bluuebunny/crossref_metadata_2025 huggingface dataset:
First Nations Pneumonia Admissions: Different Patients or Different Attitudes?
Authors: Anthonisen NR
Published: March 2016

In this issue of the Canadian Respiratory Journal, Marrie et al (pages 336‐342) present a database study of hospital admissions among First Nation Aboriginals (FNAs) in Alberta that is fascinating, at least to me. They captured all hospital admissions for "status" FNAs from 1997 to 1999, along with data on where and how long they were hospitalized, the severity of the pneumonia, the number of comorbidities present, whether they were readmitted and the costs involved. They compared these finding with a group of age‐ and sex‐matched non‐FNAs who were also hospitalized for pneumonia. There are, of course, weaknesses in the study that commonly occur in most exercises using administrative databases. Pneumonia is a hospital record diagnosis (there is no information about chest x‐rays, sputum cultures, etc). Pneumonia severity assessment relies on information regarding hospital transfers, intensive care unit admissions and events such as shock, artificial ventilation and death (there is no information available to apply an accepted grading system) (1). Further, "status" FNAs were probably not entirely representative of FNAs in general; indeed, some nonstatus FNAs may well have been included in the control group. However, I strongly doubt that these or similar objections are substantial enough to greatly influence the findings of Marrie et al.
The Costs of Implementing the 1999 Canadian Asthma Consensus Guidelines Recommendation of Asthma Education and Spirometry for the Family Physician
Authors: Corrigan Susan P , Cecillon David L , Sin Don D , Sharpe Heather M , Andrews Elaine M , Cowie Robert L , Man SF Paul
Published: March 2016

BACKGROUND: National and international asthma guidelines recommend that patients with asthma be provided with asthma education and spirometry as a component of enhanced asthma care. The cost of implementing these interventions in family physician practices is not known.

OBJECTIVE: The objective of the present study was to determine the cost of providing recommended asthma care to adult patients in the family practice setting.

METHODS: The present study was conducted using three scenarios of care in family practice. Small, medium and large asthmatic patient populations were used. The incremental costs of implementing enhanced asthma care based on the Canadian Asthma Consensus Guidelines, including the provision of spirometry and asthma education in both group and individual sessions, and the resources required for these interventions were calculated for each scenario.

RESULTS: For a physician with 50 asthmatic patients, the cost of providing enhanced asthma care with spirometry and group education sessions was approximately $78 per patient in the first year of implementation. For individual sessions, the cost increased to $100 per patient for the first year. If the physician had 100 asthmatic patients, the per patient cost would decrease; however, the overall cost of the program would be $7,000.

CONCLUSIONS: The costs of providing enhanced asthma care are significant. In most cases, physicians are inadequately reimbursed (or not reimbursed) for these interventions. In light of the evidence of the effectiveness of these interventions, health insurance plans should consider adding these services to fee schedules.
McArdle′s Disease Presenting as Unexplained Dyspnea in a Young Woman
Authors: Voduc Nha , Webb Katherine A , D′Arsigny Christine , McBride Ian , O′Donnell Denis E
Published: March 2016

McArdle′s disease is a rare, inherited deficiency of myophosphorylase, an enzyme required for the utilization of glycogen. Patients with myophosphorylase deficiency classically present with exercise intolerance, leg pain and muscle fatigue. The case of a young woman with exertional dyspnea and leg cramps is described. Exercise testing confirmed the presence of exercise intolerance and demonstrated an accelerated heart rate response, despite the absence of an anaerobic threshold and a respiratory exchange ratio of less than 1.0. Subsequent ischemic forearm testing and muscle biopsy confirmed the diagnosis of myophosphorylase deficiency. Evaluation of lung mechanics with esophageal pressure measurements demonstrated the presence of respiratory muscle weakness and early fatiguability, suggesting that the patient′s dyspnea might have been attributable to an increased respiratory effort. Dyspnea is not a classic symptom associated with myophosphorylase deficiency, although subclinical respiratory muscle impairment may be present. No previous studies have evaluated respiratory muscle function during exercise in patients with myophosphorylase deficiency.
Uropathogen Antibiotic Resistance in Adult Women Presenting to Family Physicians with Acute Uncomplicated Cystitis
Authors: McIsaac Warren J , Mazzulli Tony , Moineddin Rahim , Raboud Janet , Ross Susan
Published: March 2016

BACKGROUND: Increasing rates of trimethoprim‐sulfamethoxazole (TMP‐SMX) resistance among uropathogens have raised concerns about its continued role in empirical treatment of acute uncomplicated cystitis in adult women.

OBJECTIVES: To determine current rates of antibiotic resistance among uropathogens in the community.

METHOD: Urine culture reports from adult women with symptoms of cystitis attending the offices of family physicians from across Canada were examined. Antibiotic sensitivities and the total number of antibiotics an organism was resistant to was determined.

RESULTS: In 446 women, 235 (61.4%) positive urine cultures were identified. Of these, 38.2% were resistant to at least one antibiotic and 21.5% were resistant to two or more antibiotics. The rate of ampicillin resistance was 34.1%. For TMP‐SMX, resistance was reported in 10.8% of samples. Antibiotic resistance was higher in British Columbia (55%) and western provinces (48%), compared with Ontario (33.3%) and the eastern provinces (26.3%, P=0.04, Fisher′s exact test). Multidrug resistance was also higher in western Canada (33.9%) than in eastern Canada (16.6%, P=0.007).

CONCLUSIONS: TMP‐SMX resistance in Canada remains within current recommended guidelines, allowing for its continued use as a first line empirical treatment for acute cystitis in adult women. The reasons for higher rates of antibiotic resistance in western Canada merit further study.
Managing Cancer Pain ‐ Simple Rules, Major Benefits
Authors: Moulin Dwight E
Published: March 2016

In the developed world, approximately one in three individuals will be diagnosed with cancer and one‐half of those will die of progressive disease (1). At least 75% of patients with cancer develop pain before death. It is therefore not surprising that pain is one of the most feared consequences of cancer for both patients and families (2). The good news is that cancer pain can be controlled with relatively simple means in more than 80% of cases based on guidelines from the World Health Organization (3). Mild pain can be treated with acetaminophen or nonsteroidal anti‐inflammatory drugs (Step 1 of the analgesic ladder). Moderate pain requires the addition of a ′minor′ opioid such as codeine (Step 2), and severe pain mandates the use of a major opioid analgesic such as morphine (Step 3). In this issue of Pain Research & Management, Gallagher et al (pages 188‐194) highlight some of the barriers to adequate cancer pain management based on a cross‐sectional survey of British Columbian physicians. The survey response rate of 69% attests to the validity of their findings.
The Introduction of Oxygen for Pneumonia as Seen Through the Writings of Two Mcgill University Professors, William Osler and Jonathan Meakins
Authors: Warren C Peter W
Published: March 2016

Oxygen was identified at the end of the 18th century by three independent researchers. It was first used indiscriminately with other gases for treatment of pulmonary diseases by Thomas Beddoes. In the 19th century, the physiological properties of oxygen were identified by many researchers. In that same century, physicians used oxygen empirically for a variety of conditions. Osler, who wrote on pneumonia, appreciated that blood was "imperfectly oxidised" (sic) in pneumonia, but concluded that the toxicity of oxygen more than outweighed its possible benefits. Meakins applied the lessons he learned from studying the hypoxemia that resulted from poison gas in World War I to pneumonia. He confirmed that patients with severe pneumonia were hypoxemic and that many of their symptoms appeared to be relieved by inhalation of oxygen. Oxygen then became the standard therapy for pneumonia.
Potential Capsule Switching from Serogroup Y to B: The Characterization of Three such Neisseria meningitidis Isolates Causing Invasive Meningococcal Disease in Canada
Authors: Tsang Raymond SW , Law Dennis KS , Tyler Shaun D , Stephens Gwen S , Bigham Mark , Zollinger Wendell D
Published: March 2016

Three group B Neisseria meningitidis isolates, recovered from meningococcal disease cases in Canada and typed as B:2c:P1.5, were characterized. Multilocus sequence typing showed that all three isolates were related because of an identical sequence type (ST) 573. Isolates typed as 2c:P1.5 are common in serogroup Y meningococci but rare in isolates from serogroups B or C. Although no serogroup Y isolates have been typed as ST‐573, eight isolates showed five to six housekeeping gene alleles that were identical to that of ST‐573. This suggested that the B:2c:P1.5 isolates may have originated from serogroup Y organisms, possibly by capsule switching.
Styles of Pain Coping Predict Cardiovascular Function Following a Cold Pressor Test
Authors: Edwards Robert R , Fillingim Roger B
Published: March 2016

BACKGROUND: While many studies have examined the impact of pain‐related coping in adjustment to chronic pain, relatively few have evaluated the physiological consequences of differences in pain‐coping styles.

OBJECTIVE: The association between strategies for coping with pain and cardiovascular functioning following exposure to painfully cold water was evaluated.

METHODS: Impedance cardiography was used to assess cardiovascular functioning in 50 healthy subjects before and after a cold pressor test.

RESULTS: The self‐reported use of active pain‐coping strategies was associated with reductions in mean arterial pressure and cardiac contractility from pre‐ to post‐cold pressor. In contrast, higher levels of pain catastrophizing were related to increases in cardiac contractility following acute cold pain. Importantly, coping variables predicted cardiovascular responses, whereas characteristics of the noxious stimulus (pain tolerance time and pain ratings) did not.

CONCLUSIONS: These findings highlight the importance of coping styles in shaping physiological responses to pain and suggest that interventions targeting increases in adaptive coping and decreases in pain catastrophizing may reduce pain′s adverse impact.
Effect of a Single Dose Montelukast Sodium on Methacholine Chloride PC20
Authors: Davis Beth E , Cockcroft Donald W
Published: March 2016

BACKGROUND: It is currently recommended that leukotriene modifiers (receptor antagonists and synthesis inhibitors) be withheld for a minimum of 24 h before direct bronchoprovocation testing, but there is little evidence to support this recommendation.

OBJECTIVE: To examine the effect of a single oral dose of montelukast sodium 10 mg on airway response to methacholine chloride‐induced bronchoconstriction.

METHODS: A double‐blind, placebo‐controlled, randomized crossover trial was performed in 12 subjects with asthma whose methacholine chloride concentration causing a 20% decrease in the forced expiratory volume during the first second of exhalation (PC20) was 8 mg/mL or lower and a baseline forced expiratory volume during the first second of exhalation of 70% predicted or greater. Two‐minute tidal breathing methacholine chloride inhalation challenges were performed 1 h and 25 h after both 10 mg montelukast sodium and identical‐appearing placebo.

RESULTS: There were no significant differences in the methacholine chloride PC20 between active treatment and placebo at 1 h post‐10 mg montelukast sodium (1.0 mg/mL versus 1.3 mg/mL; n=12; P=0.17, respectively) or at 25 h post‐10 mg montelukast sodium (1.4 mg/mL versus 1.9 mg/mL; n=11; P=0.15, respectively).

CONCLUSION: A single dose of montelukast sodium did not affect methacholine chloride‐induced bronchoconstriction measured after 1 h and 25 h.
A Review of the Use of Methadone for the Treatment of Chronic Noncancer Pain
Authors: Lynch Mary E
Published: March 2016

Methadone, although having been available for approximately half a century, is now receiving increasing attention in the management of chronic pain. This is due to recent research showing that methadone exhibits at least three different mechanisms of action including potent opioid agonism, N‐methyl‐D‐aspartate antagonism and monoaminergic effects. This, along with methadone′s excellent oral and rectal absorption, high bioavailability, long duration of action and low cost, make it a very attractive option for the treatment of chronic pain. The disadvantages of significant interindividual variation in pharmacokinetics, graduated dose equivalency ratios based on prerotation opioid dose when switching from another opioid, and the requirement for special exemption for prescribing methadone make it more complicated to use. The present review is intended to educate physicians interested in adding methadone to their armamentarium for assisting patients with moderate to severe pain.
The Risk of Tuberculosis Transmission in Solid Organ Transplant: Is It More Than a Theoretical Concern?
Authors: Rose Gregory
Published: March 2016

The present case report describes a therapeutic dilemma regarding the transmission of Mycobacterium tuberculosis during transplantation of solid organs, places this phenomenon within the context of the literature, and makes recommendations for screening and therapy.
Complicated Urinary Tract Infection in Adults
Authors: Nicolle LE
Published: March 2016

BACKGROUND: Complicated urinary tract infection occurs in individuals with functional or structural abnormalities of the genitourinary tract.OBJECTIVE: To review current knowledge relevant to complicated urinary tract infection, and to provide evidence‐based recommendations for management.METHODS: The literature was reviewed through a PubMed search, and additional articles were identified by journal reference review. A draft guideline was prepared and critically reviewed by members of the Association of Medical Microbiology and Infectious Disease Canada Guidelines Committee, with modifications incorporated following the review.RESULTS: Many urological abnormalities may be associated with complicated urinary infection. There is a wide spectrum of potential infecting organisms, and isolated bacteria tend to be more resistant to antimicrobial therapy. Morbidity and infection outcomes in subjects with complicated urinary infection are principally determined by the underlying abnormality rather than the infection. Principles of management include uniform collection of a urine specimen for culture before antimicrobial therapy, characterization of the underlying genitourinary abnormality, and nontreatment of asymptomatic bacteriuria except before an invasive genitourinary procedure. The antimicrobial regimen is determined by clinical presentation, patient tolerance, renal function and known or anticipated infecting organisms. If the underlying abnormality contributing to the urinary infection cannot be corrected, then early post‐treatment recurrence of infection is anticipated.CONCLUSIONS: The management of complicated urinary infection is individualized depending on patient variables and the infecting organism. Further clinical investigations are necessary to assist in determining optimal antimicrobial regimens.
Urgent Care Costs of Uncontrolled Asthma in Canada, 2004
Authors: Seung Soo Jin , Mittmann Nicole
Published: March 2016

It has been more than a decade since Krahn evaluated the direct and indirect costs of asthma in Canada. Asthma is often uncontrolled and the cost of providing urgent care has not been determined. Hospitalizations, unscheduled physician visits, emergency department visits, drug treatments and ambulance rides are resources used by the uncontrolled asthmatic population, resulting in $162 million in costs annually. Improved control of asthma could decrease these costs.
The Laboratory Diagnosis of HIV Infections
Authors: Fearon Margaret
Published: March 2016

HIV diagnostic testing has come a long way since its inception in the early 1980s. Current enzyme immunoassays are sensitive enough to detect antibody as early as one to two weeks after infection. A variety of other assays are essential to confirm positive antibody screens (Western blot, polymerase chain reaction [PCR]), provide an adjunct to antibody testing (p24 antigen, PCR), or provide additional information for the clinician treating HIV‐positive patients (qualitative and quantitative PCR, and genotyping). Most diagnostic laboratories have complex testing algorithms to ensure accuracy of results and optimal use of laboratory resources. The choice of assays is guided by the initial screening results and the clinical information provided by the physician; both are integral to the laboratory′s ability to provide an accurate laboratory diagnosis. Laboratories should also provide specific information on specimen collection, storage and transport so that specimen integrity is not compromised, thereby preserving the accuracy of laboratory results. Point of Care tests have become increasingly popular in the United States and some places in Canada over the past several years. These tests provide rapid, on‐site HIV results in a format that is relatively easy for clinic staff to perform. However, the performance of these tests requires adherence to good laboratory quality control practices, as well as the backup of a licensed diagnostic laboratory to provide confirmation and resolution of positive or indeterminate results. Laboratory quality assurance programs and the participation in HIV proficiency testing programs are essential to ensure that diagnostic laboratories provide accurate, timely and clinically relevant laboratory results.
Endobronchial Mimics of Primary Endobronchial Carcinoma: A Clinical Study of 25 Cases
Authors: Magro Cynthia M , Ross Patrick
Published: March 2016

While endobronchial lesions that present with symptoms of obstruction may be reflective of primary bronchogenic malignancy, there have been a number of reports of bronchial lesions other than primary bronchogenic carcinoma simulating primary endobronchial epithelial malignancy clinically. Twenty‐five cases of symptomatic endobronchial disease were encountered with pathological assessment demonstrating an endobronchial process other than carcinoma, representing metastatic disease (breast, colon, renal, head and neck origin), fungal infection, Hodgkin′s lymphoma, primary bronchogenic melanoma, lipoma, broncholith and inflammatory pseudopolyp. The present report underscores the potential pathogenetic heterogeneity encountered in lesions presenting with signs and symptoms of endobronchial obstruction, emphasizing the critical role of biopsy for establishing a definitive diagnosis.
Asthma Management at Discharge from the Emergency Department: A Descriptive Study
Authors: Gervais Pascale , Larouche Isabelle , Blais Lucie , Fillion Anne , Beauchesne Marie-France
Published: March 2016

BACKGROUND: The management of asthma remains suboptimal despite the publication of Canadian asthma guidelines in 1999.

OBJECTIVES AND METHODS: A descriptive study was conducted to estimate the proportion of patients admitted to the emergency department (ED) for an asthma exacerbation who received a management plan at discharge that was in accordance with seven criteria stated in the Canadian asthma guidelines. The present study took place in two tertiary care hospitals in Montreal, Quebec.

RESULTS: A total of 37 patients were enrolled. Three (8%) patients received a management plan at discharge that was in accordance with all seven criteria. Inhaled corticosteroids and oral corticosteroids were prescribed at discharge for 29 (78%) and 35 (95%) patients, respectively. Minimal asthma education was provided for 29 (78%) patients and a medical follow‐up was recommended to 22 (60%) patients. Airflow obstruction was evaluated at discharge for only 20 (54%) patients.

CONCLUSION: Overall, asthma management at discharge from the ED was generally not in accordance with the 1999 Canadian asthma guidelines. A standardized management plan should be implemented in the ED to improve the care of patients with asthma exacerbations.
Enhanced Surveillance for Acute and Likely Acute Hepatitis B in Canada: 1999 to 2002
Authors: Boulos David , Goedhuis Neil J , Wu Jun , Baptiste Beverley , Poliquin Darlene , Furseth Janet , Chan Jessica Ip , Bolesnikov Grlica , Barichello Faye , Andonov Anton , Giulivi Antonio
Published: March 2016

OBJECTIVE: To assess the incidence of clinically identified hepatitis B cases, as well as the demographic and risk behaviour profiles of these cases in a defined Canadian population.

METHODS: An enhanced hepatitis surveillance system was established in October 1998 to identify acute hepatitis B and C cases in Canada. Acute and likely acute cases, as determined by laboratory testing, collectively defined incident clinical hepatitis B cases. Data from 1999 to 2002 on incidence, demographic characteristics and risk behaviour characteristics were collected and analyzed.

RESULTS: During the 1999 to 2002 surveillance period, 379 cases were identified in a target population ranging from 3,128,179 to 8,576,071 individuals. The observed hepatitis B incidence rate was 1.93/100,000 person‐years in the surveillance area. The incidence rate was 2.74 times higher in men. The observed incidence rates decreased for all age groups over the surveillance period but remained high in the 20‐ to 29‐year‐old and 30‐ to 39‐year‐old age groups, as well as in men. Of the incident cases, 55.9% self‐identified as being born in Canada and 18.5% as being born in Asia, while 18.7% did not identify a birth area. Of the Canadian‐born cases, 61.3% identified themselves as Caucasian, 11.3% as Aboriginal and 23.6% as no ethnic category. Injection drug use was the most reported risk behaviour (19.1%), followed closely by sex‐associated risk behaviours. A large proportion, 24%, indicated none of the known risk behaviours.

CONCLUSIONS: The hepatitis B incidence rate has shown some decrease in the surveillance population from 1999 to 2002 and this may be due, in part, to past intervention programs (eg, vaccination programs and health promotion campaigns). The authors′ results identify some high‐risk groups that would benefit from additional prevention and control programs, and further targeted research and intervention.
The Laboratory Diagnosis of Syphilis
Authors: Ratnam Sam
Published: March 2016

Syphilis has several clinical manifestations, making laboratory testing a very important aspect of diagnosis. In North America, many unsuspected cases are discovered by laboratory testing. The etiological agent, Treponema pallidum, cannot be cultured, and there is no single optimal alternative test. Serological testing is the most frequently used approach in the laboratory diagnosis of syphilis. The present paper discusses the various serological and alternative tests currently available along with their limitations, and relates their results to the likely corresponding clinical stage of the disease. The need to use multiple tests is discussed, and the importance of quality control is noted. The complexity of syphilis serology means that the services of reference laboratories and clinical experts are often needed.
Chlamydia pneumoniae and Atherosclerosis: The End?
Authors: Nicolle LE
Published: March 2016

In this issue of the Journal, Patrick et al (pages 298‐300) report on the results of a pilot study testing the hypothesis that seropositivity to Chlamydia pneumoniae together with a specific bacteriophage protein is associated with first‐episode myocardial infarction or unstable angina. The study evolved from an earlier report suggesting that C pneumoniae with phage seropositivity was strongly associated with the presence of abdominal aortic aneurysm. The phage association suggested a potential explanation for some of the variability in previous studies exploring C pneumoniae as a cause for atherosclerosis (ie, only selected strains of C pneumoniae were pathogenic). Patrick et al found no significant association or trend, and the authors concluded that the negative findings in their pilot study did not support further studies to address this potential association.
A Case of Congenital Cutis Laxa (Generalized Elastolysis)
Authors: Champion Paul , Ryan Frank
Published: March 2016

Cutis laxa (generalized elastolysis) is characterized by sagging folds of loose skin on the face and trunk. Although grouped with hyperelastic skin conditions such as Ehlers‐Danlos syndrome, cutis laxa shows an almost total lack of skin elasticity. Because it is a generalized state, it may present as an abnormality in the connective tissue of more than one organ system. The authors report a patient who had end‐stage renal failure related to heavy chain disease, a recognized association of cutis laxa. Although the patient’s vascular abnormalities were significant, she died of respiratory failure at 41 years of age from cutis laxa‐induced emphysema.
A Comparison of Pertussis Rates in the Northwest Territories: Pre‐ and Postacellular Pertussis Vaccine Introduction in Children and Adolescents
Authors: Kandola Kami , Lea Amy , White Wanda , Santos Maria
Published: March 2016

INTRODUCTION: During the past decade, a trend toward increasing cases of Bordetella pertussis in older children and adults has been witnessed in Canada. The National Advisory Committee on Immunization now recommends that the adult formulation of the acellular pertussis (adult dTap) vaccine combined with diphtheria and tetanus toxoids be substituted for diphtheria and tetanus toxoids alone for the 14‐ to 16‐year‐old booster dose. In October 2000, the government of the Northwest Territories was one of the first to adopt adult dTap into their territorial immunization program free of charge.

OBJECTIVE: To evaluate the effect of the acellular pertussis vaccine in children and adolescents on the epidemiology of pertussis in the Northwest Territories.

METHODS: Pertussis is a reportable disease in the Northwest Territories, and data on the incidence rates of pertussis are available from 1989 to 2004. The present study reviews pertussis cases during three four‐year periods: the whole‐cell vaccine era (1993 to 1996); the preadult dTap era (1997 to 2000); and the postadult dTap era (2001 to 2004).

RESULTS: The incidence of pertussis decreased from 18.0 cases per 10,000 population in 1993 to 0.2 cases per 10,000 population in 2004. The number of cases decreased from 186 to 129 to 19 cases in the three chronological time periods (ie, whole‐cell vaccine era, preadult dTap era and postadult dTap era, respectively), with the most substantial reduction coming with the introduction of postadult dTap.

CONCLUSIONS: There appears to be a decrease in the incidence of pertussis with the targeted introduction of adult dTap in the Northwest Territories.
Toll Like Receptors 4 and 2 Expression in the Bronchial Mucosa of Patients with Cystic Fibrosis
Authors: Hauber Hans-Peter , Tulic Meri K , Tsicopoulos Anne , Wallaert Benoit , Olivenstein Ron , Daigneault Patrick , Hamid Qutayba
Published: March 2016

BACKGROUND: Cystic fibrosis (CF) is a lung disease characterized by chronic infection with Gram‐negative bacteria Pseudomonas aeruginosa and Gram‐positive bacteria Staphylococcus aureus. Recently, toll‐like receptor (TLR) 4 has been shown to be responsible for the lipopolysaccharide (LPS)‐mediated immune response. While TLR2 mediates responses driven by bacterial lipoproteins and peptidoglycans from Gram‐positive bacteria, LPS derived from P aeruginosa may stimulate the immune response in the airways of patients with CF via activation of TLR4.

OBJECTIVES: To investigate TLR4 and TLR2 expression in the bronchial mucosa of patients with CF and normal control subjects.

PATIENTS AND METHODS: Endoscopic bronchial biopsies from seven patients with CF and six healthy control subjects were obtained. TLR4 and TLR2 expression was assessed using immmunocytochemistry. Real‐time polymerase chain reaction was used to detect TLR4 messenger RNA in blood cells from patients with CF and to compare TLR4 expression in CF bronchial epithelial cells with non‐CF bronchial epithelial cells.

RESULTS: In patients with CF, the number of TLR4‐positive cells was significantly increased in their submucosa (P<0.05) but significantly reduced in their epithelium compared with control subjects (P<0.05). The majority of TLR4‐positive cells were neutrophils. Patients with CF (n=4) and control subjects (n=4) had a similar percentage of TLR4‐expressing neutrophils and monocytes/lymphocytes in peripheral blood. CF cells (IB‐3) had significantly decreased basal TLR4 messenger RNA expression compared with non‐CF cells (Calu‐3) (P<0.05). Although there was a trend toward reduced TLR2 expression in the airway epithelium of patients with CF (P=0.07), there was no significant difference in TLR2 expression in the submucosa of patients with CF compared with that of control subjects.

CONCLUSIONS: Both TLR4 and TLR2 expression in the bronchial epithelium of patients with CF were significantly reduced compared with healthy control subjects. In contrast, the number of TLR4‐positive neutrophils in the submucosa of patients with CF was higher than in control subjects. This may suggest that the loss of epithelial TLR expression may contribute to the impaired defense against LPS.
The Use of Noninvasive Mechanical Ventilation for the Treatment of Acute Exacerbations of Copd in Canada
Authors: Drummond Jennifer , Rowe Brian , Cheung Lawrence , Mayers Irvin
Published: March 2016

BACKGROUND: Noninvasive mechanical ventilation (NIMV) is accepted as a life‐saving treatment for patients presenting to the emergency department and other acute care settings with severe exacerbations of chronic obstructive pulmonary disease (COPD).

OBJECTIVE: It was hypothesized that there is marked national variability in the use of NIMV. Therefore, the use of NIMV for COPD exacerbations in urban centres across Canada was evaluated.

METHODS: All Canadian hospitals affiliated with a university training program were surveyed, and a request for involvement in this survey was posted on the Canadian Society of Respiratory Therapy professional practice listserv. Survey information was received from all 33 sites (100%) that were contacted.

RESULTS: Marked differences in the application of NIMV were identified across all regions in Canada, ranging from requiring extensive monitoring in the intensive care unit to application on a general internal medical unit with intermittent noninvasive blood pressure monitoring. There were sites that rarely used NIMV for COPD exacerbations and others where it was routine practice.

CONCLUSIONS: NIMV is a life‐saving treatment for acute exacerbations of COPD. Despite clear clinical evidence, its use has not penetrated throughout all the larger urban hospitals in Canada. This may be more problematic in sites without 24 h respiratory therapy support. There are barriers to the routine application of NIMV that can be overcome using established guidelines and available evidence.
Cost‐Effectiveness of Treprostinil Versus Epoprostenol in Patients with Pulmonary Arterial Hypertension: A Canadian Analysis
Authors: Einarson Thomas R , Granton John T , Vicente Colin , Walker John H , Engel Greg , Iskedjian Michael
Published: March 2016

BACKGROUND: Pulmonary arterial hypertension (PAH) is associated with substantial morbidity and mortality, exerting a tremendous health and economic impact on patients. In the present study, an economic evaluation of patients with PAH treated with either treprostinil or epoprostenol was performed.

METHODS: A cost‐minimization analysis (a cost‐effectiveness subtype) was performed under the assumption that treprostinil and epoprostenol were clinically equivalent. Two cohorts of 60 patients, treated with treprostinil or epoprostenol, were evaluated over three years by using a dynamic spreadsheet model. The evaluation included both the provincial ministries of health and societal perspectives. Resource valuation data for drugs, medical supplies, consultations, and surgical and diagnostic procedures were obtained from standard lists. Costs of hospitalizations and adverse events were derived from published sources. Additional outpatient costs were considered equivalent and, therefore, were excluded from the analysis. Costs are presented in 2003 Canadian dollars discounted at 3%. Sensitivity analyses were performed testing all uncertainties in the model.

RESULTS: In the base‐case analysis (over three years), treatment with treprostinil resulted in an expected savings of $2,610,642 and $2,781,438 from the ministries of health and societal perspectives, respectively. On a per‐patient level, treatment with treprostinil resulted in an average annual savings of $14,504 and $15,452, respectively. The greatest savings with treprostinil came from reduced hospitalizations. Multivariate sensitivity analyses estimated cost savings in greater than 99% of scenarios.

CONCLUSIONS: By initiating and continuing treprostinil treatment over a three‐year period, the economic burden associated with PAH may be reduced compared with epoprostenol treatment.
A Case of Cryptogenic Organizing Pneumonia Occurring in Crohn’s Disease
Authors: Carratù Pierluigi , Dragonieri Silvano , Nocerino Maria Cristina , Trabucco Senia Maria Rosaria , Lacedonia Donato , Parisi Giuseppe , Resta Onofrio
Published: March 2016

A 29 year‐old‐man with Crohn′s disease, who developed diffuse pulmonary infiltrates and hypoxemia two months following oral administration of mesalazine, was examined. Clinical findings and computed tomography were suggestive of, and lung histology was diagnostic of, bronchiolitis obliterans organizing pneumonia, also known as cryptogenic organizing pneumonia. Although the data did not allow for definitive conclusions, they did suggest that the pulmonary disease was an extraintestinal manifestation of Crohn′s disease, rather than an adverse reaction to mesalazine. In fact, the patient showed clinical, radiological and functional improvements, despite the treatment with mesalazine and the withdrawal of steroid therapy.
Ventrolateral Partial Dorsal Root Entry Zone Rhizotomy for Occipital Neuralgia
Authors: Rasskazoff Serge , Kaufmann Anthony M
Published: March 2016

OBJECTIVE AND IMPORTANCE: Medically refractory occipital neuralgia (ON) has been treated with a variety of neuroablative procedures. The present case report supports the effectiveness of ventrolateral partial rhizotomy (pVL‐DREZ) of the C1 to C3 cervical dorsal roots, a relatively unknown procedure.

CLINICAL PRESENTATION: A 46‐year‐old woman had a 14‐month history of severe right‐sided ON. Multiple trials of medical treatments, nerve blocks and local steroid injections had failed. Her daily opioid requirements had escalated to include frequent injections in addition to prescribed oral opiates.

INTERVENTION AND RESULTS: A pVL‐DREZ at the right C1 to C3 level was performed through a C1 laminectomy and C2 right laminotomy. The ipsilateral upper cervical dorsal roots were exposed and a 1 mm deep incision was made at a 45° angle to the sagittal midline at the ventrolateral aspect of each dorsal rootlet entry. The patient experienced postoperative opioid withdrawal seizure and transient disequilibrium for two weeks. Touch sensation was preserved and complete abolition of ON over a four year follow‐up was achieved.

CONCLUSION: The pVL‐DREZ procedure provided complete pain relief for the patient and avoided the potential complications often encountered with other destructive interventions. pVL‐DREZ should be considered among the available options for the treatment of refractory ON.
The Laboratory Diagnosis of Genital Human Papillomavirus Infections
Authors: Coutlee François , Rouleau Danielle , Ferenczy Alex , Franco Eduardo
Published: March 2016

Human papillomaviruses (HPVs) are the etiological agents of several genital cancers, including cancer of the uterine cervix. The detection of HPV infection in genital samples may increase the sensitivity of primary and secondary screenings of cervical cancer. HPV testing may also improve the specificity of screening programs, resulting in the avoidance of overtreatment and cost savings for confirmatory procedures. The major determinants of clinical progression of HPV infection include persistence of HPV infection, involvement of high‐risk HPV types, high HPV viral load, integration of viral DNA and presence of several potential cofactors. Signal amplification HPV‐DNA detection techniques (Hybrid Capture II, Digene Corporation, USA) are standardized, commercially available, and capable of detecting several high‐risk HPV types. They also increase the sensitivity of screening for high‐grade lesions in combination with cytology. The sensitivity of these techniques to detect high‐grade lesions is higher than that of cytology, but the referral rate for colposcopy is greater. These techniques are approved for the triage to colposcopy of women with cervical smears interpreted as atypical squamous cells of undetermined significance. Triage and screening for cervical cancer using HPV will probably be restricted to women aged 30 years or older because of the high prevalence of infection in younger women. Amplification techniques are ideal for epidemiological studies because they minimize the misclassification of HPV infection status. These techniques can detect low HPV burden infections. Consensus primers amplify most genital types in one reaction, and the reverse hybridization of amplicons with type‐specific probes allows for the typing of HPV‐positive samples. Consensus PCR assays are currently under evaluation for diagnostic purposes. HPV testing is currently implemented for the clinical management of women.
Hepatic Hydrothorax: How Would You Manage It?
Authors: Al-sharif Hassan , Sharma Sat
Published: March 2016

A 53‐year‐old woman with a history of chronic alcoholism presented with symptomatic large right‐sided pleural effusion with no evidence of ascites. After a diagnosis of hepatic hydrothorax was established, her symptoms improved with therapeutic thoracente
Where are all the new antibiotics? The new antibiotic paradox
Authors: Conly JM , Johnston BL
Published: March 2016

At the beginning of the 20th century, illnesses caused by infectious agents ranked among the most common causes of death in North America and, indeed, worldwide. By the middle of the century, dramatic advances in the diagnosis, management and prevention of infectious diseases had occurred, and hopes were raised that many infectious diseases would be eliminated by the end of the 20th century. Much of this success in the management of infectious diseases was related to a continuous new armamentarium of antibiotics. The discovery of penicillin by Fleming in 1928 followed by the discovery and clinical use of sulphonamides in the 1930s heralded the age of modern antibiotherapy (1,2). Penicillin came into widespread use during the early 1940s. By the 1950s, the ′golden era′ of antibiotic development and use was well underway, and multiple new classes of antibiotics were introduced over the next two decades (Table 1) (3).
Private Costs of Patients Hospitalized with Community‐Acquired Pneumonia
Authors: Jacobs Philip , Marrie Thomas J , Calder Peter
Published: March 2016

BACKGROUND: Community‐acquired pneumonia (CAP) is a condition which frequently requires hospitalization and consequently, can result in high costs. Little is known of the additional personal resources that are used by patients hospitalized for CAP.

OBJECTIVE: To measure the private costs for persons who were hospitalized with CAP for the 30 days after being admitted to hospital using a systematic method of measurement.

METHODS: Potential personal cost items were identified by nurses familiar with the treatment of CAP and categorized. Using telephone interviews in conjunction with the cost‐identification framework, 60 patients from the Edmonton, Alberta area were surveyed for their private costs associated with CAP for 30 days after admission to hospital.

RESULTS: Of the 60 patients surveyed, 49 were older than 65 years of age. The mean private cost was $505, which amounted to 5.6% of the total societal costs of $8,970. The distribution was skewed with a small number of patients that had high costs.

CONCLUSIONS: This method allows the determination of the societal costs for patients hospitalized with pneumonia, and the costs were not much greater than those to the health care system.
Alveolar Soft‐Part Sarcoma Presenting with Eosinophilia and Shunt
Authors: Almansori M , Turner AR , Girgis S , Vethanayagam D
Published: March 2016

Alveolar soft‐part sarcoma (ASPS) is a rare soft tissue tumour found in young adults that usually arises in skeletal muscle and occurs most frequently in the lower limbs. Radiological and pathological findings of ASPS in a 34‐year‐old man who presented with increasing shortness of breath over a period of four to six weeks with peripheral blood eosinophilia, hypoxemia and a significant arteriovenous shunt are reported. The present article is the fourth report of eosinophilia in association with sarcoma, and the first involving ASPS.
Avian Influenza: Myth or Mass Murder?
Authors: Louie Carol
Published: March 2016

The purpose of the present article was to determine whether avian influenza (AI) is capable of causing a pandemic. Using research from a variety of medical journals, books and texts, the present paper evaluates the probability of the AI virus becoming sufficiently virulent to pose a global threat. Previous influenza A pandemics from the past century are reviewed, focusing on the mortality rate and the qualities of the virus that distinguish it from other viruses. Each of the influenza A viruses reviewed were classified as pandemic because they met three key criteria: first, the viruses were highly pathogenic within the human population; second, the viruses were easily transmissible from person to person; and finally, the viruses were novel, such that a large proportion of the population was susceptible to infection. Information about the H5N1 subtype of AI has also been critically assessed. Evidence suggests that this AI subtype is both novel and highly pathogenic. The mortality rate from epidemics in Thailand in 2004 was as high as 66%. Clearly, this virus is aggressive. It causes a high death rate, proving that humans have a low immunity to the disease. To date, there has been little evidence to suggest that AI can spread among humans. There have been cases where the virus has transferred from birds to humans, in settings such as farms or open markets with live animal vending. If AI were to undergo a genetic reassortment that allowed itself to transmit easily from person to person, then a serious pandemic could ensue, resulting in high morbidity and mortality. Experts at the World Health Organization and the United States Centers for Disease Control and Prevention agree that AI has the potential to undergo an antigenic shift, thus triggering the next pandemic.
Screening for Sexually Transmitted Infection Pathogens in Semen Samples
Authors: Peeling RW , Embree J
Published: March 2016

The transmission of sexually transmitted infection (STI) pathogens from an infected donor to the recipient of a semen donation in assisted conception may result not only in acute infection but also in long‐term reproductive complications or adverse outcomes of pregnancy, including infection of the offspring. Screening for bacterial STI pathogens, Chlamydia trachomatis and Neisseria gonorrhoeae is strongly recommended because these pathogens can cause serious reproductive complications in the recipients of semen donations and infection in their offspring. Screening for these pathogens should be performed using the most sensitive methods, such as nucleic acid amplified tests. False‐negative results due to inhibitory substances in the semen sample should be monitored using amplification controls. Where specimen transport is not a problem and culture facilities are available, N gonorrhoeae can also be detected by culture. Laboratories performing screening should subscribe to proficiency programs and have strict quality controls. Although Trichomonas vaginalis, group B streptococcus and genital mycoplasmas have been associated with adverse outcomes of pregnancy, the frequent finding of these organisms in healthy individuals brings into question the validity of mandatory inclusion of these organisms in the screening panel. Although viral STI pathogens and Treponema pallidum ‐‐ the causative agent of syphilis ‐‐ may be detected in semen, their presence may be more sensitively detected through antibody testing of the donor. Screening donors for HIV, hepatitis B and syphilis by serology is uniformly recommended in all of the guidelines, but the value of screening either donors or semen samples for cytomegalovirus, herpes simplex viruses and human papilloma viruses is less clear.
Sexually Transmitted Infections
Authors: Nicolle LE
Published: March 2016

Sexually transmitted infections (STIs) other than HIV have reappeared as an important public health problem in developed countries (1). In the late 1970s and early 1980s, research and treatment of the ′classic′ STIs ‐ gonorrhea, syphilis and chlamydia ‐ were a major focus of infectious diseases practice and research. There were large outbreaks of syphilis in parts of Canada (2), penicillin‐resistant Neisseria gonorrhoeae was a concern (3), and high rates of Chlamydia trachomatis infection with complications of pelvic inflammatory disease and ectopic pregnancy were being reported (4,5). Then, HIV infection emerged, with its spectre of a wasting, early death. There was no effective treatment, and safe sexual practices were embraced and adhered to by high‐risk populations as the only effective way to avoid infection. These practices effectively prevented other STIs; rates of syphilis, gonorrhea and chlamydia infection plummeted in developed countries (5). For at least a decade, it appeared that HIV might be an end to all STIs, at least for some parts of the world. STIs continued unabated in developing countries, as many epidemiological and therapeutic studies explored the association of STIs with HIV infection.
Ode to Oseltamivir and Amantadine?
Authors: Conly JM , Johnston BL
Published: March 2016

Influenza A and B viruses are the two major types of influenza viruses that cause human epidemic disease. Influenza A viruses are further categorized into subtypes based on two surface antigens: hemagglutinin (H) and neuraminidase (N). Influenza B viruses are not categorized into subtypes (1). Influenza A viruses are found in many animal species, including humans, ducks, chickens, pigs, whales, horses and seals, whereas influenza B viruses circulate only among humans. The H antigen contains common and strain‐specific antigens, demonstrates antigenic variation, and acts as a site of attachment of the virus to host cells to initiate infection (1). The N antigen contains subtype‐specific antigens and also demonstrates antigenic variation between subtypes. It is a surface glycoprotein possessing enzymatic activity essential for viral replication in both influenza A and B viruses. The N antigen allows the release of newly produced virions from infected host cells, prevents the formation of viral aggregates after release from the host cells, and prevents viral inactivation by respiratory mucous (2,3). It is thought that this enzyme may also promote viral penetration into respiratory epithelial cells and may contribute to the pathogenicity of the virus by promoting production of proinflammatory cytokines such as interleukin‐1 and tumour necrosis factor from macrophages (4‐6).