33rd Annual Resident Research Day - Department of Medicinemed-fom-medicine.sites.olt.ubc.ca/files/2017/05/RRD-2017-Program... · today to the 33rd Annual Resident Research Day,

33rd Annual Resident Research Day

Wednesday, May 17th, 20178:00a - 4:30p

Medical Student & Alumni Centre[MSAC]

2750 Heather St

33rd Annual UBC Dept of Medicine Resident Research Day May 17, 2017

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33rd AnnualResident

Research DayWednesday, May 17th, 2017

Medical Student & Alumni Centre [MSAC]

2750 Heather Street


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Schedule8:00a Breakfast

8:30a Opening Remarks - Teresa Tsang & Mark Roberts

8:45a Podium Presentations - Session 1

Hardwick Hall

Poster Presentations - Session 1

Latham Student Activities Centre

10:00a Break

10:30a Podium Presentations - Session 2

Hardwick Hall



11:55p Lunch

1:00p Podium Presentations - Session 3

Hardwick Hall



2:25p Break

3:00p Podium Presentations - Session 4

Hardwick Hall

4:15p Closing Remarks

6:00p Resident Research Day Awards Dinner

University Golf Club

5185 University Blvd

*MSAC Wi-Fi Password: internet@msac


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INTRODUCTION

We are very pleased to welcome you here today to the 33rd Annual Resident Research Day, an important celebration of the scholarly endeavors of the Residents and Fellows in our program. Today we take time to recognize the many hours of hard work, dedication and effort necessary to execute these scholarly research projects, and acknowledge the efforts of the faculty mentors who have contributed to the success of these projects.

The Department of Medicine is the largest department in the Faculty of Medicine,

with over 1200 faculty members and staff across the province of BC. Our members represent 18 distinct divisions which focus on understanding the nature, cause, and prevention of adult disease. The mission of the Department is to provide the highest possible standards of excellence in patient care, teaching, and research. As residents trained in the Department of Medicine, you all play an integral part in helping deliver this mission by directly contributing to the high standards of patient care and research for which UBC Department of Medicine is

recognized. Each year your hard work contributes to the over 1000 peer reviewed publications and abstracts. Your dedication to the creation, dissemination and translation of new knowledge is part of evolving health care landscape.


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Today we encourage you to reflect on the lessons you have learned throughout your research projects and carry these forward as you develop your own practice. We hope that you will continue to develop and utilize evidence to inform your decision making, and contribute to the strong history of patient care through innovation.

Diane Lacaille, MD, FRCPC, MHScMary Pack Chair in Arthritis ResearchProfessor, Division of RheumatologyAssociate Head Academic Affairs and Co-Acting Head, UBC Department of Medicine

Andrea Townson, MD, FRCPC, MScHPEdMedical Co-Chair, Regional Rehab Program, VCHA Clinical Professor, Division of Physical Medicine and Rehabilitation Associate Head Education and Co-Acting Head, UBC Department of Medicine

Teresa S.M. Tsang, MD, FRCPC, FACC, FASEDirector of Echo Lab, VGH and UBCProfessor, Division of CardiologyAssociate Head Research and Co-Acting Head, UBC Department of

Medicine


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MODERATOR

Dr. John Staples is an academic General Internist based at St Paul’s Hospital and a Clinical Assistant Professor at UBC. After graduating from medical school at the University of Alberta, he completed a residency and fellowship in General Internal Medicine (UBC), a Masters of Public Health (Harvard University), a New England Journal of Medicine Editorial Fellowship, and a Health Services Research Fellowship (Institute for Clinical Evaluative Sciences, Toronto). His research interests include traffic safety and medical risk factors for injury.

John Staples, MD, FRCPC, MPH


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PODIUM ADJUDICATORS

John Cairns is a cardiologist whose research has focused on the modification and non-invasive measurement of myocardial infarct size in humans and dogs, antithrombotic therapies for acute ischemic syndromes and for atrial fibrillation, and post-myocardial infarction arrhythmias.

He has published over 200 papers and has practiced cardiology for many years in Ontario, focusing on acute coronary care and invasive cardiology. He is a member of the CCS group which developed the 2010 Atrial Fibrillation Guidelines and the 2012, 2014 and 2016 Updates, chairing the chapters on stroke prevention. He has held a number of academic leadership roles including Chair of Medicine, McMaster University (1988-96) and Dean of Medicine, UBC (1996-2003). He led the CIHR Clinical Research Initiative in 2004-05, which proposed a variety of programs to strengthen the support of Clinical research in Canada, he co-chaired CANNeCTIN (a CIHR/CFI-funded CV clinical trials network 2008-13) and he was a member of CIHR’s External Advisory Group on Multi-site Clinical Studies (2012).

He is immediate Past-President of the Canadian Academy of Health Sciences.

John A Cairns, OBC, MD, FRCPC, FACC


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PODIUM ADJUDICATORS cont.

Melanie Murray is an Assistant Professor in the Division of Infectious Diseases, Department of Medicine, at the University of British Columbia (UBC). Her PhD studies involved the examination of viral factors involved in mother to child transmission of HIV.

She is now a clinician scientist at the Oak Tree Clinic at BC Women’s Hospital and at St. Paul’s Hospital in Vancouver, BC. She has research expertise on engagement of vulnerable HIV-positive populations, and co-morbidities of aging with HIV, with a focus on women.

Dr. Murray has extensive experience employing Weltel (a bidirectional text-messaging platform) with highly vulnerable HIV-positive patients, with resultant improvements in care-provider/patient relationships, patient agency and clinical outcomes.

Melanie Murray MD, PhD, FRCPC


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POSTER ADJUDICATORS

Dr. Paul Campsall works as an intensivist and internist in Kamloops, BC. He completed his medical training at UBC followed by an internal medicine residency in St. John’s, NL, and a Critical Care Medicine fellowship in Calgary. Dr. Campsall is heavily involved in medical education in Kamloops including simulation and bedside U/S training and acts as the rotation coordinator for internal medicine.

Paul Campsall, MD, FRCPC


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POSTER ADJUDICATORS cont.

Dr. Zalunardo is a Nephrologist at Vancouver General Hospital and a Clinical Associate Professor at the University of British Columbia, Department of Medicine. She obtained her Doctor of Medicine degree from the University of British Columbia, where she also completed her residency in Internal Medicine and Nephrology. She then undertook a research fellowship focused on renovascular disease and obtained a Masters of Science degree in Clinical Epidemiology from the Harvard School of Public Health Dr. Zalunardo joined the UBC Nephrology Division at Vancouver General Hospital in 2006. She is the medical director of the Kidney Care Clinic at VGH. Her interests are in optimizing predialysis CKD care, including various aspects of hemodialysis vascular access preparation.

Nadia Zalunardo, MD


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AWARDS

RESEARCH AWARDS

• The G.B. John Mancini Resident Research Achievement Prize Senior Resident Award

• The Stefan Grzybowski Prize Best Research Project by a PGY4/PGY5/PGY6

• A. Dodek Outstanding Clinical and Ethical Performance in Cardiology Award Awarded to incoming cardiology fellow • Best Oral Presentation by a PGY1 • Best Oral Presentation by a PGY2 • Best Oral Presentation by a PGY3 • Best Oral Presentation by a PGY4/5/6• Best Poster Project by a PGY1 • Best Poster Project by a PGY2 • Best Poster Project by a PGY3 • Best Poster Project by a PGY4/5/6


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AWARDS

TEACHING AWARDS

• The Richard Edward Beck Prize Outstanding Teaching by a Senior Resident/Fellow (Nominated by Faculty & Voted by Core Residents)

AWARDS

• Shelly Naiman Awards x 2 For Outstanding Faculty Teaching

• Outstanding Clinical Teaching by a PGY2• Outstanding Clinical Teaching by a PGY3• Outstanding Clinical Teaching by a PGY4/PGY5/PGY6


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PODIUM PRESENTATIONSSESSION 1

8:45a When trainees reach competency in performing EUS: A systematic review

Neal Shahidi, PGY4

Sponsor: Jennifer Telford

8:57a Recognition of Lynch Syndrome Amongst Newly Diagnosed Colorectal Cancer at St. Paul’s Hospital

Steven Pi, PGY2

Sponsor: Robert Enns

9:09a Incidence of suicide in inflammatory bowel disease, a systematic review

Chaoran Zhang, PGY1

Sponsor: Brian Bressler

9:21a Low Dose and Ultra-Low Dose CT vs MRI Derived Renal Volumes in Subjects with Autosomal Dominant Polycystic Kidney Disease

Tae Won Yi, PGY2

Sponsors: Adeera Levin & Mike Bevilacqua

9:33a The Economic and Social Impact of Allergic Diseases

Kateryna Vostretsova, PGY3

Sponsor: Donald Stark

9:45a MDMA Assisted Psychotherapy for Treatment Refractory Post-Traumatic Stress Disorder

Hayden Rubensohn, PGY3

Sponsor: Ingrid Pacey

10:00a Break + Poster Viewing


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10:30a Smoothing Out the Transition from Junior to Senior Resident

Meghan Ho, PGY5 and Hamed Nazzari, PGY3

Sponsor: Rose Hatala

10:42a Recurrent versus de novo metastatic non-small-cell lung cancer: Impact on outcomes

Sara Moore, PGY3

Sponsors: Cheryl Ho

10:54a Clinical Outcomes after Whole Genome Sequencing in Patients with Metastatic Non Small Cell Lung Cancer

Erica Tsang, PGY2

Sponsor: Janessa Laskin

11:06a Creating Capacity for HIV Care in Rural and Remote Communities of Saskatchewan

Geoffrey Shumilak, PGY5

Sponsor: Natasha Press

11:18a Emerging Group C and G Streptococcal Endocarditis: A Canadian Perspective

Sylvain Lother, PGY4

Sponsor: Yoav Keynan

11:30a Hepatitis C Cascade of Care among People Who Inject Drugs in Vancouver, Canada

Samantha Young, PGY3

Sponsor: Kanna Hayashi

11:42a The Management of TB-HIV Co-infection in Northern Uganda: A Retrospective Cohort Review

Carl Boodman, PGY1

Sponsor: Jan Hajek

11:55a Lunch + Poster Viewing

SESSION 2


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1:00p The Relationship Between Heart Failure Readmission And Mortality In Patients Receiving Transcatheter Aortic Valve Implantation

Hamed Nazzari, PGY3

Sponsor: Mustafa Toma

1:12p Does ST depression help predict coronary artery disease after an out-of-hospital cardiac arrest?

Chris Cheung, PGY4

Sponsor: Krishnan Ramanathan

1:24p The Utility of Heart Rate and Blood Pressure Responsiveness during Exercise in Catecholaminergic Polymorphic Ventricular Tachycardia

Thomas Roston, PGY3

Sponsor: Santabhanu Chakrabarti

1:36p Systematic review: the cost-effectiveness of exercise programs used as a primary prevention in patients with moderate to high risk of cardiovascular disease

Kate Shoults & Alice Mai, PGY3

Sponsor: Scott Lear

1:48p Automatic Quality Assessment of Echo Apical 4 Chamber Images Using Computer Deep Learning

Christina Luong, PGY6

Sponsor: Teresa Tsang

2:00p Detecting Underlying Cardiovascular Disease in Young Competitive Athletes

Hamed Nazzari, PGY3

Sponsor: Saul Isserow

2:12p Quantification of Pleural Effusions by Two-Dimensional Echo cardiography

Alice Chang, PGY2


SESSION 3


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3:00p Atrial Arrhythmias in Adult Congenital Heart Disease

Darryl Wan, PGY3

Sponsor: Santabhanu Chakrabarti

3:12p A narrative review on future directions for personalizing atrial fibrillation therapy

Scott Barichello, PGY1

Sponsor: Zachary Laksman

3:24p Palliative Care in Congestive Heart Failure: Impact on Hospital Readmission

Katie Wiskar, PGY3

Sponsor: Barret Rush

3:36p Preventability of 28-Day Hospital Readmissions in General Internal Medicine Patients: A Retrospective Analysis at a Canadian Quaternary Hospital

Constantin Shuster & Andrew Hurlburt, PGY3

Sponsor: Penny Tam

3:48p The Impact of LVAD Infections on Post Cardiac Transplant Survival: Systematic Review and Meta-Analysis

Daljeet Chahal

Sponsor: Mustafa Toma

4:00p Clinical Outcomes of Start-low, Go-Slow Methadone Initiation for Cancer-Related Pain

Lawrence Chow, PGY3

Sponsor: Pippa Hawley

4:15p Closing Remarks

2:25p Break + Poster Viewing

SESSION 4


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POSTER PRESENTATIONS

8:45a Comparing outcomes of neoadjuvant endocrine therapy versus chemotherapy in ER-positive breast cancer: Results from a prospective institutional database

Nathalie Levasseur, PGY4

Sponsor: Christine Simmons

8:57a Patterns of practice in EGFR mutation positive NSCLC: Use of gefitinib versus afatinib

Zamzam Al Hashami, PGY3

Sponsor: Cheryl Ho

9:09a Personalized Oncogenomic Analysis of Adenoid Cystic Carcinomas: Using Whole Genome Sequencing to Influence Clinical Decision Making

Manik Chahal, PGY1

Sponsors: Janessa Laskin & Tony Ng

9:21a Attrition Across The Hiv Cascade Of Care Among A Diverse Cohort Of Women Living With Hiv In Canada

Geneviève Kerkerian, PGY3

Sponsor: Mary Kestler

9:33p IV to PO antibiotic stepdown on medical floors at a tertiary care centre: low hanging fruit for an antimicrobial stewardship intervention?

Matthew Michaleski, PGY2

Sponsor: Jennifer Grant

9:45a BNP to Predict Post-Liver Transplant Mortality: Systematic Review and Meta-Analysis

Daljeet Chahal, PGY1

Sponsors: Jan Hajek & Titus Wong

10:00a Break + Poster Viewing

SESSION 1


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10:30a Validity of algorithms for estimating left sided filling pressures on echocardiography in a population referred for pulmonary arterial hypertension

Eric Leung, PGY3

Sponsors: Nathan Brunner & John Swiston

10:42a Relationship Between Cardiomegaly by Chest X-Ray and Left Ventricular Size by Echocardiography

Alice Chang, PGY2


10:54a The Effects of Targeted Temperature Management on Mortality and Neurologic Outcome: A systematic review and meta-analysis

Vesna Mihajlovic, PGY2

Sponsor: Graham Wong

11:06a Fluid Challenge during Right Heart Catheterization: An experience from a tertiary pulmonary hypertension referral centre

Nima Moghaddam, PGY1

Sponsor: Nathan Brunner

11:18a Increased prevalence of sub-clinical atherosclerosis in individuals with damaging mutations in ABCA1 and APOA1

Omar Abdel-Razek, PGY1

Sponsor: Liam Brunham

11:30a CALI: Fellows as Clinical Teachers in the Outpatient Internal Medicine Clinic

Allison Nakanishi, PGY3

Sponsors: Cary Cuncic, Aman Nijjar, & James Tessaro

SESSION 2


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1:00p Management of Complex Pancreatic Fluid Collections Using the Nagi™ Lumen-Apposing Metal Stent

Stephen Taylor, PGY3

Sponsor: Fergal Donnellan

1:12p Indications for Colonoscopy Pre- and Post- Implementation of the Colon Screening Program at St. Paul’s Hospital

Steven Pi, PGY2

Sponsor: Robert Enns

1:24p Improving Resident Confidence: A Simulated Night On Call

Colleen Foster, PGY2

Sponsor: Alison Walzak

1:36p Inferior Vena Cava Variability in Mechanically Ventilated Patients with Spontaneous Breathing Effort: An Observational Study

Constantin Shuster & Andrew Hurlburt, PGY3

Sponsors: John Boyd & Demetrios Sirounis

1:48p Post Transplant Diabetes in the Renal Transplant

Jacob Zamora, PGY2

Sponsors: Breay Paty & M. Al Mehthel

2:00p The risk of solid tumour malignancies in non-dialysis- dependent chronic kidney disease: A systematic review

Justin Gill, PGY3

Sponsor: Adeera Levin

2:25p Break + Poster Viewing

SESSION 3


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PODIUM PRESENTATIONS


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When trainees reach competency in performing EUS: A systematic reviewNeal Shahidi MD, George Ou MD, Eric Lam MD, Robert Enns MD, Jennifer

Telford MD

Background: The American Society for Gastrointestinal Endoscopy (ASGE) recommends that trainees complete 150 endoscopic ultrasound (EUS) procedures prior to assessing competency. However, this recommendation is largely based on limited evidence and expert opinion.

Objective: With new evidence suggesting that this historical threshold is underestimating training requirements we evaluated the learning curve for achieving competency in EUS.

Methods: From 1946 to March 25, 2016 two investigators independently searched MEDLINE for full-text citations assessing the learning curve for achieving competency in EUS. A learning curve was defined as either a tabulated or graphic representation of competency as a function of increasing EUS experience.

Results: Eight studies assessing 28 trainees and 7051 EUS procedures were included. When stratifying studies based on procedural indication: 3 studies assessed competency in evaluating mucosal lesions, 3 studies assessed competency in EUS fine needle aspiration (EUS-FNA), and 2 studies assessed comprehensive competency. Among studies assessing mucosal lesion T-staging accuracy, competency was achieved by 65 to 231 procedures. Among studies assessing EUS-FNA, competency was achieved by 30 to 40 procedures. Among the 2 studies assessing comprehensive competency in EUS, competency was not achieved in either study across all trainees. Only 4 of 17 trainees reached competency by 225 to 295 EUS procedures. In conclusion, as EUS competency assessment has evolved to more closely reflect independent clinical practice, the number of procedures required to achieve competency has risen well above ASGE recommendations. Advanced endoscopy training programs and specialty societies need to re-assess the structure of EUS training.


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Recognition of Lynch Syndrome Amongst Newly Diagnosed Colorectal Cancer at St. Paul’s Hospital

Steven Pi, Estello Nap-Hill, Jennifer Telford, Robert EnnsSupervisor: Dr. James Johnston

Background: Lynch syndrome (LS) is the most common cause of inherited colorectal cancer (CRC). Numerous strategies exist for identifying patients with LS. In BC, most hospitals utilize clinical criteria (Amsterdam II criteria, Revised Bethesda guidelines, or the BCCA’s Hereditary Cancer Program criteria) to determine further first-line testing. Limitations exist with this strategy and consequently, LS is thought to be under-recognized.

Objective: To investigate whether LS is under-recognized when compared to the reported prevalence and, if so, identifying what factors contribute to this.

Methods: A retrospective chart review of all CRC diagnosed at SPH from 2010-2013 was conducted. The list of all CRC was obtained through SPH Department of Pathology.

Results: Of 246 patients, 96% (235/246) had a family history available. 76% (83/109) with a family history of malignancy were unable to recall the specific malignancy or age of diagnosis. 18% (45/235) were only asked about a history of gastrointestinal-related malignancy and 26% (65/246) met at least 1 of 3 clinical criteria but only 21% (13/63) received further investigation. Patients who received further testing had a statistically significant younger age (66 vs. 49, p<0.01), past medical history of malignancy (0.16 vs. 0.38, p=0.03) and family history of malignancy (0.46 vs. 0.92, p<0.01). Only 1.6% (4/246) were found to have LS compared to the reported prevalence of 2-5% of all CRC.

Conclusion: This data supports that LS is under-recognized. Contributing factors include poor recollection of family histories by patients, incomplete family histories by physicians, and under-investigation for those at risk of LS. A system such as that suggested by the latest AGA Guidelines where all cancers are universally tested needs consideration to minimize the risk of missing LS patients.


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Suicide and Inflammatory Bowel DiseaseChaoran Zhang

Background: Crohn’s disease and ulcerative colitis are chronically inflammatory conditions affecting the gastrointestinal tract and are characterized by a chronic, relapsing and remitting nature. Patients with chronic medical diseases are known to have increased incidence of psychiatric disorders including suicidality.

Objective: To identify if patients with inflammatory bowel disease have a clinical significant increase in mortality through suicide.

Methods: A systematic literature search was performed using MEDLINE and EMBASE (up to March 2017) to identify all studies evaluating the mortality rate from suicide in patients with IBD. Hand searching bibliographies of relevant reviews and included articles was subsequently performed to identify any further studies for inclusion.

A meta-analysis was performed on 14 distinct populations with either Crohn’s disease or ulcerative colitis gathered from 8 cohort studies. The standardized mortality ratio and number of suicidal death were extracted from each paper. Natural logarithms of the SMRs were used in analysis and given that the confidence interval varied across studies, the standard error of log SMR was recalculated based on Poisson distribution and delta method. Meta-analysis for each IBD condition (CD and UC) were conducted separately as well as combined.

Results: The meta-analysis for Crohn’s disease included six cohort studies and a clinically significant standardized mortality ratio of 1.52 (95% CI 1.12-2.04) was found and the meta-analysis for ulcerative colitis included seven distinct cohort studies (eight distinct populations) and a standardized mortality ratio of 1.15 (95% 0.84-1.58) was found. The SMR for all studies was 1.27 (95% 1.02-1.6) and there was no significant heterogeneity found between studies (p=0.698, 0.198 and 0.259 for CD, UC and all respectively; Cochran’s Q-test.

A statistically significant SMR for suicide was found Crohn’s disease through this meta-analysis which may reflect the chronicity, severity of disease and lack of curative treatments in Crohn’s disease.


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Low Dose and Ultra-Low Dose CT vs MRI Derived Renal Volumes in Subjects with Autosomal Dominant Polycystic Kidney Disease

TaeWon Yi

Background: Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited kidney disorder, occurring in 1 of 400 to 1000 live births. The course of ADPKD is quite variable with the rate in change of kidney size being an early marker of disease progression. Different modalities can be used measure total kidney volume (TKV) with the gold standard being an MRI. Current measurement with MRI involves tedious and time-consuming manual tracing of each individual image to calculate the TKV that is not suitable for clinical use.

Objective: To compare the measure of TKV between ultra-low dose CT, low dose CT, and MRI scans of the kidneys using manual tracing, stereology, and single slice method to compare the reliability between the modalities in TKV calculation.

Methods: A prospective study which included 30 adult patients with an established diagnosis of ADPKD were recruited. Patients were either contacted via mail through a generated list through PROMIS, the BC nephrology clinical information system or referred to the study directly by the nephrologists. All patients underwent imaging studies at St. Paul’s Department of Radiology. The TKV will be calculated and compared using the three imaging modalities and be analyzed with three different calculation methods. The intra and inter-rater reliability will be assessed to determine reproducibility and use in clinical settings.

Results: 30 participants were assessed and imaging via the three modalities was obtained. At the time of submission, statistical analysis is still underway and these findings will be presented when available.


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The Economic and Social Impact of Allergic DiseasesKateryna Vostretsova, Dr. Donald Stark

Background: The prevalence of allergic diseases is increasing globally and this is associated with substantial economic and medical costs. There is currently no cure for allergic diseases and the factors responsible for this escalation in prevalence are yet to be elucidated. Allergies are a major burden on health and resource utilization and Canadian studies addressing the cost of illness of these conditions are lacking. Available studies are often out-dated, in a language other than English or the results are not generalizable to the population in Canada.

Objective: To review the current literature on the social and economic burden of allergic disease including direct and indirect costs associated with treating these conditions.

Methods: A systematic review was undertaken. Original research was identified from PubMed, EMBASE, and EMCare databases (cross-sectional, observational, or longitudinal) from 2000 to present on the burden of allergic conditions including Asthma, Allergic Rhinitis, Anaphylaxis, Angioedema, Eczema/dermatitis, Food allergy and Urticaria in Canada. The time frame was selected to reflect more recent developments in the treatment and management of allergic diseases.

Results: Allergic diseases pose a massive burden on our health care system both in direct and indirect costs. Surprisingly, Canadian data on most allergic conditions other than Asthma is lacking. Given the rising healthcare costs, it is imperative to understand the economic burden of these conditions in Canada in order to ensure that the growing needs of allergic diseases is sufficiently addressed.


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MDMA Assisted Psychotherapy for Treatment Refractory Post-Traumatic Stress Disorder

Hayden Rubensohn

Background: Morbidity and mortality are high amongst those who suffer from PTSD, and the costs to the medical system are significant. Current therapies have limited effectiveness in treating this illness, and many patients fail multiple lines of intervention.

Objective: To establish dose-response information and to accumulate safety data on the use of 3,4-methylenedioxymethamphetamine (MDMA) as an adjunct to psychotherapy amongst patients with treatment-refractory PTSD.

Methods: Between 2004 and 2016, a prospective, placebo controlled randomized trial with crossover was carried out at various centres internationally. 107 patients with chronic refractory PTSD were randomized to receive either a treatment dose of MDMA (75 to 125mg), a sub-treatment dose (25 to 40mg), or a placebo dose (0mg) on two to three occasions with intervening therapy sessions. Subjects randomized to receive sub-treatment or placebo doses were offered the opportunity to receive two to three unblinded treatment sessions following collection of primary endpoint data. Physiologic data and suicidal ideation and behaviour were assessed for safety. Change in score on the Clinic-Administered PTSD Scale (CAPS4) from baseline to completion of the blinded portion of the study was utilized as a marker of efficacy of the treatment.

Results: Overall, 31 patients with a mean baseline CAPS4 score of 81.3 received sub-therapeutic or placebo doses of MDMA. All of these patients received therapy as laid out by the study protocol, resulting in a mean change in CAPS4 score of -11.6. 74 patients with a mean baseline CAPS4 score of 85.8 received treatment doses of MDMA along with therapy. This produced a mean change in CAPS4 score of -37.8, p<0.001. No serious adverse events were noted, while mild and moderate side effects were all transient.


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Smoothing Out the Transition from Junior to Senior ResidentMeghan Ho, Hamed Nazzari, Rose Hatala

Background: The progression from Junior to Senior Resident in Internal Medicine (IM) residency involves a significant change in residents’ roles and responsibilities, and can be a stressful and anxiety-provoking experience. Residents in the University of British Columbia (UBC) IM Program implemented a Transition Program in 2015.

Objective: To examine the impact of a structured Junior to Senior Resident Transition Program and determine what attributes and factors are important for such a program to be successful.

Methods: We used a mixed-methods approach, including a quantitative questionnaire and qualitative focus group interviews. Likert-style questionnaires were administered to UBC IM PGY-2 and PGY-3 residents pre-implementation of the Transition Program in 2013, and to PGY-2 residents post-Transition program in 2015 and 2016 to evaluate residents’ transition experience. Results were analyzed using unpaired t-tests on the pre- vs. post-program data. Three months after the transition program was completed in 2016, three focus groups (two with volunteer sampling facilitated by the authors and one with convenience sampling facilitated by an independent sub-specialty fellow, total n=18) were conducted. Focus group transcripts were transcribed anonymously, and each transcript was independently coded by 2-3 members of the research team. Codes were then grouped into themes using an iterative approach during research team meetings.

Results: The percentage of Seniors who indicated that they felt prepared for the Senior Resident role significantly increased from 48% in 2013 to 60% in 2015 and 70% in 2016 (response rates: 67/100, 25/50, and 22/50, p = 0.04). Fifty-one percent of Seniors surveyed felt they needed more training in skills required for their first Senior block in 2013 (response rate: 65/100); this significantly decreased to 28% and 32% in 2015 and 2016 respectively (p=0.04).

Qualitative data demonstrated that the Transition Program created a true transitional educational period by balancing independence and support through a simulated, but realistic on-call experience. The program improved residents’ sense of preparedness, achieved important learning outcomes, and had other emotional (e.g. increased confidence) and unintended effects (e.g. collegiality, early loss of Junior role). Through the focus groups, barriers to successful administration of the program, as well as potential solutions were also identified.

Conclusion: The Transition Program provides a structured opportunity for Junior Residents to learn the Senior Resident role through graduated responsibility in a supportive environment, creating a beneficial transitional period in residents’ educational development.


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Recurrent versus de novo metastatic non-small cell lung cancer: Impact on outcomes

Sara Moore MD, Bonnie Leung MN-NP, Jonn Wu MD FRCPC, Cheryl Ho MD FRCPC

Background: Metastatic non-small-cell lung (NSCLC) cancer has a poor prognosis, with a 5 year survival less than 5%. The majority of patients present with stage IV and many patients treated curatively with stage I-III will develop recurrent metastatic disease. It is unknown if the natural history differs between patients with recurrent versus de novo metastatic NSCLC. Objective: To compare overall survival in patients presenting with de novo metastatic NSCLC and those who experience recurrent metastatic disease after initial curative treatment.

Methods: A retrospective review was completed of all patients with NSCLC referred to the BC Cancer Agency from 2005-2012. Two cohorts were created; de novo metastatic disease and patients treated with curative intent (surgery or radiotherapy) that developed recurrent, metastatic disease. Information was collected on known prognostic and predictive factors. Overall survival was calculated from the date of diagnosis of metastatic disease, and multivariate analysis of survival was performed adjusting for known prognostic factors. Results: A total of 9656 patients were referred, 5783 (60%) with de novo stage IV disease, and 3873 (40%) with stage I-III disease. Of patients with initial stage I-III, 1801 received curative therapy (751 surgery, 1050 radiotherapy) and 802 developed metastases. Patients in the de novo cohort were more likely to be male (52% vs 47%), have poorer performance status (ECOG≥2 50% vs 43%), and receive no palliative chemotherapy (67% vs 61%). The median overall survival in the de novo cohort was 4.7 m vs 6.9 m in the recurrent cohort (p<0.001). De novo status was associated with shorter overall survival and this remained significant in a multivariate model that incorporated gender, ECOG and lines of palliative chemotherapy (hazard ratio 1.228[95% confidence interval 1.134-1.330], p-value <0.001).


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Clinical Outcomes after Whole Genome Sequencing in Patients withMetastatic Non Small Cell Lung Cancer

Erica Tsang, Yaoqing Shen, Negar Chooback, Cheryl Ho, Martin Jones, Daniel Renouf, Howard Lim, Sophie Sun, Stephen Yip, Erin Pleasance, Yussanne Ma, Yongjun Zhao, Andrew Mungall, Richard Moore, Steven Jones, Marco Marra,

Janessa Laskin

Introduction: The Personalized OncoGenomics (POG) program at the BC Cancer Agency integrates whole genome (DNA) and RNA sequencing into practice for metastatic malignancies. We examine patients with metastatic NSCLC and report the prevalence of actionable targets, treatments, and outcomes.

Methods: Between 2012-2016, 217 patients had a tumor biopsy and blood sample with comprehensive DNA (80X; 40X normal) and RNA sequencing followed by in-depth bioinformatics to identify potential cancer “drivers” and/or actionable/treatable targets. In NSCLC cases, we compared the progression-free survival (PFS) of “POG-informed therapies” with the PFS of the last regimen prior to POG (PFS ratio). Results: In 29 NSCLC cases, median age was 60.2 years (range 39.4-72.6), 11 were male (38%), and histologies were: adenocarcinoma (93%); squamous cell carcinoma (7%). Potential molecular targets (i.e. cancer “drivers”) were identified in 26 (90%), and 21 (72%) had actionable targets. 13 received POG-informed therapies, of which 3 had no therapy before POG. Of 10 patients with POG-informed therapy, median PFS ratio was 0.94 (IQR 0.2-3.4). 3 (30%) had a PFS ratio ≥1.3, and 3 (30%) had a PFS ratio ≥0.8 and <1.3.

Conclusion: In this small cohort of NSCLC, 30% demonstrated longer PFS with POG-informed therapies. Larger studies will help clarify the role of whole genome analysis in clinical practice.


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Creating Capacity for HIV Care in Rural and Remote Communities of Saskatchewan

Shumilak G, Wudel B, Stevens E, Ng K, Mah A, Stewart K, Sanche S, Kasper K, Hull M, Press N

Objectives: Saskatchewan continues to experience an outbreak of HIV infection that is disproportionately impacting rural and remote communities. Lack of access to HIV care providers, limited HIV awareness, stigma, and isolated geography are significant barriers to implementing routine HIV testing programs, early initiation of cART, and retaining individuals in care. Decentralizing HIV care by enabling family physicians in rural and remote communities to engage in routine HIV testing and longitudinal care of persons living with HIV has been identified as a potential strategy to end the outbreak.

Methods: A focused educational seminar targeting family physicians and allied healthcare providers was developed. The seminar contained 12 hours of material and employed both didactic and interactive teaching techniques. Material focused on the 4 domains of HIV Pathophysiology, HIV Transmission and Diagnostics, Principles of Antiretroviral Use, and Longitudinal Care of Persons Living with HIV. Paired-samples t-test was conducted to compare participant knowledge scores prior to the seminar and following completion.

Results: The seminar was delivered to 61 healthcare providers at 4 sites. 37 participants consented to the study. Knowledge scores significantly improved in all 4 assessed domains. There was significant improvement when comparing overall scores prior to the seminar (M=28.5, SD=16.1) and following completion (M=88.9, SD=11.6); t(36)= 17.9, p<0.01. Comfort in providing HIV-related care significantly improved when comparing scores prior to the seminar (M=2.0, SD=1.4) and following completion (M=7.4, SD=1.5); t(36)= 18.3, p<0.01. The level of optimism regarding the state of the HIV outbreak minimally improved when comparing scores prior to the seminar (M=4.0, SD=1.9) and following completion (M=5.3, SD=2.1); t(36)= 3.9, p<0.01.

Conclusion: Focused educational seminars targeting family physicians and allied healthcare providers are an effective intervention to increase the knowledge, comfort, and capacity to provide HIV care to persons living with HIV in rural and remote communities.


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Emerging Group C and G Streptococcal Endocarditis: A Canadian Perspective

Lother SA, Jassal DS, Lagacé-Wiens P, Keynan Y

Background: The incidence of Lancefield group C and G β-hemolytic streptococci (GCGS) bacteremia is on the rise in Canada and worldwide. We have observed a concurrent shift in microbial pathogens responsible for infective endocarditis (IE) including an increase in GCGS-associated IE in Manitoba, Canada. The burden of disease, clinical characteristics, and outcomes are not completely understood.

Objectives: To describe incidence of IE in patients with GCGS bacteremia and characterize clinical presentations, risk factors, and outcomes from GCGS IE.

Methods: Individuals with blood cultures growing GCGS in Manitoba, Canada, between January 2012 and December 2015 were included. Clinical and echocardiographic parameters were collected retrospectively. Using the modified Duke’s criteria and review of the transthoracic echocardiographic (TTE) studies, IE was suspected or confirmed.

Results: A total of 209 bacteremic events occurred in 198 patients. TTE was performed in only 33% of the study population. Of those, 18% had suspected IE. Four cases of definite and 8 cases of possible IE were found. Native valve infection was more common than prosthetic valve and device-related infection (75%, 17%, and 8%, respectively). Metastatic infection was observed in 64%, primarily to the lungs (57%), skin (43%), musculoskeletal system (29%), and central nervous system (29%). Disease was severe with sepsis occurring in 58%, and Streptococcal Toxic Shock Syndrome in 50% of those with IE. The length of hospitalization for survivors was 26±17 days. Mortality from IE was 17% (2 events).

Conclusion: High rates of IE are seen with GCGS bacteremia. Severe disease, embolic events, and mortality are common. IE from GCGS is likely under diagnosed due to low rates of TTE. All GCGS bacteremic events should prompt investigation for IE.


31

Hepatitis C Cascade of Care among People Who Inject Drugs in Vancouver, Canada

Samantha Young, Sabrina Dobrer, Ekaterina Nosova, MJ Milloy, Kora DeBeck, Evan Wood, Thomas Kerr, Kanna Hayashi

Background and Objective: People who inject drugs (PWID) have high rates of Hepatitis C Virus (HCV) infection. Little is known about the rates of diagnosis and treatment for HCV among PWID. Therefore, this study sought to characterize the cascade of HCV care among PWID in Vancouver, Canada to improve HCV treatment access and delivery for PWID.

Methods: Data were derived from three prospective cohort studies of PWID in Vancouver, Canada between December 2005 and May 2015. We identified the progression of participants through five steps in the cascade of care: (1) chronic HCV; (2) linkage to HCV care; (3) disease staging; (4) initiation of treatment; and (5) completion of treatment. Predictors of undergoing disease staging were identified using a multivariable extended Cox regression model.

Results: Among 1571 participants with chronic HCV, 1359 (86.5%) had ever been linked to care, 1257 (80.0%) had undergone disease staging, 163 (10.4%) had ever started HCV treatment, and 71 (4.5%) had ever completed treatment. In multivariable analyses, HIV seropositivity, use of methadone maintenance therapy, and hospitalization in the past 6 months were independently and positively associated with disease staging (all P < 0.001), while daily heroin injection was independently and negatively associated with disease staging for HCV treatment (P < 0.001).

Conclusion: Among this cohort of PWID, few had been started on or completed treatment for HCV. Our findings highlight the importance of interventions targeting both prescribers and patients to improve education surrounding the prescribing of HCV treatment among PWID with active substance use.


32

The Management of TB-HIV Co-infection in Northern Uganda: A Retrospective Cohort Review

Carl Boodman, Jan Hajek, Willy Agings, Paska Opiyo

Background: TB is the leading cause of death among patients with HIV worldwide. In Northern Uganda, the rates of TB and HIV are high due to recent conflict and resource limitations. A challenge in the management of TB-HIV co-infection involves the induction of cytochrome 3A4 by Rifampin and an ensuing reduction in concentrations of Protease Inhibitors (PI) to sub-therapeutic levels.

Objective: To describe treatment strategies and patient outcomes in a cohort of TB-HIV co-infected patients on PI-based therapy at Gulu Regional Referral Hospital (GRRH).

Methods: A retrospective review of all HIV-positive patients treated at GRRH from January 1st, 2013 to December 31st, 2016 was conducted. Patients were identified through GRRH’s HIV treatment registry. Chart review was performed to establish overlapping chronology of TB-HIV treatment and clinical outcomes. A review of GRRH’s TB registry from Jan 2015-June 2015 was performed to improve linking of TB and HIV data. Descriptive analysis of the TB-HIV cohort was performed.

Results: 5096 patients were treated at GRRH’s antiretroviral clinic from January 2013 to December 2016. 22 patients with a documented history of TB treatment were treated with a PI-based antiretroviral regimen. Charts were available to demonstrate chronology of TB-HIV treatment in 10 patients. 6 patients had concomitant therapy with Rifampin and PIs. Of these, 5 had poor clinical outcomes with 3 documented cases of immunologic or virologic failure. Of the 4 patients without Rifampin-PI overlap, all experienced good clinical outcomes with 3 documented cases of virologic suppression.

Conclusions: While gaps in GRRH’s charting system led to an underestimate of problematic TB-HIV regimen combinations, the poor clinical outcomes of patients on concomitant Rifampin-PI treatment suggests the need for increasing awareness of TB-HIV drug interactions. Advocacy for additional pharmaceutical options remains important in Uganda for management of people living with HIV.


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The Relationship Between Heart Failure Readmission and Mortality in Patients with Receiving Transcatheter Aortic Valve Implantation

Hamed Nazzari, MD, PhD, Nathaniel Hawkins, MD, Sandra Lauck, PhD, Lillian Ding, MSc, Jopie Polderman, RN, Maggie Yu, BSc, Justin Ezekowitz, MD, Robert

Boone, MD, Anson Cheung, MD, Jian Ye, MD, David Wood, MD, John Webb, MD, Mustafa Toma, MD

Background: Symptomatic severe aortic stenosis (AS) is associated with significant morbidity and mortality. Transcatheter aortic valve implantation (TAVI) is an option for select high-risk patients with AS. Whereas the risk for stroke and other clinical outcomes have been reported, the risk for heart failure (HF) hospitalization post-TAVI is unclear. We examined the 30-day and 1-year heart failure (HF) and non-HF hospitalization rates and their associated mortality rates.

Objective: To examine the 30-day and 1-year heart failure (HF) and non-HF hospitalization rates and their associated mortality rates.

Methods: Retrospective analysis of all patients who underwent TAVI between August 6th, 2010 and March 31st, 2014 at St. Paul’s Hospital, in Vancouver, British Columbia. We used data from the CSBC TAVI registry, and linked this to the CIHI DAD and Vital Statistics for hospitalization and mortality.

Results: A total of 535 patients were included in the study population. Within 1-year, 256 (48%) were hospitalized, of which 108 (20%) had a HF hospitalization (HFH), 171 (32%) had a non-HFH, and 256 (47%) were not hospitalized. No differences in age, sex, presence of severe COPD, and history of PCI, CABG and AVR between the three groups. The pre-TAVI mean LVEF, aortic valve area and gradients were not different between groups. The HFH cohort had more patients with baseline eGFR <60 (65% vs. 50% vs. 53%, p = 0.03), atrial fibrillation (52% vs. 31% vs. 31%, p = 0.001) and NYHA III/IV (94% vs. 80% vs. 87%, p = 0.003) when compared to the non-HFH and not hospitalized groups, respectively. The 30-day HFH and non-HFH rates were 9.0% and 10%, respectively, while the 1-year hospitalization rates were 21% and 35% for the HFH and non-HFH cohorts respectively. The 30-day and 1-year all-cause mortality was 8% and 12% for not hospitalized group, 0% and 9% for the non-HFH group, and 3% and 29% for the HFH group, respectively (p < 0.001 at 1-year).

Conclusions: Readmission rate post-TAVI is high, with 56% of patients requiring hospitalization within one year, with over one-third of these readmissions due to heart failure. Understanding predictors of readmissions post TAVI will allow for better risk stratification, implementation of strategies to facilitate transition of care and improve outcomes in patients receiving TAVI. Careful clinical management post-TAVI, with vigilance for HF particularly, is important in order to prevent HF hospitalizations.


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Does ST depression help predict coronary artery disease after an out-of-hospital cardiac arrest?

Christopher Cheung, Darryl Wan, Brian Grunau, Carolyn M Taylor, Marc W Deyell, Christopher Fordyce, Josh Wenner, Omid Kiamanesh, Kendeep Kaila,

Jim Christenson, Michael E. Farkouh Krishnan Ramanathan

BACKGROUND: Following an out-of-hospital cardiac arrest (OHCA), guidelines support immediate coronary angiography (CA) for patients with acute ST-elevation (STE), although no such recommendations exist for ST-depression (STD).

OBJECTIVE: To examine the relationship between the documented arrest rhythm and immediate post-arrest ECG on CA findings in a large cohort of OHCA patients.

METHODS: We performed a retrospective analysis of consecutive patients with OHCA in the Metro Vancouver region from 2009-2015, using the Resuscitation Outcomes Consortium Cardiac Arrest Registry. Patients that did not survive to admission, or with known non-cardiac cause for OHCA were excluded. ST-segment change of >0.1mV in 2 contiguous leads was considered significant. Coronary artery disease was defined as stenosis (any artery ≥70% or left main ≥50%) or occlusion (any artery 99-100%).

RESULTS: A total of n=604 OHCA met inclusion criteria. The median age was 64 years (range 20-101) with 75% males. Most cardiac arrests were witnessed (67%) with 60% receiving bystander CPR. The documented arrest rhythm was ventricular tachycardia/fibrillation (VT/VF; 50%), pulseless electrical activity (18%), asystole (19%), and unspecified (12%). After exclusion of LBBB (n=22) and uninterpretable ECGs (n=36), the immediate post-arrest ECG demonstrated STE (35%), STD (30%), and no ST abnormality (35%). The overall rate of CA was 45% (22% stenosis, 54% occlusion 54%). The median LVEF was 42% (IQR 35-55%). In non-STE patients (n=116), the odds ratios for VT/VF arrest were 3.05 (95% 1.33-4.94) and 4.66 (95% CI 1.30-16.7) for coronary stenosis and occlusion, respectively. The degree of STD correlated weakly with coronary occlusion (ROC C-statistic 0.61, 96% specificity when STD > 3mm).

CONCLUSIONS: In OHCA patients without STE, VT/VF as the initial arrest rhythm was a better harbinger of underlying ischemia when compared to marked STD. Reliance on STD alone may underestimate the number of patients in whom reversing ischemia could improve outcomes after OHCA.


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The Utility of Heart Rate and Blood Pressure Responsiveness during Exercise in Catecholaminergic Polymorphic Ventricular Tachycardia

Thomas Roston

Background: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a life-threatening syndrome defined by ventricular ectopy (VE) during exercise stress testing (EST). Despite an association between stress and VE, the usefulness of autonomic measures such as heart rate (HR) and blood pressure (BP) during EST in risk stratification is unknown.

Objective: To determine the usefulness of HR and BP response during EST in predicting arrhythmia susceptibility.

Methods: This was a retrospective study of children (<19 years old) and first degree relatives with CPVT from 2 centers. BP and HR were correlated with VE on ESTs using a standard arrhythmia score. Chi-square and Wilcoxon Rank Sum testing was used for univariate analysis with p<0.05 defined as significant.

Results: There were 134 ESTs analyzed from 22 patients, with a median of 4 ESTs (range 1-14) per patient. Median age at first EST was 13 years (range 7-50). Thirty-one patients were not on therapy for ≥1 EST, including 18 with an index EST off therapy. In those with index ESTs, mean peak HR on EST was lower in patients with couplets/VT compared to those without arrhythmias (132 vs 202 bpm; p<0.001). For all ESTs, patients with couplets/VT had a higher peak HR and a greater EST-induced HR response compared to those without arrhythmias (146 vs 123 bpm; p<0.002 and 89 vs 65 bpm; p<0.001, respectively). HR at first VPB was lower in patients with couplets/VT compared to those with only VPBs (114 vs 134 bpm; p<0.001). Patients with bigeminy on EST had lower resting and lower peak systolic BPs compared to patients without arrhythmias (104 vs 115 mmHg; p<0.003 and 149 vs 168 mmHg; p<0.007, respectively). Patients with couplets/VT had a smaller rise in systolic BP compared to patients with VPBs (29 vs 43 mmHg; p<0.004). In conclusion, the EST provides valuable information beyond making a CPVT diagnosis. HR and BP during exercise is associated with severity of VE. A hypotensive response to exercise may be a novel prognosticator, implying that the autonomic nervous system plays a role in disease modulation.


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Systematic review: the cost-effectiveness of exercise programs used as a primary prevention in patients with moderate to high risk of cardiovascular

disease.Alice Mai & Katherine Shoults

Purpose: Exercise intervention for the secondary prevention of cardiovascular disease is well supported by evidence, but reports on its cost-effectiveness in primary prevention are rare. We aim to review the current knowledge concerning the cost-effectiveness of exercise programs used in patients with moderate to high risk of cardiovascular disease.

Methods: A search was performed for economic evaluations of exercise interventions in patients with at least one risk factor for cardiovascular disease. A search containing terms including “exercise”, “costs and cost analysis” and “cardiovascular disease” was performed and reviewed independently by two researchers. Cost-effectiveness was described based on a model for evaluating interventions intended to promote physical activity.

Results: Our search resulted in 306 articles, 12 of which met our inclusion criteria. Eight were randomized controlled trials and 4 were models with hypothetical cohorts. Six studies examined diabetic patients, 1 examined hypertensive patients, 2 examined obese patients, and 3 examined patients with combined risk factors for cardiovascular disease. Exercise interventions were broad, ranging from 6 hours to 10 years. Ten studies concluded their interventions as cost-effective, 1 as not cost-effective, and 1 as inconclusive.

Conclusion: The literature on exercise interventions used in primary prevention for patients with moderate to high risk of cardiovascular disease strongly supports their cost-effectiveness. However, the studies reviewed were very heterogeneous in the duration and intensity of their interventions. Future research directions should examine the efficacy and cost-effectiveness of standardized lifestyle interventions, with the aim of garnering enough evidence to support or refute their utility in the primary healthcare setting.


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Automatic Quality Assessment of Echo Apical 4 Chamber Images Using Computer Deep Learning

Christina Luong

Background: Echocardiography is a noninvasive imaging modality that allows for assessment of cardiac structure and function for clinical decision-making.However, scanning is a resource intensive technical procedure, which is dependent on operator skill and experience.

Objectives: We sought to develop a method to automatically compute an image quality score of a specific echo image (end-systolic apical 4-chamber view) for future application to a real-time feedback platform for optimization of images at the time of acquisition.

Methods: The model used for this application was a deep convolutional neural network model trained on a large set of labeled samples. Randomly fetched end-systolic apical 4-chamber images were obtained from a clinical database. A total of 6 916 images were manually graded by a single observer for image quality with a score ranging between 0 (unacceptable image) and 5 (good quality). Of these labeled images, 80% were used to train the network and the remaining 20% were used to test the model for agreement with manual scoring.

Results: The performance of the model is based on the 1 387 images for testing. The average absolute error of the model compared with manual scoring was 0.68±0.58, with 91% of the images obtaining a score difference of <1. Using a sample of 200 images, intraobserver variability demonstrated high agreement; within subject standard deviation was 0.65 (κ = 0.80). The average time required for the network computation of the image quality score was 10 ms.

Conclusion: Deep convolutional neural networks can reproducibly and accurately score the quality of apical 4-chamber images as compared with manual scoring.


38

Detecting Underlying Cardiovascular Disease in Young Competitive Athletes

Hamed Nazzari, MD, PhD, Daniel Lithwick, BSc, Barbara Morrison, BSc, Michael Luong, MD, Christopher Fordyce, MD, MSc, Jack Taunton, MD,

Andrew Krahn, MD, Brett Heilbron, MD, James McKinney, MD, MSc, Saul Isserow, MD

Background: Sudden cardiac death (SCD) is frequently the first manifestation of underlying cardiovascular disease in young competitive athletes (YCAs), yet there are no Canadian guidelines for preparticipation screening in this population. The goal of this study was to determine the prevalence of potentially lethal cardiovascular disease in a sample of Canadian YCAs by comparing 2 screening strategies.

Methods: We prospectively screened 1419 YCAs in British Columbia, Canada (age 12-35 years). We initially screened 714 YCAs using the American Heart Association 12-element recommendations, physical examination, and electrocardiogram (ECG) examination (phase 1). This strategy yielded a high number of false positive results; 705 YCAs were subsequently screened using a novel SportsCardiologyBC (SCBC) questionnaire and ECG examination in the absence of a physical examination (phase 2).

Results: Overall, 7 YCAs (0.52%) were found to have clinically significant diagnoses associated with SCD (4 pre-excitation, 1 long QT syndrome, 1 mitral valve prolapse, 1 hypertrophic cardiomyopathy). Six of the 7 athletes (85.7%) with disease possessed an abnormal ECG. Conversely, only 2 had a positive personal or family history (1 athlete had an abnormal ECG and family history). The SCBC questionnaire and protocol (phase 2) was associated with fewer false positive screens; 3.7% (25 of 679) compared with 8.1% (55 of 680) in phase 1 (P = 0.0012).

Conclusions: The prevalence of conditions associated with SCD in a cohort of Canadian YCAs was comparable with American and European populations. The SCBC questionnaire and protocol were associated with fewer false positive screens. The ECG identified most of the positive cases irrespective of screening strategy used.


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Quantification of Pleural Effusions by Two-Dimensional EchocardiographyAlice Chang

Background: Pleural effusion (PLE) is a common occurrence in patients with heart disease, and often incidentally detected on 2D transthoracic echocardiograms (TTE). A method for echocardiographic quantification of PLE has not been developed to date, and thus considerable variability exists in the reporting of this finding.

Objective: Our aim was to determine whether PLE measured from routine TTE views correlate with the amount visualized on CXR. Furthermore, we sought to assess the predictive ability of the TTE to delineate between small vs. moderate or large PLE.

Methods: A retrospective analysis of 204 patients (mean age 71.5 years, 53% men) who underwent clinically indicated TTE at Vancouver General Hospital between 1/2015 – 1/2017 were conducted. Inclusion criteria were presence of PLE indicated by the final TTE report, and upright CXR performed ±2 days. Linear measurements of the largest PLE pocket were obtained from parasternal long axis (PLAX), apical four chamber views, and subcostal views. On CXR, size of PLE was determined and categorized to small, moderate and large. The strength of association between TTE and CXR measures of PLE was assessed. The ability of TTE to predict “large” PLE on CXR was tested using AUROC.

Results: There are statistically significant associations between PLE size assessed by TTE by certain views and CXR: Apical, PLAX (Depth), and PLAX (Length), all P<0.05. Despite this significant association, the predictive ability of TTE is minimal; Area Under the Curve from ROC for Apical Left, Apical Right, and PLAX (Depth) were 0.68 (95% CI [0.47, 0.89]), 0.67 [0.46, 0.88], and 0.612 (95% CI [0.35, 0.88]), none of which were significantly better than chance. Optimal TTE thresholds for predicting ‘large’ PLE on CXR were 2.25cm (accuracy = 40%), 2.3cm (43%), and 9cm (48%).


40

Atrial Arrhythmias in Adults with Congenital Heart DiseaseDarryl Wan, Santabhanu Chakrabarti

Background: Atrial arrhythmias are common in adults with congenital heart disease. Patients with complex congenital heart disease develop atrial arrhythmias at a young age, but long-term data and associated thromboembolic risk is not well established.

Objectives: This study aims to describe patient characteristics, associated co-morbidities, and thromboembolic complications in adult patients with Transposition of the Great Arteries (TGA) and Tetralogy of Fallot (ToF) in a longitudinal retrospective cohort.

Methods: A retrospective cohort study of all TGA and ToF patients in a single tertiary care center was conducted. Patients < 18 years of age or with < 1year follow-up were excluded. Patients were identified by diagnostic coding and data was extracted by chart review.

Results: 125 patients with TGA were included (76 D-TGA, 49 L-TGA) and 260 patients with ToF were included. Mean age was 38.8 years for patients with TGA and 37.6 years in patients with ToF. Atrial fibrillation (AF) was found in 20.3% and 9.23% of patients with TGA and ToF respectively. 11/25 (44%) patients with atrial fibrillation in the TGA cohort had stroke or TIA, whereas this was only evident in only 2/32 (6.3%) patients in the ToF cohort. Traditional risk factors such as hypertension and diabetes were not associated with thromboembolic events in this study.

Conclusion: Adult patients with congenital heart disease form a young population who have a significant burden of atrial arrhythmia when compared to the general population. This may be associated with an increased lifetime risk of thromboembolism, but traditional risk factors may not apply to this population.


41

Personalizing Therapy for Atrial FibrillationScott Barichello

Atrial fibrillation is a complex disease, characterized by an interplay of processes that act in broad spatial and temporal dimensions and that have an incompletely understood ionic and molecular basis. Disturbance in numerous pathways have been implicated in producing the commonly observed atrial fibrillation phenotype, and considerable inter-patient variability exists in the underlying pathological processes responsible for a given patient’s disease. The known pathogenic variability underlying this very common disease helps to explain the highly variable efficacy of current standard therapies in the population and provides the rationale for adopting a personalized approach that moves away from the one size fits all therapy and instead recognizes the many distinct pathophenotypes of the disease.

Achieving increasingly personalized management of atrial fibrillation will necessarily involve ongoing efforts in three parallel domains: improved understanding of the underlying mechanisms, novel methods to detect the culprit pathological processes underlying a given patient’s disease, and development of highly efficacious, mechanistically targeted therapies.

This review examines in detail: i) the common and rare genetic variants conferring susceptibility to AF ii) The evolving role of stem cell models as preclinical models for anti-arrhythmic testing in AF and iii) the role of personalized computer simulation models for understanding the mechanisms of AF and guiding ablation therapies in individual patients.


42

Palliative Care in Congestive Heart Failure: Impact on Hospital ReadmissionKatie Wiskar

Background: End-stage heart failure (HF) is characterized by high symptom burden and frequent hospitalization. For this reason, Palliative Care (PC) is recommended for advanced HF by several major societies. While small studies suggest that PC may decrease readmission in advanced HF, this has not been well-studied.

Objective: To examine the relationship between inpatient PC consultation during HF hospitalization and 6-month hospital readmission rates.

Methods: We performed a retrospective cohort study using the Nationwide Inpatient Sample, isolating patients age ≥18 hospitalized with a primary diagnosis of HF (ICD9 code 428.XX) during 2013. This cohort was segregated into patients who received inpatient PC consultation (ICD9 code V667) and those who did not. The National Readmission Database was used to calculate 6-month readmission rates. A multivariate logistic regression model was created to predict the result of hospital readmission for HF, and a propensity score for the intervention of PC referral was created.

Results: We analyzed 14,325,172 hospitalizations and identified 102,746 patients who survived an admission for HF in the first 3 months of 2013. Of these, 2,287 (2.2%) patients were referred to PC as inpatients. In a multivariate analysis, PC referral was associated with significantly reduced risk of readmission (OR 0.23, 95% CI 0.20-0.25, p<0.01). In a propensity-matched cohort of 2,282 patients, those receiving PC referral were less likely to be readmitted for HF (9.3% vs 22.4%, p<0.01) or for any cause (29.0% vs 63.2%, p<0.01) during the 6-month follow-up period.

Conclusions: In this nationally representative sample, inpatient PC referral during a hospital admission for HF significantly decreased all-cause and HF-specific 6-month readmission rates. This has important implications for both patient care and healthcare economics, and highlights the value of integrating PC into the care of advanced HF patients.


43

Preventability of 28-Day Hospital Readmissions in General Internal Medicine Patients: A Retrospective Analysis at a Canadian Quaternary

HospitalDr. Constantin Shuster, Dr. Andrew Hurlburt, Dr. Terence Yung, Dr. Tony Wan,

Dr. John A. Staples, Dr. Penny Tam

Background: Unplanned hospital readmissions are associated with increases in patient mortality, patient dissatisfaction and healthcare costs. In Canada, about 13.5% of medical admissions undergo unplanned hospital readmission within 30 days, yet only a fraction are likely to be preventable.

Objective: The purpose of our study was to identify preventable hospital readmissions and their common causes in order to inform local readmission prevention interventions.

Methods: We performed a retrospective cohort analysis of 28-day hospital readmissions to the general internal medicine teaching service at Vancouver General Hospital, a quaternary care Canadian hospital. From Sept-2015 to Jan-2016 patients ≥ 18 years were recruited following readmission for ≥ 24 hours; readmission was identified via the hospital electronic medical record (EMR) system. Data was gathered via structured review of hospital charts and EMRs along with standardized patient interviews. Unique to our study, a multidisciplinary panel of physicians, nurses and hospital administrators adjudicated preventability and identified common causes of readmission.

Results: Fifty-five hospital readmissions were identified; 53% were adjudicated to be preventable. There was no difference in any variable analyzed between preventable and non-preventable readmissions. LACE index and HOSPITAL score did not correlate with preventability. The most common causes of preventable readmissions were inadequate coordination of community services upon discharge, insufficient clinical post-discharge follow-up and suboptimal end-of-life care.


44

The Impact of LVAD Infections on Post Cardiac Transplant Survival: Systematic Review and Meta-Analysis

Daljeet Chahal, Amir Sepehrya, Alissa Jade Wright, Mustafa Toma

Background: Left ventricular assist devices (LVADs) improve survival for patients with end stage heart failure while they wait for transplantation. LVADs may develop complications, such as infections. Development of an infection decreases survival while on LVAD support. The impact that LVAD related infections may have on outcomes after transplantation is less well studied. We sought to determine if the presence of infection while on LVAD support negatively influences clinical outcomes after cardiac transplantation.

Methods: We searched Medline, Embase, and Cochrane Central Register of Controlled Trials for eligible full text studies. We also hand searched study bibliographies. Eligible studies included those that identified LVAD related infections during support and reported on outcomes after cardiac transplantation. Reviewers determined quality and collected baseline and outcomes data. Meta-analyses of post-transplant survival were conducted utilizing a random effects model.

Results: Electronic search identified 2373 records; 13 were selected for analysis (n=6631, 82% male, mean age 50 +/- 14 years). 3718 continuous flow LVADs and 1752 pulsatile LVADs were identified. Of these, 2586 developed LVAD related infections. Patients with LVAD related infections were younger (49.7 +/- 13.1 vs. 52.5 +/- 12.5), had higher mean BMIs (28.5 vs. 26.6), lower incidence of ischemic etiology of heart failure (40% vs. 44%), and longer LVAD support times (252 days vs. 221 days). Meta-analysis of all studies demonstrated significantly decreased post-transplant survival in those patients who had a documented LVAD infection (HR 1.3, p<0.001). Sub-group meta-analyses by CF and pulsatile device type also demonstrated significant hazard ratios (1.47, p<0.001 and 1.71, p=0.004), whereas meta-analyses by infection type did not. Sub-group analyses by study size revealed significant HR when studies with greater than 100 patients were used (HR 1.35, p<0.001) but not with smaller studies. Post-hoc analysis revealed significant impact of age, BMI, and LVAD duration on post-transplant survival.

Conclusions: Our data suggests that LVAD related infections have a detrimental impact on post cardiac transplantation survival. Patients who develop LVAD infections have higher BMIs and longer LVAD support times. Interventions aimed at reducing infection rates during LVAD support would improve outcomes both before and after cardiac transplantation.


45

Clinical Outcomes of Start-low, Go-Slow Methadone Initiation for Cancer-Related Pain

Lawrance Chow

Background: Palliative care physicians are increasingly prescribing methadone for cancer related pain, a drug which has unique pharmacologic properties particularly for pain refractory to traditional opioids. Limited data exists on its effectiveness and how best to transition to methadone therapy in the outpatient setting.

Objective: To present our provincial experience of new methadone starts for malignancy-associated pain with a focus on efficacy, safety, and method of transition primarily utilizing the Start-Low-Go-Slow method.

Methods: Charts were reviewed of patients referred to the Pain and Symptom Management/Palliative Care clinics at the 6 BC Cancer Agency’s regional centres that underwent initiation of methadone for analgesia over a 14-year period between 2000-2013. Patient characteristics, mechanism of pain, patterns of prescribing, method of start, and outcomes of methadone treatment were recorded.

Results: Of the 652 identified patients, we were able to determine outcomes of methadone initiation in 564 (86.5%). Among these, 422 (74.8%) were deemed successful initiations, as determined by whether or not the patient remained on methadone at follow-up with subjective improvement in pain control, on a stable dose of methadone. Of 450 patients who were on strong opioids at the time of transition, 376 (84%) transitioned gradually with the Start-Low-Go-Slow method. Of the unsuccessful trials, 97/142 were due to adverse drug reactions with 16 hospitalizations that were conceivably related to methadone therapy and 1 documented death from deliberate overdose.

Conclusions: Initiation of methadone for analgesia in ambulatory cancer patients can be done safely in an outpatient setting using a Start Low-Go Slow method, and can be expected to be helpful in approximately 75% of patients. The most common reason for discontinuation is due to adverse drug, rather than for inadequate analgesia. Serious adverse events requiring hospitalization were rare (2.5%) but may be underestimated due to the retrospective nature; future prospective trials would be beneficial.


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POSTER PRESENTATIONS


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Comparing outcomes of neoadjuvant endocrine therapy versus chemotherapy in ER-positive breast cancer: Results from a prospective

institutional databaseLevasseur N1, Yip W2, Li H2, Willems K2, Illman C2, McDermott M2, Simmons

C1

1 Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, Canada

2University of British Columbia, Vancouver, Canada

Background: While neoadjuvant chemotherapy (NACT) has been established as the standard of care for medically fit patients, there has been renewed interest in utilizing neoadjuvant endocrine therapy (NET) for the treatment of women with estrogen-receptor (ER) positive, HER-2 negative breast cancer. Rates of pCR are known to be low in this population, but there is inconsistent data regarding downstaging and long-term outcomes in a non-trial setting with NET vs NACT.

Methods: A prospective institutional database of breast cancer pts treated with neoadjuvant therapy at the BC Cancer Agency from 2012-2016 was analyzed to identify all pts with ER positive, HER2 negative breast cancer. Pts were then divided into two groups: those who received NET or NACT. Baseline characteristics were compared between groups. A matched analysis (age, stage and grade) was then performed to compare rates of downstaging, pCR and scores from a validated neoadjuvant therapy outcomes calculator (CPS+EG).

Results: A total of 154 patients met eligibility criteria for this study. One hundred and six patients (69%) received NACT and 48 (31%) received NET. Women offered NACT were significantly younger (51 vs 64y, p<0.001) than those offered chemotherapy and presented with a higher clinical stage (LR 27.93, p=0.002). According to multiple linear regression for downstaging, clinical stage followed by NACT were the most important predictors of downstaging. When matched for age, stage and grade, downstaging was significantly higher with NACT (31/48, 65%) as compared to NET (12/48, 25%), p<0.001. Of these, 12.5% achieved pCR with NACT as compared to 2.1% with NET, LR 4.243, p=0.039. No significant differences in CPS+EG scores were identified when comparing NACT to NET.

Conclusions: Significantly higher rates of downstaging were achieved with NACT as compared to NET when patients were matched for age, stage and grade. Rates of pCR remain low for ER-positive breast cancer patients. Although not validated with the use of NET, CPS+EG scores predicting long-term outcomes were not significantly different with NET compared to NACT.


48

Patterns of practice in EGFR mutation positive NSCLC:Use of gefitinib versus afatinib

Zamzam Al-hashami, Cheryl Ho, Janessa Laskin

Introduction: The standard of care for metastatic epidermal growth factor receptor (EGFR) mutated non small cell lung cancer (NSCLC) has been a first generation (Gefitinib) EGFR tyrosine kinase inhibitor since 2009. Recently a comparison trial of first generation gefitinib versus second generation afatinib in the first line setting was conducted. LUXLUNG7 showed an improvement with afatinib over gefitinib in PFS with a hazard ratio of 0.71.

Objectives:To evaluate patient and tumor factors that impact clinician decision making regarding first line gefitinib versus afatinib in EGFR mutation positive diseaseTo assess rates of toxicity associated with gefitinib and afatinib respectively.To compare dose reductions and alternate dose schedules with gefitinib versus afatinib.

Methods: A total of 250 patients with stage IV NSCLC who referred to the BCCA between Oct 2014 and Dec 2015 and received first line gefitinib or afatinib for EGFR mutation positive disease were enrolled in the study. 119 patients received gefitinib as first line therapy while 25 patients had first line afatinib. Patients with Inadequate follow up to evaluate treatment, toxicity and outcomes were excluded. Comparisons was made using Chi squared test, Fishers exact test, Kruskal Wallis test. Multivariate analysis to evaluated factors used in treatment selection was conducted using logistic regression. PFS and OS were calculated using the Kaplan Meier method and compared using the log rank test.

Result: Table 1 outline the baseline characteristics. Afatinib therapy associated with more toxicity requiring change in therapy (dose reduction 52%, dose interruption 32%) compared to gefitinib which was more tolerable. Interestingly, the median OS is 36.8 months in patient who had change in therapy due to toxicity compared to 28.8 months in those who tolerated the therapy. (P value 0.113). The PFS was 27.7 months in patient who had change in therapy secondary to toxicity compared to 23 months in those who tolerated therapy. Most common side effects rash and diarrhea in both groups.

Discussion: The study showed significant improvement in OS and PFS in patients who had dose reduction. Most patients who had dose reduction were treated with afatinib. However, this improvement was not seen when OS was calculated separately for Gefitinib and afatinib. Larger studies need to be conducted to assess this association.


49

Personalized Oncogenomic Analysis of Metastatic Adenoid Cystic Carcinoma: Using Whole Genome Sequencing to Influence Clinical Decision

MakingManik Chahal, IM R1, Erin Chapman, Pathology and Lab Med Fellow, Erin

Pleasance, BCCA/Michael Smith Genome Sciences Centre, Tony Ng, Pathology and Lab Med, Janessa Laskin, Medical Oncology

Background: Metastatic adenoid cystic carcinomas (ACC), though relatively rare, can cause significant morbidity and mortality. Recently, molecular profiling studies have begun to reveal the genetic landscape of these poorly understood cancers.

Objective: To use whole genome sequencing and mRNA analysis to better understand the genetic alterations underlying the pathology of ACC and determine actionable therapeutic targets.

Methods: We report 5 cases of metastatic ACC in patients enrolled in the Personalized Onco-Genomics Program at the BC Cancer Agency. Genomic workup was performed on fresh-frozen tumor biopsies obtained specifically for molecular analysis, archival tissue, and peripheral blood samples as a germline DNA reference. Molecular analyses included targeted deep sequencing of a panel of cancer-related genes, whole-genome sequencing, and RNA sequencing. Data was processed using a well-established bioinformatics pipeline. Literature review for drug-targeted combinations and pharmacogenetics was integrated to identify potential therapeutic recommendations.

Results: Analysis thus far reveals small mutational burden in 4 of 5 cases, with one case of ACC originating in the floor of the mouth exhibiting a significantly higher number of mutations. BAP1, a known tumor suppressor gene, exhibited greater than one mutation in all 5 cases. Notably, the only recurrent structural aberration identified is the well-described MYB-NFIB fusion that is present in 4 of 5 cases, with the 5th case exhibiting a closely related MYBL1-NFIB fusion. Other genes involved in structural variation are currently under review. Furthermore, therapeutic targets were identified in all 5 cases, and directed therapy in 3 cases to date. Our findings therefore confirm a role for the MYB-NFIB fusion in ACC pathogenesis, and suggest that whole-genome and transcriptome sequencing can yield clinically useful and actionable information.


50

Attrition Across The Hiv Cascade Of Care Among A Diverse Cohort Of Women Living With Hiv In Canada

G. Kerkerian, M. Kestler, A. Carter, L. Wang, P. Sereda, E. Roth, M. J. Milloy, N. Pick, D. Money, N. Kronfli, A. Lacombe Duncan, K. Webster, M. Desbiens, D. Dubuc, R. S Hogg, A. de Pokomandy, M. Loutfy, A. Kaida, on behalf of the

CHIWOS Research Team

Background: In North American settings, women are less likely to be engaged across the HIV care cascade. Among Canadian women living with HIV (WLWH), we explored cascade attrition by stage and key sub populations, and assessed correlates of attrition from ‘antiretroviral (ART) adherence’ to ‘viral suppression’.

Methods: We analyzed baseline survey data from 1,425 WLWH (=16 years; trans-inclusive) enrolled in the Canadian HIV Sexual and Reproductive Health Cohort Study (CHIWOS), Canada’s largest community-based cohort of WLWH. We measured the proportion of women engaged in seven nested stages of the care cascade, via self-report: HIV-diagnosed, linked to HIV care, retained in HIV care, initiated ART, currently on ART, ART adherence (=90%), and viral suppression (< 50 copies/mL). We examined attrition across stages overall and by age, ethnicity, housing stability, food security, illicit drug use, and violence. Among those currently on ART, multivariable logistic regression identified factors associated with not being suppressed.

Results: Median age was 43 (IQR: 35-50); 96% of women identified as cis-gender; 22% were Indigenous, 29% African/Caribbean/Black, and 41% Caucasian/White. Median years living with HIV was 11 (IQR: 6-17). Overall: 98% were linked to care; 96% retained; 88% initiated ART; 83% were currently on ART; 68% were adherent; and, among those on ART, 72% were virally suppressed with variation (45% 84%) by sub-population. The largest attrition occurred between ‘on ART’ and ‘ART adherence’ (-17%), with the greatest losses among women with Indigenous ancestry (-25%), current violence (-27%), and current illicit drug use (-32%). Substantial attrition also occurred between ‘linked to HIV care’ and ‘initiated ART’(-11%), with the greatest losses occurring among women 16-29 years (-20%) and with unstable housing (-27%). Adjusted odds of not being virally suppressed were significantly higher among women who were young [aOR: 1.4 (95% CI: 1.1-1.79) per 10 years younger], food insecure [1.77 (1.03-3.05)], incarcerated in the past year [3.84 (1.56- 9.45)], and currently using illicit drugs [3.25 (1.46-7.25)].

Conclusions: Nearly one-in-three WLWH in this Canadian cohort were lost across the HIV care cascade, with significant differences by stage, sub-population, and social inequities. Targeted interventions are needed to improve engagement across the care cascade for a diverse community of WLWH.


51

IV to PO antibiotic step-down on medical floors at a tertiary care centre: low hanging fruit for an antimicrobial stewardship intervention?

M. Michaleski,* S. Shajari, D. Ghag, J. Grant.

BACKGROUND: The safety of early transition from IV to PO antibiotics in many clinical syndromes is well established. Transition to PO antibiotics reduces adverse outcomes associated with IV therapies such as thrombophlebitis and nosocomial infections. IV to PO transition also can reduce length of stay (LOS) and decrease health care costs.

OBJECTIVE: Using a two-week sampling, we project the savings of a comprehensive IV to PO conversion programme in medical wards at a major tertiary care centre.

METHODS: We reviewed the charts of all patients admitted to 8 medical wards (including Internal Medicine and Hospitalist) receiving IV antibiotics for greater than 48 hours. Using validated criteria to identify patients eligible for IV to PO step-down, we followed patients for 30 days after transition to oral therapy to assess for discharge date, C. difficile infection, MRSA colonization, VRE colonization, and treatment failure.

RESULTS: We identified 72 patients on IV antimicrobials for over 48 hours. Forty-two (58%) were eligible for step-down. Of these patients, 19 (45%) were appropriately transitioned to PO medication, while 23 (55%) patients continued IV therapy. There were 58 days of unnecessary IV antibiotics. The most common clinical syndromes not transitioned to PO therapy were CAP (n = 8), aspiration pneumonia (n = 6) and UTI (n = 6), with an average unnecessary time on IV therapy of 1.75 days, 2.5 days, and 2.6 days, respectively. This translates to 1500 excess IV antimicrobial days per annum with a potential cost savings of over $2 million per annum if all patients could be transitioned to PO therapy.

CONCLUSION: Despite clear evidence that early transition from IV to PO antimicrobials is safe and prudent, prolonged IV therapy remains a problem. Antimicrobial stewardship interventions aimed specifically at this aspect of care will play a key role in reducing treatment costs and improving patient flow.


52

BNP to Predict Post-Liver Transplant Mortality: Systematic Review and Meta-Analysis

Daljeet Chahal, Alan Yau, Vladimir Marquez

Background: Cardiac events are a major cause of mortality after liver transplantation. Brain Natriuretic Peptide (BNP) is elevated in cirrhotic patients and is used to predict cardiac events after non-cardiac surgery. It’s utility to predict mortality after liver transplantation is unknown.

Methods: We searched Medline, Embase, Cochrane Register of Controlled Trials and bibliographies. Eligible studies included those with peri-operative BNP data, those which stratified patient cohorts by BNP level or presence of post-transplant heart failure, and those with post-transplant outcomes data. Reviewers determined study quality and collected data. Meta-analyses were performed using random effects modeling.

Results: Electronic search yielded 192 records; 7 were eligible for analysis (n=2010, age 52.5 +/- 9.3, 51.5% to 81.3% male, MELD 21.4 +/- 9). Hepatitis C was the most prevalent etiology (38%), followed by alcohol (23%). 335 patients were identified as having high BNP levels or heart failure post-transplant. These patients were older (56.1 vs. 54), had lower BMIs (25.2 vs. 27.1), higher MELD scores (24.5 vs. 19.1) and lower LVEFs (55.9% vs. 61.7%). Post-transplant mortality was higher in patients with high BNP (25% vs. 7%) or post-transplant heart failure (39% vs. 25%). Meta-analysis of three studies examining post-transplant mortality based on elevated BNP revealed a hazard ratio of 3.1 (95% CI 1.9 – 5.0). Meta-analysis of two studies examining post-transplant mortality based on post-transplant heart failure revealed a hazard ratio of 1.6 (95% CI 1.3 – 2.1). Analysis of one study examining post-transplant cardiac events based on elevated BNP revealed a hazard ratio of 7.9 (95% CI 1.8 – 34.7). Patients with high BNP or post-transplant heart failure may also have higher rates of cardiac arrest, sepsis, dialysis, and longer ventilation times.

Conclusions: BNP is useful to predict post-liver transplant mortality. Future studies should focus on further establishing which patients are at high risk for post-transplant mortality.


53

Validity of algorithms for estimating left sided filling pressures on echocardiography in a population referred for pulmonary arterial

hypertensionEric Leung

Background: The determination of LV filling pressure is integral to the diagnosis of pulmonary arterial hypertension (PAH). The American Society of Echocardiography (ASE) has devised algorithms for their estimation. We aimed to test these algorithms in a population referred for suspected PAH.

Methods: In our retrospective study, we evaluated the accuracy of the ASE Algorithms compared to right heart catheterization done within 3 months, in patients seen from 2006-2014. All echocardiograms were classified as showing normal, elevated or indeterminate filling pressures. Those with indeterminate pressures were excluded. We evaluated the diagnostic properties of this algorithm to predict a pulmonary artery wedge pressure (PAWP) and left ventricular end diastolic pressure (LVEDP) > 15 mmHg.

Results: A total of 96 patients were included. The ASE algorithms yielded indeterminate results in 40 (41.7%) patients. This occurred more commonly in older patients and with higher BMI. The algorithm had a negative predictive value of 92.3% for predicting an elevated LVEDP (95% CI 74.9, 99.1), but a positive predictive value of only 61.9% (95% CI 38.4, 81.9). The negative predictive value and positive predictive values for predicting elevated PAWP were lower, at 75.8% (95% CI 57.7, 88.9) and 56.5% (95% CI 34.5, 76.8), respectively.

Conclusions: The ASE algorithm for predicting LV filling pressures often cannot be applied in populations with suspected PAH. When they are interpretable, they have a high negative predictive value for elevated LVEDP, with a modest positive predictive value. We recommend caution when using these algorithms in populations with suspected PAH.


54

Relationship Between Cardiomegaly by Chest X-Ray and Left Ventricular Size by Echocardiography

Alice Chang

Background: The diagnostic accuracy of cardiothoracic ratio (CTR) on chest x-ray (CXR) to detect left ventricular (LV) enlargement has been criticized due to low sensitivity and specificity. Although several studies have compared CTR against linear and volumetric LV measurements on TTE, there is paucity of data incorporating LV end-diastolic dimension indexed (LVEDD) to body surface area (BSA).

Objective: Our aim was to investigate the correlation between CTR and LVEDD indexed, and to determine the predictive value of CTR to detect enlarged LV (defined by >30 mm/m2).

Methods: Consecutive patients who underwent transthoracic study at tertiary care hospital 1/2015-1/2017 and also had a posteroanterior CXR within 60 days were identified. Patients were excluded if there was presence of pericardial effusion. Using the parasternal long-axis view, LVEDD (mm) was measured by standard techniques according to the recommendations of the American Society of Echocardiography and indexed to BSA (m2). Cardiothoracic ratio was calculated by dividing maximum transverse diameter of the heart shadow by the maximum transverse diameter of right and left lung boundaries. Pearson correlation was used, with ability of CTR to predict ventricular enlargement (LVEDD indexed) > 30mm/m2 assessed using the Area-Under the Receiver-Operating Characteristic curve (AUROC) with cutpoint for accuracy defined with the Youden criteria.

Results: A total of 187 patients (mean age 68.5 ± 12 years, 51% men) were reviewed. There was a weak (r = 0.215), but statistically significant (p = 0.043) (graph) correlation between CTR and indexed LVEDD. The ability of CTR to predict LV enlargement (LVEDD indexed > 30mm/m2) was also minimal with an ROC area under the curve of 0.58 (95%CI 0.48, 0.68) and accuracy of 59% with a CTR cutpoint of 0.55.


55

The Effects of Targeted Temperature Management on Mortality and Neurologic Outcome: A systematic review and meta-analysis Drs. Vesna Mihajlovic, Dylan Stanger, Graham Wong

Background: Two randomized controlled trials in 2002 demonstrated that induced hypothermia (32-34°C) had neuroprotective effects in patients with out-of-hospital cardiac arrest (OHCA) and initial shockable rhythm.

Objective: To conduct a systematic review, and where applicable meta-analyses, to examine the evidence underpinning the use of targeted temperature management (TTM) following resuscitation from cardiac arrest.

Methods: Nine PICO questions were developed and MEDLINE Ovid, EMBASE, and Cochrane CENTRAL were used to search for publications between January 2000 and February 2016. Studies selected were assessed for quality using Grading of Recommendations, Assessment, Development and Evaluations (GRADE), Cochrane Risk of Bias Tool, and National Institute of Health Study Quality Assessment Tools. The primary outcomes for each PICO question were mortality and poor neurological outcome.

Results: Low quality evidence demonstrated that TTM at 32-36°C, compared to no TTM, decreased mortality (RR 0.76, 95% CI 0.61-0.92) and poor neurological outcome (RR 0.73, 95% CI 0.60-0.88) amongst adult survivors of OHCA. TTM use did not benefit survivors of in-hospital cardiac arrest (IHCA) nor OHCA survivors with a non-shockable rhythm. Moderate quality evidence demonstrated no benefit of pre-hospital TTM initiation in reducing mortality nor poor neurological outcomes. Low quality evidence showed no difference between endovascular versus surface cooling systems, nor any benefit of adding feedback control to TTM systems. Very low quality evidence suggested that TTM be maintained for at least 18 hours. The benefit of preventing post-rewarming fever remains unclear.

Conclusions: Low quality evidence supports the in-hospital initiation of TTM at 32-36°C amongst adult survivors of OHCA with an initial shockable rhythm. The effects of TTM on other populations, the optimal rate and method of cooling and rewarming, and effects of fever require further study.


56

Fluid Challenge during Right Heart Catheterization: An experience from a tertiary pulmonary hypertension referral centre

Nima Moghaddam, John R Swiston, Robert D Levy, Victor F Huckell, Nathan W Brunner

Background: Differentiating pre-capillary or pulmonary arterial hypertension (PAH) from post-capillary pulmonary hypertension (PH) is challenging. Patients with PH secondary to left heart disease (PH-LHD) may do poorly if treated with PAH targeted therapies. In PAH, the pulmonary arterial wedge pressure (PAWP) is ≤15 mmHg at right heart catheterization (RHC). However, a normal PAWP is a poor predictor for absence of left heart disease. Therefore, there has been an interest in using fluid challenge to unmask PH-LHD.

Objective: To evaluate the impact of fluid challenge in the classification and management of a real world population of patients with PH.

Methods: The PH clinic charts were reviewed to identify patients who underwent fluid challenge during RHC from July 1, 2013 to March 31, 2016. Only patients with a baseline PAWP of ≤15 mmHg were included. A structured chart review was undertaken comparing the clinical, echocardiographic and RHC data for patients with a positive fluid challenge (PFC) to those with negative fluid challenge (NFC).

Results: We identified 47 patients who met the inclusion criteria. Fluid challenge was associated with an increase in PAWP by 5.7±2.7 mmHg and 2.2±2.3 mmHg for PFC and NFC, respectively. A PFC correlated with a lower transpulmonary pressure gradient (TPG; 19.6 vs. 26.3 mmHg) and diastolic pressure gradient (DPG; 9.1 vs. 14.0 mmHg). 83% of patients with PFC were classified as WHO Group 2 PH compared to only 30% of patients with NFC (P<0.001). The majority of patients with PFC were not started on advanced PH therapies (36% vs. 63%, P=0.08) and subsequently were discharged from PH clinic (46% vs. 9%, P=0.006)

Conclusion: A positive fluid challenge is associated with parameters associated with left heart disease, such as a lower DPG and TPG. In our population, it influences the classification of PH, and whether patients are started on therapy or discharged from clinic.


57

Increased prevalence of sub-clinical atherosclerosis in individuals withdamaging mutations in ABCA1 and APOA1

Omar Abdel-Razek

Background: A low level of high density lipoprotein (HDL) cholesterol is a common clinical scenario and poses challenges for management because of the lack of approved therapies and uncertainty regarding the causal relationship between HDL and atherogenesis. Many patients with low HDL cholesterol harbor a damaging mutation in one of several genes, such as ABCA1 or APOA1. However, it is unknown whether patients with such mutations have increased atherosclerosis relative to patients with low HDL cholesterol without a mutation.

Objectives: The purpose of this study was to investigate the prevalence of clinical or subclinical atherosclerosis among patients in whom a major genetic cause of low HDL was established.

Methods: Our study included 67 patients referred to a specialty lipid clinic with HDL cholesterol levels below the 10th percentile. We sequenced patients using a customized next-generation sequencing assay designed to capture the coding regions of genes with established roles in lipid metabolism. We examined the prevalence of clinical atherosclerosis (established coronary artery disease or cerebrovascular disease) or sub-clinical atherosclerosis (presence of plaque on carotid ultrasound, non-zero coronary artery calcium score or presence of coronary atherosclerosis on CT coronary angiogram). Results: We identified a known disease-causing or likely pathogenic variant in the ABCA1 or APOA1 genes in 10 patients (14.9%). Seventy percent of patients with a damaging mutation in ABCA1 or APOA1 had evidence of atherosclerosis compared to 38.6% with low HDL cholesterol without such a mutations (p=0.03). To gain further insight into the mechanism of atherosclerosis, we examined cholesterol efflux capacity in the plasma of these patients. Patients with damaging mutations in ABCA1 or APOA1 had lower cholesterol efflux capacity compared to patients without a mutation (25.9% vs. 30.1%).

Conclusion: Our results indicate that the presence of a damaging mutation in ABCA1 or APOA1 confers an increased risk of atherosclerosis relative to patients without such a mutation at a comparable level of HDL cholesterol, possibly because of a reduction in cholesterol efflux. Therapies targeted to increase cholesterol efflux in such patients may result in clinical benefit.


58

CALI: Fellows as Clinical Teachers in the Outpatient Internal Medicine Clinic

Allison Nakanishi

Background: “Residents as teachers” (RaT) is a Royal College mandated goal of training for Internal Medicine. In the role as teacher, residents have the opportunity to be scholars and leaders. The majority of the training that residents receive about teaching occurs in the inpatient setting. Yet, a large part of eventual independent practice is in the outpatient setting. There is a paucity of resources to prepare residents to be teachers in the outpatient setting. With third year medical students set to complete a mandatory rotation in the internal medicine clinics at UBC, there is the opportunity to develop a curriculum for RaT, or fellows as teachers, in the outpatient setting.

Objective: To develop a curriculum for Fellows as teachers specifically for the outpatient internal medicine setting, based on the themes identified from interviews with staff, fellows and students working in that setting.

Methods: Staff, fellows, and students are retrospectively interviewed about their experience with Fellows as Teachers in the outpatient internal medicine clinic. The interviews involve a standard set of questions, with the opportunity to explore experiences further if thought to be relevant.

Results: This is a review of the interim findings of the pilot year of CALI: Fellows as Teachers. Four staff, four fellows and one student have been interviewed. Preliminary analysis reveals that fellows feel teaching students in the inpatient setting differs from the outpatient setting, and their experience influences their readiness to accept learners once they are in full independent practice. There is the need to develop a curriculum to prepare them for teaching in the outpatient setting. Further, more guidance is needed for staff regarding the organization of clinic to accommodate this process and provide feedback. Finally, more students need to be interviewed to further analyze their experience at this time.


59

Management of Complex Pancreatic Fluid Collections Using the Nagi™ Lumen-Apposing Metal Stent

Stephen A. Taylor, Michael Byrne, Alan Weiss, Fergal Donnellan

Background: Lumen-apposing metallic stents (LAMS) are a novel device designed for transmural drainage of symptomatic pancreatic fluid collections (PFC’s). Theoretical advantages over conventional double plastic pigtail stents are due to a larger luminal diameter optimizing drainageparticularly in cases of walled of necrosis (WON).

Aims: The aim of our study was to evaluate the efficacy and safety of a NAGITMstent in the management of PFC’S.

Methods: This was a retrospective single center study. Between February 2015 and July of 2016, 17 patients underwent EUS guided PFC drainage using the NAGITM CSEMS. Primary endpoints included technical success (stent deployment), clinical success identified by radiographic resolution (PFC<2cm) and symptomatic resolution, stent related complications and rates of re-intervention.

Results : There were 17 patients (mean age: 53.5) with symptomatic PFC’s: 12 patients (71%) with WON and 5 (29%) with a simple pancreatic psuedocyst.

The NAGI™ stent was successfully placed via the transgastric approach in all 17 patients and left in situ for a median of 46 days (range 12-146). Endoscopic trans mucosal drainage was clinically successful in 100% of patients with pancreatic pseudocysts and 91% for WON. In the patients with WON, 58% (7/12) required additional necrosectomy and/or irrigation: 4 required oneintervention and 3 required more than one intervention to achieve resolution. Major complications were identified in 2 of 17 patients secondary to PFC infection due to stent obstruction. Minor complications identified included self-limited bleeding secondary to tract puncture (n=1), transient fever (n=1) and possible reflux esophagitis secondary to stent malposition.

Conclusions: Our study supports the literature that the LAMS are an effective, and safe modality for the treatment of PFC’s. Future studies are needed to assess for superiority over conventional plastic stents and other existing FSCEMS particularly in the drainage of WON.


60

Indications For Colonoscopy Pre- And Post-Colon Screening Program At St. Paul’s Hospital

Steven Pi, Estello Nap-Hill, Robert Enns, Jennifer Telford

Background: The removal of premalignant adenomas as well as the detection and resection of early asymptomatic colorectal cancer (CRC) has been shown to reduce incidence and mortality. In 2013, the Colon Screening Program (CSP) was implemented with the goal of standardizing British Columbia’s CRC screening strategy. Prior to this, no such strategy existed and significant variation existed in the diagnosis of CRC.

Objective: To investigate how the implementation of the CSP in BC has changed the indications for colonoscopy amongst newly diagnosed CRC.

Methods: A retrospective chart review of all CRC diagnosed at SPH from 2010-2015 was conducted. The list of all CRC was obtained through SPH Department of Pathology.

Conclusions: After implementation of the CSP, a greater proportion of CRCs were diagnosed via FIT and surveillance colonoscopy and a lesser proportion diagnosed via symptoms. The proportion of CRCs diagnosed via primary colonoscopy also significantly declined. The data also suggests that family physicians in BC are almost universally favouring FIT. These results support that the CSP has been successful in aligning the indications for colonoscopy with the recommendations made by the Canadian Task Force on Preventative Health Care.


61

Improving Resident Confidence: A Simulated Night On CallColleen Foster

Background: The on call experience is a part of transitioning from student to resident that trainees frequently identify as a stressor. This is likely due to a lack of clinical experience and fatigue associated with changing work schedules. Simulation is becoming a common means of increasing trainees’ exposure to common medical situations and therefore improving confidence and preparedness amongst residents.

Objective: To have a subset of first year residents complete a 12 hour night on call simulation prior to their first independent night shift and determine if the experience improves resident confidence and decreases resident anxiety.

Methods: Incoming first year internal medicine residents were asked to participate in the study. A subset of residents partook in the 12 hour night on call simulation prior to their first independent on call shift. Prior to the simulation, they completed a questionnaire on anxiety (STAI-6). The residents then completed 5 different patient situations including a GI bleed, chest pain, shortness of breath, delirium and pronouncing a patient’s death. The sessions were supervised by second and third year internal medicine residents who debriefed with the participants at the end of the mock shift. The participants completed the same anxiety questionnaire just prior to their first call shift. Another subset of residents only completed the questionnaire before their first call shift without completing the simulation training.

Results: A total of 14 residents participated in the simulation sessions with 23 residents serving as controls. A t-test was performed comparing the responses on the questionnaire of those residents who participated in the simulation to those residents who did not. There was a statistically significant difference in residents’ confidence between the two groups (p=0.016). Unfortunately, no significant difference was found in the level of anxiety between the two groups of residents prior to their first on call shift.


62

Inferior Vena Cava Variability in Mechanically Ventilated Patients with Spontaneous Breathing Effort: An Observational Study

Dr. Constantin Shuster, Dr. Andrew Hurlburt, Dr. Ken Kaila, Dr. Demetrious Sirounis, Dr. John Boyd

Background: Respiratory variation in inferior vena cava (IVC) size has been shown to predict fluid responsiveness (FR) in critically ill patients. It has been validated in mechanically ventilated patients without spontaneous breathing effort and in non-ventilated spontaneously breathing patients. Limited data exists about the utility of IVC variability in patients who are mechanically ventilated using a spontaneous breathing mode, who make up the majority of patients in the critical care setting.

Objective: Our primary aim was to evaluate how variation in positive end-expiratory pressure (PEEP) would impact IVC size. Our secondary goal was to assess whether IVC variability can predict FR.

Methods: From Jan-2017 to Mar-2017, we prospectively recruited patients at St. Paul’s Hospital (Vancouver) who were admitted to the intensive care unit (ICU), mechanically ventilated using a spontaneous breathing mode and ≥ 18 years. IVC diameter was measured throughout the respiratory cycle using M-mode echocardiography from the subcostal view. IVC measurements were performed at PEEPs of 0, 5, 10, 15 and 20. An 8mL/kg intravenous bolus of 0.9% normal saline was administered to determine FR. A peripheral pulse contour analysis device (FloTrac™/Vigileo™, Edwards Life Sciences, USA) was used to monitor cardiac output, starting at 5 minutes prior to fluid administration and ending 20 minutes after fluid bolus completion. Patients with an increase in cardiac index or mean arterial pressure of ≥ 15% were classified as fluid responders. Patients were excluded from the study if it was unsafe to vary PEEP. If it was unsafe to administer fluids or patients were not in sinus rhythm, they were excluded from the FR assessment only.

Results: Twenty-six patients were recruited, of which 21 underwent FR assessment. Twelve patients were found to be fluid responsive. PEEP variation influenced inspiratory IVC diameter but not expiratory. IVC variability did not predict FR.


63

Diabetes in the Renal Transplant at the Vancouver General Hospital Post-transplant Clinic

Dr. Jacob Zamora, Dr. Mohammed Almehthel, Dr. Breay Paty

Background: Diabetes is one of the leading causes of end-stage renal disease leading to renal transplant. Many factors influence renal function after transplant including pre-existing diabetes and the development of Post-transplant Diabetes (PTDM).

Objectives: To review patients followed at the Vancouver General Hospital (VGH) Post-transplant Clinic to determine the patient demographics and impact of diabetes and glycemic control on one year graft function. To determine the incidence of PTDM.

Methods: A retrospective chart review of patients that underwent renal transplant from 2014-2015 and followed in the Post-transplant clinic at VGH. Patient demographics, past medical history, medication profile, glycemic control and renal function were analyzed comparing those with a diagnosis of diabetes to non-diabetics. Data was analyzed at their pre-transplant, six month and twelve-month assessment.

Results: Of the patients that received a renal transplant at VGH from 2014-2015 two patients were identified to have a diagnosis of Post-Transplant Diabetes giving a de novo incidence of PTDM of 4% within the first year of follow up. Average age of transplant for patients with diabetes was 5 years older (50.9yrs vs. 45.7yrs) and average weight at one year follow up was nine kilograms more (80.8Kg vs. 71.1Kg). Despite a significant difference in HbA1C and fasting glucose at 6 and 12 months there is a non-significant difference in renal function (creatinine, estimated glomerular filtration rate).

Conclusion: Diabetes is a common risk factor for end-stage renal disease although it was not found to impact one year renal function post transplant. Further studies are required to evaluate the factors influencing PTDM and long term graft function in patients with diabetes.


64

The Risk of Solid Tumour Malignancies in Non-Dialysis-Dependent Chronic Kidney Disease: A Systematic Review

Justin Gill

Background: Chronic kidney disease (CKD) is a major public health issue affecting a growing number of individuals. It is known that there is an increased incidence of cancer in end stage renal disease and post-renal transplant patients compared to the general population, but what remains to be answered is the incidence of malignancy in non-dialysis-dependent CKD patients to guide population-specific cancer screening recommendations.

Objective: To review the available literature on the incidence of solid tumour malignancies in non-dialysis-dependent CKD.

Methods: A systematic review of available literature was conducted using a search strategy adapted from the PICO process. CKD was defined as an eGFR less than 60 ml/min/1.73m2 or a urine ACR greater than 1.11 mg/mmol, and the outcome measure was the incidence of primary breast, prostate, lung, renal, bladder, thyroid, skin and/or colorectal cancer. The search was conducted using the Medline and EMBASE databases by two independent reviewers to assess the reproducibility of the results. The abstracts of potentially relevant manuscripts were reviewed and full-text articles were ordered if a reviewer regarded the publication as applicable.

Results: A total of 3,599 manuscripts were screened, of which 9 were included in the final analysis. Three of six studies assessing all cancers in non-dialysis-dependent CKD as a collective found a statistically significant increase in incidence. There was no significant increase in the incidence of breast, prostate, or skin cancer in this group, and there were variable results among colorectal and lung cancers, with one of seven and two of six studies, respectively, demonstrating increased risk. Unanimous among all but one study for each is that renal and bladder cancer had a higher incidence of development in non-dialysis-dependent CKD.


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33rd Annual Resident Research Day - Department of Medicinemed-fom-medicine.sites.olt.ubc.ca/files/2017/05/RRD-2017-Program... · today to the 33rd Annual Resident Research Day,