June 2020: 62:5 Pages 153–184 An unusual finding from fecal immunochemical testing: A case report

IN THIS ISSUE Novel website connects general surgeons during COVID-19 crisis Epidemiology of COVID-19 in BC Medical education during COVID-19 Obesity: A risk factor for severe infection with coronavirus

bcmj.org BC Medical Journal vol. 62 no. 5 | june 2020 153 You can now use Dr. Bill absolutely free. Use our powerful billing software to submit as many claims as you want at no charge.

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154 June 2020 Volume 62 | No. 5 Pages 153–184

“Medical education during COVID-19: Lessons from a pandemic” by Dr Roger Wong begins on page 170.

n 157 Editorials Corporatization of family medicine 170 Special Feature A conversation from sometime in the in BC, Robert H. Brown, MD Medical education during n future, David R. Richardson, MD Search engine to identify the most COVID-19: Lessons from a Is there a new, better normal? affordable drug, coverage availability, pandemic, Roger Y. Wong, MD Cynthia Verchere, MD and special authority resources, Anthony Chiam, RPh 172 Special Feature 160 President’s Comment UBC Reticulum: A novel website 165 BCCDC Forever changed, Kathleen Ross, MD connecting general surgeons in BC Epidemiology of COVID-19 in during the COVID-19 crisis, Hamish 161 Letters BC: The first 3 months, Caren Rose, Hwang, MD, Shiana Manoharan, n COVID-19 pharmacologic therapy PhD, BCCDC Surveillance Team, MD, Taryn Zabolotniuk, BSc, guidance for BC, British Columbia Kate Smolina, PhD S. Morad Hameed, MD COVID-19 Therapeutics Committee n COVID-19 pandemic and CLINICAL 174 College Library adolescents’ vaping epidemic, Thank you, and a helping . . . email? Aki Nilanga Bandara, BSc, Mehara 167 An unusual finding from fecal Niki Baumann Seneviratne, Senara Wanniarachchi, immunochemical testing: Contents continued on page 156 BSc, Ricky Jhauj, BKin, Vahid A case report, David Sanders, Mehrnoush, MD MD, Hui-Min Yang, MD, S. Ian Gan, MD

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BC Medical Journal vol. 62 no. 5 | june 2020 155 On the cover An unusual finding from fecal immunochemical testing: A case report This case report peels back the layers of endoscopic and histologic investigations following a positive fecal immunochemical test result, eventually leading to the detection of a rare mucosa-associated lymphoid tissue lymphoma. Art materials: toilet paper, cardboard.

The BCMJ is published by Doctors of BC. The journal provides peer-reviewed clinical and review articles written primarily by BC physicians, for BC physicians, along with debate on medicine and medical politics in editorials, letters, and In addition to providing medical care to the entire Skeena Valley, Dr Horace Wrinch (pictured here) built two essays; BC medical news; career and CME listings; hospitals, created a farm to supply the hospitals, and established a nursing school. A new book about him, physician profiles; and regular columns. Service on the Skeena: Horace Wrinch, Frontier Physician by Geoff Mynett, is reviewed on page 176. Print: The BCMJ is distributed monthly, other than in January and August.

Web: Each issue is available at www.bcmj.org. Contents continued from page 155 Subscribe to print: Email [email protected]. Single issue: $8.00 175 COHP n Canada per year: $60.00 Research to address impact of Foreign (surface mail): $75.00 Obesity: A risk factor for severe COVID-19 on medication use Subscribe to notifications: infection with coronavirus and mental health for people with To receive the table of contents by email, visit www.bcmj.org and click on “Free e-subscription.” SARS-CoV-2, Priya Manjoo, MD, arthritis n Prospective authors: Consult the Katie Bowers, MPP Research to better diagnose “Guidelines for Authors” at www.bcmj.org COVID-19 n for submission requirements. 176 News Virtual stroke-recovery sessions n n Book review: Service on the Skeena: Ontario researchers join global Horace Wrinch, Frontier Physician initiative to study loss of smell in n 2020 Family Physicians’ Awards COVID-19 patients n n Editor Web and social media 2020 Rural Awards, BC recipients How to embed AI and digital David R. Richardson, MD coordinator n Amy Haagsma MSP coverage relating to technology into physicians’ training Editorial Board COVID-19 and practices Jeevyn Chahal, MD Cover concept and n n David B. Chapman, MBChB art direction, Jerry Wong, Health data coalition expands Remote surgery: Exploring Brian Day, MB Peaceful Warrior Arts data-sharing application emergency care at a distance Caitlin Dunne, MD Design and production n David J. Esler, MD Website for Canadians to ask Laura Redmond, Yvonne Sin, MD 180 CME Calendar Scout Creative COVID-19 questions and get Cynthia Verchere, MD Printing answers Managing editor n 181 Classifieds Mitchell Press Jay Draper BC PharmaCare COVID-19 Advertising Associate editor information for prescribers Tara Lyon Joanne Jablkowski 604 638-2815 Editorial and production or [email protected] coordinator ISSN: 0007-0556 Tara Lyon Established 1959 Copy editor Barbara Tomlin

Proofreader Ruth Wilson

156 BC Medical Journal vol. 62 no. 5 | June 2020 editorials

A conversation from sometime in the future

“ ey, great-grandpa, how did you sur- protective equipment (PPE), such as dental The people of BC have been asked to physi- vive the COVID-19 pandemic?” offices, have been sharing with those who need cally distance themselves, self-isolate, and avoid “Mostly, I just sat around and them. All manner of organizations in unrelated gatherings. I have been beyond impressed by the Hsent funny memes to my social media contacts.” fields have asked what they could produce and general response to these measures, despite the Back in February, I wrote an editorial about are now manufacturing gowns, masks, gloves, significant financial and social losses incurred. the novel coronavirus and my hope that if it face shields, and more. Some companies are The general population is being respectful yet became a global pandemic even designing and look- kind while doing their part to flatten the curve. humanity would respond ing to make ventilators if My spirits have been lifted, as has my belief with kindness and grace Despite fear of need be. in the basic goodness of people. Despite fear (published in the April physical illness and I have been touched to of physical illness and financial ruin, so many issue). As I now sit in financial ruin, so many my core by the 7:00 p.m. are reaching out to others less fortunate than front of my computer in are reaching out to shout-out to health care themselves. I am confident we will get through early April and reflect on workers and first respond- this pandemic together with perhaps a kinder the staggering spread of others less fortunate ers. The banging of pots and gentler world waiting on the other side. n COVID-19 and the re- than themselves. and clapping of hands —David R. Richardson, MD sulting unheard of soci- brings a tear to my eye etal adjustments, I am every time. Restaurants pleasantly surprised by the positive response that might be forced to close due to a drastic to this pandemic. Sure, there have been cases reduction in their business have been selflessly of people fighting over toilet paper or gouging providing much-needed meals to health care Doctors their neighbors by reselling medical supplies at workers at local hospitals. The outpouring of Helping ridiculous markups. But these are exceptions. support and gratitude has been truly amazing Doctors I have been impressed by how the majority of during this difficult time. 24 hrs/day, people are reacting. There are numerous reports People’s creativity has also been on display. 7 days/week of individuals reaching out to the vulnerable in Window decorations with hearts and positive their communities by picking up their groceries, messages adorn many neighborhoods. Colorful prescriptions, and other necessities. Others are decorated rocks now line pedestrian paths and The Physician Health trying to ease the social isolation many elderly walkways. Social media is providing a constant Program of British are experiencing by sharing music and conver- stream of funny memes to lighten the load Columbia offers help 24/7 sation. Groups that aren’t using their personal and share joy as we navigate this pandemic. to B.C. doctors and their families for a wide range of personal and professional problems: physical, psychological and social. If something is on your mind, give us a call at 1-800-663-6729. Or for more information about our services, visit www.physician health.com.

BC Medical Journal vol. 62 no. 5 | june 2020 157 Editorials

Is there a new, better normal?

ost of us could enumerate fairly difficult. Most patients are not allowed to have Can we take this time to think about ways to closely the number of deaths re- family members with them in hospital—when encourage a new, perhaps better, normal? Could ported to have occurred on 11 Sep- they are vulnerable or unable to advocate for safe shopping be the standard? Do we need Mtember 2001: 2977 victims and 19 hijackers. But their own needs. Most face-to-face and hand- to have 10 000 whateverologists fly to attend our focus on the tragedy would leave us mis- to-hand interaction is limited or distracted a national meeting, or can we have adequate taken in our answer. In truth, in the US, about by the protections needed. Appointments are knowledge transfer and social interaction in a 7500 people die each day, so the vast majority limited and less timely. Rounds, education, different, safer way? How much business has of people who died on 9/11 did so in the more meetings, communication, to be conducted in person, usual way. That day, approximately 100 people students, and residents all versus over a 30-minute likely died in motor vehicle accidents and 31 have a weakened or dis- Will necessity give Zoom meeting? Do we in firearm incidents. In Canada, approximately tracted presence, and some birth to ideas that need to have thousands 600 people were likely diagnosed with cancer may bear the scars long would previously have of people crowd together and 22 died by suicide. It’s easy to lose track term. Learners graduat- been overpowered for football, basketball, when everything is focused on one huge event. ing during this time may and soccer games? Maybe COVID-19 is a new disease, a novel virus, not have the same experi- by the status quo? there is a way to maintain a puzzle with unpredictable and cruelly shaped ence or rigor of evaluation the enjoyment and fellow- pieces that we are trying to assemble in the dark. in their fields. Studies are ship while reducing public Living through the effects of physical-distanc- being fast-tracked into the public domain and risk. Can we appreciate the performing arts in ing guidelines, watching the news, and seeing being interpreted and dispersed prior to full a safer way without sacrificing the power of the economic consequences, we may forget that peer review. Funding for research is devastated artistic immediacy? Will necessity give birth most of the usual medical statistics are still tick- by economic predictions. International fellow- to ideas that would previously have been over- ing along. Front-line health care workers are not ships may be practically impossible for the time powered by the status quo? Can our patients, all looking after COVID patients; the majority being. Technology is being used more than ever and communication of their issues, be treated in many centres are looking after the ordinary as we slowly distill what is important and what more effectively in the ways we are using now? illnesses, injuries, and complications. Kids will is possible, and accept that not all things fit well. Life may not go back to the way it was. It get leukemia, women will get breast cancer, This pandemic will have implications for medi- shouldn’t. But as we have done already with elderly people will break their hips. Caring for cine, practitioners, education, and non-COVID airline security, electronic ID tags, recycling and these issues is always challenging, but doing so patient outcomes quite possibly for years. composting, smart phones, and electric vehicles, during a serious pandemic is many degrees more We will eventually become a physically we change when things need to change, and we closer community again. Elective surgeries will can handle it. again be slated, people will see their more usual COVID news is updated, and some days— British Columbia Medical Journal lives, illnesses, and injuries somewhat prioritized sometimes hourly—contradicts its previous it- @BCMedicalJournal again. But even with the possibility of an ef- erations. By the time this editorial is published, BCMJ Blog: Stopping the spread: Managing fective vaccine or scientifically supported treat- we may have a new set of rules in place. There substance use disorders amid SARS-CoV-2 ment for COVID-19, it is more likely than not are likely to be active protocols affecting life Many people with untreated or undertreated substance use disorder are currently facing dual that there will be another SARS, or MERS, or for many months. But we will at some point public health emergencies—the SARS-CoV-2 Spanish flu on the horizon. Hopefully things have to reprioritize the more ordinary things pandemic and the overdose crisis. will have changed so we can respond effectively that will need to be done in our practices. We Read the post: bcmj.org/blog/stopping with less drastic reactions, or maybe even have likely will have to do this during a time of se- -spread-managing-substance-use-disorders- reduced risks for our population. We in health rious economic consequences and a scarred, amid-sars-cov-2 care, who hold many of the stakes directly and overrun system. I hope open minds, kindness, on behalf of our patients, may have to be the team playing, and long-term vision will lead ones to spearhead changes during our return, our way. n even if economic benefactors of the status quo —Cynthia Verchere, MD push in other directions. Follow us on Facebook for regular updates

158 BC Medical Journal vol. 62 no. 5 | June 2020 Doctors of BC Links and resources for COVID-19

Doctors of BC is actively supporting members during the coronavirus (COVID-19) pandemic in a variety of ways. Work includes advocacy on behalf of physicians with government, the provincial health officer, and health authorities, as well as ensuring members have access to appropriate tools, benefits, and insurance.

An information resource from Doctors of BC, updated regularly: www.doctorsofbc.ca/covid-19

This page has information on: • Clinical and practice supports • Billing and fee code changes • Virtual care • Insurance, benefits, and income supports • Advocacy and engagement • Physician health and wellness • FAQs (e.g., prescribing, financial supports, PPE)

For questions or concerns about COVID-19, contact us directly at [email protected] president’s comment

Forever changed

“I am not afraid; I was born to do this.” —Joan of Arc

14 April 2020

any of my communications over The majority of our medical training is their homes, often with family around them. It these past few weeks have fo- grounded in honing clinical skills while we see feels less intrusive and several have commented cused on the impressive and co- patients in person. Our key triad includes listen- that this type of health care is more “fun” than Mhesive response of our profession to the rising ing to our patients’ concerns, watching them for coming to the office. SARS-CoV-2 pandemic. Together, we worked important clues as they relate their history, and It is obvious that our health care system, with our partners to ensure we were as ready of course the incredible hands-on skills required along with many other aspects of our so- as we could be to treat the most ill patients as to ascertain the main differential diagnoses. ciety, will be forever changed. We will refer they needed hospitalization and ventilation. We are comfortable with our skills and can to medical practice as “pre-COVID-19” and The speed with which we mobilized and col- rely on our clinical judg- “post-COVID-19” in the laborated across all sectors was unprecedented. ment based on our visual, years to come. There is no Our professional organization led the charge auditory, and tactile senses I have every confidence holding back the wave. to ensure the most up-to-date information was after years of practice and that our profession will Health care will need to accessible in the most convenient ways. Grass- hands-on experiences. We continue to adapt. We will continue to meet the roots divisions of family practice and medical can remember what an in- learn to work with more staff associations banded together to facilitate carcerated hernia feels like virtual care model with than one sense impaired optimal patient care and physician protection. and what the subtle signs the same cohesion with and we will learn to know Truly inspiring work has been done by an un- of heart failure sound like. which we have met the when we need that miss- told number of people to pull this all together. Often what we smell will rest of this pandemic. ing sense to complete an Now we wait. point us toward the diag- exam. We know there is Physical distancing and the provincial health nosis, such as an infec- something uniquely spe- officer’s plea to “just stay home” have certainly tion or C. difficile colitis. cial and healing in the made a difference to case numbers to date. At We know when a sick person in our presence face-to-face encounters with our patients that this point, it is still too early to know for sure is mildly or severely ill, often even before we is not present over Skype. Yet, for now, this is if our curve is flattening. Added to this, we examine them. very necessary to slow the community spread have patients who need health care outside of Now enter the world of virtual health. In of SARS-CoV-2 and keep our patients and COVID-19, and we are successfully rising to many ways, it is as if we have lost one or two ourselves safe. I have every confidence that our this challenge. of our senses. We can obtain the same history profession will continue to meet the virtual care A truly critical piece of that success has been and ask the same important questions that often model with the same cohesion with which we the widespread adoption of virtual medicine lead us to the differential diagnoses without an have met the rest of this pandemic. We know across medical practices in both primary and in-person exam. That said, hands-on, in-person, with certainty that we can do this. We are not consultant care. We have never seen such a rap- face-to-face clinical care is our gold standard. afraid of change. We were in fact, born to do id and violent shake-up in the way we deliver Times have changed in our virtual-care this. health care in Canada. Admittedly, the advent world. I stare at my patients on tiny screens. —Kathleen Ross, MD of electronic medical records allowing instant My patients stream themselves using cameras Doctors of BC President search and visualization of data in a patient’s and Internet connections of varying quality chart was definitely a revolution in care, just as they discuss their issues. I feel blunted and not as rapid or as widespread as what we are perhaps harbor the nagging feeling that my as- living through right now. sessment is incomplete. Patients seem to enjoy speaking to their doctors from the comfort of

160 BC Medical Journal vol. 62 no. 5 | June 2020 authorities, the Ministry of Health Pharma- ceutical Services Division (MOH PSD), and We welcome Letters to the editor university researchers. Clinical health profes- original letters of less than 300 words; we may edit them for clarity sion members include specialists from critical and length. Letters may be emailed to [email protected], submitted care, infectious diseases, medical microbiology, online at bcmj.org/submit-letter, or sent through the post and must include general internal medicine, emergency medicine, your mailing address, telephone number, and email address. Please disclose hematology, rheumatology, anesthesia, family any competing interests. practice, pharmacy, transplant medicine, and antimicrobial stewardship. The CTC developed its own terms of refer- ence that outline how material will be reviewed COVID-19 pharmacologic well as providing a weekly update and concrete and how changes will be made to provincial therapy guidance for BC recommendations about various experimental recommendations as evidence evolves. Virtual therapies. This summary of evidence and rec- meetings occur weekly to review new material To date (22 April 2020), there are no Health ommendations can be found on the BCCDC and decide on changes to recommendations. Canada–approved COVID-19 pharmacolog- website.3 There is also an active group on the videocon- ic treatments, yet there is intense interest and The committee convened on 13 March 2020 ferencing platform Slack, where sharing and media coverage of potential pharmacological 1,2 and initially consisted of front-line clinicians discussions can take place in preparation for the agents. In BC, we have had the benefit of a at Vancouver General and St. Paul’s Hospitals. weekly conference. Each drug class/therapeutic diverse group of experts (the BC COVID-19 As the need for a provincial-level group was intervention is assigned to a small subgroup Therapeutics Committee [CTC]) scanning acknowledged, the group quickly expanded to of CTC members who ensure that the latest and summarizing the emerging literature, as 37 members, with representation from all health material is summarized weekly. New literature

British Columbia COVID19 Therapeutics Committee (CTC) Clinical Practice Guidance for Antimicrobial and Immunomodulatory Therapy in Adult Patients with COVID-19 Last updated May 11, 2020

Recommendations in this document There is limited clinical evidence to guide antiviral management for ill patients with COVID-19. apply to patients >18 years of age. For recommendations in special populations, The guidelines recommend that specialist consultation (which may include Critical Care/Infectious Disease/Hematology/Rheumatology) be obtained if any investigational refer to the complete guidelines. treatment is offered to a patient with COVID-19 outside of a clinical trial, and that informed consent be obtained from the patient or substitute decision-maker

SEVERITY OF ILLNESS ANTIVIRAL THERAPY ANTIBACTERIAL THERAPY IMMUNOMODULATORY THERAPY

Chloroquine or hydroxychloroquine (with or Empiric therapy with ceftriaxone 1-2g IV Corticosteroids are not recommended without azithromycin) is not recommended q24h x 5 days is recommended if there is outside of approved clinical trials unless outside of approved clinical trials or where concern for bacterial co-infection (Alternative there are other indications for its use** Critically Ill Patients other indications would justify its use for severe beta-lactam hypersensitivity: There is insufficient evidence at this time to Hospitalized, ICU-based moxifloxacin 400 mg IV q24h x 5 days) recommend for or against the use of Patients requiring ventilatory and/or Lopinavir/ritonavir is not recommended corticosteroids for acute respiratory distress circulatory support; also includes patients outside of approved clinical trials Add azithromycin 500 mg IV q24h x 3 days syndrome (ARDS) requiring high-flow nasal cannula, or higher to ceftriaxone empiric therapy if atypical concentrations of oxygen by mask Remdesivir* is not recommended outside of infection is suspected (azithromycin is not Tocilizumab (IL-6 receptor blocker) is not *Suggeset Enoxaparin 30 mg SC bid for approved clinical trials needed if empiric therapy is moxifloxacin) recommended outside of approved clinical DVT prophylaxis trials. If considered on an individual basis in De-escalate on the basis of microbiology patients with cytokine storm, it should only be results and clinical judgment done so with expert consultation (Infectious diseases and Hematology/Rheumatology)

Moderately Ill Patients Chloroquine or hydroxychloroquine (with or Antibacterial therapy is not routinely Corticosteroids are not recommended Hospitalized, ward-based, long-term care without azithromycin) is not recommended recommended outside of approved clinical outside of approved clinical trials unless there Patients requiring low-flow supplemental outside of approved clinical trials or where trials or where other indications would justify are other indications for its use** oxygen *Consider Enoxaparin 30 mg SC bid other indications would justify its use its use (eg. suspected bacterial co-infection in for DVT prophylaxis COVID positive patients) Tocilizumab (IL-6 receptor blocker) is not Lopinavir/ritonavir is not recommended recommended outside of approved clinical Mildly Ill Patients outside of approved clinical trials trials Ambulatory, outpatient, long-term care Patients who do not require supplemental Remdesivir* is not recommended outside of oxygen, intravenous fluids, or other approved clinical trials physiological support

Note: This document is dynamic and will be updated as changes to recommendations occur. The complete and most up-to-date version of the guidelines is available at * currently unavailable in Canada http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/clinical-care/treatments ** e.g. asthma exacerbation, refractory septic shock, obstetric use for Original infographic design Greater Toronto Area COVID-19 Therapy Committee fetal lung maturation

Figure. Antimicrobial and immunomodulatory therapy in adult patients with COVID-19

BC Medical Journal vol. 62 no. 5 | june 2020 161 letters and unpublished materials are sourced by CTC COVID-19 pandemic and president of the New York State Academy of member searches, and a daily service from the adolescents’ vaping epidemic Family Physicians, “Now more than ever, it is MOH PSD. There are three active documents critical for the State and medical community After careful review of more than 800 research under constant development, to which all mem- to take actions to prevent our youth from ever papers on e-cigarettes, the National Acade- bers have editing access: using these highly addictive, deadly products, mies of Sciences, Engineering and Medicines’ 1. The working document where new studies and to help our patients to reduce their risks evidence-based clinical guidelines concluded and information is summarized in point through FDA-approved cessation and tele- that there is “moderate evidence” for increased form. health during this pandemic.”4 cough and wheeze in adolescents who use 2. The formal summary of evidence (including 1 The Canadian Paediatric Society has de- e-cigarettes. In addition, nicotine-containing complete citations), based on the working veloped a COVID-19 resource for the health e-cigarette aerosols have the potential to ad- document, which is used to update the ma- care community. The society encourages pe- versely impact several host defence mechanisms terial posted on the BCCDC website. diatricians and other health professionals who in the lungs. Independent of nicotine, expo- 3. The one pager—a very brief overview of work with adolescents, youth, and families to sure to particulates and flavorings in e-cigarette the recommendations. communicate the message that smoking and aerosols could also potentially impair lung func- The committee has also developed an info- 1 vaping may increase the risk of acquiring the tion. Meanwhile, the Forum of International graphic to act as a quick reference for clinicians COVID-19 infection.5 Respiratory Societies, a collaborative of nine in- [Figure]. The infographic is dynamic and will According to scientific evidence, COVID-19 ternational professional organizations that was be updated as changes to recommendations could be a serious threat to those who smoke created to promote respiratory health world- occur. The complete and most up-to-date ver- e-cigarettes, combustible tobacco, or mari- wide, published a position statement in 2018 sion of the guidelines is available at www.bccdc juana. Moreover, smoking or vaping increases warning that exposure to e-cigarette aerosol in .ca/health-professionals/clinical-resources/ people’s vulnerability to severe illness once in- adolescence and early adulthood can result in covid-19-care/clinical-care/treatments. 2 fected, and anything that makes the lungs less pulmonary toxicity. Weekly, after the committee has its virtual healthy will weaken our survival chances against With the growing evidence of potential risk meeting, the updated material is submitted COVID-19. factors related to the COVID-19 pandemic, to the BC Health Emergency Coordination We strongly believe that the recent evi- the immediate health effects of e-cigarette vap- Centre Clinical Reference Group—Clinical dence needs to be appropriately reflected in ing have become apparent and are alarming. Care Guidelines Working Group for final con- COVID-19 prevention and control efforts. Fur- Also, the new evidence suggests COVID-19 sideration. The approved documents are then ther, this information should be widely circu- and other respiratory infections will not only posted to the BCCDC website and distributed lated as an emerging clinical guideline in order increase the risk of developing complications throughout the province via communications to assist front-line physicians’ informed clinical from the coronavirus but will increase chances teams at each of the health authorities. decision making efforts to treat COVID-19. —British Columbia COVID-19 Therapeutics of spreading it to others. Some American states —Aki Nilanga Bandara, BSc Committee are even issuing specific health advisories on Founding Chair, Global coalition to empower 3 Postscript: For concerns pertaining to the recom- vaping and COVID-19. The evolving knowl- adolescent and youth on harmful therapeutic in- mendations made by the BC COVID-19 Therapeu- edge is especially worrisome, and in light of terventions to prevent combustible tobacco use tics Committee, please contact Dr David Sweet at this evidence, serious efforts should be made to Instructor, UBC Faculty of Land and Food [email protected]. increase public awareness of the harmful effect System of e-cigarette use. Physicians should step up and —Mehara Seneviratne, Senara Wanniarachchi, References redouble their cessation and counseling efforts. BSc, and Ricky Jhauj, BKin 1. Health Canada. Vaccines and treatments for COVID-19: Smoking and vaping also seem to be asso- Coordinators, Global coalition to empower List of all COVID 19 clinical trials authorized by Health ciated with poor survival; therefore, we need adolescent and youth on harmful therapeutic in- Canada. Accessed 20 April 2020. www.canada.ca/en/ to bring sensible policies to protect our young terventions to prevent combustible tobacco use health-canada/services/drugs-health-products/covid —Vahid Mehrnoush, MD 19-clinical-trials/list-authorized-trials.html. people from devastating effects of COVID-19. Senior Advisor, Global coalition to empower 2. Panetta A.Trump’s touting of unproven COVID-19 drug The American Academy of Family Physicians is unusual. We’ll soon see if he’s right. CBC News. 8 recently developed clinical guidance to high- adolescent and youth on harmful therapeutic in- terventions to prevent combustible tobacco use April 2020. Accessed 20 April 2020. www.cbc.ca/ light the well-known risk. People who smoke news/world/trump-drug-covid-hydroxychloroquine Section of Trauma, Acute Care, and Global Sur- or use e-cigarettes have a significantly higher -tests-1.5525690. gery, Vancouver General Hospital, UBC 3. British Columbia COVID-19 Therapeutics Committee. risk of contracting respiratory infections like BC Centre for Disease Control. Unproven therapies for the coronavirus, and people with decreased lung References COVID-19. Updated 27 April 2020. Accessed 30 April function caused by smoking or vaping are more 2020. www.bccdc.ca/Health-Professionals-Site/Docu 1. National Academies of Sciences, Engineering, and Med- ments/Guidelines_Unproven_Therapies_COVID-19.pdf likely to develop serious complications caused icine, et al. Public health consequences of e-cigarettes. by infections. According to Dr Barbara Keber, Washington, DC: National Academies Press; 2018.

162 BC Medical Journal vol. 62 no. 5 | June 2020 letters

2. Ferkol TW, Farber HJ, La Grutta S, et al. Electronic cig- electronic medical record systems. They give health records of the patients registered with arette use in youths: A position statement of the Fo- rum of International Respiratory Societies. Eur Respir more freedom to the individual physicians who them. While it can be argued that the medi- J 2018;51:1800278. have no financial obligations to the practice. cal records belong to both the patient and the 3. Commonwealth of Massachusetts, Office of At- They have definitely filled a void in medical physician, there have been instances in BC torney General Maura Healey. COVID vaping advi- care in BC, but the question arises whether where conflicts have arisen between private sory. Accessed 30 April 2020. www.mass.gov/doc/ covid-vaping-advisory. they will have a net benefit to the people of the clinic owners and physicians working in those 4. New York State Academy of Family Physicians. State- province. After all, it is the people of BC who clinics. These conflicts have resulted in physi- ment by NYSAFP on link between tobacco use and pay for them through taxation and fees paid to cians being physically locked out of the pri- COVID-19. Accessed 30 April 2020. www.nysafp.org/ these corporations through physicians’ billings. vate premises and being denied access to their News/What-s-New/COVID-19-Resources. 5. Chadi N, Bélanger R. Canadian Paediatric Society. CO- So, one must first ask: Why would private patients’ medical records. This is a dangerous VID, youth, and substance use: Critical messages for corporate entities want to invest in primary care situation for the people of BC. youth and families. Accessed 30 April 2020. www.cps delivery? All private companies exist to make As well, private corporate structures can .ca/en/blog-blogue/covid-youth-and-substance-use money for the owners of those companies. In terminate the contracts of physicians who work -critical-messages-for-youth-and-families. health care this is no different. on their premises. If this happens, these physi- The answer is that private companies have cians are at the mercy of the corporations when Corporatization of family seen the void in the organization of primary it comes to supplying them with their patients’ medicine in BC care in BC and identified it as a business op- electronic medical records. And not having im- portunity. The owners of these companies all mediate access to patients’ electronic medical Over the past decade there has been a remark- want financial compensation for their invest- records makes practising medicine very difficult, able change in the ownership of family medicine ment. If this compensation can be attained by if not impossible. practices in BC. Large numbers are now owned driving efficiencies in primary care and saving I think it is both prudent and necessary for and operated by private corporations, which are money globally, then the corporations can be the Ministry of Health and Doctors of BC to neither owned nor controlled by the physicians viewed as a net benefit for the people of BC review the status of primary care in BC as it re- who work in them. This has occurred largely and also for the physicians who work for them. lates to private ownership of medical clinics. The because family physicians are neither business If, however, these private companies exces- corporatization of primary care in BC reminds people nor endowed with the upfront financial sively control the behavior of the physicians who me of the corporatization of all medicine in the resources to invest in the start-up of increasingly work in them, and demand excessive profits for US. I practised in the US for nearly a decade, large and complex office structures. their efforts, then they will be viewed through a and I have intimate knowledge of the abuse of These corporate structures often operate ef- different lens. It must also be understood that corporate medicine. Currently in the US, over ficiently and all are well equipped with modern these private companies control the electronic 65% of all family physicians work in privately

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BC Medical Journal vol. 62 no. 5 | june 2020 163 letters owned corporate structures. These corporate structures use something called “economic cre- dentialing” when they review the usefulness of the physicians who are contracted to work in the clinics. If physicians don’t make enough money for the private corporations, they are let go. Conversely, if the physicians make more money for the corporations, they are rewarded financially. This means that these family physi- cians end up working for the benefit of the cor- porations, not for the benefit of their patients. This is one of the many fundamental stumbling blocks in American health care. This letter is meant to serve as a warning for the possible storm on the horizon in BC. We do not want to have anything resembling the American health delivery system in Canada. The time to conduct this due diligence is now, before private corporations become any more power- ful in the ownership of family medicine in BC. —Robert H. Brown, MD, CCFP North Saanich Search engine to identify the most affordable drug, coverage availability, and special Figure. The results of a search for Entresto on Drugsearch.ca. authority resources

Drugsearch.ca is a free search-engine website much the government would pay per dose. I had paid nearly $2000 over a year for Entresto that shows the price of medications (brand and have also found that most pharmacists and and did not receive PharmaCare assistance for generic), whether a medication is covered by prescribers do not realize that costs only from his other medications. It was later found that specific BC PharmaCare plans, and whether covered medications count toward satisfying a the special authority had been missed by both special authority is first needed for coverage. patient’s annual deductible, meaning that the pharmacists and prescribers, resulting in the When special authority applies, links to the increased prescribing of noncovered medica- Entresto drug costs not being applied toward special authority criteria and application forms tion actually hinders a patient from receiving his annual deductible, which needed to be met are provided. The search engine is refreshed PharmaCare assistance. before PharmaCare coverage could begin. Un- monthly and syncs drug wholesaler pricing with Drugsearch.ca allows a prescriber to search fortunately, BC PharmaCare policy does not the PharmaCare database. The website can also for and compare medications by brand or ge- permit retroactive reimbursement to the patient be accessed via the Pathways platform using neric name, filter the search results by appli- in these situations. “drugsearch” as a search term. cation (e.g., inhaled versus topical), and see My hope is that patients, pharmacists, and I created this website, with the help of a the price that a patient would pay inclusive of prescribers can use drugsearch.ca to minimize local software developer, for several reasons. I pharmacy fees. The price takes into account patients’ financial burdens and reduce the once encountered a child with severe asthma whether the medication is covered by Phar- amount of paperwork faxed to pharmacies re- whose parents had purchased only Ventolin, maCare and how much a patient would pay if questing alternative covered medications. avoiding the steroid due to costs. I realized it is covered. Drugsearch.ca results also show if —Anthony Chiam, RPh that if the prescriber had a rapid way to see a drug first requires special authority applica- North Vancouver which inhaled steroid was covered, the situation tion to activate PharmaCare coverage, and has Disclosure: We are applying for a grant from the could have been averted. I am also frequently one-click links to the PharmaCare criteria page Ministry of Health for revenue to support the up- contacted by physician friends and colleagues and application forms [Figure]. The need for a keep and cover host and server fees. The website asking for the prices of different medications fast way to show pharmacists and prescribers will not track or sell data; all users are anonymous. because the PharmaCare formulary website special authority availability arose after I en- There will be no advertisements on the site. does not show the full retail price, only how countered the case of an elderly pensioner who

164 BC Medical Journal vol. 62 no. 5 | June 2020 BCCDC

the first 3 months of the pandemic compared Epidemiology of COVID-19 with many other countries, mirroring Australia’s epidemic curve.3 While the age and sex distri- in BC: The first 3 months bution of cases in BC was similar to what was observed across Canada, there were relatively fewer reported cases among youth and relatively 11 May 2020 more reported fatalities among individuals over 80 years old compared with global patterns. This is likely a reflection of variations in testing s of mid-May 2020, more than 2000 Fraser Health and Vancouver Coastal Health.1 practices and because most COVID-19-related diagnosed cases of COVID-19 in Lab-confirmed cases were evenly distributed by deaths in Canada have occurred in long-term British Columbia were reported to sex. Two-thirds of cases were among individu- care facilities. The observed sex difference in publicA health.1 The epidemic in BC began with als aged 30 to 69, and only 2% were pediatric BC for severe COVID-19-related outcomes, the first lab-confirmed case reported on 26 Jan- (younger than 19 years). Approximately one with men more likely to be hospitalized, re- uary 2020. Cases through to the end of Febru- in five cases was among quire critical care, and die, ary were among international travelers or close health care workers. By 6 is consistent with interna- contacts of travelers to an area with community May 2020, 49 outbreaks One in five British tional statistics.4 transmission. In early March 2020, the first case had been declared, the Columbians who tested As the restrictions and of community transmission in BC was reported, majority (n = 41, 84%) in positive for COVID-19 measures put in place to and the first two outbreaks of COVID-19 were health care facilities, and was hospitalized. prevent community trans- identified (one at a conference, and one at a eight in other settings mission in BC continue long-term care facility). This was followed by (e.g., correctional facilities, to ease over the coming the increase in case counts. workplaces). weeks, the province will Cases related to travel slowed coincident One in five British Columbians who tested continue to monitor the dynamics and epide- with restrictions on non-essential travel, manda- positive for COVID-19 was hospitalized, and miology of the pandemic. n tory quarantine upon return to BC, and border of those two in five required critical care. The —Caren Rose, PhD closures (3rd week of March 2020). A variety of crude case fatality rate was 5%, with age-specific BCCDC, PHSA public health measures were implemented, and rates ranging from 0.8% among individuals School of Population and Public Health, UBC lab testing capacity continued to be expanded, younger than 70 years, to 10% among indi- —BCCDC Surveillance Team with testing initially focused on those most viduals aged 70 to 79, and 28% in individuals BCCDC, PHSA likely to transmit infection or who were part 80 years and older. The majority (> 60%) of —Kate Smolina, PhD of clusters or outbreaks. The daily number of deaths were among residents of long-term care BC Observatory for Population and Public Health, BCCDC incident reported cases peaked in the 4th week facilities. Males were at 70% increased risk of School of Population and Public Health, UBC of March at close to 100 new cases.1 Thereafter, death and were also more likely to be hospital- there was a slow decline and leveling in the ized compared to females (25% for males, 15% References number of new cases identified daily through females). The number of individuals requiring 1. British Columbia Centre for Disease Control. British April. In late April, low-threshold testing began, hospitalization and/or critical care peaked in Columbia COVID-19 daily situation report, May 8, and case numbers remained stable. Five weeks the first week of April about 10 days after the 2020. Accessed 11 May 2020. www.bccdc.ca/Health after the peak, most cases were acquired locally peak in cases. At the peak, there were nearly -Info-Site/Documents/BC_Surveillance_Summary _May_8_2020_Final.pdf. through contact with a known case or cluster 150 cases in hospital across the province; after 2. Public Health Agency of Canada. Coronavirus disease with very little community transmission. the peak, the number steadily declined. 2019 (COVID-19). Daily epidemiology update. Accessed All five regional health authorities reported Across Canada, every province has expe- 11 May 2020. www.canada.ca/content/dam/phac-aspc/ cases of COVID-19; 84% of cases were from rienced its own epidemic: a series of regional documents/services/diseases/2019-novel-coronavirus the two most populous health authorities, epidemics.2 While BC represents 14% of the -infection/surv-covid19-epi-update-eng.pdf. 3. Johns Hopkins University COVID-19 Dataset. Accessed Canadian population, it accounts for less than 11 May 2020. https://github.com/CSSEGISandData/ 4% of national COVID-19 cases and deaths so COVID-19/tree/master/csse_covid_19_data. 2 This article is the opinion of the BC Centre far. BC’s epidemic curve was most similar to 4. Global Health 5050. COVID-19 sex-disaggregated Saskatchewan’s, both in terms of the magnitude data tracker. Accessed 11 May 2020. https://global for Disease Control and has not been health5050.org/covid19. peer reviewed by the BCMJ Editorial relative to the population, as well as the overall Board. trajectory. Internationally, BC fared favorably in

BC Medical Journal vol. 62 no. 5 | june 2020 165 Clinical

David Sanders, MD, Hui-Min Yang, MD, S. Ian Gan, MD, FRCPC An unusual finding from fecal immunochemical testing: A case report

Endoscopic and histologic investigations following a positive fecal immunochemical test (FIT) result eventually led to the detection of a rare mucosa-associated lymphoid tissue (MALT) lymphoma.

ABSTRACT: This case report describes the presenta- case, investigation included esophagograstroduo- Her colonoscopy revealed a 1-cm pedun- tion, workup, and management of a 73-year-old denoscopy and CT imaging. The results from all culated polyp in the ascending colon and two patient with multifocal extranodal mucosa-associ- investigations eventually led to the detection of 5-mm semi-pedunculated polyps in the trans- ated lymphoid tissue (MALT) lymphoma. The MALT a rare gastric cancer. Despite the patient being verse colon. Evidence of mild colitis was found lymphoma was identified through a process that from a part of the world with high rates of endemic in the rectosigmoid region and tissue was ob- began with routine fecal immunochemical testing, Helicobacter pylori, the MALT lymphoma identified tained for biopsy [Figure 1]. Retroflexion in which is recommended in BC for screening average- was not associated with H. pylori and was probably the rectum revealed only internal hemorrhoids. risk patients for colorectal cancer. The fecal immu- related to a systemic inflammatory disorder. The ascending colon polyp was a tubulovillous nochemical test (FIT) used for screening requires adenoma with low-grade dysplasia. The trans- the patient to submit a stool sample collected at Case data verse polyps were a sessile serrated adenoma home using a simple kit. The sample is then ana- A 73-year-old female with average risk of co- without dysplasia and a tubular adenoma with lyzed for the presence of blood. However, because lon cancer presented for routine fecal immu- low-grade dysplasia. bleeding can occur with benign pathologies such nochemical testing. She had been screened in Histologic sections of the rectosigmoid as hemorrhoids, inflammatory bowel disease, and the past with the fecal immunochemical test biopsies revealed an atypical lymphoid infil- vascular lesions, further investigation is required (FIT). Her medical history was significant for a trate that had expanded the lamina propria when certain pathologies are found on colonos- cerebrovascular accident, dyslipidemia, osteopo- and replaced the glands [Figure 2]. Scattered copy done in the colon screening program. In this rosis, and an inflammatory spondyloarthropahy lymphoepithelial lesions were identified. Im- with inflammatory sacroiliitis. Her medications munohistochemistry demonstrates an atypical B included ASA, alendronate, and naproxen as cell population positive for CD20 and negative Dr Sanders is a gastroenterology resident needed. She was a nonsmoker with no alcohol for CD3, CD5, CD10, and CD43. A lambda at the University of British Columbia and consumption and had moved to Canada from light chain restriction was observed. The find- is based at Vancouver General Hospital. Hong Kong. She had a second-degree relative ings were consistent with low-grade B cell Dr Yang is a consultant pathologist diagnosed after age 60 with colorectal cancer. mucosa-associated lymphoid tissue (MALT) at Vancouver General Hospital and After having negative FIT results in 2014 lymphoma. an associate clinical professor in and 2015, the patient had a positive FIT re- The patient underwent an esophagograstro- the Department of Pathology and sult in July 2018 with a value of 171 ng/mL. duodenoscopy (EGD) that revealed atrophic Laboratory Medicine at the University When assessed prior to colonoscopy, she re- gastric mucosa in the proximal stomach. Ery- of British Columbia. Dr Gan is a ported no hematochezia or melena and regular thema with an abnormal mucosal pattern was gastroenterologist at Vancouver General bowel movements with no change in her bowel seen from the mid-gastric body extending into Hospital and an associate professor in habits. She had no early satiety, epigastric pain, the antrum, pylorus, and first part of the duo- the Division of Gastroenterology at the nausea, or vomiting. Her weight was stable. She denum [Figure 3]. Biopsies of the gastric and University of British Columbia. had no fevers, chills, or night sweats. Physical duodenal mucosa again showed a clonal popula- examination revealed no abdominal masses or tion of CD20 lymphocytes with lambda light This article has been peer reviewed. peripheral lymphadenopathy. chain restriction and confirmed the diagnosis

166 BC Medical Journal vol. 62 no. 5 | June 2020 Sanders D, Yang H-M, Gan SI Clinical

Figure 1. Visualization of the rectosigmoid by colonoscopy reveals an abnormal Figure 3: Visualization of the antrum by esophagograstroduodenoscopy reveals vascular pattern and hyperemia. erythema with an abnormal mucosal pattern.

A

B

Figure 2. Immunohistochemistry findings.A: Hematoxylin and eosin staining Figure 4. Immunohistochemistry findings. A: CD20 staining reveals a clonal B of biopsied rectosigmoid tissue reveals an atypical polymorphous lymphoid cell population in the deep lamina propria (see bottom right corner) and atypical infiltrate that expands the lamina propria and replaces the colonic glands.T he lymphoid cells that are positive for CD20 (original magnification × 200).B: CD3 majority of the atypical lymphoid cells are intermediate-size with centrocytic staining reveals scattered background reactive T cells (original magnification nuclei and variably abundant pale cytoplasm. Occasional larger lymphoid × 200). C: Lambda light chain immunohistochemistry shows lesional cells that cells with vesicular chromatin and distinct nucleoli are also present (original exhibit monotypic reactivity for immunoglobulin (original magnification × 200). magnification × 200).B: Hematoxylin and eosin staining shows that the atypical D: Kappa light chain immunohistochemistry highlights a few non-neoplastic lymphoid infiltrate extends into the submucosa and is poorly circumscribed plasma cells (original magnification × 200). (original magnification × 40).

BC Medical Journal vol. 62 no. 5 | june 2020 167 CliniClinicalcal An unusual finding from fecal immunochemical testing: A case report of extranodal marginal zone MALT lymphoma A C [Figure 4]. Other investigations revealed the patient’s hemoglobin level was 117 g/L, her WBC was 3.5 x 109 /L, and her platelet count was 163 x 109 /L. The patient was also found to have a lactate dehydrogenase (LDH) level of 187 IU/L, creatinine of 74 μmol/L, and beta-2 mi- croglobulin of 2.4 mcg/mL. Her serum protein electrophoresis showed a monocloncal IgM lambda band in the beta 2 region. Helicobacter pylori, bacteria endemic in the patient’s area of origin and typically associated with this lym- phoma, were not identified by biopsy or by a urea breath test. A bone marrow biopsy showed no bone involvement. A CT scan showed ab- normal wall thickening in the gastric antrum, proximal duodenum, and lower rectum [Figure 5]. There were prominent subcentimetre lymph nodes near the stomach and rectosigmoid. The patient was followed by her oncologist and a repeat EGD and colonoscopy were done at 6 months and found to show no endoscopic or histologic changes. Currently the patient remains on an active surveillance schedule and is receiving no therapy as she is asymptomatic B and has a good performance status.

Discussion Extranodal mucosa-associated lymphoid tissue lymphomas are induced by chronic inflam- mation,1 with MALT lymphoma being the most common of marginal zone B cell lym- phomas.2 The prototypical infection for MALT involvement of the stomach is H. pylori. A study published in 2010 found the incidence of H. pylori-associated MALT lymphoma has de- clined3 compared with an earlier study that found H. pylori infection in 92% of all gastric MALT lymphomas considered.4 US data indicate that extranodal marginal zone lymphoma is rare, with 18.3 cases per 1 million person years, and that the median age at diagnosis is 66 years.5 The stomach is the most frequent site of involvement, but MALT can also involve the colon, salivary glands, ocu- lar adenexa, lungs, thyroid, breast, and liver.6 Symptoms can include reflux, epigastric pain, anorexia, weight loss, and gastrointestinal bleed- ing.7 Monoclonal gammopathy is found in 27% Figure 5. CT findings. A: Coronal view shows diffuse thickening of the gastric antrum. B: Transverse view 8 shows thickening of the rectosigmoid (arrows). C: Sagittal view shows fat stranding (arrow) associated with to 36% of patients. colonic involvement.

168 BC Medical Journal vol. 62 no. 5 | June 2020 Sanders D, Yang H-M, Gan SI Clinical

epidemiology, and end results database. Cancer 2013; This case is interesting because the diagno- testing, and CT imaging. Although the patient 119:629 - 638. sis was made with the help of the BC Cancer was not found to have H. pylori-associated dis- 3. Luminari S, Cesaretti M, Marcheselli L, et al. Decreas- Colon Screening Program, which identifies ease, she did have inflammatory spondyloar- ing incidence of gastric MALT lymphomas in the era of those at risk of colon cancer using the FIT—a thropahy with inflammatory sacroiliitis. Her anti-Helicobacter pylori interventions: Results from a simple test that requires patients to provide a systemic inflammatory disorder may have been population-based study on extranodal marginal zone lymphomas. Ann Oncol 2010;21:855-859. stool sample for analysis. If blood is detected, a factor in her MALT diagnosis, since extra- 4. Wotherspoon AC, Ortiz-Hidalgo C, Falzon MR, follow-up procedures are ordered. This case is nodal mucosa-associated lymphoid tissue lym- Isaacson PG. Helicobacter pylori-associated gastritis also interesting because the patient had multi- phomas are known to be induced by chronic and primary B-cell gastric lymphoma. Lancet 1991; focal disease with involvement of the stomach, inflammation. 338(8776):1175-1176. 5. Khalil MO, Morton LM, Devesa SS, et al. Incidence of small bowel, and rectosigmoid, yet had no evi- marginal zone lymphoma in the United States, 2001- dence of H. pylori infection. Besides H. pylori 2009 with a focus on primary anatomic site. Br J Hae- infection, autoimmune diseases such as sys- The mechanism matol 2014;165:67-77. temic lupus erythematous, Sjögren’s syndrome, 6. Zucca E, Conconi A, Pedrinis E, et al.; International Ex- postulated in cases such tranodal Lymphoma Study Group. Nongastric marginal Hashimoto disease, and relapsing polychondri- zone B-cell lymphoma of mucosa-associated lymphoid 1,9,10 tis have been associated with MALT. This as this is that chronic tissue. Blood 2003;101:2489-2495. patient had inflammatory spondyloarthropahy inflammation leads to 7. Koch P, del Valle F, Berdel WE, et al. Primary gastrointes- with inflammatory sacroiliitis. The mechanism tinal non-Hodgkin’s lymphoma: I. Anatomic and his- the local accumulation tologic distribution, clinical features, and survival data postulated in cases such as this is that chronic and proliferation of of 371 patients registered in the German multicenter inflammation leads to the local accumulation study GIT NHL 01/92. J Clin Oncol 2001;19:3861-3873. and proliferation of antigen-dependent B cells antigen-dependent 8. Wöhrer S, Streubel B, Bartsch R, et al. Monoclonal immu- and T cells. B cell clones will remain that still B cells and T cells. noglobulin production is a frequent event in patients with mucosa-associated lymphoid tissue lymphoma. depend on the antigen-stimulated immune re- Clin Cancer Res 2004;10:7179-7181. sponse for growth and survival. With acquisi- 9. Ramos-Casals M, la Civita L, de Vita S, et al. Characteriza- tion of additional mutations, the tumor becomes tion of B cell lymphoma in patients with Sjögren’s syn- antigen-independent and capable of systemic drome and hepatitis C virus infection. Arthritis Rheum spread.11 The stomach is the most common site af- 2007;571:161-170. 10. Ekstrom Smedby K, Vajdic CM, Falster M, et al. Autoim- Historically, the Lugano staging system was fected, but MALT lymphoma can also involve mune disorders and risk of non-Hodgkin lymphoma used for gastrointestinal lymphomas, but mod- the colon, salivary glands, ocular adenexa, lungs, subtypes: A pooled analysis within the InterLymph els such as the Paris Staging System12 can also thyroid, breast, and liver. Symptoms may include Consor tium. Blood 2008;111:4029 - 4038. be used. This patient was designated stage IV as reflux, epigastric pain, anorexia, weight loss, and 11. Park YK, Choi JE, Jung WY, et al. Mucosa-associated lym- phoid tissue (MALT) lymphoma as an unusual cause she had disseminated extranodal involvement gastrointestinal bleeding. Once identified, treat- of malignant hilar biliary stricture: A case report with in multiple areas of the gastrointestinal tract. ment of MALT lymphoma may include H. literature review. World J Surg Oncol 2016;14:167. In H. pylori-associated cases, bacteria eradi- pylori-eradication therapy, chemotherapy, or 12. Zucca E, Copie-Bergman C, Ricardi U, et al. ESMO Guide- cation therapy should be prescribed regardless radiation. In this case, the patient is currently lines Working Group. Gastric marginal zone lympho- 1,12 ma of MALT type: ESMO Clinical Practice Guidelines of disease stage. Eradiation of the bacteria asymptomatic and remains on an active surveil- for diagnosis, treatment and follow-up. Ann Oncol 13 should then be documented with a breath test. lance schedule without therapy. The patient was 2013;24(suppl 6):vi144-vi148. The decision to use rituximab, chemotherapy, referred for a radiation oncology opinion for 13. Fallone CA, Chiba N, van Zanten SV, et al. The Toronto or radiation is dependent on symptoms and symptom management or to delay the need for consensus for the treatment of Helicobacter pylori infection in adults. Gastroenterology 2016;151:51-69. disease distribution.12 Long-term follow-up systemic therapy. She was offered radiation to with physical examinations, blood testing (in- the gastric lesion, but declined treatment due cluding a CBC), cross-sectional imaging, and to lack of symptoms and concern around the endoscopy should be implemented to monitor side effects of radiation.n for progression and transformation.12 Competing interests Summary None declared. In the case described here a 73-year-old female was diagnosed with mucosa-associated lym- References 1. Zucca E, Bertoni F. The spectrum of MALT lymphoma phoid tissue lymphoma after a process that be- at different sites: Biological and therapeutic relevance. gan with routine fecal immunochemical testing. Blood 2016;127:2082-2092. A positive FIT result led to the patient undergo- 2. Olszewski AJ, Castillo JJ. Survival of patients with mar- ing colonoscopy, esophogastrodenoscopy, blood ginal zone lymphoma: Analysis of the surveillance,

BC Medical Journal vol. 62 no. 5 | june 2020 169 special feature

Medical education during COVID-19: Lessons from a pandemic

Key lessons learned during COVID-19 at the UBC Faculty of Medicine.

Roger Y. Wong, MD, FRCPC, FACP, FCAHS

he impact of COVID-19 on medical This cannot be overstated. We know that medi- Effective communication is especially criti- education is unprecedented, far reach- cal students report feelings of uncertainty and cal during the pandemic. To ensure messaging ing, and presents unique challenges to anxiety3 about personal safety and continuity is consistent, the task force develops key mes- medicalT schools.1-3 Mitigating strategies should of learning experience. Many have questions sages regularly to add clarity to what students, be principle based, forward looking, and com- on how the pandemic impacts their graduation faculty, and staff can expect. A multimodal com- passionate. Lessons learned from the medical timeline, financial liability, and housing inse- munication approach is helpful, using email, education adaptations during the pandemic curity. The latter stressors, albeit nonacademic, YouTube video messages, and website postings. can potentially be extrapolated to other cri- must be adequately addressed through enhanced Also, early engagement of internal (university sis situations. This article outlines key lessons student advising services. administration) and external (health authori- learned during COVID-19 at the UBC Faculty To recommend and implement educational ties) stakeholders is crucial. of Medicine, which is home to a provincially adaptations, we constructed two rapid-response During the pandemic, we are learning that distributed medical undergraduate program teams at the outset. The first, the COVID-19 medical curricular adaptations should be flex- that is composed of three regional medical cam- advisory working group, makes high-level steer- ible in terms of delivery and administration, puses in addition to the main campus. ing recommendations to the dean’s office on building on the existing pedagogical design. For all educational adaptations during educational adaptations as part of the medical The governance structure of the curriculum COVID-19, the foundational consideration is school’s response. The second, the undergradu- should be maintained to ensure compliance to embrace the safety and well-being of students ate medical education COVID-19 task force, with accreditation standards. in the context of providing patient-centred care. implements these recommendations. This task With physical distancing required, all force, co-chaired by the undergraduate associate in-person classes (e.g., case-based learn- dean and a regional associate dean, comprises ing, lectures, discussion groups) transitioned to Dr Wong is the executive associate dean, student representatives from all years and cam- remote teaching via an online platform, literally education, and a clinical professor in puses, as well as multidisciplinary faculty mem- within several days. Our approach has been the Department of Medicine at the UBC bers and administrative staff. This approach to expand the video delivery platform that is Faculty of Medicine. helps to empower students and faculty, who already in place for our provincially distrib- can serve as champions for change. uted medical education program. Case-based This article has been peer reviewed.

170 BC Medical Journal vol. 62 no. 5 | June 2020 special feature learning is delivered via videoconferencing, and the medical program uses YouTube teaching videos, mobile apps, and previously recorded di- Many adaptations, such as dactic sessions. We recognize that emergency effective online instruction, remote teaching may not contain all the best 4 are catalyzed by the practices in effective online instruction, and we apply continuous quality improvement urgency of the pandemic. processes to enhance the learning experience. In the meantime, in the interest of student and patient safety, early clinical experiences (years 1 and 2) and clinical clerkship (core and elective rotations, years 3 and 4) have been placed on hold for all medical students. This is a uniform adaptation across all 17 medical schools in Canada and helps manage the fi- nite amount of personal protective equipment available. Close liaison with the Association of Faculties of Medicine of Canada is helpful. Adaptations made to replace in-person early clinical experiences (years 1 and 2) include on- line posting of clinical skills, development of Similar to the curricular adaptations, we new webinars, and videoconferencing delivery Competing interests have made parallel modifications to the as- of family medicine teaching. For year 3 students, None declared. sessment framework, preserving the over- the module of clinical clerkship has been tem- all programmatic assessment approach while porarily pulled out and replaced with flexible Acknowledgments allowing flexibility by shifting the formative learning experience projects, which normally Dr Wong would like to express his heartfelt thanks and summative components. Portfolio ses- occur in year 4. The exact timing of clerkship re- to the countless faculty, clinical colleagues, staff, sions have switched to online delivery, and instatement remains uncertain at this time and and students who contribute to the MD under- workplace-based assessments have been de- will depend on the rapidly evolving pandemic graduate education program at the University of ferred to after reinstatement of clinical clerk- situation. We understand this can be a source of British Columbia. ship. Multiple-choice examinations are now anxiety for students, and we are offering proac- delivered online and made formative. We also tive academic advising and student counseling. References delivered the first online objective structured 1. Rose S. Medical student education in the time of Year 4 students have already completed the core clinical examination (OSCE) to the final year COVID-19. JAMA 2020. doi:10.1001/jama.2020.5227. curriculum, short of 2 weeks of electives, which students and are deferring it for students in the 2. Ahmed H, Allaf M, Elghazaly H. COVID-19 and medi- have been now replaced by public health or re- cal education. Lancet Infect Dis 2020. doi.org/10.1016/ remaining years. search projects. These final-year students will S1473-3099(20)30226-7. We have made adaptations to faculty devel- 3. Gallagher TH, Schleyer AM. “We signed up for this!” – graduate on time in May 2020, and will start opment in preparing and supporting teachers Student and trainee responses to the Covid-19 pan- residency training in July 2020, contributing to via online, open-access resources.6 We have demic. N Engl J Med 2020. doi:10.1056/NEJMp2005234. the physician workforce. 4. Hodges C, Moore S, Lockee B, et al. EDUCAUSE Re- also launched a number of COVID-19-related Concurrently, we are empowering all medi- view. The difference between emergency remote webinars, free of charge, to support our teach- cal students to actively engage in a number of teaching and online learning. Acessed 30 April 2020. ers as part of the medical school’s continuing https://er.educause.edu/articles/2020/3/the-difference public health activities at the provincial level professional development services. -between-emergency-remote-teaching-and-online that do not involve physical patient contact, -learning. While it is important to act quickly when such as conducting COVID-19 contact trac- 5. Bauchner H, Sharfstein J. A bold response to the COV- making adaptations during COVID-19, it is ing, staffing telephone hotlines and call centres ID-19 pandemic: Medical students, national service, and equally important to anticipate the long-term public health. JAMA 2020. doi:10.1001/jama.2020.6166. in regional health authorities, and performing shifts that may become the new normal. Many 6. Office of Faculty Development, University of British background literature searches for public health. Columbia. COVID-19 and faculty development and adaptations, such as effective online instruction, The engagement of our students as part of the support. Accessed 10 April 2020. https://facdev.med are catalyzed by the urgency of the pandemic. public health response demonstrates the social .ubc.ca/covid-and-faculty-development-support. We should begin to plan to sustain the adapta- 7. Emanuel EJ. The inevitable reimagining of medical responsibility of the medical school, an approach 7 n education. JAMA 2020;323:1127-1128. 5 tions as we refresh medical education. that has been mirrored in other jurisdictions.

BC Medical Journal vol. 62 no. 5 | june 2020 171 special feature

such as Airbnb and MLS, UBC Reticulum uses UBC Reticulum: A novel tags to tailor the site to a user’s interests. Users identify subspecialties and other interests, and website connecting general corresponding tags were created to attach to applicable research projects and message posts. Users who list specific interests on their pro- surgeons in BC during the file receive an email or text notification when another user posts something tagged with that COVID-19 crisis interest. Examples of tags include subspecialty interests such as community surgery, colorectal The UBC Reticulum website was launched in May 2019 to help surgery, gastric oncology, and critical care. Ex- amples of other interests include billing, global connect general surgeons throughout the province. Following the health, medicolegal issues, wellness, medical emergence of COVID-19, the website has become a communication education, and telehealth. hub connecting surgeons during the crisis. Netter topics include links to other websites, billing tips, resources for telehealth, information Hamish Hwang, MD, FRCSC, FACS, Shiana Manoharan, MD, Taryn Zabolotniuk, BSc, S. Morad to share with patients, endoscopy algorithms, Hameed, MD, MPH, FRCSC, FACS COVID-19 data resources, announcements about canceled conferences, government tax information, wellness resources, perioperative he UBC Reticulum website was The initiative was funded by the University PPE protocols, alternative sourcing of PPE, launched in May 2019 to help con- of British Columbia, and the site was created by advice on triaging office consults, impacts on nect general surgeons across British Actualize8, a website design company in Van- residents and qualifying examinations, and invi- Columbia.T The site’s primary function was to couver. Inspired by social media apps such as tations to webinars. Figure 3 shows a screenshot connect surgeons based on their name, loca- Facebook, Twitter, and Instagram, and websites of a feeder post and a few comments on the tion, specialty area, and the procedures they carry out. Figures 1 and 2 show screenshots of the website’s map function that displays where surgeons are located throughout the province. Other features included matching surgeons with mentors, a repository of proposed and completed research projects, a locum-matching function, and a message board dubbed “Netter.” The site (www.ubcreticulum.com) is restricted to general surgeons, residents, and associated administrators and researchers.

Dr Hamish Hwang is a clinical associate professor at the University of British Columbia and associate head of the UBC Division of General Surgery. Dr Shiana Manoharan is a general surgery resident at UBC. Ms Taryn Zabolotniuk is a medical student at UBC. Dr S. Morad Hameed is an associate professor of surgery and critical care medicine at UBC and head of the UBC Division of General Surgery. Figure 1. The map function of the UBC Reticulum website showing where surgeons are located throughout This article has been peer reviewed. the province.

172 BC Medical Journal vol. 62 no. 5 | June 2020 special feature message board (user identifiers are greyed out). On 15 March 2020, a COVID-19 tag was created. By 25 March 2020 there were 31 feeder posts on Netter with 63 follow-up comments posted by 24 users from all five geographic regions of the province. After 10 days, more surgeons were engaged on the website than previously seen on any other topic. Over the following 4 weeks, there were 60 additional Netter posts, including a link to a daily Zoom update hosted by surgeons at Vancouver Gen- eral Hospital and attended by surgeons across the province. An additional 40 users signed up for the website, bringing the total to 232. On 6 April 2020, a new feature went live— the COVID-19 Surgical Oncology Transfer Network. This feature, pictured inFigure 4, allows an at-a-glance view of all the hospitals in the province and their capacity to perform Figure 2. The map function showing general surgeons in Greater Vancouver. urgent cancer surgery. Each site has a designated surgeon contact to facilitate urgent transfers of cancer patients; if cancer operations become no In the face of the unprecedented COVID- a networking website such as this was realized longer possible at one hospital patients could be 19 crisis, general surgeons in BC have been able in an unpredictable circumstance. Opportunities transferred to another hospital in the network to use this new technology to connect and help to repurpose the network for other pandemics that still has access. The network is maintained each other in real time in a way never before or disaster scenarios in the future are sure to by a volunteer UBC medical student. seen. The potential for collaboration created by be discovered. n

Figure 3. A screenshot of a feeder post on the Figure 4. A screenshot of the COVID-19 Surgical Oncology Transfer Network. message board (Netter).

BC Medical Journal vol. 62 no. 5 | june 2020 173 college library

Thank you, and a helping . . . email?

hank you to everyone for all you’re do- e-books for background information: www quick, evidence-based clinical answers or in- ing in this unusual situation. Normally .cpsbc.ca/files/pdf/Ebooks-to-Assist-with formation on the go. the College Library would extend a -Pandemic-Management.pdf. You may enter Last, but definitely not least, we’ve been helpingT hand, but even though we washed it for requests for information on more specific top- receiving questions about health care profes- over 20 seconds, maybe we can offer a helping ics on our literature search sionals’ mental health, and email instead? form: www.cpsbc.ca/ we can provide informa- For doctors on the front lines: if you need literature-search-requests. We continue to provide tion about sources of information, we’re here for you. We’ve been an- For doctors continuing access to point-of-care support for you and your swering many questions related to COVID-19 to provide care to patients tools in case you need colleagues, such as www and know how challenging it is to find infor- with other disorders, our quick, evidence-based .bccdc.ca/health-profes mation on an emerging disease. The College services are still available, sionals/clinical-resources/ clinical answers. Library has created a list of pandemic-related with an emphasis on covid-19-care/health-care electronic delivery. We’ve -provider-support. This article is the opinion of the Library of been working on many Hope that you and the College of Physicians and Surgeons of non-COVID-19 questions, and we continue yours stay safe and well. —Niki Baumann BC and has not been peer reviewed by the to provide access to quality resources such as Librarian BCMJ Editorial Board. point-of-care tools and apps in case you need

174 BC Medical Journal vol. 62 no. 5 | June 2020 coHp

Obesity: A risk factor for severe infection with coronavirus SARS-CoV-2

he COVID-19 pandemic is of par- and more serious infection from SARS-CoV-2. References ticular relevance to patients with obe- Obesity is a state of chronic inflammation with 1. Onder G, Rezza G, Brusaferro S. Case-fatality rate and sity. Early clinical reports from China, high concentrations of pro-inflammatory cy- characteristics of patients dying in relation to COVID-19 in Italy. JAMA 2020. doi: 10.1001/jama.2020.4683. Italy, and the US identified that age, hyperten- tokines, which causes reduced macrophage T 2. Zhou F, Yu T, Du R, et al. Clinical course and risk fac- sion, cardiac disease, and diabetes are strongly activation and blunted cytokine production con- tors for mortality of adult inpatients with COVID-19 in associated with severe disease and death from tributing to impaired innate immunity.10 Leptin Wuhan, China: A retrospective cohort study. Lancet infection with SARS-CoV-2.1-5 Obesity was is a hormone made by fat cells and is a marker 2020:395(10229):1054-1062. 3. Guan WJ, Ni Z-Y, Hu Y, et al. Clinical characteristics of demonstrated to be an important risk factor for of the degree of adiposity. Leptin levels are high coronavirus disease 2019 in China. N Engl J Med 2020. severe infection from the in patients with obesity doi: 10.1056/NEJMoa2002032. influenza A H1N1 virus,6 BMI correlates positively and it has been shown to 4. Grasselli G, Pesenti A, Cecconi M. Critical care uti- lization for the COVID-19 outbreak in Lombardy, and emerging evidence interfere with the body’s with the concentration Italy: Early experience and forecast during an emer- suggests that this is also ability to mount an effec- of infectious virus in gency response. JAMA 2020. doi: doi:10.1001/jama the case for SARS-CoV2. tive immune response to .2020.4031. Recent studies from exhaled breath. vaccination or infection. It 5. Arentz M, Yim E, Klaff L, et al. Characteristics and outcomes of 21 critically ill patients with COV- China, France, and the is possibly the basis of the ID-19 in Washington State. JAMA 2020. doi: 10.1001/ US show that COVID-19 poor vaccination success jama.2020.4326. positive patients with a higher body mass index rates in patients with obesity as well as their 6. Morgan OW, Bramley A, Fowlkes A, et al. Morbid obe- (BMI) have greater odds of experiencing disease increased susceptibility to viral infections.11 sity as a risk factor for hospitalization and death due to 2009 pandemic influenza A(H1N1) disease. PLoS One requiring acute or critical care, and may be less Persons with obesity shed influenza A vi- 2010;5:e9694. 7-9 likely to survive. rus for longer periods, increasing the chance 7. Peng YD, Meng K, Guan HQ, et al. [Clinical character- The largest study to date, evaluating the as- of spread.12 This is important in determining istics and outcomes of 112 cardiovascular disease pa- tients infected by 2019-nCoV]. 2020;48:E004. sociation of BMI with SARS-CoV-2 infection self-isolation times. Furthermore, BMI cor- 8. Lighter J, Phillips M, Hochman S, et al. Obesity in pa- was a retrospective analysis of 3615 COVID-19 relates positively with the concentration of in- tients younger than 60 years is a risk factor for Covid-19 positive symptomatic patients in a New York fectious virus in exhaled breath and evidence hospital admission. Clin Infect Dis 2020. doi: 10.1093/ academic hospital.7 Among patients younger suggests that the obesity microenvironment cid/ciaa415. 13,14 9. Simonnet A, Chetboun M, Poissy J, et al. High preva- than 60 years, persons with a BMI between 30 contributes to greater disease virulence. lence of obesity in severe acute respiratory syndrome 2 and 34 kg/m were 2 times more likely to be ad- Mounting evidence supports obesity as a coronavirus-2 (SARS-CoV-2) requiring invasive mechani- mitted to acute care and critical care. Similarly, risk factor for severe COVID-19 disease. Iso- cal ventilation. Obesity (Silver Spring) 2020. doi: 10.1002/ patients younger than 60 years with a BMI ≥ 35 lation of positive cases and physical distancing oby.22831. 2 10. Bahr I, Spielmann J, Quandt D, Kielstein H. Obesity- kg/m , were 4 times more likely to be admitted are currently the primary interventions. Per- associated alterations of natural killer cells and immu- to critical care. This study adjusted for age but sons with obesity should be especially careful nosurveillance of cancer. Front Immunol 2020;11:245. not comorbid conditions. to avoid infection. Physicians should also be 11. Painter SD, Ovsyannikova IG, Poland GA. The weight of obesity on the human immune response to vacci- There are several biologically plausible aware of the psychological toll associated with nation. Vaccine 2015;33:4422-4429. mechanisms for the association between obesity obesity and the need to support our patients’ 12. Maier HE, Lopez R, Sanchez N, et al. Obesity increases physical and mental well-being amid the global the duration of influenza A virus shedding in adults. J n Infect Dis 2018;218:1378-1382. This article is the opinion of the Nutrition pandemic. —Priya Manjoo, MD 13. Honce R, Karlsson EA, Wohlgemuth N, et al. Obesity- Committee, a subcommittee of Doctors related microenvironment promotes emergence of —Katie Bowers, MPP of BC’s Council on Health Promotion, and virulent influenza virus strains. mBio 2020;11:e03341-19. 14. Yan J, Grantham M, Pantelic J, et al. Infectious virus in is not necessarily the opinion of Doctors exhaled breath of symptomatic seasonal influenza of BC. This article has not been peer cases from a college community. Proc Natl Acad Sci reviewed by the BCMJ Editorial Board. U S A 2018;115:1081-1086.

BC Medical Journal vol. 62 no. 5 | june 2020 175 News We welcome news items of less than 300 words; we may edit them for clarity and length. News items should be emailed to [email protected] and must include your mailing address, telephone number, and email address. All writers should disclose any competing interests.

fractious settlers. A true generalist, Wrinch’s order to better provide for the people of the Book review: name deserves wide recognition as one of the Upper Skeena. Service on the outstanding medical pioneers of the country. This biography—well researched and well Skeena: Horace Horace Wrinch arrived with his wife in the written—provides in-depth local history, Wrinch, Frontier Upper Skeena in 1900 to serve the people of the wonderful stories of early medicine in the Up- Physician region and was responsible, as the only physi- per Skeena, and anecdotes of the challenges cian, for providing care over hundreds of miles Wrinch faced. For instance, not long after ar- By Geoff Mynett. Ronsdale in every direction. In the days when churches riving in the Upper Skeena, he was required Press, 2019. Paperback. in Canada took considerable responsibility for to write examinations in order to qualify for The achievements of physicians working in providing hospital care, Wrinch brought a deep a licence to practise in British Columbia. This remote areas in the early days of this country faith as well as remarkable medical skill to his involved a 125-mile winter hike from Hazelton are legendary. In his book Service on the Skee- work. to Stewart, boat travel to Victoria, and then a na, Mynett does us great service by telling the This doctor, with early training in agri- return journey, all of which took over a month. story of one of those legendary pioneers. It is culture, not only provided essential medical Mynett not only tells the story of Wrinch’s a fascinating story of Harold Wrinch, a man services, but built two hospitals, established a remarkable medical achievements, including his motivated by service, dedicated to the people of nursing school, and created a farm that sup- lockdown of Northern BC during the Spanish a remote region, working through tremendous plied the hospitals. He also provided an early flu epidemic, but also of his involvement in the challenges to provide care to Indigenous com- practical example of medical insurance, years famous Simon Gunanoot case. He also details munities as well as to isolated and sometimes before it became a topic of wide concern, in Wrinch’s work as a member of the provincial

2020 Family Physicians’ Awards The BC College of Family Physicians’ (BCCFP) awards and honors program recognizes BC’s exceptional family physicians, residents, and medical students, and highlights the value of family medicine. Winners of the 2020 awards are listed below. For more information about the winners and the awards, visit https://bccfp.bc.ca/2020-award-recipients.

BC Family Physician of the Year Award My Family Doctor Award First Five Years of Practice Award The BC Family Physician of the Year Award The My Family Doctor Award is the BC- The First Five Years of Practice Award rec- recognizes a family physician who provides CFP’s patient-nominated award that honors ognizes an exceptional family physician in exemplary care to patients and takes part the patient-doctor relationship. Nominations the early stage of their career. in activities that contribute to excellence in are accepted from patients or family members. Dr Alyssa Cantarutti family medicine. Dr Rachel Collins (Fraser Health) Dr Tahmeena Ali Dr Kalen Geddes (Northern Health) Resident Leadership Award Dr Peter Lutsky (Vancouver Coastal Health) The BCCFP offers financial awards for resi- Family Medicine Advocate Award Dr Patricia Olsen (Island Health) dents in the UBC Family Practice Residency The Family Medicine Advocate Award rec- Dr Mark Szynkaruk (Interior Health) Program, including this leadership award. ognizes a BCCFP member who has demon- Dr Rebekah Eatmon strated a strong commitment to advocating Dr Manoo and Jean Gurjar Award for the value of family medicine. Dr Jessica Briggs Dr Lawrence Yang Dr Anmol Lamba

176 BC Medical Journal vol. 62 no. 5 | June 2020 news

2020 Rural Awards, BC recipients The Society of Rural Physicians of Canada (SRPC) has named the recipients of its 2020 Rural Awards. The SRPC recognizes physicians and organizations that have made a significant contribution to rural medicine in Canada. Nominees must be members of the SRPC, with the exception of the Keith Award, Rural Education Award, and the Rural Health Champion Award. BC physicians have been recognized in the following categories. The complete list of 2020 award recipients is available at https://srpc.ca/srpc_awards_2020.

Rural Service Award Fellowship of Rural and Lifetime Membership Award The Rural Service Award recognizes SRPC Remote Medicine of the SRPC The SRPC Lifetime Membership Award physician members of 5 years or longer who The Fellowship of Rural and Remote Medi- recognizes longstanding members (10 years live and work in rural Canada, and who have cine of the SRPC recognizes expertise in the or more), who have reached age 65. served their rural communities for 10 years practice of rural medicine in Canada. The Dr Gord Hutchinson, Victoria or longer. Fellowship award is presented to SRPC phy- Dr Michael Wright, Fort St. John Dr Bret Batchelor, Revelstoke sician members who are previous recipients Dr Pamela Frazee, Tofino of the Rural Service Award and who have Rural Community Impact Award Dr Joshua Greggain, Hope acquired a minimum of 10 points. Points are This award, new for 2020, recognizes a phy- Dr Courtney Rennie, Revelstoke accumulated as follows: sician who has had a significant impact on • Each year serving as a rural preceptor for their community through clinical services, Rural Long Service Award students and residents. teaching, research, volunteer work, or other The Rural Long Service Award recognizes • Each SRPC sanctioned event attended. community involvement continually advocat- SRPC physician members of 5 years or longer • Each full year serving on an SRPC com- ing for the best health care available. who live and work in rural Canada, and who mittee. Dr Onuora Odoh, Houston have served their rural communities for a • Each skill: GP surgery, GP anesthesia, minimum of 20 years. Individuals must be a GP obstetrics. Rural Health Champion Award previous recipient of the Rural Service Award. • One point for having published in the This award, new for 2020, is a presented to Dr Bruce Mohr, Whistler Canadian Journal of Rural Medicine. a nonphysician who has had a significant Dr Leah Seaman, Kaslo Dr Stephen Arif, Invermere impact on rural health care delivery, either Dr Tandi Wilkinson, Nelson Dr Karen Forgie, Halfmoon Bay through clinical care or system-level impact Dr Marius Mostert, Fort Nelson in a community, province, or nationally. Ms Brenda Fowler, Gabriola Island

legislature in trying to create a form of provin- or confirmed cases of COVID-19. Services for Health data coalition expands cial health insurance in the 1930s. unrelated conditions that are performed on data-sharing application This book will greatly appeal to those inter- MSP non-eligible patients will remain unin- ested in the history of medicine, the local his- sured. Physicians and other health care provid- The Health Data Coalition (HDC) has ex- tory of early British Columbia and the people ers are responsible for determining if a patient panded HDC Discover, a data-sharing appli- who built it, and the history of the church’s meets the criteria for coverage. Services related cation that allows family doctors to compare work in medicine. to COVID-19 for non-MSP eligible patients electronic medical record (EMR) data from I highly recommend this excellent biography should be billed using the following Personal their clinic to provincial averages. Doctors can of an outstanding pioneer doctor. Health Number (PHN): 9703740703. then share the information with their colleagues —Peter Newbery, MDiv, MD Providers may also notice an increase in and work together to improve their practices Hazelton patients presenting to them with confirmation in order to improve patient care and inform of coverage letters. These letters have been is- strategic decision making. MSP coverage relating to sued in response to access to care during the Dr Kathleen Ross, president of Doctors of COVID-19 COVID-19 pandemic. For more information BC, emphasizes that as more physicians enroll, on billing this general PHN, contact MSP: HDC will be able to generate a more robust Patients who are not eligible for coverage un- Vancouver: 604 456-6950, other areas of BC: picture of population health, helping physi- der MSP will be provided provincially insured (toll-free): 1 866 456-6950. cians identify and develop ways to improve health coverage for services relating to suspected patient care.

BC Medical Journal vol. 62 no. 5 | june 2020 177 news

This physician-governed not-for-profit has Website for Canadians to ask how COVID-19 has affected access to and use worked closely with government and led the COVID-19 questions and get of their arthritis medications, and how it has negotiation with technology companies to pro- answers impacted their mental health. The study will vide access to information that will change the also assess patients’ experiences with care and way health care is delivered in the province. The The Canadian Medical Association, alongside access to their physician. This includes tele- application was created to provide a community the Royal College of Physicians and Surgeons health, treatment decisions, and mental health view of primary care data across BC, which had of Canada and the College of Family Physicians checkups. been unavailable until now. of Canada, has partnered with spark*advocacy Patient input is needed so decisions made Dr Shirley Sze, chair of the HDC board to launch a campaign that provides a way for by doctors and health care systems can be in- of directors, points out that this tool creates Canadians to ask Canada’s doctors COVID-19 formed and optimized during the pandem- the opportunity for family doctors to use data questions that are top of mind. The website ic and beyond. For more information about to learn about their individual and collective www.covidquestions.ca lists questions submit- the study, visit www.arthritisresearch.ca/ workloads and complexity of diseases, and begin ted by Canadians and answers sourced from participants-needed-understanding-the to build strategies. reputable organizations, with the option for -experiences-of-individuals-with-immuno HDC signed an adaptor development anyone to submit new questions that have not suppressive-conditions-during-the-covid-19 agreement with Intrahealth and Telus in 2018 yet been addressed. -pandemic-unified. to expand the original application, which previ- ously allowed sharing only by Medical Office BC PharmaCare COVID-19 Research to better diagnose Information System (MOIS) and OSCAR information for prescribers COVID-19 users. The Intrahealth adaptor has gone live BC PharmaCare has developed online resources and WELL Health has signed an agreement Radiologists at Vancouver General Hospital, for issues related to COVID-19 about drug to ensure continuity for OSCAR EMR users. the University of British Columbia, and Van- supply, anticoagulant/antiplatelet coverage and Now that all adaptors are complete, the majority couver Coastal Health Research Institute are testing, special authority extensions, care for of primary care physicians across the province leading an international study to better pre- people who use drugs, and limited coverage can access HDC Discover. dict the presence of COVID-19 based on CT inhalers for asthma and chronic obstructive Contributing data to HDC is a sign of a scans. Radiologists, fellows, residents, and UBC pulmonary disorder. The COVID-19 Infor- doctor’s professional commitment to improving medical students are collecting, analyzing, and mation for Prescribers page is online at www2 clinical practice improvement and providing labeling thousands of CT scans, and in some .gov.bc.ca/gov/content/health/practitioner-pro valuable data for the overall goal of resource cases chest X-rays, from COVID-19 patients fessional-resources/pharmacare/prescribers/ planning. Pressures to improve the quality of around the globe. Information gleaned from covid-19-prescribers. services delivered to patients are increasing, and the scans will form the basis for an open source artificial-intelligence model to predict the pres- these pressures underscore the need for physi- Research to address impact of cians and organizations to engage in measurable ence, severity, and complications of COVID-19 quality improvement processes. Using insights COVID-19 on medication use on CT scans. The model will integrate clinical from the data results in a professionally satisfy- and mental health for people data to help support and supplement existing ing practice and leads to improved patient out- with arthritis tools to improve patient care. For example, it comes. Physicians can access this data through could help physicians determine whether in- a secure, simple-to-use program that maintains Arthritis Research Canada’s research scientist dividuals are best treated at home or whether patient and provider confidentiality. Dr Mary De Vera and her team have launched they may require hospitalization/ventilation. It The application was recently certified by the a study, UNIFIED, which seeks to better un- will not replace current testing. The model will Privacy by Design framework. This project is derstand the experiences of individuals with also assist in detecting similarities and differ- supported and funded by the General Practice rheumatic diseases and immunosuppressive ences in variations of patterns across different Services Committee, a partnership of Doctors conditions during the COVID-19 pandemic. cultural and ethnic groups, and help researchers of BC and the Ministry of Health. HDC was During the pandemic, people living with understand early and late stages of patterns of established in April 2016 through a merger of arthritis, such as rheumatoid arthritis, gout, and disease. It could also help flag those who may two previous initiatives, Aggregated Metrics lupus, are more vulnerable to infection because ultimately develop permanent lung damage/ for Clinical Analytics and Research and the of their arthritis and the medications used for fibrosis. Researchers are confident this new tool Physician’s Data Collaborative, to support a their treatment. What is not known is how the will help them predict disease severity and its network of physicians for the collaborative use pandemic has impacted people with arthritis clinical impact in different patient populations. of clinical data. Learn more about HDC and and how to better support arthritis patients. Once developed, the new artificial- enroll at https://hdcbc.ca. Through surveys and interviews, the UNI- intelligence model will be piloted at Vancouver FIED study will ask people living with arthritis General Hospital with an aim to embed it in

178 BC Medical Journal vol. 62 no. 5 | June 2020 news routine diagnostic procedures to improve the of COVID-19 as it could allow for earlier technology in a newly released report, “Cool accuracy of COVID-19 diagnostics. self-isolation advice. Ideas: Remote Surgery.” This paper aims to Funding for this project is provided by While there are existing therapies that spark a conversation on whether remote robotic the UBC Community Health and Wellbeing can aid in regaining a sense of smell, it’s cur- surgery could reduce costs, expand access, and Cloud Innovation Centre (UBC CIC), opened rently unknown whether they are effective for improve surgical services in the North, in the in January 2020 and powered by Amazon Web COVID-19 patients. The long-term conse- near term or distance future. Services (AWS), as well as the AWS Diagnostic quences of anosmia in COVID-19 patients Looking to remote robotic surgery to help Development Initiative (DDI). are also unknown. Researchers encourage any- residents in Canada’s North and other remote For more information about the project, visit one who has been diagnosed with COVID-19 regions access important surgical needs requires https://cic.ubc.ca/covid-19-ct-scans. or another respiratory illness to complete the addressing many issues, including technologi- survey if they are able. The survey is currently cal, cultural, logistical, and social concerns. But Virtual stroke-recovery available in 10 languages at www.covidand first, northerners need to determine if remote sessions smell.com. surgery is something they want to consider. “Cool Ideas: Remote Surgery” is the second The Stroke Recovery Association of BC is of- How to embed AI and digital report in the Cool Ideas series. This series aims fering virtual stroke-recovery programs. Phy- technology into physicians’ to raise awareness about emerging opportuni- sicians are encouraged to tell their patients training and practices ties while weighing the costs and benefits of about this service. No referral necessary; ev- new systems against the risks and challenges. eryone is welcome. For more information and The Royal College of Physicians and Surgeons The first report of the series was titled “Revo- to register, visit https://strokerecoverybc.ca/ of Canada’s Task Force on Artificial Intelligence lutionary Building for the North: 3D Printing programs-locations/virtual-programs. Email (AI) and Emerging Digital Technologies un- Construction.” Both reports are available from any questions to [email protected]. veiled 12 foundational recommendations on www.conferenceboard.ca/e-library. how to prepare physicians for the technological Ontario researchers join changes coming to their practices. global initiative to study loss While not the focus of the report, the im- of smell in COVID-19 patients portance of AI and emerging digital tech- nologies for supporting and responding to As part of an initiative called the Global Con- unprecedented shifts in health care become sortium for Chemosensory Research (GCCR), even more pronounced as physicians adhere scientists at Lawson Health Research Institute to expectations of physical distancing while and Western University are studying the sudden treating patients (e.g., telehealth, robotics), and BC Medical Journal Follow loss of smell (anosmia) in COVID-19 patients. challenge organizations to rethink how they @BCMedicalJrnl They are asking individuals with confirmed or prepare residents and fellows for rapid deploy- The BC Medical Journal provides continuing medical presumptive cases of COVID-19 worldwide ment of new and emerging AI technologies. education through scientific research, review articles, and updates on contemporary clinical practice. #MedEd to participate in a survey to better understand Members of the task force include fellows President’s Comment: #COVID-19 reflections. this symptom. of the Royal College and AI experts who con- A sudden loss of smell has been widely re- This is a time unlike any we have seen before, sulted with stakeholders, interviewed experts, and one I hope we will not see again in our ported as a marker of COVID-19. More re- and reviewed survey responses from over 4000 lifetime. #coronavirus @DrKathleenRoss1 search is needed but emerging evidence suggests fellows and resident affiliates to inform the find- Read the article: bcmj.org/presidents-comment -covid-19/covid-19-reflections that more than 60% of COVID-19 patients ings. The recommendations aim to inform the experience anosmia and that it is often the first future of care and physician training in Canada. symptom of the disease. The report is available at www.royalcollege In the new study, patients with loss of smell .ca/rcsite/health-policy/initiatives/ai-task will answer questions through a publicly ac- -force-e. cessible survey. They will be asked about their experiences with COVID-19 and other respi- Remote surgery: Exploring ratory illnesses. An immediate goal is to better emergency care at a distance understand the association between anosmia and COVID-19, and determine if loss of smell Could remote robotic surgery play a role in is the same in symptomatic and asymptomatic improving health outcomes for residents in patients. The team also hopes to determine if remote and northern communities? The Con- Follow us on Twitter for regular updates loss of smell happens before other symptoms ference Board of Canada explores the use of this

BC Medical Journal vol. 62 no. 5 | june 2020 179 CME calendar Rates: $75 for up to 1000 characters (maximum), plus GST per month; there is no partial rate. If the course or event is over before an issue of the BCMJ comes out, there is no discount. Deadlines: Online: Every Thursday (listings are posted every Friday). Print: The first of the month 1 month prior to the issue in which you want your notice to appear, e.g., 1 February for the March issue. The BCMJ is distributed by second-class mail in the second week of each month except January and August. Planning your CME listing: Advertising your CME event several months in advance can help improve attendance; we suggest that your ad be posted 2 to 4 months prior to the event. Ordering: Place your ad at www.bcmj.org/cme-advertising. You will be invoiced upon publication. Payment is accepted by Visa or MasterCard on our secure online payment site.

COVID-19 PHYSICIAN PEER SUPPORT a 2-week introductory session every spring and MINDFULNESS IN MEDICINE FOR Online (Tue & Thu) fall at BC Cancer–Vancouver. This program PHYSICIANS & PARTNERS provides an opportunity for rural family physi- The BC Physician Health Program (PHP) is Tofino, 25–28 Sep (Fri–Mon) cians, with the support of their community, to offering free drop-in Physician Peer Support Physician heal thyself. Join Dr Mark Sher- strengthen their oncology skills so that they can Sessions every Tuesday and Thursday from 4–5 man and your community of colleagues for provide enhanced care for local cancer patients p.m. PST via Zoom. Join other physicians, psy- a transformative workshop, 25–28 Septem- and their families. Following the introductory chiatrist Dr Jennifer Russel, and PHP’s Rox- ber, will be held at Long Beach Lodge Resort, session, participants complete a further 30 days anne Joyce to talk over any challenges and issues Tofino. The workshops focus on the theory of clinic experience at the Cancer Centre where in providing care as the COVID-19 pandemic and practice of mindfulness and meditation— their patients are referred. These are scheduled continues. Sessions are drop-in, no commitment reviewing definitions, clinical evidence, and flexibly over 6 months. Participants who com- necessary, focusing on peer support not psychi- neuroscience, and introducing key practices of plete the program are eligible for credits from atric care. E-mail peersupport@physicianhealth self-compassion, breath work, and sitting medi- the College of Family Physicians of Canada. .com for the link to join by phone or video. tation to nurture resilience and healing. This Those who are REAP-eligible receive a stipend annual meditation retreat is an opportunity to and expense coverage through UBC’s Enhanced GP IN ONCOLOGY TRAINING delve deeply into meditation practice in order Skills Program. For more information or to Vancouver, 14–25 Sep and 8–19 Feb 2021 to recharge, heal, and build a practice for life. apply, visit www.fpon.ca, or contact Jennifer (Mon–Fri) Each workshop is accredited for 16 Mainpro+ Wolfe at 604 219-9579. BC Cancer’s Family Practice Oncology Net- group learning credits and has a 30 person limit, work offers an 8-week General Practitioner in so please register today! Contact us at hello@ Oncology education program beginning with livingthismoment.ca, or check out www.living thismoment.ca/event for more information.

Expand your practice to #virtualCARE by seeing patients via phone and video. For resources, FAQs and tips visit doctorsofbc.ca/covid-19

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180 BC Medical Journal vol. 62 no. 5 | June 2020 Classifieds Advertisements are limited to 700 characters. Rates: Doctors of BC members: $50 + GST per month for each insertion of up to 350 characters. $75 + GST for insertions of 351 to 700 characters. Nonmembers: $60 + GST per month for each insertion of up to 350 characters. $90 + GST for insertions of 351 to 700 characters. Deadlines: Ads must be submitted or canceled by the first of the month preceding the month of publication, e.g., by 1 November for December publication. Visit www.bcmj.org/classified-advertising for more information. Ordering: Place your classified ad online at www.bcmj.org/classified -advertising. Payment is required at the time that you place the ad.

Employment immediate openings for a Kim Graffi at kimgraffi@ [email protected], website: physician with enough patient hotmail.com or by phone at powellrivermedicalclinic.ca. ARE YOU A PHYSICIAN volume where your panel could 604 987-0918. SOUTH SURREY/WHITE LOOKING FOR A NEW ROLE? be filled in 3 to 6 months. You POWELL RIVER—LOCUM ROCK—FP Physicians for You—leaders in would work as an independent Busy family/walk-in practice in physician recruitment in Canada. contractor with a fee-for-service The Medical Clinic Associates is South Surrey requires GP to Our strong reputation is built on split. We also offer an attractive looking for short- and long-term build family practice. The exceptional service and results. signing bonus and look forward locums. The medical community community is growing rapidly Locum, contract, long-term, city, to hearing from you soon! Please offers excellent specialist backup and there is great need for family rural, we have it all. Whether email Amy Markovitz, Amy. and has a well-equipped 33-bed physicians. Close to beaches and you’re a physician looking for [email protected], or hospital. This beautiful commu- recreational areas of Metro work across Canada, or a Nanci Harper, nanci_anne@ nity offers outstanding outdoor Vancouver. OSCAR EMR, medical facility requiring hotmail.com. recreation. For more information nurses/MOAs on all shifts. physicians, we can help. Your contact Laurie Fuller: NANAIMO—GP CDM support available. needs are our focus. Save time 604 485-3927, email: and effort; let us do all the General practitioner required for legwork. Let our 10 years of locum or permanent positions. experience in Canada, extensive The Caledonian Clinic is located knowledge of the processes for in Nanaimo on beautiful licensure, and our personalized, Vancouver Island. Well- friendly service work for you. established, very busy clinic with Check out our current job 26 general practitioners and two postings online and contact us specialists. Two locations in today. Website: www.physicians Nanaimo; after-hours walk-in foryou.com. Email: info@ clinic in the evening and on physiciansforyou.com. weekends. Computerized Office: 1 778 475-7995. medical records, lab, and pharmacy on site. Contact Lisa EDMONTON, AB—FAMILY Wall at 250 390-5228 or email PRACTICE PHYSICIAN [email protected]. REQUIRED Visit our website at Callingwood Crossing Medical www.caledonianclinic.ca. Clinic is vibrant and growing! NORTH VAN—FP LOCUM West Edmonton location. Newly renovated dynamic office Physician required for the operating for over 28 years with busiest clinic/family practice on an extremely loyal patient base. the North Shore! Our MOAs We use Med Access EMR, have are known to be the best, helping an attached pharmacy, and are your day run smoothly. Lucrative one of the largest clinic members 6-hour shifts and no headaches! of Edmonton West Primary For more information, or to Care Network. We have book shifts online, please contact

BC Medical Journal vol. 62 no. 5 | june 2020 181 Classifieds

Competitive split. Please contact to see only booked patients or and reception area with two PATIENT RECORD STORAGE—FREE Carol at Peninsulamedical@ add walk-ins for variety. Oscar built-in desks. Lots of storage live.com or 604 916-2050. EMR. Positions in Richmond space. Office designed by Retiring, moving, or closing your also available. Contact Dr Balint Richard Salter. Ideal for two family or general practice, SURREY/DELTA/ Budai at [email protected]. physicians: pediatrician, family physician’s estate? DOCUdavit ABBOTSFORD—GPs/ physician, or specialist. Contact Medical Solutions provides free SPECIALISTS VICTORIA—FULL/PART-TIME [email protected]. storage for your active paper or FAMILY PHYSICIAN Considering a change of practice electronic patient records with style or location? Or selling your Work in the most beautiful place miscellaneous no hidden costs, including a practice? Group of seven on earth. Option to bring your patient mailing and doctor’s web CANADA-WIDE—MED locations has opportunities for own practice or for long-term page. Contact Sid Soil at TRANSCRIPTION family, walk-in, or specialists. locum. Our office is bright, DOCUdavit Solutions today at Full-time, part-time, or locum friendly, and well run with low Medical transcription specialists 1 888 781-9083, ext. 105, or doctors guaranteed to be busy. shared expenses. We value since 2002, Canada wide. email [email protected]. We provide administrative work-life balance. Contact Excellent quality and turn- We also provide great rates for support. Paul Foster, Narissa Arter, office manager, around. All specialties, family closing specialists. 604 572-4558 or pfoster@ phone: 250 478-2133, email: practice, and IME reports. denninghealth.ca. [email protected]. Telephone or digital recorder. VANCOUVER—TAX & ACCOUNTING SERVICES Fully confidential, PIPEDA VANCOUVER ISLAND— VICTORIA—GP/WALK-IN Rod McNeil, CPA, CGA: Tax, ISLAND HEALTH SEEKING compliant. Dictation tips at Shifts available at three beautiful, accounting, and business PSYCHIATRISTS www.2ascribe.com/tips. busy clinics: Burnside (www. Contact us at www.2ascribe.com, solutions for medical and health Island Health welcomes psychia- burnsideclinic.ca), Tillicum [email protected], or toll free at professionals (corporate and trists to apply for full-time or (www.tillicummedicalclinic.ca), 1 866 503-4003. personal). Specializing in health part-time positions that span the and Uptown (www.uptown professionals for the past 11 FREE MEDICAL RECORD continuum of care from child medicalclinic.ca). Regular and years, and the tax and financial STORAGE and youth, to adult, to addic- occasional walk-in shifts issues facing them at various tions, to geriatric. Whether you available. FT/PT GP post also Retiring, moving, or closing your career and professional stages. prefer oceanfront living or available. Contact drianbridger@ family practice? RSRS is The tax area is complex, and sweeping mountain vistas, gmail.com. Canada’s #1 and only physician- practitioners are often not aware Vancouver Island provides an managed paper and EMR of solutions available to them Medical office space affordable lifestyle in family medical records storage company. and which avenues to take. My friendly communities, excep- Since 1997. No hidden costs. VANCOUVER (BROADWAY goal is to help you navigate and tional outdoor year-round Call for your free practice closure CORRIDOR)—MED OFFICE keep more of what you earn by recreation, and a healthy work/ package: everything you need to SPACE FOR RENT minimizing overall tax burdens life balance. Sponsored site plan your practice closure. where possible, while at the same visits/interviews available as well Office space available for rent in Phone 1 866 348-8308 (ext. 2), time providing you with person- as relocation assistance to the prestigious Fairmont email [email protected], or visit alized service. successful candidates. Medical Building (750 West www.RSRS.com. Website: www.rwmcga.com, Recruitment incentives may be Broadway) not far from VGH. email: [email protected], available as per the MOH Rural No extra overhead expenses; one phone: 778 552-0229. Recruitment Contingency Fund. of three offices most suitable for Contact us today at physicians@ psychiatrist or psychologist. viha.ca or view opportunities at Contact: [email protected]. medicalstaff.islandhealth.ca/ VANCOUVER (BROADWAY Information on COVID-19 from Doctors of BC, careers. CORRIDOR)—OFFICE FOR SALE updated regularly: VANCOUVER/RICHMOND—FP/ Broadway Medical (943 W SPECIALIST Broadway). Spectacular North www.doctorsofbc.ca/covid-19 The South Vancouver Medical Shore view, turnkey, 650 sq. ft. Clinic seeks family physicians seventh-floor office with three and specialists. Split is up to exam rooms and one office (one 80/20. Closing your practice? exam room and office with Want to work part-time? Join us mountain view), waiting area,

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