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Vertebral Metastatic Disease: A Practice Guideline for the General Practitioner

Vertebral Metastatic Disease: A Practice Guideline for the General Practitioner

Teaser: 

Michael S. Taccone,1 Markian Pahuta,2 Darren M.Roffey,3,4Eugene K. Wai,2,3,4

1Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
2Division of Orthopedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
3Ottawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, ON, Canada.
4Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.

CLINICAL TOOLS

Abstract: Vertebral metastatic disease afflicts a significant proportion of cancer patients, most commonly those with breast and lung disease. Symptoms can include tumor-related pain, neurological deficit from spinal cord or nerve compression and pathological fracture with mechanical instability. Appropriate workup includes identifying the primary disease, defining the extent of spinal and extra-spinal pathology and classifying spinal stability based on the pattern of osseous involvement. Specific therapy for the vertebral metastatic disease can include pharmacologic therapy to deliver analgesia, steroids, bisphosphonate, anti-neoplastic therapy, radiation therapy as either primary or adjuvant therapy and surgical intervention for mechanical or neurologic instability.
Key Words: Vertebral metastatic disease, metastatic epidural spinal cord compression, spinal instability, spine surgery, spinal radiation therapy, pathologic fracture.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

Pre-test CME Quiz Post-test CME Quiz
Red flags are non-specific and unreliable means of determining spinal malignancy in patients with back pain. Clinical suspicion combined with history and physical exam are best for increasing pre-test probability of imaging studies.
Initial evaluation and referral to definitive management should be made within 24 hours of detection of significant neurological deficit, significant metastatic epidural spinal cord compression or instability.
MRI is the imaging modality of choice for initial evaluation and assessment of overall spinal tumor burden.
Vertebral metastatic disease is very common in patients with cancer.
SINS, ESCCS, Tomita score, Tokuhashi score and the Modified Bauer scores are all important tools for determining the most appropriate referral.
In eligible candidates, surgery with adjuvant radiotherapy yields faster and more sustainable neurologic stability and recovery.
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Related Terms: Back Health, Vertebral metastatic disease, metastatic epidural spinal cord compression, spinal instability, spine surgery, spinal radiation therapy, pathologic fracture

Error in Radiology: Negligence or Human Nature

D'Arcy Little, MD CCFP FRCPC, Chief of Diagnostic Imaging, Orillia Soldiers' Memorial Hospital,
Adjunct Clinical Lecturer, Department of Medical Imaging, University of Toronto, Toronto, ON,
Forensic Radiologist, Forensic Sciences and Coroners' Complex, Toronto, ON,
2015 Resident in Scientific Communications, Banff Centre, Banff, AB.

Related Terms: Radiology, radiology, errors

A Reticulate Hyperpigmented Abdominal Patch Associated with Chronic Abdominal Pain

A Reticulate Hyperpigmented Abdominal Patch Associated with Chronic Abdominal Pain

Teaser: 

Julie Man, MD,1 Joseph M. Lam, MD, FRCPC,2

1Department of Family Medicine, University of Alberta, Edmonton, AB.
2Assistant Clinical Professor, Department of Paediatrics, Associate Member, Department of Dermatology, University of British Columbia, BC.

CLINICAL TOOLS

Abstract: A 13-year-old girl presented with a 3-month history of a reticulate hyperpigmented patch over the lower abdomen. Her past medical history was significant for recurrent abdominal pain, Ehlers-Danlos syndrome, a mild learning disability, and multiple allergies. On physical examination, she had a reticulate, hyperpigmented patch distributed diffusely over the lower abdomen (Figure 1). The remainder of her exam was unremarkable. Upon questioning, it was revealed that the patient had been applying a hot water bottle to the lower abdomen for the last 4 months to help relieve the discomfort associated with the abdominal pain. This history led to the diagnosis.
Key Words: Erythema ab igne, hyperpigmentation, reticulate, thermal injury.
Erythema ab igne may present as a transient erythematous eruption, or as a reticulate hyperpigmentation.
Erythema ab igne is a clinical diagnosis which rarely requires biopsy confirmation.
Direct questioning about heat sources, such as prolonged laptop computer use, aids the diagnosis.
Treatment consists of patient education and removal of the heat source.
1. Erythema ab igne is a recognizable condition associated with chronic exposure to heat sources such as heating pads, hot water bottles, electric blankets, space heaters and laptop computers.
2. The differential diagnosis for erythema ab igne includes livedo reticularis, livedoid vasculitis, cutis marmorata telangiectatica congenita, a reticulate port-wine stain and poikiloderma.
3. The most important treatment for erythema ab igne is recognition and removal of the source of infrared radiation.
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Related Terms: Dermatology, erythema ab igne, hyperpigmentation, reticulate, thermal injury

Anticipatory Conversations: Is there a connection to Ice Cream?

Anticipatory Conversations: Is there a connection to Ice Cream?

Teaser: 

Michael Gordon, MD, MSc, FRCPC,

Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Abstract: Advance care planning has become a much touted and potentially very important addition to the new operative structure of meeting the many challenges of an ever increasingly older population. From what used to be discussions about CPR and DNR the process has evolved into what many expect might become the basis of end-of-life decision-making that may assist family members and health care providers to meet the needs, wishes and priorities of the elderly population, particularly when they are nearing that last trajectory of life.
Key Words: Artificial nutrition and hydration, advance care planning, living wills, end-of-life planning.
1. Planning before there is a medical crises can help avoid medical decisions that may not be in keeping with your wishes and values.
2. Artificial nutrition and hydration may not be what you really want, even though in its simplest form it may seem desirable as a way of avoiding death.
Communication with those who will be responsible for decision-making when you are no longer able to do so is key to having your end-of-life wishes fulfilled and should not be left to crises situations.
If you have favorite foods, make sure your substitute decision-makers know about them so that when the time comes you will not be deprived of your most enjoyed foods, because some health care provider deems them to be "unhealthy" or not in keeping with an "optimal diet".
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Related Terms: Dementia, artificial nutrition and hydration, advanced care planning, living wills, end-of-life planning

Diagnostic Radiology in Low Back Pain

Diagnostic Radiology in Low Back Pain

Teaser: 

Dr. Ted Findlay, D.O., CCFP,1 Amar Suchak, MD, FRCP(C),2

1Clinical Assistant Professor, Department of Medicine, University of Calgary, Private Family Medicine practice, Medical Staff, Alberta Health Services, Calgary Zone, Calgary, Alberta.
2Clinical Assistant Professor Department of Radiology, Department of Nuclear Medicine, University of Calgary, Calgary, Alberta.

CLINICAL TOOLS

Abstract: Many clinicians believe that imaging is necessary to accurately diagnose and manage low back pain. However, there is good evidence that in the absence of "Red Flags", there is an overuse of both routine X-rays and advanced diagnostic imaging such as MRI. When imaging is used without appropriate clinical indications, it is rare for the results to lead to a change in a treatment plan. Management is based on adequate history and confirmatory physical examination. This article uses three actual cases as the basis for exploring the place of diagnostic imaging in treating low back pain.
Key Words: low back pain, diagnosis, radiology, indications, appropriate.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

Pre-test CME Quiz Post-test CME Quiz
1. While imaging may be required in the management of specific cases of low back pain particularly when "Red Flags" are present, it is rare that unexpected findings will result in a change of the treatment plan.
2. Be very cautious about the terminology used to describe the results of imaging studies and whenever possible normalize the results for the patient. Many abnormal findings may be "normal" for patients in older age groups. Many may be present in patients who are pain free.
3. Ensure that the patient understands that the results of the images are not necessarily a barrier to recovery.
4. Except to establish the boney contours of the spine, when advanced imaging is required an MRI examination is often the preferred option.
5. Be very cautious about attributing the cause of a patient's pain to the results found on imaging. Careful correlation with the clinical presentation is required before deciding on any change in treatment.
In the absence of clinical "Red Flags", there is no indication to image the spine before initiating treatment.
It is never appropriate to delay treatment for mechanical low back pain to wait for an imaging procedure.
Prepare the patient, before advanced imaging is performed, that there is a very high likelihood that the investigation will find "abnormalities" but that these changes are usually the result of natural aging and no cause for concern.
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Related Terms: Back Health, low back pain, diagnosis, radiology, indications, appropriate

Sacral Neuromodulation for Overactive Bladder

Teaser: 

Dr. Dean S. Elterman, MD, MSc, FRCSC,1 Harkiran K. Sagoo, BSc(Hons),2

1Attending Urologic Surgeon, Toronto Western Hospital, University Health Network, Assistant Professor, Division of Urology, Department of Surgery, University of Toronto, Toronto, ON.
24th Year Medical Student at GKT School of Medicine, King's College London, U.K.

CLINICAL TOOLS

Abstract: Sacral Neuromodulation (SNM) is a FDA-approved minimally invasive surgical therapy offered as a third-line treatment for refractory overactive bladder (OAB). Studies report improvements in continence, mean number of voids/day, quality of life, depression and sexual function in patients receiving SNM compared to medical therapy, with treatment success sustained long-term and with few adverse events. SNM is recommended by CUA and AUA guidelines in the treatment of OAB in carefully selected patients.
Key Words:Neuromodulation, Neurostimulation, Overactive, Bladder, Incontinence.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

Pre-test CME Quiz Post-test CME Quiz
Sacral neuromodulation should be offered as third-line treatment for patients with overactive bladder symptoms refractory to conservative/behavioural and/or pharmacological treatment.
Sacral neuromodulation is a minimally invasive procedure that may be offered to carefully selected patients with severe refractory overactive bladder that are willing to undergo a surgical procedure.
Sacral neuromodulation activates inhibitory sympathetic neurons using low-amplitude electrical stimulation of S3 afferent nerve roots to prevent detrusor contraction.
A prospective, randomized multi-center trial (level 1 evidence) reported improvements in incontinence, mean number of voids/day, quality of life, depression and sexual function in patients receiving sacral neuromodulation compared to standard medical treatment.
Adverse events/complications associated with SNM use include: pain at the implantation site, lead migration, wound-related complications, bowel dysfunction, infection, and generator problems.
Sacral neuromodulation is a FDA-approved minimally-invasive surgical therapy used as third-line treatment of overactive bladder symptoms/refractory overactive bladder. It is carried out in two stages, the first (evaluation) stage involves insertion of a temporary generator to assess clinical efficacy, and the second stage involves insertion of a permanent neuromodulator implant in patients that have demonstrated >50% improvement in symptoms during the evaluation stage.
Evidence from randomized, controlled trials, prospective multicenter, prospective single-center and retrospective studies demonstrates clinical efficacy of SNM in reducing symptoms of overactive bladder in these patients and therefore SNM is recommended by CUA and AUA guidelines in the treatment of overactive bladder in carefully-selected patients, as the risks of the procedure outweigh the burdens of the overactive bladder syndrome.
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Related Terms: Gender & Health, Men’s Health, Women’s Health, Neuromodulation, Neurostimulation, Overactive, Bladder, incontinence

Part 3: Using Your EMR Effectively

Part 3: Using Your EMR Effectively

Teaser: 

Ian PUN, MD,

Family Physician, Scarborough, Ontario. OSCAR McMaster EMR user since 2010.

CLINICAL TOOLS

Abstract: The leading-edge generation of EMR usage comprises extended interconnectivity to other healthcare databases, expanded communication between providers and their patients and integration of medical diagnostic and support devices ready for remote monitoring. These features are being developed and will become widely adopted in the near future.
Key Words: EMR, OSCAR McMaster EMR, OLIS, HRM, Cancer Care registry, vaccine cold chain.
Have your EMR connect to government websites so information is directly pushed into your EMR.
Health Card databases (HCV), OHIP billing database (MCEDT), Cancer database (CCO SAR), lab database (OLIS), Hospital databases (HRM) and outpatient lab databases (HL7).
Connect medical devices to your EMR.
Communicate with your colleagues electronically through secure means.
Set up your EMR to have working functionality with the CCO SAR, HRM, OLIS and lab databases.
Communicate online with your referring and consulting colleagues.
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Related Terms: Technology in Medicine, EMR, OSCAR McMaster EMR, OLIS, HRM, Cancer Care registry, vaccine cold chain

Lessons to be Learned from History and the Perspective of Grandparents and Vaccination of Children

Lessons to be Learned from History and the Perspective of Grandparents and Vaccination of Children

Teaser: 

Michael Gordon, MD, MSc, FRCPC,

Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Abstract: The progress of medicine over previous decades includes benefits in the world of vaccination against especially childhood disease. It is therefore surprising to witness the growing and vociferous opposition to childhood vaccination, especially for measles. This poses substantial personal and public health risks. It is important to understand the reasons that anti-vaccination sentiment has taken hold among many often highly educated parents.
Key Words: Vaccination, anti-vaxxers, polio, measles vaccine.
The public are not always convinced by the best of medical evidence.
Medicine is always evolving—the public does not always understand the process.
The history of vaccination is long with many great heroes some of whom were not medical or scientific professionals.
Trying to convince people who believe vaccination causes childhood diseases may not respond to more and more evidence as their belief is almost religious in nature.
Sometimes it is the perspective of those old enough to remember the scourge of childhood infectious illnesses who can play a role in helping their children who may oppose vaccination come to their parental senses.
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Related Terms: Dementia, vaccination, anti-vaxxers, polio, measles vaccine

Managing Adolescent Idiopathic Scoliosis (AIS) in Primary Care

Managing Adolescent Idiopathic Scoliosis (AIS) in Primary Care

Teaser: 

Paul J. Moroz, MD, MSc, FRCSC,1 Jessica Romeo, RN (EC), MN, BScN,2Marcel Abouassaly, MD, FRCSC,3

1Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario.
2Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario.
3Fellow in Pediatric Orthopedic Surgery at the Children's Hospital of Eastern Ontario, Ottawa, Ontario.

CLINICAL TOOLS

Abstract: Adolescent Idiopathic Scoliosis (AIS) is a condition requiring early detection for appropriate management. Bracing can be effective in preventing curve progression so failing to detect a small AIS curve in a growing child could result in losing the opportunity to avoid a major surgical procedure. Doubts about cost-effectiveness have ended most school screening programs and assessment is now provided mainly by primary care providers. The ability to conduct a quick effective scoliosis examination is important for the busy practitioner. This article illustrates the main features of the screening test, offers guides for imaging, and outlines appropriate tips for specialist referral.
Key Words: Adolescent Idiopathic Scoliosis (AIS), diagnosis, physical exam, Adams Forward Bend Test, primary care.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

Pre-test CME Quiz Post-test CME Quiz
1. This can be done with a patient's gown open or closed at the back.
2. The measurement is performed with the examiner sitting and observing the patient from behind. It can be done at the same time as the AFBT, since the examiner is in the same position.
3. With the patient standing erect in bare feet and with the knees extended, the examiner rests his/her hands on top of the iliac crests with fingers extended and palms parallel to the floor. With both the patient's feet flat on the floor, the relative levels of the hands give a surprisingly sensitive estimate of significant LLD (Figure 2).
4. There are alternative methods to measure leg lengths with the patient supine by using a tape measure. These techniques require familiarity with pelvic and ankle landmarks, are time consuming and are remarkably prone to measurement errors.
IMAGING FOR SUSPECTED SPINAL DEFORMITY
1. Radiation exposure using modern radiographic techniques, including digital radiography, is significantly lower than in the past.5
2. Radiologists' reports may use terms related to the spine that can be misleading and worrisome. Cobb angles less than 10 degrees should not be described as scoliosis but rather as "spinal asymmetry" since the term "scoliosis" may prompt an unnecessary referral to a specialist.
3. If imaging is indicated, it is best done at a centre where the patient will be seen in consultation. Radiologists at these centres have the experience to accurately interpret imaging results and correctly report spinal deformity. This also avoids the unfortunate situation where inadequate imaging done elsewhere must be repeated at the referral centre, significantly increasing the patient's radiation dose.
4. Never order a "scoliosis series". It is an obsolete term that referred to pre-operative assessment films. It is still found on some x-ray requisition forms and may be ordered in a misguided attempt to provide the surgeon with as much information as possible. Since the vast majority of patients seen by the spine surgeon will not require surgery, this option is needlessly expensive and the added radiation may be harmful to the patient.
5. The authors allow patients to take smart phone or tablet images of their own spinal x-rays. This engages the patient and their parents or guardians in the management. Take account of all regulatory and privacy issues regarding patient's recording of even their own images.
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Related Terms: Back Health, Adolescent Idiopathic Scoliosis, diagnosis, physical exam, Adams Forward Bend Test, primary care

Diagnosis and Management of Cervical Myelopathy

Teaser: 

Sean Christie, MD, MSc, FRCSC,1 Aaron S. Robichaud, MD,2

1Associate Professor, Department of Surgery (Neurosurgery), Department of Medical Neurosciences, Dalhousie University, Halifax, Nova Scotia.
2Clinical Fellow, Department of Surgery (Neurosurgery), Department of Medical Neurosciences, Dalhousie University, Halifax, Nova Scotia.

CLINICAL TOOLS

Abstract: Cervical myelopathy is a degenerative disease that occurs secondary to direct spinal cord compression and compromise of spinal vasculature through a process of gradual spinal canal narrowing. Patients generally present with signs and symptoms of long tract compromise. Once myelopathy is suspected on clinical grounds, MRI is the test of choice to confirm canal stenosis and cord injury. Treatment involves surgical decompression, anteriorly and/or posteriorly of the spinal. Despite optimal management in this patient population, outcomes may be poor and are usually limited to halting progression of the disease rather than relieving deficits already present.
Key Words: Cervical myelopathy, cervical stenosis, degenerative spine disease, spondylosis.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

Pre-test CME Quiz Post-test CME Quiz
Cervical spondylotic myelopathy is a degenerative disease that results from compression of the spinal cord with subsequent cord injury and impaired conduction along the tracts contained within it.
Myelopathy is a clinical diagnosis based on signs and symptoms of spinal cord dysfunction and should not be used to refer to isolated imaging findings of spinal cord degeneration or stenosis.
MRI is the most sensitive test to identify cervical canal stenosis and injury to the cord and should be arranged when myelopathy is found on clinical evaluation to identify a specific diagnosis and guide management.
Surgical decompression can prevent progression of cervical spondylotic myelopathy, and in some patients improve gait and hand function.
Cervical myelopathy can be differentiated from radiculopathy on clinical exam by the presence of upper motor neuron signs as a result of injury to the spinal cord, which will be absent in radiculopathy.
MRI is helpful in working up cervical spondylotic myelopathy as it allows visualization of the elements causing compression, provides an estimate of the extent of stenosis through loss of CSF space surrounding the cord, and allows identification of cord injury manifest as hyperintense signal change in the cord on T2 weighted imaging.
Patients with symptomatic cervical myelopathy should be referred to a spine surgeon for evaluation and management.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Back Health, Cervical myelopathy, cervical stenosis, degenerative spine disease, spondylosis