bluuebunny/crossref_metadata_2025 huggingface dataset:
Does Exposure to Analgesics in Utero Cause Schizophrenia?
Authors: O’Reilly Richard L
Published: March 2016

The cause of schizophrenia, a serious mental illness characterized by hallucinations, delusions and a marked deterioration in social functioning, is an enigma that continues to perplex the scientific community. While we know that approximately 80% of the risk of developing schizophrenia is conferred by genes (1), no research group has yet located a gene(s) contributing to the cause of schizophrenia. Moreover, while a significant environmental contribution is indicated by the fact that one‐half of monozygotic twins pairs are discordant for schizophrenia, the nature of this environmental contribution is still controversial. The past theory that an abnormal family upbringing was the causative environmental factor has not stood up to scientific scrutiny. In recent years, the search for causative environmental factors has focused on the possibility that some type of prenatal insult predisposes the fetus to develop schizophrenia in early adult life. The initial suspicion of an intrauterine insult was based on indirect evidence. First, dermatoglyphic patterns in patients with schizophrenia were noted to be abnormal. The dermal ridges are laid down between the third and fifth month of gestation, in effect leaving a fossilized record of neurodevelopmental perturbation. Second, minor physical anomalies, typically involving the mouth, ears and eyes, occur with increased frequency in schizophrenia. Much like dermatoglyphic abnormalities, minor physical anomalies represent a disruption of the final phase of the developmental shaping of the face, which takes place in the second trimester. Of course, both abnormal dermatoglyphic patterns and minor physical anomalies may reflect the effects of abnormal genetic regulation of development rather than an extrinsic insult.
Cerebral Mycobacterium avium abscesses: Late immune reconstitution syndrome in an HIV‐1‐infected patient receiving highly active antiretroviral therapy
Authors: Fortin Claude , Rouleau Danielle
Published: March 2016

A patient who developed an atypical manifestation of Mycobacterium avium complex (MAC) infection almost two years after starting effective highly active antiretroviral therapy is described. The recurrence, manifested as brain abscesses in the central nervous system, was an uncommon form of MAC disease usually reported postmortem. An increased CD4 cell count, localized and suppurative infection, and the absence of systemic evidence of infection were consistent with a late immune reconstitution syndrome. The present case report adds to the understanding of MAC disease in HIV‐infected patients.
Increased Expression of the Calcium‐Activated Chloride Channel in Hclca1 in Airways of Patients with Obstructive Chronic Bronchitis
Authors: Hauber Hans-Peter , Bergeron Celine , Tsicopoulos Anne , Wallaert Benoit , Olivenstein Ron , Holroyd Kenneth J , Levitt Roy C , Hamid Qutayba
Published: March 2016

BACKGROUND: Interleukin (IL)‐9 and its effect on enhancing the human calcium‐activated chloride channel 1 (hCLCA1) expression have been shown to induce mucin production. Increased expression of hCLCA1 may, in turn, contribute to mucus overproduction in chronic obstructive pulmonary disease (COPD) with a chronic bronchitis (CB) phenotype.

OBJECTIVE: To determine the expression of IL‐9, IL‐9 receptor (IL‐9R), hCLCA1 and mucoglycoconjugates in COPD.

METHODS: Bronchial biopsies were obtained from six patients with obstructive CB and six healthy control subjects. IL‐9, IL‐9R and hCLCA1 expression were detected using immunohistochemistry. Additionally, in situ hybridization was performed to determine the expression of hCLCA1 messenger RNA. Mucin production was assessed using periodic acid‐Schiff staining.

RESULTS: There was a significantly higher number of IL‐9 immunoreactive cells in the submucosa of patients with COPD than that of healthy control subjects (P<0.05). Also, a significant increase in the expression of IL‐9R, hCLCA1 (protein and messenger RNA) and mucin (periodic acid‐Schiff‐positive cells) was noted in the bronchial epithelium of patients with COPD compared the control subjects (P<0.05).

CONCLUSIONS: Increased expression of IL‐9, IL‐9R and hCLCA1 in the bronchial mucosa of patients with obstructive CB suggests that mucus overproduction in this disease may be, at least in part, due to hCLCA1.
A Review of the Literature Refuting the Concept of Minor Impact Soft Tissue Injury
Authors: Centeno Christopher J , Freeman Michael , Elkins Whitney L
Published: March 2016

BACKGROUND: Minor impact soft tissue (MIST) is an insurance industry concept that seeks to identify late whiplash as a psychosocial phenomenon. However, the medical literature in this area has not been systematically reviewed since the Quebec Task Force′s review in 1995.

OBJECTIVE: To review the medical literature which claims that late whiplash is an organic phenomenon causing significant disability.

METHODS: The medical literature was reviewed in a narrative format.

RESULTS: There are a significant number of studies which refute the MIST concept.

CONCLUSIONS: A review of the literature did not support the validity of MIST.
Effects of Flotation‐Restricted Environmental Stimulation Technique on Stress‐Related Muscle Pain: What Makes the Difference in Therapy ‐ Attention‐Placebo or the Relaxation Response?
Authors: Bood Sven A , Sundequist Ulf , Kjellgren Anette , Nordstrom Gun , Norlander Torsten
Published: March 2016

INTRODUCTION: The purpose of the present study was to examine the potential effects of attention‐placebo on flotation tank therapy. Flotation‐restricted environmental stimulation technique is a method whereby an individual lies in a floating tank and all stimuli are reduced to a minimum.

METHODS: Thirty‐two patients were diagnosed as having stress‐related muscular pain. In addition, 16 of the participants had received the diagnosis of burnout depression. The patients were treated with flotation‐restricted environmental stimulation technique for six weeks. One‐half of the patients were also given special attention for 12 weeks (high attention), while the remainder received attention for only six weeks (normal attention).

RESULTS: The participants exhibited lowered blood pressure, reduced pain, anxiety, depression, stress and negative affectivity, as well as increased optimism, energy and positive affectivity. The results were largely unaffected by the degree of attention‐placebo or diagnosis.

CONCLUSION: It was concluded that flotation therapy is an effective, noninvasive method for treating stress‐related pain, and that the method is not more affected by placebo than by other methods currently used in pain treatment. The treatment of both burnout depression and pain related to muscle tension constitutes a major challenge for the patient as well as the care provider, an area in which great gains can be made if the treatment is effective. Flotation therapy may constitute an integral part of such treatment.
The Validity of Diagnosing Chronic Obstructive Pulmonary Disease from a Large Administrative Database
Authors: Lacasse Yves , Montori Victor M , Lanthier Claude , Maltis François
Published: March 2016

BACKGROUND: Health authorities create and maintain administrative databases. Despite the potential advantages of these databases, the validity of the information they include must be considered.

OBJECTIVE: To examine the validity of diagnosing chronic obstructive pulmonary disease (COPD) from a large administrative database.

METHODS: Physician services and prescription claims data related to COPD and asthma were extracted from the Quebec universal medical insurance register (Régie de l′assurance‐maladie du Québec; RAMQ) from the period of April 1, 1994 to March 31, 1999. Before obtaining the data, criteria for the validity of the COPD diagnosis in the database were formulated based on the epidemiology of COPD in the province. The extent to which the database satisfied these criteria are described within the present paper.

RESULTS: For patients aged 65 years or older, COPD was two times more prevalent in the RAMQ database than in the 1994/1995 National Population Health Survey. One in three patients with a RAMQ‐diagnosis of COPD also had a RAMQ‐diagnosis of asthma, and 47% of patients aged 65 years or older with a RAMQ‐diagnosis of COPD did not fill any prescription for beta‐2‐agonists. In addition, 42% of patients with a RAMQ‐diagnosis of COPD who never had a RAMQ‐diagnosis of asthma appeared only once with that diagnosis in the database. Of all patients aged 65 years or older with a RAMQ‐diagnosis of COPD, 37% and 23% met the operational definitions of ′possible COPD′ and ′probable COPD′, respectively.

CONCLUSIONS: Most RAMQ‐diagnoses of COPD lack validity; therefore, the validity of database diagnoses should be routinely ascertained before using administrative databases in clinical and health services research.
Jumping to Conclusions: Things are Never What They Seem
Authors: Broder Sarah
Published: March 2016

A 46‐year‐old Aboriginal man presented with a massive pleural effusion. A diagnosis of sarcoidosis was established. To the author′s knowledge, this is the first reported case of sarcoidosis in a North American Aboriginal patient.
The Editorial Board is Changing
Authors: Nicolle LE
Published: March 2016

The success of The Canadian Journal of Infectious Diseases & Medical Microbiology over the past 16 years is largely attributable to the continuing and substantial support from a dedicated and enthusiastic Editorial Board. The individuals who have participated are listed on the masthead in each issue of the Journal. Many of the current Editorial Board members have participated continually since the initiation of the Journal ‐ a commitment of over 16 years. They have provided oversight as the Journal has evolved, and their critical insights in the discussion of issues as they have developed, as well as their suggestions for new directions, have significantly contributed to the maintenance of Journal quality. Our associate editors have been particularly active. They have coordinated and, frequently, developed much of the content for the special sections ‐ adult and paediatric infectious disease notes, clinical vignettes and reviews. They have also facilitated the peer review of submitted manuscripts by identifying reviewers and making recommendations for revisions and publication. These contributions have been essential to the continuing operation and high, scientific quality of the Journal.
Laser Therapy for an Obstructing Primary Tracheal Lymphoma in a Patient With AIDS
Authors: Louie Brian E , Harlock John , Hoesin Alana , Miller John D
Published: March 2016

A patient with AIDS presented with progressive dyspnea leading to respiratory failure with near complete airway obstruction due to primary tracheal lymphoma. Laser therapy was used locally to debulk the tumour, which facilitated extubation and led to definitive treatment with chemotherapy. Alternatives for local airway control are discussed.
The Lack of Association Between Bacille Calmette‐Guerin Vaccination and Clustering of Aboriginals with Tuberculosis in Western Canada
Authors: Cook Victoria J , Hernández-Garduño Eduardo , Kunimoto Dennis , Hershfield Earl S , Fanning E Anne , Hoeppner Vernon H , Elwood R Kevin , FitzGerald J Mark , Canadian Molecular Epidemiology of Tuberculosis Study Group
Published: March 2016

BACKGROUND: Tuberculosis (TB) remains a major health problem for Aboriginal people in Canada, with high rates of clustering of active TB cases. Bacille Calmette‐Guérin (BCG) vaccination has been used as a preventive measure against TB in this high‐risk population.

OBJECTIVE: The study was designed to determine if BCG vaccination in Aboriginal people influenced recent TB transmission through an analysis of the clustering of TB cases.

METHODS: A retrospective analysis of all culture‐positive Mycobacterium tuberculosis cases in Aboriginal people in western Canada (1995 to 1997) was performed. Isolates were analyzed using standard methodology for restriction fragment length polymorphism and spoligotyping.

RESULTS: Of 256 culture‐positive Aboriginal TB cases, BCG status was confirmed in 216 (84%) cases; 34% had been vaccinated with BCG, 57% were male and 56% were living on‐reserve. Patients who had been vaccinated with BCG were younger than unvaccinated individuals (mean age 32.4±1.65 years versus 45.0±1.8 years, P<0.0001). Clustering was found in 62% of cases: 59% of non‐BCG vaccinated cases were clustered versus 68% of those vaccinated with BCG (P=0.16). Younger patients (younger than 60 years of age) were more likely to be clustered in the univariate analysis (P<0.01). When age, sex, province, and HIV and reserve status were controlled for, BCG vaccination was not associated with clustering (OR 1.3, 95% CI 0.7 to 2.6).

CONCLUSIONS: BCG vaccinated Aboriginal people were no less likely to have active TB from recently transmitted disease. BCG vaccination appears to have limited value in preventing clustering of TB cases within this high‐risk community.
An Outbreak of Human Coronavirus OC43 Infection and Serological Cross‐Reactivity with SARS Coronavirus
Authors: Patrick David M , Petric Martin , Skowronski Danuta M , Guasparini Roland , Booth Timothy F , Krajden Mel , McGeer Patrick , Bastien Nathalie , Gustafson Larry , Dubord Janet , MacDonald Diane , David Samara T , Srour Leila F , Parker Robert , Andonov Anton , Isaac-Renton Judith , Loewen Nadine , McNabb Gail , McNabb Alan , Goh Swee-Han , Henwick Scott , Astell Caroline , Guo Jian Ping , Drebot Michael , Tellier Raymond , Plummer Francis , Brunham Robert C
Published: March 2016

BACKGROUND: In summer 2003, a respiratory outbreak was investigated in British Columbia, during which nucleic acid tests and serology unexpectedly indicated reactivity for severe acute respiratory syndrome coronavirus (SARS‐CoV).

METHODS: Cases at a care facility were epidemiologically characterized and sequentially investigated for conventional agents of respiratory infection, SARS‐CoV and other human CoVs. Serological cross‐reactivity between SARS‐CoV and human CoV‐OC43 (HCoV‐OC43) was investigated by peptide spot assay.

RESULTS: Ninety‐five of 142 residents (67%) and 53 of 160 staff members (33%) experienced symptoms of respiratory infection. Symptomatic residents experienced cough (66%), fever (21%) and pneumonia (12%). Eight residents died, six with pneumonia. No staff members developed pneumonia. Findings on reverse transcriptase‐polymerase chain reaction assays for SARS‐CoV at a national reference laboratory were suspected to represent false positives, but this was confounded by concurrent identification of antibody to N protein on serology. Subsequent testing by reverse transcriptase‐polymerase chain reaction confirmed HCoV‐OC43 infection. Convalescent serology ruled out SARS. Notably, sera demonstrated cross‐reactivity against nucleocapsid peptide sequences common to HCoV‐OC43 and SARS‐CoV.

CONCLUSIONS: These findings underscore the virulence of human CoV‐OC43 in elderly populations and confirm that cross‐reactivity to antibody against nucleocapsid proteins from these viruses must be considered when interpreting serological tests for SARS‐CoV.
Acanthamoeba Species Keratitis in a Soft Contact Lens Wearer Molecularly Linked to Well Water
Authors: Mubareka Samira , Alfa Michelle , Harding Godfrey K , Booton Gregory , Ekins Marilyn , Caeseele Paul Van
Published: March 2016

Acanthamoeba species keratitis has been associated with soft contact lens wear. In the present report, an epidemiological link was established between the patient′s isolate and well water from the home using molecular methods. To the authors′ knowledge, this is the first case in Canada where such a link has been established. Primary care practitioners and specialists, including ophthalmologists and infectious diseases specialists, must maintain a high degree of clinical suspicion in soft contact lens wearers with keratitis unresponsive to conventional topical and systemic treatment.
Analytical and Biological Variables Influencing Quantitative Hepatitis C Virus (HCV) Measurement in HIV-HCV Coinfection
Authors: Cooper Curtis , MacPherson Paul , Cameron William
Published: March 2016

The present review considers issues pertaining to the precision and variability of quantitative hepatitis C virus (HCV) measurement in general, outlines the characteristics of HCV RNA in HIV-HCV coinfection and evaluates those factors which may affect this measure. The clinical relevance of accurate HCV measurement in HIV-HCV coinfection is discussed.
A Magician′s Tale
Authors: Semret Makeda , Law Angeline , Turner Stephen , de Varennes Benoit , Ward Brian J , Huynh Thao
Published: March 2016

Case presentation A 19‐year‐old male university student and part‐time magician presented with a two‐week history of fever with rigors, nausea, vomiting, headaches and migrating polyarthralgia. The patient′s medical history was significant for a childhood murmur that was presumed benign. The patient denied use of illicit drugs and was not on any medication at the time of presentation. The patient owned several pets, including a dog, a monitor lizard and rabbits used for his magic tricks.
Pandemic Influenza and Canada′s Children
Authors: Langley Joanne M
Published: March 2016

Paediatricians and others who care for children are familiar with the regular epidemic of respiratory illnesses that accompanies the annual visit of influenza virus each winter. In recent years, media interest in new strains of influenza has generated much public interest in, and often anxiety about, the threat of an influenza pandemic. Around the world, local, regional and national jurisdictions are engaged in contingency planning for the inevitable surge of illness, shortage of human and material resources, and societal disruption that is expected to accompany this event. In the present Paediatric Infectious Disease Note, we review briefly the potential implications of pandemic influenza for Canadian children, and the actions that paediatricians and others who care for children can take to prepare for this inevitable event.
Children’s Self‐Reports of Pain Intensity: Scale Selection, Limitations and Interpretation
Authors: von Baeyer Carl L
Published: March 2016

Most children aged five years and older can provide meaningful self‐reports of pain intensity if they are provided with age‐appropriate tools and training. Self‐reports of pain intensity are an oversimplification of the complexity of the experience of pain, but one that is necessary to evaluate and titrate pain‐relieving treatments. There are many sources of bias and error in self‐reports of pain, so ratings need to be interpreted in light of information from other sources such as direct observation of behaviour, knowledge of the circumstances of the pain and parents’ reports. The pain intensity scales most commonly used with children – faces scales, numerical rating scales, visual analogue scales and others – are briefly introduced. The selection, limitations and interpretation of self‐report scales are discussed.
The American Thoracic Society’s Spirometric Criteria Alone is Inadequate in Asthma Diagnosis
Authors: Gjevre John A , Hurst Thomas S , Taylor-Gjevre Regina M , Cockcroft Donald W
Published: March 2016

BACKGROUND: The diagnosis of asthma is based on clinical symptoms, physical examination and pulmonary function tests, and can be very challenging. Most patients with asthma have a significant postbronchodilator response on spirometry indicating airway hyperresponsiveness. However, having a significant bronchodilator response by itself is not diagnostic of asthma. The definition of a ‘significant’ response has also been controversial. Many respirologists use the American Thoracic Society (ATS) postbronchodilator response criteria of 12% (provided it is 200 mL or greater) improvement in forced expiratory volume in 1 s (or forced vital capacity) from the baseline spirometry.

METHODS: In the present study, 644 patients who met the ATS criteria for a significant postbronchodilator spirometric response were retrospectively reviewed. The staff respirologist’s diagnosis of asthma, based on all clinical and pulmonary function data, was used as the standard for the diagnosis of asthma.

RESULTS: Relying on spirometric criteria alone was inadequate in asthma diagnosis because only 54.7% of 310 patients who met the ATS bronchodilator response criteria were thought to have clinical asthma. Increasing the postbronchodilator percentage improvement from the ATS criteria only marginally improved diagnostic specificity and resulted in a decline in sensitivity.

CONCLUSIONS: The results of the present study further emphasize the need to use spirometric criteria as a guide but not as an unimpeachable gold standard with which to make a diagnosis of asthma. The diagnosis of asthma depends on expert physician correlation of patient history, physical examination and pulmonary function test results.
Progressive Dyspnea Associated with a Crazy‐Paving Appearance on a Chest Computed Tomography Scan
Authors: Maimon Nimrod , Paul Narinder , Downey Gregory P
Published: March 2016

A ‘crazy‐paving’ appearance of the lungs on computed tomography scanning of the chest was first described nearly 20 years ago in patients with pulmonary alveolar proteinosis, and was thought to be characteristic of this condition. However, this pattern has subsequently been reported in a variety of pulmonary diseases and is now considered to be nonspecific. The present report describes a case of a 74‐year‐old man in whom congestive heart failure presented with a crazy‐paving appearance of the lungs on a chest computed tomography scan. This uncommon association illustrates the importance of the correlation of clinical and radiographic information.
Antibiotic Therapy for Crohn’s Disease: A Review
Authors: Lal Simon , Steinhart A Hillary
Published: March 2016

Increasing evidence suggests that gut bacteria play a pathogenic role in Crohn’s disease (CD), providing a rationale for the use of antibiotics in the primary treatment of the disease. While there are data to suggest that antibiotics may be effective in treating active luminal, particularly colonic, and/or perianal CD, evidence for their use in these settings is hampered by the lack of well-designed, adequately powered, placebo-controlled trials. Furthermore, although nitroimidazole antibiotics have been shown to reduce postoperative recurrence following ileocolonic resection, their use is limited by side effects. There is a current need for rigorous multicentre studies looking into the role of antibiotics in treating perianal and luminal CD, as well as a need for the large-scale assessment of novel antibiotics, with low systemic absorption, which may improve patient tolerance.
A Case of Acquired Rifampin Resistance in Mycobacterium bovis Bacillus Calmette‐Guérin‐Induced Cystitis: Necessity for Treatment Guidelines
Authors: Wolfe Joyce N , Blackwood-Antonation Kym S , Sharma Meenu K , Cook Victoria J
Published: March 2016

A case of presumed bacillus Calmette‐Guérin (BCG) cystitis in an elderly female patient following direct intravesical BCG instillation treatment for papillary transitional cell carcinoma is reported. The organism cultured from urine samples was eventually identified as a rifampin‐resistant Mycobacterium bovis BCG isolate. Because the patient had received rifampin monotherapy during the course of treatment for presumed BCG disease, the clinical picture favoured acquired rifampin resistance. Sequencing of the target gene for rifampin (rpoB) confirmed a known mutation responsible for conferring high levels of resistance to both rifampin and rifabutin (Ser531Tyr). To the authors′ knowledge, this is the first reported case of M bovis BCG disease in a non‐HIV patient where the organism had acquired drug resistance to rifampin, and the second reported case of M bovis BCG that had acquired drug resistance. The present case demonstrates the necessity to re‐evaluate appropriate guidelines for the effective treatment of BCG disease.
Bronchoscopic Management of Airway Obstruction in Pediatric Endobronchial Tuberculosis
Authors: Wong Jeff SW , Ng Calvin SH , Lee Tak Wai , Yim Anthony PC
Published: March 2016

The present report describes a case of severe airway obstruction caused by endobronchial tuberculosis in an 11‐year‐old girl who was successfully treated by bronchoscopic balloon dilation. This case illustrates the insidious presentation and the increasingly important role of bronchoscopic intervention in the management of endobronchial tuberculosis. In addition, a brief literature review of the condition in the pediatric age group is included.
Ethical and Scientific Issues Surrounding Solid Organ Transplantation in Hiv‐Positive Patients: Absence of Evidence Is Not Evidence of Absence
Authors: Christie Timothy , Jiwani Bashir , Asrat Getnet , Montessori Valentina , Mathias Richard , Montaner Julio
Published: March 2016

End‐stage liver disease is emerging as a leading cause of death among HIV‐positive patients. Historically, an HIV diagnosis was a contraindication for a liver transplant; however, because of the efficacy of highly active antiretroviral therapy (HAART), HIV‐positive patients have one‐year, two‐year, and three‐year post‐transplantation survival rates similar to that of HIV‐negative patients. Based on this evidence, HIV‐positive patients are now considered eligible for transplantation. However, newly emerging guidelines include the stipulation that HIV‐positive patients must be on HAART to be placed on a waiting list for transplantation. The purpose of the present paper is to evaluate the scientific and ethical probity of requiring HIV‐positive patients to be on HAART as a condition for being on a liver transplant waiting list. It is argued that the emphasis should be placed on the probability of post‐transplantation HAART tolerance, and that concerns about pretransplantation HAART tolerance are of secondary importance.
Hepatitis C Eradication and Improvement of Cryoglobulinemia-Associated Rash and Membranoproliferative Glomerulonephritis with Interferon and Ribavirin after Kidney Transplantation
Authors: Zeman Marilyn , Campbell Patricia , Bain Vincent G
Published: March 2016

Postrenal transplant hepatitis C is increasing in frequency due to the high prevalence of hepatitis C among patients with renal failure. Despite this, there is still no standard hepatitis C treatment available for renal transplanted recipients. Combination antiviral hepatitis C therapy, the standard of care in the nontransplant population, is generally avoided because of documented renal graft rejection secondary to interferon treatment. A case of a male patient with postrenal transplant hepatitis C, which was associated with cryoglobulinemia and glomerulonephritis of the graft, is presented. He was treated with standard interferon with ribavirin. Sustained viral clearance was achieved despite ongoing evidence of cryoglobulinemia. Renal function, which had been deteriorating before treatment, improved as evidenced by the stabilization of serum creatinine and marked improvement of proteinuria. In conclusion, in selected patients, combination antiviral therapy may still be a viable option postrenal transplant.
Adult-to-Adult Living Donor Liver Transplantation
Authors: Shah Shimul A , Levy Gary A , Adcock Lesley D , Gallagher Gary , Grant David R
Published: March 2016

The present review outlines the principles of living donor liver transplantation, donor workup, procedure and outcomes. Living donation offers a solution to the growing gap between the need for liver transplants and the limited availability of deceased donor organs. With a multidisciplinary team focused on donor safety and experienced surgeons capable of performing complex resection/reconstruction procedures, donor morbidity is low and recipient outcomes are comparable with results of deceased donor transplantation.
Factors Associated with Length of Stay in Hospital for Suspected Community‐Acquired Pneumonia
Authors: Huang Jane Q , Hooper Peter M , Marrie Thomas J
Published: March 2016

OBJECTIVE: To determine factors associated with the length of stay (LOS) for patients with suspected community‐acquired pneumonia (CAP) who required hospitalization for treatment.

STUDY DESIGN: The authors studied a population‐based prospective cohort of 2757 adults with suspected CAP who were admitted over a two‐year period. Logistic regression, multiple linear regression, and classification and regression trees were used to determine the factors associated with LOS.

SETTING: The study was conducted in two community and tertiary care hospitals, two community and secondary care hospitals, and two community hospitals in the Capital Health Region of Edmonton, Alberta.

RESULTS: Symptoms such as sweats, shaking chills and wheezing were associated with an LOS of seven days or shorter, whereas weight loss, functional impairment, heart, renal or neoplastic diseases and time to first dose of antibiotic were predictive of an LOS greater than seven days. Regression tree analysis indicated that rapid achievement of physiological stability was associated with a shorter LOS. The use of an indwelling urinary catheter was found to be an important determinant of LOS.

CONCLUSIONS: The present study found several new associations with increased LOS in patients with CAP, including functional status, time to receipt of first dose of antibiotic therapy, use of certain antibiotics, presence of a urinary catheter and the importance of time to physiological stability. An intervention targeting avoidance of urinary catheters may be associated with a shorter LOS.
Canadian Consensus on Medically Acceptable Wait Times for Digestive Health Care
Authors: Paterson William G , Depew William T , Paré Pierre , Petrunia Denis , Switzer Connie , van Zanten Sander J Veldhuyzen , Daniels Sandra ,   for the Canadian Association of Gastroenterology Wait Time Consensus Group
Published: March 2016

BACKGROUND: Delays in access to health care in Canada have been reported, but standardized systems to manage and monitor wait lists and wait times, and benchmarks for appropriate wait times, are lacking. The objective of the present consensus was to develop evidence- and expertise-based recommendations for medically appropriate maximal wait times for consultation and procedures by a digestive disease specialist.

METHODS: A steering committee drafted statements defining maximal wait times for specialist consultation and procedures based on the most common reasons for referral of adult patients to a digestive disease specialist. Statements were circulated in advance to a multidisciplinary group of 25 participants for comments and voting. At the consensus meeting, relevant data and the results of voting were presented and discussed; these formed the basis of the final wording and voting of statements.

RESULTS: Twenty-four statements were produced regarding maximal medically appropriate wait times for specialist consultation and procedures based on presenting signs and symptoms of referred patients. Statements covered the areas of gastrointestinal bleeding; cancer confirmation and screening and surveillance of colon cancer and colonic polyps; liver, biliary and pancreatic disorders; dysphagia and dyspepsia; abdominal pain and bowel dysfunction; and suspected inflammatory bowel disease. Maximal wait times could be stratified into four possible acuity categories of 24 h, two weeks, two months and six months.

FUTURE DIRECTIONS: Comparison of these benchmarks with actual wait times will identify limitations in access to digestive heath care in Canada. These recommendations should be considered targets for future health care improvements and are not clinical practice guidelines.
Infectious Disease Management: Lessons from Cuba
Authors: Macdonald Noni E , Halperin Beth , Chaple Enrique Beldarrain , Scott Jeff , Kirk John M
Published: March 2016

Over the past decade in Canada, infectious disease outbreaks have repeatedly been in the public spotlight. The Escherichia coli outbreak in Walkerton, Ontario (1), the severe acute respiratory syndrome outbreak in Toronto, Ontario (2) and the Clostridium difficile hospital outbreak in Montreal, Quebec (3), have cost lives, grabbed headlines and stressed local health care systems. Each outbreak raised questions about our ability to prevent outbreaks, detect outbreaks early, and respond efficiently and effectively to infectious disease crises; these outbreaks also highlighted gaps in Canada′s preparedness for managing major infectious disease problems when multiple jurisdictions are involved (4). Canada′s poor track record of tuberculosis control in the north (5) raises the concern that this problem is not limited to crisis situations, but rather has deeper implications for the management of infectious diseases in Canada.
Drotrecogin Alpha (Activated) in Two Patients with the Hantavirus Cardiopulmonary Syndrome
Authors: McDermid Robert C , Gibney RT Noel , Brisebois Ronald J , Skjodt Neil M
Published: March 2016

Hantavirus cardiopulmonary syndrome (HCPS) is associated with rapid cardiopulmonary collapse from endothelial injury, resulting in massive capillary leak, shock and severe hypoxemic respiratory failure. To date, treatment remains supportive and includes mechanical ventilation, vasopressors and extracorporeal membrane oxygenation, with mortality approaching 50%. Two HCPS survivors initially given drotrecogin alpha (activated) (DAA) for presumed bacterial septic shock are described. Vasoactive medications were required for a maximum of 52 h, whereas creatinine levels and platelet counts normalized within seven to nine days. Given the similar presentations of HCPS and bacterial septic shock, empirical DAA therapy will likely be initiated before a definitive diagnosis of HCPS is made. Further observations of DAA in HCPS seem warranted.
Organ Transplantation in HIV Infected Individuals: The Time Has Come ‐ Should there Be Criteria?
Authors: Walmsley Sharon
Published: March 2016

Before the advent of highly active antiretroviral therapy (HAART), HIV and its associated infectious and malignant complications were the major causes of death in patients with HIV infection, including those with serious comorbidities involving the heart, liver or kidney (1). Consequently, therapy of the underlying liver disease, such as hepatitis C virus (HCV), was often not attempted, and transplantation of scarce organs was not a consideration.
Tumour Necrosis Factor Inhibitors and Infection: What Is there to Know for Infectious Diseases Physicians?
Authors: Johnston BL , Conly JM
Published: March 2016

At this year′s meeting of Digestive Disease Week in Los Angeles, California, it was noted that antitumour necrosis factor (anti‐TNF) inhibitors showed further evidence of efficacy in Crohn′s disease (1). TNF antagonists have been used increasingly in the treatment of a number of other inflammatory diseases, especially rheumatoid arthritis (RA), where they have revolutionized treatment (2). At the same time, their use has been associated with an increased risk of serious infections (3). As more patients are treated with these agents, it is inevitable that infectious diseases physicians will see a variety of infections, both common and uncommon, requiring familiarity with this new class of drugs and their infectious complications.
Whiplash Injuries Can be Visible by Functional Magnetic Resonance Imaging
Authors: Johansson Bengt H
Published: March 2016

Whiplash trauma can result in injuries that are difficult to diagnose. Diagnosis is particularly difficult in injuries to the upper segments of the cervical spine (craniocervical joint [CCJ] complex). Studies indicate that injuries in that region may be responsible for the cervicoencephalic syndrome, as evidenced by headache, balance problems, vertigo, dizziness, eye problems, tinnitus, poor concentration, sensitivity to light and pronounced fatigue. Consequently, diagnosis of lesions in the CCJ region is important. Functional magnetic resonance imaging is a radiological technique that can visualize injuries of the ligaments and the joint capsules, and accompanying pathological movement patterns.

Three severely injured patients that had been extensively examined without any findings of structural lesions were diagnosed by functional magnetic resonance imaging to have injuries in the CCJ region.

These injuries were confirmed at surgery, and after surgical stabilization the medical condition was highly improved.

It is important to draw attention to the urgent need to diagnose lesions and dysfunction in the CCJ complex and also improve diagnostic methods.
13C Urea Breath Test for Helicobacter pylori: Determination of the Optimal Cut-Off Point in a Canadian Community Population
Authors: Mauro Marina , Radovic Vladimir , Zhou Pengfei , Wolfe Melanie , Kamath Markad , Bercik Premsyl , Croitoru Ken , Armstrong David
Published: March 2016

AIM: To determine the test characteristics and the optimal cut-off point for the 13C urea breath test (13C UBT) in a Canadian community laboratory setting.

METHODS: Of 2232 patients (mean age ± SD: 51±21 years, 56% female) who completed a 13C UBT, 1209 were tested to evaluate the primary diagnosis of Helicobacter pylori infection and 1023 were tested for confirmation of eradication following treatment. Cluster analysis was performed on the 13C UBT data to determine the optimal cut-off point and the risk of false-positive and false-negative results. Additionally, 176 patients underwent endoscopic biopsy to allow validation of the sensitivity and specificity of the 13C UBT against histology and microbiology using the calculated cut-off point.

RESULTS: The calculated cut-off points were 3.09 δ‰ for the whole study population (n=2232), 3.09 δ‰ for the diagnosis group (n=1209) and 2.88 δ‰ for the post-treatment group (n=1023). When replacing the calculated cut-off points by a practical cut-off point of 3.0 δ‰, the risk of false-positive and false-negative results was lower than 2.3%. The 13C UBT showed 100% sensitivity and 98.5% specificity compared with histology and microbiology (n=176) for the diagnosis of active H pylori infection.

CONCLUSIONS: The 13C UBT is an accurate, noninvasive test for the diagnosis of H pylori infection and for confirmation of cure after eradication therapy. The present study confirms the validity of a cutoff point of 3.0 δ‰ for the 13C UBT when used in a large Canadian community population according to a standard protocol.
Suppurative Mediastinitis Secondary to Burkholderia Cepacia in a Patient with Cystic Fibrosis
Authors: George Ronald B , Cartier Yannick , Casson Alan G , Hernandez Paul
Published: March 2016

Burkholderia cepacia is an important opportunistic pathogen among patients with cystic fibrosis (CF); it is associated with deterioration of lung function, poor outcome following lung transplantation and increased mortality. Fever, an elevated white blood cell count, weight loss and an often fatal deterioration in pulmonary function characterize a particular clinical course, termed ‘Cepacia syndrome’. The present case report describes a 40‐year‐old man with CF who developed Cepacia syndrome complicated by suppurative mediastinitis, from which B cepacia was isolated. Despite optimal medical and surgical therapy, this patient succumbed to his illness. Those caring for patients with CF should be aware of this potentially catastrophic complication of B cepacia infection, especially in the setting of Cepacia syndrome.
Role of Duodenogastroesophageal Reflux in the Pathogenesis of Esophageal Mucosal Injury and Gastroesophageal Reflux Symptoms
Authors: Xu Xiao-rong , Li Zhao-shen , Zou Duo-wu , Xu Guo-ming , Ye Ping , Sun Zhen-xing , Wang Qing , Zeng Yan-jun
Published: March 2016

BACKGROUND AND AIM: Patients with gastroesophageal reflux disease (GERD) usually suffer from acid reflux and duo-denogastroesophageal reflux (DGER) simultaneously. The question of whether DGER has an important effect on the development of GERD remains controversial. The aim of the present study was to investigate the role of DGER in the pathogenesis of GERD and its value for the diagnosis of nonerosive reflux disease (NERD).

METHODS: GERD was initially diagnosed using the reflux disease questionnaire. For further diagnosis, results of the upper gastrointestinal endoscopy (excluding a diagnosis of Barrett’s esophagus) were considered in conjunction with simultaneous 24 h esophageal pH and bilirubin monitoring.

RESULTS: According to endoscopic findings, 95 patients (43 men, 50±10 years of age) were divided into two groups: the reflux esophagitis (RE) group (n=51) and the NERD group (n=44). Three DGER parameters, the percentage of time with absorbance greater than 0.14, the total number of reflux episodes and the number of bile reflux episodes lasting longer than 5 min, were evaluated in the study. For the RE group, the values of the DGER parameters (19.05%±23.44%, 30.56±34.04 and 5.90±6.37, respectively) were significantly higher than those of the NERD group (7.26%±11.08%, 15.68±20.92 and 2.59±3.57, respectively, P<0.05 for all) but no significant difference was found in acid reflux. Of NERD patients, 18.5% were diagnosed with simple DGER. The positive diagnosis rate of NERD could be significantly elevated from 65.9% to 84.1% (P<0.05), if bilirubin monitoring was employed in diagnosis.

CONCLUSIONS: DGER may occur independently but plays an important role in the development of RE and GERD symptoms. Simultaneous 24 h esophageal pH and bilirubin monitoring is superior to simple pH monitoring in helping identify patients at risk for NERD.
Ensuring Pain Relief for Children at the End of Life
Authors: Grégoire Marie-Claude , Frager Gerri
Published: March 2016

Pain management in the context of pediatric palliative care can be challenging. The present article reviews, through a case‐based presentation, the nonpharmacological and pharmacological methods used to ensure adequate pain control in children facing end of life. Details on the impressive range of opioid dosages required and routes of administration are highlighted from published literature and clinical experience. Where available, evidence‐based recommendations are provided. Potential side effects of pain medication and barriers to good pain control are discussed. Novel analgesics and innovative delivery methods are presented as future tools enhancing pain relief at the end of life. Some challenges to ethically grounded research in this important context of care are reviewed.
Colorectal Cancer Screening: Physicians’ Knowledge of Risk Assessment and Guidelines, Practice, and Description of Barriers and Facilitators
Authors: Sewitch Maida J , Burtin Pascal , Dawes Martin , Yaffe Mark , Snell Linda , Roper Mark , Zanelli Patrizia , Pavilanis Alan
Published: March 2016

BACKGROUND: Physician nonadherence to colorectal cancer (CRC) screening recommendations contributes to underuse of screening.

OBJECTIVE: To assess physicians’ knowledge of CRC screening guidelines for average-risk individuals, perceived barriers to screening and practice behaviours.

METHODS: Between October 2004 and March 2005, staff physicians working in three university-affiliated hospitals in Montreal, Quebec, were surveyed. Self-administered questionnaires assessed knowledge of risk classification and current guidelines for average-risk individuals, as well as perceptions of barriers to screening and practice behaviours.

RESULTS: All 65 invited physicians participated in the survey, including 46 (70.8%) family medicine physicians and 19 (29.2%) general internists. Most physicians knew that screening should begin at 50 years of age, all knew to screen men and women and 92% said they screened average-risk patients. Fifty-seven (87.7%) physicians correctly identified three common characteristics associated with high risk for developing CRC. Physicians who screened average-risk patients preferred fecal occult blood testing (88.3%) and colonoscopy (88.3%) to flexible sigmoidoscopy (10.0%) and double-contrast barium enema (30.0%). Most physicians knew the correct screening periodicity for fecal occult blood testing (87.6%), but only 40% or fewer could identify correct screening periodicities for the other modalities. Barriers and facilitators focused on health care delivery system improvements, better evidence on which to base recommendations and development of practical screening modalities.

CONCLUSIONS: Physicians lacked knowledge of the recommended screening modalities and periodicities to appropriately screen average-risk individuals. Because CRC screening can reduce mortality, efforts to improve physician delivery should focus on physician knowledge and changes to the health care delivery system.
Effects of Hydrofluoroalkane and Dry Powder‐Formulated Corticosteroids on Sputum Inflammatory Markers in Asthmatic Patients
Authors: Hauber Hans-Peter , Taha Rame , Bergeron Celine , Migounov Vladimir , Hamid Qutayba , Olivenstein Ron
Published: March 2016

BACKGROUND: Inhaled corticosteroids are powerful drugs that can suppress airway inflammation in asthmatic patients. Deposition of most of the inhaled corticosteroid occurs mainly in the central airways. However, a new hydrofluoroalkane formulation of beclomethasone dipropionate (HFA‐BDP) is preferentially deposited in the distal airways. Inflammatory characteristics of induced sputum have been shown to differ in samples collected early after sputum induction compared with later.

OBJECTIVE: To compare the effects of HFA‐BDP and budesonide in a dry powder inhaler (DPI‐BUD) on inflammatory cells and inflammatory cytokine expression in early and late induced sputa compared with placebo.

METHODS: Seventeen patients with mild, intermittent bronchial asthma were randomly assigned to two treatment groups: eight patients received HFA‐BDP and nine patients received DPI‐BUD. Each patient was treated with one of the active treatments and placebo (for four weeks), with a two‐week washout interval in between. Inflammatory cells and expression of interleukin (IL)‐4 and IL‐5 were measured in early and late induced sputa before and after active treatment, as well as before and after placebo treatment using immunocytochemistry and in situ hybridization.

RESULTS: Compared with placebo, eosinophils were significantly reduced in both early and late induced sputa after HFA‐BDP treatment (P<0.05), whereas DPI‐BUD had a significant effect only on early induced sputum. Both HFA‐BDP and DPI‐BUD decreased IL‐4 expression in early and late induced sputa, but the effect was more prominent with HFA‐BDP. IL‐5 expression was reduced in both early and late induced sputa after HFA‐BDP treatment. DPI‐BUD significantly decreased IL‐5 expression in early but not in late induced sputum. The number of lymphocytes was not altered by either treatment.

CONCLUSIONS: HFA‐BDP reduced eosinophilic inflammation and T helper 2‐type cytokine expression in both early and late induced sputa, whereas the effect of DPI‐BUD on inflammation was predominantly demonstrated in early induced sputum.