Search

Good Clinical Judgment (GCJ) is associated with clinical excellence and accolades whereas poor clinical judgment is often associated with suboptimal care and the need for remediation. Although commonly referenced in practice, a shared definition for GCJ based on primary data is lacking. We interviewed 16 clinicians and surgeons across different specialties at one Canadian academic center to understand their conceptualization of GCJ. The data analysis led to the formulation of three pillars that were viewed by participants as core ingredients of GCJ. These included (1) a strong baseline knowledge and breadth of clinical experience, (2) the demonstration of curiosity, reflection, and wisdom, and (3) an ability to attend to contextual factors and understand the “bigger picture” when providing care to patients. Although there were inconsistent opinions regarding whether GCJ is innate or learned, participants reflected on strategies to support the development or improvement in clinical judgement for trainees.

Supplementary Figure 1 from The MET Receptor Tyrosine Kinase Is a Potential Novel Therapeutic Target for Head and Neck Squamous Cell Carcinoma

Supplementary Figure Legends 1-2, Table Legend 1 from The MET Receptor Tyrosine Kinase Is a Potential Novel Therapeutic Target for Head and Neck Squamous Cell Carcinoma

Recurrent/metastatic head and neck cancer remains a devastating disease with insufficient treatment options. We investigated the MET receptor tyrosine kinase as a novel target for the treatment of head and neck squamous cell carcinoma (HNSCC). MET/phosphorylated MET and HGF expression was analyzed in 121 tissues (HNSCC/normal) by immunohistochemistry, and in 20 HNSCC cell lines by immunoblotting. The effects of MET inhibition using small interfering RNA/two small-molecule inhibitors (SU11274/PF-2341066) on signaling, migration, viability, and angiogenesis were determined. The complete MET gene was sequenced in 66 head and neck cancer tissue samples and eight cell lines. MET gene copy number was determined in 14 cell lines and 23 tumor tissues. Drug combinations of SU11274 with cisplatin or erlotinib were tested in SCC35/HN5 cell lines. Eighty-four percent of the HNSCC samples showed MET overexpression, whereas 18 of 20 HNSCC cell lines (90%) expressed MET. HGF overexpression was present in 45% of HNSCC. MET inhibition with SU11274/PF-2341066 abrogated MET signaling, cell viability, motility/migration in vitro, and tumor angiogenesis in vivo. Mutational analysis of 66 tumor tissues and 8 cell lines identified novel mutations in the semaphorin (T230M/E168D/N375S), juxtamembrane (T1010I/R988C), and tyrosine kinase (T1275I/V1333I) domains (incidence: 13.5%). Increased MET gene copy number was present with >10 copies in 3 of 23 (13%) tumor tissues. A greater-than-additive inhibition of cell growth was observed when combining a MET inhibitor with cisplatin or erlotinib and synergy may be mediated via erbB3/AKT signaling. MET is functionally important in HNSCC with prominent overexpression, increased gene copy number, and mutations. MET inhibition abrogated MET functions, including proliferation, migration/motility, and angiogenesis. MET is a promising, novel target for HNSCC and combination approaches with cisplatin or EGFR inhibitors should be explored. [Cancer Res 2009;69(7):3021–31]

Supplementary Table 1 from The MET Receptor Tyrosine Kinase Is a Potential Novel Therapeutic Target for Head and Neck Squamous Cell Carcinoma

Background Trainees in acute care specialties often grapple with the decision to perform an invasive procedure in a rapidly decompensating patient, for whom the benefits and risks are inherently uncertain. The difference between trainees who know when to act and when to seek supervision and those who do not is often linked to individual trainee psychological and cultural perceptions of uncertainty. But how much comfort with uncertainty relates to the situational context rather than the trainee traits is underexplored. Objective The objective of this study was to explore trainee actions around decompensating patients and assess the degree to which invasive intervention and supervision seeking depend on situational certainty or individual trait-based perceptions of uncertainty. Methods A total of 41 internal medicine residents completed a survey to measure anxiety related to uncertainty using the Physicians’ Reactions to Uncertainty (PRU) tool and to measure uncertainty avoidance using the Values Survey Module (VSM) before responding to 14 written emergency situations. Half of the scenarios contain sufficient diagnostic certainty to warrant aggressive intervention, and half lack sufficient diagnostic clarity to offset the risk of intervention. Mixed multivariable modeling was used to identify the relationship between planned invasive intervention, situational uncertainty, and trait-based perceptions of uncertainty measured in the PRU and VSM. Results Trainees’ first actions were appropriate in 60% of cases. Multivariable modeling suggested that situational certainty was more predictive of upfront intervention (odds ratio [OR], 30.5; P

BACKGROUND The incidence of opioid-related fatality has reached unparalleled levels across North America. Patients with comorbid hepatitis C virus (HCV) remain the most vulnerable and difficult to treat. Considering the unique challenges associated with this population, we aimed to re-examine the impact of HCV on response to medication assistant treatment for opioid use disorder and establish sex-specific risk factors affecting care. METHODS This study employs a multi-center prospective cohort design, with 1-year follow-up. Patients aged ≥18, receiving methadone for opioid use disorder were recruited from a network of out-patient opioid addiction treatment centers across Southern Ontario, Canada. Patients with ≥50% positive opioid urine screens over 1 year of follow-up were classified as poor responders. The prognostic impact of HCV on response was established using a propensity score matched analysis. Sex-specific regression models were constructed to evaluate risk factors for treatment response. RESULTS Among participants eligible for inclusion (n = 1234), HCV was prevalent in 25% (n = 307). HCV patients exhibited significantly higher rates of high-risk opioid consumption patterns 35.29% (standard deviation 0.478). Sex-specific examination revealed females with HCV incur a 2 times increased risk for high-risk opioid consumption behaviors (female odds ratio: 1.95, 95% confidence interval 1.23, 3.10; P = 0.01). CONCLUSIONS Findings from this study establish the link between HCV and poor treatment response, with differentially higher risk among female patients. In light of the high potential for overdose among this population, concerted efforts are required for distinguishing the source for sex-based disparities, in addition to establishing trauma and gender informed treatment protocols.

Surgical therapies for symptomatic bladder outlet obstruction (BOO) due to benign prostatic hyperplasia (BPH) are many, and vary from minimally invasive office based to high-cost operative approaches. This Guideline presents effective evidence-based surgical management of male lower urinary tract symptoms secondary/attributed to BPH (LUTS/BPH). See accompanying algorithm for a detailed summary of procedures (figure[Figure: see text]).The Minnesota Evidence Review Team searched Ovid MEDLINE, Embase, Cochrane Library, and AHRQ databases to identify eligible studies published between January 2007 and September 2020, which includes the initial publication (2018) and amendments (2019, 2020). The Team also reviewed articles identified by Guideline Panel Members. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, information is provided as Clinical Principles and Expert Opinions (table[Table: see text]).Twenty-four guideline statements pertinent to pre-operative and surgical management were developed. Appropriate levels of evidence and supporting text were created to direct urologic providers towards suitable and safe operative interventions for individual patient characteristics. A re-treatment section was created to direct attention to longevity and outcomes with individual approaches to help guide patient counselling and therapeutic decisions.Pre-operative and surgical management of BPH requires attention to individual patient characteristics and procedural risk. Clinicians should adhere to recommendations and familiarize themselves with criteria that yields the highest likelihood of surgical success when choosing a particular approach for a particular patient.

Competency-based medical education (CBME) led to the widespread adoption of workplace-based assessment (WBA) with the promise of achieving assessment for learning. Despite this, studies have illustrated tensions between the summative and formative role of WBA which undermine learning goals. Models of workplace-based learning (WBL) provide insight, however, these models excluded WBA. This scoping review synthesizes the primary literature addressing the role of WBA to guide learning in postgraduate medical education, with the goal of identifying gaps to address in future studies.The search was applied to OVID Medline, Web of Science, ERIC and CINAHL databases, articles up to September 2020 were included. Titles and abstracts were screened by two reviewers, followed by a full text review. Two members independently extracted and analysed quantitative and qualitative data using a descriptive-analytic technique rooted in Billett's four premises of WBL. Themes were synthesized and discussed until consensus.All 33 papers focused on the perception of learning through WBA. The majority applied qualitative methodology (70%), and 12 studies (36%) made explicit reference to theory. Aligning with Billett's first premise, results reinforce that learning always occurs in the workplace. WBA helped guide learning goals and enhanced feedback frequency and specificity. Billett's remaining premises provided an important lens to understand how tensions that existed in WBL have been exacerbated with frequent WBA. As individuals engage in both work and WBA, they are slowly transforming the workplace. Culture and context frame individual experiences and the perceived authenticity of WBA. Finally, individuals will have different goals, and learn different things, from the same experience.Analysing WBA literature through the lens of WBL theory allows us to reframe previously described tensions. We propose that future studies attend to learning theory, and demonstrate alignment with philosophical position, to advance our understanding of assessment-for-learning in the workplace.

The 2019 CSIM national meeting included a workshop focused on current topics related to medical education across Canada. The workshop topics included leadership in education, teaching point of care ultrasound, teaching clinical reasoning, and using competency based medical education to design a maintenance of competency program for practicing specialists. This article reflects the experience and discussions from the session, with the goal of stimulating national conversations and collaborations betweenCSIM members.

Takotsubo syndrome is a well described clinical phenomenon that often mimics acute coronary syndrome. We present an atypical case of Takotsubo syndrome, characterized by delayed troponin elevation and electrocardiogram changes suggestive of acute coronary syndrome, but a normal coronary angiogram. We describe the integration of cardiac magnetic resonance imaging to identify syndrome overlap, and discuss the utilization of diagnostic modalities beyond coronary angiogram if clinical equipoise exists, including B-type natriuretic peptide/troponin ratio, intravascular coronary imaging, and cardiac magnetic resonance imaging.

Catastrophic antiphospholipid syndrome (CAPS) involves sudden multiorgan dysfunction from thrombosis due to antibodies that cause platelet activation and endothelial dysfunction. Treatment variably combines anticoagulation, corticosteroid use, therapeutic plasma exchange (TPE), and high-dose intravenous immunoglobulin (IVIG). A 42-year-old male with antiphospholipid syndrome (APS) presented with severe thrombocytopenia, encephalopathy, cardiac ischemia, and acral purpuric cutaneous lesions. CAPS was identified and he received heparin infusion, methylprednisolone, and IVIG. On day 7 he developed new purpuric lesions on his right foot despite detectable arterial pulses representing new microthrombosis refractory to IVIG. He was treated with TPE which resolved the right foot ischemia and eventually his CAPS. To our knowledge, this is the first patient with CAPS reported that failed initial treatment with IVIG and subsequently had excellent response to TPE. Our observations also support recent literature indicating that onset of thrombocytopenia in APS is a warning of progression to CAPS requiring treatment escalation.

Despite the massive volume of scientific evidence on the benefits of immunisation, vaccine hesitancy is still a global health threat and represents an obstacle to controlling the spread of viruses such as SARS-CoV-2 and its associated COVID-19. Thus, the present study aimed to adapt and validate an Italian version of the Vaccination Attitudes Examination (VAX) scale. The Italian version of the scale (VAX-I), along with validation measures (general health perceptions, perceived sensitivity to medicines, intention to get the flu vaccine, and trust in health authorities) were administered to a sample of 534 Italian participants aged 18 to 87 (M = 32.41, SD = 15.35). The original version of the VAX scale was translated into Italian using a back-translation method. The parallel and confirmatory factor analyses showed that the scale’s four-factor structure fits the data well, as in the original version. Reliability coefficients indicated that the VAX-I scale showed good internal consistency and measurement invariance results demonstrated that the VAX-I scale is stable across gender. Construct validity was supported by the significant negative correlation with general health perceptions, intentions to get the flu vaccine, and trust in health authorities, and the weak but significant and positive correlation with perceived sensitivity to medicines. Overall, the VAX-I scale appears to be a valid instrument to assess vaccine hesitancy in the Italian context.

Over the past 50 years, the CTU has remained a core part of training for residents within internal medicine training programs. At the same time, the needs of society have changed significantly over the years, and current training needs to reflect this change. This is not a novel idea, but one that we feel requires greater attention to adequately address the needs of academic teaching hospitals across the country. ResumeAu cours des 50 dernières années, la CTU est restée un élément essentiel de la formation des résidents dans le cadre des programmes de formation en médecine interne. Dans le même temps, les besoins de la société ont considérablement évolué au fil des ans, et la formation actuelle doit refléter ce changement. Il ne s’agit pas d’une idée nouvelle, mais d’une idée qui, selon nous, nécessite une plus grande attention afin de répondre adéquatement aux besoins des hôpitaux universitaires d’enseignement à travers le pays.

Opioid substitution therapy is a life-saving, first-line treatment for patients with opioid use disorder. It is a key intervention to prevent further mortality and morbidity during the opioid crisis that is claiming lives across Canada. Traditionally, patients must be experiencing at least m

Benign prostatic hyperplasia (BPH) is a histologic diagnosis describing proliferation of smooth muscle and epithelial cells within the prostatic transition zone. The prevalence and severity of lower urinary tract symptoms (LUTS) in aging men are progressive and impact the health and welfare of society. This revised Guideline provides a useful reference on effective evidence-based management of male LUTS/BPH. See the accompanying algorithm for a summary of the procedures detailed in the Guideline (figures 1 and 2[Figure: see text][Figure: see text]).The Minnesota Evidence Review Team searched Ovid MEDLINE, Embase, Cochrane Library, and AHRQ databases to identify eligible English language studies published between January 2008 and April 2019, then updated through December 2020. Search terms included Medical Subject Headings (MeSH) and keywords for pharmacological therapies, drug classes, and terms related to LUTS or BPH. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, information is provided as Clinical Principles and Expert Opinions (table 1[Table: see text]).Nineteen guideline statements pertinent to evaluation, work-up, and medical management were developed. Appropriate levels of evidence and supporting text were created to direct both primary care and urologic providers towards streamlined and suitable practices.The work up and medical management of BPH requires attention to individual patient characteristics, while also respecting common principles. Clinicians should adhere to recommendations and familiarize themselves with standards of BPH management.

Housing is often described in the media as a problem to be solved, especially when housing is seen as targeted toward households in poverty. A class bias in the portrayal of housing policy makes housing people who have trouble affording rent a problem and discourages government involvement in the housing market. This problematizing of government work to assist people in poverty undermines public support for subsidized housing policies and discourages attention to the ways that middle- and upper-class households also benefit from housing policy.

Hospitals are a critical touchpoint for people who use drugs (PWUD). However, hospital policies, both formal and informal, can have a detrimental impact on PWUD in acute care settings. Introducing new policies, or revising existing policies that inadvertently harm or stigmatize PWUD while hospitalized, could be an effective harm reduction intervention for this high-risk population. This paper explores seven areas where institutional policy change could improve the hospital experience of PWUD: (1) use of nonprescribed substances in hospital, (2) supporting inpatient addiction consultation services (3) in-hospital supervised consumption spaces (4) supply and distribution of safe drug use equipment and naloxone, (5) role of security services and personal searches, (6) use of hospital restrictions, and (7) involvement of PWUD in policy development.

Introduction Infective endocarditis (IE) is a severe and highly prevalent infection among people who inject drugs (PWID). While short-term (30-day) outcomes are similar between PWID and non-PWID, the long-term outcomes among PWID after IE are poor, with 1-year mortality rates in excess of 25%. Novel clinical interventions are needed to address the unique needs of PWID with IE, including increasing access to substance use treatment and addressing structural barriers and social determinants of health. Methods and analysis PWID with IE will be connected to a multidisciplinary team that will transition with them from hospital to the community. The six components of the Second Heart Team are: (1) peer support worker with lived experience, (2) systems navigator, (3) addiction medicine physician, (4) primary care physician, (5) infectious diseases specialist, (6) cardiovascular surgeon. A convergent mixed-methods study design will be used to test the feasibility of this intervention. We will concurrently collect quantitative and qualitative data and ‘mix’ at the interpretation stage of the study to answer our research questions. Ethics and dissemination This study has been approved by the Hamilton Integrated Research Ethics Board (Project No. 7012). Results will be presented at national and international conferences and submitted for publication in a scientific journal. Clinical trail registrarion Trial registration number: ISRCTN14968657 https://www.isrctn.com/ISRCTN14968657.

Context Assessment for and of learning in workplace settings is at the heart of competency-based medical education. In postgraduate medical education (PGME), entrustable professional activities (EPAs) and entrustment scales are increasingly used to assess competence. However, the educational impacts of these assessment approaches remain unknown. Therefore, this study aimed to explore trainee perceptions regarding the impacts of EPAs and entrustment scales on feedback and learning processes in the clinical setting. Methods Four focus groups were conducted with postgraduate trainees in anaesthesia, emergency medicine, general internal medicine and nephrology at McMaster University in Hamilton, Ontario, Canada. Data collection and analysis were informed by principles of constructivist grounded theory. Results Entrustable professional activities representing well-defined tasks are perceived as potentially effective drivers for feedback and learning. Use of EPAs and entrustment scales, however, may augment existing tensions between developmental (for learning) and decision-making (of learning) assessment functions. Three key dilemmas seem to influence the impact of EPA-based assessment approaches on residents' learning: (a) standardisation of outcomes versus flexibility in assessment to align with individual learning experiences; (b) assessment tasks focusing on performance standards versus opportunities for learning, and (c) feedback focusing on numeric entrustment scores versus narrative and dialogue. Use of entrustment as an assessment outcome may impact trainees' motivation and feelings of self-efficacy, further enhancing tensions between learning and performance. Conclusions Entrustable professional activities and entrustment scales may support assessment for learning in PGME. However, their successful implementation requires the careful management of dilemmas that arise in EPA-based assessment in order to support competence development.

La Cirugía Mayor Ambulatoria (CMA) es una modalidad asistencial, es decir una forma organizativa, de gestión sanitaria y de atención en salud específico para pacientes quirúrgicos, que en los últimos años ha alcanzado un importante desarrollo en gran parte del mundo desarrollado, donde cerca del 80% de toda la cirugía electiva se realiza de esta manera. En el servicio de cirugía bajo el régimen de cirugía mayor ambulatoria se atendieron 625 pacientes de los cuales se ingresaron 165 que representa 26.4%, en el presente estudio cuyo periodo está delimitado de 01 enero de 2019 a 31 diciembre de 2019. Metodología utilizada en el estudio: Se trató de un estudio observacional descriptivo, de corte transversal, retrospectivo. Área de estudio unidad de Cirugía Mayor Ambulatoria del Hospital Militar Escuela Dr. Alejandro Dávila Bolaños, Universo o población de estudio, Todos los pacientes que acudieron al Hospital Militar Escuela “Dr. Alejandro Dávila Bolaños” al área de CMA en el periodo de estudios por el servicio de Cirugía. Los resultados de referencia del estudio: El cuanto a sexo de los participantes Sexo Femenino: 84 (58.52%) fue el más frecuente; El municipio de origen del paciente de Managua 120, (83.3%), la edad en años de los participantes 40-44: 27, (18.8%) En cuanto a la cobertura de los pacientes del estudio se encontró que INSS: 117; (81.3%), De acuerdo al índice de masa corporal, se demostró que el intervalo: 30-34.9: 57, (39.6%), De acuerdo a los Antecedentes Personales Patológicos se demostró que el grupo que no tuvo antecedentes represento la mayoría con: 114, (79.2%); En el presente estudio el procedimiento que se realizó con mayor frecuencia fue la Colecistectomía laparoscópica: 42, (29.2%), En relación a otro procedimiento realizado: hernioplastía incisional: 9, (6.25%); En cuanto a duración del procedimiento quirúrgico en minutos se organizó en 6 intervalos: 30-59: 45, (31.3%); En relación de horas de estancia en la unidad de salud de ingreso no programado de procedimientos quirúrgicos en el servicio de cirugía: >13: 129: (89.6%). En relación de la llegada del paciente y el ingreso al quirófano: 8-10: 42, (29.2%); En relación a la razón de ingreso del paciente se organizó en 6 grupos obteniendo frecuencia de: Nauseas - vómitos: Si: 33, (22.9%); Fiscalización de cirugía posterior a las 15 horas: Si: 126 (87.5%)

Bedside point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. At present, no consensus exists for what POCUS curriculum is appropriate for internal medicine residency training programs. This document details the consensus-based recommendations by the Canadian Internal Medicine Ultrasound (CIMUS) group, comprising 39 members, representing 14 institutions across Canada. Guiding principles for selecting curricular content were determined a priori. Consensus was defined as agreement by at least 80% of the members on POCUS applications deemed appropriate for teaching and assessment of trainees in the core (internal medicine postgraduate years [PGY] 1-3) and expanded (general internal medicine PGY 4-5) training programs. We recommend four POCUS applications for the core PGY 1-3 curriculum (inferior vena cava, lung B lines, pleural effusion, and abdominal free fluid) and three ultrasound-guided procedures (central venous catheterization, thoracentesis, and paracentesis). For the expanded PGY 4-5 curriculum, we recommend an additional seven applications (internal jugular vein, lung consolidation, pneumothorax, knee effusion, gross left ventricular systolic function, pericardial effusion, and right ventricular strain) and four ultrasound-guided procedures (knee arthrocentesis, arterial line insertion, arterial blood gas sampling, and peripheral venous catheterization). These recommendations will provide a framework for training programs at a national level.

Background Allied health care professionals can contribute meaningfully to goals-of-care discussions with seriously ill hospitalized patients and their families. We sought to explore the perspective of hospital-based allied health care professionals on their role in goals-of-care discussions and to identify barriers to their participation. Methods We surveyed allied health care professionals (social workers, physiotherapists, occupational therapists, registered dietitians, speech-language pathologists and pharmacists) on internal medicine, hematology-oncology, medical oncology and radiation oncology wards at 2 tertiary care hospitals in Hamilton, Ontario, from April 2013 to May 2014. We modified a validated questionnaire originally designed to assess barriers to discussing goals of care from the perspective of nurses, residents and staff physicians on hospital medical wards. Respondents rated the questionnaire items on a 7-point Likert scale. Results Of the 47 allied health care professionals invited, 32 (68%) participated: 9 physiotherapists, 7 social workers, 6 occupational therapists, 4 registered dietitians, 3 pharmacists and 2 speech-language pathologists; in 1 case, the profession was unknown. The greatest perceived barriers to engaging in goals-of-care discussions were lack of patient decision-making capacity (mean rating 5.9 [standard error (SE) 0.3]), lack of awareness of patients' previous discussions with other team members (mean rating 5.7 [SE 0.3]) and family members' difficulty accepting a poor prognosis (mean rating 5.6 [SE 0.2]). Although the respondents felt it was most acceptable for staff physicians, residents and advanced practice nurses to exchange information and reach a final decision during goals-of-care discussions, they felt it was acceptable for a broader range of allied health care professionals to initiate discussions (mean rating 4.7-5.8) and to act as decision coaches (clarifying values, weighing options) with patients and families (mean rating 5.3-6.1). Interpretation Allied health care professionals are willing to initiate goals-of-care discussions and to act as a decision coach with seriously ill hospitalized patients and their families. By improving interprofessional collaboration, we can engage the entire health care team in this process.

Background Point-of-Care Ultrasound (PoCUS) is an ultrasound examination performed by the clinician to answer a focused question or guide an invasive procedure. Despite gaining popularity and evidence supporting the use of PoCUS, core Internal Medicine (IM) residency programs in Canada have yet to implement a comprehensive PoCUS curriculum. The objective of this study was to create a formal PoCUS curriculum. Methods We conducted a systematic needs assessment with a survey that assessed IM attending and resident comfort, training, and application of PoCUS. We also performed a literature review of selected PoCUS-guided procedures and diagnostics to assess the evidence. A working group analyzed the collected data and designed a graduated 3-year curriculum. Results The needs assessment demonstrated that PoCUS education was both necessary and in high demand. The PoCUS-guided procedures and diagnostics that were identified by the survey to be necessary for IM training were then evaluated by a literature review. Based on the evidence, a progressive 3-year curriculum was created. The working group decided on the method and timing of curriculum delivery. Conclusion McMaster University is the first IM residency program to introduce a graduated 3-year curriculum complete with competency assessment and quality assurance. Résumé Contexte L'échographie ponctuelle est un examen d'échographie effectué par le clinicien pour répondre à une question ciblée ou guider une procédure invasive. Malgré l'obtention de la popularité et des preuves appuyant l'utilisation de la messagerie instantanée, les programmes de résidence au Canada pour la médecine interne de base (GI) n'ont pas encore mis en œuvre un programme exhaustif. L'objectif de cette étude était de créer un programme d'études officiel. Méthodes Nous avons effectué une évaluation systématique des besoins avec un sondage qui évaluait la présence de GI et le confort des résidents, la formation et l'application de ces programmes. Nous avons également effectué un examen de la documentation de certaines procédures et diagnostics guidés pour évaluer la preuve. Un groupe de travail a analysé les données collectées et conçu un programme gradué de trois ans. Résultats L'évaluation des besoins a démontré que l'éducation était à la fois nécessaire et trèsdemandée. Les procédures et les diagnostics qui ont été identifiés par le sondage comme étant nécessaires à la formation en GI ont ensuite été évalués par un examen de la documentation. Sur la base des données probantes, un programme d'études progressive de trois ans a été créé. Le groupe de travail a décidé de la méthode et ducalendrier de l'exécution des programmes. Conclusion L'Université McMaster est le premier programme de résidence en GI à présenter un programme gradué de trois ans complété par l'évaluation des compétences et l'assurance de la qualité.

The most common extraintestinal complication of Entamoeba histolytica is amebic liver abscess (ALA). Hepatic vein and inferior vena cava (IVC) thrombosis are rare but well-documented complications of ALA, typically attributed to mechanical compression and inflammation associated with a large abscess. We present a case of a previously healthy 43-year-old Canadian man presenting with constitutional symptoms and right upper quadrant abdominal pain. He was found to have thrombophlebitis of the IVC, accessory right hepatic vein, and bilateral iliac veins. Extensive investigations for thrombophilia were negative. Magnetic resonance imaging of the liver demonstrated a 3.2-cm focal area of parenchymal abnormality that was reported as presumptive hepatocellular carcinoma, and a 1.9-cm lesion in the caudate lobe with diffusion restriction and peripheral rim enhancement. Despite multiple biopsy attempts, a histopathological diagnosis was not achieved. Abdominal pain and fever 4 months later prompted repeat ultrasound demonstrating a 10.4- × 12.0-cm rim-enhancing fluid attenuation lesion felt to represent a liver abscess. Thick dark "chocolate brown" drainage from the lesion and positive serology for E. histolytica confirmed the diagnosis of ALA acquired from a previous trip to Cuba. The patient was started on treatment with metronidazole and paromomycin and repeat abdominal ultrasound demonstrated resolution of the abscess. This case is the first to demonstrate extensive IVC thrombosis secondary to a relatively small occult ALA and emphasizes the thrombogenic potential of ALA. Amebic infection should be considered as a rare cause of IVC thrombosis in the correct clinical context.

This editorial, "Internal Medicine Point of Care Ultrasound: Indicators It's Here to Stay" (DOI: 10.1007/s11606-019-05268-0), was intended to accompany "Education Indicators for Internal Medicine Point-of-Care Ultrasound: a Consensus Report from the Canadian Internal Medicine Ultrasound (CIMUS) Group".

Editorial

Chymase plays an important and diverse role in the homeostasis of a number of cardiovascular processes. Herein, we describe the identification of potent, selective chymase inhibitors, developed using fragment-based, structure-guided linking and optimization techniques. High-concentration biophysical screening methods followed by high-throughput crystallography identified an oxindole fragment bound to the S1 pocket of the protein exhibiting a novel interaction pattern hitherto not observed in chymase inhibitors. X-ray crystallographic structures were used to guide the elaboration/linking of the fragment, ultimately leading to a potent inhibitor that was >100-fold selective over cathepsin G and that mitigated a number of liabilities associated with poor physicochemical properties of the series it was derived from.

A new class of chymase inhibitor featuring a benzimidazolone core with an acid side chain and a P1 hydrophobic moiety is described. Incubation of the lead compound with GSH resulted in the formation of a GSH conjugate on the benzothiophene P1 moiety. Replacement of the benzothiophene with different heterocyclic systems such as indoles and benzoisothiazole is feasible. Among the P1 replacements, benzoisothiazole prevents the formation of GSH conjugate and an in silico analysis of oxidative potentials agreed with the experimental outcome.