bluuebunny/crossref_metadata_2025 huggingface dataset:
PROFIL HASIL PEMERIKSAAN MINI MENTAL STATEEXAMINATION (MMSE) PADA WANITA POSTMENOPAUSE DI POSYANDU LANSIA REJOAGUNG, WILAYAH KERJA PUSKESMAS KEDUNGWARU, TULUNGAGUNG, JAWA TIMUR
Authors: Wildan Muhamad , Ma’roef M , Djauhari Tonthowi
Published: July 2018

Profil Hasil Pemeriksaan Mini Mental State Examination (MMSE) pada Wanita Postmenopause di Posyandu Lansia Rejoagung, Wilayah kerja puskesmas Kedungwaru, Tulungagung, Jawa timur. Wanita pada masa postmenopause akan mengalami penurunan produksi hormon estrogen. Beberapa penelitian menunjukkan bahwa menurunnya hormon estrogen dapat menyebabkan terjadinya aterosklerosis yang merupakan salah satu faktor penyebab gangguan kognitif. Penelitian ini bertujuan mengetahui profil hasil pemeriksaan MMSE pada wanita postmenopause. Penelitian ini merupakan studi deskriptif observasional dengan pengambilan sampel secara total sampling terhadap semua wanita di posyandu lansia Rejoagung yang sudah postmenopause. Instrumen yang digunakan ialah Mini Mental State Examination. Hasil pemeriksaan MMSE wanita postmenopause didapatkan insiden gangguan kognitif terbanyak pada usia 65-69 tahun, dengan 31,2% stadium ringan dan 56,3% stadium sedang. Insiden gangguan kognitif terbanyak terjadi pada wanita postmenopause dengan pendidikan terakhir SMP dengan 54% stadium ringan. Didapatkan juga gangguan kognitif terbanyak pada wanita dengan lama masa postmenopause 11-15 tahun sekitar 45% gangguan kognitif stadium ringan dan wanita dengan lama masa postmenopause >15 tahun sekitar 33,3% stadium sedang. Berdasarkan hasil pemeriksaan MMSE pada wanita postmenopause didapatkan sebanyak 45% dari sampel yang mengalami gangguan kognitif dan 55% yang tidak mengalami gangguan kognitif.Kata kunci: Wanita postmenopause, gangguan kognitif, MMSE
PENGARUH AKAR PASAK BUMI (Eurycoma Longifolia) TERHADAP PENURUNAN KADAR SERUM GLUTAMIC OXSALOASETIC TRANSAMINASE (SGOT) DAN SERUM GLUTAMIC PYRUVIC TRANSAMINASE (SGPT) PADA TIKUS PUTIH (Rattus novergicus) YANG DIINDUKSI KARBON TETRAKLORIDA
Authors: Shiyamita Dian , Noer W Abi , Hanifwati Anisa
Published: July 2018

Pengaruh Akar Pasak Bumi (Eurycoma longifolia) terhadap Penurunan Kadar Serum Glutamic Oxsaloasetic Transaminase (SGOT) dan Serum Glutamic Pyruvic Transaminase (SGPT) pada Tikus Putih (Rattus novergicus) yang Diinduksi Karbon Tetraklorida. Latar Belakang: Kerusakan hati dapat disebabkan oleh hepatoksin yaitu CCl4. Hepatoksin ini dapat menyebabkan peningkatan kadar SGOT dan SGPT. Akar pasak bumi (Eurycoma Longifolia) mengandung senyawa golongan alkaloid dan quassinoid. Senyawa ini dapat berperan dalam memperbaiki peroksidasi lipid sehingga mencegah nekrosis dari sel. Tujuan: Untuk membuktikan adanya pengaruh ekstrak akar pasak bumi terhadap penurunan kadar SGOT dan SGPT pada tikus putih yang diinduksi CCl4. Metode :Jenis penelitian eksperimental,populasi tikus putihjantan dengan sampel 25 ekor yang terbagi menjadi5 kelompok perlakuan.CCl4 diberikan dengan injeksi sub kutan dengan dosis 1,3 mg/kg BB. Ekstrak akar pasak bumidiberikan dengan 750 mg/Kg, 1000 mg/kg, dan 1250 mg/kg. Hasil: Hasil uji One Way Anova menunjukan penurunan kadar SGOT dan SGPT tikus putih secara sangat bermakna (p< 0,01) dengan pemberian ekstrak akar pasak bumi. Dari hasil uji regresi menunjukkan koefisien determinan SGOT = 0, 919 dan SGPT = 0,860. Penurunan kadar SGOT dan SGPT telah mencapai kadar normal dengan dosis 1250 mg/kg BB. Kesimpulan : Pemberian ekstrak akar pasak bumi dapat menurunkan kadar SGOT dan SGPT tikus putih yang diinduksi CCl4.
PENGARUH OLAHRAGA BERSEPEDA DALAM MENURUNKAN DERAJAT DISMENORE PADA MAHASISWI FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH MALANG ANGKATAN 2008
Authors: Fatmawati Masrida , Hasanah Anissa , . Isbandiyah
Published: July 2018

Pengaruh Olahraga Bersepeda Dalam Menurunkan Derajat Dismenore pada Mahasiswi Fakultas Kedokteran Universitas Muhammadiyah Malang Angkatan 2008. Latar Belakang: Dismenore banyak dialami wanita. Di Indonesia angka kejadian dismenore sebesar 64,25%. Bersepeda merupakan salah satu pengobatan non-medikamentosa yang menurunkan derajat dismenore. Tujuan: Mengetahui pengaruh olahraga bersepeda dalam menurunkan derajat dismenore. Metode: Penelitian dilakukan bulan Februari – Maret 2012, menggunakan metode observasi analitik pendekatan secara kohort. Sampel penelitian 38 mahasiswi dan dibagi menjadi 2 kelompok, kelompok perlakuan olahraga bersepeda selama 1 bulan dan kelompok kontrol tanpa olahraga bersepeda. Hasil: Analisis menggunakan uji-t berpasangan. Hasil penelitian menunjukkan nilai t- hitung 7,398, dan nilai signifikansi 0,000 yang artinya terdapat pengaruh olahraga bersepeda dalam menurunkan derajat dismenore. Hasil perhitungan menggunakan uji korelasi rank didapatkan hasil sebesar 66,3% yang artinya besar pengaruh olahraga bersepeda dalam menurunkan derajat dismenore sebesar 66,3%. Insiden dismenore mahasiswi Fakultas Kedokteran Universitas Muhammadiyah Malang angkatan 2008 sebesar 62,5% dari 72 mahasiswi. Derajat dismenore terbanyak sebelum melakukan olahraga bersepeda adalah derajat sedang (skala 6 VAS), 31,6% untuk kelompok perlakuan dan 36,8% untuk kelompok kontrol. Derajat dismenore terbanyak setelah melakukan olahraga bersepeda adalah derajat ringan (skala 2 VAS) sebesar 47,7% untuk kelompok perlakuan dan derajat sedang sebesar 42,1% untuk kelompok kontrol. Kesimpulan: Olahraga bersepeda berpengaruh dalam penurunan derajat dismenore pada mahasisiwi Fakultas Kedokteran Universitas Muhammadiyah Malang angkatan 2008.
PENGARUH REBUSAN DAUN SIRIH MERAH (Piper Crocatum) TERHADAP PENURUNAN KADAR GULA DARAH PADA TIKUS PUTIH (Rattus norvegicus YANG DIINDUKSI Alloxan)
Authors: Hati Kusuma , Setiawan Meddy , Yuliarta Dian
Published: July 2018

Latar Belakang : Pengobatan diabetes mellitus dengan obat anti diabetes sintetis sering menimbulkan efek samping. Untuk itu perlu dikembangkan system pengobatan tradisional sebagai alternatif pengobatan diabetes yang aman dan mudah cara pembuatannya, yaitu daun sirih merah (Piper crocatum). Tujuan penelitian : Untuk membuktikan adanya pengaruh rebusan daun sirih merah terhadap penurunan kadar gula darah pada tikus putih yang diinduksi alloxan Metode Penelitian : Jenis penelitian eksperimental, populasi tikus putih jantan dengan sampel 24 ekor yang terdiri dari 6 kelompok perlakuan dan 4 kali pengulangan. Alloxan diberikan pada hari ke-8 sampai dengan hari ke-14 dan rebusan daun sirih merah diberikan pada hari ke-15 sampai hari ke-28. Pemeriksaan kadar gula darah pada tikus putih dilakukan pada hari ke-7, ke- 14, dan ke-28. Hasil Penelitian : Hasil uji One Way Anova menunjukan adanya pengaruh perlakuan terhadap penurunan kadar gula darah tikus putih secara sangat bermakna (p< 0,01). Koefisien korelasi = 0,925 menunjukan korelasi positif yang kuat antara dosis rebusan daun sirih merah dengan penurunan kadar gula darah. Kesimpulan : Pemberian rebusan daun sirih merah dapat menurunkan kadar gula darah tikus putih yang diinduksi alloxan.Kata kunci : Daun sirih merah, kadar gula darah
EFEKTIFITAS PELAKSANAAN 3M (MENGURAS, MENUTUP, DAN MENGUBUR) UNTUK MENURUNKAN KEJADIAN DEMAM BERDARAH DENGUE (DBD) DI KOTA BLITAR PADA PERIODE 2010-2011
Authors: Prasetyo Utomo Ari , Ningsih Soebakti , EBS Febri
Published: July 2018

EFEKTIFITAS PELAKSANAAN 3M (MENGURAS, MENUTUP, DAN MENGUBUR) UNTUK MENURUNKAN KEJADIAN DEMAM BERDARAH DENGUE (DBD) DI KOTA BLITAR PADA PERIODE 2010-2011. Penyakit DBD di Indonesia merupakan penyakit yangmematikan dengan angka kejadian yang meningkat dari tahun ke tahun. Akan tetapi di Kota Blitar pada periode 2010-2011 terjadi penurunan kasus yang cukup signifikan. Tujuan : mengetahui tingkat efektifitas pelaksanaan 3M untuk mencegah kasus DBD di Kota Blitar. Metode : Deskriptif analitik dengan uji korelasi row Spearman. Pengambilan sampel secara random sampling, besar sampel yang memenuhi kriteria inklusi sebesar 88 responden. Analisis data menggunakan statistik uji Spearman dengan α=0.05. Hasil penelitian menunjukan bahwa kecamatan A mempunyai tingkat keefektifitasan paling tinggi di antara seluruh kecamatan di Kota Blitar dengan persentase 39,8%. Kecamatan B memperoleh persentase 30,7%, dan Kecamatan C memiliki persentase terendah sebesar 25,5%. Hasil uji Spearman menunjukan nilai koefisien -0,841 dan nilai signifikansi 0,000 (dengan nilai p<á 0.05) sehingga terdapat hubungan yang signifikan (bermakna) dan negatif antara pelaksanaan 3M dengan angka kejadian DBD di Kota Blitar periode 2010-2011. Kesimpulan : Terdapat hubungan negatif antara efektifitas 3M dengan angka kejadian Demam Berdarah Dengue di Kota Blitar perode 2010-2011.Kata Kunci : efektifitas 3M, kader juru pemantau jentik, DBD di Kota Blitar.
HUBUNGAN ANTARA PENGETAHUAN TENTANG ANEMIA PADA IBU HAMIL TRIMESTER II DAN III DENGAN RESIKO TERJADINYA ANEMIA DALAM KEHAMILAN DI PUSKESMAS SUKORAME KEDIRI
Authors: Rachmaniar Rabitha , Nelasari Halida , Widiwanto Bambang
Published: July 2018

Hubungan Antara Pengetahuan Tentang Anemia Pada Ibu Hamil Trimester II dan III dengan Resiko Terjadinya Anemia dalam Kehamilan di Puskesmas Sukorame Kediri. Latar Belakang: Tingkat pengetahuan ibu hamil yang rendah menimbulkan resiko anemia dalam kehamilan. Tujuan: Mengetahui hubungan pengetahuan tentang anemia pada ibu hamil dengan resiko terjadinya anemia dalam Metode: Observasional analitik dengan pendekatan CrossSectional. Hasil dan Diskusi: Hasil uji Chi – Square yang menunjukkan nilai X2 = 7,108 dengan nilai signifikansi (p=0,029)<0,05. Kesimpulan: Terdapat hubungan antara pengetahuan ibu hamil tentang anemia pada ibu hamil trimester II dan III dengan resiko terjadinya anemia dalam kehamilan di Puskesmas Sukorame Kediri.
A Systematic Review of Combination Therapies for Smoking Cessation
Authors: Nhan Charles , Windle MPH Sarah B. , Eisenberg MD, MPH Mark J. , Franck MSc Caroline , Gore MLIS Genevieve , Budlovsky BA Talia , Filion PhD Kristian B.
Published: July 2018

Introduction: The use of pharmacological and behavioural therapies has been shown to help smokers quit. However, the efficacy of combining smoking cessation therapies remains poorly understood. We conducteda systematic review of randomized controlled trials (RCTs) with factorial designs to assess the efficacy of combination smoking cessation therapies.Methods: We performed a systematic search of the Cochrane Library, EMBASE, PsycINFO, and PubMed databases for RCTs of combination therapies for smoking cessation. We included RCTs with factorial designs,reporting biochemically validated point prevalence or continuous abstinence outcomes at 6 or 12 months.Combination therapies were either two pharmacotherapies or apharmacotherapy with behavioural therapy.Pharmacotherapies included nicotine replacement therapies (NRTs), bupropion, and varenicline. Behavioural therapies included counselling and minimal intervention.Results: A total of 11 RCTs met our inclusion criteria: 4 combinations of pharmacotherapies and 7 combinations of a pharmacotherapy with behavioural intervention. Combinations were two NRTs (2 RCTs), bupropion with NRT (3 RCTs), bupropion with behavioural intervention (4 RCTs), and NRT with behavioural intervention (3 RCTs). No identified trials combined varenicline with other included pharmacotherapies. Combining pharmacotherapies did not increase smoking abstinence at 6 or 12 months, compared with pharmacologicalmonotherapies. Evidence suggests a modest yet inconsistent benefit from combining pharmacotherapy withbehavioural therapy.Conclusion: Evidence from RCTs with factorial designs does not conclusively show combination smoking cessation therapies to be superior to monotherapies. Pharmacotherapies could be prescribed without behavioural therapy, with minimal loss of treatment efficacy.Key words: Smoking cessation, combination therapy, systematic review
Breaking-Out Bad: A Case of Levamisole-Induced Vasculitis
Authors: Hou MD Chenchen , Kronfli MD Nadine , Azzam Khalid , Panju MSc MD Mohamed
Published: July 2018

The addition of harmful adulterants to cocaine has become widespread in recent years and constitutes a novel etiological agent for disease. One agent in particular, the veterinary anthelmintic “levamisole,” has been increasingly used, owing to its potentiating effects of cocaine and its ability to pass crude methods of detection. Levamisole has been shown to cause a vasculitic syndrome of retiform purpura and skin necrosis, as well as leukopenia and autoantibody formation.
A 44-Year-Old Man with Fever, Mucocutaneous Ulcers, and a Rash
Authors: Ho MD Meghan J , Sherifi Ines , Cavalcanti MSc MD Rodrigo
Published: July 2018

We report the case of a 44-year-old man who presented with mucocutaneous ulcers, purpuric rash, fever, pharyngitis, cervical lymphadenopathy, and arthralgias. The patient’s symptoms resolved with prednisone treatment. He later experienced recurrence of oral ulcers that responded to colchicine treatment. Behcet’s disease is a systemic vasculitis characterized by recurring oral and genital mucocutaneous lesions and accompanying ocular, gastrointestinal, articular, pulmonary, neurologic, or peripheral vascular manifestations. Sweet’s syndrome typically presents with flulike symptoms, fever, neutrophilia, and painful erythematous skin lesions. Along with skin biopsy, classification criteria exist for both conditions, which may help differentiate the two diagnoses on initial presentation.
Severe Hypomagnesemia with Long-Term Use of a Proton Pump Inhibitor: A Case Report
Authors: M Trottier MSc MD Amy , S Gibson MD FRCPC Paul
Published: July 2018

Hypomagnesemia is a rare, though likely under-recognized, adverse effect of long-term use of proton pump inhibitors (PPIs), one of the most commonly prescribed classes of medications in North America. Hypomagnesemia can cause potentially life-threatening neurologic abnormalities, cardiac arrhythmias, and secondary electrolyte disorders. In this manuscript we present the case of a long-term PPI user who presented with an episode of decreased level of consciousness. He was found to have severe hypomagnesemia with avid renal retention of magnesium, secondary hypocalcemia with an inappropriately normal parathyroid hormone level, and hypokalemia. His serum magnesium and other electrolyte abnormalities rapidly corrected with cessation of PPI use and electrolyte supplementation. Given the propensity for patients with hypomagnesemia associated with PPI use to go unrecognized until they present with severe symptomatic hypomagnesemia, we recommend that patients being started on a PPI for an intended long-term course have baseline testing of serum magnesium and monitoring of magnesium on an annual basis, or sooner, if they develop symptoms.
An Unusual Cause of Severe Immunosuppression
Authors: Bami MD Karan , Chan MD Winnie , Steen MD Oren , Prebtani MD Ally PH , Singhal MD Nishma
Published: July 2018

Ectopic adrenocorticotropic hormone secretion (EAS) is a rare cause of endogenous Cushing’s syndrome and is associated with immunosuppression and opportunistic infections. We report the case of a person who presented with rapid onset of hypertension, diabetes mellitus, and severe hypokalemia in the context of significantly elevated adrenocorticotropic hormone (ACTH) levels and marked hypercortisolism. Subsequent investigations led to a diagnosis of EAS without an identifiable source. Her clinical status continued to deteriorate despite medical management of her hypercortisolemia, thus an urgent bilateral adrenalectomy was performed. This patient’s course was complicated by multiple opportunistic infections with cytomegalovirus, Pneumocystis jirovecii (PJP), Mycobacterium tuberculosis and possibly BK virus. To the best of our knowledge, this is the first description of this specific constellation of opportunistic infections in the setting of EAS. Our case highlights the need to consider multiple and rare opportunistic infections while managing EAS and supports early bilateral adrenalectomy in critically ill patients with EAS of unknown origin.
How to Maximize Bedside Teaching in Our Busy World
Authors: Daniels MD, MHPE, FRCPC Vijay
Published: July 2018

Bedside teaching is becoming less frequent. A lack of attending physicians’ time and perceived teaching skill, as well as concerns regarding the impact of bedside teaching on the relationship with patients have been cited as barriers to bedside teaching. The purpose of this paper is to offer some tips on how to increase the frequency and quality of bedside teaching in light of these barriers. The main recommendations are to 1) be explicit about the competencies around which you are teaching; 2) incorporate bedside teaching into your daily workflow, allowing the available cases and patients to dictate the learning competencies; and 3) use a framework that incorporates published teaching tools to guide your bedside teaching. The first step of this framework is preparation, which involves choosing the most appropriate teaching competency (history-taking, physical exam, clinical reasoning, or decision-making) based on the learner, case, and patient. Next is delivery, including orienting learners and patients to the task, choosing the instructional modality that fits the competency (such as One Minute Preceptor, SNAPPS, or Mini-CEX), and then debriefing and providing feedback. The final step is reflection on the teaching session, which can include peer observation.
Acute Care SINS: Surgical Insights for the Non-surgeon - Chapter 13: Spine 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 13 of this series, the authors address the brain and neurosurgery Part Two.
Diagnostic Approaches: Images in GIM Acute Infectious Epiglottitis
Authors: Shrum MD Jeff , Wilson BJ Ben J
Published: July 2018

A 36-year-old man presented to the emergency department with 1 week of sore throat, odynophagia, change in voice and inability to swallow saliva. His oropharynx was unremarkable with no palpable cervical lymphadenopathy, but his anterior neck was tender to light palpation. Lateral cervical radiograph showed substantial epiglottal swelling manifesting as the ‘thumb sign’ (Figure 1). Bedside flexible nasal laryngoscopy revealed an erythematous edematous epiglottis, with preserved vocal cord structure and function. Acute infectious epiglottitis was diagnosed, and improved with intravenous antibiotics.
Deep Vein Thrombosis and Pulmonary Embolism as a Complication of Traditional Chinese Acupuncture and Cupping
Authors: Dang Bsc ThucNhi T , Yeung MSc, MD Albert A.C.
Published: July 2018

We provide the first reported case of deep vein thrombosis with pulmonary embolism following acupuncture and cupping. This is a reminder that although serious adverse events associated with acupuncture and cupping are reportedly rare when performed by qualified practitioners, life-threatening complications can still arise.
An Internist’ Journey with Behavioural Medicine
Authors: Goldberg MD, DSc (Hon), FRCPC, FACP W.M.
Published: July 2018

This is the story of a Behavioural Medicine Unit that was developed in 1975 at St. Joseph’s Hospital in Hamilton Ontario. It explains why a general internist decided to assemble a team skilled in the principles of cognitive behavioural therapy to help patients who were responding poorly to traditional medical care. The principles that were applied at that time continue to be as important in 2015. Despite the success of the program and of others that were developed over the next 40 years, these principles have not been adequately utilized by ‘main stream’ medicine nor have they been emphasized sufficiently in undergraduate or residency curricula. It is hoped that the story will stimulate the promotion and integration of the principles of cognitive behaviour into medical education and patient care.
Severe Acute Cytomegalovirus Infection Complicated by Disseminated Intravascular Coagulation and Pneumonitis in a Healthy Female
Authors: Chagla MD Zain , Siegal MD Deborah , El-Helou MD Phillippe , Lim MD Wendy , Rudkowski MD Jill
Published: July 2018

Cytomegalovirus (CMV) is an endemic infection worldwide. Among healthy individuals, infections are usually asymptomatic. An infectious mononucleosis-type syndrome is classically described. More serious manifestations, such as pneumonitis, hepatitis, and meningoencephalitis have been described in otherwise healthy populations. Disseminated intravascular coagulation is a life-threatening complication that is extremely rare in competent hosts. We describe a case of pneumonitis and DIC associated with acute CMV infection that resolved with antiviral therapy.
Seeing Wisely: The Pursuit of Clinical Expertise
Authors: Wilson MD Ben J
Published: July 2018

Clean white hallways. Brightness. Rooms. Rooms with beds. Beds lined up in series, against each wall. People in the beds. Patients. A person in a suit, sometimes a white coat, sitting. At the bedside. Sometimes thinking. Sometimes feeling or listening. Always at the bedside. Always with patients. My earliest thoughts of medicine consist of these powerful, though fragmented, concrete images. At their heart, they embody intimate human connection and healing and the profound fulfillment that inevitably results from this combination. These endeavors – human connection and healing - contribute to my life’s purpose and meaning. Inevitably then, these images have become inextricably linked to deep, visceral emotions. These images, and the emotions they invoke, have inspired my insatiable passion for medicine
Unilateral Adrenal Hemorrhage and the Challenge Of Early Recognition
Authors: Alkhiari MBBS Resheed , Attar MBBS Dana , Kraeker MD Christian
Published: July 2018

Adrenal hemorrhage (AH) is a rare condition with an estimated prevalence of 1% among hospital-based autopsies. It is usually discovered incidentally on computed tomography.1 Most cases are associated with the use of anticoagulation, especially in the setting of heparin-induced thrombocytopenia, anti-phospholipid antibody syndrome, trauma, metastatic disease, sepsis, and critical illness.5-7 We report a case of acute unilateral adrenal hemorrhage associated with Escherichia coli pyelonephritis in the context of recent prolonged steroid use.
Assessing Physician Barriers to Cardiac Rehabilitation Referral Rates in a Tertiary Teaching Centre
Authors: Duncan MD Andrew , Natarajan MK , Schwalm JD
Published: July 2018

Introduction: Cardiac rehabilitation (CR) has a proven morbidity and mortality benefit, yet rates of referral remain low. We sought to elucidate the knowledge, utilization, referral, and endorsement practices of cardiac rehabilitation in a tertiary care centre.Methods: A 13-question survey was electronically distributed to all Internal Medicine residents, Cardiology residents and subspecialty fellows, General Internal Medicine attendings and Cardiology attendings practising in a tertiary care centre. The survey assessed the physicians’ knowledge of what CR entails, its benefits, patient eligibility and personal practices with respect to CR referral.Results: The survey was distributed to 153 physicians with a response rate of nearly 60 percent. Compared to their medicine counterparts, Cardiology residents and staff had significantly improved knowledge with respect to what CR entails and eligibility criteria for referral (6.92 vs. 6.11 out of 9, p=0.036; 12.04 vs. 10.76 out of 17, p = 0.013). Medicine residents and staff were less likely to be familiar with CR guidelines (72.02 vs. 32.69, p<0.01), and were less likely to discuss the importance of CR attendance with their patients (43.28 vs. 71.15, p=0.0002). A higher proportion of those in Medicine also reported being unsure of both how to refer eligible patients (59.12 vs. 13.46, p<0.0001) and which patients were eligible for CR (64.92 vs. 23.08, p<0.0001). Higher knowledge scores and familiarity with CR guidelines was associated with higher self-reported referral rates. Conclusion: This survey has identified clear physician barriers, most significant among internal medicine residents and staff. These barriers can help inform interventions to improve CR referral and enrolment rates.
Ethylene Glycol Intoxication
Authors: Sun, MBBCh, CCFP G R , Yarema, MD, FRCPC Mark
Published: July 2018

A 38-year-old female presented to the ER reporting difficulty sleeping, poor concentration and anxiety over the preceding 2 months. On the day of admission, the patient felt compelled to drink anti-freeze. She drank approx 1 cup and then felt sleepy so she went to bed. She was found by her husband 2 hours later and he called the Emergency medical service. She reported 1 episode of emesis. The patient denied that this it was a suicide attempt.There was no derangement in the CBC, INR or liver enzymes. A summary of other laboratory measurements are summarized in Table 1.The nephrology service was consulted and the patient underwent hemodialysis. Formepizole, sodium bicarbonate and thiamine were administered. After medical stabilization she was transferred to psychiatry
The Future is Bright for Competency-based Education in General Internal Medicine
Authors: Card MD, FRCPC Sharon E. , Kassam MD, MHPE, FRCPC, FACP Narmin
Published: July 2018

The Royal College of Physicians and Surgeons of Canada (RCPSC) is embarking on a multi-year, transformational, educational effort entitled Competence by Design (CBD). General Internal Medicine (GIM) will be part of the 2016 cohort for Competence by Design. One of the first questions is, “What should each graduate be able to do on their first day in practice?” This paper outlines the key educational concepts behind CBD. It was presented in workshop format at the Canadian Society of Internal Medicine Meeting in September 2014. The workshop provided the authors with an opportunity to gather the perspectives and perceptions of more than 40 participants. The authors believe CBD will be an excellent format to ensure our GIM graduates are well prepared for a changing health care system.
Refractory Hypercalcemia in a Jamaican Woman
Authors: Balitsky MSc, MD Amaris , So, PhD, MD Jonathan , Chessex, MSc, MD Carolyn
Published: July 2018

The two common differential diagnoses for hypercalcemia are malignancy and hyperparathyroidism. In this case of a young woman with hypercalcemia refractory to bisphosphonate treatment, Vitamin D and parathyroid hormone releasing peptide (PTHrP) levels were normal. She was found to be positive for HTLV-1 and later diagnosed with Adult T-cell leukaemia/ lymphoma, with CNS involvement. After treatment with R-CHOP therapy with intrathecal methotrexate, her symptoms improved and her calcium returned to normal. The differential diagnosis and treatment of hypercalcemia is further discussed.
Considering Values and Contexts in Clinical Practice Guidelines: Are We Becoming More Person-Centred?
Authors: Chin-Yee BSc MA Benjamin , Richardson MD MA FCRPC Linda
Published: July 2018

Clinical practice guidelines (CPGs) have become ubiquitous in medicine, created to promote rational and standardized clinical decision-making. CPGs are often criticized for overlooking patient values and contexts, which many argue deserve a more explicit place in recommendations. This article explores the role of patient values and contexts in CPGs based on a critical discourse analysis of Canadian Diabetes Association (CDA) Guidelines from 1992-2013. We highlight emerging discourses related to person-centred care in CDA guidelines during this period, which support an increasing emphasis on collaboration and shared decision-making, as well as consideration of patient values and contexts. We discuss possible reasons for this shift and the implications for practitioners. Despite this encouraging trend, our analysis also suggests areas for improvement, particularly concerning the integration of patient preferences in clinical decision making and research.
Cushing's, Dilated Cardiomyopathy and Stroke: Case Report and Literature Review
Authors: Gill MBBS Aasha , Dean MBBS Naeem , Al-Agha MD Rany
Published: July 2018

Dilated cardiomyopathy(DC) is a rare complication of Cushing ’s syndrome. Hypertension and coronary artery disease tend to persist even after treatment of source of hypercortisolism as evidenced by previous studies. Based on a few case reports, Dilated Cardiomyopathy appears to be completely reversible with treatment of Cushing’s. We suggest that, in patients with idiopathic dilated cardiomyopathy, Cushing’s syndrome should be considered in the differential diagnosis. In patients with clinical features of Cushing’s, appropriate screening tests for Cushing’s should be carried out, which are inexpensive, non-invasive and readily available.
Hyponatremia Due to an Interaction Between Hydromorphone and Desmopressin in a Patient with Central Diabetes Insipidus: A Case Report
Authors: Mazzetti MD Gillian , Steen MD Oren , Patel MD Ameen , McInnes MD Natalia
Published: July 2018

There are case reports of opiate-induced hyponatremia thought to be mediated by increased secretion of antidiuretic hormone. We report a case of hyponatremia in a woman with central diabetes insipidus treated with desmopressin after receiving large doses of hydromorphone which suggests a different mechanism of opiate action.
Inadequate Presentation of Evidence in an Internal Medicine Conference
Authors: Allen MD MSc Michael , D. O'Brien MD MSc Brian , Simpson MD FRCPC FACP David , Lightfoot MA MD Candidate Katie , MacLeod MSc Tanya
Published: July 2018

Studies have found that physicians are more likely to consider therapy effective when information is presented in relative terms (e.g., RRR, OR, HR) rather than in absolute terms (ARR, NNT). In an earlier study of family physician (FP) therapeutics conferences, we found that speakers presented data more frequently in relative than absolute terms, but most frequently in general terms such as frequencies, percentages, graphs, and P-values with no data.
Inferior Vena Cava Filter Fracture and Migration: A Case Report and Review of the Literature
Authors: Lepic MD FRCPC Kylie , Ginsberg MD FRCPC Jeffrey S. , Anand MD PhD Sonia S. , Patel MB FRCPC Ameen
Published: July 2018

Inferior vena cava (IVC) filters are an option for the prevention of pulmonary emboli in patients who have venous thrombosis and a contraindication to anticoagulation, but their placement is not without risk. We describe a case of a patient with a Gunther-Tulip IVC filter that fractured and migrated to the left distal pulmonary artery. The leg was removed using bronchoscopy forceps and a French sheath without complication. Fracture and migration of IVC filters is rare with only a few case reports in the literature. It is important to consider given the potential for significant morbidity and mortality.
A 54-Year-Old Woman with Progressive Ataxia
Authors: Huang MD PhD Kun , Parker MD FRCPC Robin , Firoz MD FRCPC Tabassum
Published: July 2018

Paraneoplastic cerebellar degeneration (PCD) is a rare but devastating syndrome associated with autoantibodies targeting cerebellar antigens expressed by tumours outside of nervous system. PCD is most often associated with breast and gynecological cancers and can precede clinical manifestations of the cancer. Of the dozen autoantibodies associated with PCD, anti-Yo is the most commonly identified. In this report, we present a case of a woman with progressive cerebellar ataxia and anti-Yo antibody, who has microscopic high-grade serous carcinoma found with empiric total abdominal hysterectomy bilateral salpingo-oophorectomy (TAH-BSO). This case highlights the challenges in diagnosis, difficulty in identifying the occult malignancy, and the need for multidisciplinary collaboration between Internal Medicine, Neurology, Gynecology and Pathology. The literature relating to diagnosis, prognosis and treatment of PCD is also reviewed.
Abstracts from the 2016 Rocky Mountain/ACP Internal Medicine Conference
Authors: Hager, MD Drew , Battad, MD, FRCPC Anthony
Published: July 2018

Abstracts from the 2016 Rocky Mountain/ACP Internal Medicine Conference
The Role of Emergency Care in Patients with Advanced Dementia
Authors: Quinn Kieran Lewis
Published: July 2018

The prevalence of advanced dementia (AD) is expected to increase dramatically over the next few decades.  Patients with AD suffer from recurrent episodic illnesses that frequently result in transfers to acute care hospitals.  The default pathway followed by the emergency physicians, internists and intensivists who see those patients there is prioritize disease-directed therapies over attention to the larger picture of advanced dementia.  While this strategy is desired by many families, some families prefer a different approach.  This essay examines the reason why this phenomenon occurs and offers suggestions for improvement.  Gaps in information and physician workload are important factors, but we argue that until physicians who see patients in emergency departments learn to pause first and ask “Why are we doing this?" they will revert to their comfort zone of ordering tests and therapies that may be unwanted.  A separate emergency palliative care pathway may be one solution.  Shifting the focus back to the larger picture of AD and away from the physiologic disturbance of the moment may alter the trajectory of care in ways that truly respect the wishes of some patients and their families.
Échographie au point d’intervention en médecine interne
Authors: Levine Mitch
Published: July 2018

Au cours des dernières décennies une variété d'avancées technologiques ont radicalement changer la manière dont les médecins de pratiquer la médecine. Tant sur le plan clinique et administratif de l'exercice de la médecine est en évolution - par exemple, au lieu d'endoprothèses la chirurgie et les dossiers de santé numériques au lieu des cartes papier. Pour les médecins de médecine interne de l'une des plus grandes transformations par rapport à la façon dont nous allons pratiquer la médecine n'est qu'à l'horizon. L'utilisation courante du point de service (échographie PoCUS) va devenir une compétence essentielle pour l'interniste pratiquant. La demande de passe dans le domaine de la médecine interne est immense - évaluer avec précision le JVP chez les patients gravement malades, les ponctions veineuses et artérielles, le diagnostic de tamponnade péricardique ou la détermination de la probabilité d'une embolie pulmonaire, ou le diagnostic et le traitement de l'élimination des liquides organiques, pour n'en nommer que quelques-uns.Bien que certains de nos collègues ont adopté cette technologie comme un complément à l'examen clinique ou comme une aide à la conduite des procédures de chevet la plupart n'ont pas adopté cette routine comme un ensemble de compétences. Certains des obstacles, notamment l'insuffisance de la formation et de l'absence d'un accès facile à l'équipement dans tous les environnements cliniques. Mais cela va changer, et l'utilisation de PoCUS finira par devenir une compétence requise de tous les internistes.Dans le numéro actuel de CJGIM Lewis et al ont procédé à une évaluation des besoins en répondant à l'une ou l'autre un PoCUS question clinique ou dans l'orientation d'une procédure. Comme le Collège royal des médecins et chirurgiens n'a pas encore besoin de tous les programmes de résidence en médecine interne à fournir un curriculum formel PoCUS, l'objectif de leur étude était de procéder à une évaluation systématique des besoins de l'introduction d'un programme à un PoCUS Programme de médecine interne. Les résultats ont montré que certains résidents de médecine interne ont été déjà PoCUS pourtant ils n'avaient jamais été entraînés dans la compétence formelle. On peut se demander ce qu'une enquête similaire menée s'il parmi les internistes.Bien que chaque programme de résidence sera inévitablement l'élaboration d'un programme d'études pour leurs stagiaires PoCUS, il restera un défi pour la formation continue des internistes déjà dans la pratique. L'importance de cette compétence ne peut pas être sous-estimée et il faudra que les dirigeants de la communauté de médecine interne pour s'assurer qu'elles donnent l'occasion pour tous les internistes à maîtriser l'utilisation de l'incantatoire.
Hepatic Ductopenia and Vanishing Bile Duct Syndrome Following Anabolic Androgenic Steroid Use: A Case Report and Literature Review.
Authors: Mazzetti Adam Edward , Alkhiari Resheed , Nair Vidhya , Xenodemetropoulos Ted
Published: July 2018

Vanishing bile duct syndrome (VBDS) is a rare acquired disorder associated with progressive destruction and disappearance of intrahepatic bile ducts which eventually leads to cholestasis. VBDS has been linked to a variety of etiologies, including autoimmune disorders, infectious diseases, primary neoplasms, genetic abnormalities, and many classes of medications, including antibiotics, nonsteroidal anti-inflamatories (NSAIDs), anticonvulsants, antipsychotics and others. We present the case of VBDS associated with anabolic androgenic steroid (AAS) exposure in an otherwise healthy 29-year-old male.

Resume

Le syndrome de disparition des canaux biliaires (SDCB) est une affection acquise rare caractérisée par la destruction progressive et la disparition des canaux biliaires intrahépatiques entrainant une cholestase. Le SDCB a été associé à diverses étiologies, dont des affections auto-immunes, des maladies infectieuses, des néoplasmes primaires, des anomalies génétiques et de nombreuses classes de médicaments, incluant des antibiotiques, des anti-inflammatoires non stéroïdiens, des anticonvulsivants, des antipsychotiques et autres. Nous présentons un cas de SDCB associé à la prise d’un stéroïde androgénique anabolisant chez un homme de 29 ans par ailleurs en bonne santé.
A Perplexing Case of the Pituitary Apoplexy
Authors: Huang Wenyin , Haddad Taleen , Hasimja Saraqini Delvina
Published: July 2018

We report an unusual clinical presentation of adrenal insufficiency. A 54-year-old post-menopausal woman with well-controlled hypertension presented with 1 month of progressive anorexia and intermittent low-grade fever. She underwent extensive initial investigations that included computed tomography (CT) of the head, chest, and abdomen; gastroscopy; infectious and autoimmune workups; all of which were unrevealing. The head CT did not demonstrate any hyperintense or space-occupying lesion. When she represented to hospital, we noticed an empty sella on the initial CT. This prompted a magnetic resonance imaging study that revealed pituitary apoplexy, leading to eventual diagnosis of secondary adrenal insufficiency (morning cortisol 81 nmol/L and ACTH 1 pmol/L). Her symptoms resolved within 24 hours of glucocorticoid replacement. Diagnosis was elusive due to patient’s atypical presentation – she did not have visual symptoms or cranial nerve deficits to suggest pituitary apoplexy, and also did not have any objective findings such as hypotension or electrolyte abnormalities to suggest adrenal insufficiency.

RÉSUMÉ

Nous rapportons ici un tableau clinique inhabituel en matière d’insuffisance surrénale. Une femme de 54 ans, ménopausée, dont l’hypertension est bien contrôlée, souffre depuis un mois d’anorexie progressive et d’une fièvre légère intermittente. Elle a subi de nombreux examens, notamment de tomodensitométrie (TDM) de la tête, du thorax et de l’abdomen; une gastroscopie; ainsi que des investigations techniques sur les plans infectieux et auto-immuns. Tous ces examens ont été vains. La TDM de la tête n’a montré aucune lésion hyperintense ou étendue. Lorsque la patiente s’est présentée de nouveau à l’hôpital, une relecture de la TDM initiale indiqua une selle turcique vide. Cela nous a incité à effectuer un examen d’imagerie par résonnance magnétique, qui révéla une apoplexie hypophysaire et nous mena finalement à un diagnostic d’insuffisance surrénale secondaire (taux de cortisol matinal de 81 nmol/L et ACTH de 1 pmol/L). Les symptômes se sont résorbés dans les 24 heures qui suivirent l’administration de glucocorticoïdes. C’est en raison du tableau atypique des symptômes de la patiente que le diagnostic a été difficile à cerner – il y avait absence de symptômes au niveau des yeux et absence de déficits au niveau des nerfs crâniens, ce qui aurait pu indiquer une apoplexie hypophysaire. De plus, il y avait absence de signe objectif comme de l’hypotension ou des anomalies électrolytiques indiquant une insuffisance surrénale.
Hepatic Sarcoidosis
Authors: Nero Joshua , Gilmour Gregory
Published: July 2018

Sarcoidosis is an idiopathic multisystem disease, characterized by non-caseating granulomas in affected organs. Pulmonary involvement is the most common site of disease activity, although the disease can also affect the liver, bone marrow, and heart. We report a case of symptomatic hepatic sarcoidosis in a 31-year-old African-Canadian woman which responded to treatment with doxycycline.

The patient was referred to internal medicine from a peripheral emergency department after presenting with fever, hepatitis, and thrombocytopenia with a computed tomography scan concerning for hepatic abscesses. The patient remained febrile with worsening liver enzymes despite broad spectrum antibiotics. An extensive infectious workup was negative. Biopsies of bone marrow and liver revealed non-caseating granuloma, and an elevated angiotensin-converting enzyme level. Doxycycline, initially started for presumptive infective etiology, lead to rapid resolution of symptoms and normalization of biochemical markers. To our knowledge, this is the first case report of doxycycline used to treat hepatic sarcoidosis in Canada.

Résume

La sarcoïdose est une maladie multisystémique idiopathique, caractérisée par la présence de granulomes non caséeux dans les organes affectés. Les poumons sont le plus souvent le site de la maladie, quoique celle-ci se manifeste aussi dans le foie, la moelle osseuse et le cœur. Nous décrivons ici un cas de sarcoïdose hépatique symptomatique chez une afro-canadienne de 31 ans qui a répondu à un traitement à la doxycycline.

La patiente a été aiguillée en médecine interne par un service des urgences en périphérie après s’y être présentée avec de la fièvre, une hépatite et une thrombopénie et y avoir subi une tomodensitométrie relative à des abcès au foie. Malgré l’administration d’antibiotiques à large spectre, la patiente est demeurée fébrile et ses enzymes hépatiques ont continué de se dégrader. Les nombreux tests infectieux effectués se sont révélés négatifs. Des biopsies de la moelle osseuse et du foie ont révélé la présence de granulomes non caséeux et un taux élevé de l’enzyme de conversion de l'angiotensine. La doxycycline, initialement administrée pour une étiologie infectieuse présumée, a rapidement entrainé la résorption des symptômes et la normalisation des marqueurs biochimiques. À notre connaissance, il s’agit du premier cas rapporté au Canada de traitement d’une sarcoïdose hépatique par la doxycycline.
Delayed Allergic Cutaneous Hypersensitivity to Icodextrin
Authors: Adunuri NIKESH Reddy , Zafar Saira
Published: July 2018

Rashes pose a unique challenge to general internists. Here we present a case of a 51-year-old female with end-stage renal disease (ESRD) on peritoneal dialysis who presented to a General Internal Medicine clinic with a vesiculobullous rash on palms and soles 6 months after using icodextrin dialysate, a widely used osmotic agent in peritoneal dialysis. The investigations were positive for an elevated eosinophil count, elevated IgE level and a skin biopsy consistent with an allergic reaction. Her symptoms and labs normalized after stopping icodextrin. There are some reports of allergic reactions to icodextrin which usually occur within a month of initiation of the agent and are self-limiting. Here we hope to report a case of a reaction that occurred 6 months after using icodextrin.

Resume

Les éruptions cutanées posent un défi particulier aux internistes généraux. Nous rapportons ici le cas d’une femme de 51 ans atteinte d’insuffisance rénale terminale (IRT), sous dialyse péritonéale, qui se présente à une clinique de médecine interne générale avec une éruption cutanée vésiculo-bulleuse sur les paumes et la plante des pieds. Depuis six mois, la patiente utilise un dialysat d’icodextrine, un agent osmotique largement utilisé en dialyse péritonéale. Les analyses ont révélé une numération élevée des éosinophiles, un taux élevé d’IgE et une biopsie cutanée a indiqué la présence d’une réaction allergique. Les symptômes et les résultats d’analyses se sont normalisés après l’arrêt de l’icodextrine. Des réactions d’allergie à l’icodextrine ont déjà été rapportées, mais celles-ci surgissent habituellement dans le mois suivant le début de l’usage de l’agent et se résorbent d’elles-mêmes. Nous désirons signaler un cas de réaction survenue six mois après le début de l’utilisation de l’icodextrine.
A Curious Case of Hypercalcemia
Authors: Motomura Douglas Ian Noboru , Cameron Paul Allan
Published: July 2018

Hypercalcemia is a clinical entity commonly seen on Internal Medicine inpatient units. Through standard diagnostic algorithms, the etiology of most cases can be elucidated. Brivaracetam is a novel anti-epileptic agent that binds synaptic vesicle protein 2A shown to significantly reduce seizure frequency. We describe the first case of hypercalcemia secondary to brivaracetam.

Résumé

L'hypercalcémie est une entité clinique couramment observée sur les unités d'hospitalisation en médecine interne. Grâce à des algorithmes de diagnostic standard, l'étiologie de la plupart des cas peut être élucidée. Brivaracetam est un nouvel agent anti-épileptique qui lie la protéine de vésicule synaptique 2A montrée pour réduire significativement la fréquence de saisie. Nous décrivons le premier cas d'hypercalcémie secondaire à Brivaracetam.
Q Fever Endocarditis: A Diagnostic Dilemma
Authors: Jeffery Rebecca Angela , Walsh Steve , Haroon Babar
Published: July 2018

Q fever is a zoonotic disease, typically spread by aerosol transmission from infected animals to humans. It can present with a variety of clinical manifestations, but endocarditis is the most common manifestation. We present a case of an 80-year-old man with a prior bioprosthetic aortic valve (AV) replacement who presented with chronic constitutional symptoms that acutely worsened over two days leading up to his presentation. An initial echocardiogram was equivocal for endocarditis, and bloodwork revealed a bicyotpenia, elevated ferritin, and negative blood cultures. He was diagnosed with Q fever endocarditis after positive serology for Coxiella burnetti. Treatment for this patient involved a 24-month course of doxycycline and hydroxychloroquine.

Résumé

Q la fièvre est une maladie zoonotique, généralement propagée par la transmission en aérosol des animaux infectés aux humains. Il peut présenter avec une variété de manifestations cliniques, mais l'endocardite est la manifestation la plus commune. Nous présentons un cas d'un homme de 80 ans avec une valve aortique antérieure de bioprothèse (AV) de remplacement qui a présenté des symptômes chroniques de la Constitution qui s'est aggravée de façon aiguë pendant deux jours menant à sa présentation. Un échocardiogramme initial a été équivoque pour l'endocardite, et analyses a révélé une bicyotpenia, une élévation de la ferritine et des cultures sanguines négatives. On lui a diagnostiqué une endocardite de fièvre Q après une sérologie positive pour Coxiella burnetti. Le traitement pour ce patient a impliqué un cours de 24 mois de doxycycline et de hydroxychloroquine.