bluuebunny/crossref_metadata_2025_split huggingface dataset:
Health Care Professionals’ Pain Narratives in Hospitalized Children’S Medical Records. Part 2: Structure and Content
Authors: Rashotte Judy , Harrison Denise , Coburn Geraldine , Yamada Janet , Stevens Bonnie J , the CIHR Team in Children’s Pain  
Published: March 2016

BACKGROUND: Although clinical narratives – described as free‐text notations – have been noted to be a source of patient information, no studies have examined the composition of pain narratives in hospitalized children’s medical records.OBJECTIVES: To describe the structure and content of health care professionals’ narratives related to hospitalized children’s acute pain.METHODS: All pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized in 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was performed.RESULTS: Three major structural elements with their respective categories and subcategories were identified: information sources, including clinician, patient, parent, dual and unknown; compositional archetypes, including baseline pain status, intermittent pain updates, single events, pain summation and pain management plan; and content, including pain declaration, pain assessment, pain intervention and multidimensional elements of care.CONCLUSIONS: The present qualitative analysis revealed the multidimensionality of structure and content that was used to document hospitalized children’s acute pain. The findings have the potential to inform debate on whether the multidimensionality of pain narratives’ composition is a desirable feature of documentation and how narratives can be refined and improved. There is potential for further investigation into how health care professionals’ pain narratives could have a role in generating guidelines for best pain documentation practice beyond numerical representations of pain intensity.
Bile Acid Malabsorption in Chronic Diarrhea: Pathophysiology and Treatment
Authors: Barkun Alan , Love Jonathan , Gould Michael , Pluta Henryk , Steinhart A Hillary 
Published: March 2016

BACKGROUND: Bile acid malabsorption (BAM) is a common but frequently under-recognized cause of chronic diarrhea, with an estimated prevalence of 4% to 5%.METHODS: The published literature for the period 1965 to 2012 was examined for articles regarding the pathophysiology and treatment of BAM to provide an overview of the management of BAM in gastroenterology practice.RESULTS: BAM is classified as type 1 (secondary to ileal dysfunction), type 2 (idiopathic) or type 3 (secondary to gastrointestinal disorders not associated with ileal dysfunction). The estimated prevalence of BAM is >90% in patients with resected Crohn disease (CD) and 11% to 52% of unresected CD patients (type 1); 33% in diarrhea-predominant irritable bowel syndrome (type 2); and is a frequent finding postcholecystectomy or postvagotomy (type 3). Investigations include BAM fecal bile acid assay, 23-seleno-25-homo-tauro-cholic acid (SeHCAT) testing and high-performance liquid chromatography of serum 7-α-OH-4-cholesten-3-one (C4), to determine the level of bile acid synthesis. A less time-consuming and expensive alternative in practice is an empirical trial of the bile acid sequestering agent cholestyramine. An estimated 70% to 96% of chronic diarrhea patients with BAM respond to short-course cholestyramine. Adverse effects include constipation, nausea, borborygmi, flatulence, bloating and abdominal pain. Other bile acid sequestering agents, such as colestipol and colesevelam, are currently being investigated for the treatment of BAM-associated diarrhea.CONCLUSIONS: BAM is a common cause of chronic diarrhea presenting in gastroenterology practice. In accordance with current guidelines, an empirical trial of a bile acid sequestering agent is warranted as part of the clinical workup to rule out BAM.
Establishing a Normal Range for Induced Sputum Cell Counts in Western Canada
Authors: Davidson Warren J , The Stephanie , Leigh Richard 
Published: March 2016

BACKGROUND: Induced sputum cell counts are a noninvasive, reliable method for evaluating the presence, type and degree of airway inflammation. Whether current reference values for induced sputum cell counts are applicable in other induced‐sputum laboratories, particularly those in Western Canada or at elevated altitude, is not clear.OBJECTIVES: To describe the normal range of induced sputum cell counts in healthy adults in Western Canada.METHODS: A total of 105 healthy nonsmoking adults with normal bronchial responsiveness and no history of lung disease proceeded with sputum induction. Sputum samples were fixed in formalin.RESULTS: Sixty‐nine subjects were included in the final analyses. The mean ± SD and median (interquartile range) of the cell counts, respectively, were: total cell count 2.453±2.108, 2.000 (2.512); neutrophils 1.212±1.491, 0.721 (1.016); eosinophils 0.034±0.069, 0.005 (0.043); macrophages 1.050±1.213, 0.696 (1.005); lymphocytes 0.057±0.161, 0.001 (0.049); and bronchial epithelial cells 0.041±0.126, 0.000 (0.027). The respective differential cell percentages were: neutrophils 50.3±23.5, 51.9 (32); eosinophils 1.4±2.3, 0.3 (2); macrophages 43±22.8, 39.3 (32); lymphocytes 2.6±5.2, 0.4 (2.5); and bronchial epithelial cells 2.2±4.8, 0.0 (2.9). Bland‐Altman analysis and intraclass correlation coefficients revealed excellent interobserver agreement for measurement of sputum cell types.DISCUSSION: The range of induced sputum cell counts performed in a laboratory in Western Canada in healthy nonsmoking adult subjects was described; cellular distributions were similar to previous studies. This was also the first description of normal values for formalin‐fixed induced sputum samples.CONCLUSIONS: These results confirm that current reference values for induced sputum are generalizable across different laboratories, including those in Western Canada and those at elevated altitude, and are also generalizable to formalin‐fixed samples, allowing use in the broader Canadian asthma population.
A Delphi Study to Identify Indicators of Poorly Managed Pain for Pediatric Postoperative and Procedural Pain
Authors: Twycross Alison M , Chorney Jill MacLaren , McGrath Patrick J , Finley G Allen , Boliver Darlene M , Mifflin Katherine A 
Published: March 2016

BACKGROUND: Adverse health care events are injuries occurring as a result of patient care. Significant acute pain is often caused by medical and surgical procedures in children, and it has been argued that undermanaged pain should be considered to be an adverse event. Indicators are often used to identify other potential adverse events. There are currently no validated indicators for undertreated pediatric pain.OBJECTIVES: To develop a preliminary list of indicators of undermanaged pain in hospitalized pediatric patients.METHODS: The Delphi technique was used to survey experts in pediatric pain management and quality improvement. The first round used an electronic questionnaire to ask: “In your opinion, what indicators would signify that acute pain in a child has not been adequately controlled?” Responses were grouped together in semantically similar themes, providing a list of possible adverse event indicators. Using this list, an electronic questionnaire was developed for round 2 asking respondents to indicate the importance of each potential indicator.RESULTS: All but one indicator achieved a level of consensus ≥70%. Separate indicators emerged for postoperative and procedural pain. An additional distinction was made between indicators that could be identified by chart review and those requiring observation of practice and assessment from the child or parent.DISCUSSION: The adverse care indicators developed in the present study require further refinement. There is a need to test their clinical usability and to determine whether these indicators actually identify undermanaged pain in clinical practice. The present study is an important first step in identifying undermanaged pain in hospital and treating it as an adverse event.CONCLUSION: The adverse care indicators developed in the present study are the first step in conceptualizing mismanaged pain as an adverse event.
Patient-Identified Quality Indicators for Colonoscopy Services
Authors: Sewitch Maida J , Dubé Catherine , Brien Stephanie , Jiang Mengzhu , Hilsden Robert J , Barkun Alan N , Armstrong David 
Published: March 2016

BACKGROUND: Current quality improvement tools for endoscopy services, such as the Global Rating Scale (GRS), emphasize the need for patient-centred care. However, there are no studies that have investigated patient expectations and/or perceptions of quality indicators in endoscopy services.OBJECTIVES: To identify quality indicators for colonoscopy services from the patient perspective; to rate indicators of importance; to determine factors that influence indicator ratings; and to compare the identified indicators with those of the GRS.METHODS: A two-phase mixed methods study was undertaken in Montreal (Quebec), Calgary (Alberta) and Hamilton (Ontario) among patients ≥18 years of age who spoke and read English or French. In phase 1, focus group participants identified quality indicators that were then used to construct a survey questionnaire. In phase 2, survey questionnaires, which were completed immediately after colonoscopy, prompted respondents to rate the 20 focus group-derived indicators according to their level of importance (low, medium, high) and to list up to nine additional items. Multiple logistic regression analysis was used to determine the factors that influenced focus group-derived indicator ratings. Patient-identified indicators were compared with those used in the GRS to identify novel indicators.RESULTS: Three quality indicator themes were identified by 66 participants in 12 focus groups: communication, comfort and service environment. Of the 828 surveys distributed, 402 (48.6%) were returned and 65% of focus group-derived indicators were rated highly important by at least 55% of survey respondents. Indicator ratings differed according to age, sex, site and perceived colorectal cancer risk. Of the 29 patient-identified indicators, 17 (58.6%) were novel.CONCLUSIONS: Patients identified 17 novel quality indicators, suggesting that patients and health professionals differ in their perspectives with respect to quality in colonoscopy services.
Relationship between the Number of Positive Fecal Occult Blood Tests and the Diagnostic Yield of Colonoscopy
Authors: Muinuddin Ahmad , Aslahi Ramona , Hopman Wilma M , Paterson William G 
Published: March 2016

BACKGROUND: In 2007, Ontario launched a colon cancer screening program for average-risk individuals based on biennial fecal occult blood tests (FOBTs) on three fecal samples, followed by colonoscopy for individuals who tested positive.OBJECTIVE: To determine whether >1 positive screening FOBT was predictive of finding advanced neoplasia at colonoscopy.METHODS: A retrospective chart review of outpatient colonoscopic procedures performed at Hotel Dieu Hospital (Kingston, Ontario) in the first two years of the colon cancer screening program was conducted, focusing on endoscopic and pathological findings.RESULTS: Of 5556 individuals undergoing colonoscopy, 346 were referred for positive FOBT. Overall, 41 (11.8%) patients with a positive FOBT had colon cancer. In 16 (4.6%) cases, the number of positive FOBTs was not reported. For the 330 individuals in whom the number of positive tests was specified, 198, 71 and 61 cases had one, two and three positive results, respectively. Cancer was found at colonoscopy in 11 (5.6%), 11 (15.5%) and 18 (29.5%) of individuals with one, two and three positive FOBT results, respectively (OR 3.0 [95% CI 1.2 to 7.3] and 6.5 [95% CI 2.8 to 15.0] for two or three positive FOBTs compared with one; P=0.015 and P<0.001, respectively). High-risk adenomas (>1 cm in diameter, villous component and/or high-grade dysplasia) were found in 41 (20.8%), 29 (42.0%) and 25 (41.0%) individuals with one, two and three positive FOBTs, respectively (OR 2.8 [95% CI 1.5 to 5.0] and 2.4 [95% CI 1.3 to 4.5] for two or three positive FOBTs compared with one; P=0.001 and P=0.006, respectively).CONCLUSIONS: The diagnostic yield of colonoscopy varied directly with the number of positive FOBTs. This information may be useful in assigning scheduling priority for patients with positive FOBTs.
Summary of Guidelines for Infection Prevention and Control for Flexible Gastrointestinal Endoscopy
Authors: Hookey Lawrence , Armstrong David , Enns Rob , Matlow Anne , Singh Harminder , Love Jonathan 
Published: March 2016

BACKGROUND: High-quality processes to ensure infection prevention and control in the delivery of safe endoscopy services are essential. In 2010, the Public Health Agency of Canada and the Canadian Association of Gastroenterology (CAG) developed a Canadian guideline for the reprocessing of flexible gastrointestinal endoscopy equipment.METHODS: The CAG Endoscopy Committee carefully reviewed the 2010 guidelines and prepared an executive summary.RESULTS: Key elements relevant to infection prevention and control for flexible gastrointestinal endoscopy were highlighted for each of the recommendations included in the 2010 document. The 2010 guidelines consist of seven sections, including administrative recommendations, as well as recommendations for endoscopy and endoscopy decontamination equipment, reprocessing endoscopes and accessories, endoscopy unit design, quality management, outbreak investigation and management, and classic and variant Creutzfeldt-Jakob Disease.DISCUSSION: The recommendations for infection prevention and control for flexible gastrointestinal endoscopy are intended for all individuals with responsibility for endoscopes in all settings where endoscopy is performed.
Development and Mixed‐Methods Evaluation of a Pain Assessment Video Training Program for Long‐Term Care Staff
Authors: Gagnon Michelle M , Hadjistavropoulos Thomas , Williams Jaime 
Published: March 2016

INTRODUCTION: Inadequacies in pain assessment and management in long‐term care have been well documented. Insufficient pain education and inaccurate beliefs about the nature of pain and aging have been identified as possible contributors. The present study addresses the need for improved, efficient and feasible continuing pain education through the use of an assessment training video.METHODS: A total of 148 long‐term care staff viewed and evaluated the training video. Knowledge changes and pain beliefs were assessed postvideo and at a four‐week follow‐up. Beliefs about pain, as well as pain and aging, were also examined using multivariate procedures to determine whether these variables influenced participants’ evaluation of the video. Focus groups were also conducted, and transcripts were analyzed using thematic content analysis.RESULTS: Pain assessment knowledge improved postvideo and at the four‐week follow‐up. Participants positively evaluated the content and quality of the video. Individuals who held stronger beliefs (at baseline) about the organic nature of pain provided more positive evaluations. Barriers to implementation of practices in the video identified by the focus groups (and qualitative analysis) included time, workload and resistance to change. Facilitators to implementation included continued management support and observing the benefits to implementation.DISCUSSION: The present study provides support for the use of video training. However, based on the focus group results, top‐down implementation approaches with ongoing management involvement throughout the implementation process may be needed to achieve sustained changes in pain assessment practices. A model useful for sustained implementation was proposed and discussed, and is hoped to facilitate future research.
A Health Technology Assessment of Transient Elastography in Adult Liver Disease
Authors: Steadman Rodney , Myers Robert P , Leggett Laura , Lorenzetti Diane , Noseworthy Tom , Rose Sarah , Sutherland Lloyd , Clement Fiona 
Published: March 2016

BACKGROUND: An estimated one in 10 Canadians have some form of liver disease. The reference standard for staging and monitoring liver fibrosis is percutaneous liver biopsy – an invasive procedure associated with risks and complications. Transient elastography (TE) represents a noninvasive, ultrasound-based alternative.OBJECTIVE: To assess the efficacy of TE compared with liver biopsy for fibrosis staging in adults with five common types of liver disease: hepatitis B, hepatitis C, nonalcoholic fatty liver disease, cholestatic liver disease and complications post-liver transplantation.METHODS: A systematic review of published and grey literature from 2001 to June 2011 was conducted. Included were observational studies evaluating the accuracy of TE using liver biopsy as the comparator. An economic model was developed to estimate the cost per correct diagnosis gained with liver biopsy compared with TE. Identification of moderate fibrosis (stages 2 to 4) and cirrhosis (stage 4) were considered.RESULTS: Fifty-seven studies were included in the review. The diagnostic accuracy of TE for the five clinical subgroups had sensitivities ranging from 0.67 to 0.92 and specificities ranging from 0.72 to 0.95. Liver biopsy was associated with an additional $1,427 to $7,030 per correct diagnosis gained compared with TE. The model was sensitive to the sensitivity and specificity of TE and the prevalence of fibrosis.CONCLUSIONS: TE is an accurate diagnostic method in patients with moderate fibrosis or cirrhosis. TE is less effective but less expensive than liver biopsy. Systemic implementation of TE should be considered for the noninvasive assessment of liver fibrosis.
Continuing Methadone for Pain in Palliative Care
Authors: Hawley Philippa , Liebscher Ryan , Wilford Jessica 
Published: March 2016

BACKGROUND: Methadone is one of the most important medications used for the treatment of refractory pain in the palliative care setting, and is usually initially prescribed by one of a limited number of physicians who have acquired authorization for its use. A lack of authorized physicians able to take over prescribing when the patient is stable is a barrier to accessing methadone for analgesia.OBJECTIVE: To determine the barriers to family physicians becoming authorized to prescribe methadone for pain in palliative care.METHODS: A survey exploring the perceived barriers to continuing methadone for pain in palliative care following initial prescription by a specialist was mailed to a randomly selected group of 870 family physicians in British Columbia.RESULTS: The response rate was 30.9%. Of the 204 responding physicians, 76.1% described themselves as positioned to provide ongoing palliative care to their patients. Within this group, 38 (18.6%) were already authorized to prescribe methadone for pain. The remaining 166 (81.4%) had significant knowledge deficits regarding methadone use in palliative care, but were largely aware of their deficits, and more than one‐half were willing to learn more and to obtain an authorization if requested.CONCLUSIONS: Responding family physicians had mostly received little education regarding methadone for pain, but were aware of their need for education and were willing to learn. Physicians who had already become authorized were generally satisfied with the process of authorization, and believed the process of education through authorization was appropriate and not onerous.
Clinical Features and Symptom Recovery on a Gluten-Free Diet in Canadian Adults with Celiac Disease
Authors: Pulido Olga , Zarkadas Marion , Dubois Sheila , MacIsaac Krista , Cantin Isabelle , La Vieille Sébastien , Godefroy Samuel , Rashid Mohsin 
Published: March 2016

BACKGROUND: Celiac disease can present with mild or nongastrointestinal symptoms, and may escape timely recognition. The treatment of celiac disease involves a gluten-free diet, which is complex and challenging.OBJECTIVE: To evaluate clinical features and symptom recovery on a gluten-free diet in a Canadian adult celiac population.METHODS: All adult members (n=10,693) of the two national celiac support organizations, the Canadian Celiac Association andFondation québécoise de la maladie coeliaque,were surveyed using a questionnaire.RESULTS: A total of 5912 individuals (≥18 years of age) with biopsy-confirmed celiac disease and/or dermatitis herpetiformis completed the survey. The female to male ratio was 3:1, and mean (± SD) age at diagnosis was 45.2±16.4 years. Mean time to diagnosis after onset of symptoms was 12.0±14.4 years. Abdominal pain and bloating (84.9%), extreme weakness/tiredness (74.2%), diarrhea (71.7%) and anemia (67.8%) were the most commonly reported symptoms at the time of diagnosis. Many respondents continued to experience symptoms after being on a gluten-free diet for >5 years. Sex differences were reported in clinical features before diagnosis, recovery after being on gluten-free diet and perceived quality of life, with women experiencing more difficulties than men.CONCLUSIONS: Delays in diagnosis of celiac disease in Canada remain unacceptably long despite wider availability of serological screening tests. Many patients report continuing symptoms despite adhering to a gluten-free diet for >5 years, with women experiencing more symptoms and a lower recovery rate than men. Awareness of celiac disease needs improvement, and follow-up with a physician and a dietitian is essential for all patients with celiac disease.
What Constitutes a Clinically Important Pain Reduction in Patients after Third Molar Surgery?
Authors: Martin Wilhelmus JJM , Ashton-James CE , Skorpil NE , Heymans MW , Forouzanfar T 
Published: March 2016

BACKGROUND: For patients with surgical third molar removal, it is unknown what constitutes a clinically important change in patients’ visual analogue scale (VAS) reports of pain intensity.OBJECTIVES: To determine what constitutes a clinically important change in pain intensity on a VAS following surgical removal of the third molar.METHODS: The study population consisted of patients participating in three randomized trials. Patients were asked to rate their pain three times per day over a period of seven days on a 100 mm VAS after surgical removal of the third molar. Global Perceived Effect was measured on day 1 and day 7 and was used as the external criterion for assessing clinically important pain reduction. Global Perceived Effect scores of 6 (‘much improved’) or higher were classified as clinically ‘successful’, and scores of 5 (‘slightly improved’) or below were classified as clinically ‘unsuccessful’. For each trial, the mean absolute and relative changes in VAS scores were calculated for both ‘successful’ and ‘unsuccessful’ treatments. Sensitivity and specificity analyses were performed.RESULTS: The patients who reported ‘successful’ pain reduction showed a relative pain reduction of ≥69% and an absolute pain reduction >2.5 cm on the VAS, whereas patients who classified their pain reduction as ‘unsuccessful’ had a relative pain reduction of ≥18.5% and an absolute pain reduction <0.5 cm on the VAS. Furthermore, sensitivity and specificity analyses showed that a cut‐off point of ≥50% relative pain reduction exhibited the best balance of sensitivity and specificity.CONCLUSION: Relative pain reduction of ≥50% and an absolute pain reduction of ≥2.5 cm on the VAS were most accurate in predicting a successful pain reduction after a given treatment.