bluuebunny/crossref_metadata_2025 huggingface dataset:
Infectious Diseases on a General Internal Medicine Clinical Teaching Unit
Authors: Nicolle LE , Uhanova J , Orr P , Kraut A , Van Ameyde K , Dow G
Published: March 2016

OBJECTIVE: To describe the spectrum of infectious diseases and characteristics of patients admitted with infections on a general internal medicine clinical teaching unit.

DESIGN: Retrospective review of patients admitted to one general internal medicine unit at a tertiary care teaching hospital during two three‐month periods.

METHODS: Data collection through chart review.

OUTCOME MEASURES: Descriptive analysis of types of infections: therapeutic interventions; consultations and outcomes, including death; hospital‐acquired infection; and length of stay.

RESULTS: During the two three‐month periods, 76 of 233 (33%) and 52 of 209 (25%) admissions were associated with a primary diagnosis of infection. An additional 23 (10%) and 24 (12%) patients had infection at the time of admission, but this was not the primary admitting diagnosis. Pneumonia, urinary infection, and skin and soft tissue infection were the most frequent diagnosis at the time of admission, but these accounted for only about 50% of admissions with infection. Patients admitted with infection were characterized by a younger age, greater number of therapeutic interventions in the first 24 h, and increased medication costs, entirely attributable to antimicrobial therapy, but patients admitted with infection did not differ in comorbidity, death, nosocomial infection or length of stay compared with patients without infection.

CONCLUSIONS: A wide variety of infections contribute to admissions to general internal medical clinical teaching units. Patients with infection have more interventions and an increased cost of care, but do not differ in outcome.
A Canadian Multicentre Case‐Control Study of Sporadic Escherichia coli 0157:H7 Infection
Authors: Holton Donna , Wilson Jeff , Ellis Andrea , Haldane David , April Nicole , Grimsrud Karen , Friesen Brent , Spika John
Published: March 2016

OBJECTIVE: To evaluate further risk factors for Escherichia coli 0157:H7 infection including consumer preferences related to the consumption of ground beef and the role of person‐to‐person transmission of this infection.

PATIENTS AND METHODS: A case‐control study of sporadic E coli 0157:H7 infection was undertaken in five Canadian cites from June to December 1991. One hundred cases of E coli 0157:H7 infection were age‐ and sex‐matched to 200 neighbourhood controls. Cases and controls were interviewed face‐to‐face to obtain information on potential risk factors for infection and health outcomes. Daycare providers of case and control children were interviewed regarding risk factors for infection at the institutional level. Contacts of cases and controls who reported diarrhea in the seven days before the case onset date were also interviewed about their symptoms and risk factors.

RESULTS: All cases had diarrhea during the course of their illness and 90 (90%) reported bloody diarrhea. Four (4%) were reported to have developed hemolytic uremic syndrome; however, there were no fatalities. Sixty‐one (61%) of patients were hospitalized. Two variables were associated with infection in the final conditional logistic regression model: eating pink hamburger patties (odds ratio = 12.4, P=0.0001, population attributable fraction =40.2%) and contact with a nonhousehold member suffering from diarrhea (odds ratio = 7.0, P=0.0054, population attributable fraction = 10.3%) in the seven days before illness. Forty per cent of cases and controls who indicated that they prefer well done hamburgers said they would eat a ‘pink’ hamburger if served to them rather than ask that the hamburger be cooked longer.

CONCLUSIONS: Health care workers should remain vigilant in their efforts to educate the public as to the risks associated with the consumption of ground beef that is inadequately cooked, and the importance of personal hygiene in the prevention of enteric illness.
External Quality Assessment of Transporting Infectious Substances in Canada
Authors: Tiffin Shelley M , Noble Michael A
Published: March 2016

OBJECTIVE: To determine the degree of compliance with Transport Canada’s Transportation of Dangerous Goods Regulations for transporting infectious substances in Canada.

DESIGN: A three‐phase study including observation of packages arriving at the British Columbia Centre for Disease Control (BCCDC) provincial laboratory; observation of requested samples of either an Escherichia coli culture or serum, not human immunodeficiency virus (HIV) or HbsAg positive, from laboratories; and a questionnaire concerning training and certification of packers in laboratories.

RESULTS: During phase 1, 500 packages arriving at the BCCDC provincial laboratory were assessed. All arrived intact, with 384 (76.8%) in a firm outer package. Only 178 (35.6%) contained absorbent material. Six samples were known to contain human immunodefiency virus or hepatitis B; all were appropriately packaged. Of the remainder, 11 (2.2%) were considered overpackaged, 192 (38.4%) acceptably packaged and 191 (38.2%) inadequately packaged. In phase 2, 138 requested packages were assessed. All arrived intact, 132 (95.7%) in a firm outer package. Ninety‐six (69.6%) contained absorbent material. Only six (4.3%) were considered inadequately packaged. In phase 3, 171 laboratories responded to a questionnaire. Fifty‐nine were from small laboratories, 53 from intermediate laboratories and 23 from large laboratories. Most laboratories (55.4%) relied on in‐house resources to train packers. Only 26 (15.3%) facilities had no certified packers, and 60.8% noted they had a formal copy of the regulations available in the laboratory. Laboratory characteristics associated with the likelihood of overpackaging included number of technologists (χ2=5.72; P=0.058), number of samples processed by laboratories (χ2=8.46; P=0.015) and being a private laboratory as opposed to being a hospital laboratory (Fisher Exact two‐tailed 0.040).

CONCLUSIONS: Canadian laboratories tend to package safely and within the acceptable range of regulation, although not within the precision of regulation. Most laboratories have trained and certified packers. The most common error is the use of outer packaging that is not firm. Larger laboratories tend to overpackage resulting in increased costs.
Tuberculosis in the 1990s: From Bedside to Bench and Back
Authors: Jamieson Frances B , Chedore Pamela
Published: March 2016

Since the mid‐1980s, the rate of new cases of tuberculosis (TB) diagnosed in Canada ceased to follow a downward trend, and has instead stabilized at approximately 7 cases/100,000 population. In the United States, a similar trend emerged, such that in the early 1990s there was an increase in new cases of TB. Outbreaks of drug‐resistant TB also occurred with devastating clinical impact. These observations prompted laboratories to re‐examine their role in halting the spread of TB. Laboratories play a critical part in the diagnosis of TB; procedures must be optimized to provide rapid and accurate results. This review discusses the role of the mycobacteriology laboratory in the diagnosis of TB, and how new technologies available today have enhanced the ability of the laboratory to provide timely, efficient and accurate results.
Antimicrobial Regimens Prescribed by Canadian Physicians for Chemotherapy‐Induced Febrile Neutropenic Episodes
Authors: Laverdière Michel , Bow Eric J , Rotstein Coleman , Ioannou Stratis , Carr Danielle , Moghaddam Narguess , the Canadian Fluconazole Study Group
Published: March 2016

OBJECTIVE: To study the antimicrobial management of cancer patients with chemotherapy‐induced neutropenia by Canadian physicians.

SETTING: A cohort of 274 cancer patients with severe neutropenia (ie, less than 0.5×109 neutrophils/L) who participated in a prospective double‐blind, placebo controlled study on antifungal prophylaxis conducted in 14 Canadian university‐affiliated centres. Antifungal prophylaxis (oral fluconazole 400 mg daily) was administered to 153 of 274 (56%) patients.

RESULTS: Antibacterial prophylaxis with a quinolone was given to 87 patients (32%) at the onset of chemotherapy whereas trimethoprim/sulphamethoxazole was given to 56 (20%) patients. Fever (ie, 38°C or over) occurred in 216 (79%) patients after a median duration of neutropenia of four days (range one to 31 days). Empirical antibacterial antibiotics were administered in 214 febrile patients. In 164 (77%) patients antibiotics were started during the first 24 h of fever. Monotherapy with a third generation cephalosporin and duotherapy with a antipseudomonal beta‐lactam and an aminoglycoside were prescribed in 69 (32%) and 61 (28%) of the febrile patients, respectively. Inclusion of vancomycin in the initial empirical regimen was noted in 32 (15%) patients. Modifications of the initial regimen occurred in 187 (87%) patients after a median of five days (range one to 28 days). Empirical systemic amphotericin B was added after a median duration of nine days (range one to 34 days) of the empirical antibacterial regimen.

CONCLUSIONS: Overall, the antimicrobial management of cancer patients with chemotherapy‐induced neutropenia by Canadian physicians follows the current guidelines promulgated by the Infectious Diseases Society of America.
Leukotriene Receptor Antagonists in the Treatment of Asthma: Implications for Eosinophilic Inflammation
Authors: Moqbel Redwan
Published: March 2016

Recent advances in the treatment and management of asthma have suggested that leukotriene (LT) receptor antagonists may be very beneficial as a second generation therapy with steroid‐sparing properties and negligible side effects. These agents have shown interesting effects on peripheral blood and sputum eosinophils. A major contributor to the damage in the airway of asthmatic patients is the eosinophil, which, upon activation, releases a battery of granule‐associated cytotoxic, cationic proteins, including the major basic protein and eosinophil peroxidase, and membrane‐derived de novo‐synthesized bioactive lipid mediators, including LTC4, LTD4 and LTE4, as well as platelet activating factor. These products have deleterious effects on the airway tissue including mucosal and smooth muscle layers. Accumulating evidence suggests that these agents may also influence the accumulation and maintenance of eosinophilic responses at the site of inflammation. This article reviews the possible anti‐inflammatory mode of action of these therapies. It also discusses where there may be a gap in the knowledge regarding the potential direct and indirect effects of LT modifiers on eosinophil function and recruitment.
Factors that Influence Emergency Department Visits for Asthma
Authors: Tough SC , Hessel PA , Green FHY , Mitchell I , Rose S , Aronson H , Butt JC
Published: March 2016

BACKGROUND: Asthma can usually be controlled through allergen avoidance and/or appropriate medication. An emergency department visit for an acute exacerbation of asthma often represents a breakdown in asthma management. Emergency department treatment results in significant health care expenditures and reflects a compromised quality of life.

OBJECTIVES: To identify risk factors associated with an emergency department visit for asthma.

METHODS: This case‐control study compared 299 people (76% of 390 cases contacted) who attended one of two emergency departments in Alberta in 1992 and 1993 for an acute exacerbation of asthma (cases) with 212 unmatched community controls with asthma who were located by random digit dialing. Cases and controls were asked to complete a mailed questionnaire to obtain data regarding severity, visits to doctors and emergency departments, medication use, allergies and other triggers, and smoking history. Data analysis included bivariate analysis of risk factors and multivariate model development using logistic regression.

RESULTS: The response rate was similar between cases and controls. Cases were younger than controls (odds ratio [OR] 2.16, 95% CI 1.34 to 3.48) and more often reported their asthma to be severe (OR 4.25, 95% CI 2.24 to 8.06), and had experienced nocturnal symptoms (stratified OR range 1.36 to 6.82). Cases used more health care services in the previous year, had been admitted to hospital at some time for asthma (OR 1.62, 95% CI 1.10 to 2.38) and used more medication than controls.

CONCLUSIONS: Physicians and other health care workers should be sensitive to the risk factors and target interventions to high risk individuals.
Reasons for Choice of Antibiotic for the Empirical Treatment of CAP by Canadian Infectious Disease Physicians
Authors: Pendergrast Jacob , Marrie Thomas
Published: March 2016

BACKGROUND: Previous studies have documented substantial variation in physician prescribing practices for the treatment of community‐acquired pneumonia. Much of this variation is the result of empirical treatment, in which physicians must choose antibiotics in the a8bsence of culture and sensitivity data.

OBJECTIVE: To explore the factors that influence antibiotic choice for the empirical treatment of community‐acquired pneumonia.

MATERIALS AND METHODS: Case‐based questionnaires were mailed to all 157 members of the Canadian Infectious Disease Society in June 1996. The questionnaires presented three clinical cases and asked respondents which antibiotics they would most likely prescribe. Half the questionnaires were closed‐ended, and half were open‐ended. In the former, respondents were asked to explain their antibiotic choice by assigning weights to a list of clinical factors. In the latter, respondents were asked to explain their antibiotic choice by providing a short written answer. Respondents were grouped by the class of antibiotics they selected. These groups were then compared with regards to respondent characteristics (age, years of infectious disease experience, adult versus pediatric practice, country of training, province of practice) and rationale for the treatment chosen. Rationale for drug choice was analyzed statistically for the closed‐ended questionnaires and qualitatively for the open‐ended questionnaires.

RESULTS: A response rate of 84.6% was obtained. For the first clinical case, in which the patient was young and had no underlying illness, the majority of respondents chose a macrolide (74.7%). In the second case, in which the patient was older and had evidence of comorbidity, the most common choice of antibiotic was a penicillin (40.8%). In the third case, in which the patient had intensive care unit‐requiring pneumonia, the most popular choice was combination therapy of a third‐generation cephalosporin and a macrolide (43.2%). There was decreasing consensus regarding the choice of antibiotics as the complexity of the cases increased. There was evidence that prescribing variation could occasionally be attributed to both respondent characteristics and the use of different decision‐making strategies.

CONCLUSIONS: Despite the relative homogeneity of the physicians studied, considerable variation in antibiotic choice was observed. In the first case, this variation was based on the issue of whether the patient had a typical or atypical infection. In the second case, the choice of antibiotic was related to the issue of infection by Haemophilus influenzae, although the results of the Gram stain suggested a pneumococcal infection. In the third case, variance appeared to be based more on the respondent’s age and province of practice than on any difference in decision‐making strategy.
PCR Detection of Viral Nucleic Acid in Fatal Asthma: Is the Lower Respiratory Tract a Reservoir for Common Viruses?
Authors: Macek Vasilija , Dakhama Azzeddine , Hogg James C , Green Francis HY , Rubin Bruce K , Hegele Richard G
Published: March 2016

BACKGROUND: There is indirect evidence implicating viral respiratory tract infections in the pathogenesis of fatal asthma. However, it is unknown whether viruses are present within the lower respiratory tract in fatal asthma.

OBJECTIVES: To apply a nine‐virus polymerase chain reaction (PCR) panel to postmortem specimens of lower airway secretions and compare the prevalence of viral nucleic acid among patients who died of asthma, asthmatic patients who died of other causes and persons who died without lung disease.

PATIENTS AND METHODS: Postmortem specimens of lower airway secretions from patients who died of asthma (fatal asthma [n=10]), asthmatic patients who died of other causes (n=4) and nonasthma controls (n=6) underwent PCR for nine common respiratory viruses. The prevalence of each virus was compared among the three groups.

RESULTS: PCR was positive for at least one virus in 19 of 20 cases, and multiple viruses were detected in 14 of 20 cases. The prevalence of each virus was similar in the three groups studied.

CONCLUSIONS: In fatal asthma, lower airway secretions do not show a specific pattern of viral nucleic acid. Intriguingly, these results suggest that the lower respiratory tract may act as a potential reservoir for common respiratory viruses.
Everyday and Exotic Foodborne Parasites
Authors: Lee Marilyn B
Published: March 2016

Everyday foodborne parasites, which are endemic in Canada, include the protozoans Entamoeba histolytica, Giardia lamblia and Cryptosporidium parvum. However, these parasites are most frequently acquired through unfiltered drinking water, homosexual activity or close personal contact such as in daycare centres and occasionally via a food vehicle. It is likely that many foodborne outbreaks from these protozoa go undetected. Transmission of helminth infections, such as tapeworms, is rare in Canada because of effective sewage treatment. However, a common foodborne parasite of significance is Toxoplasma gondii. Although infection can be acquired from accidental ingestion of oocysts from cat feces, infection can also result from consumption of tissue cysts in undercooked meat, such as pork or lamb. Congenital transmission poses an immense financial burden, costing Canada an estimated $240 million annually. Also of concern is toxoplasmosis in AIDS patients, which may lead to toxoplasmosis encephalitis, the second most common AIDS‐related opportunistic infection of the central nervous system. Exotic parasites (ie, those acquired from abroad or from imported food) are of growing concern because more Canadians are travelling and the number of Canada?s trading partners is increasing. Since 1996, over 3000 cases of Cyclospora infection reported in the United States and Canada were epidemiologically associated with importation of Guatemalan raspberries. Unlike toxoplasmosis, where strategies for control largely rest with individual practices, control of cyclosporiasis rests with government policy, which should prohibit the importation of foods at high risk.
′Pseudo′ Treatment Failure of Pulmonary Tuberculosis in Association with a Tuberculoma
Authors: Long Richard , Chomyc Sylvia , Der Evelina , Sitar Daniel S
Published: March 2016

Failure of tuberculosis patients to respond to treatment is usually explained by one or more of five mechanisms: improper drug prescription; patient nonadherence to prescribed therapy; primary or acquired drug resistance; drug malabsorption; and rarely, exogenous reinfection with a drug‐resistant isolate. Response to treatment is best measured bacteriologically; two different smear and one culture criteria for failure are widely used. Patients meeting either smear, but not culture, criteria for treatment failure may be said to have ′pseudo′ treatment failure. Whether a patient can meet both smear criteria for failure, and not have a mechanism for treatment failure nor meet culture criteria, is unknown. A case of ′pseudo′ treatment failure is reported in which both smear criteria for failure were met, but no mechanism for failure was proven to be operative.
The CIHR Circulatory and Respiratory Health Institute
Authors: King Malcolm
Published: March 2016

The Canadian Institutes of Health Research (CIHR) was officially established on June 7, 2000. Among the 13 institutes that were created, the Institute for Circulatory and Respiratory Health (C&R or CnR), which brings together researchers in the fields of heart, stroke, lung and blood research, has become the principal outlet for respiratory research in this country. Although this large, combined institute was not the first choice of our society or of the respiratory research community at large, we must respect this choice within the context of the new direction for Canadian health research and help to make it work. Over this past summer, the process of recruiting the scientific directors and advisory board members for each CIHR institute has proceeded at a rapid pace. As we go to press, the decisions on the appointment of the 13 inaugural scientific directors are being made. In addition, over the next few weeks, the institute advisory boards will be appointed. The CIHR Governing Council has the ultimate responsibility for these appointments. The Council represents a very broad cross‐section of the health research community in Canada; all of us on the Council sincerely wish to see the very best team of directors and board members selected to fulfill these roles.
Leptospira Infections in Trappers from Ontario
Authors: Warshawsky Bryna , Lindsay L Robbin , Artsob Harvey
Published: March 2016

BACKGROUND: Four trappers presented to the Middlesex‐London Health Unit in November, 1997 with similar clinical presentations. All four complained of fever, chills and headache, and three of the four had severe muscle aches. All gave histories of trapping raccoons before the onset of illness. Three of the four men exhibited diagnostic seroconversions to Leptospira grippotyphosa.

OBJECTIVE: To describe the four suspected cases of leptospira infections and to determine whether raccoons might serve as a reservoir of infection using field studies.

DESIGN: Raccoon serology were undertaken using the microscopic agglutination test against eight serovars of Leptospira interrogans including L grippotyphosa. Raccoons were trapped using Tomahawk live traps, anaesthetized with intramuscular injection of ketamine and acepromazine, bled by cardiac puncture and released.

RESULTS: Forty‐two raccoons were trapped in Middlesex (n=36) and Kent counties (n=6) from April 25 to May 2, 1998, and 10 (23.8%) of these animals had antibodies to L grippotyphosa.

CONCLUSIONS: Infections due to L grippotyphosa or a closely related serovar are a risk for trappers in Ontario, and raccoons are a likely reservoir of this bacterium.
Long Term Trends in the Occurrence of Nosocomial Blood Stream Infection
Authors: Taylor Geoffrey , Buchanan-Chell Maureen , Kirkland Teresa , McKenzie Margaret , Wiens Rhoda
Published: March 2016

OBJECTIVE: To determine trends in the occurrence of nosocomial blood stream infection at the University of Alberta Hospital.

METHODS: A prospective survey of nosocomial blood stream infection was conducted; cases from August 1986 to December 1996 were reviewed. Cases were detected by a review of positive blood cultures reported by the microbiology laboratory. Centers for Disease Control and Prevention definitions of nosocomial infection were used to categorize isolates as nosocomial, community acquired or contaminant.

RESULTS: There were 2389 cases; primary bacteremia was the most common source (57%), followed by urinary tract, respiratory tract and surgical site sources (10% each). The nosocomial blood steam infection rate rose progressively from 6.0/1000 admissions and 4.59/10,000 patient days in 1986 to 11.2/1000 admissions and 14.31/10,000 days in 1996 (P<0.01); 48% of the total increase in rate occurred between 1995 and 1996. Significant increases occurred between 1986 and 1996 in primary infections (from 3.2 to 7.5/1000 admissions, P<0.01) and infections from all secondary sources (from 2.5 to 3.8/1000 admissions, P=0.01). Coagulase‐negative staphylococci (27%), Staphylococcus aureus (19%) and enterococci (9%) were the most common microbial causes. Aerobic Gram‐negative bacilli accounted for 28% and candida for 6%. Coagulase‐negative staphylococci, enterococci and candida all became more prevalent as causes of infection over the study period.

CONCLUSIONS: The nosocomial blood stream infection rate in the hospital has nearly doubled in the past 10 years, largely due to increased primary bacteremia.
Evaluation of the Rubella Surveillance System in Quebec
Authors: Perron Lina , Wals Philippe De , Milord François
Published: March 2016

OBJECTIVE: To evaluate the validity of information in the rubella surveillance system in Quebec.

DATA AND METHODS: Cases of rubella in the provincial registry of notifiable diseases, "Maladies à declaration obligatoire" (MADO), from 1994 to 1996 were matched with laboratory‐identified cases and with cases in a reference file created from all case investigation records of regional departments of public health for the same period. Sensitivity and the proportion of cases in agreement were calculated.

RESULTS: Compared with laboratories, the sensitivity of the provincial registry was 56%. Compared with the reference file, global sensitivity (confirmed cases plus clinical cases) was 58% and the positive predictive value was 50%. Of the 356 cases reported to regional public health departments, 65% were classified in the same diagnostic category (confirmed case, clinical case, excluded case) by public health professionals and a group of experts (weighted kappa=0.32). Information on rubella vaccination status was missing in 25% of cases in the MADO file for rubella.

CONCLUSIONS: Notification of positive results for immunoglobulin M antibodies and viral cultures should be required of all laboratories. Uniform procedures should be adopted and applied for the validation of cases that are reported to regional departments of public health. In the context of the rarefaction of rubella, any immunoglobulin M‐positive result should be interpreted using all available epidemiological information.
Multidrug-Resistant Tuberculosis: Long Term Follow-Up of 40 Non-HIV-Infected Patients
Authors: Avendaño Monica , Goldstein RS
Published: March 2016

BACKGROUND:There has been a steady increase in referrals of patients with multidrug-resistant tuberculosis (MDR-TB) who are human immunodeficiency virus (HIV) negative. Between 1986 and 1999, 40 patients were admitted to the authors' institution, eight of whom were admitted between January and June 1999. The management of such individuals is difficult. Although they are a clinically and epidemiologically important group of patients, few reports detail their management.

OBJECTIVES:To review the demographics, clinical management and long term outcome of 40 non-HIV-infected individuals with MDR-TB referred to the only specialized TB inpatient service in Ontario.

PATIENTS AND METHODS:Clinical hospital records were reviewed.

RESULTS:Twenty-one men and 19 women (mean age 41±18 years) were admitted between January 1986 and June 1999 with MDR-TB and negative serology for HIV. Thirty-eight patients (95%) were born outside of Canada. Twenty-six patients (65%) had a history of previous TB. All were symptomatic with productive cough and positive sputum smears for acid-fast bacilli. There was a delay of 4.5 months between the initial diagnosis of TB and the recognition of the presence of MDR-TB. Four patients (10%) had TB resistant to isoniazid and rifampin only. Over 50% of patients had TB with additional resistance to streptomycin, and over 40% had additional resistance to ethambutol. Coexisting resistance was also found in significant numbers for pyrazinamide, ethionamide, para-aminosalicylic acid and cycloserine. Bacteriological conversion was achieved in 34 patients (85%). Six patients underwent surgical resection for localized lung disease. Twenty-four patients completed treatment and have remained free of disease for 33±25 months. All five patients (12%) who died had longstanding disease before their referral. CONCLUSIONS: MDR-TB is most frequently seen among immigrants with a previous history of TB, especially if they come from countries in which TB is highly prevalent. Outcome can be improved by a more timely recognition of MDR-TB.
Comparison of Once‐ with Twice‐Daily Dosing of Fluticasone Propionate in Mild and Moderate Asthma
Authors: Boulet Louis-Philippe , Cowie Robert L , Negro Roberto Dal , Brett Wade , Gold Milton , Marques Agostinho , Thorburn William S , Stepner Nate M , Bobson Reid
Published: March 2016

OBJECTIVES: Two 12‐week, randomized, double‐blind, parallel‐group studies were performed to compare the efficacy and safety of once‐ and twice‐daily dosing of fluticasone propionate (FP) in the treatment of mild to moderate asthma, considered to require the equivalent of either 200 or 500 µg of FP daily.

PATIENTS AND METHODS: In study A, 461 patients with asthma received FP either 200 µg once daily or 100 µg twice daily. In study B, 443 patients with asthma received FP, either 500 µg once daily or 250 µg twice daily.

RESULTS: In both studies, regardless of the treatment regimen to which patients were randomly assigned, small improvements over baseline were observed in morning peak expiratory flows (PEF) and forced expiratory volume in 1 s (FEV1) following 12 weeks of treatment. In study A, the mean morning PEF improved by 2.4% and 4.3% (once daily versus twice daily, P=0.008).  In study B, the mean morning PEF improvement was 0.2% and 3.7% (once daily versus twice daily, PÃ0.001). For both studies, the increases observed in FEV1 were not significantly different between the two groups (P = not significant). The incidence of exacerbations of asthma and related events was 13% and 5%, respectively, in the patients with mild asthma for the once‐daily group versus the twice‐daily group; these exacerbations were 12% and 10%, respectively, in patients with moderate asthma. Otherwise, the incidence and types of adverse events were comparable for the two treatment regimens. Although twice‐daily dosing demonstrated small but statistically significant improvements over once‐daily dosing, patients of both groups generally maintained a good level of asthma control on both regimens according to current treatment guidelines.

CONCLUSIONS: Twice‐daily dosing of FP is more effective than once‐daily dosing, although the latter can maintain asthma control in most patients.
Oxygen Therapy
Authors: Solmes Bonnie
Published: March 2016

LTOT is prescribed for people with chronic lung disease in whom there is a decrease in the ability of the lungs to supply enough oxygen to the body. The heart is obliged to pump faster to meet the body's oxygen requirements. This may place undue stress on the heart, resulting in palpitations, dizziness and fatigue. A low oxygen level in arterial blood is also harmful to the heart, the brain and the pulmonary blood vessels. Oxygen therapy is used to break this cycle. A person with low blood oxygen will often be able to accomplish more with less fatigue with the help of supplemental oxygen therapy. Shortness of breath is a mechanical problem resulting from the effects of chronic obstructive pulmonary disease. Oxygen therapy may or may not reduce shortness of breath, but it will help the lungs and heart to function with less stress.
Cluster Headache and Its Cousins: A Family of Pain Management Problems
Authors: Edmeads John
Published: March 2016

Cluster headache causes great misery because of the severity, frequency and repetitiveness of its attacks, and the fear (justified in a few sufferers) that the attacks will respond to nothing and will never cease. For most people with cluster headaches there is effective treatment, both for the acute attacks (subcutaneous sumatriptan, injected dihydroergotamine and oxygen inhalation) and for prophylaxis (verapamil, valproate, ergotamine, methysergide, lithium carbonate and corticosteroids). For the 10% of suffers who respond to no medications, or have to discontinue them because of serious adverse effects, surgical ablation of the trigeminal root or nervus intermedius is a last resort that helps only some. Correct diagnosis is an essential prelude to an appropriate treatment. Serious disease such as carotid dissection, and aneurysm may occasionally mimic cluster headache, but seldom perfectly enough to confuse a careful clinician. In terms of sorting out the diagnosis, the recently recognized relatives of cluster headache ‐‐ chronic and episodic paroxysmal hemicrania, and short‐lasting unilateral neuralgiform headache with conjunctival injection and tearing syndrome ‐‐ are more problematic. These are important to recognize because they do not respond to ′cluster treatment′, but the paroxysmal hemicranias respond to indomethacin, whereas the cluster headache does not. A more distant family member, hemicrania continua, is usually, but not always, responsive to indomethacin and sometimes bears a passing resemblance to cluster headache. An unrelated entity, hypnic headache, has confused a few clinicians who did not bear in mind that a detailed history is the key to headache diagnosis.
Neuronal Plasticity Associated with Burn Injury and Its Relevance for Perception and Management of Pain in Burn Patients
Authors: Coderre Terence J , Choinière Manon
Published: March 2016

Through the introduction of the gate control theory and various subsequent works, Ronald Melzack has inspired many investigators worldwide to realize two important facts about pain. First, incoming pain messages are subject to both negative and positive modulation, which significantly affect its perception. Second, the progression of knowledge about the basic mechanisms underlying persistent and chronic pain is critically dependent on the increased understanding of the complexity of the symptoms experienced by pain patients. The present paper examines these two very important issues in an effort to understand better the mechanisms that underlie the pain suffered by burn patients. The physiological responses to burn injury involve many different mediators and mechanisms, all of which contribute to pain perception and development of neuronal plasticity underlying short and long term changes in pain sensitivity. While experimental burn injuries in humans and animals are typically well controlled and mild, in burn victims, the severity is much more variable, and clinical care involves repeated traumas and manipulations of the injured sites. Recurrent inputs from damaged and redamaged tissue impinge on a nervous system that becomes an active participant in the initiation of changes in sensory perception and maintenance of long term sensory disturbances. Recently acquired experimental evidence on postburn hyperalgesia, central hyperexcitability and changes in opioid sensitivity provides strong support that burn patients need an analgesic approach aimed at preventing or reducing the ′neural′ memory of pain, including the use of more than one treatment modality. Burn injuries offer a unique opportunity to combine experimental and clinical research to understand pain mechanisms better. Over the years, Ronald Melzack has insisted that one of the most laudable enterprises in research is to span the gap between these two often separate worlds.
Neural Blockade in the Evaluation and Management of Chronic Pain: An Overview
Authors: Gilron Ian
Published: March 2016

Local anesthetic and neurolytic nerve blocks have been used for over a century in the evaluation and management of chronic pain, despite a the dearth of evidence supporting their application. This article provides a general overview of the physiology and pharmacology of nerve blocks and suggests how they may affect pathophysiological mechanisms of chronic pain. Following a discussion of the rationale, clinical application and potential complications of nerve blocks, existing evidence of efficacy is reviewed. Further research evaluating mechanisms and efficacy of nerve blocks is vital to define their role in chronic pain management.
A Randomised Controlled Trial of High Dose, Inhaled Budesonide Versus Oral Prednisone in Patients Discharged from the Emergency Department following an Acute Asthma Exacerbation
Authors: FitzGerald J Mark , Shragge David , Haddon Jennifer , Jennings Barbara , Math Joanna Lee M , Bai Tony , Pare Peter , Kassen David , Grunfeld Anton
Published: March 2016

OBJECTIVE: Prednisone (PRED) is recommended at discharge to reduce the relapse rate following emergency treatment for an asthmatic attack. However, PRED has systemic side effects. Inhaled anti‐inflammatory medications, such as budesonide (BUD), are well tolerated. This study was designed to compare the effectiveness of PRED and BUD on relapse rate.

DESIGN: A prospective, randomized, double‐blind, double dummy, parallel group design.

SETTING: Tertiary referral emergency departments.

POPULATION STUDIED: One hundred and eighty‐five patients with acute asthma who received standard treatment with bronchodilators and systemic glucocorticosteroids in the emergency department, had a forced expiration volume in 1 s (FEV1) greater than 50% predicted and who were deemed well enough to be discharged from the emergency department.

INTERVENTION: Patients were randomized to receive either BUD Turbuhaler 600 µg qid or PRED 40 mg in the morning for seven to 10 days. At discharge and final visit, symptoms, medication use, FEV1, peak expiratory flow (PEF) and quality of life (QoL) were assessed. Relapse rate to the emergency department during the follow‐up was determined by a yes and/or no questionnaire.

MAIN RESULTS: The PRED (n=85) and BUD (n=90) treatment groups were comparable at baseline (emergency department discharge) for age (mean ± SD; 27.6±8.5 years and 29.2±8.7 years) and prebronchodilator FEV1 (1.77±0.79 L and 1.75±0.78 L), respectively. BUD was at least as effective as PRED in preventing a relapse to the hospital; relapse rate was 10 (11.8%) during PRED treatment and nine (10.0%) for BUD treatment (95% CI PRED‐BUD, ‐7.5% to 11.0%). Improvements in FEV1, asthma symptoms, PEF and QoL were not significantly different between treatments.

CONCLUSIONS: In  patients whose acute asthma has been stabilized in the emergency department, high dose BUD may be an alternate to PRED as a follow‐up treatment.
Double‐Blind, Randomized Study of the Effects of Influenza Vaccination on the Specific Antibody Response and Clinical Course of Patients with Chronic Fatigue Syndrome
Authors: Sleigh Kenna M , Danforth Donelda G , Hall Raymond T , Fleming Jonathan A , Stiver H Grant
Published: March 2016

OBJECTIVE: To determine whether influenza immunization is associated with early side effects, a deleterious impact on the illness course and depressed antibody response in patients with chronic fatigue syndrome (CFS).

DESIGN: Prospective, randomized, double‐blind, placebo controlled trial. CFS patients and healthy volunteers filled out a questionnaire on immunization side effects and had hemagglutination‐inhibiting (HI) antibody titres measured pre‐ and three weeks after immunization. CFS patients completed symptom and function questionnaires before and during the six‐week, postimmunization period.

SETTING: Ambulatory care.

POPULATION STUDIED: Convenience sample of 40 CFS patients fulfilling the Centers for Disease Control and Prevention criteria and 21 demographically matched healthy volunteers.

INTERVENTIONS: CFS patients were randomly selected to receive commercially available whole virus influenza vaccine (n=19) or an injection of saline placebo (n=21). Healthy volunteers received vaccine only.

MAIN RESULTS: As a group, immunized CFS patients had lower geometric mean HI antibody rises than healthy volunteers (P<0.001). However, there was no difference in the rates of fourfold titre rises, and immunization did achieve a probably protective titre (1:32 or greater) in most CFS patients. No difference could be detected between immunized and placebo CFS patients in immunization side effects, although CFS patients as a group reported four times as many side effects as healthy volunteers. Further, in the six weeks following immunization, placebo and immunized CFS patients did not demonstrate any differences in terms of functioning, symptom severity and sleep disturbance.

CONCLUSIONS: In patients with CFS, influenza immunization is safe, not associated with any excess early reactions, and stimulates an immunizing response comparable with that of healthy volunteers.
Prolonged Relief of Chronic Pain from Local Anaesthetic Blocks
Authors: Thompson Ellen N
Published: March 2016

In a fascinating essay on the future of local anesthetic agents, Wall (1) cited a 1990 paper from the Karolinska Institute in Stockholm, Sweden, entitled ′Prolonged relief of neuralgia after regional anesthetic blocks: A call for further experimental and systematic clinical studies′ (2). The Swedish researchers had found that two‐thirds of 38 patients with neuralgia experienced prolonged (up to six days) relief of pain after blocking of the injured nerve.
Welcome to Toronto. Welcome to the CIHR
Authors: King Malcolm
Published: March 2016

May 6 to 10, 2000 is a great time for the Canadian respiratory community. It is the 100th anniversary of our Lung Association, and it is our chance to host the respiratory world at the American Lung Association, American Thoracic Society International Conference and the Canadian Thoracic Society Annual Meeting. The name Toronto comes from a Mohawk word meaning ′meeting place′. The rivers that run into Lake Ontario were traditional gathering places for the aboriginal peoples that lived in this area before the coming of the European settlers. My ancestors include both Mohawks and the Mississaugas of the Credit, the native tribe that occupied the Toronto area as its traditional territory until the late 18th century.
A Question of Demand and Supply? Defining the Demand and Providing a Supply of Respirologists
Authors: Jones Norman L
Published: March 2016

In this issue of the Canadian Respiratory Journal, we are invited to think about respirology manpower in Canada. I believe it is the first time that the Journal has published on the topic, perhaps suprisingly, for the issues that are raised are of great importance to all physicians who care for patients with chest problems. Dr Don Cockcroft and Dr David Wensley (pages 451‐455) conducted a survey of program directors and obtained data regarding Royal College Fellows, which allowed them to estimate the number of chest specialists currently in practice and to predict what will happen to these numbers in the foreseeable future. Based on the numbers and the waiting times for outpatient appointments, their main conclusions are that there is a shortfall in adult respirologists that may be as high as 50%; that the shortfall is at least as large for pediatric specialists; and that current output from training programs is unlikely to meet the shortfalls. Currently, they estimate a total of 361 adult specialists, or one for every 86,000 population, but with regional differences that account for a variation from one to 69,000 in Alberta to one to 253,000 in New Brunswick.
Evaluating Treatment Outcome in an Interdisciplinary Pediatric Pain Service
Authors: Bennett Susan M , Chambers Christine T , Bellows Doria , Court Colleen A , Huntsman Elizabeth , Montgomery Carolyne , Oberlander Tim F , Sheriff Michelle , Siden Harold
Published: March 2016

OBJECTIVE: To provide descriptive data evaluating outcome and treatment satisfaction among former pediatric patients and their parents seen in an interdisciplinary treatment program for complex pain syndromes.

DESIGN: Retrospective telephone interview.

SETTING: Pediatric academic health care centre.

SUBJECTS AND METHODS: A semistructured interview designed for this study was administered by phone with 24 former patients (mean age 15.63 years) and parents, seen over the previous three years in the Complex Pain Consultation Service. Participants provided both qualitative and quantitative information about pre‐ and post‐treatment levels of pain and functioning, achievement of treatment goals and satisfaction with the treatment program.

RESULTS: Findings indicated significantly lower frequency and intensity of pain, as rated by patients, when current pain levels were compared with recalled pretreatment levels. As well, improvements were reported in strategies for managing pain and participation in regular activities of daily living.  Satisfaction with the team treatment was generally very high, and most felt that their goals were partially to completely met. Child and parent ratings of outcome and satisfaction were consistent.

CONCLUSIONS: These descriptive data provide preliminary support for the application of an interdisciplinary model to treating disabling complex pain syndromes in children and youths.
Regional Distribution of Gas in the Lung
Authors: Milic-Emili Joseph
Published: March 2016

In 1966, a paper entitled "Regional distribution of gas in the lung" was published in the Journal of Applied Physiology and became one of the 100 most‐cited papers of clinical research from 1961 to 1978. The senior author provides the background and state‐of‐the art at the time of its publication, and reviews the main findings of the paper and subsequent developments.
Influence of Asthma Education on Asthma Severity, Quality of Life and Environmental Control
Authors: Côté Johanne , Cartier André , Robichaud Patricia , Boutin Hélène , Malo Jean-Luc , Rouleau Michel , Boulet Louis-Philippe
Published: March 2016

BACKGROUND:Several studies have examined the influence of asthma education, focusing mainly on the use of health services.

OBJECTIVES:To assess the influence of an asthma education program (AEP) on airway responsiveness, asthma symptoms, patient quality of life (QOL) and environmental control.

DESIGN:A prospective, randomized, controlled study with parallel groups.

SETTING:Three tertiary care hospitals in Quebec.

POPULATION:One hundred and eighty-eight patients with moderate to severe asthma.

INTERVENTION:After optimization of asthma treatment with inhaled corticosteroids, patients were randomly assigned to receive either an education program based on self-management (group E) or usual care (control group C).

RESULTS:One year after an AEP, there was a significant decrease in the number of days per month without daytime asthma symptoms in group E only (P=0.03). Asthma daily symptom scores decreased significantly in group E in comparison with group C (P=0.006). QOL scores improved markedly in both groups after treatment optimization during the run-in period (P<0.01). After an AEP, the QOL score increased further in group E patients in comparison with group C patients (P=0.04). The concentration of methacholine that induces a 20% fall in forced expiratory volume in 1 s (PC20) improved significantly in both groups (group E 1.2±1.1 to 2.4±0.2, group C 1.5±1.2 to 2.4±1.3, P<0.01). After one year, 26 of 37 patients from group E sensitized to house dust mites (HDM) adopted the specific measures recommended to reduce their exposure to HDM, while none of the 21 subjects from group C did (P<0.001). Among the patients sensitized to cats or dogs, 15% of patients from group E and 23% of patients in group C no longer had a pet at home at the final visit (P>0.5).

CONCLUSIONS:One year after the educational intervention, it was observed that the program had added value over and above that of optimization of medication and regular clinical follow-ups. The education program was highly effective in promoting HDM avoidance measures but minimally effective for removing domestic animals, suggesting that more efficient strategies need to be developed for the latter.