Rising to the Challenge of Rare Diagnoses.

Patients with rare conditions often experience substantial delays between presentation and diagnosis, and some remain undiagnosed. In this Perspective, we outline the many challenges in diagnosing rare conditions in the modern clinical context. We review relevant concepts of diagnostic reasoning as they relate to rare conditions.

A retrospective analysis of the use of electronic consultation in general internal medicine.

Background: General internists in Canada are subspecialty providers in the inpatient and outpatient settings. Electronic consultations (eConsult) allow primary care providers (PCPs) to virtually consult specialists to address clinical questions. There is a paucity of literature examining the utility and benefits of eConsults by general internists.

Using the Electronic Medical Record to Identify Patients at High Risk for Frequent Emergency Department Visits and High System Costs.

Background: A small proportion of patients account for a high proportion of healthcare use. Accurate preemptive identification may facilitate tailored intervention. We sought to determine whether machine learning techniques using text from a family practice electronic medical record can be used to predict future high emergency department use and total costs by patients who are not yet high emergency department users or high cost to the healthcare system.

The first report of a previously undescribed EBV-negative NK-cell lymphoma of the GI tract presenting as chronic diarrhoea with eosinophilia.

A 74-year-old man presented with a 2-month history of watery diarrhoea. His complete blood count showed lymphopaenia and marked eosinophilia. Investigations for common infectious causes including Clostridium difficile toxin, stool culture, ova and parasites were negative.

Effect of a postdischarge virtual ward on readmission or death for high-risk patients: a randomized clinical trial.

Importance: Hospital readmissions are common and costly, and no single intervention or bundle of interventions has reliably reduced readmissions. Virtual wards, which use elements of hospital care in the community, have the potential to reduce readmissions, but have not yet been rigorously evaluated.

Objective: To determine whether a virtual ward-a model of care that uses some of the systems of a hospital ward to provide interprofessional care for community-dwelling patients-can reduce the risk of readmission in patients at high risk of readmission or death when being discharged from hospital.

Nabilone therapy for cannabis withdrawal presenting as protracted nausea and vomiting.

Cannabis is one of the most commonly used recreational drugs worldwide. Psychoactive properties of the principal compound, δ-9-tetrahydrocannabinol include euphoria, a sense of relaxation and increased appetite. Chronic cannabis use has been associated with the development of a withdrawal syndrome on abrupt discontinuation.

Lateral medullary syndrome: a diagnostic approach illustrated through case presentation and literature review.

Patients with lateral medullary syndrome classically present with crossed hemisensory disturbance, ipsilateral Horner syndrome, and cerebellar signs, all of which are attributable to infarction of the lateral medulla. However, variability in the presentation of this syndrome is the rule, as illustrated in this case presentation and literature review. We propose an approach to diagnosis and management of the lateral medullary syndrome and illustrate the need to integrate clinical information with an understanding of brainstem anatomy with the goal of determining which patients require urgent neuroimaging and acute stroke therapies.

Morning report blog: a web-based tool to enhance case-based learning.

Background: Morning report is an interactive case-based teaching session common to internal medicine training programs across North America.

Description: We report here on a morning report web log ("blog"), created and updated after morning report sessions by the Chief Medical Resident with pertinent clinical topics, links to journal articles, and medical images. Trainees on their internal medicine rotation were e-mailed a web link with each posting.

Design and implementation of a low-cost multimodal procedure cart for an internal medicine ward.

Introduction: General internists perform a large number and variety of procedures in the ward and emergency department settings. Initiatives are needed to facilitate learning and increase efficiency of procedural skill acquisition by trainees. In this article, we describe our experience developing and implementing a low-cost multimodal procedure cart in an academic health sciences center.

Instruction using a high-fidelity cardiopulmonary simulator improves examination skills and resource allocation in family medicine trainees.

Introduction: High-fidelity cardiopulmonary simulators have proven promising in various areas of medical education but have yet to be studied in Family Medicine training.

Methods: A 2-hour curriculum, combining didactic and simulator exposure, and addressing common valvular pathologies, was offered to post-graduate year 1 and 2 Family Medicine residents. Residents' abilities to describe and diagnose four simulated murmurs were assessed before the teaching sessions and 2 to 4 weeks after.

Patient and healthcare professional factors influencing end-of-life decision-making during critical illness: a systematic review.

Objectives: The need for better understanding of end-of-life care has never been greater. Debate about recent U.S.

Sex and critical illness.

Purpose Of Review: The article reviews and speculates on potential mechanisms underlying sex-related differences in admission patterns, care delivery and outcome of critical illness.

Recent Findings: Evidence from many countries suggests men are more commonly admitted to intensive care units than are women, and may be more likely to receive aggressive life support. These differences may be confounded by differences in incidence of conditions leading to critical illness, such as acute lung injury and sepsis, both more common among men, or to differences in provision of medical or surgical care that require intensive care unit.

Oncoming tides in the Age(ing) of Aquarius.

The demographic shift in the age of most industrialized countries' populations is profoundly impacting all areas of healthcare, perhaps nowhere more so than critical care. As the proportion of elderly patients increases, so to will our consideration for admission of elderly patients to the intensive care unit (ICU). Whether explicitly acknowledged or not, intensivists routinely debate (both inwardly and outwardly) the benefit, utility, and patient-focused dignity of admitting very elderly patients to the ICU.

The effect of income on anaphylaxis preparation and management plans in Toronto primary schools.

Background: Outcomes of serious allergic reactions are worse at school than at home. Prompt administration of epinephrine is the first-line treatment for anaphylactic reactions, and the EpiPen device is not subsidized by Ontario public health insurance. This study examines the relationship between the proportion of low-income households in Toronto neighbourhoods and the adequacy of anaphylaxis management plans in primary schools.

Reversible assembly of helical filaments by de novo designed minimalist peptides.

We have designed a series of 15 short, helical de novo peptides consisting of lysine, isoleucine, and alanine. We have termed this the KIA series. These peptides differ only in their hydrophobic interface, and thus their self-association is largely a consequence of hydrophobic interactions.