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Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area.

https://arctichealth.org/en/permalink/ahliterature185499
Source
JAMA. 2003 Jun 4;289(21):2801-9
Publication Type
Article
Date
Jun-4-2003
Author
Christopher M Booth
Larissa M Matukas
George A Tomlinson
Anita R Rachlis
David B Rose
Hy A Dwosh
Sharon L Walmsley
Tony Mazzulli
Monica Avendano
Peter Derkach
Issa E Ephtimios
Ian Kitai
Barbara D Mederski
Steven B Shadowitz
Wayne L Gold
Laura A Hawryluck
Elizabeth Rea
Jordan S Chenkin
David W Cescon
Susan M Poutanen
Allan S Detsky
Author Affiliation
University of Toronto, Mount Sinai Hospital, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada.
Source
JAMA. 2003 Jun 4;289(21):2801-9
Date
Jun-4-2003
Language
English
Publication Type
Article
Keywords
Adult
Aged
Anti-Inflammatory Agents - therapeutic use
Antiviral Agents - adverse effects - therapeutic use
Biological Markers - blood
Communicable Diseases, Emerging - blood - diagnosis - epidemiology - therapy
Comorbidity
Cough - etiology
Demography
Disease Outbreaks
Disease Progression
Dyspnea - etiology
Female
Fever - etiology
Hospitalization
Humans
Hydrocortisone - therapeutic use
Infection Control
Intensive Care Units
Lung - radiography
Male
Middle Aged
Ontario - epidemiology
Proportional Hazards Models
Respiration, Artificial
Retrospective Studies
Ribavirin - adverse effects - therapeutic use
SARS Virus - isolation & purification
Severe Acute Respiratory Syndrome - blood - diagnosis - epidemiology - therapy
Statistics, nonparametric
Survival Analysis
Abstract
Severe acute respiratory syndrome (SARS) is an emerging infectious disease that first manifested in humans in China in November 2002 and has subsequently spread worldwide.
To describe the clinical characteristics and short-term outcomes of SARS in the first large group of patients in North America; to describe how these patients were treated and the variables associated with poor outcome.
Retrospective case series involving 144 adult patients admitted to 10 academic and community hospitals in the greater Toronto, Ontario, area between March 7 and April 10, 2003, with a diagnosis of suspected or probable SARS. Patients were included if they had fever, a known exposure to SARS, and respiratory symptoms or infiltrates observed on chest radiograph. Patients were excluded if an alternative diagnosis was determined.
Location of exposure to SARS; features of the history, physical examination, and laboratory tests at admission to the hospital; and 21-day outcomes such as death or intensive care unit (ICU) admission with or without mechanical ventilation.
Of the 144 patients, 111 (77%) were exposed to SARS in the hospital setting. Features of the clinical examination most commonly found in these patients at admission were self-reported fever (99%), documented elevated temperature (85%), nonproductive cough (69%), myalgia (49%), and dyspnea (42%). Common laboratory features included elevated lactate dehydrogenase (87%), hypocalcemia (60%), and lymphopenia (54%). Only 2% of patients had rhinorrhea. A total of 126 patients (88%) were treated with ribavirin, although its use was associated with significant toxicity, including hemolysis (in 76%) and decrease in hemoglobin of 2 g/dL (in 49%). Twenty-nine patients (20%) were admitted to the ICU with or without mechanical ventilation, and 8 patients died (21-day mortality, 6.5%; 95% confidence interval [CI], 1.9%-11.8%). Multivariable analysis showed that the presence of diabetes (relative risk [RR], 3.1; 95% CI, 1.4-7.2; P =.01) or other comorbid conditions (RR, 2.5; 95% CI, 1.1-5.8; P =.03) were independently associated with poor outcome (death, ICU admission, or mechanical ventilation).
The majority of cases in the SARS outbreak in the greater Toronto area were related to hospital exposure. In the event that contact history becomes unreliable, several features of the clinical presentation will be useful in raising the suspicion of SARS. Although SARS is associated with significant morbidity and mortality, especially in patients with diabetes or other comorbid conditions, the vast majority (93.5%) of patients in our cohort survived.
Notes
Comment In: ACP J Club. 2004 Jan-Feb;140(1):1914711290
Comment In: JAMA. 2003 Jun 4;289(21):2861-312734146
Erratum In: JAMA. 2003 Jul 16;290(3):334
PubMed ID
12734147 View in PubMed
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The effect of English language proficiency on length of stay and in-hospital mortality.

https://arctichealth.org/en/permalink/ahliterature181208
Source
J Gen Intern Med. 2004 Mar;19(3):221-8
Publication Type
Article
Date
Mar-2004
Author
Ava John-Baptiste
Gary Naglie
George Tomlinson
Shabbir M H Alibhai
Edward Etchells
Angela Cheung
Moira Kapral
Wayne L Gold
Howard Abrams
Maria Bacchus
Murray Krahn
Author Affiliation
Division of General Internal Medicine, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada.
Source
J Gen Intern Med. 2004 Mar;19(3):221-8
Date
Mar-2004
Language
English
Publication Type
Article
Keywords
Aged
Canada
Communication
Communication Barriers
Female
Hospital Mortality
Humans
Language
Length of Stay - statistics & numerical data
Male
Odds Ratio
Patient Admission - statistics & numerical data
Retrospective Studies
Abstract
In ambulatory care settings, patients with limited English proficiency receive lower quality of care. Limited information is available describing outcomes for inpatients.
To investigate the effect of English proficiency on length of stay (LOS) and in-hospital mortality.
Retrospective analysis of administrative data at 3 tertiary care teaching hospitals (University Health Network) in Toronto, Canada.
Consecutive inpatient admissions from April 1993 to December 1999 were analyzed for LOS differences first by looking at 23 medical and surgical conditions (59,547 records) and then by a meta-analysis of 220 case mix groups (189,119 records). We performed a similar analysis for in-hospital mortality.
LOS and odds of in-hospital death for limited English-proficient (LEP) patients relative to English-proficient (EP) patients.
LEP patients stayed in hospital longer for 7 of 23 conditions (unstable coronary syndromes and chest pain, coronary artery bypass grafting, stroke, craniotomy procedures, diabetes mellitus, major intestinal and rectal procedures, and elective hip replacement), with LOS differences ranging from approximately 0.7 to 4.3 days. A meta-analysis using all admission data demonstrated that LEP patients stayed 6% (approximately 0.5 days) longer overall than EP patients (95% confidence interval, 0.04 to 0.07). LEP patients were not at increased risk of in-hospital death (relative odds, 1.0; 95% confidence interval, 0.9 to 1.1).
Patients with limited English proficiency have longer hospital stays for some medical and surgical conditions. Limited English proficiency does not affect in-hospital mortality. The effect of communication barriers on outcomes of care in the inpatient setting requires further exploration, particularly for selected conditions in which length of stay is significantly prolonged.
Notes
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Comment In: J Gen Intern Med. 2004 Mar;19(3):288-9015009787
PubMed ID
15009776 View in PubMed
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The impact of severe acute respiratory syndrome on medical house staff: a qualitative study.

https://arctichealth.org/en/permalink/ahliterature174259
Source
J Gen Intern Med. 2005 May;20(5):381-5
Publication Type
Article
Date
May-2005
Author
Gloria Rambaldini
Kumanan Wilson
Darlyne Rath
Yulia Lin
Wayne L Gold
Moira K Kapral
Sharon E Straus
Author Affiliation
Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada.
Source
J Gen Intern Med. 2005 May;20(5):381-5
Date
May-2005
Language
English
Publication Type
Article
Keywords
Adult
Communication
Disease Outbreaks
Humans
Internal Medicine - education
Internship and Residency
Ontario
Patient Education as Topic
Qualitative Research
Severe Acute Respiratory Syndrome - epidemiology - therapy
Social Isolation
Stress, Psychological
Abstract
To explore the impact of severe acute respiratory syndrome (SARS) on a medical training program and to develop principles for professional training programs to consider in dealing with future, similar crises.
Qualitative interviews analyzed using grounded theory methodology.
University-affiliated hospitals in Toronto, Canada during the SARS outbreak in 2003.
Medical house staff who were allocated to a general internal medicine clinical teaching unit, infectious diseases consultation service, or intensive care unit.
Seventeen medical residents participated in this study. Participants described their experiences during the outbreak and highlighted several themes including concerns about their personal safety and about the negative impact of the outbreak on patient care, house staff education, and their emotional well-being.
The ability of residents to cope with the stress of the SARS outbreak was enhanced by the communication of relevant information and by the leadership of their supervisors and infection control officers. It is hoped that training programs for health care professionals will be able to implement these tenets of crisis management as they develop strategies for dealing with future health threats.
Notes
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Comment In: J Gen Intern Med. 2006 Jan;21(1):10116423134
Comment In: J Gen Intern Med. 2005 Oct;20(10):97316191156
PubMed ID
15963157 View in PubMed
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Impact on health care workers employed in high-risk areas during the Toronto SARS outbreak.

https://arctichealth.org/en/permalink/ahliterature159132
Source
J Psychosom Res. 2008 Feb;64(2):177-83
Publication Type
Article
Date
Feb-2008
Author
Rima Styra
Laura Hawryluck
Susan Robinson
Sonja Kasapinovic
Calvin Fones
Wayne L Gold
Author Affiliation
Department of Psychiatry, University Health Network, University of Toronto, Toronto, Ontario, Canada. rima.styra@uhn.on.ca
Source
J Psychosom Res. 2008 Feb;64(2):177-83
Date
Feb-2008
Language
English
Publication Type
Article
Keywords
Adult
Canada - epidemiology
Catchment Area (Health)
Demography
Disease Outbreaks
Employment
Factor Analysis, Statistical
Female
Health Personnel - statistics & numerical data
Health status
Humans
Male
Occupational Diseases - epidemiology - etiology
Occupational Exposure - adverse effects
Questionnaires
Risk factors
Severe Acute Respiratory Syndrome - epidemiology - physiopathology
Abstract
A number of publications focusing on health care workers (HCWs) during a severe acute respiratory syndrome (SARS) outbreak have suggested that HCWs experienced psychological distress, particularly increased levels of posttraumatic stress symptomatology (PTSS). Factors contributing to increased distress in HCWs working in high-risk areas treating patients with SARS have not been fully elucidated. The goal of this study was to quantify the psychological effects of working in a high-risk unit during the SARS outbreak.
HCWs in a Toronto hospital who worked in high-risk areas completed a questionnaire regarding their attitude toward the SARS crisis along with the Impact of Event Scale-Revised, which screens for PTSS. The comparison group consisted of clinical units that had no contact with patients infected with SARS.
Factors that were identified to cause distress in the 248 respondent HCWs were the following: (a) perception of risk to themselves, (b) impact of the SARS crisis on their work life, (c) depressive affect, and (d) working in a high-risk unit. In addition, HCWs who cared for only one SARS patient in comparison to those caring for multiple SARS patients experienced more PTSS.
As expected, HCWs who were working in high-risk units experienced greater distress. Contrary to expectations, HCWs who experienced greater contact with SARS patients while working in the high-risk units were less distressed. This suggests that HCW experience in treating patients infected with SARS may be a mediating factor that could be amenable to intervention in future outbreaks.
PubMed ID
18222131 View in PubMed
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Interpretation of diagnostic laboratory tests for severe acute respiratory syndrome: the Toronto experience.

https://arctichealth.org/en/permalink/ahliterature182157
Source
CMAJ. 2004 Jan 6;170(1):47-54
Publication Type
Article
Date
Jan-6-2004
Author
Patrick Tang
Marie Louie
Susan E Richardson
Marek Smieja
Andrew E Simor
Frances Jamieson
Margaret Fearon
Susan M Poutanen
Tony Mazzulli
Raymond Tellier
James Mahony
Mark Loeb
Astrid Petrich
Max Chernesky
Allison McGeer
Donald E Low
Elizabeth Phillips
Steven Jones
Nathalie Bastien
Yan Li
Daryl Dick
Allen Grolla
Lisa Fernando
Timothy F Booth
Bonnie Henry
Anita R Rachlis
Larissa M Matukas
David B Rose
Reena Lovinsky
Sharon Walmsley
Wayne L Gold
Sigmund Krajden
Author Affiliation
University of Toronto , Ont.
Source
CMAJ. 2004 Jan 6;170(1):47-54
Date
Jan-6-2004
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Aged, 80 and over
Clinical Laboratory Techniques - standards
Communicable Diseases, Emerging - diagnosis - epidemiology
Diagnosis, Differential
Female
Humans
Male
Middle Aged
Ontario - epidemiology
Reverse Transcriptase Polymerase Chain Reaction
Sensitivity and specificity
Severe Acute Respiratory Syndrome - diagnosis - epidemiology
Abstract
An outbreak of severe acute respiratory syndrome (SARS) began in Canada in February 2003. The initial diagnosis of SARS was based on clinical and epidemiological criteria. During the outbreak, molecular and serologic tests for the SARS-associated coronavirus (SARS-CoV) became available. However, without a "gold standard," it was impossible to determine the usefulness of these tests. We describe how these tests were used during the first phase of the SARS outbreak in Toronto and offer some recommendations that may be useful if SARS returns.
We examined the results of all diagnostic laboratory tests used in 117 patients admitted to hospitals in Toronto who met the Health Canada criteria for suspect or probable SARS. Focusing on tests for SARS-CoV, we attempted to determine the optimal specimen types and timing of specimen collection.
Diagnostic test results for SARS-CoV were available for 110 of the 117 patients. SARS-CoV was detected by means of reverse-transcriptase polymerase chain reaction (RT-PCR) in at least one specimen in 59 (54.1%) of 109 patients. Serologic test results of convalescent samples were positive in 50 (96.2%) of 52 patients for whom paired serum samples were collected during the acute and convalescent phases of the illness. Of the 110 patients, 78 (70.9%) had specimens that tested positive by means of RT-PCR, serologic testing or both methods. The proportion of RT-PCR test results that were positive was similar between patients who met the criteria for suspect SARS (50.8%, 95% confidence interval [CI] 38.4%-63.2%) and those who met the criteria for probable SARS (58.0%, 95% CI 44.2%-70.7%). SARS-CoV was detected in nasopharyngeal swabs in 33 (32.4%) of 102 patients, in stool specimens in 19 (63.3%) of 30 patients, and in specimens from the lower respiratory tract in 10 (58.8%) of 17 patients.
These findings suggest that the rapid diagnostic tests in use at the time of the initial outbreak lack sufficient sensitivity to be used clinically to rule out SARS. As tests for SARS-CoV continue to be optimized, evaluation of the clinical presentation and elucidation of a contact history must remain the cornerstone of SARS diagnosis. In patients with SARS, specimens taken from the lower respiratory tract and stool samples test positive by means of RT-PCR more often than do samples taken from other areas.
Notes
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PubMed ID
14707219 View in PubMed
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The laboratory impact of changing syphilis screening from the rapid-plasma reagin to a treponemal enzyme immunoassay: a case-study from the Greater Toronto Area.

https://arctichealth.org/en/permalink/ahliterature141580
Source
Sex Transm Dis. 2011 Mar;38(3):190-6
Publication Type
Article
Date
Mar-2011
Author
Sharmistha Mishra
Marie-Claude Boily
Victoria Ng
Wayne L Gold
Tom Okura
Marsha Shaw
Tony Mazzulli
David N Fisman
Author Affiliation
Division of Infectious Diseases, University of Toronto, and Department of Microbiology, Mount Sinai Hospital, Toronto, Ontario, Canada. sharmistha.mishra@utoronto.ca
Source
Sex Transm Dis. 2011 Mar;38(3):190-6
Date
Mar-2011
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Child
Female
Humans
Immunoenzyme Techniques - methods - utilization
Incidence
Linear Models
Male
Mass Screening - methods
Middle Aged
Ontario
Reagins - blood
Retrospective Studies
Sensitivity and specificity
Syphilis - blood - diagnosis - epidemiology - immunology
Syphilis Serodiagnosis - methods
Treponema pallidum - immunology - isolation & purification
Young Adult
Abstract
In 2005, syphilis screening in the Greater Toronto Area of Canada moved from the rapid plasma reagin (RPR) to a treponemal enzyme immunoassay (EIA). We sought to understand the consequences of this change on laboratory results and testing patterns with a population-based retrospective study of laboratory-based diagnoses of syphilis.
Samples positive under RPR (1998-2005) and EIA (2005-2008) screening were confirmed with an alternate treponemal test, and during the latter period underwent RPR testing. We compared monthly rates and the forecasting relationship between positives and future submissions with time-series methods, and assessed risk factors for EIA(+)/RPR(-) results using Poisson regression.
A total of 3,092,938 submissions were included. Following EIA implementation, confirmed positive rates increased by 10.3 per 100,000 population (P50 years (IRR: 2.4, 95% CI: 1.6-3.5) than those with EIA(+)/RPR(+) results. We detected a significant positive feedback loop between positive tests and subsequent submissions. This relationship was only transiently evident for EIA(+)/RPR(-) results up to 1 year following the changeover.
EIA screening facilitates identification of probable latent syphilis and earlier serological detection of infectious syphilis, but may transiently cause increases in testing and indirectly suggests that physicians' interpretation of RPR(-) serology may lead to partner testing. In the absence of a true gold standard, implementation of EIA screening warrants careful communication regarding serological interpretation.
PubMed ID
20706176 View in PubMed
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Morning report blog: a web-based tool to enhance case-based learning.

https://arctichealth.org/en/permalink/ahliterature122771
Source
Teach Learn Med. 2012;24(3):238-41
Publication Type
Article
Date
2012
Author
Isaac I Bogoch
David W Frost
Suzanne Bridge
Todd C Lee
Wayne L Gold
Daniel M Panisko
Rodrigo B Cavalcanti
Author Affiliation
Herbert Ho Ping Kong Centre of Excellence in Education and Practice, Toronto Western Hospital, Toronto, Ontario, Canada. Isaac.Bogoch@utoronto.ca
Source
Teach Learn Med. 2012;24(3):238-41
Date
2012
Language
English
Publication Type
Article
Keywords
Blogging
Data Collection
Education, Medical - methods
Educational Measurement - methods
Educational Status
Faculty, Medical
Humans
Internet
Ontario
Problem-Based Learning - methods
Teaching - methods
Abstract
Morning report is an interactive case-based teaching session common to internal medicine training programs across North America.
We report here on a morning report web log ("blog"), created and updated after morning report sessions by the Chief Medical Resident with pertinent clinical topics, links to journal articles, and medical images. Trainees on their internal medicine rotation were e-mailed a web link with each posting. The aim was to enhance learning on clinical topics discussed at morning report by reinforcing topics and promoting further reading.
The educational impact of the blog was evaluated using detailed web metrics and surveys of attendees. The intended audience spent on average more than 5 min reading the blog and viewed more than 3 pages per visit. Almost half of attendees accessed the blog after completing their internal medicine rotation. The blog was also accessed by a global audience. Trainees rated the blogs a useful learning tool and cited it to be among the top 3 educational resources accessed during their rotation.
In summary, a morning report blog was perceived by learners to be an effective complement to case-based teaching sessions. The combination of novel web metrics and survey data allowed for a multifaceted evaluation of the educational impact of the blog.
PubMed ID
22775788 View in PubMed
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One-year outcomes and health care utilization in survivors of severe acute respiratory syndrome.

https://arctichealth.org/en/permalink/ahliterature162831
Source
Arch Intern Med. 2007 Jun 25;167(12):1312-20
Publication Type
Article
Date
Jun-25-2007
Author
Catherine M Tansey
Marie Louie
Mark Loeb
Wayne L Gold
Matthew P Muller
JoAnne de Jager
Jill I Cameron
George Tomlinson
Tony Mazzulli
Sharon L Walmsley
Anita R Rachlis
Barbara D Mederski
Mike Silverman
Zev Shainhouse
Issa E Ephtimios
Monica Avendano
James Downey
Rima Styra
Deborah Yamamura
Marvin Gerson
Matthew B Stanbrook
Theodore K Marras
Elizabeth J Phillips
Noë Zamel
Susan E Richardson
Arthur S Slutsky
Margaret S Herridge
Author Affiliation
Department of Medicine, University Health Network, and Mount Sinai Hospital, Toronto, Ontario, Canada.
Source
Arch Intern Med. 2007 Jun 25;167(12):1312-20
Date
Jun-25-2007
Language
English
Publication Type
Article
Keywords
Adult
Delivery of Health Care - utilization
Disability Evaluation
Disease Outbreaks
Female
Follow-Up Studies
Humans
Male
Middle Aged
Ontario - epidemiology
Outcome Assessment (Health Care)
Prognosis
Prospective Studies
Quality of Life
Questionnaires
Respiratory Function Tests
Severe Acute Respiratory Syndrome - epidemiology - physiopathology - rehabilitation
Walking - physiology
Abstract
Severe Acute Respiratory Syndrome (SARS) became a global epidemic in 2003. Comprehensive information on 1-year outcomes and health care utilization is lacking. Research conducted during the SARS outbreak may help inform research planning for future public health emergencies. The objective of this study was to evaluate the 1-year outcomes in survivors of SARS and their family caregivers.
The study was prospective and observational. We evaluated 117 SARS survivors from Toronto, Ontario. Patients were interviewed and underwent physical examination, pulmonary function testing, chest radiography, a 6-minute-walk test, quality-of-life measures, and self-report of health care utilization. At 1 year, informal caregivers were identified for a survey on caregiver burden.
The enrolled survivors of SARS were young (median age, 42 years), and most were women (67%) and health care workers (65%). At 1 year after hospital discharge, pulmonary function measures were in the normal range, but 18% of patients had a significant reduction in distance walked in 6 minutes. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) domains were 0.3 to 1.0 SD below normal at 1 year. Of the patients, 17% had not returned to work by 1 year. Fifty-one patients required 668 visits to psychiatry or psychology practitioners. During the SARS epidemic, informal caregivers reported a decline of 1.6 SD below normal on the mental component score of the SF-36.
Most SARS survivors had good physical recovery from their illness, but some patients and their caregivers reported a significant reduction in mental health 1 year later. Strategies to ameliorate the psychological burden of an epidemic on the patient and family caregiver should be considered as part of future pandemic planning.
PubMed ID
17592106 View in PubMed
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Outbreak of acupuncture-associated cutaneous Mycobacterium abscessus infections.

https://arctichealth.org/en/permalink/ahliterature165574
Source
J Cutan Med Surg. 2006 Jul-Aug;10(4):166-9
Publication Type
Article
Author
Patrick Tang
Scott Walsh
Christian Murray
Cecilia Alterman
Monali Varia
George Broukhanski
Pamela Chedore
Joel DeKoven
Dalal Assaad
Wayne L Gold
Danny Ghazarian
Michael Finkelstein
Marjolyn Pritchard
Barbara Yaffe
Frances Jamieson
Bonnie Henry
Elizabeth Phillips
Author Affiliation
Department of Laboratory Medicine, Toronto, ON, Canada.
Source
J Cutan Med Surg. 2006 Jul-Aug;10(4):166-9
Language
English
Publication Type
Article
Keywords
Acupuncture Therapy - adverse effects
Adult
Aged
Aged, 80 and over
Disease Outbreaks
Female
Humans
Infection Control - standards
Male
Middle Aged
Mycobacterium Infections, Nontuberculous - epidemiology - etiology
Needles
Ontario - epidemiology
Retrospective Studies
Skin Diseases, Bacterial - epidemiology - etiology
Abstract
Cutaneous atypical mycobacterial infections have been increasingly described in association with cosmetic and alternative procedures.
We report an outbreak of acupuncture-associated mycobacteriosis. Between April and December 2002, 32 patients developed cutaneous mycobacteriosis after visiting an acupuncture practice in Toronto, Canada.
Of 23 patients whose lesions were biopsied, 6 (26.1%) had culture-confirmed infection with Mycobacterium abscessus. These isolates were genetically indistinguishable by amplified fragment length polymorphism. The median incubation period was 1 month. Of 24 patients for whom clinical information was available, 23 (95.8%) had resolution of their infection. All patients developed residual scarring or hyperpigmentation.
Nontuberculous mycobacteria should be recognized as an emerging, but preventable, cause of acupuncture-associated infections.
PubMed ID
17234114 View in PubMed
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13 records – page 1 of 2.