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Despite recent success in reducing its incidence, tuberculosis remains a considerable challenge in Canada, particularly among foreign-born and Indigenous populations. A key component of the strategy for controlling the disease is the treatment of latent tuberculosis infection (LTBI). The standard treatment consists of isoniazid (INH) daily for nine months. In recent years, shorter regimens have been developed in the hope of increasing rates of treatment acceptance and completion. Of these, the shortest and most recently developed is a combination of INH and rifapentine taken once weekly for 12 doses (3HP), typically using directly observed therapy. This regimen has been approved by the Food and Drug Administration in the United States but is not yet authorized for use in Canada. Based on a rapidly expanding number of observational studies and randomized controlled trials, 12 weeks of 3HP appears to have similar efficacy to nine months of INH, a favourable adverse event profile and potentially improved rates of treatment completion. Although rates of treatment acceptance, the role of self-administered therapy and the regimen's cost-effectiveness within the Canadian context remain uncertain, 3HP is a promising alternative to existing treatments for LTBI. [ABSTRACT FROM AUTHOR]

Although Canada has a low incidence of tuberculosis (TB), certain populations, including the foreign-born and Canadian-born Indigenous peoples, continue to be disproportionately represented among reported cases. The overall incidence rates of active TB in Canada have not significantly changed in the past decade and work still needs to be done to reach TB elimination goals set by the World Health Organization (WHO). In trying to achieve TB elimination in Canada, primary care clinicians, with the support of public health professionals and TB experts, can help by focusing on 1) targeted screening and treatment of latent TB infection (LTBI) and 2) timely diagnosis and referral of active TB disease. The following article focuses on some key primary care considerations to keep in mind in day-to-day patient care. To help conduct targeted screening and treatment for LTBI, several key populations, including immigrants from high TB burden countries, Indigenous peoples and several other at-risk groups, are outlined. Reactivation of LTBI plays a significant role in TB burden and is likely an area of major potential impact in achieving TB elimination. Advancement in LTBI treatment, including short course therapy, is also described. In addition, to help make a timely diagnosis of active TB, several key risk factors, including several co-morbidities which increase the risk of developing TB disease, can be considered. Being front-line in patient care, keeping in mind some of these key pearls may aid primary care providers to have potential impact on eliminating TB in Canada. [ABSTRACT FROM AUTHOR]

Background Cancer is a health concern in Inuit populations. Unique cultural, dietary, and genetic factors and geographic isolation influence cancer epidemiology in this group. Inuit-specific data about oncology treatments and survival outcomes in Canadian Inuit referred to urban treatment centres are lacking. Methods A retrospective chart review of Inuit patients referred to The Ottawa Hospital Cancer Centre (TOHCC) from the Baffin region of Nunavut between 2000 and 2010 was conducted. Nunavut cancer registry data were used to establish the percentage of cancer cases referred and their survival outcomes. Results Of 307 cancer patients registered among Baffin-region Inuit, 216 [70% (63 men, 153 women)] were referred to tohcc for chemotherapy (CT) and radiation therapy (RT). Mean age in the referred group was 59.3 years (range: 25-89 years), and current smokers constituted half the group (52%). The cancers most commonly leading to referral in men were lung (55%), colorectal (19%), and nasopharyngeal (11%) cancers; in women, they were lung (46%), colorectal (24%), breast (10%), nasopharyngeal (6%), and cervical (5%) cancers. Of the 216 referred patients, 82 (38%) had already undergone surgery, and 18 (8%) received chemoradiation or RT only, all given with curative intent. Among the surgical patients referred, 33 (40%) and 23 (28%) went on to receive adjuvant CT and adjuvant RT respectively. Among 116 patients referred for palliative care, 64 (55%) received CT, 76 (66%) received RT, 43 (37%) received both CT and RT, and 19 (16%) received neither treatment. Median all-stage overall survival was 10 months for patients with lung cancer [95% confidence interval: 6.1 to 13.9 months] and 37 months for patients with colorectal cancer [95% confidence interval: 14.8 to 59.2 months]. Conclusions High uptake of palliative and adjuvant CT and RT was observed in the Inuit patients referred to TOHCC. Lung cancer was the most common cancer in referred Inuit men and women. The survival rates for Inuit lung cancer patients referred to TOHCC were comparable to those in the rest of Canada. Further research is required to understand reasons for non-referral of Canadian Inuit to TOHCC. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented in which the editor discusses the 2013 data from the Canadian Tuberculosis (TB) Reporting System which suggests the incidence rate of active TB disease in Canada has not changed.

The article offers information on a study that used a case-finding method to identify adults in the community with respiratory symptoms but without a diagnosed lung disease. Topics include the study's methodology, which involved enrollment in a randomized trial to determine if early diagnosis and treatment reduce health care utilization and improve outcomes, and the results, which showed lower health care utilization.

Background: Tuberculosis (TB) screening in migrant children, including immigrants, refugees and asylum seekers, is an ongoing challenge in low TB incidence countries. Many children from high TB incidence countries harbor latent TB infection (LTBI), and some have active TB disease at the point of immigration into host nations. Young children who harbor LTBI have a high risk of progression to TB disease and are at a higher risk than adults of developing disseminated severe forms of TB with significant morbidity and mortality. Many countries have developed immigration TB screening programs to suit the needs of adults, but have not focused much attention on migrant children., Objective: To compare the TB immigration medical examination requirements in children in selected countries with high immigration and low TB incidence rates., Design: Descriptive study of TB immigration screening programs for systematically selected countries., Results: Of 18 eligible countries, 16 responded to the written survey and telephone interview., Conclusion: No two countries had the same approach to TB screening among migrant children. The optimal evidenced-based manner in which to screen migrant children requires further research.

Setting: Rates of multidrug-resistant tuberculosis (MDR-TB) are currently as high as 7.7% in retreatment cases in KwaZulu-Natal, South Africa. MDR-TB prevalence is known to be high in patients categorized as treatment failures. Recent reports have questioned the effectiveness of the World Health Organization (WHO) Category II regimen in retreatment TB cases., Objective: To determine whether treatment category predicts susceptibility patterns and outcomes in a hospitalized population of retreatment TB cases., Design: Retrospective cohort of 197 pulmonary retreatment cases., Results: Retreatment cases treated with the standard retreatment regimen had a high in-hospital mortality (19.8%), or poor outcome (26.4%) and a high rate of MDR-TB (16.2%). The 'treatment failure' category predicted resistance, with 57.1% of patients exhibiting any resistance compared to other treatment categories (P = 0.02); 53.8% of patients with any resistance experienced poor outcomes, compared to 16.6% of pan-susceptible cases (P = 0.02). There was a trend towards poor outcome in the treatment failure category (42.9%, P = 0.13)., Conclusion: The retreatment category 'treatment failure' is associated with a high prevalence of resistance in an area of high human immunodeficiency virus (HIV) prevalence. The 'treatment failure' category should be used to identify patients who may benefit from alternative regimens using directed, intensified therapy or second-line agents instead of the current standard retreatment regimen.

Blastomyces dermatitidis is a dimorphic fungus endemic to north-western Ontario, Manitoba and some parts of the United States. The fungus is also endemic to parts of Africa. Pulmonary and extrapulmonary findings of a 24-year-old African man who presented with weight loss, dry cough and chronic pneumonia not resolving with antibiotic treatment are presented. The unusual occurrence of pulmonary blastomycosis associated with skin lesions and a moderate pleural effusion is reported.

Background: Asthma mortality and morbidity continue to be a serious global problem. Systematic reviews provide an opportunity to review risk factors in detail., Objective: To review all of the literature for risk factors associated with near-fatal asthma (NFA) and fatal asthma (FA)., Methods: A literature search from 1960 to January 2004 in MEDLINE and EMBASE was conducted. Studies were included based on the following criteria: NFA was defined as an asthma exacerbation resulting in respiratory arrest requiring mechanical ventilation or a partial pressure of CO2 of at least 45 mmHg or asthma resulting in death (FA); the study reported the number of cases (NFA and/or FA) and asthmatic controls; there was explicit reporting of risk factors; cases that were adult and pediatric in nature; and all study types. Studies that included patients with chronic obstructive pulmonary disease were excluded., Results: Four hundred and three articles were identified, of which 27 met the inclusion criteria. Increased use of medications such as beta-agonists via metered dose inhalers (OR=1.67, 95% CI 0.99 to 2.84, P=0.057) and nebulizers (OR=2.45, 95% CI 1.52 to 3.93, P=0.0002), oral steroids (OR=2.71, 95% CI 1.34 to 5.51, P=0.006) and oral theophylline (OR=2.02, 95% CI 1.03 to 3.98, P=0.04) and a history of hospital (OR=2.62, 95% CI 1.04 to 6.58, P=0.04) and/or intensive care unit (OR=5.14, 95% CI 1.91 to 13.86, P=0.001) admissions and mechanical ventilation (OR=6.69, 95% CI 2.80 to 15.97, P=0.0001) due to asthma were predictors of NFA and FA. Prior emergency department assessment did not confer a greater risk of NFA and FA (OR=1.13, 95% CI 0.43 to 2.92, P=0.810). The use of inhaled corticosteroids (ICS) measured in a dose-independent fashion (did the patient take ICS previously; yes or no) inferred equivocal risk of NFA and FA (OR=1.31, 95% CI 0.83 to 2.05, P=0.25). However, two studies measured the use of ICS in a dose-dependent fashion (ie, measured the number of prescriptions filled within the previous six to 12 months). Both studies showed a trend toward a protective effect against FA. One study showed that the premature cessation of ICS can hasten death., Conclusions: In the present study, risk factors of NFA and FA have been more accurately defined. Clinicians should identify patients with these characteristics to reduce their risk of NFA and FA. Further research should focus on quantifying the impact of risk factors on asthma deaths.

Setting: Edendale Hospital, Pietermaritzburg, KwaZulu Natal, South Africa, a 1275-bed hospital that serves a mainly ethnic African population of 1.6 million., Objective: To describe the demographic and clinical characteristics of hospitalised active tuberculosis (TB) cases, and correlates of their in-hospital survival., Methods: A retrospective cohort study of adult TB cases admitted to the medical wards, 16 November to 13 December 2001., Results: Of 760 (28%) admissions, 215 had active TB, of whom 26.5% died in hospital. Patients were mostly young, first diagnosed on admission, and had pulmonary TB. Human immunodeficiency virus (HIV) co-infection was common and predicted by lower absolute lymphocyte count (OR 1.2, 95% CI 1.05-1.38). Extra-pulmonary TB, including pleural and pericardial, was significantly associated with not having HIV infection. In-hospital death was predicted by TB diagnosed prior to admission (OR 3.18, 95% CI 1.67-6.07), acquired immune-deficiency syndrome (AIDS) associated disease, and higher total leukocyte count--by higher leukocytes only in patients without AIDS (OR 8.52, 95% CI 2.67-27.13)., Conclusion: Active TB was common in in-patients at an acute care hospital. TB patients presented late in disease and had high in-hospital mortality. Early detection and effective treatment of active TB in the community is likely to reduce hospitalisation and improve survival.