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When to Scratch Beyond the Surface of the Diagnosis—A look at Atopic Dermatitis Mimickers and Their Response to Topical Corticosteroids

Teaser: 

Briar Findlay1Joseph M. Lam, MD, FRCPC,2

1 Paediatric Resident, BC Children's Hospital, Vancouver, BC.
2Associate Clinical Professor, Department of Paediatrics, Associate Member, Department of Dermatology, University of British Columbia.

CLINICAL TOOLS

Abstract: Many dermatoses occur in the pediatric population that can mimic atopic dermatitis based on their morphology or their propensity for triggering itch. This review will highlight some of the common skin conditions that can mimic atopic dermatitis, their typical response to topical corticosteroids and helpful features that can help distinguish these conditions from atopic dermatitis.
Key Words: atopic dermatitis mimickers, topical corticosteroids, chronic inflammatory skin disease, paediatrics.
Many dermatitic eruptions can mimic atopic dermatitis but features such as their typical response to topical corticosteroids can be a helpful distinguishing feature.
Some atopic dermatitis mimickers can worsen with topical corticosteroids and these include periorificial dermatitis and tinea corporis.
Some atopic dermatitis mimickers will only partially improve with topical corticosteroids alone and these include allergic contact dermatitis and molluscum dermatitis.
Other atopic dermatitis mimickers such as psoriasis and seborrheic dermatitis can respond to topical corticosteroids and the correct diagnosis can be made using other morphological or historical features.
AD is a prevalent, chronic and relapsing condition in infancy and childhood.
Morphology, distribution and age of onset can be important in distinguishing between AD and common mimickers.
Response to corticosteroids is not diagnostic for AD as many mimickers may have an initial or complete response to topical corticosteroids; however, corticosteroid usage in some mimickers of AD may lead to complications and unnecessary side effects of topical corticosteroids.
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Community Resources for Management of Back Pain

Teaser: 

1Naazish Shariff, BHSc. Candidate, 2Eugene K. Wai, MD, MSc, CIP, FRCSC,

1Faculty of Health Science, University of Ottawa, Ottawa, ON. 2Head—University of Ottawa Combined Adult Spinal Surgery Program, Associate Professor—Division of Orthopaedic Surgery, University of Ottawa, Cross Appointment to School of Epidemiology and Public Health, Ottawa, ON.

CLINICAL TOOLS

Abstract:Back pain is a community level health problem because of the high prevalence and burden on patients, health care and society. Many aspects of back management, such as exercise and psychosocial stress management, are suitable for a community model of care. Community models for back pain are in their infancy but lessons learned from other chronic diseases can be applied and will be discussed. This review will discuss existing evidence-based community programs, such as Exercise is Medicine® and the Stanford Model, that support exercise and self-management, and their relevance to low back pain.
Key Words: back pain, community model of care, self-management, exercise, lifestyle risk factors.

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

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Many aspects of back management such as exercise and promotion of self-management are more suited for a community model of care.
Physicians and other health care providers are important catalysts for change and must support patient engagement.
Health care practitioners should identify resources within their community as well as develop their own local creative solutions.
Evidence-supported models for community involvement in managing chronic diseases are available. This article provides resources enabling practitioners to identify these programs in their community and tailor them for their back pain patients.
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Spinal Injuries among Paediatric Patients

Teaser: 

Dr. Khaled Almansoori, MD, M.Ed, FRCSC,

Adult & Paediatric Spine Surgeon, Department of Orthopaedic Surgery, Advocate Christ Medical Center, Illinois, USA.

CLINICAL TOOLS

Abstract:Due to the distinctive anatomic and biomechanical features of the growing paediatric spine, children are susceptible to unique patterns of spinal injuries. Although clinical examination can help guide management, physicians are often required to rely on advanced imaging. Imaging interpretation can be challenging when considering that abnormal parameters among adults, are often within normal physiological limits in children. In general, spinal injuries in children younger than nine years of age are often managed non-operatively, while adolescents are typically managed by adult treatment principles. With the exception of neurologic injuries, most paediatric spinal injuries demonstrate good to excellent prognosis and outcomes.
Key Words: fracture, injury, spine, paediatric, children.

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Due to the unique properties of the growing spine, including greater elasticity, osseous plasticity, presence of growth centers, relatively strong ligaments, and greater joint mobility, paediatric patients are susceptible to unique fracture patterns and injuries.
There are absolute contraindications regarding return to play decisions.
Children under 13 years of age with vertebral body compression fractures can progressively restore their vertebral height until skeletal maturity.
The vast majority of spine injuries among children under nine years of age, even when relatively unstable, can be managed non-operatively.
Pre-adolescent patients with complete spinal cord injuries are at high risk for developing progressive scoliosis and have not been shown to demonstrate any better neurological outcomes when compared to adults.
The cervical spine is the commonest area of spine injuries with the C1-3 vertebral levels being more commonly seen in children under eight years of age.
A standard immobilization board should not be used for children under eight years of age without an occipital recess or 2-3cm of padding to elevate their body relatively to their head.
Adult radiographic spinal parameters are often unreliable in children and severe neurologic injuries can be sustained in spite of normal imaging results.
Clinical examination is fairly unreliable for identifying spinal column injuries among pre-school patients and it is often necessary to rely on advanced imaging.
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Epiglottitis: An Under-recognized, Life-Threatening Infection

Members of the College of Family Physicians of Canada may claim one non-certified credit per hour for this non-certified educational program.

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Teaser: 

Dr. Pradeep Shenoy, MD, FRCS, FACS, DLO,1
Marah Mansour2

1ENT & Neck Surgeon, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada.
2Faculty of Medicine, Tartous University, Tartous, Syrian Arab Republic.

CLINICAL TOOLS

Abstract:Acute Epiglottitis is a potentially life threatening infection of the supraglottic structures, epiglottis and aryepiglottic folds causing fatal airway obstruction. Historically described in adults before the 1960s and after the 1960s in the paediatric group causing more mortality and morbidity until the introduction of the H. influenza type B vaccine in 1993. Since then the incidence was described again more in the adult group.6 Prompt diagnosis and treatment will save the patients if failed mortality is as high as 80% in children and 20% in adults.2
Key Words: Epiglottis, H. Influenza Type B, Aspergillus, Kliebsiella, Candida, Fibroptic laryngoscopy, Humidified oxygen therapy, orotracheal intubation, naso-tracheal intubation, tracheostomy thumb sign.
Epiglottits is an acute emergency in ENT practice as mortality is high in children at about 80% and 20% in adults.
Before the 1960s epiglottitis was not seen in the paediatric group.
Since the invention of H. influenza type B vaccine the numbers in the paediatric group has declined though in adults it remains the same as there are other bacteria and fungus involved in immune compromised patients .
Acute epiglottitis is potentially life threatening both in children and adults. Prompt diagnosis with clinical examination complimented with radiographic investigation depending on the severity of cases and early treatment could save the patient
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Virtual Care for Low Back Pain Patients

Teaser: 

Ted Findlay, DO, CCFP, FCFP,1 Dr. Hamilton Hall, MD, FRCSC,2

1 is on Medical Staff with the Calgary Chronic Pain Centre at Alberta Health Services, Calgary Zone in Calgary, Alberta.
2 is a Professor in the Department of Surgery at the University of Toronto. He is the Medical Director, CBI Health Group and Executive Director of the Canadian Spine Society in Toronto, Ontario.

CLINICAL TOOLS

Abstract:The COVID-19 global pandemic has had a rapid and massive impact on health care delivery worldwide. Two of the first public health measures applied in Canada and most other developed nations have been some variety of social distancing and "stay at home" orders, which limit the ability of patients to access non-urgent health care services. Patients with chronic pain including low back pain comprise some of the most disadvantaged populations where ongoing support from their family physician is an essential aspect of management. Virtual patient care has rapidly become one of the primary means to deliver of non-urgent management and is, in many ways, ideally suited for the support of chronic low back pain patients. It will continue to be used not only until face to face appointments are again permitted but may become a permanent feature of continuing care.
Key Words: COVID-19; virtual care; video appointments; low back pain; communication.

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1. Virtual patient care is not a new concept, but its use has been accelerated due to the COVID-19 pandemic.
2. Even pre-dating the COVID-19 pandemic, organized medicine in Canada has come out strongly in favor of the delivery of health care by virtual means.
3. There are many on-line resources that can be accessed by patients to help manage their low back pain during pandemic limitations on direct patient contact.
4. Positive patient identification and documentation of consent are requirements for virtual care delivery.
5. Both the physician and the patient have a role to play in ensuring appropriate privacy for the virtual visit.
Have your patient download and test any required communications software prior to their virtual appointment.
Commercial video communication software can be compliant with provincial personal privacy and information protection laws, check with your provincial medical association and/or provincial College of Physicians and Surgeons to be certain that approved software is being used.
Have the patient perform any required clinical measurements and list current medications and any required refills prior to the start of the virtual appointment.
Make sure that unidentified number call blocking does not prevent the virtual appointment from being completed.
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Osteoporosis Prevention: What can we tell patients?

Teaser: 

Dr. Marina Abdel Malak

is a Family Medicine Resident at the University of Toronto. She graduated and completed her Bachelor of Science in Nursing and went on to study Medicine. She has a passion for medical education, patient empowerment, and increasing awareness about the relationship between mental, emotional, and physical health.

CLINICAL TOOLS

Abstract:Osteoporosis (OP) is the leading cause of hip fractures in patients. Primary prevention focusses on engaging in strategies that prevent the development of osteoporosis. Physicians often provide health information to patients on how to optimize their overall wellness, and therefore, ought to educate patients on bone health as well. Offering advice on specific interventions that decrease the risk of developing OP is an effective way to engage patients in maintaining peak bone mass. Physicians should counsel patients on key points such as dietary modifications, physical activity, and decreasing the use of alcohol and smoking. Setting mutual goals with patients and ensuring that they understand the positive impact this will have on their health is critical.
Key Words: Osteoporosis, bone health, health promotion, primary prevention, education.

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

www.cfpc.ca/Mainpro_M2

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1) Educating patients about methods to decrease the risk of osteoporosis is a critical role of the physician, as peak bone mass develops in early adulthood
2) CALCIUM (see figure 4) is a mnemonic that can help physicians recall what strategies they can address with patients: calcium/vitamin D intake, aerobic activities, limit alcohol, cut down on smoking, increase balance, use supplements if indicated, and maintain a healthy weight
3) Physicians should provide patients with resources and referrals if appropriate to ensure patients receive adequate information/support in promoting their bone health
Patients should be advised that a vitamin D supplement is required to obtain the 1000-2000 IU daily requirement
A calcium supplement is not always indicated if dietary intake is adequate
Both aerobic and weight-bearing activities are essential for OP prevention
Smoking cessation and limiting alcohol are also factors that impact bone health
Patients should be encouraged to mutually set goals around bone health with their physicians, as this increases the likelihood that their behaviour changes will be successful
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The Non-Operative Management of Scoliosis

Teaser: 

Brett Rocos, BSc (Hons), MB ChB, MD, FRCS (Tr & Orth),

Paediatric Spine Fellow, The Hospital for Sick Children, Toronto, ON.

CLINICAL TOOLS

Abstract:Scoliosis is a common condition that every primary care provider will encounter. There are many treatments available in its management, including observation, physical therapy, pain management strategies, casting, bracing and surgery. In this narrative review, the roles of each of the non-operative strategies in managing adult and paediatric scoliosis are explored, and the evidence supporting each is summarised. Scoliosis affects people at every stage of life, and an understanding of the treatments available will aid in counselling patients and making appropriate referrals.
Key Words: Scoliosis, conservative, paediatric, bracing, physiotherapy, alternative therapies, spine cast.

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

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• Scoliosis is common
• Most patients require observation only
• Patient information is essential
• Casting and bracing have roles in the growing skeleton only
• Physical therapy has limited evidence in both adult and paediatric deformity
• Alternative therapies have no proven use in the management of scoliosis
The majority of patients with scoliosis can be observed
Reliable patient information is critical
There is limited evidence that physiotherapy is effective, and no evidence that alternative therapies are effective in treating scoliosis
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What is Athletic Heart Syndrome?

Teaser: 

Dr. Alykhan Abdulla, BSC, MD, LMCC, CCFPC, DipSportMed CASEM, FCFCP, CTH (ISTM), CCPE, Masters Cert Phys Leader, ICD.D

Assistant Professor University of Ottawa Faculty of Medicine, Academic Clinical Professor University of Ottawa Faculty of Nursing Medical Director The Kingsway Health Centre, The Kingsway Travel Clinic, The Kingsway Cosmetic Clinic, Beechwood Medical Cosmetic Physio Pharmacy, Editor in Chief/Author Journal of Current Clinical Care SPORTS MEDICINE, Vice Chair Section of General and Family Practice Ontario Medical Association, Board Director Eastern Ontario Regional Lab Association, Bruyere Foundation

CLINICAL TOOLS

Abstract: A common term for an enlarged heart that is associated with repeated strenuous exercise is athletic heart syndrome (AHS). This article reviews AHS, other serious conditions that appear similar to AHS, and how to identify a young athlete at risk for sudden cardiac death.
Key Words: athletic heart syndrome, enlarged heart, strenuous exercise, sudden cardiac death.
The changes in heart structure and function seen in athletic heart syndrome would suggest illness if seen in non-athletes.
When abnormalities in heart structure or function are detected in an athlete, it is important to ensure the abnormalities are indeed due solely to exercise conditioning, and not to a cardiac disorder.
Consider a clinical history of drug abuse, the use of anabolic steroids, recent viral infections and very tall athletes with arachnodactily or an arm span greater than their height.
Clinically suspicious athletes need to go for further testing.
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Navigating the COVID-19 Pandemic as a Healthcare Provider

Teaser: 

Dr. Marina Abdel Malak

is a Family Medicine Resident at the University of Toronto. She graduated and completed her Bachelor of Science in Nursing and went on to study Medicine. She has a passion for medical education, patient empowerment, and increasing awareness about the relationship between mental, emotional, and physical health.

CLINICAL TOOLS

Abstract: The COVID-19 pandemic is an unprecedented situation. Feelings of isolation, uncertainty, fatigue, and a loss of control have created stress among individuals across the world. Healthcare providers are in a position where they must balance their personal, familial, and work obligations during the pandemic. As frontline workers, healthcare providers are particularly vulnerable to the physical, mental, emotional, and social stressors encountered during crises. This can contribute to burn out, physical illnesses, and dissatisfaction. It is therefore essential that healthcare providers are supported in acknowledging and normalizing these feelings, and accessing resources to help them cope. To maintain social distancing and provide around-the-clock services, there are a variety of online resources available to support healthcare providers during this time. By utilizing various coping skills and seeking support, healthcare providers can protect their mental, emotional, physical, and social (MEPS) health during the COVID-19 situation.
Key Words: COVID-19, pandemic, wellness, physical health, resilience.
The COVID-19 pandemic has created a level of uncertainty, fear, and distress across the world. Feelings of isolation, anxiety, and stress are normal during this time.
Healthcare providers are, in particular, are faced with difficult decisions and situations in the COVID-19 crisis. Balancing personal, familial, and work obligations can be extremely challenging.
Mental, emotional, physical, and social health (MEPS) are equally important. As healthcare providers, we cannot take care of others if we do not care for ourselves first.
Various resources are available to help healthcare providers during the COVID-19 pandemic. Developing and utilizing a range of coping tools can promote MEPS health.
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Development and Implementation of a National Canadian Spine Surgery Registry

Teaser: 

1Greg McIntosh,2Dr. Michael Craig, 3Dr. Charles Fisher,

1Director of Research Operations, Canadian Spine Outcomes and Research Network.
2Neurosurgery Resident at Vancouver General Hospital, University of British Columbia. 3Professor and Head of the Division of Spine Surgery, Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia.

CLINICAL TOOLS

Abstract:The goal of the Canadian Spine Outcomes and Research Network (CSORN) is to develop a registry for Canadian orthopaedic and neurosurgical spine surgeons to participate in prospective multi-centre trials and retrospective reviews utilizing multivariable analyses. The design allows ongoing research and contains clinical details necessary for epidemiological assessment. Currently, 21 hospital sites, representing 9 provinces, participate CSORN. A total of 81 investigators have enrolled over 11,000 spine patients; 78% thoracolumbar and 22% cervical. Predictive models, effectiveness of surgical procedures, wait time issues and patient-surgeon expectations are some of the specific topics already published with CSORN data.
Key Words: registry, spine surgery, data quality, outcomes.

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

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Collection, feedback and publication of registry data is now a recognized way of informing clinical practice, driving quality improvement and improving patient outcomes.
The Canadian Spine Outcomes and Research Network (CSORN) is a multicentre national initiative that prospectively enrols consecutive patients with spinal pathology requiring surgical treatment.
The CSORN registry is designed to assess the value of operative techniques on patient outcomes.
Both patients and providers can feel powerless to enact any real change over the healthcare system. Patient participation in a properly designed registry gives them the opportunity to contribute to improving healthcare delivery.
The need for documentation of clinical outcomes is as important in spinal surgery as it is in other medical specialties.
If the value of spine surgery is not well established, then the cheapest options, rather than potentially better ones, are more likely to be endorsed.
Registries require fewer resources and often avoid the constraints of randomized clinical trials; as a result, registry findings usually have strong external validity and generalizability.
Collecting quality of life and patient-reported outcome measures data are essential for treatment evaluation.
Patients (and their physicians) should not fear participation in well-designed registries.
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