bluuebunny/crossref_metadata_2025 huggingface dataset:
Socioeconomic Factors and Work Disability: Clues to Managing Chronic Pain Disorder
Authors: Teasell Robert W , Finestone Hillel M
Published: March 2016

Disability is a multifactorial phenomena in chronic pain disorders, as it is for other painful and nonpainful medical conditions. Socioeconomic factors are important determinants of disability, although this aspect of disability in chronic pain disorders is often ignored. Lower socioeconomic status has been shown to be associated with an increase in the frequency and severity of disability, and the rate of progression to disability in patients with chronic pain. Work disability in lower socioeconomic groups is associated with issues of physical work demands and work flexibility (ie, the ability to control the pace of work, take unscheduled breaks or engage in modified work). Workplace interventions, particularly in the subacute phase, that are geared to workers′ limitations offer the best opportunity to reduce the current burden of disability. Where such work modifications are not available, disability will be problematic.
Similar Bronchodilation with Formoterol Delivered by Aerolizer or Turbuhaler
Authors: Lötvall J , Mellén A , Arvidsson P , Palmqvist M , Radielovic P , Kottakis J , Pfister P
Published: March 2016

BACKGROUND: In many countries, two dry powder formulations of inhaled formoterol are available for clinical use; one uses a single‐dose device (Foradil, Aerolizer), and the other uses a multiple‐dose device (Oxis, Turbuhaler).

OBJECTIVES: To study the bronchodilating effect of formoterol 12 μg when delivered via the Aerolizer and Turbuhaler devices over 12 h.

STUDY DESIGN: Randomized, double‐blind, placebo controlled crossover study. Forced expiratory volume in one second (FEV1) was monitored during a 12 h period.

PATIENTS: Nineteen nonsmoking asthma patients were included in the trial on the basis of reversibility of symptoms in response to inhaled salbutamol (either 200 or 400 μg given cumulatively; minimum reversibility 15%).

RESULTS: There were no significant differences between the two dry powder devices regarding the change from baseline of FEV1 over 12 h, the area under the curve of FEV1 over 12 h or the maximum value of FEV1. The improvement in FEV1 with formoterol 12 μg versus placebo was highly significant for both devices.

CONCLUSIONS: Formoterol is similarly effective when used as a dry powder when given by either Aerolizer or the Turbuhaler.
Catastrophizing, Functional Disability and Pain Reports in Adults with Chronic Low Back Pain
Authors: Vienneau Theresa L , Clark Alexander J , Lynch Mary E , Sullivan Michael JL
Published: March 2016

OBJECTIVE: To test the hypothesis that subjective reports of pain severity, pain intensity and functional disability correlate positively with catastrophizing.

PATIENTS: Adults with chronic low back pain for six months or longer presenting to a tertiary care Pain Management Unit.

METHODS: Catastrophizing was measured with the Pain Catastrophizing Scale (PCS) in 40 subjects (23 males, 17 females). Functional disability was measured with the Pain Disability Index and pain severity/intensity was quantified with the McGill Pain Questionnaire. Statistical analysis included Student′s t test and Pearson correlation analysis.

RESULTS: Student′s t tests on all dependent variables showed no significant sex differences. Correlational analysis revealed a significant relationship between catastrophizing and pain severity (r=0.35, P<0.05), between catastrophizing and pain intensity (r=0.39, P<0.05), and between catastrophizing and disability (r=0.55, P<0.001). Further analysis revealed the helplessness component of the PCS correlated most strongly with functional disability. Analysis of the relationship between pain intensity and disability revealed no significant relationship.

CONCLUSIONS: These observations support the finding that disability in chronic pain results from various causes, and is not solely a function of pain or pathology. The helplessness component of catastrophizing is most strongly related to disability. The implication of this finding is that psychological variables need proper assessment when there is significant disability. The PCS appears to be a useful tool to delineate further psychological components of chronic pain.
A Survey of Suctioning Practices among Physical Therapists, Respiratory Therapists and Nurses
Authors: Brooks Dina , Solway Sherra , Graham Ian , Downes Laurie , Carter Margaret
Published: March 2016

OBJECTIVE: To assess the current tracheal and oropharyngeal suctioning practice variability within and among the professions of physical therapy, respiratory therapy and nursing.

DESIGN: A mail survey of physical therapists, respiratory therapists and registered nurses who perform suctioning. The survey instrument consisted of questions about professional characteristics, clinical suctioning practice and sociodemographics.

SETTING: The survey was restricted to professionals practising within the province of Ontario.

PARTICIPANTS: Random samples (n=448) were drawn from membership of the regulatory boards of all three professions.

MAIN RESULTS: Fifty‐eight per cent of respondents returned completed questionnaires. There was large variation in reports of gloving procedure (eg, double clean: 26% for physical therapists, 5% for respiratory therapists, 55% for registered nurses, P<0.0001) and technique of catheter use (sterile, inline or clean, P<0.01). There was also discrepancy in the techniques used to minimize harmful effects, ie, prelubrication with gel (83% for physical therapists, 54% for respiratory therapists, 17% for registered nurses, P<0.0001), use of hyperinflation (12% of physical therapists, 25% of respiratory therapists, 39% of registered nurses never hyperinflate) and use of instillation (7% of physical therapists, 0% of respiratory therapists, 19% of registered nurses never instill). However, there was agreement about the routine application of hyperoxygenation (74% or more) and there was almost perfect agreement (99% or more) within and across the three professions that secretion removal was the main indication for suctioning.

CONCLUSIONS: The results of this study indicate a wide variation in suctioning techniques among physical therapists, respiratory therapists and registered nurses. Comparisons among professions revealed inconsistencies in some areas, such as the use of in‐line catheters, gloving procedures, prelubrication and hyperinflation.
Interaction of Staphylococcal Toxic Shock Syndrome Toxin‐1 and Enterotoxin A on T Cell Proliferation and TNFα Secretion in Human Blood Mononuclear Cells
Authors: De Boer Monica L , Kum Winnie WS , Chow Anthony W
Published: March 2016

BACKGROUND: The majority of menstrual toxic shock syndrome (MTSS) cases are caused by a single clone of Staphylococcus aureus that produces both toxic shock syndrome toxin‐1 (TSST‐1) and staphylococcal enterotoxin A (SEA).

OBJECTIVE: To determine whether the two superantigens interact to cause an enhancement of biological activity in human peripheral blood mononuclear cells (PBMCs).

DESIGN: PBMCs from nine healthy donors were stimulated with TSST‐1 or SEA, either alone or in combination at their minimum effective concentrations.

SETTING: In vitro study.

INTERVENTIONS: Human PBMCs were stimulated in vitro with TSST‐1 (1 pg/mL), SEA (0.1 pg/mL) or combination for 20 to 72 h. Mitogenic response was determined by [3H]‐thymidine incorporation. PBMC culture supernatants were assayed for the presence of tumour necrosis factor‐alpha (TNFα), interleukin (IL)‐1β and IL‐6 by ELISA.

MAIN RESULTS: The combination of TSST‐1 and SEA induced significantly greater mitogenesis in human PBMCs compared with either toxin alone (P<0.05, paired Student’s t test, two‐tailed). Similarly, the production of TNFα in culture supernatants was significantly greater in the combination of TSST‐1 and SEA compared with either TSST‐1 or SEA alone (P<0.05). In contrast, no enhancement in the levels IL‐1 or IL‐6 was observed.

CONCLUSIONS: These data suggest that the co‐production of TSST‐1 and SEA by S aureus may provide some biological advantage to the organism throughs an enhanced effect of these superantigens on T cell activation and TNF secretion.
Effect of Dead Volume on the Efficiency and the Cost to Deliver Medications in Cystic Fibrosis with Four Disposable Nebulizers
Authors: Ho Sharon L , Coates Allan L
Published: March 2016

OBJECTIVES: To evaluate the factors that affect nebulizer efficiency and to compare the relative cost effectiveness of nebulized medications used in the treatment of cystic fibrosis (CF), delivered by four types of disposable jet nebulizers that are widely used in hospitals.

DESIGN: The Hudson 1730 Updraft II, Baxter Misty‐Neb, Marquest Whisper Jet (WJ), and Marquest Acorn II were evaluated in terms of respirable aerosol output (particles 5 µm or less), nebulizer dead (residual) volume (VD), and time for complete nebulization using saline, salbutamol and tobramycin at flows of 6 and 8 L/min. The respirable fraction (RF) was determined by laser diffraction, and drug output was calculated from the initial volume and concentration of the drug in the nebulizer minus the product of final drug concentration and the VD following nebulization.

COST ANALYSIS: The expected pulmonary deposition (DE) was estimated, and incorporated with the material and labour costs to determine the cost effectiveness of each type of nebulizer.

RESULTS: With a DE greater than two times that of the WJ at a cost of 2.4 times less, the Updraft II proved most efficient and cost effective of all the nebulizers evaluated in this study.

CONCLUSIONS: The cost effectiveness of each nebulizer was determined by its efficiency, which in turn was predominantly related to its VD and RF at each flow. The efficiencies of these four devices were different and could not have been predicted from specifications provided by the respective manufacturers.
A Cross‐Canada Surveillance of Antimicrobial Resistance in Respiratory Tract Pathogens
Authors: Davidson Ross J , Canadian Bacterial Surveillance Network  , Low Donald E
Published: March 2016

OBJECTIVE: To determine the prevalence of antimicrobial resistance in clinical isolates of Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis from medical centres across Canada.

METHODS: Fifty laboratories from across Canada were asked to collect up to 25 consecutive clinical isolates of S pneumoniae, H influenzae and M catarrhalis at some time between September 1994 and May 1995, and then again between September and December of 1996. A total of 2364 S pneumoniae, 575 H influenzae and 200 M catarrhalis samples were collected. H influenzae and M catarrhalis isolates were tested for the production of beta‐lactamase. S pneumoniae isolates were characterized as penicillin susceptible, intermediately resistant or high level penicillin‐resistant. Minimal inhibitory concentrations (MICs) were determined using a microbroth dilution technique described by the National Committee of Clinical Laboratory Standards.

RESULTS: Between the two collection periods, there was a significant increase in highly penicillin‐resistant S pneumoniae from 2.1% to 4.4% (P<0.05) and an increase in intermediately penicillin‐resistant strains from 6.4% to 8.9% (P<0.05). A significant increase in high level penicillin‐resistant S pneumoniae was noted among paediatric isolates. No significant difference in the susceptibilities of comparator agents was detected. A significant increase in the number of beta‐lactamase producing H influenzae, 34% to 43% (P<0.05) was observed. Ninety‐five per cent of M catarrhalis isolates were beta‐lactamase producers in both time periods.

CONCLUSIONS: During the course of this study, the incidence of penicillin resistance in S pneumoniae doubled. As a result of this increase, infections due to this organism in sites where poor penetration of beta‐lactam antibiotics occur may become increasingly difficult to manage.
The Quebec Task Force on Whiplash‐Associated Disorders and the British Columbia Whiplash Initiative: A Study of Insurance Industry Initiatives
Authors: Teasell Robert W , Merskey Harold
Published: March 2016

Two studies on whiplash‐associated disorders that were generated by insurance companies were reviewed. The Quebec Task Force (QTF) report was comprised of a cohort study, a best evidence synthesis and consensus recommendations. The British Columbia Whiplash Initiative (BCWI) propagated the QTF recommendations.

The Quebec Task Force Cohort Study: This study was designed to determine retrospectively the natural history of whiplash injuries, however, recovery from whiplash injuries was determined by the discontinuation of payments and not by the resolution of symptoms. Patients complaining of ′recurrences′, who comprised a substantial percentage of the total number of patients studied, were specifically excluded from the data set. When these patients were included in the data set, the percentage of patients who failed to recover (based on whether they were still receiving compensation) had risen from the reported 2.9% to as high as 12.4% after one year. It is impossible to draw valid conclusions about the natural history of whiplash injuries from this study because it did not study recovery from whiplash symptoms and excluded the majority of patients who were classified as ′recurrences′ from the final study analysis.

The Quebec Task Force Best Evidence Synthesis Including Interventions: This analysis identified the paucity of conclusive research regarding treatments for whiplash. The paucity of conclusive research limited the number of conclusions that could be drawn.

The Quebec Task Force Consensus Recommendations: Despite a recognized lack of quality research, a consensus report that focused on therapeutic interventions was made. This consensus report is of concern because there was limited evidence to support the consensus, the classifications and recommendations were entirely arbitrary, the cohort data that the consensus panel relied upon to identify a natural history was seriously flawed, funding for the study was partisan, there was potential for abuse of guidelines, and there was a failure to deal with chronic whiplash injuries.

The British Columbia Whiplash Initiative: This report, which was designed as a set of educational modules, relied heavily on the QTF, particularly the cohort study and the consensus recommendations. As a result, the report was based upon a flawed and overly optimistic picture of the natural history of whiplash disorders, and an arbitrary classification and management system. Both the QTF and the BCWI draw attention to the potential dangers of insurance industry initiatives designed to persuade medical and allied health professionals to accept viewpoints that appear overoptimistic and potentially self‐serving.
Preoperative Predictors of Low Back Surgery Outcome: Preliminary Six‐Month Review Findings
Authors: Young Richard B , Jones Kenneth V
Published: March 2016

Research has shown that for patients undergoing low back surgery preoperative physical, psychological, and demographic and social information are predictive of outcome. However, some of the research findings have been conflicting, difficult to replicate and made questionable because of major methodological shortcomings. This study attempts to clarify further which preoperative variables best predict low back surgery outcome, using refined methodology. The sample comprised 140 patients (87 males, 53 females; age range 19 to 84 years; mean ± SD, 48.5±15.4 years) scheduled to undergo first‐time low back surgery. Before surgery, patients were interviewed, and completed a comprehensive psychometric test battery. Perioperative information was collected on every patient. Outcome was assessed at six months following surgery, and surveyed patient pain levels, perceived pain relief, level of disability, return to work and analgesic use. Outcome was evaluated in terms of pain relief, and pain relief in conjunction with the level of disability, return to work status and analgesic use. Outcome was correlated with preoperative psychosocial variables alone. The variables found to be predictive of outcome included: compensation involvement; previous serious illness; having close family members who had experienced chronic pain; childhood hospitalization for serious illness; a nonorganic pain drawing; catastrophizing; depression; psychological maladjustment and psychological issues suspected by the interviewer. The preliminary findings suggest that preoperative psychosocial assessment is of great importance for first‐time low back surgery outcome. Further follow‐up of the study sample is required to confirm the reliability of findings.
Use of Methadone in Treating Chronic Noncancer Pain
Authors: Hays Helen , Woodroffe Mary Ann
Published: March 2016

Chronic, noncancer pain is often very difficult to treat. Opioids continue to be the most effective analgesics in relieving severe pain, and recently their long‐term use has gained wider acceptance because patients report benefits related to improved comfort and/or enhanced function. There is no best choice of opioids, but rather analgesics are chosen according to individual needs and response. It may be beneficial to trial various opioids because of the possibility that opioid responsiveness may vary from drug to drug. The authors′ clinical experiences using oral methadone and the switchover process from the previously used opioid to methadone are reported. This potent analgesic has a wide variation in elimination half‐life and clearance. Consequently, there are inherent risks, such as severe sedation, in using opioid equianalgesic charts when switching to methadone from alternate opioids. Therefore, it is imperative that treatment be individualized, and that practitioners be familiar with prescribing opioids and have a good understanding of their pharmacokinetics. The authors′ experiences are with an out‐patient population, and the gradual changeover process that they use demonstrate safety without loss of pain control. This method may also be useful in those suffering terminal illness.
Efficacy and Abuse Potential of Opioid Analgesics and the Treatment of Chronic Noncancer Pain
Authors: Darke Andrew C , Stewart John H
Published: March 2016

While the role of opioid analgesics has been established in the treatment of cancer pain, reservations persist about appropriate use in patients with chronic noncancer pain. Recent evidence from controlled clinical trials supports the effectiveness of opioids for treating noncancer pain of varying etiologies. The safety of opioids in noncancer patients has been an area of controversy because of confusion between physical dependence, which develops in all patients receiving opioids chronically, and addiction, which is a behavioural diagnosis that is rarely made in patients appropriately treated with opioids for pain. Abuse by secondary recipients of opioids is well documented and arises as a result of diversion by primary recipients, double‐doctoring, forgery and theft. The frequency of forgery and theft of different opioids appears to be largely related to the corresponding number of legitimate prescriptions. While it is legitimate medical practice to prescribe opioid analgesics to patients with chronic noncancer pain, there is clear evidence that prescribing is affected by concerns of regulatory sanctions. Recent guidelines, including most recently comprehensive guidelines issued by the Canadian Pain Society, should help to reduce inappropriate undertreatment because of such concerns.
Centralization of a Regional Clinical Microbiology Service: The Calgary Experience
Authors: Church Deirdre L , Hall Paula
Published: March 2016

Diagnostic laboratory services in Alberta have been dramatically restructured over the past five years. In 1994, Alberta Health embarked on an aggressive laboratory restructuring that cut back approximately 30% of the overall monies previously paid to the laboratory service sector in Calgary. A unique service delivery model consolidated all institutional and community‐based diagnostic testing in a company called Calgary Laboratory Services (CLS) in late 1996. CLS was formed by a public/private partnership between the Calgary Regional Health Care Authority (CRHA) and MDS‐Kasper Laboratories. By virtue of its customer service base and scope of testing, CLS provides comprehensive regional laboratory services to the entire populace. Regional microbiology services within CLS have been successfully consolidated over the past three years into a centralized high volume laboratory (HVL). Because the HVL is not located in a hospital, rapid response laboratories (RRLs) are operated at each acute care site. Although the initial principle behind the proposed test menus for the RRLs was that only procedures requiring a clinical turnaround time of more than 2 h stay on‐site, many other principles had to be used to develop and implement an efficient and clinically relevant RRL model for microbiology. From these guiding principles, a detailed assessment of the needs of each institution and extensive networking with user groups, the functions of the microbiology RRLs were established and a detailed implementation plan drawn up. The experience at CLS with regards to restructuring a regional microbiology service is described herein. A post‐hoc analysis provides the pros and cons of directing and operating a regionalized microbiology service.
Unilateral Facial Pain and Headache: Effects of Both Indomethacin and Sumatriptan
Authors: Sjaastad Ottar , Fredriksen Torbjörn A , Pareja Juan A , Stolt-Nielsen Andreas
Published: March 2016

Three female patients presented with a similar pattern of unilateral facial pain and headache, reminiscent of atypical facial pain. The neck and ipsilateral shoulder (n=2) were also involved. The attacks of pain lasted from several hours to days. There was some tenderness in the neck, but upper cervical nerve anesthetic blocks did not provide any positive results. Indomethacin, taken at the time of the attacks, exerted a very marked effect. Sumatriptan produced an even more rapid and complete effect, but with intolerable side effects, including malaise and breathing difficulties. The unilateral facial pain and headache described in these cases resembles both cervicogenic headache (CEH) and hemicrania continua (HC), especially the former, which may be associated with both facial and shoulder pain. Indomethacin is, however, generally not effective in CEH. A clear sumatriptan effect in the cases studied is remarkable because there is usually little or no sumatriptan effect in HC. Atypical facial pain is difficult to treat, and probably does not respond well to indomethacin. The present study found that some patients with a similar symptomatology may benefit from indomethacin. The demonstrated effectiveness of indomethacin or sumatriptan makes it important to recognize such cases. Future serotonin agonists may have a more favourable effect to side effect ratio than sumatriptan and provide a more ideal approach to therapy in such cases.
Protease Inhibitor Phenotype BsaskatoonM Is Not Associated with Emphysema – A 20‐Year Follow‐Up Study
Authors: Jokic Ruzica , Fisher Kendra L , Cockcroft Donald W
Published: March 2016

OBJECTIVE: To investigate the association between the PiBsaskatoon variant of alpha‐1 protease inhibitor (α1 Pi), present in the heterozygous state and the development of emphysema.

DESIGN: Twenty‐year follow‐up in the third generation of a family with the variant, naturally controlled with regard to both environmental influences and other genetic factors.

SETTING: University teaching hospital.

POPULATION STUDIED: Ten siblings, five with PiBsaskatoonM phenotype and five with PiM phenotype, 33 to 46 years of age.

INTERVENTIONS: Respiratory symptoms and smoking histories; pulmonary function tests, including static lung volumes, dynamic lung volumes before and after salbutamol 200 μg, and diffusing capacity; allergen prick skin tests; serum α1 Pi level, chest radiographs and high resolution computerized tomography lung scans.

MAIN RESULTS: The two groups of siblings had similar mean ages, smoking histories and prevalence of current mild respiratory symptoms. Pulmonary function data showed normal mean values and no statistically significant differences for all the variables between the two groups. Chest radiographs were normal in all subjects. High resolution computerized tomography scans were normal in eight subjects, and demonstrated mild and very mild centrilobular emphysema in the two subjects with greatest smoking histories (approximately 30 pack‐year each); both of these were PiBsaskatoonM phenotype.

CONCLUSION: There is no evidence of an association between α1 Pi phenotype PiBsaskatoonM and the development of emphysema.
Observations from a Multicentre Study on the Use of the Sputum Specimen in Patients Hospitalized with Community‐Acquired Pneumonia
Authors: Taylor EL , Marrie TJ , Fine MJ , Obroskyl DS , Kapoor WN , Coley C , Singer DE
Published: March 2016

OBJECTIVE: To describe the use of sputum Gram stain and culture in patients with community‐acquired pneumonia (CAP) and to determine the factors that are associated with obtaining sputum for culture.

TYPE OF STUDY: Prospective observational cohort study of patients hospitalized for treatment of CAP at four medical institutions in three geographic locations.

MAIN MEASUREMENTS: Results of Gram stain and culture of sputum; comparison of patients who had sputum processed for culture within 24 h of admission with those who did not have such a specimen processed during the first week of hospitalization; and the results of investigator assignment of etiology of pneumonia according to predefined criteria.

RESULTS: Four hundred and seventy‐eight of 1339 (36%) patients had a sputum specimen processed for culture within 24 h of admission. Patients who had a sputum specimen processed within 24 h of admission were more likely to be hospitalized at the Boston site (odds ratio [OR] 20.6) or Pittsburgh sites (3.4) and to have current sputum production, chronic obstructive lung disease and moderate or large amount of sputum. Female sex (0.4), neutropenia (0.05), and do not resuscitate status (0.36) were important predictors of failure to have a sputum processed for culture. The rate of Streptococcus pneumoniae isolation was highest in Boston, 53 of 269 (19.3 %) patients (P<0.001) compared with the other sites; Moraxella catarrhalis was isolated only at the Boston site. Sputum culture results served as the basis for the assignment of an etiological diagnosis of the pneumonia by investigators in 67% of 397 patients. CONCLUSIONS: Sputum is not processed for culture in the majority of patients with CAP. The factors that determine whether sputum is processed for culture within 24 h of admission are site of care and a variety of patient factors. Common respiratory pathogens when present in sputum culture tend to be used to assign an etiological diagnosis. A positive sputum culture result appears not to result in a more favourable outcome.
Nonasthmatic Chronic Cough: No Effect of Treatment with an Inhaled Corticosteriod in Patients without Sputum Eosinophilia
Authors: Pizzichini Marcia MM , Pizzichini Emilio , Parameswaran Krishnan , Clelland Lynda , Efthimiadis Ann , Dolovich Jerry , Hargreave Frederick E
Published: March 2016

BACKGROUND: Inhaled corticosteroids are effective in suppressing a chronic cough without asthma associated with sputum eosinophilia.

OBJECTIVE: To investigate the inflammatory characteristics in the induced sputum of patients with a chronic cough without asthma or known cause and the effects of budesonide treatment on chronic cough in those patients.

PATIENTS AND METHODS: Forty‐four adults (mean [minimum, maximum] age of 45 years [20,75], 28 women, 17 atopic subjects and 32 nonsmokers]), with a daily bothersome cough for at least one year and who had no evidence of asthma or other known cause for the cough, were consecutively enrolled. The trial was a randomized, double‐blind, controlled parallel group trial of budesonide 400 mg twice daily for two weeks versus placebo. Patients then received open administration of the same dose of budesonide for a further two weeks. Sputum was induced before and at the end of each treatment period. Cough severity was documented by a visual analogue scale.

RESULTS: Thirty‐nine (89%) patients produced mucoid sputum after induction on at least one study visit. At baseline, the majority (59%) had a mild elevation in the median proportion of neutrophils (65%). All had elevated fluid phase levels of fibrinogen (3200 µg/L) and albumin (880 µg/L), and high levels of interleukin‐8 and substance P. Interleukin‐8 correlated with neutrophils (rho=0.72, P<0.001), fibrinogen (rho=0.65, P<0.001), albumin (rho=0.67, P=0.001) and eosinophil cationic protein (rho=0.60, P=0.001). Substance P correlated with albumin (rho=0.60, P=0.006). No subject had an increase in eosino‐phils. Treatment with budesonide did not affect cough or sputum measurements.

CONCLUSIONS: Patients with nonasthmatic chronic cough enrolled in this study had evidence of a mild neutrophilia and/or microvascular leakage. Chronic cough did not respond to treatment with budesonide, perhaps because the cause was not associated with sputum eosinophilia.
Enterococcal Bacteremia in a Tertiary Care Centre in Winnipeg
Authors: Madani Tariq AA , Kabani Amin , Orr Pamela , Nicolle Lindsay
Published: March 2016

OBJECTIVE: To review experience with enterococcal bacteremia before the emergence of vancomycin‐resistant enterococcus at a tertiary care teaching hospital.

DESIGN: Retrospective chart review of episodes of enterococcal bacteremia identified through the clinical microbiology laboratory from January 1990 to December 1994. Antimicrobial susceptibilities were performed for all isolates and pulsed‐field gel electrophoresis for genetic typing of selected strains.

RESULTS: One hundred and twenty‐six episodes of bacteremia were identified in 109 patients: 108 Enterococcus faecalis, 13 Enterococcus faecium, four both E faecalis and E faecium, and one Enterococcus durans. Enterococcal isolates occurred with polymicrobial bacteremia in 62 (49%) episodes. The most common sites of infection were central venous catheters (45%) and the urinary tract (21%). Enterococcal bacteremia was usually nosocomially acquired (88%), and associated with older age, instrumentation, and prior or current antimicrobial therapy. Overall mortality was 22%, and 7.2% was partially or fully attributable to enterococcal bacteremia. Resistance to ampicillin, high level gentamicin and high level streptomycin were 0%, 32% and 31% for E faecalis, respectively, and 44%, 0% and 47% for E faecium, respectively.

CONCLUSIONS: During this review, the frequency and impact of enterococcal bacteremia at this institution was relatively limited. Isolates resistant to ampicillin and aminoglycosides were emerging, but differences in patient outcomes were similar for resistant and susceptible isolates.
Multidrug‐Resistant Tuberculosis in Alberta and British Columbia, 1989 to 1998
Authors: Hersi Ahmed , Elwood Kevin , Cowie Robert , Kunimoto Dennis , Long Richard
Published: March 2016

OBJECTIVE: To describe the extent of the problem of multidrug‐resistant tuberculosis (MDR‐TB) in Alberta and British Columbia from 1989 to 1998.

DESIGN: A retrospective, population‐based descriptive study of all notified MDR‐TB cases in the context of all notified TB cases, all notified culture‐positive TB cases and all notified drug‐resistant TB cases.

SETTING: Provinces of Alberta and British Columbia, and their TB registries.

PATIENTS: All people with TB reported to the TB registries of Alberta and British Columbia between January 1, 1989 and June 30, 1998.

MAIN OUTCOME MEASURES: Drug susceptibility testing was performed in all cases of culture‐positive TB. Demographic, clinical and laboratory data on all cases of MDR‐TB were recorded.

RESULTS: Of 4606 notified cases of TB, 3553 (77.1%) were culture positive. Of these, 365 (10.3%) were drug resistant; of the drug‐resistant cases, 24 (6.6%) were MDR. Most MDR‐TB patients were foreign‐born; of the four Canadian‐born patients, two were infected while travelling abroad. Although foreign‐born patients were significantly more likely to harbour drug‐resistant strains, 14.3% versus 4.8%, respectively (P<0.001), among those who were harbouring a drug‐resistant strain, the proportion of Canadian‐born versus foreign‐born patients with an MDR strain was the same (6.7% versus 6.6%, respectively). From 1994 to 1998 versus 1989 to 1993, the proportion of all drug‐resistant strains that were MDR was greater (9.0% versus 4.3%, respectively), but the difference was not statistically significant. Isolates from 16 of the 24 MDR‐TB cases had been archived. Each of these was fingerprinted and found to be unique. Most MDR‐TB cases (88%) were respiratory. Of those tested for human immunodeficiency virus (n=17), only one was seropositive. MDR‐TB was ‘acquired’ in 67% and ‘primary’ in 33% of cases. Eight (33%) of the MDR‐TB cases received curative courses of treatment, six (25%) are still being treated, and the remainder have either died (five, 21%), transferred out (four, 17%) or become ‘chronic’ (one, 4%). No secondary case of MDR‐TB has been identified in Alberta and British Columbia.

CONCLUSIONS: Most MDR‐TB in Alberta and British Columbia is imported. The proportion of all drug‐resistant cases that are MDR appears to be increasing, but not because of disease acquired from recent contact with MDR‐TB in Canada.
Postsurgical Pain Is Attenuated in Men with Elevated Presurgical Systolic Blood Pressure
Authors: France Christopher R , Katz Joel
Published: March 2016

Previous research has demonstrated that elevated resting blood pressure is associated with a decreased perception of experimental pain. To assess this relationship in the context of clinical pain, postsurgical pain ratings were obtained from 159 men recovering from radical prostatectomy. Participants ranged in age from 46 to 75 years (Mean=61.9, SD=5.9), and on admission to the hospital had mean systolic and diastolic blood pressures of 134.2/79.9 mmHg (SD=19.2/10.2). Pain ratings were obtained at 24 h and 48 h postsurgery using the McGill Pain Questionnaire and Visual Analog Scales administered at rest and after standardized movement (VAS‐M). Results of correlational analyses indicated that higher preoperative resting systolic blood pressure was associated with significantly lower VAS‐M pain ratings at 24 h postsurgery and significantly lower ratings on all pain measures at 48 h postsurgery. The relationships between blood pressure and pain ratings were maintained even after controlling for individual differences in age, length of surgery and postsurgical self‐administration of morphine. These results confirm and extend previous observations of decreased pain in individuals with elevated blood pressure and suggest that this effect persists despite access to morphine analgesia.
A Complication of BCG Vaccine: A Case of Localized Cutaneous Abscess due to Mycobacterium bovis
Authors: Lussier Nathalie , Bourgault Anne-Marie , Gaudreau Christiane , Turgeon Pierre
Published: March 2016

The attenuated bacille Calmette‐Guérin (BCG) vaccine is administered to prevent tuberculosis. Complications of vaccination are uncommon. A case of cutaneous abscess due to BCG is presented in a 24‐year‐old woman. The abscess developed at the inoculation site four weeks after vaccination. Routine Gram stain and bacterial cultures of the pus were negative. The auramine stain was positive. Mycobacterial cultures were positive after 14 and 18 days, using the BACTEC 12B bottle and Löwenstein‐Jensen media, respectively. The mycobacteria were identified as Mycobacterium bovis, vaccinal strain by high‐performance liquid chromatography and DNA probe assays.
Utility of Gastric Aspirates in Screening for Pulmonary Tuberculosis in High Risk Subjects: The Manitoba Experience
Authors: Bahammam A , Choudhri SH , Long R
Published: March 2016

BACKGROUND: Although gastric aspirates (GA) are one of the recommended screening procedures for asymptomatic individuals at high risk for developing tuberculosis (TB), little data exist on the utility of GA for this indication.

OBJECTIVE: To determine the utility of GA as a screening tool in asymptomatic subjects who are at high risk for developing pulmonary TB.

PATIENTS AND METHODS: The study population’s clinical, radiographical and Mantoux skin test findings were correlated with a laboratory database of all patients who underwent GA in 1994. Subjects included in the study were those at high risk of developing TB, ie, immigrants placed under surveillance for TB postlanding in Canada (surveillance foreign‐born), other foreign‐born individuals from high prevalence countries, Status Indians and close contacts of patients with active pulmonary TB.

RESULTS: Four hundred and twelve GAs were performed in 318 patients. Complete data were available in 243 patients. Canadian‐born persons who were not Status Indians and foreign‐born persons from nonendemic areas (n=37) were excluded. The remaining 206 patients had 261 GAs performed (1.27±0.7 per subject). This group consisted of surveillance foreign‐born (n=57), other foreign‐born (n=110) and Status Indians (n=39). Fifty‐three (26%) were symptomatic and 153 (74%) were asymptomatic. Ninety‐eight had a normal chest radiograph, and 108 had an abnormal chest radiograph. Fourteen subjects (26%) in the symptomatic group had Mycobacterium tuberculosis isolated from their GA versus one (0.65%) in the asymptomatic group (P<0.001). One subject (1%) in the normal chest radiograph group versus 14 (12%) in the abnormal chest radiograph group (P=0.005) had M tuberculosis isolated from their GA. Thirty‐six subjects were both symptomatic and had abnormal chest radiographs. In this group, 12 (33%) had M tuberculosis isolated from their GA, while none of the patients who were asymptomatic and had normal chest radiographs had a positive M tuberculosis culture. There was no difference in the yield of GA between Mantoux skin test‐positive and Mantoux skin test‐negative groups.

CONCLUSIONS: GAs have a low yield when used to screen asymptomatic high risk subjects. The results suggest that screening of asymptomatic individuals or those with normal chest radiographs may not be warranted. This will spare many asymptomatic subjects the discomfort of undergoing the procedure and produce a significant cost saving.
Antibiotic and Oral Contraceptive Drug Interactions: Is There a Need for Concern?
Authors: Zhanel George G , Siemens Shannon , Slayter Kathryn , Mandell Lionell
Published: March 2016

OBJECTIVE: To assess the clinical significant of antibiotic and oral contraceptive drug interactions.

DATA SELECTION: MEDLINE search from 1975 to 1998 (September) inclusive. Search terms ‘antitiobic’, ‘oral contraceptive’ and ‘pregnancy’ were included. Published papers as well as references from these papers were reviewed. Papers documenting mechanistic interactions between antibiotics and oral contraceptives were included.

DATA EXTRACTION: Studies reporting oral contraceptive pharmacokinetics, mechanisms, incidence, implicated antibiotics and clinical consequences of antibiotic/oral contraceptive drug interactions.

DATA SYNTHESIS: Reports of oral contraceptive failure seem to be most numerous in women using preparations containing 30 μg of ethinylestradiol and 150 μ g of levonorgestrel. Rifampin is the only antibiotic that has been reported to reduce plasma estrogen concentrations. When taking rifampin, oral contraceptives cannot be relied upon and a second method of contraception is mandatory. Amoxicillin, ampicillin, griseofulvin, metronidazole and tetracycline have been associated with contraceptive failure in three or more clinical cases. When these agents are used, the clinician should discuss the available data with the patient and suggest a second form of birth control. Other antibiotics are most likely safe to use concomitantly with oral contraceptives.

CONCLUSIONS: Rifampin is the only antibiotic to date that has been reported to reduce plasma estrogen concentrations. Oral contraceptives cannot be relied upon for birth control while taking rifampin.
Prevalence of Gastroesophageal Reflux in Infants with Recurrent Brief Apneic Episodes
Authors: Sheikh Shahid , Stephen Thomas C , Sisson Barbara
Published: March 2016

BACKGROUND: Apnea in an infant can be a diagnostic dilemma for the treating pediatrician. It is suggested that in some infants, gastroesophageal reflux (GER) might be a factor in the pathogenesis of apnea, although its role as a cause of apnea is still controversial.

OBJECTIVE: To evaluate the prevalence of GER in infants presenting with recurrent brief apneic periods.

PATIENTS AND METHODS: A retrospective review of the medical records of all the infants who underwent prolonged esophageal pH studies for brief apneic episodes (n=105) at the Kosair Children’s Hospital in the six years from January 1992 to December 1997 was performed. Infants presenting with apparent life‐threatening episodes were excluded.

RESULTS: Of 105 infants, 72 (68.6%) were younger than two months of age and 22 (21%) were born preterm. Fifty of 105 infants (47.6%) had positive esophageal pH studies for acid reflux. Among infants with positive pH studies, only 21 (42%) had associated gastrointestinal or feeding complaints.

CONCLUSION: GER is present in a large number of infants presenting with brief apneic episodes. Though the relationship between the two is still not fully established, GER may be a significant risk factor for such apneic episodes in infants.
Spectroscopic Approach to Capillary‐Alveolar Membrane Damage Induced Acute Lung Injury
Authors: Wang Jing , Oppenheimer Luis , Fata Paola , Pintin Julio , Stimpson Ross , Mantsch Henry H
Published: March 2016

BACKGROUND: Acute (or adult) respiratory distress syndrome (ARDS) is often associated with a high mortality rate in the critical care population. The term acute lung injury (ALI), a primitive phase of ARDS, was introduced by the European and American consensus groups to provide early diagnoses of ARDS. The pathophysiological characterization of ALI/ARDS – an increased pulmonary capillary‐alveolar membrane barrier permeability – is generally not included in current intensive care unit diagnosis criteria.

OBJECTIVES: To apply the infrared (IR) spectroscopic technique, in combination with the administration of hydroxyethyl starch (HES), to patients with ALI and ARDS.

PATIENTS AND METHODS: This retrospective study involved 67 patients from the intensive care unit at the Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba. The methodology was based on the IR spectroscopic determination of HES in patient’s bronchial washing fluid. Exaggerated infiltration of HES into the alveolar space was taken as evidence of damage to the pulmonary capillary‐alveolar membrane, which in turn provided a diagnosis of ALI/ARDS.

RESULTS: The accuracy of determining pulmonary HES leakage in severe lung injury (Partial pressure of arterial oxygen/fraction of inspired oxygen [PaO2/FiO2] less than 100 mmHg [n=10]), was 100%. The subgroups with PaO2/FiO2 between 100 and 200 mmHg (n=23), and PaO2/FiO2 between 200 and 300 mmHg (n=22), 56.5% and 77.3%, respectively, showed IR positive for HES leakage.

CONCLUSIONS: The proposed IR bronchial washing assay is very sensitive in determining the pulmonary HES leakage in severe lung injury. It is also suitable for evaluating pulmonary leakage at an early phase of the injury, a fact that is particularly important for supportive treatment. The method is advantageous because no radioactive tracers are employed, little sample preparation is required, and it is rapid and minimally invasive, making it convenient to use in the critical care environment.
New Delivery Systems and Propellants
Authors: Dolovich Myrna
Published: March 2016

The removal of chlorofluorocarbon (CFC) propellants from industrial and household products has been agreed to by over 165 countires of which more than 135 are developing countries. The timetable for this process is outlined in the Montreal Protocol on Substances that Deplete the Ozone Layer document and in several subsequent amendments. Pressured metered dose inhalers (pMDIs) for medical use have been granted temporary exemptions until replacement formulations, providing the same medication via the same route, and with the same efficacy and safety profiles, are approved for human use. Hydrofluoroalkanes (HFAs) are the alternative propellants for CFCs‐12 and ‐114. Their potential for damage to the ozone layer is nonexistent, and while they are greenhouse gases, their global warming potential is a fraction (one‐tenth) of that of CFCs. Replacement formulations for almost all inhalant respiratory medications have been or are being produced and tested; in Canada, it is anticipated that the transition to these HFA or CFC‐free pMDIs will be complete by the year 2005. Initially, an HFA pMDI was to be equivalent to the CFC pMDI being replaced, in terms of aerosol properties and effective clinical dose. However, this will not necessarily be the situation, particularly for some corticosteroid products. Currently, only one CFC‐free formulation is available in Canada – Airomir, a HFA salbutamol pMDI. This paper discusses the in vitro aerosol characteristics, in vivo deposition and clinical data for several HFA pMDIs for which there are data available in the literature. Alternative delivery systems to the pMDI, namely, dry powder inhalers and nebulizers, are briefly reviewed.
Inhaler Education for Hospital‐Based Pharmacists: How Much Is Required?
Authors: Jackevicius Cynthia Anne , Chapman Kenneth R
Published: March 2016

OBJECTIVE: To compare the effectiveness of a more intensive educational intervention with a less intensive intervention on the ability of hospital pharmacists to be prepared to educate patients regarding inhaled device technique.

DESIGN: Randomized controlled trial. Inhaler technique and knowledge were assessed pre‐education, immediately after and three months after education by a research assistant blinded to the educational allocation.

SETTING: Tertiary hospital pharmacy department.

POPULATION STUDIED: Hospital‐based pharmacists.

INTERVENTION: A 1 h ‘hands‐on’ session with feedback (more intense education, MIE) or written materials describing inhaler use (less intense education, LIE).

MAIN RESULTS: The change in overall score from pre‐education to early posteducation for MIE was greater than for LIE (mean [95% CI]) (2.64 [1.27 to 4.01] versus 1.26 [0.05 to 2.47], P<0.001). Assessment scores improved for all device demonstrations and general knowledge. The change in score from the pre‐education to the late posteducation period was only slightly higher in the MIE group than the LIE group, a difference that was not statistically significant (1.78 [0.82 to 2.74] versus 1.22 [0.06 to 2.39], P=0.09). Scores in both groups were lower in the late posteducation period compared with the early posteducation period. Greater increases in total score in the immediate posteducation period were associated with a low baseline score and the MIE intervention.

CONCLUSION: Individual coaching in inhaler technique produces greater improvement in inhaler knowledge among hospital pharmacists than provision of written materials. However, the advantage of the more intensive intervention was short‐lived, with little advantage evident in three months.