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									Thursday April 28, 2011


   Oral Presentations
    Theatre One - HSC
   10:30 am - 11:50 pm

  Poster Presentations
   HRIC Atrium - TRW
   11:50 pm - 1:30 pm

   Oral Presentations
   Theatre One - HSC
   1:30 pm - 4:30 pm


Presenting Guest Judge:
 Dr. Georges Bordage,
     MD, MSc, PhD
         2011 Internal Medicine
         Residents Research Day
             Awards Dinner

       YOU ARE INVITED TO ATTEND THE INTERNAL
          RESIDENTS RESEARCH DAY DINNER
             THURSDAY APRIL 28TH, 2011.

       WHEN:            APRIL 28TH 2011
                        COCKTAILS: 6:00PM - 6:30PM
                        DINNER: 6:30PM - 9:30PM


       WHERE:            LYNX RIDGE GOLF CLUB
                         8 LYNX RIDGE BLVD NW




             PRESENTING KEYNOTE SPEAKER:
         DR GEORGES BORDAGE, MD, MSC, PHD


 PLEASE RSVP TO CHARLENE BRASS BY FRIDAY, APRIL 8, 2011 AT
(403)944-2146 OR CHARLENE.BRASS@ALBERTAHEALTHSERVICES.CA
   2011 Internal MedIcIne research day
        Oral PresentatIOns, aPrIl 28, 2011
Time              Resident Name                 Title                                                  Subgroup
                                                Predictors of Mortality Among Patients Admitted
                                                to Hospital for Ischemic Colitis: A Population-Based
1035 - 1050       Sadler, Matthew               U.S. Study                                             Health Sciences Research

                                                Evaluating the importance of defining healthcare-
1050 - 1105       Lenz, Ryan                    associated bloodstream infections                      Health Sciences Research
                                                Physician Workflow During Walk-Rounds Using a
                                                Real Time Locating System; A Qualitative Pilot
1105 -1120        Ward, David                   Study                                                  Health Sciences Research
                                                Implementation and Evaluation of an Electronic
                                                Nurse-initiated Geriatric Order Set to Improve the
                  Boscan, Alejandra             Quality of Care Provided to Older Hospitalized
1120 - 1135       Groshaus, Horacio             Patients                                               Quality Improvement
                                                Development and Prospective Evaluation of a
                                                Nurse Assessed Patient Comfort Scale (NAPCOMS)
1135 - 1150       Ross, Erin                    for Colonoscopy                                        Quality Improvement
                                                A Fulminant Neurologic Presentation fo Systemic
1330 - 1345       Bhavsar, Sankalp              Lupus Erythematosus                                    Case Report
                                                Gestational Trophoblastic Neoplasm Presenting as
1345 - 1400       Saini, Kirandeep              an Isolated Pulmonary Nodule                           Case Report
                                                Community Acquired Pneumonia in a Patient with
                                                history of Antiphospholipid Syndrome: severe
1400 - 1415       Nguyen, Phuong-Thao           sepsis or Catastrophic Antiphospholipid Syndrome?      Case Report
                                                Development of Assessment Tools for Evaluation of
1415 - 1430       Walzak, Alison                Procedural Skills in Internal Medicine                 Medical Education
                                                Switching disciplines during residency: does the
1430 - 1445       Chapelsky, Sarah              length of undergraduate training matter?               Medical Education
                                                MRSA Screening Swab status and its Association
1500 - 1515       Reynolds, Stephen             with Bacteremias in Hemodialysis Patients              Health Sciences Research
                                                The Role of Vitamin D Supplementation on Aortic
                                                Augmentation Index and Pulse Wave Velocity in
1515 - 1530       Abdi Ali, Ahmed               Humans                                                 Health Sciences Research
                                                Emergency Department Factors Associated with
                                                the Development of Acute Lung Injury in Patients
1530 - 1545       Wilson, Ben                   with Severe Sepsis                                     Health Sciences Research
                                                Prednisolone and Budesonide for Short and Long-
                                                Term Treatment of Microscopic Colitis: A
1545 - 1600       Stewart, Michael              Systematic Review and Meta-Analysis                    Systematic Review
                                                A survey of Canada-based, nation-wide data
                                                collections: compromised socioeconomic status
                                                (income and level of education) as a risk factor for
1600 - 1615       Sinclair, Caitlin             diabetes mellitus                                      Systematic Review




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
       Predictors of Mortality Among Patients Admitted to Hospital for Ischemic Colitis: A
                                 Population-Based U.S. Study

 Matthew D. Sadler, James N. Hubbard, Subrata Ghosh, Paul L. Beck, Chris Prusinkiewicz, Gilaad
                                         G. Kaplan

BACKGROUND:
Ischemic colitis has been associated with significant mortality; however, few population-based
studies have published outcomes for ischemic colitis in North America.
OBJECTIVE:
We assessed in-hospital mortality and determined independent predictors of mortality in a
nationally-representative sample of US hospitals.
METHODS:
We used the Nationwide Inpatient Sample to identify all patients with discharges for ischemic
colitis (ICD-9 557.X) as a primary diagnosis between 1993 and 2008. We described in-hospital
mortality and performed multivariate logistic regression analyses to determine independent
predictors of mortality after adjusting for age, gender, insurance status, ethnicity, Charlson
comorbidities, and interventions.
RESULTS:
From 1993-2008 we identified a total of 97,592 discharges of ischemic colitis. In-hospital
mortality was 13.0% (95% CI: 12.7-13.3) and colectomy was performed on 14.2% (95% CI: 13.9-
14.4) of patients with ischemic colitis. Chronic pulmonary disease [21.2% (95% CI: 20.9-21.5)],
diabetes mellitus [15.2% (95% CI: 14.9-15.4)], congestive heart failure [CHF; 14.5% (95% CI: 14.2-
14.8)], renal disease [8.7% (95% CI: 8.5-8.9)], peripheral vascular disease [8.4% (95% CI: 8.2-
8.6)], and myocardial infarction [6.3% (95% CI: 6.1-6.4)] were the most commonly associated
comorbidities in patients presenting with ischemic colitis. Mortality was associated with: older
age 65–85 years [OR=4.21 (3.38-5.26)] and 50-64 years [OR=2.29 (1.84-2.84)] versus 18–34
years; Medicaid [OR=2.03 (1.81–2.27)], self-pay (OR=1.78 (1.52–2.09)], and Medicare [OR=1.53
(1.42–1.65)] vs. private health insurance; and comorbidities such as liver disease [OR=3.18 (2.89-
3.51)], metastatic solid tumor [OR=2.27 (1.95-2.63)], AIDS/HIV [OR=2.22 (1.22-4.02)], renal
disease [OR=2.10 (1.97-2.23)], and CHF [OR=1.87 (1.78-1.97)]. Patients who underwent
colonoscopy or sigmoidoscopy [OR=0.47 (0.43-0.51)] had lower mortality whereas colectomy
[OR=2.38 (2.26-2.50)] was associated with increased mortality. Women had lower mortality
than men [OR=0.84 (0.81-0.88)] and fewer women required colectomy [OR=0.70 (0.68-0.73)]
despite representing a greater proportion of IC patients [68.88% (95% CI: 68.56-69.20)]. Lower
mortality was observed in Asians (OR=0.49 (0.36-0.66)) and Hispanics (OR=0.80 (0.71-0.90)
whereas African Americans (OR=1.13 (1.04-1.24) were associated with increased mortality, as
compared to Caucasians.
CONCLUSIONS:
Ischemic colitis was associated with several common conditions and carried a high mortality
rate, especially in older patients. Furthermore, colectomies were commonly performed on
hospitalized patients with ischemic colitis, and these patients had worse mortality.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
    Evaluating The Importance Of Defining Healthcare-Associated Bloodstream
                                   Infections
                       R. Lenz*, J.R. Leal, D.L. Church, D.B Gregson, T. Ross, K.B. Laupland

Background:

Bloodstream infections have been traditionally classified as either community or nosocomial in origin.
However, more recently the category of healthcare-associated community onset disease has been
recognized. The objective of this study was to evaluate characteristics of adults with bloodstream
infection according to acquisition setting.

Methods:

All first episodes of incident bloodstream infections (BSI) occurring among adults admitted to hospitals
in a large health region in Canada during 2000-2007 were included. BSI cases were classified as either
nosocomial (NA), community acquired (CA), or community onset healthcare associated (HCA) infections.
NA BSI was defined as first culture positivity ≥ 48 h following hospital admission or within 48 h of
discharge. HCA BSI was defined as (i) discharge from an home parenteral therapy clinic within 2-30 days
before BSI (ii) attendance at a hospital clinic or emergency room within 2-30 days before BSI; (iii)
hospital admission for two or more days within 90 days before BSI; (iv) sample sent from a nursing home
or a long-term-care facility resident; and (v) outpatient haemodialysis. CA BSI were defined as those with
first culture-positivity within <48 h of admission or >48 h after discharge from hospital, provided no HCA
criteria was met.

Results:

A total of 7,712 patients were included; 2,132 (28%) NA, 2,492 (32%) HCA, and 3,088 (40%) community-
acquired infection. Patients with CA BSI were significantly younger and less likely to have co-morbid
medical illnesses than patients with HCA or NA disease (p<0.001). The proportion of cases in males was
higher for NA (60%; p<0.001 vs. others) as compared to HCA or CA (52% and 54%; p=0.13). The
proportion of cases that had a poly-microbial etiology was significantly lower for CA (5.5%; p<0.001)
compared to both NA and HCA (8.6 vs. 8.3%). The microbiology of infections differed between
acquisition setting, with the distribution of organisms causing HCA intermediate in the spectrum
between NA and CA. The median length of stay was 29.9 days for NA, 9.1 days for HCA, and 7.5 days for
CA (p<0.001). Thirty-day all cause case-fatality rates were 26%, 19%, and 10% for NA, HCA, and CA
disease, respectively (p<0.001).

Conclusion:

Healthcare-associated infections are distinctly different from CA and NA infections. These data support
the classification of community-onset disease into separate CA and HCA categories.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
 Physician Workflow During Walk-Rounds Using a Real Time Locating System; A
                           Qualitative Pilot Study
            David Ward, MD, Jane Lemaire, MD, Alecia Greenough, BA, William Ghali, MD MPH

Background:
Walk-rounds, a common component of medical education, usually consist of a combination of teaching
outside of the patient room as well as in the presence of the patient. The latter is known as bedside
teaching. The optimal ratio of these components of walk-rounds has not been determined. However,
the proportion of time dedicated to bedside teaching has declined over the years despite research
demonstrating the benefits of this activity. Increasing complexities of patient care and perceived
impediments to physician workflow are often cited as reasons for their declining use. Research using
real-time locating systems (RTLS) has been purported to improve workflow through precise monitoring
of patients and equipment.

Objectives:
We sought to use RTLS technology on an internal medicine teaching ward to observe and track the
patterns of movement of attending physicians during walk-rounds.

Methods:
During a project to assess the efficacy of RTLS technology to track equipment and patients on an internal
medicine ward, we conducted a small-scale preliminary study to observe attending physician work flow
patterns. Over a period of eight weeks from December 2009 to January 2010, a consecutive sample of
all attending physicians on the unit was targeted. Of these, eight agreed to participate during their walk-
rounds. Data collected using the RTLS system was pictorially represented as linked points overlaying a
floor plan of the unit, to represent each physician’s motion through time. Visual analysis of time-motion
was independently performed by two researchers and disagreement resolved through consensus. Each
rounding event was described as a sequence of approximate proportions of time engaged within or
outside patient rooms. A total of four attending physicians and five events were studied.

Results:
Walk-rounds varied in duration from 60 to 425 minutes. The median time at the bedside was
approximately one third the total duration of rounds (range approximately 20-50%). Three styles of
walk-rounds were identified. In the first, minimal time was spent at the bedside. In the second, an equal
distribution of time was spent between the bedside, and hallways or conference rooms. In the third, a
greater proportion of time was spent at the bedside. There was no correlation between increasing
length of rounds and increased time at the bedside.

Conclusion:
Using RTLS technology to track physician movements during walk-rounds, a variety of styles were
observed. Future studies could examine how the proportion of time spent at the bedside during walk-
rounds impacts outcomes such as patient satisfaction, learner satisfaction, and physician workflow.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
Implementation and Evaluation of an Electronic Nurse-initiated Geriatric Order Set to Improve
                the Quality of Care Provided to Older Hospitalized Patients

        Alejandra Boscan MD, Horacio Groshaus MD, Jayna Holroyd-Leduc, MD FRCPC.
   Department of Medicine, University of Calgary and Alberta Health Services. Calgary, Alberta


Statement of the problem

Hospitalized older adults are at risk of complications such as falling, delirium, functional decline,
and long-term care placement. There is an increasing need for evidence-based care practices
targeted to improve the quality of care of older hospitalized patients.

Improvement related question

 The aim was to pilot an intervention targeted at enhancing care of older medical inpatients. The
intervention involved evidence-informed strategies that focused on decreasing falls and delirium
rates, and on maintaining function, nutrition and continence. It involved three components: i)
an electronic nurse-initiated order set, ii) brief educational in-servicing, and iii) a resource
binder.

Methods

A stepped-wedge trial design was conducted on 6 medical units at 2 Calgary hospitals. We
studied all patients 65 years or older admitted to the 6 units during the 12 week implementation
period. Both a quantitative and qualitative analysis was planned. The primary quantitative
outcome was the number of times the order set was ordered, while secondary outcomes
included length of stay, fall rates, and consults to related services. For the qualitative analysis,
interviews will be conducted 6-months post-implementation to assess the use of and the
barriers/facilitators to the intervention.

Results /Lessons learned

The order set was used (Mean rate 3 (95%CI 2-5)) and decreased odds of falling (P=0.01), while
having no impact on length of stay or consults. Qualitative data will determine if modification is
needed before broad implementation and evaluation.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
 Development and Prospective Evaluation of a Nurse Assessed Patient Comfort
                    Scale (NAPCOMS) for Colonoscopy
 Erin Ross, Catherine Dube, Robert Hilsden, Veronica Webbink, Breanna Gillett, Thomas Lee, Matt Rutter,
                                                Alaa Rostom
Statement of the problem:
Colonoscopy is a commonly performed procedure in gastroenterology, both for the investigation of
symptomatic patients as well as colorectal cancer screening. The importance of standards for quality
assurance regarding colonoscopy is recognized and advocated by many leaders in the field. However, to
date there are no validated instruments or scales to measure patient comfort during colonoscopy. A
validated instrument would allow for tracking of patient comfort outcomes and tracking of the sedation
level required to achieve these outcomes. The hope is that this scale can be incorporated into quality
assurance programs to allow for objective development of stopping rules for procedures with significant
patient discomfort.
Improvement Related Question:
The purpose of this study is to develop and validate a Nurse Assessed Patient Comfort Scale to provide
an objective assessment of patient comfort during a colonoscopy.
Methods:
Seven endoscopists and four nurses from the United Kingdom and Canada utilized a modified Delphi
approach to modify the Gloucester Comfort Score and create a new comfort scale with appropriate face
validity. A convenience sample of 300 patients (150 from both Canada and the UK) was selected to
achieve a 95% confidence interval of approximately 10% around the point estimate for the intraclass
correlation coefficient (ICC). So far 100 patients who presented for a screening colonoscopy at the
Forzani and MacPhail Colon Cancer Screening Centre in Calgary have been included in this study.
Patients with significant psychiatric or cognitive disorders were excluded. Two nurses were asked to
observe each colonoscopy and then complete the new comfort scale. Both patients and physicians
completed a four-point Likert scale which rated overall comfort during the procedure. Patients also
rated the procedure as better than expected, worse than expected, or as expected. Patients then
completed the same comfort scale 1 week after the procedure, and returned it via a self-addressed,
stamped envelope. The reliability of the new comfort scale was measured by calculating the ICC
between the two nurse observers, and the validity of the scale was assessed by calculating the
correlation between the nurse reported scale and patient reported comfort.
Results: To date 100 Canadian patients have enrolled in this study, 53 female and 47 male, with an
average age of 55.4 years. The ICC between the two nurses was 0.811 (95% confidence interval 0.732 to
0.869). The Spearman correlation coefficient between the nurse comfort scale and patient comfort
rating was 0.604. The Spearman correlation coefficient between the physician comfort rating and
patient comfort rating was 0.532. Out of the 100 patients in this study, 5 patients rated the procedure as
worse than expected (5%), 30 rated it as expected (30%), and 65 rated the procedure as better than
expected (65%). A Wilcoxon signed-rank test showed no statistically significant difference between
patient responses the day of the procedure and 1 week later.
Key Lessons Learned:
The interim Canadian data shows that this Nurse Assessed Patient Comfort Scale has a high reliability
and correlates well with patient comfort ratings. Preliminary data suggests a NAPCOMS pain score of 4
or higher is correlated with the patient rating the experience as having moderate or severe discomfort.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
       A Fulminant Neurologic Presentation fo Systemic Lupus Erythematosus
                                                    Sankalp Bhavsar

Learning Objectives:

    1. To review the neurologic manifestations of systemic lupus erythematosus (SLE)
    2. To review the causes, presentation, radiologic features, and management of posterior reversible
       encephalopathy syndrome (PRES)
    3. To review the definition and general management of antiphospholipid antibody syndrome (APS)
    4. To review the presentation of mononeuritis multiplex


Case Information:

A 23-year-old woman presented with a rash, acute onset of left hand weakness and numbness, and
fluctuating level of consciousness in the setting of a 4-week history of constitutional symptoms. On
exam, she had new significant hypertension, decreased visual acuity in both eyes, and marked weakness
in the left hand. Initial labs showed elevated inflammatory markers. CT Head showed bilateral
hypodensities posteriorly suggestive of PRES but also bilateral hypodensities in the frontal regions,
which is atypical for PRES.

Her BP was lowered acutely and a vasculitis work-up was ordered. She was started on pulse steroids in
the interim. MR brain showed changes consistent with PRES but also infarcts as well as a non-occlusive
cerebral venous sinus thrombosis. She was therefore started on ASA.

The vasculitis work-up now showed a strongly positive ANA. A renal biopsy was done and showed Class
III lupus nephritis. She then developed new neurologic signs and symptoms in the right leg. Nerve
conduction studies were consistent with mononeuritis multiplex and a repeat MR brain showed new
infarcts despite good BP control, ASA, and a course of pulse steroids. She was started on heparin for
concern regarding APS and on cyclophosphamide for suspected SLE.

Later the antibody profiles in the setting of the clinical presentation confirmed the diagnoses of SLE and
APS. Her neurologic status and nephritis remained stable on a combination of ASA, anticoagulation,
antihypertensive therapy, cyclophosphamide (later transitioned to mycophenolate mofetil), prednisone
(later tapered), and azathioprine.


Discussion:

This is a unique case of simultaneous central and peripheral neurologic manifestations of SLE. It is also
rare for SLE to present initially with neurologic manifestations. To our knowledge, this is the first
reported case of such a fulminant neurologic presentation with involvement of both the central and
peripheral nervous system as the initial presentation of SLE with PRES, cerebral venous sinus and arterial
thromboses, and mononeuritis multiplex. This is also the first case report of a patient with SLE having all
these entities.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
        Gestational Trophoblastic Neoplasm Presenting as an Isolated Pulmonary Nodule

                                                Kirandeep Saini

Learning Objective:

Pulmonary nodules identified in the context of an unexplained elevation in bHCG need to be
evaluated thoroughly for gestational trophoblastic neoplasm (GTN).

Case Information:

A 36 year old multiparous (G5, P2) woman of Japanese origin is found to have a solitary
pulmonary nodule consistent with gestational trophoblastic neoplasm as the explanation for her
persistently elevated/climbing BHCG. The patient is described to have a spontaneous abortion
in July 2010 and upon follow-up in Nov 2010 is found to have an elevated BHCG of 3700 with a
peak value of 8027 noted in Dec 2010. Despite two diagnostic laparoscopy and uterine
dilatation a source for the BHCG production is not identified. The patient received
Methotrexate therapy for a presumed chronic ectopic pregnancy; lowering but not normalizing
her bHCG level. Of note, CXR from Dec 2010, showed a left sided 13 mm density not clearly
visualized in the lung parenchymal versus breast tissue. Repeat chest x-ray in Feb 2011,
localized the lesion to the left lower lung. It was described as a lobulated, cavitating nodule
stable in size compared to previous imaging (12 x 14 mm). The patient subsequently
underwent a biopsy of the nodule which showed atypical epithelioid cells.
Immunohistochemistry stains were positive for AE1/AE3, bHCG, inhibin, which identified the
cells as trophoblasts. The patient was presumed to have metastatic GTN and started on
biweekly Actinomycin D chemotherapy with serial bHCG monitoring.

Implication/Discussion:

Although a rare entity, there are case reports of primary lung parenchymal GTN, which requires
chemotherapy with or without additional surgical resection as treatment. In this case, the
temporal relationship with spontaneous abortion is suggestive of metastatic GTN; regardless a
similar therapeutic approach applies. Early identification of a pulmonary focus of malignant
GTN, may change patient outcomes in terms of therapeutic options and monitoring parameters




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
   Community Acquired Pneumonia In A Patient With History Of Antiphospholipid Syndrome:
                Severe Sepsis Or Catastrophic Antiphospholipid Syndrome?

                                              Phuong-Thao Nguyen.

Learning objectives:

Catastrophic Antiphospholipid Syndrome (CAPS) is an accelerated form of Antiphospholipid
syndrome which causes extensive microvascular thrombosis and has a high mortality rate. The
objective of this case study is to review the manifestation and diagnostic criteria for CAPS and also
to review current treatment available for CAPS.

Case information:

A 37 year-old male with a history of APS that has been well controlled for 5 years with a target INR
between 3-4, presented to the emergency department with acute onset of severe abdominal pain
in the setting of recently starting levofloxacin for community acquired pneumonia. His acute
abdominal pain was attributed to significant bilateral adrenal haemorrhages (right adrenal gland
measured 5cmx9cmx15cm) due to supra-therapeutic INR from drug interaction. He was admitted
and treated for severe pneumosepsis. His anticoagulation therapy was held and he remained on
no anticoagulation therapy for 10 days. His hospitalization course subsequently was complicated
by acute kidney injury, NSTEMI, adrenal insufficiency and thrombocytopenia. He then developed
bilateral PE, atrial clots and multiple clots in the superficial veins in his extremities when his INR
was sub-therapeutic. APS antibodies levels were strongly positive. A diagnosis of probable CAPS
was made and he was restarted on dalteparin with plans for PLEX. Unfortunately, he suffered a
PEA and died.

Implications/discussion:

The current diagnostic criteria for CAPS include evidence of three or more organs, system and/or
tissue involvement and manifesting simultaneously or within a week; confirmation by
histopathology of small vessels occlusion in at least one organ or tissue and a laboratory
demonstration of lupus anticoagulant, and/or anti-cardiolipin and/or beta2 GPI antibodies. In our
patient, it was difficult to determine whether multi-organ failure was secondary to the severe
pneumosepsis and drug interaction resulting in adrenal haemorrhage or CAPS. In addition, the
patient has already been diagnosed with APS with significant evidence of anti-cardiolipin and lupus
coagulant antibodies at baseline. Consequently, he was treated as severe sepsis and a diagnosis of
probable CAPS was made after the development of bilateral PE and multiple thrombi peripherally.

According to the 2003 International Consensus Statement on CAPS, anticoagulants, steroids, and
therapeutic plasma exchange and/or IV IG and immuno-suppression offer the best outcome for
these patients. However, in our patient, this posed a therapeutic dilemma as our patient had
sepsis as well as significant haemorrhage and thrombocytopenia. Immuno-suppression,
anticoagulation in this setting appear to be counter-intuitive. The question of whether his
outcome would be different had CAPS been diagnosed earlier remains debatable.

Conclusion:

The diagnosis and management of CAPS can be challenging in the setting of severe sepsis with DIC.



Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
       Medical Education: Development of Assessment Tools for Evaluation of
                       Procedural Skills in Internal Medicine
                                     Ali Walzak, PGY-1 Supervisor: Dr. Irene Ma

Problem
Evaluation of procedural skills across Internal Medicine training programs is currently carried out in an
informal fashion. A standardized approach has not been established.
Description of Program
This research program will develop a set of procedural checklists for each of the seven core bedside
procedures: central venous catheter insertion, lumbar puncture, peripheral arterial catheter insertion,
abdominal paracentesis, endotracheal intubation, thoracentesis, and knee joint aspiration. Using a
group of six to eight experts per procedural checklist, we will conduct an iterative process using the
modified Delphi method1 in which each member of the panel will be asked to rate each item on the
checklist in terms of importance and difficulty level. Once consensus is achieved, the Angoff method2
will be used to generate minimum passing scores for each checklist. These checklists will then be used to
evaluate Internal Medicine trainees in Objective Structured Assessment of Technical Skills (OSATS)
scenarios using task trainer models.
Objectives of Program
      1) Develop and validate assessment tools for the seven core bedside procedures in Internal
           Medicine.
      2) Implement the use of these checklists in the evaluation of Internal Medicine trainees in
           standardized settings.
Findings to Date
Checklists have been developed for lumbar puncture, knee aspiration, and thoracentesis. We have
assembled an expert panel of reviewers for each checklist. The knee aspiration checklist is currently in
its first iteration of review. In this stage, the reviewers are asked to grade each step on importance
(using a five-point scale) and whether the item should be included. They are also given the opportunity
to provide additional written comments. The lumbar puncture checklist is in its second iteration. During
this phase the reviewers are again asked to assess each item for importance using a three-point scale as
well as difficulty level (easy/medium/hard). They are also asked to identify the percentage of borderline
trainees that would perform the step correctly.
Key Lessons Learned
      1) Simulation training using task trainer models provides a safe and standardized setting for
           instruction of procedural skills.
      2) Accurate assessment of procedural skill competency requires reliable and valid evaluation tools.
      3) The modified Delphi method is an effective way to allow consensus to be reached on
           assessment checklist items between members of an expert panel.
      4) The Angoff method can be applied to an assessment checklist to determine minimum passing
           scores for the procedure.

References
    1. Clayton, M. Delphi: A technique to harness expert opinion for critical decision making tasks in
       education. Educ Psychol. 1997(17): 373-86.
    2. Angoff, W. Scales, norms, and equivalent scores. In: Thorndike, R, ed. Educational Measurement
       2nd ed. Washington, DC: American Council on Education; 1971: 508-600.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
      Switching Disciplines During Residency: Does The Length Of Undergraduate Training Matter?

                          Sarah Chapelsky, Leslie Forward, Harish Amin, Maria Bacchus

Statement of Problem or Question
Are medical trainees who graduated from a 3-year undergraduate program more likely to change
disciplines during residency than trainees who graduated from a 4-year program?

Description of Program/Intervention
We obtained data from the Canadian Post-M.D. Education Registry (CAPER). A ‘switch’ was counted as
having taken place when there was incongruity between a resident’s first and most recent field of post-
M.D. training. We did not include changes between primary specialities and their subspecialties,
changes to palliative medicine, and changes between infectious disease and medical microbiology. Only
Canadian graduates who changed disciplines were included; international medical graduates, those who
changed programs but not disciplines, and those who withdrew from medical training were not
included.

Objectives of Program/Intervention
There are two 3-year undergraduate medical programs in Canada. Students from these medical
programs have less time to decide on their specialty, and may have less clinical exposure before they are
required to make that decision. We hypothesize that graduates from 3-year medical schools will be
more likely to change disciplines during residency.
Such information may impact potential undergraduate medical students who are evaluating prospective
programs. It is also useful for educators and administrators involved in recruitment, clinical curricula,
and career counselling.

Findings to Date
We have obtained data for the cohort of Canadian medical graduates who started residency in 2002,
following along until the 2010/2011 training year. Overall, the rate of switching was 8.7% (127/1328).
For 3-year program graduates, it was 2.4% (4/165); for 4-year program graduates, it was 9.6%
(123/1163). The rate of switching was 8.1% (59/665) for females and 9.3% (68/663) for males. For
residents who were under 25 when beginning residency, the rate of switching was 6.5% (37/535); 26 to
30 years 10.9% (80/654); 31 to 35 year 8.4% (9/98); and 36 and over 2.4% (1/41).
Based on available data from the Canadian Residency Matching Service (CaRMS) for the year 2002,
89.1% (801/899) of medical students graduating from 4-year undergraduate programs matched to their
first choice disciplines versus 94.1% (159/169) of 3-year undergraduates. There is considerable year-to-
year variability, with the overall rates for the years 2002-2009 being 91.8% (1613/1758) for 3-year
programs and 90.3% (9875/10 937) for 4-year programs.

Key Lessons Learned
These data suggest that graduates from 3-year medical programs may be less likely to change field of
training during residency than graduates from 4-year programs. Part of this may be related to the higher
rate of success of 3-year graduates in the CaRMS match.
Further work will look at a larger cohort of residents.



Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
         MRSA Screening Swab Status and Its Association with Bacteremias in
                             Hemodialysis Patients
  Stephen Reynolds Supervisor: Dr. Louis Girard Collaborators: Dr. M. James, Dr. B. Hemmelgarn, Dr. D.
                                     Gregson, and Dr. K. Laupland

Background:
Hemodialysis (HD) patients with methicillin-resistant Staphylococcus aureus (MRSA) infections face high
morbidity and mortality. Blood stream infections (BSI) are the second leading cause of death in HD
patients. Nasal carriage of MRSA is thought to play an important role as an endogenous source for HD-
access related infections that contribute significantly to morbidity, mortality and cost of end-stage renal
disease (ESRD) management. The correlation between MRSA nasal swab status and the frequency and
type of BSI remains unclear.

Objective:
To determine the association between MRSA nasal swab status and the risk/type of blood stream
infections among patients receiving hemodialysis.

Methods:
This is a cohort study of HD patients in the Southern Alberta Renal Program (SARP) between January 1,
2004 and December 31, 2007. Patients will be first identified using an administrative database (Province
of Alberta Renal Information System – PARIS). They will be censored for death, dialysis modality change,
and transplantation. All HD patients in Southern Alberta undergo regular MRSA nasal swab screening
and patients identified using PARIS will be linked to a Calgary Lab Services (CLS) database to identify
them as MRSA swab positive or negative. A single positive swab result will be sufficient to consider the
patient as MRSA positive. These patients will then be screened using the CLS database for the presence
of BSI using blood culture results during the study period.

The primary outcome is the occurrence of BSI, defined as growth of a pathogenic organism from at least
1 set of blood cultures. Common skin contaminants are not to be included in the analysis due to the
inherent difficulty in establishing their clinical significance. The secondary outcome is the determination
of an association between MRSA nasal swab status and the type of bacteria isolated. Specifically, we are
looking for a correlation between the type of Staphylococcus aureus (methicillin-sensitive or resistant) in
BSI.

Timeline:
Ethics approval has been obtained and the identification of patients using the PARIS database is nearly
completed. The linking of data between PARIS and CLS will proceed shortly with planned data analysis
to follow soon thereafter. Ideally, data collection and analysis should be completed in 2011.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
    The Role of Vitamin D Supplementation on Aortic Augmentation Index and
                         Pulse Wave Velocity in Humans
                        Abdi-Ali A, Hemmelgarn BR, MacRae JM, Sola DY, and Ahmed SB

Vitamin D (VD) status is an increasingly important predictor of cardiovascular disease (CVD). Arterial
stiffness, as measured by the aortic augmentation index (AIx) or by the pulse wave velocity (PWV), is an
important parameter for the assessment of CVD risk. To clarify the influence of VD on arterial stiffness,
first, we studied the relationship between VD status, baseline arterial stiffness, and arterial response to
angiotensin II (AngII) challenge; an indirect measure of the intrinsic RAS activity in the vascular system.
Second, we studied the effect of VD supplementation on these same parameters in VD-deficient healthy
humans.

Thirty four normotensive, non-obese, healthy subjects (19 females and 15 males) were studied in a high
salt balance; a state of maximal RAS suppression. All female subjects were studied in the same phase of
their menstrual cycle. AIx and brachial PWV were measured by radial tonometry at baseline and in
response to graded AngII infusion (3ng/kg/min x30min, 6ng/kg/min x30min). A subset of eight VD-
deficient (serum 25(OH)-VD < 50 nmol/L) subjects ingested 5000U of VD daily for 28 days and
underwent repeat measurements of arterial stiffness.

Results were analyzed according to serum 25(OH)-VD status: deficient (<50nmol/L, n=10), insufficient
(50-79nmol/L, n=13), and sufficient (>80nmol/L, n=11). Baseline AIx differed according to 25(OH)-VD
status, with increasing 25(OH)-VD status being associated with a decreased AIx (15.6±3.5% vs. 8.4±3.4%
vs. 3±5.9%, p=0.024 for trend). All subjects demonstrated an increase in AIx in response to AngII
challenge (p=0.0002), though this response did not differ by 25(OH)-VD status (11.8±2.7% vs. 16.9±4.2%
vs. 8.2±4.5%, p=0.7). No association was detected between baseline brachial PWV (p=0.8) or the
brachial PWV response to AngII (p=0.7) and 25(OH)-VD status. In the second phase of the study, baseline
mean serum 25(OH)-VD levels increased from 47.7±3.8 nmol/L to 105.8±13.4 nmol/L post-
supplementation (p=0.0007). Baseline AIx decreased with VD supplementation (12.5±4.2 % vs.7.8±5.4%,
pre- vs. post- VD supplementation), though this did not achieve statistical significance (p=0.09).
Similarly, VD supplementation increased the AIx response to AngII challenge (9.1±2.4% vs.14.2±3.4%,
p=0.08). In contrast, VD supplementation did not significantly alter baseline brachial PWV (7.45±0.29
m/s vs.7.51±0.69 m/s, p=0.7) or the brachial PWV response to AngII infusion (1.5±0.56 m/s vs.1.09±
0.48m/s, p=0.8).

Our study show that low VD status is associated with increased arterial stiffness and may be associated
with the up-regulation of RAS activity in the vasculature of healthy humans. Supplementation of VD
stores may improve these parameters and may ultimately decrease CVD risk.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
  Emergency Department Factors Associated With the Development of Acute Lung Injury in Patients
                                      with Severe Sepsis

              Ben Wilson, Hamish Cowan, Tracy Elliot, Dan Zuege, Jason Lord, And David Zygun

Background:

Acute lung injury (ALI) is a common and mortal condition that incurs significant health care costs in the
intensive care unit (ICU). Severe sepsis is the most common cause of ALI, with approximately 50% of
affected patients going on to develop the condition. Currently, it is unclear which patients with severe
sepsis ultimately go on to develop ALI.

Objective:

To identify physiologic and therapeutic variables associated with development of ALI in emergency
department patients with severe sepsis.

Methods:

This investigation was a retrospective cohort study. Consecutive adult patients admitted to any of the
three former Calgary Health Region multi-system ICUs with severe sepsis or septic shock between
October 1, 2005 and September 30, 2006 were identified by the ICU Tracer database and subsequent
chart review. Demographic, physiologic, and therapeutic factors were then extracted from patient
charts. Descriptive statistics and boxplots were used to analyze each variable. The Student’s t-test,
Mann Whitney U test, and Fisher’s exact test were then used. Factors found to be significant in
univariate analysis (p<0.2) will be entered into multivariate regression analysis to determine factors
independently associated with ALI development.

Results:

One hundred twenty-four patients were identified. Nine patients had ALI in the ED and were excluded
from analysis. Nineteen patients developed ALI in the ICU. Mortality in those with and without ALI was
42.1% (8/19) and 13.5% (13/96), respectively. Preliminary bivariate analysis demonstrated that those
with ALI had significantly greater maximum respiratory rate, INR, creatinine, frequency of bacteremia
and significantly lower total bilirubin, pH, and bicarbonate level. Statistical analysis is still underway.

Conclusion:

ALI carries a significant mortality rate. Increased respiratory rate, INR, creatinine and degree of
metabolic acidosis are associated with the development of ALI in ED patients with severe sepsis.
Multivariate analysis will be performed to determine those factors independently associated with ALI
development.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
Prednisolone And Budesonide For Short- And Long-Term Treatment Of Microscopic Colitis: A
                           Systematic Review And Meta-Analysis
      Michael J. Stewart, Md1, Cynthia H. Seow, Mbbs, Msc1,2, Martin Storr Md, Phd1,2
                    1
                   Department of Medicine, University of Calgary, Calgary, Alberta, Canada
                2
                 Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada.
Background:
Microscopic colitis is a chronic inflammatory disorder that comprises collagenous and lymphocytic
colitis. The incidence of microscopic colitis and its disease burden is increasing, yet effective treatment
can be challenging. There is limited systematic information addressing the use of conventional
corticosteroids and budesonide in microscopic colitis. Additionally, new data on the use of budesonide
for microscopic colitis has emerged since previous reviews were undertaken.
Aims: To conduct a systematic review and meta-analysis on the short- and long-term efficacy of
corticosteroids in the treatment of microscopic colitis.
Methods: Relevant trials were identified through MEDLINE, EMBASE, the Cochrane Central Register of
Controlled Trials, proceedings of major gastroenterology meetings, and reference lists of trials and
review articles. Randomized controlled trials that met predetermined selection criteria were included in
the quantitative analysis.
Results: Eight randomized trials were identified. A total of 248 patients were randomized to
corticosteroid versus placebo. The intervention was budesonide in seven trials and prednisolone in one
trial. Treatment with budesonide was significantly more effective than placebo for both short-term
clinical response (RR 3.07, 95% confidence interval [CI] 2.06 - 4.57) and long-term clinical response (RR
3.22, 95% CI 1.05-9.89). Prednisolone was not found to be superior to placebo for short-term clinical
response (RR 2.00, 95% CI 0.38-10.58). Significant histological improvement was seen with both short-
and long-term budesonide (RR 3.76, 95% CI 2.00-7.06, and RR 2.50, 95% CI 1.25-4.98, respectively).
Symptom relapse occurred in 46% to 80% of patients within six months of treatment cessation. Patient
withdrawal due to adverse effects occurred at a rate of 4.4% with no difference between study groups
(p=0.55).
Conclusion: Both short- and long-term treatment with budesonide is effective and well tolerated for
both collagenous and lymphocytic colitis, however, the rate of symptom relapse once budesonide is
discontinued is high. Further studies are needed to determine optimal treatment duration, dose, and
withdrawal procedure.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
   A Survey Of Canada-Based, Nation-Wide Data Collections: Compromised Socioeconomic
        Status (Income And Level Of Education) As A Risk Factor For Diabetes Mellitus
                                                      Caitlin Sinclair

Background: In International literature (European and American), compromised socioeconomic status
(SES) has been correlated with both increased prevalence (Espelt et al, 2008) and incidence of type 2
diabetes mellitus (DMII) (Maty et, al, 2005). The relationship is exaggerated in women (Espelt et al,
2008). In Calgary, specifically, lower income has been associated with higher BMI’s and less
advantageous lipid profiles on initial presentation to the Diabetes Education Clinic (Rabi et al, 2007) as
well as greater burden of atherosclerosis and greater myocardial jeopardy scores in patients presenting
for cardiac catheterization (Rabi, Edwards et al, 2009).
Socioeconomic disadvantage in Canadian Aboriginal people has been well documented; as of 2001,
Aboriginal peoples living on reserves were more likely than the general population to have attained less
than a grade 12 education (48.6% versus 22.5%) and more likely to have an annual income < $20,000
(65.1% of people aged 25-64 versus 36.3%). Aboriginal people are also at increased risk of developing
DM II and in Alberta, both the incidence and prevalence of DM II in Status Aboriginal peoples continued
to rise between 1995-2006 (Johnson, Hemmelgarn et al, 2009). Overall, both prevalence and incidence
of DM II are greater in Aboriginal women versus men (Johnson, Hemmelgarn et al, 2009).
Objective: Survey published literature and clarify established role of socioeconomic status in the
development of DM II in Canadian citizens. Specifically, clarify the role of income versus level of
education as independent risk factors and markers of socioeconomic status.
Methods: Systematic literature review using multiple databases: Medline Ebsco, Ovid and Pub Med.
Search terms included DM II, socioeconomic status, disadvantaged, vulnerable populations, income,
education, poverty, poverty areas, Canada, First Nations, Aboriginal. Inclusion criteria: Canada-wide
data collections in which the focus was Diabetes prevalence or incidence with respect to socioeconomic
determinants of health. Studies conducted outside of Canada (and outside of the Canadian Health Care
System) were excluded.
Results: Two major prevalence studies (Dasgupta et al, 2010 and Dinca-Panaitescu et al, 2010) and one
major incidence study (Ross et al, 2010) agree that a correlation exists between compromised SES
(income and education) and DM. With regards to income, a 14-year DM incidence study found an
increased risk of developing DM in the lowest income groups (HR 1.7 (1.3-2.3)) relative to the highest
income groups (HR 1.0). The effect was exaggerated in women (HR 2.4 (1.5-3.7)) versus men (1.4 (0.9-
2.1) and specifically, female Southeast Asian/Aboriginals (HR 3.1 (1.7-5.7)) versus males (HR 1.7 (0.7-
3.9)). The two major prevalence studies corroborated this effect, with low income/female subjects
having the greatest odds of diabetes prevalence. With regards to level of education, the 14-year
prevalence study demonstrated that education level less than secondary was associated with the
greatest risk of developing DM (HR 1.9 (1.5-2.4)), again, with an exaggerated risk in the female cohort
(HR 2.4 (1.7-3.3)) versus male cohort (1.5 (1.1-2.2)) and in Southeast Asian/Aboriginal females (HR 3.3
(1.8-5.9)) versus males (HR 3.2 (2.1-4.8)), again corroborated by the prevalence studies. Obesity also
exaggerated the risk significantly. Furthermore, a nation-wide survey (Gucciardi et al, 2009) correlated
diabetes prevalence with household food insecurity (OR 1.40 (1.28-1.54)), demonstrating an
exaggerated risk in young women age 12-45 yrs (OR 3.17 (2.23-4.40)) and Status Aboriginal peoples (OR
1.56 (0.93-2.23)). Unfortunately, all of these nation-wide studies excluded people living on reserve.
Conclusions: Recent Canada-wide literature describes a correlation between diabetes prevalence and
incidence and compromised SES, mirroring the trends seen internationally. Low income may be
relatively more important than lower levels of educational attainment as a risk factor for DM II, but both
are independent risk factors. The effect is exaggerated in women and specifically, SEA/Aboriginal
women and overweight/obese people. These data failed to clarify determinants for aboriginal people
with DM II living on reserve, an unfortunate omission, given the well-documented health disparity of
Aboriginal peoples living on reserve.



Internal Medicine Resident Research Day Thursday, April 28, 2011 – Oral Presentation Abstracts
Basic Science Poster Abstracts

 Resident Name Title
                          Enteropathogenic E. coli induces intestinal epithelial cell apoptosis via
 Flynn, Andrew            pathways involving caspases and apoptosis-inducing factor
                          Impact of oral quinolone vs IV quinolone on the microbiome; looking for a
                          linkage between between antibiotic use preferences and rising rates of
 Kwok, Clement            C.difficile infection




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Basic Science Poster Abstracts
   Enteropathogenic E. Coli Induces Intestinal Epithelial Cell Apoptosis Via Pathways Involving
                            Caspases And Apoptosis-Inducing Factor

                                          Andrew N. Flynn and Andre G. Buret

Inflammation Research Network, University of Calgary, 2500 University Dr., NW, Calgary, AB, T2N 1N4, Canada

Background

The attaching and effacing pathogen enteropathogenic Escherichia coli (EPEC) is a major cause of infant diarrhea in
developing countries, and causes significant levels of morbidity and mortality. This bacterium tightly adheres to
intestinal epithelial cells (IECs), leading to programmed cell death (apoptosis) which may play a role in the
pathogenesis of EPEC. Therefore, understanding the mechanisms behind EPEC-induced IEC apoptosis is crucial
for appreciating the overall disease processes initiated by this pathogen.

Objective

The objective of this study was to determine the mechanisms by which EPEC initiates IEC apoptosis.

Methods

Cultured human T84 IECs were exposed to EPEC at a multiplicity of infection of 100:1. Apoptosis was detected
using poly(ADP-ribose) polymerase (PARP) immunoblotting and a Cell Death ELISA. Colorimetric assays were
used to detect the activity of caspases, and pharmacological agents employed to inhibit their function. RNA
interference was used to knockdown the expression of apoptosis-inducing factor (AIF).

Results

EPEC infection led to IEC apoptosis in a time-dependent fashion. Cellular caspases were activated during infection
and were required for the initiation of apoptosis. Cytosolic AIF expression was increased during infection, and its
processing to the apoptogenic 57 kDa fragment required caspase activity. AIF expression was necessary for EPEC-
induced IEC apoptosis.

Conclusions

The mechanisms by which EPEC causes IEC apoptosis have not been fully elucidated. We tested the hypothesis
that caspases and AIF are involved in apoptosis induced by EPEC. Taken together, our data suggest that caspase-
dependent mobilization of AIF contributes to EPEC-induced epithelial cell apoptosis. Further studies are warranted
to clarify specific interactions between bacterial effectors and the host cell apoptotic machinery. Greater
understanding of these pathways may lead to the development of more effective antimicrobial agents against
attaching and effacing pathogens.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Basic Science Poster Abstracts
Impact of Oral Quinolone Vs IV Quinolone on the Microbiome; Looking For a Linkage between
             Antibiotic Use Preferences and Rising Rates of C.Difficile Infection
                                       Kwok, Clement
BACKGROUND

There has been growing interest in addressing how a change in the human gut microbiota is associated with
disease states such as IBD, IBS, antibiotics associated diarrhea and obesity. It was thought that the diverse
microorganisms in the human gut along with their collective genome—the human gut microbiome—provides
important metabolic and immunological functions and a disturbance of the human gut microbiome predisposes
to disease states.
Specifically, there has been increasing incidence of Clostridium difficile infection related to antibiotics use. It
was shown that fluoroquinolones predispose patients to Clostridium difficile associated disease and that the
number of ciprofloxacin prescriptions to outpatients associates with the incidence of Clostridium difficile
infections.

HYPOTHESIS

In this study, we are aiming to explore the degree of disturbance to the human gut microbiome with different
regimens of Ciprofloxacin. By using intravenous Ciprofloxacin to minimize exposure of the human gut to the
antibiotic, we hypothesize that there may be potentially less adverse changes to the human gut flora that will
predispose individuals to Clostridium difficile related diarrhea.

METHODS

Participants
Patients with pyelonephritis who had not taken any antibiotics in the past 6 months, who are not pregnant with
no known history of previous bowel surgeries or irritable bowel syndrome or inflammatory bowel disease are
included in the study.
The patients will either receive intravenous Gentamicin, intravenous Ciprofloxacin or oral ciprofloxacin for the
first 7 days of their 14 day course antibiotic treatment. All of them will receive oral ciprofloxacin for the
remainder of the course of therapy. Stool samples will be collected at day 0,4,7,10,14 of initiation of antibiotics
and also 1 week after a total of 14-day course of antibiotics. The stool samples will then be analyzed by both
cultures and culture-free techniques by means of qPCR of 16s rRNA genes of different genus of human gut
flora to look for the effects of different antibiotics and route of administration on composition of human gut flora.

RESULTS

This research project proposal is currently in the process of undergoing ethics approval.

CONCLUSION

This study will explore the effects of different regimen of Ciprofloxacin on human gut flora and resistance
genes pattern. This will provide important information to help guide clinicians in their empiric antibiotic choices
in the context of treating pyelonephritis while minimizing the risk of Clostridium difficile related diseases.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Basic Science Poster Abstracts
                        Case Report Poster Abstracts

Resident Name       Title

Borman, Meredith    Sudden Vision Loss in a Patient with Mitral Valve Prolapse

                    Long term follow-up of untreated, recurrent sarcoidosis in a transplanted
Brown, Kathryn      heart


Cerquozzi, Sonia    May-Thurner Syndrome in an Active and Healthy Young Female

Chin, Melanie
Wilson, Ben         Disseminated herpes zoster in an immunocompetent individual

                    Intravenous Lipid Emulsion Therapy for Sustained Release Diltiazem
Cruikshank, Jack    Poisoning

                    A Case Report of an Extremely Rare and Aggressive Tumor---Primary
Feng, Xiaolan       Pericardial Mesothelioma

Gutierrez, Leanne   Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS)

                    Two cases of large bowel perforation after placement of a colonic stent
Imbulgoda, Amal     and treatment with bevacizumab-containing chemotherapy

Meshi, Bernard      A Case of Pulseless Disease
     SUDDEN VISION LOSS IN A PATIENT WITH MITRAL VALVE PROLAPSE
                                     Meredith Borman and Marcy Mintz


LEARNING OBJECTIVES:
Review the epidemiology of mitral valve prolapse and the associated neurological
sequelae with a specific focus on retinal artery occlusion.

CASE INFORMATION:
We report a case of a 49-year-old woman with known mitral valve prolapse, and a history
of vasovagal syncope and transient global amnesia. She presented with acute painless
vision loss secondary to a left retinal artery occlusion. An extensive workup including CT
angiography, trans-esophageal echocardiography, 24-hour holter monitoring, vasculitis
serology and hypercoaguability testing revealed no risk factors for stroke other than her
known mitral valve prolapse.

IMPLICATIONS/DISCUSSION:
Mitral valve prolapse, the most common form of valvular heart disease in adults, is a
multifactorial valvular abnormality most commonly caused by myxomatous degeneration
of the valve leaflets. Although generally associated with an excellent prognosis, a number
of neurological sequelae have been described in patients with mitral valve prolapse,
including transient ischemic attacks, cerebral infarction, seizures, syncope and retinal
artery occlusion. The postulated mechanism of cerebral ischemic events is embolization
of platelet-fibrin thrombi from the surface of myxomatous mitral leaflets, however this
finding has rarely been demonstrated pathologically. Although mitral valve prolapse is
associated with an increased risk of cerebrovascular events, these occur mainly in older
patients with high-risk valve features and advanced mitral regurgitation and as such,
prophylactic aspirin treatment is not strongly supported by available data.




Internal Medicine Resident Research Day, April 28, 2011 – Case Report Poster Abstract
     Long Term Follow-Up of Untreated, Recurrent Sarcoidosis in a Transplanted Heart

                                     Dr. Kathryn M. Brown and Dr. Deborah Isaac

                                                    Dept of Cardiac Sciences

Learning Objectives (1-2)

     -    Review of the pathogenesis of cardiac sarcoidosis and the role of transplantation in
          therapy
     -    Review of the surveillance options (endomyocardial biopsy, Cardiac MR vs. traditional
          function assessments ie: echo, MUGA) and indications for therapy in recurrence

Case Information

We present the 5th case (extensive review of the literature) of recurrent cardiac sarcoidosis post
transplant in a 61 year old man, now 12 years post orthotopic cardiac transplant. Ours is the first
case of confirmed recurrence that has not been treated with aggressive immune suppression and
is the longest post-transplant follow up to date. Interestingly, the patient’s functional capacity is
excellent with no evidence of conduction disease or impaired ventricular function despite
endomyocardial biopsy and cardiac MR confirmation of recurrent sarcoidosis within 1 year post
transplant. This unique, long term perspective calls into question the role for immediate
resumption of steroid therapy for recurrent sarcoid in cardiac transplants.

This case is unique in that it provides a longitudinal follow up of transplantation for cardiac
sarcoid, with documented recurrence, and no clinically significant disease has occurred despite a
lack of traditional immunosuppressive therapy.

Implications/Discussion

Transplantation for cardiac sarcoid remains the final therapeutic option for clinically significant,
refractory disease. Less than twenty detailed case reports of cardiac transplant for sarcoidosis
exist in the literature. Recurrence of sarcoidosis in the transplanted organ is exceedingly rare.
This may be due to the inherent difficulty in monitoring such as the “hit and miss” nature of
endomyocardial biopsies and non-specific MRI features of early sarcoidosis. This case is unique
in that it provides a longitudinal follow up of transplantation for cardiac sarcoid, with clearly
documented recurrence, and no clinically significant disease occurrence despite a lack of
traditional immunosuppressive therapy for more than a decade.




Internal Medicine Resident Research Day, April 28, 2011 – Case Report Poster Abstract
         May-Thurner Syndrome In An Active And Healthy Young Female
  Sonia Cerquozzi MD, Graham F. Pineo MD, FRCPC, FAFP, Jason K. Wong, MD, Dr.
                        Karen Valentine PhD, MD, FRCPC.


Abstract:

May-Thurner syndrome is a rare condition involving external compression of the
left common iliac vein by the right iliac artery, which was first described in the
1850s. It predominates in females typically between the third and fourth decade of
life and has been associated with thrombophilias. Importantly, the syndrome is
amenable to endovascular treatment. Here, we describe a case of a young female
with an incidental finding of an iliac vein thrombosis while taking oral
contraceptives, who was identified as having May-Thurner syndrome with positive
testing for Factor V Leiden mutation.




Internal Medicine Resident Research Day, April 28, 2011 – Case Report Poster Abstract
              Disseminated Herpes Zoster In An Immunocompetent Individual

                                          Melanie Chin and Ben Wilson

Learning objectives:

1. Risk factors for disseminated herpes zoster

Case information:

A 58 year old Caucasian woman with a past medical history of B12 Deficiency,
peripheral sensory neuropathy NYD, hypertension and hypercholesterolemia presented .
with an erythematous, vesicular and bullous rash over her right forhead and eyelid that
were exquisitely tender, spared the tip of her nose, and did not cross the midline. On her
torso, back, right arm and right upper thigh she had small erythematous, non-tender
papules, some of which were vesicular. Both her facial and body lesions were direct
fluorescence antibody positive for varicella zoster. On history and laboratory
investigations she was found to be immunocompetent with negative hepatitis, HIV 1 and
2 and syphilis tests, a haemoglobin A1c of 5.5%, no known malignancy or family history
of immune deficiency, however she had a significant history of drinking 1 litre of wine
per day for at least 10 years. She was treated with a 14day course of IV acyclovir and
upon discharge from hospital all of her lesions had cleared.

Implications/Discussion:

Disseminated herpes zoster (DHZ) is a rare infection in immunocompetent individuals
such that a significant defect in cell-mediated immunity is believed to be necessary. In
the few reported cases of DHZ in immunocompetent individuals, age-related decreases in
varicella zoster-specific T cell function have been proposed to account for the
dissemination. In the absence of known immunodeficieny, predisposing condition, or
advanced age, we propose that ethanol abuse, with subsequent impact cell-mediated
immunity, may have allowed for the reactivation and dissemination of HZ to occur in this
patient.

The implication of this case is that patients with Varicella Zoster and a significant history
of ethanol use could be considered immunocompromised and should be treated early,
aggressively, and monitored for dissemination and possible need for admission to
hospital for IV acyclovir.




Internal Medicine Resident Research Day, April 28, 2011 – Case Report Poster Abstract
  Intravenous Lipid Emulsion Therapy for Sustained Release Diltiazem Poisoning:

                                                    Jack Cruikshank


Introduction

Sustained Release (SR) diltiazem is a potential target for Invravenous Lipid Emulsion
(ILE) therapy. We report a case of SR diltiazem overdose and early ILE therapy with
successful resuscitation.

Case report

A 57 year old female was brought to the emergency department with hypotension
secondary to SR diltiazem overdose. She had a blood pressure 65/40 mmHg, heart rate
of 55/min, respiratory rate 22/min, and oxygen saturation 97% on 5L/min.
Comprehensive urine drug screen by gas chromatography-mass spectrometry was
positive for codeine, norcodeine, hydrocodone, morphine, diltiazem and dimenhydrinate.
Despite aggressive resuscitation with glucagon, dopamine, norephinephrine and
vasopressin hypotension ensued. ILE therapy was instituted and a significant
hemodynamic response occurred. Vasopressors were subsequently weaned off and the
patient went on to make a full recovery.

Discussion

Our case of ILE rescue therapy in SR diltiazem overdose is unique in that it is the first to
describe a significant hemodynamic response. It is possible that ILE improved MAP
through fatty-acid induced increases in myocardial calcium level and subsequent
increases in inotropy.

Conclusion

ILE therapy is a useful for treating SR diltiazem overdoses when vasopressor therapies
have failed.




Internal Medicine Resident Research Day, April 28, 2011 – Case Report Poster Abstract
       A Case Report of an Extremely Rare and Aggressive Tumor---Primary
                            Pericardial Mesothelioma

  Dr Xiaolan Feng MD PhD, Dr Guangming Han, MD, Dr Moosa Khalil MD, Dr Vanessa
                                        Krause MD

    1. To understand that primary pericardial mesothelioma is an extremely rare
Learning Objectives:

        tumor and carries a dismal prognosis.
    2. To truly appreciate our knowledge limitations in regard to etiology and
        treatment for primary pericardial mesothelioma

Herein, we report a 72-year-old previously healthy Caucasian man who presents
Case Presentation:

with pericardial effusion, constrictive pericarditis and malignant pleural effusion.
His only initial symptoms are subjective feeling of head fullness when lying flat and
intermittent chest pain. Fluid analysis from pericardiocentesis and initial
pleurocentesis is negative for malignancy.             He subsequently underwent a
pericardiectomy for relief of symptoms and searching for a diagnosis. At operation,
a chronically thickened pericardium and 4 walnut-size, firm nodules located around
his heart were found. A partial resection of pericardium and nodules were
performed. Subsquent biopsy and pathology revealed a primary biphasic
mesothelioma The patient’s condition ameliorated in the postoperative period. He
was transferred to medical oncology service and received one cycle of cisplatin and
pemetrexed. He developed acute kidney injury as a result of chemotherapy. His
creatinine was somewhat stabilized. However, he passed away suddenly without
much warning symptoms. The time of death was 1 month after diagnosis and 5
months after the first symptoms. At autopsy, the pericardium was transformed by
the tumor that also extended into the mediastinum and had set metastases to the
liver. The final report of autopsy is still pending at time of this case report is written.


The incidence of primary pericardial mesothelioma is less than 0.0022% from a
Literature Review/Discussion:


very large autopsy report. A Canadian epidemiology study reported its annual
incidence as 1 in 40 millions. A literature review revealed that the higher incidence
is observed among man than woman. Median age is 46 (range, 19 to 76). Although
there is a strong association between asbestos exposure and pleural mesothelioma,
this association is less evident in pericardial mesothelioma. Other suspected risk
factors are radiation exposure, SV40, TB, non-asbestos mineral fiber such as erionite.
Presenting symptoms are initially insidious and nonspecific such as chest pain,
cough and dysnea but eventually may result in constrictive pericarditis, tamponade
and congestive heart failure. The prognosis is poor with a median survival time is
approximately 6 months. Complete surgical resection of tumor is the main curative
treatment but impossible in most cases. Partial resection of the tumor can give
temporally symptom relief. Chemotherapy and radiation therapy appear to be of
little value in case of non-resectable tumor. However, there are scant case reports
thus far reported patients that had extended survival with aggressive surgical
resection, chemotherapy and radiotherapy.

Internal Medicine Resident Research Day, April 28, 2011 – Case Report Poster Abstract
           Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS)

                                                Leanne Gutierrez
                                        Supervisor: Dr. LeeAnn Hawkins

Background:

Adult hyperinsulinemic hypoglycemia is usually caused by an insulinoma or exogenous
insulin administration. Non-insulinoma pancreatogenous hypoglycemia syndrome
(NIPHS), or nesidioblastosis, is a rare cause of hyperinsulinemic hypoglycemia,
representing only 0.5 to 5% of adult cases. The diagnosis can be facilitated by using
selective arterial calcium stimulation, which helps demonstrate diffuse islet cell
hyperactivity.

Case:

We present a case of a 79 year old male with recurrent post-prandial hyperinsulinemic
hypoglycemia, presenting with neuroglycopenic symptoms, with an absence of
autonomic symptoms. In hospital fasting studies were negative, and imaging failed to
demonstrate a pancreatic mass or insulinoma. A selective arterial calcium stimulation
test revealed a 2 to 3 fold increase in insulin levels in the gastroduodenal and superior
mesenteric arteries, indicating diffuse pancreatic B-cell hyperplasia. Initial treatment
with the calcium channel blocker nifedipine, resulted in only a mild improvement in
glucose levels, with ongoing episodes of occasional hypoglycemia. When medical
therapy was switched to diazoxide, glucose levels remained within a more optimal range.

Discussion:

We have identified an adult patient with postprandial hyperinsulinemic hypoglycemia,
likely secondary to diffuse islet cell disease. Our case demonstrates the utility of
selective arterial calcium stimulation in making a diagnosis of NIPHS. In addition, it
supports the use of diazoxide over a calcium channel blocker, as first line medical
therapy, and supports delaying surgical therapy until after a trial of medical therapy is
given.




Internal Medicine Resident Research Day, April 28, 2011 – Case Report Poster Abstract
   Two Cases Of Large Bowel Perforation After Placement Of A Colonic Stent And Treatment
                        With Bevacizumab-Containing Chemotherapy

                      Amal Imbulgoda MD1, Michael Vickers MD FRCPC2
                 1. Department of Medicine, University of Calgary, Calgary, AB
   2. Department of Oncology, University of Calgary and Tom Baker Cancer Centre, Calgary, AB

Learning objective:

To review the current literature regarding large bowel perforation following the use of self-
expanding metallic stents (SEMS) or chemotherapy, particularly with bevacizumab is used. To
what extent is the risk of this complication increased when the two treatments are used in
combination?

Case Information:

Case 1- A 68-year-old man is diagnosed with metastatic colon cancer after presenting to the
emergency department with large bowel obstruction. He goes on to have two colonic stents
placed. Six weeks later, he begins palliative chemotherapy with FOLFIRI and bevacizumab.
Within two months, perforation occurred posterior to one of the stents, forming a pelvic
abscess. The patient is treated surgically with a diverting ileostomy.

Case 2- A 55-year-old woman presenting with right lower quadrant pain is found to have a
transverse colonic mass with metastases to the liver. Palliative stenting was done. This was
followed by treatment with one cycle of FOLFIRI plus bevacizumab one month later. A fatal
perforation occurred two weeks into chemotherapy.

Discussion:

SEMS have been increasingly used in malignant colorectal obstruction, particularly in advanced
stage cancers in which resection is often not a feasible means of palliation. It is not without
risks, the most feared of which is perforation. Debate exists in literature as to whether the risk
of this complication is increased when chemotherapy is administered to patients with stents.
Of particular concern is the concurrent use of the vascular endothelial growth factor inhibitor
bevacizumab, an agent which has been shown to increase the risk of perforation in the absence
of a stent.

It would then be expected that the combination of bevacizumab-containing chemotherapy and
the use of SEMS would be associated with even higher perforation rates, but little data exists in
the literature to quantify this. Further research is needed to better determine the level of risk
when these treatments are used together.




Internal Medicine Resident Research Day, April 28, 2011 – Case Report Poster Abstract
                                           A Case of Pulsless Disease
                                Dr Bernard Meshi and Dr Aurora Fiffi-Mah

Takayasu’s arteritis is a rare, large vessel granulomatous arteritis that mostly affects young
women and has a significant morbidity and mortality. Due to obstruction of the main branches
of the aorta, Takayasu's arteritis can present as pulseless upper extremities which may be why
it is also commonly referred to as the "pulseless disease." History and physical exam can be the
most important clues to the diagnosis.

We present a case of 23 year old Caucasian female, previously healthy, who presented to ER
with one month history of several pre-syncopal and syncopal episodes. Physical exam revealed
absent upper extremity pulses and laboratory findings showed only a mild microcytic anemia.
CTA of the chest and latter MRA showed diffuse circumferential thickening of the Aorta and a
proximal and a complete occlusion of the left subclavian artery as well as a high grade stenosis
of the left common carotid artery. Pt was started on high dose steroids, but unfortunately soon
after admission, she suffered a right MCA stroke with a complete occlusion of the right
common carotid artery for which she received rTPA and ASA. Her course has been further
complicated by seizures and continued pre-syncopal episodes.

In addition to several months of high dose steroid treatment, because of her disease continuing
to be active, her immunosuppressive therapy has included methotrexate and most recently
addition of Ramicade. Angioplasty has also been discussed as a possible option once the active
disease is being controlled.

Takyasu’s arteritis is characterized by adventitial thickening, focal leukocytic infiltration and
intimal hyperplasia leading to fixed stenosis of the aorta and or complete occlusion of its
branches. It has 74% morbidity with 67% 10-year survival in those with one or more serious
complications. The rarity of this condition predisposes to delayed diagnosis and treatment. In
addition, there are no specific markers to monitor the disease activity and response to
treatment. Despite the lack of clinical trials, the immunosuppressant therapy is the main stay of
treatment and novel biologic agents are currently being investigated with some promise.




Internal Medicine Resident Research Day, April 28, 2011 – Case Report Poster Abstract
                  Health Sciences Research Abstracts
 Resident Name                     Title
 Afra, Kevin                       Incidence, Risk Factors and Outcomes of Fusobacterium Bacteremia
                                   A Descriptive Trail of Combination Therapy for the Treatment of Pulmonary
 Brazil, Aiden                     Arterial Hypertension using Bosentan and Sildenafil
                                   Pulmonary Mycobacterium avium complex (MAC) infections in Southern
 Davis, John (Paul)                Alberta: Success of treatment
                                   Postnathal Exposure Through Lactation to High-Dose Ace-Inhibitors and/or
                                   Betablockers used to Treat Maternal Cardiac Disrders - Infant Growth,
 Erum, Uzma                        Hemodynamics and Renal Function Over the First year of Life
                                   Response to ATG in Acute Graft Versus Host Disease in Patients
 Jamani, Kareem                    Prophylaxed for Graft Versus Host Disease with ATG
                                   Long-term Complications Responsible for Hospital Re-admission Following
 Kachra, Rahim                     a Colectomy for Ulcerative Colitis: A Population-Based Analysis
                                   Cardiovascular Magnetic Resonance For the Detection of Myocardial
                                   Tissue Injury in Heart Transplant Patients without Histological Evidence of
 Khosla, Amit                      Graft Rejection
 Kumeliauskas, Linas               Cannabis use in Patients with Inflammatory Bowel Disease
 Leitch, Meghan                    Malnutrition in a Cirrhotic Patient Admitted at FMC
                                   Increasing HIV Subtype Diversity in Canadian Born Patients Living in
 Luft, LeeAnne                     Southern Alberta.
                                   Profile Of Circadian Variation Of Blood Pressure In Patients With TIA And
 Mateer, Abdul                     Stroke
                                   Incidence, Risk Factors, and Outcomes of Anerobic Bloodstream Infections
 Ngo, Jennifer                     in a Large Canadian Region
 Parimi, Sunil                     Treatment of Anemia in Hospitalized Hemodialysis Patients
                                   Convergent Epidemics: The Prevalence of Diabetes Mellitus in Incident
 Russell, Michael                  Cases of Tuberculosis in Calgary, AB.
                                   A Proposal to Investigate Vitamin D Levels In The Immigrant Population of
 Sandercock, Linda                 Calgary
                                   Identifying Limiting Factors to Treatment and Optimizing Chemotherapy in
 Skolnik, Kate                     Advanced Stage Non-Small Cell Lung Cancer
                                   Incidence of Post-operative Complications in Rheumatic Patients on Anti-
 Somayaji, Ranjani                 TNF-α Therapies Following Orthopaedic Procedures
                                   Risk-Treatment discordance in HFPEF patients undergoing cardiac
 Verma, Ashim                      catheterization




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
          Incidence, Risk Factors and Outcomes of Fusobacterium Bacteremia
                                      Kevin Afra, Supervisor: Dr. Dan Gregson

BACKGROUND

Fusobacterium are anaerobic gram-negative rods that are found in large numbers in the oral cavity. Two
species of Fusobacterium are of prime clinical importance: nucleatum and necrophorum. They have
been implicated not only in gingival and periodontal disease, but also in numerous extra-oral infections.
Fusobacterial infections are uncommon, which leads to challenges in defining its epidemiology and
clinical characteristics.

OBJECTIVE

This study aims to more clearly define the population-based incidence of Fusobacterium infections. We
seek to better elucidate the clinical manifestations, risk factors, and outcomes of Fusobacterium
infections.

METHODS

All persons who resided in the Calgary Health Region between 2000 and 2010 are included in our
retrospective, population-based surveillance cohort. Calgary Lab Services database will be used to
identify positive Fusobacterium spp. cultures. Using the Calgary Health Region database, the medical
chart, and a mortality database we will extract data regarding age, gender, bacterial culture information,
patient characteristics, infection characteristics, therapy decisions, and mortality. Statistical analysis will
be used to calculate the population-based incidence of Fusobacterial infections in the Calgary Health
Region. Our data will also allow us to describe the clinical manifestations, risk factors, and patient
outcomes of these infections.

RESULTS

During the 10 year study, 130 patients with Fusobacterium infections have been identified. At the
present time, speciation into necrophorum and nucleatum strains is being completed at Calgary Lab
Services. Once that is complete, we will be able to undertake our statistical analysis.

CONCLUSIONS

We hope to better describe the incidence, clinical manifestations, risk factors, and outcomes in
Fusobacterium infections.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
     A Descriptive Trial Of Combination Therapy For The Treatment Of Pulmonary Arterial
                          Hypertension Using Bosentan And Sildenafil

                                         A. Brazil, N. Hirani, D. Helmerson

Background:
Pulmonary arterial hypertension (PAH) is a rare clinical entity associated with increased
morbidity and mortality. To date, only three medication classes have been approved for use in
PAH: prostacyclins, endothelin-receptor antagonists and phosphodiesterase type 5 inhibitors.
Their approval was based on small, poorly controlled observational studies. Given the rarity of
the disease, approximately 30-50 cases per million, high powered, well controlled, double
blinded studies are extremely difficult. In addition, the cost of individual medications is often
prohibitive. For example, bosentan costs approximately $43,000 per year. This has led to a
further limitation in assessing the efficacy of early dual combination therapy. At present, the
standard of care is sequential addition of medications as the illness progresses.
Methods:
In association with Actelion, patients with a new diagnosis of pulmonary arterial hypertension
will be enrolled in a small descriptive clinical trial of early combination therapy with bosentan,
an endothelin receptor antagonist, and sildenafil, a phosphodiesterase type 5 inhibitor. Clinical
parameters that will be measured include: WHO functional class, six minute walk test, Borg
dyspnea scale, CAMPHOR questionaire, hemodynamic measurements obtained at baseline and
four month follow up intervals, as well as echocardiography data.
Results:
To date, eight patients have been enrolled. Two have a diagnosis of idiopathic pulmonary
arterial hypertension and six have systemic sclerosis as the underlying etiology. Two patients
were removed from the study (due to worsening symptoms requiring an escalation in therapy)
before repeat hemodynamic data was obtained. A third patient is newly enrolled and has not
yet had a second right heart catheterization to obtain follow up hemodynamic data.
The preliminary results show decreases in pulmonary vascular resistance (948 units to 550.4),
mean pulmonary artery pressure (51.0 mmHg to 44.4), symptoms (CAMPHOR score of 13.4 to
7.1), and ability to take partake in everyday activities (CAMPHOR score 10.5 to 8.7). Also,
improvements have been noted in distance on 6 minute walk test (299.6 m to 337.4) and
cardiac output (3.6 L/min to 5.5 L/min). No difference is yet apparent for measurements of
WHO functional class (all remain class III), Borg dyspnea scale after 6 minute walk test (4.0 to
4.6), quality of life (CAMPHOR score 7.9 to 7.1), and right atrial pressure (10.6 mmHg to 12.2).
Conclusions:
Patients are continuing to be enrolled in this study. Given the limited data so far, conclusions
will be difficult to make until enrollment has ceased. However, preliminary results are
encouraging for benefits in combining oral therapy for pulmonary arterial hypertension early in
the clinical course.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
    Pulmonary Mycobacterium avium complex (MAC) infections in Southern Alberta:
                              Success of treatment.
                            JP Davis, R Cowie, D Fisher, S Field and J Jarand

Background:
The incidence of pulmonary Mycobacterium avium complex (MAC) infections is increasing.
Pulmonary MAC infections cause significant morbidity to patients and require prolonged
antibiotic courses for treatment often with inadequate success.

Objective:
To assess the treatment success rate of pulmonary MAC infections in Southern Alberta and to
identify factors which may contribute to treatment success, failure or recurrence of infection.

Methods:
A retrospective chart review of all pulmonary MAC infections in Southern Alberta between
1990 and 2010 was performed. Successful treatment was defined as conversion to culture
negative sputum. Recurrence was defined as the return of culture positive sputum following
the completion of antibiotic therapy. Treatment failure was defined as an inability to convert to
culture negative sputum despite appropriate antibiotic therapy.

Results:
From 1990-2010, in Southern Alberta there were 122 patients who fulfilled ATS criteria for
pulmonary MAC infection and met inclusion criteria for this study. The rate of pulmonary MAC
infections diagnosis increased markedly over the duration of the study. In the first ten years
only 20 cases were identified, while 111 cases were diagnosed between 2000-2010. Females
made up the majority of patients (76.3%) and they also had higher frequencies of
bronchiectasis (75.0% vs 51.6%) and AFB smear positivity (54.0% vs 38.7%), when compared to
male patients. Of the 110 patients that had initial culture negativity following treatment 76%
have not had a recurrence of infection. 19 (17.3%) of patients have had one recurrence, while 7
(6.4%) have had two. The main factor contributing to recurrence of MAC infection is inadequate
duration of antibiotic therapy (12 months of therapy after sputum is culture negative). Ten
percent of patients failed to convert to AFB culture negativity despite prolonged antibiotic
therapy. Factors contributing to treatment failure include: immunocompromisation, bilateral
disease, cavitary lung disease and smear positivity.

Conclusions:
The incidence of pulmonary MAC infections in Southern Alberta appears to be rising. Increased
awareness as well as improved accessibility to CT scans may be contributing to this
phenomenon. The rate of treatment success in this study is comparable to what has been
reported in the literature in other jurisdictions. Adequate antibiotic treatment duration is a key
factor in preventing recurrence. Approximately ten percent of patients had treatment failure
and immune suppression as well as the burden of underlying lung disease are important factors
in this regard.


Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
Postnatal Exposure through Lactation to High-Dose Ace-Inhibitors and/Or Betablockers Used
 To Treat Maternal Cardiac Disorders – Infant Growth, Hemodynamics and Renal Function
                                over the First Year of Life
                                      Dr. Uzma Erum
Background
Maternal cardiac disorders are on rise due to advanced maternal age at first pregnancy, obesity, diabetes and
advanced medical care of congenital heart disease which allows more women to reach child bearing age.
These conditions require long-term use of cardiac medications in therapeutic doses. The data regarding the
safety of these medications in lactation is lacking.
Many women decided to forego lactation due to lack of safety data. Many women however choose to
breastfeed regardless. These women are the target population of our study.
 Objectives
Primary Objective
The primary objective of this study is to closely monitor infants of mothers with cardiac disorders requiring high-
dose ACE-Inhibitor and/or beta-adrenergic blocking agents, who choose to breastfeed regardless of possible
drug transmission risk.
Secondary Objective
1. To analyze maternal milk and plasma for drug and drug-metabolite quantification.
Methods
Hypothesis
Therapeutic dose ACE-Inhibitor and/or betablocker use during lactation does not result in negative clinical
outcomes on breastfed infants and suggests that lactation in this population of medically complicated
postpartum women is acceptable.
Inclusion Criteria
Women who choose to breastfeed requiring one or more of: Enalapril (>20 mg/day), Captopril (>75 mg/day),
Carvedilol (any dose) or Metoprolol (>100 mg/day) and they understand the lack of evidence to support
breastfeeding on high-dose single or combination therapy will be enrolled.
Exclusion Criteria
     1. Women who do not intend to breastfeed
     2. Pre-term infants (<37 weeks gestational age).
     3. Term infants with medical issues that may impair drug clearance (renal or hepatic dysfunction, cardiac
         dysfunction )
     4. Term infants with other medical complications thought to increase risk associated with drug exposure.
     5. Term infants with severe hyperbilirubinemia (serum bilirubin >425 µmol/L).
     6. Term infants with severe intrauterine growth restriction (<5 percentile).
Study Design and Variable Measurement
Enrolled women and their infants will be followed closely over a 12 month period. Periodic sampling of breast
milk and serum will be done for drug levels. A community lactation consultant will assess enrolled women.
Laboratory investigations of infants including serum creatinine and electrolytes, complete blood count and
urinalysis will be checked at regular intervals. Infants who show any signs of clinical/laboratory deterioration
will be assessed in hospital.
Estimated sample size is around 20-24 patients over 2 year period. All data will be analyzed using STATA
statistical software (Stata Press, College Station, Texas).
Study Limitations
The primary limitation is the low sample size. Other confounders would be infant race, sex, maternal ante-
partum medications, maternal weight, race, smoking status, other medical problems, heterogeneity in regards
to quantity and dose of medications, and duration of lactation.
 Summary
The safety data of new ACEI and beta blockers on lactation is lacking and with rise of maternal cardiac
diseases, this study will be landmark if we will be able to prove the safety of these medications in lactation.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
  Response to ATG in Acute Graft Versus Host Disease in Patients Prophylaxed for Graft
                            Versus Host Disease with ATG
                        Kareem Jamani, Supervisor: Jan Storek

Background
Allogeneic hematopoietic stem cell transplant (HSCT) is increasingly being used to cure many
malignant and non-malignant hematologic diseases. Advances in pre-transplant conditioning
regimens, HLA typing and supportive care post-transplant have allowed a broader range of
patients to be eligible for HSCT1. However, graft versus host disease (GVHD) is likely the
major cause of morbidity and mortality post-transplant1. GVHD, an immunologic disease that
can occur acutely in up to 50% of patients as well as chronically after HSCT, arises when donor
T-cells react to incompatible antigens on host cells2. This ultimately leads to host tissue damage-
in the acute setting target organs are the skin, liver, and gastrointestinal tract. When first line
therapy for grade 2 or higher acute GVHD- high dose corticosteroids- fail, antithymocyte
globulin (ATG) has commonly been used as a second line agent3.

Objective
ATG is commonly used for the treatment of steroid refractory acute GVHD following HSCT as
well as for GVHD prophylaxis during pre-transplant conditioning. Based on clinical experience,
we suspect that the efficacy of ATG used as treatment in patients who have already received
ATG as prophylaxis is limited. The objective of this study is to determine the likelihood of
response to ATG in patients both prophylaxed and treated with ATG for GVHD as well as
survival of these patients.

Methods
In this retrospective study, patients will be identified from an approximately 800 patient database
that includes all HSCT patients in Calgary from 1999 onwards. Patients who received ATG
prophylaxis pre-transplant and developed steroid refractory grade 3 or 4 acute (including classic,
late onset, and overlap syndrome) GVHD and were treated with ATG will be included in the
study. The primary endpoints of this study are response to ATG (determined by comparing the
maximum GVHD grade within 1 week prior to receiving ATG to maximum GVHD grade at 3-5
weeks and at 1-3 months post ATG) and mortality. As the mortality is expected to be high, we
will also attempt to determine the main cause of mortality for each patient (GVHD, infection,
relapse or other).

Results and Conclusion - To be completed once all data is collected.

References
1- Mohty, M. & Apperley, J.F. Long-term physiologic side effects after allogeneic bone marrow
transplantation. Am Soc Hematol Educ Program, 2010;2010: 229-236.
2- Goker, H., Haznedaroglu, I.C. & Chao, N.J. Acute graft versus host disease: pathobiology and
management. Experimental Hematology, 2001;29: 259-277.
3- Paczesny, S., Choi, S.W. & Ferrara, J.L.M. Acute graft versus host disease: new treatment
strategies. Current Opinion in Hematology, 2009;16: 427-436.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
 Long-Term Complications Responsible For Hospital Readmission Following A Colectomy For
                     Ulcerative Colitis: A Population-Based Analysis
                                                      Rahim Kachra

Background
Patients with ulcerative colitis (UC) refractory to medical therapy are managed by surgical intervention.
Although a colectomy is curative, up to 58% of patients will experience short- or long-term
postoperative complications. To date, studies exploring these complications have relied on
administrative databases or have not been population-based. We gathered data directly through patient
chart review to analyze post-colectomy complications responsible for readmission to hospital in patients
with UC.

Objectives
We propose to identify all patients with UC who have underwent colectomy, and who were readmitted
to hospital for a complication of this procedure in adult Calgary Health Zone Hospitals between 1996
and 2010 in order to meet the following objectives:
1.      To define the incidence rate of readmissions to hospital post-colectomy for UC in the Calgary
Health Zone.
2.      To evaluate for disease, medication, patient specific, and health care related factors that predict
readmission for a postoperative complication.
3.      To determine temporal trends for incidence and health resource utilization for UC patients who
are readmitted to hospital post-colectomy.

Methods
Population-based surveillance was conducted in the Calgary Health Zone between January 1, 2002 and
December 31, 2007 using administrative databases to identify UC patients (≥ 18 years) who underwent a
colectomy (n=209). We reviewed these charts to confirm the diagnoses and extract the following clinical
data: age; smoking status; comorbidities; emergency versus elective operation; disease extent;
operation for cancer or dysplasia; and preoperative medication use including intravenous (IV)
corticosteroid administration. Patients were subdivided into two groups: 1) patients not readmitted or
those admitted for a second stage procedure; and 2) patients readmitted for a complication within two
years of their surgery. Fisher exact and Wilcoxon Rank Sum test were performed to evaluate whether
clinical factors during the admission for colectomy were associated with readmission to hospital for a
complication.

Results
From the total cohort of patients, 13.4% were readmitted to hospital within two years of colectomy for
complications related to the procedure. The median time for readmission was 17 days, with an
interquartile range of 7.0 – 180.5 days. Complications most commonly responsible for readmission were
small bowel obstruction (35.7%), acute renal failure (17.9%), abscess (10.7%), adrenal insufficiency
(10.7%), and venous thromboembolism (7.1%). The only variable found to be statistically associated
with readmission to hospital with a complication was preoperative IV corticosteroid duration. Median
duration in days was 13 in the cohort admitted for complications vs. 8 in the control group (p=0.006).

Conclusion
Postoperative complications are common in patients receiving a colectomy for UC. Duration of
preoperative IV corticosteroid use was identified as a risk factor for readmission, and may lead to
complications such as infection or adrenal insufficiency.


Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
  Cardiovascular Magnetic Resonance For the Detection of Myocardial Tissue Injury in Heart
            Transplant Patients without Histological Evidence of Graft Rejection

Amit Khosla MD, Myra Cocker Msc, Andreas Kumar MD MSc, Debra Isaac MD, Matthias G. Friedrich MD
                                            FESC

   Stephenson Cardiovascular MR Center at the Libin Cardiovascular Institute of Alberta, University of
                                     Calgary, Alberta, Canada

Background
The early detection of heart transplant rejection is routinely performed using endomyocardial biopsy
(EMB) following standards of the International Society of Heart and Lung Transplantation (ISHLT). In
patients with biopsy proven allograft rejection, various Cardiovascular Magnetic Resonance (CMR)
sequences have been shown to confirm histological rejection. It has been suggested that CMR may be a
more sensitive tool to help predict clinical and histological rejection, reducing the need for repeated
EMB. We hypothesize that the CMR Lake Louise criteria, used in the setting of myocarditis, can detect
myocardial inflammation in a heart transplant population negative for graft rejection as per ISHLT biopsy
criteria.

Methods
We extended our previously reported study in asymptomatic heart transplant patients to include those
with both ISHLT grade 0 and grade 1 scores on EMB. A total of 19 patient data sets were retrospectively
extracted from a database of heart transplant patients. 20 healthy, volunteers were used as controls.
The CMR Lake Louise criteria included sequences for edema (T2), early contrast enhancement (T1) for
hyperemia, and for necrosis / fibrosis (late gadolinium enhancement), obtained on a 1.5 T clinical MRI
system (Siemens Avanto, Siemens, Germany). The CMR study was rated positive when 2/3 or 3/3 of the
semi-quantitative imaging criteria were positive.

Results
Data collection for the extended study group and the control group has been completed. Blinded
reading of the additional CMR studies has been repeated to ensure accuracy of the reported volumetric
parameters and tissue charterization. Comparative analysis of patients in the study group and control
group will be performed as well as comparison between those with and without inflammation on CMR.

Discussion
In this analysis of clinically asymptomatic heart transplant patients with no histological rejection, we are
looking to determine the usefulness of CMR in the detection of inflammation that may precede allograft
rejection. A control group was added to the pilot study to ensure markers of inflammation detected by
CMR are not present in healthy patients. If the Lake Louise criteria remain positive in a significant
number of transplant patients, this will lend support to our previous finding of presumed inflammation
in this setting. The extended study group may help magnify the quantitative differences in functional
parameters such as cardiac output noted in the pilot study between transplant patients with
inflammation and those without. With this information, further studies on the role of CMR in allograft
rejection may be facilitated.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
                 Cannabis use in patients with Inflammatory Bowel Disease
                        Linas Kumeliauskas, Christopher N. Andrews, Martin Storr

Background:
Crohn’s disease (CD) and ulcerative colitis (UC) are the two major subcategories of
inflammatory bowel disease (IBD), characterized by chronic gastrointestinal inflammation of
unknown origin.
A variety of complementary and alternative medications are used by patients to treat
symptoms of IBD, including cannabis products.
The extent to which IBD patients use cannabis, the symptomatic benefits and side effects,
where patients learn about these effects and disease outcomes with cannabis use are presently
unknown in the IBD population.
We therefore aimed to study these variables among IBD patients around the world.
Objectives:
Little is known on IBD patient motivation, benefit, or risks of cannabis use.
Our aim was to assess the extent and motives for cannabis use in IBD patients, as well as the
beneficial and adverse effects associated with cannabis self-administration.
From this data, we can determine the pattern of cannabis use in IBD patients in various regions
of the world and their role of treating and alleviating symptoms associated with the IBD.
Methods:
An informed consent was sought from all participants. The anonymous questionnaire was sent
to the participants to various regions in the world via E-mail.
Consecutive patients with IBD (n=311) completed a structured anonymous questionnaire
covering motives, pattern of use and subjective beneficial and adverse effects associated with
cannabis self-administration.
The 192 participants were selected based on completeness of the questionnaires.
The data were analyzed and the percentile values were calculated.
Results:
Cannabis had been used by 88.55% of respondents specifically to relieve symptoms associated
with their IBD, the vast majority by inhalational route (99.41%). IBD patients reported that
cannabis improved abdominal pain (92.94%), abdominal cramping (88.23%), joint pain (65.88%)
and diarrhea (46.47%), although side effects were frequent, including increased appetite (80.58
%), being “high” (71.76%), and having dry mouth (47.05%). Respondents by using cannabis for
their IBD sought to have greater control of their life (23.44 %), worried about side effects of
conventional treatment (20.68%), and thought differently about the causes and treatments of
the IBD than their doctors (17.36%).
Conclusions:
Cannabis use is common in IBD patients and subjectively improved the pain and diarrheal
symptoms. Patients using cannabis should be cautioned about potential harm, until clinical
trials to evaluate safety and efficacy would be available.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
                                           Malnutrition in a Cirrhotic Patient Admitted at FMC
                                            Meghan Leitch Supervisor: Dr. M. Kothandaraman

The role of nutrition in liver cirrhosis has been of interest to clinicians since nutritional status was included in the original Child-
Turcotte classification to assess prognosis in end stage liver disease. It has been well established that there is a correlation between
protein malnutrition and increased morbidity and mortality in cirrhotic patients. Malnutrition can occur in any a patient with any
Child-Pugh (CP) class of severity, however, the degree of malnutrition tends to correlate with increasing severity of underlying
disease. Protein malnutrition is highly prevalent in cirrhotic patients with malnutrition being identified in up to 25% of patients with
CP class A disease and up to 80% in CP class C [3]. Malnutrition has been associated with increased in-hospital risk of development
of ascites, hepatorenal syndrome and increased rates of infection, especially spontaneous bacterial peritonitis. Merli et al. (2010)
demonstrated protein malnutrition in cirrhotic patients increased the risk of bacterial infection by 1.5 to 10 times and the risk of in-
hospital mortality by 2.8-38.5 times compared to well-nourished cirrhotic patients. Malnutrition is associated with poor quality of
life, as determined by questionnaires. Protein malnutrition is also associated with increased hospital length of stay with Sam &
Nguyen (2009) showing that malnutrition increased the length of stay by 47% in cirrhotic patients. Protein restriction is also not
recommended as a general strategy to decrease hepatic encephalopathy. Short term (2-3 days) of decreased protein may help with
resolution of encephalopathy, but this should be used sparingly and for short periods of time only. Some patients may be protein
sensitive and unable to maintain their protein requirements without becoming encephalopathic, and for those patients, BCAA are
recommended by the ESPEN guidelines since it is important to avoid protein malnutrition (2006). Replenishing protein deficit can
prolong life expectancy, improve quality of life and decrease complications.
Malnutrition in cirrhotic patients is somewhat controversial to diagnose as the disease causes derangements that can render usual
tests unreliable. Edema and ascites can influence the findings of anthropometry and bioelectric impedance, while serum proteins
rely on normal liver function for production. Viral infection and concurrent alcohol use can alter immune function. The subjective
global assessment (SGA) is frequently recommended to use in the assessment of nutritional status in cirrhotic patients. The ESPEN
guidelines (2006), recommend the use of SGA or anthropometry as level C evidence and phase angle ∝ or body cell mass as
determined by bioelectric impedance analysis, despite recognized limitations, as level B evidence. The SGA and BIA, plus a
combination of other tests, are generally recommended to assess nutritional status. ESPEN guidelines also address
recommendations regarding nutritional requirements and management of malnutrition in in-patients.
As evidenced above, there is as yet no gold standard to diagnose malnutrition in patients with cirrhosis. There are also no
recommendations made regarding screening of newly admitted cirrhotic patients for malnutrition. There are also no specific
recommendations as to what micronutrients should be tested when malnutrition is diagnosed.
Our objectives are to gather data from cirrhotic patients on admission to MTU teams to obtain an estimate of the prevalence of
malnutrition in patients at our institution. We will also be obtaining laboratory values for certain micronutrients to look for
associations between cirrhosis and specific micronutrient deficiencies. We will also be following the course in hospital to track rates
of infection, other complications of liver disease and length of hospital stay. We will also be recording whether the MTU team makes
any recommendations regarding nutrition and if so, what is the nature of these recommendations. We will also follow to see if a
dietician is consulted and what recommendations the dietician makes.
We will be consecutively enrolling 50 patients admitted to the MTU at the FMC with a diagnosis of cirrhosis. Patients can be
admitted with an acute decompensation of chronic liver disease, cirrhosis and another medical issue causing admission or for pre-
transplantation workup. At the present time, exclusion criteria have not been settled upon, but will likely include co-infection with
HIV or concurrent treatment with steroids or other immunosuppressive therapy. Informed consent will be obtained; a chart review
for demographics, a history and physical exam will be performed, including SGA and BIA. Laboratory investigations will be done and
these will likely include serum levels of vitamin B12, RBC folate, albumin, vitamin D and retinol. A dietician with the research team
will assess caloric and macronutrient intake from a 3-day in- hospital food record. The patients will be followed until discharge and
incidence of infection, hepatic encephalopathy, development of ascites, gastrointestinal bleeding and hepatorenal syndrome will be
recorded. Number of days kept NPO and total length of stay will be noted. As well, nutritional assessment and interventions made
by the admitting team will be recorded, including initiation of oral supplementation or enteral nutrition and any consults to the
registered dietician and outcomes of the consult.
We will be interested to see what prevalence of malnutrition we find in our cohort of patients and whether this agrees with
prevalence rates generally found in other studies. We will be looking to see if malnutrition also shows an association with increased
morbidity and mortality in our patients. We will be looking for an association between malnutrition and specific micronutrient
deficiencies. We are also interested to see if the MTU teams manage malnutrition in cirrhotic inpatients as recommended by the
ESPEN guidelines, or whether there is room for improvement to practice more evidence-based management of malnutrition. If there
is a discrepancy between recognized guidelines and local practice, it could provide an area for intervention, for example, creation of
an admission order set for cirrhotic patients to optimize screening for and treatment of malnutrition in cirrhotic patients.



Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
     Increasing HIV Subtype Diversity In Canadian Born Patients Living In Southern Alberta
                                  LeeAnne M. Luft, Brenda Beckthold, M. John Gill

Background

The early spread of HIV within Canada, the United States, and Western Europe, was due to HIV-1, Group
M, subtype B infection, and it occurred mainly within the men who have sex with men, and then
intravenous drug use (IDU) communities. Recent reports worldwide, including Canada, have all
highlighted the increasing global genetic diversity of HIV-1 subtypes. However, transmission of these
non B subtypes, outside the traditional risk groups defined by country of origin for that subtype, have
seldom been reported.

Objective

To discover if Canadian-born HIV patients are still exclusively infected with subtype B and immigrant and
refugee populations, especially from Africa, are still exclusively infected with non-B subtypes.

Methods

We reviewed all individuals receiving care at the regional HIV program for southern Alberta (SAC) for HIV
subtype, country of birth, and risk activities (including travel) for HIV infection.

Results

We identified 24 Canadian-born patients with a non-B HIV-1 infection. This represents 3% (24/714) of
Canadian born HIV patients with a known subtype. While 2 patients reported unprotected sexual activity
outside North America, 22 patients reported no travel outside Canada. Four of these 24 patients (16 %)
reported a history of IDU, three (12%) had been incarcerated, and six (25%) identified a sexual contact
with immediate links to an endemic area. We also identified 10 of 208 (5%) African-born patients with a
known subtype, as having subtype B infection. We have found that Canadian-born patients are
increasingly infected with a non-B virus without travel exposure and such infections are most frequently
seen in heterosexual women.

Conclusions

Our data suggests that traditional assumptions are no longer sufficient to predict the occurrence of non-
B HIV-1 infection in developed countries. Migration, travel as well as in-country transmission will
continue to feed local viral diversity. Attention to measuring subtype will become increasingly important
as the clinical and epidemiologic differences between subtypes continue to be explored.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
         Profile Of Circadian Variation Of Blood Pressure In Patients With TIA And Stroke

    Abdul Mateer, Bilal Hameed, Ashfaq Shuaib, Khurshid Khan. University of Alberta, Edmonton, AB,
                                               Canada

BACKGROUND:

Circadian variation of blood pressure has been associated with increased risk of cardiac and other
vascular events. Hypertension is one of the main risk factor for stroke. We sought to explore blood
pressure variability in apparently well treated hypertensive with a diagnosis of transient ischemic attack
(TIA) or stroke.

METHOD:

In an ongoing prospective, observational 24 hours (hrs) ambulatory blood pressure monitoring trial
(ABPM), patients were recruited from stroke clinic. Inclusion criteria included age above 18 years,
written consent, diagnosis of TIA or stroke and clinic manual BP reading < 140/90. Normal (ABPM) was
taken as 120/80. ABPM was recorded at one hour intervals.

RESULTS:

Thirty seven patients (mean age 66.4 ± SD 12.7 years; 51.3% women) with clinical, CT or MRI proven
diagnosis of Stroke or TIA (stroke 17/37(45.9%), TIA 19/37 (51.3%) and 1/37 (2.7%) with intracererbral
hemorrhage were analyzed. Among these with established diagnosis of hypertension (eHTN) alone were
16/37 (43.2%), Diabetes (DM) plus HTN 9/37 (24.3%), non-DM plus non-HTN 11/37 (29.7%), and 1(2.7%)
had just diabetes. Average 24hrs Systolic/Diastolic ABPM was 124.7 ± SD 13.1 / 70.1 ± SD 9.01 mmHg.
Twenty four hrs Systolic/Diastolic blood pressures above normal were 55.2% / 21.2% mmHg. Systolic
Non-dipping (SND) was seen in 24/37 (64.8%), among these (eHTN11/24, DM plus HTN 5/24 and non-
DM plus non-HTN 7/24). Diastolic Non-dipping (DND) was seen in 17/37 (45.9%) among these (eHTN
9/17, DM plus HTN 3/17and non DM plus non HTN 5/17). Morning surges (MS) of BP were seen in 32/37
(86.4%), (e HTN 14/32, DM plus HTN 9/32 and non-DM plus non HTN 8/32). Morning Rise in BP was seen
in 29/37 (78.3%) of patients (e HTN12/29, DM plus HTN 9/29 and non-DM plus non HTN 8/29). Reversed
Dipping (RD) was observed in 7/37, (e HTN6/7, DM plus HTN 1/7). Average Pulse Pressure (PP) in 37
patients was 54.46 ± SD 11.1mmHg, (eHTN 59.6, DM plus HTN 55.8 and non-DM plus non-HTN
47.8).Mean Arterial Blood pressure (MAP) was 90 ± SD 9.5mmHg, (e HTN 92.3, DM plus HTN 93.4 and
non DM plus non HTN 85.2).

CONCLUSION:

Our data shows high risk ABPM profile after the diagnosis of TIA or stroke in patients with established
and treated hypertension. The clinical significance of these variables on the incidence of future TIA or
stroke remains to be established.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
Incidence, Risk Factors, and Outcomes of Anerobic Bloodstream Infections
                         in a Large Canadian Region
              Jennifer Ngo, Research Supervisors: Dr. M. Parkins, Dr. K. Laupland


Background:

Detailed population-based data on the epidemiology of Gram-negative anaerobic
bloodstream infections are sparse. We sought to describe the incidence of, risk factors
for, and outcomes associated with anaerobic bacteremia.

Methods:

Population-based surveillance for anaerobic bacteremia was conducted in the Calgary
Health Region (CHR, population: approx. 1.2 million) during the period from 2000 to
2008.

Results:

A total of 904 incident cases of anaerobic bacteremia were identified in CHR residents
for an overall population incidence of 8.7 per 100,000; 231 (26%) were nosocomial, 300
(33%) were healthcare-associated community onset, and 373 (41%) were community
acquired. Relative to the general population, risk factors for anaerobic bloodstream
infection included male sex, increasing age, diagnosis of cancer, chronic liver disease,
hemodialysis, heart disease, diabetes mellitus, stroke, inflammatory bowel disease, HIV
infection, and/or chronic obstructive pulmonary disease. Overall mortality was 20%.
Increasing age, nosocomial acquisition, presence of malignancy, surgical disease, and
several other comorbid illnesses were independently associated with an increased risk
of death.

Conclusion:

This is the first population-based study to document the major burden of illness
associated with anaerobic bacteremia and identifies groups at risk of infection and
subsequent mortality.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
                     Treatment of Anemia In Hospitalized Hemodialysis Patients
                            Drs. Ben Wong, Sunil Parimi, Robert Quinn


Trials such as CHOIR and CREATE have demonstrated that chronic kidney disease patients realize
no improved quality of life nor reduced cardiovascular events when physicians normalize their
sub-therapeutic hemoglobin values. However, no study has attempted to prove this in the
acutely ill. Our study focuses on finding potentially significant benefits through dose
adjustments of erythropoeitin-stimulating agents (ESAs) in hospitalized CKD patients.

Our primary endpoint is decreased need for blood transfusions three months following patients’
hospital admission. Secondary outcomes sought include impact on length of stay in hospital,
hemoglobin level at three to six months, time to reach target hemoglobin level, overshooting
target hemoglobin levels at three to six months, overall cardiovascular outcomes, and death.

We will perform a retrospective chart review with the following inclusion criteria: patients >18
years old; receiving hemodialysis for at least a 90 day period (with no dialysis-free periods
greater than 14 days) between our data accrual dates of June 1, 2004 and March 31, 2008; and
hemoglobin value between 70 to 100 g/dL with transferrin saturation > 0.2 at time of admission.
Exclusion criteria include admissions for major bleeding episodes and elective surgeries, direct
admissions to the CCU and ICU, and patients who have had a hospital admission in the previous
six months.

We will use the PARIS and CIHI discharge database to obtain baseline information and labwork
on each patient, and trend them over the course of our study dates. We will also determine the
baseline doses of ESAs and iron prescribed to each patient in the six weeks prior to our study
dates. Finally, we will calculate our variables of interest and see how they impact our primary
and secondary outcomes. These variables include the following: adjusted prescribed dose of
ESA, % change of ESA-prescribed dose, adjusted administered dose of ESA, and % change in ESA-
administered dose.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
    Convergent Epidemics: The Prevalence of Diabetes Mellitus in Incident Cases of
                           Tuberculosis in Calgary, AB.

                                     Russell, M2., Jarand, J1,2., and D. Fisher1,2.

                 1Division   of Respirology, Department of Medicine, University of Calgary
                           2Department   of Internal Medicine, University of Calgary



Tuberculosis (TB), a multi-system disease resulting from infection with Mycobacterium tuberculosis,
has recently re-emerged as a significant cause of morbidity and mortality worldwide. As well, the
global incidence of diabetes mellitus is increasing with some of the most dramatic growth in areas
with highly prevalent TB. Although diabetes is recognized as a risk factor for the development of
TB, the magnitude and significance of this association is not well characterized. Furthermore,
anecdotal observations suggest that diabetics may be more likely to fail anti-tuberculosis therapy,
although there is a paucity of literature in this area. We are seeking to examine the prevalence of
diabetes in incident cases of tuberculosis in Calgary, AB from 2007-2010 by employing a
retrospective chart review. Subsequent analysis will examine the significance of any differences in
observed prevalence of diabetes in incident TB cases versus a control population. Further analyses
will explore the relationship between TB treatment failure and diabetes as well as gender, age,
ethnicity, estimated renal function and blood glucose control, as possible variables affecting the co-
existence of diabetes and TB and/or failure to respond to TB therapy. The goal of this study is to
provide proof of principle regarding an association between diabetes and TB and to determine if
the presence of coexistent disease predisposes to failure of TB treatment. Should a correlation be
found, the results will be used to design a prospective trial examining the utility of employing
diabetes screening for incident cases of TB to help predict risk of treatment failure and potentially
guide treatment selection.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
   A Proposal to Investigate Vitamin D Levels In The Immigrant Population of Calgary

                                   Dr. Linda Sandercock and Dr. Otto Rorstad

Background

Vitamin D is important for skeletal health and vitamin D deficiency may also have an effect on
cardiovascular health, diabetes, cancer and immune function. Risk factors for vitamin D
deficiency include the latitude at which someone lives, their skin pigmentation, and diet. At
latitudes above 35°N little vitamin D can be synthesized in the winter months. Calgary is at 51
°N and therefore its population is at increased risk of vitamin D deficiency. Calgary is also a
multicultural centre. According to the latest census in 2001, the immigrant population was 21%.
They come to Calgary from all over the world- the majority from Asia. Between 1996 and 2000
10% of immigrants who came to Calgary were categorized as refugees. The Calgary Catholic
Immigration Society 2009-2010 annual report showed the majority of their clients, 38% of
whom are refugees, came from Asia and Africa. Depending on their skin pigmentation, they
can be at increased risk for vitamin D deficiency. Finally, recent immigrants are also twice as
likely to have incomes that fall below the median family income. This, in addition to cultural
preferences, can impact diet and supplement choices. Thus, the immigrant and refugee
population of Calgary has multiple risk factors for vitamin D deficiency warranting a study into
the levels of vitamin D in this population.

Objective

To gather data regarding the vitamin D levels in the immigrant population of Calgary. Data
obtained from such a study could be used to design a program of intervention if required.
The background literature search and research study proposal to date will be presented.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
 Identifying Limiting Factors to Treatment and Optimizing Chemotherapy in Advanced Stage
                                  Non-Small Cell Lung Cancer
                                         Kate Skolnik

Background
Despite treatment innovations, Non small cell lung cancer (NSCLC) continues to be a major contributor
to mortality. Many patients present with advanced, inoperable disease and the focus becomes palliative
treatment. Platinum based chemotherapy is the mainstay of treatment for Stage IIIb and Stage IV
disease, supported by a systematic review by the NSCLC Collaborative Group which showed a
statistically significant mortality benefit and increase in progression-free survival compared to
supportive care. Mortality benefit was seen despite patient age and variations in tumor histology. In
contrast, radiation and targeted biologic agents did not show the same widespread benefit in NSCLC
patients with advanced disease
Proposed question
A research group based out of Calgary (Bebb et al) compiled the Glans-Look Lung Cancer Database, a
collection of patients diagnosed with NSCLC in the Calgary Health Region between 2003 and 2006.of the
1502 patients newly diagnosed, 832 had advanced disease. While the majority of patients (78%)
received palliative radiation, only 23 % received palliative systemic therapy despite the apparent survival
advantage. Furthermore, 18% of patients received no treatment. We set out to find the reasons why
only a small percentage of individuals received palliative chemotherapy and why a notable proportion of
patients did not receive any palliative therapy at all.
Methods
We propose to answer these questions with a retrospective study using the Glans- Look Lung Cancer
Database. The population will include 832 patients diagnosed with advanced stage (Stage IIIb or Stage
IV) NSCLC at the time of first presentation. In addition to basic demographic data, clinical variables and
treatment modalities will be determined and supplemented with a chart review using the ARIA system.
We will also determine the time intervals between diagnosis, referral, and treatment, whether
chemotherapy was discussed with the patient, and if side effects were addressed.
Outcome Measures/Results
The primary outcome measures will be to determine if there are any prevalent features that differ
between the systemically treated and untreated groups (age, performance status, sex, cardiovascular or
pulmonary disease, language, ethnicity, capacity, marital status, and geography).
The secondary outcome measure will be to determine the percentage of untreated patients fit into the
following categories: those who refused themselves, whose family refused on their behalf, whose
physician did not recommend it secondary to poor performance status, whose physician did not
recommend it secondary to age, who were not offered chemotherapy, and who passed away within 3
months of their first appointment with an oncologist.
Hypothesis
We anticipate that there will be common demographic and health factors that differ between the
subgroups that were treated with chemotherapeutics and those that were not. Specifically, we
hypothesize that patients with age greater than 70, poor performance status, and rural location were
less likely to receive systemic therapy. We hope to clarify it there are any barriers to receiving or
continuing treatment and by doing so, identify areas where physicians, clinics, and public education can
optimize access and treatment.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
  Incidence Of Post-Operative Complications In Rheumatic Patients On Anti-TNF-Α Therapies
                             Following Orthopaedic Procedures
    Ranjani Somayaji, Cheryl Barnabe & Liam Martin, Faculty of Medicine, Division of Rheumatology,
                                         University of Calgary


Objective:

 Post-operative orthopaedic complications are more commonly reported in rheumatic patients. Though
tumour necrosis factor blockers have been revolutionary for the treatment of rheumatic disease, they
have been associated with delayed healing and increased infection risk. The data regarding the
incidence of post-operative complications in rheumatic patients on biologic therapies is limited. In this
study, we examined the incidence of post-operative complications following orthopaedic surgery in such
patients and sought to identify other potential risk factors for complications.

Methods:

Eligible subjects were selected from the Calgary Health Region database and included rheumatic
patients on anti-TNFα therapies who underwent an orthopaedic procedure between 2005-2009.
Demographic data and clinical information in the peri-operative period was recorded for each patient.
Patients were followed for a minimum of one year and post-operative complications were recorded. The
complication rates were compared between surgery types, and with the rates recorded in the literature.

Results Obtained:

Between 2005 and 2009, a total of 58 patients on TNFα antagonist therapy underwent 91 orthopaedic
procedures. Rheumatoid arthritis (RA) was the most frequent diagnosis (98%). A total of 16
complications occurred (17.6%) which was higher than the 6% complication rate reported for
orthopaedic procedures in RA patients. The complications were stratified into post-operative wound
infections (11/91, 12.1%) and other types of complications (5/91, 5.5%). No independent predictors for
post-operative complications were identified in this group.

Conclusions:

Tumour necrosis factor-α therapy in rheumatic patients appears to confer an increased risk of post-
operative complications. Larger scale studies are required to elucidate how best to manage rheumatic
patients and biologic therapies in the peri-operative period.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
   Risk-Treatment Discordance In HFPEF Patients Undergoing Cardiac Catheterization

       Ashim Verma MD, Jonathan Howlett MD, Diane Galbraith RN, Merril Knudston MD

Introduction

Patients with heart failure and preserved ejection fraction (HFPEF) suffer increased morbidity
and mortality burden. Use of ACE inhibitors, ARBs, and beta blockers, for which there has been
much survival benefit in systolic dysfunction, may not always correlate with mortality risk. This
was demonstrated in the EFFECT trial where patients highest for risk of death were least likely
to receive these treatments1. To our knowledge, no studies have evaluated for similar risk-
treatment discordance in HFPEF where many experts advocate for the use of beta blockers. We
therefore elected to review patterns of beta blocker use in this population, stratified according to
mortality risk and to the use of another aggressive strategy, cardiac catheterization.

Methods

Heart failure admission data was obtained from a search of the Alberta Provincial Project for
Outcome Assessment in Coronary Heart Disease (APPROACH) registry between 2005 and
2010. Data was supplemented using echocardiography registries. Results were filtered to include
only those with documented LVEF > 40%. Study participants with LVID > 56 mm, moderate or
worse LV dysfunction, high-grade (Type II or III) AV block, HR < 60 beats/min, concomitant
pacemaker, or documented allergy to beta blocker therapy were excluded. Remaining
participants were further stratified according to risk of 30-day and 1-year mortality according to
a validated scoring system2. Patterns of beta blocker use, defined as beta blocker prescription at
the time of enrolment into APPROACH, were examined according to mortality risk. Univariate
single and stepwise multivariable logistical regression (forcing beta blocker use) in addition to
propensity analysis to determine factors associated with both 30-day and 1-year mortality were
determined.

Results

Conclusions

References
   1. Lee et al. Risk treatment mismatch in the pharmacotherapy of heart failure. JAMA
      2005;294(10):1240-1247.
   2. Lee et al. Predicting mortality among patients hospitalized for heart failure. JAMA
      2003;290(19):2581-2587.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Health Sciences Research Poster Abstracts
                    Medical Education Poster Abstracts

Resident Name           Title
                        I’m Post-call and Feel Like Goo: The Content of Facebook Status Updates Posted by
Chapelsky, Sarah        Internal Medicine Residents


Hall, Stacey            Do Medical Residents Employ a Bayesian Approach to Diagnose?

                        Effectiveness of Scenario-based Simulation Training Versus Traditional Workshops in
Kerr, Brendan           Continuing Medical Education: A Randomized Controlled Trail




        Internal Medicine Resident Research Day Thursday, April 28, 2011 – Medical Education Poster Abstracts
  I’m Post-Call And Feel Like Goo: The Content Of Facebook Status Updates Posted By Internal
                                       Medicine Residents
                                                       Sarah Chapelsky, MD, BSc, MSc


Statement of Problem or Question
What proportion of status updates posted on facebook by internal medicine residents make reference to medicine, and
what are the most common topics?

Description of Program/Intervention
I considered facebook status updates posted between December 1 and February 28, 2011 by members of the facebook
group Calgary Internal Medicine Residents 2009. Each update was categorized as medicine-related or not. Medicine-related
updates were further categorized by topic: patient encounter, workday event that is not a patient encounter, examinations,
vacation, call, rotation update, medical reference, and other commentary. All updates were evaluated for tone. Updates
deemed negative in tone were further appraised for humorous or sarcastic content.

Objectives of Program/Intervention
The concept of the social networking website, of which facebook is the most pervasive, has not yet reached its adolescence;
research regarding this phenomenon is in its infancy. In medical literature, discussion of physician use of facebook largely
focuses on its impact on medical professionalism. As such, most studies have focussed on identifying the frequency of
publicly available content which may be interpreted as unprofessional. The role of facebook as a communication tool that
physicians use to reach their facebook “friends” – be they colleague, family, acquaintance, or classically defined friend – has
not been much considered. This study aims to describe the nature of facebook communication in a physician subgroup.

Findings to Date
Of 22 eligible residents, there are 17 members of the facebook group Calgary Internal Medicine Residents 2009. I excluded
myself from analysis. During the study period, 7 residents did not post any status updates; 4 residents posted 1 to 10
updates; and 5 residents posted greater than 10 updates.
Of the 9 active posters, only 1 resident did not make any medicine-related updates. In fact, 52% (60/116) of updates were
medicine-related. The most common topic was call, which accounted for 32% (19/60) of updates. Only 2 updates referred
to specific patient encounters.
47% (28/60) of medicine-related updates had a negative tone compared to 30% (17/56) of other updates. The negative tone
of the update was tempered with humour or sarcasm in 75% (21/28) of negative medicine-related updates, and 76%
(13/17) of other negative updates.

Key Lessons Learned
Residents post status updates on facebook with great variability. Among active facebook users, more than half of all status
updates related to medicine. The most common topic was call, which made up nearly one-third of these posts. Medicine-
related posts were more likely to have a negative tone than other posts. No matter the topic of a negative post, roughly
three-quarters are presented with a veil of humour or sarcasm.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Medical Education Poster Abstracts
                   Do Medical Residents Employ a Bayesian Approach to Diagnose?

                          Dr. Stacey Hall, Dr. Kevin McLaughlin, Dr. William Ghali

Background

Despite advances in medical sciences, physicians still misdiagnose 15% of their patients. While
the relationship between information processing, expertise, and diagnostic performance is
complex, it is clear that diagnosing begins with automatic information processing, which
generates an initial hypothesis, and that this initial hypothesis may be refined by analytical
information processing. Analytic processing uses working memory to consciously deliberate on
the congruence between case data and possible diagnoses. There is a variety of analytic
processing approaches that can be used (and taught) when diagnosing, including hypothetico-
deductive reasoning, scheme-inductive reasoning, or a Bayesian/probabilistic approach. The
latter is an attempt to incorporate evidence-based and/or rational clinical examination into
diagnosing. While prior studies have suggested that a Bayesian approach can improve
diagnostic performance, probabilistic reasoning may be challenging to the unfamiliar, and
might add to the already high cognitive load of diagnosing.

Objectives

In our study we will evaluate the accuracy of a Bayesian approach when used by Internal
Medicine residents to diagnose uncommon and common medical conditions.

Methods

We have designed four written clinical cases. One case is a commonly encountered disease that
will have typical findings; the second is a commonly encountered disease in which the case will
have atypical findings. The last two cases will be uncommonly encountered diseases, one with
typical findings, and the other atypical findings. The study subjects will be the internal medicine
residents at the University of Calgary. The participants will be asked to read the cases and then
answer what their post-test probabilities of a specific disease is based on the information
provided. Actual post-test probabilities have been calculated based on prevalence of the
disease and evidence based likelihood ratios of each clinical finding in the case. The results will
be analyzed by comparing the mean probability to the calculated probability using a one-
sample mean comparison test, and we will stratify our results based upon case characteristics
(common vs. uncommon, and typical vs. atypical).

Results

We are currently in the process of submitting our documentation to the Ethics Review Board.
Estimated study completion date is the fall of 2011.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Medical Education Poster Abstracts
     Effectiveness of Scenario-based Simulation Training versus Traditional
   Workshops in Continuing Medical Education: A Randomized Controlled Trial
  Brendan Kerr, Dr. Irene Ma, Internal Medicine Physician, University of Calgary; Dr. Lee‐Ann Hawkins,
                       Obstetric‐Internal Medicine Physician, University of Calgary

Statement of Question

Simulation‐based training is increasingly used in medical education. Its role in continuing
medical education is unknown. This study is design to evaluate the effectiveness of
scenario‐based simulation training compared with traditional workshops on knowledge and
self‐reported confidence in a continuing medical education conference.

Description of Intervention

Attendees of the Rocky Mountain Conference for Internal Medicine interested in attending a
workshop on Obstetric‐Internal Medicine (OIM) will be invited to participate in our study.
Consenting participants will be randomized to attend either a traditional small group workshop
or scenario‐based simulation workshop, where participants will be exposed to the same OIM
clinical scenario.
Pre, immediately and at one month, participants will complete an evaluation, assessing for
knowledge and satisfaction with workshops and self‐reported confidence.

Objective of the Intervention

To assess if exposure to scenario‐based simulation impacts immediate knowledge acquisition,
short‐term knowledge retention, confidence with the clinical scenario, and attitudes toward
simulation as a learning tool.

Findings to Date/Key Lessons Learned

Study will commence in November 2011. Findings will be reported at a later date.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Medical Education Poster Abstracts
              Quality Improvement Poster Abstracts

Resident Name                                                       Title
                                                                    An Audit of the Factors Related to
Binding, Andrew                                                     Multidisciplinary Care of Sickle Cell Disease
                                                                    Patients in the Calgary area

                                                                    A Cross-Sectional Study Comparing Work
Elliott, Meghan                                                     Attitudes and Experiences of Medical
Fabreau, Gabriel                                                    Teaching Unit Health Care Providers Before
Khanna, Suneil                                                      and After Implementation of the Senior
Minty, Evan                                                         Resident Rotation Bundle
                                                                    A Review of the Treatment of Thrombotic
                                                                    Thrombocytopenic Purpura in Patients in the
Goodarzi, Zahra                                                     Foothills Medical Center Catchment Area

                                                                    Use of Thromboprophylaxis within the Three
Rodriguez - Velez, Cesar                                            Major Hospitals in the City of Calgary




      Internal Medicine Resident Research Day Thursday, April 28, 2011 – Quality Improvement Poster Abstracts
  An Audit Of The Factors Related To Multidisciplinary Care Of Sickle Cell
                   Disease Patients In The Calgary Area
                                    Binding, A. Netrakanti, V. Sayani, F.

Quality Improvement/Patient Safety
Statement of the Problem
Sickle Cell Disease is a heritable hematological condition associated with significant morbidity
and mortality. Specifically, this condition results in frequently severe pain crises, infections,
anemia and increased incidence of stroke. With immigration rates from sub-Saharan Africa rising
in the Calgary area this is increasingly becoming a local concern. A multidisciplinary approach to
care of SCD patients has been shown to improve several prognostic factors in other North
American centres. The lack of such a system in Calgary suggests that there is room for
improvement in SCD patient care. However, little is known about Calgary’s SCD population as a
whole.

Improvement related Question
Can a multidisciplinary clinic directed towards rare blood disorders such as SCD be organized
and implemented in Calgary.

Methods
Phase I: Chart review of all known adult SCD patients in Calgary in order to compile a database
of demographic and medical information.
Phase II: Recruitment of specialists and patients, and organization of clinic.
Phase III: Prospective efficacy study and expansion of multidisciplinary model internationally.

Results – Pending

Key Lessons Learned – Pending

Future Directions
This Database will be used for the recruitment and organization of a proposed multidisciplinary
rare blood disorders clinic, and could subsequently be used to further clinical research on SCD.
Specifically, it will provide baseline information for a prospective study of the efficacy of this
clinic. Also, given the broad scope of parameters included in the proposed database, combined
with similar data from other Canadian centres, it could be a powerful resource for various
retrospective studies.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Quality Improvement Poster Abstracts
 A Cross-Sectional Study Comparing Work Attitudes and Experiences of Medical
  Teaching Unit Health Care Providers Before and After Implementation of the
                        Senior Resident Rotation Bundle
Meghan Elliott, Gabriel Fabreau, Suneil Khanna, Evan Minty, Aleem Bharwani, Janet Gilmour, Garielle Brown, Jean
Wallace, Jill de Grood, Mary Widas, Jennifer Cowles, Rhonda Niebrugge, Sonja Morrison, Susan Campeau, and Jane
                                                     Lemaire

Background

Extended duty hours have been associated with preventable medical errors, motor vehicle crashes,
percutaneous “needle-stick” injuries, and higher burnout rates amongst physicians. While many
residency programs are switching to shift-based work hours, recent reviews have expressed concern
that the increased number of handovers could compromise patient care.

Problem

In the 2010-2011 academic year, a new model of patient care, the Senior Resident Rotation Bundle
(SRRB), was trialled in the University of Calgary Internal Medicine Residency Program. The SRRB
consists of changing from traditional 26-hour shifts to a five-day night float model; developing a
handover tool to enhance continuity of care; and developing an education week for senior residents.
We propose that this model could alleviate duty hours, improve handover, enhance resident education,
and improve health care worker attitudes.

Methods

This cross-sectional study uses a series of pre- and post-intervention surveys to assess health care
worker attitudes before and after institution of the SRRB. Surveys were sent to all Internal Medicine
residents (n=65), staff physicians (n=35) and nurses (n=190) with work experience on either one of two
university hospital MTUs during 2010. The survey measures the respondents’ perceived impact of the
24-hour shifts upon aspects of senior resident self/work with single-item responses and multi-item
scales, all with a 5-point Likert response set coded as strongly disagree (1), disagree (2), neither agree
nor disagree (3), agree (4), strongly agree (5) with reverse coding where appropriate.

Results

Response rates for the pre-intervention survey were 94%, 60% and 34% for residents, staff physicians
and nurses, respectively. The post-intervention has been distributed and data are currently being
collected. Final analyses of the surveys and comparisons of the attitudes of health care workers prior to
and following implementation of the SRRB are pending.

Conclusions

The impact of the SRRB on work attitudes, safety and wellbeing of health care providers as well as on
patient outcomes is to be determined following analysis of the complete data set.



Internal Medicine Resident Research Day Thursday, April 28, 2011 – Quality Improvement Poster Abstracts
  A Review Of The Treatment Of Thrombotic Thrombocytopenic Purpura In Patients In The Foothills
                                    Medical Center Catchment Area
  Dr. Zahra Goodarzi, Principle Investigator: Dr. Sayani Co-Investigators: Dr. Klassen, Dr. Valentine, Dr.
                                           Girard, Dr. Duggan

Background: Thrombotic Thrombocytopenic Purpura (TTP) represents a clinical emergency with up to
90% mortality without treatment. TTP is a thrombotic microangioapthy (TMA), which is characterized
by thrombus formation in the small vessels that can result in end organ damage, thrombocytopenia
and profound hemolysis. Often accompanied by renal failure due to TMA, this disease can have a broad
clinical appearance depending on the location of the platelet aggregation and resultant tissue ischemia.
TTP can be a primary diagnosis; however, there are several secondary causes of TTP that are essential
to know when developing a treatment strategy. According to current practice, upon the diagnosis of
thrombocytopenia plus microangiopathic hemolytic anemia the patient should be started on emergent
plasmapheresis. With plasmapheresis mortality due to TTP has decreased mortality to 10-20%. Most
cases of TTP respond well to plasmapheresis alone, however there are a significant number of patients
that become refractory (recurrent thrombocytopenia and MAHA off of plasmapheresis). It is these
patients that require immunosuppressive therapies and in some cases even splenectomy. There is
currently a lot of contention in the literature on how to proceed with refractory TTP patients. This
largely revolves around the timing of plasmapheresis, tapering and the use/duration of
immunosupression such as rituximab and cyclophosphamide. There are many studies going on
currently looking at the use of rituximab for TTP. While initial results are promising, more research is
required to verify the safety, durability of response, and overall efficacy of the therapy. Such difficulties
have been noted in our center, where cases of refractory TTP become difficult to manage as there is
little consensus of how to proceed. As such, our study aims to review our current management of TTP
and, in the future, compare this to the existing data in order to create treatment guidelines for TTP,
thus improving our care of these patients.
Objective: The goal of this study is to review the treatment of Thrombotic thrombocytopenic purpura
(TTP) in adult patients with in the Foothills Medical Center Catchment area (Southern Alberta, South
Eastern British Columbia, and parts of Saskatchewan) from January 2005 to December 2010. The
treatment of TTP has focused largely blood plasma exchange. However, when patients are refractory
or relapse on our primary therapy, uncertainty exists as to how further treatment should proceed. By
evaluating the patients that have been treated in Calgary, we hope to come up with a consensus of
local treatment, which will hopefully form guidelines for best practice in the future.
Methods: By reviewing the medical and apheresis charts for patients who present with TTP in Calgary
over the past 5 years, we will be able to identify the course of therapy and disease for those patients.
All patients who present with thrombocytopenia (a count <150) and microangiopathic hemolytic
anemia (MAHA) (schistocytes and red cell fragments on smear, elevated LDH) and are initiated on
plasmapheresis will be included. These patients will be identified by apheresis records, as patients who
received PLEX for TTP. A patient with refractory disease would be defined as the need for tertiary
therapies or surgery to induce remission of disease. Remission will be defined as a normal platelet
count with no MAHA off of therapy. Relapsing disease would be defined as TTP which meets criteria
for remission, but at a later date requires therapy for TTP because recurrent thrombocytopenia or
MAHA. From this data we will be able to follow the clinical course of each patient, focusing on how
they were treated and their response to the same. This information when combined between all the
included subjects will enable us to create a consensus for local treatment. Overall a lot of information
can be obtain in a retrospective study such as this, and will hopefully help to inform future best
practice for refractory/relapsing TTP.



Internal Medicine Resident Research Day Thursday, April 28, 2011 – Quality Improvement Poster Abstracts      1
       Use of Thromboprophylaxis within the Three Major Hospitals in the City of Calgary
                     Elizabeth MacKay, MD, FRCP(C), MPH; Cesar M. Rodriguez Velez, MD

Introduction:
Venous thromboembolism is one of the most common complications for admitted patients, regardless
of reason or service of admission, accounting for one third of all cases of VTE (DVT and/or PE). In several
studies it has been demonstrated that thromboprophylaxis is one of the most effective and cost-
effective measures to prevent complications in admitted patients. Despite this, it has been previously
demonstrated that there is a significant under-usage of thromboprophylaxis, in as much as 80% of
eligible admitted patients. In 2007 the VTE Prevention Project was launched within the former Calgary
Health Region, with the aim of increasing awareness and prevention of VTE.

Objectives:
To assess the usage of different methods of thromboprophylaxis in the three major health centres in
Calgary (FMC, PLC, RGH). In this way, we expect to identify different risk groups, across different sites,
admitting services, age and gender. Based on these findings we would be able to provide specific
recommendations on the use of thromboprophylaxis across the different groups. As well, we will
compare our current data with previously data, and be able to identify if previous suggestions and
changes have increased the awareness of VTE prevention among different specialties and health
providers, and have increased the usage of different appropriate thromboprophylactic measures.

Methods:
Data has been collected from all three major adult health centres in Calgary (FMC, PLC, RGH). Statistical
analysis of the raw data has started, utilizing statistical software Stata V10.0.

Acknowledgements:
We thank Sophia Niu, Quality Safety and Health Information, for providing hospital admission and
discharge data, and use of the different available thromboprophylactic methods.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Quality Improvement Poster Abstracts
                  Systematic Review Poster Abstracts

Resident Name                                                         Title

Li, Xuemei                                                            Should the Use of Hand-Carried Ultrasound
                                                                      be Integrated into Undergraduate and
                                                                      Postgraduate Training

Ma, Jeffrey                                                           The effect of Angiotensin-Converting Enzyme
                                                                      Inhibitors in the setting of Coronary
                                                                      Angiogram Contrast Induced Nephropathy

Poon, Tiffany                                                         A Critical Review of Interferon Release Assay
                                                                      in Screening of Latent Tuberculosis as
                                                                      Compared to Mantoux Testing

Varughese, Rhea                                                       Tuberculosis and Diabetes Mellitus: A Global
                                                                      Conundrum




       Internal Medicine Resident Research Day Thursday, April 28, 2011 – Systematic Review Poster Abstracts
   Should The Use Of Hand-Carried Ultrasound Be Integrated Into Undergraduate And Postgraduate
                                                Training
                    Dr. Xuemei Li MD, PGY2 Internal Medicine , University of Calgary
              Dr. Irene Ma, MD, Staff Physician, Assistant Professor , University of Calgary

Hand-carried Ultrasound(HCU) is a a promising new diagnostic tool that may assist internists in bedside
patient care. Inaccuracies in the interpretation of traditional bedside physical examinations may result in
missed or incorrect diagnoses. The use of HCU may improve a physician`s diagnostic accuracy for
detecting a variety of disease states compared with physical examination alone. A number of studies
suggest that medical trainees and clinicians without formal training in Ultrasound can acquire, relatively
rapidly, the limited skills required to use the HCU device to perform narrowly defined tasks. But the
overall impact of HCU educational programs is unknown.

This systematic review will summarize available evidence on the use of HCU in medical education to
come with conclusion if the use of HCU should be integrated into undergraduate and postgraduate
Training.
For identification evidence, we searched different database between Jan 1950 and Dec 2010 using
MEDLINE, PubMed, Education Resource Information Centre(ERIC) , Exceprta Medica(EMBASE), Cochrane
Centre Register of Controlled Trials, the Cumulative Index of Nursing and Allied Health Literature(CINAL),
Research Development and Resources Base,Health STAR, and WebofScience. A search strategy using
the medical subject headings (MeSH): (ultrasonography; ultrasound$; echocardiography) or (Doppler;
handheld; hand-held; portable; point of care) and (education; teach$; learn$; train$; medical student;
medical school; residen$; curricula, in service training; medical undergraduate; postgraduate; internship
and residency; student, medical; physical examination). All MeSH terms will be exploded. No language
restriction will be placed. Screening of search results will be done independently by two investigators.
We yielded 666 citations. Of those, 204 citations were selected for abstract review, 16 articles were
selected for final fulltext review.
Inclusion criteria: We included primary research articles if they described a educational intervention on
ultrasound administered to medical learners and compared either clinical or radiologic findings between
those by medical trainees compared with those by formally trained ultrasonographers, radiologists, or
echocardiographers.
We excluded articles with trained learners (hospitalists, internists, intensivists, cardiologists, and
fellows), non primary studies, without described education interventions, non controlled studies.
Results
2 individual investigators are doing extensive literature search with assistance of research librarians. We
have not combined the search results yet.
Below is my own preliminary search results.
Reviewed 204 abstracts, selected 16 relevant primary studies, 7 of them on residents,3 of them on
medical students; most studies were done for cardiac assessment(left ventricular function, valvular
diseases, pericardial effusion, wall motion abnormalities, LVH, hypertrophic cardiomyopathy), 2 studies
were done for clinical volume status assessment, one study was done for the measurement of
abdominal aortic aneurysm. All the studies are consistent with positive results, which showed similar
sensitivity and specificity between trainees and ultrasonographers vs echocardiographers; and by using
HCU improved the accuracy of physical examination remarkably; and HCU technique is relatively easy
and fast to learn by trainees.

Conclusions not yet finalized.


Internal Medicine Resident Research Day Thursday, April 28, 2011 – Systematic Review Poster Abstracts
      The Effect of Angiotensin-Converting Enzyme Inhibitors in the Setting of
                Coronary Angiogram Contrast Induced Nephropathy
                                             Jeffrey Ma, Matthew James

Background

Contrast induced nephropathy (CIN) is a term applied to acute kidney injury (AKI) caused by iodinated
radiocontrast agent exposure that occurs with coronary angiography. With increasing use of contrast
media for angiographic procedures, CIN has become the third leading cause of hospital acquired acute
kidney injury (AKI) in adults and has been linked to adverse health care outcomes including mortality
and increased medical resource utilization. The effect of angiotensin-converting enzyme inhibitors (ACE-
I) in this setting has been varied according to studies.

Objective

The purpose of this systematic review and meta-analysis is to summarize data from all studies published
on effect of ACE-I’s with AKI/CIN after coronary angiography. Furthermore, we would like to correlate
these data with the findings from the Calgary Health Region Database.

Methods

MeSH heading searches for observational cohort studies (prospective or retrospective design), case
control studies, or observational comparisons from RCTs will be explored from MEDLINE databases
(OVID 1950 through March 2010 plus Non-Indexed & In Process Citations). Statistical analysis (Stata
Version 10) employed against set of endpoints.

Results and Conclusions

Preliminary results are pending. Outcomes include (as defined by study) mortality (short and long),
major adverse cardiovascular event (including MI, CHF, arrhythmia, TIA/CVA, need for revascularization,
hospitalization for cardiovascular event), prolongation of hospital stay (difference in number of days of
hospitalization), progression of chronic kidney disease (CKD), development of end stage renal disease
(ESRD)/ chronic dialysis. The intent is to further correlate the findings of our review with localized
findings in the Calgary Health Region Database.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Systematic Review Poster Abstracts
A Critical Review of Interferon Release Assay in Screening of Latent Tuberculosis as Compared
                                      to Mantoux Testing
                                         Tiffany Poon

Background
It is estimated that latent infection by Mycobacterium tuberculosis affects approximately two
billion people each year. Up until 2001, the only widely available screening tool for latent
infection was the tuberculin skin test (TST). Although used for almost a century, the tuberculin
skin test has limitations.

Objective
To review recent studies on the specificity, sensitivity and cost effectiveness of using interferon
release assays in screening for latent tuberculosis as compared to the currently used Mantoux
test.

Methods
A search was done on Pub Med and Medline using the keywords tuberculosis and interferon
gamma release assay (IFN-γ). The search was limited to full text articles on human subjects
published in English. Nineteen articles were found and these were further screened to only
include those published in the last 10 years looking at latent tuberculosis infection in the adult
population. The remaining five articles were reviewed.

Results
Based on the studies examined, the sensitivity of available IFN-γ release assays was shown to be
similar to the TST while their specificity was higher than the currently used Mantoux. The
studies showed that IFN-γ release assays may be used in place of the tuberculin skin test in
many situations.

Conclusions
Current studies have shown that IFN-γ release assays are comparable to the currently used TST
in sensitivity but have a higher specificity. Both tests may be used in similar situations to test for
latent M. tuberculosis infection. IFN-γ assays have the added benefit of not being affected by
previous BCG vaccination and eliminates the need for follow up test reading. Further research is
needed to determine if using IFN-γ assays is cost effective.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Systematic Review Poster Abstracts
                 Tuberculosis and Diabetes Mellitus: A Global Conundrum
                                             R. Varughese, D. Fisher

Background:

Tuberculosis is a global disease that continues to spread, infecting an estimated 8.8 million people per
year. Likewise, the prevalence of diabetes mellitus is rising globally with an estimated 171 million
people affected in the year 2000 and estimates of 300 million affected people by 2030. Multiple studies
illustrate a strong association between diabetes mellitus and tuberculosis; diabetes is becoming a risk
factor for tuberculosis.

Objectives:

Compile the evidence supporting the association between diabetes mellitus and tuberculosis.
Determine whether tuberculosis treatment is affected by diabetes mellitus.

Methods:

A literature search was performed using MEDLINE and Google scholar using “diabetes mellitus” and
“tuberculosis” as keywords. A secondary search added “drug level” as a keyword. Only English articles
were selected. Articles were chosen if they compared diabetic patients to non-diabetic patients or if
they described levels of anti-tuberculosis drugs in diabetic patients.

Results:

Several studies confirm an association between diabetes mellitus and tuberculosis using populations
from different countries; the relative odds ratio of developing tuberculosis in diabetic patients is 2.44 to
8.33 when compared to non-diabetic patients. In diabetic patients, the relative risk of developing
sputum positive pulmonary tuberculosis is up to five times higher and the length of sputum positivity is
longer than non-diabetic patients. Studies have also revealed that diabetics may have slower responses
to therapy with extended treatment duration and increased recurrence. Multiple studies measured
levels of anti-tuberculosis drugs to explain the difficulties of treating diabetic patients with tuberculosis.
Rifampin levels during the continuation phase of treatment were lower in diabetic patients; however,
drug levels of rifampin, pyrazinamide, and ethambutol during the treatment intensive phase did not
change with diabetes status. Also, studies have demonstrated that diabetic patients are at increased
risk of death from pulmonary tuberculosis.

Conclusions:

The link between diabetes mellitus and tuberculosis is increasingly important as the prevalence of
diabetes mellitus is growing globally, particularly in countries with high tuberculosis rates. Studies
demonstrate that diabetic patients have a higher risk of developing tuberculosis, increased probability
of sputum positivity, and more challenges with treatment. Also, rifampin levels are lower in diabetic
patients. Although these connections are becoming clearer, many questions still exist. Examples include
why are diabetics predisposed to tuberculosis and how does diabetes management affect tuberculosis
treatment. Therefore, further research is needed to delineate the details of the tuberculosis and
diabetes relationship.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Systematic Review Poster Abstracts
   AdditionAl AbstrActs submitted

                                                                       Fatal case of Bronchiolitis obliterans with
                                                                       organizing pneumonia, as initial
                                                                       presentation of rheumatoid arthritis in a
                                                                       Sudanese traveler; case report and short
Billington, Emma                                                       review of literature
Brown, Kristen                                                         Clinical Significance of Peptinophilus spp.
                                                                       Comparison of combined psychosocial and
                                                                       pharmacotherapy with varenicline versus
                                                                       bupropion for smoking cessation as part of
                                                                       a cardiac rehabilitation program post
                                                                       myocardial infarction – a three-armed,
                                                                       placebo controlled, randomized clinical
Connors, William                                                       trial
                                                                       Implementation of a Multidisciplinary
                                                                       Strategy Promoting Basal Bolus Insulin
                                                                       Results in Improved Glycemic Control and
                                                                       Shorter Length of Stay for Diabetic
Dechant, Anthony                                                       Inpatients
                                                                       Internal Medicine Trainees Perceptions
Ionescu, Andreea                                                       Toward Scenario-based Simulation
                                                                       Fatal case of Bronchiolitis obliterans with
                                                                       organizing pneumonia, as initial
                                                                       presentation of rheumatoid arthritis in a
                                                                       Sudanese traveler; case report and short
Villar, Erwin                                                          review of literature




      Internal Medicine Resident Research Day Thursday, April 28, 2011 – Additional Submitted Abstracts
        Enterococcal Bloodstream Infection: A Population-Based Study
           Emma Billington Supervisors: Dr. K Laupland (on sabbatical) & Dr. M Parkins

Background:
The enterococci are a common and clinically significant cause of bloodstream infection (BSI),
particularly in the nosocomial setting. Enterococcal BSI is associated with 25-50% mortality, and
its treatment is complicated by high rates of resistance to cephalosporins, and increasing
resistance to ampicillin and vancomycin. Infection with Enterococcus faecium in particular has
been associated with higher rates of antibiotic resistance and mortality. To date, no population-
based studies have examined the patient characteristics and clinical outcomes associated with
enterococcal BSI.

Objective:
The purpose of this study was to characterize the incidence, risk factors for acquisition,
microbiological characteristics and clinical outcomes of enterococcal bacteremia within the well-
defined population of a large Canadian health region.

Methods:
This retrospective cohort study used a database to identify all episodes of enterococcal
bloodstream infection in the Calgary Health Region between 2000 and 2008. Clinical
characteristics of all patients with incident enterococcal bloodstream infections during this
timeframe were obtained from the database, including demographics, comorbidities and
outcome data. Microbiological characteristics of all enterococcal bloodstream isolates including
speciation, antibiotic susceptibility profiles and concurrent positive cultures at other body sites
were also obtained.

Results: During the 9-year study period, a total of 710 incident enterococcal BSIs occurred in 695
patients. Total incidence was 6.9 per 100,000 per year, with elderly males being at the highest
risk of infection. The overall case-fatality rate was 23%. Of all incident infections, 338 (48%)
were nosocomial and 184 (26%) were polymicrobial. E. faecalis was recovered in 467 (70%) of
incident isolates, whereas 169 (25%) grew E. faecium, and 31 (4%) grew a different enterococcal
species, or more than one species of enterococcus. Case-fatality rate (30% vs 16%) and
ampicillin resistance (70% vs 4%) were both significantly higher with E. faecium BSI than with E.
faecalis.

Conclusion:
Bacteremia with Enterococcus faecium is common within our health region, and is associated
with considerable ampicillin resistance and associated mortality.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Additional Submitted Abstracts
                              Clinical Significance of Peptinophilus spp.
                                                      Kristen Brown
Learning objective:
This paper will describe the first case series of Peptinophilus spp. isolated from bacteremic patients,
providing evidence that these organisms may be more pathogenic than originally realized.
In the past it has been difficult to determine the clinical significance of any given species of Gram-
positive anaerobic cocci (GPAC) as previous phenotypic and biochemical forms of characterization
allowed for heterogenus grouping of bacteria. More recently, sequencing of 16S rDNA and rRNA has
allowed for more appropriate homogenous phylogenetic grouping of Gram-positive anaerobes. There
are currently seven Peptinophilus spp. that have been recognized on the basis of genetic sequencing
(Ezaki et al. 2001, Song, Liu & Finegold 2007). Peptoniphilus are Gram-positive, non-spore-forming, non-
motile, obligately anaerobic cocci (Ezaki et al. 2001). All seven species have been isolated from various
human clinical specimens, however, their pathogenicity has been assumed to be low as they are
typically found only in association with other anaerobic bacteria in relatively low grade infections (Song,
Liu & Finegold 2007). Dowd et al. (2008) found that Peptinophilus spp. were the second most prevalent
bacteria identified by molecular methods in diabetic foot ulcers, being found in twenty-five of forty
samples. The type species P. asaccharolyticus has been isolated from vaginal discharge as well as
ovarian and peritoneal abscesses (Ezaki et al. 2001, Murdoch, Mitchelmore & Tabaqchali 1994). P.
lacrimalis was first isolated from a human lachrymal gland abscess (Ezaki et al. 2001) and has
subsequently been associated with persistent bacterial vaginosis (Marrazzo et al. 2008). P. harei was
first isolated from a purulent sacral ulcer in a diabetic patient (Ezaki et al. 2001), and has also been
found in superficial abscesses. P. ivorii was first found in a leg ulcer (Ezaki et al. 2001). P. gorbachii and
P. olsenii were first isolated from lower extremity infections in diabetic patients, including superficial
ulcers, cellulitis and osteomyelitis (Song, Liu & Finegold 2007).

References

        Dowd, S.E., Wolcott, R.D., Sun, Y., McKeehan, T., Smith, E. & Rhoads, D. 2008, "Polymicrobial
nature of chronic diabetic foot ulcer biofilm infections determined using bacterial tag encoded FLX
amplicon pyrosequencing (bTEFAP)", PloS one, vol. 3, no. 10, pp. e3326.

        Ezaki, T., Kawamura, Y., Li, N., Li, Z.Y., Zhao, L. & Shu, S. 2001, "Proposal of the genera
Anaerococcus gen. nov., Peptoniphilus gen. nov. and Gallicola gen. nov. for members of the genus
Peptostreptococcus", International Journal of Systematic and Evolutionary Microbiology, vol. 51, no. Pt
4, pp. 1521-1528.

         Marrazzo, J.M., Thomas, K.K., Fiedler, T.L., Ringwood, K. & Fredricks, D.N. 2008, "Relationship of
specific vaginal bacteria and bacterial vaginosis treatment failure in women who have sex with women",
Annals of Internal Medicine, vol. 149, no. 1, pp. 20-28.

        Murdoch, D.A., Mitchelmore, I.J. & Tabaqchali, S. 1994, "The clinical importance of gram-
positive anaerobic cocci isolated at St Bartholomew's Hospital, London, in 1987", Journal of medical
microbiology, vol. 41, no. 1, pp. 36-44.

         Song, Y., Liu, C. & Finegold, S.M. 2007, "Peptoniphilus gorbachii sp. nov., Peptoniphilus olsenii
sp. nov., and Anaerococcus murdochii sp. nov. isolated from clinical specimens of human origin", Journal
of clinical microbiology, vol. 45, no. 6, pp. 1746-1752.



Internal Medicine Resident Research Day Thursday, April 28, 2011 – Additional Submitted Abstracts
    Comparison Of Combined Psychosocial And Pharmacotherapy With Varenicline Versus
     Bupropion For Smoking Cessation As Part Of A Cardiac Rehabilitation Program Post
    Myocardial Infarction – A Three-Armed, Placebo Controlled, Randomized Clinical Trial.
                                      William Connors

Background:
Smoking is widely cited as a leading cause of preventable mortality and morbidity in North
America. In Canada, smoking accounts for more than 37,000 deaths per year, almost 11,000 of
which are the result of cardiovascular disease. Smoking cessation alone can result in a 36%
reduction in crude relative risk of mortality compared to continued smoking. Cardiac
rehabilitation programs, intensive multiple risk factor reduction models, have be shown to be
effective at reducing mortality and are now the standard of care in chronic disease
management. However, the structure and efficacy of smoking cessation strategies as part of a
cardiac rehabilitation program following acute coronary heart disease (CHD) remains unclear.

Objective:
To evaluate whether combined psychosocial and pharmacologic therapy with either varenicline
or bupropion SR improves smoking cessation rates compared to psychosocial therapy and
placebo in patients participating in a cardiac rehabilitation program following acute myocardial
infarction.

Methods:
Rolling enrollment of subjects referred to the Cardiac Wellness Institute of Calgary (CWIC)
following hospitalization for myocardial infarction. Double blinded randomization of subjects to
one of the three study arms (varenicline, bupropion, placebo) followed by a 14 week study
period with one and two year post study follow-up as part of the routine CWIC cardiac
rehabilitation program. Nicotine dependence, withdrawal severity, and cardiac health will be
quantified as part of the study.

Results:
This study is presently in the inception stage with planned subject enrollment starting Summer
2011. The primary outcome will be smoking cessation after 12 weeks of the active treatment.
Secondary outcomes will be smoking reduction, withdrawal severity, and cardiac health. Study
follow-up will occur at one and two years to evaluate smoking status and cardiac health.

Conclusions:
To evaluate the efficacy of current first line therapies for smoking cessation in the setting of
cardiac rehabilitation following acute myocardial infarction. Given the prevalence and mortality
of smoking in this population and the dramatic potential for secondary prevention mortality
benefit, this trial addresses a relevant and pressing problem in chronic disease management. It
is the hope of this trial’s investigators that its outcomes may be able to contribute to the
development of population specific evidence-based smoking cessation programs for cardiac
rehabilitation.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Additional Submitted Abstracts
   Implementation of a Multidisciplinary Strategy Promoting Basal Bolus Insulin Results in Improved
                Glycemic Control and Shorter Length of Stay for Diabetic Inpatients

           Karmon Helmle, MSc, MD, Anthony Dechant, MSc, MD, and Alun Edwards, MB, FRCPC

Body/Objective:
To determine medical residents' practices regarding inpatient diabetes management, insulin use and to
implement and evaluate an educational initiative promoting basal bolus insulin therapy (BBIT). We
hypothesize that BBIT will reduce the frequency of hyper and hypoglycemia and decrease length of
hospital stay when compared to sliding scale insulin (SSI) use.

Methods:
Data from a retrospective audit of electronic health records for patients admitted to the Medical
Teaching Unit (MTU) over a 12 month period prompted the introduction of a new diabetes management
protocol emphasizing BBIT as a replacement for commonly prescribed SSI. A subsequent chart audit
over the following 9 months evaluated the proportion of patient-days that met the Canadian Diabetes
Association published glycemic targets, the frequency of hypoglycemic events, and the length of hospital
stay compared to patients treated with SSI.

Outcomes:
724 patients (37031 glucose results), and 355 patients (18600 glucose results) were analyzed pre- and
post-intervention, respectively. Pre-intervention, patients prescribed SSI had an increased frequency of
hyperglycemia (BG>18mmol/L (324mg/dl), 4.4% vs. 8.1% p<0.0001), hypoglycemia (BG<4mmol/L
(72mg/dl), 3.5% vs. 3.1%, p=0.045), and a longer length of stay (27.7 days vs. 16.0 days, p=0.0002) when
compared to those not treated with SSI.

An intensive educational initiative including multi-disciplinary seminars, pocket-cards and a web-based
teaching tool focussing on BBIT was promoted on the MTU. 355 diabetic patients, resulting in 18600
blood glucose results were analyzed following the intervention. Frequency of BBIT prescription doubled
following the intervention. Initial post-intervention data suggested that BBIT, when compared to SSI,
was associated a 37% increase in patient-days entirely within glycemic targets (32.0% vs. 43.8% on BBIT,
p<0.001), without a statistically significant increase in the frequency of hypoglycaemia (3.3% vs. 4.4% on
BBIT, p=0.06). Length of stay was dramatically shortened for those treated with BBIT (28.2 days vs. 13.2
days, p<0.001).

Conclusions:
Our BBIT protocol maintains patients' blood glucose within target more frequently and is associated
with reduced length of stay when compared with SSI. We have designed an electronic order set to
standardize BBIT prescription, and are undertaking a knowledge translation initiative to promote uptake
and utilization of BBIT within the multidisciplinary hospital framework.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Additional Submitted Abstracts
            Internal Medicine Trainees Perceptions Toward Scenario-based Simulation

                     Andreea Ionescu PGY2 Internal Medicine at U of C, Dr. Irene Ma MD



Background :

Scenario-based simulation is increasingly used in medical education. The objectives of this study are to
explore the responses of internal medicine residents to a newly-implemented scenario-based simulation
curriculum for general internal medicine and secondarily to explore effective and ineffective elements of
this teaching modality.

 Method :

Learner perceptions will be explored using qualitative research methods .All University of Calgary -
Internal Medicine residents will be invited to participate in a focus group. Up to a total of 60 participants
will be interviewed in groups of 6-10. A semi-structured interview protocol will be used to explore
learner perceptions regarding the use of simulation in the Internal Medicine curriculum. Interviews will
be video-recorded, transcribed verbatim without participant identifiers and results will be fed back to
residents to confirm accuracy. Independent coding and thematic analysis will be used. Emerging themes
will be identified.

Results: will be independently analyzed, transcribed and presented at later time.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Additional Submitted Abstracts
  Fatal Case Of Bronchiolitis Obliterans With Organizing Pneumonia, As
Initial Presentation Of Rheumatoid Arthritis In A Sudanese Traveler; Case
                  Report And Short Review Of Literature.
                                                ERWIN VILLAR

OBJECTIVES:
   1. To emphasize that not all patients presenting as pneumonia has an infectious etiology,
       and at some point in their course that they are not responding to broad spectrum
       antibiotics and cultures persist to be negative, we have to step back and reconsider our
       diagnosis and management.
   2. To reiterate that pulmonary manifestation of rheumatoid arthritis can precede or occur
       simultaneously as the joint manifestations.

CASE INFORMATION:
         We present a case of a 51 year old Sudanese gentleman who traveled back to Sudan and
presented with flu-like symptoms as fever, chills, cough, fatigue and polyarthralgias and has
been admitted as a case of pneumonia. Chest x-ray showed bilateral lower lobe consolidation.
Blood, sputum and bronchial wash cultures have been negative and has been treated with
broad spectrum antibiotics but despite this has deteriorated requiring ICU admission, and
mechanical ventilatory support, and eventually died for multiorgan failure secondary to possible
sepsis. Autopsy however showed mainly lung disease with 3 main histologic features: pleural
fibrosis (organizing fibrinous pleuritis), acute and organizing diffuse alveolar injury (or ARDS)
with features of acute fibrinous and organizing pneumonia in some areas, and obliteration of
bronchioles throughout the lung parenchyma (obliterative bronchiolitis) . The three primary
pathologic processes identified have all been associated with autoimmune disorders. Serologic
test report that came after patient died showed high anti-CCP antibodies which was highly
specific for Rheumatoid Arthritis.

DISCUSSION:
         The respiratory system is a frequent extra-articular site of involvement in patients with
rheumatoid arthritis (RA). Respiratory disease in rheumatoid arthritis may present as
rheumatoid-associated lung disease like interstitial pneumonitis, organizing pneumonia,
obliterative bronchiolitis, rheumatoid nodules, pleural thickening or pleural effusion, or
vasculitis and pulmonary hypertension, as well as drug-related lung disease secondary to drugs
used to treat rheumatoid disease and infection secondary to immunosuppression. In most cases,
organizing pneumonia (OP) develop during the course of RA, and articular symptoms preceded
pulmonary manifestations. In 3 cases OP preceded the clinical onset of arthritis in 2 weeks, 1
month, and several months, respectively. Diagnosis may occasionally be made with a
transbronchial lung biopsy, but more commonly an open or thoracoscopic lung biopsy is
required. Up to two thirds of patients with BOOP respond well to steroid therapy. If the patient
cannot tolerate steroid therapy, or deteriorates despite treatment, a cytotoxic therapy with
cyclophosphamide should be started.




Internal Medicine Resident Research Day Thursday, April 28, 2011 – Additional Submitted Abstracts

								
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