bluuebunny/crossref_metadata_2025 huggingface dataset:
Younger Age and Prognosis in Diverticulitis: A Nationwide Retrospective Cohort Study
Authors: Razik Roshan , Chong Christopher A , Nguyen Geoffrey C
Published: March 2016

BACKGROUND: Traditionally regarded as a disease of the elderly, the incidence of diverticulitis of the colon has been on the rise, especially in younger cohorts. These patients have been found to experience a more aggressive disease course with more frequent hospitalization and greater need for surgical intervention.

OBJECTIVE: To characterize factors that portend a poor prognosis in patients diagnosed with diverticulitis; in particular, to evaluate the role of demographic variables on disease course.

METHODS: Using the Canadian Institute for Health Information Discharge Abstract Databases, readmission rates, length of stay, colectomy rates and mortality rates in patients hospitalized for diverticulitis were examined. Data were stratified according to age, sex and comorbidity (as defined by the Charlson index).

RESULTS: In the cohort ≤30 years of age, a clear male predominance was apparent. Colectomy rate in the index admission, stratified according to age, demonstrated a J-shaped curve, with the highest rate in patients ≤30 years of age (adjusted OR 2.3 [95% CI 1.62 to 3.27]) compared with the 31 to 40 years of age group. In-hospital mortality increased with age. Cumulative rates of readmission at six and 12 months were 6.8% and 8.8%, respectively.

CONCLUSION: In the present nationwide cohort study, younger patients (specifically those ≤30 years of age) were at highest risk for colectomy during their index admission for diverticulitis. It is unclear whether this observation was due to more virulent disease among younger patients, or surgeon and patient preferences.
Methicillin‐Resistant Staphylococcus aureus Colonization among Health Care Workers in a Downtown Emergency Department in Toronto, Ontario
Authors: Saito Gregory , Thom Jessica , Wei Yanliang , Gnanasuntharam Piraveina , Gnanasuntharam Pirasanya , Kreiswirth Nathan , Willey Barbara , Loftus Michelle , Varner Catherine , Porter Vanessa , McGeer Allison , Borgundvaag Bjug
Published: March 2016

BACKGROUND: Methicillin‐resistant Staphylococcus aureus (MRSA) acquired in the community, otherwise known as community‐acquired MRSA, has emerged rapidly in recent years. Colonization with MRSA has been associated with an increased risk of symptomatic and serious infections and, in some settings, health care workers (HCWs) exhibit a higher prevalence of MRSA colonization.

OBJECTIVE: To determine MRSA colonization in emergency department (ED) HCWs in the setting of a moderate prevalence of MRSA in skin and soft tissue infections.

METHODS: The present study was conducted at a downtown ED in Toronto, Ontario. ED HCWs completed a brief questionnaire and swabs were taken from one anterior nare, one axilla and any open wounds (if present). Swabs were processed using standard laboratory techniques.

RESULTS: None of the 89 staff (registered nurses [n=55], physicians [n=15], other [n=19]) were MRSA positive and 25 (28.1%) were colonized with methicillin‐susceptible S aureus.

CONCLUSIONS: Contrary to common belief among HCWs and previous studies documenting MRSA colonization of HCWs, MRSA colonization of this particular Canadian ED HCW cohort was very low and similar to that of the local population.
Mechanical Analysis of Insertion Problems and Pain During Colonoscopy: Why Highly Skill-Dependent Colonoscopy Routines are Necessary in the First Place... and How They May be Avoided
Authors: Loeve Arjo J , Fockens Paul , Breedveld Paul
Published: March 2016

BACKGROUND: Colonoscopy requires highly skill-dependent manoeuvres that demand a significant amount of training, and can cause considerable discomfort to patients, which increases the use of sedatives. Understanding the underlying fundamental mechanics behind insertion difficulties and pain during colonoscopy may help to simplify colonoscopy and reduce the required extent of training and reliance on sedatives.

METHODS: A literature search, anatomical studies, models of the colon and colonoscope, and bench tests were used to qualitatively analyze the fundamental mechanical causes of insertion difficulties and pain. A categorized review resulted in an overview of potential alternatives to current colonoscopes.

RESULTS: To advance a colonoscope through the colon, the colon wall, ligaments and peritoneum must be stretched, thus creating tension in the colon wall, which resists further wall deformation. This resistance forces the colonoscope to bend and follow the curves of the colon. The deformations that cause insertion difficulties and pain (necessitating the use of complex conventional manoeuvres) are the stretching of ligaments, and stretching of colon wall in the transverse and longitudinal directions, and the peritoneum.

CONCLUSIONS: Four fundamental mechanical solutions to prevent these deformations were extracted from the analysis. The current results may help in the development of new colonoscopy devices that reduce – or eliminate – the necessity of using highly skill-dependent manoeuvres, facilitate training and reduce the use of sedatives.
Asthma and Chronic Obstructive Pulmonary Disease Guideline Implementation: Lessons Learned on Recruitment of Primary Care Physicians to a Knowledge Translation Study
Authors: Boulet Louis-Philippe , Hernandez Paul , Devlin Hollie , Freeman Marni A , Gupta Samir
Published: March 2016

BACKGROUND: Implementation of current clinical practice guidelines in asthma and chronic obstructive pulmonary disease (COPD) is suboptimal. New implementation strategies should be developed and evaluated.

METHODS: The authors report the rationale and planned methods of a project that sought to use a multifaceted knowledge translation intervention consisting of interactive education, mentorship through quality circles and practice‐based tools in primary care to address key asthma and COPD care gaps. The present study was aborted due to inadequate primary care physician recruitment. Accordingly, the authors provide a critical review of their recruitment strategies and discuss alternative approaches and examples based on previous literature.

DISCUSSION: These practical lessons and discussion seek to inform researchers involved in designing and recruiting for future knowledge translation studies addressing chronic disease management in primary care.
Emergency Department Surveillance as a Proxy For The Prediction of Circulating Respiratory Viral Disease in Eastern Ontario
Authors: Hall Geoffrey , Krahn Thomas , Majury Anna , Van Dijk Adam , Evans Gerald , Moore Kieran , Maier Allison
Published: March 2016

BACKGROUND: Seasonal outbreaks of winter respiratory viruses are responsible for increases in morbidity and mortality in the community. Previous studies have used hospitalizations, intensive care unit and emergency department (ED) visits as indicators of seasonal influenza incidence.

OBJECTIVES: To evaluate whether ED visits can be used as a proxy to detect respiratory viral disease outbreaks, as measured by laboratory confirmation.

METHODS: An Emergency Department Syndromic Surveillance system was used to collect ED chief complaints in Eastern Ontario from 2006 to 2010. Comparable laboratory‐confirmed cases of respiratory viral infections were collected from the Public Health Ontario Laboratory in Kingston, Ontario. Correlations between ED visits and laboratory‐confirmed cases were calculated.

RESULTS: Laboratory‐confirmed cases of selected respiratory viruses were significantly correlated with ED visits for respiratory and fever/influenza‐like illness. In particular, respiratory syncytial virus (Spearman’s rho = 0.593), rhinovirus (Spearman’s rho = 0.280), influenza A (Spearman’s rho = 0.528), influenza B (Spearman’s rho = 0.426) and pH1N1 (Spearman’s rho = 0.470) increased laboratory test levels were correlated with increased volume of ED visits across a number of age demographics. For the entire study population and all studied viruses, the Spearman’s rho was 0.702, suggesting a strong correlation with ED visits. Laboratory‐confirmed cases lagged in reporting by between one and two weeks for influenza A and pH1N1 compared with ED visit volume.

CONCLUSION: These findings support the use of an Emergency Department Syndromic Surveillance system to track the incidence of respiratory viral disease in the community. These methods are efficient and can be performed using automated electronic data entry versus the inherent delays in the primary care sentinel surveillance system, and can aid the timely implementation of preventive and preparatory health interventions.
A Controlled Investigation of Continuing Pain Education for Long‐Term Care Staff
Authors: Ghandehari Omeed O , Hadjistavropoulos Thomas , Williams Jaime , Thorpe Lilian , Alfano Dennis P , Bello-Haas Vanina Dal , Malloy David C , Martin Ronald R , Rahaman Omar , Zwakhalen Sandra MG , Carleton R Nicholas , Hunter Paulette V , Lix Lisa M
Published: March 2016

BACKGROUND: The underassessment and undertreatment of pain in residents of long‐term care (LTC) facilities has been well documented. Gaps in staff knowledge and inaccurate beliefs have been identified as contributors.

OBJECTIVES: To investigate the effectiveness of an expert‐based continuing education program in pain assessment/management for LTC staff.

METHODS: Participants included 131 LTC staff members who were randomly assigned to either an interactive pain education (PE) program, which addressed gaps in knowledge such as medication management, or an interactive control program consisting of general dementia education without a specific clinical focus. Participants attended three sessions, each lasting 3 h, and completed measures of pain‐related knowledge and attitudes/beliefs before, immediately after and two weeks following the program. Focus groups were conducted with a subset of participants to gauge perception of the training program and barriers to implementing pain‐related strategies.

RESULTS: Analysis using ANOVA revealed that PE participants demonstrated larger gains compared with control participants with regard to pain knowledge and pain beliefs. Barriers to implementing pain‐related strategies certainly exist. Nonetheless, qualitative analyses demonstrated that PE participants reported that they overcame many of these barriers and used pain management strategies four times more frequently than control participants.

CONCLUSIONS: Contrary to previous research, the present study found that the interactive PE program was effective in changing pain beliefs and improving knowledge. Continuing PE in LTC has the potential to address knowledge gaps among front‐line LTC providers.
Impact of a Cleaners’ Strike on Compensation Claims for Asthma among Teachers in Ontario
Authors: Ribeiro Marcos , Buyantseva Larisa V , Liss Gary M , Luce Carol E , Tarlo Susan M
Published: March 2016

BACKGROUND: A review of Workplace Safety and Insurance Board (WSIB) claims in Ontario from 1998 to 2002 showed an unusual spike in the number of claims accepted for work‐exacerbated asthma (WEA) in April 2001.

OBJECTIVE: To identify the cause for the spike in the number of WSIB claims for WEA in April 2001.

METHODS: File reviews were performed to identify the occupations of workers with claims accepted for WEA in April 2001 compared with claims during March and May 2001, and during the same months in 2000 and 2002.

RESULTS: In April 2001, there were 61 accepted WEA claims; the most common occupation was ‘teacher’. In contrast, among educational workers, there was only one WEA claim in the previous month and one in the following month. From March to May in the preceding and following years, there were only four and two claims, respectively. The most frequently implicated causative agents were dust and dirt exposure, which were responsible for 98% of claims; the mean (± SD) number of lost workdays was 6.5±10. The only identified environmental change associated with this spike was a cleaners’ strike at all elementary and high schools in the Toronto District School Board in Ontario, which started on March 31, 2001 and ended on May 1, 2001.

CONCLUSION: The spike in accepted WEA claims in Ontario in April 2001 was temporally associated with a strike by Toronto District School Board cleaners, suggesting acute symptomatic effects of poor workplace (school) maintenance on asthmatic employees. The WSIB database was sufficiently sensitive to capture this phenomenon.
Directing Therapy in Pulmonary Arterial Hypertension Using a Target 6 Min Walk Distance
Authors: Porhownik Nancy Rose , Myers Renelle , Bshouty Zoheir
Published: March 2016

BACKGROUND: The most effective approaches to escalating advanced therapies in pulmonary arterial hypertension (PAH) are controversial.

OBJECTIVE: To compare outcomes before and after introducing a target 6 min walk distance (6MWD) treatment strategy in PAH using registry data.

METHODS: From 2001 to 2005, WHO class II to IV patients were treated with bosentan or prostanoids. In July 2005, a target 6MWD strategy was adopted. Monotherapy continued if 6MWD remained >350 m. For patients in whom 6MWD was ≤350 m, sildenafil was added. If 6MWD remained <350 m, prostanoids were considered. Changes in 6MWD, WHO class and survival rate were compared between periods.

RESULTS: Before using the 6MWD strategy, there was a statistically significant improvement in mean WHO class at six, nine and 12 months (2.5±0.8 [P<0.015]; 2.5±0.8 [P<0.005]; and 2.5±0.9 [P<0.03], respectively) compared with baseline (2.9±0.9). There was a statistically significant increase in mean 6MWD at three, six, nine and 12 months (383±113 m [P<0.005]; 401±102 m [P<0.006]; 400±109 m [P<0.001]; and 399±110 m [P<0.004], respectively) compared with baseline (321±119 m). The survival rate was 95% at one and two years. From 2005 to 2009, there was a statistically significant improvement in mean WHO class at three, six, nine and 12 months (2.6±0.8 [P<0.05]; 2.3±0.9 [P<0.0001]; 2.3±0.9 [P<0.0001]; and 2.3±1.0 [P<0.0005], respectively) compared with baseline (2.8±0.7). There was statistically significant improvement in 6MWD at six months (381±126 m [P<0.05]), followed by a decline toward baseline (354±117 m). One‐ and two‐year survival rates in the 6MWD target era were 95% and 80%, respectively.

CONCLUSION: Based on registry data, adoption of this strategy did not affect survival rates, nor cause a sustained improvement in 6MWD by 12 months. WHO class improved similarly in both treatment groups.
Daily Changes in Pain, Mood and Physical Function in Youth Hospitalized for Sickle Cell Disease Pain
Authors: Zempsky William T , Palermo Tonya M , Corsi John M , Lewandowski Amy S , Zhou Chuan , Casella James F
Published: March 2016

BACKGROUND: Youth with sickle cell disease (SCD) are commonly hospitalized for treatment of painful vaso‐occlusive episodes (VOE). However, limited data are available concerning the course of hospitalization for these children and adolescents and, in particular, whether daily changes occur in pain, emotional status and physical function.

OBJECTIVES: To characterize changes in daily pain intensity, physical function and mood over the course of hospitalization, and to determine whether specific clinical characteristics were associated with these changes.

METHODS: Daily ratings of pain (0 to 10 numerical rating scale) and mood (Positive and Negative Affect Scale for Children) were completed by 25 youth (11 to 20 years of age) with SCD over a total of 152 days (mean [± SD] = 6.7±5.6 days) of hospitalization. Trained raters determined each youth’s daily physical function.

RESULTS: Linear mixed modelling was used to examine changes in pain, mood and physical function during hospital stay. The rate of change over the course of hospitalization was significant for reductions in pain intensity (P<0.001) and improvements in physical (motor) function (P=0.001). Positive affect over time was significantly associated with subjects’ physical function scores (B 0.24 [95% CI 0.12 to 0.35]) but not with their pain scores. In contrast, negative affect was positively associated with pain and inversely associated with physical function scores (B 1.58 [95% CI 0.23 to 2.93]).

CONCLUSIONS: The results of the present study demonstrated that children made daily improvements in physical function and pain over hospitalization for VOE. Mood was related to changes in pain and physical recovery. Assessment of physical function and mood during hospitalization may help guide strategies to better understand the pain experience in youth with SCD hospitalized with VOE.
A Comparison of Work‐Exacerbated Asthma Cases from Clinical and Epidemiological Settings
Authors: Henneberger Paul K , Liang Xiaoming , Lemière Catherine
Published: March 2016

BACKGROUND: Clinical and epidemiological studies commonly use different case definitions in different settings when investigating work‐exacerbated asthma (WEA). These differences are likely to impact characteristics of the resulting WEA cases.

OBJECTIVES: To investigate this issue by comparing two groups of WEA cases, one identified using an intensive clinical evaluation and another that fulfilled epidemiological criteria.

METHODS: A total of 53 clinical WEA cases had been referred for suspected work‐related asthma to two tertiary clinics in Canada, where patients completed tests that confirmed asthma and ruled out asthma caused by work. Forty‐seven epidemiological WEA cases were employed asthma patients treated at a health maintenance organization in the United States who completed a questionnaire and spirometry, and fulfilled criteria for WEA based on self‐reported, work‐related worsening of asthma and relevant workplace exposures as judged by an expert panel.

RESULTS: Using different case criteria in different settings resulted in case groups that had a mix of similarities and differences. The clinical WEA cases were more likely to have visited a doctor’s office ≥3 times for asthma in the past year (75% versus 11%; P<0.0001), but did not seek more asthma‐related emergency or in‐patient care, or have lower spirometry values. The two groups differed substantially according to the industries and occupations where the cases worked.

CONCLUSIONS: Findings from both types of studies should be considered when measuring the contribution of work to asthma exacerbations, identifying putative agents, and selecting industries and occupations in which to implement screening and surveillance programs.
Life‐Threatening Adverse Events Following Therapeutic Opioid Administration in Adults: Is Pharmacogenetic Analysis Useful?
Authors: Madadi Parvaz , Sistonen Johanna , Silverman Gregory , Gladdy Rebecca , Ross Colin J , Carleton Bruce C , Carvalho Jose C , Hayden Michael R , Koren Gideon
Published: March 2016

BACKGROUND: Systemic approaches are needed to understand how variations in the genes associated with opioid pharmacokinetics and response can be used to predict patient outcome. The application of pharmacogenetic analysis to two cases of life‐threatening opioid‐induced respiratory depression is presented. The usefulness of genotyping in the context of these cases is discussed.

METHODS: A panel of 20 functional candidate polymorphisms in genes involved in the opioid biotransformation pathway (CYP2D6, UGT2B7, ABCB1, OPRM1, COMT) were genotyped in these two patients using commercially available genotyping assays.

RESULTS: In case 1, the patient experienced adverse outcomes when administered codeine and morphine, but not hydromorphone. Genetic test results suggested that this differential response may be due to an inherent propensity to generate active metabolites from both codeine and morphine. These active metabolites are not generated with hydromorphone. In case 2, the patient experienced severe respiratory depression during postoperative recovery following standard doses of morphine. The patient was found to carry genetic variations that result in decreased morphine efflux transporter activity at the blood‐brain barrier and increased sensitivity to opioids.

CONCLUSIONS: Knowledge of the relative contribution of pharmacogenetic biomarkers and their influence on opioid response are continually evolving. Pharmacogenetic analysis, together with clinical history, has the potential to provide mechanistic insight into severe respiratory depressive events in patients who receive opioids at therapeutic doses.
Methotrexate‐Induced Pulmonary Toxicity
Authors: Jakubovic Baruch D , Donovan Andrea , Webster Peter M , Shear Neil H
Published: March 2016

Methotrexate is a widely used medication with an array of recognized side effects. The present report describes a case of methotrexate‐induced pneumonitis in a patient with psoriasis, and demonstrates the hallmark clinical and investigational findings that support this infrequently encountered diagnosis. The ensuing discussion reviews the pathogenesis, management and prevention of this adverse drug reaction.
Antibiotic‐Resistant Escherichia coli in Women with Acute Cystitis in Canada
Authors: McIsaac Warren J , Moineddin Rahim , Meaney Christopher , Mazzulli Tony
Published: March 2016

BACKGROUND: Trimethoprim‐sulfamethoxazole (TMP‐SMX) has been a traditional first‐line antibiotic treatment for acute cystitis; however, guidelines do not recommend TMP‐SMX in regions where Escherichia coli resistance exceeds 20%. While resistance is increasing, there are no recent Canadian estimates from a primary care setting to guide prescribing decisions.

METHODS: A total of 330 family physicians assessed 752 women with suspected acute cystitis between 2009 and 2011. Physicians documented clinical features and collected urine for cultures for 430 (57.2%) women. The proportion of resistant isolates of E coli and exact binomial 95% CIs were estimated nationally, and compared regionally and demographically. These estimates were compared with those from a 2002 national study.

RESULTS: The proportion of TMP‐SMX‐resistant E coli was 16.0% nationally (95% CI 11.3% to 21.8%). This was not statistically higher than 2002 (10.9% [P=0.14]). TMP‐SMX resistance was increased in women ≤50 years of age (21.4%) compared with older women (10.7% [P=0.037]). In women with no antibiotic exposure in the previous three months, TMP‐SMX‐resistant E coli remained more prevalent in younger women (21.8%) compared with older women (4.4% [P=0.003]). The proportion of ciprofloxacin‐resistant E coli was 5.5% nationally (95% CI 2.7% to 9.9%), and was increased compared with 2002 (1.1% [P=0.036]). Ciprofloxacin resistance was highest in British Columbia (17.7%) compared with other regions (2.7% [P=0.003]), and was increased compared with 2002 levels in this province (0.0% [P=0.025]). Nitrofurantoin‐resistant E coli levels were low (0.5% [95% CI 0.01% to 2.7%).

DISCUSSION: The proportion of TMP‐SMX‐resistant E coli causing acute cystitis in women in Canada remains below 20% nationally, but may exceed this level in premenopausal women. Ciprofloxacin resistance has increased, notably in British Columbia. Nitrofurantoin resistance levels are low across the country. These observations indicate that TMP‐SMX and nitrofurantoin remain appropriate empirical antibiotic agents for treating cystitis in primary care settings in Canada.
Synergistic Interaction between Metformin and Sulfonylureas on Diclofenac‐Induced Antinociception Measured Using the Formalin Test in Rats
Authors: Ortiz Mario I
Published: March 2016

BACKGROUND: There is evidence that biguanides and sulfonylureas block diclofenac‐induced antinociception (DIA) in rat models. However, little is known about the interaction between these hypoglycemics with respect to DIA.

OBJECTIVE: To determine whether metformin‐sulfonylurea combinations affect DIA during the formalin test.

METHODS: Rats received the appropriate vehicle or diclofenac before 1% formaldehyde was injected into the paw. Rats were also pretreated with vehicle, glibenclamide, glipizide, metformin or glibenclamide/metformin and glipizide/metformin combinations before the diclofenac and formaldehyde injections, and the effect on antinociception was assessed. Isobolograms of the combinations were constructed to test for a synergistic interaction.

RESULTS: Systemic injection of diclofenac resulted in antinociception during the second phase of the test. Systemic pretreatment with the combinations of glibenclamide (0.56 mg/kg to 10 mg/kg)/metformin (10 mg/kg to 180 mg/kg) and glipizide (0.56 mg/kg to10 mg/kg)/metformin (10 mg/kg to 180 mg/kg) blocked DIA. The derived theoretical effective doses for 50% of subjects (ED50) for the glibenclamide/metformin and glipizide/metformin combinations were 32.52 mg/kg and 32.42 mg/kg, respectively, and were significantly higher than the actual observed experimental ED50 values (7.57 mg/kg and 8.43 mg/kg, respectively).

CONCLUSION: Pretreatment with glibenclamide, glipizide or metformin blocked DIA in a dose‐dependent manner, and combining either sulfonylurea with metformin produced even greater effects. The observed ED50s for the combinations were approximately fourfold lower than the calculated additive effects. These data indicate that sulfonylureas interact to produce antagonism of DIA. Combination therapy is a common second‐line treatment for patients with diabetes and metabolic syndrome, a group that experiences pain from multiple sources. The results suggest that at least some anti‐inflammatory agents may not be effective in this group.
Type II Congenital Pulmonary Airway Malformation in an Esophageal Lung
Authors: Martínez-Martínez Blanca Estela , Furuya María Elena Yuriko , Martínez-Muñiz Irma , Vargas Mario H , Flores-Salgado Rosalinda
Published: March 2016

A seven‐month‐old girl, born prematurely (birth weight 1000 g) from a twin pregnancy, was admitted to hospital due to recurrent pneumonia and atelectasis. She experienced cough and respiratory distress during feeding. The right hemithorax was smaller than the left, with diminished breath sounds and dullness. Chest x‐rays revealed decreased lung volume and multiple radiolucent images in the right lung, as well as overdistention of the left lung. An esophagogram revealed three bronchial branches arising from the lower one‐third of the esophagus, corresponding to the right lung and ending in a cul‐de‐sac. A diagnosis of esophageal lung was established. On bronchography, the right lung was absent and the trachea only continued into the left main bronchus. Echocardiography and angiotomography revealed agenesis of the pulmonary artery right branch. The surgical finding was an esophageal right lung, which was removed; the histopathological diagnosis was type II congenital pulmonary airway malformation in an esophageal lung.
Diagnostic practices and disease surveillance in Canadian children with congenital central hypoventilation syndrome
Authors: Amin Reshma , Moraes Theo J , Skitch Amy , Irwin Meredith S , Meyn Stephen , Witmans Manisha
Published: March 2016

OBJECTIVE: To assess the diagnostic and surveillance practices of Canadian pediatric subspecialists for children with congenital central hypoventilation syndrome (CCHS).

METHODS: The present analysis was a prospective cross‐sectional study. A web‐based survey was sent to 303 pediatric subspecialists in Canada: 85 pediatric respirologists, 77 pediatric neurologists and 141 neonatologists. The survey included 36 questions about the current diagnostic and surveillance management of pediatric CCHS. Differences in responses among respirologists, neurologists and neonatologists were evaluated for each question, where feasible, and responses were compared with the 2010 American Thoracic Society (ATS) Clinical Policy Statement for CCHS.

RESULTS: A total of 83 (27%) participants responded to the survey; the highest survey response rate (40%) was from respirologists. For the diagnosis of CCHS, 25% of respondents did not order genetic testing, either alone or with another test, to make a diagnosis of CCHS. The criteria and tests recommended by the ATS to make a diagnosis of CCHS – genetic testing, diagnosis of exclusion, polysomnogram and plus or minus a hypercapnic challenge – were ordered by 23 (43%) of the 54 respondents. Although polysomnograms were ordered for more than 90% of children with CCHS, only 37% of respirologists aimed for a carbon dioxide range of 35 mmHg to 40 mmHg during polysomnogram titrations.

CONCLUSIONS: The results demonstrate variability in the diagnostic and surveillance practices of pediatric subspecialists in children with CCHS across Canada. The present study provides an initial needs assessment and demonstrated that there are significant deviations in practice from the 2010 ATS guidelines.
Low-Dose Acetylsalicylic Acid Use and the Risk of Upper Gastrointestinal Bleeding: A Meta-Analysis of Randomized Clinical Trials and Observational Studies
Authors: Valkhoff Vera E , Sturkenboom Miriam CJM , Hill Catherine , Veldhuyzen van Zanten Sander , Kuipers Ernst J
Published: March 2016

BACKGROUND: Low-dose acetylsalicylic acid (LDA, 75 mg/day to 325 mg/day) is recommended for primary and secondary prevention of cardiovascular events, but has been linked to an increased risk of upper gastrointestinal bleeding (UGIB).

OBJECTIVE: To analyze the magnitude of effect of LDA use on UGIB risk.

METHODS: The PubMed and Embase databases were searched for randomized controlled trials (RCTs) reporting UGIB rates in individuals receiving LDA, and observational studies of LDA use in patients with UGIB. Studies were pooled for analysis of UGIB rates.

RESULTS: Eighteen studies were included. Seven RCTs reported UGIB rates in individuals randomly assigned to receive LDA (n=22,901) or placebo (n=22,923). Ten case-control studies analyzed LDA use in patients with UGIB (n=10,816) and controls without UGIB (n=30,519); one cohort study reported 207 UGIB cases treated with LDA only. All studies found LDA use to be associated with an increased risk of UGIB. The mean number of extra UGIB cases associated with LDA use in the RCTs was 1.2 per 1000 patients per year (95% CI 0.7 to 1.8). The number needed to harm was 816 (95% CI 560 to 1500) for RCTs and 819 (95% CI 617 to 1119) for observational studies. Meta-analysis of RCT data showed that LDA use was associated with a 50% increase in UGIB risk (OR 1.5 [95% CI 1.2 to 1.8]). UGIB risk was most pronounced in observational studies (OR 3.1 [95% CI 2.5 to 3.7]).

CONCLUSIONS: LDA use was associated with an increased risk of UGIB.
Update on Clinical Inflammometry for the Management of Airway Diseases
Authors: Nair Parameswaran
Published: March 2016

Airway inflammation is a central feature of many airway diseases such as asthma, chronic bronchitis, bronchiectasis and chronic cough; therefore, it is only logical that it is measured to optimize its treatment. However, most treatment recommendations, including the use of anti‐inflammatory therapies such as corticosteroids, are based on assessments of only airflow and symptoms. Over the past 10 years, methods have been developed to assess airway inflammation relatively noninvasively. Quantitative cell counts in sputum and the fraction of exhaled nitric oxide are the most validated tests. Judicious use of currently available drugs, such as corticosteroids, bronchodilators and antibiotics, and other anti‐inflammatory therapies guided by sputum eosinophil and neutrophil counts, have been demonstrated to decrease exacerbations of asthma and chronic obstructive pulmonary disease, ameliorate cough, improve quality of life in patients with these diseases and is cost effective compared with treatment strategies based on guidelines that do not incorporate these measurements. Thus, it is unfortunate that this is not used more widely in the management of airway diseases, particularly in patients with severe asthma and chronic obstructive pulmonary disease who experience frequent exacerbations.
Sporotrichosis in Renal Transplant Patients
Authors: Gewehr Paulo , Jung Bruno , Aquino Valerio , Manfro Roberto C , Spuldaro Fábio , Rosa Regis G , Goldani Luciano Z
Published: March 2016

The current report describes two renal transplant recipients who presented with sporotrichosis. In addition, the authors review the general aspects of sporotrichosis in renal transplant recipients reported in the literature. Sporotrichosis is a rare fungal infection in transplant patients and has been reported primarily in renal transplant recipients not treated with antifungal prophylaxis. Extracutaneous forms of sporotrichosis without skin manifestations and no previous history of traumatic injuries have been described in such patients and are difficult to diagnose. Renal transplant recipients with sporotrichosis described in the present report were successfully treated with antifungal therapy including amphotericin B deoxycholate, lipid amphotericin B formulations, fluconazole and itraconazole.
Sex as an Independent Prognostic Factor in a Population-Based, Non-Small Cell Lung Cancer Cohort
Authors: Pitz Marshall W , Musto Grace , Navaratnam Srisala
Published: March 2016

BACKGROUND: Males with non-small cell lung cancer (NSCLC) tend to experience worse outcomes, as do those with nonadenocarcinoma histology; however, the independent effects of these factors remain unclear.

OBJECTIVE: To evaluate the independent effect of sex and histology on mortality in a population of patients with NSCLC.

METHODS: All patients with NSCLC in Manitoba from 1985 to 2004 were identified from the Manitoba Cancer Registry. Treatment data were extracted from the Manitoba Health administrative databases and linked to the registry. Cox regression analysis was used to determine the independent effect of sex on survival.

RESULTS: A total of 10,908 patients (6665 male, 4243 female) with NSCLC were identified. Females had a median overall survival of 9.4 months versus 6.8 months for males (P<0.001). The adjusted HR for death for males compared with females was 1.13 (95% CI 1.04 to 1.23; P=0.004). Sex modified the effect of surgical treatment on survival (HR 1.26 [95% CI 1.13 to 1.40]; P<0.001). Adenocarcinoma histology modified the effect of sex on survival (HR 1.36 [95% CI 1.24 to 1.50]; P<0.001) when treatment was accounted for.

CONCLUSION: Females experienced a significantly better survival rate than males independent of treatment, age, year of diagnosis and histology. This was greatest in surgically treated patients and in those with adenocarcinoma.
Transnasal Endoscopic Evaluation of Swallowing: A Bedside Technique to Evaluate Ability to Swallow Pureed Diets in Elderly Patients with Dysphagia
Authors: Sakamoto Torao , Horiuchi Akira , Nakayama Yoshiko
Published: March 2016

BACKGROUND: Endoscopic evaluation of swallowing (EES) is not commonly used by gastroenterologists to evaluate swallowing in patients with dysphagia.

OBJECTIVE: To use transnasal endoscopy to identify factors predicting successful or failed swallowing of pureed foods in elderly patients with dysphagia.

METHODS: EES of pureed foods was performed by a gastroenterologist using a small-calibre transnasal endoscope. Factors related to successful versus unsuccessful swallowing of pureed foods were analyzed with regard to age, comorbid diseases, swallowing activity, saliva pooling, vallecular residues, pharyngeal residues and airway penetration/aspiration. Unsuccessful swallowing was defined in patients who could not eat pureed foods at bedside during hospitalization. Logistic regression analysis was used to identify independent predictors of swallowing of pureed foods.

RESULTS: During a six-year period, 458 consecutive patients (mean age 80 years [range 39 to 97 years]) were considered for the study, including 285 (62%) men. Saliva pooling, vallecular residues, pharyngeal residues and penetration/aspiration were found in 240 (52%), 73 (16%), 226 (49%) and 232 patients (51%), respectively. Overall, 247 patients (54%) failed to swallow pureed foods. Multivariate logistic regression analysis demonstrated that the presence of pharyngeal residues (OR 6.0) and saliva pooling (OR 4.6) occurred significantly more frequently in patients who failed to swallow pureed foods.

CONCLUSIONS: Pharyngeal residues and saliva pooling predicted impaired swallowing of pureed foods. Transnasal EES performed by a gastroenterologist provided a unique bedside method of assessing the ability to swallow pureed foods in elderly patients with dysphagia.
Catheter Removal versus Retention in the Management of Catheter‐Associated Enterococcal Bloodstream Infections
Authors: Marschall Jonas , Piccirillo Marilyn L , Fraser Victoria J , Doherty Joshua A , Warren David K , for the CDC Prevention Epicenters Program
Published: March 2016

BACKGROUND: Enterococci are an important cause of central venous catheter (CVC)‐associated bloodstream infections (CA‐BSI). It is unclear whether CVC removal is necessary to successfully manage enterococcal CA‐BSI.

METHODS: A 12‐month retrospective cohort study of adults with enterococcal CA‐BSI was conducted at a tertiary care hospital; clinical, microbiological and outcome data were collected.

RESULTS: A total of 111 patients had an enterococcal CA‐BSI. The median age was 58.2 years (range 21 to 94 years). There were 45 (40.5%) infections caused by Entercoccus faecalis (among which 10 [22%] were vancomycin resistant), 61 (55%) by Enterococcus faecium (57 [93%] vancomycin resistant) and five (4.5%) by other Enterococcus species. Patients were treated with linezolid (n=51 [46%]), vancomycin (n=37 [33%]), daptomycin (n=11 [10%]), ampicillin (n=2 [2%]) or quinupristin/dalfopristin (n=2 [2%]); seven (n=6%) patients did not receive adequate enterococcal treatment. Additionally, 24 (22%) patients received adjunctive gentamicin treatment. The CVC was retained in 29 (26.1%) patients. Patients with removed CVCs showed lower rates of in‐hospital mortality (15 [18.3%] versus 11 [37.9]; P=0.03), but similar rates of recurrent bacteremia (nine [11.0%] versus two (7.0%); P=0.7) and a similar post‐BSI length of hospital stay (median days [range]) (11.1 [1.7 to 63.1 days] versus 9.3 [1.9 to 31.8 days]; P=0.3). Catheter retention was an independent predictor of mortality (OR 3.34 [95% CI 1.21 to 9.26]).

CONCLUSIONS: To the authors’ knowledge, the present article describes the largest enterococcal CA‐BSI series to date. Mortality was increased among patients who had their catheter retained. Additional prospective studies are necessary to determine the optimal management of enterococcal CA‐BSI.
Role of Blind Closed Pleural Biopsy in the Management of Pleural Exudates
Authors: Pereyra Marco F , San-José Esther , Ferreiro Lucía , Golpe Antonio , Antúnez José , González-Barcala Francisco-Javier , Abdulkader Ihab , Álvarez-Dobaño José M , Rodríguez-Núñez Nuria , Valdés Luis
Published: March 2016

INTRODUCTION: The performance of blind closed pleural biopsy (BCPB) in the study of pleural exudates is controversial.

OBJECTIVE: To assess the diagnostic yield of BCPB in clinical practice and its role in the study of pleural exudates.

METHODS: Data were retrospectively collected on all patients who underwent BCPB performed between January 1999 and December 2011.

RESULTS: A total of 658 BCPBs were performed on 575 patients. Pleural tissue was obtained in 590 (89.7%) of the biopsies. A malignant pleural effusion was found in 35% of patients. The cytology and the BCPB were positive in 69.2% and 59.2% of the patients, respectively. Of the patients with negative cytology, 21 had a positive BCPB (diagnostic improvement, 15%), which would have avoided one pleuroscopy for every seven BCPBs that were performed. Of the 113 patients with a tuberculous effusion, granulomas were observed in 87 and the Lowenstein culture was positive in an additional 17 (sensitivity 92%). The overall sensitivity was 33.9%, with a specificity and positive predictive value of 100%, and a negative predictive value of 71%. Complications were recorded in 14.4% of patients (pneumothorax 9.4%; chest pain 5.6%; vasovagal reaction, 4.1%; biopsy of another organ 0.5%).

CONCLUSIONS: BCPB still has a significant role in the study of a pleural exudate. If an image‐guided technique is unavailable, it seems reasonable to perform BCPB before resorting to a pleuroscopy. These results support BCPB as a relatively safe technique.
Outpatient Parenteral Antimicrobial Therapy for Surgery Patients: A Comparison with Previous Standard of Care
Authors: Yang Anjie , Fung Ron , Brunton James , Dresser Linda
Published: March 2016

BACKGROUND: Current literature reports that outpatient parenteral antimicrobial therapy (OPAT) programs improve cure rates, and reduce length of hospitalization and costs. OPAT programs are still relatively new in Canada.

OBJECTIVE: To evaluate the benefits of an OPAT program initiated at a multispecialty tertiary care facility in Toronto, Ontario, compared with the previous standard of care.

METHODS: The present retrospective observational study was conducted using data from a group of surgical patients who were treated for active infections. Between February 1, 2010 and November 30, 2010, a total of 108 surgical patients were enrolled in the OPAT program. Patients were matched 1:1 with historical controls discharged between January 1, 2001 and January 1, 2010 according to age, sex, type of surgery, infection and comorbidities (Charlson Comorbidity Index). Cure rate, 30‐day rehospitalization and length of stay were evaluated as primary end points.

RESULTS: Of 108 eligible OPAT patients, 21 were matched to the control group using the prespecified criteria. For this cohort, the OPAT program was associated with improved cure rates (OPAT 61.7% versus control 57.1%; P>0.10), reduction in rehospitalization rate (14.3% versus 28.6%; P>0.10) and reduced length of stay (10.7 versus 13.9 days, P>0.10) compared with the control group.

CONCLUSIONS: For this cohort of surgery patients, the OPAT program demonstrated a trend toward improved outcomes but did not achieve statistical significance. Due to the lack of statistical power, further evaluation is required to determine the full benefit of OPAT to patients and the health care system.
Influenza Infection Screening Tools Fail to Accurately Predict Influenza Status for Hospitalized Patients During Pandemic H1N1 Influenza Season
Authors: Mulpuru Sunita , Roth Virginia R , Lawrence Nadine , Forster Alan J
Published: March 2016

BACKGROUND: Following the severe acute respiratory syndrome outbreak in 2003, hospitals have been mandated to use infection screening questionnaires to determine which patients have infectious respiratory illness and, therefore, require isolation precautions. Despite widespread use of symptom‐based screening tools in Ontario, there are no data supporting the accuracy of these screening tools in hospitalized patients.

OBJECTIVE: To measure the performance characteristics of infection screening tools used during the H1N1 influenza season.

METHODS: The present retrospective cohort study was conducted at The Ottawa Hospital (Ottawa, Ontario) between October and December, 2009. Consecutive inpatients admitted from the emergency department were included if they were ≥18 years of age, underwent a screening tool assessment at presentation and had a most responsible diagnosis that was cardiac, respiratory or infectious. The gold‐standard outcome was laboratory diagnosis of influenza.

RESULTS: The prevalence of laboratory‐confirmed influenza was 23.5%. The sensitivity and specificity of the febrile respiratory illness screening tool were 74.5% (95% CI 60.5% to 84.8%) and 32.7% (95% CI 25.8% to 40.5%), respectively. The sensitivity and specificity of the influenza‐like illness screening tool were 75.6% (95% CI 61.3% to 85.8%) and 46.3% (95% CI 38.2% to 54.7%), respectively.

CONCLUSIONS: The febrile respiratory illness screening tool missed 26% of active influenza cases, while 67% of noninfluenza patients were unnecessarily placed under respiratory isolation. Results of the present study suggest that infection‐control practitioners should re‐evaluate their strategy of screening patients at admission for contagious respiratory illness using symptom‐ and sign‐based tests. Future efforts should focus on the derivation and validation of clinical decision rules that combine clinical features with laboratory tests.
Peripheral Interleukin‐1β Levels are Elevated in Chronic Tension‐Type Headache Patients
Authors: Vedova Chris Della , Cathcart Stuart , Dohnalek Alan , Lee Vanessa , Hutchinson Mark R , Immink Maarten A , Hayball John
Published: March 2016

BACKGROUND: Tension‐type headache is the most common form of headache and its chronic form, chronic tension‐type headache (CTTH), is one of the most difficult to treat. The etiology of CTTH is not well understood, but is believed to be multifactorial and to vary among individuals. In the present study, the authors sought to identify common mechanisms of CTTH pathology. Empirical studies have implicated various immunomodulatory cytokines as mediators of chronic pain disorders, including CTTH.

OBJECTIVES: To determine the role of peripheral cytokines and genetic factors in the development of CTTH.

METHODS: A panel of cytokines hypothesized to play a role in the pathogenesis of CTTH was measured using cytometric bead arrays and ELISAs in 56 individuals with CTTH and 42 healthy control participants between 18 and 65 years of age.

RESULTS: Levels of interleukin (IL)‐1β were significantly elevated in participants diagnosed with CTTH relative to healthy controls, while IL‐18 levels were found to be significantly elevated in men with CTTH. Because the levels of these immune mediators were increased in the apparent absence of injury or infection, the authors sought to determine whether genetic changes were responsible for fluctuations in cytokine levels. Polymerase chain reaction and restriction fragment length polymorphism analyses were used to determine individual genotypes at key single nucleotide polymorphism positions in the IL-1B gene. No association was observed between CTTH and single nucleotide polymorphisms in the IL‐1β gene.

CONCLUSIONS: These findings suggest that increases in key proinflammatory cytokine levels are associated with CTTH and the pathology of the disorder involves sterile neurovascular inflammation.
Prolonged Treatment Duration is Required for SuccessfulHelicobacter pyloriEradication with Proton Pump Inhibitor Triple Therapy in Canada
Authors: Fallone Carlo A , Barkun Alan N , Szilagyi Andrew , Herba Karl M , Sewitch Maida , Martel Myriam , Fallone Stefanie S
Published: March 2016

BACKGROUND: Traditional seven-day proton pump inhibitor triple therapy forHelicobacter pylorieradication has recently shown disappointing results outside of Canada. Prolonging therapy may be associated with poorer compliance and, hence, may not have a better outcome in a real-world setting.

OBJECTIVE: To compare the outcomes of seven- and 14-day triple therapy for first-line treatment ofH pyloriinfection in an effectiveness setting in Canada.

METHODS: A total of 314 consecutive treatment-naive, adultH pylori-infected patients were allocated to either a seven- or 14-day triple therapy regimen, with a subgroup of 172 consecutive patients quasi-randomized to treatment according to date of visit. Eradication was confirmed using either urea breath test or gastric biopsies. Analysis was by intention to treat.

RESULTS: Eradication was achieved in a higher proportion of patients who underwent 14-day versus seven-day treatment regimens (overall: 85% versus 70% [P≤0.001]; subgroup: 83% versus 64% [P≤0.01]). Although successful eradication was also associated with older age and a diagnosis of ulcer disease, multivariate analysis revealed only longer treatment duration and lack of yogurt ingestion as independent predictors of successful eradication. There was a trend toward reduced success in the latter years of the study. Side effects were similar in both groups and were not prevented by yogurt ingestion.

CONCLUSIONS: The currently recommended duration of proton pump inhibitor triple therapy in Canada should be increased from seven to 14 days, the latter having achieved an excellent result in this particular real-world setting. Yogurt added no benefit. Further study is required to compare 10-day with 14-day treatment regimens.
Cursing the Darkness: Reactions to Fibromyalgia
Authors: Harth Manfred
Published: March 2016

Erratum to “Cursing the Darkness: Reactions to Fibromyalgia”dx.doi.org/10.1155/2013/612849