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Lessons to be Learned from History and the Perspective of Grandparents and Vaccination of Children

Lessons to be Learned from History and the Perspective of Grandparents and Vaccination of Children

Teaser: 

Michael Gordon, MD, MSc, FRCPC,

Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Abstract: The progress of medicine over previous decades includes benefits in the world of vaccination against especially childhood disease. It is therefore surprising to witness the growing and vociferous opposition to childhood vaccination, especially for measles. This poses substantial personal and public health risks. It is important to understand the reasons that anti-vaccination sentiment has taken hold among many often highly educated parents.
Key Words: Vaccination, anti-vaxxers, polio, measles vaccine.
The public are not always convinced by the best of medical evidence.
Medicine is always evolving—the public does not always understand the process.
The history of vaccination is long with many great heroes some of whom were not medical or scientific professionals.
Trying to convince people who believe vaccination causes childhood diseases may not respond to more and more evidence as their belief is almost religious in nature.
Sometimes it is the perspective of those old enough to remember the scourge of childhood infectious illnesses who can play a role in helping their children who may oppose vaccination come to their parental senses.
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Related Terms: Dementia, vaccination, anti-vaxxers, polio, measles vaccine

Managing Adolescent Idiopathic Scoliosis (AIS) in Primary Care

Managing Adolescent Idiopathic Scoliosis (AIS) in Primary Care

Teaser: 

Paul J. Moroz, MD, MSc, FRCSC,1 Jessica Romeo, RN (EC), MN, BScN,2Marcel Abouassaly, MD, FRCSC,3

1Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario.
2Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario.
3Fellow in Pediatric Orthopedic Surgery at the Children's Hospital of Eastern Ontario, Ottawa, Ontario.

CLINICAL TOOLS

Abstract: Adolescent Idiopathic Scoliosis (AIS) is a condition requiring early detection for appropriate management. Bracing can be effective in preventing curve progression so failing to detect a small AIS curve in a growing child could result in losing the opportunity to avoid a major surgical procedure. Doubts about cost-effectiveness have ended most school screening programs and assessment is now provided mainly by primary care providers. The ability to conduct a quick effective scoliosis examination is important for the busy practitioner. This article illustrates the main features of the screening test, offers guides for imaging, and outlines appropriate tips for specialist referral.
Key Words: Adolescent Idiopathic Scoliosis (AIS), diagnosis, physical exam, Adams Forward Bend Test, primary care.

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. This can be done with a patient's gown open or closed at the back.
2. The measurement is performed with the examiner sitting and observing the patient from behind. It can be done at the same time as the AFBT, since the examiner is in the same position.
3. With the patient standing erect in bare feet and with the knees extended, the examiner rests his/her hands on top of the iliac crests with fingers extended and palms parallel to the floor. With both the patient's feet flat on the floor, the relative levels of the hands give a surprisingly sensitive estimate of significant LLD (Figure 2).
4. There are alternative methods to measure leg lengths with the patient supine by using a tape measure. These techniques require familiarity with pelvic and ankle landmarks, are time consuming and are remarkably prone to measurement errors.
IMAGING FOR SUSPECTED SPINAL DEFORMITY
1. Radiation exposure using modern radiographic techniques, including digital radiography, is significantly lower than in the past.5
2. Radiologists' reports may use terms related to the spine that can be misleading and worrisome. Cobb angles less than 10 degrees should not be described as scoliosis but rather as "spinal asymmetry" since the term "scoliosis" may prompt an unnecessary referral to a specialist.
3. If imaging is indicated, it is best done at a centre where the patient will be seen in consultation. Radiologists at these centres have the experience to accurately interpret imaging results and correctly report spinal deformity. This also avoids the unfortunate situation where inadequate imaging done elsewhere must be repeated at the referral centre, significantly increasing the patient's radiation dose.
4. Never order a "scoliosis series". It is an obsolete term that referred to pre-operative assessment films. It is still found on some x-ray requisition forms and may be ordered in a misguided attempt to provide the surgeon with as much information as possible. Since the vast majority of patients seen by the spine surgeon will not require surgery, this option is needlessly expensive and the added radiation may be harmful to the patient.
5. The authors allow patients to take smart phone or tablet images of their own spinal x-rays. This engages the patient and their parents or guardians in the management. Take account of all regulatory and privacy issues regarding patient's recording of even their own images.
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Related Terms: Back Health, Adolescent Idiopathic Scoliosis, diagnosis, physical exam, Adams Forward Bend Test, primary care

Diagnosis and Management of Cervical Myelopathy

Teaser: 

Sean Christie, MD, MSc, FRCSC,1 Aaron S. Robichaud, MD,2

1Associate Professor, Department of Surgery (Neurosurgery), Department of Medical Neurosciences, Dalhousie University, Halifax, Nova Scotia.
2Clinical Fellow, Department of Surgery (Neurosurgery), Department of Medical Neurosciences, Dalhousie University, Halifax, Nova Scotia.

CLINICAL TOOLS

Abstract: Cervical myelopathy is a degenerative disease that occurs secondary to direct spinal cord compression and compromise of spinal vasculature through a process of gradual spinal canal narrowing. Patients generally present with signs and symptoms of long tract compromise. Once myelopathy is suspected on clinical grounds, MRI is the test of choice to confirm canal stenosis and cord injury. Treatment involves surgical decompression, anteriorly and/or posteriorly of the spinal. Despite optimal management in this patient population, outcomes may be poor and are usually limited to halting progression of the disease rather than relieving deficits already present.
Key Words: Cervical myelopathy, cervical stenosis, degenerative spine disease, spondylosis.

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
Cervical spondylotic myelopathy is a degenerative disease that results from compression of the spinal cord with subsequent cord injury and impaired conduction along the tracts contained within it.
Myelopathy is a clinical diagnosis based on signs and symptoms of spinal cord dysfunction and should not be used to refer to isolated imaging findings of spinal cord degeneration or stenosis.
MRI is the most sensitive test to identify cervical canal stenosis and injury to the cord and should be arranged when myelopathy is found on clinical evaluation to identify a specific diagnosis and guide management.
Surgical decompression can prevent progression of cervical spondylotic myelopathy, and in some patients improve gait and hand function.
Cervical myelopathy can be differentiated from radiculopathy on clinical exam by the presence of upper motor neuron signs as a result of injury to the spinal cord, which will be absent in radiculopathy.
MRI is helpful in working up cervical spondylotic myelopathy as it allows visualization of the elements causing compression, provides an estimate of the extent of stenosis through loss of CSF space surrounding the cord, and allows identification of cord injury manifest as hyperintense signal change in the cord on T2 weighted imaging.
Patients with symptomatic cervical myelopathy should be referred to a spine surgeon for evaluation and management.
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Related Terms: Back Health, Cervical myelopathy, cervical stenosis, degenerative spine disease, spondylosis

Non-Muscle-Invasive Bladder Cancer: Review of Diagnosis and Management

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.

Pre-test CME Quiz Post-test CME Quiz
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.
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: Cancer, bladder cancer, diagnosis, treatment, non-muscle-invasive