bluuebunny/crossref_metadata_2025 huggingface dataset:
Disability and Borderline Personality Disorder in Chronic Pain Patients
Authors: Sansone Randy A , Sinclair J David , Wiederman Michael W
Published: March 2016

BACKGROUND AND OBJECTIVE: Few studies have examined the relationship between disability and borderline personality symptomatology, and, among those that have, findings have been inconsistent. In the present study, the relationship between medical disability and borderline personality symptomatology was examined in a sample of chronic pain patients.

METHODS: In a consecutive insured sample of male and female chronic pain patients (n=117), who were being initially evaluated by an outpatient pain specialist, the criterion of having “ever been on medical disability” and features of borderline personality disorder were examined using the borderline personality scale of the Personality Diagnostic Questionnaire‐4.

RESULTS: While 35% of participants acknowledged having ever been on medical disability, there was no statistically significant difference between those with a history versus those without a history of medical disability with regard to the prevalence of borderline personality symptomatology.

CONCLUSIONS: Findings suggest that among chronic pain patients, there may be no meaningful relationship between having ever been on medical disability and borderline personality symptomatology.
Associations between Adult Attachment Dimensions And Attitudes Toward Pain Behaviour
Authors: McWilliams Lachlan A , Murphy Paul DJ , Bailey S Jeffrey
Published: March 2016

BACKGROUND: Despite the important role positive reinforcement of pain behaviour is believed to play in chronic pain, there is a paucity of research regarding factors that influence the provision of such reinforcement. Attachment theory suggests that individuals high in attachment avoidance view the pain behaviour of others in a negative manner and would, therefore, provide little reinforcement of pain behaviour. As an initial step in evaluating this model, relationships between attachment dimensions and attitudes toward pain behaviour were examined. Attachment avoidance was hypothesized to be negatively associated with accepting attitudes toward pain behaviour.

METHODS: A sample of undergraduate students (n=160) completed the Relationships Structures Questionnaire, which provides global ratings of adult attachment dimensions (anxiety and avoidance) by assessing attachment across four relationship targets (friend, mother, father and romantic partner). Attitudes regarding the acceptability of pain behaviour were assessed using male and female versions of the Appropriate Pain Behaviour Questionnaire (APBQ).

RESULTS: Consistent with the hypothesis, attachment avoidance was negatively correlated with both APBQ‐Female and APBQ‐Male scores. Multiple regression analyses were used to investigate the relationships between the attachment scales and the APBQ scales while statistically adjusting for sex and testing for interaction effects. The findings revealed complex relationships involving interaction effects that provided further support for the hypothesis.

CONCLUSIONS: The findings provided support for the hypothesis that attachment avoidance is associated with less accepting attitudes toward pain behaviour. Additional research regarding the role of attachment and attitudes on responses to pain behaviour is warranted.
Diagnostic Value of Endoscopic and Endoscopic Ultrasound Characteristics of Duodenal Submucosal Tumour-Like Heterotopic Gastric Mucosa
Authors: Eguchi Koichi , Aoyagi Kunihiko , Nimura Satoshi , Sakisaka Shotaro
Published: March 2016

OBJECTIVE: Recent studies have reported that duodenal heterotopic gastric mucosa (HGM) has been observed in 8.9% of patients who undergo esophagogastroduodenoscopy. However, there are few reports concerning the endoscopic and endoscopic ultrasound characteristics of submucosal tumour-like HGM in the duodenum.

METHODS: Endoscopic, endoscopic ultrasound (EUS) and histological findings were analyzed in six patients with submucosal tumour-like HGM, which were confirmed by pathological examination of biopsy or endoscopic polypectomy specimens.

RESULTS: Endoscopically, the lesions appeared as a solitary, sessile submucosal tumour-like mass with a depression at the top. In four of six patients, small granular structures were found in the depressed area of the mass. On EUS, all masses demonstrated a heterogeneous pattern, among which four patients presented anechoic areas while two patients showed no anechoic areas. All lesions were localized within the mucosa and submucosa on EUS. Histologically, they consisted of gastric glands and some dilated glands, and were covered with normal duodenal epithelium. In four of six lesions, the tumours were composed of gastric-type foveolar epithelium showing papillary growth, fundic glands and pyloric glands, while the others consisted of gastric-type foveolar epithelium and pyloric glands.

CONCLUSION: A heterogeneous pattern on EUS and small granular structures on esophagogastroduodenoscopy represent valuable diagnostic features of submucosal tumour-like HGM.
Use of Continuous Negative Pressure Around the Chest Increases Exercise Performance in Chronic Obstructive Pulmonary Disease Patients: A Pilot Study
Authors: Chaturvedi Rakesh K , Zidulka Arnold
Published: March 2016

BACKGROUND: Patients with severe chronic obstructive pulmonary disease (COPD) often have intrinsic positive end-expiratory pressure. Continuous positive airway pressure has been shown to decrease the inspiratory work of breathing and increases exercise capacity in these patients.

OBJECTIVE: To determine whether continuous negative pressure (CNP) around the chest is able to bring the positive end-expiratory pressure closer to atmospheric pressure, thereby reducing the threshold load and increasing exercise capability.

METHODS: A pilot study was undertaken with eight COPD patients who had been hospitalized for exacerbation and were close to discharge. For CNP, a shell (around the thorax from under the axillae to the mid abdomen) and wrap were used. Each of the eight patients was assessed with a 6 min walk test in three modes (in randomized order) with 30 min of rest in between: a control walk with no shell or wrap; a sham CNP in which the applied CNP was negligible; and CNP, with pressure chosen by the patient that provided maximal relief of dyspnea at rest.

RESULTS: At the end of each of the 6 min walk tests, there was no difference in heart rate, oxygen saturation or level of dyspnea among the three test modes. Respiratory rate was reduced with CNP compared with sham. The patients walked furthest with CNP compared with control (mean ± SD) (313±66.2 m versus 257±65.2 m; P<0.01) and compared with sham.

CONCLUSIONS: In the present pilot study, COPD patients improved their exercise performance with CNP.
Reducing the Risk of Severe Complications among Patients withClostridium difficileInfection
Authors: Manek Kamran , Williams Victoria , Callery Sandra , Daneman Nick
Published: March 2016

BACKGROUND: The incidence and severity ofClostridium difficileinfections are increasing, and there is a need to optimize the prevention of complicated disease.

OBJECTIVE: To identify modifiable processes of care associated with an altered risk ofC difficilecomplications.

METHODS: A retrospective cohort study (with prospective case ascertainment) of allC difficileinfections during 2007/2008 at a tertiary care hospital was conducted.

RESULTS: Severe complications were frequent (occurring in 97 of 365 [27%]C difficileepisodes), with rapid onset (median three days postdiagnosis). On multivariable analysis, nonmodifiable predictors of complications included repeat infection (OR 2.67), confusion (OR 2.01), hypotension (OR 0.97 per increased mmHg) and elevated white blood cell count (OR 1.04 per 109cells/L). Protection from complications was associated with initial use of vancomycin (OR 0.24); harm was associated with ongoing use of exacerbating antibiotics (OR 3.02).

CONCLUSION:C difficileinfections often occur early in the disease course and are associated with high complication rates. Clinical factors that predicted a higher risk of complications included confusion, hypotension and leukocytosis. The most effective ways to improve outcomes for patients withC difficilecolitis are consideration of vancomycin as first-line treatment for moderate to severe cases, and the avoidance of unnecessary antibiotics.
Endoscopic Treatment of Obesity
Authors: Swidnicka-Siergiejko Agnieszka , Wróblewski Eugeniusz , Dabrowski Andrzej
Published: March 2016

BACKGROUND: The increasing incidence of obesity and overweight among children and adolescents will be reflected by the imminent increase in the number of obese patients who require more definitive methods of treatment. There is great interest in new, safe, simple, nonsurgical procedures for weight loss.

OBJECTIVE: To provide an overview of new endoscopic methods for the treatment of obesity.

METHODS: An English-language literature search on endoscopic interventions, endoscopically placed devices and patient safety was performed in the MEDLINE and Cochrane Library databases.

RESULTS: The literature search yielded the following weight loss methods: space-occupying devices (widely used), gastric capacity reduction, modifying gastric motor function and malabsorptive procedures. A commercially available intragastric balloon was the most commonly used device for weight loss. In specific subgroups of patients, it improved quality of life, decreased comorbidities and served as a bridge to surgery. More evidence regarding the potential benefits and safety of other commercially available intragastric balloons is needed to clarify whether they are superior to the most commonly used one. Moreover, early experiences with transoral gastroplasty, the duodenaljejunal bypass sleeve and an adjustable, totally implantable intragastric prosthesis, indicate that they may be viable options for obesity treatment. Other agents, such as botulinum toxin and a device known as the ‘butterfly’, are currently at the experimental stage.

CONCLUSION: New endoscopic methods for weight loss may be valuable in the treatment of obesity; however, more clinical experience and technical improvements are necessary before implementing their widespread use.
Cystic Echinococcosis: Late Rupture and Complication of a Stable Pulmonary Cyst
Authors: Fisher J , Shargall Y , Krajden S , Moid F , Hoffstein V
Published: March 2016

Cystic echinococcosis is observed worldwide. Traditional management includes an invasive surgical approach with adjunctive chemotherapy. It has been suggested that observation alone may be appropriate in asymptomatic individuals with stable cysts. A case involving a 38‐year‐old Peruvian man with an asymptomatic bronchogenic cyst (suspected to be due to echinococcus, but never definitely diagnosed) is presented. The cyst was first noted in 1998, and was followed for 10 years during which time he remained asymptomatic with minimal radiographic change. One year later, in 2009, he presented with acute rupture of the cyst causing empyema. The patient required thoracotomy, decortication and resection of the ruptured cyst. Final pathology showed Echinococcus organisms. The patient responded well to treatment with albendazole and praziquantel, and became completely asymptomatic within six months.

The present case demonstrates that echinococcal cysts may be at risk of spontaneous rupture, even after many years of clinical stability, thus supporting the case for resection of asymptomatic cysts suspected of being echinococcal at the time of diagnosis. In addition, the case illustrates that medical therapy with albendazole and praziquantel, in conjunction with surgical drainage, can be successful in the treatment of echinococcal empyema.
A Case of Acute Cholecystitis Caused by Methicillin‐Resistant Staphylococcus aureus in an Immunocompromised Patient
Authors: Kim Joseph , Gregson Daniel B. , Church Deirdre L.
Published: March 2016

Although infections with Staphylococcus aureus can implicate multiple organ systems, involvement of the biliary tract is rare. A case of acute cholecystitis and bacteremia with methicillin‐resistant S aureus (MRSA) in a patient with HIV infection is presented. The MRSA isolate was found to be a community‐associated strain. The present case highlights the invasive nature of staphylococcal infections and the emerging importance of community‐associated MRSA strains.
Mycobacterium senegalense Tissue Infection in a Child After Fish Tank Exposure
Authors: Talavlikar Rachel , Carson Julie , Meatherill Bonnie , Desai Shalini , Sharma Meenu , Shandro Cary , Tyrrell Gregory J. , Kuhn Susan
Published: March 2016

The present report describes the first known case of an otherwise healthy child who developed a soft tissue infection due to Mycobacterium senegalense – a pathogen usually found in east Africa that is responsible for infecting various animals. The patient presented with nonhealing wounds after sustaining facial lacerations from the shattered glass of a fish tank. The patient responded well to scar revision and antibiotics, with no subsequent relapse.
Catastrophizers with Chronic Pain Display more Pain Behaviour when in a Relationship with a Low Catastrophizing Spouse
Authors: Gauthier Nathalie , Thibault Pascal , Sullivan Michael JL
Published: March 2016

The present study examined the relationship between couple concordance of catastrophizing and adverse pain outcomes. Possible mechanisms underlying the relationship between couple concordance of catastrophizing and pain outcomes were also explored. Fifty‐eight couples were recruited for the study. The chronic pain patients were filmed while lifting a series of weighted canisters. The spouse was later invited to view the video and answer questions about the pain experience of their partner. Median splits on Pain Catastrophizing Scale scores were used to create four ‘catastrophizing concordance’ groups: low catastrophizing patient‐low catastrophizing spouse; low catastrophizing patient‐high catastrophizing spouse; high catastrophizing patient‐low catastrophizing spouse; and high catastrophizing patient‐high catastrophizing spouse. Analyses revealed that high catastrophizing pain patients who were in a relationship with a low catastrophizing spouse displayed more pain behaviours than patients in all other groups. These findings suggest that high catastrophizing chronic pain patients may need to increase the ‘volume’ of pain communication to compensate for low catastrophizing spouses’ tendency to underestimate the severity of their pain experience. Patients’ perceived solicitousness and punitive response from the spouse could not explain the group differences in pain behaviour. Theoretical and clinical implications of the findings are discussed.
Can a Self‐Management Education Program for Patients with Chronic Obstructive Pulmonary Disease Improve Quality of Life ?
Authors: Labrecque Manon , Rabhi Khalil , Laurin Catherine , Favreau Helene , Moullec Gregory , Lavoie Kim , Julien Marcel
Published: March 2016

OBJECTIVE: To assess the effects of a self‐management program on health‐related quality of life (HRQoL) and morbidity commonly associated with chronic obstructive pulmonary disease (COPD).

METHODS: A total of 57 outpatients with stable COPD received four weeks of self‐management education, while 45 patients received usual care. Patients were evaluated at baseline, at three months and one year following the educational intervention. The primary outcome variable was HRQoL measured by the St George’s Respiratory Questionnaire (SGRQ). The secondary outcome variables were number of emergency room visits and hospitalizations for exacerbation.

RESULTS: The intervention group’s HRQoL improved significantly at three months (total score A=−5.0 [P=0.006]) and 12 months (total score A=−6.7 [P<0.001]), as evidenced by decreased scores on the SGRQ. In contrast, the SGRQ scores increased significantly in the control group at three months (total score A=+3.7 [P= 0.022]) and 12 months (total score A=+3.4 [P=0.032]). Global impact appeared to be responsible for the change in the intervention group. Moreover, in the intervention group, the number of hospitalizations dropped from 0.7/person/year to 0.3/person/year (P=0.017), and emergency room visits dropped from 1.1 person/year to 0.2/person/year (P=0.002), while subjects in the control group did not experience any significant decreases in these parameters.

CONCLUSIONS: A planned education program improved HRQoL while decreasing the number of emergency room visits and hospitalizations in patients with stable COPD; this improvement persisted at 12 months.
Urothelial Bladder Cancer with Cavitary Lung Metastases
Authors: Kurian Anil , Lee Jason , Born Abraham
Published: March 2016

Transitional cell carcinoma (TCC) of the bladder tends to remain superficial; however, in 5% to 20% of cases, it progresses to muscle invasion and, more rarely, can metastasize. TCC of the bladder primarily spreads via regional lymphatics. The most common sites of distant metastases of TCC are the liver, lung, mediastinum and bone. Long‐term survival of patients with metastatic bladder cancer is rare. Patterns of pulmonary metastasis include multiple nodules, a solitary mass or interstitial micronodule. When multiple nodules are present, they are round and well‐circumscribed, without calcification or cavitation. An unusual case of rapidly metastatic TCC to the lung causing large cavitary masses and nodules is presented. Imaging performed after the patient began chemotherapy revealed widespread necrosis of the metastatic cavitary masses causing moderate volume hemoptysis.
Strategic Plan of the Canadian Institutes of Health Research Institute of Nutrition, Metabolism, and Diabetes
Authors: Sherman Philip M , Makarchuk Mary-Jo , Belanger Paul , Roberts Eve A
Published: March 2016

The present document provides the new and updated strategic plan for the Institute of Nutrition, Metabolism, and Diabetes (INMD) of the Canadian Institutes of Health Research. This plan provides an overarching map for the strategic activities of the INMD during the five years from 2010 to 2014. These strategic priorities will guide the way that the INMD uses its resources over this period of time, and will provide opportunities to build new partnerships and strategic alliances that enhance and leverage the capacity to fund targeted research initiatives.
Burkholderia Gladioli– A Predictor of Poor Outcome in Cystic Fibrosis Patients Who Receive Lung Transplants? A Case of Locally Invasive Rhinosinusitis and Persistent Bacteremia in a 36-Year-Old Lung Transplant Recipient with Cystic Fibrosis
Authors: Quon Bradley S , Reid James D , Wong Patrick , Wilcox Pearce G , Javer Amin , Wilson Jennifer M , Levy Robert D
Published: March 2016

There have been very few reports describing postlung transplant outcomes in patients’ infected/colonized withBurkholderia gladiolipretransplant. A case involving a lung transplant recipient with cystic fibrosis who ultimately died as a result of severe rhinosinusitis due toB gladioliinfection in the context of postlung transplant immunosuppression is reported.
The ‘Mystery’ of Opioid‐Induced Diarrhea
Authors: Bril Silviu , Shoham Yoav , Marcus Jeremy
Published: March 2016

Bowel dysfunction, mainly constipation, is a well‐known and anticipated side effect of opioids. The physician prescribing an opioid frequently confronts the challenge of preventing and treating bowel dysfunction. Different strategies have emerged for managing opioid‐induced constipation. These strategies include physical activity, maintaining adequate fluid intake, adhering to regular daily bowel habits, using laxatives and other anticonstipation medications and, recently, using a peripheral opioid antagonist, either as a separate drug or in the form of an opioid agonist‐antagonist combination pill. What options exist for the physician when a patient receiving opioids complains of diarrhea, cramps and bloating, rather than the expected constipation? The present article describes a possible cause of opioid‐induced diarrhea and strategies for management.
Point-of-Care, Peer-Comparator Colonoscopy Practice Audit: The Canadian Association of Gastroenterology Quality Program – Endoscopy
Authors: Armstrong David , Hollingworth Roger , MacIntosh Donald , Chen Ying , Daniels Sandra , Gittens Stuart , Bridges Ron , Sinclair Paul , Dubé Catherine
Published: March 2016

BACKGROUND: Point-of-care practice audits allow documentation of procedural outcomes to support quality improvement in endoscopic practice.

OBJECTIVE: To evaluate a colonoscopists’ practice audit tool that provides point-of-care data collection and peer-comparator feedback.

METHODS: A prospective, observational colonoscopy practice audit was conducted in academic and community endoscopy units for unselected patients undergoing colonoscopy. Anonymized colonoscopist, patient and practice data were collected using touchscreen smart-phones with automated data upload for data analysis and review by participants. The main outcome measures were the following colonoscopy quality indicators: colonoscope insertion and withdrawal times, bowel preparation quality, sedation, immediate complications and polypectomy, and biopsy rates.

RESULTS: Over a span of 16 months, 62 endoscopists reported on 1279 colonoscopy procedures. The mean cecal intubation rate was 94.9% (10th centile 84.2%). The mean withdrawal time was 8.8 min and, for nonpolypectomy colonoscopies, 41.9% of colonoscopists reported a mean withdrawal time of less than 6 min. Polypectomy was performed in 37% of colonoscopies. Independent predictors of polypectomy included the following: endoscopy unit type, patient age, interval since previous colonoscopy, bowel preparation quality, stable inflammatory bowel disease, previous colon polyps and withdrawal time. Withdrawal times of less than 6 min were associated with lower polyp removal rates (mean difference −11.3% [95% CI −2.8% to −19.9%]; P=0.01).

DISCUSSION: Cecal intubation rates exceeded 90% and polypectomy rates exceeded 30%, but withdrawal times were frequently shorter than recommended. There are marked practice variations consistent with previous observations.

CONCLUSION: Real-time, point-of-care practice audits with prompt, confidential access to outcome data provide a basis for targeted educational programs to improve quality in colonoscopy practice.
Chronic Constipation: Current Treatment Options
Authors: Liu Louis Wing Cheong
Published: March 2016

Chronic constipation is a common functional gastrointestinal disorder that affects patients of all ages. In 2007, a consensus group of 10 Canadian gastroenterologists developed a set of recommendations pertaining to the management of chronic constipation and constipation‐dominant irritable bowel syndrome. Since then, tegaserod has been withdrawn from the Canadian market. A new, highly selective serotonin receptor subtype 4 agonist, prucalopride, has been examined in several large, randomized, placebo‐controlled trials demonstrating its efficacy and safety in the management of patients with chronic constipation. Additional studies evaluating the use of stimulant laxatives, polyethylene glycol and probiotics in the management of chronic constipation have also been published. The present review summarizes the previous recommendations and new evidence supporting different treatment modalities – namely, diet and lifestyle, bulking agents, stool softeners, osmotic and stimulant laxatives, prucalopride and probiotics in the management of chronic constipation. A brief summary of lubiprostone and linaclotide is also presented. The quality of evidence is presented by adopting the Grading of Recommendations, Assessment, Development and Evaluation system. Finally, a management pyramid for patients with chronic constipation is proposed based on the quality of evidence, impact of each modality on constipation and on general health, and their availabilities in Canada.
Evaluation of Colonoscopy Skills – How Well Are We Doing?
Authors: Mohamed Rachid , Shaheen Abdel Aziz , Raman Maitreyi
Published: March 2016

Colonoscopy is a complex task that requires the interplay of motor and cognitive skill sets. Traditional teaching of colonoscopy involves observation in an apprenticeship model. Individual trainees vary in their rate of their skill acquisition, and this trial-and-error method often results in frustration and anxiety for both the educator and the learner. Currently, there are no guidelines to determine the competence or proficiency of an individual for colonoscopy. Furthermore, there is a paucity of information regarding formal training curricula for colonoscopy skills acquisition. The present study investigated a formal and validated educational framework for colonoscopy teaching and compared it with the traditional apprenticeship model in first-year trainees.
Usefulness of Endoscopic Ultrasonography in Hepatology
Authors: Bissonnette Julien , Paquin Sarto , Sahai Anand V , Pomier-Layrargues Gilles
Published: March 2016

Endoscopic ultrasonography (EUS) is used to evaluate patients with hepatobiliary diseases. The technique is useful for the diagnosis of esogastric varices in selected cases of portal hypertension, and to evaluate the pathogenic role and prognostic value of the collateral circulation in patients with this condition. When coupled with the Doppler technique, EUS can be used to guide injection sclerotherapy and to verify the obliteration of varices (particularly fundal varices) after endoscopic treatment. Hemodynamic changes induced in the collateral circulation by vasoactive drugs can also be measured with Doppler-EUS. Fine-needle aspiration under EUS guidance is useful in the diagnosis of focal liver lesions and perihepatic adenopathy, and in the evaluation of biliary tract diseases. New indications can be developed in the future after adequate experimental validation.
Practices and Perceptions Regarding Pain and Pain Management during Routine Childhood Immunizations: Findings from a Focus‐Group Study with Nurses Working at Toronto Public Health, Ontario
Authors: Kikuta Andrew , Gardezi Fauzia , Dubey Vinita , Taddio Anna
Published: March 2016

INTRODUCTION: Despite the availability of a variety of evidence‐based interventions, it has previously been reported that the majority of infants and children undergo vaccine injections without the benefit of analgesia. Nurses in public health administer a substantial number of injections; however, their attitudes and practices surrounding acute pain during vaccine injections have not been previously explored.

METHODS: A focus‐group interview was conducted in Toronto, Ontario, with 10 nurses who immunize children. Participants reported their perceptions and practices with regard to vaccine injection pain and pain management.

RESULTS: Three key themes emerged: environmental and process factors, perceptions regarding the effectiveness of different analgesic interventions, and perceptions regarding pain and fear. Participants reported a lack of control over their environment, resulting in fear and discomfort for children. They recommended increased support from external partners such as school teachers and administrators. Participants reported that pharmacological interventions, such as topical local anesthetics, were not used; however, psychological and physical interventions were commonly used. Nurses questioned the effectiveness of topical anesthetics, and indicated that more education was required regarding effective analgesic interventions. Needle pain was reported to be the most prominent concern for children undergoing vaccine injections, and children were described as being fearful.

DISCUSSION: Nurses reported vaccination setting, analgesic effectiveness and relative importance given to pain as important factors for pain and pain management during vaccine injections. Future studies should explore whether additional perspectives are present in vaccinators in other geographical regions. The effectiveness of educational resources and pain management programs aimed at improving current practices should be investigated.
Comparison of Polysomnographic and Portable Home Monitoring Assessments of Obstructive Sleep Apnea in Saskatchewan Women
Authors: Gjevre JA , Taylor-Gjevre RM , Skomro R , Reid J , Fenton M , Cotton D
Published: March 2016

OBJECTIVES: To compare a commercially available, level III in‐home diagnostic sleep test (Embletta, Embletta USA) and in‐laboratory polysomnography (PSG) in women with suspected obstructive sleep apnea (OSA).

METHODS: Consecutive women scheduled for routine PSG testing for evaluation of clinically suspected OSA and who met inclusion/exclusion criteria, were invited to participate. An in‐home Embletta portable monitor test was performed one week before or after diagnostic PSG.

RESULTS: Forty‐seven of 96 women who met the inclusion/exclusion criteria agreed to participate. The mean (± SD) age of the patients was 52.0±11.0 years, with a mean body mass index of 34.86±9.04 kg/m2, and 66% (31 of 47) of patients were at high risk for OSA according to the Berlin score. Paired analysis of the overall population revealed no significant difference in mean apnea/hypopnea index (AHI) between the two diagnostic methods (P=0.475). At an AHI of ≥5, the Embletta test was highly sensitive (90.6%) in determining abnormal versus normal OSA, with a positive predictive value of 82.7%. However, a higher Embletta AHI threshold of ≥10 may be more useful, with a higher level of agreement (kappa coefficient) with PSG testing and a positive predictive value of 92.3%. The in‐home study was less useful at distinguishing severe from nonsevere OSA, yielding a sensitivity of 50%.

CONCLUSIONS: In women believed to be at high‐risk for OSA, Embletta in‐home sleep testing is useful for the detection of sleep disordered breathing.
Retrospective Analysis of Radiation Exposure During Endoscopic Retrograde Cholangiopancreatography: Critical Determinants
Authors: Kim Edward , McLoughlin Mark , Lam Eric C , Amar Jack , Byrne Michael , Telford Jennifer , Enns Robert
Published: March 2016

BACKGROUND: Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) has a logarithmic relationship with radiation exposure, and carries a known risk of radiation exposure to patients and staff. Factors associated with prolonged fluoroscopy duration have not been well delineated.

OBJECTIVES: To determine the specific patient, physician and procedural factors that affect fluoroscopy duration.

METHODS: A retrospective analysis of 1071 ERCPs performed at two tertiary care referral hospitals over an 18-month period was conducted. Patient, physician and procedural variables were recorded at the time of the procedure.

RESULTS: The mean duration of 969 fluoroscopy procedures was 4.66 min (95% CI 4.38 to 4.93). Multivariable analysis showed that the specific patient factors associated with prolonged fluoroscopy duration included age and diagnosis (both P<0.0001). The endoscopist was found to play an important role in the duration of fluoroscopy (ie, all endoscopists studied had a mean fluoroscopy duration significantly different from the reference endoscopist). In addition, the following procedural variables were found to be significant: number of procedures, basket use, biopsies, papillotomy (all P<0.0001) and use of a tritome (P=0.004). Mean fluoroscopy duration (in minutes) with 95% CIs for different diagnoses were as follows: common bile duct stones (n=443) 5.12 (3.05 to 4.07); benign biliary strictures (n=135) 3.94 (3.26 to 4.63); malignant biliary strictures (n=124) 5.82 (4.80 to 6.85); chronic pancreatitis (n=49) 4.53 (3.44 to 5.63); bile leak (n=26) 3.67 (2.23 to 5.09); and ampullary mass (n=11) 3.88 (1.28 to 6.48). When no pathology was found (n=195), the mean fluoroscopy time was 3.56 min (95% CI 3.05 to 4.07). Comparison usingttests determined that the only two diagnoses for which fluoroscopy duration was significantly different from the reference diagnosis of ‘no pathology found’ were common bile duct stones (P<0.0001) and malignant strictures (P<0.0001).

CONCLUSIONS: Factors that significantly affected fluoroscopy duration included age, diagnosis, endoscopist, and the number and nature of procedures performed. Elderly patients with biliary stones or a malignant stricture were likely to require the longest duration of fluoroscopy. These identified variables may help endoscopists predict which procedures are associated with prolonged fluoroscopy duration so that appropriate precautions can be undertaken.
Factors Associated with the Appropriate Use of Asthma Drugs
Authors: Jobin Marie-Sophie , Moisan Jocelyne , Bolduc Yves , Dorval Eileen , Boulet Louis-Philippe , Grégoire Jean-Pierre
Published: March 2016

BACKGROUND: When used properly, asthma drugs can reduce asthma-related morbidity and mortality.

OBJECTIVE: To assess the use of asthma drugs, and to identify factors associated with appropriateness of use among patients 12 to 45 years of age.

METHODS: Asthmatic patients were interviewed about their asthma drug(s) use and the factors potentially associated with appropriateness of use according to the 2003 Canadian Asthma Consensus Conference guidelines. To determine the factors associated with the appropriate use of asthma drugs, a multivariate logistic regression model was built using a stepwise procedure, and ORs and associated 95% CIs were calculated.

RESULTS: Of the 349 study participants, 43 (12.3%) reported appropriate use of their asthma drugs. Respondents who were more likely to report appropriate use were patients with sound knowledge of their asthma drugs (OR 2.61 [95% CI 1.29 to 5.29]), those in good, very good or excellent self-perceived health (OR 3.37 [95% CI 1.31 to 8.71]), those who had consulted a specialist during the preceding year (OR 2.28 [95% CI 1.05 to 4.97]) and those who declared themselves short of drugs due to a lack of money (OR 2.78 [95% CI 1.26 to 6.17]).

CONCLUSIONS: Results of the present study suggested that recommendations in the current guidelines regarding the appropriate use of asthma medications are being poorly implemented. Educational interventions with the aim of improving quality of care and knowledge about asthma drugs should be offered.
Transient Elevation of the Ipsilateral Hemidiaphragm Associated with Pneumonia
Authors: Fretzayas Andrew , Moustaki Maria , Nicolaidou Polyxeni , Alexopoulou Efthimia , Priftis Konstantinos N
Published: March 2016

Seventeen children with lobar or segmental pneumonia and ispilateral elevation of the diaphragm are described. These children did not differ significantly with respect to clinical and laboratory findings from their counterparts with pneumonia but without elevation of the hemidiaphragm. The elevation was transient and resolved by the time the repeat chest x-ray was taken six to eight weeks later.
Pulmonary Actinomycosis in a Male Patient with a Tracheal Bronchus
Authors: Costiniuk Cecilia T , Voduc Nha , de Souza Carolina
Published: March 2016

BACKGROUND: Tracheal bronchus is a congenital malformation comprising an abnormal bronchus originating from the trachea or other bronchus. This malformation has been associated with recurrent pneumonia in children, but is rarely associated with infection in adults.Actinomycesspecies are rare causes of necrotizing pneumonias that often masquerade as malignancy, lung abscesses and tuberculosis.

METHODS AND RESULTS: A case involving a 46-year-old man with a tracheal bronchus and chronic pneumonia syndrome is presented. Bronchialveolar lavage and transthoracic needle biopsy demonstrated the presence ofActinomyces meyeriandFusobacteriumspecies.

CONCLUSIONS: The present article reports the first documented case of actinomycosis occurring in a patient with a tracheal bronchus.
A Comparison between Enriched and Nonenriched Enrollment Randomized Withdrawal Trials of Opioids for Chronic Noncancer Pain
Authors: Furlan Andrea D , Chaparro Luis E , Irvin Emma , Mailis-Gagnon Angela
Published: March 2016

An enriched enrollment randomized withdrawal (EERW) trial design has been advocated to be useful for the study of drugs that are beneficial to only a fraction of the individuals who take them. Some investigators defend the use of enrichment designs for opioids in chronic noncancer pain (CNCP), reasoning that opioids may appear to underperform in clinically heterogeneous contexts, ie, that substantial efficacy in a particular patient subgroup may be diluted or masked by poor efficacy in another subgroup. The authors previously published a systematic review of opioids for CNCP in 2006; however, at that time, there were only a few EERW trials available for comparison. This more exhaustive, updated review compares the results between EERW and non‐EERW trials of opioids for a variety of CNCP conditions.

BACKGROUND: An enriched enrollment randomized withdrawal (EERW) design excludes potential participants who are nonresponders or who cannot tolerate the experimental drug before random assignment. It is unclear whether EERW design has an influence on the efficacy and safety of opioids for chronic noncancer pain (CNCP).

OBJECTIVES: The primary objective was to compare the results from EERW and non‐EERW trials of opioids for CNCP. Secondary objectives were to compare weak versus strong opioids, subgroups of patients with different types of pain, and the efficacy of opiods compared with placebo versus other drugs.

METHODS: MEDLINE, EMBASE and CENTRAL were searched up to July 2009, for randomized controlled trials of any opioid for CNCP. Meta‐analyses and meta‐regressions were conducted to compare the results. Treatment efficacy was assessed by effect sizes (small, medium and large) and the incidence of adverse effects was assessed by a clinically relevant mean difference of 10% or greater.

RESULTS: Sixty‐two randomized trials were included. In 61 trials, the duration was less than 16 weeks. There was no difference in efficacy between EERW and non‐EERW trials for both pain (P=0.6) and function (P=0.3). However, EERW trials failed to detect a clinically relevant difference for nausea, vomiting, somnolence, dizziness and dry skin/itching compared with non‐EERW. Opioids were more effective than placebo in patients with nociceptive pain (effect size=0.60, 95% CI 0.49 to 0.72) and neuropathic pain (effect size=0.56, 95% CI 0.38 to 0.73).

CONCLUSION: EERW trial designs appear not to bias the results of efficacy, but they underestimate the adverse effects. The present updated meta‐analysis shows that weak and strong opioids are effective for CNCP of both nociceptive and neuropathic origin.
Interstitial Cells of Cajal: A Novel Hypothesis for the Pathophysiology of Irritable Bowel Syndrome
Authors: Eshraghian Ahad , Eshraghian Hamed
Published: March 2016

Irritable bowl syndrome (IBS) affects a large proportion of the world’s population, and accounts for a considerable number of visits to gastroenterologists and general practitioners. Despite its high prevalence, the precise mechanism of IBS has not been identified to date. The interstitial cells of Cajal (ICC) participate in the production of slow waves and the regulation of their propagation through the gastrointestinal system; thus, they are important components of gastrointestinal motility. The present review proposes that ICC play a central role in the pathophysiology of IBS. This hypothesis is based on many links between ICC and currently proposed mechanisms of IBS pathophysiology. It appears that ICC may be involved in almost all of the previously explained pathogenic mechanisms of IBS. If proven, this hypothesis may provide a key to solving the IBS mystery.
A Comparison of Hospital and Nonhospital Colonoscopy: Wait Times, Fees and Guideline Adherence to Follow‐Up Interval
Authors: Ivers Noah , Schwandt Michael , Hum Susan , Martin Danielle , Tinmouth Jill , Pimlott Nick
Published: March 2016

BACKGROUND: Although colonoscopy is increasingly performed in nonhospital facilities, studies to date examining differences between colonoscopy services in hospital and nonhospital settings have been limited, in large part, to administrative databases.

OBJECTIVES: To describe the experiences of patients receiving colonoscopy in hospital and nonhospital settings, and to compare these settings with respect to wait times and recommended follow‐up interval to the next colonoscopy.

METHODS: A postal survey of 2000 patients, 50 to 70 years of age, from an urban academic family practice was conducted. Most recent colonoscopy was classified as either occurring in a hospital or nonhospital setting. Multivariable logistic regression analysis was used to examine the association among wait times, follow‐up intervals and patient factors with respect to colonoscopy setting.

RESULTS: Patients who underwent their most recent colonoscopy outside of a hospital were more likely to be men (P=0.01) and to have undergone more than one previous colonoscopy (P=0.02). For patients with a normal screening colonoscopy and no family history of colorectal cancer or polyps, nonhospital clinics less often recommended a 10‐year follow‐up interval (OR 0.13 [95% CI 0.04 to 0.47]). Reported wait times at nonhospital clinics were shorter for patients receiving screening colonoscopy (OR 2.11 [95% CI 1.28 to 3.47]), but not for symptomatic patients (OR 1.74 [95% CI 0.88 to 3.43]). For individuals attending nonhospital clinics, 10% were referred from a hospital by the same specialist performing the procedure; 31.7% reported paying a fee.

CONCLUSION: Nonhospital clinics were far less likely to adhere to guidelines regarding follow‐up intervals for low‐risk patients. Given the implications for both health care costs and patient safety, further study is needed to determine the cause of this disparity.
The Impact of Enrollment in a Specialized Interdisciplinary Neuropathic Pain Clinic
Authors: Garven Alex , Brady Shauna , Wood Susan , Hatfield Melinda , Bestard Jennifer , Korngut Lawrence , Toth Cory
Published: March 2016

BACKGROUND: Chronic pain clinics have been created because of the increasing recognition of chronic pain as a very common, debilitating condition that requires specialized care. Neuropathic pain (NeP) is a multifaceted, specialized form of chronic pain that often requires input from multiple disciplines for assessment and management.

OBJECTIVE: To determine the impact of an interdisciplinary clinic for evaluation and treatment of patients with NeP.

METHODS: Patients with heterogeneous etiologies for NeP were prospectively evaluated using an interdisciplinary approach every six months. Diagnostic evaluation, comorbidity evaluation, education, and pharmacological and/or nonpharmacological management were completed. Severity (visual analogue scale) and features of pain (Modified Brief Pain Inventory), sleep difficulties (Medical Outcomes Study – Sleep Scale), mood/anxiety disruption (Hospital Anxiety and Depression Scale), quality of life (European Quality‐of‐Life Five‐Domain index), health care resources use, patient satisfaction (Pain Treatment Satisfaction Scale and Neuropathic Pain Symptom Inventory) and self‐perceived change in well‐being (Patient Global Impression of Change scale) were examined at each visit.

RESULTS: Pain severity only decreased after one year of follow‐up, while anxiety and quality‐of‐life indexes improved after six months. Moderate improvements of sleep disturbance, less frequent medication use and reduced health care resource use were observed during enrollment at the NeP clinic.

DISCUSSION: Despite the limitations of performing a real‐world, uncontrolled study, patients with NeP benefit from enrollment in a small interdisciplinary clinic. Education and a complete diagnostic evaluation are hypothesized to lead to improvements in anxiety and, subsequently, pain severity. Questions remain regarding the long‐term maintenance of these improvements and the optimal structure of specialized pain clinics.
New Treatment Options for Chronic Constipation: Mechanisms, Efficacy and Safety
Authors: Camilleri Michael
Published: March 2016

The present review has several objectives, the first of which is to review the pharmacology and selectivity of serotonergic agents to contrast the older serotonergic agents (which were withdrawn because of cardiac or vascular adverse effects) with the newer generation serotonin receptor subtype 4 agonists. Second, the chloride ion secretagogues that act through the guanylate cyclase C receptor are appraised and their pharmacology is compared with the approved medication, lubiprostone. Third, the efficacy and safety of the application of bile acid modulation to treat constipation are addressed. The long‐term studies of surgically induced excess bile acid delivery to the colon are reviewed to ascertain the safety of this therapeutic approach. Finally, the new drugs for opiate‐induced constipation are introduced. Assuming these drugs are approved, practitioners will have a choice; however, patient responsiveness will be based on trial and error. Nevertheless, the spectrum of mechanisms and demonstrated efficacy and safety augur well for satisfactory treatment outcomes.
Granulomatous Pneumocystis Jiroveci Pneumonia Associated with Immune Reconstituted HIV
Authors: Sabur Natasha F , Kelly Margaret M , Gill M John , Ainslie Martha D , Pendharkar Sachin R
Published: March 2016

Pneumocystis jiroveci pneumonia uncommonly presents with pulmonary nodules and granulomatous inflammation. An unusual case of granulomatous P jiroveci pneumonia in an HIV patient with a CD4+ lymphocyte count of greater than 200 cells/mm3, occurring in the context of immune reconstitution with highly active antiretroviral therapy, is described. The case highlights the importance of establishing this diagnosis to institute appropriate therapy.
Feasibility of a Provincial Voluntary Reporting System for Work‐Related Asthma in Ontario
Authors: To Teresa , Tarlo Susan M , McLimont Susan , Haines Ted , Holness D Linn , Lougheed M Diane , Liss Gary M , Cicutto Lisa
Published: March 2016

OBJECTIVE The Ontario Work‐Related Asthma Surveillance System: Physician Reporting (OWRAS) Network was established in 2007 to estimate the prevalence of work‐related asthma (WRA) in Ontario, and to test the feasibility of collecting data for cases of WRA from physicians voluntarily.

METHODS: More than 300 respirologists, occupational medicine physicians, allergists and primary care providers in Ontario were invited to participate in monthly reporting of WRA cases by telephone, postal service or e‐mail.

RESULTS: Since 2007, 49 physicians have registered with the OWRAS Network and, to date, have reported 34 cases of occupational asthma and 49 cases of work‐exacerbated asthma. Highly reactive chemicals were the most frequently reported suspected causative agent of the 108 suspected exposures reported.

CONCLUSION: Despite the challenge of enlisting a representative sample of physicians in Ontario willing to report, the OWRAS Network has shown that it is feasible to implement a voluntary reporting system for WRA; however, its long‐term sustainability is currently unknown.