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Canadian Journal of General Internal Medicine
Volume 15, Issue 1, 2020 33
Abstracts
Rocky Mountain ACP/AMA
Internal Medicine Conference
November 14–16, 2019
Research Abstracts
General Internal Medicine Fellows as Teachers in
the
Ambulatory Clinic
CaryCuncic, MD, FRCP(C),MMEd, MSc., JamesTessaro,
MD, FRCP(C), MHPE, HarpinderNagi, MD, FRCP(C),
AmanNijjar, MD, FRCP(C), MPH
Department of Medicine, University of British Columbia
Background
Recruitment and retention of preceptors in medical student
ambulatory clinic is challenging; reasons cited include hospital –
based medical teaching units being more familiar and a lack of
remuneration. As a solution, we assigned our General Internal
Medicine (GIM) fellows to teach in clinic, in hoping to decrease
the teaching load and serve as early faculty development.
Methods
We assigned medical students to GIM fellows during their
longitudinal clinic. Fellows were responsible for the teaching
and assessment of the students. We interviewed attending
physicians, fellows and students about their experiences in this
model. Using a grounded theory approach to both data collection
and analysis and subsequent conversations with a key informant,
we identified emergent themes and best practices.
Results
The model was successful with students and fellows. The students
felt that the learning environment was supportive, the fellow was a
positive role model, and that they received good quality teaching
and feedback. The fellows felt that the students’ enthusiasm was
contagious, that they learned different skills as a clinic “junior
attending, and many agreed that they would continue to teach
in clinic. Attending physicians had a mixed view. Those who
had not taught students prior felt ill – prepared. Some questioned
the fellows’ educational experience. All agreed that the current
model was untenable, due to the lack of organization.
Conclusions
Having GIM fellows as teachers in the internal medicine
ambulatory clinic is pedagogically sound, as it offers benefits
to both sets of learners. In addition, faculty development is
occurring at the level of the fellow, so as to recruit future clinical
teachers. However the operationalization was unsuccessful due
to the chaotic nature. We propose adding a GIM fellow as a
“junior attending” to the blocked medical student clinic to help
ameliorate the identified challenges.
To Evaluate and Compare the Expectations and
Attitude Towards Precision Medicine Among the
Patients and Physicians in Oncology
Dr.WinsonCheung
1
, Dr. Gwen Bebb
2
,DrNavdeep
Dehar
3
***
Department of Medical Oncology, TBCC1,
2
, Department
of Internal Medicine, University of Calgary
3
Background
Despite the potential benefits of genomic testing in cancer
diagnosis and treatment, this technology is relatively new to
most cancer patients. Prior research has reported insufficient
understanding of genomic testing, as well as apprehensiveness
towards the potentially overwhelming test results. However, there
has been very few studies of patient knowledge and expectations
of genomic testing and it remains unclear how the perspectives
of patient and physician differ in regards to the use of this
new technology. Such discrepancies in patient and physician
knowledge and expectations can often result in suboptimal
cancer management and follow-up care. We propose a survey
study that aims to examine the potential differences patient and
physician views towards genomic testing in cancer.
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Canadian Journal of General Internal Medicine
34 Volume 15, Issue 1, 2020
Rocky Mountain Conference Abstracts
Objective
To evaluate and compare the expectations and attitude towards
precision medicine among the patients and physicians in Oncology
Research Methodology
This study will be conducted in Oncology clinics at the TBCC. The
participating oncologists will be asked to complete the physician
survey and approach patients they are diagnosing and treating
and who meet the inclusion criteria. Interested patients will be
asked complete the survey questionnaire in paper format. Two
separate but complementary self-administered questionnaire
survey have been developed and will be distributed for a period
of 1-2 years. Survey responses from patients will be matched
with those of their oncologists to form patient-oncologist pairs,
respectively.
Statistical Analysis
Multivariable logistic regression analyses will be conducted
to calculate the odds ratios for discordant genomic testing
expectations, dependent on patient factors and physician
characteristics. All tests will be two-sided, where a P value less
than .05 will be considered statistically significant.
Conclusion
Identifying the areas of agreement and disagreement between
patients and providers can assist the development of strategies
to improve education and counseling of genomic testing, which
can in turn enhance its use and optimize patient-specific cancer
management.
Determining Patient and Provider Variables that
Contribute to the Selection of In-Hospital Diabetes
Regimen in Patients Admitted to Acute Care
Hospitals
Erin Helson (MD), Evan Hagen (BSc), Karmon Helmle
(MSc, MD), Edwin Rogers (Senior analyst), and
Shannon Ruzycki (MPH, MD)
Department of Medicine, University of Calgary
Background
Basal bolus insulin therapy (BBIT) is recommended over sliding
scale (SS) regimens for patients with diabetes admitted to the
hospital. Despite this, many patients are placed on SS. The patient
or clinical characteristics that are associated with selection of
BBIT or SS are not known. The aim of this study is to determine
patient and provider factors that influence in-hospital glycemic
management regimens.
Methods
We performed a retrospective cross-sectional study of adult
patients with diabetes admitted to internal medicine for greater
than 48 hours between April 1st, 2016 and July 31st, 2018 in
Calgary, Alberta. We included patients with a HbA1c result
within six months prior to admission, and who received insulin
during admission. Patients admitted from long term care,
admitted to intensive care, who were pregnant, who received
a blood transfusion, who had type 1 diabetes, or had palliative
goals of care were excluded.
Results
Eight-hundred and three patients were included; 469 [58%]
were on BBIT and 334 [42%] were on SS. Compared to those
on SS, BBIT patients were younger (61.5 vs. 68.6; p<0.001), less
often at target HbA1C (52% versus 18%; p<0.001), and more
likely to use insulin prior to admission (92% vs 10%; p<0.001).
BBIT patients had higher mean glucose in the first 48 hours of
admission compared to those on SS (10.9 mM [3.69] versus 8.9
mM [2.32]; p<0.001). A greater proportion of BBIT patients
had hypoglycemic events (26% vs 5%; p<0.001) and severe
hyperglycemic events (35% vs 6%; p<0.001).
Conclusion
These results suggest that there may be important differences
between patients who are started on BBIT and those started on
SS. Any non-randomized study that compares outcomes between
these regimens may be susceptible to important confounding.
Retrospective Study of Patients with Upper
Extremity Clots Presenting to Emergency
Departments in Tertiary Care Hospitals
in Calgary in the Last Five Years.
Tania Pannu, MD
1
*, EricHerget, MD1 and
DeepaSuryanarayan, MBBS
1
1
University of Calgary, Calgary, AB, Canada
Objective
5 year retrospective study of patients presenting to emergency
departments at the four tertiary care hospitals in Calgarywith
upper extremity (UE) deep vein thrombosis (DVT) to determine
practice patterns and management ofUEclots.
Methods
Patientswith suspectedUEDVTwithdiagnostic imagingfromJanuary
2014 to December 2018were included in the study. Inclusion criteria
includedage above18 years.Exclusion criteria were any known
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Canadian Journal of General Internal Medicine
Volume 15, Issue 1, 2020 35
Rocky Mountain Conference Abstracts
cancer or life expectancy under 6 months. Basic demographic
data were collected, in addition to disposition from emergency,
choice of anticoagulant, duration of anticoagulation, history of
thrombophilia and thoracic outlet obstruction (TOO) work-up.
Results
1236 patient records were reviewed, of which 12.2%were positive
for UEDVTand 9.2%for superficial vein thrombosis (SVT).
Mean age was 47 years and 50.2% were males.Mean duration of
treatment for DVT and SVTwas5.01 months and 1.15 months,
respectively.22.5% of all DVTs were recommended lifelong therapy.
21 (18.4%)patientswere treated for more than 45 days for SVT,
of which only 9 had another indication for anticoagulation.Line
associated thrombosis was the most common risk factor identified
(17.2%).Anticoagulant agents for DVT included low molecular
weight heparin (7.9%), direct oral anticoagulants(39.1%) and
warfarin (42.4%). 8.6% of the DVTs received no treatment.
30.5% of the patients with DVT were referred toGeneral Internal
Medicine,24.5% toHematologyand 33.7% to their family doctor.
39.7% of the people with DVT were tested for thrombophilia, of
which 10% tested positive for any type of thrombophilia. 29.8%
were tested for TOO, of which 48.9% werepositiveand 11.1%
received surgery for same.
Conclusion
Our study demonstrates significant variability in the management
ofUE clots.Next steps include developing a structured,
standardized approachtohelp reduce this variability and
optimizemedicalmanagement.
Using a TRIZ to Understand the Current Challenges
and Potential Solutions in the Medical Teaching
Unit
Pirani F, MD;AltabbaaG, MD, MSc;
GrinmanM, MD, MPH
Background
The modern Medical Teaching Unit (MTU) is confronted
with the challenge of balancing increasing patient complexity,
increasingworkload&limited resources, with the need to provide
safe &cost-effective care in an optimum teaching environment
for trainees that maintains physician wellbeing.
Aim
To better understand the MTU environment at our hospital, we
designed a TRIZ to elicit current challenges/potential solutions
as perceived by various healthcare providers.
Improvement/Innovation
We conducted 3 sessions – two with residents/medical students,
and another with allied health staff. These results are being used
to design a quality-improvement initiative in the upcoming year.
When askedtodescribethe worst possible MTU” participants
generated a theoretical list of problems. They were then asked to
identify which of theseare currently happening, andsuggest potential
solutions. Subsequently, participants prioritized the problem/
solution list according to ease of implementation&potential
impact.A fishbone diagram was created for thematic analysis.
Among the ten major issues identified, the most common
themes were a lack of communication (oral/written) between
team members and organizational structure of daily activities,
both of which have easily implementable solutions with relatively
high potential impact.
Measures
When a change initiative is implemented, we will select measures
to determine if we are achieving the Quadruple Aim - improved
patient/provider satisfaction(eg:surveys), healthcare resource
utilization(eg:length of stay)&patient outcomes(eg:complication
rate).
Next Steps
Our results have implications for changing several processes,
many of which impact attending physicians. Therefore, we will
perform a TRIZ with the facultynext to inform the design &
implementation of a change initiative directed toward improving
the quadruple aim on the MTU.
Impact
We expect this study will enable us to better understand the
needs of different healthcare providers through a systems-
thinking approach that optimizes operations striving to achieve
the Quadruple Aim.
Identifying Learning Needs in Medical Assistance
in Dying of Postgraduate Medical Residents
Dr. Krista Reich, Dr. Jacqueline Hui, Dr. Amy Tan
University of Calgary
Medical Assistance in Dying (MAiD) is now legal in Canada.Therefore,
integratingMAiDinto the medical curriculum will be important
for providing trainees with the skills, knowledge, and attitudes
to care for patients requesting assistance in dying. To date, there
is no literature available on educational content and format of
MAiD teaching. The objective ofthisstudy was to determine
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Canadian Journal of General Internal Medicine
36 Volume 15, Issue 1, 2020
Rocky Mountain Conference Abstracts
the learning needs in MAiD of postgraduate Internal Medicine
(IM) residents.
A learning needs assessment was completed during an IM
academic half day at the University of Calgary. Demographic
information and data on prior teaching in MAiD was obtained
before the session. Residents were then taken through three cases,
independently online, and then as a group facilitated by an expert
in MAiD content. The cases were designed to test situational
judgement and resident knowledge in MAiD. A thematic analysis
was performed to identify learner gaps in knowledge.
Demographic data was obtained from 20 participants, all
IM residents, of which 65% were femaleand 50% were in their
first year of residency. A total of 40% (8/20) of the residents
received MAiD teaching before residency, with an average of
3.75±1.5hours. In assessing confidence in responding to a
MAiD request, 74% (14/19) of residents reported to be “not
very confident, and 100% of residents (20/20) thought more
education in MAiD should be incorporated into their residency
training.Highlevel themesincluded “resident discomfort with
discussingMAiD, lack of understanding of the local MAiD
policy and procedures,and perceptions that MAiD isonly an
optionwhen symptoms areoptimized”.
Preliminary resultsdemonstrate gaps of knowledge in
eligibility, policy and procedures, including referral process,
and understanding the roleandobligationsof residentsin the
request process. Overall, there is aneed for more residency
training in this specialized area.
An Alternative Prophylaxis for Deep Vein
Thrombosis Using Intermittent Electrical
Stimulation
KahirA Rahemtulla
1,3
,Dirk G Everaert
1,3
,
MichelJAGauthier
3
,Vivian K Mushahwar
1,2,3
1
Department of Medicine, Faculty of Medicine and Den-
tistry,University of Alberta,Canada
2
Neuroscience and Mental Health Institute,University of
Alberta,Canada
3
Sensory Motor Adaptive Rehabilitation Technology
(SMART) Network, University of Alberta, Canada
kahir@ualberta.ca
Funding support received: Glenrose Hospital Foundation,
Canada Foundation for Innovation, National Sciences and
Engineering Research Council scholarship, Government
of Alberta scholarship, Faculty of Medicine and Dentistry
(UofA) scholarship
Background
Deep vein thrombosis (DVT) affects approximately 45,000
Canadiansannually. Of specific concern areimmobilizedpatients
whocannotuseanti-coagulants because of bleeding risks or
compression devices due to discomfort. Intermittent electrical
stimulation (IES)maypresent an alternativeprophylactic
interventionby activating the calf-muscle pump to increase
venous return and prevent stasis.The objective of this study
was to determine the required stimulationintensityto increase
venous velocityin typicaland mobility impaired subjects.
Methods
Thestudyincludedthree groups. The first group consisted of
typical subjects (n=12). Testing was performed on the right
leg, stimulating the gastrocnemius and the tibialis anterior
musclessequentially.Gastrocnemius stimulation intensitywas
modulated to produce gradual increases in force. Doppler
ultrasound was used to measure the baseline (beforestimulation)
and peak (during stimulation)popliteal venous velocities.Isometric
ankleforceswere measured using a custom-built apparatus.The
second group consisted of typical subjects (n=10); femoraland
popliteal venous velocity were measured.Thethirdgroup
consisted ofin-patients, post-stroke whowere relatively immobile
(n=10); testing was performed on the more affected leg.Lastly,a
questionnaire determined each subject’s comfort.
Results
Intypical subjects, asignificanceincreaseinpopliteal venous
velocity(6.27±1.81 cm/s versus 55.27±25.89 cm/s, p=0.014)and
femoral venous velocity(7.89±2.58 cm/s versus 38.84±13.31 cm/s,
p=0.002)from baseline,was achieved at 11-20% MVC.Post-stroke
subjectsshowed anincreaseinpoplitealvenousvelocitycompared
to baseline(8.93±1.98 cm/s versus 52.92±22.38 cm/s, p=0.013)at51-
60%of the maximumrecordedcontractionwithstimulation.The
level of discomfortofthe stimulation was rated “very little” to
moderate”in all subjects.
Conclusion
Anincreaseinpopliteal[all subjects]and femoral[typical
subjects]venous velocitieswas achievedat comfortable levels.Further
research is required in acute care settings to further determine
the feasibility of IESas a prophylactic method for DVT.
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Canadian Journal of General Internal Medicine
Volume 15, Issue 1, 2020 37
Burnout and its Associated Factors AmongMedical
Residents: A Meta-Analysis
and Meta-Regression
Zahra Sohani MD PhD
1,2
andLeenNajiMD
3
1
Faculty of Medicine, University of Toronto, Toronto, ON,
Canada
2
Department of Internal Medicine, McGill University,
Montreal, QC, Canada
3
Department of Family Medicine, McMaster University,
Hamilton, ON, Canada
Background
Burnout is increasingly recognized as a crisis in the medical
profession, affecting both physician wellbeing and patient care.
As resident physicians are tasked with tremendous responsibility
whilst learning and integrating new skills, they are a particularly
susceptible group.
Objectives
Ourprimarily aimedto establish the prevalence of burnout
among medical residents based on a meta-analysis of global
literature. Secondarily, we usedthisdata to: 1)identify risk and
protective factorsfor burnout, and 2) use meta-regression to
establish whetherprevalence in burnout varies bycountry of
training, year of study, and specialty of training.
Methodology
We searchedMedline, EMBASE,PsycINFO, Cochrane, Web
of Science and ERIC from their inception to August 21,
2018. Burnout prevalence and study characteristicsfrom 197
studieswere extracted in duplicate by 5 investigators.Pooled
prevalencewasestimatedusinga random effectsmodel withthe
restricted maximum-likelihood estimator.For our secondary
analysis, we employed meta-regression using a random effects
model.
Results
Our study encompasses data collected over 30 years
among 44,000 residentsacross 47 countries. We found the
pooledglobalprevalenceof burnout to be 47.3%(95% CI
43.1%; 51.5%).Four datasets studied Canadian residents and
had aburnoutprevalenceof39.5%.Among studies included in
our review, a majority found depression, stress, and lower job
satisfaction to be associated with higher rates of burnout. Our
analysis alsouncovered three novel findings: we reportthatdespite
changes in duty hours,the prevalence of burnouthas not changed
over the past 2 decades. Burnout appears tovaryby region, with
residents of European countriesexperiencing the lowest level.
Lastly,we found burnout to beunaffectedby specialty of practice.
Conclusions
We establish a prevalence of burnout at 47% among resident
physicians. Our findings suggest that systemic factors have an
important role in resident wellness.
“R1On-CallNightmares”:A Collaborative
Multi-Residency Curriculum to Prepare Junior
Residents for Medical Emergencies
Jordan Sugarman
1
, Erica McKenzie
2
, Tim Chaplin
3
,
GhazwanAltabbaa
1
1
Department of Medicine, University of Calgary, Calgary,
Alberta
2
Department of Clinical Neurosciences, University of Cal-
gary, Calgary, Alberta
3
Department of Emergency Medicine, Kingston Health
Sciences Centre, Kingston, Ontario
Background
First-year physicians-in-training feel ill-prepared for and anxious
about responding to medical emergencies.The opportunity for
residents to practice the assessment and management of acute
inpatient medical situationsin asimulatedlearning environment
is a valuable adjunct to training and facilitates increased resident
comfort and patient safety on the wards.2A high-fidelity simulation
courseaimed at improving comfort with medical emergencieshas
already been successfully implemented at Queen’s University
in Kingston, Ontario.2Peer-reviewed data demonstratesthis
courseto be a cost-effective way of reinforcing essential skills
and increasing comfort and competency at managing acute
medical issues. Here, we discuss the design and deploymentof
a similar curriculum at the University of Calgary.
Methods
Afour-track half-day simulation courseentitled “R1 On-Call
Nightmares, followed by a 30-minute debriefing session,waspiloted
in August 2019.Participants includedfirst-yearpostgraduate
medical residents from the Internal Medicine and Neurology
residency programs. Participants were administered a5-point
Likert scalepost-participation survey. Quantitative measures were
aggregated using traditional statistical methods and standard
errors of the mean were calculated. Narrative feedback was
collected and aggregated in a two-question post-participation
questionnaire.
Results
Forty first-year residents from the Internal Medicine and Neurology
residency programs participated in the course.Scenarios were
Rocky Mountain Conference Abstracts
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Canadian Journal of General Internal Medicine
38 Volume 15, Issue 1, 2020
Rocky Mountain Conference Abstracts
felt to be relevant and realistic to actual ward emergencies
(average 5-point Likert response 4.75 +/- 0.037), with participants
reporting high awareness of overnight resources available in a
medical emergency after the course (4.58 +/- 0.081). The course
was highly recommended for future first-year residents (4.89 +/-
0.050).The cost of the course was $25 per resident participant.
Conclusions
The “R1On-CallNightmares”course is a safe, cost-effective
and highly-recommended intervention in addressing resident
discomfort with medical emergencies. Future directionsincludethe
addition oftwo new scenariosandexpanding the delivery in
collaboration withother residency programs.
Clinical Teaching Unit Design: A Systematic Review
of Evidence-Based Practices for Clinical Education
and Health Service Delivery
Brandon Tang MD
MSc
1
,KatrinaDutkiewiczMD
2
,Stephan Saad
MD
3
,Jocelyn Chai
4
, Kristin Dawson PhD
4
, Ryan
Sandarage4, Vanessa Kitchin
5
, Iain McCormickMD
BAH
2
,Barry KassenMDFRCP FACP MACP
6
1
Department of Medicine, University of British Colum-
bia,British Columbia, Canada
2
Division of General Internal Medicine,University of Brit-
ish Columbia, British Columbia, Canada
3
Division of Infectious Diseases,University of British Co-
lumbia, British Columbia, Canada
4
Faculty of Medicine, University of British Columbia, Brit-
ish Columbia, Canada

Vancouver Fraser Medical ProgramandWoodward Li-
brary, University of British Columbia, British Columbia,
Canada
6
Clinical Teaching UnitDirectorandActing Head of the
Divisionof Community General Internal Medicine,Di-
vision of General Internal Medicine,University of British
Columbia, British Columbia, Canada
Funding:This work was supported bytheDepartment of
MedicineatSt. Pauls Hospitalin Vancouver, British Co-
lumbia, Canada
Background
The Clinical Teaching Unit (CTU) hasemerged asa near ubiquitous
model ofclinicaleducation across Canadian and international
medical schools,since it was first proposed over 50 years ago.
However, health care has changed dramatically over this period,
and we thus aimed to review existing evidence on principles of
CTU design that optimizeclinicaleducation andhealth service
deliveryin the 21st century.
Methods
We performed a systematic review in accordance with the
CochraneReview protocol. Databases, including MEDLINE,Embase,
Cochrane Database of Systematic Reviews and CINAHL, were
searched to find primary research articles published from 1993
to 2019whichdiscussedtrainee education and/or health care
deliveryin context of a clinical teaching unitorother teaching
ward.
Results
After deduplication, our search yielded1938potentially relevant
articles which are currently undergoinga two-stepscreeningprocess
of abstract and full-text review.Studieswhichmet inclusion criteria
after full-text review wereanalyzedaccording to the Star Model
whichviewshealth systems as a collection of interdependent
subsystemsincluding:strategy, structure, human resources,
incentives, and information and decision support. We added a
sixthsubsystem for education given its core relevance to CTUs.
Initial results suggest that most existing evidence focuses on
the structure and education subsystems, including approaches
to ward rounds, optimal call structures, and novel educational
strategies. However,the majority ofarticles involved low to
moderate quality evidence as per the GRADE system.
Conclusion
Efforts should be made to generate higher quality evidence on
the design of clinical teaching units as adualmodel for both
clinical education and healthservicedelivery. In addition, further
knowledge translation efforts may be necessary to ensure that
known best practice in CTU design becomes common practice.
Keywords:Clinical teaching unit, systematic review, medical
education, evidence-based education,health service delivery
Best Research Poster - Dr. Erin Helson
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Canadian Journal of General Internal Medicine
Volume 15, Issue 1, 2020 39
Hamman’s Sign: A Precordial Sound Leading to
Diagnosis of Spontaneous Pneumomediastinum
from Labour And Delivery
Contributing author: Dr. Lillian Chan (Obstetric Medicine
and GIM Fellow; University of Alberta)
No funding sources.
Supervising Faculty: Dr. JordanMarit
Background
Spontaneous pneumomediastinum is uncommon. It often
presents with chest pain, dyspnea, and swelling or subcutaneous
emphysema. Hammans sign is an auscultatory clue that suggests
pneumomediastinum.
Case Description
A healthy 24-year-oldprimiparouswoman at 41 weeks and 5
days’ gestation developed a generalized tonic-clonicseizure
immediately after delivery. She had a prolonged second stage
of labour that lasted 4.5 hours. Post-seizure, her main symptom
was pharyngeal pain. On exam, a loud, systolic scratching noise
was auscultated over the left sternal border. Oxygen saturation
was 97% on 2 liters of oxygen. The remainder of her vital signs
and physical examination was normal. The abnormal sound
prompted urgent chest imaging. A chest X-ray and subsequent CT
chest demonstrated a moderate amount of pneumomediastinum
and a small left pneumothorax. There was emphysema in the
retropharyngeal soft tissues. A trace amount of intraperitoneal
air was noted, due to air tracking from the mediastinum. There
was no evidence of esophageal perforation on CT. A CT and
MRI brain were normal. Lab investigations were significant only
for hyponatremia at 125 mmol/L that resolved spontaneously,
and elevated serum lactate and CK levels secondary to seizure
activity. There were no convincing signs or symptoms to suggest
eclampsia as the cause of her seizure. After consultation with
thoracic surgery, she was managed conservatively with oxygen
therapy and serial chest imaging until resolution.
Conclusion
Spontaneous pneumomediastinum is a rare complication with
a reported incidence of less than 1:44 000, and even lower at
1:100 000 in pregnancy or labour. It is likely underdiagnosed,
and can occur in situations of prolonged Valsalva, such as
hyperemesis gravidarum or diabetic ketoacidosis, coughing,
and labour. Hammans sign, a systolic crunching noise caused
by movement of the heart amid mediastinal emphysema, may
be a useful diagnostic clue for pneumomediastinum.
A Mysterious Case of Night Sweats
C. Collins and L. Bridgland
A previously healthy 59-year-old woman was admitted to
Internal Medicine with a 2-month history of night sweats, fevers,
polyarthralgias, hallucinations (auditory/visual), weight loss,
and perioral vesicular lesions. These symptoms started after a
trip to Mexico. Investigations revealed elevated inflammatory
markers with new onset anemia (hemoglobin 89). A lumbar
puncture showed an elevated WBC count of 31 (predominantly
lymphocytes) with a negative viral panel.
A CT head and MRI brain were normal. Extensive infectious
work up was negative. She was treated with intravenous acyclovir
for presumed HSV encephalitis. Her symptoms resolved in
hospital.
Given her constitutional symptoms, a CT chest/abdomen/
pelvis was done which revealed a solitary pulmonary nodule
and no lymphadenopathy. She, therefore, underwent a PET
CT that showed metabolic activity within the ascending colon.
Subsequent gastroscopy, colonoscopy and CT enterography
were inconclusive. She had recurrence of fevers and night sweats
following discharge. Inflammatory markers remained elevated.
Rocky Mountain ACP/AMA
Internal Medicine – Banff
Case Study Abstracts
The winners were as follows:
Best Abstract, Clinical Case - Dr. Brandon Tang
Best Abstract, Original Research - Dr. Zahra Sohani and Dr. Leen Naji
Best Clinical Case Poster - Dr. Victoria Nkunu
Best Research Poster - Dr. Erin Helson
Rocky Mountain Conference Abstracts
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Canadian Journal of General Internal Medicine
40 Volume 15, Issue 1, 2020
Rocky Mountain Conference Abstracts
A bone marrow biopsy showed atypical lymphoid aggregates
suspicious for B cell lymphoma. The decision at lymphoma rounds
was to monitor clinically. A repeat CT chest showed extensive
patchy consolidation throughout both lungs. Although she had
no respiratory symptoms, she had bronchoscopy, which was
unremarkable. A repeat PET CT revealed a pattern suggestive
of organizing pneumonia. Open lung biopsy revealed foci of
organizing pneumonia and non-necrotizing granulomas. Initial
AFB stain was positive, but the culture was negative.
A diagnosis of organizing pneumonia (OP) was made based
on radiographic and histopathologic features. Asymptomatic OP
occurs in up to 14% of patients. OP can be idiopathic, secondary to
infection, or occur in a specific context (e.g., rheumatoid arthritis).
In our case, HSV or gastrointestinal illness were hypothesized
to be the cause. Treatment generally consists of corticosteroids;
however, in our patient treatment was deferred while awaiting
AFB culture. Symptoms and laboratory abnormalities resolved
without treatment.
Diagnosis of Central Diabetes Insipidus in a
Patient withAcute Myeloid Leukemia
Victoria Nkunu, MD, Justin Smith, MD, Lauren Bolster,
MD,MEd,FRCPC
Division of Hematology, Faculty of Medicine, University of
Alberta, Edmonton, Canada
Introduction
Central diabetes insipidus (DI) is a rare clinical manifestation of
acute myeloid leukemia (AML), primarily described in case reports
within the medical literature. While a distinct pathophysiology
linking central DI and AML is unknown, their relationship has
important implications for diagnosis and prognostication of AML.
Case Descriptions
A thirty-two-year-old woman was admitted afteracomplete blood
count revealedanemia, leukocytosis and69%circulatingblasts.
History revealed six-months of constitutional symptoms, polydipsia,
and polyuria.Bone marrow biopsyconfirmed AML withabnormal
cytogenetics (45,XX,-7,inv(3)).Thepatientsinitialsodium
level was normal at 140 mmol/L. After depriving oral intake for
an abdominal ultrasound, she developed hypernatremia (155
mmol/L), with a concurrent low urine osmolality of 141 mmol/
kg. Magnetic resonance imaging of the sella turcica demonstrated
thickening of the pituitary stalk with absence of the posterior
pituitary bright spot, suggesting leukemic involvement of the CNS
with secondary diabetes insipidus, despite initial CSF analysis
being negativefor blasts. The patient received oral desmopressin
(DDAVP) which normalized serum sodium levels, increased urine
osmolality, and improved her symptoms of DI.She was treated
with induction chemotherapy (IDAC), howeverrepeat bone
marrow done at day 17 for intractable bone pain demonstrated
refractory leukemiaand she is presently receivingre-induction
chemotherapy(NOVE-HDAC).
Discussion
Symptoms of DI (polyuria and polydipsia) may precede
initial diagnosis of AML. In a minority, DIis diagnosedin
patientswithAMLinremission, developing prior totheirleukemia
relapse.Electrolyte workup and response to DDAVP therapy
confirms the diagnosis of central DI. On MRI, there is often
pathology detected in the pituitary stalk, but often no evidence
on either CSF analysis or autopsy of leukemic infiltration of the
pituitary. Unfortunately, these patients tend to haveaggressive
leukemiawithmostresponding poorly tochemotherapy,anda
high mortality ratedue to refractory leukemia.
A Case of
StreptococcusCanis
Bacteremia,
Osteomyelitis,Sacroiliitis,Myositis, and Abscess
AllyshiaVanTol
1
, Brandon Tang MD MSc
2
,
Iain MackieMD FRCPC
3
1
Faculty of Medicine, University of British Columbia, Brit-
ish Columbia, Canada
2
Department of Medicine, University of British Colum-
bia,British Columbia, Canada
3
Division of General Internal Medicine,Vancouver Gen-
eral Hospital andUniversity of British Columbia,British
Columbia, Canada
Funding:No sources of funding to report.
A previously healthy 26-year-old male presented to the
emergency department with a2-dayhistory of erythema,
pain,and swelling of theleft foot, consistent with acute cellulitis.
The patient was initially dischargedhome on oral cephalexin,
butlaterrecalled after 2/2 blood culturesgrewgram positive
cocci.Blood cultures speciatedasStreptococcuscanis, agroup
G beta-hemolyticStreptococcusspecieswhich resideson the
skinand mucosalsurfacesofdogs.
History was unremarkablesave fora2-week history of
lowerback pain precipitated by a wrestling injury.The patient
had occasional contact with a friend’s dog (species unknown),
but there was no history oftraumatic injuryto the foot, canine
bite,or scratch wound. Given the subacute back pain, CT spine
was obtained which demonstratedpossiblerightpiriformis
myositis and S1 osteomyelitis.These findings were confirmed on
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Canadian Journal of General Internal Medicine
Volume 15, Issue 1, 2020 41
a subsequent MRI, which additionally demonstratedrighterector
spinaemyositis,right sacroiliitis,andmultiplecollectionsinthe
right posterior paraspinal soft tissues(largest 25 x
19mm).Transthoracic echocardiogramdid not demonstrate
valvular vegetations. TheS.caniswas pan-sensitiveand the
patient was eventuallydischarged home on penicillin G to
completea6-weekcourse ofIV antibiotics.
S.canisrarely causes infectionin humans, however, it can
manifest in many different formswhen it does. According to the
literature, these includeskin and soft tissue infections(n=39;
57%), bacteremia(n=17; 25%),osteoarticular infections (n=4;
6%), andendocarditis(n=3; 4%).Aclear portal of entry,
such as a break in the skin,is not necessary for infection.We
suggest that management ofS.canisbacteremia should
involvescreeningforsites ofmetastaticinfection in addition to
infectious diseases consultation.However, despiteitspropensity
for systemic involvement,S.canisis oftensusceptible to narrow
spectrum antibioticsincludingpenicillin.
Rocky Mountain Conference Abstracts
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