bluuebunny/crossref_metadata_2025 huggingface dataset:
Cardiac Resynchronization Therapy: Who is and who is not a Candidate? Who Decides?
Authors: McIntyre MD, FRCPC William F. , Seifer MB (Hons), FRCP(UK) Colette M.
Published: July 2018

It is estimated that nearly 500,000 Canadians are currently living with heart failure, a disease process associated with considerable morbidity and mortality. Despite significant evidence for effective medical therapies, heart failure remains one of the leading causes of hospitalization in Canada and patients with the disease experience an annual mortality of up to 10%.Approximately one in three patients with systolic heart failure have some degree of intraventricular conduction delay, manifest as increased QRS duration on electrocardiogram (ECG), the most common of which is left bundle branch block (LBBB). This conduction delay, or electrical dyssynchrony, can lead to mechanical uncoupling and inefficiency, which, in turn, can lead to exacerbation of systolic dysfunction, altered myocardial metabolism, functional mitral regurgitation, negative remodeling and worsening clinical outcomes.Cardiac resynchronization therapy (CRT), also known as biventricular pacing, involves coordinating contraction between the left (LV) and right ventricles (RV) through programmed pacing of both ventricles. CRT is an established non-pharmacological therapy for patients with systolic heart failure due to a low ejection fraction, who have a QRS >130 ms and who are symptomatic despite optimal medical therapy. In carefully selected patients, CRT has been shown to promote positive LV remodeling, increase functional capacity, improve quality of life, reduce heart failure hospitalizations and reduce mortality.2 CRT systems can include defibrillator capabilities (CRT-D) or act as a stand-alone pacemaker (CRT-P).The insertion of a CRT system consumes significant resource (costs), requires a commitment to regular clinical follow-up, and the acceptance of permanent implantation of a large medical device. Clinicians are tasked with identifying patients who would be expected to benefit from CRT and making the decision whether to proceed with CRT implantation. Therefore a careful consideration of the risks and benefits of this technology is required by both the healthcare providers and the patient.Herein we hope to offer guidance on identifying ideal candidates for CRT and to remind health care providers that the patients’ goals must be taken into consideration when counseling a patient for treatment with CRT.
The General Internal Medicine Certification Examination: Does it Measure What it Should?
Authors: Pugh MD, MHPE, FRCPC Debra
Published: July 2018

A certification exam for the new sub-specialty of General Internal Medicine (GIM) was recently developed by an examination board at the Royal College of Physicians and Surgeons (RCPSC). The board sought to create an exam that would reflect the challenges faced by practising general internists, while minimizing repetition of material already assessed by the Internal Medicine certification exam. In this paper, the authors present evidence for the validity of the content of the exam.
Message from the Editor in Chief
Authors: Levine Mitch
Published: July 2018

In the current issue of the Canadian Journal of General Internal Medicine (CJGIM), McIntyre and Seifer have identified the clinical benefits of cardiac resynchronization therapy (CRT) for patients with heart failure and conduction abnormalities (QRS > 130 msec). These benefits include a reduction in mortality and hospitalization. They also point out that the individual probability of benefiting from a CRT is variable amongst patients. For example, the larger the QRS interval the greater the potential benefit.
Message du rédacteur en chef
Authors: Levine Mitch
Published: July 2018

Dans le présent numéro de la Revue canadienne de médecine interne générale (RCMIG), McIntyre et Seifer présentent les avantages cliniques d’un traitement de resynchronisation cardiaque (TRC) pour les patients souffrant d‘insuffisance cardiaque et de troubles de la conduction (QRS > 130 msec). Les avantages incluent une réduction du taux de mortalité et du nombre d’hospitalisations. Les auteurs soulignent également que la probabilité individuelle de tirer profit d’un TRC varie selon les patients. On note, par exemple, que le bénéfice potentiel est supérieur lorsque l’intervalle du complexe QRS est plus grand.
Pseudo-Locked-In Syndrome and Apnea Due to Critical Illness Myopathy
Authors: Au MD Selena , Cotton MD Darrel , Kramer Andreas , Joseph Jeffery
Published: July 2018

Critical Illness myopathy and polyneuropathy are common complications that occur in critically ill patients. Critical Illness myopathy and polyneuropathy are typically recognized in the ICU setting by the development of acquired weakness and failure to wean from ventilatory support. We report a case of a patient who developed severe critical illness myopathy that resulted in near-quadriplegia, apnea and ophthalmoplegia.
Reducing Deaths by Diet: A Call for Public Policy to Prevent Chronic Disease
Authors: Campbell CM, MD, FRCPC Norm , Sauvé MD FRCP FACP FCCP MSc Michel
Published: July 2018

Chronic diseases including cardiovascular disease and cancer are the leading causes of disability and death in Canada.1,2 The majority of chronic diseases are caused by physical inactivity, tobacco use, excess alcohol consumption and unhealthy diet.3-6 In particular, unhealthy diet is the leading risk factor for death and disability in Canada resulting in an estimated 64,000 deaths and over 1 million years of disability (DALYs) in 2010 alone.7 Worldwide, a staggering 11 million deaths and over 200 million DALYs were attributed to unhealthy eating in 2010.
Graft Versus Host Disease
Authors: Desy MD Janeve , Deschenes MD Marc
Published: July 2018

Graft Versus Host Disease (GVHD) is a rare complication of liver transplantation with a mortality rate exceeding 65%. A 53-year-old male presented with a diffuse maculopapular rash, diarrhea, lymphopenia, fever, and confusion 14 days after orthotopic liver transplantation for hepatitis B cirrhosis. Skin biopsy and HLA- typing of peripheral blood confirmed a diagnosis of solid organ transplant related GVHD. This report summarizes what is known about this disease and emphasizes the importance of early diagnosis, which is one of the only factors known to improve the mortality of this deadly condition.
Resident-driven Quality Improvement Pre-post Intervention Targeting Reduction of Emergency Department Decision to Admit Time
Authors: Kachra MD Rahim , Walzak MD Alison , Hall MD Stacey , Connors MD William JA , Eso MS Katherine A , Boscan MD Alejandra , Clement PhD Fiona , Holroyd-Leduc MD Jayne M
Published: July 2018

Long Emergency Department (ED) wait times represent a key point for quality improvement in many healthcare systems. A delayed ED disposition decision may lead to increased length of hospital stay, healthcare cost, and mortality. The objective of this resident-driven quality improvement (QI) intervention was to determine if a standardized resident admission protocol could reduce the ‘decision-to-admit’ (DTA) time of patients being assessed for admission to internal medicine (IM) at 3 tertiary care teaching hospitals.
Improving Code Status Discussions on the General Internal Medicine Ward with Simulation-Based Resident Education
Authors: Gottheil MD Stephanie , Ibrahim MD FRCPC Christine , Sibbald MSc Robert
Published: July 2018

Code status discussions (CSDs) address patient wishes regarding resuscitation. At teaching hospitals, CSDs are often conducted by junior residents. However, residents often omit the prognosis and outcomes during these conversations. Our aim was to develop a brief educational intervention to improve resident skills in leading CSDs.
Informed Discharge: An Assessment of Patient Knowledge and Perspectives
Authors: Fernandes MD Nisha , Ning MD Shuoyan , Chan MD Winnie , Pottruff BA/PhD Candidate Molly , Holbrook MD Anne , Patel MD Ameen , Kraeker MD Christian
Published: July 2018

Background: This study evaluated patients’ knowledge of their hospital course and satisfaction with the discharge process from internal medicine units.
EKG and U - Atrial Flutter Imitating Inferior ST-Elevation Myocardial Infarction
Authors: Miller MD Robert , Veenhuyzen MD George
Published: July 2018

A 73-year-old woman presented to the emergency department for 3 hours of palpitations and a feeling of “heaviness all over” including chest heaviness. Her past medical history was significant for paroxysmal atrial flutter managed with amiodarone and oral anticoagulation, hypertension, and asthma.
Selected Abstracts from the 2016 Rocky Mountain/ACP Internal Medicine Conference
Authors: Hager, MD Drew , Battad, MD, FRCPC Anthony , Mai, MD Alice , Shoults, MD Katherine , Lear, PhD Scott , Stokes, MD William , Ruzycki, MD Shannon , Jainarine, MD Ramdeo , Isaac, MD, FRCPC Debra , Cole, MD Joanna
Published: July 2018

Selected Abstracts from the 2016 Rocky Mountain/ACP Internal Medicine Conference
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.
Le problème des opioïdes
Authors: Levine Mitch
Published: July 2018

Au Congrès annuel de la SCMI tenu récemment à Toronto, la séance plénière s’intitulait « La crise des opioïdes en Amérique du Nord ». Ce sujet en est un de grande importance pour les internistes. En effet, dans nos cliniques ou à l’hôpital, nous rencontrons fréquemment des patients qui ont des problèmes de dépendance aux opioïdes et nous nous devons d’avoir une stratégie médicale judicieuse et empreinte de compassion pour prendre en charge ces situations. C’est aussi pour nous l’occasion de contribuer à prévenir un problème qui débute souvent par une prescription médicale.
Late Presentation of Disseminated Bacillus Calmette-Guerin infection in an Immunocompetent Male: a Case Report
Authors: Captan Virgil Vasile , Dokouhaki Pouneh , Solez Kim , Szkotak Artur , Morales Fraulein
Published: July 2018

Intravesical administration of Bacillus Calmette-Guerin (BCG) is a cornerstone of adjuvant treatment for low-grade urothelial carcinoma. Complications from administration are relatively rare and generally evident within one month. Systemic BCG infections are typically diagnosed within 14 days post BCG administration; however, cases have been reported of infections being diagnosed as late as 17 years after treatment. Here, we describe the unusual case of a 55-year-old immunocompetent male who was diagnosed with disseminated BCG infection 3 years after initial adjuvant treatment for urothelial carcinoma.

Résumé

L'administration intravésicale de Bacillus Calmette-Guerin (BCG) est la pierre angulaire du traitement adjuvant du carcinome urothéliales de faible teneur. Les complications de l'administration sont relativement rares et généralement évidentes dans un délai d'un mois. Les infections systémiques du BCG sont généralement diagnostiquées dans les 14 jours après l'administration du BCG; Toutefois, des cas ont été signalés d'infections diagnostiquées aussi tard que 17 ans après le traitement. Ici, nous décrivons le cas inhabituel d'un mâle immunocompétents de 55 ans qui a été diagnostiqué avec une infection de BCG disséminée 3 ans après le traitement adjuvant initial pour le carcinome urothéliales.
Implementation of a Progressive Three-Year Point of Care Ultrasound Curriculum for Internal Medicine Residents
Authors: Lewis Kim , Martin Leslie , Mazzetti Adam , Khalifa Abubaker , Geukers Karen , Sibbald Matthew , Gibson Andrew , Khalid Zahira , Whitehead Lori , Azzam Khalid
Published: July 2018

Background
Point-of-Care Ultrasound (PoCUS) is an ultrasound examination performed by the clinician to answer a focused question or guide an invasive procedure. Despite gaining popularity and evidence supporting the use of PoCUS, core Internal Medicine (IM) residency programs in Canada have yet to implement a comprehensive PoCUS curriculum. The objective of this study was to create a formal PoCUS curriculum.
Methods
We conducted a systematic needs assessment with a survey that assessed IM attending and resident comfort, training, and application of PoCUS. We also performed a literature review of selected PoCUS-guided procedures and diagnostics to assess the evidence. A working group analyzed the collected data and designed a graduated 3-year curriculum.
Results
The needs assessment demonstrated that PoCUS education was both necessary and in high demand. The PoCUS-guided procedures and diagnostics that were identified by the survey to be necessary for IM training were then evaluated by a literature review. Based on the evidence, a progressive 3-year curriculum was created. The working group decided on the method and timing of curriculum delivery.
Conclusion
McMaster University is the first IM residency program to introduce a graduated 3-year curriculum complete with competency assessment and quality assurance.
Résumé
Contexte
L'échographie ponctuelle est un examen d'échographie effectué par le clinicien pour répondre à une question ciblée ou guider une procédure invasive. Malgré l'obtention de la popularité et des preuves appuyant l'utilisation de la messagerie instantanée, les programmes de résidence au Canada pour la médecine interne de base (GI) n'ont pas encore mis en œuvre un programme exhaustif. L'objectif de cette étude était de créer un programme d'études officiel.
Méthodes
Nous avons effectué une évaluation systématique des besoins avec un sondage qui évaluait la présence de GI et le confort des résidents, la formation et l'application de ces programmes. Nous avons également effectué un examen de la documentation de certaines procédures et diagnostics guidés pour évaluer la preuve. Un groupe de travail a analysé les données collectées et conçu un programme gradué de trois ans.
Résultats
L'évaluation des besoins a démontré que l'éducation était à la fois nécessaire et trèsdemandée. Les procédures et les diagnostics qui ont été identifiés par le sondage comme étant nécessaires à la formation en GI ont ensuite été évalués par un examen de la documentation. Sur la base des données probantes, un programme d'études progressive de trois ans a été créé. Le groupe de travail a décidé de la méthode et ducalendrier de l'exécution des programmes.
Conclusion
L'Université McMaster est le premier programme de résidence en GI à présenter un programme gradué de trois ans complété par l'évaluation des compétences et l'assurance de la qualité.
Integrating the Health of Socially Vulnerable Populations into Residency Programs.
Authors: Rannelli Luke , Tang Karen , Kachra Rahim , Desy Janeve , Fabreau Gabriel
Published: July 2018

In Canada, growing disparities in health disproportionally affect socially vulnerable populations. The Royal College of Physician and Surgeons of Canada has attempted to incorporate health equity for socially vulnerable populations within the competency training objectives set forth for internal medicine (IM) residents. However, trainee exposure to these populations beyond inpatient contact in tertiary care hospitals has not traditionally been a requirement of IM training. At the University of Calgary, we have developed a four-week clinical rotation that aims to expose residents to social determinants for socially vulnerable populations.

To our knowledge this is the first clinical rotation within an IM program in Canada dedicated to exposing and educating residents on the broader care of socially vulnerable populations. Our goal is to train internists and subspecialists to gain the empathy, skills, and knowledge to better provide care for socially vulnerable populations and to advocate for health equity, throughout their careers.

Résumé

Au Canada, les disparités croissantes de santé affectent de manière disproportionnée les populations socialement vulnérables. Le Collège royal des médecins et chirurgiens du Canada a tenté d'intégrer l'équité en santé pour les populations socialement vulnérables dans les objectifs de formation aux compétences énoncés pour les résidents en médecine interne (GI). Toutefois, l'exposition des stagiaires à ces populations au-delà des contacts avec les patients hospitalisés dans les hôpitaux de soins tertiaires n'a pas toujours été une exigence de la formation en GI. À l'Université de Calgary, nous avons mis au point une rotation clinique de quatre semaines qui vise à exposer les résidents aux déterminants sociaux des populations socialement vulnérables.

À notre connaissance, il s'agit de la première rotation clinique au sein d'un programme de GI au Canada consacré à l'exposition et à l'éducation des résidents sur les soins plus larges des populations socialement vulnérables. Notre objectif est de former des internistes et des sous-spécialités pour acquérir l'empathie, les compétences et les connaissances pour mieux fournir des soins aux populations socialement vulnérables et pour plaider en faveur de l'équité en santé, tout au long de leur carrière.
The Top 5 Papers of 2016-2017 for General Internists
Authors: Quinn Kieran Lewis , Hughes Emily , Verma Amol A
Published: July 2018

Each year, the Canadian Society for Internal Medicine (CSIM) Annual Meeting features a presentation of the “Top 5 Papers” in internal medicine (IM). We reviewed the publications in all major IM journals ( New England Journal of Medicine, Journal of the American Medical Association, Lancet, Annals of Internal Medicine, British Medical Journal, and JAMA Internal Medicine ) between November 2016 and October 2017 to identify 5 papers that we felt were particularly influential and important to practicing clinicians. These articles were all discussed on the free weekly podcast that we produce, The Rounds Table ( http://healthydebate.ca/about-us/the-rounds-table ). This article summarizes these “Top 5” papers.
Time for Change
Authors: Levine Mitch
Published: July 2018

As of April 1st, 2018 I will step down as Editor-in-Chief and Dr. Jim Douketis will assume that role. In addition, the journal has recently added three new Deputy Editors to the Editorial Board. I am confident that Jim and his team will bring with them new ideas and energy that will take CJGIM to a new level of activity and excellence.
Use of Rivaroxaban for Prophylaxis of Superficial Venous Thrombosis in Klippel-Trenaunay-Weber Syndrome
Authors: Qamar Hina , Wu Cynthia
Published: July 2018

Klippel-Trenaunay-Weber syndrome (KTWS) is a congenital malformation syndrome involving blood and lymph vessels and disturbed bone and soft tissue growth. Complications of KTWS include deep-vein thrombosis, pulmonary embolism, gastrointestinal bleeding, and vascular (usually lymphatic) blebs within capillary malformations. We present a case of a young male patient with KTWS who presented with superficial venous thrombosis and microangiopathic hemolytic anemia in a presentation similar to disseminated intravascular coagulation. He was ultimately maintained on prophylactic rivaroxaban to prevent recurrent thrombotic events. We performed a literature search to identify similar cases and to summarize common presenting features and treatment modalities that were offered.

Résumé

Le syndrome de Klippel-Trenaunay-Weber (KTWS) est un syndrome de malformation congénitale impliquant le sang et les vaisseaux lymphatiques et les os perturbés et la croissance des tissus mous. Les complications de la KTWS comprennent la thrombose veineuse profonde, l'embolie pulmonaire, les saignements gastro-intestinaux et les bulles vasculaires (habituellement lymphatiques) dans les malformations capillaires. Nous présentons un cas d'un jeune patient mâle avec KTWS qui a présenté une thrombose veineuse superficielle et une anémie hémolytique microangiopathique dans une présentation semblable à la coagulation intravasculaire disséminée. Il a finalement été maintenu sur des rivaroxaban prophylactiques pour prévenir les épisodes récurrents de purpura. Nous avons effectué une recherche documentaire pour identifier des cas similaires et pour résumer les caractéristiques communes de présentation et les modalités de traitement qui ont été offerts.
Hypercalcemia and Upper GI Symptoms
Authors: Moza Dasha , Dasgupta Kaberi , Daskalopoulou Stella
Published: July 2018

Hypercalcemia is a common clinical presentation encountered in day to day practice. The most common causes of hypercalcemia have been shown to be primary hyperparathyroidism and hypercalcemia of malignancy accounting for around 90% of all cases. We present the case of a 78 year old male admitted to hospital with delirium and an uncommon cause of hypercalcemia, milk alkali syndrome (MAS) in the context of Peptic ulcer disease (PUD). MAS, caused by excessive intake of calcium based antacids, was first identified in the 1920’s when the Sippy regimen, consisting of milk or cream and calcium salts was used to treat peptic ulcers. With the advent of proton pump inhibitors and histamine-2 blockers, it had become a rare cause of hypercalcemia responsible for <1% of the cases. However, there has been a re-emergence of MAS due to the increased use of calcium supplements for osteoporosis prevention and over-the-counter preparations for dyspepsia. Interestingly, apart from the well-known classic symptoms of hypercalcemia, chronic hypercalcemia also increases gastric acid production and worsens PUD which in this case, could likely have lead to increased calcium–based antacid ingestion, worsening the hypercalcemia and creating a vicious cycle. This case report explores the physiology of the connection between hypercalcemia and PUD and emphasizes the need to keep MAS on the differential diagnosis for hypercalcemia.
Point of Care Ultrasound for the General Internist: Pleural Effusions
Authors: Cotton Darrel William , Lenz Ryan , Kerr Brendan , Ma Irene
Published: July 2018

Pleural effusions are a common finding in many clinical settings and have important diagnostic and therapeutic implications.   They may be identified by physical exam, chest radiography, chest computerized tomography (CT) scans or point of care ultrasonography (POCUS).  The use of POCUS for the diagnosis and management of pleural effusions offers several advantages relevant to the practice of the general internist.  For the diagnosis of pleural effusion, POCUS has superior sensitivity and specificity when compared to chest radiography and physical exam.  Abnormal sonographic features of the pleural fluid and the adjacent pleura may suggest the presence of an exudative or malignant effusion. POCUS can be used to quickly estimate the size of a pleural effusion.  Lastly, the use of ultrasound guidance when performing a thoracentesis reduces the risk of pneumothorax and hemorrhage.
Designing and Implementing a Comprehensive Simulation Curriculum in Internal Medicine Residency
Authors: Azzam MBBS Khalid , Wasi MD Parveen , Patel MB Ameen
Published: July 2018

Medical simulation is the use of a device or series of devices to emulate anatomy, real-life clinical situations, and clinical procedures for the purposes of education, evaluation, and research.1,2 Simulation is a powerful tool in the education and evaluation of physicians and is rapidly becoming a central thread in the fabric of medical education.3 The effectiveness of simulation-based medical education (SBME) can be optimized by integrating simulation into an overall curriculum.4 Internal medicine training programs are introducing procedural training using simulation but are not as advanced as other programs, such as anesthesia and emergency medicine, in the use of technology-based simulation utilizing high-fidelity fullsize mannequins.5 We feel simulation can be used to teach a wide range of CanMEDS competencies, and a comprehensive simulation curriculum should become a standard in internal medicine residency training.
Disseminated Herpes Zoster in an Apparently Healthy Middle-Aged Woman
Authors: Wilson MD Ben J. , Chin MD Melanie , Schaefer MD Jeffrey P.
Published: July 2018

Herpes zoster is a characteristic dermatomal maculovesicular rash that results from reactivation of varicella-zoster virus (VZV). Dissemination, or widespread distribution of vesicular lesions beyond the limits of the primarily involved dermatome, occurs almost exclusively in individuals with severe underlying immunodeficiency, such as malignancy, human immunodeficiency virus, and advanced age. Waning cell-mediated immunity is thought to be the final common pathway permitting reactivation and dissemination. Here, however, we present a case of disseminated herpes zoster (DHZ) that occurred in an apparently immunocompetent patient without any traditional risk factors.
“Keepers of the Meaning”
Authors: Farquhar MD SM Donald
Published: July 2018

Albert Schweitzer once remarked, “Example is not the main thing in influencing others. It is the only thing.” How true that is in so many spheres, but particularly so in the health professions. Former Queen’s University vice-dean of medicine Dr. Robert Maudsley observed that, of the four fundamental components of medical education – planned and organized curriculum, structured experience, role modelling and the learning environment – role modelling is considered the most important, by far, by medical school deans.1
Implementation of a Comprehensive Procedural Skills Examination for Internal Medicine Using Simulation at the University of Calgary: A Descriptive Report
Authors: Ma MD MSc Irene W. Y. , Bacchus MD MSc Maria , Glow Jennifer , Brass Charlene , Fradgley BHSc Liz , Fisher MD MSc Michael , Altabbaa MD Ghazwan , Schaefer MSc MD Jeffrey P.
Published: July 2018

Competency in the performance of a number of bedside procedures is an objective of training, set forth by the Royal College of Physicians and Surgeons of Canada. These procedures include venous access including central line placement, lumbar puncture, peripheral arterial catheter insertion, abdominal paracentesis, endotracheal intubation, thoracentesis, and knee arthrocentesis.
Perspectives on the Clinician-Scientist Pathway: A Survey of Cardiology Fellows
Authors: Desplantie MDCM Olivier , Filion PhD Kristian B. , Eisenberg MD MPH Mark J.
Published: July 2018

In recent decades, it has become increasingly difficult to attract medical trainees to the clinician-scientist pathway. Several measures have been undertaken to increase the number of clinician-scientists, but the anticipated results have not been obtained.1 In many ways, the clinician-scientist can be considered an “endangered species.”2 To promote this career path, there is increasing interest in some specialties in developing training programs that would encourage medical students to pursue research by increasing their exposure to research early in their training.3 Our study sought to examine cardiology fellows’ perceptions of the clinician-scientist career path, and their ideas on how to promote it.
Medical Dreams and Academic Pressure: The Terror of Indecision
Authors: Wilson MD Ben J.
Published: July 2018

As I write this, it is November, a time when PGY4 residents in general internal medicine (GIM) must make weighty decisions about whether to pursue additional clinical or research training before setting off into independent clinical practice. Such questions pre-suppose answers to deeper questions: What is our underlying personal medical mission? How can we launch ourselves into a program or career aligned with our sense of purpose? Too often the passion associated with initial medical career decisions can become dampened by the academic culture that defines residency training programs. Consideration of the next steps in our career paths and the consequences of our decisions can be associated with significant anxiety.
Managing the Patient Being Treated with Biologic Agents for Rheumatic Disease: Pearls for the General Internist
Authors: Cividino MD FRCPC FACR Alfred A.
Published: July 2018

Rheumatoid arthritis (RA) is a chronic polyarticular disease with systemic consequences leading to impairment and disability. Typical pharmacological treatment consists of nonsteroidal anti-inflammatory drugs and disease-modifying drugs such as methotrexate, sulfasalazine, hydroxychloroquine, and leflunomide. When disease activity persists, the next level of treatment is the biologic drugs. Some of these agents have been available since 1999. Currently, there are nine biologic drugs available for the treatment of RA. Some agents such as the tumour necrosis factor (TNF) inhibitors also have approved indications for psoriatic arthritis, ankylosing spondylitis, and inflammatory bowel disease.
Status Epilepticus Management: A Short Review
Authors: Savard MD Martin
Published: July 2018

Status epilepticus is a common neurological emergency, with high morbidity and mortality, now defined as 5 minutes or more of (1) continuous clinical and/or electrographic seizure activity or (2) recurrent seizure activity without recovery (returning to baseline) between seizures. In observational studies, many disparities exist in management among different medical teams. Here, the author reviews evidence-based medicine data on this management, with emphasis on the use of drugs and electroencephalography. Benzodiazepine (either IV lorazepam or IM midazolam) are the recognized first line of treatment. When a patient is still seizing thereafter, the second line is usually either IV phenytoin or IV valproate, where available. A persisting status epilepticus should then be considered as refractory and managed with anaesthetic drug, keeping in mind that the natural history of that state is to evolve to nonconvulsive status epilepticus, where an emergent EEG is the only way to diagnose that condition with certainty.
Medical Problems in Pregnant Women
Authors: Mahone MSc MD Michèle , Sauvé MD Nadine
Published: July 2018

The American College of Chest Physicians (ACCP) published its latest (9th edition) guidelines in February 2012. This document is a valuable reference for all clinicians. In the current article, through the analysis of three clinical cases, the authors review, describe, and analyze the most significant new information from the chapter “VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy”: (1) strategies for clinicians facing the prescription of a new drug during pregnancy with little available data; (2) recommendations about indications of thromboprophylaxis for asymptomatic thrombophilias; and (3) thrombophilia screening and secondary prevention for placental complications.
Education Research Productivity of Academic Physicians
Authors: Rourke PhD Liam , Storie MA MLIS Dale
Published: July 2018

For several decades, organizations such as the Royal College of Physicians and Surgeons of Canada have encouraged academic physicians to engage in medical education research. The extent to which these efforts have been persuasive is unclear. This article discusses a study whose purpose was to describe changes in the educational research productivity within this group from 1997 to 2010. The authors found that there has been a substantial increase in the publishing reports of medical education research by Canadian academic physicians.
Lessons from History: Still Relevant in the “Information Age”
Authors: Brindley MD Peter G.
Published: July 2018

In this edition of CJGIM, Aujnarain et al. present an interesting case and a fascinating disease. In so doing, they also provide several reminders for our specialty: (1) before you can treat a disease, you must think of it; (2) our work remains as much cerebral as procedural; and (3) when all else fails, perform (and then re-perform) a full history and physical examination. It is also a chance for those of us excited by history and discovery (the so-called “exploration of alleyways to see if they are blind”) to retell a story that is equal parts science, tradition, and innovation1 – much like medicine itself.
Acute Care SINS: Surgical Insights for the Non-surgeon - Chapter 5: Small Bowel SINS
Authors: Khadaroo MD PhD Rachel G. , Fathimani MD Kamran , 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 5 of this series, the authors discuss the small bowel – its anatomy, its obstruction, and small bowel/mesenteric ischemia.
Physicians’ Appraisal and Response to Early Evidence on Cardiovascular Risk Associated with Rosiglitazone: Knowledge Translation in Clinical Practice
Authors: Brown Garielle E. , Lewin MSc Adriane M. , De Souza BSc Michael A. , Edwards MD Alun L , Ghali MD MPH William A. , Rabi MD MSc Doreen M.
Published: July 2018

In 2007, a high-profile meta-analysis raised concerns about the safety of rosiglitazone, a thenpopular oral hypoglycemic agent. In this study, the authors describe how physicians accessed, evaluated, and applied this information clinically. Their findings showed that although a highly publicized meta-analysis raised concerns among physicians, meta-analyses can be challenging to interpret. Efforts are needed to improve the understanding of this methodology to aid physicians in translating results into practice.
Acute Care SINS: Surgical Insights for the Non-surgeon - Chapter 6: Colon
Authors: Mueller MD Sarah , Brindley MD Peter G. , Khadaroo MD PhD Rachel 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 6 of this series, the authors discuss the colon, covering the areas of anatomy, obstruction, colitis, and surgery.
Acute Care SINS: Surgical Insights for the Non-surgeon - Chapter 7: Liver and Portal Venous SINS
Authors: Khadaroo MD PhD Rachel G. , Karvellas MD SM Constantine J. , 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 7 of this series, the authors address the liver and portal veins; their discussion includes anatomy, surgeries, and transplantation.
Orthostatic Hypotension and Supine Hypertension in the Patient with Autonomic Failure
Authors: Lamarre-Cliche MD Maxime
Published: July 2018

Orthostatic hypotension and supine hypertension are two cardiovascular symptoms of autonomic failure that can coexist in the same patient. Treatment of these conditions is difficult and needs to be tailored according to the objectives that should be set through a discussion with the patient.
Thoracic Aortic Dissecting Aneurysm Presenting with Stroke, Disseminated Intravascular Coagulopathy (DIC), and Gastrointestinal Hemorrhage
Authors: Moghadam MD, Soraya , Nakamura MD, Yoshitsugu , Quantz MD, Mackenzie , Kao MD Raymond
Published: July 2018

Acute ischemic stroke secondary to vessel occlusion from an aneurismal dissection is an uncommon presentation. Disseminated intravascular coagulation (DIC) can present as a consequence of aortic dissection, although this is also rare. In some cases, the laboratory diagnosis of DIC uncovers a vascular abnormality or bleeding diathesis. This article describes a patient presenting with three sequential complications of a dissecting thoracic aortic aneurysm: ischemic stroke, upper gastrointestinal bleeding, and consumptive coagulopathy.
Rumpel-Leede Phenomenon: A Case Report
Authors: HU, MBBS, FRCPC Rehman , J, MD Kambo
Published: July 2018

A 72-year-old woman presented with a one-week history of fever, non-productive cough, and three unwitnessed syncopal episodes, with no other associated symptoms. She had poor recollection of the episodes, but denied urinary/fecal incontinence, tongue biting, numbness, parasthesias, or weakness. Her medical history was significant for hypertension, dyslipidemia, leg ulcers, psoriasis, stress incontinence, and gastroesophageal reflux disease. She did not have diabetes, coronary artery disease, or peripheral vascular disease. Her medications included Atorvastatin, Enalapril, Hydrochlorothiazide, Lansoprazole, and Calcium. She did not smoke or drink. On examination, her vital signs were stable and she was afebrile. Chest auscultation revealed crackles in the right lower base. She developed an erythematous, lacy sharply demarcated rash on her left hand that lasted for 3–4 hours after her blood pressure was taken on the same arm (Figures 1 and 2). Blood tests were unremarkable and included glucose, complete blood count, electrolytes, urea, creatinine, liver function tests, and coagulation studies.
Acute Care SINS: Surgical Insights for the Non-surgeon
Authors: Kinnaird Adam , Fairey Adrian , Khadaroo Rachel , Rourke Keith , Brindley Peter
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 9 of this series, the authors address the genitourinary system and Urology SINS.
On the Shoulders of Giants
Authors: HMB HMB
Published: July 2018

“We see further”…for many reasons: better teaching, better access to information, better diagnostic tools. Sometimes we are fortunate to meet—and learn from—giants in the profession, whose accumulated wisdom and experience are shared with junior learners. Usually this advice is gleaned with great difficulty; it is not written down or etched in stone. It is a passing remark, a knowing smile, a saying that just sticks in the mind. There have been many “condors” and “eagles” that have shown me the updrafts of medicine, whose vision has been inspiring, and whose integrity and insight are beacons for those that follow.
Sudden Bilateral Deafness
Authors: Morriello MD Florence , Granieri MD Enrico
Published: July 2018

Basilar artery occlusion is associated with a high mortality rate and poor functional outcome in survivors. The most common prodromal symptoms are motor and oculomotor deficits. Hearing loss is not a major prodromal symptom. Sudden deafness usually results from either circulatory disturbances or inflammation. Deafness of vascular etiology generally occurs unilaterally. Occlusion of basilar arterial origin suggests that thrombosis is the primary mechanism of stroke, especially in elderly patients. This case highlights the importance of hearing loss as either a main manifestation or a warning of impending brainstem ischemia. Clinicians should be aware of the possibility of vertebrobasilar ischemia in patients with bilateral sudden deafness, even when classic brainstem or cerebellar signs are mild or absent. This case also highlights the importance of prodromal signs and symptoms.
PRONATEC: AMPLIAÇÃO DAS AÇÕES FRAGMENTÁRIAS E INTENSIFICAÇÃO DA PRIVATIZAÇÃO DA FORMAÇÃO DO TRABALHADOR
Authors: Ventura Jaqueline , Lessa Ludmila , Souza Samantha
Published: July 2018

Este estudo objetiva analisar o Programa Nacional de Acesso ao Ensino Técnico e Emprego (Pronatec), especialmente a sua iniciativa Bolsa-Formação, tomando por base os documentos oficiais do programa no período entre 2011 e 2013. Apresenta o que é e como está estruturado o Pronatec, bem como sua amplitude e seu alcance. Discute, também, as implicações políticas do tipo de qualificação profissional priorizada nesse programa com o esforço de análise de seus limites e suas contradições. O texto conclui que as ações do Pronatec intensificam o processo de privatização da formação do trabalhador.
EDUCAÇÃO PROFISSIONAL INTEGRADA NA REDE PÚBLICA ESTADUAL DA BAHIA: A EXPERIÊNCIA DO CENTRO TERRITORIAL DA REGIÃO METROPOLITANA DE SALVADOR/BA
Authors: Santos Aline , Mutim Avelar
Published: July 2018

O artigo apresenta resultados de uma pesquisa que discutiu a política de educação profissional (EP) no Brasil e teve por objetivo apresentar os desafios da construção da proposta de Educação Profissional Integrada (EPI) na Rede Pública Estadual da Bahia. Foi realizada a análise da literatura pertinente e de documentos que estruturam a Rede Pública de Educação Profissional da Bahia, de 2007 a 2014, além da pesquisa de campo no Centro Territorial de Educação Profissional da Região Metropolitana de Salvador - CETEP-RMS onde se ouviu gestores, discentes e docentes. Concluiu-se que a proposta de Educação Profissional Integrada se constitui como desafio de natureza epistemológica, histórica, política e pedagógica.
THE NONLINEARITY OF BRAZILIAN MONETARY POLICY IN THE INFLATION-TARGETING PERIOD: AN ANALYSIS BASED ON AN MS-VAR MODEL
Authors: Fonseca Mateus Ramalho Ribeiro da , Oreiro José Luis da Costa , Araújo Eliane Cristina de
Published: July 2018

This article theoretically and empirically analyzes the hypothesis of the nonlinearity of Brazilian monetary policy following the implementation of inflation-targeting regime. At the theoretical level, it discusses growth and macroeconomic regimes and their effect over Brazilian economy according to the behavior of a number of variables. Empirically, it tests the hypothesis of the nonlinearity of monetary policy in Brazil, estimating a Markov-switching vector autoregressive (MS-VAR) model. The results identify two different monetary regimes: the first regime, which primarily occurred between 2000 and 2007, and the second regime, which primarily occurred between 2007 and 2013. In the case of the second regime, a contractionary monetary policy had more persistent effects on both the public debt and the exchange rate.
Gastrostomía endoscópica percutánea en ancianos: indicaciones, seguridad y desenlaces
Authors: Atencio Diana Patricia , Blanco Pérez Angela Gabriela , Otero Rengino William
Published: July 2018

Introducción: la gastrostomía endoscópica percutánea (GEP) se ejecuta cada vez con mayor frecuencia en ancianos con alteraciones deglutorias, sin importar su condición física, mental o funcional. En nuestromedio se desconocen sus complicaciones y desenlaces.Objetivo: el propósito del estudio es determinar las indicaciones, tasa de complicaciones y desenlaces a corto y largo plazo en el seguimiento de hasta de 5 años.Pacientes y métodos: estudio descriptivo retrospectivo de pacientes mayores de 60 años de edad hospitalizados con indicación de gastrostomía endoscópica percutánea y atendidos en la Clínica Fundadores en el período comprendido entre enero de 2008 y junio del 2013; fueron excluidos pacientes menores de 60 años, realización de gastrostomía abierta o GEP fallida. Se realizó revisión de historias clínicas y seguimiento telefónico de los pacientes.Resultados: de los 135 pacientes con indicación de GEP, 96 fueron incluidos, media de edad 77,5±9 años, 38 hombres (39,5%). La indicación para la GEP fue la incapacidad para la deglución por evento cerebrovascular (32,89%), demencia (30,26%) u otras causas (36,85%). La hipertensión arterial fue la comorbilidad más frecuente. La complicación más común asociada con la GEP fueron los síntomas gastrointestinales (32,9%). No hubo mortalidad asociada con el procedimiento.Conclusiones: la GEP es segura para el aporte enteral a los pacientes ancianos, sin embargo, no demostró benefi cio en aquellos pacientes asociados con demencia. Es importante un manejo interdisciplinario previo para definir la alimentación por gastrostomía en ancianos.
Seroprotección para hepatitis B luego de 3 dosis de vacunación en niños colombianos menores de 18 años de edad con infección por VIH
Authors: Sánchez Pérez Maira Patricia , Velasco Benítez Carlos Alberto , López López Pío
Published: July 2018

Introducción: la seroprotección (SP) (títulos cuantitativos de anticuerpos para antígeno de superficie [Anti- HBsAg] >10 UI/L) para el virus de la hepatitis B (VHB) en niños con el virus de inmunodeficiencia humana (VIH) es baja. Objetivo: establecer la SP para VHB y los posibles factores asociados en niños con VIH de Cali, Colombia. Metodología: estudio de SP para VHB en 85 niños <18 años de edad luego de 3 dosis de vacunación. Fueron consideradas variables clínicas, paraclínicas, ambientales y sociodemográficas. El análi- sis estadístico incluyó estimación de proporción por ocurrencia, IC 95%, porcentajes, promedios y desviación estándar, y análisis univariado entre variable exposición y efecto; también se evaluó confusión (tablas de 2 x 2 y estimación de OR con IC 95%). Se utilizó prueba de Chi2 con significancia p <0,05. El modelo multivariado se realizó por el método de eliminación hacia atrás. Se eliminaron variables con p >0,10 por likelihood-ratio test. Resultados: la SP fue del 35,3% (IC 95% 25,2-46,4) (n = 30) en niños con edad promedio 101±44 meses, con predominio del género femenino, raza mestiza, estadio C para VIH según los Centros para el Control y Prevención de Enfermedades (CDC) de los Estados Unidos y promedio de tiempo de tratamiento de 5 años, sin relación entre el tiempo transcurrido entre dosis 1, 2 y 3 de vacunación y SP, ni entre diagnóstico y colocación de dosis 3 de vacunación y SP. En el modelo multivariado, el factor asociado fue la relación tem- poral entre inicio de tratamiento (0-3 años) y la colocación de la última dosis de vacunación (OR = 4,3 IC 95% 0,96-19,23; p = 0,05) y >3 años de inicio de tratamiento (OR = 9,69 IC 95% 2,37-39,5; p = 0,00). Conclusión: la prevalencia de SP fue del 35,3%, con posible factor de riesgo asociado con la relación temporal entre el inicio del tratamiento y el tiempo de colocación de la última dosis de vacunación.
Helicobacter pylori y alteraciones endoscópicas en pacientes con obesidad severa, programados para cirugía bariátrica
Authors: Otero Regino William , Otero Lina , Trespalacios Alba Alicia
Published: July 2018

En los pacientes con obesidad severa, la única intervención terapéutica eficaz es la cirugía bariátrica y la más frecuentemente utilizada es el bypass gástrico con reconstrucción en “Y” de Roux (BPGYR). Helicobacter pylori es la causa de la mayoría de úlceras pépticas y de cánceres gástricos. Muchos expertos recomiendan investigar y erradicar rutinariamente la infección antes del BPGYR. En nuestro medio no se ha investigado la prevalencia de H. pylori ni las alteraciones endoscópicas en pacientes programados para BPGYR, por lo cual se decidió realizar el presente trabajo. Materiales y métodos: se incluyeron pacientes adultos con obesidad severa, sin síntomas gastroduode- nales, programados para BPGYR y sometidos a endoscopia digestiva alta preoperatoria. Resultados: desde marzo de 2007 a julio de 2014, se incluyeron 83 pacientes. El 87,95% eran mujeres. La edad promedio fue de 46,9±11,4 años (17-62 años). Se encontró H. pylori en el 57,83% (IC 95%: 47,09- 66,96), similar a los no obesos. El 60% tenía algún grado de esofagitis erosiva, várices esofágicas en 2 pacientes y GIST en 1 paciente. Ninguno tuvo atrofia severa (OLGA III o IV). Conclusión: todos los pacientes tenían alguna alteración en la endoscopia. De estos, 2 pacientes tenían várices esofágicas. La prevalencia de H. pylori es similar a la de los no obesos. Se recomienda endoscopia alta de rutina en todos los pacientes antes BPGYR.