Pub Date : 2021-06-21DOI: 10.22374/cjgim.v16i2.443
Samuel Quan, C. Lawton, A. Budd
ObjectiveTo investigate the rationale and timing of opioid prescriptions for Internal Medicine inpatients in an academic center in Saskatoon, Canada.MethodsWe performed a cross-sectional study of Internal Medicine inpatients that were prescribed opioids in Saskatoon. We examined documentation of clinical rationale and timing of opioid initiation or first escalation.ResultsOf 57 patients, 34 (60%) were opioid naive prior to admission and 48 (84%) had opioid doses either initiated or escalated. Of these 48 patients, 27 (56%) occurred during on-call hours. Rationale for escalation was documented in 31 cases (65%), with reasons including terminal care (17%), musculoskeletal pain (15%), and skin and soft tissue infections (13%).ConclusionRationale for opioid use was frequently not documented. Initial decision to change opioid dose occurred equally between daytime and on-call hours. RÉSUMÉObjectifÉtudier la justification et le moment choisi pour prescrire des opioïdes chez les patients hospitalisés en médecine interne dans un centre universitaire de Saskatoon (Canada).MéthodologieNous avons mené une étude de prévalence sur des patients hospitalisés en médecine interne chez qui on a prescrit des opioïdes à Saskatoon. Nous avons examiné la documentation concernant la justification clinique et le moment choisi pour entreprendre le traitement par les opioïdes ou effectuer la première augmentation de dose. RésultatsDes 57 patients, 34 (60 %) n’avaient jamais pris d’opioïdes avant leur hospitalisation et 48 (84 %) ont reçu leur première dose d’opioïdes ou une augmentation de dose. De ces 48 patients, 27 (56 %) ont reçu leur dose durant les heures de garde. La justification de l’augmentation de dose est documentée dans 31 cas (65 %), les raisons étant les soins de fin de vie (17 %), la douleur musculosquelettique (15 %) et les infections de la peau et des tissus mous (13 %).ConclusionSouvent, la justification de l’utilisation des opioïdes n’est pas documentée. Le moment où la décision initiale de modifier la dose d’opioïde est prise est réparti de façon égale entre le jour et durant les heures de garde.
{"title":"Opioid Prescribing on an Internal Medicine Teaching Unit","authors":"Samuel Quan, C. Lawton, A. Budd","doi":"10.22374/cjgim.v16i2.443","DOIUrl":"https://doi.org/10.22374/cjgim.v16i2.443","url":null,"abstract":"ObjectiveTo investigate the rationale and timing of opioid prescriptions for Internal Medicine inpatients in an academic center in Saskatoon, Canada.MethodsWe performed a cross-sectional study of Internal Medicine inpatients that were prescribed opioids in Saskatoon. We examined documentation of clinical rationale and timing of opioid initiation or first escalation.ResultsOf 57 patients, 34 (60%) were opioid naive prior to admission and 48 (84%) had opioid doses either initiated or escalated. Of these 48 patients, 27 (56%) occurred during on-call hours. Rationale for escalation was documented in 31 cases (65%), with reasons including terminal care (17%), musculoskeletal pain (15%), and skin and soft tissue infections (13%).ConclusionRationale for opioid use was frequently not documented. Initial decision to change opioid dose occurred equally between daytime and on-call hours.\u0000RÉSUMÉObjectifÉtudier la justification et le moment choisi pour prescrire des opioïdes chez les patients hospitalisés en médecine interne dans un centre universitaire de Saskatoon (Canada).MéthodologieNous avons mené une étude de prévalence sur des patients hospitalisés en médecine interne chez qui on a prescrit des opioïdes à Saskatoon. Nous avons examiné la documentation concernant la justification clinique et le moment choisi pour entreprendre le traitement par les opioïdes ou effectuer la première augmentation de dose.\u0000RésultatsDes 57 patients, 34 (60 %) n’avaient jamais pris d’opioïdes avant leur hospitalisation et 48 (84 %) ont reçu leur première dose d’opioïdes ou une augmentation de dose. De ces 48 patients, 27 (56 %) ont reçu leur dose durant les heures de garde. La justification de l’augmentation de dose est documentée dans 31 cas (65 %), les raisons étant les soins de fin de vie (17 %), la douleur musculosquelettique (15 %) et les infections de la peau et des tissus mous (13 %).ConclusionSouvent, la justification de l’utilisation des opioïdes n’est pas documentée. Le moment où la décision initiale de modifier la dose d’opioïde est prise est réparti de façon égale entre le jour et durant les heures de garde.","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"93 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-06-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90517317","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-03-26DOI: 10.22374/CJGIM.V16I1.468
H. M. Baillie
The words 'Final Examination' when applied to medical training seems inappropriate. Learning is lifelong, but there have to be milestones where judgement happens. In particular, an Oral Exam can invoke all sorts of excitement.
{"title":"Casebook of a Community Internist: Fun with Finals","authors":"H. M. Baillie","doi":"10.22374/CJGIM.V16I1.468","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.468","url":null,"abstract":"The words 'Final Examination' when applied to medical training seems inappropriate. Learning is lifelong, but there have to be milestones where judgement happens. In particular, an Oral Exam can invoke all sorts of excitement.","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"49 1","pages":"36-37"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79370712","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-03-26DOI: 10.22374/CJGIM.V16I1.435
S. Ruzycki, T. Harrison, Anna Cameron, K. Helmle, Julie McKeen
People with diabetes are at an increased risk for worse postoperative outcomes, compared to people without diabetes. Notably, up to one in 10 people who undergo surgery have unrecognized diabetes and an additional 10% may have postoperative hyperglycemia without meeting the criteria for a diagnosis of diabetes. Management of postoperative hyperglycemia has been demonstrated to reduce the incidence of poor outcomes, but evidence demonstrates that postoperative hyperglycemia remains a quality gap for surgical patients. In this review, we will outline the evidence for preoperative screening for postoperative hyperglycemic risk, review the evidence for perioperative glycemic management, and examine the barriers to these best practices. RÉSUMÉ Les personnes atteintes de diabète courent un risque accru de voir leurs résultats postopératoires moins bons que ceux des personne non atteinte de diabète. En particulier, près d’une personne sur dix qui subit une intervention chirurgicale présente un diabète non diagnostiqué et dix pour cent supplémentaires peuvent présenter une hyperglycémie postopératoire sans pour autant répondre aux critères de diagnostic du diabète. Il a été démontré que le traitement de l’hyperglycémie postopératoire réduit l’incidence des mauvais résultats, mais les données probantes montrent que l’hyperglycémie postopératoire demeure une lacune chez les patients opérés. Dans cette revue, nous présentons les données probantes relatives au dépistage préopératoire du risque d’hyperglycémie postopératoire, nous passons en revue les données probantes relatives à la gestion de la glycémie périopératoire et nous examinons les obstacles à ces meilleures pratiques. Postoperative Hyperglycemia Is a Modifiable Risk Factor for Worse Postoperative Outcomes Diabetes affects 20–30% of the surgical patients.1 People with diabetes who undergo surgery have worse outcomes than people without diabetes, including increased postoperative infection risk,2,3 30-day readmission rates,4 length of stay,5 and mortality.6,7 Recent evidence suggests that these poor outcomes are more strongly associated with intraoperative and postoperative hyperglycemia rather than a preoperative diagnosis of diabetes.6,8 This is especially important, as unrecognized diabetes may account for an additional 4–10% of surgical patients8,9 and approximately 10% of people without diabetes will have postoperative hyperglycemia.8,10–14 These patients may be less likely to have postoperative hyperglycemia recognized C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e V o l u m e 1 6 , I s s u e 1 , 2 0 2 1 17 Ruzycki e t a l . CJGIM_4_WKBK.indd 17 3/19/21 5:36 PM and appropriately treated, and subsequently may suffer more adverse outcomes than people with recognized diabetes.8 The association between intraoperative hyperglycemia and poor patient outcomes is less clear15,16; however, the management of intraoperative hyperglycemia is the responsibility of the anest
与没有糖尿病的人相比，糖尿病患者术后预后更差的风险更高。值得注意的是，多达十分之一接受手术的患者患有未被识别的糖尿病，另外10%的患者可能患有术后高血糖，但不符合糖尿病的诊断标准。对术后高血糖的管理已被证明可以减少不良预后的发生率，但有证据表明，术后高血糖仍然是手术患者的质量差距。在这篇综述中，我们将概述术前筛查术后高血糖风险的证据，回顾围手术期血糖管理的证据，并检查这些最佳做法的障碍。RÉSUMÉ对于糖尿病患者来说，目前的风险是不确定的，但对于那些不确定的糖尿病患者来说，这是不确定的。具体来说，有下列规定:1 .干预;1 .手术;2 .无诊断;3 .补充;3 .预防;1 .高糖份;3 .停止;3 .无诊断;i a samacest danci.917 . i a samacest danci.923 . i a samacest danci.923 . i a samacest danci.923 . i a samacest danci.923 . i a samacest danci.923 . i a samacest danci.923 . i a samacest danci.923 . i a samacest danci.923 . i a samacest danci.923 . i a samacest danci.923 . i a samacest danci.923 . i a samacest danci.923 . i a samacest danci.923 . i a samacest danci.923。在这个节目中,常识presentons les数据probantes亲戚盟depistage preoperatoire du有伤d 'hyperglycemie postoperatoire,常识passons en revue les数据probantes亲戚像治理de la glycemie perioperatoire等常识examinons les障碍ces最佳操作。术后高血糖是术后不良预后的可改变危险因素1 .糖尿病影响20-30%的手术患者接受手术的糖尿病患者的预后比非糖尿病患者差，包括术后感染风险增加、30天再入院率增加、住院时间延长和死亡率增加。最近的证据表明，这些不良结果与术中和术后高血糖的关系更大，而不是术前诊断的糖尿病。6,8这一点尤其重要，因为未被确诊的糖尿病可能占手术患者的4-10%，8,9大约10%的非糖尿病患者会出现术后高血糖。8日,10 - 14这些病人可能不太可能术后高血糖认为C n d i n J o u r n G l o f e n e r l i n t e r n a l M e d i C i n e V o l u M e 1 6, i s s u e 1 2 0 2 1 17 Ruzycki e t l。CJGIM_4_WKBK。并得到适当治疗，随后可能比确诊的糖尿病患者遭受更多的不良后果术中高血糖与患者预后不良之间的关系尚不清楚15,16;然而，术中高血糖的管理是麻醉师的责任，因此，术前和术后糖尿病管理将是本综述的重点。循证血糖管理策略已证明改善血糖控制，缩短住院时间，降低低血糖发生率。17,18观察性研究发现，维持血糖在目标范围内与较低的30天再入院率和较短的住院时间有关在妇科肿瘤患者中，干预前和干预后的研究表明，多学科、全面、坚持血糖管理最佳实践的围手术期血糖管理途径可以降低手术部位感染的发生率。RABBIT-2研究是一项具有里程碑意义的随机对照试验，该试验发现，与皮下滑动刻度胰岛素治疗方案相比，基础胰岛素治疗(BBIT)可显著减少术后患者的术后并发症在主要的社会指南中，围手术期血糖管理的建议存在相当大的差异(表1)。与澳大利亚、英国和爱尔兰的指南不同，加拿大糖尿病协会、美国麻醉医师协会、和美国糖尿病协会没有对术前血红蛋白A1C的测量或选择性手术的目标提出建议。目前的证据支持这一点，即术中和术后立即高血糖与术前血糖控制的不良预后的相关性更强。6,8,29然而，术前血红蛋白A1C检测可以识别未被识别的糖尿病患者和无糖尿病患者术后高血糖的风险。
{"title":"Perioperative Glycemic Management for Patients with and without Diabetes","authors":"S. Ruzycki, T. Harrison, Anna Cameron, K. Helmle, Julie McKeen","doi":"10.22374/CJGIM.V16I1.435","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.435","url":null,"abstract":"People with diabetes are at an increased risk for worse postoperative outcomes, compared to people without diabetes. Notably, up to one in 10 people who undergo surgery have unrecognized diabetes and an additional 10% may have postoperative hyperglycemia without meeting the criteria for a diagnosis of diabetes. Management of postoperative hyperglycemia has been demonstrated to reduce the incidence of poor outcomes, but evidence demonstrates that postoperative hyperglycemia remains a quality gap for surgical patients. In this review, we will outline the evidence for preoperative screening for postoperative hyperglycemic risk, review the evidence for perioperative glycemic management, and examine the barriers to these best practices. RÉSUMÉ Les personnes atteintes de diabète courent un risque accru de voir leurs résultats postopératoires moins bons que ceux des personne non atteinte de diabète. En particulier, près d’une personne sur dix qui subit une intervention chirurgicale présente un diabète non diagnostiqué et dix pour cent supplémentaires peuvent présenter une hyperglycémie postopératoire sans pour autant répondre aux critères de diagnostic du diabète. Il a été démontré que le traitement de l’hyperglycémie postopératoire réduit l’incidence des mauvais résultats, mais les données probantes montrent que l’hyperglycémie postopératoire demeure une lacune chez les patients opérés. Dans cette revue, nous présentons les données probantes relatives au dépistage préopératoire du risque d’hyperglycémie postopératoire, nous passons en revue les données probantes relatives à la gestion de la glycémie périopératoire et nous examinons les obstacles à ces meilleures pratiques. Postoperative Hyperglycemia Is a Modifiable Risk Factor for Worse Postoperative Outcomes Diabetes affects 20–30% of the surgical patients.1 People with diabetes who undergo surgery have worse outcomes than people without diabetes, including increased postoperative infection risk,2,3 30-day readmission rates,4 length of stay,5 and mortality.6,7 Recent evidence suggests that these poor outcomes are more strongly associated with intraoperative and postoperative hyperglycemia rather than a preoperative diagnosis of diabetes.6,8 This is especially important, as unrecognized diabetes may account for an additional 4–10% of surgical patients8,9 and approximately 10% of people without diabetes will have postoperative hyperglycemia.8,10–14 These patients may be less likely to have postoperative hyperglycemia recognized C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e V o l u m e 1 6 , I s s u e 1 , 2 0 2 1 17 Ruzycki e t a l . CJGIM_4_WKBK.indd 17 3/19/21 5:36 PM and appropriately treated, and subsequently may suffer more adverse outcomes than people with recognized diabetes.8 The association between intraoperative hyperglycemia and poor patient outcomes is less clear15,16; however, the management of intraoperative hyperglycemia is the responsibility of the anest","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"1 1","pages":"17-23"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76156525","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-03-26DOI: 10.22374/CJGIM.V16I1.440
J. M. Radford
A 33-year-old G7P0 female at 8 weeks gestation presented to the emergency department (ED) following a syncopal episode. She complained of chest pain and dyspnea, and had hemodynamic instability, which responded to intravenous fluids. Continued fluid resuscitation, supplemental oxygen, as well as therapeutic dose low molecular weight heparin (LMWH) were administered in the ED. Computed tomography (CT) pulmonary angiogram confirmed saddle pulmonary embolism (PE). After 12 h of continued chest pain and high oxygen requirements, a decision was made to use catheter-directed thrombolysis (CDT) involving alteplase with manual thrombus maceration in bilateral pulmonary arteries. There were no immediate hemorrhagic complications and follow-up fetal ultrasound demonstrated a normal viable intrauterine pregnancy. She clinically improved and was discharged on LMWH. Cesarean section was scheduled, and the patient delivered a healthy term infant at 37 weeks gestation without complications. Our case demonstrates that CDT may be a safe and effective treatment for submassive PE in pregnancy. RÉSUMÉ Une femme âgée de 33 ans et enceinte de huit semaines (G7P0) se présente aux urgences à la suite d’un épisode syncopal. Elle se plaint de douleurs thoraciques et de dyspnée et présente une instabilité hémodynamique qui répond aux solutés intraveineux. Une réanimation liquidienne continue, une oxygénothérapie ainsi qu’une dose thérapeutique d’héparine de faible poids moléculaire sont administrées aux urgences. L’angiographie pulmonaire par tomodensitométrie confirme une embolie pulmonaire en selle. Après 12 heures de douleurs thoraciques continues et de besoins élevés en oxygène, on décide d’utiliser la thrombolyse dirigée par cathéter (TDC) à l’aide de l’altéplase avec macération manuelle du thrombus dans les artères pulmonaires bilatérales. Il n’y a pas eu de complications hémorragiques immédiates et le suivi échographique du fœtus a démontré une grossesse intra utérine normale et viable. Son état clinique s’est amélioré et elle a obtenu son congé sous héparine de faible poids moléculaire. Une césarienne a été planifiée et la patiente a accouché d’un enfant à terme et en bonne santé à 37 semaines de grossesse, sans complications. Notre cas démontre que la TDC peut être un traitement sûr et efficace de l’embolie pulmonaire submassive en cours de grossesse. C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e 24 V o l u m e 1 6 , I s s u e 1 , 2 0 2 1 Case Reports and Clinical Images CJGIM_4_WKBK.indd 24 3/19/21 5:36 PM Case Report A 33-year-old female, 8 weeks pregnant (Gravida 7, Para 0), with past medical history significant for hypothyroidism, uterine leiomyomas, and seven spontaneous abortions (all <20 weeks’ gestational age) presented to the emergency department (ED) with chest pain, right upper quadrant abdominal pain, and dyspnea. She had reported a brief syncopal episode on ambulation earlier that day. Medications included levothyroxi
{"title":"What to Do When They’re Eating for Two? A Case of Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism in Pregnancy","authors":"J. M. Radford","doi":"10.22374/CJGIM.V16I1.440","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.440","url":null,"abstract":"A 33-year-old G7P0 female at 8 weeks gestation presented to the emergency department (ED) following a syncopal episode. She complained of chest pain and dyspnea, and had hemodynamic instability, which responded to intravenous fluids. Continued fluid resuscitation, supplemental oxygen, as well as therapeutic dose low molecular weight heparin (LMWH) were administered in the ED. Computed tomography (CT) pulmonary angiogram confirmed saddle pulmonary embolism (PE). After 12 h of continued chest pain and high oxygen requirements, a decision was made to use catheter-directed thrombolysis (CDT) involving alteplase with manual thrombus maceration in bilateral pulmonary arteries. There were no immediate hemorrhagic complications and follow-up fetal ultrasound demonstrated a normal viable intrauterine pregnancy. She clinically improved and was discharged on LMWH. Cesarean section was scheduled, and the patient delivered a healthy term infant at 37 weeks gestation without complications. Our case demonstrates that CDT may be a safe and effective treatment for submassive PE in pregnancy. RÉSUMÉ Une femme âgée de 33 ans et enceinte de huit semaines (G7P0) se présente aux urgences à la suite d’un épisode syncopal. Elle se plaint de douleurs thoraciques et de dyspnée et présente une instabilité hémodynamique qui répond aux solutés intraveineux. Une réanimation liquidienne continue, une oxygénothérapie ainsi qu’une dose thérapeutique d’héparine de faible poids moléculaire sont administrées aux urgences. L’angiographie pulmonaire par tomodensitométrie confirme une embolie pulmonaire en selle. Après 12 heures de douleurs thoraciques continues et de besoins élevés en oxygène, on décide d’utiliser la thrombolyse dirigée par cathéter (TDC) à l’aide de l’altéplase avec macération manuelle du thrombus dans les artères pulmonaires bilatérales. Il n’y a pas eu de complications hémorragiques immédiates et le suivi échographique du fœtus a démontré une grossesse intra utérine normale et viable. Son état clinique s’est amélioré et elle a obtenu son congé sous héparine de faible poids moléculaire. Une césarienne a été planifiée et la patiente a accouché d’un enfant à terme et en bonne santé à 37 semaines de grossesse, sans complications. Notre cas démontre que la TDC peut être un traitement sûr et efficace de l’embolie pulmonaire submassive en cours de grossesse. C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e 24 V o l u m e 1 6 , I s s u e 1 , 2 0 2 1 Case Reports and Clinical Images CJGIM_4_WKBK.indd 24 3/19/21 5:36 PM Case Report A 33-year-old female, 8 weeks pregnant (Gravida 7, Para 0), with past medical history significant for hypothyroidism, uterine leiomyomas, and seven spontaneous abortions (all <20 weeks’ gestational age) presented to the emergency department (ED) with chest pain, right upper quadrant abdominal pain, and dyspnea. She had reported a brief syncopal episode on ambulation earlier that day. Medications included levothyroxi","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"1 1","pages":"24-30"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91211265","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-03-26DOI: 10.22374/CJGIM.V16ISP1.530
F. Borges, S. Ofori, M. Marcucci
One in 60 patients who undergo major noncardiac surgery dies within 30 days following surgery. The most common cause is cardiac complications, of which myocardial injury after noncardiac surgery (MINS) and perioperative atrial fibrillation (POAF) are common, affecting about 18 and 11% of adults, respectively, after noncardiac surgery. Patients who suffer MINS are at a higher risk of death compared to patients without MINS. Similarly, patients who develop POAF are at a higher risk of stroke and death compared to patients who do not. Most patients who suffer MINS are asymptomatic, and its diagnosis is not possible without routine troponin monitoring. Observational studies support the use of statins and aspirin in the management of patients with MINS. The only randomized controlled trial to date that has specifically addressed the management of MINS was the MANAGE trial that demonstrated the efficacy and safety of intermediate dose dabigatran in this population. There are no specific prediction models for POAF and no randomised controlled trial evidence to guide the specific management of POAF. Management guidelines in the acute period follow the management of nonoperative atrial fibrillation. The role of long-term anticoagulation in this population is still uncertain and should be guided by a shared care decision model with the patient, and with consideration of the individual risk for stroke balanced against the risk of bleeding. In this review, we present a case-based approach to the detection, prognosis, and management of MINS and POAF based on the existing evidence. RÉSUMÉUn patient sur 60 qui subit une intervention chirurgicale majeure non cardiaque meurt dans les 30 jours suivant l’opération. La cause la plus fréquente est celle des complications cardiaques, dont les lésions myocardiques après une chirurgie non cardiaque (LMCNC) et la fibrillation auriculaire périopératoire (FAPO) sont courantes et touchent respectivement environ 18 et 11 % des adultes après une chirurgie non cardiaque. Les patients présentant des LMCNC sont exposés à un risque plus élevé de décès que les patients qui ne présentent pas de LMCNC. De même, les patients chez qui on voit apparaître une FAPO ont un risque plus élevé d’accident vasculaire cérébral et de décès que ceux qui ne connaîtront pas cette complication. La plupart des patients atteints de LMCNC sont asymptomatiques, et il est impossible d’établir un diagnostic sans surveiller régulièrement la troponine. Des études d’observation appuient l’utilisation des statines et de l’aspirine dans la prise en charge des patients atteints de LMCNC. À ce jour, le seul essai contrôlé randomisé qui s’est penché précisément sur le traitement des LMCNC est l’essai MANAGE qui a démontré l’efficacité et l’innocuité du dabigatran à dose intermédiaire chez cette population. Il n’existe aucun modèle de prédiction précis pour la FAPO ni aucune donnée probante provenant d’essais contrôlés randomisés pour orienter précisément son trai
每60名接受非心脏手术的患者中就有1人在手术后30天内死亡。最常见的原因是心脏并发症，其中非心脏手术后心肌损伤(MINS)和围手术期心房颤动(POAF)是常见的，分别影响约18%和11%的成年人在非心脏手术后。与没有MINS的患者相比，患有MINS的患者死亡风险更高。同样，与未发生POAF的患者相比，发生POAF的患者中风和死亡的风险更高。大多数患有MINS的患者是无症状的，没有常规肌钙蛋白监测是不可能诊断的。观察性研究支持他汀类药物和阿司匹林在急性脑梗死患者治疗中的应用。迄今为止，唯一一项专门针对MINS管理的随机对照试验是MANAGE试验，该试验证明了中剂量达比加群在该人群中的有效性和安全性。目前还没有具体的POAF预测模型，也没有随机对照试验证据来指导POAF的具体治疗。急性期的管理指南遵循非手术性心房颤动的管理。长期抗凝在这一人群中的作用仍不确定，应与患者共同制定护理决策模型，并考虑个体卒中风险与出血风险之间的平衡。在这篇综述中，我们基于现有的证据提出了一种基于病例的方法来检测、预后和治疗MINS和POAF。RÉSUMÉUn患者体重60公斤，接受一次手术干预，不可抗力，非心脏测量，术后30小时。无原因、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织、无组织。将患者与LMCNC进行比较，将暴露的患者与无风险的患者进行比较，将患者与无风险的患者进行比较。De même, les患者在血管装置上有缺陷;trune FAPO不存在危险，并伴有心血管事故;cvac; cvac; cvac; cvac; cvac; cvac; cvac;大多数患者没有症状，因此不可能在诊断时使用肌氨酸来检测患者的病情。他汀类药物的使用和阿斯匹林类药物的使用对LMCNC患者的治疗起着重要的作用。À在我们的研究中，我们的研究对象是:contrôlé随机抽样抽样，我们的研究对象是:随机抽样，我们的研究对象是:随机抽样，我们的研究对象是:随机抽样，我们的研究对象是:随机抽样，我们的研究对象是:随机抽样，我们的研究对象是:随机抽样，我们的研究对象是:随机抽样，我们的研究对象是:随机抽样。将不存在一个简单的模型来预测，一个简单的模型来预测，一个简单的模型来预测，一个简单的模型来预测，一个简单的模型来预测，一个简单的模型来预测，一个简单的模型来预测。《关于管理与自由交换的组织》aiguë《关于管理与自由交换的组织》(关于管理与自由交换的组织)。Le rôle de l '抗凝血长期chechete人群测试encore incertain et devrae être guide - par un modere de prise de danci..com决定部分患者的平均年龄为1 / 3，患者的平均年龄为1 / 4，患者的平均年龄为1 / 4，心血管疾病患者的平均年龄为1 / 4，患者的平均年龄为1 / 4，心血管疾病患者的平均年龄为1 / 4。正如我们所看到的那样，有一种办法可以确定的是，有一种办法可以确定的是:有一种办法可以确定的是:有一种办法可以确定的是:有一种办法可以确定的是:有一种办法可以确定的是:有一种办法可以确定的是:有一种办法可以确定的是:有一种办法可以确定的是:有一种办法可以确定。
{"title":"Myocardial Injury after Noncardiac Surgery and Perioperative Atrial Fibrillation","authors":"F. Borges, S. Ofori, M. Marcucci","doi":"10.22374/CJGIM.V16ISP1.530","DOIUrl":"https://doi.org/10.22374/CJGIM.V16ISP1.530","url":null,"abstract":"One in 60 patients who undergo major noncardiac surgery dies within 30 days following surgery. The most common cause is cardiac complications, of which myocardial injury after noncardiac surgery (MINS) and perioperative atrial fibrillation (POAF) are common, affecting about 18 and 11% of adults, respectively, after noncardiac surgery. Patients who suffer MINS are at a higher risk of death compared to patients without MINS. Similarly, patients who develop POAF are at a higher risk of stroke and death compared to patients who do not. Most patients who suffer MINS are asymptomatic, and its diagnosis is not possible without routine troponin monitoring. Observational studies support the use of statins and aspirin in the management of patients with MINS. The only randomized controlled trial to date that has specifically addressed the management of MINS was the MANAGE trial that demonstrated the efficacy and safety of intermediate dose dabigatran in this population. There are no specific prediction models for POAF and no randomised controlled trial evidence to guide the specific management of POAF. Management guidelines in the acute period follow the management of nonoperative atrial fibrillation. The role of long-term anticoagulation in this population is still uncertain and should be guided by a shared care decision model with the patient, and with consideration of the individual risk for stroke balanced against the risk of bleeding. In this review, we present a case-based approach to the detection, prognosis, and management of MINS and POAF based on the existing evidence.\u0000RÉSUMÉUn patient sur 60 qui subit une intervention chirurgicale majeure non cardiaque meurt dans les 30 jours suivant l’opération. La cause la plus fréquente est celle des complications cardiaques, dont les lésions myocardiques après une chirurgie non cardiaque (LMCNC) et la fibrillation auriculaire périopératoire (FAPO) sont courantes et touchent respectivement environ 18 et 11 % des adultes après une chirurgie non cardiaque. Les patients présentant des LMCNC sont exposés à un risque plus élevé de décès que les patients qui ne présentent pas de LMCNC. De même, les patients chez qui on voit apparaître une FAPO ont un risque plus élevé d’accident vasculaire cérébral et de décès que ceux qui ne connaîtront pas cette complication. La plupart des patients atteints de LMCNC sont asymptomatiques, et il est impossible d’établir un diagnostic sans surveiller régulièrement la troponine. Des études d’observation appuient l’utilisation des statines et de l’aspirine dans la prise en charge des patients atteints de LMCNC. À ce jour, le seul essai contrôlé randomisé qui s’est penché précisément sur le traitement des LMCNC est l’essai MANAGE qui a démontré l’efficacité et l’innocuité du dabigatran à dose intermédiaire chez cette population. Il n’existe aucun modèle de prédiction précis pour la FAPO ni aucune donnée probante provenant d’essais contrôlés randomisés pour orienter précisément son trai","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"60 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83066837","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-03-26DOI: 10.22374/CJGIM.V16I1.439
G. Prosperi-Porta, B. Wilson
A 66-year old femal with longstanding seropositive rheumatoid arthritis was admitted to the internal medicine service with bilateral foot pain and new painless raised fluid filled black lesions on her feet. Two weeks prior she underwent a right great toe amputation for "gangrene" by podiatric surgery. Five months prior, the patient discontinued all disease modifying therapies to pursue naturopathic remedies. The patient was diagnosed with rheumatoid arthritis vasculitis and despite immunosupressive therapies, the patient ultimately underwent bilateral transmetatarsal amputations for progression disease progression. This case reinforces the imporance for physicians to strongly discourage only using naturopathic remedies in rheumatoid arthritis and to consider vasculitis in any patient with rheumatoid arthritis presenting with new skin lesions as late detection can have severe implications.
{"title":"Rheumatoid Vasculitis Following Change to Naturopathic Remedies","authors":"G. Prosperi-Porta, B. Wilson","doi":"10.22374/CJGIM.V16I1.439","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.439","url":null,"abstract":"A 66-year old femal with longstanding seropositive rheumatoid arthritis was admitted to the internal medicine service with bilateral foot pain and new painless raised fluid filled black lesions on her feet. Two weeks prior she underwent a right great toe amputation for \"gangrene\" by podiatric surgery. Five months prior, the patient discontinued all disease modifying therapies to pursue naturopathic remedies. The patient was diagnosed with rheumatoid arthritis vasculitis and despite immunosupressive therapies, the patient ultimately underwent bilateral transmetatarsal amputations for progression disease progression. This case reinforces the imporance for physicians to strongly discourage only using naturopathic remedies in rheumatoid arthritis and to consider vasculitis in any patient with rheumatoid arthritis presenting with new skin lesions as late detection can have severe implications. ","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"3 1","pages":"34-35"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75615506","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-03-26DOI: 10.22374/CJGIM.V16I1.546
James D. Douketis
{"title":"The SARS-CoV-19 Pandemic…one year later / La pandémie du SRAS-CoV-19... un an plus tard","authors":"James D. Douketis","doi":"10.22374/CJGIM.V16I1.546","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.546","url":null,"abstract":"","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"40 1","pages":"6-7"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74243836","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-03-26DOI: 10.22374/CJGIM.V16I1.432
Christopher Oleynick, Pouya Motazedian, G. Prosperi-Porta
Sodium-glucose co-transporter 2 (SGLT-2) inhibitors are a relatively new class of medications available in Canada used in the treatment of type 2 diabetes mellitus (T2DM). There is an abundance of emerging literature that these drugs are not only effective in the treatment of T2DM but also offer robust clinical benefits for renal disease, cardiovascular disease, and congestive heart failure. Despite the clinical benefits, SGLT-2 inhibitors may be underutilized as some physicians are unfamiliar with the medications or are concerned about their side-effect profile. Given the high prevalence of T2DM and the above comorbidities frequently encountered within Internal Medicine, it is important for internists to be familiar with SGLT-2 inhibitors. This is a short article encapsulating important aspects about these medications that we believe internists should know. RÉSUMÉ Les inhibiteurs du cotransporteur sodium-glucose de type 2 (SGLT-2) sont une classe relativement nouvelle de médicaments offerts au Canada et utilisés dans le traitement du diabète de type 2 (DT2). Une profusion de nouvelles études montre que ces médicaments sont non seulement efficaces dans le traitement du DT2, mais qu’ils offrent également de solides avantages cliniques pour les maladies rénales, les maladies cardiovasculaires et l’insuffisance cardiaque congestive. Malgré ces avantages cliniques, les inhibiteurs du SGLT-2 sont peut-être sous-utilisés, car certains médecins ne connaissent pas ces médicaments ou s’inquiètent de leur profil d’effets secondaires. Étant donné la forte prévalence du DT2 et les affections comorbides susmentionnées fréquemment rencontrées en médecine interne, il est important que les internistes connaissent bien les inhibiteurs du SGLT-2. Voici un court article qui résume les aspects importants de ces médicaments que les internistes devraient connaître. Sodium-Glucose Co-Transporter 2 Inhibitors Are a Relatively New Class of Drugs Used in the Treatment of Type 2 Diabetes Sodium-glucose co-transporter 2 (SGLT-2) inhibitors inhibit glucose re-absorption in the proximal convoluted tubule of the kidney, thereby promoting glucosuria and reducing serum glucose in a mechanism of action that is independent of insulin. They yield a modest reduction in hemoglobin A1c (HbA1c) between 0.5 and 1%, and cause a sustained average weight loss of 2–3kg after initiation.1,2 Although metformin is still recommended for first-line pharmacotherapy for type 2 diabetes mellitus (T2DM), multiple guidelines including Diabetes Canada are recommending C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e 14 V o l u m e 1 6 , I s s u e 1 , 2 0 2 1 O r i g i n a l R e s e a r c h CJGIM_4_WKBK.indd 14 3/19/21 5:36 PM reducing the risk for cardiac decompensation.7,8 Internists should strongly consider the use of SGLT-2 inhibitors in patients with T2DM and CHF, and dapagliflozin for patients with CHF and an LVEF <40%, regardless of their diabetic status. Sodium-Gl
钠-葡萄糖共转运蛋白2 (SGLT-2)抑制剂是加拿大用于治疗2型糖尿病(T2DM)的一类相对较新的药物。有大量的新兴文献表明，这些药物不仅对治疗2型糖尿病有效，而且对肾脏疾病、心血管疾病和充血性心力衰竭也有很强的临床疗效。尽管有临床益处，SGLT-2抑制剂可能未被充分利用，因为一些医生不熟悉药物或担心其副作用。鉴于T2DM的高患病率和上述合并症在内科经常遇到，内科医生熟悉SGLT-2抑制剂是很重要的。这是一篇简短的文章，概括了这些药物的重要方面，我们认为内科医生应该知道。RÉSUMÉ 2型钠-葡萄糖共转运蛋白(SGLT-2)抑制剂为一类相关研究，新发现的2型糖尿苷与2型糖尿苷共转运蛋白(DT2)之间存在相关性。一个缤纷de新式练习曲的东西,这些药物的非seulement efficaces在traitement du DT2,但是他们offrent并非de固体优点之一倩碧倒les疾病肾,les疾病cardiovasculaires et l 'insuffisance cardiaque充血性。恶性肿瘤具有优势，SGLT-2的抑制作用较弱，但有一些恶性肿瘤的影响，如:-être小效用型肿瘤，某些恶性肿瘤的影响，如:恶性肿瘤的影响，小效用型肿瘤的影响。Étant donnere la forte pracentvalence du DT2 et et et的影响因素包括:将SGLT-2的内部因素与SGLT-2的内部因素联系起来;将SGLT-2的内部因素与SGLT-2的内部因素联系起来。在法院的第1条中，规定了一些重要的方面，例如:<s:1> <s:1> <s:1>树的内部因素。钠-葡萄糖共转运蛋白2抑制剂是一类用于治疗2型糖尿病的相对较新的药物钠-葡萄糖共转运蛋白2 (SGLT-2)抑制剂抑制肾脏近曲小管的葡萄糖重吸收，从而促进血糖和降低血糖，其作用机制不依赖于胰岛素。它们使血红蛋白糖化血红蛋白(HbA1c)适度降低0.5 - 1%，并在开始后持续平均体重减轻2-3kg。1、2尽管二甲双胍仍然推荐为一线药物治疗2型糖尿病(T2DM)病人体内,多个指南包括糖尿病加拿大建议C n d i n J o u r n a G l o f e n e r l i n t e r n a l M e d i C i n e 14 V o l u M e 1 6, i s s u e 1 2 0 2 1 o r G我n l r e s e r C h CJGIM_4_WKBK。2014年3月19日下午5:36降低心脏失代偿的风险。7,8内科医生应强烈考虑在T2DM和CHF患者中使用SGLT-2抑制剂，在CHF和LVEF为30 mL/min/1.73 m2的患者和所有蛋白尿亚组中使用达格列净。内科医生应强烈考虑使用SGLT-2抑制剂治疗T2DM患者和有肾脏疾病证据且肾功能正常的患者。最近的DAPA-HF试验表明，在症状性CHF且左室射血分数(LVEF)降低<40%的患者中，达格列净可使CHF恶化或心血管死亡减少26% (HR 0.74 [95% CI 0.65-0.85]， P = 0.00001)，使CHF恶化包括住院的患者减少30% (HR 0.70 [95% CI 0.59-0.83]， P = 0.00003)。不管他们是否患有糖尿病一项比较EMPAREG OUTCOME(恩帕列净)、CANVAS (canagliflozin)和declre - timi -58 (dapagliflozin)试验的荟萃分析指出了相似的结果，即SLGT-2抑制剂可使CHF住院率降低31% (HR 0.69 [95% CI 0.71-0.84]， P = 0.0001)，而与lve7无关。7改善CHF患者预后的作用机制被认为是继发于这些药物的肾保护作用和钠尿作用。从而C n d i n J o u r n a G l o f e n e r l i n t e r n a l M e d i C i n e V o l u M e 1 6, i s s u e 1 2 0 2 1 15 Oleynick e t l。CJGIM_4_WKBK。内科医生应注意停用钠-葡萄糖共转运蛋白2抑制剂的情况由于SGLT-2抑制剂有通过利尿引起轻度脱水的倾向，它们可能导致肾前损伤恶化，因此大多数因急性肾损伤(AKI)住院的患者或重病患者应停用SGLT-2抑制剂与围手术期酮症酸中毒和AKI发生率增加有关，建议择期手术前3天停用恩格列净、卡格列净和达格列净，以降低发生上述并发症的风险。
{"title":"Important Things Internists Should Know about Sodium-Glucose Co-Transporter 2 Inhibitors","authors":"Christopher Oleynick, Pouya Motazedian, G. Prosperi-Porta","doi":"10.22374/CJGIM.V16I1.432","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.432","url":null,"abstract":"Sodium-glucose co-transporter 2 (SGLT-2) inhibitors are a relatively new class of medications available in Canada used in the treatment of type 2 diabetes mellitus (T2DM). There is an abundance of emerging literature that these drugs are not only effective in the treatment of T2DM but also offer robust clinical benefits for renal disease, cardiovascular disease, and congestive heart failure. Despite the clinical benefits, SGLT-2 inhibitors may be underutilized as some physicians are unfamiliar with the medications or are concerned about their side-effect profile. Given the high prevalence of T2DM and the above comorbidities frequently encountered within Internal Medicine, it is important for internists to be familiar with SGLT-2 inhibitors. This is a short article encapsulating important aspects about these medications that we believe internists should know. RÉSUMÉ Les inhibiteurs du cotransporteur sodium-glucose de type 2 (SGLT-2) sont une classe relativement nouvelle de médicaments offerts au Canada et utilisés dans le traitement du diabète de type 2 (DT2). Une profusion de nouvelles études montre que ces médicaments sont non seulement efficaces dans le traitement du DT2, mais qu’ils offrent également de solides avantages cliniques pour les maladies rénales, les maladies cardiovasculaires et l’insuffisance cardiaque congestive. Malgré ces avantages cliniques, les inhibiteurs du SGLT-2 sont peut-être sous-utilisés, car certains médecins ne connaissent pas ces médicaments ou s’inquiètent de leur profil d’effets secondaires. Étant donné la forte prévalence du DT2 et les affections comorbides susmentionnées fréquemment rencontrées en médecine interne, il est important que les internistes connaissent bien les inhibiteurs du SGLT-2. Voici un court article qui résume les aspects importants de ces médicaments que les internistes devraient connaître. Sodium-Glucose Co-Transporter 2 Inhibitors Are a Relatively New Class of Drugs Used in the Treatment of Type 2 Diabetes Sodium-glucose co-transporter 2 (SGLT-2) inhibitors inhibit glucose re-absorption in the proximal convoluted tubule of the kidney, thereby promoting glucosuria and reducing serum glucose in a mechanism of action that is independent of insulin. They yield a modest reduction in hemoglobin A1c (HbA1c) between 0.5 and 1%, and cause a sustained average weight loss of 2–3kg after initiation.1,2 Although metformin is still recommended for first-line pharmacotherapy for type 2 diabetes mellitus (T2DM), multiple guidelines including Diabetes Canada are recommending C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e 14 V o l u m e 1 6 , I s s u e 1 , 2 0 2 1 O r i g i n a l R e s e a r c h CJGIM_4_WKBK.indd 14 3/19/21 5:36 PM reducing the risk for cardiac decompensation.7,8 Internists should strongly consider the use of SGLT-2 inhibitors in patients with T2DM and CHF, and dapagliflozin for patients with CHF and an LVEF <40%, regardless of their diabetic status. Sodium-Gl","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"411 1","pages":"14-16"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79912989","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-03-26DOI: 10.22374/CJGIM.V16I1.353
Farah Zarka, T. Slaoui, Jean-Paul Makhzoum
Prompt treatment of autoimmune encephalitis can prevent long-term neurological sequelae. However, the data and evidence for the treatment of autoantibody negative encephalitis are limited, particularly so for rhombencephalitis. We report the case of a seronegative autoimmune rhombencephalitis successfully treated with rituximab. A 21-year-old woman was transferred to our center for progressive neuropsychiatric symptoms and neurological deficits progressing into a Locked-in state despite first-line immunotherapy with corticosteroids and immunoglobulins. She was started on a rituximab induction protocol with noticeable improvement within days. The patient then received a maintenance dose and during a follow-up after 9 months was still in remission, suggesting that rituximab can be an efficient treatment for severe refractory seronegative rhombencephalitis
{"title":"Case of Severe Seronegative Autoimmune Rhombencephalitis Successfully Treated with Rituximab","authors":"Farah Zarka, T. Slaoui, Jean-Paul Makhzoum","doi":"10.22374/CJGIM.V16I1.353","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.353","url":null,"abstract":"Prompt treatment of autoimmune encephalitis can prevent long-term neurological sequelae. However, the data and evidence for the treatment of autoantibody negative encephalitis are limited, particularly so for rhombencephalitis. We report the case of a seronegative autoimmune rhombencephalitis successfully treated with rituximab. A 21-year-old woman was transferred to our center for progressive neuropsychiatric symptoms and neurological deficits progressing into a Locked-in state despite first-line immunotherapy with corticosteroids and immunoglobulins. She was started on a rituximab induction protocol with noticeable improvement within days. The patient then received a maintenance dose and during a follow-up after 9 months was still in remission, suggesting that rituximab can be an efficient treatment for severe refractory seronegative rhombencephalitis","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"499 1","pages":"31-33"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91088898","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-03-26DOI: 10.22374/CJGIM.V16I1.415
Victoria David, Michael H. Walsh, J. Lockyer, M. Mintz
The Royal College of Physicians and Surgeons of Canada introduced Competence by Design (CBD) as an educational model along with Entrustable Professional Activities (EPAs) as markers of achievement that could be directly observed on a frequent basis. In 2017, the University of Calgary Internal Medicine (IM) program piloted CBD. The purpose of this study was to (1) assess whether written feedback from EPAs were actionable, valuable, and disruptive to workflow and (2) assess the time required to complete an EPA.
{"title":"Entrustable Professional Activities: An Analysis of Faculty Time, Trainee Perspectives and Actionability","authors":"Victoria David, Michael H. Walsh, J. Lockyer, M. Mintz","doi":"10.22374/CJGIM.V16I1.415","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.415","url":null,"abstract":"The Royal College of Physicians and Surgeons of Canada introduced Competence by Design (CBD) as an educational model along with Entrustable Professional Activities (EPAs) as markers of achievement that could be directly observed on a frequent basis. In 2017, the University of Calgary Internal Medicine (IM) program piloted CBD. The purpose of this study was to (1) assess whether written feedback from EPAs were actionable, valuable, and disruptive to workflow and (2) assess the time required to complete an EPA.","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"9 6 1","pages":"8-13"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77591978","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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