Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Herpes simplex viruses (HSVs) are DNA viruses that present as vesicles in clusters on an erythematous base. Infection occurs when close contact between an individual without antibodies against the virus and a person shedding the virus takes place. Most HSV infections are self-limited. Lesions tend to reappear at or near the same location of the initial site of infection. Systemic symptoms such as fever, malaise and acute toxicity may appear, especially in primary infection. A viral culture from the skin vesicles can identify up to 80 to 90% of untreated infection early in the course. Antiviral treatments aim at shortening the disease course and preventing viral dissemination and transmission. Treatments are most effective when they are administered at the first sign of symptom onset.

Dr. Pradeep Shenoy, MD, DLO, FRCS, FACS, is the ENT service chief, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada.
Dr. Michael Aldea, MD, Anesthesiologists, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada.
Dr. Jami Sridhar, MD, Anesthesiologists, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada.

Abstract

Tonsillectomy is a routine surgery performed in Campbellton Regional Hospital. Before January 2012 all the tonsillectomies were one day procedure. Due to reduction in the hospital beds, there was a significant pressure on the ENT service to perform more of tonsillectomies as day case procedures.

A Prospective and retrospective study was done for the day case tonsillectomies from January 2012 till June 2013 and results are reported.

Key words: DCT (day-case-tonsillectomy), post-tonsillectomy hemorrhage (PTH), post-tonsillectomy pain (PTP),Post-operative nausea and vomiting (PONV), ASA (American Society of Anaesthesiologist) grading of patients, PACU (Post-anesthesia care Unit).

Dr. Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH, is a Family Physician practising Sport and Exercise Medicine at the Toronto Rehabilitation Institute, University Health Network. In addition, she trained as a physiotherapist and maintained an active license for 30 years. She is appointed at the University of Toronto, Department of Family and Community Medicine as an Associate Clinical Professor.

Greg McIntosh, MSc, completed his Masters in Epidemiology from the University of Toronto’s Faculty of Medicine. He is currently the Director of Clinical Research for CBI Health Group and research consultant to the Canadian Spine Society.

Abstract
This article helps clinicians decide on appropriate referral to rehabilitation professionals while answering some of the common questions that clinicians are often asked by low back patients. The evidence for appropriate rehabilitation techniques will be interwoven into this article to promote a critical appraisal approach to evaluating rehabilitation outcomes. At the conclusion of this paper, clinicians should be able to identify best practices for rehabilitation referral.
Key Words: Low back pain, indications, rehabilitation, inter-professional referral.

Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

Abstract
The end of one's life is always a challenge for all involved; the patient reaching what may be recognized as the last stages of life, family members who in general only want the best for their loved one, and health care professionals who are professionally, legally, and ethically dedicated to provide the best care possible. For health care providers who combine the philosophy of palliative and hospice care with the care of elders, even greater challenges commonly occur because of the complex nature of family dynamics, relationships, and belief systems, that often influence family expectations and thus patient care. The challenge to healthcare providers is to navigate the many potential minefields when such challenges exist. When successful, the satisfaction that result from achieving a clinically compassionate, caring, and comfortable death for the patient and give solace to the family are well worth the effort.
Key Words:Hospice care, palliative care, end-of-life care, family conflicts, ethical and legal duties of staff, palliative sedation, client-centered care, patient-centered care.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Tinea incognito is a superficial dermatophyte infection in which the clinical appearance of the symptoms has been altered by inappropriate treatments, such as topical corticosteroids.
Dermatophyte infection may result from contact with infected humans, animals, or inanimate objects. An erythematous, pruritic, annular and scaly plaque is characteristic of a symptomatic infection. A potassium hydroxide (KOH) examination of skin scrapings is usually diagnostic. If topical corticosteroids have been applied recently, the amount of surface scales may be reduced and may lead to false negative results. Topical therapy is the first line treatment for localized infections. Systemic antifungals should be used in extensive condition, immunosuppression, resistance to topical antifungal therapy.

Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

Abstract
The use of artificial nutrition and hydration (ANH) has become relatively commonplace. With the development of the PEG years ago, the difficulties that surrounded the use of naso-gastric feeding tubes have all but disappeared. However, the clinical, ethical and legal aspects of ANH have replaced issues of procedural techniques and the discomfort experienced by older patients when the nasogastric tubes were used for prolonged periods. Many in the field of aging and long-term care in particular are particularly sensitive to the long-term implications for the patient and family once ANH is implemented. The issues of starting such intervention when its discontinuation may cause moral conflict, legal challenges and for many who are believers religious conundrums must be considered especially when such decisions are being made during a period of crises and clinical uncertainty.
Key Words: artificial nutrition, hydration, long-term care, implications.

Shannon Humphrey, MD, FRCPC, FAAD, Clinical Assistant Professor, Director of Continuing Medical Education, Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada.

Abstract
The pathogenesis of acne is tied to Propionibacterium acnes (P. acnes), an anaerobic bacteria. There has been a dramatic rise in resistance to antibiotics that are usually prescribed to treat acne. Given resistance to antibiotic therapy can occur in more pathogenic bacteria than P. acnes, and the fact that a rise in pathogenic P. acnes has been reported, the development of antibiotic resistance in acne is a public health matter globally. Clinical practice guidelines are aiming to curb the further development of antibiotic resistance without detracting from effective management of both inflammatory and non-inflammatory acne.
Key Words: acne vulgaris, antibiotic resistance, benzoyl peroxide, anti-inflammatory, sub-antimicrobial dosing.

P.K. Shenoy, MD, FRCS, DLO, FACS, ENT Service Chief, Campbellton Regional Hospital, Campbellton, NB, Canada.

Dr. Lyew Warren, MD, FRCSC, Consultant Pathologist, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada.

Abstract
Nasal vestibular mass are not commonly seen in ENT practice. We are presenting a patient with a large right nasal vestibular mass, who complained of nasal obstruction and epistaxis. Differential diagnosis of the similar growths in the nasal vestibule with their pathology and the treatment options, have been reviewed from the literature.
Key Words: Nasal vestibular mass, papilloma, 0 and 30 degree endoscopes, lateral rhinotomy.

Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

Abstract
With the rapidly increasing numbers of elders in North American Society, the prevalence of those living with dementia is clearly on the increase. According to the most recent document provided by the Alzheimer Society of Canada, The Rising Tide the growth in the numbers of those living with dementia will increase from 480,600 in 2008 (1.5% of Canada's population) to in the year 2038—1,125,200 people with dementia (2.8% of Canada's population).¹ All the challenges that Canadian society faces with this growing population merely mirror the enormous complexities that those living with dementia, their families and health care professional providers must increasingly contend with. Government policy makers must find ways to address this increasing population in which Dementia plays a prominent role. The result of the Supreme Court ruling on the Rasouli case has major potential implication for those facing the later stages of dementia and those under whose care members of this population will be entrusted.
Key Words: dementia, aging population, substitute decision makers.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Hairy tongue, or known as lingua villosa, is a result of hypertrophy, elongation, and defective desquamation of the filiform papillae of the tongue. This condition may present in a variety of colors depending on the specific etiology. Etiologies of hairy tongue include poor oral hygiene, lack of mechanical stimulation and debridement of the tongue, the use of medications (especially broad-spectrum antibiotics), and therapeutic radiation of the head and the neck. This condition is also commonly seen in people having high consumption in coffee and tea, heavy use of tobacco, individuals addicted to drugs, patients who are HIV positive, and intravenous drug users. In most cases, non-pharmacologic interventions are used for the management of hairy tongue. Treatment involves brushing the tongue with a toothbrush or using a commercially available tongue scraper to retard the growth or to remove elongated filiform papillae. If Candida albicans is present, topical antifungal medications are used for patients who are symptomatic.
Key Words: Hairy tongue, Lingua villosa, Glossopyrosis, Halitosis.