THE UNIVERSITY OF MANITOBA DEPARTMENT OF...

THE UNIVERSITY OF MANITOBA

DEPARTMENT OF INTERNAL MEDICINE POSTGRADUATE EDUCATION PROGRAM

RESIDENT RESEARCH DAY MAY 272008

SCIENTIFIC PROGRAM THEATRE B BMSB

DEPARTMENT OF INTERNAL MEDICINE RESIDENT RESEARCH DAY PROGRAM

THURSDAY MAY 27 2008 THEATRE B CONCOURSE BMSB 2ND FLOOR

IpOSTER PRESENTATIONS AI

Time will be adhered to with 5 minutes for presentation and 5 minutes for questions

1315 (Clinical Investigation) The Effectiveness of the CancerCare Manitoba (CCMB) Anticoagulation CLinic (ACe) Vi Dao Supervisors D Szwajcer

D Houston

1325 (Case Report) A Case of Idiopathic Anaphylaxis Ashraf Farag Supervisor D Szwajcer

1335 (Clinical Investigation) Cholangitis Associated Septic Shock RoLe of Rapidity of Antimicrobial Therapy and Source Control Brendan McCarthy Supervisor A Kumar

1345 (Case Report) A Possible Advantage for JAK2 Mutation Sara Dunsmore Supervisor D Houston

1355 (Case Report) When Thin Turns to Thick The Hyperviscosity Syndrome and Lactic Acidosis Aaron Low Supervisor G Drobot

1405 (Case Report) Myocardial Siderosis Due to Hemochromatosis in an Individual with Hypertrophic Cardiomyopathy Ainslie Hildebrand Supervisor D Jassal

1415 (ClinicaL Investigation) Clinical Utility of Tissue Doppler Imaging in Patients with Acute MyocardiaL Infarction Complicated by Cardiogenic Shock Adnan Hameed Supervisor D Jassal

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1425 (Clinical Investigation) Contraceptive Prescription and Counseling on the General Internal Medicine Ward Nicola Matthews Supervisor K Wiebe

1435 (Case Report) Neurocysticercosis in Rural Manitoba Previously Healthy Young Man Jonathan Gabor

A Case Report of Seizures in a

Supervisor J Embil

1445-1515 Break

1515 (Case Report) Hyperferritinemia Pam Skrabek

An Unexpected Result of Treatment with Danazol Supervisor D Houston

1525 (Clinical Investigation) Electrocardiographic Predictors of In-Hospital Survival in Cardiogenic Shock Due to Myocardial Infarction A Prespecified Analysis from the Manitoba Cardiogenic Shock Registry Investigators Robin Ducas Supervisor F Hussain

1535 (Case Report) The Use of High Dose Dexamethasone in a Palliative Care Setting to Preserve Quality of Life in a Patient with Breast Carcinoma and Known Intracranial Metastases Jonathan Wong Supervisor G Crawford

1545 (Case Report) Vasogenic Cerebral Edema Edward Tam

A PRES-ing Matter Supervisor K Humphreys

1555 (Case Report) Disseminated I nfection Due to a Unique Mycobacteria in an Elderly Patient Myles Horton Supervisor P Orr

1605 (Case Report) Clues to the Pathogenesis of Kikuchi-Fujimotos Disease in Non-Twin Siblings Susan Teschke Supervisor M Seftel

IpOSTER PRESENTATIONS 8 1

1315 (ClinicaL Investigation) Early Changes in Serum Creatinine and Vasopressors are Associated with Mortality in Septic Shock Faisal Siddiqui Supervisor A Kumar

1325 (Case Report) Effect of GLuten Free Diet on Osteoporosis in Patient with Celiac Disease Massud Ali Supervisor D Duerksen

1335 (Case Report) Hepatic PortaL Venous Gas from Perforated Diverticulitis Gregory Deans Supervisor G Drobot

1345 (Case Report) A Case Report of Adult Presentation of Anomalous Left Coronary Artery Originating from the Pulmonary Artery Thang Nguyen Supervisor G Drobot

1355 (Clinical Investigation) Gestational Diabetes in Manitoba during a Twenty Year Period Naji Aljohani Supervisor G Shen

1405 (Clinical Investigation) Observations on Internal Medicine Consults Generated in the Emergency Department Stephen Goulet Supervisors J Horton

K Kasper

1415 (Case Report) Non-Neutropenic Capecitabine-Induced Enterocolitis Vallerie Gordon Supervisor P Czaykowski

1425 (Case Report) Tricked by Trichinosis Michael Sochocki Supervisor J Embil

1435 (Clinical Investigation) Cardiovascular Morbidity and MortaLity and Reamputation Rates Among Persons with Lower Extremity Amputations Due to Peripheral Vascular Occlusive Disease - A Manitoba Perspective Doug Priestley Supervisor A Arneja

1445-1515 Break

1515 (Clinical Investigation) ProLonged EEG-Video Monitoring in Psychogenic Non-Epileptic Seizures Atheer AI-Kaabi Supervisor Y Aghakani

1525 (Case Report) Two cases of Neurofibromatosis Type I and Medically Intractable Complex Partial Seizures Abdulmuhsen Almulla Supervisor Y Aghakani

1535 (ClinicaL Investigation) Clinical Utility of Joint Spectrophotometry in Identifying SubclinicaL Synovitis in Patients Presenting with ArthraLgia Daniela Stroescu Supervisor C Hitchon

1545 (Case Report) Acute Kidney Injury in Patients Receiving Subcutaneous Deferoxamine Therapy Arjuna Ponnampalam Supervisor D Houston

1555 (Case Report) P-ANCA Positive VascuLitis Manifesting as Crescentic GLomeruLonephritis and PuLmonary Hemorrhage Alan Smith Supervisor M Sood

1605 (Case Report) Liver Enzyme Abnormalities Secondary to Combination Therapy with Bosentan and Atorvastatin Kimberley Mulchey Supervisor Z Bshouty

1615 (Case Report) An Unclassified Case of Hisitocytosis Jonathan Gi lmore Supervisor Z Bshouty

POSTER DISPLAYED IN RESIDENTS ABSENCE

(Case Report) Colorectal Cancer in Pregnancy An Aggressive Malignancy Maria Ho Supervisor P Czaykowski

The Department of Internal Medicine gratefully acknowledges the participation of our guest speaker and judge Dr Ralph Meyer and our local faculty adjudication teams Dr Gary Harding Dr Carol Hitchon Dr Alexandra Ilnyckyj Dr Clare Ramsey Dr Leroy Stars ley and Dr Kim Wiebe





1315 (Clinical Investigation) The Effectiveness of the CancerCare Manitoba (CCMB) Anticoagulation Clinic (ACC) Vi Dao Supervisors D Szwajcer

D Houston


1335 (Clinical Investigation) Cholangitis Associated Septic Shock - Role of Rapidity of Antimicrobial Therapy and Source Control Brendan McCarthy Supervisor A Kumar




1415 (Clinical Investigation) Clinical Utility of Tissue Doppler Imaging in Patients with Acute MyocardiaL Infarction Complicated by Cardiogenic Shock Adnan Hameed Supervisor D Jassal




Supervisor J Embil

1445middot1515 Break


An unexpected Result of Treatment with Danazol Supervisor D Houston



154 5 (Case Report) Vasogenic Cerebral Edema Edward Tam


1555 (Case Report) Disseminated Infection Due to a Unique Mycobacteria in an Elderly Patient Myles Horton Supervisor P Orr


The effectiveness of the CancerCare Manitoba (CCMB) anticoagulation clinic (ACC) Vi Dao Pascal Lambert David Szwajcer and Don Houston

Venothromboembolism (VTE) in patients with active malignancy is associated with adverse outcomes and effective anticoagulation for extended duration with either oral vitamin K antagonist (VKA) or low molecular weight heparin (LMWH) is indicated for as long as the cancer is active Although current literature suggests that LMWH is more efficacious in reducing VTE recurrence in patients with cancer when compared with oral VKAl the need for daily injection and high drug cost are major drawbacks to the up front use of LMWH in this setting At CCMB we treat all patients with first line VKA managed by a specialized pharmacist-run anticoagulation clinic (ACC) switching to LMWH if thrombosis recurs despite VKA The aim of this retrospective review is to access the efficacy and safety of this approach comparing outcomes between patients with cancer to a convenient cohort (control) on VKA managed by the same Ace Results The quality ofanticoagulation with oral VKA is inferior in patients with VTE and active cancer when compared to control patients (TSTR 54 versus 64 pltOOOl) but rate ofVTE recurrence and bleeding is similar However patients with cancer is more likely to experience VKA failure (OR 722 95 CI 147-355) and risk of death (OR 448 95 CI 272-734) No significant predictors were identified for recurrent VTE but those with poor INR control were more likely to suffer from bleeding complications Thus oral VKA remains an effective option for anticoagulation for most patients and LMWH can be reserved for patients with additional risks such as VKA failure and those with poor INR control due to increased risk of bleeding

A Case 0 Idiopathic Anaphylaxis

Ashraf Farag MD David Szwajcer MD Kristine Roland MD

Introduction

Systemic mastocytosis (SM) denotes a spectrum of disorders and is characterized by the dysregulated proliferation and accumulation of mast cells in different organs The rarity of SM and the fact that many of its recognized symptoms are shared by other more common disorders serve to delay or hinder its diagnosis Clinical manifestations of SM are ascribed to the local or remote effects of mast cellshygenerated mediators which may lead to facial flushing tachycardia hypotension headache nausea vomiting diarrhea urticaria anaphylaxis and syncope

case description

50 year-old male farmer presented with recurrent attacks of syncope preceded by dyspnea palpitations tongue swelling throat tightening and flushing His first seriOUS attack occurred in 1998 following several bee stings Following this episode an epinephrine pen was prescribed The frequency of attacks has gradually increased and over the last several years have been unprovoked When seen in early January of 2008 attacks were occurring every other day He was being managed with a combination of cetrizjne montelukast prednisone ranitidine as well as the epinephrine pen Physical examination was unremarkable Laboratory investigations revealed an elevated eosinophil count of 051X109L with an elevated serum tryptase of 31 mcgl Bone marrow aspirate examination showed an excess of spindle shaped mast cells Flow cytometry revealed a population of C0117+ C02+ complex granular cells Cytochemical staining of the core biopsy for toluidene blue confirmed increased spindle shaped mast cells scattered diffusely throughout the specimen CKIT and FIP1li-POGFRA mutations were not demonstrated Diagnosis Indolent Systemic Mastocytosis (World Health Organization)

Discussion

Systemic mast cell disorders are uncommon and will occur at any age While cutaneous manifestations are more common in childhood systemic mastocytosiS is more common after the third decade of life Systemic mast cell disorders fall on a spectrum from Indolent Systemic Mastocytosis (ISM) to Mast Cell leukemia The case presented has several uncharacteristic features While the majority of patients with ISM have cutaneous involvement there was no evidence of characteristic maculopapular rash The patients idiopathic anaphylactic episodes have been unresponsive to a combination of therapy consisting of systemic corticosteroids histamine Hi and H2 blockade and leukotriene inhibition ISM is usually managed with a conservative approach however given the debilitating nature of the patients symptoms a course ofcytoreductive therapy with cladribine was initiated

Conclusion

When conSidering the differential diagnosis of Hymenoptera venom allergy when there are mUltiple episodes of unprovoked anaphylaxis a serum tryptase should be obtained to exclude systemic mast cell disorders The majority of patients with ISM may only require infrequent conservative therapy however certain cases may benefit from a more aggressive approach

CHOLANGITIS ASSOCIATED SEPTIC SHOCK - ROLE OF RAPIDITY OF ANTIMICROBIAL THERAPY AND SOURCE CONTROL

McCarthy B Fu W Sullivan K Peters C Muggaberg S Kravetsky L Bohmeier R Kumar R Kosick T Chan C Ren J Paulin H Khan F Campbell L Kumar A and the CA TSS Database Research Group

University of Manitoba Winnipeg Manitoba

Objective The aim of this study is to evaluate the mortality differences with delays of appropriate antibiotic therapy and source control in patients with cholangitis associated with septic shock admitted to intensive care units Methods A retrospective analysis was performed using medical records from ICU admissions to multiple centres From these records 126 patients were collected and analysis focused on timing of effective antishymicrobial therapy and appropriate source control and their combined effects on mortality Results Ofthe 126 patients mean age was 68years with a mean APACHE score of24 Overall 30 day mortality was 3 I with a mean ICU length of stay of9 days Of patients with positive bacterial cultures the most common isolates were EcoJi Klebsiella and Enterobacter(4120 and 55 respectively) After the development of septic shock the median time to effective antibiotic therapy and effective source control was 4 hours and 85 hours respectively The rate of mortality was found to increase with increased delays in antibiotic therapy and source control The survival rates for patients with effective antibiotics within 6hours 6-12hours and gt12hours were 78 625 and 33 respectively The survival rates for patients with source control performed within 9hours 9-24hours and gt24hours were 89 76 and 50 respectively There was noted to be a synergistic effect with early combined therapy as compared to delayed effective therapeutics(96 survival vs 54) Conclusion This study reveals that early effective antibiotics and source control in patients with septic shock from cholangitis results in increased survival

A POSSIBLE ADVANTAGE FORJAK2 MUTATION Sara Dunsmore Internal Medicine Resident University of Manitoba Winnipeg MB Supervisor Don Houston Professor Hematology University of Manitoba Winnipeg MB

The JAK2V617F activating mutation has been well documented as an important factor in the myeloproliferative disorders (MPDs) It is found in over 95 of polycythemia vera patients and 50-60 of those with essential thrombocythemia and idiopathic myelofibrosis Mutation in the JAK2 tyrosine kinase results in increased intracellular signalling in erythroid and myeloid cells This process is independent of erythropoietin and other stimulating factors and results in proliferation ofcell lines in the MPDs The JAK2V617F mutation is also seen in up to 5 ofmyelodysplastic syndromes (MDS) This is unlikely due to random chance as other similar disorders such as chronic myelogenous leukemia (CML) have a very low prevalence ofJAK2V617F Unlike the MPOs the development ofJAK2V617F does not have a clear causative role in marrow failure states such as MDS

A 42 year old woman initially presented at the age of six with anemia and was subsequently diagnosed with congenital dyserythropoietic anemia (CDA) type 1 At initial presentation the other blood counts including platelets were normal When she returned to hematology clinic as an adult her anemia was unchanged but she had elevated platelet and white blood counts Bone marrow biopsy showed changes consistent with essential thrombocythemia superimposed on COA type I and testing for the JAK2V617F mutation showed it was present

This patient has a unique pairing ofcongenital dyserythropoietic anemia and a myeloproliferative disorder Archival tissue is not available so it is impossible to be certain which disorder arose first The normal platelet count and WBC at age 6 support the inference that the myeloproliferative disorder arose later as an acquired somatic mutation Among patients with essential thrombocythemia those who have the JAK2V617F mutation tend to have higher hemoglobin levels though in her case the development of the JAK2V 617F mutation did not lead to improvement ofher anemia We hypothesize that the hematopoietic failure state associated with CDA may like that ofMDS create an environment in which a geneticallyshymediated proliferative advantage due to an acquired mutation may be especially favoured and may thus have been a factor in the development ofthe myeloproliferative disorder

When Thin turns to Thick The Hyperviscosity Syndrome and Lactic Acidosis

R Aaron Low Supervisor Dr G Drobot

Waldenstroms macroglobulinemia is a malignant lymphoproliferative disorder characterized by monoclonal synthesis and secretion of IgM antibodies It commonly presents with fatigue weakness weight loss or epistaxis and in approximately 15 to 31 ofpatients is associated with the hyperviscosity syndrome Common features of this entity include oronasal and retinal bleeding headache as well as focal neurological deficits

In this report we describe the case of an 80-year-old female who was brought to the ER after several days of diarrhea and a syncopal episode In hospital she was noted to have intermittent periods of significant lactic acidosis (L-Iactate gt I 0 mmolL) and synthetic liver dysfunction I~vestigations revealed a mild anemia an IgM level of 8060 (normal 06-26g1L) and a serum viscosity of 54 (normal 11-18 centipoises) She was accordingly diagnosed with Waldenstroms macroglobulinemia and associated hyperviscosity syndrome Plasmapheresis was initiated and her episodes oflactic acidosis and hypoglycemia did not recur To our knowledge this is the first reported case of the hyperviscosity syndrome presenting with lactic acidosis and synthetic liver dysfunction

MYOCARDIAL SIDEROSIS DUE TO HEMOCHROMATOSIS IN AN INDIVIDUAL WITH HYPERTROPHIC CARDIOMYOPATHY

Ainslie M Hildebrand MDI Davinder S Jassal MD F ACC FRCPC2

-4

J Department of Internal Medicine University of Manitoba Winnipeg Manitoba Canada 2 Section of Cardiology Department ofCardiac Sciences University of Manitoba Winnipeg Manitoba

Canada 3 Department of Radiology University of Manitoba Winnipeg Manitoba Canada 4 Institute of Cardiovascular Sciences University ofManitoba Winnipeg Manitoba Canada

It is well known that hypertrophic cardiomyopathy (HCM) may transition to a stage resembling the morphologic and functional features of a dilated cardiomyopathy with systolic dysfunction and left ventricular dilation However given the poor prognosis associated with this dilated phase consideration of potentially reversible etiologies ofa concomitant dilated cardiomyopathy is important

We report a case ofa patient with HCM and transfusion dependent sideroblastic anemia who presented with decompensated heart failure Cardiac magnetic resonance (CMR) imaging demonstrated a dilated cardiomyopathy with marked signal hypo intensity on T2-weighted images within the left ventricular myocardium liver and pancreas with relative sparing of the spleen consistent with the diagnosis ofprimary hemochromatosis

This case demonstrates the utility of CMR as a non-invasive modality to assess the etiology of new systolic dysfunction in the setting ofHCM CMR is able to differentiate between the dilated burnedshyout phase of HCM and a concomitant dilated cardiomyopathy secondary to myocarditis or hemochromatosis

Clinical ntility of tissue Doppler imaging in patients with acute myocardial infarction complicated by cardiogenic shock

Adnan K Hameedl Tirath Gosatz Tielan Fang3

Roien Ahmadie3 Matthew Lytwyn3

Ivan Barac3

Shelley Zieroth2 Farrukh Hussain2 and Davinder S Jassal234

lDepartment of Medicine University of Manitoba Winnipeg Manitoba Canada 2CardioJogy Division Department of Cardiac Sciences St Boniface General Hospital University of Manitoba Winnipeg Manitoba Canada 3Institute ofCardiovascular Sciences Cardiology Division Department of Cardiac Sciences St Boniface General Hospital University of Manitoba Winnipeg Manitoba Canada and 4Department of Radiology St Boniface General Hospital University of Manitoba Winnipeg Manitoba Canada

Background Echocardiography is widely used in the management of patients with cardiogenic shock (CS) Left ventricular ejection fraction (EF) has been shown to be an independent predictor of survival in CS Tissue Doppler Imaging (TDI) is a sensitive echocardiographic technique that allows for the early quantitative assessment of regional left ventricular dysfunction TDI derived indices including systolic velocity (S) early (E) and late (A) diastolic velocities of the lateral mitral annulus are reduced in heart failure patients (EF lt 30) and portend a poor prognosis In CS patients the application ofTDI prior to revascularization remains unknown

Objective To characterize TDI derived indices in CS patients as compared to patients with chronic CHF

Methods Between 2006 and 2007 100 patients were retrospectively evaluated who underwent echocardiography for assessment of LV systolic function This population included Group I) 50 patients (30 males 57 plusmn l3 years) with chronic CHF as controls and Group II) 50 patients (29 males 58 plusmn 10 years) with CS Spectral Doppler indices including peak early (E) and late (A) transmitral velocities EIA ratio and E-wave deceleration time were determined Tissue Doppler indices including S E and A velocities of the lateral annulus were measured

Results Of the entire cohort the mean LVEF was 25 plusmn 5 Cardiogenic shock patients demonstrated significantly lower lateral S E and a higher EIE ratio (p lt 001) as compared to CHF patients The in-hospital mortality in the CHF cohort was 5 as compared to the CS group with an in hospital mortality of40 In the subset ofCS patients (n = 30) who survived the mean S at presentation was higher as compared to those patients who died in hospital (35 plusmn 05 vs 18 plusmn 05 cms)

Conclusion Despite similar reduction in LV systolic function CS patients have reduced myocardial velocities and higher filling pressures using TDi as compared to CHF patients Whether TDI could be a reliable tool to determine CS patients with the best chance of recovery following revascularization is yet to be determined

CONTRACEPTIVE PRESCRIPTION AND COUNSELING ON THE GENERAL INTERNAL MEDICINE WARD NE Mattbews KL Wiebe Department of Internal Medicine University of Manitoba Winnipeg MB Canada Background The care of women of reproductive age has always been tempered by a need to consider the potential effects of any medical therapy on fertility and pregnancy In no area is this more obvious than in the prescription of medications many of which are known to have potentially harmful effects on the growing fetus Despite the knowledge that many medications have the potential to cause harm to the fetus during pregnancy a number of studies have shown that 4- 7 of women are prescribed class D or X drugs during pregnancy Given the known risks of many medications patients taking these drugs should receive contraceptive counseling andor prescription of contraception to prevent fetal exposures A recent study however showed that fewer than 20 of women prescribed potentially teratogenic medications received contraceptive counseling or prescriptions Women with chronic diseases many of whom may be seen in an internal medicine setting are more likely to be prescribed class D and X drugs during pregnancy Furthermore in the United States general internists along with family physicians accounted for 43 of prescriptions for class D and X medications To date no Canadian data is available regarding contraceptive counseling or prescription of teratogens to at-risk populations Objectives To determine the proportion of female inpatients of child-bearing age admitted to the general internal medicine ward that are at risk secondary to comorbid conditions or prescription of teratogenic medications To determine current practices on the internal medicine ward regarding contraceptive prescription and counseling Methods The WRHA medicine database was used to identify all women aged 18-44 years admitted to an internal medicine ward at Health Sciences Centre between January 151 and December 31 $1 2007 The database also provided comorbid conditions for each patient Charts were reviewed to identify medications on admission and discharge and to document contraceptive counseling Results One hundred and thirty women were admitted to the ward during the study period Most patients either had a moderate to high risk comorbidity or were on a pregnancy Class D or X medication at discharge The majority of patients were not using contraception either at the time of admission or discharge No patients received contraceptive counseling from the internal medicine service including those with moderate-high risk comorbidities or potentially teratogenic medications Conclusions Most women of child-bearing age admitted to the internal medicine service are potentially at risk for pregnancy complications secondary to chronic disease or medications These patients are not receiving counseling regarding pregnancy planning and contraception during their admission

NEUROCYSTICERCOSIS IN RURAL MANITOBA A CASE REPORT OF SEIZURES IN A PREVIOUSLY HEALTHY YOUNG MAN

Jonathan Y Gabor and John M Embil Departments ofMedicine and Medical Microbiology amp Infectious Diseases Faculty ofMedicine University ofManitoba Winnipeg Manitoba

Introduction A 27-year-old previouslywell man presented to a rural emergency department with two simple partial seizures occurring over several hours Both seizures were self-terminating and lasttd no longer than several minutes

Case Description There was no history of previous seizures He did not have a significant past medical history and did not take any medications here was no history of alcohol abuse illicit drug use or other risk factors for infection with the Human Immunodeficiency Virus (HIV) There was no history of infectious prodrome or contacts The patient lived in a small rural farming community and was employed as a truck driver He denied recent travel out ofCanada however he had immigrated to Canada from Mexico during his childhood approximately 20 years earlier While in Mexico he lived on a farm where cattle and pork were routinely slaughtered and prepared On examination the patient was alert however confused and agitated Vital signs were unremarkable and the patient was afebrile Neurological examination was significant for confusion dysarthria myoclonus of the right leg and diminished reflexes and strength in the right upper extremity Meningismus was not observed The remainder of the neurological examination was unremarkable Examinations of the head and neck cardiorespiratory systems abdomen and periphery were likewise unremarkable and non-contributory Laboratory investigations revealed a leukocytosis of 137 (xlOe9 cellsL) with neutrophil predominance Serum biochemical profile was normaL Computed axial tomographic (CT) scan of the brain demonstrated the presence ofnumerous intraparechymal cysts in both cerebral hemispheres with most of the cysts demonstrating a central dot of high attenuation The radiographic appearance of the cysts was considered very suggestive of infection with Taenia solium larvae and the history ofprior residence in Mexico added further substantiation Subsequent serology for T solium was positive

Discussion The patient was treated with a l5-day course of praziquantel 50 mglkg Phenytoin was prescribed for control of seizures and dexamethasone was given to attenuate the host inflammatory response to the disintegration of encysted T solium larvae The patients neurological deficits resolved promptly No further seizures occurred and the patient remained asymptomatic Repeat CT -scans at two weeks and four months after presentation continued to demonstrate regression of the cysts however with increasing areas of punctate calcification The patient has since returned to work as a truck driver This case illustrates the use of computed tomography in the diagnosis of neurocysticercosis and the importance of a high index-of-suspicion in evaluating patients from areas where T solium is endemic

HYPERFERRITINEMIA AN UNEXPECTED RESULT OF TREATMENT WITH DANAZOL

2Pam Skrabek MDI Donald S Houston MD FRCPCI Department oflnternal Medicine l and Section ofHematologyOncology2 University of Manitoba Winnipeg Manitoba

Hyperferritinemia is most often found in patients as a result of iron overload infection inflammation or malignancy Danazol a synthetic derivative ofethinyl testosterone has not been reported to cause hyperferritinemia

We present three patients observed to have an extreme increase in serum ferritin during treatment with danazol The first two cases are of a 67 year old male with autoimmune hemolytic anemia and a 79 year old female with immune thrombocytopenic purpura The third case had the most dramatic fmdings This is a 56 year old female witl autoimmune hemolytic anemia characterized by both warm and cold agglutinins with a refractory course After less than one month on danazol (200 mg twice daily) her ferritin increased from 521 JlglL to 2877flglL Severe hyperferritinemia persisted until danazoJ was discontinued At this time there was an abrupt fall from 26281lgL to 191 jtgL In each case there was no alternative explanation for the changes in ferritin

Synthesis of mUltiple plasma proteins by hepatocytes is known to be influenced by androgenic receptor interaction but this has not been reported to be the case for ferritin It is thought that higher ferritin levels in men are a result ofhigher iron stores (due to the absence of menstrual blood losses) The effect ofdanazol in the cases presented may thus represent either an indirect effect or a non-specific effect ofthe drug One possibility is a previously-unreported influence ofandrogens on ferritin synthesis This may be most apparent in patients with moderate iron overload (two ofour patients had elevated baseline ferritin levels) The rapid return to baseline after discontinuation of danazol shows that the effect was not due to a change in iron stores Finally the possibility exists that danazol (or a metabolite thereof) interferes with the assay of ferritin in serum

This observation should be considered when measuring ferritin in patients receiving danazol Hyperferritinemia in these patients is an unreliable marker of iron overload Whether there is any implication of this observation for toxicity of danazol is not known

ELECTROCARDIOGRAPHIC PREDICTORS OF IN-HOSPITAL SURVIVAL IN CARDIOGENIC SHOCK DUE TO MYOCARDIAL INFARCTION A PRESPECIFIED

ANALYSIS FROM THE MANITOBA CARDIOGENIC SHOCK REGISTRY INVESTIGATORS

Ducas R Hussain F Philipp R Ducas J Hodge S Kashour T Elliott J Jassal DS Shaikh N Tam J Raabe M Menkis A Dzavik V Light B Roberts D Moussa T Schaeffer A Daba L Garber PJ Munoz A LoezashyAceves S Chateau D University of Manitoba Faculty of Medicine Department of Intemal Medicine Winnipeg MB

Objective To identify independent electrocardiographic (ECG) predictors of in-hospital survival from a large Canadian cardiogenic shock (CGS) registry in a prespecified analysis

Methods All consecutive patients with a diagnosis ofCGS who also had cardiac catheterization during the same admission were included over a four year period from Sept 2002-Sept 2006 in two teniary care centers in Manitoba Detailed chart review of multiple electrocardiographic parameters and outcomes were analyzed ECG analysis was performed within 24 hours prior to and following coronary angiogram revascularization Infarct location ST segment analysis pre and post angiogramrevascularization q waves ST resolution automated QT interval QRS duration and presence of heart block were measured Patients with LBBB or paced rhythm were excluded Descriptive statistical methods were utilized to summarize the data with a negative binomial logistic regression model used to identify univariate and multivariate independent predictors of in-hospital survival

Results ECG analysis was performed in 210 patients Eight patients underwent both PCI and CABG ST elevation infarctions were present in 140 (67) cases (PCI - 1111130 CABG 2747 Medical therapy 9141) and Non-ST elevation was present in 70 cases (PCI - 19130 CABG 2047 Medical therapy 3241)

In the overall group ST deviation (elevationdepression) resolution 50 occurred in 6J01o of patients while ST abnormality resolution 70 occurred in 57 ofpatients In the PCI group ST resolution ~ 50 occurred in 891116 (77) patients vs 2638 (68) in the CABG group vs 1333 (39) in the medical therapy arm Type of infarction maximal ST deviation location and ECG intervals did not predict survival Univariate predictor ofdeath included cumulative ST elevation post procedure (p=o02l 56) Univariate predictors of survival to discharge included ST resolution 50 (p=00037X2

84) and ST resolution 70 (P=0027X2 49) The only multivariable predictor of survival from the above was ST resolution 50 (pO04 OR 048 95 CI 024-097) showing a reduction in mortality

Conclusion Multiple ECG characteristics are outlined in this substudy for a cardiogenic shock cohort ST resolution 50 is an easily obtainable independent predictor of survival to hospital discharge in this cohort and can be utilized routinely to predict in-hospital prognosis To our knowledge this has not been described previously in this popUlation

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Wong J Crawford G

Case study The use of high dose dexamethasone (48 mgd) in a palliative care setting to preserve quality of life in a patient with breast carcinoma and known intracranial metastases

Abstract Corticosteroids have been widely used to treat symptomatic brain edema secondary to intracranial tumours or metastases Where appropriate dexamethasone is administered at a low to moderate dose (4-16 mgd) in order to achieve symptomatic relief while minimizing inevitable side effects such as steroid induced myopathies emotional lability and altered glycemiC control Due to the well established but variable side effects of dexamethasone treatment dosing should be tailored to individual patient responses to minimize toxicity The use of high dose dexamethasone (gt16 mgd) to treat symptomatic brain edema in a palliative care setting however has not been adequately explored

This case study will highlight the use of high dose dexamethasone (48 mgd) in a palliative care patient suffering from breast carcinoma with metastatic disease to brain bone and liver This patient was admitted to the SBGH palliative care unit for increased nausea vomiting headache and decreased level of consciousness unrelieved by other medications Her symptoms were thought to be secondary to increasing intracranial pressure as imaging of her head demonstrated Significant mass effect from intracranial metastatic disease Through discussions with her family it was decided to upwardly titrate her dexamethasone treatment in hopes of providing symptomatic relief The treatment was successful at controlling her admission symptoms and more importantly was able to improve her functional status and quality of life albeit for only a matter of weeks before she succumbed to her disease

In addition to highlighting the above case this case report will review the current use of dexamethasone for the treatment of symptomatic brain edema secondary to intracranial tumours and metastases the use of dexamethasone in a palliative care setting as well as to propose future directions for research

VASOGENIC CEREBRAL EDEMA a PRES-ing MAITER ETam K Humphreys

Department of Medicine University of Manitoba Winnipeg MB

Posterior Reversible Encephalopathy Syndrome (PRES) is a clinical-radiographic diagnosis characterized by headache altered mental status visual disturbances and seizures occurring in the setting of changes on brain imaging indicative of posterior vasogenic cerebral edema It is an important diagnostic consideration in certain clinical scenarios as the findings both clinical and radiographic are potentially reversible

A 62 year-old woman presented to the Emergency Room with a 1-day history of fluctuating level of consciousness confusion and lethargy On physical examination she was alert but disoriented and unable to follow simple commands She was afebrile with blood pressure 12360 and heart rate 80 No focal neurological deficits were present and there was an absence of meningeal signs Initial laboratory investigations revealed normal electrolytes complete blood count and urinalysis Uninfused computed tomography (CT) scan of the head was also normal Despite multiple attempts at lumbar puncture a cerebrospinal fluid sample was not attainable and empiric antimicrobial coverage for both bacterial meningitis and herpes simplex encephalitis was initiated

The patient continued to have a fluctuating level of consciousness and on the third postshyadmission day had a witnessed tonic-clonic seizure Repeat CT scan of the head at that time revealed bilateral white matter hypodensities in the occipital lobes which in the setting of the clinical findings were consistent with a diagnosis of PRES A medication and literature review revealed no potentially offending agents among the patients regimen Antimicrobial coverage was discontinued and focus was instead shifted to seizure prophylaxis and judicious normalization of the patients blood pressure which although normal on presentation was noted to be moderately elevated during the admission Within five days the patient recovered to her previously normal neurologic baseline and was discharged from hospital

This case illustrates the importance of considering a diagnosis of PRES in the appropriate clinical scenario When this clinical-radiographic syndrome is suspected close collaboration with radiology is instrumental in establishing the diagnosis Most often described in the setting of hypertenSion PRES is also associated with immunosuppressive medications and other medical conditions Treatment of the causative medical condition or withdrawal of the offending medication often results in reversal of the clinical and radiographic abnormalities

DISSEMINATED INFECTION DUE TO AN UNIQUE MYCOBACTERIA IN AN ELDERLY PATIENT

Abstract Dr Myles Horton R2 Neurology University of Manitoba (Winnipeg MB)

Dr Pamela Orr Professor Internal Medicine and Medical Microbiology University of Manitoba (Winnipeg MB)

Many different species of identified mycobacteria have been known to cause various forms of infection in diverse groups of individuals We present a single case of disseminated infection due to a unique unnamed mycobacteria species

A 70-year-old male patient with Type II Diabetes hypertension and a history ofchronic alcohol abuse presented to hospital with progressive muscle weakness fatigue and weight loss over the course of one year He had also developed sensory loss in the distal extremities gait abnormalities resulting in several falls and dysphagia There was no history of travel outside of Southern Manitoba in the previous decade and he denied sick contacts

Physical examination revealed cachexia with diffuse weakness The patient was able to move his limbs against gravity or mild resistance only Perception ofall sensory modalities was lost distally from the mid-humerus and from the mid-femur bilaterally Reflexes were hypoactive in the upper limbs and absent in the lower limbs The remainder of the examination was unremarkable

Electromyography and nerve conduction studies recorded evidence ofa severe generalized sensorimotor axonal neuropathy with a superimposed myopathy Computed tomography scans of the chest and abdomen revealed paraesophageal paraaortic and inguinal lymphadenopathy Subsequent biopsies of inguinal lymph node muscle and nerve tissues as well as sputum analysis revealed positive staining for acid-fast bacilli Microscopic analysis ofall samples revealed mycobacterial infection Further investigations at the National Mycobacterial Laboratory included PCR methodology and gene sequencing on the obtained tissues These techniques revealed that organism was a unique mycobacterial species that had not been previously recorded Extensive investigations for the presence of a paraneoplastic process rheumatologic disease or pathology specific to the immune system were negative After several months in hospital the patient eventually succumbed to his illness despite antimycobacterial therapy A subsequent autopsy revealed additional mycobacterial infiltration of the esophagus spleen and lungs

This case illustrates the potential severity ofnon-tuberculous mycobacterial infections and the diagnostic utility of histopathological examination of biopsy material Clinicians should be aware that nonshytuberculous mycobacterial infection may affect multiple systems within a single patient Although encounters are rare infections with mycobacterial species that have not been previously documented represent exceptional diagnostic and therapeutic challenges

CLUES TO THE PATHOGENESIS OF KIKUCHI-FUJIMOTOS DISEASE IN NONshyTWIN SIBLINGS

Susan Teschke Resident] Allison Stasi uk Medical Studene

Gaynor Williams Associate Professor Don Houston Associate Professor]

Matthew SefieI Assistant Professor] 1 - Department of Intemal Medicine University ofManitoba Winnipeg Manitoba

2 - Department of Pathology University of Manitoba Winnipeg Manitoba

Kikuchis disease also known as KikuchiFujimoto disease (KFD) is a selflimiting benign condition which typically presents with cervical lymphadenopathy fever and leukopenia most commonly in young women The etiology of this syndrome remains unknown although associations have been made with various infections and systemic lupus erythematosus (SLE) Additionally human leukocyte antigens (HLA) associations have been found in non-familial cases (All DRI2) and recently in a single case report offamilial KFD (B35) We report two non-twin sisters with similar presentations of KFD within the space of three years The first a 19 year old woman presented with a three week history of bilateral cervical lymphadenopathy nausea vomiting chills and weight loss A lymph node aspirate was not diagnostic Before excisional biopsy could be performed the lymphadenopathy spontaneously resolved and she has remained healthy since hospital discharge No acute infectious cause was revealed Two years later her younger sister presented at the same age with a one month history of night sweats weight loss anorexia and diffuse lymphadenopathy Excisional biopsy established the diagnosis ofKFD Within one month of presentation she became afebrile and the lymphadenopathy resolved An infectious disease work up was negative Given the amount of time between presentation and the lack of an identifiable environmentalinfectious cause these cases are suspicious for a genetic association To this end HLA typing will be completed to confirm or contrast the only other familial case report

IpOSTER PRESENTATIONS]j

1315 (Clinical Investigation) Early Changes in Serum Creatinine and Vasopressors are Associated with Mortality in Septic Shock Faisal Siddiqui Supervisor A Kumar

1325 (Case Report) Effect of Gluten Free Diet on Osteoporosis in Patient with Celiac Disease Massud Ali Supervisor D Duerksen

1335 (Case Report) Hepatic Portal Venous Gas from Perforated Diverticul1tis Gregory Deans Supervisor G Drobot




K Kasper

1415 (Case Report) Non-Neutropenic Capedtabine-Induced Enterocolitis Vallerie Gordon Supervisor P Czaykowski


1435 (Clinical Investigation) Cardiovascular Morbidity and Mortality and Reamputation Rates Among Persons with Lower Extremity Amputations Due to PeripheraL Vascular Occlusive Disease - A Manitoba Perspective Doug Priestley Supervisor A Arneja

1445-1515 Break

1515 (Clinical Investigation) Prolonged EEG-Video Monitoring in Psychogenic Non-Epileptic Seizures Atheer AI-Kaabi Supervisor Y Aghakani

1525 (Case Report) Two cases of Neurofibromatosls Type I and Medically Intractable Complex Partial Seizures Abdulmuhsen Almulla Supervisor Y Aghakani

1535 (Clinical Investigation) Clinical Utility of Joint Spectrophotometry in Identifying Subclinical Synovitis in Patients Presenting with Arthralgia Daniela Stroescu Supervisor C Hitchon


1555 (Case Report) P-ANCA Positive Vasculitis Manifesting as Crescentic Glomerulonephritis and Pulmonary Hemorrhage Alan Smith Supervisor M Sood


1615 (Case Report) An Unclassified Case of Hisitocytosis Jonathan Gilmore Supervisor Z Bshouty


(Case Report) CoLorectaL Cancer in Pregnancy An Aggressive Malignancy Maria Ho Supervisor P Czaykowski

The Department of Internal Medicine gratefully acknowledges the participation of our guest speaker and judge Dr Ralph Meyer and our local faculty adjudication teams Dr Gary Harding Dr Carol Hitchon Dr Alexandra Ilnyckyj Dr Clare Ramsey Dr leroy Storsley and Dr Kim Wiebe

EARLY CHANGES IN SERUM CREATININE AND VASOPRESSORS ARE ASSOCIATED WITH MORTALITY IN SEPTIC SHOCK

Siddiqui FI Chateau D2 Kumar Al and the CATSS Database Research Group I Division oCritical Care Medicine and1Department oCommunity Health Sciences Faculty 0Medicine University 0Manitoba Winnipeg MB Canada

Objective Mortality prediction in patients with septic shock have relied on clinical and laboratory data taken in the first 24 hours after presentation to the intensive care Wlits (SAPS APACHE II MPM24)

This study attempts to detennine ifearly changes in serum creatinine are associated with outcome to a comparable degree as 24 hr change in pressors and APACHE II Methods Using a database of5410 septic shock cases the change in serum creatinine (septic shock presentation to 3middot9 hours-post) pressors in the (ITst 24 hours and APACHE II were compared in relation to survival to hospital discharge Pressor change was scored as decreased (Group 1 =314 of patients) uncertain (Group 2=311) or increased (Group 3=375) Change in creatinine and APACHE II score was divided into 3 comparably sized groups (low intennediate and high values) Results The average age was 625 years (I 164 SE) APACHE II score of262 (plusmn 84 SE) and admission

s represented below Survival in each group Decreased No Change Increased

24 h pressor change 685 563 216 24 h APACHE II 658 494 229 3-9 hr creatinine change 684 456 260 Correlation to survival for all 3 variables as measured by Chi-squared test was pltOOOI No variable exhibited significant superiority (similar X2 values) and each had independent predictive power Other admission laboratory values (lactate platelet count INR) did not correlate to outcome Conclusion The correlation between early change in serum creatinine and mortality is comparable the correlation with 24 hr pressor change and APACHE II score The 3-9 hr changes in serum creatinine may be useful for early stratification of septic shock mortality risk

EFFECT OF GLUTEN FREE DIET ON OSTEOPOROSIS IN PATIENT WITH CELIAC DISEASE

Massud Ali MD And Donald Duerkesn MD

Abstract

It is well known that the celiac disease (CD) is associated with low bone mineral density (BMD) and osteoporosis The pathogenesis is unclear and potential mechanisms include malabsorption of nutrients including calcium and vitamin D and increased inflammatory mediators causing increased bone resorption

It is also well known that the treatment of celiac disease with gluten free diet (GFD) can improve the bone mineralization density (BMD) but in general the benefit is modest The role of additional treatment of osteoporosis treatment in newly diagnosed patients with celiac disease is unclear In this report we describe a patient with severe malnutrition with a dramatic improvement in BMD with a gluten free diet

A39 year old premenopausal female patient was diagnosed with CD based on a positive endomysial antibody and duodenal biopsy She presented with manifestations of severe malabsorption including weight loss amenorrhea muscle weakness bone pain in lower back and hip region and was found to have low albumin low calcium low iron and increased cholestatic and hepatocellular liver enzymes Because ofher severe malnutrition she required short term hospitalization and treatment with total parentral nutrition A baseline BMD demonstrated a T score of -47 and - 40 in spine and hip respectively In addition to a GFD she was started on calcium supplements She was also started on didrocal approximately 6 months after her BMD Two years later her BMD improved to - 09 T and -14 T in the spines and hip respectively Four years after starting a GFD her BMD was (-10 and -14 T score) of the spine and hip bone respective I y

Previous studies have demonstrated an approximate 7 improvement in BMD in newly diagnosed celiac disease on a GFD In this case we describe a case where the BMD improved 60 on a GFD This patient also received short term bisphosphonate therapy but it is unlikely that this would account for the dramatic improvement in BMD This patient had severe malnutrition and evidence ofmalabsorption and correction of this with a GFD may have resulted in the dramatic improvement in bone density Further studies are needed to determine which patients with celiac disease and low BMD are likely to improve their BMD with a GFD and the role of bisphosphonate therapy in those with osteoporosis

HEPATIC PORTAL VENOUS GAS FROM PERFORATED DIVERTICULITIS Deans GD Drobot GR Department of Internal Medicine University of Manitoba Winnipeg Manitoba

A 48-year-old man was seen in the emergency department after an episode of near syncope He had been unwell for 10 days beginning with chills rigors and intermittent lower abdominal cramps On the third day after symptom onset his stools became loose and his urine became dark in colour Over the next few days he began to experience nausea and vomiting he continued to have occasional episodes of abdominal pain but was more troubled by increasing anorexia and weakness On the day ofpresentation he became pre syncopal during a bowel movement and was brought to the emergency department Apart from a 30 pack-year smoking history and daily ethanol consumption he had no history of medical or surgical illness

On arrival in the emergency department the patient was alert and pain-free but diaphoretic His initial blood pressure of 6040 mmHg improved significantly after resuscitation with crystalloid fluid His body temperature was 376deg C On physical examination he was volume depleted with scleral icterus His abdomen was soft and nontender with no palpable mass Investigations revealed that his leukocyte count was 323 x JQ9 1L alkaline phosphatase 212 UfL gamma-glutamyl transpeptidase 219 UfL and his total and direct bilirubin were 142 and 140 J1mollL respectively Serum lactate was within normal limits He was started on broad-spectrum intravenous antibiotics and sent for imaging of his hepatobiliary tree

His liver was initially visualized with ultrasound which found a large amount of air within the portal venous system On this basis he was sent immediately for computed tomographic (CT) scan of the abdomen The CT showed sigmoid diverticulitis with rupture of a sigmoid diverticulum into a 9 x 8 em abscess anterior to the rectum This gas-filled abscess appeared to be communicating with the inferior mesenteric vein resulting in gas being seen in the inferior mesenteric vein splenic vein main portal vein and intrahepatic portal veins There were no other findings to suggest intestinal ischemia

Emergency laparotomy revealed perforated diverticulitis at the rectosigmoid junction associated with a feculent pelvic abscess The patient underwent an anterior resection with colostomy Blood cultures from his initial presentation grew Escherichia coli The immediate postoperative course was uneventful but he required readmission one month later for a newly-developed hepatic abscess He responded well to a prolonged course of intravenous antibiotics His colostomy was reversed I year later

Hepatic portal venous gas (HPVG) is a rare clinical occurrence that is most commonly associated with intestinal ischemia Complicated diverticulitis has also been reported to cause HPVG and based on a recent review of the literature may be the second most common cause The mechanism of air gaining access to the venous system is not clear but one theory suggests that gas under pressure in the lumen or abscess cavity passes through disrupted mucosa into the mesenteric veins Early surgical intervention is recommended in most cases as the complications leading to HPVG are often life-threatening There are no known sequellae from the HPVG itself once the underlying cause has been treated

A CASE REPORT OF ADULT PRESENTATION OF ANOMALOUS LEFT CORONARY ARTERY ORIGINATING FROM THE PULMONARY ARTERY Thang Nguyen Glen Drobot University of Manitoba

Introduction Bland-White-Garland Syndrome is characterized by an anomalous left coronary artery originating from the pulmonary artery It is a rare congenital anomaly that usually presents in the pediatric population The syndrome may lead to ischemia congestive heart failure or sudden cardiac death

Case Description A 51 year-old male presented to the emergency room with complaints of palpitations and dypsnea He was found to be in atrial fibrillation with a rapid ventricular rate The patient eventually converted to normal sinus rhythm after medications and electrical cardioversion Bloodwork revealed rising troponin T levels deemed out of proportion for atrial fibrillation He was treated as a non-ST -elevation myocardial infarction and a coronary angiogram was arranged

The coronary angiogram revealed an extremely large right coronary artery (RCA) with an extensive collateral system The left main (LM) coronary artery originated from the pUlmonary artery Pulmonary artery (PA) pressures were 48 mmHg 122 mmHg The LM artery demonstrated a 11 1 left to right shunt fraction Echocardiography demonstrated a left ventricular ejection fraction of 50-60 with no regional wall motion abnormalities Extensive subendocardial infarction of the anterior wall of the left ventricle was seen on cardiac magnetic resonance imaging Exercise stress technetium sestamibi exhibited a fixed defect in the anterior wall with a large reversible area of the anterior and lateral wall of the left ventricle

Eventually the patient was discharged after consultations with interventional cardiology and cardiac surgery He was arranged for an elective percutaneous procedure at a larger cardiac centre Unfortunately before the procedure occurred the patient had a cardiac arrest with subsequent anoxic brain injury It was then decided to proceed with a surgical ligation of his LM artery and a bypass graft ofhis left internal mammary artery to his left anterior descending artery Prior to discharge the patient received an implantable cardiac defi bri lIator

Discussion The above case demonstrates a rare occurrence of Bland-White-Garland syndrome that was asymptomatic until the 5th decade It further demonstrates that despite many years of good cardiac function patients are still at risk for sudden cardiac death and require urgent surgical intervention

GESTATIONAL DIABETES IN MANITOBA DURING A TWENTY YEAR PERIOD Naji Aljohani l Brenda M Rempel Sora Ludwi~l2 Margaret Morris l

Kelly McQuillen2

Mary Cheangl Robert Murrayl Garry X Shen University ofManitoba1

and Manitoba Health2 Winnipeg MB Canada

Objective Gestational diabetes mellitus (GDM) is associated with postnatal obesity and type 2 diabetes We conducted a retrospective database study to determine the prevalence ofGDM in the province ofManitoba in the years 1985-2004 and its relationship with advanced age ethnicity rural residence and history ofGDM of pregnant women

Methodology Manitoba Health collected computerized data on 324605 deliveries by 165969 Manitoban women during the time frame Other parameters examined in the present study included maternal age delivery date self-declared First Nation status rural or urban residence and previous history of GDM The data were analyzed using multivariate logistic regression models

Results The prevalence ofGDM during the 20 year period was 292 Statistically significant increases in the prevalence of GDM were detected over the time from 195 in 1985-86 to 372 in 2003-04 (plt001) The trend of increase in the prevalence of GDM in Manitoba sustained after modifications in the diagnostic criteria of GDM in the Canadian Diabetes Association Clinical Practice Guidelines The prevalence of GDM was substantially higher in First Nation women (694) than that in non-First Nation women (236 pltOOl) The prevalence ofGDM was higher in pregnant women living in rural regions (312) compared to those in urban areas (270 pltOOl) The prevalence ofGDM in pregnant women who were 235 years old (592) was greater than those lt35 years of age (260 pltO 01) The prevalence of recurrent GDM in First Nations was 4812 compared to 4239 in non-First Nations pregnant women (plt001) Adjusted odds ratios (95 confidence interval) ofGDM for First Nation status advanced maternal age and previous history of GDM were 220 (200 242) 238 (224 254) and 2509 (2315 2719) The adjusted odds ratio for rural residence was 077 (074 082) but had an interaction of 166 (148 186) when associated with First Nation status

Conclusion The results of the present study indicate that the prevalence of GDM increased in Manitoba during the 20 year time frame First Nation status advanced maternal age and a history of GDM are independent risk factors for GDM in Manitoba Further research to determine the cause and consequence of the increase in prevalence of GDM is required (Supported by Canadian Institutes of Health Research and The Lawson Foundation)

OBSERVATIONS ON INTERNAL MEDICINE CONSULTS GENERA TED IN THE EMERGENCY DEPARTMENT

Presenting Stephen Goulet MD Supervisors J Horton MD and K Kasper MD Department oflnternal Medicine University of Manitoba Winnipeg Manitoba

Objectives To examine the consults generated in the emergency department and answered by the internal medicine service The goal of the data collection is to characterise the type of consults according to reasons for referral time of the consult what service generated the consult and the disposition of the patients for whom the consults are generated Methods Over a period of three months in 2007 July to September internal medicine residents were asked to keep a log of consults generated in the emergency department and answered by the internal medicine service at the Health Sciences Centre (HSC) and Saint Boniface General Hospital (SBGH) two tertiary care facilities This log included the following characteristics about the consults time of consult generation time to seeing consult service generating the consult the reason for referral and whether the consult resulted in admission to a clinical teaching unit (CTU) under internal medicine A subjective scale was used to judge the appropriateness of the consult by the internal medicine resident answering the consult The consult was judged on a numbered scale between 0 and 5 for appropriateness least to most appropriate respectively Results Over a period three months a total of 1175 consults were generated 712 at HSC and 463 at SBGH This resulted in an average number consults of 85 per day and 6 per day at HSC and SBGH respectively The percentage of those consults that ultimately resulted in admission to a CTU was 743 at HSC and 773 at SBGH It was observed that 74 and 81 of consults seen by residents were judged to have an appropriateness rating of 4 or greater at HSC and SBGH respectively Also observed was a linear relationship between the rating of the appropriateness of a consult and the percentage of those admitted to a CTU Of those consults with a rating of 0 or 1 lt 12 were admitted to a CTU while about 95 of those with a rating of 5 were admitted to a CTU Thus the higher the appropriateness rating the higher percentage of consults in that category that resulted in admission to a CTU It was observed that only 30 and 406 of consults generated from the emergency departments at HSC and SBGH respectively were generated between the regular working hours of 830 am to 500 pm with higher proportions tending to occur bewteen 700 pm and midnight A wide variety of reasons for referral were seen at both sites with some differences in the proportion of certain types bewteen the two hospitals The largest difference was in the amount of consults generated for ACS 73 vs 19 of all consults at HSC and SBGH respectively However a higher percentage of consults regarding CHF were seen at SBGH (86 of all consults) vs HSC (42) Conclusions Over a three month period consults generated in the emergency departments at two tertiary care teaching hospitals HSC and SBGH and answered by residents on the internal medicine service it was observed that while the majority of the were judged to be appropriate consults the majority of these consults were generated outside of regular working hours of the hospitals when many of the usual supports allied health interventions and diagnostic modalities are not available

NON-NEUTROPENIC CAPECITABINE-INDUCED ENTEROCOLITIS Vall erie Gordon Gary Harding Piotr Czaykowski University ofManitoba Winnipeg Manitoba

Enterocolitis is an infrequent but potentially serious complication reported with the use of the chemotherapy agent fluorouracil amongst others Very few cases are reported in the literature in association with the use oforal fluorouracil pro-drugs (eg capecitabine) Reported cases are seen in the setting ofneutropenia or more rarely in association with Clostridium difficile induced pseudomembranous colitis We report on two cases ofnonshyneutropenic enterocolitis associated with capecitabine therapy and one case oftransient neutropenia associated enterocolitis

TRICKED BY TRICHINOSIS Mike Sochocki MD John M Emhil MD FRCPC FACP (Associate)

1 Faculty of Medicine University of Manitoba Winnipeg Manitoba Canada 2 Department of Medicine University of Manitoba Winnipeg Manitoba Canada

Trichinosis is enzootic in arctic and sub-arctic regions of North America Infected polar bear and walrus meat have been the most frequent sources of human trichonosis in the Canadian Arctic A 40-year-old previously healthy Inuit male presented with an 8-day history of generalized weakness dyspnea malaise nausea vomiting watery diarrhea associated with abdominal cramping and passage of mucous calf and thigh pain

Physical examination revealed an otherwise well looking man in moderate distress Vital signs oral temperature 365C heart rate 68 beatsminute respiratory rate 24 breathsminute lying blood pressure 119170 mmHg without a postural drop or postural tachycardia The abdomen was diffusely tender however the rest of the examination was unremarkable Initial laboratory investigations revealed white blood cell count 137 x lOJIL hemoglobin 162 gIL platelets of 465 x I091L Serum chemistry revealed potassium 29 mmollL creatinine 80 umollL creatinine kinase (CPK) was not initially measured but 3 days after presentation measured 939 lUlL (normal 55-170)

A diagnosis of rhabdomyolysis was considered the differential diagnosis included myocardial ischemia trauma seizures or illicit drug use but these were all excluded by history physical and investigations Upon further questioning the patient noted that a walrus had been killed in his community and that he had eaten some of the meat raw approximately 10 days prior to presentation Presumptive diagnosis was entertained and the patient was subsequently evacuated from his home community to a tertiary care centre for management of the rhabdomyolysis Over the ensuing 2 weeks 12 additional persons from the same community presented to medical attention with nausea vomiting myalgia and were found to have elevated CPK values All 12 persons had consumed meat from the same walrus as our patient Microscopy of some of the uneaten walrus meat was examined revealing forms compatible with Trichinella spp cysts The trichinella serology from our patient at the time of admission yielded a titre of high positive with a reading ofgt 120 od

Walrus is the most important source of human trichonosis in the arctic of the western hemisphere Human infection occurs by ingestion of raw or suboptimally cooked meat although trichinella prevention programs exist in Northern Canada Unfortunately trichonosis remains a significant health concern due to difficulty in controlling the etiologic agent as diverse popUlations of infected wild carnivores are common food sources Although trichinosis is infrequently considered in the differential diagnosis of rhabdomyoJysis this entity must be considered in the correct epidemiologic setting so that the caregivers are not tricked by trichinosis and so therapy may be instituted promptly The patient received mebendazole an oral prednisone with a prompt resolution ofsymptoms

Cardiovascular Morbidity and Mortality and Reamputation Rates Among Persons with Lower Extremity Amputations Due to Peripheral Vascular Occlusive Disease - A Manitoba Perspective D Priestley A Arneja University of Manitoba Winnipeg Manitoba Department ofPhysical Medicine and Rehabilitation

Background The primary cause oflower extremity amputation is peripheral vascular occlusive disease (PVOD) accounting for up to 80 in some studies Known independent risk factors for PVOD are smoking diabetes HTN hyperlipidemia and hyperhomocysteinemia Prior US studies have shown that up to 26 of individuals undergoing LE amputations require subsequent amputations within 12 months and up to 33 die within I year of their index amputation despite appropriate management of risk factors To date there are no Canadian studies looking at reamputation or cardiavascular complication rates or the difference between the aboriginal and non-aboriginal populations in complication rates Methods In this retrospective study we looked at the number of reamputation andlor cardiovascular complications in LE amputees over a five-year period (January 2001 to January 2006) for those admitted to our amputee rehabilitation unit (and followed in our outpatient clinic for management of risk factors and prosthesis fit) at Health Science Center in Winnipeg Manitoba We excluded LE amputation secondary to trauma malignancy or vascularl rheumatologic cause Results Of the 204 patients admitted through our unit 185 met exclusion criteria 79 (427) had complications (40 revisionsl reamputations and 39 cardiovascular complications ~ including 27 deaths) with an average duration to complication of 176 months Our I-year complication rate was 103 revisions reamputations and 65 deaths The aboriginal population had a slightly higher reamputation revision rate (118) but a lower death rate (39) compared to the non~aboriginal population (98 and 75) They also tended to be younger at first amputation (606 +~ 115 yrs compared to 665 +~ 126 years pltOO I) In the aboriginal population the greatest risk factors were diabetes (961) HTN (882) prior smoking (49) then hyperlipidemia (373) In the non-aboriginal population the risk factors were HTN (842) diabetes (782) hyperlipidemia (504) then prior smoking (466) Homocysteine was not being routinely measured throughout the study period so its importance could not be determined Conclusions This study showed for the first time the prevalence ofcomplications in Manitoban LE amputees secondary to PVOD We demonstrated lower I-year complication rates compared to the published data We also saw a difference in complication rates between the aboriginal and non-aboriginal popUlation specifically between revision reamputation rates and death rates Further studies are needed to identify risk factors which if more stringently controlled in the outpatient setting may improve our complication rates in LE amputees secondary to PVOD Funding for this project was by the War Amps of Canada

PROLONGED EEG-V1DEO MONITORING IN PSYCHOGENIC NON-EPILEPTIC SEIZURES Atheer AI-Kaabi Nagib Yahmad Alexie Yankovsky Yahya Aghakhani University of Manitoba Winnipeg Manitoba

Introduction Psychogenic non-epileptic seizures (PNES) are often misdiagnosed as epileptic seizures if routine interictal electroencephalography (EEG) shows epileptiform abnormalities We conducted this study to investigate the frequency of interictal EEG abnormalities seen during prolonged EEG-video monitoring in patients with PNES

Methods We reviewed a retrospective case series of patients with PNES admitted for prolonged EEGshyVideo monitoring at the University of Manitoba between April 2004 and July 2007 Twenty-three patients were included in the study We included patients who had at least one clinical event atypical for an epileptic seizure and not associated with any ictal epileptifonn discharge on EEG Dictated EEG reports were reviewed for the presence and location of any interictal EEG abnormalities during the admission

Results Five patients were thought to have both PNES and epileptic seizures Of the 18 patients with only PNES 22 had normal interictal EEGs 11 had only non-specific slowing and 67 had epileptiform abnormalities The most common locations of the epileptiform abnormalities in descending order were bilateral temporal independently followed by right or left temporal frontal and multifocal

Conclusion One previous study found interictal epileptiform EEG abnormalities in 123 of PNES patients We found a higher percentage at 67 This may be explained by selection bias as our patients were admitted after an extensive outpatient workup Our study emphasizes the importance of interpreting interictal EEGs only in the context of a thorough clinical assessment in patients with suspected PNES The gold standard remains the ictal EEG-video assessment

Two cases of Neurofibromatosis type I and medically intractable complex partial seizures Abdulmuhsen Almulla Owen Williams Alexei E Yankovsky Yahya Aghakhani

Background Neurofibromatosis type I (Nfl) is a neurocutaneous disorder associated on occasion with epilepsy We report two patients with complex partial seizures (CPS) and NFl one of whom also has Moya-Moya disease

Method A review ofour epilepsy database at University of Manitoba revealed two patients with NFl and medically intractable CPS

Result Patient 1 was a 26-year-old right-handed male with history of seizures since age 7 Presurgical assessment suggested the seizures originated in the left atrophic mesial temporal structures Interestingly the patient was found to have asymptomatic Moya-Moya disease during W ADA test He underwent a left selective amygdaloshyhippocampectomy (SAH) with seizure freedom at three-month follow-up

Patient 2 was a 25-year-old right-handed male with history of seizure onset at age 12 His presurgical assessment including Stereo-EEG revealed his habitual clinical seizures originated from MRI negative right mesial temporal structures However several pure electrographic seizures were recorded from the contralateral temporal lobe A right SAH was preformed which has led to a significant seizure reduction at four-month follow-up

Conclusion Epilepsy surgery could be considered as a therapeutic option in patients with NFl and intractable CPS A longer follow-up period to demonstrate durability and additional similar cases are needed to draw firm conclusions

Clinical Utility of Joint Spectrophotometry in Identifying Subclinical Synovitis in Patients Presenting with Arthralgia

Daniela Stroescu Rl Carol Hitchon MD

Objective A proportion of patients with recent onset arthralgia might also have subclinical synovitis at presentation Some patients will not develop inflammatory arthritis and others will present with clinical evidence of inflammatory arthritis at subsequent visits We sought to identify a method that will recognize the subclinical inflammation in patients presenting with arthralgia

Methods Subjects with arthralgia only and subjects with active synovitis were examined using spectrophotometry of the synovial fluid These were matched with healthy controls Clinical features including rheumatoid factor disease activity (DAS3CRP) diagnoses and also lab parameters that would influence the 02 concentration in the blood and synovial fluid respectively (HGB and Cr) were recorded First three MCPs and wrist examined at each hand

Results Out of 280 joint measurements (done on 160 joints) 200 were asymptomatic (715) 14 had arthralgia only (5) 21 were swollen (75) and 45 both swollen and tender (16) Qualitative assessment of synovial spectra reveled difference in spectra of swollen joints compared to inactive jOints clinically from either healthy subjects or patients in clinical remission

Conclusions A significant proportion of patients presenting with arthralgia will develop detectable synovitis Spectrophotometry of the jOints may be a useful investigational tool to identify patients with subclinical synovitis when presented with arthralgia only

ACUTE KIDENY INJURY IN PATIENTS RECEIVING SUBCUTANEOUS DEFEROXAMINE THERAPY

Ponnampaiam AI HOllston DS I 2bull

University of Manitoba Dept oflntemal Medicine Winnipeg MB 2University of Manitoba Dept ofHematology Winnipeg MB

Iron chelation is an important modality in treating patients with iron overload syndromes to minimize end organ damage Deferoxamine is a clinically approved and effective therapy for long term chelation but the standard protocol (12 hour subcutaneous infusion) is cumbersome for patients Twice daily subcutaneous bolus injection ofdeferoxamine has been reported to result in equivalent iron excretion and facilitates adherence An orally active chelator deferasirox has recently become available but nephrotoxicity is common with deferasirox raising serious concerns about long-term use Acute kidney injury has been described previously in patients receiving accidental overdoses of intravenous deferoxamine but not in patients receiving subcutaneous therapy We describe a case series of three patients who developed acute elevations in creatinine temporally related to bid subcutaneous bolus deferoxamine All of the patients were elderly and had mildly compromised baseline renal function (one had a kidney transplant and was on cyclosporine another had undergone a nephrectomy for renal cell carcinoma) Two of the three patients had resolution of their renal injury on discontinuation of therapy and the third had progressive decline in renal function on continued treatment Conclusion Renal toxicity appears to be a side effect ofdeferoxamine chelation which may be more prevalent ifboJus dosing is used Toxicity appears to be reversible on discontinuation of therapy Careful monitoring of serial creatinine values and minimizing other nephrotoxic agents is appropriate and prudent when managing iron overload syndromes with deferoxamine chelation therapy

Dr Alan Smith Dr Manish Sood (Nephrology SBGH)

Abstract Background We report a 27 year-old female with perinuclearshyantineutrophil cytoplasmic antibody (P ANCA)-positive vasculitis manifesting as crescentic glomerulonephritis and pulmonary hemorrhage Case and Methods The patient was a previously healthy non-smoker who presented with weakness fatigue fevers cough and hemoptysis Her creatinine was elevated and she had an active urinalysis with blood and protein She was treated with pulse then oral steroids with ongoing pulmonary hemorrhage and abnormal renal function Despite her young age and wishes for future children cyclophosphamide was started to induce a disease remission Her treatment was complicated by a deep vein thrombosis of the left lower extremity and overwhelming sepsis on cyclophosphamide Results P-ANCA was positive and she had a high level of anti-myeloperoxidase antibodies (MPO) while anti glomerular basement membrane (GBM) antibodies were negative Renal biopsy showed focal segment necrotizing glomerulonephritis with crescent formations however no glomeruli were available for immunofluorescence Conclusion This case provides an interesting description of many of the complications associated with vasculitis and the necessary considerations when beginning therapy

LIVER ENZYME ABNORMALITIES SECONDARY TO COMBINATION THERAPY WITH BOSENTAN AND ATORV ASTATIN

Kimberley D Mulchey Internal Medicine Resident University of Manitoba Winnipeg MB Supervisor Dr Z Bshouty Respirologist University of Manitoba Winnipeg MB

Hepatocellular enzyme elevation is a known side effect of both Bosentan an endothelin receptor antagonist used in the treatment of pulmonary arterial hypertension (PAH) and Atorvastatin an antilipemic agent An enzyme rise higher than may be expected with either agent individually may represent a reaction to the combination of the 2 medications that has not previously been reported

A 71yearold female presented to the Emergency Department complaining ofchest pain and shortness of breath Clinical diagnoses of atrial fibrillation and congestive heart failure were made A coronary angiogram ruled out significant coronary artery disease Echocardiogram showed an enlarged right ventricle (RY) and an RY systolic pressure of65 mm Hg Further investigation revealed the etiology of her PAH to be chronic thromboembolic disease Initial pulmonary function tests showed a restrictive pattern with a normal diffusing capacity Six minute walk testing revealed mildly reduced performance Right heart catheterization was consistent with moderate to severe PAH Baseline liver enzyme testing revealed very mild elevation in alanine aminotransferase and alkaline phosphatase The patient was currently being treated with Atorvastatin at a dose of 80 mg daily Treatment for her PAH was initiated with Bosentan at a dose of625 mg twice daily Liver enzymes were followed closely and remained at their baseline values or lower for 6 weeks at which time the Bosentan dose was increased to the usual maintenance dose of 125 mg twice daily The patient had a significant improvement in her exercise performance after starting on Bosentan Liver enzymes were first noted to be elevated 8 weeks later but were only 2 to 3 times the upper limit of normal Unfortunately six weeks later the patient presented with jaundice and a lOmiddotday history of malaise and profuse vomiting Laboratory investigations revealed a substantial elevation in her bilirubin and hepatocellular liver enzymes of approximately 15 times the upper limit of normal Bosentan and Atorvastatin were immediately discontinued and over the following 4 weeks the patients liver enzymes fell and her symptoms improved

This patient had demonstrated tolerance for Atorvastatin before the initiation of Bosentan and initially tolerated combination therapy at the lower dose of Bosentan (625 mg twice daily) Although she tolerated the Bosentan maintenance dose of 125 mg twice daily for more than 3 months she had a sudden and dramatic rise in her liver enzymes necessitating discontinuation of both drugs This enzyme rise represents a later and more severe rise than usually seen with Bosentan alone illustrating the need for diligent and frequent monitoring of patients taking endothelin receptor antagonists especially in combination with other hepatotoxic drugs

AN UNCLASSIFIED CASE OF HISTIOCYTOSIS Jonathan Gilmore (BSc MSc) Z Bshouty (MD PHD) University ofManitoba Winnipeg Manitoba

Pulmonary histiocytosis X (PHX) or pulmonary Langerhans cell histiocytosis X (PLCH) is an uncommon interstitial lung disease that is epidemiologically related to tobacco smoking

61 yr female with hypothyroidism presents with hlo Tcough Patient also gave a history for fatigue night sweats and had lost about 5kg in 6 months Laboratory and Physical exam was unremarkable as chest exam showed good air entry with no added sounds Cardiovascular exam was unremarkable There was no palpable lymphadenopathy Abdominal exam showed no tenderness no masses and no hepatosplenomegaly computed axial tomographic scan (CTscan) chest showed numerous pulmonary nodules with hilar adenopathy CT abdomen showed extensive intra-abdominal lymphadenopathy Wedge resection of the lung was sent for pathology

Treatment was initiated that consisted of high dose Corticosteriods to which the patient rapidly responded

Pathological Diagnosis lung nodules showing mixed Iympho and histiocytic proliferation with associated inflammation of uncertain histogenesis pale cells reminiscent of langerhans cells

Corticosteroids may be considered in patients with a persistence of clinically significant pulmonary or constitutional symptoms or those with documented progression ofdisease





1315 (Clinical Investigation) The Effectiveness of the CancerCare Manitoba (CCMB) Anticoagulation CLinic (ACe) Vi Dao Supervisors D Szwajcer

D Houston


1335 (Clinical Investigation) Cholangitis Associated Septic Shock RoLe of Rapidity of Antimicrobial Therapy and Source Control Brendan McCarthy Supervisor A Kumar




1415 (ClinicaL Investigation) Clinical Utility of Tissue Doppler Imaging in Patients with Acute MyocardiaL Infarction Complicated by Cardiogenic Shock Adnan Hameed Supervisor D Jassal

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