bluuebunny/crossref_metadata_2025 huggingface dataset:
Cannabinoids and Pain
Authors: Walker J Michael , Strangman Nicole M , Huang Susan M
Published: March 2016

Cannabinoids have been used to treat pain for many centuries. However, only during the past several decades have rigorous scientific methods been applied to understand the mechanisms of cannabinoid action. Cannabinoid receptors were discovered in the late 1980s and have been found to mediate the effects of cannabinoids on the nervous system. Several endocannabinoids were subsequently identified. Many studies of cannabinoid analgesia in animals during the past century showed that cannabinoids block all types of pain studied. These effects were found to be due to the suppression of spinal and thalamic nociceptive neurons, independent of any actions on the motor systems. Spinal, supraspinal and peripheral sites of cannabinoid analgesia have been identified. Endocannabinoids are released upon electrical stimulation of the periaqueductal gray, and in response to inflammation in the extremities. These observations and others thus suggest that a natural function of cannabinoid receptors and their endogenous ligands is to regulate pain sensitivity. The therapeutic potential of cannabinoids remains an important topic for future investigations, with previous work suggesting utility in clinical studies of cancer and surgical pain. New modes of delivery and/or new compounds lacking the psychotropic properties of the standard cannabinoid ligands offer promise for cannabinoid therapeutics for pain.
Munchausen’s Syndrome Presenting as Hemoptysis in a 12‐Year‐Old Girl
Authors: Bjornson Candice L , Kirk Valerie G
Published: March 2016

The case of Munchausen’s syndrome presenting as hemop‐tysis in a 12‐year‐old girl is presented. The features of Munchausen′s syndrome are reviewed. Munchausen’s syndrome should be included in the differential diagnosis of hemoptysis in a child, especially when accompanied by a dramatic presentation, changing symptoms and negative diagnostic investigations.
A Case of Pain, Factitious Disorder and Boundary Violations
Authors: Cote Isabelle
Published: March 2016

Although health professionals are usually familiar with factitious disorders, evaluating such cases may be complicated, particularly in the legal arena. This article describes a patient who presented with pain complaints to numerous doctors. Eventually, a malpractice suit was brought against one of the patient′s physicians who had diagnosed her condition as multiple personality disorder (dissociative identity disorder). Factitious disorder and the doctor′s prescription of pain medications were issues raised during the trial. In view of the issue of harm, physicians′ responsibilities and limitations during ongoing medical care are addressed in this case report.
Syncope on Steroids
Authors: Davidson Warren , Zalunardo Nadia , Gill Shawn , Wakefield Robert
Published: March 2016

An 83‐year‐old white woman sought medical attention because of a three‐day history of slurred speech and an episode of syncope. Her medical history included long‐standing rheumatoid arthritis treated with prednisone for the past five years (60 mg/day at presentation). In addition, cyclosporin (200 mg/day) had been started 16 months earlier for necrotizing scleritis.
Initial Drug Regimen for Active Tuberculosis Cases in Montreal, 1995‐1998
Authors: Rivest Paul , Tannenbaum Terry N
Published: March 2016

OBJECTIVES: To evaluate the proportion of tuberculosis (TB) cases initially treated with the recommended four‐drug regimen of isoniazid (INH), rifampin (RIF), pyrazinamide (PZA) and ethambutol (EMB) or streptomycin; and to identify factors associated with the choice of initial therapy.

DESIGN: Descriptive analysis of surveillance data obtained by TB case notifications from physicians and microbiology laboratories.

SETTING: The island of Montreal (with a population of 1,854,435 people).

STUDY POPULATION: All TB cases reported between January 1, 1995 and December 31, 1998.

OUTCOME MEASURE: The proportion of TB cases initially treated with a four‐drug regimen by sex, age, country of birth, site of disease and year of reporting.

MAIN RESULTS: Seven hundred forty‐one cases were reported during the study period. Among the 687 analyzed cases, 406 (59.1%) received the recommended initial four‐drug regimen (INH‐RIF‐PZA‐EMB), 187 (27.2%) received an INH‐RIF‐PZA regimen, 61 (8.9%) received an INH‐RIF‐EMB regimen and 33 (4.8%) received an INH‐RIF regimen only. In a logistical regression model, a four‐drug regimen was significantly associated with respiratory disease (odds ratio [OR] 4.48; 95% CI 3.15 to 6.39), age younger than 65 years (OR 2.32; 95% CI 1.55 to 3.45), being foreign‐born (OR 1.62; 95% CI 1.06 to 2.48) and later year of reporting (OR 1.27; 95% CI 1.09 to 1.47).

CONCLUSIONS: The proportion of TB cases initially treated with a four‐drug regimen has increased steadily since 1995, reaching 65% in 1998. However, given the rate of INH resistance in Montreal, efforts to promote the use of the initial four‐drug regimen must continue.
Current Hepatitis A Status in Canada
Authors: Wu Jun , Zou Shimian , Giulivi Antonio
Published: March 2016

Hepatitis A, caused by the hepatitis A virus, occurs most frequently in developing countries, but also causes sporadic cases or outbreaks in industrialized countries. The most common route of transmission is fecal‐oral. The incidence of hepatitis A varies with geography, and economic and environmental conditions. The epidemiological pattern of the disease has changed with improvements in hygiene and economic conditions. The incidence and prevalence of hepatitis A has decreased, while the average age of exposure and subsequent infection has increased. The present report describes the current status of hepatitis A in Canada. The incidence rate of reported cases in Canada varies from over 10/100,000 (1991) to 3.6/100,000 (1998), and is higher in males, 4.7/100,000 (1998), than in females, 2.5/100,000 (1998). The highest reported hepatitis A rates are in age groups 30 to 39 years and 40 to 59 years, and in British Columbia. Such information is important for assessing current immunization approaches and for decision‐making about new preventive strategies against hepatitis A in Canada.
The Role of the Aceullular Pertussis Vaccine and the Comeback of ′Pertussis Pete′?
Authors: Conly John M , Johnston B Lynn
Published: March 2016

Pertussis or whooping cough is an acute infectious disease of the respiratory tract caused principally by Bordetella pertussis and less commonly by Bordetella parapertussis (1). Until two decades ago, pertussis in adults was a medical curiosity (2‐4), but with the purification of specific Bordetella species antigens, the development of reliable enzyme immunoassays allowing accurate serological diagnosis and better understanding of the duration of immunity from vaccination, it has been clearly demonstrated that B pertussis is a common cause of prolonged cough in adults. Indeed, its incidence has been increasing gradually over the past decade in both adults and adolescents. Given the recognition of the importance of pertussis as a cause of prolonged cough in adults and the advent of the new acellular pertussis vaccines, it is timely to review current concepts of the pathogenesis of pertussis, its epidemiology in adults and the utility of the anticipated impact of the acellular vaccine.
Primary Lymphoepithelioma‐Like Carcinoma of Lung
Authors: Guerrero Alejandro , Laflamme Michael , Agoff S Nicholas , Williams William M , Karmy-Jones Riyad
Published: March 2016

Primary lymphoepithelioma‐like carcinoma (LELC) of the lung is a neoplasm seen most commonly in the nasopharynx of individuals from south China and Taiwan, and is strongly associated with the Epstein‐Barr virus. The case of a 62‐year‐old Chinese man with a rare primary lung T2N1M0 LELC of the left lower lobe is presented. The lesion was further notable because of the presence of necrotizing granulomatous inflammation. The patient was treated with surgical resection. After it was determined that the neoplasm was of primary lung origin, adjunctive chemotherapy was initiated. The role of adjunctive chemotherapy in this setting is discussed.
Bioterrorism in Canada: An Economic Assessment of Prevention and Postattack Response
Authors: John Ronald St , Finlay Brian , Blair Curtis
Published: March 2016

The present paper calculates the human and economic consequences of a bioterrorist attack on Canadian soil using aerosolized Bacillus anthracis and Clostridium botulinum. The study assumed that 100,000 people in a Canadian suburban neighbourhood were exposed over a 2 h period to an infectious dose of one of the agents. Using an epidemic curve based on the epidemiology and management of anthrax and botulinum poisoning, the costs of intervention and treatment after an attack were compared with the costs of preparedness before a bioterrorist attack. The results show that an investment in planning and preparedness to manage the consequences of an attack can reduce morbidity, mortality and economic costs. The sooner that an intervention program is instituted, the more significant are the health and economic benefits. The greatest benefits were realized when postattack intervention was initiated before day 3 after the event. The economic impact of a bioterrorist attack in Canada could range from $6.4 billion/100,000 exposed to B anthracis to $8.6 billion/100,000 exposed in an attack using C botulinum. Without the benefit of an effective consequence management program, predicted deaths totalled 32,875 from anthrax and 30,000 from botulinum toxin. Rapid implementation of a postattack prophylaxis program that includes the stockpiling of antibiotics, vaccines and antitoxins; training of first responders in the diagnosis, handling and treatment of pathogens; and the general enhancement of Canada′s response capability would reduce both human and economic losses.
Patients′ Attitudes and Prior Treatments in Neuropathic Pain: A Pilot Study
Authors: Gilron Ian , Bailey Joan , Weaver Donald F , Houlden Robyn L
Published: March 2016

BACKGROUND: Ongoing research continues to expand the knowledge of neuropathic pain. It is vital that established treatments and valuable discoveries ultimately improve patient care.

OBJECTIVES: Attitudes and prior treatments of patients being screened for neuropathic pain trials were evaluated to provide further understanding of the barriers to the management of neuropathic pain.

METHODS: A questionnaire was completed by patients with neuropathic pain who were either referred by local physicians or self referred in response to clinical trial advertisements from the authors′ facility.

RESULTS: In total, 151 patients completed the questionnaire. Diagnoses included diabetic neuropathy (55.6%), postherpetic neuralgia (29.8%), idiopathic peripheral neuropathy (9.3%) and others (5.3%). The mean pain duration was 4.7 years, and the mean daily pain (on a score of 0 to 10) was 7.6. During questioning, 72.8% complained of inadequate pain control and 25.2% had never tried any antineuropathic analgesics (tricyclic antidepressants, opioids or anticonvulsants). New antineuropathic analgesics (eg, gabapentin) were being used by only 16.6%. Opioids, tricyclic antidepressants and anticonvulsants had never been tried by 41.1%, 59.6% and 72.2%, respectively. Fears of addiction and adverse effects were expressed by 31.8% and 48.3%, respectively.

CONCLUSIONS: New, and even conventional, therapies are often not pursued, despite inadequate pain control. Several issues are discussed, including patient barriers to seeking pain management, patient and physician barriers to analgesic drug therapy, and appropriate use of and access to multidisciplinary pain centres. Failure to implement therapeutic advances in pain management not only hinders improvement in patient care, but also may render futile decades of research. Widespread professional, patient and public education, as well as continued interdisciplinary research on treatment barriers, is essential.
Economic Evaluation of the MEDENOX Trial: A Canadian Perspective
Authors: Lamy André , Wang Xiaoyin , Kent Rosanne , Smith Kelly M , Gafni Amiram
Published: March 2016

OBJECTIVE: To perform an economic evaluation of the Prophylaxis in Medical Patients with Enoxaparin (MEDENOX) trial from a Canadian perspective.

METHOD: Using a decision tree model, cost effectiveness analysis was carried out to compare the costs and consequences of thromboprophylaxis using enoxaparin 40 mg with placebo in tertiary and community settings. From a third party payer’s perspective, the model calculated the expected rate of symptomatic venous thromboembolism (VTE), and the total expected cost of prophylaxis and VTE management, including inpatient and outpatient treatment, professional fees and long term therapy. Data were derived directly from the MEDENOX trial. Costs are direct medical costs in year 2000 Canadian dollars.

RESULTS: In a tertiary setting in which the estimated inpatient to outpatient deep vein thrombosis treatment ratio was 10%:90%, the total expected cost per patient was $64 in the enoxaparin group and $62 in the placebo group. The expected symptomatic VTE rates were 0.8% and 3.1% in the enoxaparin and placebo groups, respectively. The incremental cost effectiveness of enoxaparin 40 mg versus placebo was $87/VTE avoided. In a community hospital setting (with a 50%:50% inpatient to outpatient deep vein thrombosis treatment ratio), the total expected cost per patient was $68 in the enoxaparin group compared with $72 in the placebo group, indicating that prophylaxis with enoxaparin 40 mg was cost saving. The model was sensitive to the inpatient to outpatient ratio. However, within each setting, the results were not sensitive to changes in key variables.

CONCLUSION: For patients hospitalized for acute respiratory failure, congestive heart failure or acute infectious disease and who are at moderate risk of developing VTE, thromboprophylaxis with enoxaparin 40 mg daily is a cost effective strategy in both tertiary and community settings.
Central Hyperexcitability in Chronic Musculoskeletal Pain: A Conceptual Breakthrough with Multiple Clinical Implications
Authors: Lidbeck Jan
Published: March 2016

Recent investigations of dysfunctional pain processing in the central nervous system have contributed much knowledge about the development of chronic musculoskeletal pain. Many common chronic musculoskeletal pain syndromes ‐ including regional myofascial pain syndromes, whiplash pain syndromes, refractory work‐related neck‐shoulder pain, certain types of chronic low back pain, fibromyalgia and others ‐ may essentially be explained by abnormalities in central pain modulation. The growing awareness of dysfunctional central pain modulation may be a conceptual breakthrough leading to a better understanding of common chronic pain disorders. A new paradigm will have multiple clinical implications, including re‐evaluation of clinical practice routines and rehabilitation methods, and will focus on controversial issues of medicolegal concern. The concept of dysfunctional central pain processing will also necessitate a mechanism‐based classification of pain for the selection of individual treatment and rehabilitation programs for subgroups of patients with chronic musculoskeletal pain due to different pathophysiological mechanisms.
Respiratory Symptoms and Asthma in Two Farming Populations: A Comparison of Hutterite and Non‐Hutterite Children
Authors: Rennie Donna C , Dosman James , Senthilselvan Ambikaipakan
Published: March 2016

OBJECTIVE: To determine the prevalence of asthma and respiratory symptoms in a farming population of Hutterite and non‐Hutterite children.

PARTICIPANTS AND SETTING: A population of 830 school‐age, farm‐dwelling children in rural Saskatchewan that included 83 children residing in Hutterite farming colonies.

METHODS: A cross‐sectional survey questionnaire was sent to parents of children attending grades 1 to 5 in schools within a grain‐growing and mixed‐farming region of central Saskatchewan. The questionnaire was used to identify respiratory symptoms, environmental and host characteristics, and reported doctor‐diagnosed asthma.

RESULTS: The prevalence of asthma in Hutterite children was 2.4% compared with 9.2% in non‐Hutterite children. While Hutterite children did not differ from their farming counterparts with regard to the frequency of reported respiratory allergies, they were less likely to be exposed to cigarette smoke and to participate in farm‐related activities. In the multivariate analysis, being Hutterite continued to be protective for asthma (odds ratio 0.21; 95% CI 0.05 to 0.89).

CONCLUSION: The observed lower rate of asthma in Hutterite children than in non‐Hutterite children may be related to both genetic factors and differences in farming and household factors between the two groups.
A National Survey of Antimicrobial Prophylaxis in Adult Cardiac Surgery Across Canada
Authors: Paradiso-Hardy Fran L , Cornish Patti , Pharand Chantal , Fremes Stephen E
Published: March 2016

OBJECTIVE: To characterize national and regional patterns of antimicrobial prophylaxis in adult cardiac surgery across Canada.

DESIGN: Retrospective, cross‐sectional analysis.

SETTING: Thirty‐three adult cardiac surgical centres across Canada.

INTERVENTIONS: A one‐page questionnaire collecting information regarding institutional demographics and antimicrobial prophylaxis regimens for adult cardiac surgical procedures was mailed to all adult surgical centres across Canada. If a response was not received within one month, a second survey was mailed, followed by a telephone reminder within two weeks of the second mailing.

MAIN RESULTS: The overall response rate was 100%. Prophylactic antimicrobials were used in all of the adult cardiac centres; single‐agent prophylaxis was used in 97% (32 of 33) of centres. Single‐dose antimicrobial prophylaxis was used in only 3% (one of 33) of centres. Preoperative and postoperative antimicrobial prophylaxis regimens varied both between provinces and within provinces across Canada. Cefazolin was the antimicrobial used in 88% (38 of 43) and 87% (33 of 38) of the reported preoperative and postoperative prophylaxis regimens, respectively. Antimicrobial prophylaxis was initiated in the operating room 72% (26 of 36) of the time, and intraoperative supplemental antimicrobial doses were administered for cardiac procedures that took longer than a median of 4 h (range 4 to 8 h). Overall, the median duration of antimicrobial prophylaxis treatment was 36 h (range 8 to 96 h).

CONCLUSIONS: Despite the availability of various published guidelines, the present survey identified several areas for improvement with respect to antimicrobial prophylaxis in adult cardiac surgery across Canada.
Verotoxigenic Escherichia coli (Vtec): A Major Public Health Threat in Canada
Authors: Woodward David L , Clark Clifford G , Caldeira Richard A , Ahmed Rafiq , Rodgers Frank G
Published: March 2016

BACKGROUND: Verotoxigenic Escherichia coli (VTEC) was first described in Canada during the 1980s as an emerging foodborne disease in association with morbidity and mortality in outbreaks of hemorrhagic colitis caused by E coli O157:H7.

OBJECTIVE: To describe the surveillance activities and epidemiological laboratory markers of VTEC that are used at the National Laboratory for Enteric Pathogens (NLEP) to investigate sporadic cases and outbreaks of E coli O157:H7 and non‐O157 VTEC in Canada.

METHODS: Passive surveillance was conducted by obtaining data on laboratory confirmed cases of VTEC from the Provincial Laboratories of Public Health across Canada. The laboratory epidemiological markers generated for isolates of VTEC included biotyping, serotyping, phage typing, toxin detection and characterization, and molecular typing using pulsed‐field gel electrophoresis.

RESULTS: Major outbreaks of VTEC O157:H7 disease have been associated with ground beef, unpasteurized apple juice, salami and untreated water. In 1999 and 2000, a total of 46 outbreaks of E coli O157:H7 disease were investigated. Among those, one outbreak was associated with contact at a petting zoo and a second with the consumption of salami. An outbreak in 2000 in Ontario was associated with water and resulted in more than 1000 cases of human illness, with six deaths. The NLEP has also identified more than 100 non‐O157 VTEC serotypes from cattle and meat products. At least 23 VTEC serotypes found in humans were also identical to those found in cattle and meat products.

CONCLUSIONS: The laboratory‐based information that is generated is used to define the incidence, sources of infection, risk factors, trends, distribution and transmission of VTEC to humans from food, water and animal sources. Prevention and control of outbreaks are high‐priority health concerns.
Persistent Pain Prevalence and Medical Management
Authors: Tunks Eldon
Published: March 2016

In this issue, Moulin et al (pages 179‐184) report an epidemiological survey of persistent pain and medical treatment of this pain in Canada. Two thousand twelve adult Canadians were included in a randomized sample and were interviewed by telephone. The sample was stratified to correspond to the Canadian population′s prevalences of sex, age and region, according to the 1996 census data. For this study, the Canadian Ipsos‐Reid Express Omnibus survey was used.
Additive Effect of Dornase Alfa and Nacystelyn on Transportability and Viscoelasticity of Cystic Fibrosis Sputum
Authors: Sun Feng , Tai Shusheng , Lim Thomas , Baumann Ulrich , King Malcolm
Published: March 2016

OBJECTIVE: To investigate the effect of dornase alfa (DA), Nacystelyn (NAL) and their combination on mucociliary transportability and mucus viscoelasticity of cystic fibrosis (CF) sputum, and to assess whether the combination possesses an additive effect.

DESIGN: Determination of transportability in frog palate and viscoelasticity in vitro.

SETTING: Research laboratory at a medical centre. Patients: Sputa from 15 patients with CF, chronically infected with Pseudomonas aeruginosa, were studied.

INTERVENTIONS: Sputum samples were incubated without any drug solution as a control, and with normal saline, DA, NAL and a mixture of DA and NAL in concentrations approximating those achieved in clinical practice.

RESULTS: Normal saline (10% volume) by itself had a small effect on CF sputum transportability with a mean increase of 9%, and on viscoelasticity with a mean of decrease of 0.22 log units, respectively, compared with control (incubation without saline). DA (200 nM) further increased the transportability by a mean of 35% versus saline and decreased viscoelasticity by a mean of 0.30 log units. NAL (100 µM) increased the transportability by a mean of 32% and decreased viscoelasticity by a mean of 0.22 log units from the levels achieved with saline. The mixture of DA plus NAL at one‐half of the above concentration of each agent produced an additional increase in the transportability, by a mean of 18%, and a further decrease in viscoelasticity, by a mean of 0.25 log units, compared with DA or NAL as a single treatment.

CONCLUSIONS: The combination of DA and NAL exhibits an additive effect for both the viscoelasticity and transportability of CF sputum samples. The two agents appear to act well together in breaking down the bonding due to extracellular DNA and mucins. Clinical studies should be undertaken to see whether the additive combination at lower concentration produces the anticipated benefits of improved airway clearance and fewer side effects.
A Randomized Treatment Study to Compare the Efficacy of Repeated Nerve Blocks with Cognitive Therapy for Control of Chronic Head and Neck Pain
Authors: Gale George , Nussbaum David , Rothbart Peter , Hann Beverley , Leung Van , Kanetz Gillian
Published: March 2016

This prospective study compared the efficacy of two antinociceptive modalities: nerve blocks and cognitive therapy. A consecutive series of patients receiving nerve block therapy was invited to take part in a six‐week randomized comparison of nerve blocks and cognitive therapy. Sixty‐eight of 102 patients approached by telephone agreed to participate. Patients attended eight weekly treatment sessions. Baseline and seven weekly sets of values were recorded. The principal measure of outcome was the Pain on a Visual Analogue Scale (VAS). The secondary measures were the Hospital Anxiety and Depression Scale, and the Activities of Daily Living as measured on the Primary Care Cooperative Information Project/World Organization of National Colleges, Academies (COOP‐WONCA) scale. Within the first week, one patient of 34 in the nerve block group withdrew and 12 of 34 in the cognitive therapy group withdrew from the study. After seven weeks, 33 patients in the nerve block group remained in the trial, but only 21 patients completed the questionnaires. Four of 22 patients in the cognitive therapy group completed the trial and their questionnaires. Mean VAS scores in the nerve block group dropped slightly during treatment. Mean VAS scores in the cognitive therapy group rose during the trial. However, the mean VAS score of the remaining four in the last week was below the initial group mean. Patients who had been receiving nerve blocks proved willing to remain in the study if allocated to the nerve block group and unwilling to remain in the cognitive therapy group while foregoing their accustomed treatment.
A Short Version of the Pain Anxiety Symptoms Scale (PASS‐20): Preliminary Development and Validity
Authors: McCracken Lance M , Dhingra Lara
Published: March 2016

BACKGROUND: Research has shown significant relations between fear and avoidance of pain and the suffering and disability of chronic pain. Effective measurement tools have formed the foundation for studying these relations.

METHODS: The present article describes the initial development and validation of the PASS‐20, a short form version of the Pain Anxiety Symptoms Scale (PASS). Like the original inventory, the PASS‐20 measures fear and anxiety responses specific to pain. Items were selected for the short version based on item variance, item intercorrelation and reliability analyses.

RESULTS: The PASS‐20 shows strong internal consistency, reliability, and good predictive and construct validity. Item reduction appears to result in minimal shrinkage of validity correlations.

CONCLUSIONS: Overall, the results suggest that the short form retains adequate psychometric properties. Possible research and clinical implications for the PASS‐20 include more efficient screening during evaluations of patients with chronic pain, and use when the time or effort needed for the full version is prohibitive.
Pain in Patients with Panic Disorder: Relation to Symptoms, Cognitive Characteristics and Treatment Outcome
Authors: Schmidt Norman B , Santiago Helen T , Trakowski John H , Kendren J Michael
Published: March 2016

OBJECTIVE: Although there has been a link between certain types of pain, notably chest pain, and panic disorder, the relation between pain and panic disorder has not been systematically evaluated. In the present study, the relation between pain symptoms (headache, chest pain, stomach pain, joint pain) and the clinical presentation of patients with panic disorder was evaluated.

HYPOTHESES: Pain was generally hypothesized to be related to increased symptoms of anxiety, panic‐relevant cognitive domains and treatment outcome. In terms of specific pain domains, headache and chest pain were expected to be more closely related to anxiety‐related symptoms.

PARTICIPANTS AND METHODS: Patients (n=139) meeting the criteria of the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition for panic disorder completed a set of standardized clinician‐rated and self‐reported measures. Moderator analyses were used in a subset of these patients completing a treatment outcome study.

RESULTS: Approximately two‐thirds of the participants endorsed at least one current pain symptom. The hypotheses were partially supported, with pain being associated with higher levels of anxiety and depression symptoms, as well as panic frequency. Pain was also related to several cognitive features, including anxiety sensitivity and panic appraisals. Headache and chest pain were more highly associated with anxiety symptoms than was joint pain. Cognitive measures did not mediate the relation between anxiety and pain, and pain did not significantly moderate outcome in response to cognitive‐behavioural therapy.

CONCLUSIONS: Co‐occurring pain symptoms appear to be more highly related to phenomenology than to treatment response in patients with panic disorder.
Histiocytosis X and Bronchopulmonary Adenocarcinoma: A Rare Coexistence
Authors: Kaya Akýn , Savas Ýsmail , Pen Elif , Sak Serpil Dizbay , Gungor Adem , Gonullu Uður
Published: March 2016

There exists a rarely observed association between pulmonary histiocytosis X and bronchopulmonary cancer. However, the frequency of bronchopulmonary cancer in these patients is higher than in the general population. A 28‐year‐old patient who currently smokes ten packs of cigarettes a year came to our department of pneumology with complains of cough and hemoptysis. An x‐ray of the thorax revealed bilateral cysts and a shadow in the upper part of the right pulmonary field. In addition, a chest tomography showed multiple cysts dispersed throughout the two pulmonary fields and an irregular mass with a diameter of four centimetres in the upper right lobe. Bronchopulmonary adenocarcinoma was diagnosed during a cytologic exam of the bronchial washing. We decided to perform a thoracotomy on the patient, since there was no far metastasis. An upper lobectomy and wedge resection of the upper segment of the lower right lobe, which had been invaded by the tumour, were performed. Histology confirmed the diagnosis of adenocarcinoma. A pulmonary biopsy was carried out on the tumour‐free site and showed the presence of histiocytosis X. There is a hypothesis that a neoplasm developed on the pulmonary fibrosis could be an epiphenomenon of bronchopulmonary cancer in patients who smoke and have pulmonary histiocytosis X. It is interesting to note that histiocytosis X and bronchopulmonary cancer were diagnosed at the same time, since the bronchopulmonary cancer may have occurred within a few years following the diagnosis of histiocytosis X, even if she was a smoker. Hemoptysis, which is found in 5% of patients with histiocytosis X, may suggest cancer. This young patient, a smoker, who complained of hemoptysis, is a particularly rare case of the association between pulmonary histiocytosis X and bronchopulmonary cancer whose pathogenesis is not clear cut. It is thus important to note that smoking can have major consequences, even in young people.
The Role of Health Anxiety among Patients with Chronic Pain in Determining Response to Therapy
Authors: Hadjistavropoulos Heather D , Asmundson Gordon JG , LaChapelle Diane L , Quine Allisson
Published: March 2016

Considerable research suggests that health anxiety (HA) influences the response of patients with chronic pain to pain and treatment. The present investigation extends the current understanding of HA and explores whether it affects how patients respond to a common therapeutic intervention, namely instructions to reduce pain behaviour. Sixty‐five patients with chronic pain completed measures of pain, anxiety and cognition following an active occupational therapy session in which they were specifically instructed either to inhibit or reduce pain behaviour, or to carry out the session as they normally would. Regression analyses revealed that those with higher levels of HA experienced greater anxiety, somatic sensations and catastrophic cognitions during therapy than those with lower levels of HA. The regression analyses also revealed a consistent trend for an interaction between HA and instructional set; when those with higher HA reduced their pain behaviour, they subsequently reported greater anxiety, and more somatic sensations and catastrophic thoughts than when they carried out the session as they normally would. In contrast, only those with lower HA had a tendency to benefit from reducing pain behaviour, reporting lower state anxiety and fewer somatic sensations during the session than those who did not reduce their pain behaviour. The results suggest that HA should be taken into consideration during treatment.
Oral Fluoroquinolones in the Treatment of Pneumonia, Bronchitis and Sinusitis
Authors: Mittmann Nicole , Jivraj Farah , Wong Angelina , Yoon Alice
Published: March 2016

BACKGROUND: Despite a relatively large number of clinical studies comparing oral fluoroquinolones to one antibiotic class comparator, there is limited information on the relative efficacy of different fluoroquinolones.

OBJECTIVE: To examine the efficacy and tolerability of oral fluoroquinolones in the treatment of mild to moderate community‐acquired pneumonia, acute exacerbations of chronic bronchitis and sinusitis.

METHODS: A systematic review was undertaken with a MEDLINE search for antibiotics and indications. Included studies met the following criteria: original study; random allocation to treatment groups; treatment with one of the following oral antibiotics ‐ moxifloxacin, levofloxacin, ciprofloxacin, gatifloxacin; controlled by either placebo or an active comparator medication; double‐blind, single‐blind or open treatment; men and women (18 years of age and older); diagnosis of one of the three indications; and treatment duration of at least three days. Outcome measures included efficacy and safety. Comparative and single arm meta‐analyses were conducted. Statistical differences in antibiotic success rates were evaluated. Pooled point estimates and 95% CIs for the comparative statistics (z‐scores, P‐values) and the single‐arm analysis were examined to evaluate equivalence.

RESULTS: The results of the comparative and single meta‐analyses revealed no major differences between the new fluoroquinolones. This is not surprising because the clinical studies were designed to show equivalence versus their comparators. Few comparative evaluations were conducted due to a paucity of studies. In relation to other competitors, small differences were seen.

CONCLUSIONS: Results indicate that, in general, fluoroquinolones had similar efficacy, overall safety and dropout rates.
Thunderstorm‐Associated Asthma or Shortness of Breath Epidemic: A Canadian Case Report
Authors: Wardman AE Dennis , Stefani Dennis , MacDonald Judy C
Published: March 2016

Thunderstorm‐associated asthma epidemics have been documented in the literature, but no Canadian experience has been reported. On July 31, 2000, a thunderstorm‐associated epidemic of asthma or shortness of breath occurred in Calgary, Alberta. The Calgary Health Region investigated the event using diagnostic data from emergency departments, an urgent care medical clinic and patient interviews, in addition to bioaerosol counts, pollutant data and weather data reflecting atmospheric conditions at that time. On July 31, 2000 and August 1, 2000, 157 people sought care for asthma symptoms. The expected number of people to seek care for such symptoms in a 48 h period in Calgary is 17. Individuals with a personal or family history of asthma, allergies or hay fever who were not taking regular medication for these conditions and who were outdoors before the storm appeared to have been preferentially affected. A stagnant air mass the day before the thunderstorm may have resulted in declining bioaerosol concentrations, and the possible accumulation of spore and pollen reservoirs within mould and plant structures. The elevated bioaerosol concentrations observed on the day of the thunderstorm may be attributed to the sudden onset of high winds during the thunderstorm, which triggered a sudden release of spores and pollens into the atmosphere, which was probably responsible for the epidemic. Several pollutant levels slightly increased on the day of the storm and possibly also played a role in symptom development. It is unclear whether an atmospheric pressure drop contributed to the release of spores and pollens.
Fibrothorax and Severe Lung Restriction Secondary to Lupus Pleuritis and Its Successful Treatment by Pleurectomy
Authors: Sharma Sat , Smith Robert , Al-Hameed Fahad
Published: March 2016

Pleural disease is a common pulmonary manifestation of systemic lupus erythematosus (SLE) that usually responds to corticosteroids and other immunosuppressive agents. In the present report, a new approach, pleural decortication, was used in a patient with medically refractory chronic pleuritis secondary to severe SLE. A 26‐year‐old woman with known SLE developed progressive dyspnea and pleuritic chest pain over several months. The other systemic manifestations of her lupus were controlled with cyclophosphamide and prednisone. A computed tomography scan revealed a persistent, small, loculated right pleural effusion; pleural thickening; and atelectasis of the right middle and lower lobes. Pulmonary function tests showed a severe restrictive defect. The patient was disabled by her severe dyspnea despite maximal medical therapy, and, therefore, surgery was considered. A right thoracotomy revealed entrapment of the right lung by dense visceral pleura. Decortication was performed. On pathology, pleuritis with vascular pleural adhesions was found. No lupus pneumonitis was noted. Postoperatively, a significant clinical improvement in dyspnea was evident within several weeks. On a 6 min walk test, the patient achieved 384 m with a Borg dyspnea scale rating of 2 compared with 220 m and a Borg dyspnea scale rating of 4 preoperatively. Her forced vital capacity improved from 24% predicted to 47% predicted, and her total lung capacity improved from 35% predicted to 54% predicted. Medical therapy of systemic lupus erythematosus has been proven to be effective in controlling pleuritis in most cases. However, in the event of refractory pleuritis or pleural thickening, decortication may be a viable alternative.
Multiple Sclerosis and Epstein-Barr Virus
Authors: Marrie Ruth Ann , Wolfson Christina
Published: March 2016

OBJECTIVE: To evaluate the epidemiological evidence for an etiological role of Epstein-Barr virus in multiple sclerosis (MS).

DATA SOURCES: MEDLINE and Cochrane Library searches of the medical literature identified 24 studies.

DATA EXTRACTION: Studies were categorized as seroepidemiological, case-control or historical cohort, and were then classified within each group according to methodological rigour using criteria derived from published guidelines for the epidemiological study of MS.

DATA SYNTHESIS: There was significant variability in the quality of evidence, and while two well-designed cohort studies found increased relative risks of MS in subjects with infectious mononucleosis, results from other studies were unconvincing.

CONCLUSIONS: The evidence was insufficient to accept or reject the hypothesis that Epstein-Barr virus has an etiological role in MS. Further study, ideally using large samples of incident cases with blinded, trained interviewers using confirmatory sources for recalled data, is needed.
Practice Patterns of Respirologists in Canada
Authors: Sharma Sat , Dhar Anil , McLean Laura , Sahni Perry , Lertzman Morley
Published: March 2016

The demographics and practice patterns of respirologists in Canada have not been studied. To evaluate the demographic characteristics of respirologists in practice, appraise current respirology manpower and ascertain the utilization of invasive diagnostic and therapeutic procedures (interventional pulmonology), a mail survey of all Canadian respirologists was conducted. The questionnaires were completed by 62% (n=355) of 573 possible participants. Of the respirologists who responded, 69.2% were younger than 50 years of age, 70.3% had been in practice for fewer than 20 years, 64.4% were in full‐ or part‐time academic practice, and 72.9% were based in urban centres with a catchment population of more than 250,000. The current ratio of respirologists to population in Canada, assuming a total population of 31,000,000, is 1:54,101. In the present survey, only 68.3% respirologists practised clinical respirology for 50% or more of their time, and half (49.5%) of respirologists devoted more than 50% of their time on nonrespirology or nonclinical activities. Thus, the more precise respirologist to population ratio appears to be 1:81,000. The current ratio meets the Royal College of Physicians and Surgeons of Canada recommendations, and the current training programs meet present manpower requirements. With respect to the procedures performed, most specialists carried out bedside procedures and flexible bronchoscopy; a much smaller number did invasive procedures such as rigid bronchoscopy (20.8%), transbronchial needle biopsy of lung (43%), transbronchial biopsy of mediastinal lymph nodes (38%), therapeutic bronchoscopy using laser, cryotherapy and stents (8.7%), transthoracic needle biopsy (22.2%) and thoracoscopy (11.3%). Because 97% of pulmonary specialists would like to perform invasive procedures, fellowship programs, mini‐residencies and practical courses should provide the necessary training.
Colonic Tuberculosis Clinically Misdiagnosed as Anorexia Nervosa and Radiologically and Histopathologically as Crohn’s Disease
Authors: Madani Tariq A
Published: March 2016

A case of colonic tuberculosis presenting with severe wasting was misdiagnosed as anorexia nervosa at another institution. Double contrast barium enema showed strictures, and ulcerations of the cecum and ascending colon with a skip area. The radiologist believed that these findings were due to Crohn's disease. Colonoscopic biopsies from the involved area revealed histopathological changes typical of Crohn's disease and not tuberculosis. The patient completely recovered with antituberculous therapy without steroids. The case demonstrated the clinical, radiological and histopathological difficulties and misdiagnoses that may be associated with the diagnosis of colonic tuberculosis.
Diagnosing Asthma: The Fit between Survey and Administrative Database
Authors: Huzel Lisa , Roos Leslie L , Anthonisen Nick R , Manfreda Jure
Published: March 2016

BACKGROUND:Standard methods for population studies of asthma include surveying population samples using questionnaires and examining people in laboratories. These procedures are extremely expensive. It would be helpful if, at least for some purposes, they could be replaced by cheaper techniques with adequate validity. OBJECTIVES: To determine agreement between survey and database in regard to the prevalence of asthma.

METHODS: Responses to survey questions about asthma symptoms in the past 12 months were linked to physician claims in the Manitoba Population Health Repository.

RESULTS: The overall agreement was moderate (κ=0.45 to 0.50) and increased if two years of physician claims were studied (κ=0.55 to 0.59); studying additional years had no further effect on agreement. Sex and smoking did not significantly affect the kappa scores.

CONCLUSIONS: There were several plausible reasons for discrepancies. Symptoms recorded on the survey were intrinsically different from those recorded for physician visits. Physicians also used other respiratory codes instead of asthma, and survey participants did not see a physician every year for asthma. The estimates of prevalence derived from the survey and the administrative database included two overlapping groups of people. In each, the diagnosis of asthma seems justifiable, although the agreement between the two groups was only moderate to substantial. Both methods are useful, although they are useful for different purposes. Health care utilization estimates may be particularly useful for studying trends over time.
A Retrospective Analysis of Practice Patterns in the Treatment of Methicillin‐Resistant Staphylococcus aureus Skin and Soft Tissue Infections at Three Canadian Tertiary Care Centres
Authors: Conly John M , Stiver H Grant , Weiss Karl A , Becker Debbie L , Rosner Andrew J , Miller Elizabeth
Published: March 2016

BACKGROUND: Methicillin‐resistant Staphylococcus aureus (MRSA) infections are increasingly being encountered and pose an increasing burden to the health care system in Canada.

OBJECTIVE: To elucidate and characterize the factors influencing the current MRSA treatment patterns in patients with skin and soft tissue infections (SSTIs) before linezolid became available on the Canadian market.

METHODS: A retrospective study collected demographic, treatment and resource use data on patients hospitalized at one of three geographically distinct tertiary care facilities, where MRSA SSTI treatment was initiated with intravenous (IV) vancomycin. Analysis of opportunities for IV‐to‐oral switch therapy was based on eligibility criteria.

RESULTS: Of 89 patients identified over a 43‐month period, the mean (±SD) durations of anti‐infective treatment and hospitalization were 22.4±21 days and 28.9±20.8 days, respectively. An infected surgical wound was most common, representing 62.9% of infections. The mean duration of vancomycin treatment was 19.5 days and the mean number of 1 g doses received was 29.0±32.9. The majority of patients (55.1%) initiated vancomycin therapy a mean of 5.4±8.9 days after confirmation of MRSA. Of the 70% of patients meeting criteria for IV‐to‐oral switch therapy, only 10% received oral treatment. The most common reason cited for not switching was lack of an effective oral alternative. Analysis of switch therapy criteria found that IV treatment continued for a mean of 13 days despite the appropriateness of the oral route.

CONCLUSIONS: Considerable variation exists in treatment patterns for MRSA infections. Improvements in the initiation of therapy and the use of IV‐to‐oral switch therapy may improve care and reduce the duration of hospitalization for MRSA SSTIs.
Older Adults with Alzheimer’s Disease, Comorbid Arthritis and Prescription of Psychotropic Medications
Authors: Balfour Judith E , O’Rourke Norm
Published: March 2016

OBJECTIVES: It is assumed that analgesia is underutilized among those with Alzheimer disease and that these patients may be inappropriately prescribed neuroleptics and benzodiazepines. The current study examines this assertion.

DESIGN: For this study, prescription levels of analgesics and psychotropic medications for Alzheimer disease patients with (n=245) and without (n=215) musculoskeletal conditions (ie, arthritis or rheumatism) are compared.

SETTING: A national sample of community dwelling and institutionalized older adults was identified from the Canadian Study of Health and Aging* (CSHA).

PARTICIPANTS: Persons from 36 cities and surrounding rural areas over 64 years of age were randomly identified for the CSHA from government health records in all but one province.

MEASUREMENTS: Prescribed analgesic and psychotropic medications were examined, as well as dementia severity and dementia related behavioural disturbance.

RESULTS: Less than half of Alzheimer patients with arthritis or rheumatism were treated for pain (ie, 109 of 245 patients); they were also more likely to be prescribed benzodiazepines compared with Alzheimer patients without musculoskeletal conditions (subsequent to initial consideration for analgesia, dementia severity and dementia‐related behaviours; äX2[ädf =1] =3.97, P=0.046).

CONCLUSIONS: These findings are in accord with prior research attesting to the undertreatment of pain among older adults. These results can be generalized with greater confidence, given the random composition of the patient sample.
Synchronous Lung and Liver Metastases from Medullary Thyroid Carcinoma
Authors: Yanardag H , Tetikkurt C , Tetikkurt S
Published: March 2016

Metastatic disease is one of the most common causes of calcified nodules in the lung or liver. The incidence of calcified metastasis mainly to the lung and liver is high at the initial presentation in patients with medullary thyriod carcinoma. Synchronous calcified metastasis in the lung and liver is reported for the first time. The diagnosis of medullary thyroid carcinoma may be evident from the synchronous presence of miliary calcified nodules in two different sites if they are associated with high concentrations of serum markers.