bluuebunny/crossref_metadata_2025 huggingface dataset:
Pain and Cognitive Status among Nursing Home Residents in Canada
Authors: Proctor Wendey R , Hirdes John P
Published: March 2016

BACKGROUND: There is little information available on the rates of pain in institutionalized elderly persons, and this is particularly true for Canada.

OBJECTIVES: To provide information about the prevalence and clinical correlates of pain in a sample of Canadian nursing homes, to determine whether residents with cognitive impairment experience lower rates of health conditions associated with pain (eg, arthritis) than residents without cognitive impairment and to determine whether the associations (ie, odds ratios) for pain with such health conditions vary as a function of cognitive status.

DESIGN: The study is based on a secondary analysis of data collected with the minimum data set (MDS 2.0).

SETTING AND PARTICIPANTS: The study comprised 3195 nursing home residents in Ontario, Manitoba and Saskatchewan.

SUBJECTS AND METHODS: All residents were assessed with the MDS 2.0 by trained clinicians (usually nurses). Pain was documented if it had occurred within the seven days before the assessment. Assessors were trained to look for overt signs of discomfort, such as wincing or verbalizations. Self‐report ratings were obtained when possible.

RESULTS: The overall prevalence of pain in this sample was 49.7%, and 23.7% of residents experienced pain daily. Persons with and persons without cognitive impairments did not differ with respect to the prevalence of conditions likely to cause pain and the associations of pain with such health conditions. Regional differences were found, with Ontario residents having a higher frequency and intensity of pain than their counterparts in Saskatchewan and Manitoba. This may be due, at least in part, to regional differences in nursing home admission criteria.

CONCLUSIONS: The findings suggest that the prevalence of identified pain is lower among nursing home residents with higher levels of cognitive impairment. These results do not support the notion that this is a function of lower prevalence rates of pain‐causing conditions in nursing home residents with dementia. Furthermore, the results do not support the view that residents with cognitive impairments are less sensitive to pain. This study highlights the need for more comprehensive tools to assess pain in persons with cognitive impairments. Nonetheless, the MDS may be a useful instrument for detecting pain in such populations, because it does not rely exclusively on self‐report.
Reduced Susceptibility to Penicillin among Pneumococci Causing Invasive Infection in Children ‐ Canada, 1991‐1998
Authors: Scheifele David , Halperin Scott , Pelletier Louise , Talbot James , Lovgren Marguerite , Vaudry Wendy , Jadavji Taj , Law Barbara , MacDonald Noni , Gold Ron , Wang Elaine , Mills Elaine , Lebel Marc , Déry Pierre , Morris Rob
Published: March 2016

OBJECTIVE: To determine, over time, the rate and serotypes of pneumococci with reduced penicillin susceptibility obtained from children with invasive infection.

DESIGN: Active, hospital‐based, multicentre surveillance spanning from 1991 to 1998.

SETTING: Eleven Canadian tertiary care paediatric facilities located from coast to coast.

POPULATION STUDIED: 1847 children with invasive pneumococcal infection whose isolates (from a normally sterile site) were available for serotyping and standardized testing for penicillin susceptibility at the National Centre for Streptococcus.

MAIN RESULTS: The prevalence of reduced penicillin susceptibility increased from 2.5% of 197 cases in 1991 to 13.0% of 276 cases in 1998. In the latter year, 8.7% of isolates had intermediate level resistance, and 4.3% had high level resistance. Since they were first detected in 1992, strains with high level resistance have been encountered only sporadically at most centres, but by 1998, all centres but two had encountered examples. Of 40 isolates with high level resistance and 101 isolates with intermediate level resistance, serotypes matched those included in new seven‐valent conjugate vaccines for children in 97.5% and 79.2% of cases, respectively.

CONCLUSIONS: Pneumococci with reduced susceptibility to penicillin are increasing in frequency across Canada among children with invasive infection. The Immunization Monitoring Program, Active data indicate that new conjugate vaccines could help to curb infections due to pneumococci with reduced susceptibility to penicillin but are unlikely to control completely the problem of antibiotic resistance.
Nerve Blocks and Cognitive Therapy: A Beneficial Failure
Authors: Merskey Harold , Thompson Ellen N
Published: March 2016

The trial by Gale et al (pages 185‐189) is a valuable example of a negative result ‐ the sort of finding that is published less often than a positive one. But, we can learn from the failure, both in understanding correct treatment and in planning future trials. Patients were recruited in a clinic where repeated treatment by nerve blocks is used as a palliative measure for chronic pain of all types. They were then offered the choice of entering a group with cognitive behavioural therapy or continuing with nerve blocks. For ethical reasons, patients could freely leave either branch of the trial without prejudice. At the onset, one of 34 patients in the nerve‐block group left, while 12 departed from the cognitive therapy group. All 33 patients remaining in the nerve block group completed the eight‐week trial, while only four of 34 patients completed it in the cognitive therapy group.
Polyclonal Intravenous Immunoglobulin for the Prophylaxis and Treatment of Infection in Critically Ill Adults
Authors: Laupland Kevin B
Published: March 2016

Infection is a major cause of morbidity and mortality in critically ill patients. Despite advances in technology, its mortality rate has changed minimally over the past two decades, and new therapies are needed. Polyclonal intravenous immunoglobulin (IVIG) has been investigated both as a preventive and a treatment modality for sepsis and septic shock in critically ill adult patients. Prophylaxis with IVIG has been shown to reduce significantly the incidence of infection, particularly pneumonia, in selected postsurgical intensive care patients. However, it does not reduce mortality. The risk-benefit and cost effectiveness of this therapeutic intervention have not been determined, and its routine use is therefore not recommended. Treatment with IVIG has been shown in a number of small trials and a meta-analysis to reduce dramatically sepsis and septic shock mortality. However, a large, unpublished randomized trial has apparently shown no mortality benefit with this therapy. Despite limited evidence, IVIG has become the standard of care for the management of group A streptococcal toxic shock syndrome. At present, clinical equipoise exists for the use of IVIG in the treatment of sepsis and septic shock, and further study is needed.
Increased Levels of Airway Neutrophils Reduces the Inhibitory Effects of Inhaled Glucocorticosteroids on Allergen‐Induced Airway Eosinophils
Authors: Gauvreau Gail M , Inman Mark D , Kelly Margaret , Watson Richard M , Dorman Sandra C , O’Byrne Paul M
Published: March 2016

BACKGROUND: Treatment with inhaled glucocorticosteroids attenuates allergen‐induced airway inflammation but is less effective in people with asthma who have noneosinophilic airway inflammation.

OBJECTIVE: Studies in which glucocorticosteroid treatment was used before allergen challenges were re‐examined to determine whether the efficacy of steroid treatment could be predicted by baseline levels of sputum inflammatory cells.

PATIENTS AND METHODS: Twenty‐eight nonsmoking subjects with atopic asthma controlled by beta2‐agonists participated in only one of three studies, each carried out with a double‐blind, placebo controlled, randomized, crossover design. Subjects were treated with glucocorticosteroids or placebo for six to eight days and then underwent allergen inhalation challenge. Spirometry was measured for 7 h after allergen challenge, and then sputum inflammatory cells were measured. Sputum inflammatory cells were also measured before and after treatment, and 24 h after allergen challenge. The per cent inhibition of the allergen‐induced airway responses by glucocorticosteroids was calculated.

RESULTS: Inhaled gluticocorticosteroids significantly attenuated the early and late asthmatic responses, and the number of allergen‐induced sputum eosinophils (P<0.05). There was a significant negative relationship between the number of sputum neutrophils at baseline, and the per cent inhibition of allergen‐induced sputum eosinophils measured at 7 h (r=‐0.61, P<0.001) and 24 h (r=‐0.73, P<0.0001) after challenge, suggesting that glucocorticosteroids are less effective in attenuating allergen‐induced airway inflammation in subjects with high levels of neutrophils. There was no correlation between the number of sputum eosinophils at baseline and the per cent inhibition of allergen‐induced responses.

CONCLUSIONS: Baseline airway neutrophils, not eosinophils, can be used to predict the efficacy of inhaled steroids on allergen‐induced sputum eosinophils.
Differential Predictors of Pain and Disability in Patients with Whiplash Injuries
Authors: Sullivan Michael JL , Stanish William , Sullivan Maureen E , Tripp Dean
Published: March 2016

The psychological predictors of pain and disability were examined in a sample of people who sustained whiplash injuries during rear‐end motor vehicle accidents. Sixty‐five patients referred to a specialty pain clinic with a diagnosis of whiplash injury completed measures of depression, anxiety, catastrophizing, pain and perceived disability. Regression analysis revealed that psychological variables accounted for 18% of the variance in pain ratings. The magnification subscale of the Pain Catastrophizing Scale was the only variable that contributed significant, unique variance to the prediction of pain. Psychological variables accounted for 37% of the variance in perceived disability scores. In the latter analysis, however, none of the independent variables contributed significant, unique variance to the prediction of perceived disability. Psychological variables accounted for significant variance in disability ratings, even when controlling for pain intensity. Discussion focuses on the need to draw clearer distinctions between determinants of pain and disability, and directions for interventions aimed at minimizing disability following whiplash injury are suggested.
Diagnosis and Analysis of a Recent Case of Human Rabies in Canada
Authors: Elmgren Lindsay D , Nadin-Davis Susan A , Muldoon Frances T , Wandeler Alexander I
Published: March 2016

BACKGROUND: On September 30, 2000, staff at the Canadian Food Inspection Agency's Centre of Expertise for Rabies, located at the Animal Diseases Research Institute in Ottawa, Ontario, diagnosed rabies in a child from Quebec. This was the first case of rabies in a human in Canada in 15 years and in 36 years in the province of Quebec. After spending a week in intensive care in a Montreal hospital, the nine-year-old boy succumbed to this nearly always fatal disease. The boy had been exposed to a bat in late August 2000, while vacationing with his family in the Quebec countryside.

METHODS: Antemortem specimens taken from the patient were sent to the Canadian Food Inspection Agency laboratory for rabies diagnosis. Samples included saliva, eye secretions, corneal impressions, cerebral spinal fluid and skin. Specimens were examined by direct immunofluorescence microscopy, and results were confirmed using molecular biological techniques. Virus strain identification was performed by both genetic methods and phenotypic analysis with monoclonal antibodies.

RESULTS: Initial results from direct immunofluorescence staining indicated that rabies virus was present in the skin biopsy specimen but not in the corneal impressions. This diagnosis of rabies was confirmed by polymerase chain reaction product analysis from several of the submitted specimens. Virus isolation from postmortem samples was not possible because fresh brain tissue was not available. Rabies virus was isolated from saliva and was determined to be similar to a variant that circulates in populations of silver-haired bats.

INTERPRETATION: Intravitam diagnosis of rabies in humans is very dependent on the samples submitted for diagnosis and the method used for testing. Upon first examination, only skin specimens were positive for rabies virus antigen; using polymerase chain reaction analysis, only saliva yielded positive results for rabies virus genome. Extensive testing and retesting of specimens submitted for rabies diagnosis in humans must be done to avoid false negative results.
Cannabis for Chronic Pain: Case Series and Implications for Clinicians
Authors: Ware Mark A , Gamsa Ann , Persson Jan , Fitzcharles Mary-Ann
Published: March 2016

BACKGROUND: Chronic pain is one of the most common reasons for therapeutic cannabis use.

OBJECTIVES: To describe therapeutic cannabis use among patients with chronic pain.

METHODS: Patients with chronic pain who voluntarily indicated that they used cannabis therapeutically completed a questionnaire about the type of cannabis used, the mode of administration, the amount used and the frequency of use, and their perception of the effectiveness of cannabis on a set of pain‐associated symptoms and side effects. The study was approved by the McGill University Health Centre Research Ethics Board.

RESULTS: Fifteen patients (10 male) were interviewed (median age 49.5 years, range 24 to 68 years). All patients smoked herbal cannabis for therapeutic reasons (median duration of use six years, range two weeks to 37 years). Seven patients only smoked at night‐time (median dose eight puffs, range two to eight puffs), and eight patients used cannabis mainly during the day (median dose three puffs, range two to eight puffs); the median frequency of use was four times per day (range one to 16 times per day). Twelve patients reported improvement in pain and mood, while 11 reported improvement in sleep. Eight patients reported a ′high′; six denied a ′high′. Tolerance to cannabis was not reported.

CONCLUSIONS: The results of this self‐selected case series must be interpreted with caution. Small doses of smoked cannabis may improve pain, mood and sleep in some patients with chronic pain. Clinical trials are warranted to test these effects. Further prospective studies should examine the patterns and prevalence of cannabis use among chronic pain populations.
Effects of Emotion on Pain Reports, Tolerance and Physiology
Authors: Carter Leslie E , McNeil Daniel W , Vowles Kevin E , Sorrell John T , Turk Cynthia L , Ries Barry J , Hopko Derek R
Published: March 2016

The effects of specific emotional states on a laboratory pain task were tested by examining the behavioural, verbal and psychophysiological responses of 80 student volunteers (50% female). Participants were assigned to one of four Velten‐style emotion‐induction conditions (ie, anxiety, depression, elation or neutral). The sexes of experimenters were counterbalanced. Overt escape behaviour (ie, pain tolerance), pain threshold and severity ratings, verbal reports of emotion and physiological measures (ie, electrocardiogram, corrugator and trapezium electromyogram) were recorded. A pressure pain task was given before and after the emotion induction. As predicted, those who participated in the anxiety or depression condition showed reduced pain tolerance after induction of these negative emotions; pain severity ratings became most pronounced in the depression condition. Emotion induction did not have a discernable effect on pain tolerance or severity ratings in the elation condition. A pattern of participant and experimenter sex effects, as well as trials effects, was seen in the physiological data. The influence of negative affective states (ie, anxiety and depression) on acute pain are discussed along with the unique contributions of behavioural, verbal and physiological response systems in understanding the interactions of pain and emotions.
Seroepidemiology of Coxiella burnetii Infection and its Frequency as a Cause of Community‐Acquired Pneumonia in Canada
Authors: Marrie Thomas J , Carolis Emidio de , Canadian Community Acquired Pneumonia Investigators
Published: March 2016

The present study tested acute and convalescent serum samples from 788 patients hospitalized for community‐acquired pneumonia in seven Canadian provinces for antibodies to Coxiella burnetii. One hundred nine patients (13.8%) had antibodies to this microorganism, and seven patients had acute Q fever. Serological evidence of infection with C burnetii was present in patients from all seven provinces. Three of the seven cases of acute Q fever were from Manitoba, suggesting that there may be unrecognized cases of Q fever in this province. In addition, a case of acute Q fever in Newfoundland, where there had previously been no reported cases, was noted, although subsequently, an outbreak of Q fever on goat farms has been reported.
The Addition of Salmeterol 50 µg Bid to Anticholinergenic Treatment in Patients with COPD: A Randomized Placebo Controlled Trial
Authors: Chapman Kenneth R , Arvidsson Peter , Chuchalin AG , Dhillon DP , Faurschou Peter , Goldstein Roger S , Kuipers AF
Published: March 2016

BACKGROUND: In the past, the role of long‐acting beta2‐agonists in chronic obstructive pulmonary disease (COPD) relative to other agents has been unclear.

OBJECTIVES: To compare the effect of adding salmeterol (50 µg bid) or placebo to concurrent anticholinergic therapy on symptom scores, quality of life, prebronchodilator lung function and exacerbations in patients with moderately severe COPD.

METHODS: This was a double‐blind, randomized, parallel‐group study in patients aged 40 years or older receiving anticholinergic medication. Patients were randomly assigned to treatment with placebo (n=207) or salmeterol (n=201) via a Diskus/Accuhaler inhaler for 24 weeks.

RESULTS: The morning trough (prestudy drug) forced expiratory volume in 1 s (FEV1) increased significantly above baseline levels among the salmeterol‐treated patients. Improvement in FEV1 was greater in the salmeterol group than in the placebo group at four weeks (difference 0.06 L, P <0.005), eight weeks (0.06 L, P <0.005) and 16 weeks (0.05 L, P <0.05) after the start of treatment. There was a nonsignificant trend in favour of salmeterol after 24 weeks of treatment (P=0.198). Improvements in morning peak flow were significantly greater in the salmeterol group over 24 weeks (P <0.01). Although symptom scores were numerically higher in the salmeterol group than in the placebo group and there was less requirement for rescue bronchodilator use, these differences were not statistically significant. In the salmeterol group, fewer patients had exacerbations of COPD, and there was a trend toward an improved quality of life. The safety profile of the two groups was similar.

CONCLUSIONS: Salmeterol has a beneficial effect when added to existing anticholinergic therapy in patients with COPD. The regular use of salmeterol for six months was not associated with worsening of the underlying airflow obstruction; rather, there was a tendency for the trough FEV1 to improve above the baseline levels over the treatment period.
Demographic, Clinical and Microbiological Characteristics of Maternity Patients: A Canadian Clinical Cohort Study
Authors: Wenman Wanda M , Tataryn Ivanna V , Joffres Michel R , Pearson Rachelle , Grace Michael GA , Albritton William L , Prasad Errol , The Edmonton Perinatal Infections Group
Published: March 2016

OBJECTIVE: To determine the demographic, clinical and microbiological characteristics of a representative Canadian obstetrical population.

DESIGN: A one‐year cohort study of all maternity patients who were followed to delivery, using detailed patient questionnaires containing more than 60 demographic and clinical variables, and three microbiological evaluations during gestation ‐ first trimester, 26 to 30 weeks, and labour and delivery. Outcome measurements included birth weight and gestational age.

SETTING: Labour and delivery suites of all office obstetrical practices affiliated with a single hospital.

POPULATION STUDIED: A consecutive sample of pregnant women in the study practices during one year were eligible for enrolment; 2237 consecutive patients were approached for consent, 2047 enrolled and 1811 completed the study through delivery.

RESULTS: The average patient was white, married and 29 years of age. Slightly more than half of the patients had postsecondary education, but 10% fell below the national poverty line for income. Frequency of factors linked to adverse pregnancy outcomes included cigarette smoking (19%), alcohol ingestion (18%), previously having had a premature infant (7%), and maternal diabetes (2%). Overall prevalence of genital microbes variously implicated in prematurity was 37% for ureaplasma, 11% for group B streptococcus and 4% for Mycoplasma hominis. Prevalence of bacterial vaginosis was 14%. The median gestational age for the cohort was 39 weeks, with 7% of infants born less than 37 weeks′ gestation. Mean birth weight was 3415 g.

CONCLUSIONS: The present clinical cohort represents demographic and medical characteristics of the Canadian obstetrical population. The birth outcomes are consistent with national data. This database provides valuable information about a general obstetrical population that is managed by a universal health care system.
Long Term Follow‐up of Ventilated Patients with Thoracic Restriction and Neuromuscular Disease
Authors: Brooks Dina , De Rosie James , Mousseau Margaret , Avendano Monica , Goldstein Roger S
Published: March 2016

OBJECTIVE: To evaluate the long term effects of home mechanical ventilation (HMV) on pulmonary function, nighttime gas exchange, daytime arterial blood gases, sleep architecture and functional exercise capacity (6 min walk). Patients with respiratory failure attributable to thoracic restrictive disease (TRD) (kyphoscoliosis) or neuromuscular disease (NMD) were assessed, ventilated, trained and followed in a dedicated unit for the care of patients requiring long term ventilation.

DESIGN: All patients admitted for home ventilation training since 1988 were reviewed. Measurements of lung function, gas exchange during wakefulness and sleep, as well as functional exercise capacity, were recorded before and immediately after the establishment of HMV. Measurements were repeated one to two years, five years and eight to 10 years later.

PATIENTS: Seventy‐four individuals with TRD or NMD who completed the home ventilation training program and continued with HMV during all or part of the day for at least one year were studied.

RESULTS: Forty patients had TRD. The characteristics of these patients were (mean ± SE) as follows: age 58±2.4 years; vital capacity (VC) 27%±1.6% predicted, forced expiratory volume in 1 s (FEV1) 25%±1.5% predicted; FEV1/forced VC (FVC) 78%±1.8%. Thirty‐four patients had NMD. The characteristics of these patients were as follows: age 44±3.1 years; VC 41%±4.9% predicted, FEV1 44±5.3% predicted; FEV1/FVC 83%±4.2%. There was a significant improvement in distance walked in 6 min (maximum change 51.2 m in patients with NMD and 93.0 m in patients with TRD), daytime partial pressure of arterial carbon dioxide (maximum change 12.9 mmHg in patients with NMD and 10.4 mmHg in patients with TRD) and nighttime partial pressure of arterial carbon dioxide (maximum change 11.7 mmHg in patients with NMD and 18.0 mmHg in patients with TRD) over time (P≤0.004). Ventilation resulted in an improvement in partial pressure of arterial oxygen in patients with TRD (68.1±2.8 mmHg to 80.1±3.5 mmHg) and in patients with NMD (52.9±1.7 mmHg to 65.3±2.1 mmHg), although the change was not statistically significant in patients with NMD (P=0.001 in patients with TRD; P=0.105 in patients with NMD). The improvement after ventilation was maintained over several years. Sleep efficiency (75%±18%, 79%±2.2%), the arousal index (13.4±13 events/h, 28.2±17 events/h) and the apnea‐hypopnea index (10.1±11.3 events/h, 13.9±9.5 events/h) did not change with time in either patients with TRD or patients with NMD, respectively (P≥0.5).

CONCLUSIONS: HMV was associated with sustained, long term improvements in nighttime and daytime gas exchange in patients with TRD and NMD. Function exercise capacity increased in patients with TRD and in a subgroup of ambulatory patients with NMD. In patients with TRD, these improvements were maintained for up to 10 years after HMV was established.
Combined Topical and Oral Antimicrobial Therapy for the Eradication of Methicillin‐Resistant Staphylococcus aureus (Mrsa) Colonization in Hospitalized Patients
Authors: Fung Scott K , Louie Marie , Simor Andrew E
Published: March 2016

OBJECTIVE: How to eradicate methicillin‐resistant Staphylo-coccus aureus (MRSA) colonization in hospitalized patients is uncertain. We reviewed our experience with MRSA decolonization therapy in hospitalized patients.

SETTING: An 1100‐bed, university‐affiliated tertiary care teaching hospital in Toronto, Ontario.

DESIGN: Retrospective chart review of 207 adult inpatients with MRSA colonization hospitalized between February 1996 and March 1999.

INTERVENTIONS: All patients with MRSA colonization were assessed for possible decolonization therapy with a combination of 4% chlorhexidine soap for bathing and washing, 2% mupirocin ointment applied to the anterior nares three times/day, rifampin (300 mg twice daily) and either trimethoprim/sulfamethoxazole (160 mg/800 mg twice daily) or doxycycline (100 mg twice daily). This treatment was given for seven days.

RESULTS: A total of 207 hospitalized patients with MRSA colonization were identified and 103 (50%) received decolonization therapy. Patients who received decolonization therapy were less likely than untreated patientsto have intravenous (P=0.004) or urinary catheters (P<0.001), or extranasal sites of colonization (P=0.001). Successful decolonization was achieved in 90% of the 43 patients who were available for at least three months of follow‐up.

CONCLUSIONS: Combined topical and oral antimicrobial therapy was found to be effective in eradicating MRSA colonization in selected hospitalized patients, especially those without indwelling medical devices or extranasal sites of colonization.
The “Farm to Plate” approach – Everyone’s Business
Authors: Allard Denis G
Published: March 2016

Food safety is growing in importance as a public health concern for health practitioners and the general public. The Canadian public is exposed more extensively than ever before to exotic foods and pathogens via international travel, changing lifestyles and domestic contact with fresh foodstuff that is imported from faraway lands. Global warming, changing microbial ecology and resistance, and reduced host immunity are also having their effect in increasing the risk. To manage the risk adequately, interventions must be implemented at every point of the food supply chain, from production and processing to distribution, preparation and consumption, at home and in retail food service establishments. The role of government is explained, and the roles of other stakeholders, including physicians, are reviewed briefly.
Endoscopic Management of Obstruction due to an Acquired Bronchial Web
Authors: Kovitz Kevin L , Foroozesh Mahtab B , Goyos Jose M , Rubio Edmundo R
Published: March 2016

Bronchial webs are thin, membrane‐like diaphragms that may obstruct the airway. Several congenital cases have been reported. Though rare, the true incidence of these lesions is probably underestimated because many of them are unrecognized. The case of a 71‐year‐old woman with an acquired bronchial web causing right main stem bronchus obstruction that went unrecognized for 47 years post‐trauma is reported. The lesion was successfully treated using rigid bronchoscopy with laser therapy, balloon dilation and stent placement. This is the first reported case of an acquired bronchial web formation. It is also the first reported case that was successfully treated with this technique.
Thymic Carcinoid Tumour
Authors: Parra Isabel , Remacha Antonia , Costilla Serafín , Calderon José Antonio Santos
Published: March 2016

Carcinoid tumours of the thymus are rare. The case of a 57‐year‐old asymptomatic man with a carcinoid tumour of the thymus, who showed a widened mediastinum by chest x‐ray, is presented. Fine needle aspiration suggested the diagnosis, which was confirmed by biopsy.
CTS Membership
Authors: Canadian Thoracic Society
Published: March 2016

CTS Announcements
Economic Analysis of Rotavirus‐Associated Diarrhea in the Metropolitan Toronto and Peel Regions of Ontario
Authors: Jacobs P , Shane LG , Fassbender K , Wang EL , Moineddin R , Ford-Jones EL
Published: March 2016

OBJECTIVE: To measure the economic cost of rotavirus‐ associated diarrhea for a selected group of families, in a nonexperimental setting, and to estimate the factors that influence these costs.

DESIGN: Use and other socioeconomic data from a family survey (the Pediatric Rotavirus Epidemiology Study for Immunization) of children who tested positive for rotavirus were collected for the metropolitan Toronto and Peel regions of Ontario during the rotavirus season of 1997‐1998. Service costs were estimated from provider data. A statistical regression analysis was used to explain the variances of provincial health care costs, prescription drug costs and indirect (work‐loss) costs.

SETTING: Data were collected in hospitals, emergency rooms, paediatric practices, primary care clinics and licensed daycare centres. Hospital coverage was wide, but community coverage was not.

PATIENTS AND OTHER PARTICIPANTS: Children with diarrhea were tested for rotavirus. Those who tested positive and whose parents consented for their children to participate were included in the study.

INTERVENTIONS: None

MAIN OUTCOME MEASURES: The main outcomes were provincial health care costs, drug costs, nonmedical costs and thenumber of days of work missed by parents per child, as well as factors that determine these costs.

RESULTS: Children in the most severe category incurred costs of $2,663/person, and those in the least severe categories incurred costs of approximately $350/person. The most important determinant to explain provincial health care costs was the number of health problems that the child had before having rotavirus. Costs due to work loss of parents were considerable for children in all severity groups and were influenced by family working conditions.

CONCLUSIONS: When considering the economic implications of rotavirus, prior health status should be considered and indirect costs should be recognized for their importance.
An Overview of the International Congress on Whiplash Associated Disorders
Authors: Bogduk Nikolai
Published: March 2016

Conferences such as the International Congress on Whiplash Associated Disorders, held in Berne on March 8‐10, 2001, serve several purposes. Socially, they provide an opportunity for delegates to see, hear and meet leading experts in the field, and those experts get to meet one another. Academically, such conferences offer delegates a synopsis of current information, provided by plenary lectures, and the opportunity to hear or contribute new information, in the form of free papers. A measure of the success of such a conference is the extent to which new information presented advances knowledge and understanding in the field. This essay provides an overview of the congress at hand. It compares what was known before the congress with what more was known as a result of the congress.
Attitudes Toward Opioid Use for Chronic Pain: A Canadian Physician Survey
Authors: Morley-Forster Patricia K , Clark Alexander J , Speechley Mark , Moulin Dwight E
Published: March 2016

OBJECTIVES: To measure chronic pain patient volumes seen in primary care practice; to determine what medications physicians choose for the treatment of moderate to severe chronic pain; to identify barriers to the use of opioids in the treatment of chronic pain; and to assess physicians′ attitudes toward the current management of chronic pain in Canada.

DESIGN: A computer‐assisted telephone survey of 100 regionally representative Canadian physicians with a defined interest in palliative care (PC, n=30) or noncancer pain (GP, n=70).

SETTING: A survey was conducted by Ipsos‐Reid in June 2001. 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 time to palliative care were eligible to participate.

RESULTS: In one month, the average number of patients with moderate to severe chronic pain seen by PCs was 94.2; the average seen by GPs was 44.7. The pain experienced by 83.3% of GP patients was noncancer related. For chronic cancer pain, an opioid analgesic was the treatment of choice of 79% of physicians (48% preferred morphine, 21% codeine, 10% other). For moderate to severe chronic noncancer pain, opioids were the first‐line treatment of only 32% of physicians (16% preferred codeine, 16% major opioids) because a significant number preferred either nonsteriodal anti‐inflammatory drugs (29%) or acetaminophen (16%). Thirty‐five per cent of GPs and 23% of PCs would never use opioids for noncancer pain, even when described as severe. Chronic pain was deemed by 68% of physicians to be inadequately managed. Almost 60% thought that pain management could be enhanced by improved physician education. Identified barriers to opioid use included addiction potential (37%) and side effects (25%). Seventeen per cent of GPs and 10% of PCs thought that regulatory sanctions limited opioid prescribing.

CONCLUSIONS: Even among physicians experienced in chronic pain treatment, there is a reluctance to use opioids for severe nonmalignant pain. One‐half of the survey participants believed that there was a need for improved physician education in pain management, including the use of opioids.
T Cell Costimulatory Molecules in Anti‐Viral Immunity: Potential Role in Immunotherapeutic Vaccines
Authors: Watts Tania H , Bertram Edward M , Bukczynski Jacob , Wen Tao
Published: March 2016

T lymphocyte activation is required to eliminate or control intracellular viruses. The activation of T cells requires both an antigen specific signal, involving the recognition of a peptide/major histocompatibility protein complex by the T cell receptor, as well as additional costimulatory signals. In chronic viral diseases, T cell responses, although present, are unable to eliminate the infection. By providing antigens and costimulatory molecules together, investigators may be able to increase and broaden the immune response, resulting in better immunological control or even elimination of the infection. Recent progress in understanding the function of costimulatory molecules suggests that different costimulatory molecules are involved in initial immune responses than are involved in recall responses. These new developments have important implications for therapeutic vaccine design. In this review the authors discuss the function of T cell costimulatory molecules in immune system activation and their potential for enhancing the efficacy of therapeutic vaccines.
International Congress on Whiplash Associated Disorders ‐ The Bern Symposium
Authors: Merskey Harold
Published: March 2016

We take pleasure in this issue in presenting a series of plenary session lectures and some additional contributions from the Bern Symposium, a meeting held in Berne, Switzerland from March 8 to 10, 2001. The symposium was organized by Dr Bogdan Radanov and colleagues from that city where they had themselves undertaken an enormous amount of classical work in the investigation of cervical sprain syndrome. Radanov′s work resolved a number of definitive issues in the investigation of whiplash, despite those who say otherwise for medicolegal reasons. He and his colleagues showed clearly that pain after cervical sprain injury was primarily correlated with the intensity of the initial pain, with the occurrence of premorbid injury and with age. Personality status before injury had no bearing on the outcome, and the intensity of pain at the beginning of injury was also correlated with depression or cognitive change later (1).
Another Face of Bronchiolitis Obliterans Organizing Pneumonia
Authors: Turner Mark O
Published: March 2016

A 47-year-old man presented with an eight-day history of nonproductive cough and constitutional symptoms progressing to respiratory failure. High resolution computed tomography revealed a diffuse micronodular pattern and a ‘tree-in-bud’ pattern in the lower lung zones. Transbronchial biopsy showed features consistent with bronchiolitis obliterans organizing pneumonia (BOOP). After an initially difficult clinical course, the patient responded well to long term treatment with corticosteroids, including improvement of air flow obstruction. This case illustrates a variant of BOOP characterized by a comparatively acute onset, a component of proliferative bronchiolitis, an obstructive rather than restrictive pattern of pulmonary function testing and good clinical response to corticosteroid therapy.
Risk Factors of Poor Prognosis after Whiplash Injury
Authors: Suissa Samy
Published: March 2016

Whiplash, a common injury following motor vehicle crashes, is associated with high costs and a prognosis that is variable and difficult to predict. In this paper, we review findings from the Quebec cohort epidemiological study on predictive factors of recovery from whiplash injury after a motor vehicle crash. We formed a population‐based incident cohort of all 4,759 individuals who sustained a whiplash injury resulting from a motor vehicle crash in the province of Québec, Canada, in 1987, and followed these patients for up to seven years. The data were obtained from the universal automobile insurance plan (SAAQ) that covers all seven million residents of the Province for all vehicular‐related injuries. From this cohort, we formed the cohort of 3,014 for whom a police report was completed. For this cohort, we obtained data on crash‐related factors directly from the police report. We also formed the cohort of 2,627 subjects who had strictly a whiplash injury, without associated injuries. For this cohort, the data on signs and symptoms were obtained from the medical charts kept by the SAAQ. For both cohorts, data on the outcome, the recovery time from whiplash, was obtained from the SAAQ databases. The crash‐related cohort study found that socio‐demographic factors associated with a longer recovery from whiplash include older age, female sex, having dependents and not being employed full time and that each decreases the rate of recovery by 14 to 16 per cent. Factors related to the crash conditions indicate that being in a truck or bus, with a decrease of 52% in the rate of recovery, being a passenger in the vehicle (15%), colliding with a moving vehicle (16%), and a side or frontal collision (15%) all decrease the rate of recovery. We introduce a combined risk score that predicts longer recovery. In the cohort of subjects with signs and symptoms, the median recovery time was 32 days and 12% of subjects had still not recovered after 6 months. The signs and symptoms that were found to be independently associated with a slower recovery from whiplash, besides female gender and older age, were neck pain on palpation; muscle pain; pain or numbness radiating from neck to arms, hands or shoulders; and headache. Together, the presence of all these factors in females aged 60 predicted a median recovery time of 262 days, compared with 17 days for younger males aged 20 who do not have any of these factors. In contrast, using the Quebec classification of signs and symptoms, the median recovery time varied from 17 to 123 days. We conclude that several socio‐demographic and crash‐related factors, as well as several signs and symptoms, including a combination of specific musculoskeletal and neurological ones that whiplash patients present with, are predictive of a longer recovery period. These patients should be targeted for an early intervention programme aimed at managing whiplash patients with a poor prognosis.
Methadone in the Treatment of Neuropathic Pain
Authors: Gagnon Bruno , Almahrezi Abdulaziz , Schreier Gil
Published: March 2016

BACKGROUND: Methadone, being an N‐Methyl‐D‐Aspartate receptor antagonist, may have a potential role in the treatment of neuropathic pain.

OBJECTIVES: To evaluate the effect of methadone in the treatment of neuropathic pain and to estimate the possible dose ranges needed for pain control.

METHODS: Methadone was offered as a treatment option to consecutive cancer and noncancer patients with neuropathic pain. Pain intensity was measured by the visual analogue scale (VAS) (0‐10 cm where 0 = no pain and 10 = worst possible pain). Mechanical allodynia and paroxysmal (shooting) pain were assessed clinically. All assessments were collected prospectively before treatment and once a stable dose of methadone was reached.

RESULTS: A total number of 18 patients met our inclusion criteria. The mean pretreatment VAS ± SD was 7.7±1.5 cm and this dropped significantly to 1.4±1.7 cm on a stable dose of methadone (P<0.0001). Nine of 13 patients (70 %) had a complete resolution of mechanical allodynia and all eight patients (100%) with shooting pain reported a complete response. The median stable dose of methadone was 15 mg per day.

CONCLUSION: Methadone at relatively low doses seems to be useful in the treatment of neuropathic pain.
Hospitalization for Community-Acquired Pneumonia in Alberta Patients with Human Immunodeficiency Virus Infection: A Case Control Study
Authors: Johnson David H , Carriere Keumhee C , Houston Stan , Jin Yan , Predy Gerry , Gill John , Shafran Stephen , Marrie Thomas J
Published: March 2016

BACKGROUND: To determine whether outcomes of pneumonia among human immunodeficiency virus (HIV)-positive persons differed from those among HIV-negative persons.

METHODS: Alberta hospital patient abstracts for HIV-positive persons requiring hospitalization for pneumonia from April 1, 1994, until March 31, 1999, were matched by age and sex with four HIV-negative counterparts.

RESULTS: Hospitalizations for community-acquired pneumonia decreased for those with HIV (acquired immunodeficiency syndrome [AIDS]) and increased for those with HIV (non-AIDS) during the study period. HIV (AIDS) patients admitted for community-acquired pneumonia (n=130) manifested three times higher odds for a longer length of hospital stay and had three and 10 times higher odds for excess in-hospital and one-year mortality, respectively, than their matched controls. Similarly, HIV (non-AIDS) patients admitted for community-acquired pneumonia (n=46) manifested two times higher odds for a longer length of hospital stay and had four times higher odds for excess one-year mortality than their matched controls. The in-hospital and one-year mortality rates for the HIV (AIDS) patients were 21.2% and 64.3%, respectively, during the first three years, and decreased to 8.7% and 40.7%, respectively, in the last two years of the study.

CONCLUSIONS: The outcomes for community-acquired pneumonia were worse for those with HIV (non-AIDS) and HIV (AIDS) compared with non-HIV hospitalized patients matched for age and sex, and controlling for severity of illness and comorbidity. In-hospital and one-year mortality rates for patients with HIV (AIDS) showed a marked decline over the study period.
Comparing Two Observational Systems in the Assessment of Knee Pain
Authors: Fuchs-Lacelle Shannon , Hadjistavropoulos Thomas , Sharpe Donald , Williams Jaime , Martin Ronald , LaChapelle Diane
Published: March 2016

OBJECTIVE: Research has demonstrated the utility of the Pain Behavior Measurement (PBM) system as a pain index. PBM involves the recording of sighing, rubbing, grimacing, guarding and bracing. A modification of this system has been proposed, focusing on the occurrence of joint flexing, rubbing, unloading the joint, guarding and rigidity, specifically for patients with knee pain. The aim of the present study was to compare the original PBM to the modified version in a sample of knee replacement patients to assess the utility of the more specialized approach. It was expected that the more discomforting physiotherapy activities (knee bending and quadriceps exercises) would result in more pain behaviours than intermediate activities (walking and standing), which, in turn, would result in more pain behaviours than reclining. The extent to which each system reflected this expected pattern was examined.

METHODS: Ninety‐three seniors were observed while completing a series of structured post‐knee surgery physiotherapy activities (knee bending, standing, walking, reclining and a quadriceps exercise).

RESULTS: Analyses of self‐reported levels of pain were consistent with the expected pattern of pain levels in relation to the physiotherapy activities. Specific pain behaviours within each system (eg, grimacing, rigidity) occurred in a manner consistent with the expected pattern, while other behaviours (eg, rubbing the affected area) did not.

CONCLUSIONS: Although there was no clear advantage for the modified system over the PBM, an optimal approach may involve combining specific behaviours from each system.
The Impact of Sampling and Measurement on the Prevalence of Self‐Reported Pain in Canada
Authors: Van Den Kerkhof Elizabeth G , Hopman Wilma M , Towheed Tanveer E , Anastassiades Tassos P , Goldstein David H
Published: March 2016

BACKGROUND: Pain is an important public health problem in Canada. International estimates of general population pain prevalence range from 2% to 46%.

OBJECTIVES: The purpose of this paper is to critically examine the potentially misleading use of overall prevalence estimates in the pain literature and to use two Canadian population‐based surveys to assess the impact of sampling and measurement on prevalence.

METHODS: Two of the secondary data sets used were the 1996/97 National Population and Health Survey (NPHS) and the Canadian Multicentre Osteoporosis Study (CaMos). This paper is based on the assessment of chronic pain in the NPHS, and the assessment of short term pain using the Medical Outcomes Trust′s 36‐item health survey and the Health Utilities Index, both collected by CaMos. Data are presented as frequencies and percentages overall and stratified by age and sex. CaMos prevalence estimates were age and sex‐standardized to the NPHS population.

RESULTS: The overall prevalence of pain was 39% for one‐week pain, 66% for four‐week pain and 15% for chronic pain. Women were more likely to report pain than men and the prevalence of pain increased with age.

CONCLUSIONS: This study yields useful information about the self‐reported responses to a variety of questions assessing pain in the general population. Responses to the different questions likely represent different categories of pain, such as short term versus chronic pain, which in turn may have different epidemiological risk factors and profiles. Longitudinal studies of the epidemiology, predictors and natural history of chronic pain are urgently needed in the Canadian population.
Chest Wall Hydatidosis as the Unique Location of the Disease: Case Report and Review of the Literature
Authors: Foroulis Christophoros N , Avgoustou Constantinos , Konstantinou Marios , Lioulias Achilleas G
Published: March 2016

The chest wall is a rare location of secondary hydatidosis, but secondary hydatidosis may occur from the rupture of a lung cyst, from a liver cyst invading the diaphragm into the pleural cavity, following previous thoracic surgery for hydatidosis, or by hematogenous spread. This report describes a case of chest wall hydatidosis, which was the primary disease site in the patient, who had no previous history or current disease (hydatidosis) at other sites. The cyst invaded and partially destroyed the 9th and 10th ribs and the 10th thoracic vertebra, and protruded outside the pleural cavity through the 9th intercostal space. Preoperative albendazole administration for 10 days, surgical resection of the disease through a posterolateral thoracotomy incision, and postoperative albendazole treatment resulted in a cure with no evidence of local recurrence or disease at other sites in four years of follow‐up.