bluuebunny/crossref_metadata_2025 huggingface dataset:
Medical versus Surgical Treatment of a Primary Tuberculous Pleural Peel
Authors: Long Richard , Fanning Anne , McNamee Ciaran , Barrie James , Puttagunta Lakshmi
Published: March 2016

The role and timing of surgical decortication in the management of a primary tuberculous pleural peel remains controversial. The present report describes the case of a young man with an extensive primary tuberculous pleural peel that responded dramatically to medical therapy. A serious attempt at surgical decortication three weeks into antituberculous drug therapy may have removed some compressive aspects of the peel, facilitating lung expansion. However, it had almost no measurable impact on the size of peel and was technically very difficult. Response to treatment was measured anatomically (computed tomography scans) and physiologically (pulmonary function tests).
Infection Control in Acute Care Facilities: Evidence‐Based Patient Safety
Authors: Nicolle Lindsay E
Published: March 2016

Infection control in acute care facilities has a noble history. These programs were born of the nosocomial penicillin‐resistant Staphylococcus aureus outbreaks in the post‐World War II era. Over the past four decades, an impressive body of evidence has emerged that documents the effectiveness of infection control programs and systematically evaluates specific program components. Fumigation, tacky floor mats, shoe covers and ′reverse′ isolation have disappeared. They are replaced by focused surveillance programs, prophylactic antimicrobial therapy, outbreak investigation and control, routine barrier practices and molecular typing of organisms for epidemiological analysis.
Cotrimoxazole‐Induced Hypoglycemia in an HIV‐Infected Patient
Authors: Hughes Christine A , Chik Constance L , Taylor Geoffrey D
Published: March 2016

A case of cotrimoxazole‐induced hypoglycemia is described in a male patient infected with HIV. Ten days after initiating high dose cotrimoxazole for suspected Pneumocystis carinii pneumonia, the patient developed neuroglycopenic symptoms and diaphoresis. Blood glucose levels were repeatedly low, with elevated insulin and C‐peptide levels despite multiple intravenous bolus doses and infusions of dextrose. Hypoglycemia resolved after approximately 36 h of treatment with dextrose and discontinuation of cotrimoxazole. A review of reported cases of hypoglycemia associated with cotrimoxazole is provided, including information about onset, risk factors and possible mechanism.
Bullae, Bronchiectasis and Nutritional Emphysema in Severe Anorexia Nervosa
Authors: Cook Victoria J , Coxson Harvey O , Mason Andrew G , Bai Tony R
Published: March 2016

STUDY OBJECTIVES: Pulmonary complications of anorexia nervosa are rarely documented. The case of a patient with anorexia nervosa and pulmonary disease is presented, a new quantitative computed tomography (CT) method for the detection of emphysema is employed, the literature is reviewed and the concept of ′nutritional′ emphysema is discussed.

RESULTS: The case of a 34‐year‐old, nonsmoking woman with long‐standing severe anorexia nervosa who was evaluated for cough and progressive shortness of breath is reported. Pulmonary function testing showed a predominant restrictive pattern with a marked reduction in carbon monoxide transfer and respiratory muscle strength, and an elevated residual volume. Imaging revealed bullae and bronchiectasis, and quantitative analysis of the CT scan was consistent with mild, generalized emphysema. Bronchial washings grew Pseudomonas aeruginosa. Known causes for bronchiectasis were excluded. A literature review disclosed few reported noninfectious pulmonary complications of anorexia nervosa.

CONCLUSIONS: To the authors’ knowledge, this is the first report of bullae and bronchiectasis in a patient with anorexia nervosa, and the CT analysis was consistent with mild emphysema. Malnutrition has been associated with emphysematous changes in animals and may be the primary insult in the development of emphysema, bullae and bronchiectasis in the present patient.
Mumps Caused by an Inadequately Attenuated Measles, Mumps and Rubella Vaccine
Authors: Bakker WJ , Mathias RG
Published: March 2016

PROBLEM: Reports of mumps following measles, mumps and rubella (MMR) immunization.

OBJECTIVE: To determine whether mumps was caused by immunization or whether there was a concurrent epidemic of a wild strain of mumps.

DESIGN AND PARTICIPANTS: Analysis of surveillance data and a cohort study of three schools that participated in the campaign.

OUTCOME MEASURES: Cases of clinical mumps and orchitis, and immunization history and records were reviewed. The MMR vaccine was produced by the Serum Institute of India and contained the Leningrad‐Zagreb strain of mumps virus. Four lots were used in the specific immunization campaign.

RESULTS: Sentinel health facility surveillance showed an increase in mumps after two school immunization campaigns in western Suriname and a mass immunization campaign in the same region. There was also an increase in a geographically separate region following a mass campaign with the same vaccine. Three hundred fifteen children from three schools that were targeted in the immunization campaign were interviewed. The attack rate for mumps in those immunized was 15.1%; in those not immunized, the attack rate was 4.7%. In the affected males, the attack rate for orchitis was five of 19 (21%). Assuming 90% protection by the MMR vaccine, the incidence ratio (observed to expected) was 32.

CONCLUSIONS: The mumps outbreak was caused by an inadequately attenuated MMR vaccine. Because this vaccine had not been used in these populations before in Suriname, it was not possible to determine wether the outbreak was due the virulence of the Leningrad‐Zagreb mumps strain or due to production problems with one or more specific lots of vaccine. The vaccine was withdrawn from further use.
Nicotine Replacement Combined with a Novel Compound (ProBAN) for Smoking Cessation: A Pilot Study
Authors: Leigh Richard , Viner Norman M , Cox Gerard , Balon Jeffrey W , Wilson Douglas MC , O’Shaughnessy Denise , Walker Corinne , Brosky Gerry , Sears Malcolm R
Published: March 2016

BACKGROUND: Smoking cessation rates with available pharmacological therapies remain suboptimal. Anecdotal observations with a combination of sublingual pralidoxime and ipratropium (ProBAN) suggested that these agents in combination with nicotine gum improved quit rates.

OBJECTIVE: To determine whether ProBAN together with nicotine replacement improves quit rates compared with nicotine replacement alone.

DESIGN: A 12‐week, prospective, double‐blind, randomized, placebo controlled pilot study. SETTING: University‐affiliated outpatient clinic.

POPULATION STUDIED: Healthy adult smokers were recruited via advertisements. Of 107 subjects seen at the screening visit, 27 were excluded because of comorbid illness or concomitant medication use.

INTERVENTIONS: Of 80 eligible subjects, 40 were randomly assigned to receive treatment with ProBAN sub‐ lingual tablets and nicotine gum (treatment group), and 40 to receive placebo tablets and nicotine gum (control group) for 12 weeks. The primary outcome was complete continuous abstinence of smoking from one through 12 weeks after the quit date.

MAIN RESULTS: There were no adverse effects in the treatment group. At one week after the quit date, 35% of ProBAN‐treated subjects had quit compared with 18% of control subjects (odds ratio [OR] 2.5, 95% CI 0.9 to 7.2). Corresponding quit rates at four weeks were 28% and 15% (OR 2.1, 95% CI 0.7 to 6.5), at eight weeks were 25% and 13% (OR 2.3, 95% CI 0.7 to 7.6), and at 12 weeks were 23% and 13% (OR 2.0, 95% CI 0.6 to 6.7), respectively.

CONCLUSIONS: This pilot study indicated that ProBAN combined with nicotine replacement doubled the continuous sustained quit rate compared with nicotine replacement alone, with no adverse effects. Although not statistically significant due to the size of the study, this result suggests that it may be an effective therapy for smoking cessation, and larger studies are warranted.
Opinions of Quebec Parents and Vaccinators on the Usefulness of Chickenpox Vaccine
Authors: Boulianne Nicole , Duval Bernard , Serres Gaston De , Deceuninck Geneviève , Dionne Marc , Carsley John , Valiquette Louise , Massé Richard
Published: March 2016

BACKGROUND: A chickenpox vaccine was recently licensed in Canada. Because this vaccine has caused some controversy within the health care profession, studies among Quebec parents and vaccine providers were carried out, surveying their opinions concerning chickenpox vaccination.

METHODS: Three studies among parents of preadolescents, parents of two‐year‐old children completely or incompletely vaccinated and vaccinators were completed. The studies asked for opinions concerning the usefulness of vaccinating children against chickenpox.

RESULTS: The majority of parents of preadolescents (56%), and parents of two‐year‐old children completely (64%) and incompletely vaccinated (60%) favoured chickenpox vaccination. Among vaccinators, 53% of paediatricians, 37% of general practitioners and 33% of nurses considered universal vaccination of young children to be useful. A greater proportion of health care professionals were in favour of a policy of vaccinating groups at risk, such as susceptible adolescents (86%, 75% and 58%, respectively). There was a positive association between the perceived severity of chickenpox and the potential usefulness of the vaccine.

CONCLUSION: Quebec parents are more favourably disposed to chickenpox vaccine than vaccine providers. In contrast, strategies targeting susceptible groups would be generally well received by health care professionals. A considerable amount of work will be needed to convince vaccinators of the benefits of a universal childhood vaccination against chickenpox.
Post‐Christmas Blues: A Rare Cause of Cyanosis
Authors: Barron Laurie , Biem H Jay
Published: March 2016

A patient was referred for urgent evaluation of cyanosis. Although she had symptoms and signs of an upper respiratory tract infection, she had a normal cardiorespiratory examination and normal transcutaneous oxygen saturation. Further evaluation revealed a benign cause for the cyanosis.
Short‐Acting Beta‐Agonist Research: A Perspective
Authors: Sears Malcolm R
Published: March 2016

Asthma mortality increased sharply in New Zealand in 1977, prompting a national investigation into circumstances of asthma deaths. Subsequent observations of improved asthma control in subjects withdrawn from regular beta2‐agonist treatment raised the question of whether asthma severity and, therefore, mortality could relate to frequent beta‐agonist use. A randomized controlled trial of regular inhaled fenoterol versus as‐needed bronchodilator use showed worsened asthma control during regular treatment despite concomitant use of inhaled corticosteroids. Assessment of these findings led to delay in the publishing of the American Asthma Guidelines, which were modified to suggest caution in using beta2‐agonist treatments. Simultaneously, case control studies in New Zealand suggested that prescription of fenoterol was a substantial risk factor for asthma mortality. The causal association was hotly debated, but increasing evidence pointed to an adverse effect of fenoterol on asthma severity and, hence, mortality. This was supported by dramatic decreases in both morbidity and mortality when fenoterol was effectively withdrawn from use in New Zealand. The link between worsening asthma morbidity and mortality, and the use of potent short‐acting beta2‐agonists fulfills the Bradford Hill criteria for attributing causality. Application of evidence from randomized, controlled trials of short‐acting beta‐agonist use has led to a major shift in therapy in asthma to the recommendation of as‐needed use only of short‐acting beta‐agonists and decreased patient reliance on regular bronchodilator therapy.
Asthma in Adolescents: A Randomized, Controlled Trial of an Asthma Program for Adolescents and Young Adults with Severe Asthma
Authors: Cowie Robert L , Underwood Margot F , Little Cinde B , Mitchell Ian , Spier Sheldon , Ford Gordon T
Published: March 2016

BACKGROUND: Asthma is common and is often poorly controlled in adolescent subjects.

OBJECTIVE: To determine the impact of an age‐specific asthma program on asthma control, particularly on exacerbations of asthma requiring emergency department treatment, and on the quality of life of adolescents with asthma.

METHODS: The present randomized, controlled trial included patients who were 15 to 20 years of age and had visited emergency departments for management of their asthma. The interventional group attended an age‐specific asthma program that included assessment, education and management by a team of asthma educators, respiratory therapists and respiratory physicians. In the control group, spirometry was performed, and the patients continued to receive usual care from their regular physicians. The outcomes were assessed by a questionnaire six months after entry into the study.

RESULTS: Ninety‐three subjects entered the study and were randomly assigned to the intervention or control group. Of these, only 62 patients were available for review after six months. Subjects in both the control and the intervention groups showed a marked improvement in their level of asthma control, reflected primarily by a 73% reduction in the rate of emergency department attendance for asthma. Other indexes of disease control, including disease‐specific quality of life, as assessed by questionnaires, were improved. There was, however, no discernible difference between the subjects in the two groups, with the exception of an improvement in favour of the intervention group in the symptom (actual difference 0.7, P=0.048) and emotional (actual difference 0.8, P=0.028) domains of the asthma quality of life questionnaire. The overall quality of life score favoured the intervention group by a clinically relevant difference of 0.6, but this difference did not reach statistical significance (P=0.06).

CONCLUSIONS: Although all subjects demonstrated a significant improvement in asthma control and quality of life, the improvement attributable to this intervention was limited to two domains in disease‐specific quality of life.
Cts 2002 Scientific Program
Authors: Canadian Thoracic Society
Published: March 2016

CTS Announcements
Anxiety and Related Factors in Chronic Pain
Authors: Asmundson Gordon JG
Published: March 2016

Clinicians often encounter patients who present with both chronic pain and elevated levels of anxiety. In some cases, the source of the anxiety is vague and diffuse. For others, there is an identifiable precipitating object, event or situation. For example, some patients with chronic pain are able to attribute their anxiety to the possibility of not regaining lost functional abilities, financial difficulties, feelings of social inadequacy, or uncertainty about the meaning and consequences of pain. The association between chronic pain and anxiety may not be particularly surprising when one considers that, in the acute phase, both pain and target‐oriented anxiety (or fear) motivate actions that serve to minimize the threat and maximize the likelihood of successful escape. As well, their neurobiology, while distinct, interacts in the reticular system (1). Evaluations of the association between chronic pain and fear‐relevant constructs were initiated in the 1960s and 1970s (2,3). It has only been of late, however, that theorists and researchers have begun to focus their attention on delineating the precise nature of the relationship and its specific implications for the assessment and management of pain.
To All Members
Authors: Mayers Irvin
Published: March 2016

Two years ago, after much debate and discussion, the board of the Canadian Thoracic Society (CTS) decided to combine our annual meeting with the annual meeting of the American College of Chest Physicians (ACCP). There has been ongoing discussion as to whether this was the best course of action. Many members have raised the question of why we did not meet with the American Thoracic Society (ATS) or why we did not develop a stand‐alone, made‐in‐Canada meeting.
Microscopic Pulmonary Tumour Embolism: An Unusual Presentation of Thymic Carcinoma
Authors: Sperling Brita L , Cockcroft Donald W , Chibbar Rajni
Published: March 2016

The present report describes the first reported case of microscopic pulmonary tumour embolism (MPTE) from thymic carcinoma. The carcinoma was discovered during an autopsy in a 55‐year‐old man who had undergone surgery for a pilonidal sinus two weeks before presentation. Pulmonary thromboembolism was suspected. This case was unusual because MPTE has never before been associated with thymic carcinoma, MPTE was the first clinical indication of an occult malignancy, and the clinical presentation was that of sudden onset of dyspnea associated with acute cor pulmonale. The cause of death was determined to be hypoxia secondary to extrinsic compression of the right pulmonary artery and extensive tumour emboli in the small arteries, arterioles and venules of the pulmonary parenchyma. A review of the clinical presentation and diagnosis of MPTE is included.
Insurance Research and Medical Ethics
Authors: Terry Lorie
Published: March 2016

On January 1, 1995, Saskatchewan adopted a radical, no‐fault system for motor vehicle accident insurance. Virtually no room was left for injured victims to sue for damages, whether for pain and suffering or for economic compensation. In fact, the no‐fault system removed benefits for pain and suffering altogether. Apart from the concern that arose at the denial of justice in relation to economic matters and the blanket denial of pain, there was concern over the arrangements for medical care. Under the new Automobile Accident Insurance Act, injured persons were entitled to compensation and payment for treatment, as managed by their own doctors, chiropractors or physiotherapists for the first six weeks subsequent to an injury. Thereafter, they were required to be seen by insurance company‐appointed doctors, chiropractors or physiotherapists if they wished the income replacement benefits to continue, treatment to be provided or both. They also were obliged to accept the recommendations of the insurance company doctors for the next 12 weeks, under what was called ′secondary rehabilitation′. If they claimed not to be well at the end of that period, further rehabilitation, described as ′tertiary rehabilitation′ would be ordered. Two specific ′in‐patient′ centres were established for tertiary rehabilitation in different parts of the province (Regina and Saskatoon), and victims thought to be in need of tertiary rehabilitation had to travel if they did not live in either Regina (the provincial capital) or Saskatoon. The administration and treatment of individuals under these systems were so unacceptable to many individuals that a widespread resistance movement was generated and was established as the Coalition Against No‐Fault Insurance on August 28, 1998, opening with simultaneous protests in Regina, Saskatoon, Prince Albert North Battleford and Estevan, each one organized by a local victim of the no‐fault insurance scheme.
CTS Announcements
Authors: Canadian Thoracic Society
Published: March 2016

CTS Announcements
The Effects of Catastrophic Thinking about Pain on Attentional Interference by Pain: No Mediation of Negative Affectivity in Healthy Volunteers and in Patients with Low Back Pain
Authors: Crombez G , Eccleston C , den Broeck A Van , Houdenhove B Van , Goubert L
Published: March 2016

BACKGROUND: Previous studies have shown that catastrophic thinking about pain enhances attentional interference in healthy volunteers.

OBJECTIVE: To investigate whether the attentional effects of pain catastrophizing can be accounted for by the more general predisposition of negative affectivity.

METHODS: Sixty‐seven pain‐free students participated in the first experiment, and 33 patients with chronic low back pain participated in the second experiment. In both experiments, participants performed an auditory reaction time task while being exposed to a series of threatening electrocutaneous stimuli. Retardation in reaction times to auditory probes during pain was taken as an index of the attentional interruption by pain. Participants also completed self‐report instruments of negative affectivity and pain catastrophizing.

RESULTS: In both experiments, pain catastrophizing enhanced attentional interference by pain. This effect was most pronounced immediately after the onset of the electrocutaneous stimulus. The effect remained after controlling for the effects of negative affectivity.

CONCLUSIONS: Catastrophic thinking about pain enhances attentional interruption by pain in normal samples, as well as in clinical samples of patients with chronic back pain. This effect is specific to pain catastrophizing and cannot be explained by the more general disposition of negative affectivity.
Disrupted Sleep Patterns and Daily Functioning in Patients with Chronic Pain
Authors: McCracken Lance M , Iverson Grant L
Published: March 2016

OBJECTIVE: To investigate the role of disturbed sleep in the daily functioning of persons with chronic pain.

SUBJECTS AND METHODS: Participants comprised 287 patients seeking treatment for chronic pain at a university pain clinic. All patients completed the measures employed in the present study as part of a comprehensive initial evaluation.

RESULTS: Descriptive analyses showed that 88.9% of patients reported as least one problem with disturbed sleep. Correlation analyses showed that greater sleep disturbance was associated with greater pain, disability, depression and physical symptoms, and less daily uptime. Hierarchical regression analyses showed that sleep disturbance predicted disability, daily uptime and physical symptoms independent of pain or depression.

CONCLUSIONS: Sleep disruption is usually considered to be a consequence of the pain experience. However, the results of the present study reinforce the view that sleep disturbance may have a bidirectional relation with other features of chronic pain. Future studies should confirm that repairing disrupted sleep leads to an improvement in patients′ daily activity and a reduction in their suffering.
Chronic Traumatic and Congenital Diaphragmatic Hernias: Presentation and Surgical Management
Authors: Sattler Scott , Canty Timothy G , Mulligan Michael S , Wood Douglas E , Scully J Michael , Vallieres Eric , Pohlman Timothy , Karmy-Jones Riyad
Published: March 2016

BACKGROUND: The diagnosis of chronic diaphragmatic hernias, whether due to congenital defects or trauma, may be difficult to make and may rely on clinical suspicion in the setting of persistent nondiagnostic radiographic findings. Repair is indicated to avoid catastrophic cardiopulmonary compromise and/or incarceration of abdominal organs.

STUDY OBJECTIVES: To review the varied presentations and treatment of chronic diaphragmatic hernia.

DESIGN: Retrospective review.

SETTING: University of Washington and Harborview Medical Center, Seattle, Washington.

PATIENTS: Between 1997 and 2001, nine patients presented with chronic diaphragmatic hernia (two congenital cases, seven post‐traumatic cases). Four cases involved the right diaphragm. The following clinical features were noted: asymptomatic, chest radiograph showing bowel herniation (n=1); chest wall mass (n=1); asymptomatic with the chest radiograph showing marked elevation of hemidiaphragm (n=1); dyspnea with the chest radiograph showing marked elevation of hemidiaphragm (n=1); diarrhea and heartburn (n=1); generalized gastrointestinal upset (n=1); recurrent pneumonia (n=2); recurring effusions (n=4); and dyspnea on exertion (n=5).

INTERVENTIONS: Diagnosis was confirmed by chest radiograph in two patients, chest computed tomography scan in one patient, barium studies in three patients and thoracoscopy in three patients. All hernias were repaired via thoracotomy, and two hernias were repaired with artificial patch.

CONCLUSIONS: Patients with chronic diaphragmatic hernias present with a variety of symptoms and radiographic findings. When radiology or symptoms suggest bowel involvement, barium studies are appropriate. In other cases, chest computed tomography scans and/or thoracoscopy are useful. Repair is accomplished through the ipsilateral chest, with primary repair of the diaphragm preferred over patch repair.
Review of the Use of Cephalosporins in Children with Anaphylactic Reactions from Penicillins
Authors: Hameed Tahir K , Robinson Joan L
Published: March 2016

OBJECTIVE: It is a widely accepted practice that children with anaphylaxis from penicillins should avoid cephalosporins. The purpose of the present study was to determine whether there is evidence in the literature to support this practice.

DATA SOURCES: MEDLINE, EMBASE, Toxline, Inter‐national Pharmaceutical Abstracts and PubMed were used to search the literature published from 1966 to 2001. The Canadian Medical Protective Association, Health Canada and the Boston Collaborative Drug Surveillance Program were also contacted to determine whether there were any unpublished cases of cross‐reactivity between penicillins and cephalosporins.

DATA EXTRACTION: Cases describing the use of cepha‐losporins in adults and children with positive penicillin skin tests or anaphylaxis from penicillin were evaluated. Case reports of anaphylaxis from cephalosporins in paediatric patients were identified.

DATA SYNTHESIS: There have been five reported cases of serious reactions from cephalosporins in patients with a history of anaphylaxis from penicillins. All cases occurred in adults; three developed anaphylaxis from the older, first‐generation cephalosporins, cephalothin and cephaloridine; one developed anaphylaxis from cefamandole; and one developed anaphylaxis from cefaclor. There have been 12 other published reports of anaphylaxis from cephalosporins in adults with a history of penicillin allergy or a positive penicillin skin test, but with no history of anaphylaxis from penicillin. In seven studies, in which a total of 158 patients with positive penicillin skin tests were administered cephalosporins, seven had apparent immunoglobulin E‐mediated reactions when they were given a cephalosporin. When the class of cephalosporin was able to be determined, none of the reports of reactions from cephalosporins in patients with allergies to penicillin involved third‐generation cephalosporins. There have been 13 case reports of anaphylaxis from cephalosporins in paediatric patients.

CONCLUSIONS: There are no published case reports of anaphylaxis from cephalosporins in children with anaphylaxis from penicillin, and there are only a small number of such reports in adults. Anaphylaxis from cephalosporins appears to be incredibly rare in children. There is minimal evidence in the literature to support the avoidance of cephalosporins in children with anaphylaxis from penicillins.
Canadian Respirologists’ Experience with Lymphangioleiomyomatosis
Authors: Pollock-BarZiv Stacey M , Cohen Marsha M , Maclean Heather , Downey Gregory P
Published: March 2016

BACKGROUND: Lymphangioleiomyomatosis (LAM) is a rare pulmonary disease occurring primarily in women. A literature review of LAM in Canada found sporadic mention of LAM in case reports or within lung transplant studies. The LAM Foundation, a patient support and research funding organization, lists 23 Canadian patients in its database. The present study was designed to assess the scope of LAM across Canada and to identify potential patients for further evaluation. OBJECTIVES: To ascertain Canadian respirologists’ experience with patients with LAM (current and historical), lung transplantation (single or bilateral) and deaths due to LAM, and awareness of the LAM Foundation.

METHODS: Four hundred twelve brief surveys were sent anonymously to members of the Canadian Lung Association (inserted in their newsletters) to ascertain the experience of Canadian respirologists with LAM.

RESULTS: One hundred twelve surveys were returned (27%). Fifty‐one respondents had ′ever′ been involved in the care of at least one patient with LAM; eight had cared for three or more patients. At the time of the study, 26 respondents were following a total of 46 patients with LAM; 22 of the 51 respirologists (43%) who had ever cared for a patient with LAM reported the death of a patient. Thirty‐three patients had been put on wait lists for transplantation; six died while on the wait list. Nineteen patients underwent lung transplantation ‐ six single‐lung recipients and 13 bilateral lung recipients. Of the 51 respirologists who had ever cared for a patient with LAM, only 30 (61%) were aware of the LAM Foundation’s services. Of the 112 respondents, only 47 (43%) were aware of the LAM Foundation.

CONCLUSIONS: This study identified a moderate level of awareness of a significant existing patient support and research service (the LAM Foundation). There were many patients with LAM who were unknown to the LAM Foundation and could benefit from its resources. Results suggest that there may be more patients with LAM in Canada than are reported in the existing literature.
Evaluation of Asthma Control by Physicians and Patients: Comparison with Current Guidelines
Authors: Boulet Louis-Philippe , Phillips Robert , O’Byrne Paul , Becker Allan
Published: March 2016

BACKGROUND:Current asthma consensus guidelines recommend a series of criteria for determining whether asthma is controlled. It is not known whether physicians are using these criteria to assess treatment needs and how effective such assessments are compared with patient assessment of asthma control.

OBJECTIVE: To compare the parameters used by physicians and patients with asthma to determine whether asthma control is acceptable, according to the current Canadian asthma consensus guidelines.

DATA AND METHODS: A total of 183 Canadian physicians, mostly general practitioners, evaluated 856 patients with mildly to moderately uncontrolled asthma who were not using anti‐inflammatory medications at the time of entry in the study. Physician characteristics and patient demographics were obtained. The physicians completed two questionnaires, one assessing the level of asthma control of the patient on an ordinal scale from 1 (very poor) to 5 (very good) and another indicating the parameters that were used to evaluate this level of control. Patients answered an asthma control questionnaire identical to the one completed by the physician and completed a six‐question asthma control questionnaire, with each question scored on a 0‐ to 6‐point scale.

RESULTS: Although according to current asthma guidelines all patients surveyed had uncontrolled asthma, 66.2% of patients and 43.3% of physicians rated control of asthma symptoms as adequate to very good. The average scores for patient‐ and physician‐rated asthma control were 3.0±0.2 and 2.6±0.2, respectively. The average patient score on the Juniper asthma questionnaire was 12.2±6.3. Physicians used a mean of seven parameters to assess the patient’s level of asthma control, mostly beta2‐agonist need, followed by cough, wheezing, shortness of breath, limitation of physical activities and night‐time awakenings. Pediatricians used cough more frequently as an evaluation parameter, and respirologists measured pulmonary function more often than other physcians. Some parameters not usually included in guideline criteria for control, such as fatigue, need to clear throat, colored sputum, headache and dizziness, were sometimes used by physicians. Only 10% and 18% of physicians used measurements of forced expiratory volume in 1 s and peak expiratory flow, respectively, in asthma control assessments.

CONCLUSIONS: The present study shows that the selection of asthma control criteria among physicians varies and is not always in keeping with current asthma guidelines. Both patients and physicians often consider asthma to be controlled, when according to current guidelines, it is not, and patients consider their asthma better controlled than do physicians. Objective measures of airflow obstruction are rarely used to assess asthma control. The present study stresses the need for improved dissemination ‐ to both patients and physicians ‐ of current recommendations on how asthma control should be determined.
Research 2002‐2003: Canadian Thoracic Society Fellowship Awards
Authors: Canadian Thoracic Society
Published: March 2016

CTS Announcements
Outbreak of Escherichia coli O157:H7 Related to Animal Contact at a Petting Zoo
Authors: Warshawsky Bryna , Gutmanis Iris , Henry Bonnie , Dow Joanne , Reffle Jim , Pollett Graham , Ahmed Rafiq , Aldom John , Alves David , Chagla Abdul , Ciebin Bruce , Kolbe Faron , Jamieson Frances , Rodgers Frank
Published: March 2016

OBJECTIVE: To determine the cause of an outbreak of Escherichia coli 0157:H7 related to animal exposures so that further transmission could be prevented.

DESIGN: Description of laboratory investigations and a case control study.

SETTING: Agricultural pavilion at an annual fair in Ontario.

POPULATION: People with laboratory evidence of E coli 0157:H7 (seven people) and others with diarrhea (155 people) who called the health unit following a media release were interviewed. Animals that were accessed most frequently by the public in the agriculture pavilion were tested for E coli 0157:H7. In the case control study, a case was defined as someone with laboratory‐confirmed E coli 0157:H7, or someone who developed severe or bloody diarrhea two to eight days after attending the agricultural pavilion at the fair (61 people). A convenience sample of people who attended the agricultural pavilion but did not develop diarrhea was selected as the control group (89 people).

INTERVENTIONS: Human and animal E coli 0157:H7 specimens were subtyped. Cases and controls were interviewed using a standardized questionnaire.

RESULTS: Subtyping of the seven human isolates of E coli 0157:H7 revealed five that were of an extremely uncommon phage type. Three samples from goats and one from sheep at the petting zoo in the agricultural pavilion were of this same phage type. The case control study also implicated goats (odds ratio [OR] 3.65; 95% CI 1.63 to 8.52) and sheep (OR 2.94; 95% CI 1.33 to 6.57) from the petting zoo.

CONCLUSIONS: Results of this investigation suggest strongly that the goats and sheep from the petting zoo were the source of this outbreak of E coli 0157:H7.
Blastomyscosis Acquired by Three Children in Toronto
Authors: Bernstein Stacey , Brunner Hermine I , Summerbell Richard , Allen Upton , Babyn Paul , Richardson Susan E
Published: March 2016

Three paediatric cases of blastomycosis, apparently acquired in or near Toronto, Ontario, a region not known to be endemic for this disease, are described. Blastomycosis was not suspected clinically in any of the three cases, and the diagnosis was established only when the diagnostic net was broadened to include fungal and mycobacterial cultures. All three patients were diagnosed after significant delays, which is consistent with the rarity of the disease in children and its acquisition outside previously accepted geographical boundaries. Pulmonary involvement was present in all three children, while one also had multifocal osteomyelitis. Drug therapy was successful in all three cases, either with amphotericin B followed by itraconazole, or itraconazole alone. Blastomycosis should be included in the differential diagnosis of a patient from the Toronto area who presents with a compatible history despite a negative travel history to known endemic zones.
Three‐Year Follow‐Up of protection Rates in Children Given Varicella Vaccine
Authors: Scheifele David W , Halperin Scott A , Diaz-Mitoma Francisco
Published: March 2016

OBJECTIVE: To determine the rate and severity of subsequent varicella and zoster among children given a varicella vaccine.

DESIGN: Retrospective survey conducted three years after vaccination, using standardized telephone interviews.

SETTING: Three urban Canadian centres (Halifax, Ottawa and Vancouver).

pARTICIpANTS: Of 475 eligible children, 431 aged three to 15 years participated.

INTERVENTION: participants had received one dose of a live, attenuated varicella vaccine (Oka/GSK) an average of 36 months earlier.

MAIN OUTCOME MEASURES: Interviewers asked about known varicella exposures and obtained descriptions of any illnesses reported as varicella or zoster. Reported varicella was classified as definite (vesicles present, physician confirmation), probable (vesicles reported), suspected (nonvesicular rash, recent contact with varicella) or unlikely (nonvesicular rash, no known contact).

RESULTS: parents reported 257 within‐home exposures to varicella and alleged that 80 subjects had had varicella rash after exposure. Of these, 40 cases were classified as definite or probable (vesicles present; rate 9.3% or 3.1% per year on average), 31 as suspected (no vesicles; rate 2.4% per year) and nine as unlikely. All rash illnesses were mild: among children with vesicles, 75% were said to have up to 10 and none had more than 100. The outcome of 76 exposures to household members with varicella was evaluable: 25 (32.9%) resulted in a rash, and 13 (17.1%) of those involved vesicles (maximum 40 lesions). parents alleged that three subjects had zoster, but only one illness was definite (six vesicles, physician confirmed).

CONCLUSIONS: Varicella vaccination completely prevented the development of typical chickenpox during the three years of observation. Breakthrough infections were infrequent (about 5% per year) and mild. Zoster was rare.
Long‐Term Survival in a Patient with Pulmonary Lymphangioleiomyomatosis
Authors: Reid John K , Rees Henrike , Cockcroft Donald
Published: March 2016

A patient with pulmonary lymphangioleiomyomatosis was diagnosed more than 22 years after the onset of symptoms by a thoracoscopic lung biopsy, after a high resolution computerized tomogram of the chest was highly suggestive of the disease. After nearly 30 years since the onset of her symptoms, the patient leads a relatively normal life with only mildly abnormal lung function and has minimal reduction in her exercise tolerance. There have been few reports of patients surviving for such a long time after the onset of this disease; the literature suggests that most patients die within 15 years of symptom onset.
The Effects of Exposure to Repeated Minor Pain During the Neonatal Period on Formalin Pain Behavior and Thermal Withdrawal Latencies
Authors: Johnston C Celeste , Walker Claire-Dominique
Published: March 2016

Preterm infants undergoing untreated, repeated painful procedures as part of their early experience are more likely to behave differently to pain as they mature than infants who were born at term and did not experience excessive exogenous pain. The neonatal rat model was used to investigate the short‐ and long‐term effects of repeated pain in infancy on later development of pain responses. Newborn rat pups were randomly assigned by litter to be left unhandled (UH), handled by being removed from the dam for 15 min four times daily (H), and being handled and receiving pain from a paw prick with a 26G needle four times daily (P)on postnatal days (PD) 2 through 8 (PD2‐PD8). Maternal behaviour and grooming of pups on their return to the nest were recorded at PD6 for H and P pups. At PD15, PD36 and PD65, animals were first tested for latency to thermal stimulation threshold using the Hargreaves test and then for inflammatory pain using the formalin test. Pups in the HP group received significantly more grooming from their mothers (359 s) than pups in the H group (295 s, P<0.0001). When accounting for differences in maternal grooming, a decreased thermal threshold in the P group compared with the H group (6.04 s versus 5.3 s, P<0.05) was found, although the correlations were not significant between maternal grooming and thermal thresholds. No group differences were seen with the formalin test. Interestingly, age was a significant factor in both tests, with younger animals showing fewer pain behaviours regardless of group or maternal grooming of the pup. Sex was significant at one age only in latency to thermal stimulation testing. The results suggest that changes in maternal care may be an important factor mediating the long‐term effects of repeated neonatal experiences of pain.
Food Safety and Foodborne Disease in the 21st Century
Authors: Scott Elizabeth
Published: March 2016

Over the past decade there has been a growing recognition of the involvement of the home in several public health and hygiene issues. Perhaps the best understood of these issues is the role of the home in the transmission and acquisition of foodborne disease. The incidence of foodborne disease is increasing globally. Although foodborne disease data collection systems often miss the mass of home‐based outbreaks of sporadic infection, it is now accepted that many cases of foodborne illness occur as a result of improper food handling and preparation by consumers in their own kitchens. Some of the most compelling evidence has come from the international data on Salmonella species and Campylobacter species infections.

By its very nature, the home is a multifunctional setting and this directly impacts upon the need for better food safety in the home. In particular, the growing population of elderly and other immnocompromised individuals living at home who are likely to be more vulnerable to the impact of foodborne disease is an important aspect to consider. In addition, some developed nations are currently undergoing a dramatic shift in healthcare delivery, resulting in millions of patients nursed at home. Other aspects of the home that are unique in terms of food safety are the use of the home as a daycare centre for preschool age children, the presence of domestic animals in the home and the use of the domestic kitchen for small‐scale commercial catering operations. At the global level, domestic food safety issues for the 21st century include the continued globalization of the food supply, the impact of international travel and tourism, and the impact of foodborne disease on developing nations.

A number of countries have launched national campaigns to reduce the burden of foodborne disease, including alerting consumers to the need to practice food safety at home. Home hygiene practice and consumer hygiene products are being refined and targeted to areas of risk, including preventing the onward transmission of foodborne illness via the inanimate environment. It has been said that food safety in the home is the last line of defense against foodborne disease, and it is likely that this will remain true for the global population in the foreseeable future.
Treatment Strategies for Chronic Cases
Authors: Lord Susan M
Published: March 2016

The treatment of chronic somatic pain, including pain referred to the head, neck, shoulder girdle and upper limb from somatic structures, is addressed. Levels of evidence for the various treatments that have been prescribed for chronic whiplash associated disorders are considered. The challenge to find a treatment strategy for chronic pain after whiplash that completely relieves the condition and prevents its sequelae is reviewed.
Correlation between Exposure to Bomechanical Stress and Whiplash Associated Disorders (WAD)
Authors: Castro William HM
Published: March 2016

One of the most discussed questions in WAD is: can an injury of the cervical spine occur in low velocity collisions? Before this question can be answered, the term ′low velocity′ and the kind of collisions must first be defined. From the study of Meyer et al. (1994) it is known that the speed change due to collision, Dv, is a suitable parameter to express the biomechanical stress acting on a person in a car collision. This study also showed that from a biomechanical point of view, a bumper car collision is comparable to a normal car collision. In the case of a rear‐end collision, Meyer et al. found that the biomechanical stress acting on persons exposed to bumper car collisions (Dv) at a fun fair in Germany can be as high as 15 km/h. In literature, one case could be found of an 8‐year‐old girl with ′whiplash′ after being exposed to a bumper car collision at a fun fair (Kamieth 1990). In the Netherlands, a 13‐year survey of persons who were admitted to emergency units of hospitals by the ′Consument en Veiligheid′ foundation, showed 14 persons with WAD complaints after being exposed to bumper car collisions at a fun fair. In comparison to the enormous amounts of bumper car collisions, these figures are negligible. With regard to these data, one could argue that low velocity collisions can be defined as those where Dv is below 15 km/h. However, it should be noted that the kind of collision is important. From the work of Becke et al. (1999) and Becke and Castro (2000), we know that in side collisions with a Dv of just 3 km/h, head contact with the side window of the car is possible; it can be expected that in such cases the cervical spine will also be exposed to some biomechanical stress (notice however, that not every head contact is automatically equal to an injury of the cervical spine!). In conclusion, before using expressions like ′low velocity collisions′, its definition with regard to Dv as well as the kind of collision, has to be discussed. With regard to the most common collisions that causes WAD, rear‐end collisions, low velocity collisions can arguably be defined as collisions where Dv is below 15 km/h (this is for clarity, and does not mean that those collisions can not cause symptoms; this will be discussed later!).
Oral Topical Doxepin Rinse: Anesthetic Effect in Normal Subjects
Authors: Epstein Joel B , Truelove Edmond L , Oien Hal , Le Nhu D , Epstein Mathew S
Published: March 2016

Oral doxepin rinse has been reported to provide pain relief in patients with oral mucosal lesions due to cancer or cancer therapy. The purpose of this study was to assess the anesthetic effect of doxepin oral rinse in normal subjects to identify the duration of effect and to contrast the anesthetic effect with reported pain relief in patients with oral mucosal lesions. Normal volunteers were provided a solution of doxepin (5 mg/mL) for oral rinsing. Oral numbness and adverse effects were recorded for a period of 4 h after rinsing. Doxepin rinse resulted in mucosal anesthesia in all subjects. Sedation/fatigue was reported in four of seven subjects. There were no taste complaints and no nausea reported. The limited duration of numbness/anesthesia in normal subjects compared with prior studies showing pain relief for more than 3 h in patients with mucosal lesions, suggests that the extended duration of pain relief in patients was due to analgesic effects rather than anesthetic effects. The majority of normal subjects reported sedation after use, but this was less common in patients with mucosal lesions.