bluuebunny/crossref_metadata_2025 huggingface dataset:
Pain in the Emergency Department with One‐Week Follow‐Up of Pain Resolution
Authors: Johnston C Celeste , Gagnon Anita J , Pepler Carolyn J , Bourgault Patricia
Published: March 2016

OBJECTIVES: To determine the intensity of pain in the emergency department (ED), the use of analgesics in relation to pain intensity, which patients are at risk for unresolved pain at one week post‐discharge, and the postdischarge treatment of pain.

METHODS: Patients (n=871) admitted to two urban, university‐affiliated EDs who were experiencing any pain were recruited on different shifts over the summer months of 1997. Pain intensity was self‐reported, and chart reviews of the assessment, immediate treatment and follow‐up prescriptions were conducted. Patients (n=699) were contacted one week later, and reports of pain intensity, activity, resuming normal functions and patient attitudes toward pain were documented. Descriptive and regression analyses were performed on the results of patients with complete data (n=585).

RESULTS: Mean pain intensity on admission was 6.0 (SD=2.5) on a zero to 10 visual analogue scale, and 5.0 (SD=2.9) at discharge (n=871). One‐quarter (23%) of patients were given analgesics while in the ED; their mean pain intensity was 7.0 (95% CI 6.7 to 7.3) versus 5.7 (95% CI 5.5 to 5.9) for those who were not given analgesics (P<0.001). At one week, the mean intensity for worst pain in the past 24 h was 5.2 (SD=2.9) and the usual pain intensity was 3.7 (SD=2.6). Using a cutoff point of pain greater than three on the zero to 10 visual analogue scale as residual pain at one week, 35% (n=207) remained in pain, with musculoskeletal pain accounting for half (n=102) of those cases. Logistic regression showed that the following patients were most likely to have pain at one week: women; those with pain present longer than 48 h before ED visit; those with a high discharge pain rating; those who were taking analgesics; and those who had pain of musculoskeletal origin. Both the attitudes and beliefs about pain and the treatment of pain while in the ED or on discharge were unrelated to the presence of residual pain at one week. An examination of the same factors in relation to the return to normal activities found that they were similar, with the exception that admission and not discharge pain intensity was predictive of not returning to normal activities.

CONCLUSIONS: More than one‐third of patients presenting to the ED with pain do not experience resolution of their pain. Women presenting with severe musculoskeletal pain of more than a week in duration are less likely to have resolution of their pain and to return to normal activities within a week of the ED visit.
Hepatic Actinomycosis with Infiltration of the Diaphragm and Right Lung: A Case Report
Authors: Islam Tasbirul , Athar Muhammad Nauman , Athar Muhammad Kamran , Usman Mohammed Haris Umer , Misbah Baqir
Published: March 2016

Actinomycosis is an indolent, slowly progressive infection caused by anaerobic or microaerophilic bacteria of the genus Actinomyces. Actinomycosis has a myriad of clinical presentations, inducing both a suppurative and granulomatous inflammatory response. The infection spreads contiguously through anatomical barriers and frequently forms external sinuses. The most common clinical presentations are cervicofacial, thoracic, abdominal and, in females, genital. Classic features include purulent foci surrounded by dense fibrosis that, over time, cross natural boundaries into contiguous structures, with the formation of fistulas and sinus tracts in some cases. Hepatic actinomycosis presents as single or multiple abscesses or masses. Reported here is the unusual occurrence of actinomycosis of the liver involving the diaphragm and right lung. The present case illustrates the difficulties in diagnosing this rare and unrecognized disease.
Immunization Update 2005: Stepping Forward
Authors: Macdonald Noni E
Published: March 2016

This year marks a major step forward in improving access for all children and youth in Canada to the routine vaccines recommended by the National Advisory Committee on Immunization (Figure 1) (1). The disparity in vaccine access between have and have not regions noted previously (2,3) has been narrowed through the collaboration of the federal and provincial/territorial governments in the area of immunization (4). Unfortunately, harmonization of schedules across the country still remains a dream (Table 1). This lack of harmony continues to put children and youth who relocate at potential risk for missing out on a routine vaccine due to schedule timing differences. This is not a new problem (5) but one that is now more exaggerated due to the added variation in schedules and catch‐up programs with the ?newer? vaccines (eg, varicella, conjugated pneumococcal and conjugated meningococcal vaccines) (Tables 1 and 2). Determining what a child or youth needs on arrival into a new region is often not an easy task.
Listeria Meningitis Complicating Infliximab Treatment for Crohn’s Disease
Authors: Williams Geoffrey , Khan Asad A , Schweiger Franzjosef
Published: March 2016

Infliximab, a monoclonal antibody directed against tumour necrosis factor‐alpha, is an effective therapy for Crohn′s disease. Though uncommon, serious opportunistic infections, including reactivation of tuberculosis, have occurred in patients after infliximab administration. Meningitis caused by Listeria monocytogenes developed in a 37‐year‐old man six days after the second infusion of infliximab. The patient, who also was treated with azathioprine and corticosteroids, had an uneventful recovery after a course of antibiotics. Several other recent reports have implicated infliximab therapy in the development of severe Listeria infections, particularly meningitis and sepsis. With the increasing use of tumour necrosis factor‐alpha‐neutralizing agents, clinicians should be aware of the risk of opportunistic infections caused by L monocytogenes in patients with Crohn′s disease following infliximab treatment.
A Systematic Review of Risk Factors Associated with Near‐Fatal and Fatal Asthma
Authors: Alvarez GG , Schulzer M , Jung D , FitzGerald JM
Published: March 2016

BACKGROUND: Asthma mortality and morbidity continue to be a serious global problem. Systematic reviews provide an opportunity to review risk factors in detail.

OBJECTIVE: To review all of the literature for risk factors associated with near‐fatal asthma (NFA) and fatal asthma (FA).

METHODS: A literature search from 1960 to January 2004 in MEDLINE and EMBASE was conducted. Studies were included based on the following criteria: NFA was defined as an asthma exacerbation resulting in respiratory arrest requiring mechanical ventilation or a partial pressure of CO2 of at least 45 mmHg or asthma resulting in death (FA); the study reported the number of cases (NFA and/or FA) and asthmatic controls; there was explicit reporting of risk factors; cases that were adult and pediatric in nature; and all study types. Studies that included patients with chronic obstructive pulmonary disease were excluded.

RESULTS: Four hundred and three articles were identified, of which 27 met the inclusion criteria. Increased use of medications such as beta‐agonists via metered dose inhalers (OR=1.67, 95% CI 0.99 to 2.84, P=0.057) and nebulizers (OR=2.45, 95% CI 1.52 to 3.93, P=0.0002), oral steroids (OR=2.71, 95% CI 1.34 to 5.51, P=0.006) and oral theophylline (OR=2.02, 95% CI 1.03 to 3.98, P=0.04) and a history of hospital (OR=2.62, 95% CI 1.04 to 6.58, P=0.04) and/or intensive care unit (OR=5.14, 95% CI 1.91 to 13.86, P=0.001) admissions and mechanical ventilation (OR=6.69, 95% CI 2.80 to 15.97, P=0.0001) due to asthma were predictors of NFA and FA. Prior emergency department assessment did not confer a greater risk of NFA and FA (OR=1.13, 95% CI 0.43 to 2.92, P=0.810).The use of inhaled corticosteroids (ICS) measured in a dose‐independent fashion (did the patient take ICS previously; yes or no) inferred equivocal risk of NFA and FA (OR=1.31, 95% CI 0.83 to 2.05, P=0.25). However, two studies measured the use of ICS in a dose‐dependent fashion (ie, measured the number of prescriptions filled within the previous six to 12 months). Both studies showed a trend toward a protective effect against FA. One study showed that the premature cessation of ICS can hasten death.

CONCLUSIONS: In the present study, risk factors of NFA and FA have been more accurately defined. Clinicians should identify patients with these characteristics to reduce their risk of NFA and FA. Further research should focus on quantifying the impact of risk factors on asthma deaths.
Enhanced Surveillance of non‐O157 Verotoxin‐Producing Escherichia coli in Human Stool Samples from Manitoba
Authors: Thompson Laura H , Giercke Sandra , Beaudoin Carole , Woodward David , Wylie John L
Published: March 2016

BACKGROUND: Relatively few enhanced surveillance studies have been undertaken to investigate the extent to which verotoxin‐producing non‐O157 serotypes of Escherichia coli occur in stool samples received for the detection of verotoxin‐producing organisms.

OBJECTIVES: To describe the prevalence, molecular and epidemiological characteristics, and geographical patterns associated with non‐O157 verotoxin‐producing E coli (VTEC) in Manitoba.

RESULTS: Thirty‐two VTEC isolates consisting of 10 serogroups and 13 different serotypes were isolated over a 22‐month period. Twenty‐three isolates (71.8%) possessed verotoxin‐encoding gene stx1 only, five isolates (15.6%) possessed stx2 only, two isolates (6.3%) possessed both stx1 and stx2, and two isolates (6.3%) possessed stx2c. Only three instances of indistinguishable pulsed‐field gel electrophoresis patterns were identified. The age of the individuals from whom non‐O157 VTEC were isolated ranged from eight months to 87 years. Mean and median ages were 30 and 22 years of age, respectively. Some areas of the province appeared to experience a higher than expected number of non‐O157 E coli in comparison with the number of stools that were received from these areas.

CONCLUSIONS: The present study demonstrated a large number of infections associated with non‐O157 VTEC in Manitoba. Most non‐O157 cases appear to result from sporadic infections, and these occur typically in rural areas. Continued enhanced surveillance is necessary to understand the temporal patterns of non‐O157 VTEC and the underlying epidemiological factors driving these patterns.
Probable Linezolid‐Induced Pancytopenia
Authors: Lakhani Nita , Thompson William , Bombassaro Anne Marie
Published: March 2016

A 75‐year‐old male outpatient with cardiac disease, diabetes, chronic renal insufficiency and iron deficiency anemia was prescribed linezolid 600 mg twice daily for a methicillin‐resistant Staphylococcus aureus diabetic foot osteomyelitis. After one week, his blood counts were consistent with baseline values. The patient failed to return for subsequent blood work. On day 26, he was admitted to hospital with acute renal failure secondary to dehydration, and was found to be pancytopenic (erythrocytes 2.5x1012/L, leukocytes 2.9x109/L, platelets 59x109/L, hemoglobin 71 g/L). The patient was transfused, and linezolid was discontinued. His blood counts improved over the week and remained at baseline two months later. The patient′s decline in blood counts from baseline levels met previously established criteria for clinical significance. Application of the Naranjo scale indicated a probable relationship between pancytopenia and linezolid. Clinicians should be aware of this rare effect with linezolid, and prospectively identify patients at risk and emphasize weekly hematological monitoring.
Risk Factors for New‐Onset Diabetes Mellitus in Patients Receiving Protease Inhibitor Therapy
Authors: Hughes Christine A , Cashin Richard P , Eurich Dean T , Houston Stan
Published: March 2016

BACKGROUND: Metabolic complications including diabetes mellitus (DM) have been associated with protease inhibitor (PI) therapy. Risk factors for the development of DM are not well‐defined.

OBJECTIVES: To determine risk factors for the development of new‐onset DM in patients initiated on PI therapy.

METHODS: A retrospective cohort study was conducted to identify predictors of developing DM in subjects started on PI therapy between January 1997 and January 2003. Diabetes cases were defined as physician documentation of DM in the outpatient medical chart and/or those subjects receiving an antidiabetic agent. Logistic regression was used to examine the relationship between new‐onset DM and demographic characteristics, and between new‐onset DM and total treatment days with PI therapy. Body mass index could not be entered into the model due to missing height measurements.

RESULTS: A total of 496 subjects on PI therapy were included, of which 18 (3.6%) developed DM. The mean age of the subjects was 43.4±9.4 years (range 19 to 77) and the mean duration of therapy was 3.0±1.9 years (range 0.17 to 7.9). In the multivariate model, older subjects were more likely to develop DM (OR 1.12, 95% CI 1.05 to 1.19; P=0.001). This corresponds to a 12% increased risk of DM for each one‐year increase in age. Subjects that weighed more had an increased risk (OR 1.06, 95% CI 1.03 to 1.10; P=0.001), as did those belonging to a non‐Aboriginal minority group when compared with Caucasians (OR 6.67, 95% CI 1.56 to 28.41; P=0.01). A longer duration of PI therapy was also significantly associated with developing DM (OR 1.52, 95% CI 1.07 to 2.17; P=0.02).

CONCLUSION: A longer duration of PI therapy is associated with an increased risk of developing DM. As with HIV‐negative subjects, demographic characteristics such as age, weight and ethnicity were important predictors of developing DM in the present study.
Doctor, There′s a Tadpole in my Feces!
Authors: Drisdelle Rosemary , Forward Kevin R
Published: March 2016

A 36‐year‐old male resident of a coastal Nova Scotia community presented to his family physician after he noted moving objects in his feces (Figure 1). Although concerned and revolted, he was asymptomatic. He was worried that the organisms were an intestinal parasite he had passed in his stool. The organisms were approximately 2.5 cm long and resembled tadpoles. The fecal sample was sent to the Parasitology Section at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, for identification.
Q Fever Presenting as Recurrent, Culture‐Negative Endocarditis with Aortic Prosthetic Valve Failure: A Case Report and Review of the Literature
Authors: AlShukairi Abeer N , Morshed Muhammad G , Reiner Neil E
Published: March 2016

The present report describes a case of recurrent, culture‐negative endocarditis presenting with aortic prosthetic valve dysfunction in a 62‐year‐old man who required four valve replacement surgeries. On each occasion, he presented with valve failure. Fever was only documented during his first presentation. Furthermore, no vegetations were detectable on his aortic valve at transesophageal echocardiography. On the occasion of his most recent presentation, a detailed history of animal exposure ‐‐ including hunting and skinning deer, moose and other large animals with his bare hands ‐‐ was the only clue to his diagnosis. Serum antibodies against Coxiella burnetii were strongly positive, and C burnetii DNA was detected by polymerase chain reaction from his resected aortic valve tissue. Q fever is a worldwide zoonotic infection with diverse reservoirs. This diagnosis should be considered when evaluating unexplained prosthetic valve dysfunction, particularly in the setting of animal exposure.
Pneumonia and Pleural Effusion due to Cryptococcus Laurentii in a Clinically Proven Case of AIDS
Authors: Shankar Esaki Muthu , Kumarasamy Nagalingeswaran , Bella Devaleenol , Renuka Srinivasan , Kownhar Hayath , Suniti Solomon , Rajan Ramachandran , Rao Usha Anand
Published: March 2016

Non‐neoformans cryptococci were previously considered to be saprophytes and nonpathogenic to humans. Cryptococcus laurentii is frequently used as a biological means to control fruit rot. Interestingly, C laurentii has recently been reported to be a rare cause of infection in humans. The authors report a case of pulmonary cryptococcosis caused by C laurentii in a diabetic AIDS patient who was on antituberculosis and antiretroviral treatments. The sputum smear revealed capsulated yeast cells that were identified as C laurentii. Repeated pleural fluid culture revealed growth of C laurentii. Both respiratory samples were negative for acid‐fast bacilli. Moraxella catarrhalis and Klebsiella pneumoniae were also found in the sputum, but not in the pleural fluid. The patient had a good response to oral fluconazole therapy at 600 mg/day for five weeks and was then discharged. The present article is the first to report on the rare pulmonary involvement of C laurentii in the Indian HIV population. These unusual forms of cryptococci create a diagnostic predicament in the rapid diagnosis of pulmonary cryptococcosis. A high degree of suspicion and improvement of techniques for culture and identification will contribute to the early diagnosis and treatment of unusual fungal infections.
Vibrio vulnificus Septicemia after Handling Tilapia Species Fish: A Canadian Case Report and Review
Authors: Vinh Donald C , Mubareka Samira , Fatoye Bunmi , Plourde Pierre , Orr Pamela
Published: March 2016

BACKGROUND: Vibrio vulnificus can cause a necrotizing soft tissue infection or primary septicemia; these infections are collectively known as vibriosis. This bacterium is commonly found within molluscan shellfish. Primary septicemia is often fatal, principally affecting persons with chronic liver disease.

CASE PRESENTATION: A fatal case of V vulnificus sepsis that developed in a patient with chronic hepatitis B and chronic renal failure is reported. Diagnosis was made by isolation of the pathogen by blood culture. Upon further questioning, the patient′s family recounted that the patient had handled and ingested Tilapia species fish in the hours preceding the patient′s presentation. Despite treatment with doxycycline and cefotaxime, in conjunction with supportive care in the intensive care unit, the patient died on day 7 from multiple organ dysfunction.

CONCLUSION: The present case highlights the need to consider V vulnificus in the microbiological differential diagnosis when a person presents with sepsis and bullous cutaneous lesions. The importance of educating patients with liver disease (and certain other chronic diseases) about the need to be cautious when handling or consuming seafood is underscored.
The Use of Antiviral Drugs for Influenza: Recommended Guidelines for Practitioners
Authors: Allen Upton D , Aoki Fred Y , Stiver H Grant , for the Canadian Paediatric Society and the Association of M
Published: March 2016

The present document outlines current guidelines and supporting literature relating to the use of antiviral drugs for chemoprophylaxis and influenza illness therapy in paediatric and adult settings. The focus is on the management of influenza in interpandemic periods. Where appropriate, the areas in need of additional research are identified. It will be necessary to update aspects of these guidelines as new information emerges. The recommendations that follow represent the results of a joint effort supported by the Canadian Paediatric Society and the Association of Medical Microbiology and Infectious Disease Canada.
The Association ofHelicobacter pyloriInfection and Nonsteroidal Anti-Inflammatory Drugs in Peptic Ulcer Disease
Authors: Zapata-Colindres Juan Carlos , Zepeda-Gómez Sergio , Montaño-Loza Aldo , Vázquez-Ballesteros Edgar , de Jesús Villalobos José , Valdovinos-Andraca Francisco
Published: March 2016

BACKGROUND AND AIM: Peptic ulcer disease (PUD) affects 10% of the world population.Helicobacter pyloriinfection and the use of a nonsteroidal anti-inflammatory drug (NSAID) are the principal factors associated with PUD. The aim of the present study was to evaluate a cohort of patients with PUD and determine the association betweenH pyloriinfection and NSAID use.

PATIENTS AND METHODS: The medical charts of patients with endoscopic diagnosis of PUD were retrospectively reviewed from September 2002 to August 2003. Patients were divided into three groups according to ulcer etiology:H pyloriinfection (group 1); NSAID use (group 2); and combinedH pyloriinfection and NSAID use (group 3).

RESULTS: One hundred two patients were evaluated: 36 men (35.3%) and 66 women (64.7%). Forty patients hadH pyloriinfection, 43 had used NSAIDs and 15 had combinedH pyloriinfection and NSAID use; four patients with ulcers secondary to malignancy were excluded. The frequency of women was significantly higher in group 2 (P=0.01). The mean age of patients in group 1 was significantly lower than in the other two groups (P=0.003). PUD developed earlier in group 3 than in group 2 (5.0±4.7 months versus 1.4±2.1 months, respectively, P=0.018). Thirty-two patients (32.7%) had bleeding peptic ulcer. Group 2 had a higher risk of bleeding peptic ulcer than the other two groups (P=0.001).

CONCLUSIONS: The development of PUD was observed earlier in the combinedH pyloriand NSAID group than in patients with only NSAID use. This suggests a synergic effect between the two risks factors in the development of PUD.
Prion Diseases and the Gastrointestinal Tract
Authors: Davies Gwynivere A , Bryant Adam R , Reynolds John D , Jirik Frank R , Sharkey Keith A
Published: March 2016

The gastrointestinal (GI) tract plays a central role in the pathogenesis of transmissible spongiform encephalopathies. These are human and animal diseases that include bovine spongiform encephalopathy, scrapie and Creutzfeldt-Jakob disease. They are uniformly fatal neurological diseases, which are characterized by ataxia and vacuolation in the central nervous system. Alhough they are known to be caused by the conversion of normal cellular prion protein to its infectious conformational isoform (PrPsc) the process by which this isoform is propagated and transported to the brain remains poorly understood. M cells, dendritic cells and possibly enteroendocrine cells are important in the movement of infectious prions across the GI epithelium. From there, PrPscpropagation requires B lymphocytes, dendritic cells and follicular dendritic cells of Peyer’s patches. The early accumulation of the disease-causing agent in the plexuses of the enteric nervous system supports the contention that the autonomic nervous system is important in disease transmission. This is further supported by the presence of PrPscin the ganglia of the parasympathetic and sympathetic nerves that innervate the GI tract. Additionally, the lymphoreticular system has been implicated as the route of transmission from the gut to the brain. Although normal cellular prion protein is found in the enteric nervous system, its role has not been characterized. Further research is required to understand how the cellular components of the gut wall interact to propagate and transmit infectious prions to develop potential therapies that may prevent the progression of transmissible spongiform encephalopathies.
Predictors of Loss of Asthma Control Induced by Corticosteroid Withdrawal
Authors: Belda Jose , Parameswaran Krishnan , Lemière Catherine , Kamada Dennis , O′Byrne Paul M , Hargreave Frederick E
Published: March 2016

BACKGROUND: Asthma guidelines recommend reducing the dose of inhaled corticosteroids after establishing control.

OBJECTIVE: To identify predictors of loss of control and the kinetics of symptoms, and inflammatory and physiological measurements when inhaled corticosteroids are reduced in patients with stable asthma.

PATIENTS AND METHODS: In a single‐blind study, the daily dose of inhaled corticosteroid was reduced by one‐half at intervals of 20±2 days in 17 adults with controlled asthma until loss of asthma control occurred or until the corticosteroid was replaced with placebo for 20 days. The patients recorded symptoms and peak expiratory flow each day, and forced expiratory volume in 1 s (FEV1), the provocative concentration of methacholine causing a 20% fall in FEV1 (PC20), exhaled nitric oxide, and eosinophils in sputum and blood were measured every 10 days. A loss of asthma control was defined as a worsening of the symptoms score of at least 20%, and either a decrease in FEV1 of at least 15% or a decrease in PC20 of at least fourfold.

RESULTS: Two patients had a respiratory infection and were withdrawn from the study. In eight patients, asthma became uncontrolled after a mean of 33 days (range 13 to 48 days). This was accurately reflected by a worsening of all parameters. The first parameter to change was the sputum eosinophil percentage (20 days before the loss of asthma control). Significant changes in exhaled nitric oxide, FEV1 and methacholine PC20 were observed only when the symptoms became uncontrolled. A high blood eosinophil count at baseline (risk ratio of 2.5, 95% CI 1.0 to 6.5) and an increase in sputum eosinophil count after the reduction of corticosteroids were predictors of loss of asthma control.

CONCLUSION: In patients whose asthma is controlled on inhaled corticosteroid, it is prudent not to reduce the dose further if the blood eosinophils are increased or if the sputum eosinophils increase by as little as 1% after the reduction of corticosteroids.
Clinical Diagnosis of Achalasia: How Reliable is the Barium X-Ray?
Authors: El-Takli I , O’Brien P , Paterson WG
Published: March 2016

Manometry is considered to be the gold standard for the diagnosis of achalasia. However, many physicians believe that contrast radiography, classically showing esophageal dilation with bird-beak narrowing of the gastroesophageal junction, is also accurate in either diagnosing or excluding the disorder. The aim of the current study was to determine the accuracy of barium x-ray in the diagnosis of achalasia. The radiological diagnosis of all patients manometrically diagnosed with achalasia (using conventional criteria) between January 1994 and June 1998 were reviewed. A total of 51 cases of achalasia were identified. Thirteen patients were excluded because they either did not have contrast radiography before a manometric diagnosis or had their x-rays performed more than six months previously. Of the remaining 38 patients, achalasia was stated as a diagnostic possibility in the radiologists report in only 22 (58%) of those patients. Achalasia was not considered in the remaining 16 patients: two were reported as normal, four as having stenosis/narrowing in distal esophagus, two as having presbyesophagus, one as having mild gastroesophageal reflux and seven as having nonspecific dysmotility. To determine the reason for the diagnostic failure of the barium x-ray, an expert gastrointestinal radiologist reviewed 12 of the nondiagnostic x-rays in a blinded fashion, interspersed with 10 randomly selected esophageal-contrast radiographs from control subjects to avoid bias. Of these initially nondiagnostic x-rays in achalasia patients, typical radiological features of achalasia were deemed to be present in 50%. The present study indicates that contrast radiography lacks sensitivity in the diagnosis of achalasia. This is not only due to radiologist oversight but also because of the absence of the characteristic radiological features in many cases. This reinforces the important role of esophageal manometry in patients with persistent nonstructural dysphagia.
Tweaking Innate Immunity: The Promise of Innate Immunologicals as Anti‐Infectives
Authors: Rosenthal Kenneth L
Published: March 2016

New and exciting insights into the importance of the innate immune system are revolutionizing our understanding of immune defense against infections, pathogenesis, and the treatment and prevention of infectious diseases. The innate immune system uses multiple families of germline‐encoded pattern recognition receptors (PRRs) to detect infection and trigger a variety of antimicrobial defense mechanisms. PRRs are evolutionarily highly conserved and serve to detect infection by recognizing pathogen‐associated molecular patterns that are unique to microorganisms and essential for their survival. Toll‐like receptors (TLRs) are transmembrane signalling receptors that activate gene expression programs that result in the production of proinflammatory cytokines and chemokines, type I interferons and antimicrobial factors. Furthermore, TLR activation facilitates and guides activation of adaptive immune responses through the activation of dendritic cells. TLRs are localized on the cell surface and in endosomal/lysosomal compartments, where they detect bacterial and viral infections. In contrast, nucleotide‐binding oligomerization domain proteins and RNA helicases are located in the cell cytoplasm, where they serve as intracellular PRRs to detect cytoplasmic infections, particularly viruses. Due to their ability to enhance innate immune responses, novel strategies to use ligands, synthetic agonists or antagonists of PRRs (also known as ′innate immunologicals′) can be used as stand‐alone agents to provide immediate protection or treatment against bacterial, viral or parasitic infections. Furthermore, the newly appreciated importance of innate immunity in initiating and shaping adaptive immune responses is contributing to our understanding of vaccine adjuvants and promises to lead to improved next‐generation vaccines.
Fibrous Myopathy as a Complication of Repeated Intramuscular Injections for Chronic Headache
Authors: Burnham R , McNeil S , Hegedus C , Gray DS
Published: March 2016

Two cases of fibrous myopathy associated with repeated, long‐term intramuscular injections for treatment of chronic temporomandibular joint pain and chronic headache, respectively, are described. Both patients developed severe, function‐limiting contractures in upper and lower extremity muscles used as injection sites. In one of the cases, the contractures were painful. Electrophysiological testing, magnetic resonance imaging and muscle biopsy results were all consistent with myopathy and replacement of skeletal muscle with noncontractile fibrous tissue. These cases are presented to increase awareness of fibrous myopathy and to promote surveillance for this serious potential complication of long‐term intramuscular injections in chronic headache and other pain patients.
Acute Management and Secondary Prophylaxis of Esophageal Variceal Bleeding: A Western Canadian Survey
Authors: Cheung Justin , Wong Winnie , Zandieh Iman , Leung Yvette , Lee Samuel S , Ramji Alnoor , Yoshida Eric M
Published: March 2016

BACKGROUND: Acute esophageal variceal bleeding (EVB) is a major cause of morbidity and mortality in patients with liver cirrhosis. Guidelines have been published in 1997; however, variability in the acute management and prevention of EVB rebleeding may occur.

METHODS: Gastroenterologists in the provinces of British Columbia, Alberta, Manitoba and Saskatchewan were sent a self-reporting questionnaire.

RESULTS: The response rate was 70.4% (86 of 122). Intravenous octreotide was recommended by 93% for EVB patients but the duration was variable. The preferred timing for endoscopy in suspected acute EVB was within 12 h in 75.6% of respondents and within 24 h in 24.6% of respondents. Most (52.3%) gastroenterologists do not routinely use antibiotic prophylaxis in acute EVB patients. The preferred duration of antibiotic therapy was less than three days (35.7%), three to seven days (44.6%), seven to 10 days (10.7%) and throughout hospitalization (8.9%). Methods of secondary prophylaxis included repeat endoscopic therapy (93%) and beta-blocker therapy (84.9%). Most gastroenterologists (80.2%) routinely attempted to titrate beta-blockers to a heart rate of 55 beats/min or a 25% reduction from baseline. The most common form of secondary prophylaxis was a combination of endoscopic and pharmacological therapy (70.9%).

CONCLUSIONS: Variability exists in some areas of EVB treatment, especially in areas for which evidence was lacking at the time of the last guideline publication. Gastroenterologists varied in the use of prophylactic antibiotics for acute EVB. More gastroenterologists used combination secondary prophylaxis in the form of band ligation eradication and beta-blocker therapy rather than either treatment alone. Future guidelines may be needed to address these practice differences.
An Evaluation of Extended Incubation Time with Blind Subculture of Blood Cultures in Patients with Suspect Endocarditis
Authors: Forward Kevin R
Published: March 2016

BACKGROUND: In a small proportion of patients, bacterial endocarditis is due to organisms that grow slowly and may not be recovered in conventional blood cultures incubated for five days. This has led to recommendations for prolonged incubation and routine subculture of negative cultures.

OBJECTIVE: The above‐mentioned approach is evaluated.

METHOD: The microbiology of all blood cultures subjected to prolonged incubation and the charts of individuals who had organisms recovered after five days were evaluated to determine their clinical significance.

RESULTS: In all, 507 blood cultures were handled using an extended incubation and blind subculture protocol. Fifty‐three blood cultures in 27 patients were positive. Blood cultures were positive after five days in only five cases; patient outcomes were not affected by the results in any of these cases, although several fastidious organisms (ie, Haemophilus paraphrophilus and Haemophilus parainfluenzae) were recovered in the first five days of incubation.

CONCLUSION: Prolonged incubation and blood subcultures in patients with suspected endocarditis or infections due to fastidious organisms do not represent a wise use of increasingly scarce resources.
Transfusion and Risk of Infection in Canada: Update 2006
Authors: MacDonald Noni
Published: March 2016

In Canada and other developed countries, many steps are taken to minimize the risk of infection from transfusion of blood or blood products (1). However, the infection risk can never be zero because these are biological products taken from living donors who are never ′germ free′ (2). This is in contrast to drugs that can be manufactured de novo under sterile conditions in a laboratory. The present note provides an update on transfusion infection risks in Canada. It replaces the 2005 note (3) and may be helpful to practitioners in discussions with patients and parents for informed consent before blood or blood product administration. The changes in this note include new Canadian data on risk of adverse transfusion events (ATEs), including risk of bacterial infection. Transfusion‐related acute lung injury and major allergic or anaphylactic reactions are more common than serious infections (4).
Pain, Health‐Related Quality of Life and Health Care Utilization after Inpatient Surgery: A Pilot Study
Authors: VanDenKerkhof Elizabeth G , Hopman Wilma M , Towheed Tanveer , Wilson Rosemary , Murdoch John , Rimmer Michael , Stutzman Sherri Schmidt , Tod Debbie , Dagnone Vico , Goldstein David H
Published: March 2016

BACKGROUND: Little is known about pain‐related outcomes in surgical inpatients after discharge from the hospital. An ongoing risk and outcomes monitoring system would provide valuable feedback to improve the quality of patient care.

OBJECTIVES: The purpose of the present pilot study was to describe postoperative pain, medication use, health care utilization and health‐related quality of life (HRQOL) immediately and four weeks after surgery; merge clinically captured data with Web‐based follow‐up data; and examine patients’ willingness to complete Web‐based health questionnaires.

METHODS: One hundred two consecutive surgical inpatients were approached for participation. Perioperative data were abstracted from the acute pain management service clinical database and linked to follow‐up data captured four weeks postoperatively.

RESULTS: Follow‐up questionnaires were completed by 88 participants. Clinical assessment data were successfully linked to Web‐based follow‐up data. Average pain intensity (3.7) four weeks following discharge fell just short of the acute pain management service active pain score of 3.9. At four weeks, all 88 participants reported significantly impaired HRQOL, 36 were still taking pain medications and 15 had visited an emergency room. Two‐thirds of the participants had access to the Internet at home and approximately one‐half were willing to complete on‐line health questionnaires.

DISCUSSION: The study indicates that it is feasible to link clinical and research data, and shows a significant burden of pain and reduced HRQOL in the weeks following discharge. This approach to converting clinically captured data into meaningful information about surgical outcomes is valuable in the development of an ongoing risk and outcomes monitoring system.
HIV Testing among Canadian Tuberculosis Cases from 1997 to 1998
Authors: Harris Tara , Panaro Linda , Phypers Melissa , Choudhri Yogesh , Archibald Chris P
Published: March 2016

BACKGROUND: Recent evidence suggests a global rise in adult tuberculosis (TB) cases associated with HIV/AIDS. The World Health Organization, the United States Centers for Disease Control and Prevention, and the Public Health Agency of Canada advocate universal screening of all TB cases for HIV. The contribution of HIV to the TB burden in Canada remains unclear.

METHODS: A retrospective cohort study was conducted of all TB cases reported in Canada from 1997 to 1998. The aim was to determine the proportion of patients that had an HIV test on record, and of these, the number of patients infected with HIV.

RESULTS: From 1997 to 1998, 3767 TB cases were reported to the national TB surveillance system. In the present study, 3416 case records (90.7%) were included. The number of cases with a record of an HIV test was 736 (21.5%), and of these, 41.2% were tested within one month of TB diagnosis. Among the 703 cases with known HIV test results, the prevalence of HIV infection was 14.7%. Cases with an HIV test on record were more likely to have one or more risk factors for HIV, and also were more likely to be male, aged 15 to 49 years, of Aboriginal ethnicity, and to have smear‐positive TB and both pulmonary and extrapulmonary disease at the time of diagnosis.

DISCUSSION: These results suggest that HIV testing of TB patients is not universal, but rather selective, and is likely based on perceived risk factors for HIV as opposed to TB diagnosis alone.
Phage Therapy ‐‐ Everything Old Is New again
Authors: Kropinski Andrew M
Published: March 2016

The study of bacterial viruses (bacteriophages or phages) proved pivotal in the nascence of the disciplines of molecular biology and microbial genetics, providing important information on the central processes of the bacterial cell (DNA replication, transcription and translation) and on how DNA can be transferred from one cell to another. As a result of the pioneering genetics studies and modern genomics, it is now known that phages have contributed to the evolution of the microbial cell and to its pathogenic potential. Because of their ability to transmit genes, phages have been exploited to develop cloning vector systems. They also provide a plethora of enzymes for the modern molecular biologist. Until the introduction of antibiotics, phages were used to treat bacterial infections (with variable success). Western science is now having to re‐evaluate the application of phage therapy ‐‐ a therapeutic modality that never went out of vogue in Eastern Europe ‐‐ because of the emergence of an alarming number of antibiotic‐resistant bacteria. The present article introduces the reader to phage biology, and the benefits and pitfalls of phage therapy in humans and animals.
Esophageal Intramural Pseudodiverticulosis with Food Impaction
Authors: Attila Tan , Marcon Norman E
Published: March 2016

Esophageal intramural pseudodiverticulosis is a rare condition of unknown etiology originally described in 1960. It is characterized by multiple, flask-shaped outpouchings of pinhead size in the wall of the esophagus. Very small outpouchings on endoscopy and tiny collections of barium outside of the esophagus wall on esophagography are typical diagnostic findings. During the era of widespread endoscopic and radiological evaluation of esophageal disorders, approximately 200 cases were published in the literature. A 52-year-old man with esophageal intramural pseudodiverticulosis with food impaction is reported. The patient’s symptoms of dysphagia resolved with endoscopic dilations and proton pump inhibitor therapy.
Duodenal Hematoma following Endoscopic Duodenal Biopsy: A Case Report and Review of the Literature
Authors: Diniz-Santos Daniel R , de Andrade Cairo Romilda C , Braga Hélio , Araújo-Neto Cesar , Paes Igelmar B , Silva Luciana R
Published: March 2016

Duodenal hematoma is a rare complication of endoscopic duodenal biopsy that occurs mainly in children or adults with impaired coagulation. The clinical presentation consists of signs of intestinal obstruction, and pancreatitis and direct hyperbilirubinemia are possible complications caused by ampullary obstruction. A case of a six-year-old girl who presented with a duodenal hematoma and acute pancreatitis after having an endoscopic duodenal biopsy is reported. A review of the literature and data from all similar cases reported so far are briefly presented and discussed.
Canadian Consensus Recommendations for the Optimal Use of Enfuvirtide in HIV/AIDS Patients
Authors: Rachlis Anita , Angel Jonathan , Harris Marianne , Lalonde Richard , Smaill Fiona , Tremblay Cecile , Tsoukas Chris , Walmsley Sharon
Published: March 2016

BACKGROUND AND OBJECTIVES: An eight‐member group consisting of Canadian infectious disease and immunology specialists and a family physician with significant experience in HIV management was convened to update existing recommendations, specifically intended for use by Canadian HIV‐treating physicians, on the appropriate use of enfuvirtide in HIV/AIDS patients with resistance to other antiretroviral drugs.

METHODS: Evidence from the literature and expert opinions of the group members formed the basis of the guidelines. Comments on the draft guidelines were obtained from other physicians across Canada with HIV expertise. The final guidelines represent the group′s consensus agreement.

RESULTS AND CONCLUSIONS: The recommendations were developed to guide physicians in optimal practices in patient selection for enfuvirtide treatment and subsequent patient management. The issues considered include positive predictors of response to enfuvirtide, stage of disease, optimization of the background regimen, early indicators of enfuvirtide response, and patient education and support.
Prognostic Factors and Survival in Patients with Hereditary Hemochromatosis and Cirrhosis
Authors: Beaton Melanie D , Adams Paul C
Published: March 2016

OBJECTIVES: The survival of treated, noncirrhotic patients with hereditary hemochromatosis is similar to that of the general population. Less is known about the outcome of cirrhotic hereditary hemochromatosis patients. The present study evaluated the survival of patients with hereditary hemochromatosis and cirrhosis.

METHODS: From an established hereditary hemochromatosis database, all cirrhotic patients diagnosed from January 1972 to August 2004 were identified. Factors associated with survival were determined using univariate and multivariate regression. Survival differences were assessed using the Kaplan-Meier life table method.

RESULTS: Ninety-five patients were identified. Sixty patients had genetic testing, 52 patients (87%) were C282Y homozygotes. Median follow-up was 9.2 years (range 0 to 30 years). Nineteen patients (20%) developed hepatocellular carcinoma, one of whom was still living following transplantation. Cumulative survival for all patients was 88% at one year, 69% at five years and 56% at 20 years. Factors associated with death on multivariate analysis included advanced Child-Pugh score and hepatocellular carcinoma. Patients with hepatocellular carcinoma were older at the time of diagnosis of cirrhosis (mean age 61 and 54.6 years, respectively; P=0.03). The mean age at the time of diagnosis of hepatocellular carcinoma was 70 years (range 48 to 79 years). No other differences were found between the groups.

CONCLUSIONS: Patients with hereditary hemochromatosis and cirrhosis are at significant risk of developing hepatocellular carcinoma. These patients are older when diagnosed with carcinoma and may have poorer survival following transplantation than patients with other causes of liver disease. Early diagnosis and treatment of hereditary hemochromatosis by preventing the development of cirrhosis may reduce the incidence of hepatocellular carcinoma in the future.
Internet‐Based Asthma Education ‐‐ A Novel Approach to Compliance: A case Report
Authors: O′hara Cindy , Vethanayagam Dilini , Majaesic Carina , Mayers Irvin
Published: March 2016

Asthma costs Canadians over $1.2 billion per annum and, despite advances, many asthmatic patients still have poor control. An action plan, symptom diary and measurement of peak expiratory flow have been shown to improve clinical outcomes. Effective educational interventions are an important component of good care. However, many rural sites lack not only access to education but physician care as well. It is reasonable, therefore, that an Internet‐based asthma management program may be used as an approach. In the present case report, a novel approach that may increase access in these poorly serviced areas is presented. In an Internet‐based asthma management program, patients are reviewed by a physician, receive education and are given a unique password that provides program access. Patients record symptoms and peak expiratory flow rates. The present case report shows that a patient can be assisted through an exacerbation, thus averting emergency intervention and stabilizing control, even when travelling on another continent.
Beyond Antibiotics?
Authors: Nicolle LE
Published: March 2016

The AMMI Canada meeting in March 2006 hosted a symposium exploring the potential alternatives to antibiotics for the prevention and treatment of infection. Four papers summarizing talks from that session are published in this issue of the Journal (1‐4). These reviews address the scientific underpinnings for a number of proposed concepts, and summarize the current status of clinical use. The approaches ‐ probiotics, bacteriophage therapy, and manipulation of innate immunity ‐ are all intriguing but are still removed from immediate practical applications.
Exercise and Crohn’s Disease: Speculations on Potential Benefits
Authors: Ng Victor , Millard Wanda , Lebrun Constance , Howard John
Published: March 2016

Crohn’s disease (CD) is a chronic inflammatory bowel disease that affects nearly one million people in the United States and Canada. While current pharmaceutical treatments are effective in controlling symptoms, patients continue to experience a reduced quality of life (QOL). Based on preliminary studies, QOL in CD patients may be improved by engaging in physical activity. Exercise may decrease CD activity and reduce psychological stress. Current research also suggests that low-intensity exercise does not exacerbate gastrointestinal symptoms and does not lead to flare-ups. Furthermore, exercise appears to reduce CD symptoms and improve QOL. In summary, physical activity may be beneficial to certain patient groups, but more studies are needed before broad recommendations can be made.