bluuebunny/crossref_metadata_2025 huggingface dataset:
An Outbreak of Cyclosporiasis in 1996 Associated with Consumption of Fresh Berries ‐ Ontario
Authors: Manuel DG , Neamatullah S , Shahin R , Reymond D , Keystone J , Carlson J , Ber C Le , Herwaldt BL , Werker DH
Published: March 2016

BACKGROUND: A large foodborne outbreak of cyclosporiasis occurred in North America in 1996. An index cluster of cases associated with a catered event on May 11, 1996, in Ontario sparked the recognition of this outbreak in Canada.

OBJECTIVES: To describe the Ontario experience with the North American outbreak of cyclosporiasis in 1996.

PATIENTS AND METHODS: Public health units investigated the index and subsequent event‐associated clusters. Investigations included retrospective cohort studies of clusters, traceback of suspect foods and a case‐control study of sporadic cases. These activities, coordinated with those in the United States, were part of an international investigation.

RESULTS: In Ontario, 232 cases of cyclosporiasis (20 laboratory‐confirmed and 72 clinically defined cases associated with seven events plus 140 additional laboratory‐confirmed sporadic cases) were identified between May 1 and July 30, 1996. For the index cluster, a strawberry flan with raspberries and blueberries was the only significant exposure (relative risk 2.16, P=0.02). Fresh berries were served at all seven events associated with clusters of cases. Raspberries were definitely served at three events, possibly served at three events, and not served at one event. Only imported berries were available in Ontario in May 1996, when initial clusters and sporadic cases were identified. The raspberries served at the two events with well documented traceback data came from Guatemala. Univariate analyses of the matched case‐control study demonstrated that illness was associated with consumption of raspberries (matched odds ratio 21.0, 95% CI 3.48 to 448) and strawberries (matched odds ratio 28.5, 95% CI 4.02 to 478). Further evidence amassed by the international investigation compellingly implicated Guatemalan raspberries as the vehicle of the outbreak.

CONCLUSION: Cyclosporiasis may be acquired domestically from the consumption of contaminated produce. The scope and vehicle of this international foodborne outbreak were recognized through a coordinated public health response.
Gastroesophageal Reflux and Asthma: Can the Paradox Be Explained?
Authors: Field Stephen K
Published: March 2016

BACKGROUND AND OBJECTIVE: The reported effects of asthma on gastroesophageal reflux (GER), effects of GER on asthma and the effects of antireflux therapy on asthma are conflicting. The purpose of this paper is to review the evidence for a relationship between the two conditions.

DESIGN: A search of the MEDLINE 1966 to 1999 database, combining the terms GER and asthma, was used to identify studies of the effects of acid perfusion of the esophagus, the physiological equivalent of GER and the effects of both medical and surgical antireflux therapy on asthma. Bibliographies of the identified papers were also reviewed.

MAIN RESULTS: The collected evidence suggests that GER causes asthma symptoms but has minimal effects on pulmonary function. Both medical and surgical antireflux therapy can improve asthma symptoms and asthma medication requirements without improving pulmonary function. The paradox of GER causing symptoms without affecting pulmonary function may be because of the retrosternal discomfort that accompanies GER increases minute ventilation and respiratory sensation.

CONCLUSIONS: Despite an extensive body of literature, many questions remain about the relationship between GER and asthma. A review of the data suggests a strong association between the two conditions, and that GER worsens asthma symptoms without affecting pulmonary function. Asymptomatic GER does not worsen asthma. Antireflux therapy may have a role in asthma patients with symptomatic GER, possibly being most beneficial for those with reflux‐associated respiratory symptoms. Unfortunately, many studies contain flaws such as a lack of controls and small sample sizes. Further properly designed controlled trials, including ones that measure the effects of GER and antireflux therapy on quality of life, are needed to understand better the role of GER in asthma.
Reactogenicity to a Live Attenuated Varicella Vaccine in Canadian Children
Authors: Diaz-Mitoma Francisco , Halperin Scott A , Scheifele David
Published: March 2016

OBJECTIVE: To assess the reactogenicity and safety of a thermostable, high titre, varicella vaccine in healthy infants and children.

DESIGN: Open study of 505 children monitored for 42 days after vaccination.

SETTING: Three urban Canadian centres (Halifax, Ottawa and Vancouver).

PARTICIPANTS: 505 healthy children one to 12 years of age were enrolled and 504 completed the study. All were susceptible to varicella by history.

INTERVENTIONS: All participants received one dose of live attenuated varicella vaccine (1×104.5 plaque forming units/dose) subcutaneously.

MAIN OUTCOME MEASURES: The children were monitored from the day of vaccine administration (day 0) until day 42. All local and general symptoms and signs were recorded on diary cards by the patients? parents, who were encouraged  to fill in the cards on days 2 to 3 and 18 to 24 via telephone calls from study personnel.

RESULTS: Most of the symptoms noted after vaccine administration were mild and transient, and all resolved within the respective follow‐up periods. Injection site symptoms included pain (17.5%, 13.9% and 30.4% in centres 1, 2 and 3 respectively), redness (21.1%, 32.1% and 48.8%) and swelling (7%, 10.3% and 29.2%). The general symptoms reported were fever 37.5°Cor higher (3.5%, 4.8% and 3.0%) and varicella‐like rashes (6.4%, 2.4% and 0%). Two subjects had severe symptoms (one with cervical lymphadenopathy, and one with a fever higher than 39°C) probably related to vaccine administration. No serious adverse events were reported during the entire study.

CONCLUSION: The vaccine was well tolerated.
Dangerous Liaisons?
Authors: Jones Norman L
Published: March 2016

I sometimes feel that I am so dominated by circumstances and coincidences that I have little free choice, for example, when approaching an editorial. A case in point was a few days last month during which I attended a well‐sponsored meeting of the Ontario Lung Association, reviewed a couple of papers reporting drug trials, read of the threats of litigation made by pharmaceutical companies to two Ontario researchers, heard of a public apology made by the New England Journal of Medicine regarding reviewers′ conflicts of interest and received a critical letter from Dr Rob McFadden, an associate editor of the Canadian Respiratory Journal, about a sponsored publication that accompanied the last issue of 1999. All this I suppose reflects our rather ambivalent relationship with the pharmaceutical industry that supports many professional and academic programs but clearly expects some returns in addition to corporate tax benefits. We are now dependent on the industry′s financial backing for academic and professional meetings that have become so large that they require large and expensive venues. But then the industry has the right to expect some return on its "investment" in such meetings.
Do We Need an Annual Canadian Respiratory Conference?
Authors: Boulet Louis-Philippe
Published: March 2016

Beginning in the fall of 2001, as decided at the 1999 Annual General Meeting of the Canadian Thoracic Society (CTS), the Society's annual and scientific meeting will take place jointly with the American College of Chest Physicians (ACCP). In the past, this annual event was held in conjunction with the Royal College of Physicians' meeting. Unfortunately, attendance at the Royal College meetings was quite low, and the event did not seem to fulfil the needs and interests of the Canadian respiratory community. Therefore, a three-year trial agreement was reached for a joint annual meeting with the ACCP. This joint meeting would offer, among many incentives, the opportunity for Canadian physicians and fellows to attend an international meeting at which Canadian initiatives would have a lot of visibility and educational activities would be available.
Medically Unexplained Pain Is Not Caused by Psychopathology
Authors: Gagliese Lucia , Katz Joel
Published: March 2016

This paper highlights Professor Ronald Melzack′s theoretical contributions to the understanding of psychological factors in pain. His work continues to have profound influences on pain theory, research, management and public policy. His ideas have been pivotal to the acceptance of the role of the brain and psychological factors in the experience of pain. This article briefly outlines the prevailing theories of the psychology of pain before the gate‐control theory. Melzack′s contributions argue against the simplistic linear thinking inherent in specificity theory, which leads to the attribution of pain to either ′organic′ or ′psychogenic′ causes. Nevertheless, Cartesian dualism continues to thrive. The authors illustrate the nature and extent to which dualistic thinking pervades the field, show that a dualistic conceptualization of pain introduces an element of distrust to the relationship between patient and health professional, and conclude that the available data fail to reach today′s standards for an evidence‐based approach to pain. The authors believe that medically unexplained pain is not a symptom of a psychological disorder and that it is time to abandon the thinking that separates mind and body. The challenge remains for proponents to provide the empirical evidence to prove that psychopathology causes pain and, in so doing, to specify the mechanisms by which it is generated.
A Descriptive Study of 100 Patients Undergoing Palliative Nerve Blocks for Chronic Intractable Headache and Neck Ache
Authors: Rothbart Peter , Fiedler Katherine , Gale George D , Nussbaum David , Hendlerb Nelson
Published: March 2016

OBJECTIVE: To ascertain whether repeated (palliative) nerve blocks over a long period of time provide benefit to patients with chronic intractable headache and neck ache.

SUBJECTS AND METHODS: One hundred patients who were receiving repeated nerve blocks as part of their pain management regimen completed a structured interview questionnaire. The patients had all been investigated and received a diagnosis of cervicogenic headache. Changes in pain rating, depression rating, anxiety rating, activities of daily living and quality of life were measured.

RESULTS: After each nerve block session, the subjects reported significant improvement in their levels of pain, depression and anxiety. They also reported improvements in their quality of life and in their ability to participate in activities of daily living.

CONCLUSIONS: Repeated (palliative) nerve blocks appear to be a useful modality in the armamentarium of pain control techniques for patients with chronic intractable headache and neck ache of cervical origin.
Surveillance of Antimicrobial Resistance in Salmonella, Shigella, and Virvio cholerae in Latin America and the Caribbean: A Collaborative Project
Authors: Woodward David L , Rodgers Frank G
Published: March 2016

Diarrheal disease is recognized as the most frequent cause of morbidity and mortality in children worldwide (1). Current estimates indicate that at least 3.5 million children under the age of five years die each year due to diarrhea (1). Indeed, the World Health Organization (WHO) and the Pan American Health Organization (PAHO) have identified acute gastroenteritis as a major health problem in all Latin American countries (2). Mortality associated with acute diarrhea is highest among infants younger than one year of age, and death rates average 20/1000 children born (2). The impact of lives lost, together with the high costs to local public health care systems associated with treatment of those afflicted, make prevention and control of diarrheal disease a priority health issue (2). Over the past decade, these concerns have been further reinforced by the emergence of antimicrobial resistance among the major groups of enteric pathogens causing disease.
Presynaptic control of nociceptor signalling: Differential influence of Mu Opioid and GABAergic Systems
Authors: Riley Ruth C , Trafton Jodie A , Basbaum Allan I
Published: March 2016

The relative contribution of pre‐ and postsynaptic controls to the flow of nociceptive information at the level of the spinal cord has been one of Ron Melzack′s longstanding interests and a key issue in the formulation of the gate control theory. The authors review their own studies, in which they monitored internalization of the neurokinin‐1 receptor to examine specifically the action of two classically inhibitory systems ‐ mu opioid and gamma‐amino butyric acid (GABA) ‐ on noxious stimulus‐evoked tachykinin signalling in the rat spinal cord. Evidence that opioids and GABAergic controls operate differently on the central consequences of any noxious stimulus‐induced substance P release is provided. Whereas at least 80% of the tachykinin signalling remained intact after even the highest concentration of spinal morphine or D‐Ala2, NMe‐phe4, Glyol5‐enkephalin administration, spinal administration of the GABAB receptor agonist baclofen had a dramatic inhibitory effect. These findings are discussed in light of the disappointing clinical utility of baclofen and neurokinin‐1 receptor antagonists to combat pain.
Neurogenic Tumors of the Mediastinum: A Report of 60 Cases
Authors: Topçu Salih , Alper Aysin , Gülhan Erkmen , Koçyigit Osman , Tastepe Irfan , Çetin Güven
Published: March 2016

OBJECTIVES: To analyze retrospectively 60 patients (13 infants and children, 47 adults ‐ 21 men and 39 women) with mediastinal neurogenic tumours admitted to Atatürk Centre for Chest Disease and Chest Surgery, Ankara, Turkey between 1988 and 1999. This comprised 21.2% of 283 patients who had surgical operations for all mediastinal masses during the same period.

PATIENTS AND METHODS: The patients ranged from four to 67 years of age. Thirteen patients were younger than 15 years and 47 were 15 years of age or older. Medical records were reviewed for demographic data, clinical presentation, diagnostic investigations, operative procedures, and tumour location and invasion. Postoperative morbidity and mortality were noted as well as long term follow‐up. The clinical investigations included chest x‐ray and computed tomography of the thorax in all patients, and spinal magnetic resonance imaging and bronchoscopical examination in some. Clinical variables were compared.

RESULTS: The tumours had the following characteristics: 42 (70%) were nerve sheath tumours; 15 (25%) were autonomic ganglion tumours; two (3.6%) were paragangliomas; and one (1.4%) was a malignant peripheral neuroectodermal tumour (Askin′s tumour). Nerve cell tumours comprised the majority of tumours in infants and children (nine of 13, 69%), whereas the nerve sheath tumours were most frequent in adults (39 of 47, 83%). There were 48 benign and 12 (20%) malignant tumours when all age groups were considered; the malignancy rate was 61.5% (eight of 13) in children and  8.5% (four of 47, P<0.05) in adults. All patients were operated via a posterolateral thoracotomy. Surgical resection of the tumour was complete in 56 of 60 patients (93.3%). Resection of malignant tumours was grossly incomplete in four cases (four of 12, 33.3%). All benign tumours were totally excised. There were two major complications (respiratory failure and pulmonary emboli) and 14 minor complications in the perioperative period. The mean follow‐up period was five years and seven months. Tumours recurred in 5.3% (three of 56) of patients who had a complete resection initially. There were no late deaths related to benign tumours.

CONCLUSIONS: Complete resection of tumours can be performed safely by a thoracotomy approach and is important for achieving satisfactory long term survival in most mediastinal neurogenic tumours.
A 5‐HT Antagonist (UP 26‐91) versus Codeine and Placebo in a Human Experimental Pain Study
Authors: Arendt-Nielsen Lars , Pedersen Poul , Poulsen Lars , Andersen Ole Kæseler , Bjerring Peter , Coste Isabelle , Insuasty Jorge , Sindrup Søren , Drewes Asbjørn Mohr
Published: March 2016

BACKGROUND: This double‐blind, randomized, crossover study compared the potential analgesic effect of the serotonin receptor antagonist UP 26‐91 (50 mg, 150 mg and 300 mg) with that of codeine (100 mg) and placebo by use of different human experimental pain models.

SUBJECTS AND METHODS: In experiment 1, pain detection and tolerance thresholds to heat, pressure and pain ratings during the cold pressor test were measured. In experiment 2, the pain threshold to single and repetitive (temporal summation) electrical sural nerve stimulation, and the pain intensity on a visual analogue scale to supra pain threshold electrical stimulation (stimulus‐response‐function) were measured. Tests were performed before, and 1, 2 and 6 h after drug administration.

RESULTS: UP 26‐91 did not show a marked effect on the experimental pain tests. Most of the variables tended to show a better effect from codeine than from placebo, but statistical significance for peak pain was only reached during the cold pressor test (P=0.011).

CONCLUSIONS: In the present doses, the serotonin antagonist UP 26‐91 had no effect on the experimental pain models applied.
Prosthetic Knee Septic Arthritis due to Pseudomonas stutzeri
Authors: Bishara Jihad , Robenshtok Eyal , Samra Zmira , Pitlik Silvio
Published: March 2016

Prosthetic joint infection is usually caused by Staphylococcus aureus, coagulase‐negative staphylococci and, less commonly, by Gram‐negative bacilli and anaerobes. A case of prosthetic joint infection due to Pseudomonas stutzeri in a 73‐year‐old female with acute promyelocytic leukemia is presented, and the pertinent literature is reviewed. Although the patient had prolonged neutropenia, the infection was successfully treated with antibiotics and without artificial joint replacement.
Equipoise and the Ethics of the Canadian Lung Volume Reduction Surgery Trial study: Should There Be a Randomized, Controlled Trial to Evaluate Lung Volume Reduction Surgery?
Authors: Miller John D , Coughlin Michael D , Edey Lori , Miller Patricia , Sivji Yasmin
Published: March 2016

The physical improvement is so great following lung volume reduction surgery that there is growing opinion that a randomized, controlled trial is unnecessary. A randomized, controlled trial, it is argued, would deprive those patients randomly assigned to the nonsurgical treatment arm the ′benefit′ of lung volume reduction surgery. Entering a trial in which one arm leads to a surgical intervention and the other to best medical management also poses a variety of ethical difficulties. If one is to be offered surgery, there must be perceived benefit because the physician has an obligation to offer the best possible treatment for his or her patient. If a patient agrees to have surgery, the expectation is that surgery would help. Thus, a patient randomly assigned to the medical arm of a trial may easily believe that he or she is being deprived of surgery that may help them. This paper illustrates this dilemma using the Canadian Lung Volume Reduction Surgery Trial. The authors discuss the concept of ′equipoise′ in three dimensions, adding community equipoise to theoretical equipoise and clinical equipoise earlier described by Freedman. The paper concludes that the Canadian Lung Volume Reduction Surgery Trial needs to continue because of the clinical equipoise that drives it.
The Impact of Health Care Restructuring on Nosocomially Acquired Blood Stream Infections
Authors: Taylor Geoffrey D , McKenzie Margare , Kirkland Teresa , Buchanan-Chell Maureen , Wiens Rhoda
Published: March 2016

OBJECTIVE: To assess the impact of the health care restructuring, which occurred in Alberta in 1995, on the occurrence of nosocomial blood stream infection and risk factors for these infections at the University of Alberta Hospital.

PATIENTS AND METHODS: Changes in patient population, hospital bed numbers, admissions and hospital days for 1993 and 1994 (1993/94) were compared with those for 1996 and 1997(1996/97). Central venous catheter (CVC) use in intensive care units (ICU), days of total parenteral nutrition (TPN) and hemodialysis were compared for the two time periods. Prospectively collected data obtained by monitoring blood culture results on nosocomial blood stream infections in 1993/94 were compared with those obtained in 1996/97.

RESULTS: Hospital bed number fell by 10% between 1993/94 and 1996/97. Annual admissions fell by 19% and patient days by 17%. Some services markedly increased patient days (neurosurgery 49%, nephrology 30%, orthopedic surgery 24%), and others markedly reduced patient days (obstetrics and gynecology 99%, ophthalmology 100%, adult medicine 41%, general paediatrics 38%). ICU use of CVCs increased by 41%, TPN days increased by 25% and hemodialysis runs increased by 9%. Annual nosocomial blood stream infections increased by 31% and the annual rate per 10,000 patient days increased by 60%. TPN‐related blood stream infection rates and ICU CVC infection rates did not change from 1993/94 to 1996/97.

CONCLUSIONS: Hospital restructuring has been associated with a 31% increase in nosocomial blood stream infection number and a 60% increase in rate. The increase has been associated with a change in patient populations and increases in risk factors for blood stream infection.
Pondering Parotid Masses
Authors: Miller Mark A
Published: March 2016

A49‐year‐old, human immunodeficiency virus (HIV)‐ infected, Haitian‐born woman presented with a left facial mass that she had noticed for the previous eight weeks. She was known to have been HIV‐seropositive for the previous 11 years and had been on multiple antiretroviral therapies. Her past medical history was also significant for hypertension, disseminated varicella zoster virus and recurrent oral and buttock Herpes simplex episodes. She was taking the following medications at the time of her presentation with the facial mass: stavudine, lamivudine, didanosine, nelfinavir mesylate, famciclovir, hydrochlorothiazide and cotrimoxazole. She had no complaints of fever, chills, sweats, weight loss or anorexia. She denied any pain, redness or warmth at the site of the facial swelling. Her most recent CD4 lymphocyte count was 336 cells/µL, with an HIV viral load of log102.6 copies/mL. Physical examination revealed a 4 cm fluid‐filled mass in the left parotid gland. There was no detectable induration, redness, warmth or tenderness, and no associated adenopathy. The rest of the examination was unremarkable. An aspirate of the mass was performed under sterile conditions and yielded 30 mL of turbid, yellow liquid. A Gram stain revealed no neutrophils, scant mononuclear cells and no visible organisms. An acid‐fast stain was negative as well. Routine, mycobacterial and fungal cultures showed no growth. Cytological analysis showed scant reactive lymphocytes and no malignant cells. The patient was not given therapy and was observed for another two months. The fluid reaccumulated in the left parotid gland, and the patient?s only complaint concerned the unsightly appearance of the mass. The lesion was again aspirated for 30 mL of fluid and this time, the fluid had a turbid, brown appearance. All laboratory results were identical to the results from the first aspirate. What is your diagnosis, and how would you treat this patient?
Asthma Education and Management Programs in Canada
Authors: Cowie Robert L , Cicutto Lisa , Boulet Louis-Philippe , the Patient Education Program Committee, Canadian Network Fo
Published: March 2016

OBJECTIVE: To establish the number and type of asthma patient education programs throughout Canada.

DESIGN: National survey.

SETTING: Canada.

METHODS: Over a three‐year period, contact was made with individuals and groups offering educational services for patients with asthma. Education given as part of a physician′s consultation or a pharmacist′s dispensing of medications for asthma was not considered a patient education program for the purposes of the survey. Contact was initially established by asking staff from well known asthma programs to provide lists of other such programs in their provinces or regions. Asthma programs were also identified from notices presented at Canada′s Third and Fourth National Conferences on Asthma and Education. Lung associations, lay organizations and industry representatives affiliated with the Canadian Network for Asthma Care helped to supplement the list. Once identified, each patient education program was contacted by telephone and by mail to complete a 26‐item questionnaire about their program. The province of Quebec was not included in the survey because it already had a province‐wide, structured asthma education program and register.

RESULTS: Seventy‐four asthma education and management programs were identified outside Quebec. Staff in these programs were registered nurses (n=46), respiratory therapists (n=48) and other health professionals (n=21). Forty‐one programs stated that at least one member of their staff had been trained as an asthma educator. In 71 programs, the initial patient encounter was of at least one hour′s duration. Physician referral was required by 41 programs. The province of Quebec has a joint asthma education program provided by 114 asthma education centres throughout the province under the umbrella of the Quebec Asthma Education Network (QAEN). This comprehensive program is provided in hospitals and community centres by specialized educators ‐ nurses, pharmacists or respiratory therapists ‐ to patients referred by their physicians.

CONCLUSIONS: A three‐year search for asthma education programs in Canada identified 74 patient education programs (outside Quebec) for an asthma population estimated to exceed 1.2 million. For the province of Quebec, an integrated asthma education program is provided through a network of 114 education centres ‐ the QAEN. The present survey shows that there has been progress in establishing asthma education programs in Canada, although there are significant regional differences in the availability of such programs.
Right Atrial Perforation Secondary to Implantable Cardioverter Defibrillator Insertion
Authors: Tran Nam T , Zivin Adam , Mozaffarian Darius , Karmy-Jones Riyad
Published: March 2016

Implantable cardioverter defibrillator (ICD) placements can be associated with serious complications. This paper reports a patient in whom percutaneous placement of an ICD resulted in a hemopneumothorax. This was due to an active fixation lead that perforated the right atrial wall and injured the adjacent lung parenchyma. The hemothorax was drained thoracoscopically, and the atrial injury was covered with fibrin glue.
Comparing Pressures Required to Abolish Snoring and Sleep Apnea
Authors: Hoffstein V , Oliver Z
Published: March 2016

OBJECTIVE: Snoring and obstructive sleep apnea share similar pathogenesis and similar response to treatment with continuous positive airway pressure (CPAP). The purpose of this study was to compare pressures required to abolish apneas (POSA) with pressures required to abolish snoring (PSNOR).

DESIGN: Cross‐sectional, nonrandomized cohort study.

SETTING: Sleep disorders clinic at St Michael′s Hospital ‐ a tertiary referral centre and a teaching hospital of the University of Toronto, Toronto, Ontario.

POPULATION STUDIED: Unselected consecutive 441 patients with confirmed sleep apnea who were undergoing a CPAP titration study in the sleep laboratory.

INTERVENTIONS: Nocturnal polysomnography using CPAP titration protocol, which required incremental increases in pressure until snoring and apnea were abolished or a maximum pressure of 16 cm H2O was attained. PSNOR and POSA were recorded and compared.

RESULTS: Mean (± SD) pressures required to abolish snoring and apnea were: PSNOR 8.3±2.57 cm H2O and POSA 7.9±2.72 cm H2O (P<0.0001). In 75% of patients, the PSNOR was within ±1 cm H2O of the POSA; in 92%, it was within ±2 cm H2O; and in 97%, it was within ±3 cm H2O.

CONCLUSIONS: Empirically increasing pressure by 2 cm H2O in patients on CPAP who continue to snore may abolish snoring and apnea without the necessity of another titration study.
The Classification of Patients with Chronic Pain: Age and Sex Differences
Authors: Cook Andrew J , Chastain Dania C
Published: March 2016

OBJECTIVE: To further develop an empirically based classification system for chronic pain patients through the examination of age and sex differences, and incorporation of pain duration in the grouping algorithm.

SUBJECTS: Three hundred seventy‐four chronic pain patients (300 aged 13 to 59 years; 74 aged 60 to 89 years) assessed at an outpatient, multidisciplinary pain management centre.

METHODS: Patients completed measures of demographic and descriptive information, pain intensity (box rating scale), perceived disability (modified Pain Disability Index) and affective distress (Symptom Checklist‐90 Revised) before multidisciplinary treatment. Standardized scores from the assessment measures were entered into a series of hierarchical, multivariate cluster analyses to identify underlying patient subgroups.

RESULTS: Age‐based patient groupings from prior research were partially replicated. Significant differences in clinical presentations were observed across age and sex groups. Pain duration was found to make an important contribution to the patient groupings. ′Good control′ (low pain, disability, distress) and variants of ′chronic pain syndrome′ (elevated pain, disability, distress) groupings were identified across all analyses. Two variants of a ′stoic′ profile were identified among older patients, with low levels of distress relative to pain and perceived disability. One of these profiles was associated with long pain duration and was found only among males. Several unique clinical profiles were identified for female patients.

CONCLUSIONS: There are important age and sex differences in the clinical presentations of chronic pain patients. Some older patients present with unique clinical profiles that may reflect cohort differences, and/or physiological or psychological adjustment processes. There appears to be a greater number of distinct chronic pain presentations among females. Research on the classification of chronic pain patients within homogeneous diagnostic subgroups is needed.
Orbital Myositis Complicating Sinusitis: Case Report and Review
Authors: Dylewski Joe S , Drummond Robert , Townsend Tiffany
Published: March 2016

Orbital myositis is a common cause of extraocular muscle enlargement. It is characterized by nonspecific inflammation of one or more extraocular muscles. Although often idiopathic in origin, orbital myositis has been associated with various noninfectious diseases. Several cases have also been reported as occurring after upper respiratory tract infections. The present report describes a case of orbital myositis together with subclinical sinusitis and its rapid resolution after antibiotic treatment. The literature on this clinical entity is also reviewed.
Hypersensitivity Pneumonitis with Normal High Resolution Computed Tomography Scans
Authors: Nasser-Sharif Farah J , Balter Meyer S
Published: March 2016

A case of symptomatic hypersensitivity pneumonitis with normal high resolution computed tomography (CT) scans is presented. The patient, a 32‐year‐old man with systemic lupus erythematosus, had a chronic, progressive history of respiratory symptoms, abnormal findings on examination and abnormal pulmonary function tests but normal high resolution CT scans of the chest. Diagnosis was made through open lung biopsy. Clinical improvement was seen on removal of the offending antigen. The literature on the utility of high resolution CT scans in hypersensitivity pneumonitis is reviewed.
The Emerging Epidemiology of VRE in Canada: Results of the CNISP Passive Reporting Network, 1994 to 1998
Authors: Conly John M , Ofner-Agostini Marianna , Paton Shirley , Johnston Lynn , Mulvey Michael , Kureishi Amar , Nicolle Lindsay , Matlow Anne , the Canadian Hospital Epidemiology Committee  , the Canadian Nosocomial Infection Surveillance Program
Published: March 2016

OBJECTIVE: To provide a rapid and efficient means of collecting descriptive epidemiological data on occurrences of vancomycin‐resistant enterococcus (VRE) in Canada.

DESIGN AND METHODS: Passive reporting of data on individual or cluster occurrences of VRE using a one‐page surveillance form.

SETTING: The surveillance form was periodically distributed to all Canadian Hospital Epidemiology Committee members, Community and Hospital Infection Control Association members, L′Association des professionnels pour la prevention des infections members and provincial laboratories, representing 650 health care facilities across Canada.

PATIENTS: Patients colonized or infected with VRE within Canadian health care facilities.

RESULTS: Until the end of 1998, 263 reports of VRE were received from 113 health care facilities in 10 provinces, comprising a total of 1315 cases of VRE, with 1246 cases colonized (94.7%), 61 infected (4.6%)and eight of unknown status. (0.6%). VRE occurrences were reported in 56% of acute care teaching facilities and 38% of acute care community facilities. All facilities of more than 800 beds reported VRE occurences compared with only 10% of facilities with less than 200 beds (r2=0.86). Medical and surgical wards accounted for 51.4% of the reported VRE occurences. Sixty‐five (24.7%) reports indicated an index case was from a foreign country, with 85.2% from the United States and 14.8% from other countries. Some type of screening was conducted in 50% of the sites.

CONCLUSIONS: A VRE passive reporting network provided a rapid and efficient means of providing data on the evolving epidemiology of VRE in Canada.
Hantavirus Pulmonary Syndrome in Manitoba
Authors: Lindsay L Robbin , Drebot Michael A , Weiss Elise , Artsob Harvey
Published: March 2016

The first confirmed case of hantavirus pulmonary syndrome in Manitoba was diagnosed in 1999. To define better the risk of exposure to hantaviruses in this area, the clinical features and epidemiological factors pertaining to this case were described, and a serological survey of rodents collected near the patient′s residence was undertaken. Small mammals were collected using live traps, were anesthetized via inhalation of isoflurane and were bled. Human and mouse serologies were undertaken using an ELISA to detect hantavirus‐specific immunoglobulin G and/or immunoglobulin M antibodies. In addition, a full medical and epidemiological assessment, as well as individual risk factor and exposure analysis, were conducted. A 27‐year‐old Manitoba woman presented with severe respiratory distress and diffuse bilateral air space disease radiologically. Despite extremely aggressive measures, including mechanical ventilation, antibiotics, fluid management and inotropic support, the patient′s condition rapidly deteriorated, and she died 8 h after admission. Hantavirus pulmonary syndrome was confirmed by the detection of immunoglobulin M and immunoglobulin G antibodies to the Sin Nombre virus (SNV) in her sera and by the demonstration of SNV genomic sequences in her lung tissue. Exposure to hantavirus likely occurred in and around the home or in the rural area in which she resided. A total of 252 small mammals, primarily deer mice (Peromyscus maniculatus), were collected from 17 different sites at or near where the patient lived. Antibodies to SNV were detected in 28 of 244 (11.5%) deer mice, which were collected within 9 km of the residence of the fatal case, indicating that these rodents are a significant reservoir for SNV in this area.
Hepatitis
Authors: Krajden Mel
Published: March 2016

Worldwide, approximately 170 million people are chronically infected with hepatitis C virus (HCV) and another 350 million individuals are chronically infected with hepatitis B virus (HBV) (1,2). Canada is estimated to have 240,000 to 300,000 HCV and 200,000 to 280,000 HBV chronic carriers (3,4). Without intervention, over multiple decades, approximately 15% to 30% of chronic HBV‐ and HCV‐infected individuals will develop cirrhosis, end‐stage liver disease or liver cancer, or will require liver transplantation (1,2,5). From a public health perspective, the major challenge is how best to avoid acute (incident) infections in at‐risk populations, and for those already chronically infected, how to prevent consequent morbidity and mortality.
Respiratory Failure Associated with the Lipodystrophy Syndrome in an HIV‐Positive Patient with Compromised Lung Function
Authors: Press Natasha , Montessori Valentina , Bai Tony R , Montaner Julio
Published: March 2016

Protease inhibitors, used as treatment in human immunodeficiency virus (HIV) infection, are associated with a syndrome of peripheral lipodystrophy, central adiposity, hyperlipidemia and insulin resistance. An HIV‐positive patient with chronic obstructive pulmonary disease is presented who developed the lipodystrophy syndrome that is associated with the use of protease inhibitors. It is postulated that the lipodystrophy syndrome further compromised his lung function, leading to respiratory failure. Patients who have pulmonary disease and are taking protease inhibitors require monitoring of clinical status and pulmonary function tests.
It′s Time for a National Immunization Strategy
Authors: Embree Joanne
Published: March 2016

Canada needs to develop and implement a national immunization strategy to provide optimal protection for vaccine‐preventable diseases for children, adolescents and adults. Although the federal government has a mandate to ensure that access to health care is equitable across the country, it is the mandate of provincial governments to actually provide health care services. Thus, while the federal government makes recommendations for the optimal use of various vaccines through the publications of the National Advisory Committee on Immunization, the provincial governments must develop and fund their individual immunization programs. With a national immunization strategy that is endorsed by the federal and provincial governments, the following could occur: harmonization of childhood immunization schedules across the country; efficient introduction of new vaccines; the ability to enhance the monitoring of vaccine use and adverse events; and improvements in the ability to access readily vaccine products in the most cost effective manner. A national immunization strategy would also provide opportunities for vaccine and immunization research, and for improved education of health care providers and the general public.
Economic Impact of Using an Immunostimulating Agent to Prevent Severe Acute Exacerbations in Patients with Chronic Obstructive Pulmonary Disease
Authors: Collet Jean-Paul , Ducruet Thierry , Haider Seema , Shapiro Stan , Robinson Ann , Renzi Paolo M , Contandriopoulos André-Pierre , Ernst Pierre
Published: March 2016

RATIONALE: OM‐85 BV, an immunostimulant made from bacterial extracts, has been shown to reduce the risk of hospitalization for acute exacerbation in patients with chronic obstructive pulmonary disease, as well as to reduce the length of stay for all hospitalizations.

METHODS: In conjunction with a placebo controlled, randomized clinical trial, a cost effectiveness analysis was carried out to assess the economic impact of using OM‐85 BV. In the analysis, effectiveness was defined as the difference in the number of severe acute exacerbations, assessed by the number of hospitalizations for a respiratory problem, between the placebo and OM‐85 BV‐treated groups.

RESULTS: The median cost to prevent one day of hospitalization for a respiratory condition was CDN$45, with a 95% CI of CDN$18 to CDN$210. Bootstrap of the study population and sensitivity analyses showed that the results were robust and not likely due to random fluctuation; 98.8% of the cost effectiveness and 96.8% of the cost‐benefit ratios favoured the use of OM‐85 BV. Indirect costs, defined as a need for help, were reduced by 36% in the group treated with OM‐85 BV: 779 h of help compared with 1212 h in the placebo group. This trend, while not significant, is consistent with other results and suggests a decrease in the severity of exacerbations in the OM‐85 BV‐treated group.

CONCLUSION: Given the high prevalence of chronic obstructive pulmonary disease worldwide and the high cost of acute exacerbations, immunostimulants may become a key element in the improved control of this condition.
Characteristics of Hepatitis C Virus Infection in HIV‐Infected People
Authors: Cooper Curtis L , Badley Andrew D , Angel Jonathan B
Published: March 2016

Knowledge pertaining to hepatitis C virus (HCV)/human immunodeficiency virus (HIV) co‐infection is currently incomplete or conflicting. Several points are well studied, however. Plasma HCV RNA levels are higher in matched HIV‐infected people than in HIV‐seronegative control subjects and are inversely correlated with CD4+ T lymphocyte counts. HCV genotype does not appear to influence this value. Co‐infected individuals develop histological and clinical features of HCV liver disease more rapidly than HIV‐seronegative patients. Co‐infected individuals appear to respond to interferon‐alpha therapy equally as well as HIV‐seronegative HCV‐infected adults, but minimal information exists regarding the efficacy and toxicity of combination HCV therapy (interferon‐alpha plus ribavirin) in this population. Adverse consequences of highly active antiretroviral therapy in co‐infected patients include hepatic toxicity and, in a minority of patients, an ′immune restoration syndrome′. It is unclear whether long term, highly active antiretroviral therapy positively or negatively influences the natural history of HCV infection.
Immunization ‐ Must Be Safe or We Will All Be Sorry
Authors: Hammond Greg
Published: March 2016

Immunization programs are among the most effective of all health care interventions, and they are among the few that are potentially cost‐saving. However, concerns about immunization safety appear to be increasing, despite technological developments that have created safer vaccines than ever before and despite the solid scientific evidence of the safety of current immunization programs. This is due in part to the success of immunization programs, where major advances in immunization have caused the virtual disappearance of many common communicable diseases. This has resulted in the perception by some individuals that adverse events, which occasionally follow immunization, are now more common and potentially more of a hazard than the diseases for which the immunizations were developed.
Re‐Examining Treatment of Latent Tuberculosis Infection
Authors: Johnston B Lynn , Conly John M
Published: March 2016

In April 2000, the American Thoracic Society published guidelines for targeted tuberculin testing and the treatment of latent tuberculosis infection (LTBI) (1). These guidelines are a joint statement of the American Thoracic Society and the Centers for Disease Control and Prevention, and were endorsed by both the Infectious Diseases Society of America and the American Academy of Pediatrics. Similar recommendations were published by the Infectious Diseases Society of America in its guidelines for the treatment of tuberculosis (TB) (2). These updated guidelines were developed in recognition of the importance of treating LTBI as one component of eliminating TB in the United States ‐ a goal reiterated in 1999 by the Advisory Council for the Elimination of Tuberculosis (3) ‐ but also realizing the differing risks and benefits of treatment for patients based on their individual risks of developing active disease or drug toxicity (4). The 2000 edition of the Canadian Tuberculosis Standardsprovided similar recommendations for the treatment of LTBI (formerly known as chemoprophylaxis) and reminded us of the two major Canadian TB elimination initiatives: the National Tuberculosis Elimination Strategy (Medical Services Branch, 1992), with the aim of eliminating TB in First Nations people by 2010, and the National Consensus Conference on Tuberculosis (Health Canada, 1997), with an interim goal of a 5% reduction in the number of TB cases each year in Canada (5). Given the recent publication of the American guidelines and the updated Canadian Tuberculosis Standards (Fifth Edition), it was considered timely to remind readers of the evidence supporting the use of antituberculous chemotherapy in the treatment of latent infection.
Explosive Pleuritis
Authors: Sharma Jasdeep K , Marrie Thomas J
Published: March 2016

The objective of the present paper is to describe the clinical and computed tomography features of ′explosive pleuritis′, an entity first named by Braman and Donat in 1986, and to propose a case definition. A case report of a previously healthy, 45‐year‐old man admitted to hospital with acute onset pleuritic chest pain is presented. The patient arrived at the emergency room at 15:00 in mild respiratory distress; the initial chest x‐ray revealed a small right lower lobe effusion. The subsequent clinical course in hospital was dramatic. Within 18 h of admission, he developed severe respiratory distress with oxygen desaturation to 83% on room air and dullness of the right lung field. A repeat chest x‐ray, taken the morning after admission, revealed complete opacification of the right hemithorax. A computed tomography scan of the thorax demonstrated a massive pleural effusion with compression of pulmonary tissue and mediastinal shift. Pleural fluid biochemical analysis revealed the following concentrations: glucose 3.5 mmol/L, lactate dehydrogenase 1550 U/L, protein 56.98 g/L, amylase 68 U/L and white blood cell count 600 cells/mL. The pleural fluid cultures demonstrated light growth of coagulase‐negative staphylococcus and viridans streptococcus, and very light growth of Candida albicans. Cytology was negative for malignant cells. Thoracotomy was performed, which demonstrated a loculated parapneumonic effusion that required decortication. The patient responded favourably to the empirical administration of intravenous levofloxacin and ceftriaxone, and conservative surgical methods in the management of the empyema. This report also discusses the patient′s rapidly progressing pleural effusion and offers a potential case definition for explosive pleuritis. Explosive pleuritis is a medical emergency defined by the rapid development of a pleural effusion involving more than 90% of the hemithorax over 24 h, which causes compression of pulmonary tissue and mediastinal shift to the contralateral side.
Macrolides: A Canadian Infectious Disease Society Position Paper
Authors: McKenna S , Evans GA , Canadian Infectious Disease Society Antimicrobial Agents Com
Published: March 2016

Since the introduction of erythromycin in 1965, no new compounds from the macrolide antimicrobial class were licensed in Canada until the 1990s. Clarithromycin and azithromycin, since their introduction, have become important agents for treating a number of common and uncommon infectious diseases. They have become prime agents in the treatment of respiratory tract infections, and have revolutionized the management of both genital chlamydial infections, by the use of single‐dose therapy with azithromycin, and nontuberculous mycobacterial infections, by the use of clarithromycin. The improvement of clarithromycin and azithromycin over the gastrointestinal intolerability of erythromycin has led to supplanting the use of the latter for many primary care physicians. Unfortunately, the use of these agents has also increased the likelihood for misuse and has raised concerns about a resultant increase in the rates of macrolide resistance in many important pathogens, such as Streptococcus pneumoniae. This paper reviews the pharmacology and evidence for the current indications for use of these newer agents, and provides recommendations for appropriate use.