Impact of a Center of Excellence in Confirming or Excluding a Diagnosis of Hypertrophic Cardiomyopathy.

Tertiary hospitals with expertise in hypertrophic cardiomyopathy (HCM) are assuming a greater role in confirming and correcting HCM diagnoses at referring centers. The objectives were to establish the frequency of alternate diagnoses from referring centers and identify predictors of accuracy of an HCM diagnosis from the referring centers. Imaging findings from echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging (CMR) in 210 patients referred to an HCM Center of Excellence between September 2020 and October 2022 were reviewed. Clinical and imaging characteristics from pre-referral studies were used to construct a model for predictors of ruling out HCM or confirming the diagnosis using machine learning methods (least absolute shrinkage and selection operator logistic regression). Alternative diagnoses were found in 38 of the 210 patients (18.1%) (median age 60 years, 50% female). A total of 17 of the 38 patients (44.7%) underwent a new CMR after their initial visit, and 14 of 38 patients (36.8%) underwent review of a previous CMR. Increased left ventricular end-diastolic volume, indexed, greater septal thickness measurements, greater left atrial size, asymmetric hypertrophy on echocardiography, and the presence of an implantable cardioverter-defibrillator were associated with higher odds ratios for confirming a diagnosis of HCM, whereas increasing age and the presence of diabetes were more predictive of rejecting a diagnosis of HCM (area under the curve 0.902, p <0.0001). In conclusion, >1 in 6 patients with presumed HCM were found to have an alternate diagnosis after review at an HCM Center of Excellence, and both clinical findings and imaging parameters predicted an alternate diagnosis.

Diffuse unilateral subacute neuroretinitis: a case of mistaken identity.

BACKGROUND: The report details a case of diffuse unilateral subacute neuroretinitis (DUSN) wherein a subretinal parasite was visualized and subsequently destroyed with laser photocoagulation. METHODS: Full historical and serologic investigations were carried out. A literature search to determine all possible causes of DUSN was also completed. RESULTS: Serologic results supported Baylisascaris procyonis as the cause of infection, but imaging of the worm before destruction did not support this organism as the etiologic agent. On the basis of morphologic evaluation of still imaging and videoimaging, patient exposure information, and known causes of DUSN, the infection was likely due to Alaria species, providing further evidence of a trematode cause. CONCLUSIONS: The report adds to the literature that trematodes should be recognized as a possible cause of ocular larva migrans. Although laser therapy is appropriate and effective for both nematode and trematode infections of the eye, in the case of adjunctive medical therapy, identification of the parasite group is essential.

A case of necrotizing fasciitis due to Streptococcus pneumoniae serotype 5 in Saskatchewan.

Necrotizing fasciitis due to Streptococcus pneumoniae is a rare and grave condition, and only a few cases have been reported. Suggested risk factors include minor trauma, systemic lupus erythematosus, immunosuppression secondary to medication, use of intramuscular anti-inflammatories and alcoholism. A fatal case of pneumococcal necrotizing fasciitis that occurred in a 51-year-old woman with a history of alcohol abuse and oral anti-inflammatory use is presented. Her condition was caused by a multi-etiology outbreak of community-acquired pneumonia, from which S pneumoniae serotype 5 was also isolated. The case description outlines the subtle presentation and rapid clinical progression of this condition. Because serotype 5 antigen is included in the polysaccharide 23-valent pneumococcal vaccine, the present case highlights the importance of pneumococcal immunization programs in Canada.

Generalism versus subspecialization: changes necessary in medical education.

During the initial Partners Meeting of the Association of Faculties of Medicine of Canada (AFMC), the Canadian Association for Medical Education (CAME), the College of Family Physicians of Canada (CFPC), the Medical Council of Canada (MCC), and the Royal College of Physicians and Surgeons of Canada (RCPSC) in May 2005, a plenary discussion and debate focused on the tensions that exist between generalist and subspecialty education within both the undergraduate and postgraduate educational programs in Canadian medical schools. Key issues identified in the debate included medical student selection, generalist representation on medical school faculty and in learning experiences, and the need for a greater teaching role and respect for generalism to be developed.

Ross River virus disease reemergence, Fiji, 2003-2004.

We report 2 clinically characteristic and serologically positive cases of Ross River virus infection in Canadian tourists who visited Fiji in late 2003 and early 2004. This report suggests that Ross River virus is once again circulating in Fiji, where it apparently disappeared after causing an epidemic in 1979 to 1980.

Bacillary angiomatosis in an HIV-positive man with multiple risk factors: A clinical and epidemiological puzzle.

A 36-year-old man with advanced AIDS presented with skin lesions, fever and weight loss. Physical examination revealed skin lesions suggestive of bacillary angiomatosis. Diagnostic imaging identified bone lesions, soft tissue masses and a single hepatic lesion. His clinical presentation was most consistent with Bartonella quintana; however, his risk for infection with B quintana was limited to a remote, brief period of homelessness. In contrast, his frequent contact with cats presented substantial potential exposure to Bartonella henselae.Diagnosing a Bartonella infection presents challenges. The detection of bacteremia is hindered by slow growth in BACTEC media (BD Diagnostic Systems, Canada). In the present case, recovery of the organism required blind subcultures after at least eight days of incubation. Speciation by 16s ribosomal RNA analysis confirmed B quintana as the pathogen.Because the patient presented with skin lesions, the diagnosis was straightforward; however, skin lesions are nondiagnostic in some cases. Microbiological confirmation of the diagnosis rests on sufficient clinical suspicion to apply labour-intensive laboratory protocols.

Informed consent skills in internal medicine residency: how are residents taught, and what do they learn?

PURPOSE: Obtaining informed consent is an essential skill in internal medicine (IM). The authors' informal observations and formal testing revealed deficiencies in residents' informed consent skills. This study evaluated how residents acquire informed consent skills and how informed consent skills are addressed in Canadian IM residency programs. METHOD: A questionnaire was delivered to all 16 IM program directors in Canada, asking how informed consent is taught and assessed. At the University of Saskatchewan IM residency program, residents were assessed through an objective structured clinical examination station, written examination, and a self-assessment questionnaire. RESULTS: No consistent approach to teaching or evaluating informed consent skills exists within Canadian IM programs. Program directors and residents identified informal mentoring by residents as an important learning modality. Although residents performed well in discussing procedural indications and techniques, discussing risks was inadequate. Residents focused on general and minor risks but avoided discussing serious risks and had difficulty discussing the frequency of complications. Residents lacked a structured approach to assessing capacity and often assessed only comprehension. Residents were unfamiliar with concepts such as material risk, implied consent, and therapeutic privilege. CONCLUSION: Explicit training in informed consent skills is urgently needed. Informal mentoring must be recognized as an important training method for informed consent and supported by appropriate teaching and evaluation strategies to ensure that resident-instructors do so effectively.

Mosquito bed nets: implementation in rural villages in Zambia and the effect on subclinical parasitaemia and haemoglobin.

Malaria continues to be an increasing health concern in many endemic areas where it remains a major contributor to childhood morbidity and mortality. Chemoprophylaxis and treatment are increasingly compromised by drug resistance. Vaccination for malaria is not yet available outside clinical trials. In clinical trials bed nets have been shown to be effective in reducing malarial morbidity and mortality. Their efficacy outside of the clinical trial setting has been less well documented. We describe our experience with the introduction of bed nets in a remote rural Zambian village and document the effect on malarial parasitaemia, spleen rates and haemoglobin. Children were evaluated at the end of the rainy seasons in April 1998 and April 1999. Insecticide impregnated nets were made available for purchase to the village in July 1998. Rates of parasitaemia and anaemia were significantly reduced.