Document 2054035

THE UNIVERSITY OF MANITOBA DEPARTMENT OF INTERNAL MEDICINE POSTGRADUATE EDUCATION PROGRAM RESIDENT RESEARCH DAY MAY 18, 2010 SCIENTIFIC PROGRAM Theatre B, BMSB DEPARTMENT OF INTERNAL MEDICINE RESIDENT RESEARCH DAY PROGRAM TUESDAY, MAY 18, 2010 THEATRE B, BASIC MEDICAL SCIENCES BLDG. 0800 The guest judge and speaker for the Department of Medicine Resident Research
Day will present at the Department of Medicine Grand Rounds in Frederic Gaspard
Theatre (Theatre A):
Hepatitis C Treatment: The Difficult Present and Promising Future
Curtis Cooper, MD. FRCPC Associate Professor of Medicine University of Ottawa Division of Infectious Diseases The Ottawa Hospital 0910 The resident presentations will occur in Theatre B
• Introductory remarks
Dr. D. Houston
Chair, Department of Medicine Resident Research Day
PODIUM PRESENTATIO
Time will be adhered to with 10 minutes for presentation and 5 minutes for questions.
0915 (Case Report)
Rhabdomyolysis in multiple myeloma
Sara Dunsmore, Core
Supervisor: G. Bueti
0930 (Case Report)
The successful use of rituximab as salvage therapy in steroid resistant minimal change
nephrotic syndrome
Corey Metcalf, Core
Supervisor: M. Verrelli
0945 (Case Report)
Birt-Hogg-DuM syndrome with an associated novel pulmonary neoplasm
Marcus Blouw, Respirology
Supervisor: E. Giannouli
1000 (Clinical Investigation)
Treatment of suspected herpes simplex encephalitis at HSC: A critical review
Peter Hughes, Neurology
Supervisor: A. Jackson
1015
(Clinical Investigation)
Complete revascularization improves survival in cardiogenic shack due to myocardial
infarction: Manitoba Cardiogenic Shack Registry Investigators
Robin Ducas, Core
1030
(Clinical Investigation)
The use of sublingual Fentanyl for the treatment of incident dyspnea: A retrospective
pilot study
Jonathan Wong, Core
1045
Supervisor: A.M. Shojania
(Clinical Investigation)
Evolution of endothelial injury during dialysis and the impact of kidney transplantation
Keren Mandelzweig, Core
1115
Supervisor: J. Richman-Eisenstat
(Case Report)
Congenital TIP
Alan Smith, Core
1100
Supervisor: F. Hussain
Supervisor: C. Rigatto
(Case Report)
Azacytidine as a navel agent in the treatment of acute lymphoblastic leukemia
Kris Paulson, Haematology
Supervisor: M. SeHel
1130 -1200
Break
1200 -1245
Best published paper derived from 2008 Resident Research Day
A population-based study of breastfeeding in inflammatory bowel disease:
Initiation, duration, and effect on disease in the postpartum period
Dana C. Moffatt
Alexandra IInyckyj
Charles N. Bernstein
Published in the American Journal of Gastroenterology
2009; 104:2517-2523
1300
(Clinical Investigation)
The role of 3D echocardiography in breast cancer: Comparison with 20
echocardiography, MUGA and cardiac MRI
Mehrdad Golian, Care
1315
(Case Report)
The occurrence of pulmonary sarcoidosis in a patient with gastrointestinal stromal tumors
(GISTs)
Mohmmed Aigamdl, Core
1330
Supervisor: D. Jassal
Supervisor: G. Eschun
(Clinical Investigation)
Infections. microbiology and outcomes in First Nations patients an peritoneal dialysis
Ainslie Hildebrand, Core
Supervisor: M. Sood
1345
(Case Report)
An atypical presentation of allergic broncopulmonary aspergillosis
Ali Benzaglam, Core
Supervisor: S. Sharma
1400
(Clinical Investigation)
An exploration of dialysis modality preferences: The potential role of differing renal clinic
practices as a factor
Jay Hingwala, Core
Supervisor: P. Czaykowski
1415
(Clinical Investigation)
In hospital outcomes of the "no optionn unprotected left main percutaneous intervention:
The Manitoba Left Main PCI Registry
Nader Elmayergi. Cardiology
Supervisor: F. Hussain
1430
(Clinical Investigation)
The logistic Euroscore but not the SYNTAX score predicts in-hospital mortality in high
risk unprotected left main percutaneous intervention: The Manitoba Left Main PCI
Registry
Nader Elmayergi, Cardiology
Supervisor: F. Hussain
1445 -1515
BREAK
1515
(Clinical Investigation)
The utility of the SYNTAX score in cardiogenic shock - can it help to guide
revascularization therapy?
Thang Nguyen, Cardiology
Supervisor: F. Hussain
1530
(Clinical Investigation)
Insight into leaving against medical advice from a general medical service
Joel Nkosi, Core
Supervisor: K. Lamba
1545
(Clinical Investigation)
Serum interleukin-6, cardiovascular disease, and mortality in chronic lymphocytic
leukemia
David Dawe, Core
Supervisor: J.B. Johnston
1600
(Clinical Investigation)
Pleurx - A novel management strategy for malignant pleural effUSions
Ayaz Khan, Core
Supervisor: S. Sharma
1615
(Case Report)
Multimodality imaging of a saphenous vein graft aneurysm
Kerrett Wallace, Core
Supervisor: F. Hussain
1630
(Clinical Investigation)
Clopidogrel and proton pump inhibitor use; a Canadian physicians' survey
Alireza Bagherll, Core
Supervisor: L. Targownik
1645
(Case Report)
Acute hepatitis as a manifestation of parvovirus B19 infection
Aleisha Hatakka, Core
Supervisor: A. Walkty
1700
(Case Report)
Unusual variant of metaplastic ductal carcinoma of the breast Bilateral adenosquamous
carcinoma
Daniela Stroescu, Core
Supervisor: M. Krahn
1715
(Case Report)
The occurrence of pulmonary sarcoidoso in a patient treated with interferon
Fahad Alhammad, Core
Supervisors: G. Eschun,
M. Shepertycky
1730
Closing Remarks - Dr. Don Houston
- Dr. Dan Roberts
DEPARTMENT OF INTERNAL MEDICINE RESIDENT RESEARCH DAY PROGRAM TUESDAY, MAY 18, 2010 THEATRE B, BASIC MEDICAL SCIENCES BLDG. OSTER PRESENTATIONS
Time will be adhered to with 5 minutes for presentation and 5 minutes for questions.
1300 {Clinical Investigation)
Patient outcomes in pre-hospital electrocardiograms initially negative for STEMI: A
subset of the CODE STEMI project
Robin Ducas, Core
1310 (Clinical Investigation)
Publication bias: Where have all the abstracts gone?
Kris Paulson, Haematology
1320 Supervisor: R. Wong
{Case Report}
Back pain isn't always just back pain
Daljit Gill, Core
1400 Supervisor: T. Wong
(Case Report)
Malignant peripheral nerve sheath tumor of the pelvis arising ten years after radiation
therapy for cervical cancer
Maclean Thiessen, Core
1350 Supervisor: S. Sharma
(Case Report)
Posterior reversible encephalopathy syndrome - New associations with thrombotic
thrombocytopenic purpura and rituximab
Lauren MacKenzie, Core
1340 Supervisor: M. Seftel
(Clinical Investigation}
Increased mortality and morbidity after coronary artery bypass grafting in chronic
obstructive pulmonary disease
Fawaz Alharbi, Respirology
1330 Supervisor: J. Tam
Supervisor: F. Hussain
(Clinical Investigation)
Enteral feeding tube placement: A review of institutional protocol as compared to best
practice
Owen Mooney, Core
Supervisor: N. Hajidiacos
1410 (Case Report)
Virus on the brain: An exhaustive search reveals an occult pathogen
Benjamin Goldenberg, Core
1420 (Case Report)
Cystic echinococcosis: late rupture and complication of a stable pulmonary cyst
Jolene Fisher, Core
1430 Supervisors: F. Aokl, P. Orr
Supervisor: V. Hoffstein
(Case Report)
Novel mutation of the senataxin gene in a patient with ataxia with oculomotor apraxia
type 2
Esseddegg Ghrooda, Neurology
Supervisor: A. Borys
1440 -1515 BREAK
1515 (Clinical Investigation)
Application of evidence-based guidelines and continuous quality indicators in peritoneal
dialysis: A nephrology now study
Nathan Allen, Core
1525 (Case Report)
Erythrokeratoderma variabilis with erythema gyratum repens: A case of a de novo
missense mutation in the GJB4 gene
Jason Sneath, Core
1535 Supervisor: S. Navaratham
{Clinical Investigation)
Cherchez Ie chat! A review of pasteurella multocida peritonitis in peritoneal dialysis
patients
David Allen, Core
1605 Supervisor: D. Jassal
(Clinical Investigation)
Nasopharyngeal carcinoma (NPC) patterns in Manitoba's Asian and non-Asian
population
Vallerie Gordon, Medical Oncology
1555 Supervisor: S. Silver
(Clinical Investigation)
Evaluating the effectiveness of rosuvastatin in preventing the progression of diastolic
dysfunction in aortic stenosis: A substudy of the aortic stenosis progression observation
measuring effects of rosuvastatin
Kapil Bhagirath, Cardiology
1545 Supervisor: M. Sood
Supervisor: J. Embil
(Case Report)
Neurological complications associated with profound fluctuations in serum sodium:
Osmotic or ischemic demyelination?
Kimberley Mulchey, Core
Supervisor: P. St. John
1615 (Case Report)
Challenge of treating metastatic breast cancer in the setting of acute intermittent
porphyria
Jonathan Laxton, Core
Supervisor: M. Krahn
1625 (CUnicallnvestigation)
Staphylococcus aureus pyomyositis diagnosed by 165 rONA amplification and
sequencing
Alissa Lloyd, Core
Supervisor: A. Walkty
1635 (Case Report)
Fever, rhabdomyolysis, and renal failure in an adult after emergency department rapid
sequence intubation using succinylcholine
Marc Fournier, Core
Supervisor: D. Bell
1645 TBA
David Ryan, Core
Supervisor:
1655 (Clinical Investigation)
Small changes in serum creatinine in the emergency department are associated with long
term progression to chronic kidney disease
Krista Ryz, Core
Supervisor: A. Levin
1705 (Case Report)
Mycobacterium avium intracellular complex in hot tub water as a cause of hypersensitivity
pneumonitis
Meaghan O'Brien, Core
Supervisor: F. Bovell
The Department of Internal Medicine gratefully acknowledges the participation of our guest
speaker and judge Dr. Curtis Cooper, and to our local faculty adjudication team, Dr. Mauro
Ve rrelli , Dr. Ryan Zarychanski, Dr. Ethan Rubinstein, Dr. Christine Peschken and Dr. Martina
Reslerova. Thank you to Dr. Dana Moffatt for presenting his published work derived from his 2008
resident research day presentation.
POSTERS DISPLAYED IN RESIDENT'S ABSENCE (Case Report)
A unique case of relapsed multiple myeloma presenting as a sOlitary testicular
plasmacytoma secreting a different monoclonal protein than that at the time of diagnosis
Roopesh Kansara, Core
Supervisor: M. Rubinger
(Case Report)
Desperate times, desperate measures: rotablating dissections
Kristyn Campbell, Core
Supervisor: F. Hussain
(Case Report)
Neurosarcoidosis: Presentations and management
Ernest Inegbu, Core
Supervisor: G. Eschun
(Case Report)
Idiopathic cholestasis/vanishing bile duct syndrome: A rare complication of Hodgkin's
Disease
James Paul, Core
Supervisor: A. Kraut
(Clinical Investigation)
Mortality in obstructive sleep apnea patients
Renelle Myers, Respirology
Supervisor: C. Ramsey
(Clinical Investigation)
Mycophenolate mofetil based treatment in encapsulating peritoneal sclerosis: A single
center experience
Kelvin Leung, Core
Supervisor: M. Reslerova
(Clinical Investigation)
Impact of body mass index (8MI) on early and late mortality and technique failure in
peritoneal dialysis
Kelvin Leung, Core
Supervisor: C. Rigatto
(Clinical Investigation)
Assessment of right ventricular systolic dysfunction using real time three dimensional
echocardiography after marathon running
Anthony Wassef, Core
Supervisor: D. Jassal
(Clinical Investigation)
Efficacy of rituximab for treatment of autoimmune cytopenias associated with
Iymphoproliferative disorders: Manitoba experience
Jessica Singh, Core
Supervisor: R. Kumar
RHABDOMYOLYSIS IN MULTIPLE MYELOMA
Dunsmore Sl, Bueti G 1
1. Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
Rbabdomyolysis, a condition caused by skeletal muscle injury with resultant release of muscle
contents into the systemic circulation, is a rare complication in mUltiple myeloma. We report a case of a 59­
year-old man with acute renal failure in the setting of multiple myeloma. Kappa light chain deposition was
seen on muscle biopsy when he de.veloped severe rhabdomyolysis after treatment with atorvastatin. We
postulate that rhabdomyolysis in this case may have been brought about by kappa light chain induced
muscle damage potentiated by the effect of a statin on the sarcoplamic reticulum function. This is the third
reported case of rhabdomyolysis in a patient with multiple myeloma that has shown positive kappa staining
of muscle sarcolemma and the first to identify a potentially inciting cause.
THE SUCCESSFUL USE OF RITUXIMAB AS SALVAGE THERAPY IN STEROID RESISTANT
MINIMAL CHANGE NEPHROTIC SYNDROME.
Corey Metcalf, University of Manitoba, Winnipeg, MB
Supervisor: Dr. M. Verrelli
This is the case of a 26 year old man of Metis descent who has had eight years of minimal change nephrotic
syndrome (MCNS) continually resistant to therapeutic regimens including high dose steroids, cyclophosphamide,
mycophenolate mofetil, cyclosporine, and tacrolimus. The patient was treated with four doses ofRituximab using
the non-Hodgkin lymphoma dosing protocol of375mglm2 (lgm) IV/week for four weeks. He initially responded
with a brisk diuresis within the first four months following administration allowing the tapering of large doses of
diuretics. His serum albumin and spot protein/creatinine ratios then followed with improvement from 8gIL to 31 gIL
and 20gld to 3g1d respectively at 15 months. The patient is now off of all diuretic therapy and immunosuppressive
agents and remains in partial remission 15 months since rituximab administration. This suggests the potential
efficacy of rituximab for MeNS when other therapies have failed to achieve remission.
BIRT-HOGG-DUBE SYNDROME WITH AN ASSOCIATED NOVEL PULMONARY NEOPLASM
Dr. Marcus Blouw MD - PGY4 Respirology, University of Manitoba Dr. E. Giannouli MD FRCPC - Assistant Professor, Dept ofInternal Medicine, Sections of Respirology and Sleep Medicine, University of Manitoba Dr. 1. Klein MD FRCPC, Assistant Professor, Dept of Pathology, University of Manitoba Dr. C. Rockman-Greenberg MD, CM, FRCPC, FCCMG Medical Director, Child Health programme, WRHA Professor and Head, Dept. of Pediatrics & Child Health, Univ. of Manitoba Introduction: Birt-Hogg-Dube Syndrome is a rare condition characterized by the constellation of pulmonary
cysts, renal tumors and fibrofolliculomas. The syndrome follows an autosomal dominant inheritance
pattern with variable expressivity. Spontaneous pneumothorax is a common presenting complaint in cases
of Birt-Hogg-Dube. There are no reported cases of primary pulmonary neoplasm as a manifestation of
Birt-Hogg-DuM Syndrome. The renal tumors typically associated with this disease are of the
chromophobe cell variety, and rarely metastasize. The fibrofolliculomas of Birt-Hogg-Dube are benign
tumors of the hair follicles. These present only cosmetic complications.
Case: We present the case of a 24 year-old non-smoking female from a relatively large family cohort with
known Birt-Hogg-Dube Syndrome. The patient's brother required partial nephrectomy for the removal ofa
chromophobe renal tumor. Her mother, maternal aunt, and maternal grandfather have been noted to have
fibrofolliculoma skin tumors. Our patient has had two previous hospital admissions for spontaneous
pneumothoraces at the ages of 16 and 18 years.
During routine screening for pulmonary cysts, a computed tomography (Cn scan identified a mass within
the upper lobe of the left lung. Concurrent renal ultrasound demonstrated normal kidneys without evidence
of neoplasm. Subsequent needle biopsy ofthe lung mass, conducted with CT guidance, revealed
unspecified neoplastic cells. Because of the concerning nature of the initial tissue sample, the patient
underwent left upper lobectomy with successful removal of the entire mass.
Pathologic evaluation of the tumor revealed a non-specific, endobronchial, spindle cell mass. This was best
characterized as a low-grade sarcoma. Extensive immunohistochemical testing was not able to identify the
specific tumor type or etiologic origin. Further search for an alternative primary malignancy was negative.
Discussion: Our case presents a novel manifestation of Birt-Hogg-Dube Syndrome, namely the presence of
a sarcoma, and more specifically, a primary pulmonary sarcoma. This appears to represent an isolated
finding as no history of pulmonary neoplasm has been identified within the patient's family cohort.
The original description of the genetic mutations associated with Birt-Hogg-Dube Syndrome mapped the
abnormality to chromosome 17p 11.2 and specifically to the BHD gene, also known as FLCN. Most cases
ofBirt-Hogg-Dube Syndrome have been attributed to abnormalities of the BHD gene product "folliculin."
In more recent years, mUltiple novel mutations have been identified which result in similar phenotypic
changes. All compatible clinical cases are referred to as Birt-Hogg-Dube Syndrome, regardless ofthe
specific genetic abnormality.
DNA testing of our patient and affected family members failed to identify the characteristic mutation of the
BHD gene. Identification of the specific genetic abnormality in this case has not yet been completed, and
may ultimately not be possible. Further efforts to identify the specific mutation in this case should continue
in order to search for similar pulmonary neoplasms in other cohorts with an identical mutation.
TREATMENT OF SUSPECTED HERPES SIMPLEX ENCEPHALITIS AT HSC:
A CRITICAL REVIEW
Peter S. Hughes and Alan C. Jackson
Section ofNeurology, Department ofIntemal Medicine
University of Manitoba, Winnipeg, Manitoba.
Objectives
Herpes simplex encephalitis (HSE) is a severe sporadic brain infection with an untreated mortality rate of
10%. Diagnosis is based on a combination of clinical findings, magnetic resonance (MR) imaging, and
detection of herpes simplex virus DNA in cerebrospinal fluid (CSF) using polymerase chain reaction (PCR)
amplification. The mainstay of treatment is intravenous acyclovir. Early intervention is associated with a
better outcome, and current guidelines therefore recommend that treatment be started immediately, rather
than waiting for confIrmatory test results.
It is not clear how many patients diagnosed with suspected HSE, and subsequently treated with acyclovir,
actually have the disease. Furthermore, data are lacking on how much time elapses between diagnosis and
initiation of therapy.
Methods
Hospital records were obtained for all adult inpatients who received intravenous acyclovir for suspected
HSE over a one-year period at the Health Sciences Centre (n=25). The clinical course, laboratory findings
and imaging results were assessed in each case. In addition, the time that elapsed between the diagnosis of
possible HSE and the initiation ofantiviral therapy was calculated.
Results
Only one of the 25 patients was subsequently confrrmed to have HSE. Five patients did not undergo CSF
examination, and of the 20 CSF samples obtained, only 15 were sent for PCR testing. Eight of the 25
patients did not undergo MR imaging. Acyclovir therapy was initiated a median of 19 hours (range 1-57
hours) after initial presentation. Two of the patients waited more than 48 hours for treatment to be started.
Conclusions
Compared with a similar study performed recently in the United Kingdom, our assessment shows that
therapy for suspected HSE was initiated more promptly at this centre. However, several areas were
identified in which current management ofHSE at the Health Sciences Centre might be improved.
COMPLETE REVASCULARIZATION IMPROVES SURVIVAL IN
CARDIOGENIC SHOCK DUE TO MYOCARDIAL INFARCTION:
MANITOBA CARDIOGENIC SHOCK REGISTRY INVESTIGATORS
1
Robin A Ducas Roger K Philipp 1, Steven Hodge1 , Tarek S. Kashour\ Jason Elliott1 ,
1
1
1
2
Vladimir Dzavik , Davinder S. Jassal , Nasir Shaikh , James W. Tam , Alan Menkis\
Daniel Roberts 1, Philip J. Garber 1, Daniel Chateau 1, John Ducas 1, Farrukh Hussain 1
1. University of Manitoba, Winnipeg, Manitoba, Canada.
2. Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.
Objectives: Early revascularization is the standard of care for cardiogenic shock.
Coronary bypass grafting and percutaneous intervention have complimentary roles in
providing this revascularization. The objective of this project is to identify predictors of
survival in a retrospective multicentre cohort of patients with cardiogenic shock
undergoing coronary angiography and to address whether complete revascularization
improves survival in this cohort of patients.
Methods: A total of 210 consecutive patients (mean age 66 ± 12 years) at two tertiary
centres from 2002-2006 inclusive with a diagnosis of cardiogenic shock were evaluated.
Univariate and multivariate predictors of in-hospital survival were identified utilizing logistic
regression.
Results: ST elevation infarction occurred in 67% of patients. The mean time from
symptom onset to cardiogenic shock was 23.5 ± 52 h and time to catheterization was 33.8
± 60 h. Thrombolysis was administered in 34%, PCI was attempted in 62% (B8% stented,
76% TIMI 3 flow achieved), CABG was performed in 22% (mean 2.7 grafts, 14 valve
procedures) and medical therapy alone was administered in the remainder. The overall
survival to discharge was 59% (CABG 68%, PCI 57%, medical therapy 48%).
Independent predictors of survival included the presence of complete revascularization
(p=0.013, OR=3.B7 (95% CI1.3-11.3), hyperlactatemia (p=0.046, OR=0.B8 (95% CI 0.77­
0.998) per mmol increase), baseline renal insufficiency (p=0.043, OR=0.29, (95% CI 0.09­
0.96) and the presence of anoxic brain injury (p=0.008, OR=0.12 (95% CI 0.03-0.58).
Conclusions:
Complete revascularization may be a key determinant of in-hospital survival in patients
with cardiogenic shock.
THE USE OF SUBLINGUAL FENTANYL FOR THE TREATMENT OF INCIDENT DYSPNEA: A RETROSPECTIVE PILOT STUDY Wong J.K., Riehman-Eisenstat J. (University of Manitoba, Winnipeg, Manitoba, Canada) Background: Incident dyspnea is the subjective sensation of shortness of breath resulting from activity.
Patients with a chronic pulmonary disease or malignancy frequently experience incident dyspnea,
which can lead to a significant impairment in quality of life. The use of sublingual Fentanyl for incident
pain has been established, however, there has been minimal literature looking into the use of sublingual
Fentanyl for incident dyspnea.
Objective: The objective of this retrospective, hypothesis generating pilot study was to examine whether
sublingual Fentanyl is effective in ameliorating a patient's incident dyspnea and perceived quality of life.
Methods: Data was obtained through the use ofa survey utilizing components of the Edmonton Symptom
Assessment Score (ESAS) 10 point visual analog scales. Measurements included the patients' recall of
severity of dyspnea, tiredness and drowsiness experienced with various activities with and without the use
of sublingual Fentanyl (given 10-15 minutes prior to the activity). Changes in the patients' perceived
quality of life (before and after initiation ofsublinguaJ Fentanyl therapy) were also measured using a 10
point scale.
Only patients with severe lifestyle and functional limitations due to end stage pulmonary diseases were
asked to participate. There were no limitations to type of pulmonary disease, age, gender or other
comorbidities. Previously prescribed Fentanyl dosages were maintained during the study. Patients were
recruited from a respirology out-patient clinic at the Health Sciences Centre, the pulmonary rehabilitation
unit at Riverview Health Centre and the palliative care unit at St. Boniface General Hospital.
Results: A total of 7 patients, with a variety of pulmonary diseases, agreed to participate in this pilot
study. The primary outcome was the change in the degree of dyspnea before and after activity with the use
of sublingual Fentanyl. With "talking", the mean score difference was -2.2. With "eating" (-1.75),
"washing your face" (-2.0), "getting out of bed" (-1.83), with "ambulating (-3.0), with "having a bowel
movement" (-2.75), and with "showering/bathing", (-3.8). Unexpectedly, there was a trend towards a
decrease in perceived levels of tiredness and drowsiness after the use of subUngual Fentanyl. After
initiation of Fentanyl therapy, the mean perception of quality of life improved by +3.5. The mean score for
ease of use was 1.0 (very easy).
Conclusion: This study demonstrated the potential use of sublingual Fentanyl as an efficacious treatment
of incident dyspnea. Importantly, this pilot study also demonstrated that the use of sublingual Fentanyl is
safe and does not worsen a patient's perceived level of tiredness or drowsiness. Follow up with a
prospective study of sublingual Fentanyl in the treatment of incident dyspnea is warranted to verify the
positive impact on our participant's incident dyspnea and perceived quality oflife.
.•. Congenital TTP
Smith A., 5hojania A.M. Department of Internal Medicine, University of Manitoba
BACKGROUND: Thrombotic thrombocytopenic purpura (TTP) is a disease characterized by
thrombocytopenia and microangiopathic haemolytic anemia (MAHA), as well as possible neurologic or
renal complications. Familial or congenital TTP (mp) is
arare form ofTTP which is associated with
repeated attacks of TTP, often beginning in early childhood. mp is considered to be due to a mutation
in the gene which is responsible for production of ADAMT5 13. ADAMT5 13 is a protease which cleaves
ultra large von Willebrand factor (ULVWF), shortly after its release into the bloodstream, to produce
normal size von Willebrand factor (VWF). In congenital TTP, it is thought that uncleaved ULVWF causes
activation and aggregation of platelets, leading to thrombocytopenia, thrombosis and MAHA. In the
majority of acquired forms ofTTP an antibody to ADAMTS 13 is found. PRESENTATION: We report the
case of J5, a 38 year old man who experienced multiple attacks ofTTP since birth. These attacks were,
at different times, treated with prednisone, plasmapheresiS, splenectomy and immunosuppressive
therapy. The response to plasmapheresis was generally prompt; but between attacks ofTTP, he
manifested mild thrombocytopenia and evidence of hemolysis. In 1994, the possibility of FTTP was
considered and he was started on prophylactic infusion of 2 units of cryopoor plasma (CPP) every 2
weeks. This treatment prevented acute attacks and caused resolution of chronic thrombocytopenia and
hemolysis. In 1995, he experienced an acute attack ofTTP, 3 months after a trial discontinuation of
prophylactic bi-weekly infusion of CPP. This attack promptly responded to daily infusions of CPP for 5
days. Prophylactic bi-weekly infusion of 3 units of CCP was restarted in 1995. Since resuming CPP
therapy, J5 has had only two acute attacks ofTTP, one related to a tooth extraction, and the other in
March 2010, after a viral infection. Investigations in 2006, showed that his ADAMTS 13 level was 1%
(prior to CCP infusion), and genetic studies confirmed that JS is homozygous for a frameshift mutation in
the gene encoding ADAMTS 13. DISCUSSION: The activity of ADAMTS 13 (a disintegrin and
metalloprotease with thrombospondin type 1 motif) can be measured, and molecular testing of the
gene encoding ADAMTS13.
EVOLUTION OF ENDOTHELIAL INJURY DURING DIALYSIS AND THE IMPACT OF
KIDNEY TRANSPLANTATION
Keren Mandelzweig MD, Joe Bueti MD, Claudio Rigatto MD
Department ofNephrology, University of Manitoba, Winnipeg, Manitoba
Objectives: Cardiovascular disease is known to progress after the initiation of dialysis and improves after
renal transplantation. Endothelial injury (EI) may play an important role in this progression, but changes in
EI over time on dialysis and post- transplantation are poorly characterized. Our objectives were to assess
the trend in VCAM-l over time on dialysis, and to assess the impact of transplantation on VCAM-l levels.
Methods: The study design is a retrospective cohort of patients who received a kidney transplant in
Manitoba between January ] 2000 and December 31 2005 (n= 189). 172 recipients had at least 2 archived
serum samples taken at least 6 months apart in both pre and post transplant periods, and were analyzed.
Data abstraction was by chart review. VCAM was measured by Enzyme-linked immunosorbent assay
(ELISA). Mixed linear modeling was used to describe changes in VCAM as a function of time and
transplantation, adjusted for age, gender and several time dependent variables including co-morbid
conditions, dialysis modality, and medications.
Results: VCAM levels increased over time on dialysis (46.4 nglmL per year, p<O.OOO I). Transplantation
was associated with a large decrease in VCAM (-622 nglmL, p<O.OOOl). VCAM rise was largely
attenuated after transplant (I8.8 nglmL per year, p=O.003 for comparison with pre-transplant slope).
Adjustment for all confounders did not alter these relationships. Age and non-dihydropyridine calcium
channel blockers; however, these variables did not predict change in VCAM slope before or after transplant
(i.e. all variable*time interactions=NS). Etiology of End Stage Renal Disease (ESRD), renin-angiotensin system inhibitors, beta blockers and dialysis modality were not associated with VCAM. Conclusion: We conclude that EI worsens over time on dialysis, and is significantly improved by renal transplantation. These results, derived from repeated measures data, confirm less rigorous cross-sectional observations, and may explain the elevated CVD rate in dialysis and the salutary effect of transplantation. We speculate that components of dialysis not measured in our analysis drive EI in ESRD. AZACYTIDINE AS A NOVEL AGENT IN THE TREATMENT OF ACUTE LYMPHOBLASTIC LEUKEMIA Authors: Dr. K. Paulson, Dr R. Kumar, and Dr. M.D. Seftel
University of Manitoba, Winnipeg, Manitoba, Canada
Background: 5-Azacytidine (AZA) is a hypomethylating agent with activity in myelodysplastic syndrome
(MDS) and acute myeloid leukemia (AML), but not in acute lymphoblastic leukemia (ALL). The
transformation ofMDS into ALL, while far less common than transformation into AML, is a rare but
known complication.
Objectives: We present the first case report of AZA with activity in ALL evolving from MDS.
Methods: A 74-year-old woman initially presented in 2005 with moderate thrombocytopenia (83x 109/L).
An initial bone marrow aspirate (BM) was consistent with MOS (refractory cytopenia with multilineage
dysplasia). She did not require chemotherapy or transfusions at that time. In January 2009, she developed
worsening pancytopenia, and a BM showed an abnormal popUlation of immature lymphocytes, with a pre­
B cell phenotype (CD34, CD19, CDIO, CD79a, and C022 positive, and CD20 and surface immunoglobulin
negative). This population represented 43% of all nucleated cells in the marrow by flow cytometry.
She received therapy targeting the ALL, consisting of intravenous cyclophosphamide (750mg/m2),
vincristine (1.4 mg/m2). and oral prednisone. She tolerated therapy poorly. with a prolonged hospital
admission for a febrile neutropenic episode. A second regimen consisting of 6-mercaptopurine (50 mg/m2
given intravenously 14 days out of a 21 day cycle), vincristine (1.4 mg/m2), and dexamethasone was
administered. Again, she did not tolerate this chemotherapy, and no additional systemic chemotherapy was
offered. A repeat bone marrow aspirate showed that the pre-B cell immature lymphocytes persisted.
Hypothesizing that a portion of her pancytopenia was due to the underlying MOS, she received AZA as per
protocol for MOS (75 mg/m2, subcutaneously for seven consecutive days out ofa 28 day cycle) with the
objective of improving cell counts and decreasing transfusion requirements.
Results: She received a total of 6 cycles of AZA, with a significant hematological response. There was
improvement in all of her cell lines, with a platelet count rising from 26 at presentation to 65 after four
cycles of azacytidine. A repeat bone marrow aspirate performed after four cycles of AZA showed the
immature B-cell population, which had represented 43% of all nucleated cells initially, had been reduced to
2% while the del20q abnormality remained.
Conclusion: AZA has demonstrated activity in patients with MDS and in AML, but not in ALL or other
lymphoproliferative disorders. In this ALL patient with underlying MDS, AZA resulted in significant anti­
leukemic activity. Azacytidine deserves further laboratory and clinical investigation as a possible novel
agent in the treatment of ALL.
Table 1: Bone Marrow Aspirate Results
WBC
(109/L)
ANC
(1091L)
Hb(g/L)
Platelet
Blast Count (% of
Count(1091L) nucleated cells by flow
cytometry)
Karyotype
April 7. 2005 (Initial Presentation)
3.7
1.5
128
70
None
N/A
26
43%
del20q
24
28%
del20q
64
2%
del20q
January 23rd, 2009 (Clinical Deterioration)
2.7
1.35
106
April 24, 2009 (Post Systemic Chemotherapy)
2.8
1.29
86
November 9th, 2009 (Post 4 Cycles 5-AZA)
3.52
1.58
102
The Role of 3D Echocardiography in Breast Cancer: Comparison with 2D Echocardiography, MUGA and Cardiac MR) Mehrdad Golian l , Davinder S. JassaJ2 I.Department of Internal Medicine, St. Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada 2.Institute of Cardiovascular Sciences, S1. Boniface Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada. Background: In breast cancer patients, the administration of Doxorubicin and Trastuzumab is associated with an increased risk of cardiotoxicity. Although multi gated acquisition scans (MUGA) and 2D transthoracic echocardiography (ITE) are conventional methods for baseline and serial assessment of left ventricular ejection fraction (LVEF) in these patients, little is known about the use of real time 3D TIE (RT3D ITE) in this clinical setting. Objective: The aim of the current study was to assess the accuracy of MUG A, 2D TIE and RT3D TTE for determining LVEF in comparison to cardiac MRI (CMR). Methods: Between 2007-2009 inclusive, 50 female patients with HER-2 positive breast cancer received adjuvant trastuzumab following doxorubicin. Serial MUGA, 20 TIE, RT3D TTE and CMR were performed at baseline, 6 and 12 months following the initiation oftrastuzumab. Results: A comparison of left ventricular end diastolic volume (LVEDV) demonstrated a modest correlation between 2D TIE and CMR (r=0.64 at baseline and r=0.69 at 12 months respectively). A comparison of LVEDV between RT3D TIE and CMR demonstrated a stronger correlation (r=0.87 at baseline and r=0.95 at 12 months respectively). Although 2D TTE demonstrated a weak correlation with CMR for LVEF assessment (r=O.3 I at baseline and r=0,42 at 12 months respectively), both RT3D TIE and MUGA showed a strong correlation when compared to CMR (r=0.91 at baseline and r=0.90 at 12 months respectively, Figure I). Conclusion: As compared to conventional MUGA, RT3D TTE is a feasible, accurate and reproducible alternate imaging modality for the serial monitoring of L VEF in breast cancer patients. Figure 1: Baseline
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THE OCCURRENCE OF PULMONARY SARCOIDOSIS IN A PATIENT WITH GASTROINTESTINAL STROMAL TUMORS (GISTs) Mohmmed Algamdi, Rl Medical Resident, Dept. of Medicine, University of Manitoba, Winnipeg. G. Eschun, MD, FRCPC, Section ofRespirology, Dept. of Medicine, University of Manitoba, Winnipeg.
GISTs are rare gastrointestinal tumors that are considered to be the most common mesenchymal neoplasms
of t he gastrointestinal tract. GISTs can al so 0 riginate in t he mesentery an d 0 mentum. The as sociation
between GISTs a nd Pulmonary Sarcoidosis wa 5 not de scribed be fore although; i t can very rarely b e
associated with Non Pulmonary Sarcoidosis.
A 42 years female patient known case of Crohn's Disease which was diagnosed on 1988. At that time she
was complaining ofsignificant abdominal pain and diarrhea and she was treated with prednisone and 5­
aminosalicylic acid. On 1990 she underwent i leocaecal resection and since then s he was cI inically stable
and didn't require any specific medical treatment. On 2007, a computed tomography ( CT) s can of the
abdomen was done to evaluate chronic history of diarrhea and weight loss. It shows an incidental finding of
a polypoid filling defect at the gastro-esophageal junction and no signs of active Crohn's Disease. A fine
needle aspiration was obtained by endoscopic ultrasound and the cytology shows groups of spindle cells
consistent with spindle c ell tumor. Patient un derwent a I aparoscopic wedge gastrectomy a nd surgical
pathology report shows a 2.2cm benign appearing low risk GIST of the gastric cardia. Since that time, the
patient was evaluated by regular surveillance studies regarding her GIST and Crohn's Disease. On early
2010, aCT-scan of the abdomen shows an incidental finding of small lung nodules which prompted a
complete CT-scan of the thorax which shows innumerable very small (lmm) pulmonary nodules bilaterally
which appear to have a perilymphatic distribution. Patient was referred to chest medicine clinic and at that
time she was complaining of fatigue. otherwise, there were no remarkable respiratory symptoms. She was
nonsmoker, had no significant travel history and no exposure to exotic animals. Patient was not aware of
any obvious tuberculosis exposures, no history of illicit drug use and no obvious human immunodeficiency
virus risk factors. On examination, she appeared well with no apparent distress. Vital signs were stable and
there was no lymphadenopathy. Her chest exam was entirely within normal limits and spirometry shows
mild decrease in vital capacity. Patient underwent a bronchoscopy and a transbronchial biopsy. Cytology
shows presence 0 f pulmonary macro phages and br onchial cells. There were rare giant cells and rare
lymphocytes. No malignant cells were identified and surgical pa thology report shows multiple
noncaseating granulomas consistent with sarcoidosis and Special stains for fungus and acid fast bacilli were
negative. So, a diagnosis ofP ulmonary Sarcoidosis was certainly made ba sed on t he radiological and
pathological findings. No active treatment for Sarcoidosis was indicated at that time and the plan was to
continue long-term chest medicine follow up and to do pulmonary function test and CT-scan on regular
basis to evaluate progress of the disease and to evaluate the need to start therapy.
Very few cases a f GISTs that ar e associated wi th N on Pulmonary Sarcoidosis where reported before.
However, this is the first reported case to describe the occurrence of Pulmonary Sarcoidosis in a patient
with GISTs. Such association is clinically important since Sarcoidosis is a multisystem disorderthat may
involve any organ and its clinical course is variable ranging from self-limited acute disease to a ch ronic
debilitating disease that may result in death. Sarcoidosis need to be evaluated early, followed up regularly
and under certain circumstances treated with glucocorticoid therapy.
INFECTIONS, MICROBIOLOGY AND OUTCOMES IN FIRST NATIONS PATIENTS ON
PERITONEAL DIALYSIS
A Hildebrand l , C Rigatto l ,2, M Verrelli l ,2, P Komenda l ,2, C Sathianathan l ,2, M Reslerova l ,2, L Eng, A Eng,
MM Sood l ,2
IUniversity of Manitoba, Winnipeg, Manitoba, Canada
2Section of Nephrology, University of Manitoba, Winnipeg, Manitoba, Canada
Background: First Nations patients on peritoneal dialysis experience poor outcomes. Whether discrepancies
exist regarding the microbiology, rate of infections and outcomes between First Nations and Non-First
Nations peoples remains unknown.
Methods: All adult peritoneal dialysis patients (N""727) from 1997-2007 residing in Manitoba, Canada
were included. Data was extracted from a local administrative database, Canadian Organ Replacement
Registry (CORR) and Peritonitis Organism Exit sites Tunnel infections (POET) databases. Negative
binomial regression was used to determine the relationship between rates of exit site infections and
peritonitis between First Nations and Non-First Nations peoples. Kaplan Meier analyses were performed to
determine the relationship between peritonitis and technique failure.
Results: 161 First Nations and 566 Non-First Nations were included in the analyses. The peritonitis and
exit-site infection rates were 73.0 and 511l00-pt yrs and 50.3 and 44.31l00-pt yrs in the First Nations and
non-First Nations populations respectively. First Nations were more likely to have culture negative
peritonitis (36.5 vs. 20.8%, p<O.OOOI) and staphylococcus exit-site infections (54.1 vs. 32.9%, p<O.OOOI).
The crude and adjusted rates of peritonitis were higher in First Nations for total episodes, culture negative
and gram negative peritonitis. Among those who experienced an episode of peritonitis, the time to
technique failure was shorter (median time 1034 vs. 1170 days, p<O.OOO I) in the First Nations population.
Conclusions: First Nations patients experience higher rates of peritoneal dialysis infections with differing
microbiology and shorter time to technique failure after peritonitis. Interventions to improve outcomes and
prevent infections should specifically be targeted to the First Nations population.
AN ATYPICAL PRESENTATION OF ALLERGIC
BRONCHOPULMONARY ASPERGILLOSIS
Ali Benzaglam MD, CCFP, Department of Internal Medicine,
University of Manitoba, Winnipeg, Manitoba, Canada. Dr. Sat Sharma, MD,
FRCPC, FCCP, FACP Associate Professor, Sections of Respirology and
Critical Care, Department of internal Medicine, University of Manitoba,
Winnipeg, Manitoba, Canada
BaClu!round
Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity
disorder induced by Aspergillus. ABPA is seen in 1% to 6% of all asthma patients
and 10% of all corticosteroid dependent asthma patients, or patients with cystic
fibrosis (l to 15 percent ofeF patients). It is rarely seen in anyone who does not
have asthma, with the exception of patients with cystic fibrosis. Clinical
presentation of ABPA can range from mild bronchospasm to fibrotic parenchymal
disease. Allergic bronchopulmonary aspergillosis might progress to end-stage
pulmonary fibrosis ifnot recognized earlier. Diagnosis of ABPA might be easily
missed or delayed because its clinical presentation is often indistinguishable from
the more common pulmonary disorders seen in primary care.
Case Presentation
We describe the case of a 38-year-old female with no previous history of asthma
who presented with several episodes of productive cough, fever, chills and
anorexia. She had been treated with multiple courses of antibiotics for presumed
community acquired pneumonia. Her chest radiograph showed bilateral upper lobe
infiltrates. She had mild anemia and mild peripheral eosinophilia. Serum IgE level
was elevated. ABPA was suspected initially but serum aspergillus precipitins were
negative. The thoracic CT scan showed bilateral bronchiectasis and extensive
mucus plugging. Bronchoscopy and bronchoalveolar lavage showed evidence of
aspergillus species on cytology as well as culture. Immediate skin test reactivity to
Aspergillus antigen was positive. The diagnosis of allergic bronchopulmonary
aspergillosis (ABPA) was confirmed by use of clinical, radiographic, and
immunologic criteria. The patient was treated with prednisone with clinical and
radiographic improvement.
Conclusion
ABPA is known to occur in patients with history of asthma or cystic fibrosis. We
describe a case where ABPA developed in someone with no risk factors.
Radiogrpahic and clinical pattern recognition and high index of suspicion led to
the correct diagnosis.
AN EXPLORATION OR DIALYSIS MODALITY PREFERENCES: THE POTENTIAL ROLE OF
DIFFERING RENAL CLINIC PRACTICES AS A FACTOR
Jay Hingwala, MD
Paul Komenda MD, MHA
Background: Rates ofESRD are rapidly increasing, placing tremendous burdens on healthcare resources. Peritoneal
Dialysis (PD) as an initial dialysis modality choice has been shown in numerous studies to be more cost effective,
provide better patient quality of life, and lower early mortality rates compared with Hemodialysis (HD), with few
contraindications limiting its use. Significant variation in PD penetration patterns exist throughout the world,
suggesting a complex interplay of patient, social, economical, and political factors. In Canada, the prevalence rates
for PD range from 14-35%, with significant variation within the same healthcare regions. Our study attempts to
isolate the effect of differing practice patterns on initiation of PD as a dialysis modality in the province of Manitoba.
Methods: We performed a retrospective review ofthe Manitoba Renal Program Database from January 200 I
January 2010. We calculated rates of PO starts by individual nephrologist clinic. We then constructed a 2-step
linear regression model controlling for patient demographics and comorbidites that may have affected suitability for
PD.
Results: Nephrology clinics that practiced at sites with PO on site had higher rates oftheir patients starting PD
(Mean 41%,47% at PO sites) than at the site with no PD (27%, p<O.05). Controlling for demographic and
comorbidity factors, the Odds Ratio of a patient from a non-PO site ever doing PD was 0.48, compared with 1.47 for
the PD sites. There was a high level of variability among different nephrology clinics at the non PD site for
initiation of PD.
Conclusion: : Our data suggest that on site availability and differing renal clinic practice are limiting factors ofPD
utilization, independent of case mix, dialysis funding, costs, geography, and reimbursement. If patient PO rates
could approach capacity through better policy and infrastructure, a significant amount of money and resources could
be saved or directed toward helping a larger population. Further study in other health care regions is required to
confrrm these observations.
In hospital outcomes of the "no option" unprotected left main percutaneous intervention:
The Manitoba Left Main PCI ReKistry
Nader Elmayergi, Thang Nguyen, Roger K Philipp, John Ducas, Steven Hodge, Kunal Minhas, Minh Vo, Tarek
Kashour, James Tam, Davinder Jassal, Farrukh Hussain
St. Boniface General Hospital, Winnipeg, Manitoba, Dept. of Cardiology
Background:
Although the current gold standard for significant left main disease revasvascularization has been coronary artery
bypass grafting, mUltiple registries and subsets of randomized trials have demonstrated an evolving role for
percutaneous intervention (pCI) for left main disease. We aim to describe the in hospital outcomes for a "no option"
cohort ofleft main disease patients (surgical turndowns or in extremis with no timely surgical option available).
This is the first such description of a Canadian cohort of patients to our knowledge.
MethodslResults:
We analyzed a retrospective cohort of unprotected "no option" left main PCI patients from January 2004 to Dec.
2009. Descriptive statistical methods were used to summarize data.
56 patients with mean age 69 years, 34% diabetics were included. Prior MI was present in 36% and prior PCI in
13%. Mean LV ejection fraction was 44%. ST elevation MI was present in 30%. Cardiogenic Shock was present
in 41 %, CPR was performed during admission in 16%, ventilation in 30%. The mean left main stenosis was 76%
with an occluded left main artery in 16% of patients. Bifurcation left main lesions were present in 57%,
ostium/shaft involvement in 79010 and both regions in 36%. Concomitant three vessel disease occurred in 36%, two
vessel disease in 48% and single vessel disease in 16%. Successful PCI was performed in 98%, multi vessel PCI in
73% with drug eluting stent use in 48%. A single stent strategy was used in 84% with intravascular ultrasound used
in 23%. Mean left main stent length was 15.2 rom and total stent length was 40.3 rom. Intra-aortic balloon pump
augmentation occurred in 43% for an average 000.3 hours. Mean peak CK levels were 2108 units. Glycoprotein
IIbIIIa inhibitors were used in 77%. In-hospital death occurred in 21 % with all but one death confined to the
cardiogenic shock subset entirely (97% survival stable vs. 52% shock). Extracorporeal membrane oxygenation and
ventricular assist device implantation occurred in 5 and 4% respectively. Stroke occurred in 4% with limb ischemia
in 5% and retroperitoneal hemmorrhage in 4%.
Conclusion:
"No option", high risk left main percutaneous revascularization in patients with surgical turndown or in extremis can
be performed with a high success rate, with high survival in the stable cohort and reasonable survival in the
cardiogenic shock subset. A low rate of in-hospital complications occurs. To our knowledge, this is the first
Canadian data of an extremely high risk cohort with a large percentage of bifurcation left main disease with
evidence to support PCI as a reasonable and safe strategy in this specific high risk population.
The Logistic Euroscore but not the Syntax Score predicts in-hospital mortality in high risk unprotected left
main percutaneous intervention: The Manitoba Left Main PCI Registry
Nader Elmayergi, Thang Nguyen, Roger K Philipp, John Ducas, Steven Hodge, Minh Vo, Kunal Minhas, Tarek
Kashour, Davinder Jassal, Farrukh Hussain
St. Boniface General Hospital, Winnipeg, Manitoba, Dept. of Cardiology
Background:
Previously demonstrated predictors of left main percutaneous intervention (PCI) include; LV ejection fraction <
30%, renal failure, cardiogenic shock, severe mitral regurgitation and presence of myocardial infarction. We aim to
investigate predictors of in-hospital mortality in a . 'no option" (surgical turndown or extremis with no timely
surgical availability) high risk left main coronary disease population which underwent PCL The logistic Euroscore
and SYNTAX score are well established yet quite different risk scoring systems for clinical outcomes. We aim to
determine in-hospital predictors of mortality including risk score evaluation in a high risk left main PCI popUlation.
MethodslResults:
We analyzed a retrospective cohort of unprotected "no option" left main (LM) PCI patients from January 2004 to
Dec. 2009. Univariate and Multivariate logistic regression was utilized to identify predictors of mortality. A p­
value<O.05 was considered significant.
56 patients were included with mean age 69 years and 59% male. Cardiogenic shock was present in 41 % and an
occluded left main was present in 16%. Mean SYNTAX score was 23.6. Mean logistic Euroscore was 23.5%. ST
elevation MI was present in 30%. Successful PCI was performed in 98%. Mean peak CK level was 2108 U.
Transfusion was performed in 32%. Within the Euroscore components, chronic pulmonary disease was present in
11%, extracardiac arteriopathy in 11%, Creatinine> 200 mmol in 14%, critical perioperative state present in 43%,
recent MI in 46%, emergency case in 48% and 9% of patients would require surgery other than CABG.
Univariate predictors of mortality included: peak CK level (p=0.0005), transfusion (p=O.0082), cardiogenic shock
(p<O.OOO 1), male gender (p=O.0048) and logistic euroscore (p=0.00S4).
Relevant nonpredictive variables included: age (p=0.47), prior MI (p=O.14), LV ejection fraction (p=0.49), STEM!
(p=0.43), NSTEMI (p=0.61), occluded LM (p=0.26), bifurcation LM (p=O.15), baseline creatinine clearance
(p=0.61) and SYNTAX score (p=O.31).
From the above, the two independent predictors of mortality were the logistic euroscore (p=O.OOSl) and male gender
(p=O.027).
Conclusion:
The logistic EuroScore is a largely clinically based score which predicts mortality in this extremely high risk cohort
of left main PCI patients very well and could be used to not only assess surgical risk but also perhaps provide some
estimate of PCI risk and outcome likely due to premorbid clinical state than prediction of PC I success. The
SYNTAX score alternately accurately quantitates disease burden and complexity but may not necessarily predict
short term outcome in this particular cohort.
The utility of the SVNTAX score in cardiogenic shock - can it help to guide revascularization therapy?
Thang Nguyen, Nader Elmayergi, Roger K Philipp, Steven Hodge, John Ducas, Tarek Kashour, Davinder Jassal,
James Tam, Farrukh Hussain
St. Boniface General Hospital, Winnipeg, Manitoba, Dept. of Cardiology
Background:
The SYNTAX score is a validated risk score to quantify both the burden and complexity of muitivessel and left
main coronary disease validated in multivessel and left main disease. We investigate the utility of this anatomic risk
score in predicting outcome in our cohort of cardiogenic shock and to investigate whether utilization of this score
can guide appropriate mode of revascularization.
MethodsIResults:
A retrospective cardiogenic shock registry from September 2002-September 2006 was analyzed with respect to
predictors of in-hospital mortality. Of21O patients in the registry, 154 angiographic CD's were available forreview
for SYNTAX scoring and did not have previous CABG and therefore could be analyzed.
The mean age was 66 ± 12 years, with ST elevation infarction in 67%. PCI was performed in 62% and CABG in
22% with the remainder receiving medical therapy alone. Overall survival to discharge was 59%. The mean
SYNTAX score calculated was 24.6. A low risk SYNTAX score (g2) was present in 47% (72 patients) of patients
and a high risk score (~33) was present in 27% (42 patients).
Within the high risk score cohort, 16/42 patients underwent CABG with a mortality of61l6 (37.5%), whereas 17
patients within the same cohort underwent PCI with a mortality of 11117 (64.7%). A z-score of 1.22 was obtained
(p=0.23) for this comparison. Within the low risk score cohort, 54 patients underwent PCI with a 26% mortality
(14/54 patients) and 12 patients underwent CABG with a 17% mortality (2112 patients).
Univariate predictors of mortality in the overall cohort included, baseline renal insufficiency (p<O.OOOI), oliguria
(p=O.OOI2), three vessel disease (p=O.016), anoxic brain injury (p=O.006), hyperlactatemia (p<O.OOOl), complete
revascularization (p<O.OOOl), ST segment resolution2::50% (p=O.0042), lowest cardiac index (p<O.OOOl) and the
SYNTAX score (p=0.0043).
However, the SYNTAX score did not predict mortality in an independent manner in multivariate analysis (p=0.25).
Conclusion:
The SYNTAX score predicts in hospital mortality in cardiogenic shock only in a univariate model but not in an
independent manner. The clinical difference in mortality with a high SYNTAX risk score patient undergoing
CABG vs. PCI may be an important trend to investigate further in larger cohorts, in spite of statistical
nonsignificance due to small sample size. The potential role for SYNTAX score utilization in choosing mode of
revascularization in cardiogenic shock, especially in the high risk score patient needs to be further clarified in larger
prospective studies.
INSIGHT INTO LEAVING AGAINST MEDICAL ADVICE FROM A
GENERAL MEDICAL SERVICE
RESIDENT: Joel Nkosi MBCHB CCFP R3
SUPERVISOR: Dr K Lamba
OBJECTIVES: Studying the demographics, admission diagnoses, comorbidities,
length of stay and re-admission rates of patients who leave against medical
advice (AMA) from a general medical unit at Health Sciences Centre.
METHODS: A retrospective chart review of patients who left AMA from the
general medical unit for the fiscal year of 2008 using the internal medicine
database. Information regarding the age, gender, race, admission diagnoses.
comorbidities, prior history of leaving AMA. length of stay and rehospitalisation
was collected.
RESULTS/CONCLUSION: Chart review ongoing, results pending.
SERUM INTERLEUKIN-6, CARDIOVASCULAR DISEASE, AND MORTALITY IN CHRONIC
LYMPHOCYTIC LEUKEMIA
David E. Dawe, Ju-Yoon Yoon, Spencer Gibson, James B. Johnston
University of Manitoba, Manitoba Institute of Cell Biology, CancerCare Manitoba, Winnipeg, Manitoba
Objective: To determine if interleukin-6 (IL-6) levels correlate with increased cardiovascular disease
(CVD) leading to mortality in chronic lymphocytic leukemia (CLL). Methods: ]93 patients (55.4% male;
median age 67.6 yrs) with CLL attending CancerCare Manitoba between ]11104 and 30112/08 were
evaluated. There were an equal number of patients aged < 65 yrs and ~ 65 yrs. Serum IL-6 levels were
determined by an ELISA assay. CVD was defined as cardiovascular and neurovascular symptoms or
procedures. Results: Using a cut-off of 3 pg/mL to defme an elevated IL-6 level, high IL-6 levels occurred
in 23% of patients and levels correlated with Rai stage, Ih-microglobulin and age. The median number of
traditional cardiac risk factors did not differ between patients with high and low IL-6 (1.66 vs. 1.52).
Patients with CVD had increased IL-6 (p<O.05) and there was a trend to a higher incidence of CVD in
patients with high IL-6 (36.4% VS. 22.8%, p=O.07). Patients with high IL-6 had considerably increased
mortality at 31.8% versus 12.8% for patients with low IL-6 (p=0.003). This mortality difference was
amplified in those 2: 65 years old (42.8% vs. 10.4%, p=0.OOO3). The major causes of death were
progressive CLL, second malignancies, and infections. Conclusions: High levels of IL-6 in CLL are
associated with a significantly increased risk of mortality and this is most evident in those 2: 65 years old.
Although CVD is not the primary cause of death, it is associated with high levels of IL-6 and may
contribute to progression of CLL.
Pleurx - A Novel Management Strategy for Malignant Pleural Effusions
Ayaz Khan, MD; Deborah Sciberras, RN; Sat Sharma, MD
Background: Malignant pleural effusions (MPE) result in a large number of Emergency Room
presentations as well as hospital admissions for patients suffering from cancer. It certainly adds not only
to the costs of health care systems but also has a huge impact on the quality of life for the patients and
their families. The precious time which could be spent with loved ones instead gets wasted in the
Emergency Room waiting areas and on hospital beds. Besides periodic thoracentesis, pleurodesis is
usually tried but often fails. Previous Manitoba data showed talc pleurodesis to be successful in only 30 to
40% of cases. Patients with MPE can now be treated with placement of an indwelling pleural catheter
(Pleurx) and regular self drainage by the patients or their caregivers.
Objectives: Pleurx catheter placement was introduced in Manitoba in 2007. The purpose of our study was
to examine whether the Pleurx reduced number of ER and hospital admissions in patients with MPE. We
also assessed cost savings to the health care system by utilizing this management strategy.
Methods: We performed a retrospective chart review of all patients with MPE who were treated with
Pleurx catheter placement. Data on ER and hospital admissions before and after Pleurx catheter
placement were extracted. Cost calculations were done utilizing standard hospital rates and costs of
supplies for Pleurx drainage at home.
Results: We found that a total of 20 patients had Pleurex catheter placement from August 2007 until
January 2010. 9 out of the 20 patients had advanced stage of malignancies and did not survive to the
hospital discharge. These patients were excluded from further data analysis. Of the remaining 11 patients,
7 were male and 4 were female. Average age was 72 years (range 59 to 92 years). The diagnoses were as
follows: 4 patients of primary lung cancer, 2 of breast cancer, 1 of thyroid cancer, 1 had sarcoma of the
heart, 1 with end stage heart failure, 1 of malignant melanoma and 1 had liver cancer. Before Pleurx
procedure, the total number of hospital admissions for these 11 individuals was 28 (range 1 to 10). The
total duration of hospital stay was 167 days (range 2 to 34 days). After the procedure, the total number of
hospital admissions was 3 while the total duration of hospital stay was 27 days. Average post-procedure
survival was 126 days (range 30 to 419 days). The total cost of hospital stay before the procedure was
$250,500 and after the procedure was $40,500. The total cost of supplies for drainage once is $68 and it is
done 3 times a week. Total cost of the Pleurx home drainage in 11 patients was $41,412. Adding this to
the cost of hospital stays post procedure in these patients, the total comes to $81,912. There is a net cost
saving of $168,588 for 11 patients; cost saving per patient is $15,326. Furthermore quality of life
improved and the time that these patients spent with their families instead of the hospital is immeasurable
in dollar values.
Conclusion: Malignant pleural effusions pose a serious and challenging problem to the patients and the
health care system. Pleurx is an effective palliative measure to help reduce costs and add quality of life to
the patients with advanced malignancies. We recommend that Pleurx be offered to all patients as initial
management strategy who present with symptomatic malignant pleural effusions to reduce
hospitalizations and health care costs, and to improve quality of life.
MULTIMODALITY IMAGING OF A SAPHENOUS VEIN GRAFT ANEURYSM.
Kerrett Wallace, MD 1, Davinder S. Jassal, MD, FRCP 2, lain D.C. Kirkpatrick, MD, FRCPC 3, Farrukh
Hussain, MD, FRCPC 2.
1. Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba.
2. Section of Cardiology, Department ofInternal Medicine, University of Manitoba, Winnipeg, Manitoba.
3. Department of Radioiogy, University of Manitoba, Winnipeg, Manitoba.
A saphenous vein graft (SVG) aneurysm is an infrequent but potentially fatal complication after
coronary artery bypass grafting (CABG). Most SVG are asymptomatic and are incidental fmdings on
routine chest x-ray.
A 63 year-old male with previous CABG presented with shortness of breath. On transthoracic
echocardiograpby, an echolucent mass was seen extrinsic to the left ventricle (LV) on the parasternal short
axis view. A prospectively EeG-gated contrast-enbanced computed tomographic (CT) scan demonstrated
the anterior wall of the LV indented by an aneurysmal SVG, measuring up to 5 em in diameter. Curved
planar reformation from the CT scan demonstrated the SVG aneurysm running along the LV, similar to the
corresponding coronary angiogram. Volume rendered imaging of the CT demonstrated the graft arising
from the aorta (Ao) and passing over the pulmonary artery (PA) before reaching the LV.
Multimodality cardiac imaging is instrumental in the noninvasive characterization of suspected
SVG aneurysms. This allows for optimal management of patients with medical, percutaneous and/or
surgical intervention of the SVG aneurysm to avert potential adverse outcomes.
Clopidogrel and Proton Pump Inhibitor Use; a
Canadian physicians Survey
Targownik L, Bagherli A
Department of Internal Medicine, University of Manitoba, Winnipeg
Back ground: There have been few studies; suggesting an increase risk of re-infarction
in patients who are on both Clopidogrel and PPls. Some other studies did not show such
an increase. Level of evidence is not very good and controversy still exists on this topic.
Performing a double blinded, randomized trial seems needed.
Methods: we performed a survey among Canadian Family Physicians (FP) and
cardiologists to find out how all these studies have affected their practice. An online
survey was sent to 3940 FPs and cardiologists all over Canada. The survey contained 2
case studies concerning both the initiation and withdrawal of gastro protection in high­
risk users of clopidogrel. 173 physicians replied. This includes 12 Cardiologists, 126 FPs,
and 35 unidentified-specialty physicians.
They were asked about what they would do regarding each of these medications, if they
substitute Omeprazole with another gastro protective medication or PPI, type of their
practice, age, speciality ...
Results: Regarding Clopidogrel, 6.36% would discontinue, 5.2% increase the dose,
86.1 % maintain the existing dose, and 2.31 % did not respond. With regard to
Omeprazole, 26.6% stated they would continue with the previous dose, 2.89%
discontinue it and avoid any anti-acid therapies, 30.6% replace it with an HR2A, 35.3%
replace it with another PPI, and 4.62% did not answer. 91.6% of all physicians who
replaced Omeprazole with another PPI, chose Pantoprazole; in spite of limited evidence
supporting its preferred status. These results were different among Cardiologists versus
FPs, also among doctors working in teaching hospitals versus non teaching hospitals.
Conclusions: Majority of physicians appreciate the role ofPPls in high risk patients who
are on Clopidogrel. Despite some studies in this population of patients; there are no clear
guidelines and more studies are required to properly determine the role for PPI therapy in
high risk clopidogrel users.
ACUTE HEPATITIS AS A MANIFESTATION OF PARVOVIRUS B19 INFECTION
Aleisha Hatakka, MDI, Andrew Walkty MD2
Internal Medicine Resident (PGY 1)1 Department of Medical Microbiology and Department ofintemal Medicine2
Faculty of Medicine, Health Sciences Centre, University of Manitoba, Winnipeg, MB.
Introduction: Parvovirus B 19 is a single stranded DNA virus belonging to the family Parvoviridae. In children,
parvovirus B 19 infection often results in erythema infectiousum ( fifth disease), which is characterized by a
distinctive facial rash ("slapped cheek appearance").
In adults, infection may present as an acute
arthritis/arthropathy. Hepatitis due to parvovirus B 19 infection has only been rarely reported in the literature. A
case of acute hepatitis likely caused by infection with parvovirus B 19 is described. A review of the literature
follows the case presentation. This case highlights the importance of maintaining a broad differential diagnosis in
patients presenting with acute hepatitis.
Case: A 30 year-old female with no significant past medical history was admitted to Health Sciences Centre with
new onset of fever. The patient had been unwell approximately 5 days prior to presentation. Over this time, she
reported low grade fever, diffuse arthralgias, myalgias, sore throat, anorexia, and appearance of an erythematous
rash on her legs, arms, and abdomen. Approximately 24 hours prior to admission she developed clinical jaundice.
The patient initially denied any sick contacts. There was no history of intravenous drug use, nor was there any
history of heavy alcohol consumption. The only new medication she had received was valacyclovir for an episode
of genital herpes. On examination, the patient was visibly jaundiced. Initial investigations revealed an AST of 67
UIL, an AL T of 367 UIL, an ALP of 171 UIL, a total bilirubin of 137 IlmollL, and a peripheral white cell count of
7.1 x 1091L. Serology for hepatitis A, hepatitis B, hepatitis C, EBV, CMV, and HIV, HIV viral load, hepatitis C
RNA, ANA, rheumatoid factor, antimitochondrial antibody, ANCAs, blood cultures, urine culture, and a throat swab
for bacterial and viral culture were all negative. Immunoglobulin levels were normal. An anti-smooth muscle
antibody was detected at a low titre of 1:40. Ultrasound of the liver did not demonstrate evidence of biliary
obstruction or hepatic vein occlusion. A liver biopsy was consistent with mild acute/lobular hepatitis, with no
evidence to support autoimmune hepatitis as a cause of the patient's symptoms. Given the history of rash, fever, and
arthralgias, serology for parvovirus B 19 was ordered for completeness. The patient's parvovirus IgM came back
strongly positive. Further questioning revealed that there was a recent outbreak of "slapped cheek disease" at the
school attended by the patient's daughter.
Discussion and Conclusions: There are few reports of parvovirus B 19 associated hepatitis in the literature. In a
review of fulminant hepatitis in children, parvovirus B 19 was detected in the serum of 4/21 patients with
unexplained etiology. IgM positivity was present in only one of the patients. A case published in Denmark had a
presentation similar to our patient and they found evidence of parvovirus B 19 infection, demonstrated by IgM
antibodies and confUiIled by viral polymerase chain reaction (PCR). A second case of a patient with hepatitis and
myelosuppresion demonstrated the presence of parvovirus B 19 antibody but did not demonstrate the presence of
viral DNA via PCR. The role of parvovirus B 19 in acute fulminant liver failure (AFLF) remains controversial. One
review demonstrated the presence of IA-PCR detected parvovirus B 19 in liver samples of pateints undergoing
transplant for AFLF but was unable to demonstrate acute antibody response in the serum of the same patients.
Another group was unable to demonstrate the presence of virus or antibodies in the serum of 34 patients undergoing
liver transplant for AFLF of unknown etiology. Controversy exists surrounding whether the presence of viral DNA
detected in the liver represents chronic underlying infection versus an acute infection leading to the patients'
presentation. However, a recent case report depicted a patient who presented with acute hepatitis with no obvious
etiology except for positive IgM and IgG antibodies to parvovirus. This patient deteriorated and required orthotopic
liver transplant. This case, as in ours, leaves parvovirus B 19 as the only available known diagnosis. In a case of
hepatitis where more common causes have been excluded, consideration should be given to pursuing diagnostic
testing for parvovirus B 19.
Unusual variant of metaplastic ductal carcinoma of the breast:
Bilateral adenosquamous carcinoma
Daniela Stroescu, MO Internal Medicine, University of Manitoba
Marianne Krahn, MO, Medical Oncology and Hematology, University of Manitoba
We present the case of a 72 year old female presenting with 1.8 cm spiculated left
breast mass, identified on mammogram. On ultrasound guided biopsy no lesion
was identified therefore core biopsy was done. This identified only atypical ducts,
but was not diagnostic for malignancy. Ultrasound guided lumpectomy was
proposed and this identified small tumor of 0.5 cm diameter invasive ductal
carcinoma with focal squamous metaplasia. This report was amended as the
tumor diagnosis changed to invasive low grade adenosquamous carcinoma. The
core biopsy and Ultrasound guided lumpectomy sampled two distinctly separate
lesions in the same breast.
At this time patient has decided on bilateral mastectomy for cosmetic reasons.
On right mastectomy specimen there have been identified six separate foci
ranging from 0.5 cm to 1.6 cm the largest. ER/PR/HER-2 all negative.
Discussion: Metaplastic carcinoma of the breast is a rare form of breast
neoplasm, accounting for less than 1% of all invasive mammary carcinomas,
exhibiting either mesenchymal component or squamous differentiation. This is a
triple negative malignancy for ER, PR and HER-2. As metastatic spread is rare and
local invasion more common, excision with good margins or mastectomy is
curative. We are presenting this case as this is an even rarer presentation with
bilateral lesions.
THE OCCURRENCE OF PUMONARY SARCOIDOSO IN A PATIENT TREATED WITH INTERFERON. Fahad AIHammad ,RI Medical Resident, Department of Medicine, University of Manitoba, Winnipeg Gregg Eschun, Martha Shepertycky, Section of Respirology, Department of Medicine, University of Manitoba One side effect of the immunomodulatory effect of interferon is the possible triggering or exacerbation of systemic or cutaneous sarcoidosis We report new case and offer an exhaustive review of the literature. A 45-year-old femal with type C chronic active hepatitis developed new respiratory symptoms and pulmonary infiltrates with muscle weakness and neurological symptoms with hilar and mediastinal adenopathy after 11 months of treatment with pegylated interferon. The evolution was favourable after stopping treatment. CT·scan of the thorax which shows hiJar and mediastinal adenopathy Patient was referred to chest medicine and at that time she was complaining offatigue muscle weakness ,coughing and SOB .she is non smoker no significant travel history with hx of treatment of interferon for hep c for the last II months no obvius HIV risk factor .vital signs were stable with no lymphadenopathy Patient underwent Medianscopy no malignant cells were identified and surgical pathology shows noncaseating granulomas consistent with sarcoidosis .stains for acid fast bacilli was negative .Pt was started on steroid and follow up was arranged Pulmonary side effects of interferon-alpha therapy of chronic hepatitis C seem to be rare. So far, 4 of sarcoidosis in association with interferon­
alpha treatment of chronic hepatitis C have been described.: We report on three patients who were treated with recombinant interferon-alpha2a for chronic hepatitis C, two of them in combination with ribavirin. These patients developed pulmonary sarcoidosis 12, 20 and 21 weeks, respectively, after beginning interferon therapy, one patient with Lofgren's syndrome. In one patient sarcoidosis emerged only after discontinuation of interferon therapy because of treatment failure. Clinical symptoms of sarcoidosis in the three patients were suggestive of side effects of interferon-alpha. Interferon therapy was discontinued and spontaneous remission was observed in all three cases 5, 6, and 8 months, respectively, after the onset of symptoms. The occurrence of sarcoidosis in association with interferon-alpha therapy for chronic hepatitis C may have been underestimated so far. This could be due to the fact that symptoms of sarcoidosis and common side effects of interferon are similar, and sarcoidosis may occur after the end of interferon therapy. We hypothesize that interferon-alpha as a potent stimulator for T-helper I (Thl) immune responses may trigger the compartmentalized Th 1 reaction that has been shown to take place in sarcoidosis DEPARTMENT OF INTERNAL MEDICINE RESIDEN'" RESEARCH DAY PROGRAM TUESDAY, MAY 18, 2010 THEATRE B, BASIC MEDICAL SCIENCES BLDG. TER PRESENTATIONS
Time will be adhered to with 5 minutes for presentation and 5 minutes for questions.
1300 (Clinical Investigation)
Patient outcomes in pre-hospital electrocardiograms initially negative for STEMI: A
subset of the CODE STEMI project
Robin Dueas, Core
Supervisor: J. Tam
1310 (Clinical Investigation}
Publication bias: Where have all the abstracts gone?
Kris Paulson, Haematology
Supervisor: M. SetteI
1320 (Clinical Investigation)
Increased mortality and morbidity after coronary artery bypass grafting in chronic
obstructive pulmonary disease
Fawaz Alharbi, Respirology
Supervisor: S. Sharma
1330 (Case Report)
Posterior reversible encephalopathy syndrome - New associations with thrombotic
thrombocytopenic purpura and rituximab
Lauren MacKenzie, Core
Supervisor: T. Wong
1340 (Case Report)
Malignant peripheral nerve sheath tumor of the pelvis arising ten years after radiation
therapy for cervical cancer
Maclean Thiessen, Core
Supervisor: R. Wong
1350 (Case Report)
Back pain isn't always just back pain
Daljit Gill, Core
1400 Supervisor: F. Hussain
(Clinical Investigation)
Enteral feeding tube placement: A review of institutional protocol as compared to best
practice
Owen Mooney, Core
Supervisor: N. Hajidiacos
1410 (Case Report)
Virus on the brain: An exhaustive search reveals an occult pathogen
Benjamin Goldenberg, Core
Supervisors: F. Aoki, P. Orr
1420 (Case Report)
Cystic echinococcosis: Late rupture and complication of a stable pulmonary cyst
Jolene Fisher, Core
Supervisor: V. Hoffstein
1430 (Case Report)
Novel mutation of the senataxin gene in a patient with ataxia with oculomotor apraxia
type 2
Esseddegg Ghrooda, Neurology
Supervisor: A. Borys
1440 -1515 BREAK
1515 (Clinical Investigation)
Application of evidence-based guidelines and continuous quality indicators in peritoneal
dialysis: A nephrology now study
Nathan Allen, Core
Supervisor: M. Sood
1525 (Case Report)
Erythrokeratoderma variabilis with erythema gyratum repens: A case of a de novo
missense mutation in the GJB4 gene
Jason Sneath, Core
Supervisor: S. Silver
1535 (Clinical Investigation)
Evaluating the effectiveness of rosuvastatin in preventing the progression of diastolic
dysfunction in aortic stenosis: A substudy of the aortic stenosis progression observation
measuring effects of rosuvastatin
Kapil Bhagirath, Cardiology
Supervisor: D. Jassal
1545 (Clinical Investigation)
Nasopharyngeal carcinoma (NPC) patterns in Manitoba's Asian and non-Asian
population
Vallerie Gordon, Medical Oncology
Supervisor: S. Navaratham
1555 (Clinical Investigation)
Cherchez Ie chat! A review of pasteurella multocida peritonitis in peritoneal dialysis
patients
David Allen, Core
Supervisor: J. Embil
1605 (Case Report)
Neurological complications associated with profound fluctuations in serum sodium:
Osmotic or ischemic demyelination?
Kimberley Mulchey, Core
Supervisor: P. st. John
1615 (Case Report)
Challenge of treating metastatic breast cancer in the setting of acute intermittent
porphyria
Jonathan Laxton, Core
1625 (Clinical Investigation)
Staphylococcus aureus pyomyositis diagnosed by 165 rDNA amplification and
sequencing
Alissa Lloyd, Core
1635 Supervisor:
(Clinical Investigation)
Small changes in serum creatinine in the emergency department are associated with long
term progression to chronic kidney disease
Krista Ryz, Core
1705 Supervisor: D. Bell
TBA
David Ryan, Core
1655 Supervisor: A. Walkty
(Case Report)
Fever, rhabdomyolysis, and renal failure in an adult after emergency department rapid
sequence intubation using succinylcholine
Marc Fournier, Core
1645 Supervisor: M. Krahn
Supervisor: A. Levin
(Case Report)
Mycobacterium avium intracellular complex in hot tub water as a cause of hypersensitivity
pneumonitis
Meaghan O'Brien, Core
Supervisor: F. Bovell
The Department of Internal Medicine gratefully acknowledges the participation of our guest
speaker and judge Dr. Curtis Cooper, and to our local faculty adjudication team, Dr. Mauro
Verrelli , Dr. Ryan Zarychanski, Dr. Ethan Rubinstein, Dr. Christine Peschken and Dr. Martina
Reslerova. Thank you to Dr. Dana Moffatt for presenting his published work derived from his 2008
resident research day presentation.
POSTERS DISPLAYED IN RESIDENT'S ABSENCE (Case Report)
A unique case of relapsed multiple myeloma presenting as a solitary testicular
plasmacytoma secreting a different monoclonal protein than that at the time of diagnosis
Roopesh Kansara. Core
Supervisor: M. Rubinger
(Case Report)
Desperate times, desperate measures: rotablating dissections
Kristyn Campbell, Core
Supervisor: F. Hussain
(Case Report)
Neurosarcoidosis: Presentations and management
Ernest Inegbu, Core
Supervisor: G. Eschun
(Case Report)
Idiopathic cholestasis/vanishing bile duct syndrome: A rare complication of Hodgkin's
Disease
James Paul, Core
Supervisor: A. Kraut
(Clinical Investigation)
Mortality in obstructive sleep apnea patients
Renelle Myers, Respirology
Supervisor: C. Ramsey
(Clinical Investigation)
Mycophenolate mofetil based treatment in encapsulating peritoneal sclerosis: A single
center experience
Kelvin Leung, Core
Supervisor: M. Reslerova
(Clinical Investigation)
Impact of body mass index (8MI) on early and late mortality and technique failure in
peritoneal dialysis
Kelvin Leung, Core
Supervisor: C. Rigatto
(Clinical Investigation)
Assessment of right ventricular systolic dysfunction using real time three dimensional
echocardiography after marathon running
Anthony Wassef, Core
Supervisor: D. Jassal
(Clinical Investigation)
Efficacy of rituximab for treatment of autoimmune cytopenias associated with
Iymphoproliferative disorders: Manitoba experience
Jessica Singh, Core
Supervisor: R. Kumar
PATIENT OUTCOMES IN PRE-HOSPITAL ELECTROCARDIOGRAMS INITIALLY NEGATIVE
FOR STEMI: A SUBSET OF THE CODE STEMI PROJECT
1
1
RA Ducas , A Wasseff\ RK Philipp\ LR Hall. RA Grierson , SA Hodge\ ER Weldon" J Dooley,
1
1
CM Schmidt, OS Jassal , JW Tam
1) University of Manitoba, Winnipeg, Manitoba
Background. Many centers around Canada and the US employ systems of pre-hospital EGG
interpretation to help identify acute ST elevation myocardial infarction (STEMI) and co-ordinate
reperfusion therapy. However little is known about the outcomes of patients with chest pain
presentations who have pre-hospital EGG that are initially negative for STEMI (PHENST). The
purpose of this study it to identify the outcomes of patients with such patients and compare them
to those with initial pre-hospital diagnosis of STEMI (IPHST).
Methods. In our urban centre of 658,700 people, emergency medical personnel were trained to
perform and screen ECG in acute chest pain (GP) for suspected STEMI. These ECGs were
subsequently transmitted digitally to a cardiologist's hand-held device. The cardiologist interpreted
the ECG and co-ordinated reperfusion therapy for IPHST patients according to protocol. Patients
with PHENST were transported to the closest emergency department, with variable degree of
comprehensive cardiac care. Over a 20-month period our local pre-hospital co-ordinated care for
PPCI project (CODE STEMI project) we compared all IPHSTS and PHENST.
Results. From July 2008 to March 2010, the CODE STEMI project received 307 wirelessly
transmitted pre-hospital EGG suspicious for STEMI. The cardiologist interpreted these as IPHST
in 184 and PHENST in 123. Of the 123 cases, the majority were male (68%) with an average age
of 66 years. This group included 4 (3%) truly missed acute STEMI, 13 (11%) other patients went
on to have a subsequent STEMI during the early hospital stay, while 28 (23%) were diagnosed
with non-ST segment elevation myocardial infarction (NSTEMI). A diagnosiS of acute coronary
syndrome (AGS) was made in 43% of all PHENST patients. Compared to the IPHST group, those
with PHENST had a significantly greater proportion of elderly (> 75; 37% vs 16%, Yates Chi 2 =
15.34, P < 0.0001), as well as a strong trend towards higher mortality (14% vs 7%. Yates Chi 2
3.78, P =0.052). Conclusion: With the growing use of pre-hospital EGG for chest pain
presentations, it must be recognized that despite initial negative pre-hospitals ECG for STEMI,
there is a high rate of acute coronary disease and significant in-hospital mortality. These findings
may help to divert ambulances to hospitals capable of advanced and comprehensive cardiac care,
regardless of initial ECG presentation.
=
=
PUBLICATION BIAS: WHERE HAVE ALL THE ABSTRACTS GONE?
Authors: Dr. K Paulson, M. Saeed, Dr. D. Szwajcer, and Dr. M.D. Sefiel
University of Manitoba. Wininpeg, Manitoba, Canada
Background: Only a small proportion of abstracts lead to full publication, leading to publication bias.
Clinical and "positive" studies are more likely to be published than other abstracts. This issue has not been
examined in the hematology or blood and marrow transplantation (BMT) literature.
Objectives: We intend to review the rate of publication of abstracts presented at the Canadian Blood and
Marrow Transplant Group (CBMTG) Annual Meetings, and determine factors associated with publication.
We hypothesized that as BMT centres in Canada are based at large, academic centres, the proportion of
abstracts leading to publication will be high.
Methods: All abstracts presented at the CBMTG Annual Meeting in 2002, 2004, and 2006 were reviewed
and categorized by: study type; funding source; single or multi-centre; form of presentation; "positive" or
"negative", using the authors' defmition. To determine publication, each reference was searched on
multiple databases (MEDLINE, EMBASE, Web of Science, and CINAHL) by first, second and final
authors. Two authors undertook abstract categorization and searching, and disagreements were resolved by
consensus.
Results: 141 abstracts were reviewed, of which 43 were published (30.4%); this proportion is comparable
to other medical specialties. 21 studies were published from 2002 (36.8%), as compared to 12 from 2004
(24.0%) and ] 0 from 2006 (29.4%) (p 0.35). Clinical studies (retrospective or prospective) were more
likely to be published than non-clinical studies (p = 0.0 I4). Number of centres involved and positive results
were not associated with publication likelihood. Funded studies were more likely to be published (p
0.009). Finally, oral presentations were more likely than posters to be published (p = 0.004).
Conclusion: Publication bias exists at the CBMTG meeting at a rate similar to that of other medical
disciplines. Studies with clinical outcomes, ones that were externally funded, and those presented orally
were more likely to be published. Efforts to encourage full publication of scientific abstracts should be
sought.
Predictors of Abstract Publication
Form of Presentation
Rate of PublIcation
Significance
Orel
POlIter
59.1%
25.2%
p=0.OO4
Funded Study
Non-Funded Study
70.0%
27.5%
P = 0.009
CHnlcal
Non-Clinical
38.4%
18.2%
p = 0.014
Single Centre
Multiple Centrea
27.7%
45.5%
p=0.130
Positive
Negative (or not-stated)
37.7%
26.1%
p '" 0.186
2002
2004
36.8%
24.0%
29.4%
P
Funded Study
S1udy1YPe
Number of Centre. Involved
Study Resu~ ..
Year
2006
0.350
Increased Mortality and Morbidity after Coronary Artery Bypass Grafting in
Chronic Obstructive Pulmonary Disease
Fawaz Alharbi, Supervisor: Sat Sharma BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a known risk factor for
mortality and morbidity for patients undergoing coronary artery bypass grafting (CABG).
Previous studies have shown adverse post CABG outcome in patients with "physician diagnosis
of COPD". However, more recent data where spirometry was used as a marker, COPD did not
influence mortality although length of hospital stay increased only in patients with severe airflow
obstruction.
METHODS: We performed a retrospective case control study of patients who underwent CABG
between the years 2002 and 2007 at a university-affiliated hospital. We reviewed all patients with
a previous "physician diagnosis ofCOPD" and those for whom a preoperative spirometry was
available. The "spirometrically confirmed diagnosis" was defined as presence of irreversible
airflow obstruction in smokers 50 years of age or older. An age and sex matched control group
included patients not known to have "physician diagnosis ofCOPD".
RESULTS: We reviewed 232 patients with "physician diagnosis ofCOPD", 135 patients with
"spirometrically confirmed COPD" and 176 controls. For "spirometrically confirmed" group
average age was 68.67±13.68 years, male 77.8%, 11.85 % belonged to American Association of
Anesthesiology (ASA) class III, 88.15% belonged to ASA class IV; and 48.8% were urgent or
emergent. The control group had an average age 68.91±12.l7 years, male 81.4%, 17.96%
belonged to American Association of Anesthesiology (ASA) class III, 82.03% belonged to ASA
class IV; and 40.7% urgent or emergent, p <0.05. Other demographic characteristics between the
two groups were not significantly different. The mortality rates for "physician diagnosis of
COPD", "spirometrically diagnosed COPD" and control group were 6.8%, 5.9% and 1.7%,
respectively (p <0.005). The COPD patients required reintubation 15.56±6.32% of the time
compared to the control group 3.59±1.64% (p <0.005). Patients with "spirometrically confirmed
COPD" had longer duration of mechanical ventilation (31.45±20.33 vs 17.27±9.37 hours, p
<0.05), length oflCU stay (4.33±2.51 vs 2.84±1.23 p <0.05) and hospital stay (l7.35±5.38, p
<0.05) days.
CONCLUSION: Both the "physician diagnosis ofCOPD" and "spirometrically confirmed
diagnosis of COPD" were associated with increased postoperative mortality. Patients with COPD
required prolonged mechanical ventilation and consumed considerably more intensive care unit
and hospital resources. Our study suggests that preoperative medical optimization of patients
with diagnosis of COPD and aggressive postoperative management is imperative to reduce
mortality, ICU and hospital costs.
Posterior Reversible Encephalopathy Syndrome - New Associations with Thrombotic
Thrombocytopenic Purpura and Rituximab
Dr. Lauren MacKenzie and Dr. Turnly Wong. University of Manitoba. Winnipeg, Manitoba, Canada.
Posterior Reversible Encephalopathy Syndrome (PRES) is a neurologic syndrome characterized
by seizure, headache, confusion, and Magnetic Resonance Imaging (MRI) fmdings demonstrating
vasogenic cerebral edema. Classically it has been associated with hypertension, eclampsia, and some
immunosuppressive agents, most typically cyclosporine. Here we present a case of PRES in the setting of
Thrombotic Thrombocytopenic Purpura (TTP), and the absence of hypertension.
A 75-year-old lady was transferred from a peripheral to a tertiary care hospital with acute renal
failure, fever, an elevated white blood cell count, and confusion. Initially thought to be pre-renal in origin,
the renal failure worsened despite adequate hydration. A septic workup to look for the cause of
leukocytosis and fever was negative. Computed Tomography (CT) of the brain showed no acute changes.
During the patient's course in hospital, a normocytic anemia as well as a thrombocytopenia worsened. No
evidence of blood loss was found. Pertinent laboratory evaluations showed an elevated serum lactate
dehydrogenase, a low serum haptoglobin, a normal serum bilirubin, and the peripheral blood smear showed
schistocytes. A Heparin-Induced Thrombocytopenia (HIT) assay was negative. In consultation with the
Hematology service, a diagnosis of TTP was made, and the patient was started on daily plasma exchange
therapy. Despite repeated treatments, the thrombocytopenia and anemia persisted. Consequently the patient
was started on adjuvant therapy ofrituximab. Over a week into therapy, the patient became hypoxic
secondary to pulmonary edema, and was transferred to the intensive care unit for continuous renal
replacement therapy. She remained on plasmaphoresis and rituximab, and once stabilized, was transferred
back to the medical ward with persistent anemia, thrombocytopenia, renal failure, and confusion. Shortly
after transfer back to the medical ward, the patient had a seizure. A repeat CT Brain showed no acute
changes, and there were no focal neurologic findings on clinical exam. The patient's level of consciousness
continued to deteriorate, and consequently an MRI was pursued. The MRI Brain demonstrated changes
consistent with PRES. However, unlike most presentations of PRES, the patient was not hypertensive;
blood pressure had remained close to baseline during her course in hospital. Due to the patients overall
clinical deterioration and non-response to therapy, aggressive treatment was withdrawn and palliative
treatment was pursued, following consultation with her family. The patient expired shortly after.
The association between TTP and PRES has only recently been observed. A 2009 article in
Neurology reviewed 47 cases ofTTP between 1997 and 2007, and found 5 patients with evidence of PRES
on neuroradiographic imaging I. This led the authours to conclude that PRES is an important neurologic
complication of severe TTP. Recent clinical case vignettes have also reported an association between
rituximab and PRES - one in the setting of systemic lupus erythematosus2 , and the other as part of a
chemotherapy regimen for large B-celllymphoma3 • This leaves both rituximab and TTP as the possible
culprits for PRES in this patient. This case illustrates the importance of considering PRES as a
complication ofTTP and/or rituximab use, particularly since the impressive neurologic manifestations can
resolve once the offending agent is treated/removed, though unfortunately in this case the patient's TTP
was unamenable to treatment.
IBurrus, T.M., E.F. Wijdicks, A.A. Rabinstein. Brain lesions are most often reversible in acute thrombotic
thrombocytopenic purpura. 2009. Neurology 73(1):66-70.
2Mavragani, C.P., P.G. Vlachoyiannopoulos, N. Kosmos, 1. Boletis, A.G. Tzioufas, M. Voulgarelis. A case
of reversible posterior leucoencephalopathy syndrome after rituximab infusion. 2004. Rheumatology
43(11): 1450-\.
3Hosoi, M., G. Yamamoto, Y. Imai, M., Kurokawa. Reversible posterior leukoencephalopathy syndrome
following R-CHOP therapy for diffuse large B-ceillymphoma. 2010. Ann Hematol. 89(2) 207-8.
MALIGNANT PERIPHERAL NERVE SHEATH TUMOR OF THE PELVIS ARISING TEN YEARS AFTER RADIATION THERAPY FOR CERVICAL CANCER Authors: Maclean Thiessen MD., Ralph Wong MD FRCPC.
Internal Medicine, University of Manitoba, Winnipeg, Manitoba
Malignant Peripheral Nerve Sheath Tumors (MPNST) are rare but have been reported to occur
following radiotherapy in various case studies throughout the world. Case series have documented these
tumors to occur anywhere from within the first few years following therapy to beyond the fourth decade.
The case being presented is that of a 54 year old female with a history of pelvic radiation therapy ten years
earlier for cervical cancer. She presented to her family doctor with a history of progressive buttock pain and
leg weakness. MRI of her pelvis revealed a mass involving her L4 nerve root which extended to the sciatic
nerve sheath. She was referred to neurosurgery for resection and pathology confirmed the mass to be a
malignant perineuroma. These tumors are a rare but recognized complication of radiation therapy and are
associated with a poor prognosis. This case underscores the risks associated with ionizing radiation used in
medical practice and the need for long term follow up of patients receiving radiation therapy.
BACK PAIN ISN'T ALWAYS JUST BACK PAIN
Daljit Gill, Resident, Department ofIntemal Medicine, University of Manitoba, Winnipeg, MB
Supervisor
Dr. Farrukh Hussain
Spontaneous spinal epidural hematoma (SSEH) is an extremely rare hemorrhagic spinal pathology defined
by the presence of blood in the epidural space in the absence of an underlying hematological or hemostatic
disorder, vascular malformation, or trauma. SSEH is an emergent, serious cause of acute spinal cord
compression. Symptoms and signs usually include sudden onset back pain with radicular radiation,
followed by progressive sensorimotor deficits, frequently leading to complete paralysis.
Patient JD was a 67 year old male with a history of known coronary artery disease (with a previous history
of coronary artery bypass grafting and two previous myocardial infarctions), He was admitted with an acute
coronary syndrome. He underwent percutaneous coronary intervention and received stenting of the right
coronary artery, the ramus artery, and the left main artery. He had previously been stable on his home
medications for a number of years, including aspirin and clopidogrel. Heparinization had been reversed
post.procedure to minimize bleeding risk. He was continued on eptifibatide, a group lIb/lIla inhibitor post­
procedure. He was transferred in stable condition to the coronary care unit for recovery and monitoring.
Several hours later in the early evening the patient complained of lower back pain for which he was given
Tylenol and Percocet with relief. Shortly after midnight, the patient complained again of continuing lower
back pain and then suddenly of being unable to move his legs. On examination, vital signs including
hemodynamics were stable. There was no active movement of his lower limbs. Peripheral pulses were
palpable. Reflexes in the lower limbs bilaterally were absent. Digital rectal examination revealed decreased
sphincter tone. The patient had a loss of sensation from approximately at the TIO level downwards. Urgent
magnetic resonance imaging of the spine demonstrated a large spinal epidural hematoma extending from
approximately T2 to TIl with significant resultant spinal cord compression. Neurosurgery was consulted
for emergent evacuation of the hematoma. By the time the patient was assessed he had a loss of function on
the right side from the T7 level and on the left side from the T5 level. They felt that there was no chance of
neurological recovery and suggested conservative management. Approximately 12 hours after the pain
began the previous evening, the patient suddenly had no back pain and began to regain some sensation in
his lower limbs and was able to move his feet slightly. Over the next day he continued to have increased
return of sensorimotor function. Repeat imaging showed that the hematoma was smaller in size with
significantly less cord compression. Urgent evacuation of the hematoma was performed. With aggressive
physiotherapy, the patient was able to regain the majority of sensorimotor function and is now ambulatory
with a walker.
This case illustrates the importance of early recognition of SSEH in the setting of the use of anti.platelet
agents. SSEH has already been reported with the use of aspirin and cJopidogrel, and now with group
lIbllIIa inhibitors. Early diagnosis and urgent surgical decompression of the hematoma is essential for the
best possible neurological recovery.
ENTERAL FEEDING TUBE PLACEMENT: A REVIEW OF INSTITUTIONAL PROTOCOL AS COMPARED TO BEST PRACTICE. Owen T. Mooney, MD; Nick Hajidiacos, MD, FRCPC. Department of Internal Medicine, Health Science Centre, Winnipeg, Manitoba Introduction: Enteral feeding tube placement is a common, blind bedside procedure. The risk of serious complications related to placement and monitoring of these tubes has been well documented. A Quality Improvement initiative was undertaken to identify our institutions policy as it compares to best practice and current bedside practice. Methods: The first component of this study included a full review of institutional policy around enteral feeding tubes with comparison to current evidence-based literature regarding technique for identifying correct placement and methods for continued monitoring. A search, using the terms "nasogastric", "enteral", "complications", and "aspiration" was conducted using the internal medicine/intensive care unit database over a I 0 year period. Five cases where identified and a chart review was performed on cases where complications of enteral feeding tubes were the direct cause of morbidity or mortality. Patient characteristics were recorded. The second component began over a two week period. All patients that were admitted to an internal medicine ward or medical intensive care unit who had a enteral feeding tube were identified. These charts were reviewed identifying eight predefmed objectives. Results: Fifteen patients had enteral feeding tubes placed over the two week data collection period. Seven percent (III 5) of patients had a procedure note written post-insertion. Fifty-three percent (8/15) had radiography for confirmation ordered. Twenty-seven percent (4/15) of the patients had confirmation of placement documented by a physician. Confirmation of placement included "whoosh" testing in 47% (7/15). Reinsertion or reposition was required in 20% (3/l5) cases. One serious complication as a direct result of enteral feeding tube placement was documented over the two week data collection period. Conclusions: Serious morbidity and mortality can be associated with placement and monitoring of enteral feeding tubes. Institutional evidence-based guidelines need to be developed and education around the placement and monitoring of enteral feeding needs to be promoted. A checklist, analogous to central venous catheter placement checklists, should be made mandatory for every enteral feeding tube insertion. VIRUS ON THE BRAIN: AN EXHAUSTIVE SEARCH REVEALS AN OCCULT PATHOGEN
Benjamin A Goldenberg MD, Fred Aoki MD, Pam Orr MD University of Manitoba, Faculty of Medicine
Though ubiquitous in the serum of humans from age 3 onward, the lymphotropic beta-herpes
viruses - Human herpesvirus 6a16b and Human herpesvirus 7 (HHV-7) have recently been implicated in
adverse neurological sequalae in immunocompromised patients. Active infection from HHV -7 previously
thought to be non-existent, has been described in emerging transplant infectious disease literature We
present a case of Fever of Unknown Origin associated with encephalopathy in a 55 year old male two
months post Allogeneic-Human Stem Cell Transplant for Chronic Lymphocytic Leukemia(CLL).
A Fifty-Five year old man with CLL, 64 days post transplant was readmitted to the Bone Marrow
Transplant ward with a three day history of fever (39 Celsius); confusion and mild supraorbital headache.
He also manifests a new resting tremor in the hands bilaterally. His physical exam was otherwise negative
for any further focal neurological deficits nor any other foci of possible infection. CBC reveals a moderate
leucopenia (WBC 2.9 xlO l , mm 3) with a normal differential. Serum biochemistry was normal. Blood
cultures drawn from two sites were positive for Pseudomonas aeruginosa and putida. As such, the patient
was started on IV piperacillinltazobactam and oral ciprofloxacin for a two week course. Over the next two
weeks, the patient continued to have daily fevers with temperatures ranging between 39-40 degrees Celsius.
His confusion worsened to a state of persistent amnesia. Further investigative work up included: a
Computed Axial Tomography of the chest and abdomen, Magnetic Resonance Imaging of the brain -all of
which were essentially negative; Bone Marrow Biopsy contained 100 percent donor cells and no residual
tumour; serum and cerebrospinal fluid sent for the common herpes viruses (including Herpes Simplex-l
and -2, Cytomegalovirus - commonly associated with infection in the immunocompromised host -- and
HHV6) were all negative. Finally, repeat Blood Cultures revealed no further growth. Given the patient's
worsening encephalopathy and continued intermittent fever, further study of the central nervous system was
required. Electroencephalogram revealed delta wave slowing consistent with encephalitis of unknown
etiology. Serial Lumbar Punctures over the course ofthe admission repeatedly revealed a lymphocytic
pleocytosis, mildly elevated protein and a normal glucose and grew none of the commonly pathogenic or
less common microbes. Of importance, cerebrospinal fluid was strongly positive for HSV -7 DNA by
qualitative PCR. In the absence of any other isolated pathogen - we elected to cease further anti-bacterial
therapy and begin anti-viral treatment with IV ganciclovir 5mglkg twice daily. In addition, IVIg was
administered daily for the following five days. A week after commencing antiviral therapy, the patient's
fever had normalized and his encephalopathy completely cleared, though the resting tremor remained. The
patient was discharged home with oral ganciclovir, I gram three times daily for two more weeks.
Though HHV -6 is a commonly described CNS pathogen, there is a dearth of evidence in the adult
Literature on clinical experience with its genomic cousin, HHV-7. Only a few case reports from the past
ten years detail similar success in treating encephalitides attributed to HHV -7 with gancyclovir or
foscamet. There have been no prospective randomized controlled trials examining the use of either
antiviral in the treatment ofHHV-7 implicated disease. Given its potentially fatal sequelae, we posit a
future role for screening asymptomatic pre-transplant patients as well as future studies investigating the
utility of including HHV -7 in the differential as a potential pathogen in the encephalitis of the
immunocompromised patient.
CYSTIC ECHINOCOCCOSIS: LATE RUPTURE AND COMPLICATION OF A STABLE
PULMONARY CYST.
Fisher JI, Hoffstein, y2
IDepartment of Medicine, University of Manitoba, Winnipeg, Manitoba
2Department of Medicine, University of Toronto, Toronto, Ontario
Infection with cystic echinococcosis is observed worldwide. In Canada, the majority of cases are
seen among immigrants from endemic countries. Pulmonary involvement occurs in approximately twenty­
five percent of cases and is the most common organ affected after the liver. Traditional management
includes an invasive surgical approach with adjunctive chemotherapy. More recently, Japaroscopic and
percutaneous interventions have been introduced. For certain echinococcal cysts, it is suggested that
observation alone may be appropriate. However, the evidence for guidelines regarding procedural and
medical management is limited.
A 38-year-old man from Peru was evaluated in regards to a well-circumscribed right lower lobe
opacity on chest radiograph. Computed tomography (CT) scan of the chest confirmed a rounded, low
attenuation mass with an enhancing rim, consistent with a bronchogenic cyst. The possibility of cystic
echinococcosis was raised. The patient, however, was clinically asymptomatic and therefore no further
medical intervention was pursued. The presumed bronchogenic cyst was followed radiographically for ten
years with no change. The patient remained clinically well and routine follow up was discontinued.
One year later, the patient presented with a two-week history of right-sided, pleuritic chest pain
associated with fevers, chills, night sweats and a ten-pound weight loss. These symptoms persisted despite
several courses of antibiotics. Chest radiograph and CT scan revealed that the previously well·
circumscribed cyst had ruptured and there was now a large, right-sided pleural effusion. The patient was
subsequently taken to the operating room for a right thoracotomy with decortication and resection of the
ruptured cyst. Final pathology was consistent with echinococcus. The patient was treated post-operatively
with albendazole and praziquantel. He tolerated the medications well, and at 3 months follow-up was
virtually asymptomatic.
Recently, centers experienced in cystic echinococcosis have suggested that observation alone of
certain hydatid disease is sufficient. However, this "watch and wait" approach has not been formally
evaluated. This case demonstrates that echinococcal cysts may be at risk of spontaneous rupture after many
years of clinical stability. In addition, medical therapy with albendazole and praziquantel, in conjunction
with surgical drainage, is successful in the treatment of echinococcal empyema. Further study is needed to
help identify those at risk of late complications.
CASE REPORT
Novel Mutation Of The Senataxin Gene In A Patient With Ataxia With Oculomotor Apraxia Type 2
E. Ghrooda; MD, A. Borys; MD, FRCCPC. Mhanni; MD, FRCPC
Neurology division, Internal Medicine Department, University of Manitoba
Inttroduction Ataxia with oculomotor apraxia type 2 (AOA2) is a recently described Autosomal recessive
cerebellar ataxia (ARCA) caused by a diversity of mutations within the coding region of the senataxin
(SETX) gene. it is seems to be the second most frequent form of ARCA in some parts of the world after
Freidreich ataxia. The disease is characterized primarily by slowly progressive cerebellar ataxia includes
gait ataxia, head tremor, choreoathethosis and dystonic posture with walking, a peripheral sensorimotor
neuropathy, areflexia with cerebellar atrophy on brain images which is more prominent and more sever in
the eldest patients, and elevated levels of serum a-fetoprotein as a good marker to suggest genetic testing
Aim Here, we report a non-French Canadian man from a non consanguineous healthy family, with classic
clinical features of AOA2, who was found to possess two new homozygous specific mutations within
sentaxin gene. He has inherited the mutations one from each carrier parents who were identified on separate
DNA molecular testing to have a mutation in the SETX gene each
Case report A 24-year-old college graduated boy who noticed to have difficulties with his balance and
difficulty walking since age of seven with slowly progressive course. Past medical history was significant
for Attention Deficient Hyperactivity Disorder (ADHD) diagnosed at age of 10 and had been on Ritalin
trial for few months. Developmentally there were never any concerns in regards to achieving his early
milestones. Some mild learning difficulties also noticed with no family history of any ataxia or any other
neurological disorders. He is of British ancestry on his father's side and Ukrainian on his mother's side and
there is no known consanguinity. Based on Neurological examination, Laboratory studies and MRI, the list
of other differential diagnosis were rejected. A negative results of DNA molecular testing for Freidreich' s
ataxia, Ataxia telangiectasia and DNA testing for the six most common spinalcerebellar ataxias,
SCAI,2,3,6,7,and 8 with two new homozygous specific mutation of the senataxin gene (SETX) on
chromosome 9q34 confirmed the diagnosis of AOA2
Conclusion AOA2lt is more common than what was thought, it is seems to be the second most frequent
form of ARCA in some parts of the world after Freidreich ataxia. The mode of inheritance and the new
specific mutation have never been reported. DNA molecular testing is recommended in highly suspicious
clinical scenarios cases with characteristic laboratory and imaging findings
Keywords Cerebellar ataxia; ocular motor apraxia; AOA I; AOA2; ARCA, SETX, ALS4
APPLICATION OF EVIDENCE-BASED GUIDELINES AND CONTINUOUS QUALITY INDICATORS IN PERITONEAL DIALYSIS: A NEPHROLOGY NOW STUDY Nathan D Allen\ Amy R Sood2, David Mendelsson 3, Gemini Tanna4 , Jeff Schiff, Mauro Verrelli 2,
Claudio Rigatto 2 , Paul Komenda2 , David Naimark4 , Daniel Schwartz6 , Manish M Sood2
[1] Department of Medicine,Univerity of Manitoba, Winnipeg, MB [2] Department of Medicine, Section
of Nephrology, University of Manitoba, St Boniface General Hospital, Winnipeg, MB [3] Department of
Nephrology, Humber Regional Hospital, University of Toronto, Toronto, ON [4] Sunnybrook Health
Sciences Centre Division ofNephrology, University of Toronto, Toronto ON [5] Toronto General Hospital
Division of Nephrology, University of Toronto, Toronto ON [6] Fraser Health Renal Program Division of
Nephrology University of British Columbia, Vancouver BC
Introduction: The Kidney Disease: Improving Global Outcomes (KOIGO) initiative is currently working
towards translating the best evidence into international guidelines in kidney care. Little, however, is known
about factors that affect adherence to guidelines and barriers to their implementation in the international
community. This is particularly true in the area of peritoneal dialysis. We report an international survey
that assessed guideline adherence to providers of peritoneal dialysis in the areas of evidence based practice
(EBM) and continuous quality initiatives (CQI).
Methods: Nephrology Now is a monthly mailing list that highlights clinically relevant articles in
Nephrology as selected by the editorial board. 2147 subscribers were invited to participate in an online
survey to assess baseline characteristics of dialysis providers as well as 7 EBM and 9 CQI practices. All
EBM and CQI practice questions were based on commonalities in the Caring for Australians with Renal
Impairment (CARl), International Society for Peritoneal Dialysis (lSPD) and Kidney Disease Outcomes
Quality Initiative (KDOQI) practice guidelines. Ordinal and multiple regression analyses were employed to
determine univariate and multivariate relationships between baseline characteristics and EBM and CQI
practices.
Results: 475 physicians were included in the final analysis, the majority of which were nephrologists
(89.7%).50.1% worked in academic centres, 73.1% worked in group practice and 68% utilized a personal
digital assistant (PDA) device. 13.5% of physicians practiced in Canada, 35.4% in the United States of
America, 19.4% Europe, 4.4% Oceania, 5.3% South America, 10.2% Africa and the Middle East and
12.7% Asia. In multivariate analyses, adherence to EBM guidelines was was significantly associated with
health expenditures as a percentage of contries' gross domestic product (GDP), use of a PDA, shorter
length of clinical practice and greater number of PD patients in a providers' practice. Adherence to cQr
guidelines was significantly associated with expenditures as a percentage of GDP and a greater number of
PD patients were significantly associated with adherence CQI guidelines.
Conclusion: Significant differences in peritoneal dialysis practice patterns exist internationally. In this
novel study, adherence to EBM and CQI guidelines were associated with increases in a country's health
care expenditure. These discrepancies may impact the development, applicability and implementation of
international peritoneal dialysis guidelines.
ERYTHROKERATODERMA VARIABILlS WITH ERYTHEMA GYRATUM REPENS: A CASE
OF A DE NOVO MISSENSE MUTATION IN THE GJB4 GENE
Dr. J. R.Sneath, University of Manitoba, Winnipeg, Manitoba
Dr. S. Silver, University of Manitoba, Winnipeg, Manitoba
Erythrokeratodermavariabilis (EKV) is a rare genetic skin disorder clinically characterized by the
morphologic features of variable erythema and a relatively fixed hyperkeratosis. Typically it is an
autosomal dominant inherited condition. There have been four cases previously reported in the literature of
EKV occurring with erythemagyratumrepens (EGR). The cases all occurred in a Jewish Kurdistan family
who were subsequently found to have a mutation in the Connexin 30.3 molecule.
An 8-month-old boy of Egyptian descent was referred to our clinic with a profuse rash on the
central chest arranged in a "wood grain" pattern. The mother reported that the lesion had been increasing
in a circular pattern over the preceding 3 months. She also reported that the erythema varied significantly
throughout the course of the day. Prior to the clinic visit the mother had tried hydrocortisone cream and an
antifungal cream with no benefit. There was no history of a similar eruption in any of the child's contacts.
He was otherwise healthy, born at term, and had normal development with some mild speech delay. He
was on no medications, and there was no family history of any skin diseases.On examination the central
chest was found to have erythematous rings with a sharply demarcated outline. In addition he was found to
have multiple well-demarcated, erythematous plaques with hyperkeratosis on the knees, elbows, dorsum of
both feet, as well as in the axilla. Punch biopsy was performed on the left knee in an area of both erythema
and hyperkeratosis. On review by the pathologist the sample showed a compact orthokeratosis with a small
degree of papillated epidermal hyperplasia. The granular layer of the specimen was prominent and the
microscopic morphology was ichthyosiform. There was minimal inflammation in the dermis and no fungal
organisms were identified with PAS stain. Histological findings were therefore compatible with the
clinical diagnosis of erythrokeratoderma.Gene sequence analysis of the GJB3 and GJB4 genes revealed our
patient was heterozygous for the missense mutation F137L in the GJB4 gene. The presence of this mutation
is consistent with the diagnosis ofEKV.
Families with EKV have been mapped to chromosome 1p34-p35.1 with four possible connexin
genes responsible for the mutation. The GJB4 gene has been implicated as the mutation responsible for the
variant ofEKV associated with EGR. The Fl37L mutation found in our patients results from a T>C
nucleotide substitution in the coding exon resulting in the replacement of the normal phenylalanine codon
with a leucinecodon in the resultant Connexin 30.3 protein.
Our case is unique because, unlike the previously described patients, this resulted from a de
novomissense mutation in the GJB4 gene and the resultant Connexin 30.3 protein.
Evaluating the Effectiveness of Rosuvastatin in Preventing the Progression of Diastolic Dysfunction
in Aortic Stenosis: A Substudy of the Aortic Stenosis Progression Observation Measuring Effects of
Rosuvastatin (ASTRONOMER) Study
Bhagirath KM, Jassal OS.
Background: Tissue Doppler imaging (TDI) is a noninvasive echocardiographic method for the diagnosis
of diastolic dysfunction in patients with varying degrees of aortic stenosis (AS). Little is known however on
the utility of TDI in the serial assessment of diastolic abnormalities in AS.
Objective: The aim of the current proposal was to examine whether treatment with rosuvastatin was
successful in improving diastolic abnormalities in patients enrolled in the Aortic Stenosis Progression
Observation Measuring Effects of Rosuvastatin study (ASTRONOMER), a multicentre study to assess the
effects of rosuvastatin on the progression of AS.
Methods: Baseline echo measurements including left ventricular (LV) interventricular septal thickness
(lVS), posterior wall thickness, cavity dimensions, and ejection fraction (EF) were obtained. Conventional
Doppler indices including peak early (E) and late (A) transmitral velocities, EfA ratio, and E-wave
deceleration time (DT) were measured from spectral Doppler. Tissue Doppler measurements including
early (E') and late (A') velocities of the lateral annulus were determined, and EIE' was calculated. To
compare changes in the echocardiographic variables between the two groups (placebo vs. rosuvastatin), all
follow-up values were averaged, subtracted from baseline measurements, and the changes were compared
using two-sample t-test or Wilcoxon rank test depending on the distribution of the change.
Results: The study population included 168 patients (56±I3 years) whose AS severity was categorized
based on peak velocity at baseline (Group I: 2.5-3.0 mls; Group II: 3.1-3.5 mls; Group III: 3.6-4.0 mls).
Baseline and follow-up hemodynamics, LV dimensions and diastolic functional parameters were evaluated
in all three groups. At baseline, the aortic valve peak gradients were 31±3 mm Hg (Group I), 41±4 mm Hg
(Group II) and 56±4 mm Hg (Group III) respectively (Table I). There was increased diastolic dysfunction
from baseline to follow-up in each of the placebo and rosuvastatin groups. In patients with increasing
severity of AS, the lateral E' was lower and the EIE' (as an estimate of increased left ventricular end­
diastolic pressure) was higher at baseline (p<0.05). However, there was no difference in progression of
diastolic dysfunction from baseline to follow-up at 3.5 years between patients in all three predefined groups
with AS who received placebo versus rosuvastatin (Table 1).
Conclusion: In patients with mild to moderate asymptomatic AS, rosuvastatin did not prevent the
progression of diastolic dysfunction.
Table 1: Diastolic echocardiographic parameters at baseline and followup (n=168)
Baseline
Group I (n=64)
Peak AV gradient
Mitral E velocity
Lateral E'
Lateral EIE'
Group II (n=63)
. Peak AV gradient
Mitral E velocity
Lateral E'
Lateral EIE'
Group III (n=41)
Peak AV gradient
• Mitral E velocity
Lateral E'
I Lateral E/E'
Placebo
Follow-up
Baseline
Rosuvastatin
Follow-up
p value
31±3
84±19
lO.2±4.2
8±4
42±11
88±23
8.0±3.s2
1I±3
32±3
82±20
1O.5±3.5
8+3
43±12
89±2l
S.2±3.1
11+4
0.60
0.59
0.66
0.43
41±4
80±15
7.0±1.2
1l±4
62±23
81±22
6.0±2.1
15±3
42±4
81±22
7.1±3.2
1l±3
59±14
80±27
6.1±2.6
15±4
0.35
0.82
0.66
0.62
56±4
83±17
6.0±1.2
14±3
80±19
83±26
6.1±2.1
15±2
56±4
84±26
6.l±2.4
14±5
79±16
83±27
6.1±1.3
15±4
~~---
0.85
0.44
0.74
0.77
Values are mean ± SD (percentage). *p<O.05 was considered significant between the difference of baseline
and follow-up for placebo VS. rosuvastatin.
I
Nasopharyngeal Carcinoma (NPC) Patterns in Manitoba's Asian and Non Asian Population
'it CancerCare
~MANfT08A
Vallerie Gordon MD, Carla Penner DDS, Alain Demers PhD, Piotr Czaykowski MD, Sri Navaratnam MD
University of Manitoba & CancerCare Manitoba
Background:
-A retrospective chart review was performed on all available
• Non Asian populations: very low incidence rates of NPC at
charts, and histologic review of slides was performed to
'
<1/100000 person years
reclassify according to the WHQ 2005 amended classification
- Asian populations: variable incidence rates, even within
system for NPC
'
,
"d
t
h' h
Results:
h
geograp IC regions; mCI ence ra es as 19 as
• Of the 67 paUentsidentified, 61 had confirmed NPC, the
40/100 OO? (Hong Kong),
, ,
,
others had alternate diagnoses
- When ASian groups emigrate to low inCidence regions, the
-The old chart was unavailable for review in 11 patients (8 with
incidence rates fall, but not to the leve! of the population of
confirmed NPC). and slides for the review of the histology were
unavailable for 23 of the 61 patients
the region to which they immigrate
• NPC is strongly associated with EBV, particularly in Asian
-EBV immunohistochemistry stain (LMP·1) was available on 22
groups, associated with predominately Non ~eratinjzjng
samples, and all but one was negative.
differentiated, and~ndifferentiat~dhistoIOgicsubtypel!\ !
. Treatment Pattems:
'
"
• Outcomes Of ~ian$with ,NPC:are generally consid~redto' - 44(~6%) of. the co,hort ~re treatedwlth curative,ln~nt, the
be superior' pa'rticularly. at later stages of p'resentation ;" .
. rema~!lderwlth pall.l8t1ve Int~ll.t,(~e table 3)
.
',, ',' ,',,", .",' '. • . •. ..'. " ' , , " .
•Stage of Presentation:
• MaOitoba Is composed of an ethOiClaI~d,versepopulation
' • More,latutage presentations with Asians comprising 5.4%. First Nations '13.4%. anonon
.. ,','.
. , "
Asian, non First Nations the remainder Genetic studies have
idenyfied commqnality Iinldl)gFirstN~ti()ns tQ,~ian ancestry
,
"-';~",:'1-~
"< :,,,, -::/,J;:; ,,: ,-'
~:'.
"<:"
.,:': ";',""'. :~' \, ',:'" '"
t::~"-"',''''':
'
Objective:
I
- --=-- . . :m:==:;:;r:;;;;;:r
I
- '::::c....
'Figure 1: Overall & Disease Free Survival
- To explore the impact of patient ethnicity on the histology,
treatment selection, and survival patterns for patients
diagnosed with nasopharyngeal carcinoma (NPC) in
Manitoba.
• Ideally we would be comparing First Nations to the Asian
and Non Asian population, this data currently is not
approved for release.
Methods:
• Using Manitoba Cancer Registry data, the ICD 10:119 code
identified 67 cases of NPC from January 1, 1994 • December 31,
2002
Discussion:
-Histologic Breakdown- Most Asian NPC, as expected,
is Non keratinizing undifferentiated, however EBV by
LMP1 was negative in all but one sample, likely related
to the known poor sensitivity of the LMP·1
immunohistochemistry
.
:H1I::::I:::="'"
• Stage at Presentation - 50% stage IV in Non Asian group
• Treatment Patterns - Mainly curative, particularly in the
.Asian group, one Asian patient was treated with Palliative
intent (1 Asian had no treatment and was palliated)
• Survival Patterns - no statistically Significant differences, but
interesting that the non Asian group had no difference
between the DFS & OS (Median survivals were point
estimates, and confidence intervals only available for lower
limit)
• Possible explanation: Non Asians progressed quickly to die
of the disease if they did not respond to the treatment, died
soon after recurrence, and if responding to treatment, had
prolonged survival
• Incidence rates - Asian population is overrepresented,
higher than the non Asian group
• First Nations are a portion of Non Asian group, and may
contribute to confounding the results leading to a non
significant difference in survival
• Further study is indicated to determine the incidence rates in
the First Nations population in Manitoba - particularly with the
heterogeneity seen in the Asian populations
CHERCHEZ LE CHAT! A REVIEW OF PASTEURELLA MULTOCIDA PERITONITIS IN
PERITONEAL DIALYSIS PATIENTS.
David AlienI, Philippe Legace-Wiens2, Mauro Verrelle, and John Embif,4
Department of Medicine, ISections of General Internal Medicine, 3Nephrology, and 4Infectious Diseases;
and 2Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg,
Manitoba, Canada
The prevalence of end-stage renal disease requiring renal replacement therapy is continuing to increase.
Because of its convenience, increased patient satisfaction and improved quality of life as well as reduced
financial strain on the healthcare system, it is likely that peritoneal dialysis (PD) utilization will continue to
increase. However, PD does carry increased risk of infection as compared to in-center hemodialysis. The
most significant infection is peritonitis and is normally the result of infection with microbes from the skin
flora.
Pasteurella multocida is a gram-negative bacillus that is a part of the normal flora of the oropharynx of
domestic cats and is a rare but clinically significant cause of peritonitis. To date 19 cases of P. multocida
peritonitis have been described in published reports, usually the result of a cat biting or licking the dialysis
tubing. In this report, we describe the presentation and management of six additional cases of P. multocida
peritonitis that have occurred at our institution during the past ten years and compare them with the
previously published reports. In all of the cases, patients have at least experienced a strong exposure to a
domestic animal, usually a cat prior to developing manifestations of clinical infection. Frequently, patients
recall that their cat had recently bitten or licked their dialysis tubing prior to developing P. multocida
peritonitis.
For clinicians, this serves as a reminder that in patients who have come into contact with domestic animals,
zoonotic infection must be considered. Strict attention to hygiene and ensuring that domestic animals never
come into contact with any dialysis equipment is necessary to prevent infection with P. multocida and other
zoonotic infections
NEUROLOGICAL COMPLICATIONS ASSOCIATED WITH PROFOUND FLUCTUATIONS IN
SERUM SODIUM: OSMOTIC OR ISCHEMIC DEMYELINATION?
Kimberley D. Mulchey, Internal Medicine Resident, University of Manitoba, Winnipeg, Manitoba,
Kunjumon Vadakkan, Neurology Resident, University of Manitoba, Winnipeg, Manitoba.
Supervisor: Dr. P. St. John, Internist/Geriatrician, University of Manitoba, Winnipeg, Manitoba.
Introduction: Abnonnalities of serum sodium are frequently encountered in the intensive care unit
(lCU) and on medicine wards. Management strategies are usually successful in avoiding serious
complications. Residents consequently see fewer of these complications in their training.
Case Report: A 64 year-old woman with a past history of schizophrenia presented with a recent
history of excessive salt-water consumption, confusion and uncontrollable, voluminous diarrhea. Her level
of consciousness (LOC) quickly deteriorated from an initial Glasgow Coma Scale CGCS) of 14 to 9 over a
few hours. Initial laboratory investigations showed a serum sodium of 152 mmoJlL which, despite
appropriate fluid resuscitation, climbed to ] 76 mmollL five hours later. Computed axial tomography (CT)
of her head showed atrophy and minor demyelination in the subcortical white matter. She deteriorated
neurologically, with clinical abnonnalities including dystonia, rigidity, disconjugate gaze, and reduced
LaC for which she required intubation. Her serum sodium had fallen to 156mmolIL over the preceding
nine hours. Shortly after, the patient had a tonic-clonic seizure lasting 2-3 minutes followed by two more
episodes of seizure activity that day. Forty hours after presentation, she was transferred to a tertiary care
hospital for further evaluation and management. The serum sodium was 140 mmollL at the time of transfer
and remained in the nonnal range for the duration of her stay. She remained on Dilantin and did not have
any further seizure activity. EEG was compatible with metabolic-toxic encephalopathy. Magnetic
resonance imaging (MRI) showed abnonnal signal intensity in the hippocampal fonnations as well as
occipital, subcortical, and peri ventricular demyelination of uncertain etiology. Repeat MRI one week later
showed improvement in the hippocampal structures. The patient's neurological status steadily improved
throughout her 4-week hospital stay, with delirium and generalized weakness being the last symptoms to
improve. She did not recover entirely to baseline and was discharged to live with her daughter with home
care support.
Discussion: The two most plausible clinical scenarios to explain this patient's findings are osmotic
demyelination (aD) associated with rapid correction ofhypernatremia, and ischemic demyelination. In the
latter scenario, the rapid serum sodium fluctuations caused the prolonged seizure, which lead to hypoxia
and related ischemic demyelination. Both of these clinical syndromes will be discussed.
Conclusions: Fluctuations in serum sodium concentration are associated with neurological
damage. The cornerstone of management of serum sodium abnonnalities is prevention of significant
fluctuations. This is best accomplished by frequent laboratory and clinical re-assessment.
CHALLENGE OF TREATING METASTATIC BREAST CANCER IN THE SETTING OF ACUTE
INTERMITTENT PORPHYRIA
Dr. J. T. W. Laxton, University of Manitoba, Winnipeg, MB; Dr. M. Krahn, University of Manitoba,
Winnipeg, MB; Dr. Schacter, University of Manitoba, Winnipeg, MB
Acute intermittent porphyria (AlP) is a relatively rare disorder resulting from defects in the
porphyrin pathway of haemoglobin synthesis. It produces a particular challenge in treating malignant
tumours because many anti-neoplastic medications have the potential to trigger life-threatening AlP attacks.
However, this risk must be balanced with the risk of mortality from not treating a malignant tumour.
A 39yo female with known AlP underwent lumpectomy with axillary lymph node dissection for
T2 NO MX mixed ductal and lobular carcinoma of right breast. Oestrogen and progesterone receptors were
negative, as was HER-2. She underwent 4 cycles of doxorubicin but cyclophosphamide was omitted due to
potential porphyrogenicity. She also underwent 5000cGy radiation treatment in 25 fractions with Cobalt
laser. She tolerated treatment well without any exacerbations of her AlP. Five years later she re-presented
with radiculopathy down left arm and an enlarged lymph node in left cervical chain. Chest x-ray revealed
bilateral apical pleural thickening, neck x-ray revealed degenerative changes C5-C6 vertebrae. Computed
tomography scan of chest revealed lcm lymph nodes left cervical and supraclavicular areas, 3.9cm right
pleural-based apical lesion with pleural thickening and a l.4cm axillary lymph node. There were also
sclerotic lesions in both iliac wings, the pelvis, cervical/thoracic/lumbar spine, left scapula and sternum.
Bone scan was suggestive of metastatic disease to sternum, right pelvis, bilateral humeri and skulL Biopsy
of cervical lymph node was consistent with previous breast cancer histology, oestrogen and progesterone
receptor positive (by new criteria) and HER-2 negative. Mammography revealed bilateral malignancy that
was new from one year previously. Magnetic resonance imaging confirmed diffuse bony disease, right
upper lobe pleural mass, paraspinal masses around C2 and C516 with left brachial plexus involvement of
C5/6. She underwent palliative spinal radiation 3000cGy in 10 fractions with relief of radicular symptoms.
Tamoxifen was not given due to potential for triggering AlP attack. She was given systemic capecitabine
for 33 cycles with some significant hand-foot syndrome requiring dose adjustments, however, no
exacerbations of AlP. She began to have headaches and was found to have bilateral dura enhancement with
microinvasion on left in middle cranial fossa with surrounding oedema of left temporal lobe. Therefore,
she was started on dexamethasone and given 3000cGy whole brain radiation in 12 fractions with
improvement of radiological appearance of intracranial lesions. Following this, she was switched to
vinorelbine due to poor centra1 nervous system (CNS) penetration of capecitabine. Still no AlP attacks,
both bony and CNS disease have stabilised with remission of pleural disease. Patient is currently on cycle
28 ofvinorelebine and is five years out of the diagnosis of metastatic disease.
This case is important because anti-neoplastic agents were used without triggering an attack of
AlP. Treatment of metastatic disease was also relatively successful compared to other case reports
published in which most passed away within a year of starting treatment and reported AlP attacks during
treatment. This case helps to illustrate that some chemotherapeutic agents can be used relatively safely in
AlP to treat metastatic breast carcinoma.
STAPHYLOCOCCUS AUREUS PYOMYOSITIS DIAGNOSED BY 16S rDNA AMPLIFICATION
AND SEQUENCING
Alissa Lloyd MOl, Kim Nichol MS 2, James Karlowsky PhD 2,4, Lindsay Nicolle MD, FRCPC2,3, Andrew
Walkty MD, FRCPC2,3
I Internal Medicine Resident (PGYI), Departments of Clinical Microbiologi and Medicine), Health
Sciences Centre; 4Department of Medical Microbiology. Faculty of Medicine. University of Manitoba;
Winnipeg, Manitoba, Canada
Introduction: Pyomyositis is a purulent infection of skeletal muscle, usually associated with abscess
formation. The bacterial pathogen most commonly responsible for this condition is Staphylococcus aureus.
Diagnosis is based on the combination of clinical presentation, imaging studies, and identification of a
microorganism. Presented here is a case of pyomyositis where culture was negative but demonstration of
the bacterial pathogen (S aureus) was achieved through application of molecular diagnostic techniques
(168 rDNA amplification and sequencing) to an abscess aspirate.
Case Presentation: A 32 year old female with a history of asthma presented to hospital with one week of
fever and myalgias. Physical examination revealed generalized muscle tenderness and areas of erythema
on both upper arms and the left inner thigh. The patient's condition rapidly deteriorated with the
development of hypotension requiring aggressive fluid resuscitation. Broad spectrum antibiotics were
initiated. Seven days post admission, localized areas of swelling in the arm and thigh muscles were
apparent. Imaging studies were suggestive of muscle abscesses and a diagnosis of pyomyositis was made.
Fluid aspirates from two different sites were culture negative but positive by 16S rONA sequencing for S.
aureus. Antimicrobial therapy was subsequently narrowed to agents that target S. aureus and the patient
was ultimately discharged home on oral clindamycin. Follow-up over the next several months showed
ongoing resolution of the abscesses. with no recurrence once antimicrobials were discontinued.
Methods: Isolation of bacterial DNA from abscess fluid was performed using a commercial kit according
to the manufacturer's instructions. The isolated DNA was then used as a template for polymerase chain
reaction (peR) amplification and sequencing of an 800 nucleotide fragment of 16S rONA using universal
primers previously reported in the literature. The sequence obtained was compared to sequences deposited
in the GenBank (NCBI) and Ribosomal Database Project (RDP, Michigan State University) databases, and
was found to be consistent with S. aureus.
Discussion and Conclusions: Amplification and sequencing of bacterial 16S rONA is an emerging
molecular diagnostic technique used for species identification. Unlike culture, this method does not rely on
the presence of viable organisms in a clinical sample. A limitation of this technique is determining the
clinical relevance of the organism identified, i.e. false positive results may be produced by small amounts
of bacterial DNA contaminating the reagents or introduced during sample collection, and organisms of
unknown pathogenicity may be identified. Also, molecular identification gives no information regarding
antibiotic susceptibility. Although 16S rONA amplification and sequencing does not replace conventional
culture, it may be a useful alternative for identifYing the etiology of pyomyositis and other bacterial
infections in patients that have previously received antimicrobial therapy.
FEVER, RHABDOMYOLYSIS, AND RENAL FAILURE IN AN ADULT AFTER EMERGENCY
DEPARTMENT RAPID SEQUENCE INTUBATION USING SUCCINYLCHOLINE
M. R. Fournier, BComm, MDl, S. L. MarIes, MSc, MD, FRCPC 2 and D. D. Bell, MD, FRCPC3
Departments ofInternal Medicine l , Pediatrics and Child Health], and Anesthesia, University ofManitoba,
Winnipeg, Manitoba, Canada
Rapid sequence intubation (RSI) is often performed in Emergency Departments when urgent
intubation is required. Succinylcholine is recommended to facilitate the procedure. We present a case of
adverse metabolic reaction (fever, hypercarbia, and rhabdomyolysis causing acute kidney injury which
required dialysis) following RSI with succinylcholine.
A 71-year-old morbidly obese male presented to the emergency room following four days of
increasing dyspnea. Paramedical assessment enroute to emergency documented oral temperature 36.3
degrees C, pulse 96 beats per minute, respiratory rate 28 breaths per minute, blood pressure of 170/90
mmHg and room air saturation of 70%. Emergency physician examination noted paradoxical breathing
with an oxygen saturation of85% on IOL non-rebreathe mask, impelling the physician to perform RSI
using 70 mg etomidate and 120 mg succinylcholine. Portable chest radiograph post intubation showed
extensive bilateral airspace opacities consistent with congestive heart failure. Axillary temperature two
hours following intubation was 38.3 degrees C, and serum potassium was 7.1 mmol/L prompting therapy
with intravenous insulin, sodium bicarbonate, and kayexalate. Other relevant results included: WBC 13.4
x10 91L, creatinine 83 umollL, creatine kinase 223 UIL, and troponin T < 0.01 uglL. Persistently elevated
potassium levels and carbon dioxide were observed in arterial and central venous blood gases during the
first twenty-nine hours following intubation despite increasing delivered minute ventilation.
Throughout the next 72 hours in the Intensive Care Unit, persistent hyperpyrexia with oral
temperature exceeding 39 degrees C without obvious source occurred despite broad spectrum antibiotics.
Non-oliguric renal failure ensued secondary to a severe rhabdomyolysis (peak creatine kinase 10,429 UIL).
Pyrexia and renal failure persisted until the patient was started on continuous renal replacement therapy.
Malignant hyperthermia (MH) was suspected given a "very likely" clinical grading score. Accordingly, he
was treated with three doses of intravenous dantrolene 120 mg administered every six hours. Genetic
testing for the ryanodine receptor gene (RYR 1) using tier I testing was negative. Unfortunately, only 30­
50% of malignant hyperthermia cases have been linked to the RYRI gene. We expect he will eventually
require muscle biopsy and caffeine-halothane contracture testing.
Despite the absence of a molecular diagnosis of MH, we perceive a high clinical probability of
MH in this case, and suggest physicians need to consider MH if patients develop high temperature
following intubation with succinylcholine. Adverse metabolic reactions can occur following a single dose
of succinylcholine. Medication and equipment to treat MH must be readily available to any area where
succinylcholine is administered, even if succinylcholine is only used to facilitate emergency airway
management.
SMALL CHANGES IN SERUM CREATININE IN THE EMERGENCY DEPARTMENT ARE
ASSOCIATED WITH LONG TERM PROGRESSION TO CHRONIC KIDNEY DISEASE
Krista Ryz, MO*I, Alexandra Romann 2, Frank Scheuermeyer, M03, Manraj Johal, M02, Ognjenka
Ojurdje~, Eric Grafstein, MOl, and Adeera Levin, M04 IOept of Medicine, University of Manitoba,
Winnipeg, Manitoba; 2BC Provincial Renal Agency; 3Dept of Emergency Medicine, University of British
Columbia & St. Paul's Hospital, 40ept of Medicine, University of British Columbia, Vancouver, Canada.
Objectives:
Using the recently published, new sensitive defmition of AKI, we describe the incidence of AKJ in the
Emergency department (ED), & explore associations of AKI with short and longer term patient outcomes
in particular the effect of AKI in the EO on progression to chronic kidney disease (CKO).
Methods:
We derived the analytic cohort using an EO database & collected info on all EO visits to a tertiary care
centre between Apr & June 2006. AKI was defined as a delta creatinine (Cr) of <!25umollL, within 48hr. A
case control chart review was conducted on a random subset to enrich the dataset.
Results:
Of all patients that presented to the emergency department during the study period the incidence of AKI
was 1.4%; however in those patients that AKI could be truly measured, meaning those with more than one
creatinine value drawn the incidence was much higher at 20%. AKI patients required dialysis more
frequently (7 vs 0%, p<O.OI4) & had higher in hospital mortality rates (14 vs 3%, p<O.002). Of note, the
incidence of 3 year progression to CKD, as defined by registration in the provincial renal database, after
AKI event, was 10% as compared to I % in the group without AKI.
Conclusions:
Using a sensitive definition of AKI, we describe a high incidence of AKI in the emergency department with
frequent adverse outcomes. Of primary interest, patients that developed AKI in the EO had significantly
higher rates of progression to CKD. Further research is needed to determine whether recognizing AKI
earlier modifies patient outcomes.
Mycobacterium Avium Intracellular Complex in Hot Tub Water as a Cause of Hypersensitivity
Pneumonitis
Meaghan O'Brien, Resident, Department of Medicine, University of Manitoba, Winnipeg, Manitoba
Supervisor - Dr. Frank Bovell, Department of Medicine, University of Manitoba, Winnipeg,
Manitoba
Shortness of breath is a frequent complaint encountered in medicine. While common diagnoses
account for the majority of presentations, there exist a significant number of patients for whom a common
diagnosis does not apply. Failing to consider these less common, but serious, diagnoses can lead to
significant preventable morbidity and mortality.
A previously healthy 39 year old male presented to the emergency department with 3 months of
increasing shortness of breath on exertion and 2 weeks of chest pain, productive cough, palpitations and
fevers. He was empirically started on salbutamol by his family doctor without relief. He was a non-smoker,
had no tuberculosis exposure and was on no other medications. His vital signs revealed an elevated blood
pressure and a room air oxygen saturation of 89%. Physical examination revealed bilateral, rme, end­
inspiratory crackles. Laboratory investigations revealed a partial pressure of oxygen on a room air arterial
blood gas of 51. A chest x-ray revealed widespread interstitial and air space opacification. The pulmonary
vasculature and heart were normal. An infused thorax computed axial tomographic scan showed ground
glass. A trans-thoracic echocardiogram (TIE), pulmonary function tests (PFTs) and a bronchoscopy were
ordered. The TIE was normaL The PFTs showed a restrictive pattern with a decreased diffusion capacity.
The bronchoscopy showed no obvious visual abnormalities but the transbronchial biopsy showed poorly
formed non-caseating granulomas. It was decided to proceed with an open lung biopsy. Biopsy results were
consistent with hypersensitivity pneumonitis. The pathologist examining the biopsy suggested we further
question the patient on indoor hot tub use. It was revealed that he did indeed own an indoor hot tub which
he utilized on a regular basis. A sample of the hot tub water grew mycobacterium avium intracellular
complex. The patient was discharged home on home oxygen and 50 mg of prednisone. He was also
instructed to drain the hot tub. He will be followed in the outpatient chest medicine clinic.
Hypersensitivity pneumonitis is an immunologic reaction within the lung parenchyma to an
inhaled agent, usually organic in nature. There are over 300 known causative antigens. Hypersensitivity
pneumonitis can lead to significant pulmonary fibrosis and subsequent impaired quality of life. However, if
detected and treated early with a tapering course of steroids and removal of exposure to the offending
antigen, the pathology can be reversed. This case demonstrates the need for clinicians to think beyond
common diagnoses of shortness of breath, particularly in otherwise healthy patients. A patient presenting
with shortness of breath should prompt clinicians to not only inquire about smoking history but to also
inquire about exposure to the myriad of antigens known to cause pulmonary disease and dysfunction.
A unique case of relapsed mUltiple myeloma presenting as a solitary testicular plasmacytoma secreting a
different monoclonal protein than that at the time of diagnosis
Roopesh Kansara MDI, Morel Rubinger MD FRCP(C)2
1 University of Manitoba, Internal Medicine Program, PGY2; 2 CancerCare Manitoba, Winnipeg Manitoba
Case: A 61yr male presented with hip pain in July 2003. He was found to have bony lytic lesions in his right iliac
wing and left pubic ramus. After extensive investigations, he was diagnosed with Multiple Myeloma (MM), 19A
kappa, stage lIlA (Durie Salmon staging). Initial treatment consisted of pulsed high dose dexamethasone and
bisphosphonates. Dexamethasone was administered from August to October 2003 and he achieved partial
response. In November 2003, he was deemed eligible for an autologous stem cell transplantation that he
underwent on December 18th 2003 after conditioning with high dose melphalan (200mglm 2 ). Transplantation
was uncomplicated and he achieved a near complete remission with only trace amounts of kappa light chains in
his urine. Unfortunately, in October 2004, he presented with an enlarged right testicle that on ultra sound.
revealed a testicular mass. An orchiectomy was performed with pathology revealing anaplastic plasmacytoma.
Interestingly, his serum protein electrophoresis at relapse revealed trace amounts ofIgG kappa in addition to IgA
kappa. He had thus relapsed with a biclonal gammopathy, one of which was not present at diagnosis. Subsequent
therapy included thalidomide and prednisone with which he had an initial response but subsequently progressed,
with involvement of mUltiple sites of involvement, beginning in February 2006. Therapy with cyclophosphamide
and prednisone was given with little effect and, unfortunately, patient succumbed to complications of his disease
in August 2006.
Discussion: Multiple myeloma is a hematological malignancy characterized by an abberant proliferation of
plasma cells that leads to the production of an abnormal paraprotein and multiple clinical complications such as
anemia, lytic bone lesions, renal dysfunction, hypercalcemia and other. It usually affects the bone marrow and
the bones but extra medullary involvement is not uncommon. Extra medullary sites include nasopharyngeal
pathway, lungs, kidneys and skin; it very seldom involves the testicle. Most testicular malignancies are germ cell
tumors and lymphoma. There have, however, been published isolated case reports oftesticular plasmacytomas.
These were occurring either at initial presentation or along their course of progressive multiple myeloma. As per
some case reports, isolated testicular plasmacytomas, without previous diagnosis of myeloma, can be an indicator
of future plasma cell malignancy. In contrast, cases where testicular plasmacytomas were diagnosed during the
course of disease indicated wide spread disseminated disease. These patients also had involvement of skin and
kidneys in addition to plasmacytoma. Our patient presented with biopsy proven testicular plasmacytoma at the
time of relapse. He also developed subcutaneous nodules post orchiectomy indicating wide spread disease.
Interestingly, he was found to have two different plasma paraproteins (biclonal presentation), one of which was
not present prior to testicular plasmacytoma. This is likely due to clonal presentation of MM. No other similar
reports were found upon literature search. Orchiectomy is the treatment of choice for isolated testicular
plasmacytoma if there is no evidence of monoclonal protein.lfit presents late in the course ofMM, the treatment
is a combination of orchiectomy ain conjunction with MM treatment. MM remains an incurable disease and our
patient, unfortunately, did not survive despite orchiectomy and aggressive MM treatment.
Conclusion: Testicular plasmacytomas are rare. It is even more rare to find them secrete a different form of
paraprotein compared to that at presentation of MM.
DESPERATE TIMES, DESTERATE MEASURES: ROTABLATING DISSECTIONS
Kristyn Campbell, Farrukh Hussain
University of Manitoba, Winnipeg Manitoba, Dept. of Internal Medicine
Rotational atherectomy is indicated for undilatable or calcific coronary
lesions to allow plaque modification, reducing the risk of stent underexpansion and
in stem re-stenosis and thrombosis. The presence of a dissection is a relative
contraindication to use of rotablation. To our knowledge, there are no previously
reported cases in the literature of rota blation of macro dissections . In this case,
there was no reasonable alternative but to attempt rotablation in the setting of a
dissection of the left anterior descending coronary artery (LAD).
A 73-year-old female, smoker presented with anterior ST elevation MI to our
cardiac centre for primary PCI. The LAD demonstrated 98% mid body stenosis
with TIMI II flow.
Balloon angioplasty with multiple compliant and noncompliant balloons at
pressures of up to 20 atms did not yield the lesion the LAD lesion. Multiple
aggressive strategies were attempted to liberate the stenosis. More aggressive
dilation resulted in a NHLBI type B aggressive dissection. The patient had already
received a glycoprotein I1blIIa inhibitor and was not a perfect candidate for bypass
grafting. Given the limited revascularization options with this infarction, we
proceeded with rotational atherectomy. With aggressive dilations, a rotablator
floppy wire advanced across the lesion to allow passage of a small burr (1.25 mm),
with which four passes were performed without further dissection progression Of
perforation. Subsequently, noncompliant balloon inflations did appear to yield the
lesion and a drug eluting stent was implanted with excellent angiographic results
and infarct resolution. The patient was brought back for staged PCl to the right
coronary artery, which demonstrated complete patency of the LAD stent.
Although contraindicated in the presence of arterial dissection, rotablation
was successfully used in this patient presenting with acute STEMI with calcified
plaque when there was no other reasonable alternative. A small burr with extreme
caution with burr manipulation is recommended. Although dissections should
generally not be considered to rotablation, we report the first case to our
knowledge of a frank dissection with successful rotational atherectomy.
Neurosarcoidosis: Presentations and Management; Case Report
E C Inegbu, MD, CCFP and Greg Eschun, MD, FRCPC St. Boniface General Hospital, Winnipeg, Manitoba. Sarcoidosis a multisystem granulomatous disease affects the Central nervous system more frequently than previously appreciated. The diagnosis of neurosarcoidosis is often delayed, potentially leading to serious complications. Symptoms of neurosarcoid when present are not specific and may resemble those of other neurological diseases. CASE: A 27 year old female patient presents to the Emergency Department with complaints of acute worsening of a 7 month history of Left arm weakness and tremors. Her symptoms initially started in June 2009 and include episodes of Left hand shaking every 3 - 4 weeks. Hand shaking is not precipitated by any known factor; each lasts about 10 minutes, and not associated with decrease LOC, tongue biting or incontinence. Usually resolves on its own with no post-ictal confusion but days to weeks of postictal Left hand weakness and loss of dexterity. On March 16.2010 she presented to ST Boniface Emergency room with history of acute episode of neck tension extending down her Left arm and back associated with unremitting Left hand tremor. Lorazepam and Dilantin load improved and then resolved her symptoms although residual Left arm weakness, Left shoulder tension, loss of dexterity and intermittent Left hand tremors remain. She has no family history of Sarcoidosis or seizure disorder. She was admitted for full seizure work up. MRI of her brain showed Abnormal Leptomeningeal disease primarily overlying the Right Frontotemporoparietallobe suspicious of Sarcoid. Immunologic work up was negative. CT scan of chest, abdomen and MRI abdomen were basically normal. Retinal examination showed no conjunctiva granulomas and no ocular signs of Sarcoid. Bronchoscopy and biopsy were negative for sarcoid. Neurosurgery consulted for possible brain biopsy which is the gold standard for diagnosis. Discussion: Patient presenting with Neurosarcoidosis may have no systemic features of the disease. Biopsy to establish the diagnosis, rather than empiric therapy should be considered if there is no defined systemic disease. Studies have shown that the optimal diagnostic imaging modality for neurosarcoidosis is MRI with gadolinium as it enhances visualization of granulomatous infiltration in neural tissue. IDIOPATHIC CHOLESTASISNANISHING BILE DUCT SYNDROME: A RARE COMPLICAnON
OF HODGKIN'S DISEASE
Paul JT 1, Klein JRH 2, Musuka CT2, and Kraut AG I.3•
IDepartment ofInternal Medicine, University of Manitoba, Winnipeg, Canada and 2Department of
Pathology, University of Manitoba, Winnipeg, Canada and 3Department of Community Health Sciences,
University of Manitoba, Winnipeg, Canada.
Background: Hepatic involvement occurs in 5-14% of patients with Hodgkin's Disease (HD), but
jaundice and liver dysfunction only occur in 1.4% of cases. Causes of cholestasis in HD include
lymphoma hepatic infiltration, hemolysis, and drug toxicity. Lesser common causes include vanishing bile
duct syndrome (VBDS) and its postulated precursor, idiopathic cholestasis (IC). We present here a case of
ICNBDS in a patient with HD disease.
Case report: This 60-year old woman presented with a three month history of fevers, night sweats,
weight loss (12 kg) and jaundice. Physical examination was normal except for jaundice, and generalized
abdominal tenderness. Laboratory results demonstrated a low white count (3.9 x 109 cellslL), anemia (Hgb
78 g/L), hyperbilirubinemia (total 148 mg/d), direct 104 mg/dl} and a cholestatic rise in her liver enzymes
(OOT 276 lUlL, AP 594 lUlL). She was pan-cultured and started on broad spectrum antibiotics.
Computed tomography (CT) chest and abdomen demonstrated splenomegaly, a normal liver with
no evidence of obstruction, and an incidental adrenal adenoma. There was no mediastinal or abdominal
lymphadenopathy. Hepatic ultrasound (UlS) showed fatty liver. Tests for HAV, HBV, HCV, and HIV
were all negative. Autoimmune work-up was negative. A liver biopsy showed prominent areas of zone 3
cholestasis and hepatocyte swelling. A bone marrow biopsy demonstrated granulomas with large cells
containing prominent nuclei that were CD15+/CD30+, consistent with Reed-Sternberg cells. A diagnosis
of Stage IVB HD was made. Based on the liver pathology results and cholestatic liver enzyme rise, no
obstruction on CT or liver UlS the diagnosis of ICNBDS was considered. Because of the abnormal liver
function tests and the patient's poor performance status, on day II she was initially started on
dexamethasone 40mg IV daily. Despite the dexamethasone, on day 16 the patient developed progressive
shortness of breath, with a further rise in her cholestatic liver enzymes (GOT 998 lUlL, AP 1711 lUlL). A
chest x-ray demonstrated bilateral alveolar consolidations, and a short time later the patient was intubated
for hypoxic respiratory failure. Multiple cultures were negative and it was presumed the patient had
developed acute respiratory distress syndrome (ARDS) possibly from her liver disease. Unfortunately, the
patient died of respiratory and hepatic failure twenty-four hours after the development of shortness of
breath.
Discussion: This case represents a very unusual complication of Hodgkin's disease, ICNBDS,
which is believed to be caused by cytokines released by the tumor. As evidenced in this case, Hodgkin's
patients with ICIVBDS have a poor prognosis, as it is difficult to administer chemotherapy in patients who
have liver dysfunction. However, compete resolution of ICIVBDS can occur in those patients whose
disease is amenable to radiotherapy.
Title: Mortality in Obstructive Sleep Apnea Patients
Renelle Myers, MD, Heather J Prior, MSc , Meir H. Kryger. MD, Clare Ramsey, MD
Background - Obstructive sleep apnea syndrome (OSAS) and obesity are increasing
in prevalence. There are many adverse medical conditions such as diabetes,
hypertension and coronary artery disease that are associated with OSAS and
obesity. Whether OSAS is an independent predictor of mortality, when controlling
for co-morbidities and obesity is unclear.
Objective - To determine the effect of treated OSAS on mortality while controlling
for co-morbidities compared to population controls.
Methods - The study population consisted of 4042 cases of polysomnography
confirmed OSAS, 22703 controls with documented body mass index (BMI) and
12126 population matched controls. Control groups, information on co-morbidities
(based on ICD-9 codes) and vital statistics (mortality) were obtained from the
Manitoba Population Health Data Repository. All OSAS patients were placed on
treatment fol1owing their diagnosis.
Results - The mean age of the OSAS patients, BMI and population controls were
49.8,46.4 and 50.9 years, respectively. Males accounted for 70% of the OSAS
patients and population controls and 47% of the BMI controls. The average apnea­
hypopnea index (AHI) in the OSAS group was 38.7, which is indicative of moderate
disease. The overall mortality rates in each group were 11.3 per 1000 person-years
for OSAS, 6.4 per 1000 person-years for BMI controls and 8.6 per 1000 person-years
for population controls. OSAS patients had a higher risk of death compared to
population controls [hazard ratio (HR)=1.51, 95% confidence interval (CI) 1.31­
1.73], after adjusting for age, sex and socioeconomic status. This association
remained Significant after adjusting for the development of co-morbidities over time
(HR=1.22, 95% Cl 1.05-1.42). OSAS patients had a higher mortality compared to
BMI controls (HR=1.33, 95% CI 1.09-1.61), after adjusting for BMI, age, sex and
socioeconomic status. This association was no longer significant after adjusting for
co-morbidities. Amongst the cohort of treated OSAS patients, predictors of mortality
included age, male gender, cancer, coronary artery disease, osteoporosis, stroke and
respiratory illness. Pre-treatment AHI and Epworth scores were not independent
predictors of mortality.
Conclusion - Patients with treated OSAS have a higher mortality rate compared to
population controls. However after taking into account the development of co­
morbidities over time and BMI, treated OSAS patients had did not have a higher
mortality compared to controls. This suggests the increased mortality in OSAS is
largely related to the development of co-morbidities.
MYCOPHENOLATE MOFETIL BASED TREATMENT IN ENCAPSULATING PERITONEAL
SCLEROSIS: A SINGLE CENTER EXPERIENCE
Kelvin Leung, Martina Reslerova University of Manitoba, Canada; Manitoba Renal Program, Canada. OBJECTIVE: Encapsulating peritoneal sclerosis (EPS) is a rare and fatal complication of peritoneal dialysis with mortality rates of 60-70%. Various regimes involving steroid with or without immunomodulation have been described but there is currently no consensus regarding optimal treatment strategy for EPS. A recent case report has suggested marked improvement in EPS in patients treated with mycophenolate mofetil (MMF). We describe our experience of EPS in 8 consecutive patients with MMF compared with pre-MMF era. METHODS: Between 2004-2009, total of 8 cases (per 1,000 PD patients) were identified in the Manitoba Renal Program, Manitoba, Canada. Clinical and epidemiological parameters, radiological, laparoscopy, and biopsy data were collected by retrospective chart review. Symptom onset was used as a reference for all subsequent events. RESULTS: Of the eight patients identified, all patients met EPS criteria for symptoms and radiological diagnosis. Peritoneal laparoscopy and biopsy was performed an was diagnostic in six patients. The majority (6/8) had preceding peritonitis within a month of EPS symptom onset, with Staphylococcus implicated as the culprit in half the cases. Clinical diagnosis ofEPS was considered at a mean of 12 weeks (range 4.5-29 weeks) after symptom onset. All patients developed radiological evidence ofEPS (mean 17.3 weeks, range 1-79.5 weeks). All patients received supportive care in the form of parental nutrition and conversion to hemodialysis. Six patients received MMF (500-2000mglday) along with high dose prednisone (40­
50mglday). MMF was initiated a mean 20.4 weeks (range 4-42 weeks) after symptom onset. Tamoxifen was concurrently used in two patients. All six patients (100%) on MMF improved and survived to discharge. Two patients only received supportive care, with no MMF or steroids and did not survive to discharge. CONCLUSIONS: Our provincial experience confirms that albeit rare, EPS remains a significant concern in PD population. Peritoneal laparoscopy and biopsy should be considered in those suspected of EPS as radiological changes occur late in the disease course. Our experience suggests that addition of MMF to supportive therapy of EPS improves outcomes. As the rarity of this clinical entity precludes randomized prospective evaluation of EPS treatment strategies, consideration should be given to creating a national EPS registry to compare outcomes and develop optimal treatment protocols. IMPACT OF BODY MASS INDEX (BMI) ON EARLY AND LATE MORTALITY AND
TECHNIQUE FAILURE IN PERITONEAL DIALYSIS
Kelvin Leung, Manish Sood, Paul Komenda, Mauro VerreIli, Claudio Rigatto
University of Manitoba, Canada; Manitoba Renal Program, Canada.
OBJECTIVES: Increasing BMI is consistently associated with higher mortality in the general population.
In peritoneal dialysis (PD) patients, however, the relationship between BMI and patient outcomes remains
unclear. Some studies demonstrate lower, and other studies higher mortality with higher BMI. Low BMI in
PD might be associated with early mortality «12 months) due to cachexia, inflammation and frailty,
whereas high BMI might be associated with later mortality in patients surviving beyond a year.
Alternatively, a J-curve phenomenon, with both high and low BMI associated with mortality, might exist,
as has been reported for blood pressure Either phenomenon, if present, might explain the variable results in
the literature.
METHODS: To test these hypotheses we analyzed data from a prospective database of all 727 incident
patients initiating PD between 1997 and 2007 in the province of Manitoba. Separate proportional hazards
models were constructed to model the impact of BMI on early (<12 months) and late (>12 months)
mortality and technique failure, with adjustment for the following confounders: age, sex, race, cause of end
stage renal disease, residual renal function, peritoneal KTN, peritoneal transport, and comorbid medical
conditions.
RESULTS: The average BMI was 27.1 (S.D. 5.8). Most patients (64%) were overweight (BMI>25) with
31% obese (BMI>30). Total mortality and technique failure during the follow up period was 45.9% and
47.2% respectively. Increasing BMI was associated with lower adjusted early mortality (hazard ratio [HR]
0.762, 95% CI: 0.584-0.996, P<0.05) and lower rate of adjusted early mortality or technique failure (HR
0.741,95% CI 0.601-0.914, P<O.OI). No association was apparent between BMI and late mortality, or BMI
and late technique failure. A J-curve phenomenon could not be demonstrated when BMI was analyzed as
quartiles or as a quadratic polynomial.
CONCLUSIONS: In summary, low BMI was consistently associated with high early mortality, but no
association was apparent between BMI and late mortality. The impact of low BMI seems to occur early.
These findings support, but do not prove, the concept that the association of BMI and outcomes may be
different in the early versus late period after initiation of PD.
ASSESSMENT OF RIGHT VENTRICULAR SYSTOLIC DYSFUNCTION USING REAL TIME THREE DIMENSIONAL
ECHOCARDIOGRAPHY AFTER MARATHON RUNNING
Anthony Wassef, Sacha Oomah, Negareh Mousavi, Navdeep Bhullar, Kanwal Kumar, Jonathan Walker,
Matthew Lytwyn, Jane Colish, lain Kirkpatrick, Sat Sharma, Davinder Jassal
Devision of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba
Background: Marathon running, involving the participation of amateur athletes in particular, has increased
in popularity over the past decade. The acute effects of strenuous exercise on cardiac function, in particular
the right ventricle (RV), is a subject of recent interest. Although multiple studies have demonstrated 2D
echocardiographic evidence of RV systolic dysfunction after marathon running, quantitative assessment of
the RV is challenging due to its complex geometry. Little is known about the use of real time 3D
transthoracic echocardiography (RT3DE) in this patient population.
Objective: The aim of the current study was to assess the extent and severity of change in RV function
after completion ofa half marathon, utilizing serial cardiac biomarkers, RT3D TTE and CMR.
Methods: A prospective study of 15 amateur athletes (32±6 years, 7 males) participating in the 2009
Manitoba Half Marathon were included. Cardiac biomarkers including creatinine kinase (CK), myoglobin
and troponin T (cTnT) were measured at baseline, immediately following the race and ] week post
marathon. RT3DE was performed at baseline, immediately following the race and 1 week post marathon
with offline analysis of RV volumes and ejection fraction (EF) (Tomtec imaging systems, Munich,
Germany). Cardiac MRl (CMR) was performed at baseline and immediately following the race.
Results: Myoglobin, CK and cTnT were all within normal range at baseline and increased significantly
after the race. All patients demonstrated elevated cTnT post half marathon with a median value of 0.37
uglL (interquartile range 0.26 to 0.74). Compared with baseline values, RV fractional area change by 2D
TTE, decreased significantly (41±2% vs. 33±4%, p<0.05). Similarly, RVEF by RT3DE decreased from
59±4% at baseline to 4S±S% (p<O.OS), immediately following the race. There was a strong linear
correlation between RVEF as assessed by RT3DE and CMR after the half marathon (r=0.93, p<O.Ol;
Figure I). There was no evidence of myocardial edema on T2 imaging nor findings of delayed
enhancement of the LV myocardium on CMR to suggest permanent necrosis. The RV abnormalities
recovered I week post marathon.
Conclusion: In conclusion, RV systolic dysfunction transiently occurs after a half marathon and has been
validated for the first time by RT3DE imaging.
EFFICACY OF RITUXIMAB FOR TREATMENT OF AUTOIMMUNE CYTOPENIAS
ASSOCIATED WITH LYMPHOPROLIFERATIVE DISORDERS: MANITOBA EXPERIENCE
Singh J, Kumar R, Manitoba Oncology Drug Utilization and Clinical Outcomes (MODDCO) Program.
Dept of Internal Medicine, Section of Hematology, University of Manitoba and CancerCare Manitoba.
Objective: To evaluate the efficacy ofrituximab for treatment ofautoimmune cytopenias (AIC) in patients
with a Iymphoproliferative disorder (LPD).
Methods: Charts of all patients treated with rituximab for LPD associated AIC in Manitoba between
January 1, 2003 and December 31, 2007 were identified and reviewed retrospectively using the
CancerCare Manitoba Pharmacy database and Aria™ Information system (Varis Med Oncology Software).
Results: Rituximab was administered to 16 patients with LPD who developed AIC refractory to or
dependent on steroids or other immunosuppressants. One of three regimens consisting rituximab was
administered, with a median of 4 cycles per course. Patient characteristics and responses are shown in the
table. All patients who relapsed and received a second course of rituximab achieved CR.
Conclusion: Rituximab therapy, regardless of regimen or previous relapse, appears to be safe and
efficacious for treatment of LPD associated AIC.
Ch
Patients
d
f
r--~-----
d with'
.. ..
AIHA
.~ ~----
~~~-
--~---~.-
b for LPD
ITP
----------dAIC
--­
~
AIHA+AIN
Numbers
11
4
1
Median age rituximab
started (years)
70
69
62
RCD
R-CVP
Rituximab+/ -steroid
Numbers (%)
9
3
3
CR: 12/15 (80%)
3
1
-­
--­
Median months to response
2
.
i
Number of
courses per
regimen
Responses
2
CR: 3/5(60%)
PR: 2/5 (40%)
1
CR: 111 (100%)
2
-­
Numbers
Deaths
2
-ReD = Rituximab, Cyclophosphamide, Dexamethasone; R-CVP "" Rituximab, Cyclophosphamide,
Vincristine, Prednisone; Hgb "" hemoglobin, PIts = platelets, ANC = absolute neutrophil count