bluuebunny/crossref_metadata_2025 huggingface dataset:
Asthma “Control”
Authors: Anthonisen Nick R
Published: March 2016

In this issue of the Canadian Respiratory Journal, Cowie et al (pages 555‐558) make the startling claim that "inhaled corticosteroid therapy does not control asthma". This sounds crazy: if inhaled steroids don′t control asthma, what does? It turns out not to be crazy. Cowie et al reported on the effectiveness of asthma control according to Canadian guidelines (1) in several large groups of asthmatics evaluated by cross‐sectional, one‐point‐in‐time questionnaires. They found that patients on inhaled steroids were less well‐controlled than those who were not on inhaled steroids, and that there was a dose effect, in that the larger the dose of inhaled steroids the worse the control. There is, of course, a simple explanation for this; patients with hard‐to‐control asthma are likely to be prescribed inhaled steroids, and the harder the disease is to control, the higher the dose. However, these findings are compatible with inhaled steroids having a minor effect on asthma control, something that we do not believe (2). There are excellent data from clinical trials (3) that inhaled steroids work, and in population studies (4), their use is associated with improved survival.
Recovery of Cephalosporin Resistant Escherichia coli and Salmonella from Pork, Beef and Chicken Marketed in Nova Scotia
Authors: Forward Kevin R , Matheson Katherine M , Hiltz Margot , Musgrave Heather , Poppe Cornelius
Published: March 2016

BACKGROUND: Antimicrobial use in farm animals is a potentially important contributor to the emergence of antimicrobial resistance. Resistant Salmonella may lead to serious human infections and resistant Escherichia coli may transfer plasmid‐encoded resistance genes to other pathogens.

OBJECTIVE: To determine the prevalence of E coli and Salmonella species resistant to the third generation of cephalosporins in retail meat products in Halifax, Nova Scotia in 2002.

METHODS: Ground beef, ground pork and chicken wings were tested for E coli and Salmonella. E coli were selected on ceftriaxone‐containing media. Beta‐lactamases were characterised by isoelectric focusing, polymerase chain reaction and sequencing. Pulsed field gel electrophoresis was performed to determine the relationship of strains. The transferability of plasmids and location of resistance genes was also determined.

RESULTS: Forty‐three of 75 packages of chicken wings contained ceftriaxone‐resistant E coli; 42 of these contained beta‐lactamases with isoelectric points at approximately 8.7. Six of seven CMY primer amplicons that were sequenced contained plasmid‐mediated Citrobacter freundii‐derived blaCMY‐2; the other contained a CMY‐2‐like beta‐lactamase. Pulsed field gel electrophoresis patterns demonstrated that strains were not clonal in nature. Four chicken samples contained Salmonella, one of which contained blaCMY‐2‐mediated resistance and an E coli bearing the same gene, but on different plasmids. Four of 100 beef samples contained blaCMY‐2‐bearing E coli; none contained Salmonella. Two of 75 pork samples contained ceftriaxone resistant E coli, one of which encoded for CMY‐2. One susceptible Salmonella strain was recovered from pork.

CONCLUSIONS: Chicken from retail outlets located in Halifax, Nova Scotia, commonly contained blaCMY‐2‐bearing E coli. The relationship antibiotics used in food‐producing animals and its effect on resistance of commensals and pathogens needs to be determined.
Six‐Month CTS Update Report
Authors: Bowie Dennis
Published: March 2016

With this report, I hope to bring the membership up‐to‐date regarding the activities of the Canadian Thoracic Society (CTS) during the past six to seven months. We have just had our biannual board meeting in Alberta, which was the most successful one that I have personally attended. This achievement was a result of the marked increase in the business of all the working committees and in the number of reports tabled at this meeting that chronicled the many activities taking place over the past six months.
Smoking in Health Science Students with Asthma
Authors: Krommydas Georgios , Kotrotsiou Evangelia , Raftopoulos Vasilios , Paralikas Theodosios , Gourgoulianis Konstantinos I , Molyvdas Paschalis-Adam
Published: March 2016

It is expected that asthmatic students in a health science department would avoid the hazards of cigarette smoking due to the knowledge they gain through their studies. Surprisingly, health science students with asthma had a higher prevalence of smoking than their healthy colleagues.
Physiological Changes at Altitude in Nonasthmatic and Asthmatic Subjects
Authors: Louie Dianna , Paré Peter D
Published: March 2016

Exercised‐induced asthma is not due to exercise itself per se, but rather is due to cooling and/or drying of the airway because of the increased ventilation that accompanies exercise. Travel to high altitudes is accompanied by increased ventilation of cool, often dry, air, irrespective of the level of exertion, and by itself, this could represent an ′exercise′ challenge for asthmatic subjects. Exercise‐induced bronchoconstriction was measured at sea level and at various altitudes during a two‐week trek through the Himalayas in a group of nonasthmatic and asthmatic subjects. The results of this study showed that in mild asthmatics, there was a significant reduction in peak expiratory flow at very high altitudes. Contrary to the authors′ hypothesis, there was not a significant additional decrease in peak expiratory flow after exercise in the asthmatic subjects at high altitude. However, there was a significant fall in arterial oxygen saturation postexercise in the asthmatic subjects, a change that was not seen in the nonasthmatic subjects. These data suggest that asthmatic subjects develop bronchoconstriction when they go to very high altitudes, possibly via the same mechanism that causes exercise‐induced asthma.
Should University Students Be Vaccinated against Meningococcal Disease in Canada?
Authors: De Wals Philippe
Published: March 2016

OBJECTIVE: To evaluate the benefit and costs of vaccination of university students against invasive meningococcal disease (IMD) in Canada.

METHODS: Published studies were reviewed and a simulation model was used.

RESULTS: IMD risk seems to be of low magnitude, but consequences can be dramatic. Over a 10‐year period, IMD risk reduction would be slightly greater using a monovalent C conjugate vaccine than a quadrivalent polysaccharide vaccine. From a societal perspective, costs per quality‐adjusted life‐years gained would be between $135,000 and $698,000, according to epidemiological scenarios and with vaccine purchase prices between $35 and $50 per dose.

CONCLUSIONS: Economic indices exceed proposed criteria for cost effective public health programs, but from the perspective of students and parents, the cost of vaccination might be worth the benefit.
Persistence and Compliance
Authors: Anthonisen Nick R
Published: March 2016

In this issue of the Canadian Respiratory Journal, Blais et al (pages 27 to 32) publish an interesting study of the use of inhaled steroids in chronic obstructive pulmonary disease (COPD). Using the Quebec provincial database from the years 1990 to 1996, they found that these medications were given to more and more patients during the period of the study, and that the patients tended to be sicker than those who were not given inhaled steroids: they saw more physicians, including specialists; took more bronchodilators; and had more exacerbations. This is the result that I would have predicted if asked and is therefore not surprising. What surprised me is the fact that patients did not continue to use inhaled steroids once they had been started on them; of those given these drugs for the first time, one‐half stopped them after approximately 18 months, and after five years, approximately only 20% were still taking them. Further, as the number of patients given inhaled steroids increased, persistence decreased. What are we to make of this? One could argue that the dates covered by the study of Blais et al preceded the clinical trials (1) showing that inhaled steroids reduced exacerbations in COPD and that they were not prescribed with the conviction that present‐day physicians would employ. On the other hand, it seems unlikely that COPD patients were given these medications as a temporary expedient; presumably, most prescriptions for inhaled steroids were for chronic maintenance therapy. It is therefore unlikely that the prescribing physicians told COPD patients to take the drugs until they felt better and then discontinue them. It is also possible that inhaled steroids were unique respiratory drugs in that they were expensive and that this impacted persistence negatively. Although these patients had provincial drug insurance coverage, it was probably on a reimbursement basis, as in Manitoba, and inhaled steroids presented a cash flow problem.
EMLA Cream is an Effective Topical Anesthetic for Bronchoscopy
Authors: Sohmer Benjamin , Bryson Gregory L , Bencze Steven , Scharf Maria Mouroukas
Published: March 2016

BACKGROUND: EMLA cream (AstraZeneca Inc, Canada) (1:1 eutectic mixture of lidocaine 2.5% and prilocaine 2.5%) has traditionally been used for topical anesthesia of the skin. Recent reports of EMLA′s use for anesthesia of the oral mucosa suggest an application in topical anesthesia for bronchoscopy.

OBJECTIVES: To evaluate the amount of local anesthetic administered during bronchoscopy; to assess the time required to obtain topical anesthesia; to assess the quality of the topical anesthesia as described by bronchoscopists; and to document any complications.

METHODS: Fifty‐seven unpremedicated patients had 4 mL of EMLA cream applied to the posterior third of their tongues on arrival in the bronchoscopy suite. Liquid lidocaine was applied through the bronchoscope for laryngeal anesthesia.

RESULTS: The mean time from the application of EMLA cream to insertion of the bronchoscope was 5.10±0.48 min. Fifty‐six patients (98.2%) required no supplemental anesthesia. Bronchoscopy conditions were described as ′excellent′ in 55 cases (96.5%) and ′good′ in the remaining two cases (3.5%).

CONCLUSIONS: EMLA is an effective alternative for oropharyngeal topical anesthesia that is well‐tolerated by patients.
Video‐Assisted Thoracoscopic Lung Biopsy as a Possible Cause of Acute Interstitial Pneumonia in a Patient with Nonspecific Interstitial Pneumonia
Authors: Moore D Jeffrey , McParland Colm P , Bullock Martin J , Cartier Yannick , Hernandez Paul
Published: March 2016

The present case report describes a 44‐year‐old woman who presented with dyspnea due to diffuse interstitial lung disease. High‐resolution computed tomography showed features of usual interstitial pneumonia, but the lung biopsy obtained by video‐assisted thoracoscopy was consistent with a histological pattern of nonspecific interstitial pneumonia. Following the procedure, the patient developed progressive respiratory distress and died on postoperative day 13 with a clinical picture of acute interstitial pneumonia. The autopsy showed evidence of diffuse alveolar damage superimposed on the background pattern of nonspecific interstitial pneumonia. The present case report supports the notion that patients with a variety of subtypes of idiopathic interstitial pneumonias may be at risk of exacerbation of their underlying disease following thoracic procedures, including video‐assisted thoracoscopic lung biopsy.
Steroids and/or Cytotoxic Agents Should Be Used Early in the Management of Patients with IPF ‐‐ The Con Argument
Authors: Field Stephen K
Published: March 2016

The recently published American Thoracic Society/European Respiratory Society statement distinguishes idiopathic pulmonary fibrosis (IPF), also known as usual interstitial pneumonia (UIP), from the other idiopathic interstitial pneumonias (IIPs) (1). Although the current classification of IIPs is different from the one developed by Liebow and Carrington (2) in the 1960s, the description of UIP has not changed, and it is still recognized as having distinctive clinical and pathological features that distinguish it from the other IIPs. IPF responds differently to systemic corticosteroid (steroid) therapy and has a different prognosis than the other IIPs, such as nonspecific interstitial pneumonitis, which previously were felt to be variants of the same condition (1,3,4). Despite therapy, most patients with IPF experience a progressive decline in pulmonary function, leading to respiratory failure and death, unless they undergo lung transplantation.
Rates and Patterns of Chronic Obstructive Pulmonary Disease Exacerbations
Authors: Nunes de Melo Magda , Ernst Pierre , Suissa Samy
Published: March 2016

BACKGROUND: Acute exacerbations of chronic obstructive pulmonary disease (COPD) are believed to be a common occurrence in patients with COPD and are known to be associated with considerable morbidity.

OBJECTIVE: To describe the frequency of treated COPD exacerbations in a large population‐based cohort.

SUBJECTS AND METHODS: A cohort of newly treated patients with COPD was formed from the administrative databases of Saskatchewan Health. The outcome was the occurrence of all moderate or severe exacerbations from 1990 to 1999. Exacerbations were defined in three ways: dispensing of a prescription for a systemic antibiotic; dispensing of both a prescription for an antibiotic and a prescription for an oral corticosteroid on the same day; and requiring a hospitalization with a primary discharge diagnosis of COPD.

RESULTS: There were 5645 patients who entered the COPD cohort between 1990 and 1997, of whom 4453 experienced at least one exacerbation requiring treatment during follow‐up. The overall rate of acute exacerbations was 1.12/person‐year. It was constant across all age groups, and was similar in both men and women (1.13/person‐year versus 1.11/person‐year, respectively). The rate of exacerbations was highest in the first trimester of therapy for the disease (1.39/person‐year) and stabilized thereafter at 1.04 exacerbations/person‐year.

CONCLUSIONS: The results indicate that in a population‐based cohort of patients with COPD, the average rate of exacerbations was 1.12/person‐year. Men and women had similar rates of exacerbations.
Opium the Best Remedy
Authors: Merskey Harold
Published: March 2016

Sydenham was the leading English physician of the 17th century and probably to the present time. He was using a well tried remedy. It had been known by then for about 4000 years, frequently mentioned by Hippocrates, and recognized in use in medieval Europe where it probably came through Arabic traders and was well established in use in Paris by the 12th century (2). Professional concerns up to the time of Sydenham were not about addiction. As can be seen from his text, they were about whether the drug was available in adequate preparations, whether there was any difference between opium and other narcotics, particularly comparing the natural juice with "its artificial preparations" (1) (all of which he thought to be about equal in effect), whether it was stimulant or restorative and invigorating, and whether it was being properly used for all the conditions in which it could be helpful. Addiction, dependence and insanity are not mentioned, although the fact that it could occasionally promote excitement ("frenzy") was known.
Tuberculous Lymphadenitis in Manitoba: Incidence, Clinical Characteristics and Treatment
Authors: Cook Victoria J , Manfreda Jure , Hershfield Earl S
Published: March 2016

BACKGROUND: Tuberculous lymphadenitis (TBL) is an important form of extrapulmonary tuberculosis (TB). Recent studies have shown an increase in TBL in Canada.

OBJECTIVES: To determine the incidence of TBL in Manitoba and to identify the characteristics associated with its presentation, diagnosis and treatment.

METHODS: Population data from the Manitoba Health Population Registry, the First Nations and Inuit Health Branch of Health Canada, and Statistics Canada were used to calculate incidence. Case characteristics and outcomes were determined by a systematic, retrospective review of all cases between January 1, 1990 and December 31, 2000.

RESULTS: One‐hundred forty seven cases of TBL were identified during the study period; 77% confirmed by culture; 68% women. TBL was found in Canadian‐born/nonstatus Aboriginal (12%), status Aboriginal (29%) and foreign‐born (59%) populations. Incidence of TBL was 1.17 per 100,000 person years (95% CI 0.98 to 1.36). The highest incidence was in status Aboriginals over 65 years (16.85 per 100,000 person years; 95% CI 3.37 to 30.33). TBL is seen most often in Western Pacific women. The most common presentation was a single, enlarged cervical node (80%). No atypical mycobacterium was found. Drug resistance occurred in 13% of cases and only in the foreign‐born. Cure rates (81%) were influenced by comorbidity and burden of TB disease. Relapse occurred in 8.1 per 1000 person years of follow‐up (95% CI 1.7 to 23.7).

CONCLUSIONS: Respiratory physicians, who manage the majority of TB disease in Canada, need to remain aware that TB is an important and treatable cause of enlarged lymph nodes.
Fractional Analysis of Th2‐Type Cytokines in Sequential Samples of Induced Sputum
Authors: Taha Rame , Hamid Q , Olivenstein Ron
Published: March 2016

BACKGROUND: Recent studies have demonstrated the usefulness of induced sputum in detecting the expression of Th2‐type cytokines in asthmatics and have shown that the profile of inflammatory cells in induced sputum differs with time.

OBJECTIVE: To determine whether the duration of sputum induction also affects the expression of Th2‐type cytokines in induced sputum.

METHODS: Induced sputum was collected from eight atopic asthmatics at two separated intervals (5 min each) during a 15 min sputum induction, and each sample was examined separately for cytokine expression and inflammatory cells. Using immunocytochemistry, interleukin (IL)‐4 and IL‐5 immunoreactivity, T lymphocytes (CD3), eosinophils (major basic protein), neutrophils (elastase), epithelial cells and macrophages (CD68) were compared in the induced sputum obtained from the 0 min to 5 min and the 10 min to 15 min samples.

RESULTS: The number of immunoreactive‐positive cells expressing IL‐4 and IL‐5 were significantly higher in the 10 to 15 min induced sputum sample than in the 0 min to 5 min induced sputum sample (P<0.05). The number of eosinophils was also significantly higher in the 10 min to 15 min sample than in the 0 min to 5 min sample (P<0.05). In contrast, the number of neutrophils was significantly higher in the 0 min to 5 min sample than in the 10 min to 15 min sample (P<0.01); T lymphocytes, macrophages and epithelial cells did not differ between the two samples.

CONCLUSION: This study demonstrates that the duration of sputum induction significantly affects the profile of inflammatory cells and Th2‐type cytokine expression, and underscores the need for the standardization of induced sputum procedure.
Occupational Asthma ‐‐ The Last 50 Years
Authors: Chan-yeung Moira
Published: March 2016

It was indeed a great honour for me to be this year′s Christie Memorial Lecturer. Although I have not been fortunate enough to have had personal contact with Professor Christie, one of the greatest lung physiologists of our time, I have had the opportunity over the years of interacting with and learning from the group working in the laboratory named after him ‐ the Meakins‐Christie Laboratories ‐ as a member of the Respiratory Health Network of Centres of Excellence, Canada.
Chronic Neuropathic Pain in Spinal Cord Injury: The Patient′s Perspective
Authors: Henwood Penelope , Ellis Jacqueline A
Published: March 2016

BACKGROUND: Chronic neuropathic pain (CNP) in spinal cord injury (SCI) is recognized as severely compromising, in both adjustment after injury and quality of life. Studies indicate that chronic pain in SCI is associated with great emotional distress over and above that of the injury itself. Currently, little is known about the SCI patient′s perception of the impact of living with chronic neuropathic pain.

OBJECTIVES: The purpose of this study was to explore the experience of CNP in SCI patients in relation with physical, emotional, psychosocial, environmental, informational, practical and spiritual domains, and to identify effective and ineffective pain coping strategies.

METHODS: Three focus groups were conducted that included 24 SCI individuals living in the community. Participants were selected to maximize variation in terms of type of SCI, Frankel classification, years since onset of SCI, age and sex. The sessions were audiotaped and tapes were transcribed. A qualitative analysis of data involved a constant comparison approach, in which categories and themes were identified.

RESULTS: Many complex themes emerged including: nature of pain; coping as process and product; medication failure; and the impact of CNP on physical, cognitive, emotional, interpersonal, social and life activities.

CONCLUSIONS: Medication failure was identified as a common outcome, while strategies including use of warm water, swimming, increased activity and distraction provided temporary pain relief. Learning to live with the pain appeared to be related to acceptance of pain, which in turn seemed to facilitate adjustment. Further research is warranted to determine the process by which SCI patients learn to live with CNP and coping strategies that facilitate adjustment to CNP in SCI patients.
West Nile Virus Infection in the Intensive Care Unit: A Case Series and Literature Review
Authors: Fan Eddy , Needham Dale M , Brunton James , Kern Ralph Z , Stewart Thomas E
Published: March 2016

BACKGROUND: West Nile virus (WNV) is a rapidly spreading infectious disease in North America. Critical care issues related to WNV are not well described.

OBJECTIVES: Three cases of severe WNV meningoencephalitis with flaccid paralysis are reported and relevant critical care issues are highlighted.

METHODS: Case series and a review of the literature.

RESULTS: Three patients with WNV meningoencephalitis and flaccid paralysis were admitted to the authors′ academic, tertiary‐care intensive care unit (ICU) in the late summer of 2002. All three patients were middle‐aged or elderly and presented with a febrile illness that preceded or coincided with their neurological symptoms. Confirmation of WNV infection was problematic because each patient had at least one initial negative serum serology test. Radiological testing yielded nonspecific results. Serial electroencephalograms were consistent with severe toxic metabolic encephalopathy in all cases. All patients had a severe, diffuse axonal polyneuropathy demonstrated by nerve conduction studies and electromyography. Prolonged mechanical ventilation resulted in ICU lengths of stay of 44 to 118 days. At one point, 21% of the ICU beds were dedicated for these patients. All three patients died in hospital ‐‐ two following the withdrawal of life support. One patient demonstrated resolving encephalitis and was discharged from the ICU after a 118‐day ICU stay, but later died in a step‐down unit.

CONCLUSIONS: The management of WNV‐related critical illness creates challenges in making a timely and accurate diagnosis, and predicting patient morbidity and mortality. As a consequence, end‐of‐life discussions with families are especially difficult. The prolonged ICU length of stay and growing incidence of this disease may challenge limited critical care resources.
Simulated Pain and Cervical Motion in Patients with Chronic Disorders of the Cervical Spine
Authors: Dvir Zeevi , Gal-Eshel Noga , Shamir Boaz , Pevzner Evgeny , Peretz Chava , Knoller Nachshon
Published: March 2016

The primary objective of the present study was to determine how simulated severe cervical pain affects cervical motion in patients suffering from two distinct chronic cervical disorders: whiplash (n=25) and degenerative changes (n=25). The second objective was to derive an index that would allow the differentiation of maximal from submaximal performances of cervical range of motion. Patients first performed maximal movement of the head (maximal effort) in each of the six primary directions and then repeated the test as if they were suffering from a much more intense level of pain (submaximal effort). All measurements were repeated within four to seven days. In both groups, there was significant compression of cervical motion during the submaximal effort. This compression was also highly stable on a test‐retest basis. In both groups, a significantly higher average coefficient of variation was associated with the imagined pain and it was significantly different between the two clinical groups. In the whiplash group, a logistic regression model allowed the derivation of coefficient of variation‐based cutoff scores that might, at selected levels of probability and an individual level, identify chronic whiplash patients who intentionally magnify their motion restriction using pain as a cue. However, the relatively small and very stable compression of cervical motion under pain simulation supports the view that the likelihood that chronic whiplash patients are magnifying their restriction of cervical range of motion using pain as a cue is very low.
The Effects of Sleep Deprivation on Pain
Authors: Kundermann Bernd , Krieg Jürgen-Christian , Schreiber Wolfgang , Lautenbacher Stefan
Published: March 2016

Chronic pain syndromes are associated with alterations in sleep continuity and sleep architecture. One perspective of this relationship, which has not received much attention to date, is that disturbances of sleep affect pain. To fathom this direction of cause, experimental human and animal studies on the effects of sleep deprivation on pain processing were reviewed. According to the majority of the studies, sleep deprivation produces hyperalgesic changes. Furthermore, sleep deprivation can counteract analgesic effects of pharmacological treatments involving opioidergic and serotoninergic mechanisms of action. The heterogeneity of the human data and the exclusive interest in rapid eye movement sleep deprivation in animals so far do not allow us to draw firm conclusions as to whether the hyperalgesic effects are due to the deprivation of specific sleep stages or whether they result from a generalized disruption of sleep continuity. The significance of opioidergic and serotoninergic processes as mediating mechanisms of the hyperalgesic changes produced by sleep deprivation are discussed.
Myiasis in an Urban Setting: A Case Report
Authors: Predy Gerry , Angus Mary , Honish Lance , Burnett Charles E , Stagg Andrew
Published: March 2016

Myiasis is considered to be a condition only found in tropical, developing countries. However, this paper reports a case identified in an urban, North American setting. The clinical presentation is discussed along with the underlying comorbidities and social determinants.
The Evaluation of Diagnostic Tests for Sexually Transmitted Infections
Authors: Chernesky Max A
Published: March 2016

Diagnostic tests should receive method‐ and use‐effectiveness evaluations. Method‐effectiveness evaluations determine sensitivity, specificity and predictive values for new tests. Use‐effectiveness evaluations determine how practical or convenient a new test will be in a specific setting and may not be performed in a formal way in North American laboratories. To perform a clinical method evaluation of diagnostic tests, a good relationship between laboratory and clinical personnel is essential. Studies are usually conducted separately on populations of men and women, and should include sampling from different prevalence groups. Test performance comparisons may be made on a single specimen type or on more than one specimen from the same patient, which allows for the expansion of a reference standard and includes the ability of a particular assay, performed on a specimen type to diagnose an infected individual. The following components of the evaluation should be standardized and carefully followed: specimen identification; collection; transportation; processing; quality control; reading; proficiency testing; confirmatory testing; discordant analysis ‐‐ sensitivity, specificity and predictive value calculations; and record keeping. Methods are available to determine whether sample results are true or false positives or negatives. Use‐effectiveness evaluations might determine the stability or durability of supplies and equipment; the logistics of shipping, receiving and storing supplies; the clarity and completeness of test instructions; the time and effort required to process and read results; the subjectivity factors in interpretation and reporting; and the costs. These determinations are usually more apparent for commercial assays than for homemade tests.
Chlamydial bacteriophage: No Role in Acute Coronary Events?
Authors: Patrick David M , Karunakaran Karuna , Levy Adrian R , Gin Kenneth , Remple Valencia , Chong Mei , Abbey Heather , Tarry Laura , Shen Caixia , Brunham Robert C
Published: March 2016

BACKGROUND: A relationship between Chlamydia pneumoniae infection and acute coronary syndromes has not been consistently found in published studies. It has been hypothesized that a bacteriophage‐infected subset of C pneumoniae may be uniquely equipped to promote atherosclerosis and acute coronary syndromes through the expression of phage genes. METHODS: The authors performed a pilot case‐control study of acute coronary events. Case and control subjects were characterized demographically and according to recognized coronary risk factors. These subjects also provided serum for the detection of antibody to the elementary bodies of C pneumoniae and antibody to the Vp1 protein coded by the phage. Bivariate and multivariate comparisons were performed using statistics appropriate for paired analyses. RESULTS: Antibodies to C pneumoniae, Vp1 protein or both were not associated with acute coronary events by bivariate or multivariate analysis. As expected, case subjects were significantly more likely to have hypertension, hypercholesterolemia or diabetes mellitus. CONCLUSION: The present study adds to a growing body of literature that does not support the hypothesized relationship between C pneumoniae (or a phage‐infected subset of C pneumoniae) and acute coronary syndromes.
Cardiac Device Infections due to Mycobacterium fortuitum
Authors: Hemmersbach-miller Marion , Cardenes-Santana Miguel A , Conde-Martel Alicia , Bolanos-Guerra José A , Campos-Herrero María I
Published: March 2016

Two cases of cardiac device infection due to Mycobacterium fortuitum are reported along with a discussion of their clinical management. Long‐term therapy and removal of the infected device is needed. The slow progression and absence of systemic signs and symptoms suggest a low pathogenicity of M fortuitum.
Cigarette Smoking and Asthma: A Dangerous Mix
Authors: Lemiere Catherine , Boulet Louis-Philippe
Published: March 2016

In Canada, 20% to 30% of the general population currently smoke. Smoking is as common in those suffering from asthma as it is in the general population. However, most studies on the pathophysiology of asthma and its response to treatment only include nonsmokers. Available data that examine the influence of smoking on clinical, functional and inflammatory characteristics of asthma, as well as the influence of smoking on the therapeutic response to corticosteroids, were reviewed. Active smoking is associated with an increased morbidity from asthma and impairs the response to inhaled corticosteroids. These observations emphasize the need for smoking cessation in patients with asthma and for reassessment of current treatment guidelines in this population.
Syndromes Associated with Sexually Transmitted Infections
Authors: Chernesky Max , Patrick David , Peeling Rosanna
Published: March 2016

Excellent technologies have been developed to identify the specific microbial agents of chlamydia, gonorrhea, syphilis, herpes, chancroid, trichomoniasis, human papillomavirus and HIV infection. However, it is also crucial to recognize syndromes that may be caused by one or more sexually transmitted pathogens. When laboratory services are lacking or are inadequate to provide timely results to enable appropriate treatment, some patients must be managed and treated syndromically. Most Canadian laboratories should be able to provide diagnostic services to determine the etiology of syndromes such as cervicitis, urethritis, pelvic inflammatory disease, prostatitis, genital ulcers, sexually transmitted infection (STI)‐related enteric infections, epididymitis, hepatitis, ophthalmia neonatorum, vulvovaginitis and vaginosis.
Vagus Nerve Stimulation Affects Pain Perception in Depressed Adults
Authors: Borckardt Jeffrey J , Kozel F Andrew , Anderson Berry , Walker Angela , George Mark S
Published: March 2016

BACKGROUND: Previous research suggests that vagus nerve stimulation (VNS) affects pain perception in epilepsy patients, with acute VNS decreasing pain thresholds and chronic VNS treatment increasing pain thresholds. However, no studies have investigated the effects of VNS on pain perception in chronically depressed adults, nor have controlled, systematic investigations been published on the differential effects of certain VNS device parameters on pain perception.

OBJECTIVES: The present study tried to replicate the results of previous research showing acute pronociceptive effects of VNS and determine the effects of various device parameter settings on pain tolerance. The present study also investigated the relationship among patients′ levels of depression, duration of VNS treatment and VNS‐induced changes in pain perception.

METHODS: A thermal pain challenge task was used to determine pain tolerance during VNS device activation using different combinations of VNS device parameter settings within subjects undergoing VNS therapy for chronic depression.

RESULTS: Significant pronociceptive effects were found for acute VNS activation. Individual differences were found with respect to the VNS settings associated with the largest changes in pain perception. Severity of depression was inversely related to baseline pain tolerance, but depression severity was unrelated to VNS‐induced acute changes in pain tolerance, as was the length of time participants had been undergoing VNS treatment.

CONCLUSIONS: VNS appears to affect pain perception in depressed adults. Different VNS parameter settings may be associated with unique effects from patient to patient. More studies are needed to determine the long‐term effects of VNS on pain perception.
HIV‐associated Lipodystrophy Syndrome: A Review of Clinical Aspects
Authors: Baril Jean-Guy , Junod Patrice , LeBlanc Roger , Dion Harold , Therrien Rachel , Laplante François , Falutz Julian , Côté Pierre , Hébert Marie-Nicole , Lalonde Richard , Lapointe Normand , Lévesque Dominic , Pinault Lyse , Rouleau Danielle , Tremblay Cécile , Trottier Benoît , Trottier Sylvie , Tsoukas Chris , Weiss Karl
Published: March 2016

Approximately two years after the introduction of highly active antiretroviral therapy for the treatment of HIV infection, body shape changes and metabolic abnormalities were increasingly observed. Initially, these were ascribed to protease inhibitors, but it is now clear that nucleoside reverse transcriptase inhibitors also contribute to lipodystrophy syndrome. The syndrome groups together clinical conditions describing changes in body fat distribution that include lipoatrophy, lipoaccumulation or both. However, there does not appear to be a direct link between lipoatrophy and lipoaccumulation that would support a single mechanism for the redistribution of body fat. Currently, there is no clear definition of lipodystrophy, which explains the difficulty in determining its prevalence and etiology. There are no current guidelines for the treatment of fat distribution abnormalities that occur in the absence of other metabolic complications. The present article reviews the current state of knowledge of the definition, symptoms, risk factors, pathogenesis, diagnosis and treatment of the morphological changes associated with lipodystrophy syndrome.
The Laboratory Diagnosis of Neisseria gonorrhoeae
Authors: Ng Lai-King , Martin Irene E
Published: March 2016

The present article describes the laboratory diagnosis of Neisseria gonorrhoeae by culturing of the organism from different types of clinical specimens followed by confirmatory tests. The success of culture methods requires good quality collection and transport of clinical specimens. The present guide describes the media requirements and cultural conditions for N gonorrhoeae growth and the characteristics for a presumptive identification of N gonorrhoeae. Confirmatory tests include biochemical tests, chromogenic enzyme substrate tests, immunoassays and nucleic acid methods. Nucleic acid detection methods include either amplification‐based methods or nonamplification tests, and are increasingly used in clinical laboratories where a viable culture is not possible to obtain. Nucleic acid methods can also be used to detect the presence of low numbers in a specimen. Nucleic acid detection methods need confirmation with another amplification method or gene target. Controls must be included to ensure true positive and negative results, and to rule out nucleic acid contamination. Monitoring of antimicrobial susceptibilities of N gonorrhoeae is important to investigate treatment failure and to evaluate the efficacy of currently recommended therapies. Many methods for the characterization of N gonorrhoeae require cultures. The useful typing methods for determining strain relatedness include auxotyping, serotyping, plasmid profile analysis, DNA sequencing of the porB gene and pulsed‐field gel electrophoresis. Quality assurance programs for diagnostic testing and antimicrobial susceptibility testing is reviewed.
Key Research Issues in Clostridium difficile
Authors: Zhanel George , Hammond Greg
Published: March 2016

Clostridium difficile is an emerging pathogen that causes C difficile‐associated diarrhea, an important nosocomial infection. Control of this infection remains a challenge, and much needs to be determined about the antimicrobial resistance of the organism, antibiotic stewardship, contamination of the patient environment, and various host factors that determine susceptibility or resistance to infection. A national symposium focusing on C difficile infections, the Clostridium difficile Symposium on Emerging Issues and Research, was hosted on November 23, 2004, by the Department of Medical Microbiology and Infectious Diseases at the University of Manitoba, Winnipeg, Manitoba, in partnership with the Canadian Institutes of Health Research. This symposium, which aimed to summarize key research issues regarding C difficile infections in Canada, had the following objectives: to provide a forum for learning and discussion about C difficile and its impact on the health of Canadians; to identify the key research issues that should be addressed; and to explore potential research funding opportunities and collaboration. The present report summarizes key research issues identified for C difficile infections in Canada by addressing four major themes: diagnosis and surveillance, infection prevention and control, antibiotic stewardship, and clinical management.
Pediatric Interstitial Lung Disease Masquerading as Difficult Asthma: Management Dilemmas for Rare Lung Disease in Children
Authors: Chan EY , Dell Sharon D
Published: March 2016

Idiopathic nontransplant‐related childhood bronchiolitis obliterans is an uncommon disease. Most patients present with chronic recurrent dyspnea, cough and wheezing, which are also features of asthma, by far a much more common condition. The present case study reports on a six‐year‐old girl who presented to a tertiary care centre with recurrent episodes of respiratory distress on a background of baseline tachypnea, chronic hypoxemia and exertional dyspnea. Her past medical history revealed significant lung disease in infancy, including respiratory syncytial virus bronchiolitis and repaired gastroesophageal reflux. She was treated for ′asthma exacerbations′ throughout her early childhood years. Bronchiolitis obliterans was subsequently diagnosed with an open lung biopsy. She did not have sustained improvement with systemic corticosteroids, hydroxychloroquine or clarithromycin. Cardiac catheterization confirmed the presence of secondary pulmonary hypertension. Treatment options remain a dilemma for this patient because there is no known effective treatment for this condition, and the natural history is not well understood. The present case demonstrates the need for careful workup in ′atypical asthma′, and the urgent need for further research into the rare lung diseases of childhood.
The Laboratory Diagnosis of Hepatitis B Virus
Authors: Krajden Mel , McNabb Gail , Petric Martin
Published: March 2016

Hepatitis B virus (HBV) chronically infects approximately 250,000 Canadians and 350 million people worldwide. Without intervention, approximately 15% to 40% of chronically infected individuals will eventually develop cirrhosis, end‐stage liver disease or hepatocellular carcinoma, or require liver transplantation. The availability and extensive use of the HBV vaccine has dramatically reduced the number of incident infections in Canada and worldwide. Effective therapeutic agents have been and continue to be developed to treat chronic infection. The present review provides a comprehensive overview of diagnostic tests for HBV infection and immunity, and elaborates on HBV risk factors, vaccine prevention and therapeutic monitoring. HBV diagnosis is accomplished by testing for a series of serological markers of HBV and by additional testing to exclude alternative etiological agents such as hepatitis A and C viruses. Serological tests are used to distinguish acute, self‐limited infections from chronic HBV infections and to monitor vaccine‐induced immunity. Nucleic acid testing for HBV‐DNA is increasingly being used to quantify HBV viral load and measure the effectiveness of therapeutic agents. Given the multitude of available tests and the complexity of clinical management, there is a critical need for greater coordination among clinicians, diagnostic laboratory personnel and researchers to define optimal laboratory diagnostic and monitoring assays so that the appropriate tests are used to maximize prevention and optimize treatment outcomes.
Systemic Actinomycosis Mimicking Pelvic Malignancy with Pulmonary Metastases
Authors: Lawson Edward
Published: March 2016

A 40‐year‐old woman presented with profound weight loss, anemia and multiple pulmonary nodules. Further investigation revealed a hepatic abscess and a pelvic mass associated with an intrauterine device. Cultures of the hepatic abscess and from peripheral blood demonstrated Actinomyces species. The patient underwent an exploratory laparotomy and hysterectomy. Pathological examination showed characteristic sulphur granules of actinomycosis. Long‐term therapy with high‐dose intravenous penicillin resulted in clinical and radiographic improvement.
Interpretation of Transbronchial Lung Biopsies from Lung Transplant Recipients:Inter‐ and Intraobserver Agreement
Authors: Stephenson Anne , Flint Julia , English John , Vedal Sverre , Fradet Guy , Chittock Dean , Levy Robert D
Published: March 2016

BACKGROUND: Transbronchial lung biopsy results are crucial for the management of lung transplant recipients. Little information is available regarding the reliability and reproducibility of the interpretation of transbronchial lung biopsies.

OBJECTIVE: To examine the inter‐reader variability between two lung pathologists with expertise in lung transplantation.

METHODS: Fifty‐nine transbronchial lung biopsy specimens were randomly selected. Active infection had been excluded in all cases. The original interpretations (as per the Lung Rejection Study Group) for acute rejection grade included 19 biopsies scored as A0 (none), 14 scored as A1 (minimal), 12 as A2 (mild), 11 as A3 (moderate) and three as A4 (severe). The pathologists worked independently without clinical information or knowledge of the original interpretation. The specimens were graded using the Lung Rejection Study Group criteria for acute rejection (grades A0 to A4), airway inflammation (grades B0 to B4) and bronchiolitis obliterans (C0 absent and C1 present). Between‐reader agreement for each category was analyzed using a Kappa statistic.

RESULTS: Because many transplant specialists initiate augmented immunosuppression with biopsy grades of A2 or higher, results for each reader were dichotomized as A0/A1 versus A2/A3/A4. Using this dichotomy, there was only moderate agreement (kappa 0.470, P<0.001) between readers. For categories B and C, the results were dichotomized for the absence or presence of airway inflammation and bronchiolitis obliterans, respectively. The level of agreement between readers was fair for category B (kappa 0.333, P=0.014) and poor for category C (kappa 0.166, P=0.108). The intrareader agreement for acute rejection was substantial (kappa 0.795, P=0.0001; kappa 0.676, P=0.0001).

CONCLUSIONS: Because the agreement between expert pathologists is only modest, optimum clinical decision‐making requires that transbronchial lung biopsy results be used in an integrated clinical context.
Chest Tube Drainage Under Radiological Guidance for Pleural Effusion and Pneumothorax in a Tertiary Care University Teaching Hospital: Review of 51 Cases
Authors: Cantin Luce , Chartrand-Lefebvre Carl , Lepanto Luigi , Gianfelice David , Rabbat Antoine , Aubin Benoît , Perreault Pierre , Déry Renée , Lafortune Michel
Published: March 2016

BACKGROUND: Chest tube drainage under radiological guidance has been used with increasing frequency as a treatment option for pleural effusions and pneumothoraxes.

OBJECTIVE: To evaluate the safety and usefulness of pleural drainage under radiological guidance for pleural effusion and pneumothorax in a tertiary care university teaching hospital.

METHODS: A retrospective study of cases of chest tube placement under radiological guidance over a 12‐month period in a university hospital.

RESULTS: Fifty‐one percutaneous pigtail catheter drainage cases were reviewed (30 patients). Forty‐six (90%) chest tubes were inserted as a first‐line treatment. The overall success rate of radiological drainage was 88%. Specific success rates were 92%, 85% and 91% for loculated pleural effusion, pneumothorax and empyema, respectively. The complications were few and minor.

CONCLUSIONS: Pigtail catheter insertion under radiological guidance is a useful procedure for the treatment of sterile pleural effusion, empyema and pneumothorax. This technique can be used as a first‐line procedure in the majority of cases.
Rhinoscleroma Causing Upper Airway Obstruction
Authors: Verma Geetika , Kanawaty D , Hyland R
Published: March 2016

Rhinoscleroma is a chronic granulomatous condition of the respiratory tract, and is not uncommon in tropical regions; particularly, Mexico, Central America and the Middle East. A few cases have been reported in North America, primarily involving immigrants from endemic countries. The causative organism is Klebsiella rhinoscleromatis, a Gram‐negative coccobacillus. Diagnosis is made on the basis of culture of the organism and the characteristic pathology of Mikulicz cells on light microscopy. The condition primarily affects the upper airway, and frequently presents with nasal discharge, nasal obstruction or frontal facial pain. Despite the term ′rhinoscleroma′, there may be involvement of the entire respiratory tract. Although the condition is slowly progressive, its natural course portends extensive destruction. Laryngotracheal involvement occurs in approximately 15% to 80% of cases, but patients rarely present with isolated laryngotracheal disease. In the present paper, a case of rhinoscleroma presenting with symptoms of upper airway obstruction is described.