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THE UNIVERSITY OF MANITOBA DEPARTMENT OF INTERNAL MEDICINE POSTGRADUATE EDUCATION PROGRAM I
RESIDENT RESEARCH DAY MAY 26,2009 , '
•
SCIENTIFIC PROGRAM
THEATRE B, BMSB
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DEPARTMENT OF INTERNAL MEDICINE RESIDENT RESEARCH DAY PROGRAM TUESDAY, MAY 26, 2009 THEATRE B, BASIC MEDICAL SCIENCES BLDG. 0910
• Introductory remarks
• Best published paper derived from 2007 Resident Research Day
Dr. D. Houston
Chair, Department of Medicine Resident Research Day
PRESENTATIO
Time will be adhered to with 10 minutes for presentation and 5 minutes for questions.
0915
(Clinical Investigation)
A Randomized Double-Blinded Crossover Study Assessing the Effect of Cannabinoids on
Spasticity in Spinal Cord Injury Persons: A Pilot Study
Sepideh Pooyania, PM&R
Supervisor: K. Ethans
0930
(Clinical Investigation)
Hypermucoviscous Klebsiella Pneumoniae, an Emerging Infection in South-East Asia
and Beyond
Yoav Keynan, 10
Supervisor: E. Rubinstein
0945
(Clinical Investigation)
Medical Ward Admissions Among Patients Infected with HIV
Michael Sochocki, Core
Supervisor: K. Kasper
1000
(Clinical Investigation)
A Retrospective Study of the Safety and Efficacy of ERCP in Octogenarians
Massud Ali, Core
Supervisor: D. Duerksen
1015
BREAK
1030
(Case Report)
Aseptic Meningitis as a Presentation of Primary HIV Infection
Nicola Matthews, GIM
Supervisor: K. Kasper
1045
(Case Report)
An Unintended Benefit of Anabolic Steroid Abuse: Therapy of Hemophilia B Leiden
Emily Rimmer, Core
Supervisor: M. Seftel
1100
(Case Report)
Brainstem Infarction Related to Internal Cervical Carotid Dissection
Daniela Stroescu, Core
Supervisor: D. lancu
1515
(Case Report)
Neurosyphilis: Forgotten, But Not Gone
Peter Hughes, Neurology
Supervisor: R.A. Marrie
1530
(Clinical Investigation)
Heparin-Induced Thrombocytopenia at HSC: A Five Year Review
Susan Teschke, Core
Supervisor: D. Houston
M. Rubinger
1545
(Clinical Investigation)
Histologic and Biochemical Abnormalities in Methotrexate Users with Inflammatory
Bowel Disease
Marc Fournier, Core
Supervisor: C. Bernstein
1600
(Case Report)
Dynamic Compression of the Left Main Coronary Artery by the Left Atrium
Robin Ducas, Core
Supervisors: D. Jassal
J. Ducas
1615
(Case Report)
Cardioembolic Source of STEMI
Owen Mooney, Core
Supervisor: D. Jassal
1630
(Case Report)
Differentiating an Old Organized Hemopericardium from a Pericardial Tumor: The Value
of Cardiac MRI?
Ashraf Farag, Core
Supervisor: J. Tam
1645
(Clinical Investigation)
Cardiac Outcomes Through Digital Evaluation (Code) STEMI: Coordinated Prehospital
Strategies for Reperfusion
Robin Ducas, Core
Supervisor: J. Tam
1700
(Clinical Investigation)
LHRH Analogue Use in the Manitoba Prostate Cancer Population: A Cost Savings
Analysis
Maclean Thiessen, Core
Supervisor: S. Navaratnam
1715
{Clinical Investigation)
Sublingual Sufentanil for the Management of Incident Pain
Jonathan Wong, Core
Supervisor: P. Daeninck
DEPARTMENT OF INTERNAL MEDICINE RESIDENT RESEARCH DAY PROGRAM TUESDAY, MAY 26,2009 THEATRE B, BASIC MEDICAL SCIENCES BLDG. [I POSTER PRESENTATIONS
II
Time will be adhered to with 5 minutes for presentation and 5 minutes for questions.
1315 (Case Report)
A Massive Amlodipine Overdose: The New Generation of Calcium Channel Blocker
Overdose
Thomas Jacob, Critical Care/Rheumatology
Supervisor: B. Light
1325 (Case Report)
Toxic Leucoencephalopathy after Crack Cocaine Inhalation
Jonathan Gilmore, Core
Supervisor: B. MacDougall
1335 (Clinical Investigation)
Early Administration of Crystalloid Fluids Reduces Mortality in Septic Shock
Jason Waechter, Critical Care
Supervisor: A. Garland
1345 (Case Report)
Danaparoid Induced Thrombocytopenia
Roopesh Kansara, Core
Supervisor: A.M. Shojania
(Case Report)
Stiff-Person Syndrome
Daljit Gill, Core
Supervisor: C. van Ineveld
1355 1405 (Case Report)
Neurological Manifestations of Churg-Strauss Syndrome
Alireza Bagherli, Core
Supervisor: R. Kostyk
1415 (Clinical Investigation)
Process Engineering Better Chronic Kidney Disease Care: Design Parameters in
Quality and Efficiency
Ainslie Hildebrand, Core
Supervisor: P. Komenda
1425 (Clinical Investigation)
Time of Medical Admission and Observed Patient Outcomes
Michael Semus, Core
Supervisors: K. Wiebe
K. Olafson
1435
(Case Report)
Recurrent Porphyria-Associated Hepatic Fibrosis After Orthotopic Liver Transplantation
in Adult-Presentation Erythropoietic Protoporphyria
Sheldon Perkatch, Core
Supervisor: B. Schacter
1445 -1515
BREAK
1515
(Case Report)
An Unusual Cause of Acute Right Heart Failure
Joel Nkosi, Core
Supervisor: D. Jassal
1525
(Clinical Investigation)
Relation of Biomarkers and Cardiac Magnetic Resonance Imaging After Marathon
Running
Andrew Czarnecki, Core
Supervisor: D. Jassal
1535
(Clinical Investigation)
Correlation of Bicuspid Valve Morphology and Pattern of Aortic Root Dilatation: A
Substudy of the Aortic Stenosis Progression Observation Measuring Effects of
Rosuvastatin (ATRONOMER) Study
Kapil Bhagirath, Cardiology
Supervisor: D. Jassal
1545
(Clinical Investigation)
The Utility of Tissue Doppler Imaging, Cardiac Biomarkers and Cardiac MRI in
Detecting Early Left Ventricular Dysfunction in HER2 Positive Patients Treated with
Adjuvant Trastuzumab Therapy
Anthony Wassef, Core
Supervisor: D. Jassal
1555
(Clinical Investigation)
Obstructive Sleep Apnea: Effects of Continuous Positive Airway Pressure on Cardiac
Remodeling as Assessed by Cardiac Biomarkers, Echocardiography and Cardiac MRI
Nader Elmayergi, Cardiology
Supervisors: D. Jassal
S.Sharma
1605
(Clinical Investigation)
Assessing Symptoms and Quality of Life Among Hospitalized Patients with Terminal
Illness
Tim Hiebert, GIM
Supervisor: K. Wiebe
1615
(Clinical Investigation)
Topical Pain Medications for Cancer Patients with Neuropathic Pain and Other
Pain Syndromes
Deepa Wadhwa, Core
Supervisor: J. Gingerich
1625
(Clinical Investigation)
Long Term Multi-Centre Follow Up of Blood and Marrow Transplantation for Patients
with Germ Cell Tumor
Kristjan Paulson, Core
Supervisor: M. Seftel
1635
(Case Report)
A Case of Orthodeoxia in a Patient with Normal Pulmonary Arterial Pressures and
Minimal Shunt Through a Patent Foramen
Corey Metcalf, Core
Supervisor: S. Come
1645
(Clinical Investigation)
Thrice Weekly Warfarin Dosing in Hemodialysis Patients
Arjuna Ponnampalam, Core
Supervisor: M. Sood
1655
(Clinical Investigation)
Pulmonary Dysfunction in Systemic Lupus Erythematosus (SLE)
David Dawe, Core
Supervisor: S. Mlttoo
1705
(Clinical Investigation)
Raynaud's Phenomenon in a Breast Cancer Survivor
David Allen
Supervisors:
S. Mittoo
D. Robinson
1715
(Case Report)
Haematopoietic Stem Cell Transplantation in Refractory Psoriatic Arthritis
Michael Chapman
Supervisors: D. Szwajcer
D. Robinson
1725
(Case Report)
Sodium Thiosulfate-Based Treatment in Calcific Uremic Arteriolopathy: A Provincial
Case Series
Kelvin Leung
Supervisor: M. Sood
SPLAYED IN RESIDENTS' ABSENC
(Case Report) Recurrent Pulmonary Blastomycosis: A Case Report Marcus Blouw. Core
Supervisor: E. Lo (Clinical Investigation) Trastuzumab Therapy in HER2 Positive, Metastatic Breast Cancer Alan Smith, Core
Supervisor: M. Pitz (Case Report) Intestinal Tuberculosis Ali Benzaglam, Core
Supervisor: A. IInyckyj (Case Report)
Improvement of Myelodysplasia in a Patient on Intravenous IgG Infusions for
Hypogammaglobulinemia with Non-Caseating Granulomas
David Ryan, Core
Supervisor: A.M. Shojania
(Clinical Investigation)
Effect of Electronic Prescriptions on Discharge Times
Trevor Hutchison, Core
Supervisor: N. Hajidiacos
(Case Report)
Hyponatremic Pseudo Renal Failure - A Presentation of Uroperitoneum
Jessica Singh, Core
Supervisors: C. Rigatto
A. Junaid
Title: TBA
Aaron Low, Core
Supervisor: TBA
A RANDOMIZED DOUBLE-BUNDED CROSSOVER STUDY ASSESSING THE EFFECT OF
CANNABINOIDS ON SPASTICITY IN SPINAL CORD INJURY PERSONS: A PILOT STUDY.
S. Pooyania. MD.; K. Ethans, FRCPC; T. Szturm, PHD; A. Casey, FRCPC;
D. Perry. FRCPC
Physical Medicine and Rehabilitation Department University of Manitoba
Objectives: To determine whether nabilone, a synthetic cannabinoid, alleviates spasticity in
people with spinal cord injury (SCI).
Methods: Twelve subjects were enrolled in this double-blind, placebo-controlled, crossover
study. They received either nabilone or placebo during the first four-week period (O.Smg 00 with
option to increase to O.5mg BID), then outcome measures were assessed. After a two-week
washout, subjects were crossed-over to the opposite arm.
The primary outcome was the Ashworth scale for spasticity in the most involved muscle
group, chosen by the subject and clinician. The secondary outcomes included Spasm Frequency
Scale, Visual Analog Scale, Wartenberg Pendulum Test, sum of the Ashworth Scale in eight
muscle groups of each side of the body, and the Clinician's and Subject's Global Impression of
Change.
Results: One subject dropped out during placebo arm due to unrelated urinary stricture, and
eleven completed the study. There was a significant decrease on active treatment for the
Ashworth in the most involved muscle (mean difference=0.909, SO=0.85, p=0.0039). as well as
the total Ashworth score (p=O.0010); VAS trended towards significance (p=O.0762). There was no
significant difference in other measures. Side effects were mild and tolerable.
Conclusion: Nabilone may be benefiCial to improve spasticity in people with SCI.
Key words: cannabinoids, nabilone, spasticity, spinal cord injury,THC
HYPERMUCOVISCOUS KLEBSIELLA PNEUMONIAE, AN
EMERGING INFECTION IN SOUTH-EAST ASIA AND BEYOND
Yoav Keynan, Tom Walus, James Karlowsky, *Jin-Town Wang and
Ethan Rubinstein
Department of Internal Medicine and Medical Microbiology, University
of Manitoba, Winnipeg, MB
*National University of Taiwan, Taipei, Taiwan
Objectives: Over the last >20 years a constellation of pyogenic liver abscess, klebsiella
bacteremia with or without metastatic sites of infection has been reported. The unique
hypermucoviscous klebsiella pneumoniae (HMVKp) is thought to possess virulence
factors making it resistant to phagocytosis and capable of causing deep seated infections.
Most of the reports originate from south-east Asia, in Taiwan this organism has become
the most common cause of pyogenic liver abscess and endophthalmitis and accounts for
15% of bacterial meningitis!
In the ensuing years a plethora of case reports from Europe, North-America have
primarily involved patients of South-East Asian descent. We studied the prevalence, risk
factors and clinical presentation of HMVKp among klebsiella blood stream isolates in
Manitoba.
Methods: blood stream isolates from 2 consecutive years were tested for HMVKp
phenotype as well as capsular serotype and the presence of magAirmpA genes through
collaboration with National University of Taiwan. After ethics board approval chart
review was conducted.
Results: Of 80 BSI of Kp, five isolates were identified as HMVKp, 4/5 were associated
with pyogenic liver abscess and all of these occurred in persons of Phillipino descent.
Since the study samples with confirmed phenotypic, serologic and geentypic profile
consistent with HMVKp have been submitted from Calgary, Edmonton, British Columbia
and New York.
Conclusions: our results document the occurrence of HMVKp in Manitoba, the organism
is associated with a unique clinical presentation: pyogenic liver abscess, bacteremia, with
or without additional metastatic foci, affecting people of Phillipino desent. The reservoir,
mode of acquisition and potential host predisposing factors remain to be determined.
Awareness of this entity will assist timely diagnosis of the associated liver abscess and
administration of appropriate duration of antimicrobial therapy.
ABSTRACT
Mike Sochocki
Internal Medicine R3
University of Manitoba
Dr. K. Kasper
MEDICAL WARD ADMISSIONS AMONG PATIENTS INFECTED WITH HIV
Objectives: Analysis of 528 medical ward admissions of patients with HIV. The project
will decribe the patient's demographics, admission diagnoses, comorbidities, CD4 count
status, and antiretroviral use. Methods: Admission events between 2004 and 2009 were
identified using the Medicine Database and additional data was supplemented by chart
reVIew.
Chart review is ongoing. No results available to date.
A RETROSPECTIVE STUDY OF THE SAFETY AND EFFICACY OF ERCP IN
OCTOGENARIANS
Massud Ali MD, Department of Internal Medicine, The University of Manitoba
Donald R Duerksen MD, FRCPC, Department ofInternal Medicine, The University of Manitoba
Introduction: Similar to other patient groups, octogenarians are at risk of developing both benign and
malignant disease of the pancreas and biliary tract. Because of significant comorbidities, these patients
may be at greater risk of developing complications related to endoscopic retrograde
cholangiopantreatography (ERCP). In addition, it is possible that the anatomic variations may place these
patients at greater risk of complications associated with ERCP. The purpose of this study was to compare
the indications, interventions, and complications ofERCP of octogenarians with non octogenarians.
Methods: A retrospective study was carried out of ERCP carried out in one institution during two 4 month
time periods: one in 2004 and one in 2007. All ERCPs were carried out by one of three endoscopists.
Charts were reviewed to document indication, interventions, use of conscious sedation, and complications.
Results: Patients were divided by age into 2 groups: 1) < 80 (N= 391) 2) > 80 (N=102). The diagnoses
were similar in both groups with CBD stones (Grp 1: 50%, Grp 2: 62.7%) and malignancy (Grp 1: 10.2%,
Grp 2: 9.8%) the most common diagnoses. The mean age ofGrp 1 was 56.1 years (range 21 to 79) and in
Grp 2 84.9 years (range 80 to 96). The Table below summarizes the interventions and complications
associated with ERCP in the 2 groups. There were no bleeding complications in either group.
Age < 80
N
Sphincterotomy (%)
Stent (%)
Pancreatitis (%1
Failed ERCP (%)
Versed (mg)
Fentanyl (ug)
Procedure Time
62.7
29.4
4.9
7.7
5.9
80.4
29.8
Age> 80
73.5
48
0.98
8.8
4.14
45.5
33.1
Conclusions: In this study, there were no significant differences between the procedure time, interventions
or complications of ERCP in octogenarians compared with younger individuals. Overall there was a low
rate of major complications. This study demonstrates that older age is not a contraindication to performing
ERCP.
i
i
ASEPTIC MENINGITIS AS A PRESENTATION OF PRIMARY HIV INFECTION.
Dr Nicola Matthews 1, Dr Ken Kaspe?
lDepartment of Internal Medicine, University of Manitoba, Winnipeg, Manitoba.
2Department ofInfectious Diseases, University of Manitoba, Winnipeg, Manitoba.
Forty to ninety percent of primary HIV infections (PHI) are associated with an acute retroviral
syndrome. Despite up to 85% of patients with symptomatic PHI seeking medical attention, only a quarter
are correctly diagnosed. Patients commonly experience non-specific symptoms including fever,
pharyngitis, myalgia, lymphadenopathy and fatigue. Headache is also a very common manifestation and
aseptic meningitis has been estimated to occur in 4-24% of these patients.
Identifying patients with acute HIV infections has a number of important potential ramifications.
First, it provides II. vital opportunity to limit transmission. Secondly, there is evidence that severe PHI
presentations are associated with a more aggressive virus and rapid progression of disease. Thirdly, there
is increasing data suggesting that intervention at the time of PHI may have an impact on both host
immunity and disease progression.
This case report describes two cases of aseptic meningitis (the ftrst in five years at our centre)
secondary to acute HIV infection. In these cases the patients were adolescent, aboriginal females who
were previously healthy. Both presented with typical features of aseptic meningitis including a
predominantly lymphocytic CSF pleocytosis with negative cultures for bacteria, fungi, Mycobacteria and
other viruses. Subsequent HIV serology was positive and both patients had high viral loads (> I 06) and
suppressed CD4'" counts.
These cases highlight the importance of considering the diagnosis of HIV in patients with aseptic
meningitis. Moreover, they raise important questions regarding the prognosis for these patients and the
potential role for early therapy. The similarities between the two patients may also represent underlying
genetic factors that predispose the patients to a specific presentation of PHI.
AN UNINTENDED BENEFIT OF ANABOLIC STEROID ABUSE: THERAPY OF
HEMOPHILIA B LEIDEN
Emily Rimmer, Department of Internal Medicine, University of Manitoba. Winnipeg, Manitoba.
Matthew Seftel, Section of HematologyIOn co logy, Department ofInternal Medicine, University
of Manitoba. Winnipeg, Manitoba
Hemophilia B is an X-linked recessive bleeding disorder affecting approximately 1 in
every 25, 000 males. It is characterized by a deficiency in factor IX.
A 29-year-old mlln with mild (12%) Hemophilia B presented to the emergency
depanment with acute left quadriceps swelling. He received 1,800 units offactor IX (FIX)
concentrate. The following day FIX level was 80%. On suspicion that the thigh swelling may
represent abscess rather than hematoma, blood cultures were drawn. These grew Staphylococcus
aureus. As an in-patient he received intravenous antibiotics and 1.5 liters of purulent material
was drained from the thigh. He was discharged on oral antibiotics eight days later. Intriguingly,
FIX level one month after discharge was still 61%.
Given his unusually high FIX level, his FIX gene was further investigated. Genotyping
revealed a G-7 A transition at nucleotide -6 within the promoter region of the FIX gene.
Mutations within nucleotides -21 -7 +13 of the 5' region (Leiden-specific region) ofthe FIX
promoter are associated with the Hemophilia B Leiden phenotype. This rare form of Hemophilia
improves following puberty. An androgen-response element within the FIX promoter, upstream
of the Leiden-specific region, allows a normal FIX gene to be transcribed in the presence of
androgen. This explains the rise in FIX levels that occurs following puberty.
In tbe case described, the patient disclosed that he had been using intramuscular
injections of the anabolic steroid stanozolol for several months. We propose that a further rise in
FIX levels occurred as a result of exogenous exposure to androgens in the post-pubertal period.
This deliberate use of androgens carried the unintended benefit of abolishing the Hemophilia B
phenotype.
Brainstem infarction related to internal cervical carotid dissection
D. Stroescu MD, D. lancu MD University of Manitoba
Summary
The primitive trigeminal artery (PTA) is the most common persistent carotid-basilar anastomotic channel observed
in adult life.
We report a case of persistent PTA thrombosis secondary to an occlusive internal carotid dissection, responsible ofa
brainstem infarction in a 42-year-old patient presenting with right hemiplegia, facial palsy and dysarthria.
Introduction
Four fetal anastomoses have been described between the carotid and vertebrobasilar circulations. These anastomoses
regress while the posterior communicating (PComA) and vertebral arteries (V A) develop, but they can occasionally
persist in adult age. I
Case presentation
A 42-year-old woman presented to emergency room with right side motor deficit and dysarthria. The symptoms
started the day before with headaches. three transient regressive episodes of ill-defined visual disturbance
(kaleidoscopic view) and right side numbness. She reported several osteopathic cervical manipulations in the six
previous days.
Cranial magnetic resonance imaging (MRI) and MR angiography (MRA) were performed and revealed hyperintense
diffusion-weighted imaging (OWl) with low apparent diffusion coefficient (ADC) associated with hyperintense
Fluid-Attenuated Inversion Recovery (FLAIR) and T2-weighted imaging (T2WI) localized in the left pontine and
left pontopeduncular segments suggestive of subacute brainstem infarction. Doppler sonography identified cervical
occlusion of the left ICA with good velocities and reversed flow on the intracranial left Al and MI segments.
The further diagnostic workup did not evidence concomitant heart disease, atrial fibrillation or coagulation disorders
so intravenous Heparin was started, but few days later, the right motor deficit got worse. A second MRI performed
at this time showed no hemorrhagic transformation but the presence of a new recent ischemic lesion on the territory
of the left anterior choroidal artery. Spin-echo T2 and Tl-weighted images with and without fat saturation were used
and centered skull base. These images revealed the presence of a well defined 5mm structure, hyperintense on Tl WI
with fat saturation and hypointense on T2WI, no contrast enhanced. This structure was rurming with a very similar
course to those of the trigeminal nerve. We assumed that this structure corresponds to a thrombosis of a persistent
PTA and we concluded that the brainstem stroke is due to an extensive thrombosis caused by an occlusive ICA
dissection via a persistent PTA.
AEROSOLIZED VASOPRESSIN: A NOVEL THERAPY FOR REFRACTORY HEMOPTYSIS IN
CYSTIC FIBROSIS.
Fisher J, Ramsey C
Department of Medicine. University of Manitoba, Winnipeg, Manitoba
Hemoptysis is a recurrent and life-threatening complication of bronchiectasis in patients with cystic
fibrosis. Standard therapy includes bronchial artery embolization, bronchoscopic interventions and as a last
resort surgery. Due to the refractory nature of this problem, patients often require frequent interventions.
A 21 year old female with cystic fibrosis presents with frank hemoptysis. Over an 18 month period, she
had recurrent episodes of massive hemoptysis secondary to a cavity in her left upper lobe. Management of
her hemoptysis included several embolizations with coils to her left upper lobe bronchial artery. Despite
several embolizations, she continued to have significant hemoptysis requiring hospitalization and multiple
bronchoscopies with instill of I :20,000 epinephrine to her left upper lobe bronchus. While this resulted in
slowing or stopping of her hemopytsis, she had difficulty tolerating bronchoscopy due to her deteriorating
respiratory status. She required heavy sedation for the procedure and had frequent desaturations. Her
hemopytsis became more frequent, thus additional intervention was needed. Further embolizations were
not possible, as coils could not be placed past those already in situ. She was a poor candidate for surgical
resection due to poor lung function. Therefore, she was started on inhaled vasopressin, 5-10 units twice
daily via nebulizer, upon presentation with recurrent hemoptysis. Her hemoptysis decreased significantly in
response to the therapy, delaying the time between bronchoscopies by several months and improving her
quality of Hfe.
A few case reports have used inhaled omipressin for the treatment of hemoptysis in patients with end
stage pulmonary tumors. However, this treatment has not been reported in cystic fibrosis. The use of
inhaled vasopressin in this case illustrates a potential therapy for refractory hemoptysis in patients with
bronchiectasis.
ADENOVIRUS CAUSING TUBULOINTERSTITIAL NEPHRITIS IN AN ALLOGENIC STEM CELL
PATIENT
Dr. Jay Hingwala, University of Manitoba, Winnipeg, MB
Dr. G Bueti, University of Manitoba, Winnipeg, MB
Adenovirus (ADV) in an immunocompetent patients usually present as subclinical or self-limited
pharyngitis, gastroenteritis, urocystitis, or conjunctivitis. However, in immunosuppressed individuals, such
as those with hematopoietic stem cell transplant (HSCT), adenoviruses can have a wide clinical spectrum.
Previous described urinary tract manifestations range from subclinical or self-limiting infections, to severe
hemorrhagic cystitis, fever, renal insufficiency; occasionally becoming disseminated and fatal. We report a
case of a 50-year-old woman, who day 76 post allogenic stem cell transplant, presented with gross hematuria,
abdominal pain, dysuria, fever, and acute renal insufficiency. Urine PCR was positive for ADV, while serum
PCR for ADV was negative. Renal ultrasound showed mild bilateral hydronephrosis. The patient's fevers
resolved, but had ongoing hemorrhagic cystitis, despite reduction of immunosuppressives and IVIG. 9 days
later, the patient developed nightly fevers. Extensive investigations were undertaken. Both Abdominal CT
scan and Indium WBC scan pointed toward kidney pathology. Nuclear renal scan revealed abnormal transit
time. Albeit broad antimicrobial and anti-viral coverage during this time, the fevers persisted over the next
IO days, prompting a renal biopsy. H &. E stains revealed severe granulomatous tubulointerstitial nephritis
with tubulocentric granulomas and tubular epithelial cell necrOSiS, with no evidence of immune complex
mediated glomerulonephritis. In-situ hybridization for BKV and ADV was negative; Immunohistochemistry
illustrated ADV equivocal cytoplasmic globules, but no distinct nuclear staining. Electron Microscopy
showed degenerate tubular cells with scattered viral-like particles 70-8Onm in diameter. These results were
consistent with ADV infections in previous studies. We report this case to illustrate that the diagnosis of
ADV infections in the context of an immunocompromised patient with fever and hemorrhagic cystitis,
requires high clinical suspicion and vigilance. Although the incidence of ADV infections in HSCT patients
is unknown, when present, it may cause significant morbidity and mortality.
A NEW POTENTIAL TREATMENT FOR LAZY EYE (AMBLYOPIA) USING repetitive
TRANSCRANIAL MAGNETIC STIMULATION (rTMS)
Behzad Mansouri (1), Robert Hess (2), Ben Thompson (3)
(1) Department ofinternal Medicine, Division of Neurology, University of Manitoban, Winnipeg, MB, Canada
(2) Vision Research Unit, Department of Ophthalmology, McGiJI University, Montreal, QC, Canada
(3) Department of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
Objectives: The purpose ofthis study was to test the potential of repetitive transcranial magnetic stimulation
(rTMS) as a treatment for visual loss in amblyopia. rTMS is a non-invasive technique for modulating excitability
and inhibition in the cortex. Given the cortical basis of the visual loss in amblyopia and the link between
intracortical inhibition and recovery of vision in amblyopia animals, we hypothesized that rTMS may have a
therapeutic effect in amblyopic humans.
Methods! Seven adult strabismic amblyopes participated in the study. Contrast sensitivity for the amblyopic and
fellow fixing eyes was tested for one high and one low spatial frequency before and after delivery of 600 pulses of
1Hz rTMS over visual cortex. The fellow fixing eye acted as a control measurement as no change in visual function
was anticipated for this eye. A further control was the delivery of rTMS over motor cortex to test for non-specific
effects of rTMS administration. Two participants who did not respond to the 1hz rTMS were tested with 900 pulses
of 10hz rTMS (5 second trains, 45 second inter-train-interval) over visual cortex.
Results: Five out of seven participants showed a high spatial frequency specific improvement in their amblyopic eye
contrast sensitivity directly after 1hz rTMS over visual cortex and a further improvement 30 mins after rTMS
administration. The remaining two participants who did not respond to 1hz rTMS did respond to 10hz rTMS
administration over visual cortex with a high spatial frequency specific improvement in contrast sensitivity. No
reliable changes in contrast sensitivity were found for the fellow fixing eyes and rTMS over the motor cortex had no
effect on contrast sensitivity for either eye.
Conclusions: Our initial results suggest that rTMS may be a promising treatment intervention in amblyopia. We
hypothesize that the therapeutic effect is modulated by changes in cortical inhibition, however other explanations
including changes in neural excitability and neural synchrony cannot currently be ruled out. The reported effects of a
single dose of rTMS are transient; however repeated doses may lead to more sustained improvement. Another
potentially effective application would be to combine rTMS with behavioural training regimes to optimize the
therapeutic effects of perceptual training paradigms.
LIVING DONOR EXCLUSIONS AMONG MANITOBA ABORIGINALS WITH END STAGE
RENAL DISEASE
Sara Dunsmore, MOl, Martin Karpinski MD2, Leroy Storsley MD2
lIntemal Medicine, University of Manitoba, Winnipeg, MB, 2Section of Nephrology, Department of
Internal Medicine, University of Manitoba, Winnipeg, MB
Objectives: Aboriginals comprise -35% of the end stage renal disease (ESRD) population in Manitoba yet
receive only -15% of all kidney transplants. This is primarily due to low rates of living donation, a finding
confirmed in other Canadian and Australian Aboriginal populations. Only 23% of transplants among
Manitoba Aboriginals come from living donors compared to 63% among Caucasians. Importantly, living
donor kidney transplants are associated with shorter wait times, and improved graft and patient survival
compared to deceased donor transplants. Our goal was to examine the frequency of potential living donors
and reasons for donor exclusion between Aboriginal and Caucasian ESRD patients.
Methods: This was a cross-sectional observational study of all Aboriginal and Caucasian patients on the
wait list for a deceased donor kidney transplant in Manitoba as of November 1, 2008. Demographic data
was collected for all patients on the wait list (n-385). Information on all excluded potential donors is
stored in the transplant clinic and linked with the potential recipient's chart. The number of potential donors
for each patient and the reason for exclusion were recorded. Reasons for donor exclusion were categorized
as immunologic (Le. ABO or HLA incompatibility), medical (e.g. hypertension, DM2) or non-medical (e.g.
choosing not to proceed, donor lost to follow-up).
Results: Three-hundred and eighty-five patients from the current wait list were included; 174 (45%) were
Aboriginal, and 21 I (55%) were Caucasian. Aboriginal wait list patients were significantly younger, more
often female, and more likely to have diabetes as a cause of ESRD. There was no significant difference in
either time on dialysis or time being ready for transplant. A total of 366 potential donors were identified for
these 385 wait-listed individuals. A similar proportion of Aboriginals and Caucasians had at least one
potential donor (Aboriginals n=691174, 40% vs. Caucasians 97/211, 46%; p=NS), however the mean
number of donors per wait-listed patient differed significantly (Aboriginal 1.9 vs. Caucasians 2.5; p=O.04).
Potential Aboriginal donors were significantly younger, and a greater proportion were male. Reasons for
exclusion differed between the two groups. While medical exclusions occurred with a similar frequency,
Aboriginal potential donors were more frequently excluded for non-medical reasons (49% vs. 29%) and
less frequently for immunologic reasons (21% vs. 36%) (p=0.003).
Conclusion: Manitoban Aboriginal ESRD patients have fewer potential living donors evaluated for kidney
transplantation than Caucasians. The reasons for exclusion of Aboriginal potential donors differ with a high
percentage of evaluations terminated for non-medical reasons. These findings suggest that current efforts to
increase living donation by overcoming immunological barriers (ie. paired exchange, desensitization) will
have a smaller impact on Aboriginal living donor rates.
Chemotherapy Dosing in the Largest Oncology Patients: Patterns and Effects
Maria Ho, MDl, Rick Prayag2 , Piotr Czaykowski, MD MSc FRCPC 1,3
I , Department of Internal Medicine, University of Manitoba
2. Pharmacy, CancerCare Manitoba ), Department of Medical Oncology, CancerCare Manitoba Objective: To determine the patterns of prescribing of chemotherapy in oncology patients in the
upper 10th percentile of body surface area (BSA), and to discern any effects of "empiric" dose
reductions.
Methods: Using the CancerCare Manitoba electronic health record (EHR), we identified all
oncology patients prescribed chemotherapy in 2004 and 2005 who had a height and weight
available from < 60 days prior to start of chemotherapy. Manual review of charts and/or EHR
was conducted on those in the;?: 90th percentile ofBSA (Mosteller formula); for females this
included those with BSA;?: 2.09; for males, BSA ;?: 2.15. Empiric dose reduction in cycle 1
(EDRl) was defined as delivery of ~ 90% of full dose (averaged over all agents in a multi-agent
regimen). Logistic regression was used to evaluate factors associated with EDRI.
Results/Conclusion: Of 117 patients (64 female, 53 male) in the;?: 90th percentile ofBSA, 35
(29.9%) met criteria ofEDRl. On univariate logistic regression analysis, EDRI was associated
only with increasing BSA (p<0.006); women with BSA;;;:: the median were 9 times as likely to
have EDRl, whereas for men there was a> 3 fold increase. Nine patients required a dose
reduction of;:::10% in cycle 2; this was no less common in those with EDRI (p=NS, X2). For
those who did not have EDRl, there was no discernible increase in toxicity. Thus, the largest
patients with cancer often receive empirically reduced doses of chemotherapy despite lack of
concrete evidence that full dose chemotherapy results in more toxicity. There appears to be a
threshold effect: above a certain BSA (2.20 in women, 2.36 in men), empiric dose reduction is
significantly more common. This may become especially relevant in an era where there are more
obese patients undergoing chemotherapy treatments.
SPONTANEOUS HAEMATOLOGIC AND MOLECULAR REMISSION OF ACUTE MYELOID
LEUKEMIA
Pamela Skrabek, MD, Brent Schacter MD FRCPC
Section of Haematology I Oncology, Department of Internal Medicine, University of Manitoba, Winnipeg
Manitoba
Acute myeloid leukemia results in death within months without cytoreductive chemotherapy.
There have been rare reports of spontaneous remissions. The majority of these have occurred in patients
with normal cytogenetics or a single abnormality.
We report a case of a 63 year old male who presented with signs of systemic infection and
pancytopenia with twenty percent blast cells in his peripheral blood. A bone marrow aspirate and biopsy
confirmed a diagnosis of acute myeloid leukemia (monoblastic variant). Cytogenetics revealed a clonal
population with trisomy 8, t(9;11) and the MLL- AF9 gene fusion product. A decision to forgo induction
chemotherapy and pursue palliative care was made based on the patient's systemic illness, poor
performance status and patient wishes. He was discharged home but subsequently required admission to the
palliative care ward with fever, severe pancytopenia and right inguinal lymphadenitis. He was treated with
piperacillinltazobactam, vancomycin and supported with transfusion. Culture of purulent fluid from the
inguinal region revealed Staphlococcus aureus. Again, the patient recovered and prior to discharge it was
noted that his pancytopenia had completely recovered with disappearance of blasts in the peripheral blood.
A repeat bone marrow one month later was normal with no evidence ofleukemia. There was also complete
cytogenetic remission. The patient has remained in complete remission since this time.
Spontaneous recovery of acute leukemia is thought to be immune mediated usually in association
with systemic infection as in our case. Study of the possible underlying mechanisms is important to
delineate potential new and innovative therapeutic approaches.
QUALITY OF CARE IN A MULTIDISCIPLINARY CHRONIC KIDNEY DISEASE CLINIC: THE
CURRENT STATUS IN A UNIVERSITY TEACHING HOSPITAL IN WINNIPEG
Kimberley Mulcheyl, Ainslie Hildebrand l, Jeff Arseni02, Romain Coudiere2, Joanne Plamondon3 , Paul
Komenda\ David Rusb 4, Claudio Rigatt04
lDepartment of Internal Medicine, University of Manitoba, Winnipe~, Manitoba, Canada; 2Faculty of
Engineering, University of Manitoba, Winnipeg, Manitoba, Canada; St. Boniface Hospital, Winnipeg,
Manitoba, Canada; 4Department of Nephrology, University of Manitoba, Winnipeg, Manitoba, Canada
BACKGROUND: Improvements in quality of patient care through better resource utilization is the ultimate
goal of health care. Process engineering analysis is a tool that is increasingly being used to achieve this. In
September 2008 a large prospective intervention study was conducted (in association with 2 process
engineers) in a multidisciplinary out-patient chronic kidney disease (CKD) stage 4/5 clinic in a university
teaching hospital in Winnipeg, MB. By observing practitioners (nurses, pharmacists, dieticians, and
nephrologists) during a series of clinics, the roles of each were defined, and the clinic was restructured in
an attempt to minimize redundant activities and optimize the role of each team member.
OBJECTIVES: The ultimate aim of this ongoing study is to determine if the clinic restructuring (ie. the
intervention) results in improved adherence to established guidelines (KDOQI) pertaining to quality of
patient care. The aim of this phase of the study was to define the demographics and objective parameters
of quality of care in the CKD stage 4/5 patients prior to the intervention.
METHODS: We conducted a cross-sectional observational study of all patients in the CKD stage 4/5 clinic
in the year prior to the intervention. 480 patients were identified, and data was collected on demographics,
co-morbidities, etiology of CKD, and measures of quality of care including medication use, blood pressure,
BMI, laboratory parameters, and referral for dialysis planning, and transplant assessments. One year after
the intervention (in September 2009), these data will again be collected and compared to the present data.
RESULTS: Demographics: 68% male, 32% female; 64% Caucasian, 25% First Nations, 7% Asian; mean
age 61. Co-morbidities included diabetes (75%), hypertension (86%), hyperlipidemia (49%), and
cardiovascular disease (34%). The etiologies of CKD included diabetes (53%), hypertension (10%),
glomerulonephritis (19%).
Preliminary results show variable compliance with established practice
guidelines: mean blood pressure was 145/74; mean hemoglobin was 112 gIL; mean corrected calcium was
2.34 mmoVL, and mean phosphate was 1.63 mmollL. Mean utilization of select medications was as
follows: ASA 69%; beta blocker 63%; ACEi/ARB 43%; statin 64%.
CONCLUSIONS: This phase of the study defined the demographics and objective parameters of quality of
care of patients in the CKD stage 4/5 clinic prior to the process engineering intervention described. This
study is ongoing. The aim of the next phase is to determine if there is an improvement in quality of care
outcomes post intervention.
NEUROSYPHILIS: FORGOTTEN, BUT NOT GONE
Peter Hughes and Ruth Ann Marrie Department of Internal Medicine, Section of Neurology, University of Manitoba, Winnipeg. Left untreated, syphilis can progress to a devastating and often fatal neuropsychiatric illness. Thanks to antibiotics, this and other forms of tertiary syphilis are now relatively uncommon in North America. However, vigilance is required for two reasons. Firstly, the incidence of primary syphilis has recently begun to rise among homosexual men in North America. Secondly, many immigrants to Canada come from countries where the disease is poorly controlled. We present the case ofa 65.year.old man who was brought to the emergency department with
difficulty walking, which had been gening worse for about a year. He had also recently developed slurred
speech, and his wife felt that his memory had been deteriorating. He had lost nearly 15kg in weight since
symptom onset. The patient had not been seen by a doctor for many years, and no medical records were
available. He denied any history of hypertension, diabetes, strokes or seizures, and reported consuming a
pack of cigarenes and one or two alcoholic beverages every day for the past 15 years.
On examination, the patient was somewhat disoriented, and he scored poorly on a mini mental
status exam (MMSE). He had severe ataxia and dysarthria, and was unable to stand unsupported. A serum
Venereal Disease Research Laboratory (VORL) test was positive, as was a confirmatory antibody test.
Brain imaging demonstrated diffuse atrophy ofthe cerebral hemispheres and the cerebellum.
Cerebrospinal fluid analysis revealed a lymphocytic pleiocytosis, an elevated protein content, and a VDRL
titre of 1:8.
Around one third of syphilis cases will, if left untreated, progress to the tertiary stage. This
patient's presentation and subsequent investigations are diagnostic of paretic neurosyphilis, a form of
tertiary syphilis once known as "general paresis of the insane". Paretic neurosyphilis typically arises 10 to
15 years after the initial infection by the Treponema pa/lidum bacterium, and is characterized by cognitive
deficits, behavioural changes, gait abnormalities, dysarthria and tremor. Eventually the patient becomes
bedridden. Without treatment, death usually occurs within four years. The standard of care is a two-week
course of penicillin G, repeated six months later if the CSF cell count has failed to subside.
HEPARIN-INDUCED THROMBOCYTOPENIA AT HSC: A FIVE YEAR REVIEW
Susan Teschke, Residene Don Houston, Associate Professorl Morel Rubinger, Assistant Professor l I - Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba Heparin-Induced Thrombocytopenia (HIT) is an antibody-mediated adverse reaction to heparin
that results in platelet activation and increased thrombin generation, and is associated with venous and
arterial thromboses. HIT is a "clinicopathologic syndrome" and requires both clinical (fall in platelet
count, venous or arterial thrombosis, skin lesions or acute systemic reactions) and pathologic evidence
(evidence of antibodies). In Manitoba an ELISA test is performed first (sensitive to all PF4 antibodies, not
specific only to antibodies that activate platelets), and if positive is sent out of province for a serotonin
release assay (SRA; high specificity for platelet activating antibodies). Given the morbidity and mortality
associated with HIT it is essential to suspect, diagnose and treat it promptly. Our aim therefore was to
characterize the diagnostic process at our hospital as well as to review management (adherence to the Chest
clinical practice guidelines). Metbods: Retrospective chart review of patients with a positive ELISA and
SRA HIT assay between February 2003 to November 2008, in a teaching hospital. We recorded patient
characteristics, dates on which blood was drawn, ELISA and serotonin release assay (SRA) run, confnmed,
and reported to clinicians, as well as management choices with respect to the suspicion and eventual
diagnosis of HIT, the presence of HIT complications (bleeding, thrombosis), and co-existing diagnoses.
Results: Patient characteristics: 14 medical, 14 surgical, 2 ICU only, 1 OB/GYN, I chronic dialysis patient
(chart not available). Six medical and 10 surgical patients also spent time in the leu. Average patient age
was 6lyears, 35% of the patients were female, 80% received heparin initially for prophylaxis, and 29/31
received unfractionated heparin. Time course: median 0.5 days (range 0-4) from blood draw to results
forwarded to ward (limited data available), 3 days (0-10) from blood draw to positive test recorded in chart,
and 9 days (3-18) from blood draw to final SRA report recorded in hematology lab. Management: 17/31
patients were treated appropriately initially based on the subjective pre-test probability of HIT (4 patients
received prophylactic doses of alternative anticoagulant when deemed low risk patient and HIT was
unlikely, 13 patients received therapeutic doses). In 5/31 complex clinical circumstances (e.g. active
bleeding) made management difficult, and quality of care could not appropriately be judged by adherence
to simple guidelines. Nine/31 were not treated per guideline (3 not treated at all, 5 did not receive
therapeutic anticoagulation despite high risk, I did not have warfarin reversed and alternative parenteral
anticoagulant substituted). Four patients were deemed unlikely to have HIT and were initially treated with
prophylactic subcutaneous danaparoid, but were not switched to full anticoagulant doses of danaparoid
with a positive SRA result. Conclusion: Despite the availability of a relatively rapid ELISA, there are
significant delays in the recognition of the results and in obtaining final SRA confirmatory results. It is
unclear whether this causes significant morbidity retrospectively - indeed patients may be discharged
before the result is obtained, and several charts lacked the SRA result at all. Only 42% of patients were
treated in accordance with practice guidelines. There are several areas in which care can be improved.
HISTOLOGIC AND BIOCHEMICAL ABNORMALITIES IN METHOTREXATE USERS WITH
INFLAMMATORY BOWEL DISEASE
Marc R._Fournier MOl, Julianne Klein, M02 Gerald Y. Minuk. and Charles N. Bernstein, MOI.3
Departments o(lntemal Medicine' and PathologY". University orManilobo and the Universitv
IBD Clinical and Research Centre';, Winnipeg. Manitoba, Canada
or Manitoba
Objective: Long-term methotrexate use can be required to achieve remission in the treatment of
inflammatory bowel disease (IBO). The frequency oflong-term biochemical monitoring and role for
prophylactic liver biopsy remain unclear in patients with IBD. The purpose of our evaluation is to further
characterize the spectrum of liver abnormalities' that occur while using methotrexate for IBO using
laboratory and histologic means.
Methods: A retrospective review of the clinic database at the University of Manitoba lBD Clinical and
Research Centre using the term 'methotrexate' was undertaken. Clinical and epidemiological parameters,
including risk factors for hepatotoxicity were recorded. Patients were excluded if cumulative doses of
methotrexate could not be ascertained, had a concurrent diagnosis of rheumatoid arthritis or psoriasis, or
baseline and routine liver enzyme tests (LETs) were not available in the charts. LETs were subsequently
monitored during methotrexate therapy and abnormalities were noted with respect to cumulative
methotrexate dose, severity of LET increase, and whether normalization occurred. Biopsies when
performed were classified using Roenigk's criteria for methotrexate~induced hepatotoxicity.
Results: Eighty-seven patients were included with sixty-seven (77%) having Crohn's disease, seventeen
(20%) with ulcerative colitis, and 3 (3%) with indeterminate colitis. Mean duration of therapy was 81
weeks (3-364 week range, +/~ 82.9) with a cumulative average dose of] 813 mg (25~8255 mg range, +/­
1731). Thirty-seven (43%) patients received a cumulative dose_exceeding 1500 mg. Thirty~four (39%)
subjects had at least one episode of LET elevation with seventeen (50%) of those individuals having
abnormal baseline LETs and an additional 5 (cumulative total of65%) having a risk factor for liver disease
or were taking a hepatoxic medication. When risk factors and abnormal baseline LETs were excluded,
abnormal LETs were seen in 20% of subjects. Cumulative prevalence of LET abnormalities at doses of
400mg, 650mg, 1500mg, and 3000mg was 21 (24%),26 (30010), 29 (33%), and 33 (38%), respectively. A
total of 16 liver biopsies was pursued in 10 subjects and scored as Roenigk grade I in fourteen (88%).
Roenigk's grade IIIb and IV were not seen in any individual.
Conclusions: Liver enzyme test abnormalities are common in patients with inflammatory bowel disease
taking methotrexate and are more likely to occur in those with abnormal baseline LETs, concurrent
hepatotoxic drug use, and risk factors for liver disease (65% vs. 20%). Methotrexate can be safely initiated
in those with mild abnormal baseline LETs in the absence of underlying liver disease. Monitoring for
hepatotoxicity should continue at 4~8 week intervals however, can be reduced in frequency in those
receiving cumulative doses exceeding l500mg in the absence of known liver disease or risk factors. A
larger sample size would be required to ascertain whether prophylactic liver biopsies remain justifiable,
although appear unwarranted in our small sample size.
CLINICAL VIGNETTE DYNAMIC COMPRESSION OF THE LEFT MAIN CORONARY ARTERY BY THE LEFT ATRIUM Robin A. Ducas MDI, Davinder S. Jassal MD, FRCPC2.3.4, lain D.C. Kirkpatrick MD, FRCPC 4 , Darren H.
Freed, MD PhD FRCSC3•5 Shelley R. Zieroth MD FRCPC 2•3, John Ducas MD, FRCPC2,3
1. Department oflntemal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
2. Section of Cardiology, Department of Cardiac Sciences, University of Manitoba, Winnipeg,
Manitoba, Canada.
3. Institute of Cardiovascular Sciences, St. Boniface Research Centre, University of Manitoba,
Winnipeg, Manitoba, Canada.
4. Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada.
5. Section of Cardrae Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba,
Canada.
Coronary artery compression syndromes are an uncommon but recognized cause of cardiac
ischemia. The underlying cause of coronary compression may be intra-thoracic structures encroaching on
one or more of the coronary arteries. Coronary compression may not always be evident and may require
mUltiple imaging modalities to understand the relationships of cardiac structures.
We report a case of a 67 year old woman with a past medical history of severe mitral valve
regurgitation with worsening congestive heart failure symptoms and angina. Coronary angiography
revealed dynamic limitation of contrast flow during systole in the left main coronary artery, but no
evidence of obstructive atherosclerotic disease. Intravascular ultrasound was then performed to better
elucidate the nature of the flow limitation and this demonstrated a dynamic distortion and reduction of the
left main coronary artery cross sectional area during systole by 47%. Cardiac computed tomography (CT)
was undertaken to better visualize extra-coronary structures and their relationship to the coronary anatomy.
The cardiac CT demonstrated left atrial enlargement with extrinsic distortion and compression of the left
main coronary artery. A diagnosis was made of dynamic compression of the left main coronary artery
secondary to systolic left atrial enlargement resulting from mitral regurgitation. The patient was managed
with mitral valve replacement and single vessel coronary artery bypass grafting with symptomatic
improvement, improved exercise tolerance and an improvement in congestive heart failure. To our
knowledge this is the first case report of left main coronary artery compression caused by enlargement of
the left atrium.
Style of Presentation: Oral Format
CARDIOEMBOLIC SOURCE OF
STEMI
OWEN MOONEY, PGY-II, INTERNAL MEDICINE, UNIVERSITY OF MANITOBA SUPERVISOR: DAVINDER S. JASSAL MD, FRCPC, SECTION OF CARDIOLOGY, DEPARTMENT OF CARDIAC SCIENCES, UNIVERSITY OF MANITOBA, WINNIPEG, MANITOBA, CANADA. CASE PRESENTATION
A 29 year old male with antiphospholipid syndrome, presented with an acute onset of retrostemal
chest discomfort. He denied preceding symptoms of chest pain, palpitations, syncope or infection. The
patient appeared distressed, afebrile, normotensive with a sinus tachycardia of 110 beats/min. The
cardiorespiratory examination was remarkable for an elevated jugular venous pressure at the angle of the
jaw, a left-sided third heart sound and clear lung fields. The electrocardiogram on admission confirmed an
acute inferior ST elevation myocardial infarction (STEMI). A subsequent cardiac catheterization confirmed
distal embolic occlusion of the second obtuse marginal branch of the circumflex territory. On transthoracic
echocardiography (TIE), an echodense mass measuring 11 x 12 mm attached to the base of the left
coronary cusp adjacent to the ostium of the left main coronary artery was identified. Multi-detector
computed tomography (MDCT) confirmed the mass isodense to the myocardium at the level of the aortic
valve, with no evidence of calcification. Delayed enhancement cardiac MRI imaging, following the
administration of gadolinium, confirmed a non enhancing aortic mass, indicating thrombus as the likely
etiology. Due to the high risk of a future embolic event, the patient underwent successful aortic valve
thrombectomy under cardiopulmonary bypass. The gross specimen and histologic examination was
consistent with a thrombus.
Antiphospholipid syndrome (APS) is a heterogeneous group of hypercoaguable disorders
characterized by the formation of both venous and arterial thrombi. A number of cardiac manifestations of
APS have been previously described, including premature coronary artery disease, cardiomyopathy,
pulmonary hypertension and in particular, valvular abnormalities. Valvular lesions due to APS include
thickening, stenosis, regurgitation, non infective vegetations and thrombus formation. The utility of
multimodality imaging including echocardiography, computed tomography and cardiac MRI is beneficial
in the noninvasive characterization of valvular masses. The presence of a thrombus occluding the coronary
artery ostium leading to an acute STEMI is rare, but should be considered in the differential diagnosis in
APS patients. Although long-term anticoagulation is standard in this patient population, excision of life
threatening thrombus, particularly in large masses greater than 1 em, should be performed.
DIFFERENTIATING AN OLD ORGANIZED HEMOPERICARDIUM FROM A PERICARDIAL TUMOR: THE VALUE OF CARDIAC MRI?
A. Farag, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
J. Tam, D. Jassal, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
Abstract:
An elderly gentleman underwent surveillance transthoracic echocardiography for evaluation of mechanical
aortic valve function. A large pericardial mass was identified, suspicious for malignancy. Saline contrast
administration revealed significant acoustic shadowing from the edge of the mass, suggesting calcification.
Chest X-ray and cardiac magnetic resonance (CMR) imaging confirmed the presence of an old organized,
calcified pericardial hematoma. Although echocardiography is the primary imaging modality in many
patients, ancillary investigations including CMR is sometimes necessary to assist in tissue characterization.
This is particularly helpful in assessment ofpericardiaJ diseases. A review of the literature and
comparision of various imaging modalities will be provided.
RESEARCH PROJECT CARDIAC OUTCOMES THROUGH DIGITAL EVALUATION (CODE) STEM!:
COORDINATED PREHOSPITAL STRATEGIES FOR REPERFUSION
RA Duces (1), RK Philipp (2), LR Hall (3), RA Grierson(4), SA Hodge (2), ER Weldon (4), CMJ Schmidt(4),
DS Jassal(2). JW Tam(2)
(1)
(2)
(3)
(4)
University of Manitoba, Winnipeg, Manitoba
University of Manitoba, Department of Medicine, Section of Cardiology, Winnipeg, Manitoba
Winnipeg Regional Health Authority. Cardiac Sciences Program, Winnipeg, Manitoba
Winnipeg Fire and Paramedical Services, Winnipeg, Manitoba
Objective. Guidelines for reperfusion strategies in acute ST elevation MI (STEM I) were recently modified
by the ESC in part to recognize the realities of delayed access to primary percutaneous coronary
intervention (PPCl), We have developed a blended model of pre-hospital thrombolytic (PHL) therapy or
PPCI activation and report initial 9-month data.
Methods. In our urban centre of 658,700 people, emergency medical personnel were trained to perform
and screen ECGs in acute chest pain (CP) for suspected STEMI. These ECGs were then transmitted
digitally to a cardiologist's hand-held device. The cardiologist coordinated initiation of either PHL or PPC!.
Patients presenting during weekday hours (0600 - 1800) or with contraindications for PHL received PPC!.
Results. From July 21, 2008 to April 21, 2009, the CODE STEMI project received 158 calls. Calls were
excluded for failed transmission (6), absence of STEMI by ECG (66), absence ofCP (3) and other (3). The
remaining 80 patients (age 6].4 +/- 12.6y; 67.5 % men) received PPCI (n=63), angiography alone (n=4; 3
with normal coronaries, 1 with spontaneous reperfusion) or PHL (n=13). Available investigations showed
peak CK of 1423 +/- ) 185 units and post infarction LVEF of 49 +/- 11 %. Cardiogenic shock or arrest
occurred in 19 patients. Seventy-eight of80 patients survived to hospital discharge (1 death in each ofPPCI
and PHL). In PPC!, median time from first medical contact to reperfusion was 74 minutes (IQR = 66-90
minutes). Forty-nine of63 (78%) patients had PPCl within 90 minutes, while 58 (92%) had PPCI within
120 minutes. Twenty of29 patients (69%) received off-hours PPCI in < 90 minutes from first medical
contact. In PHL, median time from first contact to needle was 36 minutes (IQR = 30-42 minutes). Two
patients had intracranial hemorrhage following PHL; one died while the other survived without neurologic
deficit. Achievement of target time with PPCI (49/63 < 90 minutes, including 20129 patients done off­
hours) was more likely than achievement of target time with PHL (4/13 <30 minutes), Yates chi squared =
9.2; p 0.00247.
Conclusions. Through a model of digital transmission, direct communication with a cardiologist and rapid
coordinated service, we demonstrate that first medical contact time to reperfusion therapy in STEMI can be
achieved, even early in the study period. The creation and adoption of similar strategies in other urban
centres could allow for achievement of ESC guideline times, particularly for PPC}, regardless of time of
day.
Style of Presentation: Oral Format
LHRH ANALOGUE USE IN THE MANITOBA PROSTATE CANCER POPULATION: A COST
SAVINGS ANALYSIS
Maclean Thiessen, MD, University Of Manitoba, Winnipeg, Manitoba; Sri Navaratnam, MD FRCP
University Of Manitoba, Winnipeg, Manitoba; Amitava Chowdhury, MD FRCP University Of Manitoba,
Winnipeg, Manitoba
Objectives: To determine whether the cost of LHRH analogues at Cancer Care Manitoba (CCMB) can be
reduced by altering current prescription practices and performing orchiectomy were appropriate.
Methods: We looked at all CCMB prostate cancer patients receiving LHRH analogues in January 2007
using the CCMB electronic charting system and CCMB pharmacy database. Patients were divided into
three groups based on indication for LHRH analogue treatment. These groups were as follows: for
treatment in conjunction with radiation therapy (RT); for rising PSA indicating a biochemical failure in
patients who had previously received RT or surgery; and for monotherapy, indicated in patients either with
metastatic disease or who were was not appropriate for curative radiation therapy or surgery. The total cost
of the prescriptions for LHRH analogues in January was then compared with the estimated cost if these
prescriptions had been replaced with prescriptions for the agent which provided the least expensive cost per
day of coverage. The total cost in January was also compared to what the cost of these agents would have
been if both the less expensive agent had been used and patients with metastatic disease were treated with
orchiectomy as appose to an LHRH analogue.
Results: We reviewed a total of 145 men with median age of 72. Of our cohort, 39% received these agents
as part of a combined treatment program with RT, 38% received these agents for biochemical failure and
23% received LHRH analogues as monotherapy. The total cost of prescriptions for the month studied was
$142832, this cost was reduced by 18% when the agent which provided the least expensive cost per day of
coverage was chosen; the cost was reduced by a total of 37% if metastatic disease was also treated with
orchiectomy as appose to an LHRH analogue.
Conclusion: We concluded that limiting prescriptions to the LHRH analogue which provides the least
expensive cost per day of coverage would provide a simple method for reducing the cost of treating
prostate cancer in the CCMB population. Furthermore, when this strategy is combined with orchiectomy
for metastatic disease the cost of LHRH analogues could be substantially reduced.
SUBLINGUAL SUFENTANIL FOR THE MANAGEMENT OF INCIDENT PAIN
Wong JK I, Harlos M2, Daeninck p2, Marr H3, Chochinov HM2
Background: Incident pain, a severe transitory increase in pain from activity (transfers, dressing changes), has a
profound impact on quality of life in patients receiving palliative care. Traditionally, immediate release opioids,
such as morphine, have been administered prior to a pain-precipitating activity. However, this approach is
limited by the relatively slow onset of analgesia and prolonged duration of effect. Sufentanil is ideally suited to
treat incident pain due to its potent and rapid onset of analgesia, short duration of action and ease of
administration by transmucosal routes.
The purpose of this study was to determine the efficacy of sublingual Sufentanil in the setting of incident pain.
Methods: Patients who were eligible for inclusion in this study were asked to rate their baseline and typical
incident levels of pain using the validated Edmonton Symptom Assessment Scale (ESAS) and a Pain Visual
Analogue Scale. In accordance with the Incident Pain Protocol, Sufentanil was administered sublingually 10- I 5
minutes prior to the anticipated pain-inducing activity. At ten-minute intervals, patients were asked to quantifY
their level of pain using the Pain Visual Analogue Scale. In addition, the level of patient attentiveness (using an
auditory vigilance test), the degree of patient drowsiness and any adverse drug reactions were recorded.
Results & Conclusion: Seven eligible patients were enrolled in this study. All patients reported severe incident
pain (8-10/10) prior to any intervention. Sufentanil dosing ranged from 12.5 to 50 mcgs (average 36 megs),
Pain scores at the ten minute interval demonstrated statistically significant improvement over the non-treated
pain score (2.7110; p=O.0169 using the Wilcoxin Paired Rank Sum test). In all patients, little to no drowsiness
was observed and adverse drug events were not observed. Despite the small sample size, this study provides
some of the first empirical data demonstrating the efficacy of Sufentanil in the treatment of incidental pain.
(I)
(2)
(3)
Internal Medicine Residency Program, University of Manitoba
University of Manitoba, WRHA Palliative Care Program
Calgary Health Region, Palliative Care Program
DEPARTMENT OF INTERNAL MEDICINE RESIDENT RESEARCH DAY PROGRAM TUESDAY, MAY 26, 2009 THEATRE B. BASIC MEDICAL SCIENCES BLDG. Time will be adhered to with 5 minutes for presentation and 5 minutes for questions.
1315 (Case Report)
A Massive Amlodipine Overdose: The New Generation of Calcium Channel Blocker
Overdose
Thomas Jacob. Critical Care/Rheumatology
Supervisor: B. Light
1325 (Case Report)
Toxic Leucoencephalopathy after Crack Cocaine Inhalation
Jonathan Gilmore, Core
Supervisor: B. MacDougall
1335 (Clinical Investigation)
Early Administration of Crystalloid Fluids Reduces Mortality in Septic Shock
Jason Waechter, Critical Care
Supervisor: A. Garland
1345 (Case Report)
Danaparoid Induced Thrombocytopenia
Roopesh Kansara, Core
Supervisor: A.M. Shojania
(Case Report)
Stiff-Person Syndrome
Daljit Gill, Core Supervisor: C. van Ineveld
1355 1405 (Case Report)
Neurological Manifestations of Churg-Strauss Syndrome
Alireza Bagherli, Core
Supervisor: R. Kostyk
1415 (Clinical Investigation)
Process Engineering Better Chronic Kidney Disease Care: Design Parameters in
Quality and Efficiency
Ainslie Hildebrand, Core
Supervisor: P. Komenda
1425 (Clinical Investigation)
Time of Medical Admission and Observed Patient Outcomes
Michael Semus, Core Supervisors: K. Wiebe
K. Olafson
1435
(Case Report)
Recurrent Porphyria-Associated Hepatic Fibrosis After Orthotopic Liver Transplantation
in Adult-Presentation Erythropoietic Protoporphyria
Sheldon Derkatch, Core
Supervisor: B. Schacter
1445-1515
BREAK
1515
(Case Report)
An Unusual Cause of Acute Right Heart Failure
Joel Nkosi, Core
Supervisor: D. Jassal
1525
(Clihicallnvestigation)
Relation of Biomarkers and Cardiac Magnetic Resonance Imaging After Marathon
Running
Andrew Czarnecki, Core
Supervisor: D. Jassal
1535
(Clinical Investigation)
Correlation of Bicuspid Valve Morphology and Pattern of Aortic Root Dilatation: A
Substudy of the Aortic Stenosis ProgreSSion Observation Measuring Effects of
Rosuvastatin (ATRONOMER) Study
Kapil Bhagirath, Cardiology
Supervisor: D. Jassal
1545
(Clinical Investigation)
The Utility of Tissue Doppler Imaging, Cardiac Biomarkers and Cardiac MRI in
Detecting Early Left Ventricular Dysfunction in HER2 Positive Patients Treated with
Adjuvant Trastuzumab Therapy
Anthony Wassef, Core
Supervisor: D. Jassal
1555
(Clinical Investigation)
Obstructive Sleep Apnea: Effects of Continuous Positive Airway Pressure on Cardiac
Remodeling as Assessed by Cardiac Biomarkers, Echocardiography and Cardiac MRI
Nader Elmayergi, Cardiology
Supervisors: D. Jassal
S. Sharma
1605
(Clinical Investigation)
Assessing Symptoms and Quality of Life Among Hospitalized Patients with Terminal
Illness
Tim Hiebert, GIM
Supervisor: K. Wiebe
1615
(Clinical Investigation)
Topical Pain Medications for Cancer Patients with Neuropathic Pain and Other
Pain Syndromes
Deepa Wadhwa, Core
Supervisor: J. Gingerich
1625
(Clinical Investigation)
Long Term Multi-Centre Follow Up of Blood and Marrow Transplantation for Patients
with Germ Cell Tumor
Kristjan Paulson, Core
Supervisor: M. Settel
1635
(Case Report)
A Case of Orthodeoxia in a Patient with Normal Pulmonary Arterial Pressures and
Minimal Shunt Through a Patent Foramen
Corey Metcalf, Core
Supervisor: S. Come
1645
(Clinical Investigation)
Thrice Weekly Warfarin Dosing in Hemodialysis Patients
Arjuna Ponnampalam, Core
Supervisor: M. Sood
1655
(Clinical Investigation)
Pulmonary Dysfunction in Systemic Lupus Erythematosus (SLE)
David Dawe, Core
Supervisor: S. Mittoo
1705
(Clinical Investigation)
Raynaud's Phenomenon in a Breast Cancer Survivor
David Allen
Supervisors:
S. Mittoo
D. Robinson
1715
(Case Report)
Haematopoietic Stem Cell Transplantation in Refractory Psoriatic Arthritis
Michael Chapman
Supervisors: D. Szwajcer
D. Robinson
1725
(Case Report)
Sodium Thiosulfate-Based Treatment in Calcific Uremic Arteriolopathy: A Provincial
Case Series
Kelvin Leung
Supervisor: M. Sood
STERS DISPLAYED IN RESIDENTS' ABSENCE (Case Report)
Recurrent Pulmonary Blastomycosis: A Case Report
Marcus Blouw, Core
Supervisor: E. Lo
(Clinical Investigation}
Trastuzumab Therapy in HER2 Positive, Metastatic Breast Cancer
Alan Smith, Core
Supervisor: M. Pitz
(Case Report)
Intestinal Tuberculosis
Ali Benzaglam, Core
Supervisor: A. IInyckyj
(Case Report)
Improvement of Myelodysplasia in a Patient on Intravenous IgG Infusions for
Hypogammaglobulinemia with Non-Caseating Granulomas
David Ryan, Core
Supervisor: A.M. Shojania
(Clinical Investigation)
Effect of Electronic Prescriptions on Discharge Times
Trevor Hutchison, Core
Supervisor: N. Hajidiacos
(Case Report)
Hyponatremic Pseudo Renal Failure -- A Presentation of Uroperitoneum
Jessica Singh, Core
Title: TBA
Aaron Low, Core
Supervisors: C. Rigatto
A. Junaid
Supervisor: TBA
A MASSIVE AMLODIPINE OVERDOSE:
THE NEW GENERATION OF CALCIUM CHANNEL BLOCKER OVERDOSE
Thomas K. Jacob, Robert B. Ariano, Eleni Giannoulli, Bruce R. Light, Joel Zivot
Section of Critical Care, Department of Medicine, University of Manitoba
Abstract
We report our experience with the largest amlod/pine overdose to date (-IOOOmg or 18.5 mg/kg). Only
one other case with a similar overdose has been published before. Surveillance data points to a new era
ofincreasing toxicological exposures with long acting calcium channel blockers. We look at antidotes
for calcium channel blockers targeting the peripheral vascular system and address some ofthe
controversies associated with the effectiveness ofByperinsulinemia I Euglycemia Therapy (BIET),
calcium chloride and glucagon. Review ofthe literature shows varying and inconsistent efficacy with all
anlidotes. We have outlined an interactive mechanism in peripheral vascular cells that shows how
different antidotes can augment each other. Therapeutically, this translates into identifying through
clinical response the most tifJective antidote for a particular patient but at the same time using all
antidotes to take advantage ofthis interactive mechanism.
TOXIC LEUCOENCEPHALOPATHY AFTER CRACK COCAINE INHALA nON
Jonathan Gilmore (BSc.) and Dr. Brendan Mcdougall (Md.) University of Manitoba, Winnipeg
Manitoba
We report a case of toxic leucoencephalopathy after crack cocaine inhalation. The disease is
usually observed in drug addicts who inhale pre-heated heroin. There is 1 other report in the
literature of cocaine inhalation causing the disease. The clinical features, which is a cerebel1ar
syndrome usually occur some days or even longer after the last heroin consumption. The
cerebellar hemispheres are almost always affected; the cerebral hemispheres, the cerebellar
peduncles and the pyramidal tract may be affected. Vacuolar demyelination is characteristic of the
lesions, which are usually symmmetrical, not contrast enhancing, hypodense on CT scan and
hyperintense on T2-weighted MR!. The pathophysiology is unknown.
EARLY ADMINISTRATION OF CRYSTALLOID FLUIDS REDUCES MORTALITY IN SEPTIC SHOCK
Jason Waechter MD, Allan Garland MD, MA, Anand Kumar MD Department of Medicine, University of Manitoba, Winnipeg, MB OBJECTIVE: Despite decades of research, the mortality rate of septic shock remains as high as 50%.
Treatment predominantly includes antibiotics, intravenous fluids, and vasoactive agents. While
recent work has established that delayed antibiotic administration is associated with decreased
survival, little is known about how fluids influence survival. The purpose of this study was to
evaluate the association between survival in septic shock with early fluid administration.
METHODS: This retrospective cohort study analyzed data from patients from 28 hospitals who met
inclusion criteria between 1989 to 2007; different sites contributed data from differing portions of
time. Patients were included if they had septic shock, survived at least 24 hours from the onset of
hypotension (to avoid immortal time bias). and received antibiotics, vasoactive agents, and at least
some fliuids within 24 hours of the onset of hypotension, and had no miSSing data elements for the
dependent variables. Fluid volume data was collected for post-hypotension periods 0-1,1-6 and 6­
24 hours. The data were analyzed by multivariable logistic regression; the dependant variable was
hospital survival, adjusting for 26 covariates categorized as demographic data, chronic comorbid
disorders, severity of illness indicators. or therapeutic interventions (including delays of
administration of antibiotics and vasoactive agents). Continuous variables were tested for linearity
and transformed if non-linear. Effects were considered statisticially signficant if p<.05, using the
likelihood ratio test. Model discrimination was assessed via the c-statistic.
RESULTS: From a database of 8,672 patients with septic shock, 2,559 patients met inclusion criteria.
Hospital survival of included patients was 53%. Increased hospital survival was significantly
associated with greater volumes of "early" crystalloid administered during the 0-1, and 1-6 hour
periods, but increased survival was not associated with crystalloid volumes administered 6-24 hours
after onset of shock. Significantly lower hospital survival was associated with increased colloid
volumes administered 6-24 hours after onset of shock.
CONCLUSION: We have demonstrated that improved hospital survival is associated with early, but
not late, administration of crystalloids to patients in septic shock. These results support that
aggressive crystalloid resuscitation within the first six hours after the onset of hypotension should
be part of a multi-modal treatment approach to patients in septic shock.
DANAPAROID INDUCED THROMBOCYTOPENIA. Roopesh Kansara, PGYI Internal medicine, University of Manitoba, Winnipeg, Manitoba; Majid Shojania, Section of Hematology, CancerCare Manitoba, Winnipeg, Manitoba. Danaparoid is the most common anticoagulant used in the treatment of Heparin Induced Thrombocytopenia (HIT) in Manitoba. Although about 10% of sera from HIT patients show in vitro cross-reactivity to Danaparoid, thrombocytopenia associated with the use of Danaparoid, either de novo or due to cross­
reactivity to heparin is extremely rare. We are presenting such a case ofDanaparoid-induced thrombocytopenia (DIT) or Danaparoid associated thrombocytopenia (DA T). th
An 8lyr old woman was transferred to St Boniface General Hospital on the 5 of August 2008, for urgent
repair of ascending aortic dissection. During repair, she was anticoagulated with heparin, which was
continued for four days post-procedure for prophylaxiS against DVT. Her platelet count then was 121 x
tit
10E91L. On the 12 of August, when her platelet count dropped to 87 x IOE91L the diagnosis of delayed
onset HIT was suspected and she was started on prophylactic doses of Danaparoid. On August 13 and 14,
her platelet counts were 33 and 21 x 10E91L, respectively. On August 15,16 and 17 platelet counts were 23,
38, 40 x 10E91L, respectively. On August 17 she developed DVT of her left lower extremity and extensive
pUlmonary embolism (PE). She was started on therapeutic doses onv Danaparoid. On August 19, when
her platelet count had dropped to 23 x IOE91L, DIT was suspected. Danaparoid was discontinued and she
was started on Fondaparinux. On August 22,25,29 platelet count were 49,93, and 163 x lOE91L
respectively. HIT assay was positive for August 13 sample. Serotonin Release Assay of samples from
August 13 and 19 were positive using heparin or Danaparoid. However, it was commented that the positive
reaction to Danaparoid was due to cross-reactivity with heparin. In summary, this patient with delayed
onset HIT was placed on prophylactic dose of Danaparoid with an initial rise of platelet count. Once the
patient developed DVTIPE, a rapid drop in platelet count followed Danaparoid at therapeutic doses.
There are several possible explanations to the causes of these events. 1) It is not clear whether DVTIPE in
this case were due to failure of prophylactic doses of Danaparoid to prevent HIT thrombosis (HI'IT) or due
to DlT. 2) The thrombocytopenia following IV Danaparoid could be due to cross-reactivity ofDanaparoid
with heparin antibodies that did not occur with small SC doses of Danaparoid but did so with larger IV
doses. 3) Thrombocytopenia on August 19 may be due to increasing titer of heparin antibodies stimulated
by Danaparoid. 4) A drop in platelets on August 19 could be due to de novo development ofDanaparoid
dependent platelet antibodies following the SC doses of Danaparoid.
We recommend hyper vigilance for danaproid-induced thrombocytopenia, if there is a falllno improvement
in platelet count within 3-5 days of Danaparoid initiation in a patient with HIT. A new thromboembolic
event while on Danaparoid should also raise suspicion. Treatment should be prompt discontinuation of
Danaparoid and starting an alternative anticoagulant, as well as sending blood sample for testing for DIT.
STIFF-PERSON SYNDROME
Daljit Gill, Resident, Department of Internal Medicine, University of Manitoba, Winnipeg, MB
Supervisor - Dr. Kristel Van Ineveld
Stiff-person syndrome (SPS) is a rare immune-mediated central nervous system disorder characterized by
fluctuating muscle stiffness, disabling spasms, and a heightened sensitivity to external stimuli. The
infrequency with which it presents as well as its unusual presentation make it a diagnostic challenge.
An 80 year-old female was referred to the geriatric medicine service for assessment of ongoing functional
decline. The patient was assessed at home due to her status that day. The patient and her husband related a
vague history of onset of tremors approximately thirty years ago. She had been able to maintain an active
and functional lifestyle for a number of years, as her symptoms were infrequent at that time. About five
years ago she noticed a change in her status with an increase in severity and frequency of her symptoms.
The patient would have a number of days of what was described as limited mobility, stiffness, and tremors,
such that the patient was bedridden and required help with her basic activities of daily living. Over the next
4-5 years, she saw numerous neurologists with a history of unexplained falls, muscle spasms, and tremors
with multiple neurological assessments and investigations, all of which revealed nothing. On this
assessment, the patient's husband states that he has noted that these spasms and rigidity often appear to
occur when the patient is frightened or startled or under emotional stress. On examination, of note, the
patient was markedly rigid with increased motor tone throughout, especially axial tone limiting truncal
movement. Her right arm was held in extension with her fingers splayed and also in hyperextension. Her
left arm was similarly postured. Her legs and feet were also hyperextended. She was hyperreflexic
throughout. Based on the clinical symptoms and the unusual trigger for her condition as described by her
husband, after a literature search, a diagnosis of SPS was made. The patient was admitted for further
investigation, which was non-contributory. Antibodies against glutamic acid decarboxylase in serum were
tested for which were negative (although literature reports suggest these are only positive in 60% of
cases). The patient was treated with high doses of daily Ativan to help with symptom relief with only partial
results.
This case illustrates the challenge in making the clinical diagnosis of stiff-person syndrome and the
difficulties associated with adequate treatment of the symptoms. It also shows the value ofa complete
history in making a clinical diagnosis.
NEUROLOGICAL MANIFESTATIONS OF CHURG-STRAUSS SYNDROME
Alireza Bagherli, PGYI, Department of Intemal Medicine, University of Manitoba, Winnipeg, Manitoba
Supervisor: Dr. R. Kostyk, Department ofIntemal Medicine, University of Manitoba, Winnipeg, Manitoba
The Churg-Strauss syndrome (CSS), also called allergic granulomatosis and angiitis, is a
multisystem disorder characterized by allergic rhinitis, asthma, and prominent peripheral blood
eosinophilia. The most common organ involved is the lung, followed by the skin. Churg-Strauss syndrome,
however, can affect any organ system, including the cardiovascular, gastrointestinal, renal, and central
nervous systems.
Individual manifestations of the syndrome can occur in isolation. Lung involvement is not
universal. Some manifestations can exist for many years before additional features become clinically
apparent.
A 54 year old man presented to the local rural hospital complaining of a two week progressing
bilateral lower legs numbness, tingling and weakness. Patient had an initial Complete blood count (CBC),
which showed an Eosinophilia of 50 %. He was then referred to a tertiary care hospital in Winnipeg for
further evaluation.
Patient stated that he had been suffering from Asthma like symptoms for about a year and also
extensive Sino-nasal polyposis for many years. He also had urinary retention for the past 24 hours and
central chest pain for few hours, without any shortness of breath or nausea.
On examination his vital signs were normal, cranial nerves were normal; he had patchy, fluctuating sensory
changes in bilateral lower legs. Deep tendon reflexes (DTR) normal in upper extremities. Decreased DTRs
in left knee and both ankles. Abnormal bilateral Babinski sign. Decreased temperature and pain sensation to
mid shins, and decreased vibration sensation to knees. Left hip flexion 2/5 and left knee flexion 3/5. Rest of
the physical exam was unremarkable.
His ECG was normal. He also had a normal chest CT scan. He had a lumbar puncture done, which
revealed elevated protein, also 184 cells with 17% eosinophilia. Brain and spinal MRI revealed a possible
granulomatous infiltration from Tl to T5. All rheumatologic serlogies were negative. His troponin was
initially elevated and trended down later. Echocardiography did not reveal any abnormality.
Patient was started on high dose Corticosteroids and within few days started to show significant
improvement of his symptoms. Later on a nerve biopsy was also performed.
This case illustrated the potential of Churg-Strauss syndrome to present as an isolated neurological
manifestation that may not co-exist with other organs involvements. In this patient manifestation were
limited to central nervous system and heart and there was no involvement of kidneys or lungs which are
more commonly seen in Churg-Strauss syndrome.
PROCESS ENGINEERING BETTER CHRONIC
PARAMETERS IN QUALITY AND EFFICIENCY
KIDNEY
DISEASE
CARE:
DESIGN
Ainslie Hildebrand', Kimberly MuJchey', Jeff Arseni02 , Romain Coudiere 2, Joanne Plamondon 3, Paul
Komenda4, Manish Sood4
'Department of Internal Medicine, University of Manitoba, Winnipef.' Manitoba, Canada, 2Faculty of
Engineering, University of Manitoba, Winnipeg, Manitoba, Canada, St. Boniface Hospital, Winnipeg,
Manitoba, Canada, 4Department of Nephrology, University of Manitoba, Winnipeg, Manitoba, Canada
CONTEXT: Randomized Control Trials suggest that patients with chronic kidney disease (CKD) stages IV
and V (eGFR < 30 mUmin) derive benefit in terms of mortality once starting dialysis from being followed
in multidisciplinary clinics. What remains unclear, is how the roles of each of the members in these clinics
are defined to maximize return on investment for all of these resources by minimizing non value added
redundant activities. and optimize the core competencies of all practitioners.
OBJECTIVE: The purpose of this study was to quantify the state of resource use in the multidisciplinary
CKD clinics and define strategies to optimize efficiency and improve patient experience.
METHODS: We conducted a prospective intervention study in the multidisciplinary CKD clinics at a
university·affiliated hospital in Winnipeg, Manitoba. The program includes 339 patients (46% female, 54%
male; 790/0 Caucasian, 10% First Nations, 6% Asian; mean age of 67 years). The cause of CKD among
patients includes diabetic nephropathy (29%), ischemic nephropathy (30%), glomerulonephritis (14%), and
polycystic kidney disease (2%). Practitioners were observed during a series of clinics with regards to
clinical practices, tasks performed, duration of contact with the patient, and usage of physical space. Based
on these data, the intervention included clinic restructuring; specifically roles of each practitioner were
defined and time parameters set. Patient encounters were again observed, and similar data was collected
and compared.
RESULTS: After restructuring the clinic, cycle times (duration of patient contact) among nurses,
dieticians, and pharmacists were not significantly changed, while task performance and cycle time
decreased among nephroiogists from 13.0 min (lQR 18.0·9.0) to 10.0 min (lQR 14.0-7.0), P < 0.001,
suggesting potential redundancy of their role. Throughput time (duration of clinic visit including
consultation and wait time) decreased from 73.0 min (IQR 95.0-51.0) to 52.5 min (IQR 70.3-32.0), P <
0.001, suggesting decreased wait times and improved patient experience. Semi·quantitative metrics suggest
that reduced redundancy oftasks and more standardized patient encounters occurred post·intervention.
DISCUSSION: This is, to our knowledge, the first study that templates standard operating procedures and
resources required to optimally function in a multidisciplinary clinic setting for CKD stage IV and V
patients. Further research is underway to define and quantify markers of quality of care in CKD patients
and determine whether restructuring the clinic has any effect on achieving benchmarks in quality of care.
Time of Medical Admission and Observed Patient Outcomes
Michael Semus, PGY 3 Internal Medicine Resident, University of Manitoba
Supervisors: Dr. K. Wiebe and Dr. K. Olafson, Faculty of Medicine, University of Manitoba
Background: The hospital environment is complex, providing continuous care to patients. The delivery of
care, although seemingly unifonn, may vary across evening. nighttime and weekend hours. During these
off-hours the hospital work setting is different in a number of capacities. There is limited access to medical
resources such as imaging and consultation. Staffmg patterns often schedule fewer caregivers leading to an
increased resident/physician workload. Finally, there is a decreased presence of senior physicians leading
to diminished or even absence of direct supervision of trainees.
Purpose and Hypothesis: Patients admitted to internal medicine wards during off-hours may be at a
disadvantage given the concerns about caregiver workload, lack of supervisory presence and limited access
to resources. We hypothesize that these patients would have longer hospital stays, increased rates of in­
hospital mortality and rates of transfer to the medical intensive care unit (MICU) when compared to on­
hours admissions. Furthennore, given the increased work demands on the resident night floater and limited
availability of phannacy resources and corollary infonnation, one would expect decreased rates of
completion of the medicine reconciliation fonn and increased rates of phannacy intervention and
medication errors on admission orders for off-hours admissions.
Methods: This study is a prospective chart review of consecutive patients admitted to an internal medicine
teaching unit at the Health Science Center over a one-month period. Data collected included baseline
patient characteristics (age, sex, and admitting diagnosis) and time of medical admission. The Charlson
Comorbidity Index Score (CCIS), hospital mortality and length of stay and MICU transfer rates were
obtained from the Winnipeg Regional Health Authority (WRHA) medicine database. Completion of a
medicine reconciliation fonn and admission prescribing errors were recorded for a sub-sample of patients.
Admission prescribing errors were detennined by tracking phannacist interventions on admission orders.
Results: There were 279 admissions between April lSI and 30th, 2008. Ninety-three patients (33.3%) were admitted during on-hours (weekdays from 8:00 to 17:00); 52.7% were male with an average age of 60.2 years and an average CCIS of 3.65. During off-hours (evening, weekends and over-night), 186 (66.7%) patients were admitted; 55.9% were male with an average age of 59.6 years. The average CCIS was 3.30. There was no significant difference in age, sex or CCIS between the two groups. Both weekday and weekend admissions had a peak time period for medical admissions between 16:00 and 23:00. Patients admitted during off-hours had an average length of stay of 11.51 days, compared to 11.28
days in the on-hours group (NS). Patients admitted during off-hours had higher rates of death and MICU
transfers; however, these differences were not statistically significant. Fifteen patients admitted during off­
hours were transferred to the MICU (8.1%), and 18 died during the hospital admission (9.7%). This is
compared to 6 MICU transfers (6.5%) and 7 deaths in the on-hours group (7.5%). Medication errors were
common in both groups, with 36.7% of on-hours admissions having at least I medication error compared to
42.7% of off-hours admissions. A concerning and unexpected result showed that 11.7% of the on-hours
group and 12.4 % of the off-hours group had at least one major medication error at time of admission.
Conclusions: The majority of internal medicine admissions occurred during off hours. These patients had
higher observed length of hospital stay, in-hospital mortality, medication errors, and MICU transfers;
however, these differences did not reach statistical significance. This study was likely underpowered to
detect differences in these outcomes. A larger study is planned to further explore differences in care
depending on time of admission.
RECURRENT PORPHYRIA-ASSOCIATED HEPATIC FIBROSIS AFTER ORTHOTOPIC
LIVER TRANSPLANTATION IN ADULT-PRESENTATION ERYTHROPOIETIC
PROTOPORPHYRIA
.
Sheldon Derkatch, Resident, Department of Internal Medicine, University of Manitoba, Winnipeg,
Manitoba
B. Schacter, MD, FRCPC, Department ofInternal Medicine, University of Manitoba, Winnipeg, Manitoba
Erythropoietic protoporphyria (EPP) is a rare metabolic condition classically characterized by childhood­
onset cutaneous photosensitivity and, in a minority of patients, cholestatic liver disease leading to hepatic
failure. Despite advances in the understanding of the genetic and molecular basis of the disease, there is
currently no way to adequately predict which patients will develop any ora variety of hepatic
manifestations.
A 48 year-old agriculture-equipment repairman was referred to hematology after being diagnosed with EPP
by his dermatologist. He reported a two-year history of painful, progressive sun-sensitivity leading to the
development of erythema and bullae over chronically exposed areas such as the hands and face. In
hindsight he reported "easy sunburning" since the age of five. His past medical history included an
appendectomy, hemiorraphy, surgical mandibular repair. cholelithiasis and having been struck by lightning
ten years prior. After none of these surgical procedures did he note significant skin irritation. One of his
female siblings reported a lesser degree of photosensitivity, as well as cholelithiasis leading to
cholecystectomy and the removal of numerous dark, angular calculi of various sizes. His parents, remaining
three siblings and five children had no similar complaints. His only current medication was beta carotene as
prescribed by his dermatologist. He was a one-pack-per-day smoker and consumed alcohol only
occasionally and in moderation. Initial biochemistry revealed a mild elevation of cholestatic liver enzymes
with no abnormality of liver function. Fecal and serum protoporphyrins were elevated in a manner
consistent with the diagnosis. Shortly after his initial visit, the patient underwent a laparoscopic
cholecystectomy and liver biopsy, revealing greyish-red tissue discolouration on gross examination and
focal birefringent crystals with mild chronic periportal lymphocytic hepatitis. There was no evidence of
cirrhosis.
Just over one year later the patient underwent endoscopic retrograde cholangiopancreatography and
sphincterotomy for recurrent jaundice and right-upper-quadrant abdominal pain. No calculi were
definitively identified. Over the next eighteen months he experienced three further hepatic exacerbations
requiring treatment with hematin and cholestyramine. A decision was made by the patient and his
healthcare team to pursue liver transplantation. However, his disease subsequently became quiescent, with
normalization of hepatic biochemical markers and no clear relation to photosensitivity or plasma
protoporphyrin concentration. Two years later, exposure to operating-room-theatre lighting during another
herniorraphy procedure resulted in significant skin injury. A subsequent hepatic decompensation the
following year necessitated multiple treatments with plasmapheresis and, ultimately, orthotopic liver
transplantation. He continued to suffer from significant light-sensitivity but was otherwise well. After four
years the patient's liver function was noted to have deteriorated slightly and repeat biopsy identified stage
1-214 fibrosis and patchy canalicular cholestasis consistent with recurrent porphyria-associated liver
disease.
This case illustrates the complex, unpredictable character of protoporphyrin-associated liver disease and the
need for the development of novel therapies. Although severe hepatic failure in EPP is a rare manifestation
of an uncommon disease, its pernicious and potentially preventable nature warrant further investigation.
AN UNUSUAL CAUSE OF ACUTE RIGHT HEART FAILURE
Authors: Joel Nkosi MBCHB CCFP, Davinder Jassal MD FRCP
Introduction: Idiopathic pulmonary arterial hypertension is a rare disorder
characterized by an elevated mean arterial pressure above 25mmHg at rest or
30mmHg with exercise in the absence of secondary causes. It usually presents
with progressive exertional dyspnea. Due to symptom overlap with more
common conditions, the diagnosis is usually delayed. Without treatment, the
prognosis is poor with death usually as a consequence of right heart failure. This
is a case report of idiopathic pulmonary hypertension presenting as acute right
heart failure.
Case presentation: A 61 year old previously well male presented with acute
symptoms of exertional chest discomfort and dyspnea on minimal exertion.
These were preceeded by a syndrome of a viral upper respiratory illness. He was
normothermic. tachycardic, hypotensive, tachypneic and hypoxic requiring
supplemental oxygen. His JVP was elevated without other signs of right heart
failure. All his extremities were cool with a poor urine output. There were no signs
of pulmonary hypertension.
ECG showed a sinus tachycardia, right ventricular strain and right axis deviation
with an S1Q3T3 pattern. Serial cardiac biomarkers were unremarkable. The d­
dimer was elevated with a lactic acidosis and a modestly elevated creatinine.
Chest X Ray only showed dilated central pulmonary arteries. Helical CT chest
showed no evidence of pulmonary thromboembolism. Echocardioraphy
suggested severe pulmonary hypertension without left heart failure, valvular
abnormalities or shunts. Spirometry showed a mildly restricitive pattern.
He was admitted with a viral respiratory illness and right heart failure of unknown
cause. Supportive treatment, antibiotics and anticoagulation were initiated. He
was unsuccessfully resuscitated from a witnessed cardiac arrest. Pulmonary
histology post mortem was in keeping with pulmonary arterial hypertension, likely
idiopathic.
Discussion: Idiopathic pulmonary arterial hypertension is a rare cause of
pulmonary hypertension and right heart failure. Its presentation is usually
insidious with progressive exertional dyspnea. Very rarely, it can present with
acute right heart failure precipitated by a seemingly minor illness such as a viral
respiratory illness. If decompensation results in cardiac arrest, even if witnessed
the survival is poor. The diagnosis should always be considered and
echocardiography performed in patients presenting with dyspnea and minimal
respiratory findings or right heart failure without obvious cause. If the diagnosis is
made, first degree relatives must be screened using echocardiography.
RELATION OF BIOMARKERS AND CARDIAC MAGNETIC RESONANCE IMAGING AFTER
MARATHON RUNNING
Czarnecki A, Mousavi N, Kumar K, Fallah-Rad N, Lytwyn M, Francis A, Kirkpatrick I, Sharma S, Jassal D
Department of Medicine, University of Manitoba, Winnipeg, MB
Objective The aim of this study was to demonstrate the cardiac changes associated with participation in a
marathon using serial cardiac biomarkers, echocardiography, and cardiac magnetic resonance (CMR)
imaging.
Methods Participants were evaluated with cardiac biomarkers and echocardiography one week prior,
immediately post and one week after marathon completion. CMR imaging was performed within five days
of race completion.
Results Our study included fourteen participants (mean age 33 ::l:: 6 years, 8 men) who completed the full
marathon. Myoglobin, creatine kinase, and troponin T were elevated in all athletes after the race. There was
a strong linear correlation between right ventricular (RV) fractional area change as assessed by
echocardiography and the RV ejection fraction as assessed by CMR imaging (r = 0.96) after the marathon.
RV function, using echocardiography, transiently decreased from before to after the race (RV fractional
area change 43 ::l:: 4% vs 33 ::l:: 5%, P <0.05). There were also post-race changes in left ventricular and RV
diastolic filling. Although RV systolic changes were transient, left and right ventricular diastolic
abnormalities persisted up to 1 week after the marathon. No evidence of delayed enhancement of the left
ventricular myocardium was found on CMR imaging, suggesting that the increase in cardiac biomarkers
after the marathon may not have been due to myocardial necrosis.
Conclusion Right ventricular systolic dysfunction occurs transiently after marathon completion and has
now been validated for the first time with CMR imaging. The increase in cardiac troponin after marathon
running is likely due to the cytosolic release of the biomarker, not to the true breakdown of the myocyte, as
confirmed by delayed enhancement CMR imaging.
Correlation of Bicuspid Valve Morphology and Pattern of Aortic Root
Dilatation: A Substudy of the Aortic Stenosis Progression Observation
Measuring Effects of Rosuvastatin (ASTRONOMER) Study
Kapil M Bhagirath l ; Davinder S Jassal l ; James W Tam l ; Randy A Sochowski2; Jean G Dumesnie; P J
Giannoccar04 ; John Jue s; A S Pandey6; C D Joyner'; K K Teos; Kwan L Chan9
Univ of Manitoba, Winnipeg, Canada
Victoria Heart Institute Foundation, Victoria, Canada
3 Hopital Laval, Sainte-Foy, Canada
4 Peter Lougheed Cntr, Calgary, Canada
5 Vancouver General Hosp, Vancouver, Canada
6 Cambridge Cardiac Care Cntr, Cambridge, Canada
7 Sunnybrook HSC, Toronto, Canada
8 McMaster Univ. Hamilton, Canada
'} Ottawa Heart Institute. Ottawa, Canada
I
2
Introduction: Bicuspid aortic valve is the leading cause of aortic stenosis in patients younger than the age of SO. A
classification scheme of bicuspid aortic valves (BA V) was recently proposed based upon leaflet orientation: Type A
(fusion of right and left coronary cusps) and Type B (fusion of right and non-coronary cusps). The correlation
between BA V leaflet orientation and aortic root pathology however remains ill defmed. To describe a potential
relationship between BAV leaflet morphology and aortic root measurements in the ASTRONOMER study, a
multicentre study to assess the effect of Rosuvastatin on the progression of AS.
Methods: Transthoracic echocardiography was perfonned with 2D and Doppler imaging following a standardized
protocol. BA V morphology was classified as Type A or Type B orientation following review of the parasternal
short-axis view. Echo measurements including left ventricular and aortic root dimensions were obtained according to
the ASE recommendations.
Results: We identified 89 patients (56±11 years; 44 males). There were 63 patients with Type A and 26 with Type
B BA V. Baseline demographic, hemodynamics, aortic root and left heart dimensions are listed in Table 1. Patients
with Type A BA V had larger aortic and ascending root dimensions than those patients with Type B BA V (p<O.05).
Aortic valvular calcification and mitral annular calcification were similar between the two groups. All values are
expressed as mean±SD.
Type A
(n=63t
Type 8 ("=26)
p value
Characterletics
Age,Y
Male gender <%1
HR (bpm)
SBP(rrm H9I
OOP (rrm Hg)
551:12
30 (48)
65
8
123", 16
75:::: 11
57::: 10
14 (54)
67 ~ 8
118:!: 12
40:!: 11
37:: 9
21 :t 5
=,
73
~
10
0.46
0.49
0.59
0.18
0.36
AortIc Val.,.
Pa~ters
AV peak gradient
AV mean gradient
AortiC Root
Paranwt_
Aortic annulus (mm)
Aortic sinus (mm)
23;!c 7
24::!: 3
21
34::.c 5
31::: 5
32!: 4
Ascending root (rnm)
Left Heart Dimensions
36:::; 3
lVS(mm}
11 :t 2
PWT{mm)
LA(mm)
LVEOD(mm)
LVESD(mm)
LVEF (%)
10:!: 2
34 =: 4
50:!:. 7
30:!: G
65!; 6
:!:
2
10:!: :1
10 :t 2
35:t: 6
50:": 7
30:.5
65:!: 6
0.25
0..38
<0.05
<0.05
<0.05
0.09
0.17
0.46
0.98
0.81
0.92
Conclusion: In patients with mild to moderate asymptomatic BAV, the presence of Type A valve orientation was
associated with significantly greater aortic root parameters compared to Type B valve orientation. Whether the
morphology of BA V may predict a subset of patients who will respond to statin therapy in preventing the
progression of AS remains to be determined upon completion of the ASTRONOMER trial.
TITLE: THE UTILITY OF TISSUE DOPPLER IMAGING, CARDIAC BIOMARKERS AND
CARDIAC MRI IN DETECTING EARLY LEFT VENTRICULAR DYSFUNCTION IN HERl
POSITIVE PATIENTS TREATED WITH ADJUVANT TRASTUZUMAB THERAPY
AUTHORS: A Wassef, DS Jassal
Department of Intemal Medicine, University of Manitoba, Winnipeg, MB
OBJECTIVES: Breast cancer is the second most common and fatal cancer to affect women. The addition
of trastuzumab to anthacycline based adjuvant chemotherapy decreases recurrence and mortality in Her2
positive breast cancer patients. Cardiotoxicity is the major limiting feature of trastuzumab, especially when
used in combination with Anthracyclines. Current guidelines for monitoring trastuzumab-induced
cardiotoxicity are basedupon serial assessment ofleft ventricular ejection fraction (LVEF). Early detection
of trastuzumab induced left ventricular dysfunction may allow for prevention of this drug induced
cardiomyopathy.
METHODS: A total of 60 women with Her2 positive breast cancer were prospectively recruited from two
tertiary care centres. Patients received anthracycline-based chemotherapy in 3 to 6 cycles, with
concomittant trastuzumab for one year. Two-dimensional transthoracic echocardiography (TIE) with tissue
Doppler imaging (TDI) was performed at baseline, 3, 6, 9 and 12 months after chemotherapy initiation.
Cardiac biomarkers including troponin T, B-type natriuretic peptide and C-reactive protein were collected
at similar time points. Cardiac MRl was performed at baseline and at 12 months. Data was summarized
using a mean ± SD, and compared using the student's t test and Fischer's exact test for categorical
. parameters.
RESULTS: The mean age of the patient population was 51±9 years. There was a low prevalence of
cardiovascular risk factors including hypertension, diabetes, hyperlipidemia, smoking history, and family
history of coronary artery disease, with no difference between patients with normal LVEF (n=48; 80%)
compared with patients who developed trastuzumab mediated cardiotoxicity (n=12; 20%). By six months,
there was a statistically significant difference in L VEF between the normal cohort and those patients who
developed LV systolic dysfunction (58±3% vs. 40±3, p<O.OI). TDI revealed a decrease in mean lateral wall
systolic velocity (S') between the normal cohort and those patients who developed LV systolic dysfunction
as early as 3 months of therapy (S.4±2.3 cm/s vs. 5.7±J.6 em/s, p<O.Ol). Troponin T, CRP, and BNP
showed no statistically significant change over time. In the one-year MR1 follow-up, delayed subepicardial
linear enhancement was present in the lateral portion of the left ventricle of all 12 patients who developed
LV systolic dysfunction due to trastuzumab.
CONCLUSIONS: Tissue Doppler imaging is a sensitive, non-invasive echocardiographic technique that
can be used to detect subtle early subclinical LV dysfunction in patients undergoing adjuvant trastuzumab
therapy prior to decrease in conventional LVEF.
OBSTRUCfIVE SLEEP APNEA: EFFECfS OF CONTINUOUS POSITIVE AIRWAY PRESSURE ON CARDIAC
REMODELING AS ASSESSED BY CARDIAC BIOMARKERS, ECHOCARDIOGRAPHY AND CARDIAC MRI
Elmayergi N, Colish J, Walker J, Francis A, Fang T, Lytwyn M, Kirkpatrick I, Sharma S, Jassal DS
Dept ofCardioiogy, St Boniface Hospital, Winnipeg, MB
Background: Obstructive sleep apnea (OSA) is associated with an increased risk of cardiovascular
morbidity and mortality. Although previous echocardiographic studies have demonstrated short term
improvement in cardiovascular remodeling in OSA patients on continuous positive airway pressure
(CPAP), a long term study incorporating cardiac biomarkers, echocardiography and cardiac magnetic
resonance imaging (CMR), has not been performed to date.
Objective: To determine the long term benefits of CPAP on both right and left ventricular systolic and
diastolic function in patients with OSA using serial cardiac biomarkers, echocardiography and CMR.
Methods: A prospective study of 30 patients was performed at a single tertiary care centre from 2008-2009
inclusive. Study subjects were diagnosed with OSA on a split-night polysomnographic exam. Cardiac
biomarkers including C reactive protein (CRP), brain natriuretic peptide (pro BNP), and troponin T (TnT)
were measured at baseline and serially over one year. All patients underwent baseline and serial
transthoracic echocardiographic (TTE) studies with tissue Doppler imaging (TDI) capability. CMR
imaging was performed on all study participants at baseline, 6 and 12 months to assess for cardiac
morphology, myocardial edema and degree of fibrosis.
Results: A total 000 participants (52±11 years, 21 males) with a mean BMI 005±8 kglm 2 were recruited.
At time of emollment, mean systolic blood pressure was 134±IS mm Hg, and diastolic blood pressure was
80±18 mm Hg. Additionally, 6% of the patient population were diabetic, 27% had dyslipidemia, and S3%
were either current or former cigarette smokers. Cardiac biomarkers including CRP. proBNP and TnT were
all within normal limits at baseline. After 3 months of CPAP therapy, these levels did not change
significantly. On serial echocardiography, there was a decrease in left ventricular end diastolic diameter
(59±4 mm at baseline to 51 ±6 mm at 3 months. p <O.OS) and a decrease in right ventricular end diastolic
diameter (40±3 mm at baseline to 33±4 at 3 months, p <0.05), following 3 months of CPAP therapy. Left
atrial volume decreased from S2±3 mm at baseline to 44±4 mm at 3 months of follow-up. A decrease was
also noted in the degree of pulmonary hypertension (61±4 mm Hg at baseline to 48±6 mm Hg at 3 months,
p <O.OS). Although there were no changes in conventional parameters of diastolic dysfunction, the LA
filling pressures as reflected by EIE', decreased from 19±2 at baseline to 9±1 at 3 months, p <O.OS. Finally.
LV mass as determined by CMR, decreased from 180 glm 2 to 165 glm2 as early as 6 months of CPAP
therapy.
Conclusion: Both systolic and diastolic abnormalities in OSA patients can be reversed as early as 3 months
of CPAP therapy, with progressive improvement in cardiovascular remodeling, as assessed by
echocardiography and CMR.
ASSESSING SYMPTOMS AND QUALITY OF LIFE AMONG HOSPITALIZED
PATIENTS WITH TERMINAL ILLNESS
Tim Hiebert, Internal Medicine Resident, University of Manitoba, Winnipeg, MB. Kim Wiebe, Assistant Professor, Department oflnternal Medicine, University of Manitoba, Winnipeg, MB Introduction: Palliative Care is an approach to the care of patients suffering from life-threatening or terminal illness which focuses on improving quality of life, both of patients and their families through the relief and prevention of suffering in the physical, psychosocial. and spiritual domains. 1 In Manitoba, many patients receive formalised palliative care in the setting of palliative care wards, hospices, or as outpatients enrolled in regional palliative care programs. There are many patients, however, suffering from terminal, incurable illness on acute internal medicine wards. Over a 6 month period at the Health Sciences Centre in 2006, over 100 patients died on the internal medicine wards, 80% ofthem receiving comfort-focused care. 2 While palliative medicine encompasses a large body ofliterature, very little research has been conducted on the provision of end of life care in the setting of acute internal medicine wards. Previously conducted research reveals shortcomings in end of life communication and quality of end of life care. This project seeks to prospectively assess the burden of physical symptoms using Edmonton Symptom Assessment Scale (ESAS), the overall quality of life of patients using the McGill Quality of Life Questionnaire (MQOL), assess the validity of these surveys in the acute medicine setting, and identify areas and methods of improvement for end of life care among patients with terminal illness admitted to an internal medicine ward at the HSC. Methods: Inpatients on the internal medicine wards at the Health Sciences Centre, Winnipeg, Manitoba who are suffering from a terminal diagnosis or life-threatening diagnosis and receiving comfort focused care will be recruited for enrolment prospectively over a six month period with goal recruitment of 100 or more patients. Identified patients will be asked to complete the ESAS and MQOL instruments to assess their physical symptoms and overall quality of life. These data will be combined with demographic data, primary diagnoses, admitting diagnoses and functional status obtained from the Winnipeg Regional Health Authority (WRHA) internal medicine database and from chart review. These data will be tabulated and reported in descriptive form. Subgroups of interest will include those with common terminal diagnoses, those patients with exposure to the palliative care program and those who have not. Summary: Many patients admitted to acute internal medicine wards suffer from terminal illness. This study will assess the usefulness of ESAS and MQOL in the acute care setting, and improve our understanding of physical symptoms and quality of life among this group of patients. This understanding will allow improvements in end of life care on Internal Medicine wards. I. WHO Definition of Palliative Care. http://www.who.inticancer/palliative/definitionJen/ accessed on
April 28, 2009.
2. Wiebe K, Hiebert T, unpublished data, 2008.
TOPICAL PAIN MEDICATIONS FOR CANCER PATIENTS WITH NEUROPATHIC PAIN AND OTHER PAIN SYNDROMES Deepa Wadhwa l , Joel Gingerich
1,3,
Lindsay Lemanski 2, Marianne Krahn l ,3, Paul Daeninck l ,3
IDepartment oflntemal Medicine, University of Manitoba, Winnipeg, MB, Canada, 2Saint Boniface Hospital General Pharmacy, 3Cancercare Manitoba, Winnipeg, MB, Canada, Introduction: There is growing recognition ofthe role that topical pain medications (TPM) may play in the
treatment of a variety of pain syndromes suffered by cancer patients. These pain syndromes, most commonly
neuropathic pain (NP), may be due to either the underlying malignant disease process or the cancer therapy
employed surgery, radiation, and/or chemotherapy. Use ofTPMhas several advantages including delivery of
concentrated therapy to a specific site, avoidance of hepatic ftrst-pass effect, and few or no systemic side effects or
drug interactions.
Objective: To retrospectively evaluate the outcomes attained from the use ofTPM in cancer patients suffering from
a pain syndrome.
Methods: A retrospective chart review was conducted to identify all patients treated with TPM between June 2006
and October 2008 due to lack of benefit from systemic analgesic therapy, high side effect burden, or patient
preference.
Results: The study population comprised of30 patients (13 males). To date, data is complete on 26 patients.
Improvement in pain symptoms (via V AS) was demonstrated in 19 patients. No benefit was seen in 5 patients and 2
had worsened pain. A variety of tumour types was represented: Colorectal (8), breast (6), genitourinary (6),
hematologic (4) and others (6). Pain syndromes included NP and somatic pain due to either disease (I3) or prior
cancer therapy (15). The most common medications included in the topical gel were lidocaine and ketamine (30) in
combination with gabapentin, ketoprofen, and/or baclofen. None of the patients discontinued TPM due to adverse
effects.
Conclusion: TPM is a safe and efficacious therapy for cancer patients suffering from pain, especially NP. Larger,
prospective trials are needed to clarify which patients beneftt most, which agents are most active and at what
concentrations.
LONG TERM MULTI-CENTRE FOLLOW UP OF BLOOD AND MARROW TRANSPLANTATION FOR
PATIENTS WITH GERM CELL TUMOR
DR. KRISTJAN PAULSON - PRESENTING AUTHOR
DR. MATTHEW SEFTEL - SUPERVISING AUTHOR
UNIVERSITY OF MANITOBAICANCERCARE MANITOBA WINNIPEG, MANITOBA Objective: Patients with germ cell tumors (GCT) have a favorable prognosis, with a cure rate over 95%. For
patients who fail to remit or relapse after initial treatment with platinum based chemotherapy, outcomes are much
poorer, and the optimal therapeutic choice for such patients is unknown. One such treatment option is high dose
chemotherapy with blood and/or marrow transplantation (BMT). However, there are limited published data
regarding the role of BMT. Moreover, published BMT studies have relatively short-term follow-up. We present the
long term follow up of patients who underwent BMT for GCT at two large Canadian centres.
Methods: A multi-centre, historical cohort study of consecutive patients undergoing BMT for GCT at the Manitoba
Blood and Marrow Transplant Program (MBMT) and the LeukemiaIBMT program of British Columbia (BC)
between 0111986 and 12/2004. Detailed clinical and demographic data were reviewed to determine the long term
event free survival (EFS) and overall survival (OS) of patients who underwent BMT, to analyze complications, and
to determine prognostic factors for survival.
Results: Seventy one patients were identified. Of these, 67 had non-seminomatous GCT, while four had
seminomas. Fourteen patients presented with primary extragonadal tumors. The majority of these were primary
mediastinal (11). Diagnostic staging according to the International Germ Cell Consensus Classification (IGCCC).
was available in 64 patients. Of these, 18 (25%) had good prognosis disease, I3 (18%) had intermediate prognosis
disease, and 33 (46%) had poor prognosis disease.
Mean follow-up of surviving patients is 10.3 years (SO 4.2 years). Overall, EFS at 5 years was 45.4%, while OS at
5 years was 44.7%. 38% of patients were alive and relapse free after BMT, while 46% of patients had disease that
relapsed after BMT (95% of whom subsequently died from progressive disease). Seven patients (10%) died due to
treatment related mortality within 100 days of BMT while three patients developed secondary malignancies
(astrocytoma, gastric adenocarcinoma, and osteogenic sarcoma). Of the 33 patients that relapsed, most (30) relapsed
within one year, while one patient relapsed within two years ofBMT. There were two very late relapses - one at I3
years and another at I J years after BMT.
In multivariate analysis, IGCCC good prognosis disease at diagnosis was associated with superior EFS and OS
(p=0.OI2). Presenting with extragonadal disease was associated with inferior OS and EFS (p=O.02). However, the
strongest predictor of survival after BMT was disease sensitivity to chemotherapy. Patients with chemo-responsive
disease had a 5 year EFS of 56%, while those with resistant disease had a 5 year EFS of 15.8 % (p<O.OO 1).
Conclusions: In this multi-centre cohort study, BMT appeared to result in successful outcome for a relatively large
and distinct sub-group of patients Predictors of improved survival included good prognosis disease at time of
diagnosis, primary gonadal disease, and chemo-sensitivity at the time ofBMT. There were two very late relapses,
and three patients developed secondary malignancies. Long-term relapse has previously been reported in GCT, but
not following BMT. We recommend that further research should be aimed at minimizing BMT related toxicities
and incorporating novel therapeutic approaches for patients who are unlikely to benefit from BMT,
A Case of Orthodeoxia in a Patient with Normal Pulmonary Arterial Pressures and Minimal
Shunt Through a Patent Foramen.
Corey Metcalf HBSc, MD, Department of Internal Medicine, University of Manitoba, Winnipeg
Canada
S. Corne, MD, FRCPC, Department of Internal Medicine, Section of Respirology, University of
Manitoba, Winnipeg, Canada
A case of a 77 year old female with a prior history of lupus and Alzheimer's disease presented
with hypoxemia and dyspnea. CT chest ruled out pulmonary embolism and pneumonia as causes
of her hypoxemia and demonstrated normal appearing pulmonary arteries. A transthoracic
echocardiogram bubble study was preformed demonstrating a small patent foramen ovale (PFO).
The patient's dyspnea resolved despite minimal intervention but the patient continued to
desaturate into the low 80's when walking. Upon consultation with the respirology service it was
noted that her saturations were normal on room air in recumbence. Upon sitting upright significant
desaturation would occur. The patient denied any subjective dyspnea with these desaturations.
Arterial blood gases on 100% 02 were performed with a significant decrease in Pa02 from
340mmHg to 145mmHg with a change from supine to upright posture. A shunt calculation was
performed in the respiratory lab which was calculated to be approximately 14%. Unfortunately it
was not clear what the patient's position was at the time of the calculation. Right heart
catheterization was performed to further determine the existence of a significant shunt, which was
again demonstrated to be small in the recumbent pOSition.
There was debate whether there was enough evidence to consider a PFO closure and the
patient's comorbidities and baseline functional status were considered. A provocative TEE was
requested and delayed due to the above debate. The cardiology service at Peter Munk Cardiac
Centre was consulted and it was felt by that team that a percutaneous PFO closure was
indicated. A TEE was finally performed and the patient received her PFO closure.
There were a variety of difficulties involved in this case. The initial diagnosis of orthodeoxia is an
often missed, but well-described entity in PFOs. The patient had known dementia and this was
problematic in deciding to pursue further interventions. There was also much difficulty in
demonstrating the degree of shunt on testing due to the patient's position while the tests were
being performed. The patient needed a positional study to demonstrate her pathology and this
was never accomplished during the right heart catheterization, echocardiogram, or the shunt
calculation. We were able to demonstrate orthodeoxia and shunt only on bedside saturation
monitoring and with 100% 02 testing.
A case in which a high index of suspicion is necessary upon initial evaluation and specific
provocative testing is required to demonstrate the proposed lesion. There is also ongoing debate
as to when a PFO closure is clinically indicated.
THRICE WEEKLY WARFARIN DOSING IN HEMODIALYSIS PATIENTS Arjuna Ponnampalam, MD; Manish M Sood, MD. University of Manitoba, Winnipeg, MB. Background: Medication adherence in hemodialysis patients is often challenging due to a high pill burden, complex and dynamic medication regimens and limited patient self interest in care. The purpose of this study was to investigate the time within target INR and safety profile of thrice weekly warfarin administration in hemodialysis patients with a clinical indication for anticoagulation and documented nonadherence to medications. Methods: Thirty-seven patients from 2 hemodialysis units in Winnipeg, Manitoba. Canada were recruited and seventeen patients were treated with thrice weekly warfarin and compared to twenty patients treated with daily warfarin therapy. The patients were followed for one year with weekly international normalized ratio (INR), dosage and adverse events recorded. The primary outcome was percentage of time with INR in target and sub-«J.5) and supra-(>4) therapeutic INR. Adverse events were recorded in the two groups. Results: The thrice weekly group had a higher burden of co morbidity (Charlson Co Morbidity Index of 6.35 ± 1.77 vs. 4.55 ± 1.64, p=O.003) compared to the daily dosage group. In the thrice weekly dosage
group, time within target INR was higher (56.9 vs. 49.3%, p=O.008) and time with supra-therapeutic INR>
4 lower (2.7 vs. 4.3%, p=O.03). Neither total bleeding events (7 vs. 6) nor major bleeding events (3 vs. 2
events) were significantly different between the two groups.
Conclusion: In this pilot study, thrice weekly warfarin appears to be a safe and feasible dosing strategy in
a select patient population. A randomized controlled trial of thrice weekly warfarin is warranted.
Pulmonary Dysfunction in Systemic Lupus Erythematosus (SLE)
David E. Dawe, Zoheir Bshouty, Carol A. Hitchon, Christine A. Peschken, David
Robinson, Hani EI-Gabalawy, Andrea Craig, Shikha Mittoo
University of Manitoba, Winnipeg, Manitoba
Objective
Pulmonary function test (PFT) abnormalities are common in SLE. We set out to
determine the relationship of PFT abnormalities with clinical features and exercise
capacity in SLE.
Methods
Consecutive SLE patients, seen at a university center, who met the ACR criteria for SLE,
enrolled into the Lupus Lung Study. Clinical and serologic variables were recorded,
including: self-assessed pulmonary symptoms, a Systemic Lupus Erythematosus Activity
Measure (SLAM). SLICCACR damage index (SDI), and autoantibodies. Patients had
PFTs and 6-minute walk tests (6-MW). Restrictive lung disease (RLD) was defined as
having a forced vital capacity or total lung capacity of ~80% predicted; an abnormal
DLCO was ~80% predicted on PFT. An abnormal 6-MW was ~80% predicted meters
walked. Patients with no physician recorded respiratory symptoms on SLAM were
analyzed.
Results
Of 62 patients enrolled, 38 had no SLAM lung symptoms (35 women, 74% Caucasians)
with a mean ± SD age of 48.7 ± 12.5 years, disease duration of 13.3 ± 9.6 years, number
of fulfilled ACR criteria ofS.4 ± 1.3, and SLAM score of6 ± 2.8. By self-assessment, 22
(S8%) reported dyspnea, 16 (42%) had a cough, 12 (32%) had pleuritic chest pain, and 10
(26%) had wheezing. Abnormal PFT results were seen in 21 (55%) patients; 11 (29%)
had RLD and 16 (42%) had an abnormal DLCO; 8 patients (24%) an abnormal 6-MW.
RLD was significantly associated with a cough (p=O.02) and serositis by ACR criteria
(p=0.02) using simple logistic regression (SLR). Controlling for age, cough, serositis,
disease duration, serositis [OR=12.4, 95% CI of 1.6-96.9, p=O.02] and cough [OR=1O.1,
95% CI of 1.4-72.S, p=O.02] remained significantly associated with RLD. In SLR,
dyspnea (p=O.005) was significantly associated with an abnormal DLCO. Controlling for
dyspnea, age, and disease duration, dyspnea remained significantly associated with an
abnormal DLCO [OR= 13.8, 9S% CI of 2.4-78.7, p=O.003). An abnorma16-MW was not
associated with either RLD or an abnormal DLCO.
Conclusion
Abnormal PFTs and exercise capacity are common and occur in 55% and 24% of SLE
patients despite no SLAM respiratory symptoms. RLD was associated with serositis and
cough and an abnormal DLCO with dyspnea. PFTs should be considered in the
evaluation of SLE patients, particularly in those reporting dyspnea or who have had a
history of serositis.
RA YNAUD'S PHENOMENON IN A BREAST CANCER SURVIVOR
David Allen MOl, S. Mittoo, MD, FRCPC2, D. Robinson, MD, FRCPC 2
1. 2. Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
Section of Rheumatology, Department of Internal Medicine, University of Manitoba,
Winnipeg, Manitoba, Canada.
ABSTRACTt: A 35-year-old woman with a history of breast cancer, treated three years ago with surgery,
radiation, and chemotherapy presented with a rapid onset of severe Raynaud's phenomenon. On physical
examination, she had digital ulcers and splinter hemorrhages; there were no signs of an underlying
rheumatic condition. Laboratory evaluation revealed anemia, the presence of antinuclear antibody and
slight depression in her serum complement C3 leveL The remainder of her serologic evaluation, including
extractable nuclear antigens, anti-double-stranded DNA antibody, antiphospholipid antibodies, rheumatoid
factor, anti-neutrophil cytoplasmic antibodies, cryoglobulins, and cold agglutinins, were negative. Within
weeks of her presentation, she developed acute renal failure and bilateral lower extremity edema. A
computed tomography scan of her abdomen and pelvis showed bulky lymphadenopathy and
hydronephrosis; a pelvic lymph node biopsy revealed metastatic breast cancer.
Her Raynaud's
phenomenon was initially managed with passive rewarming strategies, topical antibiotics, vasodilator and
anti-platelet therapy, but had a neglible response. However, once she was started on chemotherapy for her
recurrent malignancy, there was a significant improvement in her Raynaud's symptoms and resolution of
her digital ulcers and her ANA & C3 normalized. Thus, a diagnosis of paraneoplastic Raynaud's
phenomenon in the context of recurrent breast cancer was made. We believe this to be the [lIst description
ofRaynaud's phenomenon as the [lIst symptom of metastatic breast cancer.
HAEMATOPOIETJC STEM CELL TRANSPLANTATION IN REFRACTORY PSORIATIC
ARTHRITIS
Michael Chapman MD. Department of Internal Medicine, The University of Manitoba
David Robinson MD, FRCPC. Department of Internal Medicine, The University of Manitoba
David Szwajcer MD, FRCPC. CancerCare Manitoba, The University of Manitoba
Haematopoietic stem cell transplantation (HSCT) is being used increasingly for severe, refractory
autoimmune diseases.
A 40-year-old native Canadian male was diagnosed with psoriatic arthritis in 2004. He developed
destructive arthropathy, uveitis, and psoriatic skin lesions. His severe disease progressed despite treatment
with methotrexate, sulfasalazine, adalimumab, cycJosporine, infliximab, leflunomide, and etanacept in
conjunction with glucocorticoids. His rheumatologic condition was further complicated by diabetes
mellitus, a history of alcohol dependency, and colonization with methicillin-resistant staphylococcus
aureus (MRSA). Serologic testing revealed positive herpes simplex, varicella zoster, and cytomegalovirus
IgG dtres. After successful MRS A eradication. on April 2nd, 2009, a conditioning regimen of
cyclophosphamide and anti-thymocyte globulin was initiated followed by prophylactic doses of fluconazole
and acyclovir. He received G-CSF and a CD34 selected autologous stem cell collection was performed
followed by successful transplantation. He was transferred back to the rheumatology service for further
rehabilitation and was discharged from hospital on April 30"\ 2009.
This case contributes to the small but growing number of reports of autologous stem cell
transplantation for progressive, refractory psoriatic arthritis unresponsive to conventional treatments.
SODIUM THIOSULFATE·BASED TREATMENT IN CALCIFIC UREMIC ARTERIOLOPATHY: A
PROVINCIAL CASE SERIES.
Kelvin Leung, Lori Wazny, Colette Raymond, Paul Komenda, Martina Res)erova, Mauro Verrelli, Claudio
Rigatto, Manish Sood, Amy Sood; University of Manitoba, Canada; Manitoba Renal Program, Canada.:
OBJECTIVES: Calcific uremic arteriopathy (CUA) or calciphylaxis, is a rare disorder with an unclear
pathogenesis that is characterized by arterial calcification leading to ischemia and necrosis of the skin and
soft tissues. It is estimated that CUA affects anywhere from 1 to 4% of ESRD patients yearly (l,4), and is
associated with a mortality rate of approximately 50% in the first year (2,8). To date, there has been
sporadic case reports on the use of sodium thiosulfate (STS) as an adjunct treatment with various success
(5,6,7). We present data on our experience with STS in 6 CUA patients, the largest known series to date.
METHODS: Between October 2006 and July 2008, patients in the Manitoba Renal Program diagnosed
with CUA and received STS treatment were identified. Through a chart review, the patient demographics
along with clinical and laboratory data were gathered. The diagnosis of eUA was based on clinical
presentation, risk factors, plus positive findings on skin biopsy andlor imaging. Patient survival, wound
size, imaging, as well as pain symptom improvement as defined by type and dose of analgesic requirements
with reference to the WHO analgesic ladder, were measured. A response was defined as an improvement in
one or more of the three parameters of wound size, imaging improvement, or symptoms.
RESULTS: Six patients were identified in this series. Diagnosis was confirmed by biopsy (212) and/or bone
scan (5/6) with most having the ulcerative subtype (5/6). The average age was 50 years (27 to 63 years),
mostly female (5/6), and all chronic dialysis (4/6 PD) for an average of 4.5 years (0.5-8 years). Most (4/6)
had an elevated CaXP04 ratio (>4.5), (3/6) hypercalcemic (CoCa>2.6mmoJ/L), and (5/6)
hyperphosphatemic (Phos> 1.8mmol/L). Only 2/5 were hyperparathyroid (PTH>300). The majority (4/6)
were on vitamin D analogues and (3/6) calcium based phosphate binders. Once diagnosed, all patients had
calcium and vitamin D analogs discontinued. Treatment with STS 2Sg three times per week was initiated
no more than 8 weeks after diagnosis in 516 patients, with an average duration of treatment of 12.5 weeks.
In addition; the majority (5/6) received pamidronate, wound care (5/6), conversion to hemodialysis (3/4 PD
patients), seve lamer (5/6), cinacalcet (2/6), and nutritional support. Of the four patients who responded to
STS, mortality was 50%. Mortality of all patients was also at 50%, with deaths within 6 months of the
initial STS dose. Two patients responded to all three parameters, with radiological improvement within 40
days, and pain and wound size reduction within 3 months and no mortality. Common adverse events were
nausea and vomiting (3/6), followed by anion gap metabolic acidosis (3/6). The average duration of
treatment was 12.5 weeks. Mean cost of treatment with STS was estimated to be $35 500 per patient (range
of $12 000-60 000). Response cannot be solely attributed to STS treatment as 3/4 of responders were also
treated with bisphosphonate, 1/4 with parathyroidectomy, 100% with sevelamer, with 1/4 having increasing
dialysis dose.
CONCLUSION: Based on our study, our overall mortality rate with STS treatment was 50%, which is
approaching that of the published mortality without STS. The successful positive fmdings in the previous
case studies of the use of STS in CVA may be due to publication bias. Due to the high cost of this treatment
and questionable outcomes, further studies are needed to justifY the use of this costly treatment for CUA
Recurrent Pulmonary Blastomycosis: A Case Report
Abstract Dr. Marcus Blouw, PGY3 Internal Medicine, University of Manitoba (Winnipeg, Manitoba) Dr. E. Lo, Assistant Professor, Internal Medicine and Medical Microbiology, University of Manitoba Introduction: Blastomycosis is a systemic infection acquired after inoculation by Blastomyces
dermatitidis. It manifests primarily as pulmonary disease but disseminated infection is also common.
Treatment options for pUlmonary Blastomycosis include Amphotericin B and the azole drugs. A specific
anti-fungal treatment regimen is usually chosen based on disease severity and distribution, drug side effect
profile and immune status of the patient. Moderate to severe pulmonary blastomycosis requires 6·12
months of antifungal therapy.
Case: A 31 year old male presents with mild symptoms of dry cough and shortness of breath. He
has a past medical history of Type 1 Diabetes Mellitus complicated by autonomic neuropathy with
intractable diarrhea. Bilateral pulmonary infiltrates on chest x-ray do not improve after multiple courses of
antibiotics. He undergoes bronchoscopy with biopsy and a diagnosis of pulmonary Blastomycosis is made.
Treatment with Itraconazole 400mg/day is initiated. The patient develops intractable nausea and
vomiting after a single dose and develops diabetic ketoacidosis (DKA) as a consequence of severe
dehydration. He requires hospitalization for re-hydration and is later discharged on a regimen of
Fluconazole 400mg orally once per day. Recurrence of vomiting, dehydration and DKA develop after two
days oftreatment with oral Fluconazole. A trial of Amphotericin B (3 mglkg) is initiated, but abandoned
after rapid development of acute renal failure. Treatment is changed to Fluconazole 400mg IV daily and
continued for a total of six months. Persistent nausea is tolerated throughout the treatment course.
Five months after completion of Fluconazole therapy, the patient begins to experience symptoms
of fever, chills, sweats, weight loss, anorexia and cough productive of grey sputum. He does not present to
hospital until seven months later. Investigations now reveal extensive pulmonary consolidation with
cavitation of the right upper lobe. Sputum cultures are positive for B. dermatitidis as well as
Mycobacterium and Candida species. The patient is diagnosed with recurrent pulmonary Blastomycosis
and is started on treatment with Liposomal Complex Amphotericin B. He quickly deteriorates with
intractable nausea, vomiting, renal failure and DKA despite aggressive medical therapy. The patient
refuses further attempts at Amphotericin therapy, and Fluconazole 400mg IV daily is re-started. He is able
to continue this treatment although nausea persists. Intravenous Fluconazole for 18 months is prescribed.
Discussion: We present a typical case of pulmonary Blastomycosis, which is complicated by
intolerance of multiple treatment regimens. Blastomycosis is a relatively rare diagnosis in Manitoba, but is
much more frequent in Northwestern Ontario. This infection is frequently mistaken for bacterial or viral
pneumonia or pUlmonary malignancy. Moderate to severe pulmonary Blastomycosis requires treatment for
6-12 months with an appropriate anti-fungal agent. Unfortunately, disease relapse is not uncommon, and
failure to eradicate the infection can result in disseminated disease with catastrophic consequences. Early
consideration ofa diagnosis of Blastomycosis and vigilance surrounding issues oftreatment adequacy will
prevent severe dissemination and infection relapse.
Trastuzumab Therapy in HERl Positive, Metastatic Breast Cancer
Alan Smith PGY2 Internal Medicine
Supervisor: Dr. Marshall pjtz
Introduction: Breast cancer is the most common cancer diagnosis among women. Trastuzumab is a
monoclonal antibody that targets breast cancer cells which overexpress the human epidermal growth factor
receptor 2 (HER2). In this study, we set out to review patients with HER2 positive, metastatic breast
cancer who were treated with trastuzumab in Manitoba, to document treatment practices, monitoring for
toxicity, and clinical outcomes. Methods: Using the Manitoba Cancer Registry and the Provincial
Oncology Drug Program database we selected all women who received trastuzumab in 2006 for HER2
positive, metastatic breast cancer. Data was collected using the electronic record. Supplemental data was
retrieved from paper charts whenever possible. Women were followed from time of diagnosis of breast
cancer until death, with administrative censoring at December 31, 2008. Results: In total, 65 women met
the study criteria. The average age at diagnosis of breast cancer was 52.3 years, and 20% already had
metastatic disease. Women were administered trastuzumab on either a weekly or three-weekly schedule for
an average duration of 19.4 months. Patients received an average of 11,109 mg of trastuzumab,
corresponding to a drug cost of $68,200. Trastuzumab was stopped in 7 women (11%) because of cardiac
toxicity. Median progression free survival for this cohort was 10.7 months with an overall survival of 20.5
months. Conclusion: In women with HER2 positive, metastatic breast cancer, trastuzumab is often used
for a long period of time resulting in significant drug costs. Many women continued trastuzumab despite
disease progression, which requires further study. Cardiac toxicity remains a common complication and
guidelines for cardiac monitoring are required.
INTESTINAL TUBERCULOSIS
Ali Benzaglam MD, CCFP I, Alexandra IInyckyj MD, F.R.C.P (C) 2.
Abstract:
Intestinal tuberculosis is a rare disease in western countries, and may mimic a variety of
gastrointestinal disorders. Here, we report the case of a 34 year old Philipino gentleman immigrated from
Philipines 2 years ago presented to ER with 2 months history of intermittent right lower quadrant post
prandial abdominal pain with diarrhea and weight loss. He had a right lower quadrant mass. CT revealed
thickened ileum with 2 skip lesions and involvement of the cecum and ascending colon with reactive lymph
nodes. He had no known TB exposure. The radiological diagnosis was Crohn's disease. Colonoscopy was
normal to cecum but the ileocecal was nodular; biopsy showed inflammation but was non diagnostic ..
Stain for Mycobacterial organisms was negative. Fine needle aspiration of lymph node with special stains
for AFB was also negative.
Due to the infrequency of Crohn's disease in non Caucasians, steroid treatment was withheld until further
investigation could be performed to exclude the possibility of Tuberculosis. The patient's pain was
managed with narcotics. Mantoux test was positive at 24 hours measuring 20 mm. A right upper lobe
density on chest x ray was seen. Induced sputum for AFB smear was negative but grew Mycobacterium
tuberculosis on culture. He was started on four drug anti tuberculousr therapy. Over several weeks he
demonstrated disease progression with the development of small bowel obstruction with peritonitis. He
underwent laparotomy with ileocolic resection and segmental small bowel resection with end ileostomy,
Pathology showed granulomatous inflammation and was positive for rare AFB. This case serves to
highlight the difficulty in making the diagnosis of gastrointestinal tuberculosis, a disease that may mimic
Crohn's disease. Incorrect diagnosis and treatment may have morbid outcomes ..
IDepartment ofinternal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
lSection of Gastroenterology, Department of internal Medicine, University of Manitoba, Winnipeg,
Manitoba, Canada
Improvement of myelodysplasia in a patient on intravenous IgG infusions
for hypogammaglobulinemia with non-caseating granulomas.
J.D.Ryan and A. Majid Shojania
Myelodysplasic Syndromes (MOS) encompass a wide array of clonal disorders to
haematopoietic stem cells characterized by varying degrees of impaired haematopoiesis,
abnormal cellular morphology and function, changes in bone marrow cellularity, and peripheral
cytopenias. Numerous immunological abnormalities have been observed in association with MOS
including T-Cell and B-Cell dysfunction, as well as hypogammaglobulinemia. However, very few
cases of MOS and non-caseating granulomas have been reported together in the literature. Here
we describe a unique case that appears to comprise of all three pathological entities.
A man born in 1951 initially presented to hospital with fever. The patient was a smoker
with a history of recurrent respiratory tract infections and a family history of leukaemia. He was on
no medications. His temperature was 38.4°C. Physical exam revealed only bilateral sensorineural
hearing loss and a palpable spleen. His complete blood count (CBC) indicated he had both
anemia and leukopenia with a low-normal platelet count. Two bone marrow examinations were
conducted on separate occasions. Hypocellularity with dysplastic changes to erythrOid and
myeloid precursors was observed. A computerized axial tomographic scan (CT scan) of the chest
and abdomen showed mediastinal and retroperitoneal lymphadenopathy in addition to marked
splenomegaly. The patient was referred to haematology clinic for follow-up. A detailed history
excluded drug use, chemical exposure and risk factors for viral aetiololgies. The patient did
consume alcohol and he was advised to abstain. Immunophenotyping and cytogenetics were
found to be normal. Likewise, stainable iron was adequate. Lymphoma was not suspected. A
diagnosis of MOS was made and the patient was followed conservatively for the next ten years.
In February 2002, a repeat bone marrow examination was grossly unchanged. However,
in March of that year the patient was referred to an immunologist after repeated episodes of
pneumonia. He was found to have low IgG, IgA, IgM, IgO and IgE. Initially the patient declined
therapy but in November 2003, he was started on intravenous IgG (IV IgG) infusion. Over the
next 21 months IgG and IgM levels improved and the infusion dosages were gradually tapered.
In March 2004, the patient was found to have worsening pancytopenia and a repeat bone
marrow examination was performed. Remarkably, the aspirate showed normal cellular
morphology and no evidence of myelodysplasia. In addition, the bone marrow biopsy was
normocellular with occasional non-caseating granulomas. A subsequent CT scan of the chest and
abdomen revealed that the spleen and lymph nodes had increased in size. In June of that year,
the patient underwent elective splenectomy and lymph node biopsy. Pathological samples were
found to contain non-caseating granulomas but no evidence of lymphoma. Sarcoidosis was
suspected. Post-splenectomy all haematological parameters became normal.
In September 2005, IV IgG infusions were discontinued and IgG and IgM levels remained
perSistently above pre-treatment levels. Sadly. eighteen months later the patient died of
overwhelming pneumococcal sepsis despite vaccination.
Screening for hypogammaglobulinemia is not routinely undertaken in patients with MOS.
Interestingly, there is a well documented association between hypogammaglobulinemia and/or
common variable immunodeficiency (CVIO) and non-caseating granulomas in the literature. In
addition, both CVIO and sarcoidosis have been documented with MOS but not simultaneously in
a single patient. This case is an intriguing reminder that a variety of immune mechanisms may be
affected in the MOS patient population and a broad differential must be considered in patients
with recurrent infections. Finally, IV IgG is not a well recognized treatment modality in MOS. While
spontaneous remission of MOS remains a possibility the timing of remission suggests a
therapeutic effect. In addition, we can find no literature documenting improvement of
hypogammaglobulinemia or CVIO in patients on IV IgG. Our case documents a potentially novel
therapeutic approach in a unique patient and suggests a possible autoimmune aetiology of his
disease.
KEY WORDS: Myelodysplasia, Myelodysplasic Syndrome (MDS),
Hypogammaglobulinemia, Common Variable Immunodeficiency (CVID),
Non-caseating Granuloma, Sarcoidosis, Intravenous IgG (IV IgG).
EFFECT OF ELECTRONIC PRESCRIPTIONS ON DISCHARGE TIMES
Trevor Hutchison, Internal Medicine, University of Manitoba, Winnipeg, Manitoba
Nick Hajidiacos FRCPC, Internal Medicine
Objectives: Pressure to discharge patients from hospitals to accommodate the steady influx of new patients
through the emergency room is a common problem for many centres. Timely discharges facilitate the
transfer of patients up to the wards and free up the emergency room. A barrier to timely discharges is
thought to be a delay in signing discharge prescriptions. This study examines if pharmacy generated
prescriptions will result in more efficient use of time and earlier times of discharge.
Methods: Data on time of day of discharge has been collected from the medical wards at Health Science
Centre, Winnipeg, Manitoba over the last couple years. Over a two month period on one of the medicine
wards, when a decision to discharge a patient was made during rounds, the team pharmacist would print a
computer-generated prescription that was then compared to the medical administration record for any
discrepancies and signed by the attending at that time. This data on discharge times over those two months
was collected and a p chart was generated to show whether the process was in control and whether there
was a trend towards earlier discharge times.
Results: During that two month period 163 patients were discharged from the medical ward. When
compared to previous data on discharge times there was not a significant gain in earlier discharge times and
the process was not in control.
Conclusion: This study demonstrates that pharmacy generated prescriptions do not result in earlier
discharge times from medicine wards.
HYPONATREMIC PSEUDO RENAL FAILURE - A PRESENTATION OF UROPERITONEUM
Jessica Singh, MDI, Claudio Rigatto, MD2, Asad Junaid, MDI
'Department of Internal Medicine and 2Section of Nephrology, University of Manitoba, Winnipeg,
Manitoba
Pseudo renal failure refers to a serum biochemical profile that mimics acute renal failure despite
normal renal function. The relative infrequency and under recognition of this clinical entity could mislead
physicians towards a false diagnostic path, and delay prompt management of the underlying aetiology of
pseudo renal failure.
A 47 year old female presented with a I week history of progressive abdominal pain and
distension. Eleven days prior, she had undergone laparoscopic direct left inguinal and ventral incision
hemiorraphies. On exam, her abdomen was tender and tense with ascites. Serum sodium level was 125
mmollL, serum potassium was 5.3 mmoVL and serum creatinine was 782 IlmollL. Serum bicarbonate was
18 mmollL and anion gap was 20 mmoVL. Urinalysis showed microscopic hematuria. Paracentesis of
ascites drained dark yellow fluid with a total nucleated cell count of 1365 per Ill, of which 70% were
neutrophils. Ascitic fluid chemistry revealed a creatinine of 1219.5 IlmoVL. Following drainage of 3 L of
ascites and intravenous hydration with normal saline over 6 hours, the patient felt comfortable, and her
serum biochemistry had normalized. An infused computed tomographic cystogram showed abdominal
peritonitis and extravasation of urine into the peritoneal cavity through a bladder perforation. The patient
was admitted and managed conservatively with antibiotics and intravenous fluids. She was discharged
home with an indwelling urinary catheter.
This case illustrates that abdominal pain, azotemia and unexplained ascites in a previously healthy
person with recent pelvic surgery should raise the suspicion of intraperitoneal bladder rupture. Reverse
auto-dialysis of urine across the peritoneal membrane into the blood stream results in serum elevation of
urea and creatinine, profound disturbances in electrolytes, and shifts in acid-base status mimicking acute
renal failure. Recognition of pseudo renal failure as a presentation of uroperitoneum can lead to timely
management of symptoms, resolution of azotemia and correction of bladder defect.