bluuebunny/crossref_metadata_2025 huggingface dataset:
Asthma Mortality in Canada, 1946 to 1990
Authors: Hogg Robert S , Schechter Martin T , Montaner Julio SG , Hogg James C
Published: March 2016

OBJECTIVE: To assess the impact of asthma on Canadian mortality rates over a 45‐year period.

DESIGN: A descriptive, population‐based study.

SETTING: Canada.

SUBJECTS: All persons who died from asthma in Canada from 1946 to 1990 as reported to Statistics Canada in Ottawa.

MAIN OUTCOME MEASURES: Standardized mortality ratios, age‐specific patterns of death, potential years of life lost (PYLL) and life expectancy lost.

RESULTS: A total of 12,010 male and 8486 female asthma deaths were recorded in Canada from 1946 to 1990. Mortality rates for both sexes declined from a high of between three to six deaths in 1951 to 1955 to approximately two deaths per 100,000 in 1986 to 1990, with the decline in rates being greater for males than females. Age‐specific mortality rates were highest al all ages in 1951 to 1955, except for 15 to 24 years when deaths rates for the 1981 to 1985 period were greater. PYLL exhibit the same pattern as mortality, peaking in 1951 to 1955 and subsequently declining with each period. Loss in life expectancy due to asthma was about one month (not significant) in all time periods.

CONCLUSIONS: Asthma mortality rates have declined significantly over the study period. This decline appears to be linked with the convergence of sex‐specific rates and with changes in the patterning or age‐specific mortality. The impact of asthma on the life expectancy of Canadians is small.
Efficacy and Cost Benefit of Inhaled Corticosteroids in Patients Considered to Have Mild Asthma in Primary Care Practice
Authors: O′Byrne Paul , Cuddy Lauren , Taylor D Wayne , Birch Stephen , Morris Joanne , Syrotuik Jerry
Published: March 2016

OBJECTIVE: Inhaled corticosteroids are infrequently used as asthma therapy in patients considered to have mild asthma in primary care practice. The purpose of this study was to determine whether the use of low doses of inhaled corticosteroids (budesonide), supplemented with bronchodilators as needed, provides clinical benefit and is cost beneficial compared with therapy with bronchodilators alone, in patients considered by their physicians in a primary care setting to have mild asthma, not requiring inhaled corticosteroids.

DESIGN: Double‐blind, randomized controlled study comparing three parallel treatment groups receiving 400 mg or 800 mg inhaled budesonide/day or placebo.

SETTING: Seven primary care practices across Canada.

PATIENTS: Fifty‐seven adult asthmatics considered to have mild asthma not needing inhaled corticosteroids.

OUTCOME MEASURES: Patients recorded morning and evening peak expiratory flow rates (PEFR) and daily asthma symptom scores. Economic data were collected regarding drug and service use and willingness to pay.

RESULTS: Budesonide significantly reduced early morning and nocturnal symptoms and sputum production, and reduced the use of a bronchodilator compared with placebo. The budesonide groups also showed significant improvements in PEFR, before and after bronchodilator. No differences were found between the two dosages of budesonide; however, the study had insufficient power to detect differences between dosages, had they been present. There was a similar frequency of adverse events in all three treatment groups. The willingness‐to‐pay assessment found that both doses of budesonide were more cost beneficial than placebo.

CONCLUSIONS: These results demonstrate that inhaled budesonide 400 mg/day provides better asthma control and is cost beneficial compared with bronchodilators alone in the management of patients with mild asthma who were not considered to need inhaled corticosteroids in primary care practice.
Chemotherapy of Drug‐Resistant Malaria
Authors: Kain Kevin C
Published: March 2016

OBJECTIVE: To review the impact of drug‐resistant malaria on current management of plasmodial infections.

DATA SOURCES: A MEDLINE search of the English‐language medical literature from 1985 to 1995; bibliographies of selected papers; international malaria advisory experts.

DATA SYNTHESIS: Combinations of artemisinin derivatives and mefloquine or atovaquone plus proguanil appear to be the most active drug regimens against multidrug‐resistant falciparum malaria from Southeast Asia. The optimal therapy for chloroquine‐resistant Plasmodium vivax is unknown, but recent data indicate that halofantrine or chloroquine plus high doses of primaquine are efficacious.

CONCLUSIONS: The incidence of drug‐resistant malaria continues to increase at a rate that exceeds new drug development. Ultimately the control of malaria will require more creative approaches than just the development of additional inhibitory drugs. These might include the identification of biochemical pathways unique to the parasite (such as drug efflux and heme polymerization), making it possible to design new classes of antimalarial agents that are selectively toxic to the parasite; methods to block parasite development in the mosquito vector; and multistage vaccines against asexual and sexual stages to block both the pathophysiology and the transmission of disease.
Occupational Exposures and Chronic Airflow Limitation
Authors: Dimich-Ward Helen , Kennedy Susan M , Chan-Yeung Moira
Published: March 2016

The recent literature was reviewed to evaluate whether chronic airflow limitation is associated with occupational exposures to dusts. Only those studies that controlled for the effects of smoking were included. There is compelling evidence that exposure to inorganic dusts, such as from coal and hardrock mining or asbestos, are associated with the development of chronic airflow limitation, independently of pneumoconiosis. Nonsmoking gold miners are particularly at high risk of airflow obstruction and emphysema. Findings from studies of organic dusts, such as exposures to wood, cotton, grain or other agricultural dusts, or to mixed dust exposures, were less consistent but tended to show positive dose‐response associations. In the majority of studies, no statistical interaction was shown between dust exposures and smoking; however, the effects of the dust exposures were often more pronounced. An occupational history should be considered, in addition to a smoking history, as an integral part of an investigation of chronic airflow limitation in a patient.
Seroprevalence of Toxoplasma Antibody in a Toronto Population
Authors: Ford-Jones EL , Kitai I , Corey M , Notenboom R , Hollander N , Kelly E , Akoury H , Ryan G , Kyle I , Gold R
Published: March 2016

OBJECTIVE: To determine the prevalence of infection with toxoplasmosis by country of birth and age in a sample of convenience.

DESIGN: Banked sera and the computerized data base of demographic and other factors from an earlier epidemiological study were retrieved.

SETTING: Thirty‐eight infant‐toddler day care centres in Toronto.

POPULATION: Day care providers from whom informed consent was obtained and banked sera were available.

MAIN RESULTS: Of the 124 providers whose serum was tested, 16 (12.9%) were seropositive. Of those providers born in Canada, 8.2% were seropositive, while of those born outside of Canada, 19.6% were positive (P=0.067, OR 2.68, 95% CI 0.91, 7.94). While there was no significant association of seropositivity with age, the association of seropositivity with country of birth was different in the providers under 30 years of age. Among those born in Canada, 4.6% were seropositive, while among those born outside of Canada 23.1% were seropositive.

CONCLUSIONS: The data supplement the limited existing data on toxoplasmosis infection in Canada. Among Canadians, those born outside of Canada were more likely to be seropositive than those born in Canada, suggesting that there may be a differential risk of congenital infection for infants whose parents were born outside of Canada.
Current Status of New Modes of Mechanical Ventilation
Authors: Kacmarek Robert M
Published: March 2016

Current approaches to managing patients requiring ventilatory support have focused on a lung protective strategy. This approach limits peak alveolar pressure and tidal volume, and allows hypercapnia. Although hypercapnia is tolerated by many patients, in some the acute acidosis markedly complicates clinical management. Tracheal gas insufflation (TGI) has been designed as an adjunct to conventional ventilation to decrease PaCO2. Although no commercial TGI systems are available, TGI holds great promise and can be expected to be available comercially in the future. Pressure ventilation has become the ventilatory approach of the 1990s, whether pressure support or pressure control. However, problems associated with varying tidal volumes have resulted in manufacturers developing ventilatory modes that combine the beneficial effects of both pressure and volume ventilation.
Comparison of Community‐Acquired Pneumonia Requiring Admission to Hospital in HIV‐and Non‐HIV‐Infected Patients
Authors: Touchie Claire , Marrie Thomas J
Published: March 2016

OBJECTIVE: To compare community‐acquired pneumonia (CAP) in hospitalized human immunodeficiency virus (HIV)‐infected patients with that in hospitalized non‐HIV‐infected patients by assessing presenting characteristics, etiology and outcomes.

DESIGN: Retrospective chart review.

SETTING: A tertiary care centre in Halifax, Nova Scotia.

POPULATION STUDIED: Thirty‐two HIV‐infected patients requiring hospitalization for treatment of CAP were identified from September 1991 to October 1993 and compared with 33 age‐matched non‐HIV‐infected patients who presented with pneumonia during the same period.

MAIN RESULTS: The two populations were comparable in age, sex and race. Fifty per cent of the HIV‐infected and 20.8% of the non‐HIV‐infected patients had had a previous episode of pneumonia. Pneumocystis carinii pneumonia (PCP) accounted for 16 of the 32 episodes of CAP in the HIV‐infected patients, while none of the non‐HIV‐infected patients had PCP. Pneumonia secondary to Streptococcus pneumoniae was more common in the non‐HIV‐infected patients (five versus one, P=0.02). Vital signs and initial PO2 did not differ between the two groups. White blood cell count was lower at admission for the HIV population (5.7×109/L versus 12.7×109/L, P=0.003). The HIV patients were more likely to undergo bronchoscopy (27.7% versus 0%, P<0.001). The length of stay in hospital, transfer to the intensive care unit and necessity for intubation were the same for both groups. The in‐hospital mortality for HIV‐infected patients was eight of 32 (25%) while for the non‐HIV‐infected patients it was none of 33 (P=0.002).

CONCLUSIONS: Patients with HIV infection who present with CAP are more likely to have PCP, to have had a past episode of pneumonia and to die while in hospital than age‐ and sex‐matched non‐HIV‐infected patients with CAP.
Superiority of Spacer/Mask Topical Anesthetic Compared with Conventional Spray and Gargle Method for Fibreoptic Bronchoscopy
Authors: Balkissoon RC , Clelland L , Whitehead L , Newhouse MT
Published: March 2016

OBJECTIVE: To compare the safety and efficacy of a new spacer‐oral nasal mask device with those of the standard needle nozzle spray method for the delivery of aerosolized lidocaine to the upper airway for pre‐bronchoscopic anaesthesia in a tertiary care hospital.

DESIGN: Single‐blind randomized control trial.

SETTING: University affiliated tertiary care hospital, ambulatory care bronchoscopy unit.

SUBJECTS: Thirty consecutive consenting patients referred for fibreoptic bronchoscopy for various indications.

INTERVENTION: Thirty randomized subjects received 150 mg of topical 1% aerosolized lidocaine via standard long needle nosed applicator (group A) or via a new oral/ nasal mask with spacer device (group B). Bronchoscopists, blinded as to the preprocedure topical anaesthetic method used, gave additional topical lidocaine at their discretion.

MEASUREMENTS: The study nurse recorded the total dose of lidocaine (mg), timing of the procedure (s), cough frequency expressed as coughs per minute (c/min), vital signs, time for return of gag reflex and patients′ subjective comments.

RESULTS: Fifteen patients were randomized to each group. The lidocaine dose required for insertion through the vocal cords (mean ± SD) was 282.6±66.3 mg in group A and 203.3±70.6 mg in group B (PÃ0.005). Total lidocaine dose required for the procedure was 330.6±70.2 mg in group A and 256.6±75 mg in group B (PÃ0.01). The mean time for passage of the bronchoscope from mouth entry to through the vocal cords was 82.7±54.5 s in group A and 110.5±64.4 s in group B (P>0.1). The mean total time for the procedure was 699.7±377.5 s in group A and 697.2±409.1 s in group B (not significant). The mean cough frequency was 8.2±6.1 c/min in group A and 7.0±5.7 c/min in group B (not significant). There were no statistically significant differences in heart rate, in return of gag reflex time or in complication rate between the two groups.

CONCLUSIONS: A statistically significant reduction in the dose of lidocaine is required to achieve equivalent topical anaesthetic for bronchoscopy with a new mask and spacer device compared with a more conventional method. Since no other variables related to the procedure showed a significant difference, the new method appears to be superior to the previous method.
Canadian Asthma Consensus Conference Summary of Recommendations
Authors: Ernst Pierre , Fitzgerald J Mark , Spier Sheldon
Published: March 2016

The Asthma Committee of the Canadian Thoracic Society invited a group of Canadian physicians with a particular interest in asthma to meet in Montebello, Quebec, March 9‐12, 1995 to arrive at a consensus statement on the optimal approach to the management of asthma in the pediatric and adult ambulatory care settings. The societies and associations represented are listed in the appendix with the names of the contributors to this document. The objectives of the Montebello conference were: 1. To review the current ambulatory care management of asthma in Canada; 2. To develop guidelines with the participation of family physicians and specialists; 3. To develop guidelines which are evidence‐based; 4. In creating evidence‐based guidelines to focus attention on aspects of asthma management that are currently not supported by randomized controlled trials; 5. To develop strategies that allow for the implementation of rational guidelines at a local level. Recommendations were based on a critical review of the scientific literature by small groups prior to the meeting and are categorized according to the strength of the scientific evidence supporting each recommendation (Table 1).
Thalamic or Central Pain States Poststroke
Authors: Teasell Robert W
Published: March 2016

Thalamic or central pain states are generally regarded as rare in stroke, occurring in fewer than 2% of patients. However, a recent study suggests that they may be more common, occurring in up to 8% of unselected stroke patients. Cerebrovascular lesions leading to central pain states do not necessarily involve the thalamus, but can occur following lower brainstem and suprathalamic lesions. Damage to the spinothalamocortical tract appears to be a prerequisite to the development of central poststroke pain (CPSP). Development of CPSP is likely related to denervation hyperexcitability of third or fourth order, thalamic or cortical neurons. Central pain is often described as a ′burning′ sensation in association with an unpleasant association of tingling, pins and needles, or numbness. Spontaneous or evoked dysesthesia and allodynia/hyperalgesia are common. Central or thalamic pain is generally intractable to most therapeutic interventions. One case is presented to illustrate the typical clinical presentation of thalamic pain states and the difficulties in treating this pain.
Pulmonary Surfactant Function in Alveoli and Conducting Airways
Authors: Enhorning Goran
Published: March 2016

Surface tension plays a very important role in aeration of the neonate′s lungs. Pulmonary surfactant, which is inadequate in the premature infant, modifies surface tension during the act of breathing and is necessary for maintenance of alveolar stability. These facts led to the development of the concept that it might be possible to treat the premature infant by supplementing the infant′s inadequate surfactant supply. In addition to maintaining alveolar stability, pulmonary surfactant might also be of vital importance for maintenance of small airway patency. Various conditions, most importantly asthma, might be the reason for a surfactant dysfunction to develop. This in turn might cause airway resistance to increase.
Plesiomonas shigelloides Septicemia and Meningitis in a Neonate
Authors: Eason Julian D , Peacock Donlim
Published: March 2016

A newborn infant is described who presented with septicemia and meningoencephalitis caused by Plesiomonas shigelloides, a Gram‐negative rod belonging to the family Vibrionaceae. This appears to be the first documented case in a neonate in Canada. Despite prompt treatment with appropriate antibiotics, he developed endophthalmitis and lytic brain lesions.
Disseminated Soft Tissue Infection and Sepsis with Stenotrophomonas maltophilia in a Bone Marrow Transplant Patient
Authors: Lipton Jeffrey H , MacDonald Kelly S
Published: March 2016

A 32‐year‐old female presented with aplastic anemia and subsequently underwent a one‐antigen mismatched bone marrow transplant from her brother. She failed to engraft and a second graft was attempted. Protracted neutropenia of three months’ duration despite the use of broad spectrum antibiotics occurred. Stenotrophomonas (Xanthomonas) maltophilia metastatic cellulitis developed that did not respond to appropriate antibiotics.
The McGill Pain Questionnaire ‐ Japanese Version, Reconsidered: Confirming the Reliability and Validity
Authors: Hasegawa Mamoru , Hattori Suguru , Ishizaki Keiji , Suzuki Shosuke , Goto Fumio
Published: March 2016

BACKGROUND: The McGill Pain Questionnaire (MPQ) is one of the most widely used instruments in the world to evaluate patients with chronic pain. However, differences in languages and cultural backgrounds have hindered its standardization in Japan.
OBJECTIVE: To standardize the MPQ in Japan.
DESIGN: The reliability and validity of a Japanese version of the MPQ (JMPQ) were examined using a translation‐based methodology, which followed a format similar to the original MPQ.
SETTING: Multidisciplinary pain treatment centre of a university hospital in Japan.
PATIENTS: Consecutive out‐patients (n=152) with chronic pain.
METHODS: Each patient completed the JMPQ, other pain rating scales (visual analogue scale, verbal rating scale, numerical rating scale) and the state‐trait anxiety inventory. A subset of these patients (n=40) were tested again two weeks later.
RESULTS: Acceptable levels of reliability and validity of the JMPQ, and independence of the JMPQ subscales from other pain rating scales were confirmed by principal component analysis. Chronic pain patients did not show marked levels of anxiety as might have been expected.
CONCLUSIONS: The findings suggest that the JMPQ possesses sufficient merits as a pain rating scale from the standpoint of its reliability and validity. Furthermore, it is suggested that the JMPQ can be used to measure qualitative aspects of pain transcending differences in linguistic characteristics.
Possible Nonopioid‐Mediated Analgesia Produced by Methotrimeprazine in Rats
Authors: Fuchs Perry N , Kerr Bradley , Melzack Ronald
Published: March 2016

BACKGROUND: Several reports in the 1960s demonstrated that methotrimeprazine (MTMZ), a phenothiazine derivative, is effective for treating acute and chronic pain. Although MTMZ has received little attention in recent decades, the fact that it derives from a class of drugs usually associated with cognitive and emotional processes, rather than the traditional analgesics, makes it interesting as a potential source of information about the mechanisms of analgesia.

OBJECTIVE: To explore the analgesic properties of MTMZ in a dose‐related design in the formalin test, and to examine whether the lowest dose of MTMZ that produces analgesia will activate endogenous opioid systems.

METHODS: The analgesic properties of three doses of MTMZ, compared with a saline control, were explored in male Sprague‐Dawley rats using the formalin test. Sedative effects were studied by using the line‐crossing test concomitantly with the formalin test.

RESULTS: MTMZ had no effect during the first phase of formalin responding. During the second phase of the formalin test, MTMZ doses of 5.0 and 10.0 mg/kg produced a significant decrease in formalin responses. Sedative effects were observed at all doses, even though the dose of 2.5 mg/kg did not significantly decrease formalin responses compared with controls. Statistical analyses revealed no significant correlation between the degree of sedation and the degree of analgesia at any dose of MTMZ. The nonspecific opioid antagonist naloxone did not alter the analgesic effect of 5.0 mg/kg MTMZ, indicating that the mechanism of action is independent of endogenous opioid systems.

CONCLUSION: MTMZ decreased responses in the formalin pain test in rats. Although the drug′s sedative effects were apparent in the line crossing test, they were not significantly correlated with pain responses. These results suggest that the decrease in formalin responses might be due, in part at least, to the analgesic properties of MTMZ. The fact that MTMZ belongs to a class of drugs that is relatively unexplored in relation to pain and analgesia indicates a potential source for the development of new pharmacological agents for treating persistent pain. Furthermore, the nonopioid mechanism of action suggests that this agent may be useful when opioid medications are contraindicated.
Pathophysiology of Headaches with a Prominent Vascular Component
Authors: Pareja Juan A , White Linda R , Sjaastad Ottar
Published: March 2016

Vascular changes, whether preliminary or secondary, seem to accompany most headaches. The literature concerning pathophysiological mechanisms in headaches where vascular phenomena are a major, integral part, ie, migraine and cluster headache syndrome, is reviewed and the most common forms of headache associated with cerebrovascular disease are discussed. Emphasis is placed on the vascular phenomena and on the abundant hypotheses and theories regarding headache mechanisms. This review also presents alternative explanatory models, and compares the available anatomical, physiological and biochemical results.
Investigation of the Role of the Cytomegalovirus as a Respiratory Pathogen in HIV‐Infected Patients
Authors: de la Hoz Rafael E , Hayashi Shizu , Cook Darrel , Sherlock Christopher , Hogg James C
Published: March 2016

OBJECTIVE: To investigate the occurrence of cytomegalovirus (CMV) pneumonitis in the setting of human immunodeficiency virus (HIV) infection and whether the presence of CMV as copathogen is associated with increased clinical severity or short term mortality in patients with Pneumocystis carinii pneumonia.

DESIGN: Retrospective cohort study.

SETTING: Tertiary care university hospital.

PATIENTS: One‐hundred and fourteen HIV‐infected homosexual men with pneumonia, followed for a minimum of four weeks.

MEASUREMENTS: Clinical indicators of severity of pneumonia, microbiology of bronchoalveolar fluid and relative risk of short term mortality.

RESULTS: Only two cases of CMV pneumonitis were found, one together with P carinii. However, 45 of the 86 patients with P carinii pneumonia were co‐infected with CMV. No difference in clinical severity was detected between patients co‐infected with P carinii and CMV and those with P carinii alone. The relative risk of short term mortality was 3.64 (95% CI 0.82 to 16.18), in patients with co‐infection compared with those with P carinii alone. The risk reached statistical significance for patients with earlier stages of HIV infection.

CONCLUSIONS: CMV pneumonitis occurs rarely in HIV‐infected patients, while CMV co‐infection occurs in at least 50% of the cases of P carinii pneumonia. Although no difference in clinical severity was detected, this study suggests that short term mortality from P carinii pneumonia may be increased by CMV co‐infection, particularly in patients with earlier stages of the disease.
Premenstrual Exacerbation of Life‐Threatening Asthma: Effect of Gonadotrophin Releasing Hormone Analogue Therapy
Authors: Edwards Alun L , Rose M Sarah , Donovan Lois E , Ford Gordon T
Published: March 2016

Variability in the severity of asthma during various phases of the menstrual cycle has been frequently suspected. However, the hormonal changes that might affect mediators of bronchospasm have yet to be elucidated. The case of a 41‐year‐old woman suffering from longstanding asthma with life‐threatening exacerbations is reported. The patient was treated with buserelin, a gonadotropin releasing hormone (GnRH) analogue, which created a temporary chemical menopause and thus permitted diagnosis of a premenstrual exacerbation of asthma and offered insight into potential therapy. GnRH analogues may therefore be of value in assessing women with severe asthma suspected to vary with the menstrual cycle. The addition of estrogens and progestins at the same time as treatment with GnRH analogue may be of value in determining the role of these hormones in the pathogenesis of menstrually related exacerbations of asthma.
Osteomalacia as a Cause of Chronic Pain
Authors: Teasell Robert W , Sue-A-Quan Greg , Wolfe Bernard M
Published: March 2016

Osteomalacia is a form of metabolic bone disease that can present as chronic pain. A 36‐year‐old woman presented with a three‐year history of bilateral leg and back pain, and proximal leg weakness. Repeated consultations and investigations failed to discover a cause for her pain, and a diagnosis of chronic benign pain was made. She was admitted to hospital where the bone scan, laboratory investigation and bone biopsy established a diagnosis of renal phosphate‐wasting adult‐onset rickets (osteomalacia). Radiographs of the hip and magnetic resonance imaging revealed bilateral femoral neck fractures and segmental, avascular necrosis of the femoral heads. The patient was treated with high dose phosphate and vitamin D with marked relief of pain. Osteomalacia should be considered in unusual cases of intractable chronic pain.
Craniofacial Pain: Brainstem Mechanisms
Authors: Sessle Barry J
Published: March 2016

This article reviews recent research advances in animals that have identified critical neural elements in the brainstem receiving and transmitting craniofacial nociceptive inputs, as well as some of the mechanisms involved in the modulation and plasticity of nociceptive transmission. Nociceptive neurones in the trigeminal (V) brainstem sensory nuclear complex can be classified as nociceptive‐specific (NS) or wide dynamic range (WDR). Some of these neurones respond exclusively to sensory inputs evoked by stimulation of facial skin or oral mucosa and have features suggesting that they are critical neural elements involved in the ability to localize an acute superficial pain and sense its intensity and duration. Many of the V brainstem nociceptive neurones, however, receive convergent inputs from afferents supplying deep craniofacial tissues (eg, dural vessel, muscle) and skin or mucosa. These neurones are likely involved in deep pain, including headache, because few nociceptive neurones receive inputs exclusively from afferents supplying these tissues. These extensive convergent input patterns also appear to be important factors in pain spread and referral, and in central mechanisms underlying neuroplastic changes in V neuronal properties that may occur with injury and inflammation. For example, application of the small fibre excitant and inflammatory irritant mustard oil into the temporomandibular joint, masseter or tongue musculature induces a prolonged but reversible enhancement of responses to cutaneous and deep afferent inputs of most WDR and NS neurones. These effects may be accompanied by increased electromyographic activity reflexly induced in the masticatory muscles by mustard oil, and involve endogenous N‐methyl‐D‐aspartate and opioid neurochemical mechanisms. Such peripherally induced modulation of brainstem nociceptive neuronal properties reflects the functional plasticity of the central V system, and may be involved in the development of headache and other conditions that manifest craniofacial pain and neuromuscular dysfunction.
Herpes Simplex Mastitis: Case Report and Review of the Literature
Authors: Brown Holly , Kneafsey Paul , Kureishi Amar
Published: March 2016

The most common sites of herpes simplex virus (HSV) infection are around the oral cavity and the genitalia. However, HSV can infect any skin or mucous membrane surface. One uncommon site of HSV infection is the breast. Reports of herpetic breast infections are predominantly cases of transmission from a systemically HSV‐infected neonate to the mother during breast‐feeding. A review of the literature identified only six reports suggesting HSV breast lesions acquired by means other than through an infected infant. Of these, only one report suggests HSV transmission to the breast from a male sexual partner. A second case of clinically unsuspected symptomatic herpes mastitis presumably acquired from sexual contact in a 46‐year‐old woman is presented. Herpes simplex type 1 was isolated by using polymerase chain reaction and restriction fragment length polymerization techniques. The purpose of this report is to alert physicians to HSV mastitis.
Bacterial Peritonitis Caused by Listeria monocytogenes: Case Report and Review of the literature
Authors: Dylewski Joe S
Published: March 2016

Although Listeria monocytogenes has been isolated from the gastrointestinal tract, it is an infrequent cause of bacterial peritonitis. Since 1963 only 23 cases of peritonitis caused by listeria have been reported. This report describes another case in a patient with cirrhosis and chronic renal failure and presents a review of the literature. Most (16) of the previous cases were cirrhotic while six were undergoing chronic ambulatory peritoneal dialysis. Eight patients were on immunosuppressive therapy. Blood cultures were positive in fewer than half (42%) of the cases and Gram stain of peritoneal fluid was positive only twice. The peritoneal fluid protein concentration was relatively high compared with other causes of bacterial peritonitis. Ampicillin was the drug most commonly used for treatment, and the majority of patients survived the acute infection.
Animals with Coxiella burnetii Infection Demonstrate a Western Immunoblot Profile of Chronic Q Fever in Humans
Authors: Marrie TJ , Yates Linda
Published: March 2016

Western immunoblotting was used to compare the immune response to Coxiella burnetii phase I and phase II antigens of humans with acute and chronic Q fever with that of infected cats, rabbits, cows and raccoons. The cats, rabbits, cows and raccoons had an immunoblot profile similar to that of the human with chronic Q fever.
Survey of Physicians Concerning the Use of Chest Radiography in the Diagnosis of Pneumonia in Out‐Patients
Authors: Marrie Thomas J
Published: March 2016

OBJECTIVE: To determine how physicians use chest radiography in the diagnosis of pneumonia in ambulatory patients.

STUDY POPULATION: A convenience sample of 176 Nova Scotia family physicians and internists selected to represent all geographic areas of the province proportional to population.

STUDY INSTRUMENT: A 35‐item questionnaire covering demographics, experience with out‐patients with pneumonia, use of chest radiographs to make this diagnosis and factors that were considered important in the decision to perform initial and follow‐up chest radiographs. Two skill‐testing questions were also included.

RESULTS: One hundred and fourteen of 176 (64.7%) responded; 88% had treated out‐patients with pneumonia in the previous three months. Fifty‐seven per cent of physicians requested chest radiographs on 90% to 100% of out‐patients in whom they had made a clinical diagnosis of pneumonia. These physicians were more likely to be internists and to have graduated before 1970. Factors that ranked most important in the decision to request the initial chest radiograph were clinical appearance, respiratory distress and physical findings, while age and smoking history contributed most to the decision to perform a follow‐up chest radiograph.

CONCLUSIONS: There is considerable variability among physicians in requesting chest radiographs on out‐patients with a clinical diagnosis of pneumonia. Physician and patient factors contribute to this variability.
Listériose Humaine : Expériences Cliniques Avec Cette Zoonose Chez 12 Patients en Estrie, Québec Sur une Période de 19 ans (1976 à 1995)
Authors: Maziade Pierre-Jean , Marcoux J André
Published: March 2016

Une étude rétrospective a été faite dans le but de réviser l’épidémiologie, les facteurs de risque, les manifestations cliniques et l’évolution des cas d’infection à Listeria monocytogenes en Estrie, Québec de 1976–1995. Les patients ont été repérés à partir des cultures positives et du diagnostic donné par le Service des maladies infectieuses du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec. Un total de 12 patients ont fait partie de l’étude. La septicémie non reliée à la grossesse (4/12) et la méningite (6/12) ont été les deux présentations cliniques majeures. Il y avait 1 cas de listériose de grossesse et 1 cas de granulomatosis infanti septica. Dix patients avaient au moins une condition prédisposante. Un seul décès a été attribué à l’infection à L monocytogenes. Des séquelles neurologiques ont été observées chez la moitié des patients avec méningite tandis qu’aucune séquelle a été notée chez ceux avec septicémie. En conclusion, la listériose est une maladie de patients âgés et immunocompromis. La présentation clinique et l’évolution ne sont pas différentes de ce qui a déjà été rapporté dans d’autres régions industrialisées.
Laboratory Diagnosis for Giardia Lamblia Infection: A Comparison of Microscopy, Coprodiagnosis and Serology
Authors: Behr Marcel A , Kokoskin Evelyne , Gyorkos Theresa W , Cédilotte Lyne , Faubert Gaetan M , MacLean J Dick
Published: March 2016

OBJECTIVE: To evaluate newer techniques such as coproantigen detection and serology in the diagnosis of symptomatic Giardia lamblia infection.

DESIGN: Blinded comparison of copro‐antigen detection (by ELISA), serology (immunoglobulin IgG and IgM anti‐G lamblia by ELISA, and IgG, IgM and IgA by immunoblot) and microscopy in clinical samples. Microscopic findings for three preserved stools were considered the gold standard.

SETTING: Travel medicine clinic.

POPULATION STUDIED: Adults, post‐travel, with gastrointestinal symptomatology.

MAIN RESULTS: For 152 previously collected stools, copro‐antigen detection had a sensitivity of 73 of 74 (98.6%) and a specificity of 78 of 78 (100%). In clinical samples of 62 patients, eight of the 62 patients (13%) were diagnosed with G lamblia infection on microscopy. Copro‐antigen diagnosis was accurate in symptomatic patients, with sensitivity of seven of eight (87.5%) and specificity of 52 of 54 (96.8%). Serology was less accurate. IgG response to G lamblia had sensitivity of four of seven and specificity of 24 of 50 (48%), and IgM response had sensitivity of three of six and specificity 27 of 48 (56%). Western blot had a sensitivity of five of seven and a specificity of 38 of 49 (78%).

CONCLUSIONS: Copro‐antigen diagnosis of G lamblia is highly accurate in patients with chronic gastrointestinal complaints, while serology is less accurate and appears to be less useful diagnostically.
Measuring Health‐Related Quality of Life: General Issues
Authors: Guyatt Gordon H
Published: March 2016

Clinicians and policy makers recognize the importance of measuring health‐related quality of life (HRQL) to make informed patient management and policy decisions. Self‐ or interviewer‐administered questionnaires can be used to measure cross‐sectional differences in quality of life among patients at a point in time (discriminative instruments) or longitudinal changes in HRQL within patients over time (evaluative instruments). Both discriminative and evaluative instruments must be valid (ie, measure what they are supposed to measure) and have a high ratio of signal to noise (reliability and responsiveness for the two instruments, respectively). Reliable discriminative instruments are able to differentiate reproducibly among persons. Responsive evaluative measures are able to detect important changes in HRQL over time, even if those changes are small. HRQL should also be interpretable B that is, clinicians and policy makers must be able to identify differences in scores that correspond to trivial, small, moderate and large differences.

There are two basic approaches to quality of life measurement: generic instruments that attempt to provide a summary of HRQL and specific instruments that focus on problems associated with individual disease states, patient groups or areas of function. Generic instruments include health profiles and instruments that generate health utilities. The approaches are not mutually exclusive. Each approach has its strengths and weaknesses and may be suitable under different circumstances. Investigations of HRQL have led to the development of instruments suitable for detecting minimally important effects in clinical trials, for measuring the health of populations and for providing information for policy decisions.
Randomized Double‐Blind Trial of the Effects of Humidified Compared with Nonhumidified Low Flow Oxygen Therapy on the Symptoms of Patients
Authors: Andres Darcy , Thurston Norma , Brant Rollin , Flemons Ward , Fofonoff Doreen , Ruttimann Ardis , Sveinson Sandra , Neil Carol
Published: March 2016

OBJECTIVE: To determine the effects of humidified versus nonhumidified low flow oxygen therapy on the subjective symptoms of patients.

METHODS: Randomized double‐blind clinical trial conducted in a tertiary care university teaching hospital. The sample included medical and surgical in‐patients receiving oxygen therapy who met criteria including medical stability, no overt cognitive impairment, English comprehension, voluntary participation and attending physician agreement. Humidified subjects numbered 96 and nonhumidified subjects were 95. The intervention was humidified or nonhumidified oxygen administration using two flowmeters covered by an opaque bag. Patients receiving oxygen therapy longer than three days (first period) were crossed to the alternate treatment (second period) and followed for three more days.

RESULTS: Mean symptom scores for nasal dryness were low (mild) for both groups; however, humidification group scores were significantly lower (P=0.018) in the first period than the nonhumidification scores. A corresponding increase in the incidence of nosebleeds was not statistically significant between groups nor were there statistically significant differences between groups for other symptoms/problems. The prevailing trend was decreased incidence of dry mouth, dry throat, headache and chest discomfort during the study.

CONCLUSIONS: Although this sample was large enough to expose statistically significant group differences in nasal dryness, the difference was not judged to be clinically significant. The predominant trend was a decrease in symptom scores over time with either treatment. In this group of patients, humidified oxygen does not appear to alleviate subjective symptoms.
Mapping Antibiotic‐Resistant Neisseria Gonorrhoeae Isolates in Metropolitan Toronto: Issues of Scale, Positional Accuracy and Confidentiality
Authors: Decker Jody F , Sharpe Bob , Dillon Jo-Anne R
Published: March 2016

The primary objective of this paper was to investigate the methodological implications of mapping Neisseria gonorrhoeae using the partial three‐digit postal code instead of the complete six‐digit postal code. The reporting locations of N gonorrhoeae isolates submitted from hospitals, doctor’s offices, private and provincial laboratories, and sexually transmitted disease (STD) clinics were used as a model. Specifically, the paper focused on variations in geographical distributions of STD data when mapped at different aggregations of postal code data and at different map scales. Such variations are of importance to those who analyze the spatial epidemiology of STDs, and the accessibility and use of health care services. This analysis showed that three‐digit postal codes are useful in summarizing overall geographic distributions, but greatly reduce positional accuracy, which can lead to inaccurate delineation of service areas and populations served. The six‐digit postal code is more appropriate for detailed analysis addressing behavioural issues. The analysis demonstrated that six‐digits can be used without breaching individual confidentiality.
Evaluation of Open Lung Biopsy in Critically Ill, Ventilator Dependent Intensive Care Unit Patients
Authors: Hughes Richard , McGuire Glenn
Published: March 2016

OBJECTIVE: Evaluation of the benefits and risks of performing open lung biopsy (OLB) in critically ill, ventilator dependent intensive care unit patients.

DESIGN: Retrospective chart review from 1990 to 1995.

SETTING: A tertiary care teaching hospital intensive care unit.

INTERVENTION: OLB in patients requiring mechanical ventilation for respiratory failure.

MEASUREMENTS: Data collected included preoperative investigations, lung injury score, diagnosis, treatment and eventual outcome.

RESULTS: Twenty‐seven patients (14 male, 13 female) were mechanically ventilated before OLB for a median duration of seven days. A change in clinical management occurred in 85% of the patients as a result of new information obtained from the OLB. There was no statistical difference in overall outcome whether OLB was performed early or later in the course of respiratory failure once the patient was mechanically ventilated. The incidence of perioperative complications was 37%. Ten patients eventually left hospital.

CONCLUSIONS: In a small percentage of intensive care patients refractory to the usual medical treatment modalities, open lung biopsy intervention is required to attempt to obtain a specific diagnosis.
Recurrent Acute Pulmonary Toxicity and Respiratory Failure Associated with Fludarabine Monophosphate
Authors: Cutler Corey , Samman Yaseen , Fraser Richard , Corris Paul , Zidulka Arnold
Published: March 2016

A case of recurrent acute fludarabine pulmonary toxicity in a 67‐year‐old man with non‐Hodgkin’s lymphoma is presented. The patient responded well to high dose steroid therapy. The literature with respect to this rare entity is reviewed.
Nonspecificity of Chronic Soft Tissue Pain Syndromes
Authors: Tunks Eldon
Published: March 2016

Persistent (or chronic) pain occurs with a prevalence of about 10% in the adult population, and chronic soft tissue pain is especially problematic. Criteria for diagnosis of these soft tissue pain disorders appear to suffer from specificity problems, even though they appear to be sensitive in distinguishing normal from soft tissue pain sufferers. A few decades ago the term ′neuraesthenia′ was used as a diagnosis in individuals who now would probably be diagnosed as suffering from fibromyalgia, chronic fatigue and anxiety disorders with fatigue. Soft tissue pain provokes skepticism, especially among third‐party payers, and controversy among clinicians. Recent epidemiological studies have demonstrated sex differences in the prevalence of widespread pain and multiple tender points, which are distributed variably throughout the adult population and tend to be correlated with subjective symptoms. Although there is a tendency for these syndromes to persist, follow‐up studies show that they tend to vary in extent and sometimes show remissions over longer follow‐up, casting doubt about the distinctions between chronic diffuse pains and localized chronic soft tissue pains. Because both accidents and soft tissue pains are relatively prevalent problems, the possibility of chance coincidence of accident and chronic soft tissue pain in an individual creates the need to be cautious in attributing these syndromes to specific accidents in medicolegal situations. At the same time, the available evidence does not support a generally dismissive attitude towards these patients.
Parvovirus B19‐Induced Constellation of Acute Renal Failure, Elevated Aminotransferases and Congestive Heart Failure
Authors: McAuley Iain W , Sepandj Farshad , Schlech Walter
Published: March 2016

This report details a case of acute renal failure and elevated aminotransferases with subsequent development of congestive heart failure in a patient with history of exposure to parvovirus B19 and serological evidence of acute infection with this agent. This constellation of organ involvement has not been previously reported in the literature.
Varicella Zoster Virus Infections in Canadian Children in the Prevaccine Era: A Hospital‐Based Study
Authors: Kuhn Susan , Davies H Dele , Jadavji Taj
Published: March 2016

OBJECTIVE: To describe the clinical course of children admitted for varicella zoster virus (VZV) infections to a pediatric hospital before the release of VZV vaccine in Canada.

DESIGN: Retrospective case series.

SETTING: Tertiary pediatric hospital. Population studied was children aged 18 years or younger admitted to hospital between 1983 and 1992 who were discharged with a diagnosis of varicella or zoster. Of the 201 children who were identified, 36 were excluded, leaving 165 for analysis.

RESULTS: There was a male:female ratio of 1.5:1 and a median age of 5.3 years (range two weeks to 18 years). The group included those who were previously healthy (70, 42.4%), immunocompromised (60, 36.4%), and those with nonimmunocompromising conditions (35, 21.2%). Comparison of immunocompetent and immunocompromised children revealed that complication of VZV infection was a more common reason for admission among the former (86 of 105, 81.9%, P<0.001), whereas treatment with acyclovir to limit dissemination was the most common reason in the latter (53 of 60, 88.3%, P<0.001). Skin and soft tissue infections were the most common complications in immunocompetent children (36 of 98) and those younger than five years (26 of 53), whereas pulmonary complications predominated among immunocompromised patients (eight of 98) and neurological complications in five‐ to 10‐year‐olds (16 of 36). Only one death (0.6%) occurred in an immunocompetent patient. Group A beta‐hemolytic streptococci and Staphylococcus aureus caused equal numbers of secondary infections (92% of all isolates).

CONCLUSIONS: Complications of VZV infections and secondary prophylactic antiviral treatment of immunocompromised children explain the majority of hospitalizations in this institution, and can be monitored after VZV vaccine introduction. Complications vary significantly with underlying healthy status and age.
Reduction in the Nephrotoxicity of Amphotericin B when Administered in 20% Intralipid
Authors: Salama Suzette , Rotstein Coleman
Published: March 2016

The administration of amphotericin B (AmB) is often limited by the development of nephrotoxicity. In a pilot crossover trial, aqueous AmB followed by a new preparation of a mixture of AmB with 20% intralipid (AmB‐IL) was administered to 10 immunocompromised patients for systemic fungal infections caused by Candida species. Mean total dose and duration of therapy with AmB‐IL exceeded that of aqueous AmB (649±165 mg versus 394±105 mg, P=0.061 and 13.2±2.5 days versus 9±2.1 days, P=0.31). However, mean creatinine clearance of the patients rose during AmB‐IL therapy by 10.7±7.7 mL/min (P=0.03). AmB‐IL warrants further investigation to assess its stability and efficacy for treating serious fungal infections.