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treatment

Surgical Management of Erectile Dysfunction

Teaser: 

Justin J. Badal, MD,1 Genevieve Sweet, MD, 2Shelley Godley, MD,3Stanley A. Yap, MD,4Dana Nanigian, MD, 5

1Department of Urology, University of California Davis, Sacramento, California.
2Department of Urology, Sutter Medical Group, Roseville, California.
3Department of Urology, Veterans Affairs Northern California Health Care System, Sacramento, California.
4Department of Urology, University of California Davis, Sacramento, California and Department of Urology, Veterans Affairs Northern California Health Care System, Sacramento, California.
5Chief of Urology, Department of Urology, Veterans Affairs Northern California Health Care System, Sacramento, California.

CLINICAL TOOLS

Abstract: Erectile dysfunction (ED) is one of the most common sexual disorders affecting men. Discussion regarding erectile function, diagnosis, and management of the disease typically begins at the primary care level. A broad understanding of the basic causative factors and initial treatment regimens gives primary care physicians the ability to treat ED. An enhanced understanding of surgical options allows for referrals to be made to urologists for advanced surgical treatment of ED in patients who have failed medical therapies. Initial diagnosis and continued workup can be performed prior to consultation with a surgical specialist. Detailed here are different causes of ED as well as their respective studies to enhance initial surgical evaluation.
Key Words:erectile dysfunction, diagnosis, management, treatment.

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

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A thorough discussion regarding the irreversibility of penile implants is strongly recommended with the patient before proceeding.
Inflatable penile prosthetics avoid the effect of the constant erection created by malleable implants.
Partner satisfaction is highest with the inflatable penile prosthesis.
The inflatable penile prosthesis is the most preferred among men.
Adverse events/complications associated with SNM use include: pain at the implantation site, lead migration, wound-related complications, bowel dysfunction, infection, and generator problems.
Postoperative outcomes can be improved with detailed counseling in regards to modifiable risk factors, such as achieving appropriate glycemic control.
Candidates for revascularization therapy should be carefully selected, with those who are younger and have sustained pelvic trauma having the best outcomes.
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Interventional Radiology Procedures for Chronic Low Back Pain

Teaser: 

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

1is a Clinical Assistant Professor in the Department of Medicine at the University of Calgary. He is also in a Private Family Medicine practice. In addition he is on Medical Staff at Alberta Health Services, Calgary Zone in Calgary, Alberta.
2Clinical Assistant Professor Department of Radiology, Department of Nuclear Medicine, University of Calgary, Calgary, Alberta.

CLINICAL TOOLS

Abstract: There is an increasing availability and clinical use of interventional radiological techniques for patients with low back pain. This can be a valuable additional tool in the management of low back pain that has not responded to conservative treatment. However, the clinical indications and appropriate uses as well as cautions that apply to this treatment modality are in many cases less well understood by the primary care practitioner. The objective of this article is to review clinical scenarios in which these procedures are commonly considered, as well as their limitations. The field of interventional radiology is one that is rapidly evolving and an area of active clinical research. It is important for the primary care practitioner to have a basic understanding of the current state of the art in order to have an informed discussion with their patients who may be seeking advice on this treatment option.
Key Words: Low back pain; treatment; interventional radiology definitions; interventional radiology indications; interventional radiology complications.

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

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1. In patients carefully selected by clinical and radiological examination, there can be satisfying clinical gains from the use of currently available interventional radiologic procedures.
2. One must not assume that abnormal findings on radiologic imaging immediately explains the anatomical cause of a patient's low back pain; a corresponding accurate history and physical examination is ideal prior to commencing injections.
3. When successful, the gains from radiological interventions should be considered one portion of a broader clinical treatment plan, rather than the entire plan of management.
4. Unsuccessful interventional procedures should not be repeated.
1. Do not apply repeated interventional procedures with an expectation that one of them will find the target source of the patient's low back pain.
2. Although they may be uncommon, interventional radiology risks can occur and the referring physician should be cognizant of these dangers that accumulate with repeated interventions.
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Median Raphe Cysts

Teaser: 

Mary Tong, BHSc, MD Candidate,1 Joseph M. Lam, MD, FRCSC,2

1McMaster University, Hamilton, ON.
2Clinical Associate Professor, Department of Pediatrics, Clinical Associate Professor, Department of Dermatology University of British Columbia, BC.

CLINICAL TOOLS

Abstract: Median raphe cysts are rare congenital lesions caused by a defect in embryological development of the male genitalia. They can present as solitary or multiple papules along the median raphe from urethral meatus to the anus. Although they are asymptomatic during childhood, they can cause problems later on as they increase in size. Surgical excision of the lesion is not necessary unless the patient becomes symptomatic.
Key Words: median raphe cysts, congenital lesions, treatment, management.
Median raphe cysts are benign cysts that can be present at birth, or acquired due to trauma or infection in the genitalia area.
Histologically, the cysts can have pseudo stratified columnar, squamous cell, or glandular epithelium, or a mixture of these cells.
Although these cysts are asymptomatic during childhood, they should be monitored overtime because they may cause problems as they increase in size with time.
Because these are benign malformations, median raphe cysts do not require excision unless they cause problems such as pain, problems with urination or sexual activity, or for cosmetic reasons.
Median raphe cysts are benign lesions that may be caused be a defect in the embryological development of the male genitalia.
The differential diagnoses of median raphe cyst include glomus tumor, dermoid cyst, pilonidal cyst, epidermal inclusion cyst, urethral diverticulum, and steatocystoma.
Treatment for asymptomatic median raphe cyst is not necessary but surgical excision can be considered if the cyst is causing problems or for cosmetic reasons.
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The Role of Nutraceuticals in Atopic Dermatitis

The Role of Nutraceuticals in Atopic Dermatitis

Teaser: 

Jacky Lo, MD,1 Joseph M. Lam, MD, FRCSC,2

1 is a resident in the Family Medicine Residency at the University of British Columbia. He was previously a registered dietitian at the College of Dietitians in BC.
2is a pediatric dermatologist and a clinical assistant professor in the Departments of Pediatrics and Dermatology at the University of British Columbia.

CLINICAL TOOLS

Abstract: Atopic dermatitis (AD) is a chronic relapsing and remitting dermatosis with no definitive cure. Because treatment often remains challenging, the use of nutraceuticals has been gaining popularity as an alternative therapy.
Key Words: Nutraceuticals, atopic dermatitis, prevention, treatment.
The use of prebiotics in formula fed infants may reduce the incidence of AD up until two years of life.
The use of prenatal and/or postnatal probiotics, especially with Lactobacillus rhamnosus and Bifidobacterium, has been shown to reduce the incidence of AD. However, the evidence for its long-term effects appears to be inconsistent.
There is conflicting evidence regarding the use of vitamin D alone and zinc in the treatment of AD.
Routine supplementation of vitamin E alone and selenium does not appear to be beneficial in the treatment of AD.
While the use of fish oil has not been shown to have any statistically significant benefit in the treatment of AD, its use has been associated with improved quality of life, reduction in area affected in a pooled analysis of two studies and pruritus in one study.
Education plays an important in the management of AD and emphasis should be made to explore patients' reasons for turning to alternative therapies.
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Benign Prostatic Hyperplasia—Medical and Surgical Treatment Options

Benign Prostatic Hyperplasia—Medical and Surgical Treatment Options

Teaser: 

Dean S. Elterman, MD, MSc, FRCSC,1 Udi Blankstein, MD,2

1Attending Urologic Surgeon, Toronto Western Hospital, University Health Network, Assistant Professor, Division of Urology, Department of Surgery, University of Toronto, Toronto, ON.
2Department of Urology, McMaster University, Hamilton, ON.

CLINICAL TOOLS

Abstract: Benign prostatic hyperplasia (BPH) affects the aging male. Treatment options vary widely. Some men will elect to conservatively monitor their symptoms and make alterations to their lifestyle choices. Pharmacotherapy options exist as well, and include alpha-blockers, 5-alpha reductase inhibitors and phosphodiesterase-5 inhibitors. Lastly, surgical options are also a viable treatment option, with many types at the disposal of the caregiver. Technological advancements have changed, and will continue to change the field in the near future. This review outlines the important aspects of this common affliction.
Key Words:Benign prostatic hyperplasia, management, treatment, referral.

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

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There is a spectrum of bother ranging from mild nuisance to significant decrease in quality of life – this is largely associated with how the patient perceives the problem.
Physical exam and medical history are imperative in the initial assessment of BPH.
Conservative measures and lifestyle changes should be the first line treatment choice.
Surgical intervention should be attempted after failure of medical therapy to alleviate symptoms and prevent kidney injury or infection.
Ensure that there are no other causes that may cause LUTS such as various medications, and other comorbidities.
When considering more invasive intervention, ensure that the surgical team knows the patient's anticoagulation status.
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Non-Muscle-Invasive Bladder Cancer: Review of Diagnosis and Management

Teaser: 

Neil Pugashetti,1 Shabbir M.H. Alibhai,3 Stanley A. Yap,1,2

1Department of Urology, University of California, Davis, Sacramento, CA.
2Division of Urology, Department of Surgery, VA Northern California Health Care System, Sacramento, CA, USA.
3Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

CLINICAL TOOLS

Abstract: Non-muscle-invasive bladder cancer (NMIBC) represents the large majority of newly diagnosed bladder tumors and represents a significant burden to both patients and the healthcare system. Although the initial standard treatment for all non-muscle-invasive tumors is surgical resection, there exist a wide variety of both surgical and medical treatment modalities based upon the tumor's specific stage and grade. Ensuring a proper diagnosis is key, and management should be tailored to the individual in order to reduce cancer recurrence and prevent progression of disease.
Key Words: Bladder cancer, non-muscle-invasive, diagnosis, treatment.

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.

Non-muscle-invasive bladder cancer consists of papillary tumors (Ta), tumors invading the submucosal lamina propria (T1), and flat lesions known as carcinoma in situ (CIS).
Proper management is key given the significant risk of tumor recurrence or progression to muscle-invasive disease.
Many treatment modalities exist including transurethral resection, intravesical chemotherapy, intravesical immunotherapy, and radical cystectomy; treatment choice depends on a variety of factors including tumor stage and grade.
The gold standard for the complete work-up of hematuria is office cystoscopy and imaging of the upper urinary tract.
Initial standard treatment of non-muscle-invasive bladder tumors is TURBT; at the time of resection, sampling of muscle surrounding the lesion is important to accurately assess depth of invasion.
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Pediatric diaper rashes: Getting to the 'bottom' of things

Pediatric diaper rashes: Getting to the 'bottom' of things

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

www.cfpc.ca/Mainpro_M2
Teaser: 

Jacky Lo1, Joseph M. Lam, MD, FRCSC2
1Medical student, Department of Pediatrics, University of British Columbia, Vancouver, BC.
2Clinical Assistant Professor, Departments of Pediatrics and Dermatology, University of British Columbia, Vancouver, BC.

Abstract
Diaper dermatitis is one of the most common skin conditions seen in the pediatric population and can cause significant distress for infants and their families. While many diaper rashes can resolve with simple treatments, having a thorough understanding of different diaper lesions can help rule out more serious conditions, guide treatment and alleviate some of the caregivers' anxiety. The following review article will provide an overview of select common and uncommon diaper eruptions.
Key Words: diaper dermatitis, pediatric, diaper rash, treatment.

Why Are Physicians Still Prescribing Sulfonylureas as First Choice for Older Diabetic Adults?

Why Are Physicians Still Prescribing Sulfonylureas as First Choice for Older Diabetic Adults?

Teaser: 

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

Abstract
Diabetes Mellitus is very prevalent in the older population. It is one of the important causes of vascular problems which may play a role in the development of dementia, especially of the mixed variety. There has been much progress in the potential medications that can help promote successful glucose control and address the other metabolic correlates of Type 2 diabetes mellitus. Sulfonylureas should be used rarely and very carefully in older especially frail individuals because of their inherent risks. Getting physicians to change their prescribing practices in this frail elderly diabetic population is an important challenge to educators and drug program administrators.
Key Words: diabetes mellitus, sulfonylureas, diabetic management, treatment.

A Practical Review of the Diagnosis and Management of Small Renal Masses

A Practical Review of the Diagnosis and Management of Small Renal Masses

Teaser: 

Stanley A. Yap,1 Shabbir M.H. Alibhai,2,3Antonio Finelli,1
1Division of Urologic Oncology, Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada. 2Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada. 3Department of Medicine, University of Toronto, Toronto, ON, Canada.


Abstract
The incidence of small renal masses (SRMs) has risen steadily over time, and SRMs now represent the majority of newly diagnosed renal lesions. Approximately 80% of newly diagnosed SRMs will be malignant. However, identifying a benign versus malignant lesion non-invasively can be difficult since no distinct imaging characteristics or growth patterns exist between the two. We have witnessed concurrent improvements in treatment strategies for small, localized tumors and have gained a better understanding of their natural history. Along with these changes there has been a shift in the manner in which we diagnose and treat SRMs. Although surgery remains the standard of care, we can now offer a variety of therapies individualized to the patient.
Keywords: kidney cancer, small renal mass, diagnosis, treatment.

A Persistent Lesion on the Chest

A Persistent Lesion on the Chest

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

www.cfpc.ca/Mainpro_M2
Teaser: 

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
Granuloma annulare (GA) is a benign and usually self-limited cutaneous condition that classically presents as arciform to annular plaques in a symmetrical and acral distribution. The exact etiology of GA is unknown. Two-thirds of patients with GA are less than 30 years old. GA is recognized based on its characteristic appearance and no specific investigation is necessary. Reassurance and clinical observation may be the treatment of choice for localized and asymptomatic disease. Spontaneous resolution occurs within 2 years in 50% of cases. Persistent lesions may be treated with very potent topical corticosteroids, intralesional corticosteroid injections, or cryotherapy. Use of more toxic treatments are controversial in recalcitrant cases.
Keywords: Granuloma annulare, Overview, Paraneoplastic, Self-limiting, Treatment.