bluuebunny/crossref_metadata_2025 huggingface dataset:
Metabolisme Asam Lemak Otot Jantung
Authors: Nurdiana Hawin
Published: July 2018

Otot jantung memiliki ATP content yang relatif rendah (5 μmol/g wet wt) dan hidrolisis ATP yang cepat ( 0.5 μmol · g wetwt–1 · s–1 at rest), jadi pada kondisi normal cadangan ATP mengalami pergantian secara lengkap tiap 10 detik (Stanley et al., 2005). Sekitar 60–70% hidrolisis ATP digunakan untuk kontraksi, sedangkan 30–40% sisanya digunakan untuk sarcoplasmic reticulum Ca2+- ATPase dan pompa ion lainnya (Suga H, 1990). Pada jantung normal kecepatan fosforilasi oksidatif berhubungan dengan kecepatan hidrolisis sehingga ATP content tetap konstan meskipun pada saat kekuatan jantung meningkat hebat (Balaban RS,1990), seperti saatexercise atau stress katekolamin akut. Fosforilasi oksidatif dalam mitokondria dicukupi oleh energi dari elektron yang ditransfer dari hasil reaksi dehidrogenasi yang menghasilkan NADH dan FADH2 pada jalur oksidasi b asam lemak, siklus asam sitrat, dan dalam jumlah kecil oleh reaksi dehidrogenasi piruvat dan glikolisis. Acetyl-CoA yang dibutuhkan dalam siklus asam sitrat dihasilkan dari dekarboksilasi piruvat dan oksidasi asam lemak. Pada jantung yang normal, 60–90% acetyl-CoA berasal dari oksidasi asam lemak dan 10–40% berasal dari oksidasi piruvat yang diperoleh dalam jumlah yang hampir sama dengan yang berasal dari glikolisis dan oksidasi laktat (Stanley et al., 2005). Oksidasi asam lemak mencukupi 60-70% kebutuhan energi otot jantung (Kudo N et al., 1995). Meskipun demikian, mekanisme uptake asam lemak rantai panjang melalui oksidasi b belum sepenuhnya diketahui (Luiken JJ et al., 2001). Kata Kunci: asam lemak, otot jantung
Hubungan antara Kejadian Asites pada Cirrhosis Hepamtis dengan Komplikasi Spontaneous Bacterial Peritonitis
Authors: Setiawan Meddy
Published: July 2018

Cirrhosis Hepatis merupakan hasil akhir dari jejas hepatoseluler yang ireversibel dan menimbulkan fibrosis dan regenerasi nodular pada hepar. Retensi air dan garam tampak jelas sebagai manifestasi klinis pada semua kasus Cirrhosis Hepatis disebut asites. Spontaneous Bacterial Peritonitis adalah komplikasi ketiga terbesar pada pasien dengan Cirrhosis Hepatis walaupun komplikasi tersebut dapat tampakpada pasien asites karena sebab yang lain. Tujuan penelitian ini adalah membuktikan adanya hubungan antara asites pada penderita Cirrhosis Hepatis dengan komplikasi Spontaneous Bacterial Peritonitis. Metode yang digunakan adalah deskriptif analitik dengan data yang diambil dari rekam medis pasienasites rawat inap di Bagian Penyakit Dalam Rumah Sakit Syaiful Anwar Malang pada tahun 2006 (1 Januari 1 – 31 Desember 2006). Data dianalisis dengan menggunakan Uji Chi-Square dan Uji Korelasi Kontingensi. Hasil penelitian menunjukkan, dari tabulasi silang penderita asites dengan Cirrhosis Hepatis dan komplikasi Spontaneous Bacterial Peritonitis, 48 % terdiagnosis Cirrhosis Hepatis dan 52 % non Cirrhosis. 51 % mengalami komplikasi Spontaneous Bacterial Peritonitis dengan 63 % nya terdiagnosa Cirrhosis Hepatis. Hal ini menunjukkan bahwa Komplikasi Spontaneous Bacterial Peritonitis lebih banyakmuncul pada pasien Cirrhosis Hepatis daripada dengan pasien Non-Cirrhosis Hepatis. Kesimpulan penelitian ini adalah adanya hubungan yang signifikan antara ascites pada penderita Cirrhosis Hepatis dengan Komplikasi Spontaneous Bacterial Peritonitis dengan hasil uji Chi-Square (c2 ) = 9,066 dengan p = 0.003 (á < 0,05) dan hasil uji Korelasi Kontingensi = 0.288 dengan p = 0.003 (á < 0,05) menunjukkan keeratan yang positif. Kata Kunci : Cirrhosis Hepatis - Asites - Spontaneous Bacterial Peritonitis (SBP)
Staff dan Redaksi
Authors: . Staff dan Redaksi
Published: July 2018

Staff dan Redaksi
HUBUNGAN LETAK TEMPAT DUDUK DENGAN PENCAPAIAN NILAI AKHIR BLOK MAHASISWA FAKULTAS KEDOKTERAN UMM ANGKATAN 2008
Authors: Krissadi Lovi , Sekar Gita
Published: July 2018

HUBUNGAN LETAK TEMPAT DUDUK DENGAN PENCAPAIAN NILAI AKHIR BLOK MAHASISWAFAKULTAS KEDOKTERAN UMM ANGKATAN 2008. Latar Belakang: Hasil kuliah yang maksimal dipengaruhiletak tempat duduk. Mahasiswa yang duduk di depan mendapatkan hasil yang lebih tinggi dibandingkan mahasiswa yangduduk di belakang. Penelitian mengenai letak tempat duduk berpengaruh terhadap hasil akhir mahasiswa denganmembandingkan rata-rata pencapaian nilai akhir mahasiswa yang duduk di barisan depan dan di barisan belakang.Tujuan: Mengetahui hubungan antara letak tempat duduk dengan pencapaian nilai akhir mahasiswa FK-UMM.Metode: Retrospektif dengan pendekatan crossectional. Sampel mahasiswa mahasiswa FKUMM semester VIIsebanyak 80 mahasiswa yang sedang mengikuti kuliah pakar selama 1 blok. Analisis data menggunakanKolmogorov – Smirnov , uji Levene, T – student independent.Hasil: Rata-rata pencapaian nilai akhir mahasiswa yang duduk di tiga baris depan yaitu 66,32, sedangkan mahasiswayang duduk di tiga baris belakang yaitu 62,3. Pada hasil uji T-student independent didapatkan hubungan yangbermakna antara letak tempat duduk dengan pencapaian nilai akhir blok.Kesimpulan: Ada hubungan antara letak tempat duduk dengan pencapaian nilai akhir blok.
PENGARUH PEMBERIAN BORAKS PERORAL SUB AKUT TERHADAP TERJADINYA ATROFI TESTIS TIKUS PUTIH JANTAN (RATTUS NOVERGICUS STRAIN WISTAR)
Authors: Mayasari Diana , Mardiroharjo Nanang
Published: July 2018

Pengaruh Pemberian Boraks Peroral Sub Akut Terhadap Terjadinya Atrofi Testis Tikus Putih Jantan (Rattus novergicus strain wistar). Latar Belakang: Penggunaan boraks banyak disalahgunakan pada makanan. Boraks merupakan salah satu bahan toksik bagi organ testis sehingga dapat menyebabkan atrofi testis melalui penghambatan spermatogenesis. Tujuan: Membuktikan pengaruh pemberian boraks peroral sub akut terhadap terjadinya atrofi testis tikus putih jantan (Rattus novergicus strain wistar) dengan mengukur diameter testis, berat testis, dan jumlah tubulus seminiferus perlapangpandang. Metode: Eksperimental, The Post Test Only Control Group Design. Sampel yang digunakan 24 ekor dibagi 4 kelompok. Kelompok 1 (kontrol negatif), kelompok 2,3,dan 4 masing-masing dengan dosis 400 mg/kgBB, 500 mg/kgBB, dan 600 mg/kgBB selama 28 hari. Dianalisis dengan oneway ANOVA, uji korelasi, dan uji regresi. Hasil penelitian dan diskusi: Terdapat perbedaan diameter testis dan jumlah tubulus seminiferus masing-masing dengan sig p=0,020 (p<0,05) dan sig p=0,00 (p<0,05), sedangkan pada berat testis tidak terdapat perbedaan dengan sig p=0,744 (p>0,05). Analisis korelasi diameter testis (p=0,001), (r=-0,613), jumlah tubulus (p=0,000), (r=0,828), kenaikan boraks menyebabkan penurunan diameter testis dan peningkatan jumlah tubulus. Analisis regresi R2 diameter testis= 0,376 dan R2 jumlah tubulus=0,685. Pada penelitian ini pengaruh boraks terlihat pada gambaran mikroskopis dibandingkan makroskopis, hal ini disebabkan oleh waktu paparan boraks yang kurang lama. Kesimpulan: Pemberian boraks peroral sub akut berpengaruh terhadap atrofi testis.Kata Kunci: Ekstrak rimpang temulawak, Staphylococcus aureus, KHM (Kadar Hambat Minimum), KBM (Kadar Bunuh Minimum).
PROFIL PENDERITA PENYAKIT KUSTA DI RUMAH SAKIT KUSTA KEDIRI PERIODE JANUARI 2010 SAMPAI DESEMBER 2010
Authors: Qoyyum Nabila Annisa , Adila Nurainiwati Sri , Handaja Djaka
Published: July 2018

PROFIL PENDERITA PENYAKIT KUSTA DI RUMAH SAKIT KUSTA KEDIRI PERIODE JANUARI 2010 SAMPAI DESEMBER 2010. Latar Belakang: Kusta adalah penyakit infeksi kronis yang disebabkan oleh Mycobacterium leprae. Kusta menyebabkan masalah kompleks, meliputi masalah medis, ekonomi, dan sosial. Tujuan: Penelitian ini bertujuan mengetahui profil penderita kusta di Rumah Sakit Kusta Kediri periode Januari 2010 sampai Desember 2010. Metode: Penelitian ini menggunakan metode deskriptif observasional dengan total sampling. Hasil: Diperoleh 120 (6.12%) penderita kusta baru dari 1960 kunjungan. Jenis kelamin terbanyak adalah laki-laki (75%). Kelompok usia terbanyak adalah 35-44 tahun (26.67%). Pekerjaan terbanyak adalah swasta (43.33%). Penderita terbanyak dari Kediri (46.67%). Tipe kusta terbanyak tipe MB (91.67%). Gambaran klinis kusta terbanyak makula (88.33%) dan anastesi (83.33%). Predileksi pembesaran saraf terbanyak pada saraf tibialis posterior (65.41%). Kecacatan terbanyak pada kaki. Tingkat kecacatan mata paling banyak tingkat 0 (95%). Tingkat kecacatan tangan terbanyak tingkat 0 (55.41%). Tingkat kecacatan kaki paling banyak tingkat 1 (44.58%). Reaksi kusta paling banyak adalah tidak terjadi reaksi (79.17%). Kesimpulan: Penderita kusta terbanyak adalah lakilaki. Kelompok usia terbanyak adalah 35-44 tahun. Tipe kusta yang paling banyak adalah tipe MB. Gambaran klinis yang sering ditemukan adalah makula dan anastesi. Kecacatan terbanyak terdapat pada kaki. Tingkat kecacatan pada mata yang terbanyak adalah tingkat 0, pada tangan tingkat 0, dan pada kaki tingkat 1.
PENGARUH PEMBERIAN KOPI TERHADAP PENURUNAN KADAR GLUKOSA DARAH PADA TIKUS PUTIH STRAIN WISTAR DIABETES MELLITUS TIPE 2
Authors: Yustisiani Alifaneta , Andari Desy , . Isbandiyah
Published: July 2018

Penilitian ini bertujuan untuk membuktikan pengaruh kopi terhadap penurunan kadar glukosa darah pada tikus putih strain wistar diabetes mellitus tipe 2.penelitin ini menggunakan metode eksperimen laboratoris rancangan the post test only control group desain. Sampel tikus putih strain wistar dibagi 4 kelompok. Sampel I : kontrol negatif, II: kontrol positif, dua kelompok lainnya diberikan kopi Robusta berbagai dosis (5,4 mL/200 gr BB/ hari, 10,8 mL/200 gr BB/hari). Analisis data menggunakan One Way Anova, uji Tukey 5%, uji korelasi dan uji regresi linier. Hasil uji One Way Anova terdapat pengaruh perlakuan dengan perbedaan yang bermakna terhadap penurunan kadar glukosa darah. Dari uji korelasi terdapat korelasi yang berbanding lurus dan sangat bermakna antara dosis kopi dan jumlah penurunan kadar glukosa darah tikus putih diabetes mellitus tipe 2 dengan nilai Pearson Correlation -0,978 pada glukosa darah puasa dan -0,932 pada glukosa darah 2 jam post pandrial, sedangkan hasil uji regresi didapatkan nilai R2 = 0,956 pada glukosa darah puasa dan 0,869 pada glukosa darah 2 jam post pandrial. Kesimpulan : Pemberian kopi berbagai dosis dapat menurunkan kadar glukosa darah tikus diabetes mellitus tipe 2.Kata kunci : diabetes mellitus tipe 2, kadar glukosa darah, kopi Robusta
EFEK GENISTEIN TOPIKAL TERHADAP EKSPRESI IL-8 PADA KORNEA TIKUS (RATTUS NOVERGICUS STRAIN WISTAR) MODEL INFLAMASI (TRAUMA KIMIA BASA)
Authors: Afkar Zulkarnain Zuhal , Sylvestris Alva , R Ruby
Published: July 2018

Efek Genistein Topikal Terhadap Ekspresi IL-8 Pada Kornea Tikus (Rattus novergicus strain wistar) Model Inflamasi (Trauma Kimia Basa). Latar Belakang: Inflamasi kornea adalah penyakit mata yang paling sering menyebabkan kebutaan. Genistein sebagai anti-inflamasi dapat menghambat IL-8. Tujuan: Mengetahui pengaruh pemberian genistein terhadap ekspresi IL-8 kornea tikus model inflamasi. Metode: The Post Test Only Control Group Design. Hasil dan Diskusi: Uji ANOVA menyimpulkan bahwa terdapat perbedaan bermakna ekspresi IL-8 pada berbagai kelompok perlakuan (Sig 0.000 < p (0.05)). Kesimpulan: Pemberian genistein topikal tetes mata pada kornea tikus putih jantan dapat menurunkan ekspresi IL-8.
EFEK PEMBERIAN SEDUHAN SELEDRI (APIUM GRAVEOLENS L.)TERHADAP KADAR ASAM URAT PADA TIKUS PUTIH JANTAN STRAIN WISTAR (RATTUS NORVEGICUS) HIPERURISEMIA
Authors: Deviandra Reni , Safitri Fathiyah , Handaja Djaka
Published: July 2018

Efek Pemberian Seduhan Seledri (Apium graveolens L.)Terhadap Kadar Asam Urat Pada Tikus Putih Jantan Strain Wistar (Rattus norvegicus) Hiperurisemia. Latar Belakang: Salah satu jenis tanaman yang diduga dapat menurunkan kadar asam urat adalah seledri. Seledri mengandung flavonoid dan 3-n butylphtalide (3nB) dapat menurunkan kadar asam urat dengan menghambat kerja enzim xantin oksidase. Tujuan: Penelitian ini bertujuan untuk mengetahui pengaruh seduhan seledri (Apium graveolens L.) terhadap penurunan kadar asam urat pada tikus putih jantan hiperurisemia. Metode Penelitian: Menggunakan eksperimental murni, dengan rancangan Randomized Post Test Control Group Design. Sampel penelitian dibagi menjadi 5 kelompok. Kelompok I: Kontrol positif (Saripati hati ayam mentah 3 ml/150grBB selama 21 hari + pakan normal selama 7 hari), II, III dan IV: diberikan Saripati hati ayam mentah 3 ml/150grBB selama 21 hari + seduhan seledri dengan dosis 50, 100, 150mg/ekor/hari selama 7 hari, V: Kontrol negatif (Pakan normal selama 28 hari). Pengukuran kadar asam urat dengan menggunakan metode kolometrik enzimatik. Hasil: Hasil pengukuran asam urat kelompok dengan pemberian seduhan seledri dosis 150 mg/ekor/hari menunjukkan kadar asam urat paling rendah (4,679±0,687) dibanding dengan kelompok kontrol positif menunjukkan kadar asam urat paling tinggi (11,563±1,541). Kesimpulan: Ada hubungan antara dosis seduhan seledri (Apium graveolens L.) terhadap kadar asam urat pada tikus putih jantan (Rattus Norvegicus) hiperurisemia.Kata Kunci: Seledri, Hiperurisemia, Kadar Asam Urat, Saripati Hati Ayam,
HUBUNGAN ANTARA PEMAKAIAN OBAT NYAMUK BAKAR DAN FREKUENSI PENYAKIT PARU OBSTRUKSI KRONIK (PPOK)
Authors: Ilyas Nampira Chandra , . Isbandiyah , Farahdila Melany
Published: July 2018

Hubungan Antara Pemakaian Obat Nyamuk Bakar dan Frekuensi Penyakit Paru Obstruksi Kronik (PPOK). Latar Belakang: PPOK menjadi masalah kesehatan masyarakat di Indonesia, dengan penggunaan obat nyamuk bakar sebagai faktor risiko PPOK. Tujuan: Membuktikan hubungan antara pemakaian obat nyamuk bakar dan frekuensi PPOK. Metode: Observasional analitik dengan pendekatan Cross Sectional. Hasil dan Diskusi: Terdapat hubungan yang bermakna antarapemakaian obat nyamuk bakar dan frekuensi PPOK (chi square p-value < 0,05). Kesimpulan: Ada hubungan pemakaian obat nyamuk bakar dan frekuensiPPOK.
Acute Care SINS: Surgical Insights for the Non-surgeon
Authors: Mapiour MD Deng , Brindley MD Peter G. , Brisebois Ronald , Khadaroo MD PhD Rachel G.
Published: July 2018

Fortunately, trauma care is evolving rapidly. Unfortunately, trauma is still ubiquitous and still one of the leading causes of death, especially amongst the young. Trauma skills are now widely taught to surgeons and non-surgeons alike via courses such as the Advanced Trauma Life Support course and the Simulated Trauma and Resuscitation Team Training course. These practical courses emphasize that the initials “MD” really mean “make a decision.”Medical practitioners should understand trauma as a complex, multisystem, and multistage disease. For example, major trauma can cause enormous physiological stresses.This means that frail patients may not survive the acute insultand that others will be left battling the medical consequences (infections, myocardial damage, rhabdomyolysis, wound healing, etc.). Trauma also creates substantial psychological burdens for both patients and caregivers, whether through lost income, depression, divorce, or post-traumatic stress.Above all, there is a growing acceptance that in order to vanquish trauma, we need comprehensive and robust systems, not just doctors trained in isolation. Trauma is evolving into a fascinating science that blends knowledge, manual skills, ongoing practice, and system-wide commitment. Accordingly, trauma belongs in the bailiwick of both surgeons and non- surgeons. This chapter offers a basic primer. If you can establish the mechanism, apply anatomy, and find a modicum of courage, then patients may increasingly live to tell the tale.
HIV Testing: Support for Routine Screening
Authors: Edwards, BSc. Pharm Brett , Vaughan MD DTMH Stephen
Published: July 2018

This article discusses the recent evolution of human immunodeficiency virus (HIV) screening recommendations with significantly expanded role for routine HIV testing. After the Centre for Disease Control (CDC) released recommendations for routine screening in 2006, it was anticipated that the United States Preventive Services Task Force (USPSTF), a national body charged with providing evidence-based recommendations for preventive services, would follow shortly. However, they refrained, citing a lack of evidence at the time to make such a recommendation, and maintained a recommendation for risk-based screening. Following an analysis of recent literature, in 2013 the USPSTF finally made a recommendation for routine HIV screening on the grounds of new evidence. The recommendations are based on the clinical benefit, the failures of risk-based screening, cost-effectiveness data with reduction in HIV related morbidity/mortality, and lower rates of transmission. This article highlights some of the literature that accounted for the change in recommendations and provides a basic review of HIV testing techniques available to the internists and the recommendations for routine screening of patients.
Effect of an Intervention to Improve Team Coordination on Patients Who are Likely to be Discharged by General Internal Medicine
Authors: Pham BA Lina , Arany Teri , Coke MD William , Lo Vivian , Wu MD Robert C.
Published: July 2018

Effective discharge planning is important to ensuring a high quality of patient care and operational efficiency. The general internal medicine (GIM) environment is very complex and fluid, with multiple health professions providing care for patients. This makes coordination of discharges difficult, even with structured daily interprofessional rounds.The purpose of this case-control study was to evaluate a discharge notification form that predicts next-day discharges. The main measures of the study, which took place in GIM wards at two academic teaching hospitals, were the completion and accuracy of the discharge forms, length of stay, discharge times, post-discharge admissions, and emergency department visits.Seventy-six of 200 patients studied had information completed on the discharge notification form. The overall effect appeared to move discharges earlier in the day, while having no effect on length of stay.Patients whose information was completed on the discharge notification form were less likely to have an emergency department visit within 30 days post-discharge.The use of a discharge notification form appears to move discharges earlier in the day, without increasing length of stay. Further refinement and evaluation is necessary to increase usage and assess the impact onoutcomes of care.
Acute Kidney Injury with Polyuria in a Patient with HIV
Authors: Silver Samuel A. , Richardson MD Robert
Published: July 2018

We describe the case of a 30-year-old man with HIV with an elevated creatinine and three litres per day of urine output. Using this patient as a framework, we review a diagnostic approach to acute kidney injury with polyuria. This case emphasizes the importance of a complete diagnostic evaluation of acute kidney injury. Without this approach, it would have been easy to attribute the patient’s acute kidney injury to his HIV and necrotizing peri-anal infection, instead of the true life- threatening cause.
Acute Care SINS: Surgical Insights for the Non-surgeon
Authors: Beed DM Martin , Khadaroo MD PhD R , Singh MD Gurmeet , Brindley MD Peter G
Published: July 2018

Summary “Surgical Insights for the Non-surgeon,” or SINS, is composed of several short chapters intended to cover fundamental surgical knowledge for non-surgeons. The authors focus on surgical pearls, operative insights, and applied anatomy. In Chapter 11 of this series, the authors address cardiothoracic surgical issues.RésuméL’ouvrage « Surgical Insights for the Non-surgeon » (aperçu de la chirurgie à l’intention du non-chirurgien) se compose de courts chapitres couvrant les connaissances fondamentales en chirurgie. Les auteurs se concentrent sur des enseignements tirés de leur expérience, desaspects opératoires et l’anatomie appliquée.
Hemophagocytic Lymphohistiocytosis Associated with Adult Vaccination: A Case of Cytokine Flurries
Authors: Liederman MD Zachary
Published: July 2018

Hemophagocytic Lymphohistiocytosis (HLH) is an often-fatal condition characterized by an overactive but ineffective immune response. Secondary HLH in adults is often caused by infection, autoimmune disease, and malignancy. A 67-year-old woman presented to hospital with a five-day history of malaise beginning hours after receiving influenza and pneumococcal vaccinations. Her medical history was significant for rheumatoid arthritis, controlled with methotrexate and prednisone. In hospital, she was found to have a new febrile pancytopenia that persisted despite empiric antibiotics and discontinuation of methotrexate. The patient did not have any additional clinical or laboratory evidence of an infectious focus or rheumatoid arthritis flare. She had splenomegaly, but there was no definitive evidence of malignancy. Further testing revealed hepatitis, coagulopathy, and an elevated ferritin. Bone marrow biopsy demonstrated hemophagocytosis, and a diagnosis of HLH was made. She was successfully treated with a modified HLH 94 protocol, using dexamethasone and etoposide. Unfortunately, following hospital discharge after being well for 18 months with no HLH relapses, the patient was diagnosed with anaplastic T-cell lymphoma. HLH was likely secondary to a two-hit process with vaccinations in the context of immune dysregulation secondary to rheumatoid arthritis and subclinical lymphoma. To the best of our knowledge, vaccinations have not been linked to adult HLH; therefore, this case illustrates a potentially novel association in a susceptible patient. We propose that HLH should be considered in all patients with unexplained fever and cytopenias, and diagnosis should prompt evaluation for underlying causes, including vaccinations.
Eosinophilia with Granulomatosis and Polyangiitis in a 57-Year-Old Man with Worsening Muscle Pain
Authors: King, MBBS, MSc. Lauren K. , Wright, MD Julie , Pagnoux, MD, MPH Christian , Kwan MD, MPH Janice L.
Published: July 2018

Eosinophilia with granulomatosis and polyangiitis (EGPA, previously called Churg-Strauss syndrome or allergic granulomatosis and angiitis) is an anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis affecting small-sized vessels, which typically occurs in patients with a history of allergic rhinitis or asthma. The most serious cases arise from the involvement of other organ systems, notably the cardiovascular system. Importantly, patients may first exhibit non-specific manifestations such as malaise, fever, anorexia, and weight loss. This variable presentation and the potential for multi-organ involvement can lengthen time to diagnosis and delay treatment.We describe a patient who presented with progressive myalgias on the background of recently diagnosed rhinosinusitis who was ultimately diagnosed with EGPA. This case is meant to alert general internists to the diagnostic challenges of EGPA.
A Streptococcus Intermedius Brain Abscess Causing Obstructive Hydrocephalus and Meningoventriculitis in an Adult Patient With Chronic Granulomatous Disease
Authors: Kamar MD Fareed , Dhingra MD, FRCPC Vinay
Published: July 2018

An inherited abnormality of phagocytosis, chronic granulomatous disease (CGD), represents an immunodeficiency characterized by recurrent infection and granuloma formation due to a genetic defect in NADPH oxidase. The 36-year-old male patient with CGD described in this case featured a brain abscess due to Streptococcus intermedius infection, complicated by meningoventriculitis and obstructive hydrocephalus. His condition was managed with broad-spectrum antibiotics, interferon gamma-1b, and bilateral external ventricular drains. This report addresses a particular paucity in the literature involving Streptococcus intermedius central nervous system infection in the adult CGD population.
Expediting the Diagnosis of Hypertension; The Canadian Hypertension Education Program 2015 Recommendations
Authors: Campbell MD FRCPC Norm , Gelfer MD Mark , Cloutier RN PhD Lyne , Lamarre-Cliche MD MSc Maxime , McLean RN NP PhD Donna , Padwal MD FRCPC Raj
Published: July 2018

The diagnosis of hypertension is fundamental to the practice of medicine. Increased blood pressure (BP) is the second leading global risk factor for death and disability (behind unhealthy diets), accounting for 18% of global deaths (>9 million deaths per year).1 Contemporary guidelines recommend assessing BP at every care visit; thus, BP measurement is probably the most commonly performed diagnostic maneuver in medicine.2 Importantly, evolving technology is making the diagnosis of hypertension more accurate, reliable, and rapid.
Scholarly Success Among Internal Medicine Residents in Canada
Authors: Jerzak MD Katarzyna , Arnold MD MSc Donald M. , Haider MD Shariq
Published: July 2018

Scholar activity is an integral component of postgraduate medical education in Canada. We describe the opportunities in research training among Canadian internal medicine (IM) programs, including program requirements and supportive infrastructure, as well as barriers and enablers of research success. Methods: An email survey was sent to all program directors (PDs) (n = 14) and core IM residents (n = 1119) from English-speaking IM Residency Training Programs in Canada to describe research support and productivity. We evaluated factors associated with achieving an abstract presentation at a scientific meeting or publication of a manuscript in a peer-reviewed journal. Results: A total of 10 of 14 PDs (71%) and 308 of 1119 residents (28%) responded to the survey. Of 10 evaluable programs, 6 had a formal research curriculum and 8 had a mechanism of pairing residents with research mentors. A total of 236 (76%) residents completed a research project during core IM training; of those, 171 (55%) published (n = 84) or presented (n = 150) their research. A mechanism for linking residents with suitable research mentors, instruction on medical writing, and instruction on data analysis were associated with residents' achieving publication in a peer-reviewed journal. Conclusion: Requirements for resident research are variable across Canadian IM programs. Instruction on medical writing and statistics, as well as a mechanism to pair residents with suitable research mentors, contribute to resident research success.
Acute Care SINS: Surgical Insights for the Non-surgeon - Chapter 12: Brain Surgery SINS
Authors: Robichaud MD Aaron S. , Clarke MDCM PhD David B. , O’Kelly MD Cian , Beed DM Martin , Brindley MD Peter G.
Published: July 2018

“Surgical Insights for the Non-surgeon,” or SINS, is composed of several short chapters intended to cover fundamental surgical knowledge for non-surgeons. The authors focus on surgical pearls, operative insights, and applied anatomy. In Chapter 12 of this series, the authors address the brain and neurosurgery Part One.
An Approach to ‘The Social Admission’
Authors: Andrew MD, PhD Melissa K. , Powell, MB, FRCP Colin
Published: July 2018

Although the ‘social admission’ is no doubt a familiar occurrence for most general internists and physicians who work in hospital-based practice, it is difficult to say exactly how common such admissions to hospital are, or what percentage of older people admitted to hospital are seen in this light. Nevertheless, this is frequent enough to merit attention to underlying causes and contributing factors; this is the aim of the current article.
A Rose By Any Other Name?
Authors: Marlin PhD Richard
Published: July 2018

In February of this year, an expert committee of the United States Institute of Medicine (IOM) released a lengthy report in which its members reviewed diagnostic criteria and proposed a new label for chronic fatigue syndrome, also historically referred to as myalgic encephalomyelitis.1 The committee’s proposed new label for this illness is Systemic Exertion Intolerance Disease. The report refers to the fact that a sizeable population is diagnosed with this illness, which causes considerable suffering and functional impairment. Many patients also feel stigmatized because of the label chronic fatigue syndrome.
Spontaneous Four Limb Compartment Syndrome
Authors: Riolo MD Giovanna , Arora MD Danny , Taylor MD David , Wood MBChB, FRCS Gavin CA
Published: July 2018

We present a unique case of atraumatic rhabdomyolysis and four-limb compartment syndrome. Edema and inflammation associated with rhabdomyolysis, was further exacerbated by aggressive saline resuscitation. This resulted in raised compartment pressures and necessitated four-limb fasciotomy. The cause of rhabdomyolysis was most likely multifactorial including systemic capillary leak syndrome seizure, illicit drug use (crack cocaine and methamphetamine) and the prescription medication, mirtazapine.
Developing, Maintaining, and Teaching Clinical Diagnostic Expertise
Authors: Fisher MD Bruce , Rourke, PhD Liam
Published: July 2018

Understanding the process of expert clinical reasoning improves our ability to develop, practice, maintain, teach, and assess clinical diagnostic expertise. The dual process model describes a synergistic interplay of associative thinking and analytical reasoning. These complimentary processes facilitate the efficient abstraction of data from clinical presentations, the identification of key features, and the production of useful problem representations. These are compared unconsciously to prototypical cases stored in memory as illness scripts for a best match. A lack of a satisfactory match may stimulate a conscious, analytic analysis of discordance, ideally reducing bias and error and promoting further script development.An awareness of this process and the use of existing observation and assessment techniques can enable both the teaching and the assessment of clinical reasoning. Learners can also be taught to use these techniques to help develop self-assessment of clinical reasoning performance. Teaching and assessing clinical reasoning in others stimulates clinician teachers to reflect on their own clinical reasoning and practice, serving as an effective form of continuous professional learning.
Tinnitus, Enophthalmos, And Transient Thrombocytopenia As Symptoms Of Metastatic Breast Cancer Without Local Disease
Authors: D’Egidio H.BSc, M.D., M.Eng Gianni , Kyeremanteng MD MHA Kwadwo
Published: July 2018

A 57 year old woman with a past medical history of oculopharyngeal muscular dystrophy presents with tinnitus, thrombocytopenia, and enophthalmos. She then develops subcutaneous skin nodules on her abdomen. Initial biopsies of the cutaneous nodules revealed adenocarcinoma of unknown origin. CT imaging of her chest, abdomen, and pelvis reveal atypical peritoneal carcinomatosis and possible diffuse bone marrow infiltration. CA -125, CEA and CA-19 are negative. Upper and lower endoscopies are normal along with bilateral mammograms of the breast. Repeat biopsy of the skin nodules and bone marrow biopsy reveals lobular carcinoma of the breast. She is treated with hormone modifying therapy for approximately one year but subsequently passes away.
The Morning Report iBook - A Novel Aprroach to the Internal Medicine Morning Report
Authors: Liederman MD Zachary , Patafio MD Francis , Green MD Jordan , Morton MD Ross , Taylor MD David
Published: July 2018

Morning Report is an integral element of residency education, however, changes in training have limited its effectiveness. To improve the effectiveness and accessibility of Morning Report, we developed an innovative electronic teaching resource.
Preparing General Internal Medicine Residents for the Future - Aiming to Match Training to Need - A Pilot Study in Saskatchewan
Authors: Card MD MSc FRCPC Founder GIM Sharon , Ward MD MSc FRCPC Heather , Broberg Lindsey
Published: July 2018

Health care workforce planning is difficult. It is even more so for a generalist specialty such as General Internal Medicine (GIM) as a key feature, worldwide, is the ability and desire of General Internists to adapt to the needs of their local context. Although this adaptability is an important resource for health care systems, it must be planned for in GIM educational curriculums. A pilot study in our province indicates that there are a broad range of competencies that all regions wished for in graduates of GIM programs. There were, however, many varied local needs that must be planned for in addition to ensuring all graduates have the broad skill set of GIM. Regions desired to employ true generalists with potentially an added skill. To truly ensure GIM graduates meet future societal needs will require ongoing links between health intelligence data and curriculum planning.
More Common than You Would Think: A Case of Catecholamine-Secreting Paraganglioma in the Urinary Bladder
Authors: Kerr MD FRCPC Jasmine , Nickel MD FRCSC J. Curtis , Marcotte MD FRCPC Laura
Published: July 2018

A 57-year-old woman presented with headache, palpitations and hypertension associated with micturition and was found to have a bladder tumour on imaging. During cystoscopy, with manipulation of the mass, the patient became symptomatic and hypertensive, and a catecholamine-secreting paraganglioma was suspected. Biochemical testing confirmed the diagnosis of paraganglioma of the urinary bladder and she underwent successful resection after preoperative treatment with alpha- and beta-adrenergic blockade and volume expansion. In this article, we outline the prevalence of extra-adrenal paragangliomas and their possible genetic basis. We also overview the diagnosis, perioperative management, follow-up testing and prognosis of these tumours.
Sheehan's Syndrome Presenting with Hyponatraemia: A Case Report
Authors: Bhattacharya MBBS MD PhD FICP FACP Prasanta Kumar , Roy MBBS Aakash , Jamil MBBS MD Md. , Phukan MBBS MD DM Pranjal , Sarma MBBS Kalyan
Published: July 2018

Sheehan syndrome (SS), or post partum necrosis of the pituitary gland, is a rare complication of post partum haemorrhage usually presenting with failure of lactation and subsequent amenorrhoea. We report a case of a 30-year-old woman with history of secondary amenorrhea and lactational failure following childbirth complicated with severe post partum hemorrhage, who presented to us with anemia, hypotension, acute confusion, neuropsychiatric manifestations, abnormal posturing and severe hyponatraemia. Hormonal assays revealed low pituitary hormones, subnormal levels of cortisol and thyroid hormones, with magnetic resonance imaging of the brain suggestive of SS. Hyponatraemia and late onset neuro-psychiatric manifestations are uncommon presentations of SS. Hence, there should be a high index of clinical suspicion for Sheehan’s syndrome in women with secondary amenorrhea and lactational failure following childbirth, who present with late onset neuro-psychiatric manifestations and hyponatremia.
Conscientious Objection and Medical Assistance in Dying (MAID) in Canada: Difficult Questions - Insufficient Answers
Authors: Brindley MD FRCPC, FRPC Edin, FRCP Lond. Peter G. , Kerrie MD, MSc (bioethics) MD, FRCPC Jeff P.
Published: July 2018

“Conscientious objection” typically implies refusal to participate in an action based on strongly held ethical beliefs. It is historically associated with refusing to fight on the grounds of personal conscience or religion.2 Like other military allusions such as collateral damage or life in the trenches, its usage has spread into wider societal use. Conscientious objection is now used in regards to opposing euthanasia in Canada. Euthanasia, in turn, is now referred to by the less emotive term, Medical Assistance in Dying (MAID). Most medical practitioners and hospitals that object do so in part because of their disagreement or discomfort with the act of killing. As such, the analogy is not wholly unjustified. What is less clear is how this construct, and this terminology, will ultimately affect patients, practitioners, administrators and politicians.
Acute Hepatitis B Co-infection in HIV-Infected Patients Despite Prior Hepatitis B Vaccination
Authors: Rolland S. , Antonova L. , Powis J. , Murdoch T. , Wong D. , James MD, MSc, FRCPC P.
Published: July 2018

Clinicians often assume that patients vaccinated for hepatitis B virus (HBV) have immunity. We report three cases of acute HBV infection in HBV-vaccinated HIV patients. These cases illustrate that patients at an elevated risk of HBV exposure presenting with acute hepatitis should be tested for HBV infection regardless of previous vaccination status.
Cardiac Metastasis: An Often Forgotten Cause of Congestive Heart Failure
Authors: Klassen MD Sheila , D Haffner MD Thomas , A Panju MD Akbar
Published: July 2018

A 35-year-old man, previously healthy, presented to a community hospital with a 1-month history of malaise, significant weight loss, and epigastric pain. Prior to his presentation, he had several episodes of non-bloody emesis, melena and mild exertional dyspnea. There was no significant family history of malignancy. His examination at the time of presentation was unremarkable.
The Admission Hamilton Early Warning Score (HEWS) Predicts the Risk of Critical Event during Hospitalization
Authors: Tam BHSc MD Benjamin , Xu BHSc Michael , Kwong BHSc Cand. Michelle , Wardell BHSc Cand. Christine , Kwong BHSc Cand. Andrew , Fox-Robichaud MSc MD FRCPC Alison
Published: July 2018

Background: Early warning scores detect patients at risk of deterioration in hospital. Our objective was to first, demonstrate that the admission Hamilton Early Warning Score (HEWS) predicts critical events and second, estimate the workload required to identify critical events during hospitalization.Methods: We prospectively identified a consecutive cohort of medical/surgical patients for retrospective review. Critical events were defined as a composite of inpatient death, cardio-pulmonary arrest or ICU transfer. Likelihood of a critical event during hospitalization and the number needed to evaluate to detect a critical event was based on highest admission HEWS.Results: We found 506 critical events occurred in 7130 cases. HEWS identified graduated levels of risk at admission. We found 2.6 and 1.8 patients needed to be evaluated in the ‘high-risk’ and very ‘high-risk’ subgroups to detect a critical event.Conclusions: HEWS identified patients at risk for critical events during hospitalization at ward admission. Few patients with high HEWS required evaluation to detect a critical event.
A Systematic Needs Assessment for Point of Care Ultrasound in Internal Medicine Residency Training Programs
Authors: Lewis Kim , McConnell Meghan , Azzam Khalid
Published: July 2018

Background: Point of Care Ultrasound (PoCUS) is an ultrasound examination performed by the clinician to answer a question or guide a procedure. Few Internal Medicine (IM) programs teach a formal PoCUS curriculum.  The objective of this study is to conduct a systematic needs assessment for the introduction of a PoCUS curriculum to an IM program.Methods: A survey was distributed to all IM staff and residents.  Participants rated their comfort, training, and use of PoCUS.   Descriptive statistics were calculated using SPSS software.Results: Participants self-identified as “neutral” on comfort for using PoCUS for diagnostic applications and many lacked formal diagnostic training (9.7% in residents vs 32% in staff, χ2=10.5, P=0.002). Despite this inexperience, 26.9% of residents use PoCUS for diagnostic applications.Conclusion: A third of residents are using PoCUS despite a lack in formal training, suggesting that PoCUS should be introduced to the IM curriculum
Polyuria: A Pathophysiologic Approach
Authors: Lithgow Kirstie , Corenblum Bernard
Published: July 2018

A 22-year-old man presented with a 3-week history of increased thirst, polydipsia, and polyuria. He described consuming large volumes of water and waking up multiple times throughout the night to drink and urinate. He also endorsed symptoms of fatigue and frequent headaches. Prior to this, he had been well. There was no history of diuretic use, lithium use, or renal disease. There was no prior head trauma, cranial irradiation, or intracranial pathology. He denied consumption of nutritional or protein supplements. Clinical exam revealed a well appearing young man with normal heart rate and blood pressure. Visual fields and general neurologic exam were grossly normal.Baselines investigations revealed serum sodium ranging from 141–142 mmol/L (reference range 133–145 mmol/L), creatinine 92 umol/L (50–120 umol/L), random glucose 5.4  mmol/L (3.3–11.0 mmol/L), potassium 4.0 (3.3–5.1 mmol/L) and ionized calcium 1.25 mmol/L (1.15–1.35 mmol/L).A 24-hour urine collection was arranged, and returned a urine volume of 5.6L (normal less than 3 litres/24  hours). Further investigations revealed a serum sodium of 142 mmol/L, serum osmolality 306 mmol/kg (280–300 mmol/kg), and urine osmolality of 102 mmol/kg (50–1200 mmol/kg). AM cortisol was 372 nmol/L (200–690 nmol/L). These results demonstrated inability to concentrate the urine, despite the physiologic stimulus of hyperosmolarity. Based on this, a presumptive diagnosis of diabetes insipidus was made. The patient was instructed to drink as much as he needed to satiate his thirst, and to avoid fluid restriction. The patient was started on DDAVP intranasal spray, which provided immediate relief from his symptoms. Magnetic resonance imaging of the brain revealed an unremarkable pituitary gland with abnormal thickening of the pituitary stalk and loss of the posterior pituitary bright spot. This confirmed the diagnosis of central diabetes insipidus, presumed secondary to infiltrative disease affecting the pituitary stalk.
A 21-Year-Old Returned Traveller with Typhoid Fever Complicated By a Multifactorial Anemia and Splenic Infarction
Authors: Lai C. Benjamin , Coomes Eric , Whalen-Browne Molly , Kraeker Christian
Published: July 2018

Typhoid fever is a rare disease in North America. We present the case of a 21-year-old female who developed invasive Salmonella typhi infection after returning from rural Pakistan. The patient presented with classic signs of enteric infection including high fever, diarrhea, and a tongue coated in white patches. The patient developed hematologic complications of anemia and splenic infarction. Investigations, imaging studies and treatment are discussed. The case outlines both common and uncommon complications of typhoid fever and reminds the clinician of its importance in the differential of fever in the returning traveller. Four key point to consider are: 1. Fever in a returning traveler has a broad differential diagnosis, but concurrent abdominal symptoms should result in blood cultures to assess for gram-negative bacteria. 2. Ceftriaxone, azithromycin, or fluoroquinolones are the treatments of choice for Salmonella typhi, although clinicians should be aware of increasing resistance to the latter and base treatment on sensitivity testing. 3. Anemia during typhoid fever can be multifactorial and include elements of gastrointestinal blood loss, hemolysis and transient marrow suppression. 4. Spleen involvement can lead to complications such as splenic infarction or abscess formation.
Are We Choosing Wisely in Canada?
Authors: Levine Mitch
Published: July 2018

The Choosing Wisely Canada program is intended to facilitate the more efficient use of health care resources. The program has messages for patients to align their expectations with an evidence based delivery of health care and to increase physician knowledge regarding evidence based directives for the appropriate use of investigations and treatments. In the current issue of CJGIM, an assessment was conducted regarding physician knowledge of the program, and the message was not positive. While many physicians acknowledged awareness of the Choosing Wisely Canada program, an appreciation of the specific messages on how to steer practice to evidence based activity was lacking amongst many. As these were the 33% who agreed to participate in the survey, one can only wonder whether a greater lack of knowledge about the program resides in the 67% that refused to participate. Despite having just laid a foundation of pessimism, I still wonder whether physicians are practicing evidence-based health care even if they do not know the detailed recommendations provided by the Choosing Wisely Canada program. The array of recommendations was developed by professional societies representing different clinical specialties in Canada. The Canadian Society of Internal Medicine (CSIM) established its Choosing Wisely Canada Top 5 recommendations by convening a Committee of 20 members that represented a diverse group of general internists from across Canada, reflecting a broad range of geographical regions, practice settings, institution types and experience.1 Below is the list of the five most recent recommendations targeted for physicians practicing in the field of internal medicine. Don’t routinely obtain neuro-imaging studies (computed tomography, magnetic resonance imaging, or carotid Doppler) in the evaluation of simple syncope in patients with a normal neurological examination.Don’t place, or leave in place, urinary catheters without an acceptable indication (such as critical illness, obstruction, palliative care).Don’t transfuse red blood cells for arbitrary hemoglobin or hematocrit thresholds in the absence of symptoms, active coronary disease, heart failure, or stroke.In the inpatient setting, don’t order repeated CBC and chemistry testing in the face of clinical and lab stability.Don’t routinely perform preoperative testing (such as chest X-rays, echocardiograms, or cardiac stress tests) for patients undergoing low risk surgeries.So, how are you doing in your practice? Mitchell LevineEditor, CJGIM
Hypercalcemia in Colorectal Cancer
Authors: Jamal Rakin , Mariano Caroline
Published: July 2018

Humoral hypercalcemia of malignancy is common in many cancers but is rarely present in colorectal cancers with only 24 documented cases in the literature. In this report, we present a case of a 67-year-old woman complaining of right sided abdominal pain and diarrhea. Imaging showed an obstructing cecal mass and the pathological diagnosis was poorly differentiated adenocarcinoma. After a hemicolectomy, she developed humoral hypercalcemia of malignancy which was treated with intravenous bisphosphonates. She continued to worsen due to her rapid progression of disease and died less than one month after her initial diagnosis. We reviewed the 24 other documented cases to investigate the prognosis of hypercalcemia in colorectal cancers along with reviewing the clinical presentation and management of humoral hypercalcemia of malignancy.

Résumé

L’hypercalcémie humorale maligne est courante dans de nombreux cas de cancers, mais elle est rare dans les cancers colorectaux; la documentation recense 24 cas seulement. Dans le présent article, nous décrivons le cas d’une femme de 67 ans se plaignant de douleurs abdominales du côté droit et de diarrhée. Un examen d’imagerie indiqua la présence d’une masse caecale obstructive dont le diagnostic pathologique s’est avéré être celui d’un adénocarcinome peu différencié. À la suite d’une hémicolectomie, la patiente a développé une hypercalcémie humorale maligne qui a été traitée à l’aide de bisphosphonates intraveineux. Son état a continué de se détériorer en raison de la progression rapide de la maladie et la patiente est décédée moins d’un mois après le diagnostic initial. Nous passons en revue les 24 cas documentés pour analyser les pronostics d’hypercalcémie dans les cas de cancers colorectaux, tout en examinant le tableau clinique et la prise en charge de l’hypercalcémie humorale maligne.