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Beyond Rasouli: What has the Supreme Court said about Late-Stage Dementia and Continued Life-maintaining Treatment?

Beyond Rasouli: What has the Supreme Court said about Late-Stage Dementia and Continued Life-maintaining Treatment?

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
With the rapidly increasing numbers of elders in North American Society, the prevalence of those living with dementia is clearly on the increase. According to the most recent document provided by the Alzheimer Society of Canada, The Rising Tide the growth in the numbers of those living with dementia will increase from 480,600 in 2008 (1.5% of Canada's population) to in the year 2038—1,125,200 people with dementia (2.8% of Canada's population).1 All the challenges that Canadian society faces with this growing population merely mirror the enormous complexities that those living with dementia, their families and health care professional providers must increasingly contend with. Government policy makers must find ways to address this increasing population in which Dementia plays a prominent role. The result of the Supreme Court ruling on the Rasouli case has major potential implication for those facing the later stages of dementia and those under whose care members of this population will be entrusted.
Key Words: dementia, aging population, substitute decision makers.

Discolouration of the Tongue

Discolouration of the Tongue

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: 

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
Hairy tongue, or known as lingua villosa, is a result of hypertrophy, elongation, and defective desquamation of the filiform papillae of the tongue. This condition may present in a variety of colors depending on the specific etiology. Etiologies of hairy tongue include poor oral hygiene, lack of mechanical stimulation and debridement of the tongue, the use of medications (especially broad-spectrum antibiotics), and therapeutic radiation of the head and the neck. This condition is also commonly seen in people having high consumption in coffee and tea, heavy use of tobacco, individuals addicted to drugs, patients who are HIV positive, and intravenous drug users. In most cases, non-pharmacologic interventions are used for the management of hairy tongue. Treatment involves brushing the tongue with a toothbrush or using a commercially available tongue scraper to retard the growth or to remove elongated filiform papillae. If Candida albicans is present, topical antifungal medications are used for patients who are symptomatic.
Key Words:
Hairy tongue, Lingua villosa, Glossopyrosis, Halitosis.

Post-test: Hairy tongue

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

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Treatment of a Patient with HBeAg-negative Chronic Hepatitis B

Treatment of a Patient with HBeAg-negative Chronic Hepatitis B

Teaser: 

Ian PUN, MD, Family Physician, Scarborough, Ontario with help from Anthony Vu, 4th Year student, University of Toronto undergraduate life science, Rob Myers, MD, Associate Professor of Medicine, Hepatologist, and Director of the Viral Hepatitis Clinic at the University of Calgary, Calgary, AB.

Abstract
It is estimated that there are 350 million world wide carriers of the hepatitis B virus, mostly coming from Asia (Lai et al., 2005). With immigration of Chinese into Western countries, hepatitis B is now becoming established in countries where it was previously uncommon. Chronic hepatitis B infection is a prevalent disease especially in the Toronto and Vancouver areas where most Asians live. Fortunately, over the past decade effective anti-viral treatments have become available. Chronic hepatitis B is mostly an asymptomatic disease, therefore, serological and imaging tests should be used to identify, follow and treat those considered high risk.
Key Words: HBV DNA (hepatitis B DNA), cirrhosis, anti-viral tenofovir, FibroScan.

Clinico-Pathological Quiz

Clinico-Pathological Quiz

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, DLO, FRCS, FACS, is the ENT service chief, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada.
Dr. Lyew Warren, MD, FRCSC, Consultant Pathologist, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada.

Abstract
A case of a fleshy, granular, pedunculated growth from the oral cavity will be presented. A differential diagnosis of similar growths from the oral cavity and the treatment options will be discussed.
Key Words: congenital epulis, epulis fissuratum, granular cell tumour, immunohistochemistry S-100, vimentin, neurone specific enolase, CO2 laser excision.

Music and Movement....Disorders

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When one thinks of music and movement, the natural association is dance. In all parts of the world and in all cultures, there is some musical expression through dance, ranging from what may appear to be relatively simple rhythmic movements to compelling drum beats to complex ballets with narratives and dozens if not more dancers doing intricate steps to full blown orchestras. Anyone that has raised children recalls how even very young children, will move and shake to rhythmic music and the massive industry in all western countries of dance lessons starting with child students attests to its natural attraction and ability to fulfill what appears to be an intrinsic human desire.

I recall as a child being taken to ballet, modern dance, musicals with dance and even the renowned Rockets at the Radio City Music Hall by my mother who herself had been a serious amateur dancer in her youth and then a lifelong ball-room and late-life folk dancer with her seniors' centre on West End Avenue in Brooklyn. There was even a period of my pre-teen years when my mother attempted to teach me ballet steps at home which very soon was transposed into my desire to learn to dance to Rock and Roll, using my sister four years my junior as my every accommodating dance partner. Even many years after, in our mature and pre-senior years, at family celebrations we often could still do a dance number to something of the order of Rock Around the Clock or the theme song for Saturday Night Fever. She has continued to engage with multi- cultural folk dancing whereas I have slowed down considerably in my abilities to participate although I enjoy watching others, dance especially my children and more recently my granddaughters.

The general assumption probably held by most individuals that with physical and especially neurological disability, the ability to engage or think about participating in dance would likely naturally diminish. For people living with conditions that impose physical challenges to free and fluid movements, the idea of dancing is more often a dream than a reality. It is likely that it would not even enter the consciousness of most people with neurological disorders, especially those like Parkinson's Disease might be able to participate in, respond to and benefit from music, especially when it is within a framework of dance.

With this in mind the recent article in October 25th issue of The Globe and Mail, by Gayle MacDonald, "Unlocking the secret of Dance" was exhilarating and inspiring. In a partnership with the world-renowned Canada's National Ballet School, with the collaboration and influence of some its most prominent members and in a cooperative effort with among others Toronto's York University and my own Baycrest Geriatric Health Care System, it is hoped that in addition to the great joy satisfaction that all the participants appear to be getting from the program, scientific research studies will demonstrate the mechanism of responsiveness and hopefully clinical improvement.

Dance appears to provide a number of benefits to those living with Parkinson's disease which affects seven million people world-wide including approximately 100,000 in Canada and a million people in the United States. It has been established that dance improves characteristics like balance, gait, posture and other physical measurements beyond the social joy and satisfaction from what is in essence a group and social undertaking. Studies are underway to try and determine what the dance does to the brain and the mechanisms by which improvements may occur and whether or not they are sustainable and may be an important adjunct to commonly used medication therapies that are not without their problems.

It has been well known for many years that those living with Parkinsonism can improve their gait by listening to rhythmic marching-type music and some have learned to use ear-phone-directed march music from iPods and other similar devices to provide the compelling rhythmic background to assist in their walking. (Neuroscience and Biobehavioral Reviews: Into the groove; Can rhythm influence Parkinson's disease? Cristina Nombela, Laura E. Hughes, Adrian M. Owen, Jessica A. Grahn, 2013. http://www.ncbi.nlm.nih.gov) In my own practice I have often taken my patients with such movement disorders and while walking with them up the corridor outside my office I hum loudly a well-known John Philip Sousa March, The Stars and Stripes Forever which most people recognize. Quite a lot of the patients and the family are amazed how all of a sudden the person who had been struggling with gait and speed would be walking alongside me to the loudly hummed musical refrain. If the result is good I instruct the person or family member to get some recordings of such marches or others if they are ones that resonate and put them on an iPod type device and place the march when the person wants to go for an enjoyable walk, for the purposes of actual exercise, or as one might in a garden or along a neighbourhood street.

If this Parkinson's ballet dance project proves successful it may result in a wide range of programs that bring dance and music to many individuals living with Parkinson's disease and provide a creative and satisfying and in many ways liberating enterprise for them.