bluuebunny/crossref_metadata_2025 huggingface dataset:
Induction Versus Noninduction Antiviral Therapy for Chronic Hepatitis C Virus in Patients with Congenital Coagulation Disorders: A Canadian Multicentre Trial
Authors: Chatterjee A , Swain MG , Lee SS , Bain VG , Peltekian K , Croitoru K , Adams PC , Kaita K , Teitel J , Heathcote EJ
Published: March 2016

BACKGROUND: Patients with congenital coagulation disorders and chronic hepatitis C virus (HCV) infection have multiple risk factors (ie, infection predominantly with genotype-1 HCV, long duration of the disease, HIV coinfection and male sex) for poor response to antiviral therapy. The present study compared induction therapy with interferon-alpha (IFN-α)-2b with standard IFN-α2b therapy. Pegylated IFN was not available at the time that the study was initiated.

PATIENTS AND METHODS: A randomized study was performed comparing the efficacy of traditional IFN-α2b therapy (group A –three million units, three times weekly for 24 to 48 weeks) and daily ribavirin (1.0 g to 1.2 g according to weight for 24 to 48 weeks), with induction IFN-α2b therapy (group B – three million units, daily for eight weeks followed by the same dose administered three times a week for a further 16 to 40 weeks) and daily ribavirin (same dose as above) in IFN-naive patients with congenital coagulation disorders and chronic HCV infection.

RESULTS: Between 2000 and 2003, 54 HIV-negative patients were recruited and randomly assigned to group A or B (n=27 each). Both groups were comparable in terms of age, sex, ethnicity, body mass index, baseline HCV RNA titre, viral genotype, liver fibrosis stage and type of coagulation disorder. Induction therapy did not significantly alter sustained virological response rates (group A 50%, group B 50%; P=1.0). Multiple logistic regression analysis indicated that induction therapy did not benefit individuals with difficult-to-treat infection (ie, those infected with genotypes 1 and 4, or those with high baseline viral loads).

CONCLUSIONS: There was no benefit with induction antiviral therapy for HCV infection in individuals with congenital coagulation disorders.
Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease – 2007 Update
Authors: O’Donnell Denis E , Aaron Shawn , Bourbeau Jean , Hernandez Paul , Marciniuk Darcy D , Balter Meyer , Ford Gordon , Gervais Andre , Goldstein Roger , Hodder Rick , Kaplan Alan , Keenan Sean , Lacasse Yves , Maltais Francois , Road Jeremy , Rocker Graeme , Sin Don , Sinuff Tasmin , Voduc Nha
Published: March 2016

Chronic obstructive pulmonary disease (COPD) is a major respiratory illness in Canada that is both preventable and treatable. Our understanding of the pathophysiology of this complex condition continues to grow and our ability to offer effective treatment to those who suffer from it has improved considerably. The purpose of the present educational initiative of the Canadian Thoracic Society (CTS) is to provide up to date information on new developments in the field so that patients with this condition will receive optimal care that is firmly based on scientific evidence. Since the previous CTS management recommendations were published in 2003, a wealth of new scientific information has become available. The implications of this new knowledge with respect to optimal clinical care have been carefully considered by the CTS Panel and the conclusions are presented in the current document. Highlights of this update include new epidemiological information on mortality and prevalence of COPD, which charts its emergence as a major health problem for women; a new section on common comorbidities in COPD; an increased emphasis on the meaningful benefits of combined pharmacological and nonpharmacological therapies; and a new discussion on the prevention of acute exacerbations. A revised stratification system for severity of airway obstruction is proposed, together with other suggestions on how best to clinically evaluate individual patients with this complex disease. The results of the largest randomized clinical trial ever undertaken in COPD have recently been published, enabling the Panel to make evidence-based recommendations on the role of modern pharmacotherapy. The Panel hopes that these new practice guidelines, which reflect a rigorous analysis of the recent literature, will assist caregivers in the diagnosis and management of this common condition.
Waiting for Treatment for Chronic Pain – a Survey of Existing Benchmarks: Toward Establishing Evidence‐Based Benchmarks for Medically Acceptable Waiting Times
Authors: Lynch Mary E , Campbell Fiona A , Clark Alexander J , Dunbar Michael J , Goldstein David , Peng Philip , Stinson Jennifer , Tupper Helen , the Canadian Pain Society Wait Times Task Force
Published: March 2016

As medical costs escalate, health care resources must be prioritized. In this context, there is an increasing need for benchmarks and best practices in wait time management. In December 2005, the Canadian Pain Society struck a Task Force to identify benchmarks for acceptable wait times for treatment of chronic pain. The task force mandate included a systematic review and survey to identify national or international wait time benchmarks for chronic pain, proposed or in use, along with a review of the evidence upon which they are based. An extensive systematic review of the literature and a survey of International Association for the Study of Pain Chapter Presidents and key informants has identified that there are no established benchmarks or guidelines for acceptable wait times for the treatment of chronic pain in use in the world. In countries with generic guidelines or wait time standards that apply to all outpatient clinics, there have been significant challenges faced by pain clinics in meeting the established targets. Important next steps are to ensure appropriate additional research and the establishment of international benchmarks or guidelines for acceptable wait times for the treatment of chronic pain. This will facilitate advocacy for improved access to appropriate care for people suffering from chronic pain around the world.
Survival after Liver Transplantation for Hepatitis C Is Unchanged over Two Decades in Canada
Authors: Watt Kymberly DS , Burak Kelly W , Deschênes Marc , Lilly Les , Marleau Denis , Marotta Paul , Mason Andrew , Peltekian Kevork M , Renner Eberhard , Yoshida Eric M ,   for the Canadian Transplant Hepatology Outcomes Research Network
Published: March 2016

Allograft failure secondary to recurrence of hepatitis C virus (HCV) infection is the most common cause of death and retransplantation among recipients with HCV infection. It has been suggested that patients transplanted for HCV have had worse outcomes in more recent years than in previous years (the ‘era effect’). A Canadian transplantation registry database was analyzed to determine the outcomes of patients transplanted over the years for HCV. The results of the present analysis of 1002 patients show that the ‘era effect’ was not seen in liver transplantation recipients with HCV in Canada, because no survival difference was noted based on the year of transplantation. All groups had overall two-year and five-year survival rates of 76% to 83% and 69% to 72%, respectively. The present study’s national results prove continued benefit to transplantation of HCV patients.
Use of the Airway Questionnaire 20 to Detect Changes in Quality of Life in Asthmatic Patients and its Association with the St George’s Respiratory Questionnaire and Clinical Parameters
Authors: Win Thida , Pearce Linda , Nathan James , Cafferty Fay , Laroche Clare
Published: March 2016

BACKGROUND AND OBJECTIVES: The usefulness of the Airway Questionnaire 20 (AQ20) – a short version of the St George’s Respiratory Questionnaire (SGRQ) – to evaluate quality of life (QOL) in asthmatic patients following a hospital admission was assessed.

METHODS: At baseline and at six months following the index admission, 135 asthmatic patients were asked to complete the AQ20 and the SGRQ. The patient’s peak flow, number of subsequent asthma exacerbations and number of repeat hospital admissions were also recorded.

RESULTS: The AQ20 scores ranged from 0 to 20, with a high score indicating poor QOL. The AQ20 had good coverage, with no obvious ceiling or floor effects. In multiple regression analysis, all three SGRQ components were important in predicting AQ20 scores (R2 values were 61.9% and 73.1% for baseline and six‐month scores, respectively). The AQ20 was closely correlated with the SGRQ, but not redundant when used together. Bias was low when the retest reliability of the AQ20 was evaluated using the Bland‐Altman method, but variation was high (−0.64). Patients with subsequent exacerbations (n=52) had higher AQ20 scores at six‐month follow‐up (P=0.002). In logistic regression, the AQ20 score was closely associated with the incidence of exacerbations (OR 1.15, 95% CI 1.05 to 1.25), with a similar magnitude of association between the AQ20 and the SGRQ. The AQ20 score did not correlate with peak flow at baseline (r=−0.05; P=0.573) or at six months (r=−0.31; P=0.006), and was not responsive to changes in peak flow (r=−0.06; P=0.583).

CONCLUSION: The AQ20 can be substituted for the more complicated SGRQ in the assessment of QOL in patients following a hospital admission for an asthma exacerbation.
The Burden of Hepatitis C Virus Infection Is Growing: A Canadian Population-Based Study of Hospitalizations from 1994 to 2004
Authors: Myers Robert P , Liu MingFu , Shaheen Abdel Aziz M
Published: March 2016

BACKGROUND: Nearly 1% of Canadians are infected with the hepatitis C virus (HCV). Simulation analyses have suggested that HCV will place an increasing burden on the health care system as the infected population ages, but supportive clinical data are limited.

OBJECTIVES: To study temporal trends in HCV-related hospitalizations and predictors of increased health care utilization from a Canadian population-based perspective.

METHODS: An administrative hospitalization database from the Calgary Health Region was used to identify patients who were admitted for HCV between 1994 and 2004. The primary outcomes were liver-related HCV hospitalizations, length of stay, hospital costs and in-hospital mortality. Average annual growth rates in outcomes were calculated and subgroup analyses were conducted according to age, sex and HIV/HCV coinfection status.

RESULTS: Between 1994 and 2004, there were 4002 HCV-related hospitalizations; 22% were liver-related. Liver-related hospitalizations, lengths of stay and in-hospital mortality increased approximately fourfold or an average of 15% to 18% annually (P<0.0005). Patients aged 40 to 59 years and HIV/HCV coinfected patients experienced the largest average annual growth rates (19% to 27% and 30% to 40%, respectively; P<0.0005), reflecting the accelerated natural history of HCV in these subgroups. Hospital costs for liver-related HCV hospitalizations increased by an average of 41% annually (P=0.001) between 2000 and 2004. The average annual increase in liver-related hospitalizations remained significant in a sensitivity analysis, even when 75% of HCV cases were under-reported in 1994.

CONCLUSIONS: The present studies’ findings confirm the growing burden of HCV on the Canadian health care system. Strategies to prevent HCV infection and maximize the dissemination and most effective use of potentially curative antiviral therapies are necessary to reduce these trends.
Nitrofurantoin‐Associated Bronchiolitis Obliterans Organizing Pneumonia: Report of a Case
Authors: Fenton Mark E , Kanthan Rani , Cockcroft Donald W
Published: March 2016

Bronchiolitis obliterans organizing pneumonia due to nitrofurantoin has rarely been reported and is associated with poor outcomes. A case of nitrofurantoin‐associated bronchiolitis obliterans organizing pneumonia responsive to drug withdrawal and corticosteroids is presented.
A Case of Necrotizing Fasciitis due to Streptococcus pneumoniae Serotype 5 in Saskatchewan
Authors: Dawar Meenakshi , Russell Bob , McClean Karen , Levett Paul N , Tyrrell Gregory J , Irvine James
Published: March 2016

Necrotizing fasciitis due to Streptococcus pneumoniae is a rare and grave condition, and only a few cases have been reported. Suggested risk factors include minor trauma, systemic lupus erythematosus, immunosuppression secondary to medication, use of intramuscular anti‐inflammatories and alcoholism. A fatal case of pneumococcal necrotizing fasciitis that occurred in a 51‐year‐old woman with a history of alcohol abuse and oral anti‐inflammatory use is presented. Her condition was caused by a multi‐etiology outbreak of community‐acquired pneumonia, from which S pneumoniae serotype 5 was also isolated. The case description outlines the subtle presentation and rapid clinical progression of this condition. Because serotype 5 antigen is included in the polysaccharide 23‐valent pneumococcal vaccine, the present case highlights the importance of pneumococcal immunization programs in Canada.
Platelet Count to Spleen Diameter Ratio for the Diagnosis of Esophageal Varices: Is It Feasible?
Authors: Baig Waqas Wahid , Nagaraja MV , Varma Muralidhar , Prabhu Ravindra
Published: March 2016

AIM: To study the value of platelet count to spleen diameter ratio as a noninvasive parameter for diagnosing esophageal varices (EVs) in liver cirrhosis.

METHODS: The laboratory and ultrasonographic variables were prospectively evaluated in 150 patients with liver cirrhosis. Only stable patients were included in the study. Patients with active gastrointestinal bleeding at the time of admission were excluded. All patients underwent screening upper gastrointestinal endoscopy.

RESULTS: The platelet count, spleen diameter and platelet count to spleen diameter ratio in patients with EVs were significantly different from patients without EVs. The platelet count to spleen diameter ratio had the highest accuracy among the three parameters. By applying receiver operating characteristic curves, a platelet count to spleen diameter ratio cut-off value of 1014 was obtained, which gave positive and negative predictive values of 95.4% and 95.1%, respectively. The accuracy of this cut-off value as evaluated by applying receiver operating characteristic curves was 0.942 (95% CI 0.890 to 0.995).

CONCLUSION: Among the noninvasive parameters studied, platelet count to spleen diameter ratio had the highest accuracy for diagnosing EVs. However, the evidence for the noninvasive diagnosis is not yet sufficient to replace endoscopy as a diagnostic screening tool for EVs in all cirrhotic patients. The platelet count to spleen diameter ratio may be a useful tool for diagnosing EVs in liver cirrhosis noninvasively when endoscopy facilities are not available.
Use of Pain Threshold Reports to Satisfy Social Needs
Authors: MacDonald Geoff
Published: March 2016

OBJECTIVE: To examine the hypothesis that experimental threats to social belongingness, interacting with individual differences in attachment security, cause modification of pain threshold reports by individuals who report high pain thresholds at baseline.

METHODS: In each of three studies, baseline pain threshold and tolerance were assessed in response to a pain task (cold pressor pain in Studies 1 and 2, finger pressure pain in Study 3). Participants then completed a measure of attachment security and were randomly assigned to a social exclusion or control condition (exclusion from a computer game in Study 1, recalling past rejection experiences in Studies 2 and 3). The pain task was administered again to examine the effects on pain threshold and tolerance.

RESULTS: Those with high anxious attachment and high baseline pain thresholds reported higher postmanipulation pain thresholds in the exclusion conditions than in the control conditions. Those with low anxious attachment and high baseline pain thresholds reported lower postmanipulation pain thresholds in the exclusion conditions than in the control conditions. No differences were found for pain tolerance.

CONCLUSIONS: Across studies, results suggested that postmanipulation pain threshold reports of individuals with high baseline pain thresholds were particularly responsive to social exclusion. The form of the response was dependent on the level of anxious attachment. The present studies provide evidence that variance in pain threshold reports not accounted for by pain intensity may reflect the use of pain reports to satisfy social needs. This work also suggests that baseline measures of pain thresholds may, in interaction with psychological variables, have predictive power beyond serving as a control variable.
Enhancing the Sexual Function of Women Living with Chronic Pain: A Cognitive‐Behavioural Treatment Group
Authors: Breton Annie , Miller Colleen M , Fisher Kim
Published: March 2016

BACKGROUND: Chronic pain significantly impacts women’s quality of life in the domain of sexual function. Treatment aimed at improving the sexual function of women living with chronic pain is minimal or absent within an interdisciplinary rehabilitation pain program.

OBJECTIVE: To evaluate a cognitive‐behavioural treatment group designed to improve the sexual function of women with chronic pelvic pain, daily headache pain and neuromusculoskeletal pain within an interdisciplinary rehabilitation pain program.

METHODS: Participants were 47 women who attended the treatment group. A physical therapist and a psychologist facilitated the group. The participants completed a modified version of the Sexual Activity Questionnaire pregroup and at one month postgroup, and a Treatment Helpfulness Questionnaire at the final group session.

RESULTS: All 47 women found the treatment group helpful. Sexual function improved as evidenced by significant differences (Wilcoxon signed‐rank test, P<0.05) from pregroup to postgroup on measures of enjoyment, lubrication, satisfaction after sexual activity and satisfaction with frequency. Improvements occurred despite no change in pain level during penetration or fatigue level from pregroup to post‐group. Treatment helpfulness results showed that women valued the knowledge and skills gained in the group. Qualitative findings suggest that a cognitive shift, and communication and partner involvement may be mechanisms of change for improved sexual function.

CONCLUSIONS: The sexual function of women with chronic pain can be significantly enhanced by a cognitive‐behavioural treatment group delivered within an interdisciplinary rehabilitation pain program.
Asthma Control Score Based on Filled Medication Prescriptions: A Validation Study
Authors: Beauchesne Marie-France , Chartier Amélie , Fillion Anne , Lemière Catherine , Lecompte Sophie , Blais Lucie
Published: March 2016

BACKGROUND: Periodic measurement of disease control is recommended to characterize asthma and monitor treatment.

OBJECTIVE: To elaborate and validate an asthma control score (ACS) for use in studies based on administrative health databases.

METHODS: Adult patients with asthma were recruited from a clinic. The ACS is based on the average number of doses of short‐acting inhaled beta2‐agonists taken per week and short courses of oral corticosteroids dispensed over a three‐month period. Data were obtained from the Régie de l’assurance maladie du Québec database in Canada. The ACS was compared with the asthma control questionnaire and the use of health care services for asthma over a 12‐month period.

RESULTS: A total of 60 patients were enrolled. They had a mean (± SD) age of 50.4±13.9 years, and 43.3% were male. Patients had had asthma for 20.8±15.1 years on average and had a mean prebronchodilator forced expiratory volume in 1 s of 77.0% of the predicted value. The mean ACS was 8.3±11.6, with a range of 0 to 60. The ACS was not found to be correlated with the asthma control questionnaire, but it was significantly associated with health care services used. For each additional point in the ACS, patients were 2% more likely to need acute care for asthma (rate ratio 1.02; P=0.02).

CONCLUSIONS: Further studies including patients followed by general practitioners are required before the general use of this score. This innovative score is useful to rapidly assess the control of asthma over long periods of time and at a low cost in studies using administrative drug databases.
Effect of Fluticasone 250 μg/salmeterol 50 μg and Montelukast on Exhaled Nitric Oxide in Asthmatic Patients
Authors: Gelb Arthur F , Taylor Colleen Flynn , Shinar Chris M , Gutierrez Carlos A , Zamel Noe
Published: March 2016

BACKGROUND: Monitoring noninvasive biomarkers of inflammation is an important adjunct in asthma therapy.

OBJECTIVE: The goal of the present study was to identify airway and alveolar site(s) of inflammation using exhaled nitric oxide (NO) as a marker in asthmatic patients, and to evaluate the NO response to maintenance fluticasone 250 μg/salmeterol 50 μg (F/S) and add‐on montelukast 10 mg (M).

METHODS: Thirty (24 women) nonsmoking, mild to moderate asthmatic patients were studied, mean age (± SD) 43±9 years, treated with F/S for more than one year. All were clinically stable for longer than eight weeks and had not taken oral corticosteroids and/or leukotriene antagonists for eight weeks before the present study. Spirometry, Juniper asthma symptom score, fractional exhaled NO (FENO) 100 mL/s, bronchial NO and alveolar NO concentration (CANO) were measured in a single‐blind, nonrandomized crossover study.

PROTOCOL: Visit 1: baseline F/S; visit 2: after four weeks of F/S plus M; visit 3: after four weeks of S plus M; and visit 4: after four weeks of S only. Values in asthmatic patients were also compared with 34 nonsmoking age‐matched healthy controls with normal lung function.

RESULTS: After 180 μg aerosolized metered dose inhaler albuterol, the forced expiratory volume in 1 s at baseline was 2.6±0.8 L (86%±16% of the predicted value) and the forced expiratory volume in 1 s over the forced vital capacity was 77%±9% (mean ± SD), and was similar at visits 2 to 4. Juniper scores were mildly abnormal at visits 1 to 3, but significantly worse (P=0.03) at visit 4 versus visits 1 to 3. FENO values at visits 1 to 3 were similar but significantly increased (P=0.007) at visit 4. Bronchial NO was higher (P=0.03) at visit 4, versus visits 1 and 2, and was no different at visit 3. Compared with the healthy subjects, FENO and bronchial NO values were abnormal (greater than the normal mean plus 2 SD) in 33% of asthmatic patients at visits 1 to 3. CANO was similar for visits 1 to 4. CANO was abnormal (greater than the normal mean + 2 SD) in 20% of asthmatic patients.

CONCLUSION: In clinically stable asthmatic patients, despite controller treatment including moderate‐dose inhaled corticosteroids and add‐on M, 33% of mild to moderate asthmatic patients have ongoing nonsuppressed bronchial sites of increased NO production, compared with healthy control subjects. These controllers have no effect on CANO, which was abnormal in 20% of the asthmatic patients studied. The addition of add‐on M to baseline moderate‐dose inhaled corticosteroid did not further reduce total exhaled, bronchial and/or alveolar NO production.
The Link between Allergic Rhinitis and Asthma: A Role for Antileukotrienes?
Authors: Kim H , Bouchard J , Renzix PM
Published: March 2016

Allergic rhinitis and asthma are both chronic heterogeneous disorders, with an overlapping epidemiology of prevalence, health care costs and social costs in quality of life. Both are inflammatory disorders with a similar pathophysiology, and both share some treatment approaches. However, each disorder has an array of treatments used separately in controlling these atopic disorders, from inhaled corticosteroids, beta2‐agonists and antihistamines to newer monoclonal antibody‐based treatments. The present article reviews the shared components of allergic rhinitis and asthma, and examines recent evidence supporting antileukotrienes as effective agents in reducing the symptoms of both diseases.
Validation of a French‐Canadian Version of the Pain Disability Index
Authors: Gauthier Nathalie , Thibault Pascal , Adams Heather , Sullivan Michael JL
Published: March 2016

OBJECTIVE: To examine the psychometric properties of the Index de l’incapacité reliée à la douleur, a French‐Canadian version of the Pain Disability Index (PDI).

METHODS: A total of 176 chronic pain patients (94 women, 82 men) completed the French‐Canadian version of the PDI (PDI‐CF), as well as other pain‐related measures. A subset of 52 patients (27 women, 25 men) also completed a lifting task designed to assess physical tolerance and pain behaviour.

RESULTS: Confirmatory factor analysis of the PDI‐CF supported the two‐factor structure of the original PDI. Reliability analyses revealed that the PDI‐CF total score had a high degree of internal consistency, comparable with the original PDI. The PDI‐CF total score was significantly correlated with self‐reported pain, pain catastrophizing, depressive symptoms, fear of movement or (re)injury, lift duration and pain behaviours.

CONCLUSIONS: The results suggest that the PDI‐CF is a reliable and valid measure of self‐reported disability that is psychometrically similar to the original scale.
Pain in Hospitalized Children: A Prospective Cross‐Sectional Survey of Pain Prevalence, Intensity, Assessment and Management in a Canadian Pediatric Teaching Hospital
Authors: Taylor Elsa M , Boyer Kristina , Campbell Fiona A
Published: March 2016

BACKGROUND: Pain is under‐recognised and undertreated. Although standards now exist for pain management, it is not known if this has improved care of hospitalized children.

OBJECTIVES: To benchmark pain prevalence, pain intensity, pain assessment documentation and pharmacological treatment of pain. The aim was to highlight areas of good practice, identify areas for improvement and inform development of hospital standards, education, future audits and the research agenda.

METHODS: The present prospective cross‐sectional survey of all medical and surgical inpatient units took place on a single day at the Hospital for Sick Children (Toronto, Ontario), a Canadian tertiary and quaternary pediatric hospital. A structured, verbally administered questionnaire was used to obtain information on patient demographics, pain before admission, pain intensity during admission and pain treatment. Charts were reviewed to establish frequency of documented pain assessment, the pain assessment tool used and analgesics given. Subgroup analysis was included for age, sex, visible minority or fluency in English, medical versus surgical services and acute pain service input.

RESULTS AND CONCLUSIONS: Two hundred forty‐one (83%) of the 290 inpatients or their carergivers were interviewed. It was found that 27% of patients usually had pain before admission, and 77% experienced pain during admission. Of these, 23% had moderate or severe pain at interview and 64% had moderate or severe pain sometime in the previous 24 h. Analgesics were largely intermittent and single‐agent, although 90% of patients found these helpful. Fifty‐eight per cent of those with pain received analgesics in the preceding 24 h but only 25% received regular analgesia. Only 27% of children had any pain score documented in the preceding 24 h. It was concluded that pain was infrequently assessed, yet occurred commonly across all age groups and services and was often moderate or severe. Although effective, analgesic therapy was largely single‐agent and intermittent. Widespread dissemination of results to all professional groups has resulted in the development of a continuous quality assurance program for pain at the Hospital for Sick Children. A re‐audit is planned to evaluate changes resulting from the new comprehensive pain strategies.
The Use of Budesonide in the Treatment of Autoimmune Hepatitis in Canada
Authors: Zandieh Iman , Krygier Darin , Wong Victor , Howard John , Worobetz Lawrence , Minuk Gerald , Witt-Sullivan Helga , Yoshida Eric M
Published: March 2016

BACKGROUND: Autoimmune hepatitis (AIH) is a chronic inflammatory disease that is successfully treated with prednisone and/or azathioprine immunosuppressive therapy in 70% to 80% of patients. The remaining patients are intolerant or refractory to these standard medications. Budesonide, a synthetic glucocorticoid, undergoes a high degree of first-pass metabolism, reducing its systemic bioavailability, and has a 15-fold greater affinity for the glucocorticoid receptor than prednisolone. Budesonide may be a potentially useful systemic steroid-sparing immunosuppressive agent in the treatment of AIH.

OBJECTIVE: To review the Canadian experience using budesonide to treat AIH.

METHODS: Patients with AIH currently or previously treated with budesonide were identified through the Canadian Association for the Study of the Liver membership. Data were collected regarding their clinical and treatment history.

RESULTS: A total of nine patients were identified. All patients were female, with an average age of 39 years (range 12 to 66 years). The indications for budesonide were adverse side effects of prednisone in two patients, noncompliance with prednisone and azathioprine in one patient and intolerance to azathioprine resulting in prednisone dependence in the remaining six patients. Patients were treated in doses ranging from 9 mg daily to 3 mg every other day for 24 weeks to eight years. Seven of nine patients had a complete response, defined as sustained normalization of the aminotransferase levels. The remaining two patients were classified as nonresponders (less than a 50% reduction in pretreatment aminotransferase levels).

CONCLUSIONS: In Canada, budesonide has been successfully used in seven of nine patients with autoimmune hepatitis who were either intolerant to prednisone and azathioprine or prednisone-dependent. No adverse effects were reported with budesonide. Budesonide is potentially a valuable treatment option for AIH patients refractory or intolerant to standard therapy, and is deserving of further study.
A Case of Successful Ablation of a Gastrophrenic Fistula withn-Butyl-2-Cyanoacrylate
Authors: Mahajan Ashish , Rao G , Lees Gordon , Owen Richard
Published: March 2016

A 79-year-old woman with a fistula between a subphrenic abscess and the fundus of the stomach was successfully treated withn-Butyl-2-Cyanoacrylate. Conservative management had failed. Clinical presentation, treatment progress and imaging findings by computed tomography scan, ultrasound, gastroscopy and fluoroscopy are presented, along with a brief review of the relevant literature.
CagA and VacAHelicobacter PyloriAntibodies in Gastric Cancer
Authors: Suriani Renzo , Colozza Maurilio , Cardesi Enrico , Mazzucco Dario , Marino Maria , Grosso Silvia , Sanseverinati Sabina , Venturini Ivo , Borghi Athos , Zeneroli Maria Luisa
Published: March 2016

BACKGROUND: Infection with different genotypes of virulentHelicobacter pyloristrains (cytotoxin-associated gene A [CagA]-and/or vacuolating cytotoxin A [VacA]-positive) can play a role in the development of atrophic gastritis, duodenal ulcer (DU) and gastric cancer (GC).

OBJECTIVE: To determine whether patients with GC andH pylori-negative histological staining had previously been infected withH pyloriCagA- and/or VacA-positive virulent strains.

METHODS: Twenty-three GC patients with a mean (± SD) age of 68.14±9.8 years who testedH pylori-negative on histological staining took part in the study. Three control groups were included. The first group comprised 19 patients with pastH pyloriinfection and DUs eradicated 10 years earlier, with a mean age of 58±18.2 years.H pylori-negative status for this group was determined every year with Giemsa staining, and follow-up testing occured 120±32 months (mean ± SD) after therapy. The subsequent control groups included 20 asymptomatic children, with a mean age of 7±4.47 years, and withH pylori-negative fecal tests; the final group contained 30 patients without clinical symptoms ofH pyloriinfection, with a mean age of 68±11.6 years, who testedH pylori-negative by histological staining.

RESULTS: Prevalence of CagA and VacA seropositivity, respectively was 82.6% and 73.91% in GC patients; 84.2% and 84.2% inH pylori-negative DU patients; 25% and 5% inH pylori-negative children; and 36.6% and 16.6% in the patients without clinical symptoms on histological staining. CagA and VacA antibody positivity was not significantly different between GC patients and patients with DUs that had been eradicated 10 years earlier. Significant positivity was found between the children’s group and theH pylori-negative (with past DUs) group (P<0.001). A statistically significant difference was found in age between groups (P<0.03).

CONCLUSIONS: Patients with GC, even whenH pylori-negative at the time of the present study, may have been infected byH pyloribefore the onset of the disease, as confirmed by CagA and VacA seropositivity. These data reinforce the hypothesis thatH pylorimay be a direct carcinogenic agent of GC.
Characterization of Serogroup A Neisseria meningitidis from Invasive Meningococcal Disease Cases in Canada Between 1979 and 2006: Epidemiological Links to Returning Travellers
Authors: Sloan Angela M , Henderson Averil M , Tsang Raymond SW
Published: March 2016

INTRODUCTION: Serogroup A Neisseria meningitidis has repeatedly caused epidemics of invasive meningococcal disease (IMD) in developing nations since the 1960s. The present study is the first detailed study of serogroup A bacteria isolated in Canada.

METHODS: Thirty‐four serogroup A meningococcal isolates collected from individuals with IMD in Canada between 1979 and 2006 were characterized by serology and multilocus sequence typing of seven housekeeping enzyme genes and genes encoding three outer membrane protein antigens.

RESULTS: Isolates were assigned to either the sequence type (ST)‐1 or the ST‐5 clonal complex. Clones within the ST‐1 complex were recovered between 1979 and 1992, while clones of the ST‐5 complex were isolated between 1987 and 2006; respectively, they accounted for 70.6% and 29.4% of all isolates studied. Isolates of the ST‐1 complex were characterized by serosubtype antigen P1.3 or P1.3,6 with PorB allele 60 (serotype 4) and FetA sequence F5‐1, while isolates of the ST‐5 complex were characterized by serosubtype antigen P1.9 with PorB allele 47 (also serotype 4) and FetA sequence F3‐1.

CONCLUSIONS: The Canadian serogroup A IMD isolates likely originated in travellers returning from hyperendemic or epidemic areas of the globe where serogroup A bacteria circulate. Although the Canadian cases of serogroup A IMD were caused by clones known to have caused epidemics in developing countries, disease incidence remained low in Canada.
Long‐Term Compliance with Continuous Positive Airway Pressure in Patients with Obstructive Sleep Apnea
Authors: Wolkove Norman , Baltzan Marc , Kamel Hany , Dabrusin Richard , Palayew Mark
Published: March 2016

BACKGROUND: Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnea (OSA). However, compliance is a significant problem and has been incompletely assessed in long‐term studies.

OBJECTIVE: To assess the long‐term compliance of OSA patients with CPAP therapy.

SUBJECTS: Eighty patients who had had a diagnosis of OSA at least four years previously and received a written prescription for CPAP were evaluated.

METHODS: Subjects were identified by reviewing sleep laboratory records. Participants were contacted by telephone and were asked to quantitate their CPAP use (hours per night, nights per week) and to evaluate whether there had been improvement in symptoms. Those who commenced but subsequently abandoned therapy and those who never initiated treatment were questioned about their reasons for noncompliance.

RESULTS: Patient demographics included mean (± SD) age (58±11 years), male sex (70 of 80 patients [88%]) and mean apnea‐hypopnea index (70±44 events/h). At the time of the interview (64.0±3.7 months after diagnosis), 43 of 80 patients (54%) were still using CPAP and most reported an improvement in symptoms. Twelve of 80 patients (15%) had abandoned CPAP after using it for 10.1±15.5 months, and 25 of 80 patients (31%) had never commenced therapy after initial diagnosis and CPAP titration. Analysis of scores reflecting initial patient sleepiness revealed a significant association of this symptom with subsequent CPAP compliance.

CONCLUSION: Although many patients with OSA derive subjective benefit from, and adhere to treatment with CPAP, a significant proportion of those so diagnosed either do not initiate or eventually abandon therapy. Initial experience with CPAP appears to be important, reinforcing the need for early education and support in these patients.
Capsule Endoscopy in the Investigation of Patients with Portal Hypertension and Anemia
Authors: Goulas Spyros , Triantafyllidou Konstantina , Karagiannis Stephanos , Nicolaou Panayiota , Galanis Petros , Vafiadis Irene , Tzivras Michael , Mavrogiannis Christos
Published: March 2016

INTRODUCTION: Data on small bowel abnormalities in patients with portal hypertension (PHT) are limited. Bleeding from the gastrointestinal tract and anemia are common complications in these patients. Capsule endoscopy (CE) was used to evaluate small bowel (SB) pathology in patients with PHT and anemia, and possible associations with various parameters were examined.

METHODS: Thirty-five patients with PHT referred for CE investigation of the SB for anemia were prospectively enrolled in the study, as well as 70 age- and sex-matched control patients with anemia, normal liver function and no evidence of PHT who underwent CE.

RESULTS: Findings compatible with portal hypertensive enteropathy (PHE) were detected in 65.7% of the patients and in 15.7% of the controls (χ2=26.641, P=0.000). Abnormalities in PHT patients included varices in 25.7%, diffuse changes of mucosa with inflammatory-like appearance in 42.9%, and angiodysplasias and/or spider angiomas in 22.9% of cases. The presence of PHE was significantly associated only with the presence of severe portal hypertensive gastropathy, while the presence of SB varices alone was significantly associated with the presence of severe portal hypertensive gastropathy, larger esophageal varices and the presence of colonic varices.

CONCLUSIONS: Varices, diffuse changes of mucosa with inflammatory-like appearance, and angiodysplasias and/or spider angiomas are detected more often in patients with PHT than in controls, and probably constitute the endoscopic characteristics of PHE. CE of the SB added a significant number of likely important findings to those detected by conventional endoscopic techniques for the clinical management of patients with PHT and anemia.
Clinical Practice Guidelines for Hospital‐Acquired Pneumonia and Ventilator‐Associated Pneumonia in Adults
Authors: Rotstein Coleman , Evans Gerald , Born Abraham , Grossman Ronald , Light R Bruce , Magder Sheldon , McTaggart Barrie , Weiss Karl , Zhanel George G
Published: March 2016

Hospital‐acquired pneumonia (HAP) and ventilator‐associated pneumonia (VAP) are important causes of morbidity and mortality, with mortality rates approaching 62%. HAP and VAP are the second most common cause of nosocomial infection overall, but are the most common cause documented in the intensive care unit setting. In addition, HAP and VAP produce the highest mortality associated with nosocomial infection. As a result, evidence‐based guidelines were prepared detailing the epidemiology, microbial etiology, risk factors and clinical manifestations of HAP and VAP. Furthermore, an approach based on the available data, expert opinion and current practice for the provision of care within the Canadian health care system was used to determine risk stratification schemas to enable appropriate diagnosis, antimicrobial management and nonantimicrobial management of HAP and VAP. Finally, prevention and risk‐reduction strategies to reduce the risk of acquiring these infections were collated. Future initiatives to enhance more rapid diagnosis and to effect better treatment for resistant pathogens are necessary to reduce morbidity and improve survival.

Erratum to “Clinical Practice Guidelines for Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia in Adults”dx.doi.org/10.1155/2008/191398
Group A Streptococcal Meningitis in a Pediatric Patient
Authors: Fanella Sergio , Embree Joanne
Published: March 2016

A case of group A streptococcal meningitis is reported in a 14‐year‐old girl with a history of recurrent otitis media. She presented to the emergency room with an altered level of consciousness; the organism was isolated from her spinal fluid and blood. Her course was complicated by a left‐sided sinus vein thrombosis with extension to the external jugular vein, which has previously been reported in the literature only once. Streptococcus pyogenes is a common cause of invasive infections, but is a highly uncommon cause of meningitis.
Obesity: A Review of Pathogenesis and Management Strategies
Authors: Kaila Brinderjit , Raman Maitreyi
Published: March 2016

The prevalence of obesity in the developed world is increasing. Approximately 23% of adult Canadians (5.5 million people) are obese. Obesity is associated with an increased risk of developing several comorbid diseases, ranging from cardiovascular diseases to cholelithiasis and nonalcoholic fatty liver disease. The etiology of obesity is multifactorial, involving a complex interaction among genetics, hormones and the environment. The available evidence and recommendations for nonpharmacological management of obesity, including dietary therapy, physical activity and behavioural therapy, in addition to pharmacotherapy are discussed. A brief discussion on endoscopic and surgical procedures is undertaken. Several antiobesity treatment options are available and may be indicated in appropriate situations. Selecting obesity therapy may be guided by body mass index measurements, comorbid illnesses and patient preference.
Case Report and Review of the Literature: Toxoplasma gondii Encephalitis in a 40‐Year‐Old Woman with Common Variable Immunodeficiency and a New Diagnosis of Large Granular Lymphocytic Leukemia
Authors: Hofmann Adam , Zaharatos Gerasimos , Miller Mark
Published: March 2016

Toxoplasma gondii has been well‐documented to cause central nervous system infections in immunodeficient patients. The present study describes a case of central nervous system toxoplasmosis in a patient with common variable immunodeficiency and newly diagnosed large granular lymphocytic leukemia, with a review of the literature for this association.
Microscopic Colitis: An Approach to Treatment
Authors: Chande Nilesh
Published: March 2016

Microscopic colitis – including collagenous colitis and lymphocytic colitis – causes chronic watery diarrhea, usually in middle-aged or elderly patients. There is an association with celiac disease and certain medications. Medical treatment includes various antidiarrheal agents, mesalamine, corticosteroids and immunosuppressant drugs. Rarely, patients require surgery for refractory disease. An evidence-based and practical approach to treatment should optimize the treatment response while minimizing potential adverse events.
Recurrent Massive Hemoptysis due to Postbronchotomy Bronchial Artery Aneurysm: A Case Report
Authors: Lioulias Achilleas , Misthos Panagiotis , Kokotsakis John , Papagiannakis Georgios , Skouteli Elian
Published: March 2016

Bronchial artery aneurysm (BAA) is a rare clinical entity. A case of intrapulmonary BAA associated with previous bronchotomy at the same site is described. A 22‐year‐old woman, who had undergone bronchotomy of the intermediate bronchus for the removal of a foreign body four years previously, presented with recurrent hemoptysis. Because of an increased risk for spinal cord ischemia, she immediately underwent lung resection rather than therapeutic embolization. The incidental finding of a BAA of any cause cannot be assumed to be stable, and immediate management should be undertaken regardless of the presence or absence of symptoms.
An Outbreak of Vancomycin‐Resistant Enterococcus faecium in an Acute Care Pediatric Hospital: Lessons from Environmental Screening and a Case‐Control Study
Authors: Drews Steven J , Richardson Susan E , Wray Rick , Freeman Renee , Goldman Carol , Streitenberger Laurie , Stevens Derek , Goia Cristina , Kovach Danuta , Brophy Jason , Matlow Anne G
Published: March 2016

BACKGROUND: The present study describes a vancomycin‐resistant enterococci (VRE) outbreak investigation and a case‐control study to identify risk factors for VRE acquisition in a tertiary care pediatric hospital.

OBJECTIVE: To report an outbreak investigation and a case‐control study to identify risk factors for VRE colonization or infection in hospitalized children.

METHODS: Screening for VRE cases was performed by culture or polymerase chain reaction. A case‐control study of VRE‐colonized patients was undertaken. Environmental screening was performed using standard culture and susceptibility methods, with pulsed‐field gel electrophoresis to determine relationships between VRE isolates. Statistical analysis was performed using SAS version 9.0 (SAS Institute Inc, USA).

RESULTS: Thirty‐four VRE‐positive cases were identified on 10 wards between February 28, 2005, and May 27, 2005. Pulsed‐field gel electrophoresis analysis confirmed a single outbreak strain that was also isolated from a video game found on one affected ward. Multivariate analysis identified cephalosporin use as the major risk factor for VRE colonization.

CONCLUSIONS: In the present study outbreak, VRE colonization was significantly associated with cephalosporin use. Because shared recreational items and environmental surfaces may be colonized by VRE, they warrant particular attention in housekeeping protocols, particularly in pediatric institutions.
Postprocedural Interpretation of Endoscopic Retrograde Cholangiopancreatography by Radiology
Authors: Khanna Nitin , May Gary , Bass Sydney , Cole Marty , Romagnuolo Joseph
Published: March 2016

BACKGROUND: With the increase in the use of endoscopic retrograde cholangiopancreatography (ERCP) (necessitating real-time interpretation), it is unknown whether post-ERCP radiologist reporting is still necessary or helpful.

OBJECTIVES: To determine the rate of discrepancy of results, and the rate of clinically relevant misses and additions, by the radiology report in a blinded setting.

METHODS: A retrospective analysis of the procedure and blinded postprocedure radiology reports of 100 consecutive ERCP cases was performed. A list of clinically relevant pathology and subgroups was made a priori. Discrepancies are described as proportions, with 95% CIs. The radiology yield regarding pathology that was clearly demonstrated at ERCP (bile leaks and stones removed) was calculated. Clinical follow-up was used to clarify additional abnormalities reported by radiology.

RESULTS: Clinically relevant discrepancies in report pairs occurred in 29.0% of cases (95% CI 20% to 39%), or 40.0% if discrepancies regarding bile duct dilation are considered (95% CI 30% to 50%). In 15 of 30 cases (50.0% [95% CI 31% to 69%]) in which bile duct stones were removed, the radiologist did not report a stone. The radiologist did not report five of eight bile leaks (62.5% [95% CI 24% to 91%]). In seven cases (7.0% [95% CI 2.9% to 13.9%]), an additional abnormality was noted by radiology, including a biliary stricture, bile duct and pancreatic duct stones, as well as sclerosing cholangitis. However, during a mean follow-up period of 5.6 months, it appeared that these radiology interpretations were likely incorrect. Discrepancy rates did not vary among the ERCP attendings or by radiology volume.

CONCLUSIONS: Discrepancies between endoscopists’ and radiologists’ ERCP reports are common. Blinded radiology interpretation frequently misses important pathology, and falsely positive additional diagnoses may be made.