bluuebunny/crossref_metadata_2025 huggingface dataset:
Opioid Tolerance and Physical Dependence: Role of Spinal Neuropeptides, Excitatory Amino Acids and Their Messengers
Authors: Jhamandas Khem , Powell Kelly , Quirion Remi , Milne B
Published: March 2016

Chronic opioid treatment results in the development of tolerance and physical dependence. The mechanisms underlying opioid tolerance and/or physical dependence are unclear. Recent studies suggest that opioid receptor or nociceptive, neural network‐based adaptations contribute to this phenomenon. At the spinal level, the genesis of tolerance and physical dependence is associated with increased excitatory amino acid activity expressed through N‐methyl‐D‐aspartate receptors in the dorsal horn. However, recent evidence also implicates spinal neuropeptide transmitters such as calcitonin gene‐related peptide (CGRP) and  substance P in the development of opioid tolerance. Long term spinal morphine treatment increases CGRP‐like immunostaining in the dorsal horn, and coadministration of morphine with CGRP8-37, a competitive CGRP1 receptor antagonist, prevents this response as well as loss of the analgesic potency. CGRP8-37, like N‐methyl‐D‐aspartate receptor antagonists, has the potential to restore morphine potency in experimental animals who are already tolerant to the opioid agonist. Recent evidence suggests that the effects of excitatory amino acid and neuropeptide receptor activity may be expressed through the generation of messengers such as nitric oxide and prostanoids. Agents that inhibit the synthesis of nitric oxide and prostanoids have the potential to inhibit and reverse spinal opioid tolerance, suggesting that this phenomenon may be expressed through the activity of these mediators. Nociceptive transmission in the dorsal horn of the spinal cord also involves activity of a number of other mediators including morphine modulatory neuropeptides, neuropeptide FF  and neuropeptide SF. The role of these mediators and their relationship with other factors implicated in tolerance remain to be determined.
Swelling of the Leg, Deep Venous Thrombosis and the Piriformis Syndrome
Authors: Bustamante Sara , Houlton Peter G
Published: March 2016

BACKGROUND: The piriformis syndrome, which was first described 60 years ago, is a well recognized cause of sciatica, leg pain and low back pain, due to the entrapment of the sciatic nerve in the piriformis and other rotator muscles. Very few complications relating to this syndrome have been described.

AIMS: To discuss how the piriformis syndrome may cause venous engorgement in the lower limb, and how the piriformis syndrome should be included as a possible cause of acute deep venous thrombosis in a not initially swollen leg. Both complications can occur independently.

METHODS: Two cases of swelling of the leg and acute deep venous thrombosis independently associated with the piriformis syndrome are presented.

CONCLUSIONS: Swelling of the leg and deep venous thrombosis are possible complications of the piriformis syndrome that occur due to entrapment of nerves and vessels within the leg, secondary to a severe spasm and hypertrophy of the piriformis and other rotator muscles.
Community‐Based Cluster of Methicillin‐Resistant Staphylococcus Aureus in Manitoba
Authors: Kurbis Carol A , Wylie John L
Published: March 2016

A community‐based, single strain cluster of methicillin‐resistant Staphylococcus aureus (MRSA) is described. The cluster of cases was identified in a small rural community in southwestern Manitoba, although some spread of the MRSA strain to neighbouring communities was observed. The majority of people were otherwise healthy, had no contact with the hospital system and did not fit the profile of those at risk for MRSA infection.
Beliefs and Behaviours of Parents Regarding Antibiotic Use by Children
Authors: Bagshaw Sean M , Kellner James D
Published: March 2016

OBJECTIVE: To determine parents′ beliefs and behaviours about antibiotic use by their children in the ambulatory setting.

DESIGN: Cross‐sectional survey, where a self‐administered questionnaire was completed by adult caregivers of children before the medical assessment of the child.

SETTING: Three paediatric acute care settings (paediatric emergency department [PED], group paediatric practice and after hours walk‐in medical clinic).

POPULATION STUDIED: Adult caregivers (n=114; 76% mothers, 19% fathers and 4% other caregivers) of children brought for acute care were surveyed.

MAIN RESULTS: Forty‐one caregivers completed the survey in the PED, 37 in the paediatric office and 36 in the walk‐in clinic. They believed that antibiotics were appropriate for ear infections (86%), pharyngitis (77%), bronchitis (49%), sinus colds (20%), cough (12%), colds (8%) and influenza (8%). Sixty‐eight per cent of children had received antibiotics in the previous year. Thirteen per cent of caregivers reported previously requesting an antibiotic for their child, 18% believed a previous antibiotic prescription had been unnecessary and 19% had not complied with prescriptions in the past. Concerns about antibiotic use included antibiotic resistance (50%), harm to the immune system (40%), adverse effects (28%) and lack of efficacy (19%).

CONCLUSIONS: In this population, parental knowledge and understanding of indications for antibiotics and their adverse effects were good; however, incorrect beliefs and disagreements with physicians did occur. To improve patterns of antibiotic use by children, it will be necessary to understand parents′ beliefs, behaviours and information sources better so that misconceptions and disagreements with caregivers can be addressed appropriately.
Population‐Based Surveillance of Invasive Group A Streptococcal Disease in British Columbia: 1996‐1998
Authors: Bjornson Gordean L , Scheifele David W , Bell Alison , King Arlene
Published: March 2016

OBJECTIVE: To identify and describe all cases of invasive group A streptococcal (GAS) infection occurring in British Columbia during a two‐year period.

DESIGN: Active, laboratory‐based surveillance with supplemental case description.

SETTING: Forty community and regional hospitals and the provincial laboratory participated, encompassing all health regions.

POPULATION STUDIED: Entire provincial population from April 1, 1996 to March 31, 1998.

MAIN RESULTS: Over the 24‐month surveillance period, 182 eligible cases were identified, yielding a mean annual incidence rate of 2.3/100,000. Patients ranged in age from two to 91 years, with a mean of 39.1 years. Soft tissue infections accounted for 89 of 130 cases (68.5%) with a defined clinical syndrome, 20 of which were necrotizing fasciitis. Injection drug use was described in 55 patients, who, as a group, were younger, more likely to have soft tissue infections and less likely to die of infection than nondrug users. Other risk factors for infection included HIV infection (19 patients); skin damage (26 patients, damage independent of injection drug use); chronic illness (27 patients); and immunosuppresion (three patients). Death from GAS infection occurred in 15 of 131 (11.5%) cases with known outcome, yielding an annual case fatality rate of 1.9/million population. Among necrotizing faciitis cases, the mortality rate was 30%.

CONCLUSIONS: Invasive GAS infections are rare in British Columbia and tend to involve persons with chronic illness or prior skin trauma, especially injection drug abuse, which accounted for nearly half of the cases.
The Lung Cancer and Cigarette Smoking Web Page: A Pilot Study in Telehealth Promotion on the World Wide Web
Authors: Grannis Frederic W
Published: March 2016

BACKGROUND: Diseases caused by tobacco products are the number one preventable health problem.

STUDY OBJECTIVES: A pilot study was performed to determine the characteristics of persons searching the World Wide Web (WWW) for information on tobacco‐caused diseases, the type of information sought and the feasibility of meeting informational needs.

METHODS: The Lung Cancer and Cigarette Smoking Web Page at the unique reference location , created in January 1996, consists of hypertext metafile language files in a ‘frequently asked questions’ format on tobacco‐caused diseases, nicotine dependence and smoking cessation. Links to other Web pages, a counter, e‐mail access and Web forms were included.

SETTING: Personal computer.

PARTICIPANTS: People browsing the WWW.

RESULTS: Between April 1996 and March 1999, there were more than 150,000 hits and 1510 individual e‐mail or form responses; 597 (51.3%) of the respondents were female and 566 (48.7%) were male. They ranged between nine and 79 years of age, with a median of 29 years and a mean of 34 years. The percentage of respondents 20 years old or younger was 34.3%. Five hundred thirteen people resided in 45 American states, and 195 individuals resided in 39 other nations. Students, people with tobacco‐caused diseases, and relatives or friends of persons with tobacco‐caused diseases made up the large majority of correspondents. Smokers represented 40.2% of the respondents, ex‐smokers 34.3% and never‐smokers 25.5%. There were three main types of questions: questions for information on the diagnosis and treatment of lung cancer, for help with smoking cessation and for information on tobacco‐caused diseases from students working on a school‐related project. Images of tobacco‐caused diseases were requested frequently.

CONCLUSIONS: An educational WWW page is a potentially important resource in the control of tobacco‐caused diseases because it fosters primary prevention of smoking in young people, facilitating smoking cessation and providing information on the diagnosis and treatment of tobacco‐caused diseases.
N‐CDAD in Canada: Results of the Canadian Nosocomial Infection Surveillance Program 1997 N‐CDAD Prevalence Surveillance Project
Authors: Hyland Meaghen , Ofner-Agostini Marianna , Miller Mark , Paton Shirley , Gourdeau Marie , Ishak Magued , the Canadian Hospital Epidemiology Committee  , the Canadian Nosocomial Infection Surveillance Program (Heal
Published: March 2016

BACKGROUND: A 1996 preproject survey among Canadian Hospital Epidemiology Committee (CHEC) sites revealed variations in the prevention, detection, management and surveillance of Clostridium difficile‐associated diarrhea (CDAD). Facilities wanted to establish national rates of nosocomially acquired CDAD (N‐CDAD) to understand the impact of control or prevention measures, and the burden of N‐CDAD on health care resources. The CHEC, in collaboration with the Laboratory Centre for Disease Control (Health Canada) and under the Canadian Nosocomial Infection Surveillance Program, undertook a prevalence surveillance project among selected hospitals throughout Canada.

OBJECTIVE: To establish national prevalence rates of N‐CDAD.

METHODS: For six weeks in 1997, selected CHEC sites tested all diarrheal stools from inpatients for either C difficile toxin or C difficile bacteria with evidence of toxin production. Questionnaires were completed for patients with positive stool assays who met the case definitions.

RESULTS: Nineteen health care facilities in eight provinces participated in the project. The overall prevalence of N‐CDAD was 13.0% (95% CI 9.5% to 16.5%). The mean number of N‐CDAD cases were 66.3 cases/100,000 patient days (95% CI
Orthodeoxia and Platypnea Secondary to a Patent Foramen Ovale Despite Normal Right Sided Cardiac Pressures
Authors: Varkul Mark , Robinson Trevor , Ng Elane , Hyland Robert
Published: March 2016

Numerous cases of orthodeoxia and platypnea have been reported. Some have been found to be due to intracardiac shunts despite normal intracardiac pressures. In the case presented, a 79‐year‐old woman was noted to have orthodeoxia and platypnea secondary to a patent foramen ovale (PFO) despite normal intracardiac pressures. She recovered after closure of the PFO. The authors postulate that recent vertebral fractures and subsequent kyphosis, as well as a dilated thoracic aorta, altered intrathoracic relationships and may have led to a stream of venous return being directed across the PFO in the upright position, despite normal intracardiac pressures.
Antimicrobial Resistance in Canada: An Update on Activities of the Canadian Committee on Antibiotic Resistance
Authors: Conly John
Published: March 2016

This article is the first in a planned series of semi‐annual updates, intended to provide readers with up‐to‐date information on antibiotic resistance in Canada and on the many current activities designed to address the problem. This information is provided by the Canadian Committee on Antibiotic Resistance (CCAR), a national organization that has a mandate to coordinate activities designed to address the growing problem of antibiotic resistance in Canada.
Multum in Parvo: Explorations with a Small Bag of Carbon Dioxide
Authors: Campbell EJM
Published: March 2016

A collection of 12 papers published between 1957 and 1972 are revisited. The papers had a common theme of the use of rebreathing carbon dioxide and explored a variety of topics in respiratory physiology. The first study established a method for the noninvasive and indirect estimation of arterial carbon dioxide pressure that was suitable for the routine clinical monitoring of respiratory failure and whose clinical utility remains to this day, but which also provided observations that were the stimulus for the studies that followed. The rate of rise in the partial pressure of carbon dioxide (PCO2) during rebreathing led to an analysis of body carbon dioxide storage capacity. Knowledge of carbon dioxide storage led to a method for quantifying lactate production in exercise without the need for blood sampling. The changes in ventilation that accompanied the increase in PCO2 provided the basis for a rapid method for measuring aspects of breathing control (Read′s method), which was later modified to measure the ventilatory response to hypoxia. The physiology of breath‐holding was explored through observations of the fall in breath‐holding time as PCO2 climbed. Rebreathing also allowed increases in voluntary ventilation to be achieved without the development of alkalosis, leading to studies of maximal voluntary ventilation and respiratory muscle fatigue. Equilibration of PCO2 during rebreathing was used to measure mixed venous PCO2 during exercise and develop an integrated approach to the physiology of exercise in health and disease; alveolar‐arterial disequilibrium in PCO2 during exercise was uncovered. Equilibration of PCO2, as well as PO2, during rebreathing of carbon dioxide and nitrogen gas mixtures showed different time courses of venous gases at the onset of exercise. Starting with the rebreathing of carbon dioxide in oxygen mixtures in a small rubber bag, an astonishing range of topics in respiratory physiology was explored, with observations that remain valid, but in some respects unresolved, to the present day.
Sputum Cell Counts and Exhaled Nitric Oxide in Patients with Gastroesophageal Reflux, and Cough or Asthma
Authors: Parameswaran Krishnan , Allen Christopher J , Kamada Dennis , Efthimiadis Ann , Anvari Mehran , Hargreave Frederick E
Published: March 2016

BACKGROUND: Gastroesophageal reflux (GER) is commonly associated with chronic cough and asthma, but there is little or no information on the nature of any associated airway inflammation.

OBJECTIVE: To observe whether the association with GER worsens airway inflammation in patients with chronic cough or asthma.

PATIENTS AND METHODS: The airway inflammatory indexes in induced sputum and exhaled air were examined in a cross‐sectional study of 11 patients with cough and GER, nine patients with mildly symptomatic asthma and GER, nine patients with mildly symptomatic asthma without GER and nine normal, healthy control subjects. GER was shown objectively by 24 h ambulatory pH recording.

RESULTS: The sputum total cell count, the proportion of neutrophils and macrophages, and the fibrinogen level were normal in all four groups, with no significant differences among the groups. The sputum eosinophil and metachromatic cell percentages, and eosinophil cationic protein levels were normal in patients with cough and GER. They were significantly increased in patients with asthma compared with healthy subjects (P<0.01) and patients with cough (P<0.01), but were not different between groups with and without GER. Exhaled nitric oxide levels showed similar results (P<0.01). The correlations between the number of episodes of reflux and the proportion of sputum eosinophils, neutrophils or exhaled nitric oxide were modest but not significant.

CONCLUSIONS: GER, when associated with cough or mildly symptomatic asthma, does not cause or aggravate existing airway inflammation as measured by induced sputum cell counts and fibrinogen level, or by exhaled nitric oxide.
Medicinal Use of Cannabis: History and Current Status
Authors: Kalant Harold
Published: March 2016

OBJECTIVE: To provide an overview of the history and pharmacology of cannabis in relation to current scientific knowledge concerning actual and potential therapeutic uses of cannabis preparations and pure cannabinoids.

METHODS: The literature on therapeutic uses of cannabis and cannabinoids was assessed with respect to type of study design, quality and variability of data, independent replications by the same or other investigators, magnitude of effects, comparison with other available treatments and reported adverse effects. The results of this review were also compared with those of major international reviews of this topic in the past five years.

CONCLUSIONS: Pure tetrahydrocannabinol and several analogues have shown significant therapeutic benefits in the relief of nausea and vomiting, and stimulation of appetite in patients with wasting syndrome. Recent evidence clearly demonstrates analgesic and antispasticity effects that will probably prove to be clinically useful. Reduction of intraocular pressure in glaucoma and bronchodilation in asthma are not sufficiently strong, long lasting or reliable to provide a valid basis for therapeutic use. The anticonvulsant effect of cannabidiol is sufficiently promising to warrant further properly designed clinical trials. There is still a major lack of long term pharmacokinetic data and information on drug interactions. For all the present and probable future uses, pure cannabinoids, administered orally, rectally or parenterally, have been shown to be effective, and they are free of the risks of chronic inflammatory disease of the airways and upper repiratory cancer that are associated with the smoking of crude cannabis. Smoking might be justified on compassionate grounds in terminally ill patients who are already accustomed to using cannabis in this manner. Future research will probably yield new synthetic analogues with better separation of therapeutic effects from undesired psychoactivity and other side effects, and with solubility properties that may permit topical administration in the eye, or aerosol inhalation for rapid systemic effect without the risks associated with smoke inhalation.
Susceptibility of Community Gram‐Negative Urinary Tract Isolates to Mecillinam and Other Oral Agents
Authors: Mazzulli Tony , Skulnick Martin , Small Glen , Marshall Wayne , Hoban Darryl J , Zhanel George G , Finn Susan , Low Donald E
Published: March 2016

OBJECTIVE: To determine the susceptibility of community outpatient Gram‐negative urinary tract isolates to mecillinam and other commonly used oral agents.

DESIGN AND SETTING: The study was a laboratory‐based study of consecutive Gram‐negative urinary tract isolates. Only those isolates considered to be significant pathogens were included in the study. Susceptibility testing was performed using agar dilution methodology following guidelines published by the National Committee for Clinical Laboratory Standards.

POPULATION STUDIED: Outpatients presenting to a family physician or clinic with signs or symptoms suggestive of a urinary tract infection were included in the study.

MAIN RESULTS: Of 2000 consecutive community isolates (91.8% Escherichia coli, 3.9% Klebsiella species, 2.0% Proteus species, 2.3% others), in vitro susceptibilities were: mecillinam 98.8%, ampicillin 77.0%, ciprofloxacin 100%, trimethoprim/sulfamethoxazole 91.6% and nitrofurantoin 95.4%. Susceptibility to mecillinam was significantly better than all other agents except ciprofloxacin (P<0.001, McNemar′s test). Organisms with reduced susceptibility to mecillinam included Citrobacter species, Pseudomonas aeruginosa and Providencia species.

CONCLUSIONS: Community Gram‐negative urinary tract isolates remain highly sensitive to mecillinam and ciprofloxacin, but a significant number have developed resistance to trimethoprim/sulfamethoxazole. Further studies are required to determine the clinical significance of these results.
Are all Older Adults with Persistent Pain Created Equal? Preliminary Evidence for a Multiaxial Taxonomy
Authors: Weiner Debra K , Rudy Thomas E , Gaur Swati
Published: March 2016

BACKGROUND: Persistent pain is grossly undertreated in older adult sufferers, despite its high prevalence in this age group. Because of its multidimensional impacts, including depression, sleep disruption and physical disability, patients with persistent pain often benefit from interdisciplinary pain clinic treatment. This treatment is expensive, however, and may not be required by all patients. The Multiaxial Assessment of Pain (MAP) has demonstrated value in predicting response to treatment in younger adults with persistent pain.

OBJECTIVE: To examine the feasibility of a MAP taxonomy for community‐dwelling adults age 65 years or older.

PARTICIPANTS AND PROCEDURES: One hundred eight subjects with persistent pain (mean age 73.8 years, SD=8.4 years) were interviewed and data collected on demographics, pain intensity, depressive symptoms, sleep disruption, pain interference with performance of basic and instrumental activities of daily living, frequency of engagement in advanced activities of daily living, cognitive function and comorbidity. A subset of these subjects underwent physical capacities testing, including maximal isometric lift strength, dynamic lifting endurance, timed chair rise and balance.

RESULTS: Analyses derived three primary clusters of patients. Cluster 1 (24%) reported less intense pain, less depression and sleep disruption, and higher activity levels. Cluster 3 (30%) suffered from more pain and were more functionally disabled. Cluster 2 (46%) had characteristics of cluster 1 and cluster 3, but with some characteristics that were clearly unique.

CONCLUSIONS: While these results are preliminary and require further validation, they indicate that older adults are heterogeneous in their response to persistent pain. Future studies should be performed to examine whether the MAP taxonomy is applicable to older adults regardless of medical diagnosis. Ultimately, this information may have meaning with regard to both treatment prescribing, and the design and interpretation of intervention studies.
Severe Complications Associated with Varicella: Province of Quebec, April 1994 to March 1996
Authors: Rivest Paul , Bédard Lucie , Valiquette Louise , Mills Elaine , Lebel Marc H , Lavoie Gilles , Carsley John
Published: March 2016

OBJECTIVE: To determine the frequency and severity of serious complications associated with varicella in Quebec; the frequency and severity of cases of congenital varicella; and hospital costs associated with hospitalizations for varicella.

STUDY DESIGN: All hospitalizations related to varicella were identified through the use of a hospital data bank and pertinent data were collected from hospital records.

SETTING: Province of Quebec with a population of 6,895,960 people.

STUDY POPULATION: All cases with a principal or secondary diagnosis of varicella hospitalized in Quebec between April 1, 1994 and March 31, 1996.

OUTCOME MEASURES: Types of complications and reason for hospitalization, risk of complications and calculation of associated costs were studied.

RESULTS: Nine hundred nine eligible hospitalizations were identified between April 1, 1994 and March 31, 1996. In all, 583 (64.1%) hospitalizations were for the treatment of complications, 127 (14.0%) for administration of intravenous acyclovir and 199 (21.9%) for supportive care. Healthy people accounted for 644 (70.8%) hospitalizations and immunosuppressed individuals for 136 (15.0%). Among children, one‐half of the principal complications were skin infections, while 13.5% and 8.4% of principal complications were pneumonia and neurological complications, respectively. Among adults, the most common complication was pneumonia, with a rate of 43.5%, followed by thrombocytopenia and skin infections, with rates of 22.2% and 14.8%, respectively. The complication rate was 29.2 cases/10,000 cases of varicella.

CONCLUSIONS: Although perceived as a benign childhood disease by the general population, varicella may be accompanied by severe complications. Morbidity associated with varicella is one of the elements that must be considered when evaluating the usefulness of varicella vaccine.
Etiology of Exudative Pleural Effusions in Adults in North Lebanon
Authors: Kalaajieh Wassim Khalil
Published: March 2016

OBJECTIVE: To establish the clinical pattern and etiology of exudative pleural effusions in adults in North Lebanon.

MATERIALS AND METHODS: All patients aged 21 years and older who were admitted with exudative pleural effusions to the Husseini Hospital, Tripoli, North Lebanon, between 1997 and 1999 were studied prospectively.

RESULTS: Of 165 patients with exudative pleural effusions, 114 (69.1%) were men and 51 (30.9%) were women. The most frequent cause of exudative pleural effusions was tuberculosis (43.7%), followed by malignancy (32.1%). The majority (88.7%) of malignant pleural effusions were due to lung cancer. Tuberculous effusions were more frequent in the first five decades of life (66.7%) and were the most common type of pleural effusion, accounting for 68.6% of patients younger than 50 years of age. Malignant effusions were more frequent among the older age groups, with 73.6% of patients with malignant effusions being older than 50 years of age. Most types of exudative pleural effusions showed a preference for the right side of the thorax. Of the diagnostic procedures used in the present study, the most useful were histological examination and culture of pleural biopsies.

CONCLUSIONS: In North Lebanon, the clinical pattern and etiology of exudative pleural effusions are similar to those in the developing countries; the most frequent cause of pleural exudates is tuberculosis, followed by malignancy, particularly malignancy due to lung cancer.
Spirometric Predictors for the Exclusion of Severe Hypoxemia in Chronic Obstructive Pulmonary Disease
Authors: Gunen Hakan , Kosar Feridun
Published: March 2016

BACKGROUND: Controversy has existed over the need for routine arterial blood gas (ABG) analysis in patients with chronic obstructive pulmonary disease (COPD). Some authors recommend it in all patients with COPD, but others find it unnecessary if the forced expiratory volume in 1 s (FEV1) is 50% of predicted or greater.

OBJECTIVES: To clarify this controversy, and to investigate correlations between severe hypoxemia and multiple spirometric parameters in patients with COPD with FEV1 50% of predicted or greater.

PATIENTS AND METHODS: In 103 consecutive patients with COPD with FEV1 50% of predicted or greater, and without any other cardiopulmonary disorder, the incidence of severe hypoxemia (partial pressure of arterial oxygen less than 60 mmHg) was established by ABG analysis. Positive and negative predictive values (PPVs and NPVs, respectively) for severe hypoxemia for multiple spirometric parameters (FEV1, FEV1/forced vital capacity [FVC], peak expiratory flow [PEF], maximal midexpiratory flow rate [FEF25-75]) were evaluated in a stepwise manner.

RESULTS: Twenty‐two patients (21%) were found to be severely hypoxemic. In the severely hypoxemic group, the mean values for FEV1, FEV1/FVC, PEF and FEF25-75 were 59.0±8.19%, 53.6±11.3, 50.6±9.3 and 34.4±14.2% of predicted, respectively. The mean values for the same parameters in the other patients were 58.0±4.6%, 52.7±7.8, 51.5±7.5 and 39.1±7.7% of predicted, respectively. Comparing these parameters between the two groups, only the difference in FEF25-75 was statistically significant (P<0.01). Valid PPVs and NPVs could not be established for any of the parameters at any level, except for the NPV for FEF25-75 50% of predicted or greater, which was 92%. This threshold value resulted in a false negative finding in less than 5% of the patients with hypoxemia.

CONCLUSIONS: The results of the present study showed that one in five patients with COPD with FEV1 50% of predicted or greater was severely hypoxemic. In such patients, hypoxemia may be excluded, and ABG analysis may not be needed when the FEF25-75 is also 50% of predicted or greater. The FEV1, FEV1/FVC and PEF parameters failed to predict or exclude severe hypoxemia.
The McGill Pain Questionnaire, Japanese Version, Reconsidered: Confirming the Theoretical Structure
Authors: Hasegawa Mamoru , Hattori Suguru , Mishima Masaru , Matsumoto Isao , Kimura Takashi , Baba Yasuko , Takano Osami , Sasaki Toshio , Kanemura Kazue , Senami Katsuhiko , Shibata Toshinari
Published: March 2016

BACKGROUND: Based on a tripartite theoretical model of pain, the Pain Rating Index (PRI) of the McGill Pain Questionnaire (MPQ) continues to be one of the most frequently used instruments to measure clinical pain. However, language and cultural barriers have hindered its wide use and standardization in Japan. Although a number of exploratory factor analysis studies have failed to support consistently the theoretical structure of the MPQ, a few previous confirmatory factor analysis studies did statistically support the a priori model.

OBJECTIVE: To test, through confirmatory factor analysis (CFA), the theoretical structure of a Japanese version of the MPQ (JMPQ), which followed a format similar to that of the original MPQ.

DESIGN: This study used CFA on prospectively collected data from 199 consecutive outpatients with chronic pain at a university hospital to test the theoretical structure of the JMPQ.

RESULTS AND CONCLUSIONS: CFA was completed on the first 16 PRI subclass scores; this process yielded a well fitting final model that explained 92% of the covariance in the observed data. The results supported the hypothesis that the sensory, affective and evaluative subscales of the PRI are representative of the multidimensionality of the pain experience, with minimal overlap. It is suggested that the theoretical structure of the MPQ is maintained in the JMPQ used in this study. Therefore, this study is the first step toward standardization of the JMPQ, serving as a cultural bridge in the field of pain medicine between Japan and English‐speaking nations such as Canada.
Enhanced Surveillance of Acute Hepatitis B and C in Four Health Regions in Canada, 1998 TO 1999
Authors: Zou Shimian , Zhang Jun , Tepper Martin , Giulivi Antonio , Baptiste Beverley , Predy Gerry , Poliquin Darlene , Morin Manon , Jones Donna , Loewen Joy , Ogonowski Margaret , Moses Stephen , Elliott Lawrence
Published: March 2016

OBJECTIVE: To assess the incidence and risk factors for acute hepatitis B and acute hepatitis C in a defined Canadian population.

PATIENTS AND METHODS: An enhanced surveillance system was established in October 1998 to identify cases of acute hepatitis B and C infections in four regions in Canada, with a total population of approximately 3.2 million people. Information on demographic and clinical characteristics, laboratory results and potential risk factors was collected using predefined questionnaires.

RESULTS: A total of 79 cases of acute hepatitis B and 102 cases of acute hepatitis C were identified from October 1998 to December 1999, resulting in an incidence rate of 2.3 and 2.9/100,000 person‐years, respectively. Males had higher incidence rates than females. The incidence of acute hepatitis B peaked at age 30 to 39 years for both males and females, whereas acute hepatitis C peaked at 30 to 39 years for males and 15 to 29 years for females. At least 34% of acute hepatitis B and 63% of acute hepatitis C were associated with injection drug use. Persons who were 15 to 39 years of age were more likely to report injection drug use as a risk factor. Heterosexual contact was reported to be a risk factor for 36.6% of acute hepatitis B cases and 3.5% of acute hepatitis C cases.

CONCLUSIONS: The surveillance provides national incidence estimates of clinically recognized acute hepatitis B and C. Both hepatitis B and C are important public health threats to Canadians. Prevention efforts for both diseases should focus on injection drug use, especially for people aged 15 to 39 years. Risky sexual behaviour is also a major concern in prevention of hepatitis B in Canada.
Alpha1‐Antitrypsin Deficiency: A Position Statement of the Canadian Thoracic Society
Authors: Abboud RT , Ford GT , Chapman KR
Published: March 2016

OBJECTIVE: To prepare new guidelines for the Canadian Thoracic Society (CTS) regarding severe alpha1‐antitrypsin (AAT) deficiency and AAT replacement therapy.

MATERIALS AND METHODS: Previously published guidelines and the medical literature about AAT deficiency and AAT replacement were reviewed. The prepared statement was reviewed and approved by the CTS Standards and Executive Committees.

RESULTS: Three studies evaluated AAT replacement. The National Heart, Lung and Blood Institute’s AAT Registry was a nonrandomized comparison of patients receiving and not receiving AAT replacement, and evaluated the decline in forced expiratory volume in 1 s (FEV1) in 927 subjects. The rate of FEV1 decline was significantly less in those receiving AAT treatment (66 ± SE 5 mL/year versus 93 ± SE 11 mL/year; P=0.03) only in the subgroup with FEV1 35% to 49% predicted. In another study comparing 198 German patients receiving weekly AAT infusions and 97 untreated Danish patients, the mean annual decline in FEV1 was significantly less in treated patients only in the subgroup with FEV1 31% to 65% predicted (62 mL versus 83 mL, P=0.04). Neither of these studies was a randomized, controlled study and, thus, cannot be taken as proof of efficacy. A randomized, double‐blind, placebo controlled trial of monthly replacement therapy over three years in 56 exsmokers with severe AAT deficiency and moderate emphysema showed a trend (P=0.07) favouring slower progression of emphysema by computed tomography scan in the group receiving AAT replacement.

CONCLUSIONS: AAT replacement therapy has not been proven definitively to be clinically effective in reducing the progression of disease in AAT‐deficient patients, but there is a possible benefit to selected patients. A placebo controlled, randomized clinical trial of AAT replacement therapy is required. The authors recommend reserving AAT replacement therapy for AAT‐deficient patients with impaired FEV1 of 35% to 50% predicted who have quit smoking and are on optimal medical therapy but continue to show a rapid decline in FEV1, and participation of all AAT‐deficient subjects in the Canadian AAT Registry.
Flesh‐Eating Disease: A Note on Necrotizing Fasciitis
Authors: Davies H Dele
Published: March 2016

There has been much media attention in the past few years to the condition dubbed ′flesh‐eating disease′, which refers, primarily, to a form of invasive group A beta hemolytic streptococcal (GABHS) infection that leads to fascia and muscle necrosis. In 1999, the Canadian Paediatric Society issued a statement on the state of knowledge and management of children, and close contacts of persons with all‐invasive GABHS disease (1). The present note is intended to deal specifically with necrotizing fasciitis (NF) by providing an update on the limited current state of knowledge, diagnosis and management. Surveillance to establish actual national rates and epidemiology of NF through the Canadian Paediatric Society is proposed.
Erysipelothrix Rhusiopathiae Endocarditis and Presumed Osteomyelitis
Authors: Romney Marc , Cheung Stephen , Montessori Valentina
Published: March 2016

Erysipelothrix rhusiopathiae is known to cause infections in humans following exposure to decaying organic matter or animals colonized with the organism, such as swine and fish. Invasive infections with this organism are unusual and are manifested primarily as infective endocarditis. The present report is believed to be the first to report a case of E rhusiopathiae endocarditis and presumptive osteomyelitis. E rhusiopathiae appears to have intrinsic resistance to vancomycin. Because vancomycin is often used empirically for the treatment of endocarditis, rapid differentiation of E rhusiopathiae> from other Gram‐positive organisms is critical. In patients with endocarditis caused by a Gram‐positive bacillus and epidemiological risk factors for E rhusiopathiae exposure, empirical treatment with vancomycin should be reconsidered.
Isolated Native Tricuspid Valve Endocarditis Caused by Viridans Streptococcus
Authors: Swiston John , Shafran Stephen D , Kassam Narmin
Published: March 2016

The present report describes a case of native tricuspid valve endocarditis caused by viridans group streptococcus in a 43‐year‐old man who had recently undergone dental extraction. The patient had no history of intravenous drug use, heart disease or right heart catheterization. Although there have been scattered reports of unusual organisms, to the authors′ knowledge, this is the first case of viridans group streptococcal endocarditis involving only the tricuspid valve after dental manipulation.
Historical Review of Croup
Authors: Marchessault Victor
Published: March 2016

In the 1960s, managing croup was simple ‐ put the child in the bathroom and run a hot shower. In most cases, the child′s symptoms would be controlled. When the mist from the shower failed to control the croup, the parents would take the child to an emergency room. Often, the child would get better on the way to the hospital, thanks to the cool, outside air. At the hospital, a ′croupette′ would be available for some children, and the health care providers hoped that the children would remain quiet in the strange tent filled with cold mist. Some hospitals even had special croup rooms where steam was piped in, and the whole room was filled with cold mist. Needless to say, nursing staff were not eager to work in these rooms. The last resort of treatment was a tracheotomy because the art of intubation had not yet been mastered. Two randomized studies failed to show the benefit of cool mist, and, today, it is rarely used (1,2).
Previous Creatinine Levels Safely Predict Amantadine Dose for Influenza a Outbreak Control
Authors: Buxton Jane A , Skowronski Danuta M , Ng Helen , Marion Steve A , Williams Michele , Forbes Anna , King Arlene , Hockin Jamie
Published: March 2016

BACKGROUND: Amantadine, an antiviral agent, is the only drug currently approved in Canada for prophylaxis of influenza A virus infection. To minimize side effects, the amantadine dose is adjusted for age and estimated creatinine clearance (CrCl) based on plasma creatinine (Cr) levels. As amantadine is used more frequently for influenza A outbreak control in care facilities for elderly people, physicians are increasingly called on to prescribe it for residents and to consider the necessity of requesting plasma Cr levels.

OBJECTIVE: To determine whether previous Cr levels are predictive in estimating current CrCl and safe amantadine dose determination.

DESIGN AND SETTING: Residents′ charts were reviewed in two facilities in Vancouver, British Columbia. CrCl estimated using previous or current Cr results, current weight and age, as well as recommended amantadine doses based on Canadian National Advisory Committee on Immunization guidelines, were studied.

RESULTS: 165 charts with Cr results in March 1998 were included; 122 had results before March 1998, and 103 had Cr results after March 1998. Pearson′s correlation coefficient for CrCl estimated from current and previous Cr values was 0.929 for results less than six months previously, 0.974 for six to 12 months previously and 0.952 for 12 to 18 months previously. The same or a more conservative dose of amantadine was predicted in 92% of cases when using a Cr result taken within the previous year and in 76% of cases when using a Cr result taken 12 to 18 months previously.

CONCLUSION: In long term care facilities, Cr levels measured up to 12 months previously can usually safely be used to estimate CrCl. Using previous Cr results permits advance preparation of doctor′s orders for amantadine prophylaxis and avoids repeating Cr testing on every resident when an outbreak occurs, reducing related staff time and cost.
Infectious Diseases Training in Canada: One Size Does Not Fit All
Authors: Lee B Craig
Published: March 2016

PURPOSE: To evaluate training in infectious diseases, determining which components of the training program best prepare residents for their career choices and where improvements are needed.

METHOD: A cross‐sectional survey was mailed to all 14 physicians who had graduated from both the Adult and Paediatric Infectious Diseases Training Program at the University of Calgary from 1985 to 1998. Responses about the adequacy of training were measured using a Likert‐type scale and a qualitative questionnaire.

RESULTS: Of 14 mailed questionnaires, nine responses were received (64%). Two‐thirds of respondents were in an academic setting, and seven (78%) graduates obtained postfellowship training. The specialists in academic settings were all engaged in multiple nonclinical activities. The clinical and diagnostic microbiological components of training received the highest scores in terms of adequacy of training.

CONCLUSION: Graduates of the University of Calgary training program indicated an overall satisfaction with their training. However, improvements are needed in career counselling, health administration, antibiotic utilization, infection prevention and specialized outpatient clinics. Potential strategies for addressing these issues include didactic lectures, enhanced exposure to clinical outpatient settings and provision of designated faculty mentors.
Bioterrorism in 2001: How Ready Are We?
Authors: Johnston B Lynn , Conly John M
Published: March 2016

On January 30, 2001, the federal Immigration Department′s headquarters in Ottawa were evacuated and shut down following a bioterrorism scare, which turned out to be a hoax. The building reopened 48 h later, after it was determined that the substance found was not anthrax (1). In the same week, a similar hoax forced the evacuation of an Ontario provincial government building in Toronto (1).
The Epidemiology of Childhood Asthma in Red Deer and Medicine Hat, Alberta
Authors: Hessel Patrick A , Klaver Justine , Michaelchuk Dennis , McGhan Shawna , Carson Mary M , Melvin Darrel
Published: March 2016

OBJECTIVES: To document the prevalence of asthma among school-aged children in two Alberta communities, to understand host and indoor environmental factors associated with asthma, and to compare these factors between the two communities.

DESIGN: A cross-sectional study with a nested, case-control follow-up.

SETTING: Red Deer and Medicine Hat, Alberta.

PATIENTS AND METHODS: Questionnaires were sent to families of children aged five to 19 years in Red Deer (n=5292) and Medicine Hat (n=5372) to identify children with current asthma. A random sample of 592 children with current asthma and 443 with no history of asthma constituted a case-control population; they were followed up by telephone to obtain responses to the European Respiratory Health Survey and, in children with current asthma, the Pediatric Quality of Life Questionnaire.

RESULTS: Cross-sectional response rates were 84% and 73% for Red Deer and Medicine Hat, respectively. The prevalence of asthma was higher in Medicine Hat (17.0%) than in Red Deer (12.8%). In the follow-up study, factors associated with the presence of asthma were parental asthma or allergies, number of siblings, presence of cats, serious respiratory illnesses before five years of age, sex, age, presence of mould and/or mildew and use of a gas cooking stove. The presence of mould and/or mildew was a significant risk factor in Red Deer but not in Medicine Hat.

CONCLUSIONS: Asthma prevalence among school children in Red Deer was consistent with recently published Canadian data; the prevalence in Medicine Hat was higher than expected, especially given the low relative humidity. Risk factor data are consistent with other studies in that parental asthma, especially maternal asthma, was a significant predictor of childhood asthma. Cats in the house (both communities) and environmental tobacco smoke (Medicine Hat only) were significantly less common among children with asthma, suggesting that preventive actions may have been taken in the homes of some children with asthma.
Pain: A Culturally Informed Experience
Authors: Ng David
Published: March 2016

I was raised in North America ‐ a culture and society in which the education emphasizes knowledge about science, its methods and its principles. The scientific method of understanding, coupled with the rudimentary knowledge that I was taught in high school biology, resulted in my conceptualization of pain as an objective truth. Pain, as I believed for a long time, was a bodily sensation with an expression that was more or less universal; to me, pain was simply the sensation that the brain experiences as a response to noxious stimuli. The pain sensation protects us from things that can hurt us; it is a warning sign that something in us is physically amiss. Thus, everybody physically reacts to the touch of a flame or experiences abdominal pain when there is appendicitis. Even now, in medical school, the pain education that I have received so far has only involved the physiology or mechanics of pain. Pain, as a physiological condition, operates independent of cultural context. However, in considering the experience of pain that my grandmother has endured, I realize that pain is much more than a mechanical bodily sensation effected by the nervous system in response to stimulus. Pain is a human experience, and as such, it is highly individualized and subjective. The proper diagnosis, care and treatment of pain necessitate a holistic understanding of pain, its physiology and its context (1).
Incidence of Pulmonary Disease Caused by Mycobacteria other than Tuberculosis in British Columbia
Authors: Elwood R Kevin , Opazo Saez Anabelle M , Lentini Vittorio , Shadmani Ramak
Published: March 2016

CONTEXT: The incidence of pulmonary disease due to mycobacteria other than tuberculosis (TB) in Canada has not been documented.

OBJECTIVE: To determine the incidence of pulmonary disease due to mycobacteria in the nonimmunocompromised population of British Columbia.

DESIGN: A retrospective cohort study of 110 cases of mycobacteria infection other than TB identified from 1991 to 1995.

SETTING: British Columbia Centre for Disease Control, Division of TB Control.

RESULTS: The overall incidence rate of infection with mycobacteria other than TB was 0.63×10-5/year. This incidence rate was significantly higher among women (relative risk [RR]=2, P=0.0006) and in those aged 55 years or older (RR=8, P<0.00001). In contrast with TB, patients were more frequently born in Canada (P<0.00001) or in industrialized countries other than Canada (P<0.00001), and were less likely to be Aboriginal (P=0.0007) or foreign born from Asia (P<0.0001). The most common organism isolated in British Columbia was Mycobacterium avium‐intracellulare (82.7%). Overall, 78 (71%) cases had underlying lung disease. Drug intolerance was very common (42%). After treatment, 55% and 41% of the patients were rendered smear negative or culture negative, respectively. Radiological improvement was noted in 55% of patients, and 60% of patients responded symptomatically to treatment.

CONCLUSIONS: The overall incidence of pulmonary disease is low. It is a disease predominantly of women 55 years and older, and targets completely different ethnic groups than TB, suggesting a protective effect of infection with Mycobacterium tuberculosis. M avium‐intracellulare was the most common pathogen isolated. Further investigation is required into the natural history of so‐called ′colonizers′. Considerable morbidity may be prevented with earlier intervention.