bluuebunny/crossref_metadata_2025 huggingface dataset:
Coxiella burnetii Seroprevalence of Shepherds and Their Flocks in the Lower Saint‐Lawrence River Region of Quebec, Canada
Authors: Dolcé Patrick , Bélanger Marie-Joële , Tumanowicz Krzysztof , Gauthier Claude P , Jutras Philippe , Massé Richard , Montpetit Claude , Bernatchez Harold , McColl Dorothy , Artsob Harvey
Published: March 2016

OBECTIVE: To determine the seroprevalence of Coxiella burnetii among the shepherds and their sheep in the lower Saint‐Lawrence River region (LSLRR) of Quebec, Canada.

DESIGN: A prospective human‐animal comparative study was conducted with 81 shepherds from 46 farms and a control group matched for sex and age. All participants answered a standardized questionnaire to evaluate their risk factors for Q fever, including a specific section on the work practices of the shepherds. All human subjects had a blood sample taken for serology to phase I and phase II antigens of C burnetii performed by indirect immunofluorescence assay. At each participating farm, seven to nine sheep had blood samples taken for C burnetii serology to be assessed by the complement fixation test.

RESULTS: The seroprevalence to C burnetii was higher in the group of shepherds (28.4%) than the control group (1.2%) (P<0.005). Among the group of shepherds, spending more than 5 h/week in the sheep barn (P=0.06) and buying and/or trading sheep within the past six months (P=0.004) were associated with positive C burnetii serology. A total of 137 of 334 sheep (41%) were seropositive for C burnetii. These positive sheep were distributed in 41 of the 46 flocks (89%). No correlation could be demonstrated between a serology for C burnetii in the herds and the shepherds.

CONCLUSION: Q fever is highly prevalent in the LSLRR of Quebec, affecting 89% of the flocks and 28% of the shepherds. Shepherds in this region are at increased risk for C burnetii infection in comparison to the general population.
Pulmonary Sclerosing Hemangioma with Lymph Node Metastases
Authors: Chan NG , Melega DE , Inculet RI , Shepherd JG
Published: March 2016

Pulmonary sclerosing hemangioma is an unusual benign tumour of uncertain histogenesis. In the past 50 years, hundreds of cases have been described. A case of sclerosing hemangioma with some unusual features, including a false‐positive fine needle aspiration biopsy and histological evidence of lymph node metastases, is described.
Sarcoidosis Confined to the Airway Masquerading as Asthma
Authors: Mixides George , Guy Elizabeth
Published: March 2016

A rare case of sarcoidosis is presented. A 32‐year‐old white woman initially diagnosed with asthma was to undergo thyroidectomy to eliminate what was thought to be the real source of her symptoms. Instead, the cause was found to be sarcoidosis involving only the major airways, without intrathoracic adenopathy, atelectasis, pulmonary parenchymal infiltrates or evidence of extra pulmonary disease. She rapidly responded to systemic glucocorticoids, which later was supplemented successfully by inhaled glucocorticoids for persistent cough.
The Benefits of Smoking Cessation
Authors: Anthonisen Nick R
Published: March 2016

In this issue of the Canadian Respiratory Journal, Demeter et al (pages 435‐441) describe lung cancer outcomes in a recent Alberta cohort. Not much is new; outcomes are bad, not much better than they were when I was in medical school more than 40 years ago. This is a particularly sad state of affairs in view of the fact that lung cancer is a self‐inflicted phenomenon related to smoking. Further, this has been known for 40 years, and only recently have lung cancer rates levelled off in men, though they have continued to increase in women.
An Outbreak of Foodborne Botulism in Ontario
Authors: Loutfy Mona R , Austin John W , Blanchfield Burke , Fong Ignatius W
Published: March 2016

Botulism is a rare paralytic illness resulting from a potent neurotoxin produced by Clostridium botulinum. Botulism in Canada is predominately due to C botulinum type E and affects mainly the First Nations and Inuit populations. The most recent outbreak of botulism in Ontario was in Ottawa in 1991 and was caused by C botulinum type A. We report an outbreak of foodborne type B botulism in Ontario, which implicated home‐canned tomatoes. The outbreak was characterized by mild symptoms in two cases and moderately severe illness in one case. The investigation shows the importance of considering the diagnosis of botulism in patients presenting with cranial nerve and autonomic dysfunction, especially when combined with gastrointestinal complaints; it also highlights the importance of proper home canning technique.
Predictors of a Positive Duplex Scan in Patients with a Clinical Presentation Compatible with Deep Vein Thrombosis or Cellulitis
Authors: Rabuka Curtis E , Azoulay Laurent Y , Kahn Susan R
Published: March 2016

BACKGROUND: Deep vein thrombosis (DVT) and cellulitis are common conditions whose symptoms lead patients to seek medical attention in the emergency department (ED). Distinguishing between these two conditions quickly and accurately is important.

OBJECTIVES: To determine the yield of duplex scanning among ED patients whose clinical presentation is compatible with DVT or cellulitis. In addition, to determine whether baseline clinical variables are predictive of the final diagnosis among ED patients with an initial clinical impression of ′DVT versus cellulitis′ who underwent duplex scanning.

METHODS: In this historical cohort study, patients with a final diagnosis of DVT (positive duplex) were compared on several baseline variables with patients with a final diagnosis of cellulitis (negative duplex and antibiotics prescribed) .

RESULTS: One hundred‐nine of 542 ED patients referred for a duplex scan were initially diagnosed as ′DVT versus cellulitis′, 17% of whom had DVT confirmed by a positive duplex scan. Comparing patients with DVT versus those with cellulitis, 0% versus 15.3% had rigors (P=0.06); 0% versus 8.3% had distinct margins of erythema (P<0.01); 5.3% versus 22.2% were currently on antibiotics (P=0.09); and 50% versus 21.3% had an elevated white blood cell count (P=0.04).

CONCLUSION: There are differences in a number of baseline characteristics of ′DVT versus cellulitis′ patients who went on to have either positive or negative duplex scans, some of which were statistically significant despite the limited sample size. These findings should be confirmed prospectively in a larger study sample since they may have the potential to aid in the clinical differentiation between DVT and cellulitis.
Treatment of Chronic Intractable Neuropathetic Pain with Dronabinol: Case Report of Two Adolescents
Authors: Rudich Zvia , Stinson Jennifer , Jeavons Michael , Brown Stephen C
Published: March 2016

OBJECTIVE: To evaluate the effectiveness of dronabinol for the treatment of neuropathic pain refractory to previous treatment.

METHODS: We studied the response (reduction of pain intensity and functional improvement) to dronabinol (5 mg/day to 25 mg/day) in two adolescents with neuropathic pain and depression refractory to previous treatments over two and five years, respectively.

RESULTS: Reduction in pain intensity (45%) was achieved in patient 2 and was unchanged in patient 1. Functional improvement was markedly increased in terms of academic performance, mood and sleep in both patients over four to five months, without major adverse effects. While these improvements dissipated over time, the patients were more reconnected with rehabilitation and focused less on the intrusiveness of their pain problem in their every day lives.

CONCLUSIONS: Dronabinol appeared to be effective in improving pain affect and psychosocial functioning in the treatment of refractory neuropathic pain and may be considered as an adjuvant medication in the rehabilitation process. Well‐controlled placebo studies are required for further evaluation.
The BC Community Pharmacy Asthma Study: A Study of Clinical, Economic and Holistic Outcomes Influenced by an Asthma Care Protocol Provided by Specially Trained Community Pharmacists in British Columbia
Authors: Mclean William , Gillis Jane , Waller Ron
Published: March 2016

OBJECTIVES: Despite advances in recent years, asthma morbidity and mortality have been noted to be on the increase in the past decade. The present study examined the failures and recommendations of past studies and introduced a new milieu for asthma care ‐ the community pharmacy. The study incorporated a care protocol with the important ingredients of asthma education on medications, triggers, self‐monitoring and an asthma plan, with pharmacists taking responsibility for outcomes, assessment of a patient′s readiness to change and tailoring education to that readiness, compliance monitoring and physician consultation to achieve asthma prescribing guidelines.

METHODS: Thirty‐three pharmacists in British Columbia, specially trained and certified in asthma care, agreed to participate in a study in which experienced pharmacists would have asthma patients allocated to enhanced (pharmaceutical) care (EC) or usual care (UC). Pharmacists less experienced were clustered by geography and had their pharmacies randomized to two levels of care; each pharmacy then had patients randomized to EC versus control, UC versus control or EC versus UC depending on their pharmacy randomization. Six hundred thirty‐one patients provided consent, of which 225 in EC or UC were analyzed for all outcomes. Patients were followed for one year.

RESULTS: Compared with patients in the UC group, the results of those in the EC group were as follows: symptom scores decreased by 50%; peak flow readings increased by 11%; days off work or school were reduced by approximately 0.6 days/month; use of inhaled beta‐agonists was reduced by 50%; overall quality of life improved by 19%, and the specific domains of activity limitations, symptoms and emotional function also improved; initial knowledge scores doubled; emergency room visits decreased by 75%; and medical visits decreased by 75%. A patient satisfaction survey revealed that the population was extremely pleased with their pharmacy services. Cost analysis reinforces the EC model, which is more cost effective than UC in terms of most direct and indirect costs in asthma patients.

CONCLUSION: Specially trained community pharmacists in Canada, using a pharmaceutical care‐based protocol, can produce impressive improvements in clinical, economic and humanistic outcome measures in asthma patients. The health care system needs to produce incentives for such care.
Use of Methadone for Neuropathic Pain
Authors: Moulin Dwight
Published: March 2016

Chronic neuropathic pain is often considered to be a common complication of injury to the central or peripheral nervous system and the pain itself is usually assumed to be intractable. Both of these assumptions are inaccurate. For example, numbness and tingling in glove and stocking distribution are common accompaniments of longstanding diabetes mellitus, but only about 10% of patients with diabetic neuropathy consider these sensory changes to be painful (1). Anticonvulsant and antidepressant treatments provide effective analgesia in up to 50% of patients with chronic neuropathic pain (2) and there is a growing body of high‐quality evidence that controlled‐release opioid analgesics provide substantial pain relief in a further subset of patients (3‐6). Even with polypharmacy, this still leaves perhaps 20% to 30% of chronic neuropathic pain sufferers lacking adequate analgesia, and side effects can be problematic. In addition, central pain appears to be more refractory to opioid treatment than pain due to peripheral nerve injury (7).
Diffuse Panbronchiolitis in a Caucasian Man in Canada
Authors: Sandrini Alessandra , Balter MS , Chapman Kenneth R
Published: March 2016

Diffuse panbronchiolitis (DPB) is a rare, chronic bronchiolar disease in non‐Asian populations and is therefore commonly overlooked in Western countries. It usually affects nonsmokers and manifests as persistent air flow obstruction, chronic cough and interstitial nodular opacities. Untreated, the prognosis is poor. In this report the authors describe a Caucasian man of Canadian descent who presented with progressive clinical and lung function impairment despite three years of bronchodilator and corticosteroid treatment with presumed asthma. His chest computed tomography scan showed diffuse centrilobular opacities. Lung biopsy revealed chronic bronchiolitis characterized by infiltration of lymphocytes, plasma cells and foam cells in respiratory and terminal bronchioles, compatible with a diagnosis of DPB. After two months of therapy with clarithromycin, the patient had already shown improvement. Physicians should be aware that DPB may occur in Western countries, and that DPB should be considered in the differential diagnosis of patients with persistent air flow obstruction and nodular shadows on chest radiograms.
Clinical Models to Compare the Safety and Efficacy of Inhaled Corticosteroids in Patients with Asthma
Authors: Parameswaran Krishnan , Leigh Richard , O′Byrne Paul M , Kelly Margaret M , Goldsmith Charlie H , Hargreave Frederick E , Dolovich Myrna
Published: March 2016

There is no consensus on the methods to compare the clinical efficacy of different inhaled corticosteroids. A comparison needs to be made in terms of relative potency, and studies should include two‐, or preferably, three‐dose comparisons. A number of clinical models and outcomes are available; they have their relative advantages and disadvantages. While measurements of symptoms and spirometry are easy and readily available, they show a flat dose‐response relationship. Measurements of bronchial hyper‐responsiveness to exercise and adenosine monophosphate, allergen‐induced airway responses, and measurements of inflammation in sputum and exhaled air show steep dose‐response relationships, particularly to low doses of inhaled steroids. An uncontrolled asthma model followed by stabilization with a short course of additional steroid, with measurements of airway responsiveness and airway inflammation, in a crossover study seems more promising than the other models. Drug deposition studies and mathematical modelling of drug pharmacokinetics in the airway may provide complementary information to clinical drug relative potency studies. Fine particle dose and emitted doses, rather than the nominal dose, should be considered in the estimation of clinical and systemic effects, respectively. When a second entry (generic) drug is being evaluated in comparison with the innovator drug (same compound and same device), it may be appropriate to consider accepting a generic as bioequivalent if it satisfies pharmaceutical equivalence.
Autopneumonectomy with Compensatory Lung Growth
Authors: Ciric I , Meyers MP , Mayba J , Anthonisen NR
Published: March 2016

A 23-year-old female immigrant from Ethiopia presented with a history of hemoptysis and an abnormal chest x-ray. A computed tomography scan showed that her left lung was greatly shrunken and her right lung was very large but structurally normal. She had a history of multiple respiratory infections as a young child but had been well since the age of five years. Her lung function was within normal limits except for an increased residual volume. It is very likely that her left lung was destroyed early in childhood and that her right lung underwent compensatory growth. She did not show airways obstruction, which is usually seen when compensatory lung growth occurs after surgical removal of lung tissue; this may indicate that, in those cases, the surgery compromised airway function.
Injury Biomechanics of the Cervical Spine in Car Collisions ‐ some Needs for Further Research
Authors: Svensson Mats Y.
Published: March 2016

The article reviews some of the existing research concerning the incidence of soft tissue neck injuries sustained in car collisions. A variety of neck injuries, including to muscles, ligaments, facet joints, discs and nerve tissue appear to result from whiplash trauma. Research questions concerning the relationship between these possible injuries and the large set of known whiplash symptoms are considered.
Three Generations of Experience and Thought in Microbiology and Infection
Authors: Goldner Morris
Published: March 2016

Views and comments were sought from Brian Lacey, who was professionally active from the 1930s to the 1970s, Alain Dublanchet, active from the 1960s to the 2000s, and Mark Pallen, active from the 1990s to 2000 and beyond. Professor Lacey was professor of microbiology at the Westminster Medical School, University of London, United Kingdom, for many years and is now retired. Docteur Dublanchet is the long time head of the laboratory of microbiology and virology at the Centre Hospitalier Intercommunal de Villeneuve‐Saint‐Georges in the greater Paris area. Professor Pallen is currently professor of bacterial genetics at the Medical School, University of Birmingham (United Kingdom); he is a keen enthusiast of genomic studies in the interest of molecular pathogenesis research. All three are medically qualified. Four questions were posed to each:

What was the situation like in the infectious disease field when you first started your career?

What do you feel have been the most important accomplishments with regard to problems of infectious disease during your period of activity?

What do you foresee as the vital matters that still need to be addressed for countering infectious disease?

Can infectious disease ever, practically, be eradicated and, if so, how would this be accomplished?
Contemporary Antiviral Drug Regimens for the Prevention and Treatment of Orolabial and Anogenital Herpes Simplex Virus Infection in the Normal Host: Four Approved Indications and 13 Off‐Label Uses
Authors: Aoki Fred Y
Published: March 2016

Herpes simplex virus (HSV) orolabial and anogenital infection causes substantial and recurring disease in healthy individuals due directly to infection of these sites and, indirectly, due to its complications. These complications include eczema herpeticum plus erythema multiforme and neonatal HSV infection, respectively. Four drugs: acyclovir, famciclovir, valacyclovir and penciclovir, are currently licensed by the Therapeutics Products Directorate of Health Canada for the management of HSV infections. Although these drugs are only approved for four orolabial and anogenital infections in healthy persons, their efficacy and safety for 13 other related uses in this population have been demonstrated in controlled clinical trials, so called off‐label uses. In this review, the evidence supporting these 17 uses, the drugs and regimens evaluated, and their current costs, are described.
Canadian Normal Lung Function Values
Authors: Anthonisen Nick R
Published: March 2016

In this issue of the Canadian Respiratory Journal, Gutierrez et al (pages 414‐424) present normal lung function values and prediction equations for white Canadians. They had six laboratories across the country each test approximately 100 volunteer, nonsmoking white adults (the target was 120 each), with appropriate variation in age and sex. Adequate representation of different ages and sex were obtained, although it appeared to be harder to recruit elderly men than elderly women. A full battery of tests was performed on each person. The equipment was not standardized and varied from centre to centre, and some centres performed slightly different tests than others; in other words, the study was done under field conditions. The results were analyzed for each centre and pooled to produce the Canadian model. This was compared with several similar models developed in Europe and the United States (1‐5).
Parental Judgments of Infant Pain: Importance of Perceived Cognitive Abilities, Behavioural Cues and Contextual Cues
Authors: Pillai Riddell Rebecca R , Badali Melanie A , Craig Kenneth D
Published: March 2016

BACKGROUND: Despite blatant indications, such as behavioural and contextual cues, infant pain is often undermanaged by adult caretakers. The belief that infants are limited in their abilities to comprehend the meaning of an experience or recall that experience has been used to minimize or deny the need for intervention in this vulnerable population.

OBJECTIVES: This investigation explored parental beliefs regarding the impact of infant cognitive capabilities, behavioural cues and contextual cues to their pain judgments. Particular interest was focused on their beliefs regarding the general cognitive capabilities of infants of different ages.

METHODS: Forty‐nine parents viewed videotapes of healthy infants, aged two, four, six, 12 and 18 months, receiving routine immunization injections and provided judgements of the severity of pain on a 100 mm Visual Analogue Scale. Upon completion of their pain judgements for each of the five age groups (two infants per age group; 10 infants total), parents completed questionnaires regarding their beliefs about the capabilities of infants in that age group and then reported the importance of the various cues utilized to formulate their pain judgements.

RESULTS: Parents attributed substantial pain to infants in all age groups, almost twice the amount they hypothesized an adult undergoing a similar injection would experience. The cues rated as most important for judgements were similar for infants of varying ages. Overall, facial expressions, sounds and body movements were consistently reported to be most important. Parents acknowledged the development of memory and understanding of pain throughout infancy. However, these beliefs were not deemed by parents as important to their pain ratings, nor were their importance ratings directly related to the pain ratings.

CONCLUSION: Parents judged that infants undergoing a routine immunization were experiencing clinically significant levels of pain. However, despite generally acknowledging a developing trajectory for memory and understanding across the five age groups, parents did not indicate that a child′s ability to remember and understand pain were essential features of their pain judgements. The results indicated that memory and understanding did not influence parental judgements of infant pain demonstrating the validity of the parents′ self‐assessments.
An Economic Evaluation of Voriconazole versus Amphotericin B for the Treatment of Invasive Aspergillosis in Canada
Authors: Rotstein Coleman , Laverdière Michel , Marciniak Anne , Ali Farzad
Published: March 2016

BACKGROUND: Invasive aspergillosis (IA) is a serious fungal infection that affects immunocompromised patients. The Global Comparative Aspergillosis study demonstrated that voriconazole, a new broad‐spectrum triazole, had better responses and improved survival compared with conventional amphotericin B deoxycholate (CAB) and other licensed antifungal therapy (OLAT) for the treatment of definite or probable aspergillosis.

OBJECTIVES: To compare costs and outcomes of voriconazole and CAB for the treatment of definite or probable aspergillosis in Canada.

METHODS: A cost‐consequence decision tree model was designed to reflect the treatment pathways used in clinical practice when using voriconazole or CAB as primary therapy for IA. Therapy included initial treatment with either voriconazole or CAB and then switched to an OLAT in the event of an inadequate response, severe toxicity or intolerance. The principal data source used was the Global Comparative Aspergillosis study.

RESULTS: The total cost of voriconazole when compared with CAB as initial therapy for IA was $38,319 versus $42,495 per patient, respectively, representing a 9.8% cost reduction for each patient treated with voriconazole. The higher mean cost in the CAB arm was primarily due to the high proportion of patients (73.7%) who were switched to an OLAT due to severe side effects or an inadequate response. Treating with voriconazole was a dominant strategy. The number of patients that had to be treated with voriconazole instead of CAB to save one additional life was eight.

CONCLUSIONS: Voriconazole as primary treatment for IA increased the chances of successful treatment, improved survival and may represent a potential cost saving strategy in Canada.
Perspectives on Emerging Zoonotic Disease Research and Capacity Building in Canada
Authors: Stephen Craig , Artsob Harvey , Bowie William R , Drebot Michael , Fraser Erin , Leighton Ted , Morshed Muhammad , Ong Corinne , Patrick David
Published: March 2016

Zoonoses are fundamental determinants of community health. Preventing, identifying and managing these infections must be a central public health focus. Most current zoonoses research focuses on the interface of the pathogen and the clinically ill person, emphasizing microbial detection, mechanisms of pathogenicity and clinical intervention strategies, rather than examining the causes of emergence, persistence and spread of new zoonoses. There are gaps in the understanding of the animal determinants of emergence and the capacity to train highly qualified individuals; these are major obstacles to preventing new disease threats. The ability to predict the emergence of zoonoses and their resulting public health and societal impacts are hindered when insufficient effort is devoted to understanding zoonotic disease epidemiology, and when zoonoses are not examined in a manner that yields fundamental insight into their origin and spread.

Emerging infectious disease research should rest on four pillars: enhanced communications across disciplinary and agency boundaries; the assessment and development of surveillance and disease detection tools; the examination of linkages between animal health determinants of human health outcomes; and finally, cross‐disciplinary training and research. A national strategy to predict, prevent and manage emerging diseases must have a prominent and explicit role for veterinary and biological researchers. An integrated health approach would provide decision makers with a firmer foundation from which to build evidence‐based disease prevention and control plans that involve complex human/animal/environmental systems, and would serve as the foundation to train and support the new cadre of individuals ultimately needed to maintain and apply research capacity in this area.
What Is Unique about the New Canadian COPD Guidelines?
Authors: O′Donnell Denis E
Published: March 2016

The prospect of digesting yet another set of ?best practice? guidelines is not an appealing one for the overwrought family physician. The Canadian Thoracic Society (CTS) panel, charged with the enormous task of developing new evidencebased recommendations, was acutely aware of this. Nevertheless, they were convinced that the time was right to tackle this important educational initiative, and somehow managed to summon considerable reserves of energy and enthusiasm to produce an excellent, state‐of‐the‐art compendium on the optimal management of this condition (1). Faced with the evidence that death rates from chronic obstructive pulmonary disease (COPD) continue to escalate in Canada and that its prevalence has risen to unprecedented levels (particularly in older women), the panel believed that there was an urgent need to raise awareness of this disease, and to optimize diagnosis and management (2).
Inhaled Corticosteroids in COPD: Determinants of Use and Trends in Patient Persistance with Treatment
Authors: Blais Lucie , Bourbeau Jean , Dheehy Odile , LeLorier Jacques
Published: March 2016

METHODS: The determinants of a new treatment with inhaled corticosteroids and secular trends in patient persistence with treatment among chronic obstructive pulmonary disease (COPD) patients were investigated. A cohort of 3768 physician‐diagnosed, elderly COPD patients was selected between 1990 and 1996 from the health care administrative database of the Régie de l′assurance maladie du Québec. A nested case‐control design was used to identify patient and physician characteristics that were associated with a new treatment with inhaled corticosteroids. Treatment persistence with inhaled corticosteroids was also estimated using Kaplan‐Meier analysis. In addition to that, changes in treatment persistence over time, from 1990 to 1995, were investigated by estimating the yearly proportion of patients persisting for less than one year.

RESULTS: Within the cohort, the yearly percentage of patients filling at least one prescription for inhaled corticosteroids was 42.2% in 1990 and increased to 53.1% in 1995 (P=0.001). Using a conditional logistic regression model, it was found that the patients most likely to initiate a treatment with inhaled corticosteroids were those who had severe COPD (rate ratio [RR] 1.7; 95% CI 1.4 to 2.0), those who were hospitalized for COPD (RR 10.0; 95% CI 5.6 to 17.9), those who consulted a respirologist in the previous month (RR 2.3; 95% CI 1.6 to 3.3) or those who visited more than three different physicians in the previous three months (RR 1.6; 95% Cl 1.3 to 1.9). The proportion of patients persisting with inhaled corticosteroids for less than one year rose by 19.4%, from 47.6% in 1990 to 67.0% in 1995 (P=0.011; test for trend).

CONCLUSIONS: The use of inhaled corticosteroids increased while patient persistence decreased between 1990 and 1995. Disease severity, as well as recent consultation to a respirologist and multiple visits to a physician, were associated with a strong likelihood of being prescribed inhaled corticosteroids. The cost of this practice is far from negligible, while their clinical impact is still uncertain.
Exploring Physicians′ Comfort Level with Opioids for Chronic Noncancer Pain
Authors: Scanlon Martin N , Chugh Urmil
Published: March 2016

OBJECTIVE: To explore the attitudes of family physicians (FPs) toward the use of opioids in the management of chronic noncancer pain (CNCP) in the Calgary Health Region (CHR), Calgary, Alberta.

METHODS: From January to February 2003, random samples of 147 FPs (32 were used to pretest the instrument and were therefore excluded from the findings) and 142 specialists practicing in the CHR were invited to participate in a 20 min survey to explore aspects of CNCP management in the CHR. Physicians′ comfort in prescribing opioids and nonsteroidal anti‐inflammatory drugs for CNCP was measured on a four‐point ordinal scale. The specialists′ subgroup served as a quasi‐control group. In addition, a short version of the survey was provided for those physicians who declined to fully partake in the study. This allowed the researchers to compare important characteristics between respondents and nonrespondents.

RESULTS: A total of 125 physicians (63 FPs and 62 specialists) participated in the study. The overall response rate was 48.6% and response rates for FPs and specialists were 54.8% and 43.7%, respectively. Response rates for the long version of the survey were 42.6% for FPs (n=49), 31.6% for other specialists (n=45) and 36.6% for both combined. The majority of FPs and specialists (98% and 71.1%, respectively) reported that ′they can handle′ nonsteroidal anti‐inflammatory drugs, Tylenol No 3 with Codeine (Janssen‐Ortho/McNeil Consumer Healthcare, Canada) (95.9% and 64.4%, respectively), morphine/MS Contin (Purdue Pharma, Canada) (61.2% and 24.4%, respectively) and Percocet (Bristol‐Myers Squibb, Canada)/OxyContin (Purdue Pharma, Canada) (61.2% and 33.3%, respectively). Fewer FPs and specialists report that ′they can handle′ Dilaudid (Abbott Laboratories, Canada)/Hydromorph Contin (Purdue Pharma, Canada) (36.7% and 13.3%, respectively), fentanyl patch (30.6% and 11.1%, respectively) and methadone (0% and 6.7%, respectively). Male FPs reported a greater degree of comfort than female FPs regarding morphine/MS Contin, Percocet/OxyContin and Dilaudid/Hydromorph Contin (Mann‐Whitney U tested at a£0.05). No sex differences were detected among specialists. No relationship was detected between comfort and years of practice or number of chronic pain patients in practice. Among specialists, a weak positive relationship was detected between the degree of comfort with methadone (Spearman′s rank correlation coefficient=0.35, a=0.03) and the significance of pain management in the practice. Except for methodone, the FPs reported a higher confidence with the drugs in question compared with specialists (a£0.05).

CONCLUSIONS: FPs in the CHR need to increase their comfort level toward opioids in general to adequately manage CNCP. Their lack of comfort may reflect a lack of education or fear of regulatory scrutiny.
The Computer‐Assisted Cognitive/Imagery System for Use in the Management of Pain
Authors: Borckardt Jeffrey J , Younger Jarred , Winkel Justin , Nash Michael R , Shaw Darlene
Published: March 2016

BACKGROUND: There is growing interest in computer‐delivered psychological interventions for a number of clinical conditions, including pain.

OBJECTIVES: This study tests the effectiveness of a new computer‐delivered pain‐management program using a laboratory pain paradigm.

METHODS: One hundred twenty undergraduate students were randomly assigned to either the computerized pain‐management group or the distraction control group. Subjects underwent a cold‐pressor task and were asked to continuously rate their subjective pain experience.

RESULTS: Women receiving the computerized pain management intervention were able to tolerate the cold‐pressor task longer than those in the control group. No effect was found for men. Subjective pain ratings were consistently lower during the cold‐pressor task for subjects in the computerized pain‐management group regardless of sex. Subjects receiving the computerized intervention reported feeling more comfortable and relaxed than control subjects during the cold‐pressor task.

CONCLUSIONS: Findings indicate that further investigations of the program used in this study are warranted to determine its potential clinical utility and that of similar computerized interventions for pain.
Asbestos and Probable Microscopic Polyangiitis
Authors: Philteos George S Rashed , Coverett Kelly , Chibbar Rajni , Ward Heather A , Cockcroft Donald W
Published: March 2016

Several inorganic dust lung diseases (pneumoconioses) are associated with autoimmune diseases. Although autoimmune serological abnormalities are common in asbestosis, clinical autoimmune/collagen vascular diseases are not commonly reported. A case of pulmonary asbestosis complicated by perinuclear‐antineutrophil cytoplasmic antibody (myeloperoxidase) positive probable microscopic polyangiitis (glomerulonephritis, pericarditis, alveolitis, multineuritis multiplex) is described and the possible immunological mechanisms whereby asbestosis fibres might be relevant in induction of antineutrophil cytoplasmic antibodies are reviewed in the present report.
The Good COPD Guidelines
Authors: Bowie Dennis
Published: March 2016

Chronic obstructive pulmonary disease (COPD) is becoming an increasing problem for health care workers. The World Health Organization predicts that in the year 2020, this disease will be the fifth most prevalent disease worldwide, up from 12th place, and it will be the third most common cause of death, up from sixth place in 1997 (1). Hospitalization and mortality rates for COPD continue to rise in Canada (2). Therefore, the burden of COPD on Canadians, the health care system and physicians is obvious.
Canadian Consensus Guidelines for the Management of Cytomegalovirus Disease in HIV/AIDS
Authors: Lalonde Richard G , Bovivin Guy , Deschênes Jean , Hodge William G , Hopkins J Jill , Klein Alex H , Lindley Janette I , Phillips Peter , Shafran Stephen D , Walmsley Sharon
Published: March 2016

BACKGROUND: The management of HIV‐infected patients with cytomegalovirus (CMV) disease has changed significantly with the availability of highly active antiretroviral therapy (HAART).

OBJECTIVES: These updated guidelines are intended to provide practical help to physicians managing HIV‐positive patients with or at risk for CMV disease.

METHODS: The 10 members of the Canadian CMV Disease in HIV/AIDS Consensus Group were infectious disease specialists, a primary care physician and ophthalmologists with expertise in HIV and CMV infection. Financial support by Hoffmann‐La Roche Canada Ltd was unrestricted, and was limited to travel expenses and honoraria. The consensus group met in June and October 2002. Key areas to be considered were identified, and group members selected, reviewed and presented relevant recent literature for their assigned section for the group′s consideration. Evidence was assessed based on established criteria, which were expert opinions of the members. Draft documents were circulated to the entire group and modified until consensus was reached. The final guidelines represent the group′s consensus agreement. The guidelines were approved by the Canadian Infectious Disease Society.

RESULTS AND CONCLUSIONS: The guidelines address symptom monitoring, screening for early detection and prevention, and treatment using oral, intravenous and intraocular anti‐CMV therapies in conjunction with HAART.
Outcome of Patients Admitted to Intensive Care Unit for Acute Exacerbation of Idiopathic Pulmonary Fibrosis
Authors: Al-hameed Fahad M , Sharma Sat
Published: March 2016

RATIONALE: The aim of this study was to evaluate the outcome of intensive care unit (ICU) admission in patients with idiopathic pulmonary fibrosis (IPF) who develop acute respiratory failure of unknown etiology.

METHODS: A retrospective study at University of Manitoba hospitals reviewed all patients admitted to the ICU from November 1988 to December 2000 with IPF requiring mechanical ventilation for unknown causes of acute respiratory failure. Survival at hospital discharge was assessed as the primary end point and ICU length of stay as a secondary end point. In the absence of open lung biopsy, major and minor clinical criteria (as per American Thoracic Society statements) were used for the diagnosis of IPF. Infections were ruled out by extensive surveillance cultures and/or bronchoscopy with bronchoalveolar lavage.

RESULTS: Eighty‐eight charts were reviewed and 25 patients met the inclusion criteria. The mean (± SD) age was 69±11 years (range 42 to 96 years) and 23 patients were male. With the exception of one survivor who was discharged home, 21 patients died while receiving mechanical ventilation, and three patients died in hospital shortly after ICU discharge (one day, 22 days and 67 days). Intubation and mechanical ventilation were administered to 21 patients, with a mean duration of 11±6 days (range two to 27 days); the other four patients were treated with noninvasive ventilation. The average duration of symptoms before ICU admission was 22±26 days. All patients were treated with systemic corticosteroids, while eight patients received additional chemotherapy.

CONCLUSIONS: In the absence of a reversible cause, patients with IPF who develop acute exacerbation of IPF may not benefit from ICU admission and mechanical ventilation. However, it is imperative that a diagnostic workup be performed to rule out an infectious or other reversible cause of respiratory failure before admission to the ICU is denied.
A Population‐Based Evaluation of a Regional Asthma Education Centre
Authors: Cowan Simone , Ernst Pierre , Cartier André , Boulet Louis-Philippe
Published: March 2016

BACKGROUND: A population‐based, ecological evaluation was conducted to determine the impact of a regional asthma education centre on reducing asthma‐related morbidity and improving the quality of prescribing.

METHODS: The number of emergency department (ED) visits for respiratory‐related illness and the prescribing of antiasthmatic medications were monitored during consecutive 18‐month pre‐ and postintervention periods in two communities with similar health care resources. Using defined daily doses, the quality of prescribing was assessed by calculating the ratio of inhaled corticosteroids to inhaled, short‐acting beta2‐agonists.

RESULTS: The reduction in the rate of respiratory‐related ED visits in subjects five to 45 years of age was 410 per 10,000 people and 450 per 10,000 people for the intervention and nonintervention communities, respectively. A significant reduction in the rate of ED visits of 698 per 10,000 people was found for patients aged 35 to 45 years in the intervention community (P<0.05). The reduction achieved statistical significance in the nonintervention community in younger patients: 557 per 10,000 people and 567 per 10,000 people for patients aged five to 14 years and 15 to 24 years, respectively (P<0.05). The ratio of inhaled corticosteroids to inhaled beta2‐ agonists increased from 0.47 to 0.78 in the intervention community ‐‐ a 66% change. However, over the course of the preintervention period, the prescribing ratio was already increasing in this community. The corresponding ratios were 0.47 and 0.53 in the nonintervention community ‐‐ an increase of 13%.

CONCLUSIONS: A conclusive association between the establishment of an asthma education centre and changes in health care use or the quality of prescribing could not be demonstrated.
Effects of Pleural Effusion on Respiratory Function
Authors: Mitrouska I , Klimathianaki M , Siafakas NM
Published: March 2016

The accumulation of pleural effusion has important effects on respiratory system function. It changes the elastic equilibrium volumes of the lung and chest wall, resulting in a restrictive ventilatory effect, chest wall expansion and reduced efficiency of the inspiratory muscles. The magnitude of these alterations depends on the pleural fluid volume and the underlying disease of the respiratory system. The decrease in lung volume is associated with hypoxemia mainly due to an increase in right to left shunt. The drainage of pleural fluid results in an increase in lung volume that is considerably less than the amount of aspirated fluid, while hypoxemia is not readily reversible upon fluid aspiration.
Screening for Common Respiratory Diseases among Israeli Adolescents
Authors: Dayan Yaron Bar , Elishkevits Keren , Goldstein Liav , Goldberg Avishay , Fichler Michel , Ohana Nisim , Levi Yehezkel , Dayan Yosefa Bar
Published: March 2016

BACKGROUND: Respiratory diseases are responsible for a significant proportion of serious morbidity among adolescents. There are few reports on the prevalence of common respiratory disorders in this population. The previous studies focused on specific diseases and screened relatively small samples.

OBJECTIVE: To define the prevalence of different common respiratory disorders among 17‐year‐old Israeli conscripts.

DESIGN: All 17‐year‐old Israeli nationals are obliged by law to appear at the Israel Defense Forces recruiting office for medical examination. Respiratory disease specialists evaluated and classified nominees with suspected respiratory disorders.

RESULTS: A high prevalence of respiratory morbidity was found among 94,805 17‐year‐old conscripts (61.5% male, 39.5% female). The most prevalent diagnosis was asthma (in 8% of male and 6.8% of female subjects). Fifty‐five per cent of the asthma patients suffered from moderate to severe disease. The prevalence of chronic obstructive pulmonary disease was 0.03% for the male and 0.01% for the female subjects. A difference in morbidity patterns between male and female adolescents was noted, particularly in the prevalence of chest deformation and spontaneous pneumothorax.

CONCLUSIONS: The most prevalent respiratory disorder among 17‐year‐old Israeli conscripts was asthma. One‐half of the asthma patients in this study suffered from moderate to severe disease. The prevalence of other respiratory disorders was much lower.
The Use of Clinical Practise Guidelines for Community‐Acquired Pneumonia in Hospitals in Atlantic Canada
Authors: Campbell Samuel G
Published: March 2016

BACKGROUND: Clinical practice guidelines (CPGs) have been shown to improve the care of patients presenting to hospital with community‐acquired pneumonia (CAP) and are considered the ′standard of care′. The extent of adoption of CPGs in Canada is unclear.

OBJECTIVE: To determine the use of CPGs by hospitals in Atlantic Canada (Newfoundland, Nova Scotia, New Brunswick, Prince Edward Island).

METHODS: Telephone survey of all hospitals listed in the Canadian Medical Directory as being situated in Atlantic Canada. Hospitals were included if they had all three of the following: an emergency department, x‐ray facilities and acute care inpatient beds.

RESULTS: Of 143 hospitals, 93 were included for analysis. Of these, 41 (44.1%) used CAP CPGs. Hospitals were less likely to be using CAP CPGs if they were smaller, rural or community hospitals, or if they did not have an intensive care unit. Of the four provinces, New Brunswick had the most hospitals using CAP CPGs (73.1%), while Newfoundland had the least (17.2%).

CONCLUSIONS: Although larger teaching hospitals are using CAP CPGs, the degree of adoption of CPGs in smaller hospitals in Atlantic Canada is low. Efforts to produce standard CPGs that can be adapted to different sites, as well as implementation strategies, are indicated.
Trouble in Anatolia
Authors: Anthonisen Nick R
Published: March 2016

In this issue of the Canadian Respiratory Journal, Gulmez et al (pages 287‐290) review the presentation, management and outcome of malignant mesothelioma in central Anatolia, Turkey. There is nothing particularly new about the disease here; it presents with chest pain, dyspnea and pleural effusion, is diagnosed by biopsy and has a miserable outcome whatever is done for it, just like malignant mesothelioma in Canada. Mesothelioma in Anatolia is unusual in that it is very common, with an approximately equal sex distribution, and frequently occurs in relatively young people. The reasons for this are not a mystery. Anatolia is a volcanic area; there is a lot of asbestos on or near the surface, and it is widely used as construction material, in painting, and as insulation (pages 287‐290)! Asbestos related disease is due to environmental, not occupational exposure, and exposure is more intense and occurs at an earlier age than in Canada. Not only that, but some areas of Anatolia are rich in erionite, and people build homes in and on erionite‐bearing rocks. Erionite is apparently something like asbestos but worse in terms of carcinogenicity (1), perhaps because its crystals have large surface areas, and areas with erionite have an even higher incidence of mesothelioma.
Atypical Presentation of Lymphomatoid Granulomatosis in a Patient with Longstanding Sarcoidosis
Authors: Koh Paul S , Foyle Annette HC , Cartier Yannick , Langley G Ross , Morrison Nancy J , Rocker Graeme , Casson Alan G
Published: March 2016

A patient was recently evaluated who had longstanding sarcoidosis with lymphadenopathy and multiple, small lung nodules, and who developed a new, 9 cm solitary pulmonary mass in the right lower lobe. After thoracotomy, this lesion was ultimately found to be lymphomatoid granulomatosis, a rare lymphoproliferative disorder. Radiographic evaluations of patients with this disorder characteristically show multiple, bilateral reticulonodular opacities that follow the bronchovascular bundles; however, presentation with a solitary, large pulmonary mass is rare. The present case illustrates the need for complete evaluation of new clinical and radiographic findings in the setting of chronic lung disease.
Exclusion Spirometry: A Bad Idea
Authors: Mcivor Andrew
Published: March 2016

No single item or combination of items from the bedside clinical examination can rule out airflow obstruction; for this purpose, spirometry is essential. I, like my colleagues, visually conceptualize chronic obstructive pulmonary disease patients using objective lung function testing. I am well aware that spirometry has neither been accepted nor widely performed outside of specialist practice (1). In this issue of the Canadian Respiratory Journal, Almirall and Bégin (pages 195 to 196) provide a very reasoned argument suggesting that obtaining isolated normal values of spirometric indexes can exclude certain conditions.