bluuebunny/crossref_metadata_2025 huggingface dataset:
Overreliance on Bronchodilators as a Risk Factor for Life‐Threatening Asthma
Authors: Ernst Pierre , Hemmelgarn Brenda , Cockcroft Donald W , Suissa Samy
Published: March 2016

OBJECTIVE: To assess the potential impact on the risk of life‐threatening asthma of current recommendations in pharmacotherapy, which emphasize the early use of steroids and the avoidance of beta‐agonist overuse.

DESIGN: Nested case‐control study.

SETTING: Province of Saskatchewan.

POPULATION STUDIED: From a cohort of 12,301 subjects dispensed 10 or more asthma medications from 1980 to 1987, 129 case patients were identified who had experienced an episode of fatal or near fatal asthma and 129 control patients matched to the cases on age, time period at risk and severity of asthma (as judged by the need for hospitalization for asthma in the preceding two years).

METHODS: Two clinicians reviewed the therapy these 258 subjects had been dispensed over the prior two‐year period and classified their treatment as ‘incompatible’ or ‘compatible’ (at least partially compatible) with current pharmacotherapeutic guide lines. In addition to this classification a treatment evaluation score was also applied to each study subject. This score was based on the use of anti‐inflammatory therapy (oral and inhaled) in conjunction with the regular use of bronchodilators, as well as the use of oral corticosteroids for patients recently discharged from hospital foll owing an attack or asthma.

RESULTS: At least one of the two clinician reviewers judged therapy to be incompatible with current standards in 49% of the case patients compared with 20% of the subjects who had not experienced a life‐threatening episode. The mean ± SD treatment score was 3.5±1.7 in cases compared with 0.8±1.4 in controls, suggesting quality or pharmacological treatment was worse in cases (P<0.001).

CONCLUSIONS: Pharmacological therapy incompatible with current recommendations was more common among cases of fatal and near fata l asthma in Saskatchewan from 1980 to 1987.
Antimicrobial Activity of Ceftriaxone Compared with Cefotaxime in the Presence of Serum Albumin
Authors: Nath Swapan K , Foster Gary A , Mandell Lionel A , Rotstein Coleman
Published: March 2016

The effect of serum albumin on the antimicrobial activity of ceftriaxone, cefotaxime, and a 1:1 ratio of cefotaxime and its desacetyl metabolite against nonpseudomonal Gram‐negative bacilli was determined. Antimicrobial activity of drugs was evaluated by measuring minimum inhibitory (mic) and bactericidal (mbc) concentrations in broth with and without human serum albumin. The analysis of logarithmically transformed mean mics and mbcs showed that there was a highly significant interaction between drug and serum albumin (P<0.0001). The inhibitory and bactericidal activities were greatest for cefotaxime followed by cefotaxime/desacetylcefotaxime and ceftriaxone (P<0.01). Time‐kill kinetics demonstrated that ceftriaxone was less bactericidal than cefotaxime in broth with albumin. On the basis of these results it was concluded that the in vitro antimicrobial activity of ceftriaxone compared with that of cefotaxime was significantly diminished in the presence of serum albumin.
Effects of High Frequency Chest Compression on Respiratory System Mechanics in Normal Subjects and Cystic Fibrosis Patients
Authors: Jones Richard L , Lester Richard T , Brown Neil E
Published: March 2016

OBJECTIVE: To investigate the short term effects of high frequency chest compression (HFCC) on several indices of respiratory system mechanics in normal subjects and patients with cystic fibrosis (CF).

DESIGN: Comparative physiological approach. Subjects were blinded to 10 randomized HFCC settings (5, 10, 15, 20 and 25 Hz) with each applied at the lowest and at the highest background vest pressure.

SETTING: Pulmonary function and lung mechanics laboratory, University of Alberta.

PARTICIPANTS: Ten normal male volunteers (24.2±3.8 years) and 11 clinically stable CF patients (23.4±6.7 years). Normal subjects were nonsmokers who had normal lung function. The CF patients had a wide range of airway obstruction.

INTERVENTIONS: HFCC was supplied by oscillating a pneumatic vest that covered the entire torso. Balloon tipped catheters were used to measure esophageal (Pes) and external chest wall (Pew) pressures. Changes in end‐expiratory lung volume (EELV) during HFCC were measured from a spirogram and were compared with baseline functional residual capacity (FRC). The HFCC induced air movement al the mouth, oscillated tidal volume (Vosc), was measured by reverse plethysmography.

RESULTS: Both normals and CF patients had similar changes in Pes and EELV. At the highest background vest pressure and at the higher oscillation frequencies, EELV decreased approximately 30% from the no‐HFCC baseline FRC. Vosc decreased with increasing oscillation frequency but normals had higher Vosc than CF patients at each frequency. Conversion of Vose to flow () revealed that the highest occurred between 10 and 15 Hz for both normals and CF patients. Also, was dependent on the overall airway function. Low forced expired volume in 1 s resulted in low , especially when was measured during spontaneous expiration.

CONCLUSIONS: CF patients with moderate or severe airway obstruction may gain maximal benefit from HFCC therapy when low vest pressure is used at an oscillation frequency of 10 to 15 Hz. The low vest pressure minimizes the decrease in EELV and 10 to 15 Hz maximizes .
Ozone: A Review of Recent Experimental, Clinical and Epidemiological Evidence, with Notes on Causation—Part 2
Authors: Bates David V
Published: March 2016

The first section of this concluding part reviews epidemiological studies relating to oxidant exposures. There are convincing data from the eastern section of the continent that ozone, in combination with aerosol sulphates and acid aerosols, is strongly associated with hospital emergency visits and in‐patient admissions for acute respiratory disease, including asthma. There is some evidence that long term exposures may be associated with an increased prevalence of asthma; disturbing initial observations suggest the possibility that a chronic respiratory bronchiolitis may be induced. The second section of this article reviews the totality of information on ozone in the light of customary criteria of ‘causality’. It is concluded that the present evidence justifies the conclusion that exist ing levels of tropospheric ozone are aggravating existing human disease, and probably increasing the prevalence and incidence of some diseases; however, it is uncertain whether this effect is being magnified by the concomitant presence of other pollutants. Although a great deal is known about the effects of ozone, there are still many important unresolved questions in relation to it.
Activity of Vancomycin, Teicoplanin and Cephalosporins against Penicillin‐Susceptible and Penicillin‐Intermediate Streptococcus Pneumoniae
Authors: Loo Vivian G , Lavallée Jocelyne , McAlear Diane , Robson Hugh G
Published: March 2016

Objective: To report in vitro susceptibilities of penicillin‐susceptible and penicillin‐intermediate Streptococcus pneumoniae isolates to cephalosporins, vancomycin and teicoplanin.

Design: Minimal inhibitory concentrations (mic) were determined according to National Committee for Clinical Laboratory Standards guidelines for 17 penicillin‐susceptible isolates (mic 0.06 mg/L or less) and 16 isolates showing intermediate susceptibility to penicillin (mic 0.12 to 1.0 mg/L).

Setting: Tertiary care university centre.

Main Results: Comparison of the mic90 values with those of other antibiotics tested demonstrated that ceftriaxone, cefotaxime and teicoplanin were the most active agents against penicillin‐susceptible strains. However, teicoplanin had the lowest mic and was superior to other agents against strains with intermediate penicillin susceptibility. The mics of all cephalosporins increased in concordance with the mic of penicillin.

Conclusion: Isolates demonstrating intermediate susceptibility or resistance to penicillin should be routinely evaluated for susceptibility to clinically important cephalosporins.
Adjunctive Corticosteroid Therapy Decreases Lung Permeability in Patients with AIDS‐Related Pneumocystis carinii Pneumonia
Authors: Guillemi Silvia , Belzberg Allan , Lawson Lindsay M , Schechter Martin T , Montaner Julio SG
Published: March 2016

OBJECTIVE: To assess the effect of adjunctive corticosteroid therapy on lung permeability as measured by Tc‐DTPA lung clearance scan in patients with AIDS‐related Pneumocystis carinii pneumonia (PCP).

METHODS: Sixteen patients with microbiologically proven AIDS‐related PCP were prospectively studied using sequential Tc‐DTPA lung clearance scan. All patients received slant.lard antimicrobial treatment. Six patients received adjunctive oral corticosteroids in addition to the usual antimicrobial therapy. Tc‐DTPA lung clearance scan was performed al baseline and during the second week of therapy. All scans were read by a blinded single observer using a standardized protocol.

RESULTS: Baseline Tc‐DTPA lung clearance halftime (T1/2) was 12±2 and 9±1 mins in the noncorticosteroid and corticosteroid treated groups, respectively. During the second week of therapy, Tc‐DTPA T1/2 lung clearance was 17±8 and 24±9 mins for the noncorticosteroid and corticosteroid treated groups, respectively. The change in Tc‐DTPA lung clearance between baseline and week 2 was significantly greater (P<0.02) in the corticosteroid treated patients.

CONCLUSION: Data suggest that the use of adjunctive corticosteroid therapy decreases lung permeability, as measured by Tc‐DTPA lung clearance scan, in patients with AIDS‐related PCP.
Immune Response to Verotoxin 1 and 2 in Children with Escherichia Coli O157:H7 Hemorrhagic Colitis and Classic Hemolytic Uremic Syndrome
Authors: Proulx François , Turgeon Jean P , Delage Gilles , Lior Hermy , Lafleur Lucette , Chicoine Luc
Published: March 2016

Objectives: To compare neutralizing antibody titres against verotoxin (vt)‐1 and vt-2 between children with uncomplicated hemorrhagic colitis (hc) and those with classic hemolytic uremic syndrome (hus). vt antibody titres were also compared in children with hc who received trimethoprim‐sulfamethoxazole with those who did not.

Design: Prospective study.

Setting: Tertiary pediatric hospital.

Population Studied: Children with hc (n=41) or classic hus (n=12).

Interventions: Serum antibodies against vt-1 and vt-2 were determined by quantitative neutralization.

Main Results: Antibodies were detected in 40% (21 of 53) of serum samples for vt-1 and in 100% (53 of 53) of samples for vt-2. A positive immune response, defined as a fourfold increase in vt antibody titres or as a single titre of 1/64 or greater, was found in 0% (0 of 12) of patients with hus compared with 7% (three of 41) of those with hc for vt-1 (P=0.4); and in 17% (two of 12) of patients with hus compared with 22% (nine of 41) of those with hc for vt-2 (P=0.3). The rate of seroconversion against either vt-1 or vt-2 was comparable in treated and untreated patients with uncomplicated hc.

Conclusions: There was no evidence that neutralizing antibody levels against vt-1 or vt-2 in classic hus or after antibiotic therapy are substantially different from those in patients with uncomplicated hc.
Health Effects of Air Pollution in Canada: Expert Panel Findings for The Canadian Smog Advisory Program
Authors: Stieb David M , Pengelly L David , Arron Nina , Taylor S Martin , Raizenne Mark E
Published: March 2016

OBJECTIVE: To review the evidence on health effects of air pollution for the Canadian Smog Advisory Program.

METHODS: Evidence was reviewed by two expert panels, who were asked to define the health effects expected at levels of exposure given by the National Ambient Air Quality Objectives, to examine a variety of issues related to communicating with the public about environmental health risks, and to draft health messages for the advisory program.

RESULTS: The panels concluded that health effects of ground‐level ozone at levels that occur in Canada include pulmonary inflammation, pulmonary function decrements, airway hyperreactivity, respiratory symptoms, possible increased medication use and physician/emergency room visits among individuals with heart or lung disease, reduced exercise capacity, increased hospital admissions and possible
increased mortality. Similar effects were felt to occur in association with airborne particles, with the exception of inflammatory changes, and with the addition of increased school absenteeism. Poor data on individual exposure were identified as a limitation of studies on hospital admissions and mortality.

RECOMMENDATIONS: The panels identified the need to reflect the evidence accurately without unduly raising public concern and recommended that advisory health messages identify expected health effects, while health care providers could more appropriately recommend protective actions to individuals. Supplementary educational strategies and evaluation of the advisory program were also recommended.
Pasteurella multocida Osteomyelitis: An Unusual Case Presentation
Authors: von Schroeder Herbert P , Bell Robert S
Published: March 2016

A healthy male farm employee developed an unusual infection caused by Pasteurella multocida. Atypical features included the chronic nature of the infection, the development of osteomyelitis of the tibia without direct animal inoculation, and lack of fever and leukocytosis. Radiographic appearance of P multocida osteomyelitis may be the result of osteoclast activation and can be confused with musculoskeletal tumour. P multocida infection requires a high degree of suspicion, and should be considered in cases of farm‐ or animal‐related injuries even if there is no history of direct animal contact.
Oligella Infections: Case Report and Review of the Literature
Authors: Baqi Mahin , Mazzulli Tony
Published: March 2016

A case of Oligella ureolytica infection of a cervical lymph node is presented and previous cases of oligella infection reported in the literature are reviewed. Underlying malignancy and urinary tract obstruction were observed in many of the cases. All patients responded to antimicrobial therapy and, in those cases associated with urinary tract obstruction, surgical relief of the obstruction. The microbiology and clinical features of oligella infections are reviewed.
Effect of Inhaled Prostaglandin E2 on Methacholine and Leukotriene D4 Airway Responsiveness in Asthmatic Subjects
Authors: Stevens Wil Hm , VanderHeyden Cheryl P , O′Byrne Paul M
Published: March 2016

Previous studies in asthmatics have demonstrated that the endogenous release of inhibitory prostaglandins limits the bronchoconstrictor response to repeated challenges with exercise and histamine, and that inhaled prostaglandin (PG) E2 attenuates allergen‐induced asthmatic responses and exercise bronchoconstriction in asthmatics. Inhaled PGE2 does not significantly attenuate methacholine airway responsiveness. These results, taken together, indicate that inhaled PGE2 attenuates the bronchoconstriction caused by stimuli, such as allergen and exercise, that result in bronchoconstriction through cysteinyl leukotriene (LT) release. The purpose of this study was to determine whether inhaled PGE2 could selectively attenuate LTD4‐induced bronchoconstriction in seven stable asthmatic subjects. Each subject was studied on four different study days. On two occasions the subjects inhaled 100 mg PGE2, 30 mins before a methacholine, or LTD4 challenge test. On the other two study days, the subjects were pretreated with its diluent. Results were expressed as the provocation concentration causing a 20% fall in forced expiratory volume in 1 s (FEV1) (PC20). PGE2 pretreatment significantly increased the LTD4 PC20, but not the methacholine PC20. The mean LTD4 PC20 increased from 2.00 mg/mL (%SEM 1.65) after diluent pretreatment to 3.01 mg/mL (%SEM 1.64) after PGE2 pretreatment (P=0.008). The mean methacholine PC20 was 1.28 mg/mL (%SEM 1.68) after diluent pretreatment and 1.62 mg/mL (%SEM 1.46) after PGE2 pretreatment (P=0.28). These results suggest that PGE2 partially attenuates LTD4‐induced bronchoconstriction; however, the magnitude of the effect is unlikely to account for its attenuation of exercise and allergen‐induced bronchoconstriction.
Meningitis in a Canadian Adult due to High Level Penicillin‐Resistant, Cefotaxime‐Intermediate Streptococcus pneumoniae
Authors: Tremblay Cécile , Bourgault Anne-Marie , St-Antoine Pierre
Published: March 2016

Invasive penicillin‐resistant pneumococcal (PRSP) infections are increasing worldwide. In Canada, the incidence of penicillin resistance among Streptococcus pneumoniae isolates is estimated at greater than 6%. In Quebec, only one case of PRSP meningitis has been reported and involved an infant. An adult patient is described who presented with meningitis caused by high level penicillin‐resistant, cefotaxime‐intermediate S pneumoniae.
Variability in Urine Culture Reporting by Canadian Microbiology Laboratories
Authors: Noble Michael A , Nikiforuk Shirley
Published: March 2016

OBJECTIVE: To determine the ability of microbiology laboratories to perform and to report urine colony counts.

DESIGN: Clinical Microbiology Proficiency Testing program participants received stabilized simulated urine samples. Laboratories were asked to perform the appropriate test and report results.

PARTICIPANTS: One hundred and nine clinical microbiology laboratories in British Columbia, Alberta and Nova Scotia.

OUTCOME MEASURES: Consistency of reporting was compared with standards for reporting results as described in the SI Manual in Health Care, 2nd edition.

RESULTS: The study demonstrated a wide variation in units used for the reporting of results. Ninety‐five (87.2%) laboratories reported quantitative urine results in a variety of unit styles. Of those laboratories providing results with units, 80 (84.2%) used one of 10 variations of SI reporting styles. Fifteen (16.8%) laboratories reported metric units in three different styles. Eleven (10.0%) laboratories reported semiquantitative values without stating units. The remaining three (2.8%) did not respond to the survey.

CONCLUSIONS: Many clinical microbiology laboratories have not adopted a consistent form of SI units for reporting quantitative urine culture results. This lack of consistency could potentially lead to interpretation confusion.
A Simple and Effective Method to Evaluate Peak Flowmeters
Authors: Wang Liman , Proudlock Melva , Liu Mingyao
Published: March 2016

OBJECTIVE: Peak flowmeters have been widely used to monitor the course of asthma. The objective of this study was to develop a simple, convenient and effective method to evaluate these devices routinely.

METHODS: A rubber band‐driven 3 L syringe was used to generate airflows, and a pneumotachometer was connected in series with the peak flowmeter as a standard. Waveforms were recorded and compared with maximal expiratory curves. The accuracy of peak flowmeters was analyzed by linear regression and by calculating the percentage of the difference measured by the flowmeter (F) and the pneumotachometer (P), expressed as (F‐‐P)/P (%).

RESULTS: This set‐up generated waveforms similar to the initial phase of maximal expiratory curves, with linear increment of peak flow rates up to 790 L/min (R=0.999, PÃ0.001). Both waveforms and peak flow rates were highly reproducible with coefficients of variation less than 5% throughout the full range tested. Fourteen peak flowmeters from seven different models were evaluated. Most of these devices revealed a satisfactory linear relationship with the pneumotachometer. The interdevice variation of different models and variations of each device at different flow rates were clearly demonstrated by (F‐‐P)/P (%).

CONCLUSION: The system developed in the present study can be easily set up and used to evaluate the performance of peak flowmeters.
Cardiopulmonary Interactions during Positive Pressure Ventilation
Authors: Granton John
Published: March 2016

Positive pressure ventilation (PPV) may lead to significant hemodynamic alterations. The cardiocirculatory effects of PPV occur through alterations in the loading conditions of the right and left ventricle and are mediated by changes in intrathoracic pressures and in lung volume. However, the net effect of PPV on cardiac output and hemodynamics is not always predictable. PPV may lead to either a decrease or an increase in cardiac performance. The cardiac consequences of PPV are also dependent on baseline loading conditions and contractile function of the heart.
Public Knowledge about Hepatitis B‐Related Issues in Korea
Authors: Chrusch C , Minuk GY
Published: March 2016

Hepatitis B infection is endemic in many parts of the world, including Korea. Basic knowledge of the hepatitis B virus by the public is a prerequisite for the development of a successful vaccination program. A survey was conducted in rural Korea to examine public knowledge of hepatitis B etiology, symptoms, transmission, risk factors and prevention. It was found that knowledge independently correlated with education and female sex, but that overall knowledge of hepatitis B was poor. The preferred information sources in order of preference were physicians, television and public health nurses. This information may be useful in designing public health education and vaccination programs in developing populations.
Outcome from Acute Repsiratory Distress Syndrome: Is It Really Improving?
Authors: Villar Jesús , Slutsky Arthur S
Published: March 2016

Assessing the severity of the acute respiratory distress syndrome (ARDS) is important in determining the prognosis in any given patient and in assessing the adequacy of various forms of therapy. Mortality from ARDS has been high since the syndrome was first described almost 30 years ago. Sepsis and extrapulmonary organ failure are the major contributing factors affecting the probability of survival in patients with ARDS. Although studies of ARDS frequently are not comparable because of varying definitions and inhomogeneity of patients, it appears that the mortality rate from ARDS has dropped by about 20% in the past 10 years.
Epidemiological Trends in Asthma
Authors: Sears Malcolm R
Published: March 2016

Many markers of asthma morbidity have shown substantial increases over the past two decades, including family physician visits, use of anti‐asthma medications, emergency room visits and hospital admissions. The reported prevalence of diagnosed asthma and of wheezing has increased, especially in children, with accompanying evidence of increased atopy and increased airway responsiveness. Allergen exposure and parental smoking are significant risk factors for childhood wheezing, whereas the influence of outdoor air pollution is uncertain. Increasing use of beta‐agonist treatment, which appears to increase the severity of asthma by increasing early and late responses to allergen, may contribute to increased morbidity and mortality, especially if potent beta‐agonists are used. Risk factors for asthma mortality include age, smoking, allergy and airway lability, as well as over‐reliance on beta‐agonists and poor compliance with other aspects of treatment. Following withdrawal of the potent beta‐agonist fenoterol in New Zealand, both hospital admissions and mortality from asthma fell abruptly. Continued patient and physician education, with emphasis on avoidance of risk factors and use of appropriate treatment, should reduce morbidity and mortality from asthma in Canada.
Influenza and Pneumococcal Vaccination in Long Term Care Facilities in Two Regions of Quebec
Authors: De Wals Philippe , Carbonneau Michel , Payette Hélène , Niyonsenga Théophile
Published: March 2016

OBJECTIVES: To evaluate the use of influenza and pneumococcal vaccines in long term care facilities.

DESIGN: Cross‐sectional survey in a random sample of 30 facilities in two regions of Quebec. Information was collected from the general manager or the chief of nursing, all consultant physicians and a random sample of 20 residents in each facility.

RESULTS: Twenty‐nine centres agreed to participate. The mean influenza vaccination rate was 70%, and was not influenced by differences in the types of facilities or the organization of the programs for immunization. The main obstacle to influenza vaccination reported by physicians was nonacceptance by a significant proportion of residents. Of the residents who did not initially request influenza vaccine, only 64% accepted vaccination when it was offered. The vast majority of residents were satisfied with the information they had received and the respect shown for their freedom of choice. Forty per cent of residents were unfit to provide a valid consent and the vaccination rate was 76% in this group. Only one‐third of the physicians regularly obtained authorization from a relative or the legal guardian before prescribing vaccination for incompetent residents. None of the facilities studied had an effective program for pneumococcal vaccination, only 43% of the physicians reported any use of pneumococcal vaccine and 98% of residents had never heard of the vaccine.

CONCLUSIONS: The national objective of 95% coverage with influenza vaccine will be difficult to achieve in long term care facilities, mainly because a minority of residents are not likely to be convinced of the benefit of immunization. Much remains to be done to promote and administer pneumococcal vaccine in this setting.
Chlamydia Infection in Street Youth: Need for More Aggressive Screening Programs
Authors: Tam R , MacDonald N , Feder S , Giglia L , Peeling R , Gully P , Toye B , Doherty J
Published: March 2016

OBJECTIVES: To determine, first, the sexual practices among street youth in the Ottawa‐Carleton, Ontario region; second, the percentage of street youth who report previous sexually transmitted disease (STD) screening; and third, the rate of previous infection with Chlamydia trachomatis in this population.

METHODS: This prospective street youth pilot study was cross‐sectional in design. Street youth aged 15 to 20 years were recruited through a drop‐in centre or shelter in Ottawa, Ontario between August and October 1993. Information on demographics, substance use, current sexual practices and STD screening and infection history were obtained through a structured face to face interview and a 75‐item questionnaire. Past C trachomatis infection was determined by microimmunofluorescence assay with purified antigens of C trachomatis (serovars A to K), Chlamydia psittaci (avian strain 6BC) and Chlamydia pneumoniae (TW‐183 strain).

RESULTS: Ninety‐eight per cent of the youth approached participated. Of the 100 street youth (61 males, mean age 17.8 years; 39 females, mean age 17.1 years), 94% were sexually active, with 21% of males and 26% of females having had four or more different sexual partners in the previous year. Only 27% of males and 8% of females reported consistent condom use with all partners all of the time. Thirty per cent of males and 50% of females reported previous STD testing. Of the 100 street youth, 22 (16 males and six females) had had previous C trachomatis infection by serotesting, but only three of 16 (19%) of these males and three of six (50%) of these females reported previous STD testing. None of the 22 recalled previous diagnosis or treatment for any STD.

CONCLUSIONS: These street youth reported a high prevalence of risky sexual behaviour, and this supports the national STD guidelines for targeted screening in this population. The current screening guidelines for C trachomatis in this population do not reach the majority of street youth.
Establishing an Approach to Mechanical Ventilation
Authors: Stewart Thomas E
Published: March 2016

Technology in the intensive care environment has progressed at an exponential rate. This progression has particularly been noticeable in relation to mechanical ventilation where advancements have arguably surpassed improvements in patient morbidity and mortality. Ventilator‐induced lung injury (VILI), which occurs secondary to lung overdistension and underinflation, may largely be responsible for this discrepancy. No matter which of the vast number of modes of mechanical ventilation are employed, simple principles can be followed that will prevent the development of VILI. A lung protective ventilatory approach incorporates the prevention of oxygen toxicity and the avoidance of lung over‐ and underinflation, while frequently using permissive hypercapnia. By establishing a lung protective approach early in the management of ventilated patients, the morbidity and mortality associated with respiratory failure may finally be reduced.
Liquid Ventilation
Authors: Cox Peter N
Published: March 2016

There has been a recent explosion of interest in the use of liquid ventilation. Over time humans have lost the physiological attributes necessary for respiration in water. However, perfluorocarbons have high solubilities for oxygen and carbon dioxide, as well as a low surface tension. These characteristics allow them to be used as a medium to assist gas exchange and recruit atelectatic‐dependent lung zones in respiratory distress syndrome. Current trials may prove perfluorocarbon to be a useful adjunct in lung protective strategies in respiratory distress syndrome.
Classification and Diagnosis of Fibromyalgia
Authors: Merskey Harold
Published: March 2016

Fibromyalgia was recently classified when a sleep disorder was described with diffuse musculoskeletal pain. The standard modern definition was reached on the basis of thorough analysis of pain patterns and characteristic tender points. The principles of classification are reviewed with respect to this diagnosis.
Psychological Research in Fibromyalgia: The Search for Explanatory Phenomena
Authors: Boissevan Michael D
Published: March 2016

This article reviews four areas of psychological research in fibromyalgia. First, the literature on depression in fibromyalgia shows that although the preponderance of studies demonstrate that fibromyalgia patients are more depressed than comparable medical patients, rigorous disconfirming evidence exists. Thus the role of depression in fibromyalgia remains unclear because consistent levels of depression are not found either between samples or between subjects. Second, the role of pain perception in fibromyalgia shows that fibromyalgia patients are consistently more responsive to aversive stimulation than other subjects with chronic pain. This pattern of hyper‐responsiveness appears to be generalized, rather than localized to tender points. These results are discussed in terms of potential central nervous system mechanisms. Third, original research in clinical cognitive psychology is presented that shows that fibromyalgia patients do not appear to demonstrate cognitive biases which are distinct from myofascial pain. Although extremely preliminary, these results argue against a unique psychological explanation for fibromyalgia symptoms. Fourth, neuropsychological research demonstrates a pattern of generalized inhibition of information processing that emulates that observed in depressive illness, except that fibromyalgia patients tend not to show the compromise in right hemisphere processing seen in depression. This suggests that cognitive abnormalities in fibromyalgia may be distinct from those seen in depression. The psychological research reviewed suggests that central nervous system anomalies may be implicated in the syndrome of fibromyalgia, but the evidence for motivated or affective psychological involvement in the syndrome remains equivocal. Suggestions are provided for future research.
First Reported Case of Bacterial Endocarditis Attributable to Actinomyces meyeri
Authors: Moffatt Susan , Ahmen A Raza , Forward Kevin
Published: March 2016

A 48‐year‐old man presented to the Victoria General Hospital, Halifax, Nova Scotia in severe congestive heart failure. Echocardiographic studies revealed significant aortic valve insufficiency. Two anaerobic blood cultures performed two weeks apart were both positive for Actinomyces meyeri. The patient was treated with high dose intravenous penicillin. Three weeks after antibiotics were begun, he underwent aortic valve replacement. Intraoperative cultures were negative. Histopathological examination revealed findings in keeping with subacute bacterial endocarditis. The patient completed a six‐week course of penicillin and was doing well three months after surgery. This is the first case of endocarditis attributable to A meyeri reported in the literature.
An Assessment of the Utilization of Diagnostic Parasitology Laboratory Services in Ontario
Authors: Richardson Harold , Fleming Christine , Palmer Josephine , Chen Erluo , Lannigan Robert , The Microbiology Committee
Published: March 2016

OBJECTIVE: Diagnostic parasitology services in Ontario were assessed to determine whether the reduction in the number of provider laboratories from 209 to 70 over the period 1977 to 1994 has affected the availability and quality of service.

DESIGN: A questionnaire on parasitology practice was distributed to all laboratories. Responses were validated against data from the requisitions, work cards and reports submitted by licensed parasitology laboratories in a pattern‐of‐practice survey.

SETTING AND PARTICIPANTS: Laboratories in Ontario are licensed by the provincial Ministry of Health and subjected to mandatory proficiency testing. Laboratories not licensed in parasitology may receive specimens for referral to another facility for processing.

MAIN OUTCOME MEASURES: Assessment included receipt of fecal specimens for parasitology, on‐site testing, the limitation of testing, work referred elsewhere for primary investigation or confirmation, laboratory to which work was referred, and the turnaround time for both on‐site and referred work.

RESULTS: Ninety‐eight per cent of 338 laboratories returned the questionnaire. Three hundred and six received specimens for parasitology. Sixty‐four performed the testing. Of the remainder, 235 referred to 40 laboratories. Approximately 31,000 specimens were processed monthly, with 78% examined within private laboratories and 62% having a turnaround time of at least three days. The yield of positive findings was 3% or more of patients.

CONCLUSIONS: The presence of fecal parasites has been reliably determined and the genus, species and stage of the organism correctly identified. Utilization must be improved through understanding of the factors increasing the pretest likelihood of a positive finding.
The Role of Ganciclovir for the Management of Cytomegalovirus Retinitis in HIV Patients: Pharmacological Review and Update on New Developments
Authors: Tseng Alice , Foisy Michelle
Published: March 2016

OBJECTIVE: To review the pharmacology and pharmacokinetics of intravenous, oral and intraocular ganciclovir, and to discuss the role of these various formulations in the management of cytomegalovirus (CMV) retinitis in AIDS patients.

DATA SOURCES: A MEDLINE search (1987 through November 1995) of English‐language literature using the main medical subject headings ‘ganciclovir’ and ‘cytomegalovirus’, and the subheading ‘acquired immunodeficiency syndrome’. Relevant articles were also selected from references of identified articles. Abstracts from recent medical conferences of infectious diseases, pharmacology and human immunodeficiency virus were screened for additional data.

STUDY SELECTION AND DATA EXTRACTION: All articles and abstracts discussing the use of ganciclovir for the management or prophylaxis of CMV retinitis in AIDS patients were considered for inclusion. Pertinent information, as judged by the authors, was selected and synthesized for discussion.

DATA SYNTHESIS: Ganciclovir has demonstrated virustatic activity against CMV, and is often administered 5 mg/kg intravenously every 12 h as first‐line therapy for CMV retinitis. Intravenous maintenance therapy at 5 mg/kg daily is usually effective at delaying retinitis progression for approximately 60 to 70 days. Neutropenia and thrombocytopenia are observed frequently, often necessitating interruption or discontinuation of therapy. Local drug administration may delay disease progression even further, and may be considered for patients who are intolerant to or failing intravenous therapy. However, systemic ganciclovir should be encouraged to reduce the risk of developing contralateral eye or end‐organ CMV disease. Oral ganciclovir at 1 g tid is almost as effective as intravenous ganciclovir 5 mg/kg/day in delaying retinitis progression and is associated with fewer line‐related complications. Absorption, drug interactions, cost and compliance should also be considered.

CONCLUSIONS: Until recently, ganciclovir was available only for intravenous use. Recent developments allow for intraocular and oral administration of this agent. A clear understanding of the advantages and disadvantages of these new formulations is required in order to select the most appropriate product for managing CMV retinitis in AIDS patients.
Bedside Pulse Oximeters with a Clinical Algorithm Make Economic Sense in the Intensive Care Unit
Authors: Leasa David J , Walker Jacqueline M
Published: March 2016

OBJECTIVE: To determine the effect on arterial blood gas (ABG) and hospital resource use by introducing a strategy of using bedside oximeters with a clinical algorithm, based on the argument that bedside pulse oximeters make economic sense in the intensive care unit (ICU) if safe patient oxygenation can be ensured at a lower cost than that of existing monitoring options.

DESIGN: A before and after design was used to examine the consequences of a pulse oximeter at each bedside in the ICU along with a pulse oximeter clinical algorithm (POCA) describing use for titrating oxygen therapy and for performing ABG analysis.

SETTING: A 19‐bed multidisciplinary ICU with a six‐bed extended ICU (EICU) available to function as a ′step‐down′ facility.

PATIENTS: All patients admitted to the ICU/EICU over two 12‐month periods were included.

RESULTS: The strategy yielded a 31% reduction in the mean number of ABGs per patient after POCA (20.0±26.1 versus 13.8±16.7, mean ± SD; P<0.001) as well as a potential annual cost savings of $32,831.

CONCLUSIONS: Bedside oximeters within the ICU, when used with explicit guidelines, reduce ABG use and result in hospital cost savings.
Comparison of Trigeminal and Postherpetic Neuralgia
Authors: Watson C Peter N
Published: March 2016

Although postherpetic neuralgia and trigeminal neuralgia (tic douloureux) are common causes of facial pain, they have very little in common aside from lancinating pain (other qualities of pain in each disorder are different). Each disorder affects different areas of the face and the treatment of each is quite dissimilar. The pathogenesis of these two disorders quite likely involves different mechanisms. This report reviews aspects of these two difficult pain problems, particularly with reference to the work of the late Gerhard Fromm, to whom this is dedicated.
Incidence and Susceptibility of Aerobic Gram‐Negative Bacilli from 20 Canadian Intensive Care Units: 1989–1993
Authors: Bryce Elizabeth A , Colby W David , Haket Jacques , Poisson Michel W , Smith John A
Published: March 2016

OBJECTIVE: To assess the prevalence of antibiotic resistance in Canadian intensive care units.

DESIGN: The antimicrobial profiles of 1939 Gram‐negative bacilli isolated in 20 Canadian intensive care units were analyzed using a custom designed MicroScan panel.

SETTING: The majority of the hospitals were tertiary care institutions, but some community hospitals were included.

PATIENTS: Adult intensive care unit patients were the sources of isolates.

MAIN RESULTS: Pseudomonas aeruginosa was the most frequently isolated microorganism overall, with Escherichia coli the most common initial isolate. Comparison of initial and repeat isolates showed that P aeruginosa readily acquired resistance to all antibiotic classes except the aminoglycosides. Enterobacter aerogenes developed resistance to ciprofloxacin and Enterobacter cloacae demonstrated resistance to all beta‐lactam antibiotics except for imipenem on repeat isolation. Other Enterobacteriaceae remained susceptible. Historical comparison with data derived four years previously from 15 of the centres showed increased resistance of P aeruginosa and Acinetobacter species to ciprofloxacin while other susceptibility patterns remained stable.

CONCLUSIONS: The prevalence of Gram‐negative resistance in Canadian hospitals is less than that reported in surveys done in some other countries, and was relatively stable over four years.
Update on the Use of Inhaled Nitric Oxide
Authors: Kacmarek Robert M
Published: March 2016

A literature review on nitric oxide would identify thousands of citations on the biological implications of this molecule. From the perspective of respiratory care, the effect inhaled nitric oxide has on pulmonary vasculature is the most intriguing. Over the past five years inhaled nitric oxide has been shown to be useful in the management of oxygenation during acute respiratory distress syndrome, alternation of pulmonary vascular tone in persistent pulmonary hypertension in the newborn, and in the management of chronic pulmonary hypertension in both heart and lung transplant candidates, as well as other potential clinical uses. The key physioligical response is vasodilation of pulmonary vessels in communication with well ventilated lung units and the absence of systemic vascular effects by rapid binding to hemoglobin. Nitric oxide therapy is considered experimental. A delivery system is not commercially available. This has resulted in the development of makeshift delivery systems, many of which may have the potential for adverse effects.
Update on Extracorporeal Oxygenation in Adults
Authors: Demajo W
Published: March 2016

The usefulness of managing adult patients with severe acute respiratory distress syndrome and hypoxemia by means of systems using extracorporeal oxygenation has been questioned. A National Institutes of Health multicentre study, published in 1979, reported survival rates of 9.5% and 8.3% in extracorporeally and ventilator managed patients, respectively. Another recent study reports survival rates of 33% and 42% in ventilator and extracorporealy managed patients, respectively. None of these differences was statistically significant. Indications for extracorporeal oxygenation may need to be re‐evaluated to clarify those cases that would not be manageable with current ventilation strategies and, hence, would merit extracorporeal support.
Postpulmonary Embolism Pericarditis: A Case Report and Review of the Literature
Authors: McAlister Finlay A , Al-Jahlan Mohammed , Fisher Bruce
Published: March 2016

Pericarditis developing as a sequela of pulmonary embolism has been rarely described. A 44‐year‐old male presented with acute dyspnea and pleuritic pain; V/Q scan showed multiple perfusion defects, and he was treated with heparin. Three days later retrosternal pain was accompanied by a pericardial friction rub. There was a rapid response to systemic corticosteroid therapy; anticoagulation was continued. Steroids were discontinued after four weeks, and anticoagulation (warfarin) was continued. Two months later he presented with clinical features of pulmonary embolus and new perfusion defects on scan. He was treated with heparin and warfarin; three weeks later clinical features of pericarditis recurred, and he was again treated successfully with four weeks′ oral prednisone. Three months later pericarditis recurred without signs of pulmonary embolism; computed tomography scan showed thickening of the pericardium. The patient was asymptomatic for five months on indomethacin. A literature search showed 11 cases of pericarditis associated with emboli, all responding promptly to steroids. Continuation of anticoagulation does not appear to increase the risk (or magnitude) of hemorrhagic pericardial effusion.
Decision Analysis Modelling of Costs and Outcomes following Cefepime Monotherapy in Canada
Authors: Halpern Michael T , Brown Ruth E , Drolet Martine , Sorensen Sonja V , Mandell Lionel A
Published: March 2016

OBJECTIVE: To evaluate the comparative cost of treatment and intermediate outcomes (percentage resistant organisms, days in hospital, etc) among cefepime and alternative parenteral antibiotics used for empiric monotherapy.

DESIGN: Decision analysis model, based on published literature, clinical trial results and information from infectious disease clinicians.

SETTING: A Canadian tertiary care hospital.

INTERVENTION: Comparison of cefepime, ceftazidime, ceftriaxone, cefotaxime and ciprofloxacin in the treatment of lower respiratory tract infections, urinary tract infections, skin/soft tissue infections, septicemia and febrile neutropenia.

MAIN RESULTS: Cefepime treatment results in the lowest average cost per patient when used as initial empiric therapy for lower respiratory tract infections and for skin/soft tissue infections. Cefepime therapy is among the lowest cost treatments for the other infectious disease conditions and has the lowest cost for a weighted ‘average’ condition. Sensitivity analysis indicates that model results are most sensitive to duration of hospitalization.

CONCLUSIONS: Initial empiric monotherapy with cefepime for serious infectious disease conditions may result in cost savings compared with alternative parenteral agents.
Double‐Blind Prospective Randomized Study Comparing Topical Mupirocin and Placebo for the Prevention of Infection Associated with Central Venous Catheters
Authors: Conly John M , Rennie Robert , Tan Leonard , Bagg Colin , Stein Karen , Peters Barb
Published: March 2016

OBJECTIVE: To compare the incidence of exit site colonization, local catheter‐related infection and catheter‐related bacteremia in patients randomized to receive either topical 2% mupirocin or placebo at the catheter exit site.

PATIENTS AND METHODS: Patients requiring central venous catheters for more than three days were randomized to receive in a double‐blind fashion either topical mupirocin or an identical placebo at the exit site three times weekly at the time of dressing change. Insertion, site care and removal of catheters were standardized. Serial semiquantitataive cultures of the skin at the catheter insertion site were performed using a sterile 25 cm2 template. The distal and proximal catheter segments were cultured using a standardized semiquantitative technique, and any suspect catheter‐related bacteremia was investigated with two sets of peripheral blood cultures, a 10 mL sample of infusate and clinical assessment. Both univariate and multivariate analyses were conducted on individual risk factors to determine factors that might influence the outcomes of local or systemic catheter‐related infection.

RESULTS: Local catheter‐related infection (defined as more than 15 colony forming units [cfu] on culture of the proximal or distal catheter segment) occurred in six of 57 (10.5%) in the mupirocin group versus 18 of 69 (26%) in the placebo group (P<0.05) for the distal catheter segments and in one of 40 (2.5%) versus 13 of 47 (27.6%) for the proximal segments in the mupirocin and placebo groups (P<0.006), respectively. Catheter‐related bacteremia occurred in one of 57 (1.8%) of the mupirocin group but in five of 69 (7.2%) of the placebo group (P=0.15). Stepwise logistic regression revealed that cutaneous colonization at the insertion site of at least 103 cfu/mL/25 cm2 (OR 2.6; CI 1.0 to 6.9) and the use of placebo (OR 3.3; CI 1.2 to 9.0) were significant factors predicting local catheter‐related infection; whereas mupirocin was associated with reciprocal protective effect (OR 0.3; 95% CI 0.1 to 0.8).

CONCLUSIONS: These findings suggest that patients receiving topical mupirocin at the exit site for long term central venous catheters have significantly less local catheter‐related infection, and there is a trend towards less catheter‐related bacteremia.