bluuebunny/crossref_metadata_2025 huggingface dataset:
In Vitro Activity of Cefepime against Multidrug‐Resistant Gram‐Negative Bacilli, Viridans Group Streptococci and Streptococcus pneumoniae from a Cross‐Canada Surveillance Study
Authors: Low Donald E , de Azavedo Joyce , Canadian Bacterial Surveillance Network  , Davidson Ross
Published: March 2016

OBJECTIVE: To determine the in vitro activity of cefepime against multidrug‐resistant Gram‐negative bacilli and Gram‐positive cocci obtained from an ongoing cross‐Canada surveillance study.

DESIGN: Clinical isolates of aerobic Gram‐negative bacilli with inducible and constitutive chromosomally mediated cephalosporinases, viridans group streptococci and Streptococcus pneumoniae were collected from laboratories serving hospitals, nursing homes and physician offices in the community from across Canada during 1996 and 1997. Laboratories were asked to submit only clinically relevant nonduplicate isolates for susceptibility testing. In vitro antimicrobial susceptibility testing was carried out on all isolates of Gram‐negative and viridans group streptococci. S pneumoniae were characterized as penicillin susceptible, intermediately resistant or highly resistant. Nonsusceptible isolates were defined as being intermediately or highly resistant (minimal inhibitory concentrations [MIC] greater than 0.06 mg/L). Only isolates of S pneumoniae that were nonsusceptible to penicillin were selected for further study. MICs were determined using a microbroth dilution technique according to the National Committee of Clinical Laboratory Standards.

RESULTS: A total of 727 Gram‐negative bacilli samples were collected. No resistance to cefepime was detected with Citrobacter freundii, Serratia marcescens, Morganella morganii and Enterobacter species. Of these strains, Enterobacter species and C freundii were the most resistant to ceftazidime, cefotaxime and ceftriaxone with MIC90S of 32 mg/L or greater and resistance rates of 6% or greater. Resistance rates of Pseudomonas aeruginosa and Acinetobacter species to cefepime were 4.8% and 3%, respectively. The two organisms had similar rates of resistance to ceftazidime. Less than 3% of the Gram‐negative bacilli were resistant to imipenem and meropenem. There were 153 viridans group streptococci, of which 22 (14.4%) were resistant to penicillin. Of 1287 S pneumoniae samples, 193 (15%) were nonsusceptible to penicillin. Cefepime, ceftriaxone and cefotaxime had comparable activity against all isolates of viridans group streptococci and S pneumoniae.

CONCLUSIONS: Cefepime demonstrated excellent in vitro activity against Gram‐negative bacilli with inducible and constitutive chromosomally mediated cephalosporinases, and had equal or superior activity versus comparator beta‐lactams against all isolates of viridans group streptococci and S pneumoniae.
What Do Nurses and Residents Know about Childhood Asthma?
Authors: Lemay Jean-François , Moore Sean I , Zegray Michele , Ducharme Francine M
Published: March 2016

OBJECTIVES: To assess residents’ and pediatric nurses’ basic knowledge of childhood asthma and to identify areas needing educational reinforcement.

DESIGN: Survey using a validated self‐administered questionnaire containing 25 true‐false and six short open‐ended questions.

PARTICIPANTS: Pediatric residents and family medicine residents who were on rotation at a tertiary care pediatric hospital over a six‐month period, and pediatric nurses on duty in the emergency department, on the wards and on the pediatric intensive care unit over a month period.

RESULTS: The participation rate was 80% (28 of 35) of pediatric residents, 89% (33 of 37) of family medicine residents, and 50% (81 of 163) of pediatric nurses. The mean score (± standard deviation) on the 31‐point questionnaire was 27.7±1.8 for pediatric residents, 25.5±3.6 for family medicine residents, and 22.3±3.8 for pediatric nurses (ANOVA, P<0.001). Most (at least 75%) participants correctly identified bronchospasm and airway inflammation as two potential mechanisms of asthma and were able to list three routinely used drugs to treat exacerbations. However, 32% of pediatric residents, 12% of family medicine residents and 72% of pediatric nurses failed to identify all three main symptoms of asthma (wheezing, cough, dyspnea). Although most participants recognized that children with frequent exacerbations should receive prophylactic therapy, 25% of pediatric residents, 52% of family medicine residents and 81% of pediatric nurses were unable to name at least two preventive asthma medications. More than 50% of participants could not name two drugs used in the prevention of exercise‐induced asthma.

CONCLUSIONS: Residents and nurses had adequate basic knowledge of the treatment of acute exacerbations. However, most individuals needed reinforcement in preventive asthma therapy and daily management.
Delayed Diaphragmatic Herniation Masquerading as a Complicated Parapneumonic Effusion
Authors: Tsang John , Ryan Frank
Published: March 2016

Injury to the diaphragm following blunt or penetrating thoraco‐abdominal trauma is not uncommon. Recognition of this important complication of trauma continues to be a challenge because of the lack of specific clinical and plain radiographic features, the frequent presence of other serious injuries and the potential for delayed presentation. Delayed diaphragmatic herniation often presents with catastrophic bowel obstruction or strangulation. Early recognition of diaphragmatic injury is required to avoid this potentially lethal complication. The case of a 35‐year‐old man with a history of a knife wound to the left flank 15 years previously, who presented with unexplained acute hypoxemic respiratory failure and a unilateral exudative pleural effusion that was refractory to tube thoracostomy drainage, is reported. After admission to hospital, he developed gross dilation of his colon; emergency laparotomy revealed an incarcerated colonic herniation into the left hemithorax. Interesting clinical features of this patient′s case included the patient′s hobby of weightlifting, a persistently deviated mediastinum despite drainage of the pleural effusion and deceptive pleural fluid biochemical indices.
The New Fluoroquinolones: A Critical Review
Authors: Zhanel George G , Walkty Andrew , Vercaigne Lavern , Karlowsky James A , Embil John , Gin Alfred S , Hoban Daryl J
Published: March 2016

OBJECTIVE: This paper reviews the literature available on the new fluoroquinolones – clinafloxacin, gatifloxacin, grepafloxacin, levofloxacin, moxifloxacin, sparfloxacin and trovafloxacin – to compare these agents with each other and contrast them with ciprofloxacin, an older fluoroquinolone.

DATA SELECTION: Published papers used were obtained by searching MEDLINE for articles published between 1994 and 1998, inclusive. References of published papers were also obtained and reviewed. Abstracts from scientific proceedings were reviewed.

DATA EXTRACTION: Due to the limited data available on several of the agents, criteria for study inclusion in the in vitro, pharmacokinetics and in vivo sections were not restrictive.

DATA SYNTHESIS: The new fluoroquinolones offer excellent Gram‐negative bacillary activity and improved Gram‐positive activity (eg, against Streptococcus pneumoniae and Staphylococcus aureus) over ciprofloxacin. Clinafloxacin, gatifloxacin, moxifloxacin, sparfloxacin and trovafloxacin display improved activity against anaerobes (eg, Bacteriodes fragilis). All of the new fluoroquinolones have a longer serum half‐life than ciprofloxacin (allowing for once daily dosing), and several are eliminated predominantly by nonrenal means. No clinical trials are available comparing the new fluoroquinolones with each other. Clinical trials comparing the new fluoroquinolones with standard therapy have demonstrated good efficacy in a variety of infections. Their adverse effect profile is similar to that of ciprofloxacin. Clinafloxacin and sparfloxacin cause a high incidence of phototoxicity (1.5% to 14% and 2% to 11.7%, respectively), grepafloxacin causes a high incidence of taste perversion (9% to 17%) and trovafloxacin causes a high incidence of dizziness (11%). They all interact with metal ion‐containing drugs (eg, antacids), and clinafloxacin and grepafloxacin interact with theophylline. The new fluoroquinolones are expensive; however, their use may result in savings in situations where, because of their potent and broad spectrum of activity, they can be used orally in place of intravenous antibiotics.

CONCLUSIONS: The new fluoroquinolones offer advantages over ciprofloxacin in terms of improved in vitro activity and pharmacokinetics. Whether these advantages translate into improved clinical outcomes is presently unknown. The new fluoroquinolones have the potential to emerge as important therapeutic agents in the treatment of respiratory tract and genitourinary tract infections.
Concurrent Neonatal Proteus mirabilis Infection in Dizygotic Twins
Authors: Sung Lillian , MacDonald Noni E , Hutchison James S
Published: March 2016

A case of concomitant infection with Proteus mirabilis in dizygotic twin neonates is presented. The first twin presented with meningitis and septic shock at eight days of age and subsequently died. An investigation of the asymptomatic second twin revealed a urinary tract infection that resolved with antimicrobial therapy. It is recommend that when infection with this virulent organism is diagnosed in one twin, the second twin should be fully evaluated for sepsis and empirical antimicrobial therapy should be considered.
Particulate Air Pollution from Motor Vehicles: A Putative Proallergic Hazard?
Authors: Polosa Riccardo , Salvi Sundeep
Published: March 2016

Air pollution generated from motor vehicle exhaust has become a major cause for scientific and public concern worldwide over recent years. The rapid and marked increase in the motor vehicle traffic and its associated emissions in urban areas have paralleled a sharp increase in the prevalence of allergic diseases such as asthma and rhinitis. Epidemiological studies have demonstrated a strong association between people living in close proximity to roads with high traffic density and increased allergic symptoms, reduced lung function and increased sensitization to common aeroallergens. Several laboratory‐based studies have demonstrated that pollutants emitted from motor vehicles can induce allergic inflammation and increase airway hyperresponsiveness, which may provide an underlying mechanism for the increasing prevalence of allergic diseases. Although the detrimental effects of air pollution on human health have been brought to public attention, it appears that less attention has been given to the potential role of road traffic fumes in the induction of the allergic state. Legislators should consider pollutants emitted from motor vehicle exhausts as a potential pro‐allergic hazard, before making important changes in environmental policy.
Bronchial Mucus Properties in Lung Cancer: Relationship with Site of Lesion
Authors: Zayas J Gustavo , Rubin Bruce K , York Ernest L , Lien Dale C , King Malcolm
Published: March 2016

OBJECTIVE: To compare the biophysical properties of mucus from the left and right mainstem bronchi in patients undergoing diagnostic bronchoscopy because of a unilateral radiological abnormality. It was hypothesized that abnormalities in the properties of mucus would be greater on the side with the lesion and that this would be most obvious in patients with unilateral lung cancer.

PATIENTS AND METHODS: Bilateral paired samples of bronchial mucus were taken from 38 nonatopic patients (aged 59.8±12.6 years) including 16 nonsmokers, 14 current smokers and eight exsmokers (more than one year). Twenty of the 38 patients had a radiologically defined unilateral abnormality. Eight of these 20, including one nonsmoker, had lung cancer. The viscoelastic properties of the collected mucus were determined by magnetic microrheometry, and the analysis was carried out without knowledge of the histological diagnosis or source.

RESULTS: The rheological properties of mucus strongly suggested which was the abnormal side. Within the group of 20 patients with a unilateral radiological abnormality, mucus from the side of the lesion had a lower value of the loss tangent, tan δ100 (P=0.004), indicating greater mucus recoil. This is consistent with poor mucus cough clearability on the lesion side. All eight cancer patients fit this mucus rheological pattern with a lower value of tan δ100 on the affected side (P=0.007). Four of the five other patients with a similar mucus abnormality were categorized as high cancer risk by other criteria, while six of seven patients with mucus that did not have this abnormality were considered to be lower risk. Based on the mucus analysis done at the time of the bronchoscopy, two of the ‘noncancer’ patients initially designated as high risk had cancer detected after several months of follow‐up. Only two of the 18 patients without a defined unilateral lesion fit the mucus ‘cancer pattern’.

CONCLUSIONS: These findings are consistent with the hypothesis that either abnormalities in mucus properties may represent a risk factor for the development of lung cancer or that bronchial mucus abnormalities may be associated with products secreted by the tumours that, in turn, may suppress mucus clearance.
Management of Exercise‐Induced Bronchoconstriction
Authors: Inman Mark D
Published: March 2016

Exercise‐induced bronchoconstriction (EIB) is a common clinical manifestation of asthma, occurring in 70% to 80% of asthmatics. Evidence suggests that exercise and the ensuing bronchoconstriction do not contribute to a worsening of asthmatic inflammation. Asthmatics should not be discouraged from exercising, and, with adequate management, most patients should be able to exercise regularly with only minor symptoms. The first step in the management of patients with EIB should be to obtain optimum control of the underlying asthma, often requiring regular treatment with inhaled steroids. Regular treatment with inhaled corticosteroids usually reduces the extent of EIB by 50% or more. Frequently, despite optimal management of the underlying asthma, patients develop EIB symptoms requiring additional treatment. Short and long acting inhaled beta2‐agonists are highly effective at reducing the magnitude of EIB, although there are concerns that the extent of protection diminishes during periods of regular use of these agents. Inhaled cromolyn and nedocromyl are effective at reducing the extent of EIB in some patients, although this protection does not extend beyond 2 to 3 h after treatment. The recently developed leukotriene receptor antagonists are effective at reducing the extent of EIB by 40% to 70%, and have the advantage that this protection lasts throughout the day and does not appear to diminish with regular use. Other agents, including anticholinergics and antihistamines, have been shown to offer partial protection against EIB, suggesting the possibility of using a combination treatment to manage some patients’ symptoms. Finally, there is encouraging evidence suggesting that modifications of the pattern of exercise can markedly reduce the extent of EIB.
Scedosporium prolificans Fungemia
Authors: Elsayed Sameer , Lannigan Robert , Chin-Yee Ian
Published: March 2016

Fungemia due to Scedosporium prolificans is described in a young woman with a relapse of acute lymphoblastic leukemia. Several days after starting reinduction chemotherapy, the patient presented with fever, neutropenia and blood cultures showing fungi on Gram stain. The patient died despite therapy with antifungal agents, including fluconazole and amphotericin B. Fungi grew from blood cultures, and was subsequently identified as Scedosporium prolificans.
Leukotriene Receptor Antagonists and Related Compounds
Authors: Wenzel Sally E
Published: March 2016

Leukotrienes (LTs), lipid mediators of inflammation, have proved to be important biochemicals involved in the symptoms and physiological changes of asthma. In the past year and a half, the development of three new drugs that modulate the LT pathway has been completed. The first subclass of these drugs, leukotriene receptor antagonists (LTRA) (zafirlukast and montelukast), blocks the interaction of the cysteinyl form of the LTs with the cell type bearing the receptor. The second subclass, the 5‐lipoxygenase (5‐LO) inhibitors (zileuton) inhibits the 5‐LO enzyme, which prevents the formation of both cysteinyl LTs and LTB4. The LT modulators have shown efficacy in inhibiting the physiological changes occurring after allergen, acetylsalicylic acid and exercise challenge in asthmatics. In addition, they have shown efficacy in improving symptoms, beta‐agonist use and forced expiratory volume in 1 s (FEV1) in chronic, ‘day‐to‐day’ asthma in patients with mild disease. Comparison studies with low doses of inhaled corticosteroids suggest that LT modulators may have similar effects on symptom scores and beta‐agonist use, but have lesser effects on FEV1. Finally, emerging data suggest that these drugs are beneficial in decreasing the dose of inhaled corticosteroids necessary to control more moderate to severe asthma. While long term studies will be helpful in determining the ‘disease modifying’ effects of these drugs, data suggest that these drugs are useful in the treatment of a broad range of asthmatic patients.
Differential Yield of Pathogens from Stool Testing of Nosocomial versus Community‐Acquired Paediatric Diarrhea
Authors: Deorari Savita , McConnell Athena , Tan Kah-Kee , Jadavji Nadeem , Ma Doreen , Church Deirdre , Katzko Gary , Gall D Grant , Jadavji Taj , Davies H Dele
Published: March 2016

OBJECTIVES: To evaluate the role of routine stool examination for all pathogens in paediatric nosocomial diarrhea (NAD) and community‐acquired diarrhea (CAD) over a two‐year period at Alberta Children’s Hospital and current practices in other Canadian hospitals. A secondary objective was to characterize features that may predict NAD or CAD etiology.

STUDY DESIGN: Retrospective cohort study and telephone survey.

SETTING: Alberta Children’s Hospital (retrospective review) and Canadian tertiary care paediatric centres (telephone survey).

METHODS: The health and microbiological records of all children with an admission or discharge diagnosis of diarrhea were reviewed using a standardized data collection form. In addition, a telephone survey of laboratories serving all paediatric hospitals in Canada was conducted using a standard questionnaire to obtain information about practices for screening for pathogens related to NAD.

RESULTS: Four hundred and thirty‐four CAD episodes and 89 NAD episodes were identified. Overall, rotavirus and Clostridium difficile were the most commonly identified pathogens. Bacterial culture was positive in 10.6% CAD episodes tested, with Escherichia coli O157:H7 identified as the most common non‐C difficile organism. In NAD, no bacteria were identified other than C difficile (toxin). Screening for ova and parasites had negligible yield. Viruses were more frequent in the winter months, while bacterial pathogens were more common in the summer and fall months. Over 50% of Canadian paediatric hospitals still routinely process NAD specimens similarly to CAD specimens.

CONCLUSIONS: There is a need for the re‐evaluation of routine ova and parasite screening, and bacterial culture in nonoutbreak episodes of NAD in children.
Lung Volume Reduction for Emphysema and The Canadian Lung Volume Reduction (CLVR) Surgery Project
Authors: Miller John D , Malthaner Richard A , Goldsmith Charles H , Cox Gerard , Higgins David , Stubbing David , Kitching Allan , Newman Toni E , McDonald Ellen
Published: March 2016

OBJECTIVE: To review the literature on the surgical treatment of emphysema and to present preliminary results from a pilot study of lung volume reduction (LVR) surgery.

DESIGN: Case series of consecutive patients referred for LVR surgery. Outcomes were quality of life, pulmonary function and exercise capacity.

SETTING: Two university‐affiliated hospitals in Ontario.

POPULATION STUDIED: Patients between the ages of 40 and 75 years with emphysema who had severe airflow limitation, hyperinflation of the lungs and impaired quality of life.

INTERVENTION: Bilateral reductions with multiple wedge resections of the lung using a linear stapling device with bovine pericardial buttressing were completed via a median sternotomy.

MAIN RESULTS: Of 50 patients referred, 24 underwent LVR surgery. Mean age of the cohort was 63 years. Operative 30‐day or in hospital mortality was 8%. Two other patients (8%) died from respiratory failure after LVR within the first year. Postoperative complications included prolonged air leaks (six of 24), tracheobronchitis (five of 24), mechanical ventilation (four of 24) and pneumonia (three of 24). Mean length of stay was 18 days (median 12 days). At one year, there was a sustained decrease in total lung capacity from 133% to 123% predicted. There were improvements in forced expiratory volume in 1 s, from 22% of predicted preoperatively to 32% postoperatively, and in 6 min walk performance, from 345 to 381 m. Improvements were also noted in the quality of life assessments.

CONCLUSIONS: Preliminary results suggest that LVR surgery is feasible and may improve the patient’s quality of life, pulmonary function and exercise capacity. A randomized clinical trial comparing LVR plus the best medical management with the best medical management alone is currently underway to determine the effectiveness of LVR.
Distribution of Hepatitis C Virus Genotypes in Canada: Results from the LCDC Sentinel Health Unit Surveillance System
Authors: Chaudhary RK , Tepper M , Eisaadany S , Gully Paul R
Published: March 2016

In a sentinel hepatitis surveillance study conducted by sentinel health units, 1469 patients were enrolled, and 959 (65.3%) were positive for antibody to hepatitis C virus (HCV). Samples from 387 patients (40.4%) were tested for HCV RNA, and 289 (74.7%) were positive for RNA. The major risk factor for HCV infection was injection drug use, reported in 71% of cases. The genotyping of HCV isolates showed that subtype 1a (48%) was predominant in Canada. The other subtypes detected were 1b (19%), 2a (6%), 2b (3%), 3a (22%) and 4a (1%). In Winnipeg, Manitoba, subtype 3a (47%) was more prevalent than subtype 1a (37%), and, in Guelph, Ontario, both subtypes 1a and 3a had equal (40%) distribution. The prevalence of subtype 3a was significantly higher in injection drug users (27%) than in nonusers (10%) (P<0.005). In Canada, injection drug use is the major risk factor for HCV infections, and subtype 1a is more prevalent.
Induced Sputum for the Investigation of Airway Inflammation: Evidence for Its Clinical Application
Authors: Hargreave Frederick E
Published: March 2016

Airway inflammation is considered to be the primary cause of airway diseases. Its prevention and reversal are the primary aims of treatment. Measurement of the inflammation is now possible relatively noninvasively and reliably by using induced sputum cell counts. The differential count indicates the presence and type of the inflammation (eosinophilic or neutrophilic) and the total cell count the intensity. Sputum eosinophilia responds to treatment with corticosteroid, while there is increasing evidence that an isolated neutrophilia does not. Clinical judgement of airway inflammation is made difficult because of the different types of inflammation and their inconsistent correlation with the clinical features. Hence, reliable measurement of induced sputum cell counts may be useful to guide treatment in clinical practice. Consideration should now be given as to how to make it more available.
Treatment of Neuropathic Pain: Focus on Antidepressants, Opioids and Gabapentin
Authors: Watson C Peter N , Watt-Watson Judith H
Published: March 2016

BACKGROUND: The treatment of neuropathic pain continues to be difficult. Randomized, controlled trials (RCTs) provide some evidence to guide therapy. Most data relate to antidepressant therapy, although there is information on anticonvulsants and other treatments. Mistaken beliefs about many of these treatments are prevalent and need to be dispelled. Opioids are increasingly being used for the refractory patient. There has been recent enthusiasm for the anticonvulsant gabapentin for the treatment of these conditions.

OBJECTIVE: To review the positive scientific data that are largely confined to RCTs in two neuropathic pain conditions that have proved to be good models for clinical investigation. These models are postherpetic neuralgia and painful diabetic neuropathy. Negative RCTs, weakly positive RCTs, other types of treatments and neuropathic conditions are also examined.

METHODS: This review of the literature used MEDLINE, CINAHL and the Cochrane Database.

RESULTS: There is extensive literature supporting the use of the older generation antidepressants, such as amitriptyline, in neuropathic pain. Newer RCTs support the use of gabapentin and opioids. Other therapies may be useful in individual cases on a trial and error basis but are largely unsupported by RCTs at this time.  

CONCLUSIONS: First‐line therapy for neuropathic pain may be either an older generation antidepressant, such as amitriptyline or nortriptyline, or the anticonvulsant gabapentin. A variety of trial and error approaches may be used, none of which has sound scientific approval. For refractory patients, chronic opioid therapy may be the only avenue of relief, and evidence is accumulating that this approach is safe if proper guidelines are observed. The possibility that some types of neuropathic pain may be prevented is exciting. Progress in the treatment of neuropathic pain has been slow but steady, and there continues to be a need to explore newer agents and approaches.
Surgical Management of Lung Gangrene
Authors: Krishnadasan Baiya , Sherbin Vandy L , Vallières Eric , Karmy-Jones Riyad
Published: March 2016

OBJECTIVE:To review the outcomes of five cases of pulmonary resection for lung gangrene.

DESIGN:A retrospective chart review.

SETTING:A tertiary referral centre.

POPULATION STUDIED:Five patients who underwent pulmonary resection for lung gangrene between April and December 1999.

MAIN RESULTS:Pathological confirmation of lung gangrene was obtained in all cases. Three patients were ventilator dependent. All five patients had ongoing sepsis despite antibiotic therapy. Additional indications for resection included bronchopleural fistula (two patients), empyema (three patients) and hemoptysis (one patient). In two cases, there was evidence of bilateral, diffuse necrotizing pneumonia, while in three cases the process was localized to one side. Computed tomography revealed cavitation in four cases and the absence of blood supply to the affected lung in one case. Surgical resection included wedge resection (one patient), lobectomy (two patients), bilobectomy (one patient) and pneumonectomy (one patient). In all cases, the bronchial stump was reinforced with an intercostal flap. Postoperative empyema occurred in two cases, one treated by thoracoscopic decortication, the other by percutaneous drainage. There were no instances of stump leak and no deaths. One patient remains ventilator dependent.

CONCLUSIONS:Resection for lung gangrene is possible even in the setting of diffuse parenchymal changes and ventilator dependency. A computed tomography scan of the chest is important to make the diagnosis of lung gangrene and to plan operative management. Reinforcement of the bronchial stump is critical.
Population‐Based Surveillance of HiB Invasive Infections in Children in British Columbia, Alberta and Ontario ‐‐ 1995 to 1997
Authors: Scheifele David , Bell Alison , Jadavji Taj , Vaudry Wendy , Waters John , Naus Monika , Sciberras Jill
Published: March 2016

OBJECTIVE: To assess vaccine effectiveness through enhanced disease surveillance following the change in childhood immunization programs in 1995, when all provinces and territories chose to use polyribosyl ribitol phosphate‐tetanus protein (PRP‐T) Haemophilus influenzae type b (Hib) conjugate vaccine, generally in combination with diphtheria‐pertussis‐tetanus inactivated polio vaccine (DPT‐IPV) (as PENTA vaccine) because the protective efficacy of this regimen had not been directly measured.

DESIGN: Prospective, active, laboratory‐based Hib case surveillance was implemented in British Columbia and Alberta, and enhanced, stimulated laboratory surveillance in Ontario during 1995 to 1997, centred on invasive infections in children. Case details and immunization histories were uniformly collected and centrally collated.

MAIN RESULTS: Thirty‐eight Hib cases were detected, but only 12 cases arose among PENTA‐eligible children, an attack rate of 0.85 cases/100,000 child‐years of observation. Annual case totals declined from 20 in 1995 to seven in 1997, when only one to three cases were encountered in each province and the incidence rate in children under age five years was 0.6/100,000. Only four cases occurred after primary immunization with PENTA, a failure rate of 0.28 cases/100,000 child‐years of observation. Three cases among PENTA‐eligible children reflected parental refusal of infant vaccinations, accounting for 25% of cases in eligible children.

CONCLUSIONS: PRP‐T conjugate vaccine was highly effective when given in combination with DPT‐IPV vaccine. Provincial programs that used this regimen resulted in the near elimination of invasive Hib disease in children, but unimmunized children remain at risk.
And a Good Time Was Had by All!
Authors: Jones Norman L
Published: March 2016

As I write this, the American Thoracic Society 2000 meeting held in Toronto has been over for a week. From every point of view it seems to have been a great success. While having the drawbacks of very large meetings, with some tiresome separation between different sessions, one could not complain about the depth of coverage, with over 6000 poster and slide presentations. I was particularly impressed with the number of senior researchers who took part and demonstrated amply that they were not merely names from the past but had much to offer research fellows, especially on a one‐to‐one basis. One could find standing in front of a poster ‐‐ Sol Permutt, Bob Hyatt, John West, Ann Woolcock, Neil Pride and many others who gave freely of their time, experience and wisdom. There can be no better meeting showcasing international respiratory research from all over the globe. The Canadian Thoracic Society (CTS) was prominent in the organization and presentation, and deserves to feel proud of the meeting′s success; the Society′s annual dinner was well and enthusiastically attended. At the dinner, Dr Clarence Guenter gave the Christie Lecture, which will appear in the Journal before the end of the year.
Number 3: Chronic Obstructive Pulmonary Disease ‐‐ Stopping Smoking: It is Never Too Late
Authors: Wilson Douglas MC
Published: March 2016

Smoking is the main cause of chronic obstructive pulmonary disease, and the function of the lungs in smokers deteriorates with time at a much faster rate than in nonsmokers or ex‐smokers. Smokers with chronic lung disease can often function better, breathe more easily and cough less, just by stopping smoking. They require less medication (puffers, etc) and the deterioration of lung function is slowed. Within 24 h, the amount of carbon monoxide in the lungs and blood returns to normal, allowing more oxygen to supply body functions.
Asthma Management in the Emergency Department
Authors: Reid John , Marciniuk Darcy D , Cockcroft Donald W
Published: March 2016

OBJECTIVES: To evaluate various aspects of the management of adult patients who present to the emergency department with acute exacerbations of asthma and who are discharged from the emergency department without hospital admission. Further, to compare the results with accepted management guidelines for the emergency department treatment of asthma.

DESIGN: A retrospective chart collection and review until each site contributed 50 patients to the survey.

SETTING: Three tertiary care hospitals in the Saskatoon Health District, Saskatoon, Saskatchewan. The study period was from July 1, 1997 to November 18, 1997.

POPULATION: Patients aged 17 years or older, who were discharged from the emergency department with the diagnosis of asthma.

METHODS: Data were collected on 130 patients from 147 emergency department visits.

RESULTS: A number of important physical examination findings were frequently not documented. In contrast to management guidelines, peak expiratory flow rates (44%) and spirometry (1%) were not commonly used in patient assessments. Only 59% of patients received treatment in the emergency departments with inhaled or systemic corticosteroids. Furthermore, specific follow‐up plans were infrequently documented in the emergency department charts (37%).

CONCLUSIONS: Adherence with published Canadian guidelines for the emergency department management of acute asthma exacerbations was suboptimal. Corticosteroid use in the emergency department was significantly less than recommended. Increased emphasis on education and implementation of accepted asthma management guidelines is necessary.
The Doctor′s Dilemma: Oranges or Apples?
Authors: Jones Norman L
Published: March 2016

George Bernard Shaw′s famous play, Doctor′s Dilemma (1), is one of the attractions at the Shaw Festival this year, and recently we went to see it on a beautiful Niagara summer day, followed by a picnic beside Ball′s Falls. Several weeks earlier, I had decided to read the play, with its 80‐page "Preface on Doctors", and was prepared for an anticlimactic experience on the day. However, the production was a delight and I gained additional insights from the live performance.
Low Prevalence of VRE Gastrointestinal Colonization of Hospitalized Patients in Manitoba Tertiary Care and Community Hospitals
Authors: Zhanel George G , Harding Godfrey KM , Rosser Stuart , Hoban Daryl J , Karlowsky James A , Alfa Michelle , Kabani Amin , Embil John , Gin Alfred , Williams Trevor , Nicolle Lindsay E
Published: March 2016

OBJECTIVE: To determine the prevalence of vancomycin‐resistant enterococci (VRE) bowel colonization in hospitalized patients in Manitoba who had stool specimens collected for Clostridium difficile toxin and/or culture testing.

DESIGN: Two tertiary care and five community hospitals in Winnipeg and three rural Manitoba community hospitals participated in this study. From January 1 to December 31, 1997 stool specimens, one per patient, submitted to hospital microbiology laboratories for C difficile toxin and/or culture testing were screened for VRE on colistin‐nalidixic acid‐vancomycin (6 g/mL) (CNAV) agar plates. The study was divided into six, eight‐week intervals. Stool specimens received in the first two weeks of each eight week interval were screened for VRE.

MAIN RESULTS A total of 1408 stool specimens were submitted over the 48‐week study period. Sixty‐seven (4.8%) patients with VRE colonization of their lower gastrointestinal tract were identified. Three of the 67 (4.5%) VRE isolates were Enterococcus faecium, with the remaining 64 (95.5%) were Enterococcus gallinarum. The three vancomycin‐resistant E faecium (VREF) (from two different Winnipeg hospitals) demonstrated the vanA genotype, and were resistant to vancomycin, teicoplanin and ampicillin. All three VREF isolates also demonstrated high level resistance to both gentamicin and streptomycin but were susceptible to quinuprisitin/dalfopristin and LY333328.

CONCLUSION: VRE colonization in hospitalized patients in Manitoba is infrequent and most commonly due to E gallinarum. The prevalence of VREF colonization in the patients studied was 0.2% (three of 1408).
How Novel Methods Can Help Discover More Information about Foodborne Pathogens
Authors: Griffiths Mansel W
Published: March 2016

Considerable emphasis is being placed on quantitative risk assessment modelling as a basis for regulation of trade in food products. However, for models to be accurate, information about the behaviour of potential pathogens in foods needs to be available. The question is how to obtain this knowledge in a simple and cost effective way. One technique that has great potential is the use of reporter bacteria which have been genetically modified to express a phenotype that can be easily monitored, such as light production in luminescent organisms. Bacteria carrying these (lux) genes can easily be detected using simple luminometers or more sophisticated low light imaging equipment.

By monitoring light output from these bacteria over time, it can easily be determined if the organism is growing (resulting in an increase in light emission), is dead (causing a decrease in light production) or is injured (light output remains constant). The use of imaging systems allows the response of bioluminescent bacteria to be studied directly on the food, making the technique even more useful. Applications of bioluminescence are discussed below and include use as reporters of gene expression; biocide efficacy and antibiotic susceptibility; sub‐lethal injury; adhesion and biofilm formation; the microbial ecology of foods; pathogenesis; and as biosensors.
An Infected Mediastinal Cyst
Authors: Lawson Lindsay M , Mason Andrew C
Published: March 2016

The authors describe a 43‐year‐old patient who had a mediastinal mass that became infected after a transbronchial needle aspirate biopsy. A paraspinal, extrapleural window with a saline‐lidocaine mixture was created that allowed the placement of a percutaneous drainage catheter into the infected lesion. This procedure resulted in an excellent clinical outcome, and obviated the need for a thoracotomy and more invasive surgical management.
Forearmed and Deceived: Diagnosis?
Authors: Miedzinski LJ , Mahood J , Sin M , Sterling G
Published: March 2016

A 58‐year‐old male with a four‐year history of noninsulin dependent diabetes presented in early January 1999 with a two‐week history of progressive right fore arm swelling, pain, and limitation of wrist and elbow movement unassociated with recognized trauma. He had been febrile in the three days before the evaluation, despite having been on an anti‐inflammatory medication for approximately one week. Progressive clinical worsening in association with a markedly elevated erythrocyte sedimentation rate prompted referral to an infectious diseases consultant regarding the possibility of osteomyelitis.
The Tragedy of Painless Needs
Authors: Loeser John D
Published: March 2016

Intractable pain demands the attention of both the patient and the physician. However, modern science and medicine cannot and should not promise the abolition of pain and suffering. The novel, Ingenious Pain, by Andrew Miller offers profound insights into the world of pain. Not all painful experiences in life are deleterious, nor should they all be prevented.
Use of the Triptans
Authors: Gawel Marek J
Published: March 2016

In the past 10 years, there have been great advances in the understanding of the pathophysiology of the migraine. This has been due in part to the realization that the migraine attack can be blocked by activating the serotonin receptor, namely the 5‐hydroxytryptamine/1D receptor. This switches off the inflammatory process around the blood vessel, which is the cause of the migraine pain, and constricts the blood vessel involved, thus relieving pressure on it. The first drug that was developed to activate this system was sumatriptan, followed by zomitriptan, naratriptan and rizatriptan. These drugs are, as a group, called the ′triptans′. This review summarizes the pathophysiology of migraine, examines the guidelines for the diagnosis of migraine, which is important because the drugs are relatively specific for migraine itself, and discusses the differences among the components in this class.
Tuberculosis in Aboriginal Canadians
Authors: Hoeppner Vernon H , Marciniuk Darcy D
Published: March 2016

Endemic tuberculosis (TB) was almost certainly present in Canadian aboriginal people (aboriginal Canadians denotes status Indians, Inuit, nonstatus Indians and metis as reported by Statistics Canada) before the Old World traders arrived. However, the social changes that resulted from contact with these traders created the conditions that converted endemic TB into epidemic TB. The incidence of TB varied inversely with the time interval from this cultural collision, which began on the east coast in the 16th century and ended in the Northern Territories in the 20th century. This relatively recent epidemic explains why the disease is more frequent in aboriginal children than in Canadian‐born nonaboriginal people. Treatment plans must account for the socioeconomic conditions and cultural characteristics of the aboriginal people, especially healing models and language. Prevention includes bacillus Calmette‐Guerin vaccination and chemoprophylaxis, and must account for community conditions, such as rates of suicide, which have exceeded the rate of TB. The control of TB requires a centralized program with specifically directed funding. It must include a program that works in partnership with aboriginal communities.
Revisiting ′Respiratory Function in Emphysema in Relation to Prognosis′
Authors: Bates David V
Published: March 2016

BACKGROUND: The 1956 paper by DV Bates, JMS Knott and RV Christie, "Respiratory function in emphysema in relation to prognosis" Quart J Med 1956;97:137‐157 is largely reprinted with a commentary by the first author, Dr David Bates. Although the pathology of emphysema was well recognized at the time, the clinical diagnosis and assessment of its severity were known to be imprecise; physiological measurements assessing and following the clinical course had not been established. The study aimed to follow systematically a group of patients, selected by clinical criteria using standardized clinical and physiological techniques, over four years and correlate physiological and clinical changes in relation to prognosis and eventually to postmortem findings. Fifty‐nine patients were recruited to an emphysema clinic at St Bartholomew′s Hospital, London, England. Inclusion criteria were dyspnea without other causes and no cor pulmonale present. Patients′ symptoms were assessed by a standardized questionnaire, and measurements were taken of lung volumes, maximal ventilatory volume, carbon monoxide diffusing capacity at rest, exercise and oxygen saturation by oximetry.  During the four years of the study, 17 patients died (actuarial expected ‐ four) and 13 presented with signs of pulmonary heart failure. All postmortem examinations (n=9) showed advanced emphysema. A seasonal variation in dyspnea was established (the period included the infamous 1952 London smog). Four patients improved, and the remainder were unchanged or deteriorated. Close relationships were shown between dyspnea and function results, particularly for the diffusing capacity of lungs for carbon monoxide (DLCO. A comparison among a group of patients with chronic bronchitis without dyspnea showed that the DLCO discriminated between them. A loss of the normal increase in DLCO during exercise was shown in emphysema.

IMPORTANCE: The study showed the value of standardized clinical and physiological techniques in following chronic obstructive pulmonary disease patients, and of separating the effects of airflow obstruction from impaired gas exchange function. Impaired gas exchange was shown to be important in influencing prognosis.
The Disparagement of Pain: Social Influences on Medical Thinking
Authors: Merskey Harold , Teasell Robert W
Published: March 2016

Patients with pain often feel that their suffering is taken lightly, dismissed or denied. Before the introduction of anesthesia, pain was regarded as an awful affliction. This view diminished somewhat once anesthesia became available, although it still holds true for some forms of pain, eg, pain associated with terminal cancer. Pain was then treated as less troublesome when it became a reason for disability compensation to be paid. Examples are given of the disparagement of complaints by individuals reporting pain in the past 150 years. Factors that encourage doctors to underestimate patients′ pain include the requirement for doctors to control the issue of narcotics; circumstances in which patients may benefit from compensation by claiming that their pain is great; and the development of attitudes that understate the importance of the relief of pain and overstate the importance of activity, exercise and not complaining. Current attitudes in this respect are associated with the insurance industry, but it has been shown that, even patients who do not have a compensable injury or have pain that is not disabling fail to receive the treatment for pain that is appropriate, eg, postoperatively. The present paper reviews and discusses these problems and suggests that disparagement of pain and disability in the medicolegal field also leads to the rejection of pain in other contexts.
The Determinants of Pain Revisited: Coordinates in Sensory Space
Authors: Casey Kenneth L , Lorenz Jürgen
Published: March 2016

Ron Melzack recognized that the gate control hypothesis of 1965 was incomplete. This led to the publication of a book chapter that would someday be referred to by some as ′the classical view′ of pain mechanisms. However, this paper presented some conceptual problems for research on pain mechanisms by using the term ′motivational‐affective′ to define a determinant of pain. To facilitate research and eventually improve practice, the determinants of pain need to be identified and quantified more clearly. In the present article, three critical dimensions of sensory experience that define pain and related sensory experiences are identified: sensory salience, affect and motivational dominance. The authors show that each of these dimensions can be measured and are mediated by specific neurophysiological mechanisms. Pain and other somatic sensations emerge from the conjoint actions of these neurophysiological systems and fall within unambiguously defined coordinates of the three‐dimensional sensory surface that they form. Pain mechanisms would be better understood if research focused on the physiology and psychology of these fundamental sensory dimensions and included a wider range of sensory systems.
Seasonal Changes in Lung Function in a Farming Population
Authors: Senthilselvan Ambikaipakan , Dosman James A , Semchuk Karen M , McDuffie Helen H , Cessna Allan J , Irviine Donald G , Crossley Margaret FO , Rosenberg Alan
Published: March 2016

OBJECTIVE: To assess the changes in respiratory health from winter to summer seasons in a rural population.

DESIGN: A longitudinal design was used in the study.

SETTING: A population‐based study was conducted as part of the Environmental Pesticide Exposure and Human Health component of the Prairie Ecosystem Study (PECOS) in southwestern Saskatchewan.

PATIENTS: In the winter season, 358 patients participated in the study. Of these patients, 234 returned for the second assessment during the summer season. After excluding 34 children aged 17 years and under, 200 adult patients were available for analysis.

MEASUREMENTS: Questionnaires were used to obtain information on demographic factors, smoking habits, occupational and environmental exposures, and respiratory conditions. Pulmonary function measurements were obtained using a volume displacement spirometer.

RESULTS: Mean ages (± SD) of the 106 men and 94 women participating in the study were 50.1±13.3 and 49.0±13.1 years, respectively. Mean percentage changes in maximal midexpiratory flow rate from winter to summer assessments indicated an improvement for town residents and a decline for farm residents. Mean percentage changes in the ratio of forced expiratory volume in 1 s to forced vital capacity indicated an improvement for town residents who were not engaged in farming, and increasing declines for town residents engaged in farming, farm residents not engaged in farming and farm residents engaged in farming.

CONCLUSIONS: Seasonal changes occurred in measurements of pulmonary function between winter and summer seasons; these changes may be related to the environmental or occupational exposures experienced by the participants during the study.