bluuebunny/crossref_metadata_2025 huggingface dataset:
Interactions between Host and Oral Commensal Microorganisms are Key Events in Health and Disease Status
Authors: Rouabhia Mahmoud
Published: March 2016

The oral cavity has sometimes been described as a mirror that reflects a person′s health. Systemic diseases such as diabetes or vitamin deficiency may be seen as alterations in the oral mucosa. A variety of external factors cause changes in the oral mucosa, thus altering mucosal structure and function, and promoting oral pathologies (most frequently bacterial, fungal and viral infections). Little is known, however, about immune surveillance mechanisms that involve the oral mucosa.

There is no direct contact between specific immune cells in the basal epithelium and microorganisms in the upper layers of the oral mucosa. The author′s hypothesis is that the protective immunity is conveyed through epithelial cells. The present brief review assesses the oral mucosa′s role as the main defence in the interactions between the host and the oral microbial community. A unique model was used to investigate these interactions as the cause of oral disease and to develop new treatments that exploit our knowledge of the host‐microorganism relationship.
Video‐Assisted Thoracic Surgery in Spontaneous Pneumothorax
Authors: Ng Calvin SH , Wan Song , Lee Tak Wai , Wan Innes YP , Arifi Ahmed A , Yim Anthony PC
Published: March 2016

The proven safety and efficacy of minimal access video‐assisted thoracic surgery has changed the way that spontaneous pneumothorax is managed. This review presents some of the experiences of the decade, discusses the controversies and reviews the current video‐assisted thoracic surgical management of spontaneous pneumothorax.
Characterizing and Developing Strategies for the Treatment of Community‐Acquired Pneumonia at a Community Hospital
Authors: Fok Mark C , Kanji Zahra , Mainra Rajesh , Boldt Michael
Published: March 2016

BACKGROUND: Patients admitted to Lions Gate Hospital, North Vancouver, British Columbia, with a primary diagnosis of community‐acquired pneumonia (CAP) have a mean length of stay (LOS) of 9.1 days compared with 7.9 days for peer group hospitals. This difference of 1.2 days results in an annual potential savings of 406 bed days and warranted an investigation into the management of CAP.

OBJECTIVE: To characterize and provide recommendations for the management of CAP.

METHODS: A retrospective chart review of patients admitted with a primary diagnosis of CAP between May 1, 2000 and August 31, 2000.

RESULTS: Fifty‐one patients were included in the study, with a mean LOS of 9.9 days and a median LOS of five days. Based on pneumonia severity index scores calculated for each patient, eight patients (16%) were admitted inappropriately. Initial empirical antibiotic choices were consistent with the Canadian CAP guidelines in 27 patients (53%), with inconsistencies arising mainly because cephalosporin or azithromycin monotherapy regimens were prescribed. Step‐down from intravenous to oral antibiotics occurred in approximately 20 patients (39%). An additional 12 patients (24%) could have undergone step‐down, and step‐down was not applicable in 19 patients (37%). The potential annual cost avoidance from implementing admission criteria based on a pneumonia severity index score, applying step‐down criteria and promoting early discharge criteria was estimated to be $220,000.

CONCLUSIONS: Considerable variability exists in the treatment of CAP. A CAP preprinted order sheet was developed to address the issues identified in the present study and provide consistency in the management of CAP at Lions Gate Hospital.
Outcome of Bacteremia and Fungemia in Pediatric Oncology Patients
Authors: Robinson Joan L , Rennie Robert P
Published: March 2016

OBJECTIVE: To determine the outcome of paediatric oncology patients with positive blood cultures.>

DESIGN: Retrospective chart review.

SETTING: Tertiary care hospital.

POPULATION STUDIED: Oncology patients up to 17 years of age with positive blood cultures from January 1, 1994 to March 31, 1999.

MAIN RESULTS: There were 121 episodes of positive blood cultures in 76 patients. Seventeen episodes were excluded because blood cultures were contaminated. Of the organisms grown from the remaining episodes, 63% were Gram‐positive organisms, 23% were Gram‐negative organisms, 3% were fungal and 11% were mixed. There were 13 episodes with pure or mixed isolates of Staphylococcus aureus, of which nine occurred within 14 days of the placement of a new central venous tunnelled catheter. Central venous tunnelled catheters were retained in 76 of the 102 episodes when they were present. There were two relapses, and four children were admitted to the intensive care unit with septic shock, but all survived.

CONCLUSIONS: The outcome was excellent with the current management of possible bacteremia in paediatric oncology patients, but the high incidence of S aureus bacteremia suggests that empirical antibiotics should be altered if sepsis is suspected within 14 days of the placement of a central venous catheter.
Safety of Fluoroquinolones: An Update
Authors: Mandell L , Tillotson G
Published: March 2016

The fluoroquinolone class of antimicrobials has been in clinical use for over 13 years. During that period, some representatives of the class have been extensively prescribed, such as ciprofloxacin and levofloxacin, while others have seen minimal use and have been restricted or withdrawn, namely, trovafloxacin and grepafloxacin. Manipulation of the fluoroquinolone structure by substituting a range of moieties around the core has yielded enhanced antibacterial activity, but in some cases this has come at a price. Specific substitutions are discussed in relation to particular recognized adverse events. In the present paper, newly introduced fluoroquinolones, such as moxifloxacin and gatifloxacin, are examined in terms of anticipated class effects and recent clinical experience. These antimicrobials are associated with reactions such as diarrhea, nausea, headache and other typical antimicrobial phenomena at rates less than 5%. New fluoroquinolone agents should be examined carefully in light of structural findings until adequate clinical data are amassed.
Risk Factors for Genital Chlamydial Infection: A Review
Authors: Navarro Christine , Jolly Ann , Nair Rama , Chen Yue
Published: March 2016

OBJECTIVE: To discuss the occurrence of genital chlamydia in developed countries and review the literature assessing the potential risk factors for this sexually transmitted disease.

DATA SOURCES: A MEDLINE search was performed for all English citations from 1985 to 2000 that contain the keywords "Chlamydia trachomatis", "chlamydial infections", "risk factors" and "sex behaviour". All relevant references cited in articles that were obtained from the search were also included.

DATA EXTRACTION: All articles obtained from the above sources were examined, and were included in the review if they met the following criteria: primary study examining sociodemographic or behavioural risk factors associated with genital chlamydial infection using multivariate analysis; study subjects 12 years of age and older; and study setting in a developed country.

DATA SYNTHESIS AND CONCLUSIONS: Genital chlamydial infection has become the most commonly reported bacterial infection in North America over the past decade. Thirty‐eight cross‐sectional studies and six cohort studies were included in the present review. Most studies demonstrated that young men and women are at higher risk of being infected with chlamydia than older subjects. Chlamydia seems to be found in a diverse group of people, and unlike gonorrhea, is not concentrated in low income, minority core groups with high rates of partner change. However, a number of studies have shown that communities with well‐established control programs are beginning to demonstrate this pattern. There is no clear evidence that chlamydia is associated with type of partners, contraceptive use, or age at first intercourse. Future research should follow this sexually transmitted disease as it evolves through the epidemiological stages to ensure that preventive and treatment services are reaching those people who are most likely to be infected.
Formoterol Thrice Weekly Does Not Result in the Development of Tolerance to Bronchoprotection
Authors: Davis Beth E , Reid John K , Cockcroft Donald W
Published: March 2016

BACKGROUND: Loss of bronchoprotection routinely follows regular
treatment with beta2‐agonists. There are no data on the effects
on bronchoprotection for thrice weekly use of a beta2‐agonist.

METHODS: A double‐blind, randomized, placebo controlled
crossover trial was conducted to investigate the effects of thrice
weekly administration of 12 μg of formoterol versus placebo on bronchoprotection
against methacholine. As an expected positive control,
formoterol 12 μg once daily was also evaluated.

RESULTS: There was no significant difference versus placebo in the
bronchoprotective effects of 12 μg of formoterol administered on day
8, following daily treatment for seven days or treatment every other
day (analysis of variance P=0.34). However, a nonsignificant trend
towards lower concentration of methacholine that caused a 20% fall
in forced expiratory volume in 1 s developed only following the daily
formoterol dosing.

CONCLUSIONS: Thrice weekly dosing does not result in the
development of tolerance to bronchoprotection against the direct
acting stimulus methacholine.
Economic Issues in the Use of Office Spirometry for Lung Health Assessment
Authors: Krahn Murray , Chapman Kenneth R
Published: March 2016

The National Lung Health Education Program (United States) has recently recommended using office spirometry to screen for subclinical lung disease in adult smokers. No published studies evaluate the economic consequences of this recommendation. This review article outlines the issues that must be considered when evaluating the costs and health benefits of office spirometry. Much of the available data on the effectiveness of screening is from studies that included smoking cessation interventions, making it difficult to determine the effects of screening alone. The sensitivity and specificity of screening spirometry are not known, but may not be important in the economic model, because even false positive test results are beneficial if they lead to smoking cessation. Costs to be considered include those of spirometry itself, of implementing and maintaining screening and smoking cessation programs, and of their consequences, ie, reduced morbidity (lower short term health care costs) and mortality (perhaps higher long term health care costs). Despite these unique challenges, data are available to perform economic analyses regarding screening spirometry. Such analyses should play a role in future clinical policy making. Even modest quit rates attributable to screening spirometry may result in highly favourable cost effectiveness ratios.
West Nile Virus Surveillance and Diagnostic: A Canadian Perspective
Authors: Drebot Michael A , Lindsay Robbin , Barker Ian K , Buck Peter A , Fearon Margaret , Hunter Fiona , Sockett Paul , Artsob Harvey
Published: March 2016

A surveillance program has been in place since 2000 to detect the presence of West Nile virus (WNV) in Canada. Serological assays are most appropriate when monitoring for human disease and undertaking case investigations. Genomic amplification procedures are more commonly used for testing animal and mosquito specimens collected as part of ongoing surveillance efforts. The incursion of WNV into this country was documented for the first time in 2001 when WNV was demonstrated in 12 Ontario health units during the late summer and fall. In 2002 WNV activity was documented by avian surveillance in Ontario by mid‐May with subsequent expansion of the virus throughout Ontario and into Quebec, Manitoba, Saskatchewan and Nova Scotia. Human cases were recorded in both Ontario and Quebec in 2002 with approximately 800 to 1000 probable, confirmed and suspect cases detected. The possible recurrence and further spread of WNV to other parts of Canada in 2003 must be anticipated with potential risk to public health. The continued surveillance and monitoring for WNV‐associated human illness is necessary and appropriate disease prevention measures need to be in place in 2003.
Sildenafil Treatment of Primary Pulmonary Hypertension
Authors: Laupland Kevin B , Helmersen Doug , Zygun David A , Viner Sidney M
Published: March 2016

A 37‐year‐old woman with primary pulmonary hypertension and worsening symptomatology underwent pulmonary artery (PA) catheterization and vasodilator trials. Oxygen had no effect, but 10 parts/million of nitric oxide reduced mean PA (PAm) pressure by 20%. Prostacyclin infusion at 8 ng/kg/min decreased the PAm pressure by 11%, but further dose increases were limited by systemic hypotension. Sildenafil in doses of 25 mg or higher resulted in an average decrease of 14% in PAm pressure. Sildenafil is a potentially useful treatment option for patients with primary pulmonary hypertension, and further investigation is warranted.
Clinical Utility of a Legionella pneumophila Urinary Antigen Test in a Large University Teaching Hospital
Authors: Dionne Michel , Hatchette Todd , Forward Kevin
Published: March 2016

OBJECTIVE: To determine the clinical utility of diagnosing Legionella pneumonia by urinary antigen testing (LPUAT) in a low prevalence centre.

DESIGN: The results of LPUATs were abstracted and analyzed from the authors′ laboratory information system. Medical records were reviewed in detail for all positive tests and a random sample of 50 negative tests.

SETTING: The Queen Elizabeth II Health Sciences Centre, a large university hospital complex.

POPULATION STUDIED: Patients who were admitted from the emergency room with pneumonia or who had developed pneumonia in hospital and who had a LPUAT performed between April 1998 and October 2000.

MAIN RESULTS: One thousand one hundred fifty‐four tests were performed on 1007 patients. Seven patients had nine positive LPUATs. Three of these patients had confirmed Legionella pneumophila pneumonia. Three others had probable or possible L pneumophila pneumonia. There was one probable false positive. Six of the seven patients were already on empirical anti‐L pneumophila therapy. Of the 50 negative tests reviewed in detail, 31 patients were on one of the antibiotics of choice for L pneumophila at the time the test was ordered; in 21 (68%) of these patients the negative result did not lead to a change in therapy.

CONCLUSIONS: The cost to diagnose each case of Legionella pneumonia by LPUAT was approximately $5,770 and most patients were already on appropriate antibiotics. In patients with negative tests, antibiotics were often not changed in response to the test result. Rigorous screening of patients is required to increase pretest probability for LPUAT to be justified.
Mediastinal Synovial Sarcoma: A Case Report and Literature Review
Authors: Cheng Linda SL , Tse Gary MK , Li Wilson WL , Lee TW , Yim Anthony PC
Published: March 2016

Synovial sarcomas are uncommon soft tissue tumours. Immunohistochemistry and cytogenetic techniques are essential for proper diagnosis and differentiation from other spindle cell neoplasms. A case of mediastinal synovial sarcoma is described, of which the unusual location, diagnosis and treatment form the basis of this report.
Evaluation of Malignant Mesothelioma in Central Anatolia: A Study of 67 Cases
Authors: Gulmez Inci , Kart Levent , Buyukoglan Hakan , Er Ozlem , Balkanli Suleyman , Ozesmi Mustafa
Published: March 2016

BACKROUND: Malignant mesothelioma (MM) is a fatal neoplasm which frequently results from exposure to asbestos or erionite.

METHOD: Sixty‐seven patients with MM were seen between 1990 and 2001. Their clinical and radiological features, as well as the therapy, were retrospectively evaluated.

RESULTS: In 51 patients (76.1%), the MM was confined to the pleura, in 14 patients it was exclusively peritoneal and in two patients, it involved both areas. Of the 67 cases, 35 (52.2%) were women. The mean (± SD) age for all cases was 57.6±11.5 years. Dyspnea (67.2%), cough (55.2%) and chest pain (50.7%) were the most frequent symptoms of onset. Pleural effusion (92.4%) was the most common chest x‐ray finding, whereas pleural effusion (60.8%), pleural nodules (34.7%) and pleural thickening (34.7%) were the most common computed tomography findings in pleural MM patients. The histological subtypes of MM were determined as epithelial in 60 patients (89.5%), sarcomatous in four patients (5.9%) and mixed in three patients (4.4%). Although 50.7% and 25.4% of the cases were exposed to erionite and asbestos, respectively, 23.9% of the cases recalled no exposure to asbestos or erionite. Exposures were environmental as opposed to occupational. Thirty‐five patients (52.2%) were administered chemotherapy, and follow‐up data were available for 22 patients. For these patients, the two‐year survival rate was 22% and the two‐year progression‐free interval was 15.7%. There were no differences between patients with asbestos and erionite exposure.

CONCLUSION: MM should be considered when exudative pleural effusion is detected in a patient who has been exposed to asbestos or erionite. MM is a major public health problem in parts of Turkey and compulsory environmental control of fibrous mineral should be considered.
Combination of ICSs and LABAs Should Be Used in the Management of Patients with COPD — The Con Argument
Authors: Road Jeremy
Published: March 2016

The management of patients with symptomatic chronic obstructive pulmonary disease (COPD) has become more clear in the past several years. New medications have been developed and their efficacy has been evaluated using important outcomes in addition to forced expiratory volume in 1 s (FEV1), such as health‐related quality of life (HRQL), frequency of exacerbations and dyspnea scores. I will review five welldesigned, randomized, controlled trials that have advanced our knowledge about the use of inhaled corticosteroids (ICSs), long‐acting beta2‐agonists (LABAs) and their combination.
Exclusion Spirometry: An Initiative to Increase Lung Function Assessment in Primary Care
Authors: Almirall José , Bégin Paul
Published: March 2016

Ongoing spirometry quality standards are difficult to bring into the daily routine of general practice. As a result, spirometry is rarely performed by primary care physicians. A new approach is proposed: exclusion spirometry. Acceptable and reproducible results are sought. However, the goal of the test is to try to reach values within normal limits, even if results do not reach quality standards. Normal results would be sufficient to exclude respiratory impairment, except in asthma. Abnormal results would require further testing in a diagnostic spirometry laboratory. The aim of the initiative is to enhance the compliance of general practitioners in using spirometers for screening.
Questionnaires
Authors: Anthonisen Nick R
Published: March 2016

In this issue of the Canadian Respiratory Journal, Bourbeau et al (pages 480‐486) publish what could be loosely described as a validation of a French‐Canadian translation of the Chronic Respiratory Questionnaire (CRQ) (1) and the St George′s Respiratory Questionnaire (SGRQ) (2). They translated the questionnaires and went over them in detail until they were convinced that the questionnaires actually asked the questions that they were supposed to. They then administered them to two groups of chronic obstructive pulmonary disease (COPD) patients. One group had stable COPD and was tested twice with a two‐week period between tests to examine test‐retest reproducibility. The second group consisted of patients who either had an exacerbation of their COPD or who underwent rehabilitation for their disease. Both situations are associated with improvements in quality of life that should be detectable by the questionnaires. These results were compared with a third standard quality of life questionnaire. The results were very good. The questionnaire results met expectations: they were reproducible in stable patients and showed when patients improved. In psychometric terms, they were reliable and valid. I recommend the paper to people who are interested in developing and testing such instruments, both for the knowledge displayed by the authors and for the clarity of their presentation.
Helical Computed Tomography Has a Role in the Screening of Lung Cancer ‐‐ The Con Argument
Authors: Davidson Warren
Published: March 2016

Screening constitutes the use of laboratory tests, physical examinations or imaging modalities performed on asymptomatic patients with the intent of identifying subclinical disease (1). As a result, screening differs from clinical investigation, in which tests are ordered after disease is suspected. A cancer screening program is a service in which everyone in a given population is (or has the opportunity to be) examined for the presence or precursor of a type of cancer. If the screening test finds that there is a likelihood of disease, a diagnostic test may be performed for confirmation (1).
EJ Moran Campbell ‐ An Appreciation
Authors: Jones Norman L
Published: March 2016

Dr EJ Moran Campbell, Founding Chairman and R Samuel McLaughlin Professor of Medicine at McMaster University, 1968 to 1975, died on April 12, 2004, following a long battle with colon cancer. He was an outstanding scientist, physician and educator, achieving a worldwide reputation as the foremost clinical respiratory physiologist of his generation who changed how respiratory medicine was taught and practiced. He was elected a fellow of the Royal Society of Canada in 1983 and appointed an officer of the Order of Canada in 2001. He suffered intermittently from a mood disorder, which was a great burden. He published an extraordinarily insightful book on his experiences with this debilitating illness titled Not Always on the Level (1).
Rapidly Progressive Pulmonary Fibrosis in a Patient Treated with Danazol for Idiopathic Thrombocytopenic Purpura
Authors: Pakhale Smita , Moltyaner Yuri , Chamberlain Dean , Lazar Neil
Published: March 2016

The case of a patient that developed pulmonary fibrosis two months after initiation of danazol for treatment of idiopathic thrombocytopenic purpura is described. Bilateral pneumothoraxes and pneumomediastinum complicated the rapidly fatal pulmonary fibrosis. An association between danazol therapy and the development of pulmonary fibrosis is suspected. There is only one other case report with this connection in the literature.
Total and Specific Immunoglobulin E and Their Relationship to Respiratory Symptoms in Quebec Children and Adolescents
Authors: Levesque Benoît , Duchesne Jean-François , Gingras Suzanne , Allard Pierre , Delvin Edgar , Aubin Jacinthe , Rhainds Marc , Lajoie Pierre , Ernst Pierre
Published: March 2016

BACKGROUND: Respiratory disease is a major cause of morbidity in young people. It is now recognized that atopy plays an important role in the development of chronic respiratory symptoms in children.

OBJECTIVE: To examine the determinants and consequences of serum total and specific immunoglobulin E (IgE) in a general population sample of Québec children and adolescents.

METHODS: In 1999, 2349 children and adolescents (nine, 13 or 16 years of age) who had participated in a respiratory symptom and disease questionnaire had their total IgE measured. Of these participants, a subsample of 451 children and adolescents was analyzed to detect antibodies to eight specific allergens (ie, allergens of dust mites [Dermatophagoides farinae and Dermatophagoides pteronyssinus], cat, dog, ragweed, Timothy grass, mould [alternaria] and cockroach).

RESULTS: The geometric mean of the total IgE was 44.4 U/mL among all participants. Concentrations were higher in boys and increased with age. More than 41% of the participants were sensitized to at least one specific allergen. Such sensitization was strongly associated with the occurrence of respiratory conditions and symptoms, namely asthma, wheezing and rhinitis. Family history, school location and ethnic origin had an impact on the prevalence of atopy and total IgE levels.

CONCLUSIONS: Allergic sensitization is a major determinant in the development of asthma, wheezing and rhinitis in children and adolescents in the province of Québec.
The Current Status of Autotitrating Continuous Positive Airway Pressure Systems in the Management of Obstructive Sleep Apnea
Authors: Hailey David , Jacobs Philip , Mayers Irvin , Mensinkai Shaila
Published: March 2016

BACKGROUND: Autotitrating continuous positive airway pressure (APAP) devices have the potential to address some of the disadvantages of titration and treatment with conventional continuous positive airway pressure (CPAP). Information on the performance of APAP in clinical use is still comparatively limited.

OBJECTIVE: To assess the status of APAP devices in the management of obstructive sleep apnea (OSA) by reviewing evidence of their efficacy, effectiveness and costs.

METHODS: A systematic search of electronic databases and a review of selected comparative studies on the use of APAP in the diagnosis, titration and treatment of OSA was undertaken. Cost analysis using data applicable to the management of OSA in Edmonton, Alberta was performed.

RESULTS: Thirty‐three studies met the selection criteria: three on the use of APAP in diagnosing OSA; six on APAP for titration; 14 that considered short‐term treatment outcomes; and 10 that addressed longer‐term treatment of OSA. In most studies, patients suffering from cardiac, pulmonary and other medical conditions were excluded. Available data suggested some potential for the use of APAP in the diagnosis of OSA, but further validation is needed. In titration, estimated treatment pressures tended to be lower with APAP than with the manual titration of CPAP. Although lower treatment pressures were achieved with APAP, there was no significant difference in clinical outcome measures between APAP and CPAP. Estimates of costs suggested that APAP may provide savings in some scenarios.

CONCLUSIONS: APAP shows promise in the management of OSA; however, given the exclusion of some categories of patients from trials of this technology, caution is still required in its use.
Hemothorax Complicating Bronchial Artery Aneurysm
Authors: Karmy-Jones Riyad , Hastreiter Dawn , Burdick Thomas
Published: March 2016

An elderly patient presented with spontaneous hemothorax. Workup identified a right‐sided bronchial aneurysm as the source, which was successfully embolized. Bronchial aneurysms can be managed by interventional techniques, although the choice of approach depends upon the clinical and anatomical settings.
Smoking Inside Canadian Acute Care Hospitals
Authors: Bardell Trevor , Brown Peter M
Published: March 2016

OBJECTIVE: To assess smoking policies at Canadian acute care hospitals.

METHOD: A questionnaire was designed, piloted and faxed to all acute care hospitals in Canada. The questionnaire was designed to address the following: what is the current policy regarding patient smoking? Are staff and/or visitors allowed to smoke inside the hospital? Is there a separate policy for psychiatric patients? Are smoking cessation products available at the hospital pharmacy? Is the policy governed by regional or municipal legislation?

RESULTS: A total of 852 hospitals were included in the study. Of these, 476 responded to the questionnaire, for an overall response rate of 56%. Twenty‐seven per cent of respondents allowed patient smoking inside the hospital. While staff smoking was not allowed inside most hospitals (93%), 32% of hospitals in Quebec allowed staff to smoke inside the building. Thirty per cent of hospitals had a separate policy for psychiatric patients, and 27% of hospitals had provisions for visitor smoking. Sixty‐seven per cent of hospitals were able to offer patients smoking cessation products while they were in hospital.

CONCLUSIONS: Many Canadian hospitals continue to allow smoking inside their facilities. There is considerable variation in hospital smoking policies across the country.
Mediastinal Hydatid Cyst Rupturing into the Pleural Cavity Associated with Pneumothorax: Case Report and Review of the Literature
Authors: Shameem Mohd , Bhargava Rakesh , Ahmad Zuber , Fatima Nazish , Shah Naveed Nazir
Published: March 2016

Hydatid disease remains a serious health problem in Mediterranean countries. Living in a rural area is an important risk factor for the disease. Hydatid cysts are usually located in the liver, lungs and brain. Mediastinal hydatid disease is very rare and has been noted only anecdotally in the literature. The present article reports a case of a mediastinal hydatid cyst rupturing into the pleural cavity, which was associated with pneumothorax of the same side. The patient’s previous chest x‐rays (posteroanterior and left lateral views) showed a well‐defined mediastinal mass on the left side, and contrast‐enhanced computed tomography of the thorax (taken a few days after the chest x‐ray) showed multiple round‐to‐oval soft tissue opacities with partial collapse of the left lung. An indirect hemagglutination test for echinococcus was positive. Even after two weeks of intercostal tube drainage, the patient’s condition did not improve. During thoracotomy, multiple daughter cysts were found in the pleural cavity, and the diagnosis of a hydatid cyst was confirmed after histopathological examination.
Anterograde Colonic Stent Placement via a Cecostomy Tube Site
Authors: Gillman Lawrence M , Latosinsky Steven
Published: March 2016

Colonic stents have been used as a method of relieving colonic obstruction since 1991. They are classically inserted in a retrograde fashion via the rectum and are deployed under a combination of endoscopic and fluoroscopic guidance. A unique case is presented where the colonic stent was passed in an anterograde fashion through a recently created cecostomy tube site as a method of palliation to relieve an obstructing hepatic flexure tumour.
The Cost-Effectiveness of Colonic Stenting as a Bridge to Curative Surgery in Patients with Acute Left-Sided Malignant Colonic Obstruction: A Canadian Perspective
Authors: Singh Harminder , Latosinsky Steven , Spiegel Brennan MR , Targownik Laura E
Published: March 2016

BACKGROUND: Over the past several years, colonic stenting has been advocated as an alternative to the traditional surgical approach for relieving acute malignant left-sided colonic obstruction. The aim of the present study was to determine the most cost-effective strategy in a Canadian setting.

PATIENTS AND METHODS: A decision analytical model was developed to compare three competing strategies: CS – emergent colonic stenting followed by elective resective surgery and reanastomosis; RS – emergent resective surgery followed by creation of either a diverting colostomy or primary reanastomosis; and DC – emergent diverting colostomy followed by elective resective surgery and reanastomosis. The costs were estimated from the perspective of the Manitoba provincial health plan.

RESULTS: The use of CS resulted in fewer total operative procedures per patient (mean CS 1.03, RS 1.32, DC 1.9), lower mortality rate (CS 5%, RS 11%, DC 13%) and lower likelihood of requiring a permanent stoma (CS 7%, RS 14%, DC 14%). CS is slightly more expensive than DC, but less costly than RS (DC $11,851, CS $13,164, RS $13,820). The incremental cost-effectiveness ratio associated with the use of CS versus DC is $1,415 to prevent a temporary stoma, $1,516 to prevent an additional operation and $15,734 to prevent an additional death.

CONCLUSIONS: Colonic stenting for patients with acute colonic obstruction secondary to a resectable colonic tumour is comparable in cost with surgical options, and reduces the likelihood of requiring both temporary and permanent stomas. Colonic stenting should be offered as the initial therapeutic modality for Canadian colorectal cancer patients presenting with acute obstruction as a bridge to definitive RS.
Perspectives that Influence Action Plans for Chronic Obstructive Pulmonary Disease
Authors: Costi S , Brooks D , Goldstein RS
Published: March 2016

BACKGROUND: Prompt treatment of acute exacerbations (AEs) in chronic obstructive pulmonary disease (COPD) improves quality of life and reduces the use of health care resources. Although patient self-management through an individualized action plan (AP) can help with early initiation of therapy, its use is critically dependent on the patient recognizing the features of an exacerbation.

OBJECTIVE: To describe COPD patients’ experiences with AEs, as well as health care professionals’ (HCPs’) attitudes toward the provision of an AP as part of self-management education.

METHODS: Thirty-two patients with moderate to severe COPD who recently experienced at least one AE, and 22 HCPs with experience in the management of COPD, were interviewed.

RESULTS: The most common symptoms and signs associated with an AE were difficulty breathing (84%), fatigue (81%), cold symptoms (59%), changes in sputum colour (53%) or amount (47%), and cough (44%). The main precipitants identified were environmental triggers (47%), infective agents (31%), excessive activities (25%), emotional factors (16%) and changes in medications (9%). Strategies for dyspnea relief included increasing medications (72%), resting (56%), avoiding exposure to environmental triggers (41%) and performing breathing exercises (31%). Patients supported the use of an AP and recommended that it be individualized for symptoms and triggers, and that it should also include strategies for addressing anxiety and depression. HCPs also supported the use of an individualized AP and recommended that it be regularly revisited, depending on the patient’s disease severity.

CONCLUSIONS: Patients’ experiences with AEs do not always conform to a standard medical definition. Therefore, an understanding of their experience is of value in the design of an individualized AP. HCPs support the use of an AP that emphasizes self-management of exacerbations as well as general COPD management.
Practice Audit in Gastroenterology (Page) Program: A Novel Approach to Continuing Professional Development
Authors: Armstrong David , Hollingworth Roger , Gardiner Tara , Klassen Michael , Smith Wendy , Hunt Richard H , Barkun Alan , Gould Michael , Leddin Desmond
Published: March 2016

BACKGROUND: Practice audit is an important component of continuing professional development that may more readily be undertaken if it were less complex. This qualitative study assessed the use of personal digital assistants to facilitate data collection and review.

METHODS: Personal digital assistants programmed with standard questionnaires related to upper gastrointestinal endoscopies (Practice Audit in Gastroenterology-Endoscopy [‘PAGE-Endo’]) and colonoscopies (PAGE-Colonoscopy [‘PAGE-Colo’]) were provided to Canadian gastroenterologists, surgeons and internists. Over a three-week audit period, participants recorded indications, and the expected (E) and reported (R) findings for each procedure. Thereafter, participants recorded compliance with reporting, the ease of use and value of the PAGE program, and their willingness to perform another audit.

RESULTS: Over 15 to 18 months, 173 participants completed PAGE-Endo (6168 procedures) and 111 completed PAGE-Colo (4776 procedures). Most respondents noted that PAGE was easy to use (99%), beneficial (88% to 95%), and that they were willing undertake another audit (92% to 95%). In PAGE-Endo, alarm features were prevalent (55%), but major reported findings were less common than expected: esophagitis (E 29.9%, R 14.8%), esophageal stricture (E 8.3%, R 3.6%), gastric ulcer (E 17.0%, R 4.7%), gastric cancer (E 4.3%, R 1.0%) and duodenal ulcer (E 11.5%, R 5.7%). In PAGE-Colo, more colonoscopies were performed for symptom investigation (55%) than for screening (25%) or surveillance (20%). There were marked interprovincial variations with respect to sedation, biopsies and technical aspects of colonoscopy.

CONCLUSION: Secure, real-time data entry with review of aggregate and individual data in the PAGE program provided an acceptable, straightforward methodology for accredited practice audit activities. PAGE has considerable potential for continuing professional development in gastroenterology and other specialties.
Comparison of the OxyMask and Venturi Mask in the Delivery of Supplemental Oxygen: Pilot Study in Oxygen‐Dependent Patients
Authors: Beecroft Jaime M , Hanly Patrick J
Published: March 2016

BACKGROUND: The OxyMask (Southmedic Inc, Canada) is a new face mask for oxygen delivery that uses a small ‘diffuser’ to concentrate and direct oxygen toward the mouth and nose. The authors hypothesized that this unique design would enable the OxyMask to deliver oxygen more efficiently than a Venturi mask (Hudson RCI, USA) in patients with chronic hypoxemia.

METHODS: Oxygen‐dependent patients with chronic, stable respiratory disease were recruited to compare the OxyMask and Venturi mask in a randomized, single‐blind, cross‐over design. Baseline blood oxygen saturation (SaO2) was established breathing room air, followed in a random order by supplemental oxygen through the OxyMask or Venturi mask. Oxygen delivery was titrated to maintain SaO2 4% to 5% and 8% to 9% above baseline for two separate 30 min periods of stable breathing. Oxygen flow rate, partial pressure of inspired and expired oxygen (PO2) and carbon dioxide (PCO2), minute ventilation, heart rate, nasal and oral breathing, SaO2 and transcutaneous PCO2 were collected continuously. The study was repeated following alterations to the OxyMask design, which improved clearance of carbon dioxide.

RESULTS: Thirteen patients, aged 28 to 79 years, were studied initially using the original OxyMask. Oxygen flow rate was lower, inspired PO2 was higher and expired PO2 was lower while using the OxyMask. Minute ventilation and inspired and expired PCO2 were significantly higher while using the OxyMask, whereas transcutaneous PCO2, heart rate and the ratio of nasal to oral breathing did not change significantly throughout the study. Following modification of the OxyMask, 13 additional patients, aged 18 to 79 years, were studied using the same protocol. The modified OxyMask provided a higher inspired PO2 at a lower flow rate, without evidence of carbon dioxide retention.

CONCLUSIONS: Oxygen is delivered safely and more efficiently by the OxyMask than by the Venturi mask in stable oxygen‐dependent patients.
Vital Capacity and Selected Metabolic Diseases in Middle‐Aged Japanese Men
Authors: Sakuta Hidenari , Suzuki Takashi , Yyasuda Hiroko , Ito Teizo
Published: March 2016

OBJECTIVE: To elucidate the association between vital capacity and the presence of selected metabolic diseases in middle‐aged Japanese men.

METHODS: A cross‐sectional analysis of the associations among forced vital capacity (FVC), static vital capacity as a percentage of that predicted (%VC) and the presence of metabolic diseases was performed.

RESULTS: In a univariate linear regression analysis, FVC and %VC were inversely associated with poor vegetable intake, cigarette smoking and body mass index, but not with physical activity or ethanol consumption. In a logistic regression analysis adjusted for lifestyle factors, body mass index and age, the odds ratios for the presence of metabolic disease per 0.54 L (1 SD) decrease in FVC were 1.24 (95% CI 1.03 to 1.50) for type II diabetes, 1.21 (95% CI 1.02 to 1.42) for hypertension, 1.34 (95% CI 1.11 to 1.63) for hypertriglyceridemia, 1.23 (95% CI 1.03 to 1.46) for high gamma‐glutamyl transferase levels and 1.63 (95% CI 1.10 to 2.41) for an episode of cardiovascular disease. FVC did not correlate with hyperhomocysteinemia, hypercholesterolemia or high white blood cell count. Similar results were also obtained for the association between %VC and metabolic diseases.

CONCLUSIONS: A decrease in FVC or %VC was associated with the presence of some metabolic diseases. The association may partly explain the reported association between low FVC and cardiovascular disease.
A Definitive Diagnosis of Primary Hodgkin Lymphoma on Endoscopic Biopsy Material Utilizing in-Depth Immunohistochemical Analysis
Authors: Horne Garnet , Medlicott Shaun AC , Mansoor Adnan , Lategan Johan , Lai Raymond , Beck P
Published: March 2016

The esophagus and stomach can be primary sites for Hodgkin lymphoma (HL). The pathognomonic feature of HL is the Reed-Sternberg cell. Because these cells can be rare in HL tumours, biopsies obtained via endoscopy are usually inadequate for establishing a definitive diagnosis. A case of a gastroesophageal junction primary HL is presented that was diagnosed on endoscopic biopsy material with the assistance of the immunohistochemical stains PAX5 and MUM1 which verified the presence of Reed-Sternberg cells. The patient was effectively treated for HL and avoided traditional laparotomy or thoracotomy procedures to obtain the diagnosis. This advanced immunohistochemical approach should be the standard in the diagnosis of primary gastrointestinal HL. An endoscopy-based approach should obviate more invasive, open biopsy procedures for establishing HL diagnosis.
A Meta-Analysis of the Success Rate ofHelicobacter pyloriTherapy in Canada
Authors: Rodgers Christopher , van Zanten Sander Veldhuyzen
Published: March 2016

BACKGROUND AND AIM:Helicobacter pyloritreatment success rates have varied. A systematic review of the success rate of anti-H pyloritherapy in Canada was performed.

METHODS: All clinical trials containing Canadian data on the success rate ofH pyloritreatment were identified using MEDLINE searches, through review of references of retrieved studies and by contacting key investigators. Both randomized and open-label trials were included. Treatment effect size was calculated using a variation of Cochran’s Q method.

RESULTS: Seventeen papers met the inclusion criteria. Both triple therapies consisting of a proton pump inhibitor (PPI), clarithromycin and either amoxicillin or metronidazole performed well, achieving a success rate of 84% and 82%, respectively. The cure rate of PPI-amoxicillin + metronidazole was 76%. Quadruple therapy consisting of a PPI, bismuth, metronidazole and tetracycline, given for seven to 10 days, achieved a success rate of 87%.

CONCLUSION: Both PPI-based triple therapy and quadruple therapy perform well in Canada for the treatment ofH pyloriinfection.
The Laboratory Diagnosis of Lyme Borreliosis: Guidelines from the Canadian Public Health Laboratory Network
Authors: Canadian Public Health Laboratory Network
Published: March 2016

Lyme borreliosis is uncommonly seen in Canada. Most cases have occurred in close proximity to small geographical areas where infected ticks have become established. Although few cases are seen, thousands of patients are tested yearly. Unless patients are carefully selected and an appropriately sensitive and specific testing algorithm is applied, large numbers of patients without Lyme borreliosis will be incorrectly diagnosed. The Canadian Public Health Laboratory Network has developed the present guidelines to assist physicians in assessing patients for Lyme borreliosis, and to help guide the choice and interpretation of laboratory testing.
Playing Cards on Asthma Management: A New Interactive Method for Knowledge Transfer to Primary Care Physicians
Authors: Boulet Louis-Philippe , Borduas Francine , Bouchard Jacques , Blais Johanne , Hargreave Frederick E , Rouleau Michel
Published: March 2016

OBJECTIVES: To describe an interactive playing card workshop in the communication of asthma guidelines recommendations, and to assess the initial evaluation of this educational tool by family physicians.

DESIGN: Family physicians were invited to participate in the workshop by advertisements or personal contacts. Each physician completed a standardized questionnaire on his or her perception of the rules, content and properties of the card game.

SETTING: A university‐based continuing medical education initiative.

PARTICIPANTS: Primary care physicians.

MAIN OUTCOME MEASURES: Physicians’ evaluation of the rules, content and usefulness of the program.

RESULTS: The game allowed the communication of relevant asthma‐related content, as well as experimentation with a different learning format. It also stimulated interaction in a climate of friendly competition. Participating physicians considered the method to be an innovative tool that facilitated reflection, interaction and learning. It generated relevant discussions on how to apply guideline recommendations to current asthma care.

CONCLUSIONS: This new, interactive, educational intervention, integrating play and scientific components, was well received by participants. This method may be of value to help integrate current guidelines into current practice, thus facilitating knowledge transfer to caregivers.
A Nosocomial Outbreak of Community‐Associated Methicillin‐Resistant Staphylococcus aureus among Healthy Newborns and Postpartum Mothers
Authors: Saunders Andrea , Panaro Linda , McGeer Allison , Rosenthal Alana , White Diane , Willey Barbara M , Gravel Denise , Bontovics Erika , Yaffe Barbara , Katz Kevin
Published: March 2016

BACKGROUND: Community‐associated methicillin‐resistant Staphylococcus aureus (CA‐MRSA) has increasingly been isolated from individuals with no predisposing risk factors; however, such strains have rarely been linked to outbreaks in the hospital setting. The present study describes the investigation of an outbreak of CA‐MRSA that occurred in the maternal‐newborn unit of a large community teaching hospital in Toronto, Ontario.

METHODS: Screening and clinical specimens collected from mothers and newborns delivered during the outbreak period, as well as from staff on the affected unit, were submitted for microbiological testing. Computerized delivery logs and nursing notes were reviewed, and a case control study was conducted.

RESULTS: Analysis by pulsed‐field gel electrophoresis revealed 38 babies and seven mothers with MRSA colonization and/or infection by the same unique strain (Canadian MRSA‐10‐related) from September to December 2004. Isolates were characterized as having the staphylococcal chromosome cassette mec type IVa and were positive for the Panton‐Valentine leukocidin gene. No one health care worker was associated with all cases; however, mothers and newborns exposed to one particular nurse (Nurse A) were almost 23 times (odds ratio 22.7, 95% CI 3.3 to 195.9) more likely to acquire MRSA than those with no such contact. MRSA was successfully isolated from Nurse A and from an environmental swab of a telephone recently used by Nurse A; both isolates matched the pulsed‐field gel electrophoresis pattern of the outbreak strain.

CONCLUSION: The first nosocomial outbreak of CA‐MRSA among healthy newborns and postpartum mothers in Canada is described. Effective control of sustained MRSA transmission within an institution may require prompt identification, treatment and monitoring of colonized and/or infected staff.