bluuebunny/crossref_metadata_2025 huggingface dataset:
Health Status Measurement Instruments in Chronic Obstructive Pulmonary Disease
Authors: Lacasse Yves , Wong Eric , Guyatt Gordon , Goldstein Roger S
Published: March 2016

Chronic obstructive pulmonary disease (COPD) is associated with primary respiratory impairment, disability and handicap, as well as with secondary impairments not necessarily confined to the respiratory system. Because the primary goals of managing patients with COPD include relief of dyspnea and the improvement of health‐related quality of life (HRQL), a direct measurement of HRQL is important. Fourteen disease‐specific and nine generic questionnaires (four health profiles and five utility measures) most commonly used to measure health status in patients with COPD were reviewed. The measures were classified according to their domain of interest, and their measurement properties ‐ specifications, validity, reliability, responsiveness and interpretability ‐ were described. This review suggests several findings. Currently used health status instruments usually refer to the patients’ perception of performance in three major domains of HRQL ‐ somatic sensation, physical and occupational function, and psychological state. The choice of a questionnaire must be related to its purpose, with a clear distinction being made between its evaluative and discriminative function. In their evaluative function, only a few instruments fulfilled the criteria of responsiveness, and the interpretability of most questionnaires is limited. Generic questionnaires should not be used alone in clinical trials as evaluative instruments because of their inability to detect change over time. Further validation and improved interpretability of existing instruments would be of greater benefit to clinicians and scientists than the development of new questionnaires.
Detection of Peripheral Ventilation Inhomogeneity in Smokers
Authors: Cotton DJ , Mink JT , Graham BL
Published: March 2016

BACKGROUND: In smokers, ‘small airways’ narrowing alters the conventional, vital capacity single breath washout (SBWVC). Although, in some studies, the test predicts smokers at risk of developing chronic airflow limitation, its wide variability partly explains its poor positive predictive value. An alternative explanation for the test’s poor predictive value is that it may not accurately reflect small airway narrowing in the lung periphery.

OBJECTIVE: To determine whether smoke‐induced increases in ventilation inhomogeneity differ between SBWVC manoeuvres, which augment topographical (apex‐to‐base) ventilation inhomogeneity, and submaximal manoeuvres (SBWSM), which enhance peripheral ventilation inhomogeneity.

STUDY GROUP AND DESIGN: Cross‐sectional study of 21 current smokers and 21 nonsmokers with similar age and forced expiratory volumes in 1 s (FEV1).

METHODS: Smokers and nonsmokers performed SBW with either slow vital capacity inhalation and exhalation of test gas without breath holding (SBWVC); or slow inhalation of test gas from functional residual capacity to one‐half inspiratory capacity and, after 0 s or 10 s of breath holding, slow exhalation to residual volume (SBWSM). For all SBW the normalized phase III helium slope (Sn), closing capacity (CC) as a percentage of total lung capacity (TLC) and mixing efficiency (Emix) were measured.

RESULTS: For SBWVC, smoking had no effect on Sn or Emix. However, CC/TLC was increased in smokers (P<0.05), but did not correlate with pack years or age. For SBWSM, smoking had no effect on Emix or CC/TLC, but resulted in a steeper Sn (P <0.05), which decreased more with breath holding (P<0.01) and correlated with pack years (P<0.05) at 0 s but not 10 s of breath holding.

CONCLUSIONS: In smokers with normal FEV1, SBWSM manoeuvres reveal increases in breath hold time‐dependent ventilation inhomogeneity in the lung periphery, not detected by conventional SBWVC.
Chronic Pain Disability in the Workplace
Authors: Teasell Robert W , Merskey Harold
Published: March 2016

Chronic pain disorders have been associated with increasing disability expenditures in Western industrialized countries. The reason for this increase is unknown. Many chronic pain disorders have been characterized by a lack of readily demonstrable pathology, resistance to treatment and associated psychosocial difficulties. The difficulties inherent in the diagnosis and treatment of chronic pain disorders are compounded by problems in determining disability and entitlement to compensation. Recent attempts to label chronic pain disorders as solely psychosocial issues to the exclusion of biological issues appear to be misguided, particularly in the light of recent evidence supporting an organic etiology in several chronic pain conditions. Such an approach will disproportionately affect those in lower socioeconomic groups in an effort to contain costs. The long term cost to society of targeting a highly vulnerable group with such an approach remains to be determined.
Chronic Lung Disease in Canadian Aboriginal Children Is Not Caused by Abnormal Cilia
Authors: Rubin Bruce K , Kumar Vijay
Published: March 2016

BACKGROUND: It has been suggested that abnormalities of the airway cilia are responsible for some of the increased prevalence of bronchiectasis among the Polynesian population of New Zealand.

OBJECTIVE: To determine whether abnormalities of the ciliary axoneme were present in Cree children with recurrent pneumonia.

DESIGN: Retrospective identification of Cree children under 18 years of age with three or more documented episodes of pneumonia, at least one of which was severe enough to require hospitalization. Physical examination and nasal brushing for ciliary ultrastructure were performed on those who consented to participate in the study.

SETTING: Out‐patient department of Moose Factory General Hospital, the referral hospital for the James Bay Region of Northern Ontario.

PATIENTS: Ten children (seven males; three females) met the diagnostic criteria and lived in Moose Factory or Moosonee. Six patients (five boys, one girl, mean age 7 years 2 months) consented to examination and nasal brushing.

RESULTS: Although the percentage of abnormal cilia (21%) was three to seven times greater than that reported for the control population, the abnormalities seen were characteristic of acquired axonemal defects rather than primary ciliary dyskinesia.

CONCLUSIONS: In this population, recurrent pneumonia did not appear to be associated with congenital defects of the ciliary axoneme (primary ciliary dyskinesia). This is consistent with a review of published transmission electron microscopy studies of nasal cilia from the Maori of New Zealand.
Short Course Monotherapy with Clarithromycin for Localized Mycobacterium Marinum Skin Infection
Authors: Weinstein Mitchell R , Low Donald E , Mazzulli Tony
Published: March 2016

In vitro studies have shown that Mycobacterium marinum is usually susceptible to clarithromycin. However, there are limited published data on the clinical use of clarithromycin for the treatment of M marinum infections. This report describes a previously healthy 58‐year‐old man who developed a chronic soft tissue infection of his right hand caused by M marinum. He responded to four weeks’ therapy with clarithromycin. Follow‐up at six months showed no relapse. Our experience and review of the literature suggest that short course monotherapy with clarithromycin may be quite effective for uncomplicated soft issue infections caused by M marinum.
A Systematic Overview of the Measurement Properties of the Chronic Respiratory Questionnaire
Authors: Lacasse Yves , Wong Eric , Guyatt Gordon
Published: March 2016

BACKGROUND: Assessment of health‐related quality of life (HRQL) of patients with chronic lung disease has become an important aspect of many clinical investigations. The authors examined the measurement properties of a disease‐specific HRQL questionnaire, the Chronic Respiratory Questionnaire (CRQ), when used by independent investigators in clinical trials and observational studies.

METHODS: All published papers citing the original 1987 CRQ publication were identified using the Science Citation Index, and abstracts presented at international conferences were found by hand search. Clinical trials and observational studies were included if they reported data bearing on the CRQ’s measurement properties.

RESULTS: Of 90 papers and 20 abstracts, 32 met the inclusion criterion. CRQ domains of fatigue, mastery and emotional function have high reliability, and face, content and construct validity in differentiating among patients with better and worse HRQL. Because of its self‐generated items, the dyspnea domain works less well in discriminating among patients with lesser and greater dyspnea. When CRQ has been used to evaluate treatment, all four domains have performed well in detecting small treatment effects. The minimal important difference in CRQ score (0.5 per item) provides guidance for both planning studies and interpreting results. To maximize CRQ interpretability, investigators should present results as the mean score per item within each domain on a seven‐point scale.

CONCLUSION: The CRQ has proved valid and responsive to change. Its standardization and continued wide use will enhance the understanding of the impact of treatments on patients’ HRQL.
Staging Lung Cancer: Current Controversies and Strategies
Authors: Karmy-Jones Riyad , Hyland Robert H , Lewis Joseph W , Kvale Paul
Published: March 2016

A consistent approach to staging is required for the rational management of lung cancer. This paper was prepared at the request of the Standards Committee of the Canadian Thoracic Society, and reviews and discusses the relative merits of the available methods of staging. Whichever methods are chosen by a particular institution, the following points must be stressed. No patient can be considered automatically "unresectable" when chest radiography and/ or computed tomography demonstrate adenopathy or only suggest local invasion. Clinical and/or radiographical evidence suggesting extensive local or metastatic disease should be evaluated as completely as possible before subjecting the patient to a possible "nontherapeutic" thoracotomy. Finally, in some cases thoracotomy is required to decide whether the lesion is "completely" resectable.
Changes in the Cardiopulmonary Response to Exercise after Cardiac Transplantation in Patients Enrolled in an Early Rehabilitation Program
Authors: Bussières Lizanne M , Pflugfelder Peter W , Taylor Albert W , Ahmad Dildar , Weernink Corinne , Kostuk William J
Published: March 2016

OBJECTIVE: To evaluate the changes in the cardiopulmonary response to exercise in the first year after cardiac transplantation in patients enrolled in a rehabilitation program in the first three months post‐transplantation.

METHODS: A graded cycle exercise test with mixed expired gas analysis was performed on patients with end‐stage cardiac failure before and serially after cardiac transplantation at one, three and 12 months.

RESULTS: Before cardiac transplantation, seven patients were fit enough to be tested. They had a low peak oxygen uptake (VO2 max) and a blunted heart rate and blood pressure response to exercise. They also displayed a restrictive pattern of ventilation during exercise. At three months following transplantation, patients (n=19) had a significantly higher VO2 max (19.9±5.3 versus 9.8±1.4 mL/kg/min, P<0.05), higher peak systolic blood pressure (177±22 versus 94±18 mmHg, P<0.05), greater peak minute ventilation (70±23 versus 34±5 L/min, P<0.05) and lower slope of minute ventilation to carbon dioxide output (35.4±6.2 versus 45.1±6.7, P<0.05) than before transplantation. The VO2 max measured at 12 months post‐transplant was similar to the three month value and was on average equal to 59% of the predicted value.

CONCLUSIONS: These results indicate that there is a rapid and marked improvement in exercise capacity in patients following cardiac transplantation. These changes are associated with significant respiratory and cardiovascular adaptations. However, despite the marked improvement in exercise capacity, the VO2 max of cardiac transplant recipients enrolled in an early rehabilitation program did not return to normal at 12 months after surgery.
Role of Computed Tomography and Mediastinoscopy in the Staging of Lung Cancer: A Canadian Opinion Poll
Authors: Jones Graham L , Miller John D
Published: March 2016

OBJECTIVES: To address the Canadian Lung Oncology group’s recently published results and recommendations suggesting that mediastinoscopy is unnecessary in the staging nonsmall cell lung cancer when computed tomography shows no enlarged mediastinal lymph nodes (larger than 1 cm in short axis); to evaluate the practice of thoracic surgeons across Canada in staging presumably operable lung cancer; and to assess the effect of the Canadian Lung Oncology Group’s recommendations on current thoracic surgical practice in Canada.

DESIGN: A survey of Canadian thoracic surgeons (n=38) regarding the roles of computed tomography and mediastinoscopy in evaluating mediastinal disease in patients with operable lung cancer.

RESULTS: There was an 89% response rate. Ninety‐one per cent of surgeons used computed tomography routinely, but only 10% of surgeons thought it to be more accurate than mediastinoscopy. Sixty‐eight per cent would rely on a negative scan (nodes smaller than 1 cm in shortest diameter) to rule out mediastinal disease.

CONCLUSIONS: There are numerous circumstances where negative computed tomography does not adequately assess nodal status. A guideline for the use of computed tomography and mediastinoscopy in evaluating and staging lung cancer is presented. Mediastinoscopy should be considered in the staging of patients with negative computed tomography if the patient is at high risk of mediastinal disease, where negative computed tomography is typically unreliable and when the risk associated with an unnecessary thoracotomy is high.
Assessing Health‐Related Quality of Life in Asthma
Authors: Juniper Elizabeth F
Published: March 2016

Many clinicians now recognize the importance of incorporating an assessment of health‐related quality of life (HRQL) into their clinical studies and practices. Conventional clinical measures provide valuable information about the status of the affected organ system but rarely capture the functional impairments (physical, emotional and social) that are important to patients in their everyday lives. To obtain a complete picture of a patient’s health status, both the conventional clinical indices and the patient′s HRQL must be measured. Both adults and children with asthma are distressed by symptoms, such as shortness of breath, cough and chest tightness, and they are limited in their day‐to‐day activities, such as sports, employment or school work and participation in activities with friends. In addition, both adults and children with asthma are concerned about having asthma, fearful of not having their medications when they need them and frightened of having an asthma attack. They become very frustrated, and children in particular often feel different and isolated from their friends. Disease‐specific HRQL questionnaires have been developed and validated for both adults and children with asthma. This paper provides a review of these questionnaires and identifies their strengths and weaknesses. The questionnaires chosen for review have good measurement properties and validity and can be used in both clinical trials and clinical practice to assess the impact of asthma on a patient’s life. Because one of the aims of treatment is to ensure that patients benefit from treatment, an essential component of clinical assessment should be evaluation of HRQL.
Pilot Study of Salbutamol in the Treatment of Acute Asthma – Little Apparent Benefit to Dose and Frequency Adjustments
Authors: Sinclair Douglas , MacKenzie MG , Bowie Dennis M
Published: March 2016

STUDY OBJECTIVE: To compare two dosing regimens of salbutamol in acute asthma.

DESIGN: Prospective randomized double‐blind trial.

SETTING: Urban emergency department.

TYPE OF PARTICIPANTS: Patients who presented to the emergency department with moderate to severe asthma.

INTERVENTIONS: All patients had pulmonary function testing and were randomized to group A (control; n=25) or group B (experimental; n=23). Group A (control) patients received salbutamol 2.5 mg delivered by wet aerosol at 0, 1 and 2 h (total dose 7.5 mg). At 20, 40, 80 and 100 mins a placebo aerosol was given. Group B patients received salbutamol 5 mg at 0 min and one‐third the initial dose every 20 mins for a total of six doses by wet aerosol (total dose 15 mg).

RESULTS: There were no differences in age, sex, preadmission medications or initial forced expiratory volume in 1 s (FEV1) between the groups. Forty‐eight patients completed the study. Both groups of patients improved with mean absolute change in FEV1 of 700 mL in group A and 590 mL in group B. There were no statistical differences between the two groups in terms of treatment response, admission rates or side effects.

CONCLUSIONS: This study of patients presenting with acute asthma demonstrated no differences in improvement during the initial 3 h of treatment with a standard dose of aerosolized salbutamol given at hourly intervals (total dose 7.5 mg) compared with a higher total dose given at 20 min intervals (total dose 15 mg).
Effect of High Dose Inhaled Acetic Acid on Airway Responsiveness in Fischer Rats
Authors: Ariel AP , Furlott HG , Chapman KR , Slutsky AS , Webster P , Zamel N , Tarlo SM
Published: March 2016

BACKGROUND: Sudden, severe airway injury has been associated with an acute, and at times persisting, airway hyper‐responsiveness with clinical features of asthma, termed reactive airways dysfunction syndrome (RADS). An attempt was made to develop a rat model of RADS by exposing inbred Fischer rats to inhaled 8 N acetic acid for 2 mins (13 N inhalation was lethal).

METHODS: Lung resistance (RL) and lung elastance (EL) were measured in 14 eight‐ to 10‐week old male rats. Baseline responsiveness to methacholine was quantified by calculating the dose required for doubling of RL. The next day, the study group (n=11) was exposed to aerosolized acetic acid. Control animals (n=3) were similarly exposed to buffered saline solution.

RESULTS: Acetic acid exposure resulted in a significant (P <0.02) increase in RL (by 80%) and EL (by 67%), lasting less than 10 mins postexposure, but no significant change in methacholine responsiveness at one day and seven days postexposure.

CONCLUSIONS: Failure to induce persistent airway hyper‐responsiveness may relate to the choice of animal, choice of irritant, or insufficient level or duration of exposure, or may reflect a lack of individual predisposing cofactors such as smoking or underlying asthmatic predisposition.
Everyday Pain in Three‐ to Five‐Year‐Old Children in Day Care
Authors: Baeyer Carl L von , Baskerville Shannon , McGrath Patrick J
Published: March 2016

A new event sampling instrument, the Dalhousie Everyday Pain Scale, was used to observe 50 children in six day care centres in Saskatoon for an average of 2.24 h each. The nature of minor painful incidents (eg, collisions and falls) was recorded, including distress behaviours and responses from peers and adults. Twenty‐nine children (58%) were observed to experience one or more painful incidents, producing a total of 51 incidents and yielding a median rate of incidents of 0.31 per child per hour, a rate similar to that reported in another Canadian sample. Seven of nine child response items met criteria for reliability in a subsample of incidents observed simultaneously by two observers. Rubbing the affected body part, crying and making verbal statements about the injury were the most common responses to painful incidents. Intervention by day care staff was strongly associated with children′s facial expression of distress: physical and first aid interventions were offered most frequently to children who displayed the greatest facial distress. Content analysis of observers′ records produced a classification scheme for causes of painful incidents. Twenty per cent of painful incidents were judged to be the result of deliberate actions by other children. The classification of causes may be a useful addition to the scale for application in future studies of everyday pain and injury prevention.
Ciprofloxacin or Imipenem Use Correlates with Resistance in Pseudomonas aeruginosa
Authors: Zhanel George G , Nicolle Lindsay E , Gin Alfred S , Karlowsky James , Kabani Amin , Hoban Daryl J
Published: March 2016

OBJECTIVE: To investigate the relationship between ciprofloxacin or imipenem use and antimicrobial resistance in Pseudomonas aeruginosa.

METHODS: A retrospective review of monthly antimicrobial susceptibility reports for ciprofloxacin (1988 to 1995) and imipenem (1987 to 1995) against P aeruginosa and hospital antimicrobial use records at a tertiary care teaching hospital in Winnipeg, Manitoba. Data were entered into a relational database, R:Base 4.5++, collated, transferred to a spreadsheet and subjected to linear regression analysis. The relationship between ciprofloxacin or imipenem use and resistance was assessed using a Pearson correlation.

RESULTS: Ciprofloxacin‐resistant P aeruginosa increased from 1.0% of all isolates in 1988 to 10.0% in 1995. A significant (P=0.05) correlation was demonstrated between the amount of ciprofloxacin use and prevalence of ciprofloxacin‐resistant P aeruginosa (r=0.73, P=0.05). Imipenem‐resistant P aeruginosa increased from 1.0% of isolates in 1987 to a maximum of 10.4% in 1991, and subsequently decreased to 5.4% in 1995. Imipenem use and the prevalence of imipenem‐resistant P aeruginosa were significantly correlated (r=0.85, P=0.014).

CONCLUSIONS: Ciprofloxacin use was directly associated with ciprofloxacin resistance, and imipenem use was directly associated with imipenem resistance in P aeruginosa.
Comparison of Salivary and Serum Enzyme Immunoassays for the Diagnosis of Helicobacter pylori Infection
Authors: Embil John M , Choudhri Shurjeel H , Smart Gerry , Aldor Thomas , Pettigrew Norman M , Grahame Gordon R , Dawood Magdy R , Bernstein Charles N
Published: March 2016

Infection with Helicobacter pylori has been established as an important risk factor for the development of peptic ulcer disease, gastritis and gastric cancer. The diagnosis of H pylori infection can be established by invasive or noninvasive techniques. Two noninvasive enzyme immunoassays (EIAs) for antibody detection – HeliSal and Pylori Stat – were compared with histology. Both assays detect immunoglobulin (Ig) G directed against purified H pylori antigen. The test populations consisted of 104 consecutive patients scheduled for upper gastrointestinal endoscopy. Of these patients, 97 (93%) had symptoms compatible with peptic ulcer disease. Saliva and serum were collected simultaneously at the time of endoscopy. Salivary EIA had a sensitivity of 66%, specificity of 67%, positive predictive value of 67% and negative predictive value of 66% compared with the serum EIA, where the results were 98%, 48%, 64% and 96%, respectively. Although the salivary EIA is an appealing noninvasive test, it was not a sensitive and specific assay. The serum EIA also lacked specificity, but was highly sensitive with a good negative predictive value. Although a negative serum EIA rules out H pylori infection, a positive result must be interpreted in the clinical context and confirmed with a more specific measure.
Relationship Between Pressure Pain Threshold and Coping Strategies in Patients with Fibromyalgia
Authors: Song Ji-Young , Noh Samuel , Harth Manfred , Merskey Harold
Published: March 2016

OBJECTIVE: To explore the hypothesis that the intensity of pain, pain thresholds and coping mechanisms differ between patients with fibromyalgia and those with rheumatoid arthritis (RA) in order to determine whether pain coping strategies contribute to the understanding of how patients adjust to fibromyalgia.

METHODS: Thirty‐eight fibromyalgia patients were compared with 15 RA patients regarding severity of pain, pain history, pressure pain thresholds (measured with a pressure algometer) and pain coping strategies (measured with the Coping Strategies Questionnaire [CSQ]).

RESULTS: Fibromyalgia patients scored significantly higher than RA patients on severity of pain and had lower pain thresholds at three pairs of nontender sites than the RA group. Fibromyalgia patients were significantly different from RA patients with respect to catastrophizing and increasing behavioural activity, but this differentiation was not maintained with respect to the three main factors of the CSQ. Overall, both the fibromyalgia and RA groups resembled previous chronic pain populations. Depression and anxiety had strong negative correlations with the combined coping scores on the seven subscales (P<0.001).

CONCLUSIONS: Patients with fibromyalgia may use some distinctive coping strategies and tend to manage their pain in many of the same ways as other patients with chronic pain.
Noninvasive Screening for Genital Chlamydial Infections in Asymptomatic Men: Strategies and Costs Using a Urine PCR Assay
Authors: Peeling Rosanna W , Toye Baldwin , Jessamine Peter , Gemmill Ian
Published: March 2016

OBJECTIVE: To evaluate cost saving strategies to screen for genital chlamydial infection in men using polymerase chain reaction (PCR) technology.

METHODS: Men with no urethral symptoms presenting to a sexually transmitted disease (STD) clinic were recruited. Study participants underwent a questionnaire interview. Urethral swabs were taken to perform a smear for polymorphonuclear leucocytes (PMN) and for the detection of Chlamydia trachomatis by culture and PCR. First‐catch urine was collected for a leukocyte esterase test (LET) and PCR.

RESULTS: C trachomatis infection was detected in 36 of 463 (7.8%) men. LET and PMN were positive in 10 (28%) and 12 (33%) infected men, respectively. Risk factors for chlamydial infection were younger than age 25 years, LET‐positive, PMN‐positive and STD contact (P<0.001). The direct cost of genital chlamydial infection in men in Canada has been previously estimated at $381/case. Based on a sensitivity of 90% for urine PCR, the estimated direct cost of testing all participants to detect 32 cases was $453/case. Using risk factors recommended in the Canadian STD Guidelines (age younger than 25 years, new partner, STD contact or unprotected sex), the same number of cases would have been detected by testing only 384 men at $376/case. Using age younger than 25 years or STD contact as the screening criterion, 78% of those infected would have been detected at $259/case, and no new cases would have been detected by adding LET‐positive or PMN‐positive as risk factors.

CONCLUSION: Targeted screening for chlamydial infection using urine PCR assay and risk factors recommended in the Canadian guidelines could substantially reduce the cost of screening at a STD clinic setting. LET and PMN smear did not appear to be useful indicators of chlamydial infection in this population.
Meal Induced Oxygen Desaturation and Dyspnea in Chronic Obstructive Pulmonary Disease
Authors: Wolkove Norman , Fu Li Yi , Purohit Ashok , Colacone Antoinette , Kreisman Harvey
Published: March 2016

OBJECTIVE: To study arterial oxygen saturation (SpO2) obtained by pulse oximetry and dyspnea during active eating (AE) and passive eating (PE) in patients with severe chronic obstructive pulmonary disease (COPD).

DESIGN: Patients were studied on two consecutive days with AE and PE, which occurred in random order. SpO2 was recorded for 20 mins before and during eating, and dyspnea was recorded by the patient using a 10 cm visual analogue scale before and upon completion of eating.

SETTING: Subjects were in‐patients at an intermediate care facility who were hospitalized for pulmonary rehabilitation or for convalescence after an exacerbation of COPD.

POPULATION STUDIED: Thirty‐five patients with severe COPD (forced expiratory volume in 1 s [FEV1] less than 50% predicted, FEV1 to forced vital capacity ratio less than 65%) were studied. Mean age was 70.5±7.1 years.

MAIN RESULTS: Mean SpO2 decreased significantly (P<0.05) from 91.7±3.4% to 90.1±4.0% during AE, and 91.7±3.2% to 90.8±3.6% during PE. Mean lowest SpO2 was lower and percentage of time with SpO2 less than 90% was greater during eating compared with corresponding control periods during both AE and PE. Dyspnea increased significantly (P<0.05) from 1.4±1.2 to 3.3±2.3 cm during AE, and from 1.5±1.5 to 2.4±2.2 cm during PE. The increase in dyspnea was significantly greater during AE than PE.

CONCLUSIONS: Eating is an activity that can adversely affect SpO2 and increase dyspnea in patients with severe COPD. Oxygen desaturation and particularly increased dyspnea may at least in part relate to the recruitment of upper extremity muscles during eating.
Is There Anything Left to Learn? A Report on the Fifth Interanational Workshop on HIV Drug Resistance
Authors: Zala C , Rouleau D , Conway B
Published: March 2016

Although insight into the viral dynamics of human immunodeficiency virus (HIV) infection has increased dramatically over the past year, there remains much to learn in the field of antiretroviral drug resistance. Transmission of isolates with primary drug resistance is increasingly recognized. With respect to reverse transcriptase inhibitors, it appears that the use of drugs in combination may forestall the development of resistance once therapy has been initiated. Further, certain findings, particularly with respect to zidovudine and lamivudine, suggest that emergence of resistance to one agent may lead to increased susceptibility to another. These data may allow evaluation of innovative treatment strategies to avoid the development of multidrug resistance, which has now been reported in a number of settings. Protease inhibitors (PIs) are, on an individual basis, the most potent antiretroviral compounds available today. A number of studies have shown that resistance to these agents develops after the accumulation of several mutations in the protease gene of HIV. As with reverse transcriptase inhibitors, the use of PIs in the context of regimens designed to suppress viral replication as much as possible appears to forestall, perhaps indefinitely, the development of drug resistance. Although different patterns of resistance mutations have been described for the different PIs available, the issue of cross‐resistance remains unresolved. For the time being, it may be best to consider all PIs as a single agent that must always be used in a regimen designed to maximally suppress viral load. In conclusion, research in the field of antiretroviral drug resistance has never been more active and productive. It is hoped that such research will lead to the development of an integrated model of the clinical and laboratory management of HIV‐infected individuals.
Onset of Bronchodilation and Finger Tremor Induced by Salmeterol and Salbutamol in Asthmatic Patients
Authors: Lötvall Jan , Lunde Helen , Svedmyr Nils
Published: March 2016

Salmeterol is a beta‐agonist with bronchodilator properties that last for at least 12 h after inhalation. However, the onset of action of salmeterol immediately after inhalation has not been sufficiently investigated. In the present study, the onset of action and tremor‐inducing effect of two doses of inhaled salmeterol (50 and 100 µg) were compared with inhaled salbutamol (200 and 400 µg) and placebo. Lung function was measured using forced expiratory volume in 1 s (FEV), and tremor was measured using a linear accelerometer. With salbutamol there was rapid bronchodilation, both doses producing more than 15% improvement in mean FEV1 within 2 mins of inhalation. With salmeterol, on the other hand, significant bronchodilation was delayed until 7 mins versus placebo, and the full bronchodilation effect was not achieved until 60 mins after inhalation. There was a much more rapid onset of tremor with salbutamol (400 µg) than salmeterol. There was a much slower onset of bronchodilation with salmeterol than salbutamol. Therefore, salmeterol cannot be recommended to relieve acute symptoms.
Pain Correlates of Depressed Mood
Authors: Walsh Trudi M , Smith Chloé P , McGrath Patrick J
Published: March 2016

OBJECTIVE: To provide an initial indication of the intensity and quality of pain in young adults reporting depressed mood and to investigate possible underlying mechanisms.

DESIGN: Case‐control study.

SETTING: University undergraduate subject pool.

PARTICIPANTS: Sixty introductory psychology undergraduates classified as either reporting high levels of depressed mood (n=30; age 18.7±0.87 years, mean ± SD) or reporting low levels of depressed mood (n=30; age 18.6±0.81 years).

MAIN OUTCOME MEASURES: Beck Depression Inventory, Short‐Form McGill Pain Questionnaire, Pain Catastrophizing Scale, Pittsburgh Sleep Quality Index and pressure dolorimeter pain thresholds.

RESULTS: Young adults reporting high levels of depressed mood had significantly higher pain intensity at testing time, as measured by a visual analogue scale (P=0.015) and a present pain index (P=0.002), affective pain intensity for the previous month (P=0.000), pain catastrophizing (P=0.025) and global sleep disturbance (P=0.000) than young adults reporting low levels of depressed mood. Within the group of young adults reporting high levels of depressed mood, significantly higher sleep disturbance scores (P=0.020) were identified in those reporting high levels of overall pain intensity.

CONCLUSIONS: The results are discussed in terms of their implications for research as well as for the assessment and treatment of pain in individuals with depression.
How Much Does It Cost to Manage Paediatric Tuberculosis? One‐Year Experience from The Hospital for Sick Children
Authors: Main Cheryl L , Ying Ethel , Wang Elaine EL
Published: March 2016

BACKGROUND: Tuberculosis (TB) is a major infection with nearly eight million cases annually worldwide. Although the majority of these cases are in the developing world, TB is also a problem in Canada.

OBJECTIVE: To determine the cost of diagnosis and management of paediatric TB in Canada.

DESIGN: Cross‐sectional study.

SETTING: In‐patients and out‐patients at The Hospital for Sick Children, Toronto, a tertiary care centre.

PATIENTS: Patients were included if they had clinical or radiological evidence of TB infection with a positive tuberculin skin test or a positive culture result, and were treated from July 1, 1995, to June 30, 1996. Twenty‐two patients met the criteria for inclusion in the study.

OUTCOME MEASURES: Patient characteristics, types of disease, types and numbers of investigations, number of in‐patient days and out‐patient appointments, course of TB treatment, TB‐related complications and antimicrobial resistance were obtained from charts. Costs were derived from allocated hospital costs, Ontario Health Insurance Plan billings and costs provided by the Pharmacy Department at The Hospital for Sick Children.

RESULTS: The total cost for one year of management of paediatric TB in a tertiary care centre was $211,576. Pulmonary TB affected one‐half of the study patients but accounted for one‐quarter of the cost. One case of meningitis resulted in almost the same costs as all cases of pulmonary TB. Hospitalization was the largest contributor to overall cost, accounting for three‐quarters of the total. The remaining costs in order of their contribution to overall costs were antimicrobial treatment, out‐patient appointments, diagnostic imaging and TB cultures.

CONCLUSIONS: From a hospital’s perspective, the costs of managing each of the 22 patients was approximately $10,000. However, there was great variability between patients, with much greater costs for those who required hospitalization or numerous investigations because TB was not suspected. To the authors’ knowledge, this is the first time that such a cost analysis has been performed for a paediatric population. A cost analysis provides a better measure of the burden of illness than is indicated by the absolute number of patients.
Lung volumes 24 Hours after Laparoscopic Cholecystectomy — Justification for Early Discharge
Authors: Ali Jameel , Gana Theophilus J
Published: March 2016

OBJECTIVE: To compare lung volumes after laparoscopic cholecystectomy (LC) and open cholecystectomy (OC).

DESIGN: Prospective study with matched historical controls.

SETTING: Referral teaching hospital.

SUBJECTS: Twenty‐six healthy female subjects (age 20 to 40 years), 13 of whom had LC.

MAIN OUTCOME MEASURES: Vital capacity (VC, % predicted), functional residual capacity (FRC, % predicted) and analgesic frequency (mean ± SD) over the first 24 h.

RESULTS: Immediately after operation, FRC was similarly depressed to 80.4±1.8% in the OC group and 80.8±2.3% in the LC group. After 24 h FRC fell to 70.5±1.9% in the OC group and increased to 91.3±2.4% in the LC group. VC fell immediately postoperation to 41.4±4.8% in the OC group but to only 62.2±1.9% in the LC group. By 24 h, VC improved slightly to 52.5±2.7% in the OC group but returned to normal, 99.0±3.2%, in the LC group. Postoperative analgesic frequency over 24 h was less in the LC group, 3.3±0.8 versus 5.0±0.8.

CONCLUSION: Depression in lung volume is less with LC. A VC that returned to normal and a FRC level not usually associated with pulmonary complications support the practice of discharging LC patients by 24 h postoperation.
Recommendations for Patients with Chronic Respiratory Disease Considering Air Travel: A Statement from the Canadian Thoracic Society
Authors: Lien Dale , Turner Mark , the Canadian Thoracic Society Standards Committee
Published: March 2016

Patients with respiratory disease regularly seek the convenience of commercial airline travel. In addition to the stresses that all patients with chronic disease encounter, these patients are exposed to the affects of acute altitudinal hypoxemia. This in turn has the potential to produce significant symptoms and complications in‐flight for patients with chronic respiratory disease. This article reviews the current literature, and seeks to help the practicing physician by providing recommendations on which patients should be assessed preflight, the type of assessment that should be carried out and recommendations for providing advice to these travelling patients.
Comparative Study of Three Different BACTEC Culture Media for the Detection of Bacteremia in Ambulatory and Hospitalized Children
Authors: Church Deirdre L , Davies H Dele , Cadrain G , Trevenen Cynthia L
Published: March 2016

To compare the yield of two aerobic and an anaerobic BACTEC blood culture media in detecting bacteremia in ambulatory and hospitalized care settings at a children’s hospital, a prospective cohort study was completed. Over an 18‐month period, equal blood volumes (minimum of 1 mL/bottle) were inoculated into a three‐bottle culture set including aerobic BACTEC NR 6A, aerobic BACTEC PEDS Plus and anaerobic NR 7A broths. Chart reviews were completed on all children with bacteremia to determine whether the isolate was clinically significant based on predefined criteria. Among 5328 evaluable blood culture sets, 323 clinically significant organisms (110 from ambulatory and 213 from hospitalized children) were isolated. Most Streptococcus pneumoniae, Haemophilus species, and Neisseria or Moraxella species were recovered from children attending the emergency department or out‐patient clinics. Important isolates in hospitalized children included most of the staphylococci and Enterobacteriaceae, and all group D enterococci, Gram‐negative nonfermentative bacilli and all Candida species. Overall, significantly more isolates were detected only in the anaerobic bottle from ambulatory children (P<0.0001), including 13 of 54 (24%) patients with S pneumoniae bacteremias presenting to the emergency department. This study indicated that different BACTEC blood culture media combinations are needed in ambulatory and hospitalized pediatric care settings to ensure the optimal recovery of all types of isolates. Whereas aerobic blood culture bottles are adequate for detection of bacteremia in hospitalized children, the common occurrence of fastidious organisms mandates the need for a combined aerobic/anaerobic culture set in ambulatory pediatric care settings.
Comparison of Methods of Sampling for Toxocara Species and Fecal Coliforms in an Outdoor Day Care Environment
Authors: Carabin Hélène , Gyorkos Theresa W , Kokoskin Evelyne , Payment Pierre , Joseph Lawrence , Soto Julio
Published: March 2016

OBJECTIVE: To compare three sampling methods and to pretest methods for the determination of fecal coliform (FC) counts and Toxocara species from sand in the day care outdoor environment.

DESIGN: The sand samples were obtained from the play area and the sandbox of a day care centre and examined for the presence of FC and Toxocara species, the common roundworm of dogs and cats. The sampling methods included random selection and two types of judgement methods. The latter included one method where domestic animals were judged to be likely to defecate and the other where children would be likely to be playing. In addition, to obtain a global estimate of contamination, the entire areas of both the sandbox and the play area were sampled on the last day.

SETTING: Outdoor day care environment.

MAIN RESULTS: The most representative levels of bacterial contamination and Toxocara species originated from the combined sample of the entire surface areas rather than from any separate random or judgement method of sampling. FCs were found in all sampled areas of the sandbox (median 910 FCs/g of sand) and of the play area (median 350 FCs/g of sand). Toxocara species were recovered from a number of areas in both the sandbox and the play area.

CONCLUSIONS: Research on environmental microbial contamination of outdoor day care settings would benefit from the application of standardized and validated sampling and laboratory methods.
Cross‐Canada Survey of Resistance of 2747 Aerobic Blood Culture Isolates to Piperacillin/Tazobactam and Other Antibiotics
Authors: Forward Kevin R , Franks Patricia A , Low Donald E , Rennie Robert , Simor Andrew E , the Canadian Piperacillin/Tazobactam Study Group
Published: March 2016

OBJECTIVE: To compare the activity of piperacillin/tazobactam with that of other broad parenteral antibiotics against aerobic and facultative anaerobic blood culture isolates in a Canada‐wide survey.

DESIGN: Fifty‐eight laboratories in nine provinces each contributed up to 50 consecutive clinically significant aerobic and facultative anaerobic isolates for susceptibility testing.

SETTING: Participating hospitals included both tertiary care and community hospitals.

MATERIALS AND METHODS: Testing was performed in five regional centres by using the same microbroth dilution method, and results were interpreted according to National Commitee for Clinical Laboratory Standards M7‐A3 and M100‐S5 guidelines.

RESULTS: Piperacillin/tazobactam and imipenem were both active against more than 99% of the 1616 strains of Enterobacteriaceae species tested. The minimum inhibitory concentration of 90% of isolates (MIC90) of all Enterobacteriaceae species was 2 mg/L for piperacillin/tazobactam compared with 64 mg/L for piperacillin alone. Seventeen per cent of strains of Enterobacteriaceae species were susceptible to piperacillin/tazobactam but resistant to piperacillin. Piperacillin/tazobactam was highly active against Pseudomonas aeruginosa, inhibiting 99.1% of strains. MIC90 was 8 mg/L. Nine per cent of P aeruginosa strains were not susceptible to imipenem. Most of these strains had a MIC of 8 mg/L, which falls in the intermediate category. Ninety‐seven per cent of P aeruginosa were susceptible to ciprofloxacin and 97.3% to tobramycin. Ninety‐six per cent of strains of Actinobacter species were susceptible to piperacillin/tazobactam, whereas only 76% of strains were susceptible to piperacillin alone. Overall, piperacillin/tazobactam was the most active agent tested; 98% of all strains were susceptible, followed closely by imipenem, to which 97.8% of strains were susceptible.

CONCLUSIONS: Aerobic blood culture isolates from Canadian centres continue to be highly susceptible to a variety of antibiotics. The broad spectrum of activity of piperacillin/tazobactam suggests that this combination should be considered for empirical treatment of sepsis while awaiting results of cultures and susceptibility testing.
A Pediatric Case of Pigeon Breeder′s Disease in Nova Scotia
Authors: Tsai Ellen , Couture Dominique , Hughes Daniel M
Published: March 2016

Pigeon breeder′s disease has been reported sporadically in the pediatric population since it was first described in children in 1967. Because of its infrequent occurrence in children, a high level of suspicion is often required before a diagnosis is made. A case of pigeon breeder′s disease in a child in Nova Scotia, where the disease is virtually unseen or at least unrecognized, is described. The need for prompt recognition of the condition is paramount because its complications may be irreversible.
An Assessment of the Current Diagnostic Criteria for Infective Endocarditis
Authors: Chan Albert W , Ross Heather J
Published: March 2016

A firm diagnosis of infective endocarditis is difficult to establish. Clinicians often face a decision‐making dilemma about whether to treat a patient presenting with some features that suggest endocarditis. This article summarizes both the previous and the recently proposed criteria for the diagnosis of infective endocarditis, and reviews the efficacy of the new criteria. The authors also discuss the experience at The Toronto Hospital, Toronto, Ontario, with this disease, paying specific attention to the application of the new criteria in the diagnostic process.
Dose‐response Protective Effect of Salbutamol on Methacholine Airway Responsiveness using Pressurized Metered Dose Inhalers and Turbuhalers
Authors: Wong Albert G , O′Byrne Paul M , Lindbladh Christer , Inman Mark D , Ståhl Elisabeth , Hargreave Frederick E
Published: March 2016

The purpose of this study was to estimate the relative dose potency of salbutamol Turbuhaler compared with salbutamol pressurized metered dose inhaler (pMDI) with respect to the protective effect against methacholine bronchoconstriction. Twenty‐three asthmatic subjects with stable asthma participated in the study. Baseline forced expiratory volume in 1 s (FEV1) was 70% or more of predicted, and baseline methacholine provocative concentration causing a 20% fall in FEV1 (PC20) was 4 mg/mL or less. The design was randomized, double‐blind, double‐dummy, crossover and placebo controlled and was conducted over seven study days. On each study day, the subjects inhaled 50 µg or 100 µg of salbutamol via Turbuhaler, 100 µg, 200 µg, 400 µg or 800 µg of salbutamol via pMDI, or placebo in randomized order. PC20 was determined 30 mins after inhalation. Increasing doses of salbutamol pMDI increased the PC20 in a dose‐dependent fashion from 3.9 mg/mL after placebo to 13.3 mg/mL after pMDI 100 µg, 19.0 mg/mL after 200 µg, 32.6 mg/mL after 400 µg, and 35.1 mg/mL after 800 µg. The half‐maximum response dose for pMDI (ED50) was 104 µg. Salbutamol Turbuhaler 50 µg increased the PC20 to 10.0 mg/mL and 100 µg to 12.6 mg/mL. Salbutamol pMDI 200 µg provided significantly greater protection to methacholine than pMDI 100 µg or Turbuhaler 100 µg and significantly less protection than pMDI 400 µg (P<0.05). This study demonstrates that the relative protective dose potency of inhaled beta‐agonists can be determined by comparing their effects on methacholine airway responsiveness. The estimated relative protective dose potency for salbutamol Turbuhaler in comparison with pMDI was 1.38 (95% CI 0.67 to 2.87) at 50 µg and was 0.96 (95% CI 0.56 to 1.64) at 100 µg.