bluuebunny/crossref_metadata_2025 huggingface dataset:
The Changing Pattern of Nontuberculous Mycobacterial Disease
Authors: Falkinham Joseph O
Published: March 2016

Nontuberculous mycobacteria are human opportunistic pathogens whose source of infection is the environment. These include both slow‐growing (eg, Mycobacterium kansasii and Mycobacterium avium) and rapid‐growing (eg, Mycobacterium abscessus and Mycobacterium fortuitum) species. Transmission is through ingestion or inhalation of water, particulate matter or aerosols, or through trauma. The historic presentation of pulmonary disease in older individuals with predisposing lung conditions and in children has been changing. Pulmonary disease in elderly individuals who lack the classic predisposing lung conditions is increasing. Pulmonary disease and hypersensitivity pneumonitis have been linked with occupational or home exposures to nontuberculous mycobacteria. There has been a shift from Mycobacterium scrofulaceum to M avium in children with cervical lymphadenitis. Further, individuals who are immunosuppressed due to therapy or HIV‐infection are at a greatly increased risk for nontuberculous mycobacterial infection. The changing pattern of nontuberculous mycobacterial disease is due in part to the ability of these pathogens to survive and proliferate in habitats that they share with humans, such as drinking water. The advent of an aging population and an increase in the proportion of immunosuppressed individuals suggest that the prevalence of nontuberculous mycobacterial disease will increase.
Pyo‐Mediastinitis: A Complication of Pulmonary Coccidioidomycosis
Authors: Rady Mohamed Y , Lopez Arturo , Patel Bhavesh M , Larson Joel S
Published: March 2016

A rare fatal case of pulmonary coccidioidomycosis complicated by mediastinal and visceral abscesses treated with antifungal medications is described. The case report discusses the potential need for early surgical intervention to drain mediastinal and visceral abscesses as a primary mode of therapy in disseminated coccidioidomycosis for a successful control of infection and clinical outcome.
Pressure Aberrations inside the Spinal Canal During Rear‐End Impact
Authors: Schmitt K-U , Muser M , Niederer P , Walz F
Published: March 2016

Minor soft tissue injuries of the cervical spine increasingly pose problems in public health. Such injuries are conveyed particularly often in rear‐end automobile collisions at low impact speeds and it has been established that they may be associated with long‐term impairment. As a possible cause for this type of injury it has been hypothesized that pressure pulses induced in cervical fluid compartments during the impact could damage the membrane of spinal nerve cells. To date, animal as well as cadaver experiments performed support this hypothesis. A theoretical analysis has been undertaken in order to investigate the pressure and flow pulse emerging in a cervical fluid compartment under conditions representing rear‐end impacts with a äv of 15 km/h. Using the finite element (FE) method, a three‐dimensional model of the cervical spine was developed. The model consists of eight vertebrae (C1‐T1), the intervertebral discs, the intervertebral joints, all the major ligaments, most of the neck muscles and the head. Additionally, a typical venous blood vessel was included. To determine the pressure behaviour inside the blood vessel, fluid‐structure interaction was taken into account. For the time interval including the development of the S‐shape, the pressure pulses were calculated and found to be in qualitative agreement with the reported measurements. The shear stresses acting on the vessel wall can be determined from the associated flow pulses. An extrapolation of the results into the interstitial space where nerve cells are located at this stage does not allow assessment of whether a damage threshold may be reached.
The chronic need to improve the management of pain
Authors: Tunks Eldon
Published: March 2016

In this issue, Drs Morley‐Forster, Clark, Speechley and Moulin report on their survey conducted by Ipsos‐Reid in June 2001 (pages 189‐194). Only physicians who met the eligibility criteria of having written 20 or more prescriptions for moderate to severe pain in the preceding four weeks or having devoted 20% of their time to palliative care were eligible to participate. Sixty‐eight per cent of the respondents thought that moderate to severe chronic pain was not well managed in Canada. Despite this opinion, 23% of physicians in palliative care practice and 34% of primary care doctors stated that they would not use opioids to treat moderate to severe chronic noncancer pain even as a third‐line treatment after two previous medications had failed. One‐quarter to one‐third were concerned about the potential for addiction, and a smaller percentage reported concern about the potential for patient abuse and/or misuse, and side effects. Fear of a College audit resulting in the loss of their medical licence was cited by 10% of primary care physicians. When asked what obstacle hindered their use of strong opioid analgesics, an unexplained 10% of palliative care doctors and 14% of primary care doctors answered "nothing in particular".
What Keeps Postpulmonary Resection Patients in Hospital?
Authors: Bardell T , Petsikas D
Published: March 2016

BACKGROUND: Prolonged air leak (longer than three days) was hypothesized to be the primary cause of extended hospital stays following pulmonary resection. Its effect on length of stay (LOS) was compared with that of suboptimal pain control, nausea and vomiting, and other causes. Predictors of prolonged LOS and of prolonged air leaks were investigated.

DESIGN: Retrospective review of 91 patients. Primary reasons for prolonged hospitalization were determined. Patient characteristics (demographic information, pulmonary function test results, body habitus measurements, smoking history), operative factors (procedure performed, duration of operation, complications) and postoperative factors (time of chest tube removal) were considered. Student′s t test and X2 analysis were used to compare continuous and ratio data, respectively, and linear regression analysis was used to define the equation relating two variables.

RESULTS: The mean postoperative LOS was 6.4 days. Only prolonged air leak was predictive of increased LOS (9.4 days versus 5.4 days, P<0.001). Forced expiratory volume in 1 s less than 1.5 L/min, carbon monoxide diffusing capacity less than 80% predicted and the detection of a pneumothorax were all predictive of prolonged air leak. A strong correlation between the time of chest tube removal and LOS was found (r=0.937, P<0.001). Linear regression analysis showed postoperative LOS and duration of thoracostomy tube insertion to be related by the equation y = 0.88x + 2.49 days.

CONCLUSIONS: These results suggest that increased LOS following pulmonary resection is due primarily to prolonged air leaks. Furthermore, patients who have their chest tubes removed sooner are discharged sooner.
Xylohypha bantiana Multiple Brain Abscesses in a Patient with Systemic Lupus Erythematosus
Authors: AlHabib Khalid F , Bryce Elizabeth A
Published: March 2016

Xylohypha bantiana is a rare cause of cerebral fungal infection (phaeohyphomycosis). We report on a 72‐year‐old man who, while taking several immunosuppressive medications for systemic lupus erythematosus, presented with multiple bilateral cerebral abscesses caused by X bantiana. The lesions were not surgically amenable and the patient died two months after discontinuing antifungal therapy.
Initial Assessment of Whiplash Patients
Authors: Gunzburg R , Szpalski M , Goethem J. Van
Published: March 2016

The article looks at how for severe trauma, the outcome of treatment depends on the initial medical care. This has now also been accepted for whiplash associated disorders, underlining the importance of a proper initial assessment. Once major injury has been excluded and the diagnosis of whiplash associated disorder has been established, the initial treatment of whiplash in the emergency room can be started. The four key points to remember are described, including reassuring the patient about evolution, no soft collar, nonsteroidal anti‐inflammatory drugs and early mobilisation.
Burning Mouth Syndrome and Other Oral Sensory Disorders: A Unifying Hypothesis
Authors: Grushka Miriam , Epstein Joel B , Gorsky Meir
Published: March 2016

Burning Mouth Syndrome (BMS) is a sensory disorder which results in constant, bilateral burning pain of the tongue, lips, and other oral mucous membranes. Atypical odontalgia (AO) is another sensory disorder, usually defined as a toothache‐like pain for which no dental cause can be identified. Previous literature has suggested that AO is often associated with a concomitant temporomandibular disorder (TMD). This hypothesis paper explores the possibility that BMS, AO and TMD can be related through hyperactivity of both the sensory and motor components of the trigeminal nerve following loss of central inhibition as a result of taste damage in the chorda tympani and/or the glossopharyngeal nerves.
Epidemiological and Economic Burden of Pneumococcal Disease in Canadian Children
Authors: Petit Geneviève , De Wals Philippe , Law Barbara , Tam Theresa , Erickson Lonny James , Guay Maryse , Framarin Alicia
Published: March 2016

BACKGROUND: With the arrival of a new conjugate pneumococcal vaccine, it is important to estimate the burden of pneumococcal diseases in Canadian children. The epidemiological data and the economic cost of these diseases are crucial elements in evaluating the relevance of a vaccination program.

METHODS: Using provincial databases, ad hoc surveys and published data, age‐specific incidence rates of pneumococcal infections were estimated in a cohort of 340,000 children between six months and nine years of age. The costs of these diseases to the health system and to families were also evaluated using data from Quebec and Manitoba.

RESULTS: Cumulative risks were one in 5000 for pneumococcal meningitis, one in 500 for bacteremia and one in 20 for pneumonia, leading to 16 deaths in the cohort. About 262,000 otitis media episodes and 32,000 cases of myringotomy with ventilation tube insertion were attributable to Streptococcus pneumoniae. Societal costs were estimated at $125 million, of which 32% was borne by the health system and 68% was borne by families. Invasive infections represented only 2% of total costs, while 84% were generated by otitis media.

CONCLUSION: Pneumococcal infections represent a significant burden for Canadian children and society that could be significantly reduced through immunization.
Re‐Evaluation of Acid‐Base Prediction Rules in Patients with Chronic Respiratory Acidosis
Authors: Martinu Tereza , Menzies Dick , Dial Sandra
Published: March 2016

RATIONALE: The prediction rules for the evaluation of the acid‐base status in patients with chronic respiratory acidosis, derived primarily from an experimental canine model, suggest that complete compensation should not occur. This appears to contradict frequent observations of normal or near‐normal pH levels in patients with chronic hypercapnia.

METHODS: Linear regression analysis was used to estimate the relationships between arterial pH, bicarbonate and partial pressure of carbon dioxide (PCO2) from 18 separate arterial blood gas measurements in 18 clinically stable outpatients with chronic hypercapnic respiratory failure from chronic obstructive lung disease, and without clinical conditions or medications likely to cause a primary metabolic alkalosis.

RESULTS: The PCO2 ranged from 45 mmHg to 77 mmHg, and pH ranged from 7.37 to 7.44. In only three of the arterial blood gas measurements were the pH values lower than 7.38. From the regression equations derived from these measurements, the pH decreased by 0.014 for each 10 mmHg increase in the PCO2, and the bicarbonate level increased by 5.1 mmol/L. These values are quite different from a decrease in pH of 0.03 and an increase in bicarbonate of 3.5 mmol/L predicted using the rules derived from the canine model.

CONCLUSIONS: In patients with chronic stable hypercapnia, acid‐base compensatory mechanisms appear to be more effective than would be predicted using the classic rules.
An Evidence‐Based Approach to the Treatment of Acute Whiplash Injury
Authors: Barnsley Les
Published: March 2016

This review has two components. The first is a selective, narrative background of some of the issues surrounding acute whiplash. The latter part is a more systematic review of the available evidence concerning the management of acute whiplash as it stood in March 2001.
Endobronchial Electrocautery and Argon Plasma Coagulation: A Practical Approach
Authors: Tremblay Alain , Marquette Charles-Hugo
Published: March 2016

The present review covers the technical and practical aspects of endobronchial electrocautery, including argon plasma coagulation, which have great potential for widespread use by pulmonologists around the world. The various electrocautery modes, power settings and electrode probes are described in detail, and the authors′ clinical and technical approach is demonstrated with a narrative description and brief case presentations. Malignant airway obstruction, hemoptysis, web‐like stenosis, stent related granulation tissue and early lung carcinomas are the most common indications for treatment. Advantages of electrocautery, such as low cost, rapid effect, safety and ease of use, are contrasted to other endobronchial therapeutic modalities. Published experience with electrocautery is reviewed.
The Management of Chronic Viral Hepatitis: A Canadian Consensus Conference 2004
Authors: Sherman Morris , Bain Vincent , Villeneuve Jean-Pierre , Myers Robert P , Cooper Curtis , Martin Steven , Lowe Catherine
Published: March 2016

Several government and nongovernment organizations held a consensus conference on the management of acute and chronic viral hepatitis to update previous management recommendations. The conference became necessary because of the introduction of new forms of therapy for both hepatitis B and hepatitis C. The conference issued recommendations on the investigation and management of chronic hepatitis B, including the use of lamivudine, adefovir and interferon. The treatment of hepatitis B in several special situations was also discussed. There were also recommendations on the investigation and treatment of chronic hepatitis C and hepatitis C‐HIV coinfection. In addition, the document makes some recommendations about the provision of services by provincial governments to facilitate the delivery of care to patients with hepatitis virus infection. The present document is meant to be used by practitioners and other health care providers, including public health staff and others not directly involved in patient care.
Interferon Treatment of Multiple Pulmonary Malignancies Associated with Papilloma Virus
Authors: Aaron SL , Wong E , Tyrrell D , Duggan M , Vallieres E , Jewell L , Romanowski B
Published: March 2016

Over a period of four years, beginning in spring 1988, a previously healthy man developed a primary squamous cell carcinoma of the tonsil, treated with radiotherapy, followed by 10 distinct, primary bronchial squamous cell carcinomas. Four of the cancers were surgically resected, all of which were positive by hybridization for human papilloma virus (type 16). Following the institution of alpha interferon, three smaller lesions disappeared and a larger one shrank in size, facilitating surgical resection. Over the following seven years no new ones have appeared. The finding of papilloma virus in malignancies should prompt consideration of antiviral therapy.
Treatment of Pediatric Chronic Pain with Tramadol Hydrochloride: Siblings with Ehlers‐Danlos Syndrome ‐ Hypermobility Type
Authors: Brown Stephen C , Stinson Jennifer
Published: March 2016

OBJECTIVE: To evaluate the effectiveness of tramadol hydrochloride for the treatment of chronic pain refractory to previous treatment in two pediatric patients.

METHODS: Tramadol hydrochloride was administered (50 mg/day to 150 mg/day) to two siblings with Ehlers‐Danlos syndrome ‐‐ Hypermobility type refractory to previous pharmacological treatments, and changes in pain intensity and physical activity were assessed.

RESULTS: Pain intensity decreased and physical activity improved within days of starting therapy. Positive results have been maintained for 30 months.

CONCUSIONS: Tramadol hydrochloride was a safe and effective treatment for relieving chronic pain in two pediatric patients suffering from the hypermobility type of Ehlers‐Danlos syndrome. No morbidity or side effects were noted during the 30‐month follow‐up.
The Canadian Optimal Therapy of COPD Trial: Design, Organization and Patient Recruitment
Authors: Aaron Shawn D , Vandemheen Katherine , Fergusson Dean , FitzGerald Mark , Maltais Francois , Bourbeau Jean , Goldstein Roger , McIvor Andrew , Balter Meyer , O′Donnell Denis
Published: March 2016

BACKGROUND: There are no published studies that have assessed whether adding long‐acting beta 2‐agonist bronchodilators and/or inhaled steroids to chronic therapy with tiotropium would provide additional clinical benefit to patients with moderate to severe chronic obstructive pulmonary disease (COPD).

METHODS: The Canadian Optimal Therapy of COPD Trial is a randomized, prospective, double‐blind, placebo‐controlled, multicentre trial funded by the Canadian Institutes of Health Research that has been designed to determine which combination of inhaled medications will most effectively prevent exacerbations and optimize disease‐specific quality of life in patients with COPD. The trial is the first to evolve from the Canadian Thoracic Society Clinical Trials Group. The study will randomize 432 patients with moderate to severe COPD to one of three parallel treatment arms for 52 weeks: tiotropium and fluticasone/salmeterol; tiotropium and salmeterol; or tiotropium and placebo inhaler. The participants will be allowed to use salbutamol as required throughout the trial period.

OUTCOMES: The primary outcome measure is the proportion of patients in the three treatment groups who experienced a respiratory exacerbation within 52 weeks of randomization. Other outcomes that will be assessed over the 52‐week trial period will include: changes in disease‐specific quality of life and changes in dyspnea, health care use and changes in lung function. A pharmacoeconomic analysis will also be performed to evaluate the cost of these therapies.

RESULTS: The study commenced recruitment in October 2003. It is currently operating at 22 centres across Canada and has randomized 137 patients during the first four months of recruitment. Recruitment is scheduled to continue until April 2005 or until 432 patients have been randomized.

CONCLUSION: The present randomized, placebo‐controlled trial offers a unique opportunity to answer the question, what is the best combination of inhaled medications to use for COPD patients? It is hoped that optimal use of inhaled medications will improve patient health and quality of life, reduce patient respiratory exacerbations, and ultimately, reduce health care resource use.
The Effects of Transcranial Electrical Stimulation on Opiate‐Induced Analgesia in Rats
Authors: Kabalak Ayla A , Senel Oytun O , Gogus Nermin
Published: March 2016

BACKGROUND AND OBJECTIVES: Recent experiments have shown that transcranial electrical stimulation significantly increases the potency and duration of the analgesic effects of opioids in humans and rats. In the present study, the influence of transcranial electrical stimulation (TCES) on the analgesic effect of remifentanil hydrochloride (HCl) in rats was determined.

METHODS: Experiments were performed on 80 albino male Wistar rats. Rats were randomly assigned to four groups: remifentanil HCl, remifentanil HCl and TCES, TCES, and control (n=20/group). Remifentanil HCl was injected on the 55th minute. Analgesia was assessed using the wet tail‐flick latency test.

RESULTS: In the remifentanil HCl group, analgesia (10.85±1.04 s) was reached at the fifth minute, and the analgesia was high for the first 10 min. In the remifentanil HCl and TCES group, the latency time peaked (16.60±1.19 s) at the fifth minute. This peak was 150% higher than that for the remifentanil HCl group, and 251% higher than the control or TCES groups. Analgesia in the remifentanil HCl and TCES group was sustained for 20 min at a statistically higher rate than the other treatment groups (P<0.001).

CONCLUSIONS: TCES markedly increased the duration and analgesic potency of remifentanil HCl in rats. This effect appeared to be related to the release of enkephalins from brain structures, thus enhancing opioid analgesia.
Clinical Characteristics at Initial Presentation and Impact of Dual Therapy on the Outcome of Bacteremic Streptococcus pneumoniae Pneumonia in Adults
Authors: Weiss K , Low DE , Cortes L , Beaupre A , Gauthier R , Gregoire P , Legare M , Neoveu F , Thibert D , Tremblay C
Published: March 2016

BACKGROUND: Approximately 10% of patients hospitalized with community‐acquired pneumonia (CAP) are bacteremic. Bacteremic Streptococcus pneumoniae pneumonia (BSPP) is the number one cause of mortality, representing up to 70% of all CAP deaths. In fact, all CAP guidelines have identified this issue as one of the most important issues when establishing their recommendations.

OBJECTIVE: To assess the impact of dual antibiotic therapy in patients with BSPP.

PATIENTS AND METHODS: All cases of BSPP in patients 18 years of age and older who were hospitalized from 1995 to 2000 were retrospectively analyzed. The standard initial therapeutic regimen used was cefuroxime with or without a macrolide from 1995 to 1997, and ceftriaxone and azithromycin or clarithromycin from 1998 to 2000. During the 1995 to 1997 period, only 16% of the patients initially received a macrolide, whereas all patients in the 1998 to 2000 period received a macrolide at admission.

RESULTS: Ninety‐five patients (49 men, 46 women) with a mean age of 63 years (range 20 to 98 years) were included in the present study. The mean pneumonia severity index at admission was 113 for the monotherapy cohort and 114 for the dual therapy group. At admission, 30.5% of patients had a leukocyte count greater than 20´109/L, 11.5% had a systolic blood pressure less than 90 mmHg, 44.2% had a respiratory rate greater than 30 breaths/min and 33.6% had nausea/vomiting, necessitating some form of therapy or preventing the patient from eating. In addition, 16.8% had no fever at admission. Overall, 72.5% became afebrile within 48 h. Fifteen (15.8%) patients died (four within the first 72 h). The mortality rate was significantly higher in the monotherapy group (11 of 42 patients; 25.6%) than in the dual therapy cohort (four of 53 patients; 7.5%) (OR 0.23; 95% CI 0.07 to 0.74). Antibiotic resistance was not associated with increased mortality.

CONCLUSION: The combination of ceftriaxone plus a macrolide significantly reduced the mortality rate compared with monotherapy (cefuroxime) in patients with CAP that have the highest mortality rate.
Blood Cultures in Ambulatory Patients Who Are Discharged from Emergency with Community‐Acquired Pneumonia
Authors: Marrie Thomas J
Published: March 2016

OBJECTIVES: To determine the factors that predict whether or not ambulatory patients with community‐acquired pneumonia (CAP) treated in an emergency room (ER) setting will have blood cultures drawn and the factors that predict a positive blood culture.

METHODS: Prospective observational study of all patients with a diagnosis of CAP, as made by an ER physician, who presented to any of seven Edmonton‐area ERs over a two‐year period.

RESULTS: Seven hundred ninety‐three (19.2%) of 4124 patients with CAP had blood cultures drawn. The site‐specific blood culture rates ranged from 7.8% to 25% (P<0.001); 41 of 793 (5.1%) were positive. Streptococcus pneumoniae accounted for 58.5% of the isolates while Staphylococcus aureus and Escherichia coli each accounted for 14.6%, or six patients each. Only two of the 24 patients with S pneumoniae bacteremia were subsequently admitted to hospital while all six of the patients with S aureus were admitted. Only one of the six patients with E coli bacteremia was treated at home. No factors were predictive of positive blood cultures on multivariate analysis.

CONCLUSIONS: Physicians are selective in ordering blood cultures on patients with ambulatory pneumonia who present to an ER, and the positivity rate of 5.1% is quite high. No factors are predictive of positive blood cultures on multivariate analysis, thus clinical judgment has to prevail in the decision to perform blood cultures. Breakthrough bacteremia can occur with microorganisms susceptible to the antibiotics that the patient is receiving.
Seasonal Fluctuations in Airway Responsiveness in Elite Endurance Athletes
Authors: Hemingson Howard B , Davis Beth E , Cockcroft Donald W
Published: March 2016

BACKGROUND: It has been suggested that exposure to winter training conditions (irritants in indoor facilities and/or cold, dry air in the outdoors) can increase airway responsiveness in elite endurance athletes.

OBJECTIVES: It has yet to be elucidated whether elite endurance athletes experience seasonal fluctuations in their airway responsiveness.

METHODS: Eighteen members of a varsity cross‐country running team underwent screening procedures and five members were enrolled in the study. Each athlete completed a respiratory and training questionnaire, and underwent allergy skin prick testing. Airway responsiveness was evaluated using a methacholine challenge on four occasions.

RESULTS: The participants demonstrated a significant (more than twofold) increase in airway responsiveness (P=0.0496) during the first winter evaluation compared with the autumn baseline. The second winter evaluation still showed an increase but it was not statistically significant. Airway responsiveness had returned to baseline (autumn) values at spring testing.

CONCLUSION: Elite endurance athletes experience seasonal fluctuations in airway responsiveness. The specific stimuli that cause this are unknown, but it is speculated to be due to exposure to cold, dry air and/or inhaled irritants that may be present in indoor training facilities.
Hospitalization for Community Acquired Pneumonia in Alberta First Nations Aboriginals Compared with Non‐First Nations Albertans
Authors: Marrie Thomas J , Carriere Keumhee C , Jin Yan , Johnson David H
Published: March 2016

BACKGROUND: The rates and outcomes of hospital admission for community‐acquired pneumonia between First Nations Aboriginal and non‐First Nations groups were compared.

METHODS: Alberta administrative hospital abstracts from April 1, 1997, to March 31, 1999, were analyzed, and each case of a First Nations Aboriginal person with pneumonia was matched by age and sex with three non‐First Nations persons with pneumonia.

RESULTS: The First Nations Aboriginal age and sex‐adjusted hospital discharge rate was 22 per 1000 (95% CI 20.7 to 23.6) compared with 4.4 per 1000 (95% CI 4.4 to 4.5) for the general population of Alberta. After accounting for comorbidity and severity of pneumonia, in‐hospital mortality and hospital length of stay were lower for First Nations Aboriginals compared with the matched non‐First Nations group (odds ratio 0.49; 95% CI 0.37 to 0.66, and odds ratio 0.87; 95% CI 0.79 to 0.97, respectively). The odds for 30‐day hospital readmission were higher in First Nations Aboriginals compared with the non‐First Nations group (odds ratio 1.42; 95% CI 1.21 to 1.68). The cost per hospital admission for First Nations Aboriginals was 94% of the average cost for the matched non‐First Nations group (CDN$4,206). However, their median daily cost was 1.25 times higher (95% CI 1.14 to 1.36) than the matched non‐First Nations group.

CONCLUSIONS: First Nations Aboriginals had higher rates of hospitalization, rehospitalization and hospital costs for community‐acquired pneumonia than non‐First Nations Albertans. It was unlikely that the high rate of hospitalizations in First Nations Aboriginals was due to more severe pneumonia or greater comorbidity. Other unexplained factors increase the burden of this disease in First Nation Aboriginals.
Intravenous Regional Sympathetic Block: Past, Present and Future?
Authors: Lake Alfred PJ
Published: March 2016

Intravenous regional sympathetic block is a valued component of the pain clinician′s armamentarium for the management of the complex regional pain syndrome type 1. Treatment of this multifaceted condition is multimodal, and despite a lack of convincing supporting evidence from clinical trials, the author makes the case for retaining the technique while recommending both appropriate guidance and further study.
Respirologists — Doing What We Can
Authors: Bowie Dennis
Published: March 2016

While governments share the major responsibility for providing health care in this country, they cannot do it alone. Health care workers and patients need to be involved to develop the best system. We, as physicians, must provide agencies with the science behind the best medicine and methods to care for patients. In addition, we have a responsibility to advocate for changes to give our patients the best service. This needs to be done in partnership with individuals using the health care system, who too often are not consulted. We must insist that our health care system be studied with rigorous scientific methods to ensure that the correct answers are obtained. After all, that is what we are trained to do.
The Asthma Quiz for Kidz: A Validated Tool to Appreciate the Level of Asthma Control in Children
Authors: Ducharme Francine M , Davis G Michael , Noya Francisco , Rich Harold , Ernst Pierre
Published: March 2016

BACKGROUND: There is an urgent need to bridge the large gap between optimal and observed asthma control among Canadian children.

OBJECTIVES: To adapt the criteria of asthma control proposed in the 1999 Asthma Consensus Statement for children and validate the proposed cut‐offs in children with asthma.

METHODS: Six clinical criteria of asthma control were phrased as questions and response options, and pretested for clarity. A cross‐sectional study was conducted in children one to 17 years of age presenting to the hospital′s asthma clinics. Children nine years of age or older and their parents were asked to complete The Asthma Quiz for Kidz separately, and then together, before the medical visit. Parents of younger children completed the questionnaire with their child. Physicians were not informed of the results of the quiz.

RESULTS: The mean age of the 343 participants was 8.0±4.4 (SD) years with a mean baseline forced expiratory volume in 1 s of 96±15% of predicted values. Asthma severity was rated as mild (67%), moderate (29%) or severe (4%). Overall, 57% of subjects endorsed at least two of the six criteria of poor control. The median (interquartile range) Asthma Quiz score was significantly higher when the physician′s assessment of asthma control was poor than when the physician′s assessment of asthma control was good (3 [1, 5] versus 1 [0, 2], P<0.001), but it did not correlate with the spirometry. A score of at least 2 out of 6 had 73% sensitivity and 59% specificity for identifying poor control.

INTERPRETATION: The Asthma Quiz score provides complementary information to, but does not replace, lung function testing. A score of 2 or more out of 6 suggests poor asthma control and should prompt patients to consult their physician for reassessment.
Sayonara
Authors: Bowie Dennis M
Published: March 2016

It is with mixed feelings that I write this last page. There is some relief in handing over the responsibilities to someone else, although I will miss the interaction with all the good people that I have met from across Canada who have made me a part of their lives. I want to take the opportunity to point out what the Canadian Thoracic Society (CTS), through its volunteer members and, in particular, its hard working committees, has accomplished in the past year.
Recurrent Chronic Ambulatory Peritoneal Dialysis‐Associated Infection due to Rothia dentocariosa
Authors: Morris Shaun K , Nag Shudeshna , Suh Kathryn N , Evans Gerald A
Published: March 2016

Rothia dentocariosa is a commensal organism of the human oropharynx. Clinical infection due to this organism is rare. A case of recurrent peritoneal dialysis‐related peritonitis caused by R dentocariosa and a review of the literature is reported. Isolation of R dentocariosa from dialysate fluid should not be dismissed as a contaminant. Although there are no interpretive criteria for antimicrobial susceptibility testing, R dentocariosa appears to be susceptible to a variety of antibiotics including beta‐lactams, vancomycin and aminoglycosides. Optimal therapy of peritoneal dialysis peritonitis caused by this organism may also require removal of the catheter.
Reference Values of Pulmonary Function Tests for Canadian Caucasians
Authors: Gutierrez Carlos , Ghezzo R Heberto , Abboud Raja T , Cosio Manuel G , Dill John R , Martin Richard R , McCarthy Dan S , Morse John LC , Zamel Noe
Published: March 2016

A multicentre, cross‐sectional study was carried out in six centres across Canada to establish a national standard for pulmonary function tests using healthy, lifetime nonsmokers, with each centre aiming to test 10 men and 10 women from each decade from 20 to 80 years of age. Data from each centre were used to derive prediction equations for each centre, and pooled data from all centres (total: 327 women and 300 men) were used to derive Canadian predicted equations. The predictive models were compared with three widely used published models for selected tests. It was found that, in general, the equations modelled for each centre could be replaced by the models obtained when pooling all data (Canadian model). Comparisons with the published references showed good agreement and similar slopes for most tests. The results suggest that pulmonary function test results obtained from different centres in Canada were comparable and that standards currently used remain valid for Canadian Caucasians.
Exclusion Spirometry: A Good Idea
Authors: Anthonise Nick R.
Published: March 2016

In this issue of the Canadian Respiratory Journal, Almirall and Bégin (pages 195 to 196) make a suggestion aimed at increasing the use of spirometry by primary care physicians, as well as family and general practitioners. The idea is that spirometry should be performed not necessarily to make specific diagnoses, but to rule in or out the possibility of a number of lung diseases, most notably, chronic obstructive pulmonary disease (COPD). If the patient demonstrates normal forced vital capacity and forced expiratory volume in 1 s, then he or she does not have COPD; if the results are not normal, then COPD is a possibility that can be further investigated.
Do Patients with Chronic Noncancer Pain Accept Treatment of Questionable Benefit More Readily that those Who Are Pain Free?
Authors: Simmonds Mark K , Rashiq Saifee , Klemka Philip , Sclanachan Alexander S
Published: March 2016

BACKGROUND: The efficacy of some common, questionable chronic pain interventions has been debated and it is unclear why sufferers of chronic noncancer pain agree to receive them. This study attempts to determine if chronic pain sufferers characteristically more readily accept treatment with questionable benefit.

OBJECTIVES: This study aims to compare the strength of acceptance or rejection of a hypothetical, mock chronic pain treatment of debatable value by two groups of patients: those reporting chronic noncancer pain and those who are ′pain free′.

METHODS: A questionnaire proposing a hypothetical treatment for chronic pain was distributed to two groups: Group 1 (n=160), patients attending a chronic pain centre, and Group 2 (n=240), patients attending a family practice centre. Patients were asked to score their ′treatment acceptance′ using a modified Likert scale. The treatment was based on the risks and benefits of epidural steroids.

RESULTS: Ninety‐three patients in Group 1 were eligible for inclusion in the ′chronic pain′ group and 92 patients from Group 2, for the ′pain free′ group. The median scores were identical at +3; nonparametric testing revealed no significant difference between the groups in their acceptance of the treatment.

CONCLUSIONS: An analogue study such as this removes the potential bias of clinical interaction with a physician, but lacks some reality. Nonetheless, the results from this study did not support the hypothesis that patients with chronic noncancer pain accept treatment of questionable benefit more readily than those who are ′pain‐free′.
Shared Pain: Lessons from the Labour Room in Istanbul
Authors: Morley-Forster Patricia K
Published: March 2016

The current issue of Pain Research & Management contains an article by Yildirim and Sahin (pages 183‐187) from the Faculty of Nursing at the University of Istanbul (Istanbul, Turkey). At first glance, this paper appears to be of interest only to those involved in the day‐to‐day care of women in labour, but a closer look reveals significant lessons for those dedicated to the improvement of pain management globally.
Inpatient Care of Community‐Acquired Pneumonia: The Effect of Antimicrobial Guidelines on Clinical Outcomes and Drug Costs in Canadian Teaching Hospitals
Authors: Marras Theodore K , Jamieson Linda , Chan Charles K
Published: March 2016

BACKGROUND: Evidence supporting antibiotic treatment guidelines and respiratory quinolones (RQs) in community‐acquired pneumonia (CAP) is limited.

OBJECTIVE: To study associations among guideline adherence, specific antibiotics, clinical outcomes and antibiotic costs.

METHODS: A retrospective cohort study in three tertiary care university
teaching hospitals in Toronto, Ontario, studying CAP inpatients
between November 1997 and June 2000. The period
encompassed 12 months when an early version of empirical antibiotic
guidelines was used (early cohort) and 18 months when recent guidelines
(including RQs) were used (recent cohort).

RESULTS: Six hundred ninety‐eight cases of CAP were reviewed,
and 91% were guideline adherent. In multivariable analyses, no association
was observed between guideline adherence and mortality or
duration of hospitalization. Guideline‐adherent cases received fewer
antibiotics in both cohorts and 0.9 days less of intravenous antibiotics
(P=0.04) in the recent cohort. There was no significant difference in
antibiotic cost according to guideline adherence, but recent cohort
guideline‐adherent cases had lower drug costs than early cohort
guideline‐adherent cases. Antibiotic selection was associated with illness
severity and was mirrored by clinical outcomes, despite controlling
for the pneumonia severity index (PSI). Treatment with
anaerobic agents (odds ratio 2.7, P=0.001) or cephalosporin plus
macrolide (odds ratio 2.7, P=0.02) was associated with higher mortality.
Treatment with RQ monotherapy was associated with a 2.3 day
shorter duration of intravenous therapy (P<0.0001) and a $19.19
lower total antibiotic cost (P<0.0001).

CONCLUSION: Findings support empirical treatment guidelines
for CAP and their recommendations regarding RQs. The association
between mortality and anaerobic coverage or combination therapy
may reflect prognostic information available at presentation but not
captured by the PSI.
Hemopneumothorax in a COPD Patient Treated with Noninvasive Positive Pressure Ventilation: The Risk of Attendant Anticoagulation
Authors: Raghavan R , Ellis AK , Wobeser W , Sutherland KB , O′Donnell DE
Published: March 2016

Noninvasive positive pressure ventilation (NIPPV) modalities have been proven to be effective in the setting of exacerbations of chronic obstructive pulmonary disease (COPD). Reported complications include pneumothorax, increased work of breathing, gastric distension and air embolism. This case demonstrates that patients with severe COPD on anticoagulant therapy are potentially at risk for the serious complication of combined lung barotrauma and hemorrhage while on acute NIPPV therapy. This is the first reported case of hemopneumothorax complicating NIPPV therapy.
Identifying Children with Persistent Asthma from Health Care Administrative Records
Authors: Kozyrskyj Anita L , Mustard Cameron A , Becker Allan B
Published: March 2016

BACKGROUND: Investigation into the origins of asthma is contingent on definitions of asthma, which can differentiate asthma from transient wheezing syndromes in children.

OBJECTIVES: This research was undertaken to develop a definition for asthma derived from health care administrative records, which would identify children with persistent asthma.

PATIENTS AND METHODS: Using population‐based, health
care administrative data, children with possible asthma were identified
as having one or more physician visits or hospitalizations for
asthma or bronchitis diagnoses from January 1995 to December 1995,
or, in the absence of asthma‐like diagnoses, one or more prescriptions
for asthma prophylaxis drugs or ketotifen concomitant with a betaagonist,
or two or more prescriptions for beta‐agonists.

RESULTS: The likelihood of persistent asthma, defined as repeated
health care and prescription use for asthma from 1996 to 1998, was
assessed for various asthma markers and risk factors in 29,198 children
with possible asthma. Children with asthma prescription drugs
or asthma health care use not limited to the winter season were
three to six times more likely than children without these characteristics
to have persistent asthma. The likelihood of persistent asthma
was elevated to a substantial degree in the presence of both of these
markers.

CONCLUSIONS:The inclusion of these measures in a diagnosisbased definition improves the ability to identify persistent asthma in children.
Antimicrobial Resistance: An Update from the Canadian Committee on Antibiotic Resistance
Authors: Canadian Committee on Antibiotic Resistance
Published: March 2016

The present article is one of a series prepared by the Canadian Committee on Antibiotic Resistance (CCAR). These articles are designed to update readers on current activities intended to limit the development and transmission of antibiotic resistance in Canada. Headquartered in Vancouver, British Columbia, the CCAR provides outreach to public and professional communities through activities focused on infection prevention and control, resistance surveillance and optimal antibiotic use.
Canadian Cardiovascular Society and Canadian Thoracic Society Position Statement on Pulmonary Arterial Hypertension
Authors: Langleben David , Archer Stephen , Granton John , Hirsch Andrew M , Levy Robert D , Mehta Sanjay , Michelakis Evangelos , Stewart Duncan J
Published: March 2016

The Canadian Cardiovascular Society and the Canadian Thoracic Society requested a position statement on pulmonary arterial hypertension from leading Canadian experts. The present document is intended to act as an update for the clinician, to provide a template for the initial evaluation of patients, to enable the understanding of current therapeutic paradigms based on approved indications for Canada, to highlight new therapies on the horizon, and to state the positions of the Canadian Cardiovascular Society and the Canadian Thoracic Society on resource management for pulmonary arterial hypertension in Canada.
Overwhelming Pulmonary Infection after a Tobogganing Accident
Authors: Singh Ravinder , Louie Brian E , Bennett William F , Allen Christopher , Kelly Tom , Lee Christine H
Published: March 2016

A 17‐year‐old male patient presented to St Joseph′s Healthcare (Hamilton, Ontario) with a radiologically opacified left hemithorax. Three days earlier, the patient had injured his left lower chest while tobogganing on his farm. He developed dyspnea and felt unwell, but only sought medical attention from his family doctor a few days after the injury, when fever and pleuritic chest pain ensued. He was treated with a nonsteroidal anti‐inflammatory agent, but his chest radiograph revealed an opacified hemithorax, for which he was referred to the hospital. In the emergency department, the patient looked ill and was in distress. His heart rate was 125 beats/min, and he had a blood pressure of 103/61 mmHg, a respiratory rate of 20 breaths/min, a temperature of 38.5°C and an oxygen saturation of 94% on ambient air. Laboratory results showed a white blood cell count of 40×109/L with a left shift. Chest radiography showed a left pleural effusion. A #28 Fr chest tube was inserted into the left hemithorax, and foul‐smelling serosanguineous fluid was drained. There was a transient improvement of tachypnea and hypoxemia despite minimal radiographic change. He was admitted and subsequently started on intravenous levofloxacin. Overnight, he deteriorated and required an increase in supplemental oxygen. A computed tomography (CT) scan of his chest revealed multiple loculated fluid collections and bilateral pulmonary parenchymal infiltrates consistent with a pneumonia and empyema.
The Laboratory Diagnosis of Bacterial Vaginosis
Authors: Money Deborah
Published: March 2016

Bacterial vaginosis (BV) is an extremely common health problem for women. In addition to the troublesome symptoms often associated with a disruption in the balance of vaginal flora, BV is associated with adverse gynecological and pregnancy outcomes. Although not technically a sexually transmitted infection, BV is a sexually associated condition. Diagnostic tests include real‐time clinical/microbiological diagnosis, and the current gold standard, the standardized evaluation of morphotypes on Gram stain analysis. The inappropriate use of vaginal culture can be misleading. Future developments into molecular‐based diagnostics will be important to further understand this complex endogenous flora disruption.
The Laboratory Diagnosis of Herpes Simplex Virus Infections
Authors: Singh Ameeta , Preiksaitis Jutta , Romanowski Barbara
Published: March 2016

Herpes simplex virus (HSV) types 1 and 2 cause genital herpes infections and are the most common cause of genital ulcer disease in industrialized nations. Although these infections are very common, the majority of them remain underdiagnosed because they are asymptomatic or unrecognized. A clinical diagnosis of genital herpes should always be confirmed by laboratory testing; this can be accomplished through the use of direct tests for viral isolation, the detection of antigen or, more recently, the detection of HSV DNA using molecular diagnostic techniques. Testing for serotypes is recommended because of the different prognostic and counselling implications. Type‐specific HSV serology is becoming more readily available and will enhance the ability to make the diagnosis and guide clinical management in select patients.
Successful Treatment of Narcolepsy and Cataplexy: A Review
Authors: Lockrane B , Bhatia P , Gore Robin
Published: March 2016

A 25‐year‐old woman with narcolepsy and cataplexy was treated with well‐recognized drugs for these conditions. Because she did not respond, a decision was made to treat her with sodium oxybate.
Fever and Shock in a Child: How ′good′ is a Good Blood Test?
Authors: Chinnan Nevin Kollannoor , Mishra Pragnyadipta , Puri GD
Published: March 2016

CASE PRESENTATION A 12‐year‐old girl presented with a history of intermittent fever (38.3°C to 40°C) for 10 days that was not associated with chills and rigours, and was relieved by antipyretics. She also had nonbilious and nonprojectile vomiting (seven days), shortness of breath (four days) and watery diarrhea (two days). At the beginning of her illness, she was treated with a complete course of oral chloroquine by a general practitioner. In the pediatric emergency room, she presented with a heart rate of 136 beats/min, a respiratory rate of 56 breaths/min, a temperature of 37.8°C, a blood pressure of 60/30 mmHg and a capillary filling time of 5 s to 6 s. Shock resuscitation measures were initiated with intravenous normal saline (20 mL/kg bolus) and dopamine 5 µg/kg/min. She developed ventricular fibrillation, which was cardioverted. After cardiac arrest, she was intubated and transferred to the intensive care unit. Two hours later, she started bleeding from the nasogastric tube and endotracheal tube. A chest radiograph revealed bilateral lung opacities suggestive of intraparenchymal bleeding. The other significant clinical findings included icterus, cervical and inguinal lymphadenopathy, soft tender hepatomegaly, moderate splenomegaly and an absence of focal neurological deficits and meningeal signs.