bluuebunny/crossref_metadata_2025 huggingface dataset:
National Surveillance of Occupational Exposure to the Human Immunodeficiency Virus
Authors: Ricketts Maura , Deschamps Linda , Elmslie Kimberly , O’Shaughnessy Michael
Published: March 2016

In September 1985, a prospective study was initiated to monitor the occurrence of occupational exposures to human immunodeficiency virus (HIV)‐infected blood and body fluids in Canada. This program was coordinated by the Federal Centre for acquired immune deficiency syndrome (AIDS) (now the Division of HIV/AIDS Epidemiology at the Laboratory Centre for Disease Control). The objective was to determine the risk to workers of acquiring HIV infection as a result of exposure to HIV‐infected blood and other body fluids. To be eligible, a worker must have sustained a documented parenteral, mucous membrane or skin contact exposure to blood or body fluids from an HIV‐infected person. A baseline specimen was collected within a week of the exposure and then at six weeks, 12 weeks, six months and 12 months. Information concerning the type of exposure, precautions used and post exposure treatment was submitted to the Federal Centre for AIDS on standard data collection forms. All information was anonymous, identified only by a code number. Guidelines for counselling an exposed employee were provided with enrollment material. As of July 29, 1991, 414 employees have been included in the study. Two hundred and thirty‐seven of the 414 exposures (57%) were needlestick injuries of which 167 (70%) were sustained by nurses. Other exposures consisted of open wound contamination, eye splashes, scalpel wounds and skin contact with blood and body fluids. To date, there have been no seroconversions among workers enrolled in the surveillance program.
Carriage of Neisseria Species in Communities with Different Rates of Meningococcal Disease
Authors: Le Saux Nicole , Ashton Fraser , Rahman Maksudar , Ryan Alan , Ellis Edward , Tamblyn Susan , Morris Joan , Borczyk Al , Mallory Caroll , Mikel Donald , Thompson Stephen , Black Lyall , Lacey Barbara , Anand Chandar
Published: March 2016

A single clone, Neisseria meningitidis serogroup C (C:2a:P1.2), was isolated from seven patients during a cluster of cases of meningococcal disease in Ontario in 1989. To determine whether the clone was present in asymptomatic individuals in the same population, pharyngeal swabs were taken from 7% (644 of 9125) of residents who were vaccinated during the outbreak. Rates of isolation of Neisseria species were also compared to those in two other geographical areas which did not have an elevated incidence of meningococcal disease. The rate of carriage of N meningitidis in the asymptomatic individuals sampled was between 1.9% and 5.4%. The clone isolated from patients was not present among the carrier strains as determined by sero‐ and subtyping and electrophoretic analysis of metabolic enzymes. Age greater than six years was the only factor associated with colonization with N meningitidis.
Extrahepatic Manifestations of Hepatitis B Virus Infection: Addison’s Disease and Myelofibrosis in a Patient with Persistent Hepatitis B Surface Antigenemia
Authors: Somlo François , Berry Gerald R
Published: March 2016

A 60‐year‐old white male patient was admitted to the hospital with acute abdominal pain, seemingly a self‐limited ileus. He was found to be hepatitis B surface antigen (HBsAg)‐positive. Previous dental treatment was suspected to be the initial source of the infection with hepatitis B virus. Five months later he was re‐admitted with a diagnosis of adrenal insufficiency (Addison’s disease) which responded well to steroids. Four years later he developed fever and leucocytosis. A bone marrow biopsy revealed myelofibrosis. He had several episodes of pyrexia during his lifetime. After a 12‐year period the patient suffered a fatal myocardial infarction. At autopsy the adrenal glands were reduced to scarred remnants and HBsAg was found to be present in the residual adrenocortical cells by immunoflouresence methods. Bone marrow at autopsy revealed myelosclerosis as well HBsAg (via immunofluoresence). Hepatitis B virus was therefore closely correlated with the development of Addison’s disease and myelofibrosis in this case.
Morbidity, Cost and Role of Health Care Worker Transmission in an Influenza Outbreak in a Tertiary Care Hospital
Authors: Yassi Annalee , McGill Myrna , Holton Donna , Nicolle Lindsay
Published: March 2016

An influenza A outbreak involving 17 health care workers (HCWs) and 16 chronic geriatric patients on a ward in a tertiary care hospital was reviewed. Thirty‐seven per cent of all HCWs and 47% of patients on the affected wards became ill with influenza. Three patients died during the outbreak. The majority of health care workers became ill prior to detecting the first patient case of influenza, suggesting that nosocomial spread from HCWs to patients may have occurred. Only 13.7% of the staff and 5.9% of the patients had been vaccinated prior to the outbreak. Lost time due to HCW absenteeism, outbreak‐related medication costs and additional staff time involved in outbreak control resulted in considerable cost to the hospital. It is suggested that much of this cost, as well as morbidity and possibly mortality, could have been avoided by increased immunization of HCWs and patients.
Pneumocystis Prophylaxis for All, Some, or No HIV‐infected Infants Less than One Year of Age: A Decision Analysis Approach
Authors: Allen Upton D , Read Stanley E
Published: March 2016

Pneumocystis carinii pneumonia (PCP) is associated with significant mortality and morbidity among infants infected with human immunodeficiency virus (HIV). The preferred prophylaxis strategy for such infants is a subject of debate. Medical decision analysis was used to determine the preferred strategy for primary PCP prophylaxis among asymptomatic HIV‐infected infants less than one year of age, and to determine the thresholds at which different variables influence decision making. Utility measures (health state preference values) were used to determine whether prophylaxis should be given to all, some or no infants. In this regard, some infants would receive prophylaxis if baseline CD4 counts are fewer than 1500 cells/mm3. The results suggest that the preferred option is to give prophylaxis to all asymptomatic HIV‐infected infants despite CD4 counts, if the risk of PCP is equal to or greater than 25%. However, if the risk of PCP is less than 25%, prophylaxis is recommended for those infants with CD4 counts of fewer than 1500 cells/mm3. The results complement current guidelines regarding PCP prophylaxis for HIV‐infected infants.
Need for Treatment of Gonorrhea to be Effective against Chlamydia trachomatis
Authors: Bowie William R , Ast Joanne , Sibau Linda , Shaw Carol , Jones Hugh D , Black William A
Published: March 2016

Men and women with gonorrhea or contact to gonorrhea are frequently co‐infected with Chlamydia trachomatis. To assess the importance of using treatment regimens active against both Neisseria gonorrhoeae and C trachomatis, tetracycline 500 mg orally four times daily for five days, with activity against both organisms, was compared with ceftriaxone, 250 mg once intramuscularly, with activity against only N gonorrhoeae. N gonorrhoeae microbiological failure occurred in six of 148 patients (4%) on tetracycline and zero of 85 on ceftriaxone. Microbiological failure for C trachomatis occurred in zero of 27 on tetracycline and 10 of 12 (83%) on ceftriaxone (P<0.001). In addition, 14 others on ceftriaxone had C trachomatis first isolated after treatment. When all types of microbiologialc and clinical failures are included, outcome was significantly better on tetracycline (P<0.001). Optimal treatment of patients with gonorrhea must include regimens with activity against both C trachomatis and N gonorrhoeae.
Containing Cefoxitin Costs through a Program to Curtail Use in Surgical Prophylaxis
Authors: Taylor Geoffrey , Blondel-Hill Edith , Kibsey Pamela , Friesen Erwin , Tisdell Ronald , Vaudry Wendy
Published: March 2016

Objective: To reduce drug costs attributable to anti‐anaerobic cephalosporins – specifically to reduce cefoxitin use in surgical prophylaxis.

Design: Before and after intervention cefoxitin use comparison.

Setting: Tertiary care hospital.

Participants: Hospitalized patients.

Interventions: Chart review of patients identified through pharmacy records as cefoxitin recipients was carried out to determine which physicians were the principal users of cefoxitin and the purpose for such use. These data were used to direct cost containment strategies.

Main Outcome Measures: Hospital quarterly pharmacy acquisition costs and grams of cefoxitin used.

Results: The departments of surgery (49%) and obstetrics/gynecology (37%) were the principal users of cefoxitin, and surgical prophylaxis was found to be the principal indication for use (63%). These departments were invited by the Antibiotic Utilization Subcommittee of the hospital’s Pharmacy and Therapeutics Committee to draft surgical prophylaxis guidelines in keeping with published recommendations. Such guidelines were written and distributed to medical staff and substituted cefazolin for most forms of prophylaxis, gentamicin/metronidazole for colorectal prophylaxis and cefoxitin only for appendectomies. Over the following 21 months, hospital‐wide cefoxitin use fell from 6093 g, $70,076 per quarter, to 1316 g, $11,515 per quarter (partially offset by a 2595 g, $9,131 per quarter increase in cefazolin use).

Conclusion: As a first step in reducing hospital costs of anti‐anaerobic cephalosporins, rationalization of cefoxitin use may be preferable to formulary interchange with alternatives such as ceftizoxime or cefotetan.
Analysis of Risk Factors Associated with Hepatitis B and C Infection in Correctional Institutions in British Columbia
Authors: Préfontaine RG , Chaudhary RK , Mathias RG
Published: March 2016

The factors associated with infection with hepatitis B (hbv) and C viruses (hcv) were studied in residents of correctional institutions in British Columbia. Four hundred and fifteen residents volunteered to participate in this study. Among 415 residents tested, 28% were positive for hvb or hcv markers. Sixty‐five per cent of the residents positive for hbv markers were also infected with hcv. However, in hbv‐negative residents, only 14% were positive for antibody to hcv (anti‐hcv). The highest rates for hbv and hcv were in 25‐ to 44‐year‐old residents. The analysis of risk factors and infection predictors in 354 residents showed that intravenous drug use and history of hepatitis were associated with infection with both hbv and hcv. The relative risk for hbv in intravenous drug users was 4.4 times that in nonusers; for hcv relative risk was 3.4 times. In the group with history of hepatitis, the relative risk was 6.2 and 4.5 times for hbv and hcv, respectively. The multivariate analysis of the data showed that both intravenous drug use and a history of hepatitis were significant (P<0.0001). Tattooing or history of transfusion was not associated with increased risk for hcv, but tattooing and age were significant factors for hbv.
Dexamethasone Therapy for Bacterial Meningitis: Better Never Than Late?
Authors: King Susan M , Law Barbara , Langley Joanne M , Heurter Helen , Bremner Diane , Wang Elaine E , Gold Ronald
Published: March 2016

A multicentre randomized controlled trial was conducted in children with bacterial meningitis using dexamethasone or placebo for four days within 24 h of starting antibiotics. Primary outcomes were hearing loss and neurological abnormalities at 12 months after meningitis. The dexamethasone (n=50) and placebo (n=51) groups were similar in age, severity of illness and etiological agent. Hearing loss occurred in 10% and 11% of the dexamethasone and placebo groups and neurological deficits occurred in 20% and 18% of patients, respectively. Duodenal perforation occurred in one dexamethasone‐treated child. In conclusion, there was no significant benefit in those receiving dexamethasone. The lack of benefit may have been due to the delay in administration of dexamethasone (median delay of 11 h after antibiotics). Therefore, if dexamethasone is used for meningitis it should be given immediately with the antibiotic.
Sacroiliitis and Septicemia Caused by Campylobacter rectus and Actinomyces odontolyticus
Authors: Harvey Pierre , Bayardelle Paul , Bélanger Raymond , Fortin Louise
Published: March 2016

Campylobacter rectus, formerly known as Wolinella recta, is an anaerobic Gram‐negative bacillus, generally recognized as an agent responsible for severe periodontitis; only two cases of extra‐oral infections have been reported. The first case of septicemia with C rectus and Actinomyces odontolyticus is described in a 37‐year‐old farmer who suffered from severe sacroiliitis. Also presented are a review of C rectus in human pathology, and a brief review of pyogenic sacroiliitis, a rather rare disease.
Pneumocystis carinii Pneumonia in HIV — Investigate or Just Treat?
Authors: Kesten Steven
Published: March 2016

Pneumocystis carinii pneumonia (PCP) is an extremely common manifistation of the acquired immunodeficiency
syndrome (AIDS) resulting from infection with the human immunodeficiency virus (HIV). Most episodes present in a fairly typical manner with increased dyspnea and/or a nonproductive cough, a diffuse interstitial pattern on chest readiograph and an elevated alveolar‐arterial oxygen gradient. The pattern has been so typical of the disorder that empirical therapy without microbiological proof of disease is often imitated by primary care physicians. This strategy has not been tested in controlled clinical trials although decision analysis models have attempted to evaluated it, it′s liekly reasonable to choose empirical antimicrobial therapy in specific clinical settings such as: (a) typical radiographic picture in a person with dyspnea and/or nonproductive cough. presence of HIV and a CD4 count of less than 200
cells/mm3:(b) previous PCP, typical appearance and the patient is known to tolerate standard anti‐PCP medications: and (c) high clinical suspicion in a patient who refuses bronchoscopy yet desires treatment or where bronchoscopy cannot he performed. However, early bronchoscopy should strongly he considered when the chest radiograph is not typical of P carinii infection or if there is failure to respond after a predefined period.
Parasite Contamination of Sand and Soil from Daycare Sandboxes and Play Areas
Authors: Gyorkos Theresa W , Kokoskin-Nelson Evelyne , MacLean J Dick , Soto Julio C
Published: March 2016

Objectives: To determine if there was parasite contamination in the sand and soil in daycare sandboxes and play areas, with the goal of developing practice guidelines for their management.

Methods: One hundred samples of sand and soil from 10 daycare centres in different regions of the province of Quebec, collected between April 22 and May 6, 1991, were examined.

Results: Toxocara eggs were found in both surface and subsurface sand from two Montreal centres and co‐occurred with Ascaris species (surface sand) in one centre and with hookworm (surface soil) in the second. Hookworm eggs were also recovered from one centre in the Quebec City region.

Conclusions: These results document the presence of potentially pathogenic helminth parasites in the daycare environment. Evidence from the literature regarding the health risk to children is insufficient and highlights the need for further research into the assessment of the risk of human infection and morbidity, the viability of these parasites under different environmental conditions and practical issues related to the management of sand and soil.
Molecular Epidemiology of Legionella pneumophila Infection at a Canadian Tertiary Care Institution
Authors: Nicolle LE , Bialkowska-Hobrzanska H , Dyck B , Sekla L , Parker S
Published: March 2016

Objective: To characterize the molecular epidemiology of Legionella species infection at one Canadian tertiary care centre.

Design: Twenty‐eight clinical isolates and 12 environmental isolates obtained over a six‐year period were analyzed by restriction fragment length polymorphism (rflp) of chromosomal dna. Isolates included 15 from 12 patients with hospital acquired illness and 13 from nine patients with community acquired infection.

Results: One nosocomial strain was Legionella micdadei and one community strain was Legionella pneumophila serotype 6; all others were L pneumophila serotype 1. rflp typing revealed one clone for all cases of a 1985 single‐ward outbreak and five of six nonoutbreak L pneumophila nosocomial cases. An rflp pattern identical or highly related to that of the nosocomial clonal type was noted among nine of 12 L pneumophila serotype 1 community isolates. The remaining three isolates had two related rflp patterns distinct from the institutional strain. The nosocomial and community strains were isolated from multiple institutional water samples in the institution. For the environmental isolates, monoclonal antibody typing was more discriminating than rflp typing: seven monoclonal antibody subtypes were distinguished among 12 environmental isolates comprising three distinct rflp patterns.

Conclusions: Despite multiple L pneumophila serotype 1 strains isolated in the authors’ institutional water, a single clone of L pneumophila produced most disease. Community acquired disease was caused by a wider variety of strains.
Screening and Treatment of Immigrants and Refugees to Canada for Tuberculosis: Implications of the Experience of Canada and other Industrialized Countries
Authors: Thomas Roger E , Gushulak Brian
Published: March 2016

Objective: To assess the incidence of tuberculosis in immigrants and refugees in Canada and other industrialized countries; the effectiveness of the screening process; the incidence of drug resistance; recommendations for prophylaxis and therapy; and indications for and effectiveness of directly observed therapy.

Data Sources: medline search of literature published from 1985 to 1995 with the key words ‘tuberculosis’, ‘Canada’, ‘screening’, ‘drug resistance’, ‘drug resistance, multiple’, ‘immigration and emigration’, and the title words ‘directly observed therapy’.

Study Selection: All studies reporting data on incidence, the outcomes of screening, drug resistance, therapy and directly observed therapy were selected.

Data Synthesis and Conclusions: Data synthesis led to the conclusions that immigrants and refugees to Canada have five times the nonimmigrant and non‐Aboriginal rate of tuberculosis; that screening programs discover new cases of tuberculosis on and after arrival and that up to 20% of those scheduled to attend a tuberculosis clinic after arrival may never attend; that drug resistance is widespread in countries from which Canada receives immigrants; and that directly observed therapy for active cases can result in 100% conversion rates.
Hepatitis E: A Newcomer to the Hepatitis Alphabet – Case Report and Review of the Literature
Authors: Weiss Karl , Poirier Louise , Varin Sylvain , Beliveau Claire , Laverdière Michel
Published: March 2016

The first Canadian case of hepatitis E is described in a patient who travelled to Asia for a six‐month period and spent most of his time in India. Hepatitis E shares some similarities with hepatitis A, notably the mode of transmission and the absence of chronic course. However, a few important differences have been noted, including a higher mortality rate and a high fatality rate in pregnant women. Hepatitis E is very common in developing countries and should be suspected more often in individuals with gastrointestinal complaints returning from endemic areas.
Community Acquired, Nursing Home Acquired and Hospital Acquired Pneumonia: A Five‐Year Review of the Clinical, Bacteriological and Radiological Characteristics
Authors: Chow CW , Lee-Pack LR , Senathiragah N , Rawji M , Chan M , Chan CK
Published: March 2016

Purpose: To assess the contemporary clinical, bacteriological and radiographic features of hospitalized patients with community acquired (ca), nursing home acquired (na) and hospital acquired pneumonia (ha) and to examine patient outcome.

Patients and Methods: All hospital records of patients with pneumonia over a five‐year period from April 1987 to March 1992 were reviewed retrospectively. Patients included in the study were all those with a diagnosis of pneumonia as identified by computer records of diagnostic codes at discharge; patients with a specific diagnosis of Pneumocystis carinii pneumonia were excluded. Of 74,435 discharges over the five‐year period, 1782 patients met the inclusion criteria.

Results: Charts of 1622 of the total 1782 cases were reviewed. Mean age was 64.4 years with 59.4% men and 40.6% women. Sixty‐three per cent were ca, 28.5% were ha and 8.5% were na. A total of 1542 patients (95%) had at least one concomitant medical condition. Chest roentgenogram was abnormal in 97%. Common organisms isolated overall were Haemophilus influenzae (from 204 patients), Staphylococcus aureas (from 152 patients), Streptococcus pneumoniae (from 143 patients ), Escherichia coli (from 113 patients) and Pseudomonas aeruginosa (from 111 patients). H influenzae and S pneumoniae were most common in ca pneumonia, whereas S aureus and Gram‐negative organisms were more common in the ha group and Gram‐negative agents in the na group. One hundred and four patients developed complications. Fifteen per cent required intensive care unit admission. The average length of hospitalization in the ca and na groups was 17 days and in the ha group, 43 days. At time of discharge 1261 patients (78%) were cured or improved, and 361 patients (22%) died during the admission.

Conclusions: These results suggest that hospitalization for pneumonia in the 1990s is primarily for elderly patients with significant co‐morbidity. Although microbiology appears unchanged compared with earlier reports, the contemporary population is significantly sicker than previous cohorts. This may account for the persistently high morbidity and mortality despite better or newer antibiotics.
Hepatitis E in a Canadian Traveller
Authors: Akai Peter S , Fonseca Kevin , Horne Duff , Ho May
Published: March 2016

Hepatitis E is clinically indistinguishable from hepatitis A and is caused by an enterically transmitted rna virus that is endemic in developing countries of Asia, Africa, the Middle East and North America. This report describes a Canadian traveller to Nepal, Thailand and India with one of the first confirmed cases of hepatitis E reported in Canada. Although this disease is usually self‐limited with no known sequelae, it may produce fulminant hepatitis with a high case fatality rate in pregnancy. Diagnosis can be confirmed by serological tests. Apart from strict food and beverage hygiene, there are presently no prophylactic measures against this disease, and pregnant women in the third trimester should avoid travel to endemic areas.
Chlamydia Pneumoniae Pneumonia: An Evolving Clinical Spectrum
Authors: Megran David , Peeling Rosanna W , Marrie Thomas J
Published: March 2016

Chlamydia pneumoniae is a recently recognized respiratory tract pathogen. It accounts for 6 to 10% of all cases of community acquired pneumonia requiring admission to hospital. Two patients hospitalized with C pneumoniae pneumonia are presented to illustrate its range of severity and the extrapulmonary manifestations.
Proceedings of a Workshop on Near Fatal Asthma
Authors: FitzGerald J Mark , Macklem Peter T
Published: March 2016

Concern has been expressed about rising asthma morbidity and mortality, although the latter appears to have declined recently. A reasonable surrogate for fatal asthma is an episode of near fatal asthma (NFA). The etiology of episodes of NFA appears to be multifactorial. Features that would characterize asthma patients at risk of NFA have been difficult to define but have included psychosocial barriers. environmental exposures, inadequate or inappropriate physician and/or patient responses to deteriorating asthma and, in particular, overreliance on symptomatic bronchodilator therapy. The association between fatal asthma and NFA with beta‐agonist use has been controversial, with it being argued that high use of beta‐agonists reflects severity of asthma as opposed to being causal. Studies in the laboratory and ambulatory care setting suggest that regular compared with as‐required use of beta‐agonists is associated with worsening in asthma control. Although a reduced perception of dyspnea has been identified in some asthma patients, it is not universally present in those with NFA. Retrospective data suggest that hyperinflation of the thorax, as judged by total lung capacity, may be a useful marker for subjects at risk of NFA. Future studies should better characterize these risk factors and develop management strategies (both therapeutic and educational) that might reduce the risk of subjects experiencing episodes of NFA and, by extension, reducing the continued unacceptable mortality associated with asthma.
Hepatic Abscess due to Burkholderia (Pseudomonas) cepacia in Cystic Fibrosis
Authors: Fraser Kristin L , Hyland Robert H , Tullis D Elizabeth
Published: March 2016

Burkholderia (Pseudomonas) cepacia has been cultured from bronchial secretions of patients with cystic fibrosis with varying frequency. The overall prevalence in patients over 18 years old at the authors’ centre in Toronto is 51%. Extrapulmonary infections are rare in nonimmunosuppressed patients with cystic fibrosis and B cepacia has been the causative organism in only three previous reports. Two
patients with cystic fibrosis are described who developed hepatic abscesses clue to B cepacia. One patient is the sibling of two brothers in whom this complication was previously described.
Hantavirus Pulmonary Syndrome: Report of Four Alberta Cases
Authors: Singh Ameeta E , Werker Denise H , Boychuk Lesia R , Miedzinski Lilly J
Published: March 2016

Four Alberta cases of hantavirus pulmonary syndrome are reported. Three cases required intensive care, with one experiencing a fulminant course resulting in death. A fourth case with milder illness was identified after epidemiological investigations. Ribavirin was used in one patient who experienced a successful outcome. A recent open label trial has not supported the efficacy of this drug. The epidemiology of Peromyscus maniculatus, the primary rodent host, and the clinical features of this syndrome are summarized.
Risk Factors for Breakthrough Pneumocystis carinii Pneumonia on Aerosol Pentamidine Prophylaxis
Authors: McIvor RA , Rachlis AR , Berger P , Pack LR Lee , Chan Charles K
Published: March 2016

OBJECTIVE: To identify baseline characteristics of human immunodeficiency virus (HIV)‐infected individuals on aerosol pentamidine for Pneumocystis carinii prophylaxis that are predictive of subsequent breakthrough Pneumocystis carinii pneumonia (PCP).

DESIGN: Nested case‐control study assembled from a cohort of patients enrolled in the Toronto aerosol pentamidine program.

METHODS: Subjects were selected from a cohort of HIV‐infected individuals were enrolled in a community based aerosol pentamidine program between May 1989 and May 1992 in Toronto, Ontario. Cases ‐ individuals who had breakthrough PCP ‐ were matched with up to two controls enrolled in the same week. Risk factors examined for development of PCP for both primary and secondary prophylaxis
included age, sex, smoking history, evidence of bronchospasm during aerosol pentamidine administration (fall of forced expiratory volume [FEV] 15% or more), administration of salbutamol before aerosol pentamidine, pulmonary function tests including lung volumes, flow rates and diffusing capacity for carbon monoxide. In the primary prophylaxis group, CD4 count at enrolment and in the secondary prophylaxis group, time from the most recent episode of PCP to enrolment for aerosol pentamidine and total time from the most recent episode of PCP to breakthrough PCP were examined as additional risk factors.

RESULTS: A total or 1344 patients we re enrolled in the aerosol pentamidine program, 78% for primary prophylaxis and 22% for secondary prophylaxis. At the time of census at the end or 1992 there had been 96 episodes or breakthrough PCP, 5% on primary prophylaxis and 14.5% on secondary prophylaxis. In the primary prophylaxis group, enrolment CD4 count was significantly lower in the cases developing breakthrough PCP: 116±74 compared with 175±85 cells/mm3 in the control group (P=0.001). There was no difference in any other variable. In the secondary
prophylaxis group, time from the most recent episode of PCP to initiation of aerosol pentamidine therapy was longer in the cases developing breakthrough PCP: mean delay 6.1±6.6 months compared with 3.1±2.1 in controls (P=0.02). There was no difference in the other variables examined.

CONCLUSIONS: The results of this study support immune augmentation for patients receiving aerosol pentamidine for primary prophylaxis, and aerosol pentamidine should be recommenced as soon as possible following an episode of PCP, for secondary prophylaxis.
Discharge Considerations for Adult Asthmatic Patients Treated in Emergency Departments
Authors: Grunfeld Anton F , FitzGerald J Mark
Published: March 2016

OBJECTIVE: To review the medical literature on outcome of treatment of acute asthma in the emergency department and issue recommendations regarding patient admission or discharge.

DATA SOURCES: A MEDLINE search was done for articles in the English language on acute asthma and treatment in the emergency department for the years 1975 to 1993. In addition, references in pertinent review articles were reviewed.

STUDY SELECTION: Studies addressing treatment of acute asthma in emergency departments were selected by consensus.

DATA SYNTHESIS: Three major areas have been shown to affect outcome and the decision to admit or discharge a patient following treatment in the emergency department: first, the severity of the attack and the response to therapy; second, historical risk factors; and third, care following discharge from the emergency department. This paper reviews the literature on outcome of acute asthma attacks and issues recommendations regarding objective airflow measurements and co‐existing risk factors to be assessed before discharging patients. The role of anti‐inflammatory therapy in emergency department treatment and in postdischarge treatment of these patients is also reviewed.

CONCLUSION: Evaluation for discharge following treatment of acute asthma should integrate objective measures of airflow obstruction with historical high risk factors. The use of systemic corticosteroids in the emergency department and following discharge, with careful follow‐up, may help control the attack and reduce relapse of asthma.
Finger Clubbing Caused by Herbal Tea
Authors: Rashiq Saifudin , Brown Neil E , Fedorak Richard N
Published: March 2016

Clubbing of the fingers is often taken to be a sign of serious illness. Its discovery, particularly if there are associated symptoms in the cardiovascular, respiratory or gastrointestinal systems, usually leads to exhaustive investigation. A case is presented in which the etiology of clubbing was found only when a new history of heavy ingestion of herbal tea was obtained, extensive work‐up having previously been unhelpful. Other cases appearing in the English‐language literature are cited, some universal etiological associations are described, and an attempt is made to explain the phenomenon, based on a recent theory of the cause of clubbing.
Diversity of Urine Bacteriology Practice in Ontario: An External Quality Assessment
Authors: Richardson Harold , Fleming Christine A , Mackenzie Andrew MR , The Microbiology Committee
Published: March 2016

OBJECTIVE: Assessment of urine bacteriology practice in Ontario regarding appropriateness of quantification and the accuracy and Système International d’Unités (SI) conformity in the reporting of results.

DESIGN AND SETTING: A simulated urine specimen with Escherichia coli at a target of 100×10 colony forming units (CFU)/L was submitted to licensed Ontario bacteriology laboratories. Data on the isolation and quantification of the pathogen were required within a stipulated time. Reference values were determined by consensus agreement of the findings of seven designated laboratories.

PARTICIPANTS: The challenge was administered to 182 Ontario laboratories licensed to perform urine bacteriological assessment. There was no stratification by type or complexity of facility.

MAIN OUTCOMES: Samples were processed by routine procedures. Date and time of receipt of the sample, date tested, bacterial count, associated quantification units and the method used were the data required. A copy of the report using the laboratory’s normal reporting format to user‐physicians was requested.

RESULTS: The organism was isolated and correctly identified by 179 laboratories. Only 58% of laboratories reported a count of 100×103 CFU/L or more, with 42% reporting a count of between 10 and 100×103 CFU/L. The majority used a standard 0.001 mL loop method. Only 87 participants reported using the correct notation of SI units, although a further 65 reported as CFU/L.

CONCLUSION: The variety of reporting formats is of concern. Processing and reporting should be standardized. Laboratories should provide an explanatory note or interpretation when nomenclature or format of a report is changed.
Diagnosis and Management of Pulmonary Embolism in Pregnancy
Authors: Broder Sarah , Paré Peter
Published: March 2016

Pulmonary embolism in pregnancy is a significant and under‐recognized problem. In British Columbia, where there are 46,000 pregnancies per year, it is estimated that there are approximately 160 pulmonary embolisms per year and one maternal death every two years secondary to pulmonary embolism. A complete assessment for suspected pulmonary embolus can be performed without putting the fetus at significant risk from radiation exposure. An algorithm is provided for the workup of pulmonary embolus during pregnancy. Heparin is the drug of choice for anticoagulating pregnant women, initially managing the situation with intravenous heparin and then switching to the subcutaneous route given in a bid or tid regimen, aiming to keep the activated partial thromboplastin time 1.5 to 2 times the control. The risks to both the fetus and the mother from anticoagulation during pregnancy are reviewed.
A Cost‐Benefit Analysis of Prenatal Screening for Toxoplasmosis
Authors: Sahai Vic S , Onyett Heather
Published: March 2016

The objective of this study was to examine critically the validity of a toxoplasma prenatal screening program, in the context of a cost‐benefit analysis, as it relates to the Canadian experience. Recently, studies have suggested that early treatment of infected infants with a combination of pyrimethamine and sulfadiazine is effective in reducing the sequelae of toxoplasmosis. It was concluded that a carefully planned screening program for detecting and treating infants infected with Toxoplasma gondii during pregnancy is cost beneficial. The cost of delivering a screening and treatment program is less than half of what it would cost to provide comprehensive long term medical, educational and other social services for the estimated 1000 children born each year with congenital toxoplasmosis. Even if an incidence as low as two infected infants per 1000 pregnancies is assumed and only 400 children were affected, the screening and preventive therapy program would be justified.
HIV‐Related Non‐Hodgkin’s Lymphoma in Calgary
Authors: Beck Paul L , Gill M John , Blahey Walter B , Sutherland Lloyd R
Published: March 2016

OBJECTIVE: To determine the incidence of human immunodeficiency virus (HIV) associated non‐Hodgkin’s lymphoma (NHL) in a cohort of patients from a distinct geographic region (southern Alberta). The type and location of NHL as well as how it affected the survival of these patients was examined.

PATIENTS AND METHODS: The Southern Alberta HIV Clinic in Calgary serves all of southern Alberta, which has an estimated population of one million. The clinic has provided primary care for 1086 patients from January 1983 to August 1995. Data were obtained by reviewing the clinic’s database and patients’ charts.

RESULTS: Over a 12‐year period, 39 cases of NHL were diagnosed in a group of 1086 HIV‐infected patients. Presentation of NHL was at an extranodal site in all but four cases, with the most common sites being the bowel and central nervous system. The mean CD4 count on presentation with NHL was 143.4±37.4×106/L (range 1 to 1219×106/L). Mean survival was 1.25±0.25 years with a range from 0 (diagnosed on autopsy) to 6.45 years. Patients with a CD4 count of less than 200×106/L and/or diagnosed with an AIDS‐defining illness before development of NHL had significantly reduced survival (0.85 years versus 2.48 years, P<0.02 and 0.57 years versus 2.09 years, P<0.001, respectively). Patients who presented with NHL involving either nodes alone or central nervous system had significantly decreased survival (0.28 years and 0.29 years, respectively, P<0.05). Patients with NHL involving the gastrointestinal tract had a longer mean survival than those with NHL elsewhere (P<0.05). All but seven cases received therapy for NHL including chemotherapy, radiotherapy, surgery or combined therapy. Fifteen patients (47% of treated) achieved a complete response that led to improved survival (P<0.01). Patients tolerated surgery, chemotherapy and radiotherapy well and no deaths were due to NHL therapy.

CONCLUSIONS: These data suggest that development of NHL in HIV is associated with reduced survival, and that survival is predominantly determined by CD4 count and site of involvement at the time of diagnosis of NHL.
Dacochordodes Bacescui Capuse, 1966: Report of the First Two Isolations from Humans
Authors: Pikula Zoran P , Spiridonov Sergei E , Drljevic Ednar T
Published: March 2016

This report describes two cases of isolation of Dacochordodes bacescui Capuse, 1966 from human intestinal infections. In the first case, two adult worms were identified in the vomitus of a man suffering from abdominal pain and nausea. In the second case, a worm was passed in the stool of a woman suffering from abdominal pain and pruritus. Human gastrointestinal infection with this parasite has not previously been reported.
Seroprevalence of Immunoglobulin G Antibody to Parvovirus B19 in Ontario
Authors: Wasfy Samia , Nishikawa John , Petric Martin
Published: March 2016

The prevalence of antibody to parvovirus B19 was assessed in two populations. In a group of 494 residents from Ontario and the Maritimes, virus‐specific immunoglobulin (Ig) M antibody, a marker of acute infection, was found throughout the year but was most prevalent during the late winter and early spring months. The overall prevalence of IgG antibody in this group was 30.3%. In an effort to examine age‐specific prevalence in this population, a second group of sera from 210 pediatric patients at The Hospital for Sick Children, Toronto, Ontario and from Red Cross blood donors was tested for the presence of B19‐specific IgG, and of these, 31.4% of the samples were positive. This prevalence varied from 3.3% in the under five‐year‐old age group to 66.7% in the 35‐ to 45‐year‐old age group. Eighty per cent of sera from females of this group were seropositive. This study provides insight into the prevalence of parvovirus B19 IgG antibody in the population.
Short‐Course Itraconazole in the Treatment of Candida Vulvovaginitis: A Multicentre Canadian Study
Authors: Canadian Itraconazole Study Group  , Austin Thomas W , Steben Marc , Powell Marion , Romanowski Barbara , Megran David W , Garber Gary E , Margesson Lynette J
Published: March 2016

OBJECTIVE: To determine the clinical and mycological effectiveness of oral itraconazole in the treatment of acute candida vulvovaginitis.

DESIGN: A prospective, randomized and single‐blinded, multicentre trial of 221 women, comparing a one‐day course of oral itraconazole 200 mg bid with vaginal clotrimazole 500 mg single‐dose therapy.

MAIN OUTCOME MEASURES: Symptoms, signs and mycological results were assessed up to two months following treatment. Adverse events were recorded and evidence of hepatotoxicity sought.

RESULTS: At 10 and 30 days post‐treatment, clinical and mycological cure rates were similar (61.3% clinical and 88.6% mycological 10 days after, and 67.7% clinical and 79.5 mycological 30 days after itraconazole; 64.0 clinical and 85.9% mycological 10 days after, and 62.1% clinical and 78.6 mycological 30 days after clotrimazole) with the majority of both treatment groups free from infection. A total of 69 patients reported adverse events, which were generally transient and mild. Itraconazole was more often associated with gastrointestinal or central nervous system complaints, while clotrimazole recipients more often had genitourinary symptoms. No evidence of hepatotoxicity was found. A higher incidence of relapse was noted among women on the birth control pill and among those who were symptomatic for longer than 10 days before treatment.

CONCLUSIONS: A one‐day course of oral itraconazole is as effective as intravaginal clotrimazole in the treatment of acute yeast vulvovaginitis. The number of patients reporting adverse events was similar for the treatment groups, although the side effect profile differed. No hepatotoxicity was observed.
Ambient Air Quality and Human Health: Current Concepts, Part 2
Authors: Guidotti TEE L
Published: March 2016

This second of two parts continues with the development of a framework for understanding air quality issues and their relationship to human health. Recognized health effects associated with air pollution are described and current controversies regarding ozone and PM10 are briefly outlined. Epidemiological methods of investigating air quality effects are discussed, comparing recent landmark studies in Canada. Comparative prevalence studies do not reflect the state of the art in air pollution epidemiology but are frequently cited and conducted in Canada as if they were definitive. The implications of setting air quality standards and objectives on this basis or to meet arbitrary levels of risk of health effects are examined. The current state of the art does not support risk‐based air quality standards. A policy of continuous improvement is most protective of both human health and the environment.
Comparison of Tuberculosis Infection Control Programs in Canadian Hospitals Categorized by Size and Risk of Exposure to Tuberculosis Patients, 1989 to 1993 – Part 2
Authors: Holton Donna , Paton Shirley , Gibson Helen , Taylor Geoffrey , Whyman Carol , Yang TC
Published: March 2016

OBJECTIVE: To analyze tuberculosis (TB) programs in acute care hospitals (hospitals) categorized by size and risk of exposure to TB patients from 1989 to 1993.

DESIGN: Retrospective survey.

PARTICIPANTS: Members of the Community and Hospital Infection Control Association‐Canada and l’Association des professionnels pour la prévention des infections who worked in Canadian hospitals received questionnaires. One questionnaire per hospital was completed.

OUTCOME: Hospitals reported the number of respiratory TB and human immunodeficiency virus (HIV) cases admitted, the engineering and environmental controls available, and the type of occupational TB screening programs available. Data were stratified by hospital size and risk of exposure to TB patients.

RESULTS: Thirty‐four (10.9%) hospitals with at least 500 beds admitted more than 50% of the TB cases, more than 40% of the multidrug‐resistant TB (MDR‐TB) cases and more than 65% of the HIV cases. Thirty‐six (11.6%) facilities classified as high risk hospitals reported more than 70% of the TB cases, more than 58% of the MDR‐TB cases and more than 75% of the HIV cases. A significantly higher pooled average tuberculin test conversion rate was found in individuals working in high risk (4.4%) than in low risk hospitals (1.5%). Significantly more high risk than low risk hospitals had an isolation room with air exhausted outside, negative air pressure and at least six air changes per hour. Only 13 high risk hospitals had all three engineering characteristics. Surgical masks were used for respiratory protection in 18 (50%) high risk and 186 (77.8%) low risk hospitals.

CONCLUSIONS: Nosocomial transmission of Mycobacterium tuberculosis may have occurred because TB programs available in many Canadian hospitals were inadequate.
Rubella Antibody Levels in School‐Aged Children in Newfoundland: Implications for a Two‐Dose Rubella Vaccination Strategy
Authors: Ratnam Samuel , West Roy , Gadag Veeresh , Williams Brett , Oates Elizabeth
Published: March 2016

OBJECTIVE: To determine the prevailing levels of rubella immunity among school‐aged children who received a single dose of measles‐mumps‐rubella (MMR) vaccine at one year of age.

DESIGN: Cross‐sectional study with a two stage cluster sampling of randomly picked schools across the province of Newfoundland.

STUDY POPULATION AND METHODS: A total of 1053, five to 17‐year‐old children were enrolled; vaccination history was verified through official records; and a sample of blood was taken. Rubella immunity was determined by enzyme immunoassay based on a serum antibody protective cut‐off titre of more than 10 IU.

RESULTS: A total of 145 (13.8%) were found to be nonimmune. The rate of susceptibility ranged from 3.2% to 25.9% for different age groups. The proportion susceptible was significantly higher at 16.5% in the age group eight to 17 years old versus 3.9% for the age group five to eight years old (χ2=24.08; df=1, P<0.001). There was a significant regression of logarithm titre values on the age of children with an average decline in titre values of 8.1% per annum.

CONCLUSIONS: A substantial number of those who were given a single dose of MMR II vaccine may not have protective immunity against rubella as they reach prime reproductive age. There is a definite need to consider a two‐dose rubella vaccination strategy in Canada, and these data suggest the second dose given after eight years of age will be most beneficial. In the move towards a routine two‐dose measles vaccination strategy in Canada, the MMR II vaccine is being used for the second dose and given either at 18 months of age or at school entry. While this approach will have an overall beneficial effect, the impact of the above timing of the second dose on long term rubella immunity cannot be predicted at this time. These data also underscore the continuing need for prenatal rubella screening program.