Calgary General Hospital

This review evaluates recent advancements in Technetium-99m pyrophosphate (99mTc-PYP) imaging for transthyretin amyloid cardiomyopathy (ATTR-CM). We summarize the advantages of single-photon emission computed tomography (SPECT) over planar imaging, the potential impact of quantitative methods, and emerging data for quantifying response to therapy. The current literature demonstrates the superior diagnostic accuracy of SPECT compared with planar imaging in 99mTc-PYP studies. Emerging quantitative methods, using hybrid SPECT/CT and artificial intelligence, show promise for enhancing diagnostic precision and risk assessment. Recent studies have also highlighted the potential of 99mTc-PYP quantification for monitoring treatment response. 99mTc-PYP SPECT imaging has exceptional diagnostic accuracy for ATTR-CM. Quantitative techniques, which can be facilitated by artificial intelligence, improve risk stratification and may aid in treatment monitoring. Future research should focus on clarifying the clinical role and optimal approach for quantification.

Background: Acute viral bronchiolitis is among the most common illnesses seen in the emergency department (ED) and is the leading cause of infant hospitalization in Canada. Successful implementation of an audit and feedback (A&F) intervention at the Alberta Children’s Hospital (ACH) reduced use of low-value interventions and tests for bronchiolitis. Opportunities to improve bronchiolitis management are likely also present in other urban and rural settings. This project will spread and scale the work completed at ACH to 16 sites across Alberta focusing on children under one-year diagnosed with bronchiolitis who managed both in ED and inpatient settings. Methods: Site implementation included two key aspects: Audit & Feedback (A&F) – review practice data, facilitated discussion with clinicians and their teams, and identify enablers and barriers to practice change. The seasonality of bronchiolitis cases (November to April) helped inform the frequency of A&F feedback reports: mid-season (February) and end-of-season (April) Clinical dashboards are being developed within the new clinical information system – ConnectCare - that will provide teams with real-time feedback on potential practice change. Site Specific Implementation Plan – Resources are tailored to fit site needs including the use of posters, handouts and practice guidelines; utilization of order sets; and staff and family education resources. The bronchiolitis initiative is eligible for Continuing Medical Education accreditation through a newly developed easy-to-navigate web-based tool, My Practice Improvement – MyPI. An Education Working Group consisting of patient and family advisors was developed. Family resources included a QR code handout to a “How to suction your baby’s nose” instructional video to help parents/families care for their child at home. The HEAL handout provided links to additional resources for families. Family centred care participants were consulted on the development of a family resource: “Bronchiolitis: A roadmap from admission until discharge”. Evaluation Methods: The primary objective of the study is a 25% absolute reduction in chest radiograph use. Chest x-rays utilization can be readily obtained from administrative data at all sites in the project. Return visits to the ED within 72 hours of discharge will be monitored as a balancing measure to assess potential unintended consequences of de-implementing low-value tests and interventions in the ED. The provincial rollout of ConnectCare and tableau dashboard integration will enable a broader array of tests and treatments that are used in the management of bronchiolitis to be reported. The spread and scale of this project has now engaged with ED sites in non-tertiary settings in urban and rural areas where patient demographics and resource availability could pose additional challenges. Providing education and resources for these sites is one way to ensure equitable healthcare access for all Albertans. Results: Six facilities implemented rollout from September to November 2021 with a total of 151 physicians attending the A&F sessions. Chest x-ray use at sites that had a 2021 session compared to sites with a planned session in 2022 revealed a decrease after one bronchiolitis season. A difference in difference analysis between the two groups demonstrated that sites with a 2021 session had a -14.3% (95%CI -21.4 to -7.1) decrease in chest x-ray use. As of November 17, 2022, there have been 12 A&F sessions attended by 255 physicians, nurses and respiratory therapists. Advice and Lessons Learned: Capacity for scale and spread intiatives should be accounted for early in planning processes. We brought on two additional medical leads to facilitate sessions in fall 2022 due to an increase in the number of sites involved. Without the additional assistance, the success of roll out may have been jeopardized. Flexibility is key. Several sites across the province are continuing to deal with staffing shortages and recent high volumes of influenza, RSV and COVID are putting EDs over capacity. Sites have demonstrated incredible flexibility with engagement and session availabiltiy despite these circumstances. We changed session dates to help balance workloads as some sites had ConnectCare implementation concurrent with the start of the bronchiolitis season.

Journal of Ultrasound in MedicineVolume 40, Issue 12 p. 2785-2786 Letter to the Editor On Recommending Specific Lung Ultrasound Protocols in the Assessment of Medical Inpatients with Known or Suspected Coronavirus Disease-19 Reply Irene W. Y. Ma MD, PhD, RDMS, RDCS, Corresponding Author Irene W. Y. Ma MD, PhD, RDMS, RDCS [email protected] orcid.org/0000-0002-7580-0171 Division of General Internal Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada Division of Emergency Ultrasound, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, Massachusetts, USA Address correspondence to Irene W. Y. Ma, MD, PhD, RDMS, RDCS, Division of General Internal Medicine, Department of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada. E-mail: [email protected]Search for more papers by this authorVicki E. Noble MD, FACEP, Vicki E. Noble MD, FACEP Department of Emergency Medicine, University Hospitals, Cleveland Medical Center, Case Western Reserve School of Medicine, Cleveland, Ohio, USASearch for more papers by this authorGregory Mints MD, Gregory Mints MD orcid.org/0000-0002-3013-2608 Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York, USASearch for more papers by this authorTanping Wong MD, Tanping Wong MD Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York, USASearch for more papers by this authorAna Claudia Tonelli MD, PhD, Ana Claudia Tonelli MD, PhD Department of General Internal Medicine, Hospital de Clinicas de Porto Alegre and Department of Medicine, Unisinos University, São Leopoldo, RS, BrazilSearch for more papers by this authorArif Hussain MD, FRCA, FCCP, Arif Hussain MD, FRCA, FCCP Division of Cardiac Critical Care, Department of Cardiac Sciences, King Abdulaziz Medical City, Riyadh, Saudi ArabiaSearch for more papers by this authorRachel B. Liu MD, Rachel B. Liu MD orcid.org/0000-0002-3997-0325 Section of Emergency Ultrasound, Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USASearch for more papers by this authorChristopher A. Hergott MD, Christopher A. Hergott MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorElaine Dumoulin MD, Elaine Dumoulin MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorAlex Chee MD, Alex Chee MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorDaniel J. Miller MD, Daniel J. Miller MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorBrandie Walker MD, PhD, Brandie Walker MD, PhD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorBrian Buchanan MD, Brian Buchanan MD Department of Critical Care, University of Alberta, Edmonton, Alberta, CanadaSearch for more papers by this authorMichael Wagner MD, Michael Wagner MD Division of Hospital Medicine, Department of Medicine, Prisma Health-Upstate, Greenville, South Carolina, USASearch for more papers by this authorShane Arishenkoff MD, Shane Arishenkoff MD Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, CanadaSearch for more papers by this authorAndrew S. Liteplo MD, Andrew S. Liteplo MD Division of Emergency Ultrasound, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this author Irene W. Y. Ma MD, PhD, RDMS, RDCS, Corresponding Author Irene W. Y. Ma MD, PhD, RDMS, RDCS [email protected] orcid.org/0000-0002-7580-0171 Division of General Internal Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada Division of Emergency Ultrasound, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, Massachusetts, USA Address correspondence to Irene W. Y. Ma, MD, PhD, RDMS, RDCS, Division of General Internal Medicine, Department of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada. E-mail: [email protected]Search for more papers by this authorVicki E. Noble MD, FACEP, Vicki E. Noble MD, FACEP Department of Emergency Medicine, University Hospitals, Cleveland Medical Center, Case Western Reserve School of Medicine, Cleveland, Ohio, USASearch for more papers by this authorGregory Mints MD, Gregory Mints MD orcid.org/0000-0002-3013-2608 Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York, USASearch for more papers by this authorTanping Wong MD, Tanping Wong MD Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York, USASearch for more papers by this authorAna Claudia Tonelli MD, PhD, Ana Claudia Tonelli MD, PhD Department of General Internal Medicine, Hospital de Clinicas de Porto Alegre and Department of Medicine, Unisinos University, São Leopoldo, RS, BrazilSearch for more papers by this authorArif Hussain MD, FRCA, FCCP, Arif Hussain MD, FRCA, FCCP Division of Cardiac Critical Care, Department of Cardiac Sciences, King Abdulaziz Medical City, Riyadh, Saudi ArabiaSearch for more papers by this authorRachel B. Liu MD, Rachel B. Liu MD orcid.org/0000-0002-3997-0325 Section of Emergency Ultrasound, Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USASearch for more papers by this authorChristopher A. Hergott MD, Christopher A. Hergott MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorElaine Dumoulin MD, Elaine Dumoulin MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorAlex Chee MD, Alex Chee MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorDaniel J. Miller MD, Daniel J. Miller MD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorBrandie Walker MD, PhD, Brandie Walker MD, PhD Division of Respiratory Medicine, Department of Medicine, University of Calgary, Alberta, CanadaSearch for more papers by this authorBrian Buchanan MD, Brian Buchanan MD Department of Critical Care, University of Alberta, Edmonton, Alberta, CanadaSearch for more papers by this authorMichael Wagner MD, Michael Wagner MD Division of Hospital Medicine, Department of Medicine, Prisma Health-Upstate, Greenville, South Carolina, USASearch for more papers by this authorShane Arishenkoff MD, Shane Arishenkoff MD Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, CanadaSearch for more papers by this authorAndrew S. Liteplo MD, Andrew S. Liteplo MD Division of Emergency Ultrasound, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this author First published: 08 February 2021 https://doi.org/10.1002/jum.15650Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookxLinkedInRedditWechat No abstract is available for this article. References 1Soldati G, Smargiassi A, Perrone T, et al. There is a validated acquisition protocol for lung ultrasonography in Covid-19 pneumonia. J Ultrasound Med 2020. 10.1002/jum.15284 Web of Science®Google Scholar 2Perrone T, Soldati G, Padovini L, et al. A new lung ultrasound protocol able to predict worsening in patients affected by severe acute respiratory syndrome coronavirus 2 pneumonia. J Ultrasound Med 2020. https://doi.org/10.1002/jum.15548 10.1002/jum.15548 Web of Science®Google Scholar 3Mento F, Perrone T, Macioce VN, et al. On the impact of different lung ultrasound imaging protocols in the evaluation of patients affected by coronavirus disease 2019. J Ultrasound Med 2020. https:/doi.org/10.1002/jum.15580 10.1002/jum.15580 Web of Science®Google Scholar 4Soldati G, Smargiassi A, Inchingolo R, et al. Proposal for international standardization of the use of lung ultrasound for COVID-19 patients; a simple, quantitative, reproducible method. J Ultrasound Med 2020; 39: 1413–1419. 10.1002/jum.15285 PubMedWeb of Science®Google Scholar 5Ma IWY, Hussain A, Wagner M, et al. Canadian Internal Medicine Ultrasound (CIMUS) expert consensus statement on the use of lung ultrasound for the assessment of medical inpatients with known or suspected coronavirus disease 2019. J Ultrasound Med 2020. https://doi.org/10.1002/jum.15571 10.1002/jum.15571 Web of Science®Google Scholar 6Ji L, Cao C, Gao Y, et al. Prognostic value of bedside lung ultrasound score in patients with COVID-19. Crit Care 2020; 24: 700. 10.1186/s13054-020-03416-1 PubMedWeb of Science®Google Scholar 7Vassalou EE, Karantanas AH, Antoniou KM. Proposed lung ultrasound protocol curing the COVID-19 outbreak. J Ultrasound Med 2020; 40(2): 397–399. 10.1002/jum.15402 PubMedWeb of Science®Google Scholar 8Millington SJ, Koenig S, Mayo P, Volpicelli G. Lung ultrasound for patients with coronavirus disease 2019 pulmonary disease. Chest 2021; 159: 205–211. 10.1016/j.chest.2020.08.2054 CASPubMedWeb of Science®Google Scholar 9Tung-Chen Y, Martí de Gracia M, Díez-Tascón A, et al. Correlation between chest computed tomography and lung ultrasonography in patients with coronavirus disease 2019 (COVID-19). Ultrasound Med Biol 2020; 46: 2918–2926. 10.1016/j.ultrasmedbio.2020.07.003 PubMedWeb of Science®Google Scholar 10Gargani L, Soliman-Aboumarie H, Volpicelli G, Corradi F, Pastore MC, Cameli M. Why, when, and how to use lung ultrasound during the COVID-19 pandemic: enthusiasm and caution. Eur Heart J Cardiovasc Imaging 2020; 21: 941–948. 10.1093/ehjci/jeaa163 PubMedWeb of Science®Google Scholar 11de Alencar JCG, Marchini JFM, Marino LO, et al. Lung ultrasound score predicts outcomes in COVID-19 patients admitted to the emergency department. Annals of Intensive Care. 2021; 11:6. https://doi.org/10.1186/s13613-020-00799-w. 10.1186/s13613-020-00799-w PubMedWeb of Science®Google Scholar 12Hussain A, Via G, Melniker L, et al. Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus. 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A 66-year-old man underwent a minimally invasive oesophagectomy for oesophageal adenocarcinoma. Surgery and recovery were routine; however, he represented 8 days later with a massive upper gastrointestinal bleed. He was stabilized, but over a 2-week period experienced several bleeds requiring transfusion and multiple endoscopies, all showing a prominent luminal vessel at the oesophago-gastric (OG) anastomosis. Haemostatic clipping was attempted resulting in pulsatile bleeding and transfer to the radiology suite where angiography showed extravasation of contrast at the OG anastomosis from the terminal portion of the gastro-epiploic arcade. Coil embolization was successful and did not result in ischaemia. It was our standard to construct the OG anastomosis with the end-to-end anastomosis circular stapler (DST™ Series EEA™), 4.8-mm staple height. However, we now use the 3.5-mm staple height for improved haemostasis and ensure that the area for anastomosis is cleared of omental tissue so as not to incorporate a visible vessel.

SummaryA substantial proportion of patients undergoing bariatric surgery are female and of reproductive age. Guidelines suggest that pregnancy should be avoided for 12–18 months following bariatric surgery, and that women be appropriately counselled regarding contraception. We present a case in which a patient underwent a Roux‐en Y gastric bypass while unknowingly in the early stages of pregnancy. After a six‐week period liquid meal replacement for perioperative weight loss, a laparoscopic Roux‐en Y gastric bypass, and a short course of oral antibiotics for a post‐operative wound infection, the patient developed epigastric pain, odynophagia, oesophageal dysphagia, bloating and nausea with oral intake. Only after an abdominal X‐ray, two upper endoscopies and an upper gastrointestinal series was an intrauterine pregnancy seen incidentally on abdominal ultrasound. Ultimately, the patient underwent elective termination of her pregnancy. Patients who are, or are planning to soon become, pregnant should not undergo bariatric surgery. All female patients of reproductive age should be counselled on the importance of effective birth control prior to planning bariatric surgery. Beta‐human chorionic gonadotropin testing should be routinely considered before embarking on meal replacement or surgery.

Healthy looking newborns may have severe combined immunodeficiency (SCID), and neonatologists frequently are the first physicians to encounter these patients. Physicians usually have a high index of suspicion for this condition in presence of certain risk factors (unexplained infants' deaths, consanguinity); however, >80% of infants with SCID have no positive family history. A timely diagnosis of this condition is crucial in decreasing both mortality and morbidity. The only way to detect SCID prior to the onset of infections is newborn screening (NBS). In term infants, NBS has 99.99% sensitivity for SCID, with no false negatives. In preterm infants, screening is less accurate due to a lack of standard T cell receptor excision circle (TREC) values in this age group. We report a case of SCID in term infants born to consanguineous parents who were presented with clinical and laboratory findings of erythroderma, severe infection, failure to thrive, eosinophilia, and elevated immunoglobulin E (IgE) together with immunodeficiency. A timely diagnosis was followed by successful hematopoietic stem cell transplantation (HSCT) therapy.

RationaleEpidemic Pseudomonas aeruginosa (PA) plays an important role in cystic fibrosis (CF) lung disease. A novel strain, the ‘Prairie Epidemic Strain’ (PES), has been identified in up to 30% of patients in Prairie-based Canadian CF centres.ObjectiveTo determine the incidence, prevalence and long-term clinical impact of PES infection.MethodsA cohort of adults with CF was followed from 1980 to 2014 where bacteria isolated from clinical encounters were prospectively collected. Strain typing was performed using pulse-field gel electrophoresis and multilocus sequence typing. Patients were divided into one of four cohorts: no PA, transient PA, chronic PA with unique strains and chronic PES. Proportional Cox hazard and linear mixed models were used to assess for CF-associated respiratory death or transplantation, and rates of %FEV1 and body mass index (BMI) decline.Results274 patients (51.7% male) were analysed: 44––no PA, 29––transient PA, 137––unique PA, 64––PES. A total of 92 patients (33.6%) died or underwent lung transplantation (2423.0 patient-years). PES infection was associated with greater risk of respiratory death or lung transplant compared with the no PA group (aHR, 3.94 (95% CI 1.18 to 13.1); p=0.03) and unique PA group (aHR, 1.75 (95% CI 1.05 to 2.92) p=0.03). Rate of lung function decline (%FEV1 predicted) was greatest in the PES group (1.73%/year (95% CI 1.63% to 1.82%); p<0.001). BMI improved over time but at an attenuated rate in the PES group (p=0.001).ConclusionsInfection with PES was associated with increased patient morbidity through three decades and manifested in an increased risk of respiratory death and/or lung transplantation.

Liver failure following hepatic resection is a multifactorial complication. In experimental studies, infusion of N-acetylcysteine (NAC) can minimize hepatic parenchymal injury. Patients undergoing liver resection were randomized to postoperative care with or without NAC. No blinding was performed. Overall complication rate was the primary outcome; liver failure, length of stay, and mortality were secondary outcomes. Due to safety concerns, a premature multivariate analysis was performed and included within the model randomization to NAC, preoperative ASA, extent of resection, and intraoperative vascular occlusion as factors. Two hundred and six patients were randomized (110 to conventional therapy; 96 to NAC). No significant differences were noted in overall complications (32.7% and 45.7%, P = 0.06) or hepatic failure (3.6% and 5.4%, P = 0.537) between treatment groups. There was significantly more delirium within the NAC group (2.7% and 9.8%, P < 0.05) that caused early trial termination. In multivariate analysis, only randomization to NAC (OR = 2.21, 95%CI = 1.16-4.19) and extensive resections (OR = 2.28, 95%CI = 1.22-4.29) were predictive of postoperative complications. Patients randomized to postoperative NAC received no benefit. There was a trend toward a higher rate of overall complications and a significantly higher rate of delirium in the NAC group. J. Surg. Oncol. 2016;114:446-450. © 2016 Wiley Periodicals, Inc.

The emphasis regarding intracranial neuroendoscopy has been traditionally advocated and focused on the role in pediatric patients, although a significant usage has developed in adult patients. In this study, we examine and contrast the role of predominantly intracranial neuroendoscopy in both a pediatric and adult population with a minimum postprocedure follow-up of 5 years. A retrospective review was conducted for patients in the two hospitals that manage neurosurgical care for Southern Alberta, Canada, undergoing neuroendoscopic surgery between 1994 and 2008. The pediatric group was defined as age ≤17 years and the adult group as age ≥18 years. A total of 273 patients who underwent a total of 330 procedures with a mean postprocedure follow-up of 12.9 years were identified. There were 161 adult and 112 pediatric patients, and both groups underwent surgery by the same surgeons. The most common procedure was endoscopic third ventriculostomy, accounting for 55% of procedures. One postoperative death occurred in an adult patient. Endoscopic third ventriculostomy success 1-year postprocedure was 81%, with only three late-term failures. Postoperative infection was the most common serious complication (two pediatric/four adult patients). Adult and pediatric patients had similar major complication rates (4.2% vs 5.7%, p=0.547). Neuroendoscopy overall had a similar role in both pediatric and adult neurosurgical populations, with the most commonly associated complication being infection. Neuroendoscopy is an important therapeutic modality in the management of appropriate adult patients.