated polio vaccine, Haemophilus influenzae type b (DTaP‐IPV‐Hib [Pediacel, sanofi pasteur, Canada]) were assessed and compared with that of Hib vaccine reconstituted with the five‐component acellular pertussis combination vaccine (DTaP‐IPV//Hib, Pentacel [sanofi pasteur, Canada]).

METHODS: Infants were recruited at vaccine study centres in Montreal, Quebec; Simon Fraser Health Region, British Columbia, and southern Alberta after the protocol had been approved by the relevant institutional ethics committees. Written informed consent was obtained from the parents or guardians of all subjects. At two months of age, the infants were randomly assigned to receive one of three consecutive production lots of DTaP‐IPV‐Hib by intramuscular injection. Reactions to vaccinations were assessed by parental observation and through telephone interviews conducted by study nurses. Blood samples were obtained at two, six, seven, 18 and 19 months of age for measurement of antibodies to vaccine antigens.

RESULTS: Most injection site and systemic reactions were mild or moderate, and of brief duration. All infants were protected against tetanus, diphtheria and all three polio serotypes after both primary and booster vaccinations. Antibody responses to pertussis antigens were similar to those observed in Swedish infants, in whom the five‐component vaccine was shown to be 85% effective. Proportions of infants with antipolyribosylribitol phosphate antibody of 0.15 μg/mL or greater and 1.0 μg/mL or greater, were 97.9% and 88.9%, respectively, following primary immunization, and 100% and 99% following booster vaccination. Safety and immunogenicity results with both reconstituted and fully liquid combination vaccines were comparable.

CONCLUSIONS: The fully liquid combination vaccine was comparable in terms of safety and immunogenicity with the reconstituted combination vaccine.
Late Presentation of Cryptococcus gattii Meningitis in a Traveller to Vancouver Island: A Case Report
Authors: Levy Ron , Pitout Johann , Long Patricia , Gill M John
Published: March 2016

Since 1999, Cryptococcus gattii has been identified as a primary pathogen on Vancouver Island in British Columbia, and it has resulted in infection of both people and animals living in that area. A previously healthy 45‐year‐old female resident of Alberta developed C gattii infection 11 months after travelling to an endemic region of Vancouver Island. A case of an immunocompetent patient, with an atypically long incubation time, who presented with subacute meningitis secondary to disseminated pulmonary cryptococcosis is presented. The present report highlights the need for clinical vigilance in treating patients presenting with atypical pulmonary infections or meningitis who have been holiday travellers to endemic areas of Vancouver Island.
Eosinophilic vasculitis: A Rare Presentation of Whipple’s Disease
Authors: Al-hamoudi Waleed , Habbab Fadi , Nudo Carmine , Nahal Ayoub , Flegel Kenneth
Published: March 2016

Whipple’s disease is a multisystem infectious disease caused by the bacteriumTropheryma whippelii. A case with an unusual presentation is reported. A 66-year-old man presented with a febrile vasculitic rash on his forearms. An extensive rheumatological, hematological and infectious workup gave negative results, apart from mild anemia and eosinophilia. An abdominal computed tomography revealed a retroperitoneal lymphadenopathy, and a skin biopsy revealed an eosinophilic vasculitis. This diverted the work toward ruling out a lymphoma or a vasculitic process. A lymph node biopsy was then performed and showed a diffuse neutrophilic inflammation with abundant foamy macrophages, fat necrosis and lipogranuloma formation. These findings were considered to be nonspecific and no further pathological investigation was carried out. After a course of corticosteroids, diarrhea and weight loss predominated and subsequently a diagnosis of Whipple’s disease was confirmed on a small-bowel biopsy. Lymph node involvement was then confirmed on re-evaluation using the appropriate stains.
Long-term Follow-Up of Individuals with Celiac Disease: An Evaluation of Current Practice Guidelines
Authors: Silvester Jocelyn A , Rashid Mohsin
Published: March 2016

INTRODUCTION: Celiac disease can be treated by following a strict gluten-free diet for life. If properly followed, the diet resolves symptoms and nutritional deficiencies. It is generally recommended that individuals with celiac disease have careful long-term follow-up. However, it is not clear which elements of disease status evaluation, laboratory investigations and self-management support should be included in follow-up.

OBJECTIVES: To examine the current practice guidelines and recommendations regarding follow-up of individuals with celiac disease.

METHODS: Guidelines issued by gastroenterological societies and associations, and recommendations by experts were retrieved using MEDLINE and other Internet search engines.

RESULTS: Practice guidelines were available from the American Gastroenterological Association; the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition; the National Institutes of Health Consensus Development Conference 2004; the World Gastroenterology Organization; the British Society for Gastroenterology and the United Kingdom-based Primary Care Society for Gastroenterology. Most guidelines recommended a scheduled annual review and regular measurements of body mass index. The British Society for Gastroenterology recommended dietary review only at times of stress, while others recommended dietary review with a nutritionist. All associations recommended serial tissue transglutaminase antibody testing. The American Gastroenterological Association and the Primary Care Society for Gastroenterology recommended annual hemoglobin, ferritin and folate checks. One guideline recommended annual hemoglobin, electrolyte, calcium, albumin, ferritin, folate, fat-soluble vitamin, liver function test, parathyroid hormone and bone density measurements (approximately $400 per patient).

CONCLUSIONS: The current practice guidelines regarding the follow-up of patients with celiac disease varied greatly in their recommendations and many were not evidence-based. Prospective studies are required to develop rational, cost-effective and risk-stratified guidelines for long-term follow-up of these patients.
The comparison of dexmedetomidine and midazolam used for sedation of patients during upper endoscopy: A prospective, randomized study
Authors: Demiraran Yavuz , Korkut Esin , Tamer Ali , Yorulmaz Ilknur , Kocaman Buket , Sezen Gulbin , Akcan Yusuf
Published: March 2016

The aim of the present prospective, randomized study was to investigate and compare the safety and efficacy of dexmedetomidine versus midazolam in providing sedation for gastroscopy. A total of 50 adult patients (25 patients receiving dexmedetomidine and 25 patients receiving midazolam), 18 to 60 years of age, and rated I and II on the American Society of Anesthesiologists physical status classification system were included. A brief questionnaire was used to collect demographic data; patients were asked to rate anxiety, satisfaction with care to date and expected discomfort on a visual analogue scale. The following parameters were measured continuously and recorded every minute: heart rate, mean arterial pressure, hemoglobin oxygen saturation and respiratory rate. The two groups were similar with regard to age, body mass index, sex, education, duration of endoscopy, and ethanol or tobacco use. After the procedure, full recovery time, mean arterial pressure, heart rate, respiratory rate and hemoglobin oxygen saturation levels were similiar in both groups. Both groups also had low levels of perceived procedural gagging, discomfort and anxiety scores (P > 0.05), and high satisfaction levels (90.1±3.0 for dexmedetomidine versus 84.9±4.5 for midazolam; P > 0.05). Retching and endoscopist satisfaction were significantly different in patients receiving dexmedetomidine versus those receiving midazolam (88.8±6.5 versus 73.5±16.4,  < 0.05; and 20.6±4.4 versus 45.2±6.0;  < 0.001). In the midazolam group, the number of patients who had adverse effects was higher than the dexmedetomidine group ( < 0.05). As a result, dexmedetomidine performed as effectively and safely as midazolam when used as a sedative in upper gastroscopy; it was superior to midazolam with regard to retching, rate of side effects and endoscopist satisfaction. It was concluded that dexmedetomidine may be a good alternative to midazolam to sedate patients for upper endoscopy.
Intermittent Bowel Obstruction Due to a Retained Wireless Capsule Endoscope in a Patient with a Small Bowel Carcinoid Tumour
Authors: Strosberg Jonathan R , Shibata David , Kvols Larry K
Published: March 2016

A 43-year-old man with a history of metastatic carcinoid disease is presented. The patient had symptoms of chronic intermittent abdominal pain two years after undergoing a wireless capsule endoscopy procedure. Radiological examinations revealed a retained capsule endoscope, and the patient underwent exploratory laparotomy with capsule retrieval. To the authors’ knowledge, this is the first case presentation of chronic, partial small bowel obstruction caused by unrecognized retention of a capsule endoscope.
Postoperative Outcome after Coronary Artery Bypass Grafting in Chronic Obstructive Pulmonary Disease
Authors: Manganas Hélène , Lacasse Yves , Bourgeois Stéphanie , Perron Jean , Dagenais François , Maltais François
Published: March 2016

BACKGROUND: It is uncertain if the presence and severity of airflow obstruction in chronic obstructive pulmonary disease (COPD) is predictive of surgical morbidity and mortality after coronary artery bypass grafting (CABG).

METHODS: Retrospective study of patients who underwent CABG between 1998 and 2003 in a university‐affiliated hospital for whom a preoperative spirometry was available. COPD was diagnosed in smokers or ex‐smokers 50 years of age or older in the presence of irreversible airflow obstruction. Patients were divided into three groups depending on the spirometry: controls (forced expiratory volume in 1 s [FEV1] 80% or more, FEV1/forced vital capacity [FVC] greater than 0.7), mild to moderate COPD (FEV1 50% or more and FEV1/FVC 0.7 or less) and severe COPD (FEV1 less than 50% and FEV1/FVC 0.7 or less).

RESULTS: Among the 411 files studied, 322 (249 men, 68±8 years of age) were retained (controls, n=101; mild to moderate COPD, n=153; severe COPD, n=68). The mortality rate (3.0%, 2.6% and 0%, respectively) was comparable among the three groups. Patients with severe COPD had a slightly longer hospital stay than controls (mean difference 0.7±1.4 days, P<0.05). Pulmonary infections were more frequent in severe COPD (26.5%) compared with mild to moderate COPD (12.4%) and controls (12.9%), P<0.05. Atrial fibrillation tended to be more frequent in severe COPD than in the other two groups.

CONCLUSION: Mortality rate associated with CABG surgery is not influenced by the presence and severity of airflow obstruction in patients with COPD. The incidence of pulmonary infections and length of hospital stay were increased in patients with severe COPD.
Endoscopic Management of a Relapsing Hepatic Hydatid Cyst with Intrabiliary Rupture: A Case Report and Review of the Literature
Authors: Manouras Andreas , Genetzakis Michael , Antonakis Pantelis T , Lagoudianakis Emmanuel , Pattas Michael , Papadima Artemisia , Giannopoulos Panagiotis , Menenakos Evangelos
Published: March 2016

Hydatid disease, although endemic mostly in sheep-farming countries, remains a public health issue worldwide, involving mainly the liver. Intrabiliary rupture is the most frequent complication of the hepatic hydatid cyst. Endoscopy is advocated, preoperatively, to alleviate obstructive jaundice caused by intracystic materials after a frank rupture and is also a useful and well-established adjunct in locating postoperative biliary fistulas.

Endoscopic retrograde cholangiography with sphincterotomy has been successful as the sole and definitive means of treatment of intra-biliary ruptured hydatid cysts. A case of an elderly woman with frank rupture is presented, where the rupture was definitively managed endoscopically in conjunction with sphincterotomy to remove the intrabiliary obstructive daughter cysts and to achieve decontamination of the biliary tree.

Endoscopic retrograde cholangiography provided an excellent diagnostic and therapeutic modality in the present case and, thus, it should be considered as definitive treatment in similar cases especially if surgical risk is anticipated to be high.
Triple Active Antiretroviral Regimen Including Enfuvirtide Via the Biojector is Effective and Safe
Authors: Loutfy Mona , Kovacs Colin
Published: March 2016

For full HIV virological suppression, three fully active antiretroviral agents are required. New drug classes should be included to ensure that agents are fully active. The addition of enfuvirtide and efavirenz to the present patient’s new antiretroviral regimen ensured that two fully active agents were in use in the setting of a moderate degree of nucleoside resistance and a high level of protease resistance, and where non‐nucleoside reverse transcriptase inhibitors were still fully active. Both viral load and CD4 count responded favourably to this regimen. The patient received support from physicians and clinic staff in the introduction and use of enfuvirtide. To reduce injection site reactions, a needle‐free injection system (Biojector) proved effective.
Mortality of Elderly Patients in Ontario after Hospital Admission for Chronic Obstructive Pulmonary Disease
Authors: Nie Jason X , Wang Li , Upshur Ross EG
Published: March 2016

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with significant mortality. It is currently the fourth leading cause of death in Canada and the world.

OBJECTIVES: To describe the mortality of elderly patients in Ontario after hospital admission for COPD.

METHODS: A retrospective cohort study was conducted using the Discharge Abstract Database from the Canadian Institute for Health Information. Patients aged 65 years and older who were admitted to hospital between 2001 and 2004 with primary discharge diagnoses labelled with International Classification of Diseases, Ninth Revision codes 491, 492 and 496 were included in the study.

RESULTS: Mortality rates were 8.81, 12.10, 14.53 and 27.72 per 100 COPD hospital admissions at 30, 60, 90 and 365 days after hospital discharge, respectively. Mortality also increased with age, and men had higher rates than women. No significant differences in mortality rates were found between different socioeconomic groups (P>0.05). Patients with shared care of a family physician or general practitioner and a specialist had significantly lower mortality rates than the overall rate (P<0.05), and their rates were approximately one‐half the rate of patients with only one physician.

CONCLUSIONS: Hospitalization with COPD is associated with significant mortality. Patients who were cared for by both a family physician or general practitioner and a specialist had significantly lower mortality rates than those cared for by only one physician, suggesting that continuous and coordinated care results in better survival.
Chronic Obstructive Pulmonary Disease in Women
Authors: Laviolette Louis , Lacasse Yves , Doucet Mariève , Lacasse Miriam , Marquis Karine , Saey Didier , Leblanc Pierre , Maltais François
Published: March 2016

BACKGROUND: Little is known about the comparative impact of chronic obstructive pulmonary disease (COPD) between women and men and about women’s response to pulmonary rehabilitation.

OBJECTIVES: To compare lung function, disability, mortality and response to pulmonary rehabilitation between women and men with COPD.

METHODS: In the present retrospective study, 68 women (mean age 62.5±8.9 years) and 168 men (mean age 66.3±8.4 years) were evaluated by means of pulmonary function testing and an incremental symptom‐limited cycle exercise test. Forty women and 84 men also participated in a 12‐week pulmonary rehabilitation program. A 6 min walking test and the chronic respiratory questionnaire were used to assess the effects of pulmonary rehabilitation. Survival status was also evaluated.

RESULTS: Compared with men, women had a smaller tobacco exposure (31±24 versus 48±27 pack‐years, P<0.05), displayed better forced expiratory volume in 1 s (44±13 versus 39±14 % predicted, P<0.05), a higher functional residual capacity (161±37 versus 149±36 % predicted, P<0.05) and total lung capacity (125±20 versus 115±19 % predicted, P<0.001). Peak oxygen consumption was not different between women and men when expressed in predicted values but lower in women when expressed in absolute values. Pulmonary rehabilitation resulted in significant improvements in 6 min walking test and quality of life in both sexes, but women had a greater improvement in chronic respiratory questionnaire dyspnea. Survival status was similar between sexes, but predictors of mortality were different between sexes.

CONCLUSIONS: Women may be more susceptible to COPD than men. The clinical expression of COPD may differ between sexes with greater degree of hyperinflation in women, who also benefit from pulmonary rehabilitation.
Canadian Economic Evaluation of Budesonide‐Formoterol as Maintenance and Reliever Treatment in Patients with Moderate to Severe Asthma
Authors: Miller Elizabeth , Sears Malcolm R , McIvor Andrew , Liovas Anna
Published: March 2016

OBJECTIVES: To compare the cost‐effectiveness of budesonide‐formoterol in a single inhaler used as both maintenance and reliever medication versus clinician‐directed titration of salmeterol‐fluticasone as maintenance medication, plus salbutamol taken as needed, in controlling asthma in adults and adolescents.

METHODS: A Canadian economic evaluation was conducted based on the results of a large (n=2143), open‐label, randomized, controlled effectiveness trial in which health resource use was prospectively collected. The primary outcome measurement was the time to the first severe exacerbation. Costs included direct medical costs (physician and emergency room visits, hospitalizations, asthma drug costs, etc) and productivity (absenteeism). The time horizon was one year, which corresponded to the duration of the clinical trial. Prices were obtained from 2005 Canadian sources. Both health care and societal perspectives were considered, and deterministic univariate sensitivity analyses were conducted.

RESULTS: In the clinical trial, budesonide‐formoterol as maintenance and reliever treatment was superior to salmeterol‐fluticasone with respect to the time to the first severe exacerbation, overall rate of exacerbations and use of as‐needed reliever medication. The annualized rate of severe exacerbations was 0.24 events/patient in the budesonide‐formoterol arm and 0.31 events/patient in the salmeterol‐fluticasone arm (P=0.0025). From a health care perspective, the mean cost per patient‐year was $1,315 in the budesonide‐formoterol arm versus $1,541 in the salmeterol‐fluticasone arm. From a societal perspective, the mean cost per patient‐year was $1,538 in the budesonide‐formoterol arm and $1,854 in the salmeterol‐fluticasone arm. Budesonide‐formoterol was dominant (more effective and less expensive) in the base case analysis from both perspectives. The results were robust under sensitivity testing.

CONCLUSIONS: The strategy that allows budesonide‐formoterol to be used in a single inhaler as both maintenance and reliever medication proved to be more effective and less expensive than a strategy of clinician‐directed titration of salmeterol‐fluticasone with salbutamol as reliever therapy.
Congenital Cholestatic Syndromes: What Happens When Children Grow Up?
Authors: Ling Simon C
Published: March 2016

Although advances in the management of children with congenital cholestasis have enabled many to survive into adulthood with their native livers, even the most common of these conditions remains rare in adult hepatology practice. Among four congenital cholestatic syndromes (biliary atresia, Alagille syndrome, Caroli disease and congenital hepatic fibrosis, and progressive familial intrahepatic cholestasis), the published data on outcomes of the syndromes into adulthood suggest that a spectrum of severity of liver disease can be expected, from cirrhosis (almost universal in adults with biliary atresia who have not required liver transplantation) to mild and subclinical (eg, in the previously undiagnosed affected parent of an infant with Alagille syndrome). Complications associated with portal hypertension and nutritional deficiencies are common, and other associated features of the cholestatic syndrome may require appropriate attention, such as congenital heart disease in Alagille syndrome. Indications for liver transplantation include synthetic failure, progressive encephalopathy, intractable pruritus, recurrent biliary sepsis and recurrent complications of portal hypertension. Improved understanding of biliary physiology will hopefully translate into improved therapy for children and adults with cholestasis.
Prevalence of USA300 Colonization or Infection and Associated Variables During an Outbreak of Community‐Associated Methicillin‐Resistant Staphylococcus aureus in a Marginalized Urban Population
Authors: Gilbert Mark , MacDonald Judy , Louie Marie , Gregson Dan , Zhang Kunyan , Elsayed Sameer , Laupland Kevin , Nielsen Diane , Wheeler Virginia , Lye Tara , Conly John
Published: March 2016

BACKGROUND: In 2004, an outbreak of the USA300 strain of methicillin‐resistant Staphylococcus aureus (MRSA) was identified in persons with histories of homelessness, illicit drug use or incarceration in the Calgary Health Region (Calgary, Alberta). A prevalence study was conducted to test the hypotheses for factors associated with USA300 colonization or infection.

METHODS: Participants were recruited at sites accessed by this marginalized population. Health care staff administered a questionnaire and collected crack pipes and nasal, axillary and skin infection swabs. Pipes and swabs were cultured according to standard techniques. MRSA isolates were further characterized by polymerase chain reaction (mecA, Panton‐Valentine leukocidin and Staphylococcal cassette chromosome mec) and typing methods (pulsed‐field gel electrophoresis, staphylococcal protein A typing and multilocus sequence typing). Colonization or infection was determined by having any one of nasal, axillary, skin infection or pipe swabs positive for USA300. Colonized participants had one or more nasal, axillary or pipe swab positive for USA300; infected participants had one or more skin infection swab positive for USA300.

RESULTS: The prevalence of USA300 colonization or infection among 271 participants was 5.5% (range 3.1% to 9.0%). USA300 cases were more likely to report manipulation of skin infections (OR 9.55; 95% CI 2.74 to 33.26); use of crack pipes was not significant despite identification of the USA300 strain on two of four crack pipes tested. USA300 cases were more likely to report drug use between sex trade workers and clients (OR 5.86; 95% CI 1.63 to 21.00), and with casual sex partners (OR 5.40; 95% CI 1.64 to 17.78).

CONCLUSION: Ongoing efforts to promote the appropriate treatment of skin infections in this population are warranted. The association of USA300 colonization or infection and drug use with sexual partners suggest a role for sexual transmission of the USA300 strain of MRSA.
IsHelicobacter pyloriBeing Treated Appropriately? A Study of Inpatients and Outpatients in a Tertiary Care Centre
Authors: Nazareno Jose , Driman David K , Adams Paul
Published: March 2016

BACKGROUND:Helicobacter pyloriis causally associated with peptic ulcer disease and gastric cancer. Although effective treatment is available, studies have shown that patients withH pyloriare often not well managed. Recently, there has also been increasing awareness of patient safety concerns arising from missed follow-up of abnormal test results.

OBJECTIVE: To examine whether inpatients and outpatients diagnosed withH pylorireceive appropriate treatment.

PATIENTS AND METHODS: All patients who were diagnosed withH pyloriby gastric biopsy in London, Ontario between January 1, 2004, and December 31, 2004, were identified. The hospital charts of these patients were reviewed. Outpatient office charts, clinic notes, pathology reports and endoscopy reports were also reviewed.

RESULTS: One hundred ninety-three patients were diagnosed withH pyloriby gastric biopsy in 2004. Of the 193 patients, 143 (74%) were outpatients and 50 (26%) were inpatients. Overall, 89% of patients received treatment forH pylori. Ninety-two per cent of outpatients were treated, while only 60% of inpatients received treatment (P<0.001). Among the inpatients, the pathology report was available in 40% of the cases before the patient was discharged from the hospital. After discharge from the hospital, 30% of inpatients received appropriate treatment and follow-up. There was no significant difference in treatment whether the patient was admitted to a medical or a nonmedical service.

CONCLUSION:H pyloriis treated relatively poorly in inpatients compared with outpatients. Results of the present study reveal opportunities to improve delivery of care for inpatients on a number of different levels. More research is needed to ensure safety, effectiveness and timeliness in the test result management process.
A Natural History of Hygiene
Authors: Curtis Valerie A
Published: March 2016

In unpacking the Pandora’s box of hygiene, the author looks into its ancient evolutionary history and its more recent human history. Within the box, she finds animal behaviour, dirt, disgust and many diseases, as well as illumination concerning how hygiene can be improved. It is suggested that hygiene is the set of behaviours that animals, including humans, use to avoid harmful agents. The author argues that hygiene has an ancient evolutionary history, and that most animals exhibit such behaviours because they are adaptive. In humans, responses to most infectious threats are accompanied by sensations of disgust. In historical times, religions, social codes and the sciences have all provided rationales for hygiene behaviour. However, the author argues that disgust and hygiene behaviour came first, and that the rationales came later. The implications for the modern‐day practice of hygiene are profound. The natural history of hygiene needs to be better understood if we are to promote safe hygiene and, hence, win our evolutionary war against the agents of infectious disease.
The Impact of Ulcerative Colitis is Greater in Unmarried and Young Patients
Authors: Maunder Robert G , Greenberg Gordon R , Lancee William J , Steinhart A Hillary , Silverberg Mark S
Published: March 2016

GOALS: To determine whether the perceived impact of ulcerative colitis (UC) on activities of living (illness intrusiveness) is greater for people who are not living in a married or common-law relationship.

BACKGROUND: In general, social and occupational achievement is not greatly impaired by UC, yet patients, especially young adults, often have interpersonal concerns.

METHODS: One hundred fifty-five outpatients with UC were assessed for disease activity, and completed self-reports of marital status, income, social support and illness intrusiveness.

RESULTS: Fifty-one patients (32.9%) were single, separated or divorced, and 104 patients (67.1%) were married or in common-law relationships. Compared with those who were married or in common-law relationships, single or separated patients were younger, had a lower household income, had lived with UC for fewer years and were less satisfied with social support. Among 135 patients in remission, marital status was significantly associated with illness intrusiveness, controlling for age, income and perceived social support (F=5.73; P=0.02). Low social support (F=4.94; P=0.03) and younger age (F=7.24; P=0.008) were independently associated with illness intrusiveness. Single patients in remission reported illness intrusiveness of similar severity to that reported by patients with active disease.

CONCLUSIONS: The perceived impact of UC on the lives of patients is greater in those who are not married or living in common-law relationships. Youth, single status and lower social support commonly coexist, and exert additive effects on the functional impact of UC. Resources to improve social support should be directed toward this group of patients.
The Clinical Cost of Delays in Switching Therapy
Authors: Walmsley Sharon
Published: March 2016

Management of the HIV patient with treatment experience continues to improve and evolve. New guidelines suggest that the goal of therapy should be maximal virological suppression. This is best achieved by using combinations of agents to which the virus is most likely to have some susceptibility and, where possible, by using agents within a new therapeutic class. The cases discussed demonstrate how the use of a potent regimen as salvage therapy can have good clinical, immunological and virological outcomes. However, if the salvage regimen selected is not potent enough to achieve these goals, the durability of the response is limited. The key lesson is that these strategies should be built on potency and agents should not be held back in case the strategy fails.
Barriers Preventing Liver Transplantation in Canadians with HIV Infection – Perceptions of HIV Specialists
Authors: Cooper Curtis L , DeForest Joanne , Gill John , Lalonde Richard ,   on behalf of the Canadian HIV Trials Network (CTN) Co-Infection Core Group
Published: March 2016

Liver transplantation is a life-saving procedure with demonstrated utility. There are accumulating data indicating that this procedure is helpful in HIV-infected patients as well. Liver transplantation is currently largely unavailable to those living with HIV in Canada. Understanding the obstacles to this procedure is the first step to increasing access. Between August 2005 and November 2005, HIV physicians, one from each Canadian HIV Trials Network site, were asked to complete a quantitative questionnaire on adult liver transplant access and need. Forty-six per cent (16 of 35) of sites responded. A median 20% of the nearly 12,700 HIV patients followed at these sites had concurrent liver disease (20% caused by hepatitis C virus, 5% caused by hepatitis B virus and 5% were alcohol-related). On average, two patients per site were thought to be appropriate candidates for liver transplant evaluation. Eighty per cent of respondents anticipated increased need for liver transplantation over the next five years. Organ supply was universally identified as the chief obstacle to transplantation in patients with HIV. Other key issues included risk of hepatitis C virus reinfection and transplant surgical team willingness. Based on these data, it is believed that these issues should be the focus of efforts designed to increase access to transplantation in Canadians with end-stage liver disease and concurrent HIV.