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THE UNIVERSITY OF MANITOBA

DEPARTMENT OF INTERNAL MEDICINE

POSTGRADUATE EDUCATION PROGRAM

RESIDENT RESEARCH

DAY

MAY 18, 2010

SCIENTIFIC PROGRAM

Theatre B, BMSB


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 PRESENT ATIO

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 Supervisor: F. Hussain

1030 (Clinical Investigation) The use of sublingual Fentanyl for the treatment of incident dyspnea: A retrospective pilot study Jonathan Wong, Core Supervisor: J. Richman-Eisenstat

1045 (Case Report) Congenital TIP Alan Smith, Core Supervisor: A.M. Shojania

1100 (Clinical Investigation) Evolution of endothelial injury during dialysis and the impact of kidney transplantation Keren Mandelzweig, Core Supervisor: C. Rigatto

1115 (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 Supervisor: D. Jassal

1315 (Case Report) The occurrence of pulmonary sarcoidosis in a patient with gastrointestinal stromal tumors (GISTs) Mohmmed Aigamdl, Core Supervisor: G. Eschun

1330 (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


RESIDENT RESEARCH DAY PROGRAM



OSTER PRESENTATIONS


1300 {Clinical Investigation) Patient outcomes in pre-hospital electrocardiograms initially negative for STEMI: A subset of the CODE STEMI project Robin Ducas, Core Supervisor: J. Tam

1310 (Clinical Investigation) Publication bias: Where have all the abstracts gone? Kris Paulson, Haematology Supervisor: M. Seftel

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 Supervisor: F. Hussain

1400 (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. Aokl, 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 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 59year-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 ofa 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 offof all diuretic therapy and immunosuppressive agents and remains in partial remission 15 months since rituximab administration. This suggests the potential efficacy ofrituximab 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 ofManitoba

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 ofpulmonary 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 REVASCULARIZA TION IMPROVES SURVIVAL IN CARDIOGENIC SHOCK DUE TO MYOCARDIAL INFARCTION:

MANITOBA CARDIOGENIC SHOCK REGISTRY INVESTIGATORS

Robin A Ducas1 Roger K Philipp1, Steven Hodge1, Tarek S. Kashour\ Jason Elliott1, Vladimir Dzavik2, Davinder S. Jassal1, Nasir Shaikh1, James W. Tam1, 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 0.770.998) per mmol increase), baseline renal insufficiency (p=0.043, OR=0.29, (95% CI 0.090.96) 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.

http:0.03-0.58

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 ofbreath 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 ofdyspnea, 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 ofpatients 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

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 preB 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 ofa 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% ofall 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 antileukemic 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 ANC Hb(g/L) Platelet Blast Count (% of Karyotype (109/L) (1091L) Count(1091L) nucleated cells by flow

cytometry)

April 7. 2005 (Initial Presentation)

3.7 1.5 128 70 None N/A January 23rd, 2009 (Clinical Deterioration)

2.7 1.35 106 26 43% del20q April 24, 2009 (Post Systemic Chemotherapy)

2.8 1.29 86 24 28% del20q November 9th, 2009 (Post 4 Cycles 5-AZA)

3.52 1.58 102 64 2% del20q

The Role of 3D Echocardiography in Breast Cancer: Comparison with 2D Echocardiography,

MUGA and Cardiac MR)

Mehrdad Golianl, 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 ofMUG 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 6 Months 12 MonthsA. c. E. ~ rwO.st7

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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 5aminosalicylic 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 ofdiarrhea 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 Komendal,2, C Sathianathanl ,2, M Resleroval ,2, L Eng, A Eng, MM Sood l,2

IUniversity of Manitoba, Winnipeg, Manitoba, Canada 2Section ofNephrology, 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

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% ofall 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 ofdiffering 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 ofPO 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

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. ofCardiology

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 ofpatients 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% ofpatients. 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 pvalue 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

The utility of the SVNT AX 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. ofCardiology

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 ofcardiogenic 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) ofpatients 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

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

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 ofCardiology, Department ofInternal Medicine, University ofManitoba, Winnipeg, Manitoba. 3. Department ofRadioiogy, University ofManitoba, 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 ofbreath. 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 ofpatients 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 highrisk 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 ofphysicians 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 ofMedical Microbiology and Department ofintemal Medicine2

Faculty of Medicine, Health Sciences Centre, University ofManitoba, 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 ofManitoba, 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.

CTscan 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 ofsarcoidosis 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


RESIDEN'" RESEARCH DAY PROGRAM



TER PRESENTATIONS


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. Sette I

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 Supervisor: F. Hussain

1400 (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 Supervisor: M. Krahn

1625 (Clinical Investigation) Staphylococcus aureus pyomyositis diagnosed by 165 rDNA 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 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

RA Ducas1, A Wasseff\ RK Philipp\ LR Hall. RA Grierson1, SA Hodge\ ER Weldon" J Dooley, CM Schmidt, OS Jassal1, JW Tam1

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 Chi2 = 15.34, P =< 0.0001), as well as a strong trend towards higher mortality (14% vs 7%. Yates Chi2 = 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 I 4). 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 ofother 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 Rate of PublIcation Significance Form of Presentation

Orel 59.1% p=0.OO4 POlIter 25.2%

Funded Study Funded Study 70.0% P = 0.009

Non-Funded Study 27.5% S1udy1YPe

CHnlcal 38.4% p = 0.014 Non-Clinical 18.2%

Number of Centre. Involved Single Centre 27.7% p=0.130

Multiple Centrea 45.5%

Study Resu~ .. Positive 37.7% p '" 0.186

Negative (or not-stated) 26.1% Year

2002 36.8% P 0.350 2004 24.0% 2006 29.4%

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 68.6713.68 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 68.9112.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

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 ofPRES in the setting of Thrombotic Thrombocytopenic Purpura (TTP), and the absence ofhypertension.

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 ofblood 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 ofPRES, 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 ofPRES 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 PAI

the university of manitoba department of … · department of internal medicine postgraduate...

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