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Cannabinoids and Low Back Pain

Teaser: 

Ted Findlay, DO, CCFP, FCFP

is on Medical Staff with the Calgary Chronic Pain Centre at Alberta Health Services, Calgary Zone in Calgary, Alberta.

CLINICAL TOOLS

Abstract:There is a great deal of interest in the use of cannabis-based products including medically authorized marijuana for the treatment of almost any pain condition including low back pain. There are many anecdotal reports of patients who found it an effective treatment for chronic low back pain, one that has allowed them in some cases to discontinue other treatments such as continuing opioid therapy. There is now easy legal access to cannabis-based preparations in Canada with or without medical authorization. However, with some notable exceptions, the evidence that would allow physicians to have a high degree of confidence in selecting this treatment modality is lacking.
Key Words: cannabis; chronic pain; low back pain; evidence.

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1. Compared to medically authorized cannabis, street sourced products are at high risk of contamination including insect remains, fungi, chemical fertilizers and herbicides.
2. Unlike most plant-sourced medications, the active ingredients are located on the cannabis leaf, which raises the risk of contaminant exposure.
3. Cannabis leaves by themselves are inert until heated in a process known as decarboxylation.
4. While inhaled cannabis has a rapid onset of action, ingested products have a delayed onset producing a risk of overdose if continuing to consume while waiting for an expected effect.
5. Little is yet known about potential drug interactions with cannabis use.
Cannabis authorizing physicians will often recommend a higher THC:CBD ratio product for evening or bedtime use, and a higher CBD:THC ratio or pure CBD for daytime use.
As is true for any potential intoxicant, patients need to be cautioned about the risks of operating a motor vehicle or any machinery while under the influence of cannabinoids, especially higher THC ratio products.
Because it is a lipid soluble chemical, urine, blood, or hair tests can detect THC for many days after use. Standardized tools and principles exist for the appraisal of credible eHealth resources.
Physicians in Canada provide medical "authorization" for cannabis use, verifying that the patient has a medical condition for which cannabis could be a valid therapeutic option. This authorization then allows the patient to purchase from a licensed producer up to a recommended quantity in grams per day. Although the basic patient demographics and birthday are required, unlike a prescription, the exact component percentage and potency, method of ingestion, and frequency are not components of the authorization.
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Electronic Health (eHealth) Solutions for Low Back Pain—The Present and The Future

Teaser: 

Dr. Eugene Wai 1 Dr. Pavel Andreev2 Alexander Chung3 Greg McIntosh, MSc4 Dr. Hamilton Hall, MD, FRCSC,5

1 is an associate professor in the Division of Orthopaedic Surgery at the University of Ottawa and is cross- appointed to the School of Epidemiology and Public Health. He is head of the University's Adult Spinal Surgery Program and is the medical lead for the region's ISAEC program. His research interests involve regional and systems-based strategies to improve physical activity in back pain.
2is an associate professor at the Telfer School of Management. His doctoral studies centered on the impact of information and communication technologies on activities such as telemedicine and e-learning. His current research program is developing methodologies that enhance healthcare practitioners care delivery.
3 is a PhD candidate at the Telfer School of Management. His research focuses on the use of behaviour change theories to anchor the design of digital technologies. Specifically, he is interested in designing systems to facilitate habit formation for users.4 completed his Masters in Epidemiology from the University of Toronto's Faculty of Medicine. He is currently the Director of Research Operations for the Canadian Spine Outcomes and Research Network.5is 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:Electronic Health (eHealth) technologies for back pain care, including websites and mobile apps, are rapidly growing. Unfortunately, the clear majority are unregulated and not considered credible. Given this growth, clinicians require the tools to help their patients navigate through the "wild west" of options towards more trustworthy platforms. Artificial Intelligence and digital technologies anchored in behaviour change theories have the potential to further transform these eHealth platforms.
Key Words: Electronic Health (eHealth) technologies, back pain care, websites, mobile apps, artificial intelligence.

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The Canadian Agency for Drugs and Technologies in Health (CADTH) has published a summary for users entitled "Can you trust Dr. Google," and it recommends that users look at the Author, Date (current), Objectivity, Purpose, Transparency and Usability.
Clinicians should become familiar with several credible eHealth resources to recommend to patients when assisting with their self-management of back pain.
Electronic Health platforms have the potential to engage patients in the self-management of their back pain.
Most available eHealth options for back pain are considered unreliable and not credible; however, several government and professional societies are beginning to publish reliable and useful content for patients.
Standardized tools and principles exist for the appraisal of credible eHealth resources.
Artificial Intelligence and anchoring mobile health solutions in behaviour change theories may further improve eHealth platforms.
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Readdressing Recalcitrant Rashes: Alternate Approaches to Atopic Dermatitis

Teaser: 

Linda Yang, BSc,1Joseph M. Lam, MD, FRCPC,2

1 Faculty of Medicine, University of British Columbia, Vancouver, BC.
2Clinical Associate Professor, Department of Pediatrics, Associate Member, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, BC.

CLINICAL TOOLS

Abstract: Atopic dermatitis is a common pediatric disease with a chronic relapsing-remitting course, causing distress to patients and family. In patients who remain recalcitrant following treatment with topical steroids, adjunctive therapies including bleach baths, wet wraps and phototherapy as well as systemic immunosuppressants may be considered. Many novel therapies are in development and act on various aspects of the immunologic cascades involved in atopic dermatitis. The following review briefly summarizes up-to-date evidence for the use of these therapies in the pediatric population.
Key Words: atopic dermatitis, pediatric disease, therapies.
Topical corticosteroids, the first-line treatment for atopic dermatitis, can be optimized with usage of an appropriate amount and within a supportive, therapeutic alliance.
Those who fail to improve with topical corticosteroids may benefit from adjunctive treatment with wet wraps, bleach baths and phototherapy with narrowband UV therapy. These have been shown to be efficacious with a minimal side effect profile.
In those who remain recalcitrant, a brief course of immunosuppressants may be indicated. Methotrexate, azathioprine and cyclosporine have evidence in the pediatric population. Of these, methotrexate has been shown to have the most sustained duration of remission.
A recent explosion of novel immunomodulators and biologics may redefine atopic dermatitis treatment. Crisaborole is a topical PDE4 inhibitor, which has been approved for used in children. Dupilumab is an injectable monoclonal antibody, which has recently been approved for the adult population and remains off-label in pediatrics.
Monotherapy when possible and regular check-ins with parents can improve adherence to topical steroid regimens, particularly within the first 3 days of treatment.
The American Academy of Dermatology recommends the use of bleach baths (1/2 cup of 6% household bleach in a 150L bathtub full of water) for 5 to 10-minute intervals 2-3 times weekly as an adjunct to topicals.
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5 Technological Innovations for Those With Dementia

Teaser: 

Holly Clark, Freelance Health Writer

Dementia can be terrifying and devastating to both caregivers as well as the loved ones affected by this disease. People with this disease can now feel some relief due to technological advancement which is meant to improve the quality of their lives. This technology can enhance autonomy as well as independence, manage possible risks in homes and get rid of stress.
In this article, we are going to look at the 5 technological innovations for those with Dementia

1. Communication Aids
Interacting with others is necessary for the quality of life in memory care. Individuals with dementia can remember how an event has made them feel, even if they are unable to recall the faces and names. Technology has simplified the interaction process with loved ones. Adapted telephones are now programmed with contacts that are frequently dialed and usually have bigger buttons which simplify their usage. It's now possible to stay connected with loved ones who are distant apart via the video chat services.
"Changes in the brain caused by dementia begin years before diagnosis. And throughout this timeframe, there are no clear signs that that person has dementia." comments Jane Byrne, Project Coordinator at FirstCare.1

2. Electrical appliance use monitoring

This innovation is meant for caregivers who do not stay together with their loved ones. It controls the use of electrical apparatuses through plugging into a power strip or wall outlet as it will notify caregivers when their appliances have been switched on or off. These technologies do not make the diagnosis of dementia easy. This disease is yet overwhelming. The dementia is now more manageable; this is due to the innovation in new technologies.

3. Reminder messages
Reminders play an important role as the caregiver does as they help to keep the loved ones safe and also retain their relationships. The recording of these messages is done on a device in the residential area and then played out loud at the most suitable time. Caregivers can record a message that when played reminds an individual to take medication at the appropriate time. Some gadgets are designed to play messages based on individuals activity. Some devices are meant to remind individuals with dementia to lock the front door when leaving home. There are other reminder messages designed to help people with dementia on when to close the door when to go to bed and provide reassurance at times when the caregiver is not present.

4. Home care robots Technological advancement has led to the invention of homecare robots which will help reduce the caregiver duty. They are not designed to replace human caregivers, but instead, they are meant to do overall housework and remind individuals who are suffering from dementia on when to take medication or notify medical experts when assistance is required. With further inventions, home care robots may replace caregivers and handle their responsibility fully.

5. In-home cameras
In-home cameras are another technological innovation that is meant to enhance the safety of your loved ones from a distance.2 By either positioning, the camera focusing on medication or in the entrance room can increase your confidence as you are sure your loved one is taking the necessary medication and also active. These cameras can monitor movements and also enable one to communicate with his or her loved one. It will also notify you if no movements have been detected for a particular period.

References

  1. https://www.firstcare.ie/
  2. http://www.scitecheuropa.eu/innovative-technology-dementia/87071/
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Dermatophyte Infections: A Fungus Among Us?

Teaser: 

Miriam Armanious, BSc, MD candidate,1 Joseph M. Lam, MD, FRCPC,2

1Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario.
2Clinical Associate Professor, Department of Pediatrics, Associate Member, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, BC.

CLINICAL TOOLS

Abstract: Superficial fungal infections are a common occurrence in adults and children alike. Dermatophytes are the primary cause of these infections, which generally present as erythematous, scaling, annular lesions. Also referred to as "tinea", these infections are classified based on where they are found on the body, as different locations can have slightly different presentations and treatment requirements. This article provides an overview of these various presentations of dermatophyte infections and their risk factors, as well as recommended therapies.
Key Words: dermatophytes, fungal infections, therapies.
Dermatophyte infections, also known as tinea, are very common fungal infections in humans. They occur on the superficial skin, hair, and nails, and can present in many different locations on the body.
Tinea captis is most common in children and can cause hair loss or abscess formation.
When tinea infections are treated with topical corticosteroids, they become harder to detect and are referred to as tinea incognito.
Tinea infections are common, but should be confirmed with KOH microscopy and/or culture from a skin scraping, nail clipping, or hair sample.
Tinea capitis can be mistaken for eczema or seborrheic dermatitis
Check patients who have tinea infection for tinea pedis, since this is a common source of infection for sites on the rest of the body
Treatment for dermatophyte infections can include oral antifungal agents such as terbinafine or grise-ofulvin in a weightdependent dose, or topical antifungal agents. Systemic agents are generally re-served for presentations that penetrate hair follicles and nails, or those that are refractory to topical treatment.
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A Case of Calcified Nodule in the Base of the Tongue

Teaser: 

Dr. Pradeep Shenoy, MD, FRCS, FACS, DLO,1 Dr. Lyew Warren, MD, FRCPC,2

1ENT & Neck Surgeon, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada.
2Consultant Pathologist, Campbellton Regional Hospital, New Brunswick, Canada.

CLINICAL TOOLS

Abstract: Calcified nodules are uncommon in the base of tongue. Solitary amyloid metaplasia can occur at the base of the tongue and can produce calcification and are difficult to diagnose by histopathological examination.1 Ossoeus choristoma of the tongue is a rare benign condition producing calcified nodule in the base of the tongue.2 Unusual ectopic osseous tongue masses are reported in dermoid cysts or teratomas.3 Osteoma of the base is also reported in the literature.4 Venous malformations with phleboliths are also described in the literature5 causing calcified nodules at the base of tongue.
Key Words: calcified nodules, amyloid metaplasia, osseous choriostoma, dermoid cyst, teratoma and phlebolith.
There are various conditions like ectopic thyroid, lipoma, lymphoma, lymphoid hyperplasia and metastatic lymphatic spread can present with base of tonge swelling. Only a few conditions discussed in the article can have calcified nodule at the base of the tongue.
Base of tongue pathology can be easily missed unless prompt examination, investigations and management is done.
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Ankylosing Spondylitis and Spinal Fractures

Teaser: 

Andrew Kanawati, BSc, MBBS MSc (Hons) UNSW Mast Anat (UNE) FRACS (Orth),1Nicolas Dea, MD, MSc, FRCSC,2Parham Rasoulinejad, BHSc, MD, FRCSC, MSc, 3Christopher S. Bailey, MD, FRCSC, MSc,4

1 Clinical Fellow, London Health Sciences Centre Spine Program, London, ON.
2Spine Surgeon, Clinical Associate Professor of Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, University of British Columbia, BC.
3 Assistant Professor, Department of Surgery, Division of Orthopaedic Surgery, Schulick School of Medicine and Dentistry, The University of Western Ontario, London, ON.4 Orthopaedic Surgeon, Division of Orthopaedic Surgery, London Health Sciences Center, and Associate Professor, Dept. of Surgery, University of Western Ontario, London, ON.

CLINICAL TOOLS

Abstract: Ankylosing spondylitis is a seronegative spondyloarthropathy associated with HLA-B27. The main site of pathology is the enthesis (site of tendon insertion). The axial skeleton is affected primarily, with the sacroiliac joints initially involved, with the enthesopathy resulting in fibrosis, calcification and fusion of the sacroiliac joints and spine. There is a high incidence of spine fractures in patients with AS, and there is a high rate of missed fractures, therefore advanced imaging in the form of CT and/or MRI is necessary. Due to their highly unstable nature, surgical management of spine fractures in AS is preferable to non-operative care.
Key Words: Ankylosing spondylitis, spondyloarthropathy, sacroiliitis, spine fracture.

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The spine and sacroiliac joints are the primary site of pathology in AS.
The natural history of the disease causes eventual fusion and kyphosis.
Spinal fractures occur at a higher incidence in AS compared to general population.
There is a high rate of missed fractures, and secondary neurologic complications.
Advanced imaging (CT and/or MRI) is mandatory to rule out fracture, because of high false-negative results of plain radiography.
The patient’s kyphosis must be taken into account when applying full spine precautions for suspected fracture.
Patients must not be forced into extension as this may shift an initially non-displaced fractures.
Loss of flexibility and ankylosis of the spinal column results in long lever arms and behavior akin to a long bone, therefore fractures of the spine are highly unstable and usually require surgical stabilization.
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Yellow and yellow-brown papules and plaques: Differentiating look-alikes in children’s dermatology

Teaser: 

Lauren Schock, BSc, MD Program,1 Joseph M. Lam, MD, FRCPC,2

1Cumming School of Medicine, University of Calgary, Calgary, AB.
2Clinical Associate Professor, Department of Pediatrics, Associate Member, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, BC.

CLINICAL TOOLS

Abstract: Yellow-hued papules and plaques in children can be difficult to differentiate as many causes are rare and may not be frequently outside of specialty pediatric dermatology settings. We will review some of the common and concerning yellow-brown papules and plaques found in infants and children and discuss appearance and distribution, pathophysiology, associated findings, and management.
Key Words: dermatology, pediatric, yellow lesions.
Nevus sebaceous typically grow in proportion with patients in early childhood. Excision should be deferred until adolescence to avoid the use of general anesthetic and an informed decision can be made by the child.
Benign cephalic histiocytosis and juvenile xanthogranuloma are both forms of non-Langerhans cell histiocytosis and are benign and self limited.
Consider a diagnosis of tuberous sclerosis in any child presenting with connective tissue nevi, especially if white macules, angiofibroma, or periungual fibroma are also found.
Screen children with necrobiosis lipodica for retinopathy and neuropathy.
Use your hands – rub a suspected lesion of mastocytosis; if urticaria is elicited (a red, itchy, swollen papule or plaque), you have found Darier's sign. Mastocytosis is likely. Be prepared to treat the child with antihistamines if needed.
Juvenile xanthogranulomas are more common under two years of age, and typically appear on the head and neck. Cutaneous xanthomas often occur overlying tendons, or as grouped papules over the extensor surfaces and buttocks.
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The Role of Screening and Brace Management for Adolescent Idiopathic Scoliosis

Teaser: 

Kedar Padhye, MBBS, DNB (Ortho), 1Reza Ojaghi, MD, 2Fábio Ferri-de-Barros, MD, MSc, FSBOT, FSBOP (Hon.), FRCSC, FCS(ECSA),3

1 Clinical Fellow (Pediatric Spine Surgery)Division of Paediatric Surgery, Section of Orthopaedic Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta.
2Orthopaedic Surgery Resident, Department of Orthopedics, University of Ottawa, Ottawa, Ontario.
3 Department of Orthopedics, Alberta Children's Hospital, Calgary, Alberta.

CLINICAL TOOLS

Abstract: Adolescent Idiopathic Scoliosis (AIS) is defined as curvature of spine in the coronal plane with a Cobb angle of more than 10°. AIS affects 1-3% of children younger than 16 years of age. Less than 20% of those children will progress to severe deformity requiring interventions. Screening with clinical examination and selective radiographic assessment seems to be a cost-effective approach to filter specialist referrals but current literature is controversial. Evidence supports brace management of AIS for skeletally immature patients with primary scoliosis measuring 25°–40. The risk reduction for progression to the surgical range (deformity greater than 50 degrees) is 56%. Timely diagnosis and evidence-based brace management of AIS seem likely to reduce the surgical burden. The implementation of screening guidelines at the primary care level is a critical step.
Key Words: scoliosis; idiopathic; Brace treatment; conservative treatment; screening.

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Bracing is an effective but time sensitive intervention for managing AIS in skeletally immature patients with primary scoliosis measuring 25 to 40 degrees.
Clinical screening is required to identify AIS patients who eligible for bracing.
Improving access to bracing for eligible patients requires a collaborative approach involving primary care physicians and specialists.
1. A systematic collaborative approach involving primary care physicians for screening patients and referring to tertiary care ensures timely assessment and management for eligible patients.
2. Evidence supports brace management of AIS for skeletally immature patients with primary scoliosisl measuring 25°–40°, with the goal of preventing deformity progression to the surgical threshold.
3. A full time (18-23h/day) rigid brace treatment may mitigate the surgical burden of AIS by approximately 30%.
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Time to Chew on Temporomandibular Disease

Teaser: 

Dr. Robert Caratun, BSc, MSc,1
Dr. Aly Abdulla, MD, CCFP, FCFP, DipSportMed CASEM, CTH, CCPE, McPL,2

1is a graduating medical student from The University of Ottawa going into Family Medicine residency at The University of Calgary in June 2019. He has a background in coaching and creating custom mental skills programs for athletes.
2 is a family doctor with specialties in sports medicine, palliative care, and cosmetic medicine. He can be found on Twitter, LinkedIn and https://ihopeyoufindthishumerusblog.wordpress.com/

CLINICAL TOOLS

Abstract: Temporomandibular disorders (TMD) are one of the most common non tooth-related chronic orofacial pain conditions that involve the muscles of mastication and/or the temporomandibular joint (TMJ) and associated structures. This article reviews the etiology, diagnosis, and treatment of this chronic pain condition.
Key Words: chronic pain, temporomandibular disorders (TMD), temporomandibular joint (TMJ).
1. The etiology of TMD is multifactorial in nature
2. TMD is a clinical diagnosis. Clinicians should perform a complete history and physical with special focus on a dental and psychiatric history.
3. Imaging can be considered if history and physical are insufficient for diagnosis. Diagnostic injections can also be used to further guide clinicians.
4. For TMD treatment, supportive patient education should be prioritized (jaw rest, soft diet, passive stretching) in addition to conservative treatment measures (e.g. NSAIDs).
The most common presenting symptoms of TMD are facial pain, ear discomfort, headache and jaw discomfort/dysfunction.
Symptoms of TMD are typically associated with jaw movement and pain in the temple, masseter, or preauricular region. If there is no pain with jaw movement, consider an alternate diagnosis.
A large volume of patients report abnormal jaw sounds with no jaw pain or dysfunction. Do not treat adventitious jaw sounds; only pain or discomfort in TMD
Patent supportive measures and conservative treatment result in significant pain reduction for the majority of patients and should be the main focus of TMD treatment.
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