Canadian Journal of General Internal Medicine最新文献

{"title":"Opioid Prescribing on an Internal Medicine Teaching Unit","authors":"Samuel Quan, C. Lawton, A. Budd","doi":"10.22374/cjgim.v16i2.443","DOIUrl":"https://doi.org/10.22374/cjgim.v16i2.443","url":null,"abstract":"ObjectiveTo investigate the rationale and timing of opioid prescriptions for Internal Medicine inpatients in an academic center in Saskatoon, Canada.MethodsWe performed a cross-sectional study of Internal Medicine inpatients that were prescribed opioids in Saskatoon. We examined documentation of clinical rationale and timing of opioid initiation or first escalation.ResultsOf 57 patients, 34 (60%) were opioid naive prior to admission and 48 (84%) had opioid doses either initiated or escalated. Of these 48 patients, 27 (56%) occurred during on-call hours. Rationale for escalation was documented in 31 cases (65%), with reasons including terminal care (17%), musculoskeletal pain (15%), and skin and soft tissue infections (13%).ConclusionRationale for opioid use was frequently not documented. Initial decision to change opioid dose occurred equally between daytime and on-call hours.\u0000RÉSUMÉObjectifÉtudier la justification et le moment choisi pour prescrire des opioïdes chez les patients hospitalisés en médecine interne dans un centre universitaire de Saskatoon (Canada).MéthodologieNous avons mené une étude de prévalence sur des patients hospitalisés en médecine interne chez qui on a prescrit des opioïdes à Saskatoon. Nous avons examiné la documentation concernant la justification clinique et le moment choisi pour entreprendre le traitement par les opioïdes ou effectuer la première augmentation de dose.\u0000RésultatsDes 57 patients, 34 (60 %) n’avaient jamais pris d’opioïdes avant leur hospitalisation et 48 (84 %) ont reçu leur première dose d’opioïdes ou une augmentation de dose. De ces 48 patients, 27 (56 %) ont reçu leur dose durant les heures de garde. La justification de l’augmentation de dose est documentée dans 31 cas (65 %), les raisons étant les soins de fin de vie (17 %), la douleur musculosquelettique (15 %) et les infections de la peau et des tissus mous (13 %).ConclusionSouvent, la justification de l’utilisation des opioïdes n’est pas documentée. Le moment où la décision initiale de modifier la dose d’opioïde est prise est réparti de façon égale entre le jour et durant les heures de garde.","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"93 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-06-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90517317","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Casebook of a Community Internist: Fun with Finals","authors":"H. M. Baillie","doi":"10.22374/CJGIM.V16I1.468","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.468","url":null,"abstract":"The words 'Final Examination' when applied to medical training seems inappropriate.  Learning is lifelong, but there have to be milestones where judgement happens.   In particular, an Oral Exam can invoke all sorts of excitement.","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"49 1","pages":"36-37"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79370712","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Perioperative Glycemic Management for Patients with and without Diabetes","authors":"S. Ruzycki, T. Harrison, Anna Cameron, K. Helmle, Julie McKeen","doi":"10.22374/CJGIM.V16I1.435","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.435","url":null,"abstract":"People with diabetes are at an increased risk for worse postoperative outcomes, compared to people without diabetes. Notably, up to one in 10 people who undergo surgery have unrecognized diabetes and an additional 10% may have postoperative hyperglycemia without meeting the criteria for a diagnosis of diabetes. Management of postoperative hyperglycemia has been demonstrated to reduce the incidence of poor outcomes, but evidence demonstrates that postoperative hyperglycemia remains a quality gap for surgical patients. In this review, we will outline the evidence for preoperative screening for postoperative hyperglycemic risk, review the evidence for perioperative glycemic management, and examine the barriers to these best practices. RÉSUMÉ Les personnes atteintes de diabète courent un risque accru de voir leurs résultats postopératoires moins bons que ceux des personne non atteinte de diabète. En particulier, près d’une personne sur dix qui subit une intervention chirurgicale présente un diabète non diagnostiqué et dix pour cent supplémentaires peuvent présenter une hyperglycémie postopératoire sans pour autant répondre aux critères de diagnostic du diabète. Il a été démontré que le traitement de l’hyperglycémie postopératoire réduit l’incidence des mauvais résultats, mais les données probantes montrent que l’hyperglycémie postopératoire demeure une lacune chez les patients opérés. Dans cette revue, nous présentons les données probantes relatives au dépistage préopératoire du risque d’hyperglycémie postopératoire, nous passons en revue les données probantes relatives à la gestion de la glycémie périopératoire et nous examinons les obstacles à ces meilleures pratiques. Postoperative Hyperglycemia Is a Modifiable Risk Factor for Worse Postoperative Outcomes Diabetes affects 20–30% of the surgical patients.1 People with diabetes who undergo surgery have worse outcomes than people without diabetes, including increased postoperative infection risk,2,3 30-day readmission rates,4 length of stay,5 and mortality.6,7 Recent evidence suggests that these poor outcomes are more strongly associated with intraoperative and postoperative hyperglycemia rather than a preoperative diagnosis of diabetes.6,8 This is especially important, as unrecognized diabetes may account for an additional 4–10% of surgical patients8,9 and approximately 10% of people without diabetes will have postoperative hyperglycemia.8,10–14 These patients may be less likely to have postoperative hyperglycemia recognized C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e V o l u m e 1 6 , I s s u e 1 , 2 0 2 1 17 Ruzycki e t a l . CJGIM_4_WKBK.indd 17 3/19/21 5:36 PM and appropriately treated, and subsequently may suffer more adverse outcomes than people with recognized diabetes.8 The association between intraoperative hyperglycemia and poor patient outcomes is less clear15,16; however, the management of intraoperative hyperglycemia is the responsibility of the anest","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"1 1","pages":"17-23"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76156525","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"What to Do When They’re Eating for Two? A Case of Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism in Pregnancy","authors":"J. M. Radford","doi":"10.22374/CJGIM.V16I1.440","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.440","url":null,"abstract":"A 33-year-old G7P0 female at 8 weeks gestation presented to the emergency department (ED) following a syncopal episode. She complained of chest pain and dyspnea, and had hemodynamic instability, which responded to intravenous fluids. Continued fluid resuscitation, supplemental oxygen, as well as therapeutic dose low molecular weight heparin (LMWH) were administered in the ED. Computed tomography (CT) pulmonary angiogram confirmed saddle pulmonary embolism (PE). After 12 h of continued chest pain and high oxygen requirements, a decision was made to use catheter-directed thrombolysis (CDT) involving alteplase with manual thrombus maceration in bilateral pulmonary arteries. There were no immediate hemorrhagic complications and follow-up fetal ultrasound demonstrated a normal viable intrauterine pregnancy. She clinically improved and was discharged on LMWH. Cesarean section was scheduled, and the patient delivered a healthy term infant at 37 weeks gestation without complications. Our case demonstrates that CDT may be a safe and effective treatment for submassive PE in pregnancy. RÉSUMÉ Une femme âgée de 33 ans et enceinte de huit semaines (G7P0) se présente aux urgences à la suite d’un épisode syncopal. Elle se plaint de douleurs thoraciques et de dyspnée et présente une instabilité hémodynamique qui répond aux solutés intraveineux. Une réanimation liquidienne continue, une oxygénothérapie ainsi qu’une dose thérapeutique d’héparine de faible poids moléculaire sont administrées aux urgences. L’angiographie pulmonaire par tomodensitométrie confirme une embolie pulmonaire en selle. Après 12 heures de douleurs thoraciques continues et de besoins élevés en oxygène, on décide d’utiliser la thrombolyse dirigée par cathéter (TDC) à l’aide de l’altéplase avec macération manuelle du thrombus dans les artères pulmonaires bilatérales. Il n’y a pas eu de complications hémorragiques immédiates et le suivi échographique du fœtus a démontré une grossesse intra utérine normale et viable. Son état clinique s’est amélioré et elle a obtenu son congé sous héparine de faible poids moléculaire. Une césarienne a été planifiée et la patiente a accouché d’un enfant à terme et en bonne santé à 37 semaines de grossesse, sans complications. Notre cas démontre que la TDC peut être un traitement sûr et efficace de l’embolie pulmonaire submassive en cours de grossesse. C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e 24 V o l u m e 1 6 , I s s u e 1 , 2 0 2 1 Case Reports and Clinical Images CJGIM_4_WKBK.indd 24 3/19/21 5:36 PM Case Report A 33-year-old female, 8 weeks pregnant (Gravida 7, Para 0), with past medical history significant for hypothyroidism, uterine leiomyomas, and seven spontaneous abortions (all <20 weeks’ gestational age) presented to the emergency department (ED) with chest pain, right upper quadrant abdominal pain, and dyspnea. She had reported a brief syncopal episode on ambulation earlier that day. Medications included levothyroxi","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"1 1","pages":"24-30"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91211265","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Myocardial Injury after Noncardiac Surgery and Perioperative Atrial Fibrillation","authors":"F. Borges, S. Ofori, M. Marcucci","doi":"10.22374/CJGIM.V16ISP1.530","DOIUrl":"https://doi.org/10.22374/CJGIM.V16ISP1.530","url":null,"abstract":"One in 60 patients who undergo major noncardiac surgery dies within 30 days following surgery. The most common cause is cardiac complications, of which myocardial injury after noncardiac surgery (MINS) and perioperative atrial fibrillation (POAF) are common, affecting about 18 and 11% of adults, respectively, after noncardiac surgery. Patients who suffer MINS are at a higher risk of death compared to patients without MINS. Similarly, patients who develop POAF are at a higher risk of stroke and death compared to patients who do not. Most patients who suffer MINS are asymptomatic, and its diagnosis is not possible without routine troponin monitoring. Observational studies support the use of statins and aspirin in the management of patients with MINS. The only randomized controlled trial to date that has specifically addressed the management of MINS was the MANAGE trial that demonstrated the efficacy and safety of intermediate dose dabigatran in this population. There are no specific prediction models for POAF and no randomised controlled trial evidence to guide the specific management of POAF. Management guidelines in the acute period follow the management of nonoperative atrial fibrillation. The role of long-term anticoagulation in this population is still uncertain and should be guided by a shared care decision model with the patient, and with consideration of the individual risk for stroke balanced against the risk of bleeding. In this review, we present a case-based approach to the detection, prognosis, and management of MINS and POAF based on the existing evidence.\u0000RÉSUMÉUn patient sur 60 qui subit une intervention chirurgicale majeure non cardiaque meurt dans les 30 jours suivant l’opération. La cause la plus fréquente est celle des complications cardiaques, dont les lésions myocardiques après une chirurgie non cardiaque (LMCNC) et la fibrillation auriculaire périopératoire (FAPO) sont courantes et touchent respectivement environ 18 et 11 % des adultes après une chirurgie non cardiaque. Les patients présentant des LMCNC sont exposés à un risque plus élevé de décès que les patients qui ne présentent pas de LMCNC. De même, les patients chez qui on voit apparaître une FAPO ont un risque plus élevé d’accident vasculaire cérébral et de décès que ceux qui ne connaîtront pas cette complication. La plupart des patients atteints de LMCNC sont asymptomatiques, et il est impossible d’établir un diagnostic sans surveiller régulièrement la troponine. Des études d’observation appuient l’utilisation des statines et de l’aspirine dans la prise en charge des patients atteints de LMCNC. À ce jour, le seul essai contrôlé randomisé qui s’est penché précisément sur le traitement des LMCNC est l’essai MANAGE qui a démontré l’efficacité et l’innocuité du dabigatran à dose intermédiaire chez cette population. Il n’existe aucun modèle de prédiction précis pour la FAPO ni aucune donnée probante provenant d’essais contrôlés randomisés pour orienter précisément son trai","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"60 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83066837","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Rheumatoid Vasculitis Following Change to Naturopathic Remedies","authors":"G. Prosperi-Porta, B. Wilson","doi":"10.22374/CJGIM.V16I1.439","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.439","url":null,"abstract":"A 66-year old femal with longstanding seropositive rheumatoid arthritis was admitted to the internal medicine service with bilateral foot pain and new painless raised fluid filled black lesions on her feet. Two weeks prior she underwent a right great toe amputation for \"gangrene\" by podiatric surgery. Five months prior, the patient discontinued all disease modifying therapies to pursue naturopathic remedies. The patient was diagnosed with rheumatoid arthritis vasculitis and despite immunosupressive therapies, the patient ultimately underwent bilateral transmetatarsal amputations for progression disease progression. This case reinforces the imporance for physicians to strongly discourage only using naturopathic remedies in rheumatoid arthritis and to consider vasculitis in any patient with rheumatoid arthritis presenting with new skin lesions as late detection can have severe implications. ","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"3 1","pages":"34-35"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75615506","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The SARS-CoV-19 Pandemic…one year later / La pandémie du SRAS-CoV-19... un an plus tard","authors":"James D. Douketis","doi":"10.22374/CJGIM.V16I1.546","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.546","url":null,"abstract":"","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"40 1","pages":"6-7"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74243836","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Important Things Internists Should Know about Sodium-Glucose Co-Transporter 2 Inhibitors","authors":"Christopher Oleynick, Pouya Motazedian, G. Prosperi-Porta","doi":"10.22374/CJGIM.V16I1.432","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.432","url":null,"abstract":"Sodium-glucose co-transporter 2 (SGLT-2) inhibitors are a relatively new class of medications available in Canada used in the treatment of type 2 diabetes mellitus (T2DM). There is an abundance of emerging literature that these drugs are not only effective in the treatment of T2DM but also offer robust clinical benefits for renal disease, cardiovascular disease, and congestive heart failure. Despite the clinical benefits, SGLT-2 inhibitors may be underutilized as some physicians are unfamiliar with the medications or are concerned about their side-effect profile. Given the high prevalence of T2DM and the above comorbidities frequently encountered within Internal Medicine, it is important for internists to be familiar with SGLT-2 inhibitors. This is a short article encapsulating important aspects about these medications that we believe internists should know. RÉSUMÉ Les inhibiteurs du cotransporteur sodium-glucose de type 2 (SGLT-2) sont une classe relativement nouvelle de médicaments offerts au Canada et utilisés dans le traitement du diabète de type 2 (DT2). Une profusion de nouvelles études montre que ces médicaments sont non seulement efficaces dans le traitement du DT2, mais qu’ils offrent également de solides avantages cliniques pour les maladies rénales, les maladies cardiovasculaires et l’insuffisance cardiaque congestive. Malgré ces avantages cliniques, les inhibiteurs du SGLT-2 sont peut-être sous-utilisés, car certains médecins ne connaissent pas ces médicaments ou s’inquiètent de leur profil d’effets secondaires. Étant donné la forte prévalence du DT2 et les affections comorbides susmentionnées fréquemment rencontrées en médecine interne, il est important que les internistes connaissent bien les inhibiteurs du SGLT-2. Voici un court article qui résume les aspects importants de ces médicaments que les internistes devraient connaître. Sodium-Glucose Co-Transporter 2 Inhibitors Are a Relatively New Class of Drugs Used in the Treatment of Type 2 Diabetes Sodium-glucose co-transporter 2 (SGLT-2) inhibitors inhibit glucose re-absorption in the proximal convoluted tubule of the kidney, thereby promoting glucosuria and reducing serum glucose in a mechanism of action that is independent of insulin. They yield a modest reduction in hemoglobin A1c (HbA1c) between 0.5 and 1%, and cause a sustained average weight loss of 2–3kg after initiation.1,2 Although metformin is still recommended for first-line pharmacotherapy for type 2 diabetes mellitus (T2DM), multiple guidelines including Diabetes Canada are recommending C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e 14 V o l u m e 1 6 , I s s u e 1 , 2 0 2 1 O r i g i n a l R e s e a r c h CJGIM_4_WKBK.indd 14 3/19/21 5:36 PM reducing the risk for cardiac decompensation.7,8 Internists should strongly consider the use of SGLT-2 inhibitors in patients with T2DM and CHF, and dapagliflozin for patients with CHF and an LVEF <40%, regardless of their diabetic status. Sodium-Gl","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"411 1","pages":"14-16"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79912989","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Case of Severe Seronegative Autoimmune Rhombencephalitis Successfully Treated with Rituximab","authors":"Farah Zarka, T. Slaoui, Jean-Paul Makhzoum","doi":"10.22374/CJGIM.V16I1.353","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.353","url":null,"abstract":"Prompt treatment of autoimmune encephalitis can prevent long-term neurological sequelae. However, the data and evidence for the treatment of autoantibody negative encephalitis are limited, particularly so for rhombencephalitis. We report the case of a seronegative autoimmune rhombencephalitis successfully treated with rituximab. A 21-year-old woman was transferred to our center for progressive neuropsychiatric symptoms and neurological deficits progressing into a Locked-in state despite first-line immunotherapy with corticosteroids and immunoglobulins. She was started on a rituximab induction protocol with noticeable improvement within days. The patient then received a maintenance dose and during a follow-up after 9 months was still in remission, suggesting that rituximab can be an efficient treatment for severe refractory seronegative rhombencephalitis","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"499 1","pages":"31-33"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91088898","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Entrustable Professional Activities: An Analysis of Faculty Time, Trainee Perspectives and Actionability","authors":"Victoria David, Michael H. Walsh, J. Lockyer, M. Mintz","doi":"10.22374/CJGIM.V16I1.415","DOIUrl":"https://doi.org/10.22374/CJGIM.V16I1.415","url":null,"abstract":"The Royal College of Physicians and Surgeons of Canada introduced Competence by Design (CBD) as an educational model along with Entrustable Professional Activities (EPAs) as markers of achievement that could be directly observed on a frequent basis. In 2017, the University of Calgary Internal Medicine (IM) program piloted CBD. The purpose of this study was to (1) assess whether written feedback from EPAs were actionable, valuable, and disruptive to workflow and (2) assess the time required to complete an EPA.","PeriodicalId":9379,"journal":{"name":"Canadian Journal of General Internal Medicine","volume":"9 6 1","pages":"8-13"},"PeriodicalIF":0.0,"publicationDate":"2021-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77591978","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}