The current generation of Chinese immigrants to Canada occupy what are increasingly recognized as transnational spaces – spaces that, with the ubiquity of the internet and the availability of daily direct flights between the Canada and China, span the territorial boundaries of the host country and the home country. This paper draws from interviews conducted as part of a study that aims to understand the vulnerability to HIV faced by the current generation of Chinese immigrants to Canada. In it we consider interview participants' narratives of what they desire and what they do in terms of sex and intimate relationships. More generally we reflect on how immigration and experiences in Canada have shaped sexuality and its expression, sexual identity, desires for partnership and the nature of the partner desired. Movement between geographical and social spaces both prompts and is prompted by new opportunities for sexual expression, particularly for men who have sex with men but also for some heterosexual women. Transnational lives are also, however, subject to new limits, pressures and constraints; downward social mobility after immigration , for example, appears as a persistent source of stress in heterosexual relationships, and was sometimes cited as the cause of extramarital sexual relationships. We examine the values that interview participants activate and endorse in their narratives of sex and intimate relationships, especially how values or worldviews deemed Chinese intersect with 'foreign' worldviews, or values considered Canadian. Our central intent with the paper is to highlight ways that sexual and partner desirability is (re)constructed in relation to im-migrants' new social and cultural circumstances in Canada, and in relation to their ongoing opportunity for transnational connections to China.
Drug-resistant Gram-positive bacteria, especially Staphylococcus aureus, are emerging as the predominant organisms involved in both nosocomial and community-acquired infections. Since the 1980s, vancomycin has been the first-line antibiotic used to treat methicillin-resistant S aureus. However, allergy and intolerance to vancomycin, the increasing number of vancomycin clinical failures and the existence of vancomycin intermediate-susceptible isolates of S aureus suggest that new antibiotics are needed. This paper reports the only known case of a successful clinical outcome with long term oral linezolid and rifampin therapy in the management of recurrent and persistent methicillin-resistant S aureus bacteremia with metastatic infections despite prolonged vancomycin use. More than two years since the initiation of linezolid and rifampin, the study patient has been clinically well with no evidence of adverse drug reactions including cytopenia and hepatic toxicities. Physicians must be aware of the novel developments in antibiotic therapy to treat drug-resistant bacterial infections.
The aims of the present study were to review the risk of invasive meningococcal disease (IMD) among education workers, particularly pregnant women, and to evaluate preventive measures, in a context of endemicity, outbreak or epidemic as observed in the province of Quebec. The literature was reviewed and persons in charge of IMD surveillance in France, Quebec, the United Kingdom and the United States were interviewed. Surveys of asymptomatic carriage of Neisseria meningitidis show that transmission among students is higher than transmission between students and teachers. IMD incidence among education workers was analyzed in Cheshire (United Kingdom) in the period from 1997 to 1999, and the results indicated a risk six times higher than that in the general population. Overestimation of the magnitude of the risk is possible because the analysis focused on a cluster. None of the population-based studies of IMD mentioned a risk of secondary cases among education workers. Six IMD cases in education workers were identified in five clusters in schools in the United Kingdom, but not in the other countries. There is no epidemiological study on IMD risk among pregnant women, and this factor was not mentioned in any published review of IMD. Immunization of education workers at the beginning of their employment, using serogroup C glycoconjugate vaccine or a combined A, C, W-135, and Y conjugate vaccine (still under development), could reduce IMD risk, but the cost effectiveness of this measure should be evaluated. The societal benefit of excluding pregnant women from the work place during an outbreak seems to be very low, even if disease risk could be decreased for this specific group. When chemoprophylaxis is indicated for the control of an outbreak in an educational setting, treatment should be offered both to students and teachers in the group at risk.
Clostridium difficile is the etiological agent of antibiotic-associated diarrhea; the most common form of nosocomial infectious diarrhea. The basis for the shock-like systemic symptoms observed in severe cases of this infection are not known. It is hypothesized that the invasion of C difficile toxins A and/or B from the gut mucosa may contribute to these symptoms.A polarized tissue culture model employing Caco-2 cells grown on transwell inserts was established to study the translocation of purified C difficile toxins A and B. C difficile toxins were (125)I labelled and inoculated onto confluent polarized Caco-2 cell monolayers to study translocation dynamics. Electrical resistance measurements were used to monitor monolayer confluence and tight junction integrity. Samples were taken from the apical and basal sides of the insert, as well as the insert itself, and tested using the human foreskin fibroblasts cell cytotoxicity assay to monitor partitioning of the radiolabelled toxins. Toxin A produced a 50% reduction in electrical resistance in 3 h whereas the same concentration of toxin B required at least 7 h to achieve the same effect. Both toxins A and B were able to translocate across confluent monolayers of Caco-2 cells. The combination of toxin A and B together was synergistic with respect to promoting the translocation of toxin B. Although the addition of toxin A resulted in a 100% increase in the amount of toxin B able to translocate, no increases in toxin A translocation were observed. These findings suggest a model of pathogenesis in which C difficile toxin A facilitates the translocation of toxin B from the gut into submucosal areas where it may play a role in inflammatory damage.
OBJECTIVES: To determine the factors that predict whether or not ambulatory patients with community-acquired pneumonia (CAP) treated in an emergency room (ER) setting will have blood cultures drawn and the factors that predict a positive blood culture. METHODS: Prospective observational study of all patients with a diagnosis of CAP, as made by an ER physician, who presented to any of seven Edmonton-area ERs over a two-year period. RESULTS: Seven hundred ninety-three (19.2%) of 4124 patients with CAP had blood cultures drawn. The site-specific blood culture rates ranged from 7.8% to 25% (P<0.001); 41 of 793 (5.1%) were positive. Streptococcus pneumoniae accounted for 58.5% of the isolates while Staphylococcus aureus and Escherichia coli each accounted for 14.6%, or six patients each. Only two of the 24 patients with S pneumoniae bacteremia were subsequently admitted to hospital while all six of the patients with S aureus were admitted. Only one of the six patients with E coli bacteremia was treated at home. No factors were predictive of positive blood cultures on multivariate analysis. CONCLUSIONS: Physicians are selective in ordering blood cultures on patients with ambulatory pneumonia who present to an ER, and the positivity rate of 5.1% is quite high. No factors are predictive of positive blood cultures on multivariate analysis, thus clinical judgment has to prevail in the decision to perform blood cultures. Breakthrough bacteremia can occur with microorganisms susceptible to the antibiotics that the patient is receiving.
1Department of Internal Medicine, Clinica Montpellier; 2Haematology consultant, Clinica Montpellier; 3Laboratorio Jose Maria Grasa Biel, Sociedad Anonima; 4Department of Neurology, Clinica Montpellier, Zaragoza, Spain Correspondence: Dr Isabel Fiteni, Andador Luis Puntes 4, 3a B, 50008 Zaragoza, Spain. Telephone 0034-9-76-590412, e-mail ifiteni@saludalia.com CASE PRESENTATION A 23-year-old woman was admitted to hospital because of intermittent fever up to 40°C accompanied by significant arthralgia and myalgia for the previous seven days. She had been receiving azathioprine 100 mg per day and prednisone 60 mg per day for Harada’s disease with frequent bouts of recurrent uveitis for the past two years. She had been complaining of diffuse muscle and joint pain, stiffness and general weakness for the previous seven months, which prevented her from walking. Steroids had been tapered during the previous several weeks for suspected iatrogenic myopathy, although there had been no improvement. She denied cough, chest pain, headache or other symptoms. She had no pets, except contact with a friend’s dog, and had not travelled recently. Physical examination revealed a cushingoid woman in no distress with no adenopathy. Chest, cardiovascular, skin and abdominal exams were normal, and no hepatosplenomegaly was noted. Blood analysis revealed pancytopenia (hemoglobin 5.4 mmol/L; leukocytes 2×109/L [0.4×109/L lymphocytes]; platelets 38×109/L), elevated liver enzymes (aspartate aminotransferase 561 U/L; alanine aminotransferase 451 U/L; lactate dehydrogenase 2300 U/L) and an increased prothrombin time by 56%. The erythrocyte sedimentation rate was 120 mm/h. Total gamma globulins were decreased (10 g/L) with low immunoglobulin G (6.53 g/L) and normal albumin (45 g/L). Triglycerides and fibrinogen were normal. Urine analysis, other routine biochemical markers and renal function were normal, as were the assays for rheumatoid factor, total complement activity, reticulocyte count and vitamin B12 levels. Autoimmmune studies (ie, antinuclear antibody, anti-DNA) and a Coomb’s test were negative, as was serology for common endemic infectious diseases (ie, Brucella species; Cytomegalovirus; Epstein-Barr virus; hepatitis A, B and C viruses; leishmania). Blood and urine cultures for bacteria were negative. A radiograph of the chest was normal, although echocardiography revealed a mild pericardial effusion. A computed tomography scan of the chest did not reveal any abnormalities. A diagnostic procedure was performed. What is the diagnosis?
here are two opposing risks when it comes to water tem-perature inside domestic water heaters; exposure toLegionella, the bacteria responsible for Legionnaires’ disease(pulmonary legionellosis), and the risk of scalding. In 1986,this dilemma was the subject of an editorial in the CanadianMedical Association Journal(1). A few months ago, Safe KidsCanada launched a media campaign aimed at preventingscalding by lowering domestic hot water temperature to 49°Cat the tap (2). Among the means considered to reach thisobjective, Safe Kids Canada, with the support of some publichealth organizations, suggests and seems to favour lowering thetemperature setting of domestic hot water heaters to 49°C.Like other authors (3,4), including the World HealthOrganization (WHO) who published a recent monograph onthe Legionella problem in drinking water (3), we believe thatthere is evidence for the transmission of legionellosis throughthe drinking water distribution systems in private homes. Thisis a serious illness associated with high death rates (up to 12%).Primary groups at risk (the elderly, smokers, the immunocom-promised and patients suffering from chronic respiratory ill-nesses), are groups who include a large proportion of thepopulation at home. Although we support prevention againsttap water scalds, we are against setting water heater thermo-stats at 49°C because we believe this could facilitate prolifera-tion of Legionella inside the tank and increase the risk oflegionellosis.Domestic water heaters, particularly electric devices, can cer-tainly be contaminated by Legionella. In Quebec, a study of 211homes (178 electric water heaters, 33 oil or gas water heaters)found Legionella contamination in 40% of electric water heaters.No water heaters using fossil fuels were contaminated (5). Theauthors concluded that, because of design variables, use of anelectric water heater was the most significant factor leading toLegionella contamination in hot water (5) in the home.The clinical and epidemiological significance of this find-ing is much debated. However, in a case-control study of spo-radic cases of community-acquired legionellosis, Straus et al(6) concluded that the residential drinking water supply wasresponsible for a substantial proportion of sporadic cases ofLegionnaires’ disease. These findings are supported by Stout et al(7) in a study of 20 Pittsburgh patients with culture-confirmed Legionnaires’ disease. A link with residential drink-ing water contamination was established for eight (40%)patients. This included three private homes (one singledwelling, two multidwellings), two senior-citizen homes, twoout-patient hospital clinics, and one industrial plant. Theauthors concluded that drinking water distribution systemswere a significant source of transmission of Legionnaires’ dis-ease (7).The importance of Legionnaire’s disease is underestimatedbecause it is difficult to diagnose and because it is reportedthrough a passive surveillance system. In an active surveillancestudy of pneumonia requiring hospitalization in Ohio, the inci-dence of Legionnaire’s pneumonia was estimated to be approx-imately seven cases per 100,000 people (8). With theobservations from the Stout et al (7) study, if active surveil-lance was performed, an estimated two cases of Legionnaire’sdisease per 100,000 people per year could be attributable topotable water in private homes and senior-citizen residences.This is at least of the same order of magnitude as the annualrates of 0.45 per 100,000 for hospitalization and 0.043 fordeath due to scalding by tap water in Quebec (9).The optimal temperature for Legionella proliferation inwater varies between 32°C and 35°C, but it can easily prolifer-ate at temperatures of up to 45°C. Usually, there is no growthabove 55°C, and a temperature of over 60°C has a bactericidaleffect. Thus, the WHO recommends that water be heated andstored at 60°C (3). However, studies in Quebec have shown,even when the thermostat is set at 60°C, a high percentage(approximately 40%) of electric water heaters remain contam-inated because of the lower temperature, about 30°C to 40°Cat the bottom of the tank. The probability of contaminationwill increase considerably if the temperature setting is loweredto 49°C. The risk of contamination is much lower for waterheaters operating with fossil fuels, and is practically nonexist-ent for these heaters set at 60°C.In our opinion, it is important to reduce both the risk ofscalds and the risk of legionellosis associated with domesticwater supplies (9). For water heaters servicing a single housingunit, electric water heater manufacturers need to market, asquickly as possible, water heaters resistant to proliferation ofLegionella. At the least, all new water heaters must be preset at60°C and equipped with antiscald devices to deliver water at49°C to the entire household. Electric water heaters alreadyinstalled should be set at 60°C to limit the risk of Legionellacontamination. Gas or oil water heaters already installed
1Departments of Pathology and Laboratory Medicine, Medicine, and Microbiology and Infectious Diseases, University of Calgary, Calgary, Alberta; 2Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia Correspondence: Dr John Conly, Departments of Pathology and Laboratory Medicine, Medicine, and Microbiology and Infectious Diseases, Room 930, 9th Floor, North Tower, 1403 29th Street Northwest, Calgary, Alberta T2N 2T9. Telephone 403-944-8222, fax 403-944-1095, e-mail jconly@ucalgary.ca Influenza is an acute self-limited febrile illness caused by infection with influenza type A or B viruses, and has been causing cyclical epidemics of febrile respiratory disease for centuries. It occurs in outbreaks in almost every winter season in northern and southern hemispheres. The attack rates vary during these outbreak cycles but have been reported as high as 20% to 40% during the peak period of influenza activity (1). Influenza continues to be associated with significant morbidity in the general population, with the elderly, the very young and patients with comorbid illnesses being particularly susceptible. Significant increases in mortality are often seen during influenza epidemics and the excess mortality is not only a direct result of pneumonitis but also of other cardiopulmonary diseases that may be exacerbated by the influenza virus infection. It has been reported that more than 20,000 influenzaassociated deaths occurred during each of nine different epidemics between 1972 and 1992 (2), although this figure has been adjusted to an average of approximately 36,000 deaths/year due to influenza in the United States during 19901999 based on different modelling (3). In the past, Health Canada has reported that, on average, 500 to 1500 deaths per year are due to influenza or pneumonia occurring as a complication of influenza. It is acknowledged that many more deaths may occur in people with underlying medical conditions complicated by influenza. After using new modelling, however, Health Canada estimates that the figure may actually be from 700 to 2500 per annum (4). Given the early and somewhat unexpected onset to this year’s influenza season, and the reappearance of avian influenza in Asia, it is timely to briefly review the current epidemiology of influenza, particularly with respect to the influenza A Fujian strain which is predominant this season. Influenza A and influenza B viruses are the two types of influenza viruses which cause human epidemic disease. Influenza A viruses are found in many different animals, including ducks, chickens, pigs, whales, horses and seals. Influenza B viruses circulate widely only among humans. Influenza A viruses are divided into subtypes based on two antigens on the surface of the virus: the hemagglutinin (H) and the neuraminidase (N). There are 15 different H subtypes and nine different N subtypes identified to date, all of which have been found among influenza A viruses in wild birds. The H antigen acts as a site of attachment of the virus to host cells to initiate infection and also to erythrocytes from which its name originally was derived (5). The H antigen contains common and strain-specific antigens and demonstrates antigenic variation. The N antigen contains subtype-specific antigens and also demonstrates antigenic variation between subtypes. The N antigen (also known as sialidase antigen) is a surface glycoprotein possessing enzymatic activity essential for viral replication in both influenza A and B viruses. The N antigen enables 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 (6,7). 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 pro-inflammatory cytokines such as interleukin-1 and tumour necrosis factor from macrophages (8-10). Wild birds are the primary natural reservoir for all subtypes of influenza A viruses and are thought to be the source of influenza A viruses in other animals. Most influenza viruses cause asymptomatic or mild infection in birds; however, the range of symptoms in birds varies greatly depending on the strain of virus. Infection with certain avian influenza A viruses (for example, some strains of H5 and H7 viruses) can cause widespread disease and death among some species of wild birds but especially affects domestic birds such as chickens and turkeys. Influenza A virus affecting humans has traditionally been classified into three subtypes based on the H antigen (H1, H2, H3) and two additional subtypes based on the N antigen (N1, N2). However, in the last decade, strains of avian influenza containing other H and N antigenic combinations and which have affected humans have been reported. Avian influenza strains were first reported from Hong Kong (11) during the 1997-1998 influenza season and were shown to be derived from avian sources without genetic reassortment between avian and human influenza viruses (11). This first avian influenza A strain (H5N1) affecting humans occurred exclusively amongst residents of the Hong Kong special administrative region and was associated with six deaths during the 1997-1998 influenza season. However, other recent outbreaks of avian influenza in humans have caused limited disease (12). Two cases of confirmed H5N1 influenza occurred in Hong Kong in February 2003, resulting in one death. An outbreak of H7N7 avian influenza in the Netherlands caused the death of one veterinarian in April 2003, and mild illness in 83 humans. Mild cases of avian influenza A(H9N2) in children occurred in Hong Kong in 1999 (two cases) and in mid-December 2003 (one
TABLE 1 National Advisory Committee on Immunization's
A number of articles have appeared in the medical literature over the past four years on the topic of patient safety, including a series in the New England Journal of Medicine in 2002 and 2003 (1).There has been considerable media interest, with a number of reports on medical errors and their associated consequences.The Royal College of Physicians and Surgeons of Canada sponsored a National Steering Committee on Patient Safety that published its report in 2002 (2).The committee made 19 recommendations intended to improve patient safety in Canadian health care (2).In 2003, the government of Canada committed $10 million/year for implementation of the recommendations, including support for the creation of a Canadian Patient Safety Institute (3).The Canadian Council on Health Services Accreditation has indicated its commitment to playing a major role in improving patient safety through accreditation (4).The Canadian Institutes for Health Information and Health Research have jointly funded the Canadian Adverse Events Study, examining the extent of adverse events in acute care hospitals with results expected to be published in 2004.This study includes 20 teaching, community and small hospitals in five provinces (British Columbia, Alberta, Ontario, Quebec and Nova Scotia).Clearly, patient safety has become a very relevant topic.From a historical perspective, Elihu Schimmel in 1964 (5) wrote that recent medical progress has brought dramatic advances in methods of diagnosis and treatment but, with each new advance, reports of adverse reactions have soon followed.As a chief resident, he undertook a prospective study of the type and frequency of complications ('episodes') occurring in response to medical care.Episodes occurring as a result of errors were excluded.There were 240 episodes in 198 of 1014 (19.5%) patients.The majority of episodes (49.6%) were reactions to therapeutic drugs, 9.6% were hospital acquired infections, 20% were life threatening or fatal, and 6.7% were fatal.Antimicrobials were associated with 29.4% of adverse reactions to medications.Six of the 16 deaths (37.5%) were in patients with hospital-acquired infections.Thirty-six years later, the Institute of Medicine (IOM) in the United States published To Err is Human: Building a Safer Health System (6).In it, they estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors.These numbers were extrapolated from the results of three studies (7-9) examining the incidence of adverse events in hospitalized patients and have been vigorously debated.In the first two of these studies, investigators retrospectively
CASE PRESENTATIONA previously healthy 16-year-old boy of East Indian origin wasadmitted to the Stollery Children’s Hospital (SCH) inEdmonton, Alberta in February 2003 for evaluation ofheadache and back pain. Lower back pain had started suddenlynine days earlier, after lifting weights, and had persisted. Athrobbing occipital headache started eight days before admis-sion. The patient thought he had possibly been febrile.There was no known exposure to tuberculosis and no historyof ill contacts. There had been recent travel to California andvisitors from India had been staying in the home. The boy hadalways lived in Canada.One day before admission to the SCH, the boy was evaluatedin a regional hospital because of worsening headache and backpain. Temperature was 38°C, pulse was 84 beats/min, respira-tory rate was 18 breaths/min and blood pressure was 120/80 mmHg.Physical examination revealed a coherent boy in mild dis-tress. He vomited for the first time during the assessment. Hisneck was stiff and a positive Brudzinski sign was present.Fundoscopy was normal. Tympanic membranes, mouth andthroat were normal. No significant lymphadenopathy was not-ed. Chest, cardiac and abdominal examinations were unre-markable. Cranial nerves, sensation, tone, power, coordinationand deep tendon reflexes were normal. On examination of themuskuloskeletal system, there was slight tenderness over thespinus processes of the third and fourth lumbar vertebrae (L3 and L4).A noncontrast brain computerized tomography scan wasnormal. Examination of cerebrospinal fluid (CSF) revealed awhite blood cell count of 6.1 × 10
Methicillin-resistant Staphylococcus aureus (MRSA) is being seen with greater frequency in most hospitals and other health care facilities across Canada. The organism may cause life-threatening infections and has been associated with institutional outbreaks. Several studies have confirmed that MRSA infection is associated with increased morbidity and mortality compared with infections caused by susceptible strains, even when the presence of comorbidities is accounted for. Treatment of MRSA infection is complicated by the fact that these organisms are resistant to multiple antimicrobial agents, so treatment options are limited. The effectiveness of decolonization therapy (attempting to eradicate MRSA carriage) is also uncertain. This paper reviews the medical management of MRSA infections, discusses the potential role of decolonization and provides an overview of evidence to support recommended infection control practices.
Despite the global public health importance of resistance of microorganisms to the effects of antibiotics, and the direct relationship of consumption to resistance, little information is available concerning levels of consumption in Canadian hospitals and out-patient settings. The present paper provides practical advice on the use of administrative pharmacy data to address this need. Focus is made on the use of the Anatomical Therapeutic Chemical classification and Defined Daily Dose system. Examples of consumption data from Canadian community and hospital settings, with comparisons to international data, are used to incite interest and to propose uses of this information. It is hoped that all persons responsible for policy decisions regarding licensing, reimbursement, prescribing guidelines, formulary controls or any other structure pertaining to antimicrobial use become conversant with the concepts of population antibiotic consumption and that this paper provides them with the impetus and direction to begin accurately measuring and comparing antibiotic use in their jurisdictions.
OBJECTIVE: To evaluate the benefit and costs of vaccination of university students against invasive meningococcal disease (IMD) in Canada. METHODS: Published studies were reviewed and a simulation model was used. RESULTS: IMD risk seems to be of low magnitude, but consequences can be dramatic. Over a 10-year period, IMD risk reduction would be slightly greater using a monovalent C conjugate vaccine than a quadrivalent polysaccharide vaccine. From a societal perspective, costs per quality-adjusted life-years gained would be between $135,000 and $698,000, according to epidemiological scenarios and with vaccine purchase prices between $35 and $50 per dose. CONCLUSIONS: Economic indices exceed proposed criteria for cost effective public health programs, but from the perspective of students and parents, the cost of vaccination might be worth the benefit.
Myiasis is considered to be a condition only found in tropical, developing countries. However, this paper reports a case identified in an urban, North American setting. The clinical presentation is discussed along with the underlying comorbidities and social determinants.
The World Health Organization, UNICEF and the World Bank released a report entitled “State of the World’s Vaccines and Immunization” in November 2002 (1). Nelson Mandela, Chair of the Vaccine Fund Board, in a foreword to the report entitled “Call to Action” eloquently pleaded for a commitment for the equitable access to immunization for all of the world’s children (2). He stated that immunization “is the most powerful of all preventive health measures for children and is central to human rights and poverty alleviation. It is the right of every child to be given this kind of protection.”
