bluuebunny/crossref_metadata_2025 huggingface dataset:
The Efficiency of Sputum Cell Counts in Cystic Fibrosis
Authors: Jayaram Lata , Labiris N Renee , Efthimiadis Ann , Vlachos-Mayer Helen , Hargreave Frederick E , Freitag Andreas P
Published: March 2016

BACKGROUND: Technical factors relating to processing viscid sputum in cystic fibrosis (CF) and their influence on the reproducibility and validity of cell counts need to be evaluated. In addition, the methods need to be standardized so that they can be applied clinically and in research.

OBJECTIVE: To examine the efficiency, reliability and validity of processing small volumes of spontaneously expectorated sputum from subjects with CF.

METHODS: Sputum was collected from adults with CF (n=35) and compared with sputum from adults with infective bronchitis or bronchiectasis (IB/B) (n=16), or with asthma or chronic obstructive pulmonary disease (AS/COPD) (n=25). Selected sputum (100 mg to 200 mg) was processed with dithiothreitol (0.1%) and filtered. Total cell count (TCC) and viability were obtained in a counting chamber and cytospins were prepared and stained with Wright’s for a differential cell count. Sputum and filter remnant were processed for TCC, viability and differential cell count, and the efficiency was determined by comparing the mean loss in cell yield to the filter. Two different portions from the same sputum sample were processed for cell counts to determine reproducibility. Results were compared with those from IB/B and AS/COPD groups.

RESULTS: Efficiency of cell dispersal was excellent and similar to that in AS/COPD and IB/B groups. Reproducibility of cell counts from two portions of a sputum sample was high (R≥0.80). CF sputum demonstrated a raised TCC and neutrophilia similar to IB/B but significantly higher than AS/COPD.

CONCLUSION: The selection method of evaluating cell counts in viscid CF sputum is efficient, reproducible and valid.
Pleuroparenchymal Lung Disease Secondary to Nonoccupational Exposure to Vermiculite
Authors: Al-Ghimlas Fahad , Hoffstein Victor
Published: March 2016

An unusual case of pleuroparenchymal lung disease caused by the inhalation of vermiculite dust, presumably containing asbestos fibers is described. The uniqueness of the case lies in the very indirect nature of exposure – the wife of a factory owner, rather than a worker exposed to asbestos, whose factory manufactured vermiculite. The present case illustrates the importance of taking careful occupational histories of all household members when presented with a patient whose chest radiograph exhibits features consistent with asbestos exposure.
Management of Chronic Hepatitis B: Consensus Guidelines
Authors: Sherman Morris , Shafran Stephen , Burak Kelly , Doucette Karen , Wong Winnie , Girgrah Nigel , Yoshida Eric , Renner Eberhard , Wong Philip , Deschênes Marc
Published: March 2016

The present document presents the proceedings of the consensus development conference on the management of viral hepatitis held in January 2007 under the auspices of the Canadian Association for the Study of the Liver and the Association of Medical Microbiology and Infectious Disease Canada. Several new agents have become available since the last such document was published in 2004, and new information has become available to help assess risk of adverse outcomes and who should be treated. In addition, the participants at the meeting identified a number of structural barriers that exist uniquely in Canada and that prevent physicians from properly managing their patients. The conference discussed the selection of patients for treatment and the drugs that can be used to treat these patients, as well as the treatment of hepatitis B in special populations. The present document should be read in conjunction with the companion document on the management of chronic hepatitis C.
Evolution of Collagenous Colitis into Severe and Extensive Ulcerative Colitis
Authors: Freeman Hugh J , Berean Ken W , Nimmo Michael
Published: March 2016

Collagenous colitis is an inflammatory mucosal disorder of the colon with distinctive histopathological features, including a thickened subepithelial collagen layer. The clinical course is usually benign, but serious complications, including death, may occur. In the present report, a 69-year-old woman with watery diarrhea and collagenous colitis developed bloody diarrhea that was refractory to treatment medications, including corticosteroids and azathioprine. Endoscopic and histopathological studies showed a focal neutrophilic inflammatory process that progressed to a diffuse and extensive form of colitis, eventually requiring total proctocolectomy. Careful histological review of the resected colon showed no evidence of persistent collagenous colitis. These findings suggest an important need for continued long-term follow-up of patients with collagenous colitis because superimposed and serious colonic complications may occur, including a severe and extensive pancolitis refractory to medications and necessitating total proctocolectomy.
Application of the Montreal Classification for Crohn’s Disease to a Single Clinician Database of 1015 Patients
Authors: Freeman Hugh J
Published: March 2016

Crohn’s disease involves different gastrointestinal sites and may be characterized by high rates of strictures and penetrating complications. The present study applied the newly described Montreal schema of classification to a large, prospectively accumulated clinical database. In addition, age dependence was evaluated at diagnosis, with regard to disease location and disease behaviour. There were 1015 consecutively evaluated patients (449 male and 566 female). Disease was most often localized in the ileocolon and was usually complex with stricture formation or penetrating complications. For both sexes, with increasing age at diagnosis, Crohn’s disease was less extensive, more often localized in the colon alone and characterized by less complex disease behaviour, especially with less penetrating disease complications. Using the Montreal classification for Crohn’s disease, these results define the clinical features in a large, single clinician database and demonstrate age dependence in the phenotypic clinical expression of Crohn’s disease.
The Utility of Ambulatory pH Monitoring in Patients Presenting with Chronic Cough and Asthma
Authors: AlHabib KF , Vedal S , Champion P , FitzGerald JM
Published: March 2016

OBJECTIVE: To evaluate the prevalence of gastroesophageal reflux disease (GERD) in patients presenting with asthma and chronic cough.

PATIENTS AND METHODS: The charts of 358 consecutive patients who were referred for ambulatory gastroesophageal pH monitoring to the Lung Centre in Vancouver, British Columbia, were reviewed, and the data of 108 (30%) patients with asthma and 134 (37%) patients with chronic cough were analyzed. The maintenance treatment for GERD was discontinued before patients underwent the pH monitoring study. One hundred eighteen (33%) patients were excluded.

RESULTS: Reflux episodes identified reflux events as the percentage of time where the pH was less than four. For asthma patients, 70 (64.8%) had distal total reflux, 50 (46.3%) had distal upright reflux, 41 (38.3%) had distal supine reflux and 73 (67.6%) had other distal refluxes. Proximal total reflux in asthmatic patients was present in 56 (52%), proximal upright reflux in 55 (51%) and proximal supine reflux in 56 (52%) patients. For chronic cough patients, 70 (52.6%) had distal total reflux, 59 (44.4%) had distal upright reflux, 45 (34.4%) had distal supine reflux and 75 (56%) patients had other distal refluxes. In chronic cough patients, proximal total reflux was present in 70 (52%), proximal upright reflux in 80 (60%) and proximal supine reflux in 59 (44%). Presenting respiratory and/or reflux symptoms were absent in approximately 25% of patients with asthma and reflux, and in approximately 50% of patients with chronic cough and reflux. During pH monitoring, symptoms did not differ significantly between those with and without distal reflux in both study groups, except for more significant heartburn in patients with chronic cough and reflux (RR 2.0).

CONCLUSIONS: The data of the present study support the observation that there is a high prevalence of GERD in patients with asthma or chronic cough. The use of different pH parameters for detecting acid reflux during 24 h ambulatory pH monitoring, such as proximal esophageal acid measurement, should be considered as part of the routine interpretation of such testing. A low threshold for diagnosing GERD in patients with asthma or chronic cough is essential, because respiratory and/or reflux symptoms can be absent or atypical in some of these patients.
The Sex Factor: Epidemiology and Management of Chronic Obstructive Pulmonary Disease in British Columbia
Authors: Camp Pat G , Chaudhry Munaza , Platt Howard , Roch Michael , Road Jeremy , Sin Donald , Levy Robert D
Published: March 2016

BACKGROUND: The prevalence and mortality of chronic obstructive pulmonary disease (COPD) in women have been predicted to overtake that of men within the next decade. These predictions are based in part on data from surveys using self‐reports of a COPD diagnosis. Whether these predictions have been realized is unknown.

METHODS: The prevalence and mortality of men and women in British Columbia were compared from fiscal years 1992/1993 to 2003/2004 using administrative health services data. Case definitions for COPD were developed using International Classification of Diseases ninth and 10th revision (ICD‐9/10) codes applied to medical and hospital data. Individuals 45 years and older, who had at least two physician visits or one hospitalization for specified COPD ICD‐9/10 codes within a 365‐day window, were considered to be cases. Cases were ascertained from 1992 to 2004.

RESULTS: In 2003/2004, men had a greater prevalence (4.7% versus 4.0% in women) and a higher all‐cause mortality rate (5.4% versus 4.1% in women) than women. Both men and women with COPD had low COPD medication use (45%) and low referral for lung function testing (55%). Including the ICD‐9 code for ‘bronchitis, not specified as acute or chronic’ (ICD‐9 490) in the case definition resulted in a greater prevalence of COPD in women than in men overall, and in the 45 to 64 year age group.

CONCLUSION: Prevalence and mortality measured with administrative health data do not show evidence of relative increase in the prevalence of COPD for women in British Columbia. However, further analysis of ICD‐9 490 may identify an early ‘at‐risk’ group, specifically in women.
Two for One: A Self‐Management Plan Coupled with a Prescription Sheet for Children with Asthma
Authors: Ducharme Francine M , Noya Francisco , McGillivray David , Resendes Sandy , Ducharme-Bénard Stéphanie , Zemek Roger , Bhogal Sanjit Kaur , Rouleau Rachel
Published: March 2016

BACKGROUND: Despite strong recommendations in the asthma guidelines, the use of written self‐management plans remains low among asthmatic patients.

OBJECTIVES: To develop a written self‐management plan, based on scientific evidence and expert opinions, in a format intended to facilitate its dispensing by health care professionals, and to test the perception of its relevance and clarity by asthmatic children, adolescents and adults.

METHODS: Inspired by previously tested self‐management plans, surveys of asthma educators, expert opinions and the 2004 Canadian Asthma Guidelines, the authors simultaneously developed French and English versions of a written self‐management plan that coupled with a prescription. The self‐management plan was tested in parents and their asthmatic children (aged one to 17 years), and it was revised until 85% clarity and perceived relevance was achieved.

RESULTS: Ninety‐seven children and their parents were interviewed. Twenty per cent had a self‐management plan. On the final revision, nearly all items were clear and perceived relevant by 85% or more of the interviewees. Two self‐management plans were designed for clinics and acute care settings, respectively. The plans are divided into three control zones identified by symptoms with optional peak flow values and symbolized by traffic light colours. They are designed in triplicate format with a prescription slip, a medical chart copy and a patient copy.

CONCLUSION: The written self‐management plans, based on available scientific evidence and expert opinions, are clear and perceived to be relevant by children, adolescents and their parents. By incorporating the prescription and chart copies, they were designed to facilitate dispensing by physicians in both clinics and acute care settings.
Capacity Enhancement of Hepatitis C Virus Treatment through Integrated, Community-Based Care
Authors: Hill Warren D , Butt Gail , Alvarez Maria , Krajden Mel
Published: March 2016

BACKGROUND: An estimated 250,000 Canadians are infected with the hepatitis C virus (HCV). The present study describes a cohort of individuals with HCV referred to community-based, integrated prevention and care projects developed in British Columbia. Treatment outcomes are reported for a subset of individuals undergoing antiviral therapy at four project sites.

METHODS: Four demonstration projects based on a public health nurse and physician partnership were established in rural and small urban centres in British Columbia. Comprehensive medical assessments determined whether individuals received treatment, or counselling and education. Outcomes of the treatment group were compared with published randomized controlled trials. Client demographics were mapped using geographical information systems applications.

RESULTS: A total of 1795 individuals were referred to the clinics for medical assessment between Septmber 2001 and December 2005. After assessment, 26% were eligible for therapy, while 74% received counselling and education. Wait times decreased annually, with one-half of all referrals assessed within 30 days. Combination antiviral therapy was initiated in 363 clients with interferon plus ribavirin (n=36) or pegylated interferon plus ribavirin (n=327). Treatment outcomes were available for 205 individuals. The overall rate of sustained virological response was 61% (126 of 205 individuals). The number of individuals assessed at each site represented, on average, 20% of the total cumulative reported HCV cases in the catchment areas.

DISCUSSION: The study findings illustrate how a public health nurse and physician partnership can service a population with complex medical needs while simultaneously increasing local capacity. Treatment outcomes were comparable with published clinical trials.
Work‐Related Asthma in Montreal, Quebec: Population Attributable Risk in a Community‐Based Study
Authors: Demir Ahmet , Joseph Lawrence , Becklake Margaret R
Published: March 2016

BACKGROUND: Occupational exposures are an important cause of adult‐onset asthma but the population attributable risk percentage (PAR%) has been less frequently studied.

OBJECTIVES: To examine the distribution and determinants of adult asthma in six centres across Canada using data gathered in a community‐based study.

METHODS: Data were gathered in a community survey of 2959 adults using the European Community Respiratory Health Survey Protocol. A subsample of 498 subjects completed detailed health and occupational questionnaires, methacholine challenge tests and allergy skin tests. Asthma was defined in three ways: current wheeze, asthma symptoms and/or medication, and airway hyperresponsiveness. Occupational exposures were classified as sensitizers or irritants. Associations between asthma and occupational exposures were examined using logistic regression analysis. Model selection was based on the findings for current wheeze, and the same model was applied to the other definitions of asthma.

RESULTS: Fifty‐six per cent of subjects reported ever having had occupational exposure to sensitizers, and 9.8% to irritants. Current wheeze was associated with exposure to irritants (PAR% 4.54%), and airway hyperresponsiveness was associated with exposure to sensitizers (PAR% 30.7%). Neither a history of childhood asthma, atopy, nor confining the analysis to adult‐onset asthma affected these associations. Analysis of effect modification suggested two types of work‐related asthma: one due to exposure to occupational sensitizers, and the other due to exposure to irritants.

CONCLUSIONS: Detailed assessment of past and current exposures is essential in the investigation of work‐related asthma. Childhood asthma reactivated or aggravated by work exposures is not easy to distinguish from asthma induced by work, a misclassification that could lead to an underestimation of work‐induced asthma. This should be taken into account in jurisdictions in which persons with work‐aggravated asthma are not eligible for workers’ compensation.
The Clinical Significance of Exhaled Nitric Oxide in Asthma
Authors: Pendharkar Sachin , Mehta Sanjay
Published: March 2016

Asthma is an inflammatory disease of the airways, for which many therapeutic options are available. Guidelines for the management of asthma suggest a stepwise approach to pharmacotherapy based on assessment of asthma severity and control. However, the assessment of asthma control presently relies on surrogate measures, such as the frequency of symptoms or the frequency of use of short‐acting beta2‐adrenergic agonists. There is no simple, noninvasive technique for the assessment of severity of actual airway inflammation in asthma. The collection and analysis of nitric oxide (NO) levels in exhaled breath has recently become feasible in humans. Based on increased exhaled NO (eNO) levels in patients with asthma, eNO analysis has been proposed as a novel, noninvasive approach to the assessment and monitoring of airway inflammation, and as a basis for adjustments in asthma therapy. In the present paper, the relationship of elevated eNO levels in asthma with inflammatory, physiological and clinical markers of asthma in adults was reviewed. Use of eNO is a promising tool for diagnosing asthma, for monitoring asthma control and for guiding optimal anti‐inflammatory asthma therapy. However, because of many unresolved questions, eNO cannot be recommended at present for routine clinical management of adults with asthma.
Coccidioides Immitis: Two Cases of Misidentified Mycosis
Authors: Lee Christine H , Wilcox Lindsay , Chorneyko Katherine , McIvor Andrew
Published: March 2016

In the present report, two cases of pulmonary coccidioidomycosis that caused a diagnostic confusion are presented. The first case was initially misdiagnosed as nonsmall cell carcinoma, and both cases were initially misidentified as blastomycosis because of the presence of an atypical morphological form of Coccidioides immitis.
Diagnosis of elastofibroma
Authors: Tetikkurt Cuneyt , Tetikkurt Seza , Bayar Nihal
Published: March 2016

Elastofibroma is a relatively rare soft tissue mass. The lesion is probably reactive and occurs most commonly in the periscapular region. It is a degenerative benign neoplasm with the clinical appearence of a malignant tumour. The present report describes the case of a 70‐year‐old man with bilateral elastofibroma. The diagnosis was established with needle aspiration biopsy and positron emission tomography/computed tomography. The present case suggests that needle aspiration biopsy and positron emission tomography/computed tomography are highly useful in the diagnosis of this rare, benign tumour.
Pain Catastrophizing in Borderline Morbidly Obese and Morbidly Obese Individuals with Osteoarthritic Knee Pain
Authors: Somers Tamara J , Keefe Francis J , Carson James W , Pells Jennifer J , LaCaille Lara
Published: March 2016

OBJECTIVE: There is limited information about how morbidly obese osteoarthritis (OA) patients cope with the pain they experience. Pain catastrophizing is an important predictor of pain and adjustment in persons with persistent pain. This may be particularly relevant in the morbidly obese (body mass index [BMI] of 40 kg/m2 or greater) OA population at risk for increased pain. The present study first examined whether borderline morbidly obese and morbidly obese OA patients report higher levels of pain catastrophizing than a sample of OA patients in the overweight and obese category (BMI between 25 kg/m2 and 34 kg/m2). Next, it examined how pain catastrophizing is related to important indexes of pain and adjustment in borderline morbidly obese and morbidly obese OA patients.

METHODS: Participants included 43 individuals with knee OA who were borderline morbidly obese or morbidly obese (BMI of 38 kg/m2 or greater). Participants completed self‐report measures of pain catastrophizing, pain, psychological distress, quality of life, binge eating and eating self‐efficacy.

RESULTS: The sample of borderline morbidly obese and morbidly obese OA patients reported significantly higher levels of pain catastrophizing (P=0.007) than a comparison sample of overweight and obese OA patients. Results suggested that patients who engaged in a high level of pain catastrophizing reported having much more intense and unpleasant pain, higher levels of binge eating, lower self‐efficacy for controlling their eating and lower weight‐related quality of life (P<0.05 for all).

CONCLUSIONS: Pain catastrophizing is related to pain and adjustment in borderline morbidly obese and morbidly obese OA patients. Clinicians working with this population should consider assessing pain catastrophizing in the patients they treat.
Treatment of a Tuberculous Empyema with Simultaneous Oral and Intrapleural Antituberculosis Drugs
Authors: Long Richard , Barrie James , Stewart Kenneth , Peloquin Charles A
Published: March 2016

A 71‐year‐old man was diagnosed with an uncomplicated tuberculous (TB) empyema. Differential penetration of anti‐TB drugs, believed to explain the phenomenon of acquired drug resistance in TB empyema, was confirmed by measurement of serum and pleural fluid anti‐TB drug concentrations. Simultaneous oral and intrapleural anti‐TB drugs were administered and a cure was achieved. The present case is discussed in the context of the literature on acquired drug resistance in TB empyema. It is argued that high‐end doses of oral drugs or combined oral plus intrapleural drugs, along with tube thoracostomy or intermittent thoracentesis, will cure uncomplicated TB empyema without threatening to induce drug resistance or having to resort to surgery.
Incidental Colorectal Computed Tomography Abnormalities: Would You Send every Patient for a Colonoscopy?
Authors: Stermer Edy , Lavy Alexandra , Rainis Tova , Goldstein Omer , Keren Dean , Zeina Abdel-Rauf
Published: March 2016

BACKGROUND: The clinical significance of colorectal wall thickening (CRWT) in patients undergoing abdominal computed tomography (CT) has not yet been definitively established.

OBJECTIVES: To compare alleged findings on abdominal CT with those of a follow-up colonoscopy.

METHODS: Ninety-four consecutive patients found to have large-bowel abnormalities on abdominal CT were referred for colonoscopy. Of these patients, 48 were referred for a suspected colorectal tumour and 46 for CRWT. Colonoscopy was performed and findings were compared.

RESULTS: Of the 48 suspected colorectal tumours, 34 were determined to be neoplastic lesions on colonoscopy. Of these, 26 were malignant and eight were benign. Colonoscopy revealed no abnormality in 30 of 46 patients with CRWT as a solitary finding, and revealed some abnormality in 16 patients (12 had diverticular disease, four had benign neoplastic lesions).

CONCLUSIONS: CRWT as an incidental and solitary finding on CT should not be regarded as a pathology prompting a colonoscopy. Approximately two-thirds of the patients had a normal colonoscopy and the remaining patients had benign lesions (12 had diverticular disease and four had benign neoplastic lesions). However, many of these patients seem to warrant colonoscopy regardless of CT findings, particularly patients who have a family history of colorectal cancer, have positive fecal occult blood test results or who are older than 50 years of age.
Is Serum Hepcidin Causative in Hemochromatosis? Novel Analysis from a Liver Transplant with Hemochromatosis
Authors: Adams Paul C , McAlister Vivian , Chakrabarti Subrata , Levstik Mark , Marotta Paul
Published: March 2016

BACKGROUND: Hepcidin is a circulating hepatic hormone that regulates iron balance. It has been speculated that hepcidin insufficiency or dysregulation may be the primary defect in genetic hemochromatosis.

METHODS: A 62-year-old woman underwent elective liver transplantation for chronic hepatitis C cirrhosis. Genetic testing for hemochromatosis was subsequently performed on the donor and recipient. Liver iron concentration was measured in the donated liver at the time of transplantation, and at day 2 and day 652 post-transplant. Serum hepcidin was measured at day 935 in the recipient and in three other liver transplant recipients.

RESULTS: The donor was discovered to have significant iron overload without fibrosis, with a liver iron concentration of 326 μmol/g (normal is 0 μmol/g to 35 μmol/g). Genetic testing confirmed that the 89-year-old female donor was a typical C282Y homozygote for hemochromatosis. The recipient did not carry either the C282Y or the H63D mutation of theHFEgene for hemochromatosis. Liver biopsy was performed on the recipient on day 2 and day 652 post-transplant; the liver iron concentrations were 333 μmol/g and 253 μmol/g, respectively. Serum hepcidin in the recipient was elevated at 111 ng/mL compared with that of the three other ambulatory liver transplant recipients (66 ng/mL, 76 ng/mL and 81 ng/mL).

CONCLUSION: The liver transplant recipient described in the present report demonstrated a slight decrease in liver iron concentration over a 1.8-year follow-up period without specific therapy. Hepcidin insufficiency as a primary cause of genetic hemochromatosis seems unlikely based on the clinical profile of the present patient and the hepcidin measurements.
Percutaneous Ethanol Ablation of Hepatocellular Carcinoma: Periprocedural Onset Alcohol Toxicity and Pancreatitis Following Conventional Percutaneous Ethanol Ablation Treatment
Authors: Burton Kirsteen Rennie , O’Dwyer Helena , Scudamore Charles
Published: March 2016

A novel case of acute pancreatitis in a patient treated with percutaneous ethanol injection (PEI) ablation for hepatocellular carcinoma is described. The most commonly reported adverse effects of PEI are hepatic or peritoneal hemorrhage, hepatic insufficiency or infarction. There are no previous reports of fatal acute pancreatitis as a result of conventional PEI.
Tobacco Control and Nicotine Addiction in Canada: Current trends, Management and Challenges
Authors: McIvor Andrew
Published: March 2016

Despite a significant decrease in tobacco use over the past four decades, cigarette smoking remains the leading preventable cause of death and disease in Canada. Nicotine addiction, unequal access to available support programs and gaps in continuity of health care are recognized as the main barriers to smoking cessation. To overcome these obstacles and to reach the Federal Tobacco Control Strategy goal of reducing smoking prevalence in Canada from 19% to 12% by 2011, several Canadian health care organizations developed extensive sets of recommendations. Improved access to affordable pharmacotherapies and behavioural counselling, better training of health care professionals and the addition of systemic cessation measures appear to be the key components in all of the proposed recommendations.

The present article provides an overview of the current approaches to smoking cessation in Canada, describes the remaining challenges, and outlines recent recommendations that are geared toward not only tobacco control but also overall improvement in long‐term health outcomes.
Laboratory Diagnosis of Mumps in a Partially Immunized Population: The Nova Scotia Experience
Authors: Hatchette TF , Davidson R , Clay S , Pettipas J , LeBlanc J , Sarwal S , Smieja M , Forward KR
Published: March 2016

BACKGROUND: In 2007, Atlantic Canada experienced a large outbreak of mumps predominately in university students who had received a single dose of measles, mumps and rubella vaccine. The present study describes the performance characteristics of reverse transcriptase polymerase chain reaction (RT‐PCR) on buccal and urine specimens and immunoglobulin M (IgM) serology in this partially immune population.

METHODS: Patients presenting with symptoms suspicious for mumps had a serum, urine and a buccal swab collected for diagnostic testing. Persons were classified as a ‘confirmed’ case according to the Public Health Agency of Canada’s definition. Sera were tested using an enzyme‐linked immunoassay. Detection of mumps virus in buccal swabs and urine samples was performed by RT‐PCR.

RESULTS: A subset of 155 cases and 376 non‐cases that had all three specimens submitted was used for calculating the performance characteristics. The sensitivity of RT‐PCR on buccal swabs, urine specimens and IgM serology were 79%, 43% and 25%, respectively. The specificity of RT‐PCR on buccal swabs, urine specimens and IgM serology was 99.5%, 100% and 99.7%, respectively. Only 12 of 134 (9%) patients had positive urine specimens in the presence of negative oral swabs.

CONCLUSION: RT‐PCR on buccal swabs is the ideal specimen for diagnosis. Testing an additional urine sample in an outbreak setting did not increase the diagnostic yield significantly, but doubled testing volume and cost. In addition, the data suggest that, in this partially immune group, IgM serology has little value in the diagnosis of acute infection.
Potential Intensive Care unit Ventilator Demand/Capacity Mismatch due to Novel Swine‐Origin H1N1 in Canada
Authors: Smetanin Paul , Stiff David , Kumar Anand , Kobak Paul , Zarychanski Ryan , Simonsen Neil , Plummer Frank
Published: March 2016

PURPOSE: To investigate the ability of Canadian intensive care units (ICUs) and ventilators to handle widespread re‐emergence of the swine‐origin H1N1 virus in the context of an aggressive strategy of vaccination.

METHOD: Data collected during the first wave in Winnipeg, Manitoba, were applied to a variety of second wave pandemic models to determine potential ICU and ventilator demand.

RESULTS: For attack rates greater than 20% to 25%, significant shortages in ventilators may be expected across Canada regardless of the duration of the pandemic if vaccination is not considered. The shortfall arises largely due to the extended durations that patients must remain on ventilation. From the Winnipeg study, 50% of patients required ventilation for more than two weeks. For larger attack rates of 35%, ventilator demand may exceed capacity for over five weeks, with a peak shortfall of 700 ventilators. Vaccination can significantly reduce the attack rates, and is expected to reduce ventilator demand to manageable levels

CONCLUSION: Canada’s health care system must be prepared for the possibility of a significant influx of ICU patients during the second wave of swine‐origin H1N1. Efficient vaccination and other disease prevention measures can reduce the attack rate to manageable levels.
Effects of the Indoor Environment on the Fraction of Exhaled Nitric Oxide in School‐Aged Children
Authors: Kovesi Thomas A , Dales Robert E
Published: March 2016

BACKGROUND: The fractional concentration of exhaled nitric oxide (FeNO) appears to be a good marker for airway inflammation in children with asthma.

OBJECTIVE: To evaluate the effect of environmental exposures on exhaled nitric oxide in a community sample of children.

METHODS: The relationship among exhaled nitric oxide, underlying disease and home environmental exposures was examined using questionnaire data and measurement of exhaled nitric oxide in a cross‐sectional study of 1135 children that included healthy children, and children with allergies and/or asthma who were attending grades 4 through 6 in Windsor, Ontario.

RESULTS: Among healthy children, there was a positive association between FeNO and occupancy (P<0.02). Compared with forced air and hot water radiant heat, electric baseboard heating was associated with a significant increase of FeNO in healthy children (P=0.007) and children with allergies (P=0.043). FeNO was not associated with environmental tobacco smoke exposure or reported surface mold. The presence of pet dog(s), but not cats, was associated with a significantly lower FeNO in healthy children (P<0.001) and in children with reported allergies (P<0.001).

CONCLUSIONS: The type of heating system, but not previously reported environmental tobacco smoke or mold exposure appears to affect exhaled nitric oxide in children. Exposure to different types of pets may have disparate effects on airway inflammation.
Add-On Cases in the Endoscopy Unit: Factors That Affect Volume
Authors: Segal B , Lam E , Amar J , Bressler B , Halparin L , Ramji A , Telford J , Whittaker S , Enns R
Published: March 2016

BACKGROUND: Although most procedures in the endoscopy clinic are elective, emergency add-on cases in hospital-based endoscopy clinics are common, frequently consuming a great deal of time and resources relative to elective endoscopy procedures.

OBJECTIVE: To determine which specific factors correlate with the high volume of add-on emergency cases in a tertiary care, hospital-based endoscopy unit.

METHODS: A retrospective chart review of all gastrointestinal add-on, and electively booked cases of esophagastroduodenoscopy (EGD), colonoscopy (C) and flexible sigmoidoscopy (FS) procedures from September 2006, to May 2007 was conducted. The day of the week, month, type of procedure and physician were recorded. Emergency add-on procedures performed during the weekends were not assessed. These cases were then compared with elective cases during a similar time frame to determine differences in the aspects of add-on cases versus those that were elective.

RESULTS: Seven hundred twenty-one add-on cases were reviewed (mean patient age 57.4 years; 46% women) and compared with 736 elective cases (mean age 56 years; 49% women; P not significant). Of the add-on cases, 377 (52%) were EGD, 216 C (30%) and 105 (15%) were FS, with 23 combined procedures (3.2%) versus 202 (27%) EGD, 442 (60%) C and 74 (10%) FS in the elective group. Add-on cases were more likely to be EGDs than elective cases (OR 2.7; 95% CI 1.8 to 4.3; P<0.0001) and less likely to be Cs (OR 0.24; 95% CI 0.15 to 0.38; P<0.0001). There were significantly more add-on cases on Mondays (OR 1.7; 95% CI 1.0 to 2.28; P>0.03). Conversely, there were significantly fewer procedures added on Fridays (OR 0.31; 95% CI 0.16 to 0.57; P=0.0001). There were statistically fewer add-on cases in September compared with the other months that were evaluated (OR 0.31; 95% CI 0.11 to 0.78; P=0.0006).

Conclusion: With the present system of performing only emergency cases on the weekend, Monday tends to have more add-on cases. Consistent with the fact that upper gastrointestinal bleeding is the most common emergency condition, EGD is more common in add-on cases than with elective cases. Although speculative, the reasons for Friday having fewer add-on cases may be the result of a change of physician on call that day; consequently, most cases may be performed earlier in the week. For unknown reasons, fewer cases tend to be added on in September than in the other months evaluated. These data demonstrate that even in the same institution with similar patients, variability in the number of add-on cases likely is a result of many additional factors governing add-on cases, which require appropriate resource planning to ensure adequate allocation of services to ensure ideal patient care.
The Safety of Infliximab Infusions in the Community Setting
Authors: Ducharme James , Pelletier Cindy , Zacharias Ramesh
Published: March 2016

BACKGROUND: Tumour necrosis factor‐alpha (TNFα) has an important role in the pathogenesis of inflammatory conditions such as rheumatoid arthritis, Crohn’s disease, ulcerative colitis and psoriasis. Infliximab, a chimeric anti‐TNFα monoclonal antibody, has been shown to reduce the severity of symptoms or induces remission of active disease. Infusions have generally been limited to the hospital setting due to cost and concerns for patient safety. Studies defining its efficacy and safety have, therefore, originated almost exclusively from hospital settings.

OBJECTIVE: To evaluate the safety of infliximab in a community clinic environment, across all types of patients.

METHODS: A retrospective chart review of 3161 patients who received a combined 20,976 infusions at a network of community clinics over 16.5 months was conducted. Adverse drug reaction (ADR) information was retrieved and coded for time of onset, severity and outcome. Only ADRs that occurred during or within the first 24 h of the infusion were included.

RESULTS: A total of 524 (2.5% of all infusions) acute ADRs in 353 patients (11.2%) were recorded. Most reactions (ie, ADRs) were mild (n=263 [50.2%, 1.3% of all infusions]) or moderate (n=233 [44.5%, 1.1% of all infusions]). Twenty‐eight reactions (5.3%, 0.1% of all infusions) were severe. Emergency medical services were called to transport patients to hospital for seven of the severe reactions, of which none required admission. As per pre‐established medical directives, adrenaline was administered three times.

CONCLUSIONS: Infliximab infusions are safe in the community setting. Severe ADRs were rare. None required active physician intervention; nurses were able to treat all reactions by following standardized medical directives.
Effects of Oxygen on Exercise Duration in Chronic Obstructive Pulmonary Disease Patients before and after Pulmonary Rehabilitation
Authors: Voduc Nha , Tessier Caroline , Sabri Elham , Fergusson Dean , Lavallee Lyne , Aaron Shawn D
Published: March 2016

BACKGROUND: Supplemental oxygen therapy has been shown to improve exercise performance in patients with chronic obstructive pulmonary disease (COPD). It is unknown whether the magnitude of this benefit would be affected by participation in a pulmonary rehabilitation program.

OBJECTIVE: To compare the effects of supplemental oxygen on exercise capacity in nonhypoxemic COPD patients before and after participation in a pulmonary rehabilitation program.

METHODS: Sixteen patients with COPD underwent two pairs of constant‐load exercise tests before and after participation in a three‐month outpatient pulmonary rehabilitation program. Each pair of exercise tests consisted of a test performed with room air and a second test performed with 50% supplemental oxygen, in random order. The primary outcome was the difference in exercise duration between tests performed with supplemental oxygen and with room air. This difference was compared before and after participation in a pulmonary rehabilitation program.

RESULTS: Supplemental oxygen therapy improved exercise duration by 75 s before participation in a pulmonary rehabilitation program and by 153 s following pulmonary rehabilitation. Rehabilitation alone improved exercise duration by 28 s, but rehabilitation appeared to augment the exercise benefits of supplemental oxygen therapy by a mean of 78 s (95% CI 11 s to 145 s; P=0.03).

CONCLUSION: The effects of supplemental oxygen therapy were augmented after pulmonary rehabilitation. The improvement in exercise duration with supplemental oxygen following rehabilitation was greater than either supplemental oxygen or pulmonary rehabilitation alone.
Replication and Meta‐Analysis of 13,000 Cases Defines the Risk for Interleukin‐23 Receptor and Autophagy‐Related 16‐Like 1 Variants in Crohn’s Disease
Authors: Cotterill Lynn , Payne Debbie , Levison Scott , McLaughlin John , Wesley Emma , Feeney Mark , Durbin Hilary , Lal Simon , Makin Alistair , Campbell Simon , Roberts Stephen A , O’Neill Catherine , Edwards Cathryn , Newman William G
Published: March 2016

BACKGROUND/OBJECTIVE: Variants in the interleukin‐23 receptor (IL23R) and the autophagy‐related 16‐like 1 (ATG16L1) genes have been associated with an increased risk of Crohn’s disease (CD). Both genes were identified through genome‐wide association scans and subsequent studies have validated these associations. To assess the effect size of these variants, an independent case‐control association study and meta‐analysis were performed.

METHODS: British Caucasian subjects with inflammatory bowel disease (n=500) and 877 ethnically matched controls were genotyped for the disease‐associated variants in IL23R and ATG16L1. In addition, meta‐analyses of 12,991 patients and 14,598 controls, and 11,909 patients and 15,798 controls, were conducted on independently published data for the associations between IL23R and ATG16L1 variants and CD, respectively.

RESULTS: In the present cohort, both susceptibility variants showed highly significant associations, including IL23R (rs11209026, P=0.0006; OR 0.37; 95% CI 0.21 to 0.67) and ATG16L1 (rs2241880, P=0.0017; OR 1.36; 95% CI 1.12 to 1.66). The meta‐analysis based on the random effects model showed similar combined effects for rs11209026 (n=26, OR 0.41; 95% CI 0.37 to 0.46) and rs2241880 (n=25, OR 1.33; 95% CI 1.28 to 1.39). There was no statistically significant gene‐gene interaction between caspase recruitment domain (CARD15) variants and the IL23R or ATG16L1 polymorphisms (P=0.44 and P=0.24, respectively).

CONCLUSION: The present cohort and meta‐analysis provides strong evidence that, in addition to CARD15, polymorphisms in both IL23R and ATG16L1 alter susceptibility to CD and that these effects are consistent across all populations of European ancestry; however, only ATG16L1 is relevant to inflammatory bowel disease in the Asian population.
Predictors of Relapse to Significant Alcohol Drinking after Liver Transplantation
Authors: Karim Zamil , Intaraprasong Pongphob , Scudamore Charles H , Erb Siegfried R , Soos John G , Cheung Elsie , Cooper Polly , Buzckowski Andrzej K , Chung Stephen W , Steinbrecher Urs P , Yoshida Eric M
Published: March 2016

BACKGROUND: End‐stage alcoholic liver disease is common, with many of these patients referred for liver transplantation (LT). Alcohol relapse after LT can have detrimental outcomes such as graft loss and can contribute to a negative public perception of LT.

OBJECTIVE: To identify factors that predict the recurrence of harmful alcohol consumption after LT.

METHODS: A total of 80 patients who underwent LT for alcoholic cirrhosis or had significant alcohol consumption in association with another primary liver disease, from July 1992 to June 2006 in British Columbia, were retrospectively evaluated by chart review. Several demographic‐, psychosocial‐ and addiction‐related variables were studied. Univariate and multivariate logistic regression analyses were used to test possible associations among the variables studied and a return to harmful drinking after LT.

RESULTS: The relapse rate of harmful alcohol consumption post‐liver transplant was 10%, with two patient deaths occurring directly as a result of alcohol relapse. Univariate analysis revealed relapse was significantly associated with pretransplant abstinence of less than six months (P=0.003), presence of psychiatric comorbidities (P=0.016), female sex (P=0.019) and increased personal stressors (P=0.044), while age at transplant of younger than 50 years approached significance (P=0.054). Multivariate logistic regression analysis revealed the following independent factors for relapse: pretransplant abstinence of less than six months (OR 77.07; standard error 1.743; P=0.013) and female sex (OR 18.80; standard error 1.451; P=0.043).

CONCLUSION: The findings of the present study strongly support a required minimum of six months of abstinence before LT because duration of abstinence was found to be the strongest predictor of recidivism. Female sex, younger age at transplant and psychiatric comorbidities were also associated with relapse to harmful drinking.
Hazards of the ‘Hard Cash’: Hypersensitivity Pneumonitis
Authors: Kupeli Elif , Karnak Demet , Sak Serpil Dizbay , Kayacan Oya
Published: March 2016

Hypersensitivity pneumonitis (HP) is a nonimmunoglobulin E-related immune-mediated parenchymal lung disease. A 45-year-old woman who was a lifelong nonsmoker with a six-month history of frequent episodes of cough and dyspnea was admitted to hospital. She had been working as a money counter for 20 years at a central bank. Bibasilar crackles on lung auscultation, ground-glass opacities and a mosaic pattern on high-resolution computed tomography, restrictive abnormality on pulmonary function tests and mild hypoxemia were the prominent findings. Bronchoalveolar lavage fluid analysis revealed a predominance of CD4-positive T cells, and she tested positive on her natural challenge test. She was diagnosed with subacute HP based on established criteria. She was advised to discontinue counting fresh banknotes. Prednisolone was commenced, then tapered to discontinue in the ensuing six months. Clinical and radiological improvement was achieved within two months. To the authors’ knowledge, the present report is the first to describe ‘hard cash HP’, possibly caused by chipping dust or printing dye.
Noninvasive Ventilation Initiation in Clinical Practice: A Six‐Year Prospective, Observational Study
Authors: Harris Chris , Saskin Refik , Burns Karen EA
Published: March 2016

BACKGROUND: Despite evidence supporting the role of noninvasive ventilation (NIV) in diverse populations, few publications describe how NIV is used in clinical practice.

OBJECTIVE: To describe NIV initiation in a teaching hospital that has a guideline, and to characterize temporal changes in NIV initiation over time.

METHODS: A prospective, observational study of continuous positive airway pressure ventilation (CPAP) or bilevel NIV initiation from January 2000 to December 2005 was conducted. Registered respiratory therapists completed a one‐page data collection form at NIV initiation.

RESULTS: Over a six‐year period, NIV was initiated in 623 unique patients (531 bilevel NIV, 92 CPAP). Compared with bilevel NIV, CPAP was initiated more often using a nasal interface, with a machine owned by the patient, and for chronic conditions, especially obstructive sleep apnea. Whereas CPAP was frequently initiated and continued on the wards, bilevel NIV was most frequently initiated and continued in the emergency department, intensive care unit and the coronary care unit. Patients initiated on bilevel NIV were more likely to be female (OR 1.8, 95% CI 1.08 to 2.85; P=0.02) and to have an acute indication compared with CPAP initiations (OR 7.5, 95% CI 1.61 to 34.41; P=0.01). Bilevel NIV was initiated more often in the emergency department than in the intensive care unit (OR 5.8, 95% CI 0.89 to 38.17; P=0.07). Bilevel NIV initiation increased from 2000 to 2005.

CONCLUSIONS: The present study illustrates how NIV is used in clinical practice and confirms that NIV initiation has increased over time.
Sore Throat Progressing to Embolic Sepsis: A Case of Lemierre’s Syndrome
Authors: Dirks Jacquelyn , Bowie Dennis
Published: March 2016

Lemierre’s syndrome is a rare clinical syndrome defined as oropharyngeal sepsis, thrombophlebitis of the internal jugular vein and septic thombo‐emboli. It is typically encountered in young, immunocompetent individuals, with a mean incident age of 20 years. The organism that is most commonly associated is an anaerobic Gram‐negative bacterium: Fusobacterium species. The defined treatment course is at least six weeks of antibiotics, with the role of anticoagulation being unclear. The present article documents a case of Lemierre’s syndrome complicated by acute renal failure and loculated pleural effusion in an otherwise healthy 16‐year‐old patient.