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A Few Degrees of Separation

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I have often talked about how important stories are when it comes to medical care. We must, of course, use the best available medical knowledge to benefit our patients, but I believe it is also important to find the humanistic aspects of care and build on them, in order to foster human relationships.The importance of learning the patient’s personal story is key to achieving this goal.

Instead of asking a new patient, “How are you?” I recommend asking, “Who are you?”—meaning, “What is your story?” Recently, before meeting a new patient, I tried to see if his name would tell me anything about who he is. Having spent many years travelling, I can often relate to people if I get a clue as to their background or nationality—which, for people with European backgrounds, is reasonably easy for me at this point in my career.

I looked at his name and could not be sure of his origins, but I thought it might be close to Greek, or at least Mediterranean. To my surprise, his wife, who appeared initially to be more outspoken, said, “we are Egyptian.” With my knowledge of Egypt, I felt comfortable enough to ask, “Are you Coptic or Jewish? The name does not appear Muslim.” The patient seemed surprised that I actually knew about the various ethnic groups in Egypt. I told him that I had lived in Israel for a number of years, so knowing about Egypt was important for many reasons.

Their eyes lit up and he said, “We are Egyptian Jews.” After I inquired further, they said that they left the country just as Gamal Abdel Nasser came to power in the 1950s and began expelling most of the country’s remaining Jewish population.

“There are only few remaining Jews in Cairo, with members of one family being responsible for maintaining the main synagogue. We knew the family, the name of which is Haroun, and the elder sister died recently so the younger one is the primary caretaker of the synagogue, along with a half a dozen or so other Jewish women—there are no Jewish men left in Cairo,” he said.

When I mentioned that some of my friends and colleagues are Coptic, he said that they were very close to the Coptic community, both being minorities and beleaguered communities in a predominately Muslim country, but had managed well for centuries, prior to the explosion of pan-Arabic nationalism.

When I retold this fascinating story to one of my Coptic medical colleagues, she said she would mention the story to her parents, without naming my patient, but but would inquire about the Haroun family.

The next morning, I received a text saying that her mother knew the Haroun family and went to school with the remaining sister. As it turns out, Magda Haroun is still involved in keeping the local synagogue active (an interview with her, titled Closing the door: the last Jews of Cairo, can be found on YouTube).

When I mentioned the follow-up to the story to one of my Coptic friends, he mentioned that he too knew the family and told me that there are in fact eight remaining Jewish women in Cairo and that Magda Haroun is the community leader.

The story reminded me that there are often only a few degrees of separation between us, and that a little searching can bring out wonderful stories (elders are often the repository of such stories). We must find these stories whenever we can, as they are our collective human legacy.

This article was originally published online at http://www.cjnews.com/

Five Dermatologic Diagnoses at Your Fingertips

Teaser: 

Rebeca Pinca, MD,1 Joseph M. Lam, MD, FRCPC,2

1Department of Dermatology & Skin Science, University of British Columbia, BC.
2Clinical Assistant Professor, Department of Pediatrics and Dermatology, University of British Columbia, BC.

CLINICAL TOOLS

Abstract: Dermatology is a visual specialty, yet palpation can also play an important diagnostic role. We present five dermatologic diagnoses that can be made at point of care by palpation or physical manoeuvres, potentially reducing unnecessary investigations, such as biopsies.
Key Words: Dermatofibromas, pilomatricomas, mastocytomas, spider angiomas, terra firma-forme dermatitis.
Dermatofibromas and pilomatricomas are benign papulonodular lesions that can be differentiated by the dimple sign, and the teeter-totter sign or tent sign, respectively.
Solitary mastocytomas can be diagnosed by Darier sign, whereby rubbing of the lesion causes a wheal and pruritus.
Spider angiomas can be diagnosed by diascopy, which involves the application of gentle downward pressure with a glass slide on the skin, resulting in blanching of the telangiectasia.
Terra firma-forme dermatitis is a benign discoloration that can be diagnosed, and treated, by gentle rubbing with isopropyl alcohol.
These dermatologic physical examination manoeuvres are quick, cost-effective, point-of-care diagnostic tools.
If in doubt, do not hesitate to biopsy lesions that appear suspicious.
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JCCC 2017 Issue 2

Table of Contents

Clinical Management of Disorders of Sex Development

Teaser: 

Danielle Wang BA,1 Leanna W. Mah MD,2 Jennifer H. Yang MD,3

1,2University of California, Davis, Department of Urology, Sacramento, CA,
3Associate Professor, University of California, Davis, Department of Urology and Division of Pediatric Urology, Sacramento, CA.

CLINICAL TOOLS

Abstract: Disorders of sex development (DSD) is an umbrella term for congenital conditions in which anatomic, gonadal, or chromosomal sex is atypical. DSD is found in 7.5% of all births defects and 1 in 5,000 babies born worldwide have significant ambiguous genitalia. Best practices involve multidisciplinary teams, informed consent and shared decision-making with the patient and family. As a group, DSD patients are rare and therefore clinically challenging. Primary care providers, family medicine physicians, and pediatricians are the foundation for patients' medical care and therefore play a key role in the initial diagnosis, guidance, coordination of care, and long-term management.
Key Words:Disorders of sex development, intersex, gender identity, sex differentiation, ambiguous genitalia.

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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The most common causes of DSD are congenital adrenal hyperplasia (CAH) and mixed gonadal dysgenesis, constituting approximately half of all DSD cases discovered in newborns.
Initial evaluation of DSD should include a thorough history, physical exam that includes assessment of genital anatomy, evaluation of sex chromosomes using karyotype and fluorescence in situ hybridization, and assessment of internal organs by abdominopelvic ultrasonography.
The three classifications within DSD are 46, XX DSD (disorders of gonadal or ovarian development and androgen excess), 46, XY DSD (disorders of gonadal or testicular development and impaired androgen synthesis or action), and chromosomal DSD (numeric sex chromosome anomalies).
Overlooked DSD diagnosis can have the fatal consequence of adrenal crisis due to CAH; phenotypic males with CAH do not present with ambiguous genitalia and therefore adrenal crisis may go undetected at birth.
Physical exam findings that should prompt a DSD workup in neonates include bilateral non-palpable testes, hypospadias in combination with a unilateral undescended testis or non-palpable testes, clitoral hypertrophy, foreshortened vulva with a single urogenital tract opening, and an inguinal hernia with a palpable gonad in a phenotypic female infant.
Initiating the connection to other patients or families and recommending support groups can alleviate isolation, normalize a DSD diagnosis, and encourage positive adaptation.
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A Spinal Control Approach to Back Pain for the Primary Care Provider

Teaser: 

Kristen H. Beange BASc,1 Tianna H. Beharriell BHK,2 Eugene K. Wai MD, MSc, FRCSC,3 Ryan B. Graham MSc, PhD,4

1School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada.
2School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada.
3Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
4School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada.

CLINICAL TOOLS

Abstract: Impaired neuromuscular control of the spine is widely recognized as an important factor in the development of low back pain (LBP). In this review, we summarize contemporary approaches for the assessment of spinal control variables such as stability, stiffness, coordination, and kinematics as well as the most current definitions within the LBP community. We discuss how these assessments can be incorporated into primary clinical care to improve diagnosis and treatment effectiveness.
Key Words: spinal control, low back pain, kinematics, stability, wearables.

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.

1. Classification of low back pain (LBP) should continue to be refined to prognosticate and guide treatment.
2. The spinal control model is based on the interaction of the passive (osteoligamentous), active (muscular), and neural feedback subsystems.
3. The spinal control model can be used as a basis to further refine classification and treatment of LBP. Technological advances allows for the development of better kinematic assessments of these subsystems and possible incorporation into clinical care.
1. Identification of specific subgroups of LBP and directing specific treatments has been identified as a future for research and management.
2. The Clinically Organized Relevant Exam (CORE) Back Tool incorporates the identification of patterns of pain based on back or leg dominant, and flexion or extension mediated pain.
3. Spinal fusion for treatment of back dominant LBP (without spondylolisthesis) is not supported by clinical practice guidelines.
4. Within the spinal control model, treatment of LBP should focus on the identification of deficiency in the active (muscular) and neural feedback subsystems and on treatment with spinal muscular strengthening and motor control exercises.
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.