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

In the winter and spring of 2012 I was privileged to be part of the executive working group that organized the fourth Canadian Conference on the Diagnosis and Treatment of Dementia (CCCDTD4) which took place in May 2012. The process as described in both of the initial publications that came out in the fall of 2012 included many participants from all of those physician groups involved in caring for those at risk of dementia, as well as those not-for-profit organizations involved in educating the public.

Publication of THE LATEST IN ULCERATIVE COLITIS CARE supplement was made possible by an unrestricted educational grant from Aptalis Pharma

¹James Gregor, MD,²Co-authors: John Howard, MD, Nitin Khanna, MD, and Nilesh Chande, MD,

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Abstract: Informed patients are one of the most important assets available in the management of patients with ulcerative colitis. Clinical experience reinforces that most patients have similar questions upon diagnosis. Anticipating these questions and tailoring them to a particular patient's disease severity and extent should not only streamline follow-up but also mitigate confusion and augment the benefit of the plethora of information available in the 21st century. Using our local experience, we have defined the 10 most common questions asked by patients and modified the answers, where necessary, to improve their specificity to patients with ulcerative proctitis, left-sided ulcerative colitis, and pancolitis.

Key Words: ulcerative colitis, patient, questions, classification, management.

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Patients can be relatively ill informed regarding the nature of their UC, its management, and its ultimate prognosis.

Generally, disease extent is divided into three categories: ulcerative proctitis, left-sided disease, and pancolitis.

A simple approach with frequently asked questions (FAQs) is a highly desirable and efficient means of transmitting information.

Clinical experience reinforces that most patients have similar questions upon diagnosis with UC.

Anticipating these questions and tailoring them to a particular patient's disease severity and extent should streamline follow-up and also mitigate confusion.

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Publication of THE LATEST IN ULCERATIVE COLITIS CARE supplement was made possible by an unrestricted educational grant from Aptalis Pharma

Geoffrey C. Nguyen, MD, PhD,

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Abstract: 5-Aminosalicylates (5-ASAs) are considered first-line therapy for mild to moderate ulcerative colitis because of their proven effectiveness and safety profile, even in pregnancy. One formulation, however, contains dibutyl phthalate (DBP) in its coating. Though DBP may cause disruptions in utero reproductive development and other congenital abnormalities in rodents, it is unclear whether it leads to physiologically significant fetal abnormalities in humans. The US Food and Drug Administration has changed its classification for DBP-containing 5-ASAs from pregnancy category B to pregnancy category C to reflect a greater degree of uncertainty regarding its effect in humans. For pregnant women with ulcerative colitis, the most important message is to take their inflammatory bowel disease (IBD) medications to prevent disease relapse, which may have the most adverse effects on pregnancy. Physicians should, however, discuss with young women who are taking 5-ASA with DBP the benefits and risks of switching to another formulation of 5-ASA without the DBP compound.

Key Words: phthalates, 5-aminosalicylate, ulcerative colitis, dibutyl phthalate, pregnancy.

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5-Aminosalicylates (5-ASAs) are effective for the treatment of mild to moderate ulcerative colitis and are generally regarded as safe to use, even during pregnancy.

Dibutyl phthalate (DBP) is found in the coating of certain formulations of 5-ASA, and in rodents has been shown to be associated with developmental and congenital abnormalities.

Though phthalates have been shown to be associated with some indicators of reduced masculinization among male fetuses, there is insufficient evidence to prove that it leads to significant harmful effects.

There are several formulations of 5-ASA that do not contain DBP.

Asacol, which contains DBP, is categorized as a pregnancy category C drug, while most other 5-ASAs are in pregnancy category B.

It should be emphasized to pregnant women that taking medications for their inflammatory bowel disease is important because the disease has a strong impact on, not just their health, but the health of their fetus too.

Women of child-bearing age who are taking a DBP-containing 5-ASA should have a discussion regarding the benefits and risks of switching to another 5-ASA, preferably before pregnancy.

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