Canadian Journal of General Internal Medicine 2019-06-11T13:02:02+00:00 Scott Bryant Open Journal Systems <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> We have lift-Off! The Launch of Competence by Design in Canada 2019-06-04T19:59:29+00:00 Leslie Martin James Douketis <p>Editorial</p> 2019-05-21T15:34:39+00:00 Copyright (c) 2019 Leslie Martin, James Douketis Nous avons un d├ęcollage ! Le lancement de la Comp├ętence par le design au Canada 2019-06-04T19:59:23+00:00 Leslie Martin James Douketis 2019-05-21T15:37:31+00:00 Copyright (c) 2019 Leslie Martin, James Douketis Oral Hypoglycemics in Patients with type 2 Diabetes and Peripheral Artery Disease 2019-06-11T13:02:02+00:00 Luke Rannelli Eric Kaplovitch Sonia Anand <p>Worldwide, in 2010, 202 million people were living with PAD, with a prevalence between 3-12 percent. The prevalence of PAD is three times greater in diabetic patients compared to those with normal glycaemia. PAD of the limbs is associated with increased cardiovascular morbidity and mortality, as well as major adverse limb events including acute limb ischemia and amputation. These risks are particularly high in patients who smoke and/or have type 2 diabetes. The goal of treatment in diabetic patients with PAD is to prevent cardiovascular events and prevent further peripheral artery stenosis leading to limb ischemia, and amputation. Poor glycemic control contributes to atherosclerotic progression; however, no randomized control trial evidence exists that demonstrates improved glycemic control reduces the risk of PAD. Oral diabetic medications are designed to lower glucose levels, reduce symptoms and the microvascular complications of diabetes without the inconvenience of daily injections. However, the data supporting benefit of these medications in diabetic populations with concurrent PAD are limited. We review the evidence for oral hypoglycemic agents in the treatment of patients with concurrent PAD and diabetes.</p> 2019-05-21T15:39:40+00:00 Copyright (c) 2019 Luke Rannelli, Eric Kaplovitch, Sonia Anand Development and Pilot Testing of a Novel Graphic Values History Tool to Support Communication and Decision Making During Serious Illness 2019-06-04T19:59:41+00:00 Peter Allatt John You (ED) <p><strong>Background: </strong>We report the development and pilot-testing of a values history tool to support patients and their substitute decision makers (SDMs) in advance care planning.<strong></strong></p><p><strong>Methods: </strong>Tool development was an iterative, multi-phase process involving expert input, literature review, patient input, and beta-testing with 35 laypersons. In a single-center, before-after pilot study, we assessed the acceptability, clarity, and potential utility of the tool. </p><p><strong>Results: </strong>Participants (n=6; 3 patients and 3 SDMs) rated the tool as clear (4.7/5), worthwhile (4.7/5), and said it did not cause distress (4.7/5).Tool completion and discussion resulted in better understanding of patient values (mean 4.5 on a 5-point scale) and helped build understanding between patient and SDM (4.3/5). Participants</p><p><strong>Conclusions: </strong>Based on development involving content experts, patients, and laypersons, we conclude that our tool has face and content validity. Our pilot study suggests it merits evaluation in larger studies to further evaluate its utility.</p> 2019-05-14T19:08:35+00:00 Copyright (c) 2019 John You (ED) Closing the Knowledge Gap: Hepatitis B Reactivation in Immunosuppression 2019-06-04T19:59:05+00:00 Yassir M Daghistani Fergus To Eric M Yoshida Patrick Doyle Hin Hin Ko Mel Krajden Jason Kur Alnoor Ramji Kam Shojania Edward Tam John Wade Graham Reid Siegfried Erb Mollie Carruthers <p><strong>Background</strong></p> <p>The usage of immunosuppressive medications (ISMs), and specifically disease modifying anti-rheumatic drugs (DMARDs), in a wide range of internal medicine subspecialties has increased the risk of hepatitis B virus re-activation (HBVr). We assessed the understanding of HBVr using a Canada-wide survey.</p> <p><strong>Methods</strong></p> <p>An electronic survey was sent to 521 members of the Canadian Rheumatology Association (CRA). The&nbsp;questions focused on the knowledge of screening, monitoring and management of patients with chronic or past infection with HBV in the setting of starting ISMs.The results were compared to the American Gastroenterology Association (AGA) guidelines.&nbsp;</p> <p><strong>Results</strong></p> <p>A total of142 respondents were included in the analysis (response rate = 27.3%). Over 50% of the respondents would order unnecessary tests such as anti-HBs or anti-HBc for monitoring a HBsAg positive patient on an ISMs. There were 43% of responders who answered incorrectly to starting anti-viral prophylaxis for HBsAg positive patients on synthetic DMARDs (sDMARDs).</p> <p><strong>Conclusion</strong></p> <p>There are some knowledge gaps amongst physicians managing rheumatology patients with chronic or past infection with HBV in the setting of ISMs. The AGA guidelines were summarized and incorporated into a user-friendly guide.</p> 2019-05-21T15:46:35+00:00 Copyright (c) 2019 Yassir Daghistani, Fergus To, Eric M Yoshida, Patrick Doyle, Hin Hin Ko, Mel Krajden, Jason Kur, Alnoor Ramji, Kam Shojania, Edward Tam, John Wade, Graham Reid, Siegfried Erb, Mollie Carruthers Thoughts on Clinical Medicine 2019-06-04T19:58:59+00:00 Hector M Baillie <p>These days, more time is spent at the computer than engaging in patient contact.&nbsp;&nbsp; And yet it is the 1:1 relationship between doctor and patient that allows us into the magical world of problem solving, differential diagnosis and management.&nbsp;&nbsp; The author shares some perspectives gained from a career in community internal medicine, in the hope that new internists will value the Art - as well as the Science - of Medicine.</p> 2019-05-21T15:49:34+00:00 Copyright (c) 2019 Hector M Baillie Health Promotion Heroes: Dr Thomas Brothers 2019-06-04T19:58:53+00:00 Bert Govig <p>NA</p> 2019-05-21T15:58:10+00:00 Copyright (c) 2019 Bert Govig A Case of Fatal Sepsis from Dog Exposure in a Young Stem Cell Transplant Patient 2019-06-04T19:58:47+00:00 Casey Park Simon Oczkowski Anjali Shroff <p><em>Capnocytophaga canimorsus</em> is a fastidious, slow growing (up to 10 days), capnophillic gram-negative rod. It is most commonly associated with zoonotic exposure, particularly dog and cat bites. There is a growing body of literature for the recognition of septic shock caused by <em>Capnocytophagia canimorsus</em> in at-risk populations, including those with asplenia as well as current or previous hematologic malignancy. This is a case of a young man in remission from a hematologic malignancy, complicated by graft versus host disease, presenting many years later in fatal septic shock due to <em>Capnocytophagia canimorsus</em> infection.</p> 2019-05-21T16:01:34+00:00 Copyright (c) 2019 Casey Park, Simon Oczkowski, Anjali Shroff Disseminated Mycobacterium Sepsis with Bone Marrow, Liver, and Lung Involvement Following Intravesical Bacillus Calmette-Guerin (BCG) Therapy 2019-06-04T19:58:41+00:00 Drew Hager Zeenib Kohja Terry Wuerz Arjuna Ponnampalam <p><strong>Introduction</strong>: BCG therapy is first line therapy for high grade non-muscle invasive bladder cancer (NMIBC).</p><p class="xmsonormal"><strong>Case Presentation:</strong> A 54-year-old male presented with fevers, rigors and hematuria one week following intravesical BCG administration for treatment of NMIBC. He developed fever, pancytopenia, elevated liver enzymes and pulmonary infiltrates with progression of symptoms despite broad spectrum antimicrobial therapy. A bone marrow biopsy showed granulomatous infiltration; cultures of urine demonstrated growth of <em>Mycobacterium bovis</em>. A diagnosis of disseminated BCG infection secondary to intravesical administration was made; rifampin, isoniazid, ethambutol, and high dose prednisone were initiated.</p><strong>Conclusion:</strong> Adverse events associated with BCG administration have been attributed to both the primary mycobacterium infection and to hypersensitivity reactions. Timely collection of histopathology can lead to early treatment of disseminated BCG with good outcomes. Internists should have a high index of suspicion for patients presenting with organ dysfunction with an immediate or remote history of intravesical BCG administration. 2019-05-21T16:04:57+00:00 Copyright (c) 2019 Drew Hager, Zeenib Kohja, Terry Wuerz, Arjuna Ponnampalam Myxedema Coma in a Hypothermic, Obtunded Patient with Post-renal Acute Kidney Injury and Bacteremia in the Intensive Care Unit 2019-06-04T19:59:35+00:00 Hernan Dario Franco Lopez Sameer Sharif John Centofanti <p>We present a case of a hypothermic, unconscious patient transferred to our Intensive Care Unit with sepsis requiring mechanical ventilation. The absence of any known past medical history as well as concurrent obstructive uropathy and bacteremia made initial diagnosis challenging. He was eventually found to be in myxedema coma in light of evolving signs and laboratory investigations. This case emphasizes the need to consider myxedema coma in the differential diagnosis of profound hypothermia, especially when other clinical signs and symptoms may obscure its initial diagnosis, and lead clinicians to focus on the triggering event in isolation rather than concurrently managing hypothyroidism. This case highlights a challenging presentation of an uncommon, but life-threatening condition. We discuss the signs and symptoms present in the hypothyroid patient with myxedema coma; emphasize the pathophysiology of myxedema coma as well as the evidence-based acute management of this condition.</p> 2019-05-21T00:00:00+00:00 Copyright (c) 2019 Hernan Dario Franco Lopez, Sameer Sharif, John Centofanti