Canadian Journal of General Internal Medicine <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> en-US <p>&nbsp;</p> <p>Articles are published under a <a href="">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> (Scott Bryant) (Kelly Brooks) Mon, 27 Aug 2018 13:39:18 +0000 OJS 60 2018: No Better Time to be a General Internist in Canada James Douketis ##submission.copyrightStatement## Mon, 27 Aug 2018 13:33:11 +0000 2018 : Pas de meilleur moment pour être un interniste général au Canada James Douketis ##submission.copyrightStatement## Mon, 27 Aug 2018 13:36:54 +0000 Patients' Satisfaction with Anticoagulant Treatment for Venous Thromboembolism <p><strong>Background</strong>: Data on treatment expectation and perception towards vitamin K antagonists (VKAs), direct oral anticoagulants (DOACs), and low molecular weight heparins (LMWH) for the management of venous thromboembolism (VTE) are sparse.</p><p><strong>Methods</strong>: Prospective observational study including subjects admitted to the hospital with a diagnosis of VTE and a prescription of VKA, DOAC, or a LMWH. Treatment expectations, convenience and satisfaction were assessed using the Perception of anticoagulant treatment questionnaire (PACT-Q) at baseline and at three months.</p><p><strong>Results</strong>: A total of 140 patients were included. Treatment expectations regarding ease of use and the ability to self-manage anticoagulation therapy were higher in patients on DOACs. However, overall treatment satisfaction scores were similar at three months between the groups.</p><p><strong>Conclusion:</strong> Patients with VTE who are prescribed an anticoagulant have different expectations at baseline, but appear to have similar treatment satisfaction regardless of the type of anticoagulant prescribed. </p> Roxanne Dault, Lucie Blais, Alain Vanasse, Paul Farand, Sylvie Perrault, Geneviève Letemplier, Marie-France Beauchesne ##submission.copyrightStatement## Mon, 27 Aug 2018 13:12:21 +0000 The Value of a Rapid Access Internal Medicine Clinic – An Observational Perspective <p><span style="font-family: Calibri;"><span style="font-size: medium;"><strong><span lang="EN-US">Background: </span></strong><span lang="EN-US">Rapid access Internal Medicine (IM) clinics aim to reduce burden on inpatient services.<span>  </span>Despite an increased prevalence of these clinics across Canada, there is a lack of evidence demonstrating their value.</span></span></span></p><p><span style="font-family: Calibri;"><span style="font-size: medium;"><strong><span lang="EN-US">Methods:</span></strong><span lang="EN-US"> An observational retrospective review was undertaken to identify the usage of our IM clinic.<span>  </span>A prospective analysis of Internal Medicine Clinical Teaching Unit (CTU) diverted admissions and a subsequent cost benefit analysis was performed.</span></span></span></p><p><span style="font-family: Calibri;"><span style="font-size: medium;"><strong><span lang="EN-US">Results:<span>  </span></span></strong><span lang="EN-US">Referrals were primarily from emergency room physicians (47%) and general practitioners (34%). Of the requests for admission over a 4 week period, 6.1% were diverted with clinic follow-up within four days.<span>  </span>Over $30,000 of inpatient care costs were prevented over the study period.</span></span></span></p><p><span style="font-family: Calibri;"><span style="font-size: medium;"><strong><span lang="EN-US">Conclusion: </span></strong><span lang="EN-US">Rapid access IM clinics help reduce demand on emergency departments and inpatient services.<span>  </span>A significant percentage of hospital admissions may be avoided by implementing rapid access clinics.<span>  </span>Further study is needed to better quantify the overall benefit.</span></span></span></p> Ryan Joseph LeBlanc, Karmen Jongewaard, Laura Farrell ##submission.copyrightStatement## Mon, 27 Aug 2018 13:15:21 +0000 ANCAassociated vasculitis in a man with scleroderma and pulmonary fibrosis <p>Systemic sclerosis, or scleroderma, is a connective tissue disease that causes fibrosis of the skin and potentially internal organs (1). The most common lung findings in those with scleroderma are interstitial lung disease and pulmonary hypertension (1). Here we describe a 58-year-old man with scleroderma, interstitial lung disease and pulmonary arterial hypertension. He presented with atypical pulmonary manifestations and an acute kidney injury caused by a new diagnosis of ANCA-associated vasculitis. </p> Alyson Wong, Christine McDonald, John Thenganatt ##submission.copyrightStatement## Mon, 27 Aug 2018 13:17:50 +0000 Dyslipidemia Management after Pre-eclampsia: What is the Threshold for Treatment Due to Increased Cardiovascular Risk? <p>Growing evidence shows that women with a history of preeclampsia, pregnancy-induced hypertension or gestational diabetes are at increased long-term risk of cardiovascular disease (CVD).&nbsp; This was incorporated in the American Heart Association’s 2011 guideline on the prevention of CVD in women and was recently reflected in the 2016 Canadian Cardiovascular Society’s guidelines, suggesting that young women who would not formerly have been considered for primary CVD prevention may benefit from screening for dyslipidemia.&nbsp; However, the indications and targets for medical treatment of dyslipidemia postpartum remain unclear.&nbsp; We present the case of a 31yo G1P1L2 woman with preeclampsia, preterm delivery and dyslipidemia who had active vascular risk reduction postpartum, including adjustment of antihypertensives, diet and exercise counselling for low-density lipoprotein cholesterol reduction and weight loss promotion, and consideration of an HMG-CoA reductase inhibitor, which was ultimately decided against given the improvements seen with conservative management.</p> <p>&nbsp;</p> Sheila Rodger, Winnie Sia ##submission.copyrightStatement## Mon, 27 Aug 2018 13:20:31 +0000 Severe Autoimmune LMWH-Induced Thrombocytopenia Presenting with Aortic Thromboses, Adrenal Hemorrhage and Pulmonary Embolism: Response to High-Dose Intravenous Immunoglobulin <p>The occurrence of heparin-induced thrombocytopenia (HIT) in the setting of low-molecular-weight heparin (LMWH) exposure is uncommon, with incidence reported at around 0.2%. Delayed-onset (autoimmune) HIT in the setting of LMWH use is rarer, with only two other case reports in the literature.</p> <p>An 83-year old man was admitted to hospital for an acute exacerbation of chronic obstructive pulmonary disease, receiving low-molecular-weight heparin (LMWH, tinzaparin) while in hospital for prophylaxis against deep venous thrombosis (DVT). One day after discharge, he presented to the emergency department with acute chest pain and dyspnea. Computed tomography revealed bilateral pulmonary embolism, multiple abdominal aortic thromboses, and unilateral adrenal hemorrhage, and he was given a bolus of intravenous unfractionated heparin (UFH) in the emergency department. His platelet count (prior to UFH bolus) was found to be markedly reduced (39 × 10<sup>9</sup>/L) from normal values two days prior. We suspected heparin-induced thrombocytopenia (HIT) to have caused the thrombocytopenia and thromboses (arterial and venous), and thus anticoagulation therapy was changed from heparin to argatroban. His HIT assay was strongly positive, including features of autoimmune reactivity (serum-induced platelet activation in the absence of heparin). HIT developing after exposure to tinzaparin is relatively rare, and use of a scoring system helped to facilitate an early diagnosis. Additionally, this case demonstrates heparin-independent platelet activation, a marker for autoimmune HIT (aHIT).&nbsp;</p> <p>The patient's serum tested strongly positive for IgG-specific anti-PF4/heparin EIA and serotonin release assay. The presence of these antibodies would also explain the further decline in his platelet count to 10 x 10<sup>9</sup>/L after he received a bolus dose of heparin at the beginning of his second hospitalization. This case highlights the third reported case of delayed-onset HIT in the setting of LMWH, and the rapid response to high-dose intravenous immunoglobulin.</p> Joshua Nero, Patricia Araneta, Theodore E Warkentin, Otto Moodley ##submission.copyrightStatement## Mon, 27 Aug 2018 13:23:56 +0000 Proton Pump Inhibition in the Management of Hypokalemia in Anorexia Nervosa with Self-Induced Vomiting <span lang="EN-US">Hypokalaemia is a dangerous complication in severe cases of eating disorders with self-induced vomiting and can result in rhabdomyolysis, cardiac arrhythmias, and death. Self-induced vomiting leads to hypokalaemia through two pathways.  First, loss of gastric acid causes hypochloraemic metabolic alkalosis, which increases filtered bicarbonate load in the nephron (exceeding the tubular resorptive threshold), and subsequently increases distal sodium bicarbonate delivery.  Secondly, hypovolaemia causes activation of the renin-angiotensin-aldosterone axis. Increased distal sodium delivery and mineralocorticoid activity together cause urinary potassium wasting.  Standard management of severe hypokalaemia in patients with anorexia or bulimia nervosa and persistent self-induced vomiting includes intravenous replacement of potassium and correction of hypovolaemia. However, hypokalaemia is often refractory in eating disorder outpatients who have ongoing self-induced vomiting after discharge. We present a case of hypokalaemia due to anorexia nervosa, binge-purge subtype with self-induced vomiting successfully treated with a proton pump inhibitor (PPI) in addition to standard therapy.</span> Natalie Jane Wainwright, Arden Azim, John David Neary ##submission.copyrightStatement## Mon, 27 Aug 2018 13:25:49 +0000 Cytomegalovirus Primary Infection in an Immunocompetent Female with Mononucleosis Features: A Review of Mononucleosis-Like Syndromes <p><strong>Background</strong></p> <p><br>The clinical triad of fever, pharyngitis, and lymphadenopathy was first described in 1889 as “glandular fever” and later defined as infectious mononucleosis. We present a case report and review of mononucleosis-like syndromes in an immunocompetent patient. The review of common etiologies includes Epstein-Barr virus (EBV), acute human immunodeficiency virus (HIV), human herpesvirus 6 (HHV-6), cytomegalovirus (CMV), and Toxoplasmosis gondii.</p> <p><br><strong>Case Vignette</strong></p> <p><br>A 37-year- old, immunocompetent female presented with a three-week history of fever, pharyngitis, fatigue, night sweats, and abdominal pain. Physical examination&nbsp;revealed hepatosplenomegaly, but no lymphadenopathy, rashes, or tender joints. Investigations showed lymphocytosis and a normal peripheral smear. A Hematology consultation excluded hematologic malignancy. Her CD4/CD8 ratio was 0.2 in keeping with a viral infection, but EBV monospot test was negative. Serology for hepatitis B and C were negative. Human immunodeficiency virus (HIV) testing was not done in the absence of risk factors. Quantitative PCR for CMV was positive with a value of 965.25 units/mL. The patient was diagnosed with CMV viremia and treated with a two-week course of valganciclovir with resolution of symptoms. A two-month follow-up revealed a normal complete blood count and resolving hepatosplenomegaly.</p> <p><br><strong>Conclusions</strong></p> <p><br>In immunocompetent patients presenting with symptoms of mononucleosis, the differential diagnosis should include EBV, CMV, HHV-6, acute HIV and Toxoplasmosis gondii. CMV commonly affects young patients and is less associated with tonsillitis, pharyngitis, and lymphadenopathy. HHV-6 can present with headaches, encephalitis, and abdominal pain. Consideration of acute HIV mononucleosis should prompt early serologic testing. Toxoplasmosis is often associated with undercooked food or cat excrement, requiring anti-IgM antibody testing to distinguish from EBV. Although EBV infectious mononucleosis may be suspected, the general practitioner should consider a complete review of other infectious etiologies.</p> Shohinee Sarma, Derek Henry Wallace Little, Tooba Ali, Emily Jones, Shariq Haider ##submission.copyrightStatement## Mon, 27 Aug 2018 13:28:57 +0000