Regional differences of nontuberculous mycobacteria species in Ulsan,Korea

Background

In Korea recently, nontuberculous mycobacteria (NTM) have been more frequently isolated in respiratory specimens, while Mycobacterium tuberculosis (MTB) isolations have decreased. The major NTM lung disease species in Korea are M. intracellulare, M. avium, and M. abscessus, whereas M. kansasii is a rare species. This retrospective study was performed to determine if there are region-specific characteristics of lung disease-causing NTM species in Ulsan, a highly industrialized city in Korea.

Methods

Between January 2010 and July 2013, the results of all acid-fast bacilli (AFB) cultures of respiratory specimens performed at Ulsan University Hospital (Ulsan, Korea) were collected. NTM were identified and regional differences of NTM species were compared.

Results

AFB cultures were performed on 33,567 respiratory specimens, obtained from 10,208 patients, during the study period. Further, 10% of the specimens (3,287/33,567) were AFB culture-positive [MTB, 2,288/3,287 (70%); NTM 999/3,287 (30%)]. The proportion of NTM isolations gradually increased between 2010 and 2013, at 25% and 38%, respectively. The most common NTM species was M. intracellulare (356/999, 36%), followed by M. kansasii (295/999, 30%), M. avium (161/999, 16%), M. abscessus (117/999, 12%) and M. fortuitum (39/999, 4%). This trend was maintained throughout the study period.

Conclusions

In Ulsan, NTM isolation from respiratory specimens is increasing, consistent with previous studies performed in Korea. The distribution of respiratory NTM species, however, differed from previous studies that were performed in other regions of Korea: M. kansasii was the second most common NTM species in Ulsan. In Ulsan, there is a regional difference in the NTM species isolated.     

Prevalence and risk factors of development of peripheral diabetic neuropathy in type 2 diabetes mellitus in a tertiary care setting

Aims/Introduction

The study was carried out to assess the prevalence of diabetic peripheral neuropathy (DPN), compare the prevalence between known diabetes mellitus (KDM) and newly detected diabetes mellitus (NDDM), identify risk factors associated, its prevalence pattern and to assess if any sex-specific differences are present.

Materials and Methods

A cross-sectional study was carried out in a tertiary care hospital. Patients with duration of diabetes ≤6 months were considered to be NDDM. DPN was diagnosed by the combination of more than one abnormal result of 10-g monofilament, pinprick sensations and ankle reflexes, and categorized according to the severity level using vibration perception threshold. The study included 1,637 KDM and 369 NDDM patients.

Results

A total of 586 participants were found to have DPN, accounting for 29.2% (95% confidence interval [CI] 27.2–31.2) prevalence. The higher prevalence was observed in KDM compared with NDDM 33.7% (95% CI 31.42–36.01) vs 9.2% (95% CI 6.3–12.2; P < 0.001). Prevalence of mild, moderate, and severe neuropathies was 8.06, 14.55 and 6.63%, respectively. Regression analysis showed age (P < 0.001), duration of diabetes (P < 0.001), dyslipidemia (P = 0.03), glycated hemoglobin (P < 0.001), the presence of other microvascular complications (P < 0.001), macrovascular complications (P = 0.003) and alcoholic status (P < 0.033) to be associated. No sex-specific differences were observed in the mean age at diagnosis of diabetes, mean age at the diagnosis of neuropathy, and duration taken for the DPN development among females and males.

Conclusions

The study showed a high prevalence (29.2%) of DPN among north Indian type 2 diabetes mellitus patients. Thus, timely screening with earlier detection and intervention would be useful in preventing the progression of neuropathy.     

Chronic obstructive pulmonary disease in women

BACKGROUND:

Little is known about the comparative impact of chronic obstructive pulmonary disease (COPD) between women and men and about women’s response to pulmonary rehabilitation.

OBJECTIVES:

To compare lung function, disability, mortality and response to pulmonary rehabilitation between women and men with COPD.

METHODS:

In the present retrospective study, 68 women (mean age 62.5±8.9 years) and 168 men (mean age 66.3±8.4 years) were evaluated by means of pulmonary function testing and an incremental symptom-limited cycle exercise test. Forty women and 84 men also participated in a 12-week pulmonary rehabilitation program. A 6 min walking test and the chronic respiratory questionnaire were used to assess the effects of pulmonary rehabilitation. Survival status was also evaluated.

RESULTS:

Compared with men, women had a smaller tobacco exposure (31±24 versus 48±27 pack-years, P<0.05), displayed better forced expiratory volume in 1 s (44±13 versus 39±14 % predicted, P<0.05), a higher functional residual capacity (161±37 versus 149±36 % predicted, P<0.05) and total lung capacity (125±20 versus 115±19 % predicted, P<0.001). Peak oxygen consumption was not different between women and men when expressed in predicted values but lower in women when expressed in absolute values. Pulmonary rehabilitation resulted in significant improvements in 6 min walking test and quality of life in both sexes, but women had a greater improvement in chronic respiratory questionnaire dyspnea. Survival status was similar between sexes, but predictors of mortality were different between sexes.

CONCLUSIONS:

Women may be more susceptible to COPD than men. The clinical expression of COPD may differ between sexes with greater degree of hyperinflation in women, who also benefit from pulmonary rehabilitation.     

Echocardiographic and electrocardiographic trends in children with acute Kawasaki disease

BACKGROUND:

Kawasaki disease (KD), while primarily an acute, self-limited, multisystem vasculitis, is more appropriately described as a pancarditis, from a cardiac perspective. Many patients are noted to have ventricular dilation on initial echocardiography; however, functional and structural measurements may remain within the normal range.

OBJECTIVE:

The authors sought to determine echocardiographic and electrocardiographic trends after acute KD.

METHODS:

Clinical data were reviewed on all patients presenting with acute KD to the Hospital for Sick Children (Toronto, Ontario). Patients with at least three electrocardiograms and echocardiograms over the first year post-KD were eligible. Mixed linear regression analysis for repeated measures was used to determine trends over time and associated factors.

RESULTS:

One hundred seventy-six eligible patients were reviewed. Mean initial coronary artery diameter Z-scores were increased, with 4% having aneurysms. The mean (± SD) initial Z-score of ejection fraction was 0.40±0.84 (P<0.001 versus normal) and left ventricular end-diastolic dimension (LVED) was 0.97±0.98 (P<0.001 versus normal). The initial mean QT dispersion was 54±23 ms (P<0.001 versus normal). Mixed linear regression analysis for repeated measures demonstrated that the LVED Z-score decreased significantly over time, and a greater Z-score was independently associated with a greater initial LVED Z-score. Increased QT dispersion was only related to higher initial dispersion, with no trend over time.

CONCLUSIONS:

While systolic ventricular dysfunction may not be evident, subclinical myocardial involvement may be indicated by subtle ventricular dilation and repolarization abnormalities.     

Cardiac and neuromuscular implications of left bundle branch block in left ventricular hypertrabeculation/noncompaction

BACKGROUND:

Left bundle branch block (LBB) is frequently found in left ventricular hypertrabeculation/noncompaction (LVHT).

OBJECTIVES:

To compare LVHT patients with and without LBB regarding LVHT location and extension, left ventricular function, symptoms, electrocardiographic findings, prevalence of neuromuscular disorders (NMDs) and mortality during follow-up.

METHODS:

The charts of patients who underwent transthoracic echocardiographic examination at the Krankenanstalt Rudolfstiftung (Wien, Austria) between June 1995 and November 2006 were examined.

RESULTS:

LVHT was diagnosed in 102 patients (30 women) with a mean (± SD) age of 53±16 years (range 14 to 94 years). A specific NMD was diagnosed in 21 patients and an NMD of unknown etiology was diagnosed in 47. The neurological investigation was normal in 14 patients and 20 patients refused the investigation. The 24 patients with LBB were older (61 versus 51 years of age; P<0.01), and suffered from exertional dyspnea (96% versus 59%; P<0.01) and heart failure (79% versus 46%; P<0.01) more often than patients without LBB. LBB patients had less frequent tall QRS complexes (8% versus 47%; P<0.01) and ST-T wave abnormalities (4% versus 50%; P<0.01) than patients without LBB. Patients with LBB had a larger left ventricular end-diastolic diameter (73 mm versus 61 mm; P<0.01), worse left ventricular fractional shortening (15% versus 26%; P<0.01) and more extensive LVHT (1.8 versus 1.5 ventricular segments; P<0.05). The prevalence of NMDs did not differ between patients with and without LBB. Survival did not differ between patients with and without LBB during follow-up.

CONCLUSIONS:

LBB is associated with increased age, decreased systolic function and increased extension of LVHT. Whether LBB is a prognostic factor in LVHT remains speculative.     

Lack of predictive power of plasma lipids or lipoproteins for gestational diabetes mellitus in Japanese women

Aims/Introduction

To determine the diagnostic potential of plasma lipids and apolipoproteins in gestational diabetes mellitus (GDM), we carried out a retrospective cohort study of 1,161 Japanese women at 20–28 weeks of gestation who underwent a glucose challenge test (GCT).

Materials and Methods

A total of 1,161 Japanese women at 20–28 weeks of gestation underwent a GCT. Participants with a positive test (GCT[+]) underwent a subsequent oral glucose tolerance test. Clinical and biochemical parameters were determined and quantification of apolipoproteins (Apo), including ApoB, ApoB48, ApoA-I and ApoC-III, was carried out.

Results

The prevalence of GCT(+; with a 130 mg/dL glucose cut-off) and GDM was 20% and 4%, respectively. There was a trend for increased triglycerides and ApoC-III in GDM(+) participants. However, the difference in plasma triglycerides, ApoC-III or ApoB48 did not reach statistical significance between GDM(+) and GDM(−) women. Values of 1-h glucose (P < 0.001) and fasting glucose (P = 0.002) were significant risk factors for GDM.

Conclusions

Prediction of GDM using only the ApoC-III value is not easy, although triglycerides and ApoC-III were higher in the GDM(+) group. The present findings show no significant difference in plasma lipid levels between women diagnosed with GDM and those with normal glucose tolerance.     

Emergence of penicillin-resistant Streptococcus pneumoniae in southern Ontario, 1993�C94

Objective:

To determine the prevalence of resistance of Streptococcus pneumoniae to penicillin and other antimicrobial agents in metropolitan Toronto.

Design:

Consecutive pneumococcal isolates from different patients were obtained from two private community-based laboratories and from patients assessed in the emergency department of a tertiary-care teaching hospital in Toronto, Ontario between June and December 1993, and between March and October 1994. In vitro susceptibility testing was done by broth microdilution in accordance with National Committee for Clinical Laboratory Standards guidelines.

Results:

Twenty (7.3±3.1%) of 274 pneumococcal isolates were resistant to penicillin; six (30%) isolates had high-level resistance (minimal inhibitory concentration [mic] 2.0 μg/mL or greater); and 14 isolates had intermediate resistance (mic 0.1 to 1.0 μg/mL). Penicillin-resistant strains were also frequently resistant to tetracycline (55%), cotrimoxazole (50%), erythromycin (40%) and cefuroxime (35%). Resistant strains comprised several serotypes: 19F (six isolates), 9V (three), 23F (three), and one each of 6A, 6B, 14, and 19A; four isolates were nontypeable.

Conclusions:

There has been a recent emergence of penicillin-resistant S pneumoniae in southern Ontario. National and regional surveillance is warranted to determine the extent of the problem elsewhere in Canada.     

Impact of the metabolic syndrome on aortic pulse pressure and ascending aortic pulsatility in patients with angiographically normal coronary arteries

BACKGROUND:

Large artery stiffness is a major determinant of pulse pressure (PP), and PP at baseline has been associated with future coronary events.

OBJECTIVE:

To evaluate the impact of the metabolic syndrome on aortic PP and ascending aortic pulsatility (AP) in patients with angiographically normal coronary arteries.

METHODS:

Forty-two patients with the metabolic syndrome and 40 age-matched control subjects without the metabolic syndrome were included in the study. All subjects had normal coronary arteries. Diagnosis of the metabolic syndrome was based on the International Diabetes Federation guidelines published in 2005. Ascending AP was estimated as the ratio of aortic PP to mean blood pressure.

RESULTS:

Aortic PP (59±12 mmHg versus 43±10 mmHg; P<0.001) and ascending AP (0.54±0.10 versus 0.48±0.10; P<0.001) were significantly higher in the metabolic syndrome group. Multiple regression analysis revealed statistically independent relationships between ascending AP and fasting blood glucose, waist circumference and systolic blood pressure (model R²=0.408; P<0.001). The metabolic syndrome, as a whole, was also independently associated with both ascending AP (P<0.01) and aortic PP (P<0.01).

CONCLUSION:

The data showed that the metabolic syndrome is independently associated with increased aortic PP and ascending AP in patients with normal coronary arteries, suggesting aortic stiffness as one of the possible mechanisms underlying the excess cardiovascular risk associated with the metabolic syndrome.     

The Ontario Universal Typing of Tuberculosis (OUT-TB) Surveillance Program �C what it means to you

BACKGROUND:

Tuberculosis (TB) is a serious disease that is transmitted primarily by the airborne route. Effective disease control and outbreak management requires the timely diagnosis, isolation and treatment of infected individuals with active disease; contact tracing to identify secondary cases likely to benefit from treatment of latent infection; and laboratory identification or confirmation of epidemiologically linked cases. TB genotyping enables the comparison of Mycobacterium tuberculosis complex (MTBC) strains and the identification of cases that may or may not be linked. The increased availability of molecular methods for genotyping has allowed for greater discrimination of MTBC strains and greatly enhanced understanding of TB transmission patterns.

OBJECTIVE:

To improve TB surveillance and control in Ontario, the Public Health Laboratories of the Ontario Agency for Health Protection and Promotion has introduced the Ontario Universal Typing of Tuberculosis (OUT-TB) Surveillance Program.

METHODS:

The first isolate from every new TB case will be genotyped with two rapid molecular methods: spoligotyping and mycobacterial interspersed repetitive unit-variable-number tandem repeat typing. MTBC isolates with nonunique genotypes and, thus, potentially linked to other TB cases, will also be genotyped by IS6110 restriction fragment length polymorphism analysis.

CONCLUSION:

By providing TB control programs using these new genotyping tools, and using traditional and new case investigation methods (eg, social network analysis), this new program will provide a clearer picture of TB in Ontario, and permit more effective use of public health resources and improve disease control.     

The role of the third acid-fast bacillus smear in tuberculosis screening for infection control purposes: A controversial topic revisited

INTRODUCTION:

Recent studies have suggested that two negative acid-fast bacillus (AFB) smears may be as effective as three when screening patients with suspected Mycobacterium tuberculosis for respiratory isolation purposes. However, current recommendations in Canada, the United States and Europe still support a three-smear approach.

METHODS:

The microbiology database of a tertiary care hospital was searched for sputum, tracheal aspirates and bronchoalveolar lavage samples from 2003 to 2007 that had been sent for mycobacterial testing. The first patient specimen to become AFB smear positive was noted. As well, the time required to collect the third specimen in hospitalized patients who remained smear negative was used to estimate the savings in isolation costs associated with a two-smear approach.

RESULTS:

There were 8347 respiratory specimens from 5168 patients in the five-year period. Of these patients, 2.2% (116 of 5168) were AFB smear positive, of whom 55.2% (64 of 116) were culture positive for Mycobacterium tuberculosis. Overall 89% (57 of 64) of patients were identified as being AFB smear positive by the first smear, 7.8% (five of 64) were identified by the second smear and 3.2% (two of 64) were identified by further smears. Smear-negative patients spent a combined 710 days in isolation awaiting collection of the third sample at a cost of approximately $142,000 over five years.

CONCLUSION:

A two-smear approach for discontinuation of respiratory isolation precautions is safe and has the potential to reduce hospital expenditures.     

Clinical features of infection caused by non-tuberculous mycobacteria: 7 years’ experience

Introduction

Non-tuberculous mycobacteria (NTM) are ubiquitous organisms associated with various infections. The aim of the study was to determine the most relevant clinical characteristics of NTM during the 7-year period.

Methodology

A retrospective study of NTM infections was conducted between January 2009 and December 2016. The American Thoracic Society/Infectious Disease Society of America criteria were used to define cases of pulmonary or an extrapulmonary site.

Results

A total of 85 patients were included in the study. Pulmonary cases predominated 83/85 (98%), while extrapulmonary NTM were present in 2/95 (2%) patients. Overall, ten different NTM species were isolated. The most common organisms were slow-growing mycobacteria (SGM) presented in 70/85 (82.35%) patients. Isolated SGM strains were Mycobacterium avium complex (MAC) in 25/85 (29.41%) patients, M. xenopi in 20/85 (23.53%) patients, M. kansasii in 15/85 (17.65%) patients and M. peregrinum and M. gordonae in 5/85 (5.88%) patients each. Isolated rapid-growing mycobacteria (RGM) strains were M. abscessus in 8/85 (9.41%) patients, M. fortuitum in 4/85 (4.71%) patients and M. chelonae in 3/85 (3.53%) patients. Almost all patients (98%; 83/85) had comorbidities. Among 75 (88.24%) patients who completed follow-up, 59 (69.41%), 10 (11.76%) and 6 (7%), were cured, experienced relapse and died, respectively.

Conclusion

In the present study, pulmonary NTM infections were more frequent compared to extrapulmonary disease forms. SGM were most common isolates with MAC pulmonary disease the most frequently found. Comorbidities have an important role in NTM occurrence. Further investigation should focus on an NTM drug susceptibility testing.

     

Prognostic effects of pulmonary hypertension in patients undergoing cardiac resynchronization therapy

Background

Aim of this study is to investigate the impact of elevated pulmonary artery systolic pressure (PASP) on mortality and the clinical outcome after cardiac resynchronization therapy (CRT).

Methods

Ninety-three patients with heart failure were enrolled into this study, and all of them have been treated by CRT for more than 6 months. Based on the level of preoperative PASP, they were divided into three groups (Group I: PASP>50mmHg, n=29; Group II: 30mmHgResults①Eight (28%), one (6%) and eight (17%) patients died in-group I, II and III respectively. Among those patients, 5 in group I and 1 in group III died of heart failure, while the patient in group II died of sudden death. ②In all three groups, CRT significantly improved heart function evaluated by NYHA heart function class and 6 minutes walking distance (6-MWT) (P<0.01). The improvement was more significant in group III than group I (P<0.01). ③At 3 months after CRT, Left ventricular ejection fraction (LVEF) increased significantly in Group III (P<0.01), but not in Group I or II (all P>0.05. At 6 months after CRT, LVEF increased significantly in all three groups (all P<0.05).

Conclusions

Elevated PASP has no prognostic effects on heart function improvement in patients undergone CRT. However, it was associated with worse LV remodeling and increased death due to aggravation of heart failure.     

Influence of preload on left ventricular relaxation in isolated ejecting hearts during myocardial depression

BACKGROUND:

The controversially discussed intrinsic effect of end-diastolic pressure (EDP) on ventricular relaxation (lusitropy) is a prerequisite for interpretation of lusitropic changes induced by physiological and pharmacological interventions because the latter usually alter the ventricular loading conditions.

OBJECTIVES:

Characterization of the lusitropic effect of preload changes at low and high absolute EDP and after spontaneous cardiodepression.

METHODS:

Repeated preload tests (increasing cardiac inflow at constant mean aortic pressure) were performed in isolated ejecting rat and guinea pig hearts. Preload was quantified by left ventricular EDP, lusitropy was quantified using peak negative left ventricular pressure change velocity (−dP/dt), and relaxation time constant τ was calculated from monoexponential and four-parametric logistic pressure fall models. Regression coefficients of relaxation indexes, −dP/dt and τ versus EDP, were calculated and compared at different degrees of cardiac depression.

RESULTS:

Increasing EDP in the ejecting hearts less than 2 h after isolation caused τ to decrease and −dP/dt to increase initially at low EDP levels. Both parameters remained constant or even reversed at higher EDP levels. In the spontaneously depressed hearts, over 3 h after isolation, basic τ values were higher and −dP/dt values were lower, but EDP changes no longer had significant lusitropic effects. The same behaviour was observed in pentobarbital depressed hearts.

CONCLUSIONS:

A positive lusitropic effect (falling τ, rising −dP/dt) was observed when preload was increased in the range of lower EDP values in undepressed hearts early after isolation. However, preload changes did not influence lusitropy in isolated hearts either early after isolation at high EDP levels or in the spontaneously depressed condition at any EDP level.     

2006 Ontario Survey on the Prevalence and Control of Hypertension (ON-BP): rationale and design of a community-based cross-sectional survey

BACKGROUND:

The presently available Canadian data, based on direct measurements of blood pressure (BP) from the Canadian Heart Health Surveys, are more than 15 years old. In view of major changes in the demographics and health status of the Ontario population, there is an urgent need to update this information. On the initiative of the Heart and Stroke Foundation of Ontario, the University of Ottawa Heart Institute, jointly with Statistics Canada, designed and implemented a population-based cross-sectional survey of hypertension in the Province of Ontario: the 2006 Ontario Survey on the Prevalence and Control of Hypertension (ON-BP).

OBJECTIVES:

To establish the prevalence of hypertension in the Ontario adult population between the ages of 20 and 79 years; to assess the awareness, current status and management of hypertension; and to gather respondent information about sex, age, physical measurements, personal health practices, socioeconomic measures, ethnicity and comorbidities.

METHODS:

The present paper describes the background history and the successive steps undertaken during the implementation of this project.

CONCLUSIONS:

The authors’ experiences from the ON-BP indicate that close co-operation between research scientists, statisticians, governmental and nongovernmental organizations – in the present case, the Heart and Stroke Foundation of Ontario – is essential to conduct a successful, large-scale survey of BP distribution.     

A randomized controlled trial to assess the efficacy of tiotropium in Canadian patients with chronic obstructive pulmonary disease

BACKGROUND:

Patients with chronic obstructive pulmonary disease (COPD) who smoke have a greater annual rate of decline in forced expiratory volume in 1 s (FEV₁) than those patients who have stopped smoking.

OBJECTIVES:

To assess the effect of tiotropium on pre-dose (trough) FEV₁ in patients with COPD followed in Canada.

METHODS:

A total of 913 patients were randomly assigned to receive either tiotropium 18 μg once daily (n=608) or placebo (usual care minus inhaled anticholinergics) (n=305) for 48 weeks in the present randomized, double-blind, parallel-group study. The effect of tiotropium on measurements of lung function (FEV₁, FEV₆ and forced vital capacity), symptoms, health-related quality of life (St George’s Respiratory Questionnaire) and exacerbations were examined.

RESULTS:

Tiotropium improved trough FEV₁ in both current and ex-smokers compared with placebo. Baseline FEV₁ in smokers and ex-smokers was 1.03 L and 0.93 L, respectively (P<0.001). At week 48, the mean difference between the tiotropium and placebo groups was 0.14±0.04 L (P<0.001) in the smoker group and 0.08±0.02 L (P<0.0001) in the ex-smoker group. Tiotropium also significantly improved trough forced vital capacity and FEV₆ compared with placebo throughout the treatment period (P<0.05, for all). Furthermore, tiotropium significantly improved the St George’s Respiratory Questionnaire total score compared with placebo at week 48 (40.9 versus 43.7 units, P<0.005).

CONCLUSIONS:

Compared with the placebo group, tiotropium provides sustained improvements in lung function in patients with COPD, with improvements for smokers and ex-smokers.     

Mortality of elderly patients in Ontario after hospital admission for chronic obstructive pulmonary disease

BACKGROUND:

Chronic obstructive pulmonary disease (COPD) is associated with significant mortality. It is currently the fourth leading cause of death in Canada and the world.

OBJECTIVES:

To describe the mortality of elderly patients in Ontario after hospital admission for COPD.

METHODS:

A retrospective cohort study was conducted using the Discharge Abstract Database from the Canadian Institute for Health Information. Patients aged 65 years and older who were admitted to hospital between 2001 and 2004 with primary discharge diagnoses labelled with International Classification of Diseases, Ninth Revision codes 491, 492 and 496 were included in the study.

RESULTS:

Mortality rates were 8.81, 12.10, 14.53 and 27.72 per 100 COPD hospital admissions at 30, 60, 90 and 365 days after hospital discharge, respectively. Mortality also increased with age, and men had higher rates than women. No significant differences in mortality rates were found between different socioeconomic groups (P>0.05). Patients with shared care of a family physician or general practitioner and a specialist had significantly lower mortality rates than the overall rate (P<0.05), and their rates were approximately one-half the rate of patients with only one physician.

CONCLUSIONS:

Hospitalization with COPD is associated with significant mortality. Patients who were cared for by both a family physician or general practitioner and a specialist had significantly lower mortality rates than those cared for by only one physician, suggesting that continuous and coordinated care results in better survival.     

Parasitic disease screening among HIV patients from endemic countries in a Toronto clinic

BACKGROUND:

Many North American-based HIV patients originate from parasitic disease-endemic regions. Strongyloidiasis, schistosomiasis and filariasis are important due to their wide distribution and potential for severe morbidity.

OBJECTIVES:

To determine the prevalence, as determined by serological screening, of strongyloidiasis, schistosomiasis and filariasis among patients in an HIV-focused, primary care practice in Toronto, Ontario. A secondary objective was to determine factors associated with positive serological screens.

METHODS:

A retrospective review of electronic patient records was conducted. Results of serological screens for parasites and relevant laboratory data were collected.

RESULTS:

Ninety-seven patients were identified. The patients’ mean CD4⁺ count was 0.45×10⁹/L, median viral load was undetectable and 68% were on highly active antiretroviral therapy (HAART). Most originated from Africa (37%) and South America (35%). Of the 97 patients, 10.4% and 8.3% had positive or equivocal screening results for strongyloidiasis, respectively, 7.4% and 4.2% had positive or equivocal screening results for schistosomiasis and 5.5% and 6.8% had positive or equivocal screens for filariasis. Persons with positive parasitic serologies were more often female (28% versus 9%, P=0.03), younger in age (36 versus 43 years of age, P<0.01), had been in Canada for a shorter duration (5 versus 12 years, P<0.0001) and had a higher viral load (10,990 copies/mL versus <50 copies/mL, P <0.001). All patients were asymptomatic. Eosinophilia was not associated with positive screening results.

CONCLUSIONS:

Using symptoms and eosinophilia to identify parasitic infection was not reliable. Screening for strongyloidiasis and schistosomiasis among patients with HIV from parasite-endemic countries is simple and benign, and may prevent future complications. The clinical benefits of screening for filariasis require further elucidation, but this practice appears to be the least warranted.     

Success in pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

BACKGROUND:

Pulmonary rehabilitation (PR) is beneficial for some, but not all, patients with chronic lung disease.

OBJECTIVES:

To determine the success rate of a comprehensive PR program for patients with chronic obstructive pulmonary disease (COPD) and to characterize the differences between responders and nonresponders.

METHODS:

A chart review was performed on patients with a clinical diagnosis of COPD who were referred for PR. Success was defined according to clinically important changes in St George’s Respiratory Questionnaire scores and/or 6 min walk test distance.

RESULTS:

The majority of subjects were men (58%) with a mean (± SD) age of 69±10 years (n=177). Sixty-two per cent of participants had a successful outcome with PR, with proportionally more responders noting subjective improvement than objective improvement on a 6 min walk test (73% versus 51%). Subjects with poor baseline St George’s Respiratory Questionnaire scores tended to improve the most (P=0.011 [ANOVA]). Successful participants had a greater forced expired volume in 1 s (1.1 L versus 0.9 L; P<0.05) and a lower BODE index (body mass index, airflow obstruction, dyspnea, and exercise capacity index) at baseline (9.6 versus 10.3; P<0.05). Success of PR was not correlated with age, sex, chronic hypoxemic respiratory failure or other chronic conditions. Successful participants were more likely to be compliant and to experience fewer adverse events (P≤0.001).

CONCLUSIONS:

Our study reinforced the belief that the majority of participants with COPD benefit from PR. Few baseline characteristics were predictive of success. Subjectively measured improvement occurred more frequently than objectively measured improvement and was greatest in those with the poorest baseline values.     

Double CT imaging can measure the respiratory movement of small pulmonary tumors during stereotactic ablative radiotherapy

Purpose

The purpose of this study was to investigate the application of double CT imaging to measuring the respiratory movement of small pulmonary tumors during stereotactic ablative radiotherapy (SABR).

Methods

A total of 122 small pulmonary tumors were measured in 45 patients. CT scans were conducted twice in all 122 tumors, once at the end of quiet inhalation and once at the end of exhalation. CT scans were conducted three times including at the end of quiet inhalation, at the end of exhalation and at free breathing in 36 tumors of 17 patients. The displacement of the tumor center in three directions was measured.

Results

The 3D motion of 122 tumors was 10.10±7.16 mm. On average, the tumors moved 1.96±2.03 mm (rang, 0-9 mm) in the X direction, 5.19±4.69 mm (rang, 0-19 mm) in the Y direction, and 7.38±6.48 mm (rang, 0-26 mm) in the Z direction. The 3D motion of tumors in the lower lung (13.00±7.64 mm) was significantly greater than that in the upper lung (7.15±5.14 mm), P<0.01. The 3D motion of the lower left lung was 16.35±7.31 mm, which was significantly greater than that of the lower right lung (11.40±7.04 mm), P<0.05. Movement in the anterior lung in the Y direction was significantly larger than in the posterior lung. The motion was 7.49±5.43 mm and 4.04±3.82 mm respectively, P<0.01.

Conclusions

Double CT imaging provides accurate data for determining the outline of each target area during stereotactic ablative radiotherapy plane. The location of small pulmonary tumor foci was significantly affected by respiratory and cardiac motion.Key words : Double CT scan, Small pulmonary tumors, Respiratory movement, Stereotactic ablative radiotherapy     

Empathy Training for Resident Physicians: A Randomized Controlled Trial of a Neuroscience-Informed Curriculum

Background

Physician empathy is an essential attribute of the patient–physician relationship and is associated with better outcomes, greater patient safety and fewer malpractice claims.

Objective

We tested whether an innovative empathy training protocol grounded in neuroscience could improve physician empathy as rated by patients.

Design

Randomized controlled trial.

Intervention

We randomly assigned residents and fellows from surgery, medicine, anesthesiology, psychiatry, ophthalmology, and orthopedics (N = 99, 52% female, mean age 30.6 ± 3.6) to receive standard post-graduate medical education or education augmented with three 60-minute empathy training modules.

Main Measure

Patient ratings of physician empathy were assessed within one-month pre-training and between 1–2 months post-training with the use of the Consultation and Relational Empathy (CARE) measure. Each physician was rated by multiple patients (pre-mean = 4.6 ± 3.1; post-mean 4.9 ± 2.5), who were blinded to physician randomization. The primary outcome was change score on the patient-rated CARE.

Key Results

The empathy training group showed greater changes in patient-rated CARE scores than the control (difference 2.2; P = 0.04). Trained physicians also showed greater changes in knowledge of the neurobiology of empathy (difference 1.8; P < 0.001) and in ability to decode facial expressions of emotion (difference 1.9; P < 0.001).

Conclusions

A brief intervention grounded in the neurobiology of empathy significantly improved physician empathy as rated by patients, suggesting that the quality of care in medicine could be improved by integrating the neuroscience of empathy into medical education.KEY WORDS: empathy, randomized controlled trial, communication skills, graduate medical education, patient–physician relationship