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Aug 17, 2017 | Editorial 

From the Editors 2017

Elizabeth Simms

THE McMASTER UNIVERSITY MEDICAL JOURNAL (MUMJ) was established in 2003 to share advances in medicine, augment our understanding of the social issues impacting individual and population health, and encourage the discussion of ethical and legal issues as they apply to the profession. 

Our 14th volume of MUMJ includes a broad array of original research, case reports, review articles, and commentaries written by medical and graduate students from across the country. Our authors outline new strategies for reducing patient anxiety during interventional radiology procedures, dig into the career paths chosen by McMaster graduates, and examine the immunology behind allergen immunotherapy. They present case reports that highlight the dangers of patient-physician miscommunication and bring our attention to unusual disease presentations. They even discuss interprofessional challenges and the importance of medical technologies in low-income countries.

This year we are proud to continue our partnership...

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Aug 17, 2017 | Original Research 

McMaster’s Medical Graduates: What do they do? Where do they go?

Christopher Russell, Dorothy Bakker

ABSTRACT:

Many medical schools are interested in the location that their graduates pursue postgraduate residency training, and where they practice after leaving their school. Decreased access to healthcare services in rural and remote areas, which is provided largely by family physicians, has lead to a focus on the geographic distribution of physicians in Canada. The combined focus on social accountability in medical education and graduate tracking has led many schools to develop, or employ, systems to monitor their medical students after graduation. Using the Canadian Post-MD] Education Registry (CAPER), a national medical education registry, this article seeks to present the proportions of McMaster undergraduate medical learners that may help to address the identified gaps in primary medical care and service to rural areas through two questions: 1) What proportion of graduates choose family medicine vs. medical/ surgical residency training and 2) In what size community do graduates who pursue family reside in after residency?

It was found that McMaster, between 2013-2015, has produced a relatively stable proportion of family medicine residents versus other medical/surgical, and that the proportion of learners pursuing family medicine is in line with the proportion of residency seats available in family medicine compared to other medical/surgical specialties across Canada. It was also found, that a relatively large proportion (~70% - 80%) of students who pursue family medicine training eventually practice in larger urban centers (population greater than 100,000), compared to other geographic locations. Further work should focus on exploring physician distribution issues from a McMaster context, utilizing registries such as CAPER to ascertain more specific and detailed information regarding practice locations and physician distribution.

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Aug 17, 2017 | Original Research 

Reducing patient anxiety during interventional radiology procedures with video glasses: a randomized trial

Jonathan Peng, MD, Elan Hahn, MD, Aninda Saha, MBBS, Sriharsha Athreya, MBBS

ABSTRACT:

Purpose: Undergoing minimally invasive procedures is a stressful experience for most patients; thus any aid to alleviate anxiety during the procedure will contribute to an improved patient experience. This study aims to see if using personal audiovisual glasses reduces anxiety levels in patients undergoing interventional radiological procedures.

Methods: 41 patients scheduled to have outpatient interventional radiological procedures at St Joseph’s Healthcare Hamilton were randomized to two groups. One group was given the intervention (video glasses, N = 21) and the other was not (no video glasses, N = 20). Patients in both groups were required to fill in the State-Trait Anxiety Inventory (STAI) form before and after the procedure. The results of the STAI before and after were compared and statistical analysis was carried out using SPSS v.21.

Results: There were no differences between average age and gender distribution between the intervention and control group. Females were shown to have a higher state anxiety score pre procedure compared to males (44.8 vs. 36.1, p = 0.04). There was a significant reduction in state anxiety score of 18.1% in the intervention group compared to a 1.5% difference in the control (p = 0.026).

Conclusions: The use of video glasses during interventional radiological procedures appears to decrease the anxiety level of patients and can thus be an effective method for improving patient wellbeing and experience.

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Aug 17, 2017 | Case Report 

A drop or a dropperful? Overdose with an aqueous iodine oral solution (Lugol’s solution)

Sarma, S, MD MPH, Dadwal, S, MD, Dr. Akbar Panju

CLINICAL PRESENTATION OF THE PATIENT

A 34-year-old female with Graves’ Disease presented to the Emergency Department with vomiting and odynophagia. She was taking Lugol’s 5% Iodine solution before an upcoming thyroidectomy. Lugol’s solution contains 100 mg/ml of potassium iodide and 50 mg/ml of iodine1. It is commonly prescribed before thyroidectomies to reduce thyroid vascularity, minimize intra-operative blood loss, and prevent thyrotoxic crises.1,3 The prescribed dose was ten drops three times daily (total 3ml daily) for ten days. Her symptoms at presentation included a two-day history of cold intolerance, headache, abdominal pain, and neck tenderness. She had regular bowel movements, no hematemesis, and was able to eat and drink. There was no other reported past medical history.

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Aug 17, 2017 | Case Report 

Extensive arterial and venous hypertrophy due to presence of an arteriovenous fistula

Varun Srivatsav, BHSc, Asem Saleh,MSc, MD, Theodore Rapanos, MSc, MD, Jacques Tittley, MD

INTRODUCTION

An arteriovenous fistula (AVF) is an abnormal connection between an artery and a vein which results in a mixing of blood, and can be of a congenital or traumatic origin.

Many traumatic fistulas are also often iatrogenic: percutaneous femoral artery cannulations, central venous cannulations, and arterial injury from percutaneous biopsies often result in an AVF.2 This connection is also surgically created in dialysis patients, and has become the preferred method of access.3

The creation of the AVF causes the vein and artery to undergo significant remodelling and hypertrophy.4,5,6 In this report, we outline the case of a 66-year-old man whose clinical course showcases significant vascular hypertrophy in the presence of an AVF. By outlining the clinical course of our patient, our report explores AVFs and their etiology, the prognosis and management of patients with an AVF, and the possible mechanisms driving the extensive vascular hypertrophy seen in our patient.

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Aug 17, 2017 | Case Report 

Foreign material in the gastrointestinal tract: medical care and review of toxidromes

Ada Gu, Tim O’Shea, Ameen Patel

ABSTRACT:

Body packing as a method of international drug transport is a potentially lethal crime that has been continually reported and studied since the first published report more than 30 years ago.¹ The typical cause of death in individuals transporting drugs, also known as ‘body packers,’ is acute drug toxicity resulting from ruptured packets. There is no definitive protocol for management of these patients; the type of concealed drug, the patient condition and the capabilities of the treatment center dictate treatment. Although surgical intervention has become more frequent due to increasingly sophisticated packaging techniques, conservative management is generally preferred; the current treatment of choice is polyethylene glycol (PEG). Early surgical management however results in fewer emergent complications such as gastrointestinal obstruction, perforation, cocaine toxicity or retention. There is a lack of guidance regarding the reporting protocol and the healthcare team faces difficulty in balancing the rights of the individual with societal and criminal reporting responsibilities. We report a case of toxicity from ingested packets of cocaine with a brief review of physician reporting considerations, and a focus on medical management and review of common toxidromes.

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Aug 17, 2017 | Case Report 

Miller Fisher Syndrome as a presentation of B cell lymphoma

Christine Tomkinson, BMBS BSc, Ahmed Attar, MBBS, FRCPC, ABPN, FAAN

INTRODUCTION

Miller Fisher syndrome (MFS) is a rare variant of Guillain-Barre syndrome (GBS), consisting of a triad of opthalmoplegia, ataxia and areflexia, with or without more classic findings of an acute neuropathy. It is generally thought to represent an autoimmune process, particularly with the presence of GQ1b antibodies in the cerebral spinal fluid (CSF), and can be associated with preceding infections as in more classic forms of GBS.2 However, the MFS clinical triad can rarely be the presentation of lymphoma.

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Aug 17, 2017 | Systematic Review 

Allergen immunotherapy - modulating the immune response in allergic disease

Matthew Boroditsky, BHSc, Michelle Yee, BSc, John-Paul Oliveria, BSc, PhD(c)

ABSTRACT:

Allergen immunotherapy (AIT) can be defined as the repeated administration of specific allergens to patients with IgE-mediated inflammatory diseases, with the ultimate goal of providing protection against allergic symptoms and inflammatory reactions associated with natural exposure to these allergens. Specifically, the therapy primarily strives to establish long-term tolerance against allergens by inducing allergen-specific regulatory B and T cell responses, in addition to modulating the mast cell and basophil activation thresholds to mitigate allergic pathogenesis. AIT is conventionally administered to patients both subcutaneously and sublingually; however, additional routes of administration (ie. intralymphatic immunotherapy) are under investigation. AIT is suitable for both adults and children for a variety of allergens including pollen, pet dander, house dust mite, venom, and a number of food allergens including peanut, egg, and milk. Nevertheless, more research is needed to elucidate many of the direct mechanisms in which AIT suppresses inflammatory immune responses.

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Aug 17, 2017 | Systematic Review 

The dual role of alveolar macrophages in allergic asthma pathogenesis

Abirami Kirubarajan, BHSc(c), John-Paul Oliveria, BSc, PhD(c)

ABSTRACT:

Allergic asthma (AA) is a chronic inflammatory disease which affects the conducting zone of the airways, particularly the bronchi and bronchioles. Due to emerging global prevalence of AA, there has been growing interest in elucidating the role of alveolar macrophages (AMs) in AA pathogenesis. AMs are resident phagocytes within the pulmonary alveoli, accounting for the largest proportion of leukocytes in the airways. In contrast to other innate immune cells, such as neutrophils, AMs are relatively long-lived within the airways, possessing an approximate lifespan of 5-6 months. Depletion studies in vitro have demonstrated that AMs play an important role in both development of innate immunity as well as initiation of adaptive immunity. Common functions of AMs include phagocytosis, professional antigen presentation, and release of both pro- and anti-inflammatory mediators. AMs have historically been neglected within the AA literature, as other immune cells such as basophils and eosinophils have more well-established roles in asthma pathogenesis. In addition, the dual role of AMs in both pro- and anti-inflammatory pathways can often complicate studies investigating their functions in pathogenesis, particularly when concerning methods of activation, released mediators, and loci of interference. This review will describe the role of AMs in AA pathogenesis, covering both their pro- and anti-inflammatory roles.

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Aug 17, 2017 | Systematic Review 

Interleukin 13 - a potential therapeutic target in the management of allergic asthma

Matthew Boroditsky, BHSc, Michelle Yee, BSc, John-Paul Oliveria, BSc, PhD(c)

ABSTRACT:

Asthma is a common chronic non-communicable disease, affecting nearly 334 million people globally, and 3 million Canadians across all age ranges. The allergic asthma phenotype is one of the more dominant forms of asthma in early life. Allergic asthma has been defined as a chronic inflammatory disorder mediated by IgE, and is associated with variable airflow obstruction, bronchial hyperresponsiveness and type 2 inflammation. The pathogenesis of allergic asthma has been associated with a increase in type 2 cytokines including IL-4, IL-5, and IL-13, which play pivotal roles in the development of IgE-mediated responses. Specifically, IL-13 plays a diverse and fundamental role in allergic asthma pathogenesis. IL-13 promotes airway inflammation through the activation of macrophages, dendritic cells, and eosinophils. It further induces airway remodeling by enhancing the proliferation of fibroblasts. IL-13 also plays a predominant role in mucus production through the stimulation of airway epithelial cells and induction of goblet cell hyperplasia. Finally, IL-13 has been shown to be one of the key drivers of airway hyperresponsiveness (AHR) through the activation of airway smooth muscle cells. This suggests that IL-13 may drive the disease progression and contribute to corticosteroid resistance in some patients. Thus, already existing anti-IL-13 monoclonal antibodies has shown great promise as an ideal therapeutic agent in the management of asthma, and the effect of anti-IL-13 therapeutics in managing allergic asthma need to be further elucidated.

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Aug 17, 2017 | Systematic Review 

Treatment of resistant neurosarcoidosis with infliximab

Tessa Campbell, BSc (Hon.), MD, PhD, Internal Medicine Resident, PGY-2, Katayoun Alikhani, MD, Assistant Professor, Aurore Fifi-Mah, MD, BSc, Clinical Assistant Professor

ABSTRACT:

Sarcoidosis is a multi-system granulomatous disorder. Symptomatic neurologic involvement, termed neurosarcoidosis, develops in 5-13% of sarcoidosis patients. The clinical continuum of neurosarcoidosis includes cranial neuropathy, aseptic meningitis, hydrocephalus, central nervous system space occupying lesions, peripheral neuropathy and myopathy. Unfortunately, numerous neurosarcoidosis patients have demonstrated resistance to the traditional corticosteroid therapy. Case reports have indicated that infliximab, a tumour necrosis factor-α inhibitor indicated for the treatment of inflammatory arthritis and inflammatory bowel diseases, has been a successful alternative in this subset of patients. In this article, we provide a current overview of neurosarcoidosis and examine the utility and challenges of treatment of steroid-resistant disease with infliximab.

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Aug 17, 2017 | Commentary 

A diagnostic dilemma: Greater clarity is required regarding Ontario homeopaths’ diagnostic privileges

Thom Ringer, JD MPhil

I. CASE

You are resident in an academic family medicine teaching unit. Ms. P is a 50 year old woman whom you receive as a new patient. She states she is “pretty healthy,” and joined the practice at her daughter’s insistence. She has no significant formal past medical history. She endorses a several year history of fatigue, but states that her homeopath, whom she sees monthly, has it “mostly under control” with a number of remedies. She provides you with a list of the preparations, but you do not recognize them, are not trained in researching the homeopathic literature, and cannot find any applicable primary biomedical research.

When you ask her what condition the tinctures are for, she says her homeopath has told her it relates to her fatigue and pain, but that he has never discussed the underlying cause. You explain that you respect her right to use complementary and alternative medicine, but that it is important that you understand what she is taking, and what the indications are. Accordingly, you obtain her permission to speak with her homeopath to clarify her existing treatments.

Her physical exam and review of systems are unremarkable. Nevertheless, because she has been taking unfamiliar medications for nonspecific symptoms and has not seen a physician for a long period of time, you order a complete blood count, serum creatinine...

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Aug 17, 2017 | Commentary 

The importance of frugal technologies in low-income countries

Elie Côté, BMSc

ABSTRACT:

Medical technology plays a vital role in the delivery of healthcare. However, many individuals in low-income countries do not have access to medical technologies. As a result, the quality of healthcare suffers in these countries. A potential solution to this problem is the implementation of cost-effective innovations, such as frugal technologies. Frugal technology is defined as “technology that is specifically developed to meet the needs of the world’s poorest people.” This commentary explores frugal technologies, and the importance of continuing to invest in their development in low-income countries.

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Aug 17, 2017 | Medical Education 

MMSRD Winning Abstracts

Marina Wang, Karishma Manji

MMSRD Recap:

This year marked the 8th annual McMaster Medical Student Research Day (MMSRD). As with the McMaster Medical program, the MMSRD encourages students to engage in evidence-based medicine and emphasize the importance of bridging the bench-to bedside gap. MMSRD continues to be a platform for medical students involved in research to engage peers and staff in scientific methodologies, critical thinking, and innovative ideas in all domains of medicine.

This year, many unique and interesting projects were brought forward. The MMSRD showcased over 70 abstract presentations in multiple categories: basic sciences, clinical research, medical education, population health, and health policy. Building off the previous year, quality improvement projects that are commonly done by first year medical students continued to be a key feature. We also welcomed Dr. Sonia Anand, BA, MD, PhD, FRCP(C) who spoke to our attendees about her research in vascular medicine and how she balances both her clinical practice and research interests.

Moving forward, MMSRD will hopefully continue to grow and provide important cross-talk opportunities for medical students and the broader community.

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