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Key and Current Issues in the Management of Insomnia

Teaser: 

Louis T. van Zyl, MD, M.Med.,1 Colin Shapiro, B.Sc. (Hon.), MB, BCh, PhD,2 Dora Zalai, MD, PhD,3

1Professor of Psychiatry (Emeritus), Queen's University, Canada. 2Professor of Psychiatry and Ophthalmology (Emeritus) University of Toronto, Canada Director of the Youthdale Child & Adolescent Sleep Clinic and International Sleep Clinic Parry Sound Toronto, Canada. 3Clinical Psychologist, Sleep on the Bay, Toronto, Canada.

CLINICAL TOOLS

Abstract: There is increasing appreciation of the relevance of sleep to general well-being, especially for those with medical—including psychiatric—illnesses. This growing recognition of the relevance of sleep is reflected in the DSM-V guidelines. We endeavor to present a nuanced understanding and usage of sedative hypnotic medications in the management of insomnia. New medications that reduce wakefulness is also mapped out in this overview. In addition, we briefly discuss the intervention of cognitive behavior therapy for insomnia (CBT-I) as the mainstay of treatment for chronic insomnia.
Key Words: sleep disorders, insomnia, management, treatment.
Insomnia is a sleep disorder in its own right. It is no longer regarded as just a symptom. It calls for specific, targeted insomnia treatment, especially in situations where insomnia is comorbid with medical conditions.
Cognitive behavioural therapy for insomnia (CBT-I) produces moderate to large effects on insomnia measures when insomnia is comorbid with chronic medical conditions. It is the mainstay of treatment in most cases of chronic insomnia.
The use of hypnotics should be planned strategically. In general, short term hypnotic use should be the objective, but for many patients long term use may be necessary and appropriate.
The initial dose of sedative-hypnotics should be determined on an individual basis and titrated in accordance with the patients' needs. While too high dose is not desirable, too low a dose would result in under-treatment and is counter-productive.
Insomnia may become a chronic disorder and as such may necessitate long-term management. Prescribe carefully-chosen hypnotics for the requisite period and re-evaluate patients in follow up. Consider CBI-I as a treatment option, independently or in conjunction with pharmacotherapy.
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Related Terms: Mental Health, sleep disorders, insomnia, management, treatment
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Principles of Geriatric Palliative Care

Teaser: 

Albert J. Kirshen, MD, FRCPC,

(Internal, Geriatric, Palliative Medicine), Emeritus Associate Professor, Dept. of Family and Community Medicine, Faculty of Medicine, University of Toronto, formerly consultant palliative care physician, The Temmy Latner Centre for Palliative Care, Interdepartmental Division of Palliative Care, Sinai Health System, Toronto, ON.

CLINICAL TOOLS

Abstract: Palliative care aims to relieve suffering and enhance the quality of life for those with chronic, progressive or life-threatening illnesses. However, seniors' palliative care needs are often poorly recognized, assessed, or managed, resulting in adverse outcomes. This article explores the importance of recognizing, assessing, and managing symptoms for older adults needing palliative care. It offers insights into how physicians and healthcare providers can improve the quality of life for seniors by addressing their pain and symptom management needs.
Key Words: palliative care, symptom management, older adults, geriatrics, pain management, quality of life, recognition, assessment.
Palliative care aims to improve the quality of life for seniors with chronic, progressive or life-threatening illnesses.
Healthcare providers need to tailor symptom management to the unique characteristics of older adults, including cognitive and sensory impairments.
Recognition, assessment, and management of symptoms are critical components of palliative care.
A comprehensive approach that includes communication, pharmacological and non-pharmacological interventions can improve the quality of life for seniors in need of palliative care.
Communication with patients, caregivers, and other healthcare professionals is key to recognizing seniors’ palliative care needs.
Assessment of seniors’ symptoms should be tailored to their unique characteristics, including cognitive and sensory impairments.
A comprehensive approach that includes pharmacological and non-pharmacological interventions is essential for optimal symptom management in seniors.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Caregiving, palliative care, symptoms, management, older adults, geriatric, pain management, quality of life, recognition, assessment

Pregnancy-Related Back Pain: When Should I Worry?

Teaser: 

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. She is appointed at the University of Toronto, Department of Family and Community Medicine as an Associate Clinical Professor.

CLINICAL TOOLS

Abstract: Clinicians are often unsure if back pain during pregnancy is due to a musculoskeletal condition, an abnormality with the pregnancy or merely part of the common discomforts associated with gestational changes. Low back pain guidelines do not include pregnant women in their criteria and there have been no randomized clinical trials to determine specific causes of low back pain during pregnancy. This article will provide the clinician with a framework for identifying pregnancy-related back pain using a high yield history and key physical examination techniques to differentiate between mechanical back pain, sacroiliac instability and symphysis pubis separation. Risk factors for low back pain and warning signs for pregnancy complications will be identified. Appropriate management strategies will be provided for the management of pregnancy-related low back pain.
Key Words: pregnancy-related low back pain, pregnancy, pelvic pain, physical examination, management.

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.

Pre-test CME Quiz Post-test CME Quiz
1. Probable Risk Factors for Low Back pain during pregnancy include: • Pre-pregnancy and past pregnancy low back pain • Low Back and Pelvic Trauma • Poor general physical condition • Joint Hypermobility • Increase body weight
2. Pregnancy related low back or pelvic pain is defined as intermittent or constant pain in the lumbar, buttock, pelvis, groin and/or upper thigh area lasting for more than one week.
3. Exercise, education and postural advice are the mainstays of treatment and can be enhanced by short term therapy with a rehabilitation professional.
1. Patients who have low back pain, in any trimester, associated with vaginal bleeding, uterine contractions, fever or hematuria should be immediately referred for obstetrical consultation.
2. The three most common causes of low back pain in pregnancy are mechanical low back strain, sacroiliac instability and symphysis pubis separation; they often occur together.1,2
3. Patient with Symphysis Pubis Dysfunction complain of significant pain during most of these activities: • Walking • Climbing Stairs • Turning in Bed • Standing on one Leg • Rising from a Chair
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Related Terms: Back Health, pregnancy-related low back pain, pregnancy, pelvic pain, physical examination, management
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What is Pediatric Alopecia Areata?

Teaser: 

Kailie Luan,1 Joseph M. Lam, MD, FRCPC,2

1Faculty of Medicine, University of Alberta, Edmonton, AB.
2Clinical Assistant Professor, Department of Pediatrics and Dermatology, University of British Columbia, BC.

CLINICAL TOOLS

Abstract: Alopecia areata is a chronic immune-mediated disorder that causes nonscarring hair loss. Although most commonly causing discrete hair loss on the scalp, the condition can affect any hair bearing area of the body and cause significant emotional and psychosocial distress. While intralesional glucocorticoids are often used as initial treatment for adults with the condition, therapeutic options for children are more limited with concerns of treatment tolerability and potential side effects. This article aims to provide an overview of alopecia areata with particular focus on managing this chronic condition in children.
Key Words: Alopecia areata, clinical presentation, diagnosis, management, pediatrics.
Alopecia areata is a chronic relapsing disorder characterized by non scarring hair loss that can affect any hair-bearing area of the body
While intralesional glucocorticoids are often used as initial treatment for adults, potent topical corticosteroids are effective as first line therapy in children due to better treatment tolerability
The diagnosis is generally made on clinical grounds with the majority of patients presenting with limited patchy disease affecting the scalp
In cases of inadequate response, topical minoxidil or immunotherapy are additional options, with systemic corticosteroids and immunosuppressive agents reserved for refractory cases, and IL-2 and JAK inhibitors as new emerging therapies for AA
Not all patients with alopecia areata require treatment as up to 50 percent of patients with limited alopecia areata will experience spontaneous regrowth of hair.4
Due to the benign nature of alopecia areata, and spontaneous remission is common, watchful waiting is considered a reasonable option in cases of limited disease.
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Related Terms: Dermatology, Alopecia areata, clinical presentation, diagnosis, management, pediatrics
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Insufficiency Fractures of the Femur and Sacrum

Teaser: 

Dr. M.S. Alam, MD, MBBS, CCFP, FCFP

Clinical Lecturer, Cumming School of Medicine, Calgary, University of Calgary, Family Medicine Department, Calgary, AB.

CLINICAL TOOLS

Abstract: Insufficiency Fractures (I.F) are non-traumatic fractures that occur in abnormal bone (low density bone). Usually occurs in elderly post-menopausal women and is non-traumatic. X-rays are unremarkable and MRI showed extensive bone marrow oedema and subchondral fracture.
Ms. Shirley Cooke, a 61 year old with a background of low bone mass, breast cancer, Diabetes Melitis type 2, HTN, splenic artery thrombosis came in with a dull pain on her left knee and occasionally some sharp element, with unremarkable examination on knees.
Recently, she was diagnosed with left ankle avulsion fracture of lateral maleolus and is wearing an ankle boot for healing.
It is important to make the correct diagnosis in order to avoid complications."
Key Words: Insufficiency Fracture (I.F), low bone mass, management.
1. With regard to I.F of femoral Condyle—Although the knee symptoms will always be unilateral, on the side of the meniscal tear, and are more frequent in older woman, the pain of an insufficiency fracture can easily be confused with that of other joint pathologies and therefore be easily missed.2
2. With regard to I.F of Femoral Neck—This fracture is seen in the elderly osteoporotic patient, often following a trivial event such as a slip without a fall. The resultant boney defect may be a compression fracture, which is inherently stable, or a transverse fracture, more common in older patients and is potentially much more serious.
3. With regard to I.F of Sacrum—The possibility of an insufficiency fracture should be considered in elderly osteoporotic patients, particularly women, following evenly seeming innocuous trauma to the posterior pelvis who exhibit constant buttock pain which may radiate to the thigh or groin and is unaffected by spinal movement.
MRI is the gold standard for Dx. I.F.
Symptoms and conventional tests may not be helpful, High Index of suspicious is needed.
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Related Terms: Women’s Health, Insufficiency Fracture, low bone mass, management
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The Need for Obstructive Sleep Apnea Screening: A Wake-Up Call to Physicians

Teaser: 

Sharon A. Chung, PhD1and Colin M. Shapiro, MBBCh, PhD, MRCPsych, FRCP(C)1-3

1Youthdale Treatment Centres, Toronto, Ontario, Canada. 2International Sleep Clinic, Parry Sound, Canada and the 3University of Toronto, Department of Psychiatry, Canada.

CLINICAL TOOLS

Abstract: Obstructive Sleep Apnea (OSA), where patients stop breathing numerous times during sleep, is a disorder linked to serious medical, socioeconomic, and psychological morbidity, yet most patients with OSA remain undetected. Physicians should consider symptoms of frequent/loud snoring, complaints of daytime sleepiness or fatigue, high blood pressure and obesity or excessive body fat distribution in the neck or upper chest area as possible indications of untreated OSA.
Key Words: obstructive sleep apnea, screening, management.
Untreated OSA is associated with significant morbidity and mortality and results in increased healthcare utilization.
OSA is more prevalent in individuals with a chronic medical illness.
Almost 90% of individuals with OSA remain undiagnosed.
Treatment of OSA improves medical outcome; this is particularly relevant in medically ill patients.
Evidence-based medicine supports screening for OSA as part of routine clinical care.
Newer technology allows doctors to 'skip the waiting line' and obtain quick and accurate sleep testing for their patients.
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Related Terms: obstructive sleep apnea, screening, management
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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.

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.

Pre-test CME Quiz Post-test CME Quiz
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.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Men’s Health, Women’s Health, erectile dysfunction, diagnosis, management, treatment

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.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Dermatology, median raphe cysts, congenital lesions, treatment, management

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.

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.

Pre-test CME Quiz Post-test CME Quiz
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.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Gender & Health, Men’s Health, benign prostatic hyperplasia, management, treatment, referral

CORE BACK TOOL 2016: New and Improved!

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

Mainpro+® Overview
Pre-test CME Quiz Post-test CME Quiz
Teaser: 

Dr. Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,1 Yoga Raja Rampersaud, MD, FRCSC,2 Jess Rogers3Dr. Hamilton Hall, MD, FRCSC,4

1 is a Family Physician practising Sport and Exercise Medicine at the Toronto Rehabilitation Institute, University Health Network. She is appointed at the University of Toronto, Department of Family and Community Medicine as an Associate Clinical Professor.
2Associate Professor Department of Surgery, University of Toronto, Divisions of Orthopaedic and Neurosurgery, University Health Network Medical Director, Back and Neck Specialty Program, Altum Health, Past President Canadian Spine Society, Toronto, ON.
3 is the Director at the Centre for Effective Practice (CEP). Jess' role includes developing evidence-based clinical guidance for providers. Jess was the Project Lead in executing the primary care provider education component of Ontario's Low Back Pain initiative including the CORE Back Tool. CEP is pleased to have funded the update of the CORE Back Tool 2016 to continue supporting primary care providers.
4 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: Through the redesign of the already successful Clinically Organized Relevant Exam (CORE) Back Tool, primary care clinicians now have a more comprehensive, user-friendly approach to clinical decision making for patients presenting with low back pain. The key components of the tool include a high yield history connected to mechanical low back pain patterns, embedded key patient messages, clear listing of appropriate radiological indications, criteria for consultant referrals as well as a management matrix geared to office practice. A clinical case will be used to demonstrate the application of the tool to practice and instruct the reader on the key features.
Key Words: Low Back Pain, Tool, Primary Care Providers, Management.

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.

Pre-test CME Quiz Post-test CME Quiz
1. Mechanical Patterns are a logical way to conceptualize, assess and manage low back pain.
2. If pain does not fit a mechanical pattern, the patient may have non-spine referred pain from organs or a chronic pain disorder.
3. Radicular (nerve) pain will have a positive straight leg raise (SLR) with reproduction of the typical leg dominant pain and possible abnormal neurological signs.
Initial patient management should include goals of reducing pain and increasing activity.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Back Health, low back pain, tool, primary care providers, management