Canadian Journal of General Internal Medicine http://cjgim.ca/index.php/csim <p><strong>The Canadian Journal of General Internal Medicine (CJGIM) ISSN: 2369-1778</strong> is the official publication of the Canadian Society of Internal Medicine (CSIM). The journal has a well respected editorial board and provides a sharp focus on the topics and issues facing the profession of Internal Medicine with a combination of society news, clinical and scientific original articles. CJGIM is published four times a year and is distributed to all members of the Canadian Society of Internal Medicine along with physicians in various subspecialties of medicine.</p> The Dougmar Publishing Group en-US Canadian Journal of General Internal Medicine 1911-1606 <p>&nbsp;</p> <p>Articles are published under a <a href="http://creativecommons.org/licenses/by-nc/4.0/">Creative Commons Attribution - Non Commercial 4.0 International License</a>.&nbsp; Authors and users are free to copy and redistribute the material in any medium or format, with proper attribution, for non-commercial purposes. Authors retain copyright to their article.</p> Emerging Barrier to Timely Care of Hip Fracture Patients: A Prospective Study of Direct Oral Anticoagulation and Time to Surgery http://cjgim.ca/index.php/csim/article/view/272 <p><strong>Introduction</strong>: Rapid surgical management of hip fracture patients is critical to reduce morbidity and mortality.  These patients may be anti-coagulated and the new direct oral anticoagulants (DOAC) may introduce delays to treatment.  Our purpose was to examine the impact of these DOAC on time to surgical management for hip fracture patients.</p><p><strong>Methods</strong>: A prospective audit of 55 consecutive operative hip fracture patients examined time from diagnosis to surgery. Indications for anticoagulation were recorded.</p><p><strong>Results</strong>: Time to surgery for the DOAC group was 66±16 hours, versus 38±21 and 25±19 hours for warfarin and control groups, respectively (P&lt;0.05). Anticoagulation was for atrial fibrillation in 93%.</p><p><strong>Conclusion</strong>: Patients on DOAC faced significant delays to surgery. Given that both DOAC use and incidence of hip fracture are expected to rise, this presents a barrier to optimized care in this vulnerable group.</p> Marlis T Sabo Fatima Mahdi Marcia Clark ##submission.copyrightStatement## http://creativecommons.org/licenses/by-nc/4.0 2018-10-16 2018-10-16 13 4 e6 e9 10.22374/cjgim.v13i4.272 A CanMEDS Competency-Based Assessment Tool for High-Fidelity Simulation in Internal Medicine: The Montreal Internal Medicine Evaluation Scale (MIMES) http://cjgim.ca/index.php/csim/article/view/280 <p><strong>Introduction:</strong> High-fidelity simulation is an efficient and holistic teaching method. However, assessing simulation performances remains a challenge. We aimed to develop a CanMEDS competency-based global rating scale for internal medicine trainees during simulated acute care scenarios.</p><p><strong> Methods:</strong> Our scale was developed using a formal Delphi process. Validity was tested using six videotaped scenarios of two residents managing unstable atrial fibrillation, rated by 6 experts. Psychometric properties were determined using a G-study and a satisfaction questionnaire.</p><p><strong>Results: </strong>Most evaluators favorably rated the usability of our scale, and attested that the tool fully covered CanMEDS competencies. The scale showed low to intermediate generalization validity.</p><p><strong>Conclusions: </strong>This study demonstrated some validity arguments for our scale. The best assessed aspect of performance was communication; further studies are planned to gather further validity arguments for our scale and to compare assessment of teamwork and communication during scenarios with multiple versus single residents.</p> Patrice Chrétien Raymer Jean-Paul Makhzoum Robert Gagnon Arielle Levy Jean-Pascal Costa ##submission.copyrightStatement## http://creativecommons.org/licenses/by-nc/4.0 2018-10-12 2018-10-12 13 4 e10 e16 10.22374/cjgim.v13i4.280 Teaching Residents how to Effectively Prescribe Nicotine Replacement Therapy on the Clinical Teaching Unit http://cjgim.ca/index.php/csim/article/view/271 <p class="Default">Residents and medical students identified a lack of knowledge regarding Nicotine Replacement Therapy (NRT) as a barrier to smoking cessation counselling. We hypothesized that a teaching session on NRT during an inpatient Internal Medicine rotation would increase learner comfort in prescribing these products.</p> <p class="Default">Medical trainees on the Internal Medicine Clinical Teaching Unit (CTU) attended a teaching session during week 4 of an 8-week rotation. Pharmacy records from the 8-week period were retrospectively analyzed to determine NRT prescribing behaviour.</p> <p class="Default">Pre-intervention, 5.8% (13/225) of new admissions received a NRT prescription. Post-intervention, 17% (31/182) of new admissions received a NRT prescription. Using a Fisher’s exact test, the percentage of new admissions that received a prescription was significantly different (p&lt;0.001) between the pre- and post-intervention time frames.</p> <p class="Default">This data suggests that integrating education on NRT into CTU teaching can significantly alter prescribing behaviour and improve access to NRT for patients who need it.</p> Shannon Riley Nicole Sitzer Sophie Corriveau Gregory Pond Yayoi Goto Jill C Rudkowski ##submission.copyrightStatement## http://creativecommons.org/licenses/by-nc/4.0 2018-10-15 2018-10-15 13 4 e17 e20 10.22374/cjgim.v13i4.271 An Unexpected Precipitant of Delirium in a Patient with Developmental Delay http://cjgim.ca/index.php/csim/article/view/259 <p><strong>Introduction</strong></p><p>Delirium is an acute change in mental status with a fluctuating course. It has numerous precipitating factors that can be classified using the DIMS-R framework, including structural changes and metabolic disturbances. Delirium is often under-recognized and numerous screening tools have been developed to aid diagnosis.</p><p><strong>Case</strong></p><p>A 52-year-old female with a history of cerebral palsy was admitted to hospital for hypernatremia and a first episode of hyperosmolar hyperglycemic state. Upon resolution of her metabolic disturbances, she developed visual hallucinations which prompted further investigations revealing a surprising diagnosis.</p><p><strong>Conclusion</strong></p><p>Visual hallucinations are the most common psychotic feature associated with delirium and are more likely to be associated with multiple medical conditions. Delirium is often multi-factorial and a full diagnostic workup, including imaging studies, should be considered to address all possible underlying etiologies. Effective treatment of delirium is dependent on treatment of all of its precipitants.</p> Sandra Rao Lawrence Jacobs ##submission.copyrightStatement## http://creativecommons.org/licenses/by-nc/4.0 2018-10-02 2018-10-02 13 4 e36 e39 10.22374/cjgim.v13i4.259 Acute Hepatitis Associated with “Thermogenic Fat Burner” Weight Loss Supplementation: A Case Report http://cjgim.ca/index.php/csim/article/view/273 <p>Thermogenic fat burner treatments are used to increase an individual’s basal metabolic rate, thus mimicking exercise and inducing weight loss. In rare circumstances, these supplements are associated with hepatotoxicity. We describe the case of a 21-year-old male who presented with painless jaundice and a weight loss of 25% of body weight following 8 weeks of thermogenic fat burner supplementation. Laboratory investigations revealed a severe transaminase and bilirubin elevation (AST/ALT&gt;2000 IU/L, total bilirubin=148 μmol/L). An otherwise extensive workup, including a liver biopsy, did not identify a precise cause. Two weeks after discharge, his condition stabilized with a significant improvement in his laboratory abnormalities. In this report, we discuss the likely ingredients that contributed to the patient’s condition, including <em>Garcinia cambogia </em>and green tea leaf extract, and review similar cases documented in the literature. <strong></strong></p> Marko Popovic Maxime Billick Matthew R. Robinson ##submission.copyrightStatement## http://creativecommons.org/licenses/by-nc/4.0 2018-10-03 2018-10-03 13 4 e32 e35 10.22374/cjgim.v13i4.273 Tumour Emboli Causing Multifocal Ischemic Stroke from Intracardiac Malignant Solitary Fibrous Tumour http://cjgim.ca/index.php/csim/article/view/268 <p>A 78-year-old woman presented to the emergency department with gait ataxia and diplopia. Her past medical history included the surgical resection of a phyllodes breast tumour 8 years prior, with no known recurrence. A computed tomography (CT) scan of the brain demonstrated multifocal right supratentorial hemispheric subacute infarcts in the frontoparietal, posterior temporal and occipital regions. The patient developed recurrent generalized seizures in hospital. Transesophageal echocardiogram demonstrated a large 2.7 × 1.8 × 0.8 cm mobile echogenic mass attached to the left posterior atrial wall. CT angiogram of the chest revealed the left atrial mass as well as a mass encasing the right bronchus intermedius. The patient opted for comfort care and passed away in hospital. Autopsy revealed the tumour to be a primary cardiac solitary fibrous tumour. We present a case of multifocal ischemic stroke and seizures secondary to tumor emboli originating from intracardiac solitary fibrous tumour.</p> Lindsay J Melvin Nicole Sitzer Rebecca Amer ##submission.copyrightStatement## http://creativecommons.org/licenses/by-nc/4.0 2018-10-10 2018-10-10 13 4 e28 e31 10.22374/cjgim.v13i4.268 Anterior Spinal Artery Syndrome as Complication of Bronchial Artery Embolization http://cjgim.ca/index.php/csim/article/view/260 <p>Bronchial artery embolization (BAE) has risen as one of the cornerstones of massive hemoptysis management. Though rare, spinal cord infarction is a potential complication. Here, we present a case of a 65 year old gentleman who presented with acute weakness and was diagnosed with spinal cord infarction following BAE. This case will also review the pathophysiology of this adverse complication.</p> Ka Hong (Casey) Chan Chris White Jason K Wong ##submission.copyrightStatement## http://creativecommons.org/licenses/by-nc/4.0 2018-10-12 2018-10-12 13 4 e25 e27 10.22374/cjgim.v13i4.260 Phlebolymphoedema: A Venous Etiology for Elephantiasis Nostras Verrucosa http://cjgim.ca/index.php/csim/article/view/288 <p>Elephantiasis nostras verrucosa is the end-stage manifestation of chronic, non-filarial, lymphatic insufficiency. While primary lymphatic disorders should be excluded, lymphoedema secondary to venous hypertension is a potentially common aetiology for this condition in developed nations. We present the case of a 62-year-old woman presenting with a four-year history of elephantiasis nostras verrucosa progressing to impairment of ambulation. Investigations for underlying pathology demonstrated the presence of bilateral chronicized deep vein thrombi, with a primary diagnosis of phelobolymphoedema being therefore retained. Following initiation of anticoagulation, wound care, and compressive bandaging, this patient was discharged to inpatient rehabilitation.</p> Hourmazd Haghbayan Eric Anthony Coomes ##submission.copyrightStatement## http://creativecommons.org/licenses/by-nc/4.0 2018-10-17 2018-10-17 13 4 e21 e22 10.22374/cjgim.v13i4.288 Challenges, Strengths, and Vision for the Future http://cjgim.ca/index.php/csim/article/view/332 <p>N/A</p> James Douketis ##submission.copyrightStatement## http://creativecommons.org/licenses/by-nc/4.0 2018-11-12 2018-11-12 13 4 e4 e4 10.22374/cjgim.v13i4.332 Défis, forces et vision pour l’avenir http://cjgim.ca/index.php/csim/article/view/333 <p>N/A</p> James Douketis ##submission.copyrightStatement## http://creativecommons.org/licenses/by-nc/4.0 2018-11-12 2018-11-12 13 4 e5 e5 10.22374/cjgim.v13i4.333 Bringing Patient Care Back to the Bedside: Collaborative Clinical and Academic Leadership http://cjgim.ca/index.php/csim/article/view/269 Mohamed Panju Leslie Martin Marianne Talman Juan Guzman Khalid Azzam ##submission.copyrightStatement## http://creativecommons.org/licenses/by-nc/4.0 2018-10-02 2018-10-02 13 4 e23 e24 10.22374/cjgim.v13i4.269