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
Basal cell carcinoma (BCC) is a type of non-melanoma skin cancer that arises from basal cells found in the lower layer of the epidermis. It is the most common type of skin cancer in humans, but they rarely metastasize. If BCC is left untreated and progresses, it may lead to significant morbidity and cosmetic disgurement. In nearly all cases, the recommended treatment modality for BCC is surgery. Small and superficial BCC may respond to local immune-modulating therapies. For tumors that are more difficult to treat or those in which tissue preservation is essential, Mohs micrographic surgery should be considered. Radiation therapy can be used for advanced and extended BCC and in those patients for whom surgery is contraindicated. Photodynamic therapy is usually used as an adjunct in BCCs with poorly defined border, in cases which oculoplastic surgery will be extensive or difficult, or in recurrent BCCs with tissue atrophy or scar formation. Oral vismodegib has been approved for the treatment of adult patients with locally advanced basal cell carcinoma who are not candidates for surgery or radiation and for those with metastatic disease. The prognosis for BCC is generally great with 100% survival rate for localized cases.
Keywords: Basal cell carcinoma, Nonmelanoma skin cancer, Hedgehog intracellular signalling pathway, Imiquimod 5% cream, 5-Fluorouracil 5% cream.

Fatemeh Akbarian, MD,¹ Mehdi Aarabi, MD,² Ali Vahidirad, MD,³ Mehrdad Ghobadi, MD,⁴ Mohaddeseh Ghelichli MD,⁵
Mohammad A. Shafiee, MD, MSc, FRCPC,^6
1Dermatologist, Research Fellow, Department of Medicine, University of Toronto, Toronto, ON. ²Research Fellow, Department of Medicine, University of Toronto, Toronto, ON. ^3,4,5Joint, Bone, Connective Tissue Research Center, Golestan University of Medical Sciences, Iran. ⁶Division of General Internal Medicine, Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.

Abstract
Cutaneous Malignant Melanoma has the highest morbidity and mortality among different types of skin cancers; as one of the most common malignancies in the world. Early detection and diagnosis of Cutaneous Malignant Melanoma followed by adequate surgical excision are the most important tasks in management of this potentially curable skin cancer. Screening methods and diagnostic criteria including clinical and dermoscopic findings will be discussed in this article.
Keywords: Melanoma, Dermoscopy, UV Exposure, Epiluminescence Microscopy (ELM).

P.K. Shenoy, MD, FRCS, DLO, FACS, ENT Service Chief, Campbellton Regional Hospital, Campbellton, NB, Canada.
Ahmad Khatib, MD, L.M.C.C, is a family physician and an ER physician, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada.

Abstract
A rare case of severe headache presenting with spontaneous pneumocephalus secondary to frontal sinus pneumocele is described. To the best of our knowledge this is the second case presented in the English literature. Clinical presentation, management, and outcome are discussed.
Keywords: spontaneous pneumocephalus, pneumocele, frontal sinus, osteoma, headache.

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
Impetigo is a gram-positive bacterial infection of the superficial layers of the epidermis. There are two forms of impetigo: bullous and nonbullous. Diagnosis of impetigo is usually based solely on the history and clinical presentation. Culture and sensitivity results can help the physician choose appropriate antibiotic therapy. Treatment of impetigo typically involves local wound care, along with antibiotic therapy, either topical alone or in conjunction with systemic therapy. For mild or localized cases, topical mupirocin or topical fusidic acid applied 2 to 3 times daily for 7 to 10 days are adequate treatment. Systemic antibiotics are indicated for widespread, complicated, or severe cases associated with systemic manifestations of impetigo. Beta-lactam antibiotics remain an appropriate initial empiric choice, with coverage against both Staphylococcus aureus and Streptococcus pyogenes. For patients with recurrent impetigo or Staphylococcus aureus nasal carriers, topical mupirocin cream or ointment can be applied inside the nostrils 3 times daily for 5 days each month to reduce colonization in the nose.
Keywords: Impetigo, Staphylococcus aureus, Group A beta hemolytic streptococci Bullous impetigo, Nonbullous impetigo.

Hamilton Hall, MD, FRCSC,¹ Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,² Yoga Raja Rampersaud, MD, FRCSC,³

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Abstract: In 1987, the Quebec Taskforce noted, "Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment." Identifying these patterns begins with the patient's history: "Where is your pain the worst?" "Is your pain constant or intermittent?" "Has there been any change in your bowel or bladder function?" This questioning establishes the mechanical nature of the pain, and a physical examination verifies or refutes the pattern established in the history. The examination involves two essential tests to detect upper motor and low sacral root involvement. A failure of the results to fit into one of four syndromes—two back dominant and two leg dominant—suggests a non-mechanical or more complex problem.

Key Words:patterns of back pain, pain location, pain characteristics, history, physical examination.

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90% of Low Back Pain is not related to serious pathology and does not require surgical intervention.

Mechanical Low Back Pain can be categorized to patterns that are identified in history and confirmed in the physical examination.

Findings on radiological imaging including x-ray, CT scan and MRI have not been found to correlate to pain-generating pathology, can increase patient anxiety and detract from successful recovery.

A concise history starts with two questions: "Where is your pain the worst?" and "Is your pain constant or intermittent?"

The goal of physical examination is to verify or refute the diagnostic assumptions made on the basis of the history.

Managing low back pain is not a one-time event. Low back pain is a chronic condition that demands ongoing care and follow-up.

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Hamilton Hall, MD, FRCSC,¹ Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,² Yoga Raja Rampersaud, MD, FRCSC,³

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Abstract: Back dominant pain is either intensified by flexion or is not aggravated by bending forward. The most common pattern, probably discogenic, subdivides into two groups: one with pain on flexion but relief on extension, the other with pain in both directions. The second pattern has symptoms with extension only. Treatment begins with education about the true benign nature of the problem. Mechanical pain responds to posture adjustment and pattern-specific movement. Medication has a secondary role. Imaging is not required for the responding patient. The inability to detect a pattern or a lack of anticipated response combined with non-mechanical findings indicates the need for appropriate referral.

Key Words:back dominant pain, education, medication, imaging, specialist referral.

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Back Dominant pain can be divided into two presentations: pain that is predominantly reproduced with flexion or pain that is reduced or unaffected by flexion.

The recognition of mechanical low back pain is based on a precise history, a validating physical examination and a positive treatment result.

Referred pain to the leg may occur with back dominant pain but, unlike radicular pain, the neurological examination will be normal.

Facilitating the patient to engage in activity that does not aggravate pain is the key to pain management and recovery.

The goal is control, not cure. Anything that relieves the pain and helps to restore mobility is valuable.

Medication has a limited and secondary role. There is no place for the routine use of narcotics or psychotropic drugs.

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Yoga Raja Rampersaud, MD, FRCSC,¹ Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,² Hamilton Hall, MD, FRCSC,³

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Abstract: Leg dominant pain suggests direct nerve root involvement: radicular, not referred symptoms. Constant pain associated with positive neurological findings usually results from an acute disc herniation. Symptoms are the result of mechanical compression but principally reflect an inflammatory response, properly designated sciatica. Intermittent leg dominant pain triggered by activity in extension and relieved by rest in flexion probably represents neurogenic claudication: nerve root ischemia secondary to spinal stenosis. Except for acute cauda equina syndrome, acute sciatica is initially managed with scheduled rest, adequate medication, and time. Non-responsive cases may require surgery. Surgery also shows superior outcomes for disabling neurogenic claudication.

Key Words:leg dominant pain, sciatica, neurogenic claudication, cauda equina syndrome, surgery.

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True spine-generated, leg dominant pain is consistently reproduced by particular spinal movements or positions.

No imaging investigation is required for a patient presenting an unequivocal clinical picture and exhibiting steady predictable improvement.

Of the four back pain syndromes, only neurogenic claudication is consistently best treated by surgery.

In contrast to the back dominant cases, in sciatica there is a definite role for short-acting narcotics or psychotropic drugs for uncontrolled pain.

Criteria for Surgical Referral

Emergency Referral The symptoms of Cauda Equina Syndrome are: - Urinary retention followed by insensible urinary overflow. - Unrecognized fecal incontinence. - Loss or decrease in saddle/perineal sensation. Acute Cauda Equina Syndrome is a surgical emergency.

Consider Elective Referral Failure to respond to a trial of conservative care: - Unbearable constant leg dominant pain. - Worsening nerve irritation tests (SLR or femoral nerve stretch). - Expanding motor, sensory or reflex deficits. - Recurrent disabling sciatica. - Disabling neurogenic claudication.

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