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Urticaria: A Brief Review

Teaser: 

Yvonne Deng,1 Amir Gohari,2 Joseph M. Lam, MD, FRCPC,3

1Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
2Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.
3Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Urticaria is a common, mast cell-driven disorder that presents with transient wheals, angioedema, or both. Clinically, it is classified into acute or chronic, depending on the duration of symptoms, and further classified by the presence or absence of inducible stimuli. Although urticaria is rarely life-threatening, it can reduce quality of life and carry significant socioeconomic burden on patients. While there is no cure to the disease, the treatment algorithm for urticaria focusses on the control of symptoms with antihistamines as the mainstay of therapy and immunosuppressive/immunomodulating therapies for severe cases.
Key Words: urticaria; pediatric urticaria; angioedema; acute urticaria; chronic spontaneous urticaria.

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Urticaria is a common pruritic condition that is divided into acute or chronic forms. It can be idiopathic or inducible by triggers that including foods, medications, infections, environmental factors, physical stimuli, and medications.
Acute and chronic urticaria are clinical diagnoses guided by a detailed history and physical examination, and diagnostic testing is not routinely indicated, unless clinical suspicion warrants exclusion of underlying causes.
Pathogenesis of urticaria involves mast cells and subsequent release of histamines and proinflammatory mediators that result in sensory nerve activation, vasodilatation, and plasma extravasation with leukocyte recruitment to lesions.
Second-generation, non-sedating H1-antihistamines are the mainstay of treatment for all types of urticaria and dosed up to fourfold to achieve adequate control.
Individual wheals typically resolve within 24 hours without leaving residual changes on the skin. If the duration of wheals is unclear, patients or clinicians can draw a line around the lesion to observe for changes or resolution
In addition to the physical stimuli in chronic inducible urticaria, other triggers of chronic urticaria include psychosocial stress, work exposures, surgical implants, and menses.
Investigations are not needed to make a diagnosis. However, a limited work-up can be considered for potential comorbidities (e.g. thyroid hormones and autoantibodies for active thyroid disease) or to exclude other diagnoses in the appropriate clinical context (e.g. skin biopsy for urticarial vasculitis).
With the exception of avoiding alcohol consumption, pseudoallergen-free or other food elimination diets should not be routinely recommended to patients for symptom control. In fact, IgE-mediated food allergy is rarely an underlying cause of urticaria.
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Related Terms: Dermatology, Urticaria, pediatric urticaria, angioedema, acute urticaria, chronic spontaneous urticaria
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Pediatric Psoriasis

Teaser: 

Yvonne Deng,1 Joseph M. Lam, MD, FRCPC,2

1 Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
2Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Psoriasis is a chronic inflammatory skin disease that affects up to 1.4% of children (aged <18 years) with a strong genetic predisposition and is mediated by dysregulation in the crosstalk between the innate and adaptive immune responses. It can have significant impact on quality of life for many patients. There are various subtypes of psoriasis with plaque psoriasis being the most common presentation in both adults and children. Pediatric psoriasis is primarily a clinical diagnosis. With the advent of biologics, the treatment landscape for pediatric psoriasis has shifted and encompasses diverse modalities of therapeutics, including topical and systemic treatments, as well as phototherapy.
Key Words: pediatric psoriasis, psoriasis, chronic, inflammatory, skin disease.

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Psoriasis affects the pediatric population and is associated with negative effects on quality of life and psychological impairments.
Lesions of pediatric plaque psoriasis may be thinner, smaller, more macerated than those classically in adult and present more commonly on the scalp, face, intertriginous areas, and extremities (flexural surfaces for younger children and extensor surfaces for older children).
Psoriasis is not an isolated condition and is correlated with higher rates of myocardial infarction, diabetes mellitus, hypertension, obesity, arthritis and liver disease.
In mild to moderate cases of psoriasis, topical therapies with a short course of corticosteroids and/or vitamin D analogue are first-line. In moderate to severe cases, narrowband UVB phototherapy, systemic agents, such as methotrexate, and biologics should be considered.
Pediatric patient should be assessed for risk factors for associated comorbidities.
A history of preceding streptococcal or viral infection can be suggestive of guttate psoriasis, which is more common in children than adults.
Approach to treatment should be guided by the extent and severity of disease, which can be quantified by BSA, the PASI score and quality of life index surveys.
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Related Terms: Dermatology, pediatric, psoriasis, chronic, inflammatory, skin disease
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Hyperhidrosis: A Brief Review

Teaser: 

Mahan Maazi, MEng,1 Joseph M. Lam, MD, FRCPC,2

1 Faculty of Medicine, University of British Columbia.
2Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Hyperhidrosis (HH) is a disorder of the eccrine sweat glands causing excessive sweating. It is caused by hyperactivity of the sympathetic nervous system resulting in excessive release of acetylcholine and activation of the sweat glands. Primary essential HH is thought to have a large genetic component, while secondary HH is the result of an underlying condition or medications. HH will often cause excessive sweating in areas with a high density of eccrine sweat glands that include the palms, soles, face, head, or axillae. Diagnosis is largely based on history and physical which can help differentiate between primary and secondary HH. Hyperhidrosis can have a significant impact on quality of life. Management includes identifying and avoiding triggers, the use of topical antiperspirants, and advanced therapies in recalcitrant cases (such as tap water iontophoresis, botulinum toxin injection and surgical options).
Key Words: hyperhidrosis (HH), primary (essential) hyperhidrosis, secondary hyperhidrosis, excessive sweating, eccrine sweat gland.

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

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Hyperhidrosis is common and affects about 5% of the population
A simple measure of the severity of hyperhidrosis can be done with the 4-question hyperhidrosis disease severity score
Secondary hyperhidrosis should be ruled out with a good history and physical exam
Patients who fail treatment with topical antiperspirants can be treated with tap-water iontophoresis, botulinum toxin injections, oral anticholinergics and surgical options.
Hyperhidrosis is excessive sweating that can be most commonly primary but can have secondary causes
Patients with hyperhidrosis can experience significant impairment on quality of life and this should be explored
First-line treatment consists of topical antiperspirants
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Related Terms: Dermatology, hyperhidrosis, primary (essential) hyperhidrosis, secondary hyperhidrosis, excessive sweating, eccrine sweat gland
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Opioid Use in Patients Undergoing Spine Surgery

Teaser: 

Eric J. Crawford MD, FRCSC,1 Ronit Kulkarni,2 Rajesh Kumar MBBS, FRCS, FCPS, FACS, FEBNS, MRCPS,3 Ted Findlay DO, CCFP, FCFP,4 Christopher J. Nielsen MD, FRCSC,5 Stephen J. Lewis MD, FRCSC,6 Robert A. Ravinsky MDCM, MPH, FRCSC,7

1 Divisions of Orthopaedic and Spine Surgery, Sunnybrook Health Sciences Centre, Toronto, ON.
2 Medical University of South Carolina, College of Medicine, Charleston, SC.
3Division of Spine Surgery, Sunnybrook Health Sciences Centre & Department of Surgery, University of Toronto, Toronto, ON.
4Calgary Chronic Pain Center at Alberta Health Services, Calgary, AB.
5Division of Orthopaedic Surgery, Toronto Western Hospital, University Health Network & Department of Surgery, University of Toronto, Toronto, ON.
6Division of Orthopaedic Surgery, Toronto Western Hospital, University Health Network & Department of Surgery, University of Toronto, Toronto, ON.
7Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC.

CLINICAL TOOLS

Abstract: Opioid medications have long been known for their analgesic properties and play an important role in the treatment of acute post-surgical pain. However, in recent years there has been an increase in chronic opioid therapy (COT) for painful conditions, in particular spinal disorders. These patients can have increased postoperative analgesic requirements and may be at increased risk of complications after surgery. In this evidence-based review, we provide guidance for managing opioid and analgesic medications for patients on COT from the preoperative assessment to post-surgical management including recommendations for appropriate opioid reduction.
Key Words: low back pain, surgery, opioid sparing, peri-operative pain management.

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1. Pre-operative chronic opioid usage is associated with poorer surgical outcomes.
2. Pre-operative chronic opioid usage is associated with prolonged post-surgical opioid therapy.
3. Pre-operative opioid tapering can achieve clinical surgical outcomes comparable to an opioid-naïve group.
4. Non-pharmacological or non-narcotic medications may help reduce pre-operative opioid usage.
5. A clear plan for a post-surgical opioid taper should be prepared prior to surgery.
The OPAL trial notes that opioids for acute non-specific low back or neck pain present no significant difference to placebo for pain at 6 weeks.
Buprenorphine is commonly used as an opioid rotation pre-operatively to assist in opioid weaning.
Discontinuing opioid prescriptions should be considered if there is a lack of overall and clinically meaningful improvement in function, quality of life or pain, or lack of progress towards meeting agreed therapeutic goals.
Gabapentin in doses over 1800 mg/day is associated with 60% increased odds of opioid related death.
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Related Terms: Back Health, low back pain, surgery, opioid sparing, peri-operative pain management

Medicine and the Humanities

Teaser: 

Michael Gordon, MD, MSc, FRCPC,

Emeritus Professor of Medicine, Member, Joint Centre for Bioethics, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Abstract: In the earliest writing of stories, physicians and illnesses often played an important role. Some of the renowned scholars in the Jewish tradition, like Moses Maimonides was a philosopher, a prolific writer, and a physician. A few of the world-famous authors include: François Rabelais (1483-1553), Anton Chekhov (1860-1904), Arthur Conan Doyle (1859-1930), Oliver Sacks (1933-2015) and the contemporary Abraham Verghese (1955-), to name just a few. The connection between medicine and the humanities appears to have diminished in some domains due partially to the focus on the scientific advances in medicine and the diminished focus on the humanities, especially in higher education. This I suggest, is a problem for medicine.
Key Words: medical humanities, education, medical students.
The exposure to the humanities in the education of physicians provides an expanded framework of understanding the person beneath the patient.
Education in the humanities should be a prerequisite or even a component of a more humanistic medical education.
As part of connecting to new patients it is important to find out who they are before asking why they are in your office or hospital bed.
Explore as many ways to connect to the patient on their life’s experiences, cultures or backgrounds in order to promote a therapeutic relationship of trust.
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Related Terms: Law and Ethics, medical humanities, education, medical students

Cauda Equina Syndrome: a review of all you need to know

Teaser: 

Vega-Arroyo Miguel, MD,1 Perry Dhaliwal, MD, MPH, FRCSC,2

1 Section of Neurosurgery, Department of Surgery, University of Manitoba.
2 Assistant Professor of Neurosurgery, Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba.

CLINICAL TOOLS

Abstract: Cauda equina syndrome (CES) is the collection of signs and symptoms produced by severe compression of the lumbar spinal nerves that form the cauda equina. The compression can be caused by lumbar degenerative changes, intraspinal tumors, epidural hematoma, and infections. Rapid diagnosis and treatment are paramount as CES requires emergent surgical decompression. With delay, the patient could develop permanent neurological deficits including loss of lower limb sensorimotor function, bladder, bowel, and/or sexual dysfunction. Unfortunately, even with expeditious surgery, neurological improvements remain unpredictable. Failure to fully explain the possible prognoses can involve all the healthcare providers in medicolegal consequences.
Key Words:Cauda Equina Syndrome, Spine Emergency, Urinary retention, MRI scanning, Saddle Anesthesia.

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1. Cauda Equina Syndrome results from pathologies that compress the nerves in the lumbosacral spinal canal, most commonly due to an acute lumbar disc herniation.
2. Early diagnosis is crucial and is made clinically by distinctive symptoms of saddle anesthesia, acute urinary incontinence combined with acute back and leg pain.
3. The most consistent early clinical sign of CES is urinary retention, and the prognosis is worse when present.
4. Urgent MRI is the study of choice and should be performed to confirm or rule out CES.
5. Surgery is highly recommended within 24 hours after CES is identified.
1. Cauda Equina Syndrome is caused by a large space-occupying lesion within the central canal of the lumbosacral spine, most commonly a large disc herniation. However, compression can also be caused by lumbar degenerative changes, intraspinal tumors, epidural hematoma, and infections.
2. Cauda equina syndrome generally presents with varying degrees of sensory loss and motor weakness in the lower extremities, saddle anesthesia, and bowel/bladder dysfunction (these last 2 are required to establish the diagnosis of CES).
3. The main clinical feature between differentiating Cauda Equina Syndrome vs Conus Medullaris Syndrome, is the absence of UPPER MOTOR NEURONS findings in CES).
4. About 70% of patients with cauda equina syndrome have a previous history of lower back pain and/or sciatica.
5. Although the prognosis is largely determined by the preoperative severity of neurological deficits, early surgery improves the chance of significant recovery so patients with CES require urgent surgical intervention.
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Related Terms: Back Health, cauda equina syndrome, spine emergency, urinary retention, MRI scanning, Saddle Anesthesia

An Ethics Journey: From Kant to Assisted Suicide

Teaser: 

Michael Gordon, MD, MSc, FRCPC,

Emeritus Professor of Medicine, Member, Joint Centre for Bioethics, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Abstract: Most of us would agree with the almost trite saving that "life is a journey". Of course it is, unless it ends tragically at birth, and even then it is a very short journey. All of us can describe how we got from one stage in life to another, whether personal, family, education or career. Many journeys seem to be in an almost straight line while others meander from one place to another, changing direction and alternating goals, sometimes zigging back and forth. I have had many wonderful journeys in my life; the choice to change career aspirations from engineering to medicine, the choice to study in medicine in Scotland, the choice to focus on geriatrics and then the choice to branch out into medical ethics to add more depth to clinical medicine. The early undergraduate study of philosophy planted the seed that eventually grew into my completing a Master's in Medical Ethics; and then expanding my teaching and practice to include palliative care and end-of-life decision-making, to most recently participating in the assessment of those requesting medical assistance in dying (MAiD in Canada).
Key Words: Kant, medical ethics, MAiD, assisted suicide, medicine.
The controversy in Canada about the evolution of MAiD legislation is an example of how polar opposite views can affect the law and the citizen’s views about end-of-life options.
One of the contemporary pillars of medical ethics is autonomy.
Doctors have to describe the benefits and risks of medications in order to get the proper consent to use the prescription.
MAiD is a complex concept. It will take time until the right balance is achieved.
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Related Terms: Law and Ethics, Kant, medical ethics, MAiD, assisted suicide, medicine

Acute Management of Cervical Spine Trauma and Spinal Cord Injury

Teaser: 

Mohamed Sarraj, MD,1 Brian Drew, MD FRCSC,2

1 Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario.
2 Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario.

CLINICAL TOOLS

Abstract: Cervical spine injury can have life-changing consequences. At every stage of injury, we can intervene to meaningfully change patients' outcomes. On the field, a high index of suspicion is critical. Spinal immobilization prevents secondary injury, but immobilization, particularly use of a hard board, must be kept to a minimum. In the trauma bay, perfusion of the spinal cord is a priority to help prevent secondary spinal cord injury. This means addressing any cause of hypotension and understanding how to manage neurogenic shock. In the spinal-cord injured patient, hemodynamic management is an important adjunct.
Key Words:Spinal Cord Injury; Trauma; Cervical; Ankylosing Spondylitis.

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1. Minimize time in rigid immobilization as much as feasible.
2. Spinal shock is temporary flaccid paralysis and loss of reflexes. You cannot give a prognosis for a spinal cord-injured patient in spinal shock.
3. Recognize patients with stiff spines (such as in ankylosing spondylitis) and immobilize them in their natural position of comfort to avoid secondary injury.
4. What we can do to improve neurologic outcomes in spinal cord injury: Maintain spinal cord perfusion through oxygenation and blood pressure management, avoid secondary injury through immobilization, and facilitate early surgical decompression (<24hr)
1. The Canadian C-spine Rule is the preferred algorithm to clear the cervical spine after trauma.
2. X-rays are not sufficient to rule out cervical spine injury. CT scan is the gold standard.
3. Neurogenic shock is a distributive syndrome characterized by the triad of hypotension, bradycardia, and peripheral vasodilation. First line treatment is fluid resuscitation, then vasopressors.
4. Patients with stiff spines (ankylosing spondylitis or DISH) have high rates of spine fractures and non-contiguous injuries. Full spine CT scans should be obtained.
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Related Terms: Back Health, spinal cord injury, trauma, cervical, ankylosing spondylitis

Pediatric Warts: 2023 Update

Teaser: 

Mahan Maazi, MEng,1 Joseph M. Lam, MD, FRCPC,2

1 Faculty of Medicine, University of British Columbia.
2Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Cutaneous warts or verruca are benign growths of the skin that affect 30 to 70% of school-age children and has a lifetime prevalence of 10 to 22% in children. It is caused by human papillomavirus (HPV) which spreads from skin-to-skin contact or fomites and infects squamous cell in areas like the hands and feet. There are different HPV subtypes that cause different types of warts including common warts (verruca vulgaris), plantar warts (verruca plantaris), flat warts (verruca plana), mosaic warts, filiform/digitate warts, epidermodysplasia verruciformis, and condyloma acuminata (genital or venereal warts). Most warts will spontaneously clear within 2 years. Diagnosis is based on history and physical examination features which may include dermoscopy and rarely, histological confirmation. Management includes treatment with topical salicylic acid and cryotherapy, the two most common and effective modalities.
Key Words: warts (verruca), human papillomavirus (HPV), common warts (verruca vulgaris), plantar warts (verruca plantaris), flat warts (verruca plana), mosaic warts, filiform/digitate warts, epidermodysplasia verruciformis (EV), condyloma acuminata (genital or venereal warts).
Cutaneous warts are a benign growth caused by human papillomavirus (HPV) infection that can cause discomfort. These are most common in school-aged children and in adolescents.
HPV infection is acquired through skin-to-skin contact, contact with fomites, or through maternal transmission during birth. The virus infects squamous cells on the skin and inserts its viral genome into the cells causing survival and proliferation of the virus.
History and physical examination help diagnose warts in children. Dermoscopy and histology may also aid in diagnosis, especially in more challenging presentations. A history of genital warts in children mandates ruling out sexual abuse.
There is a wide range of treatment modalities that can be used for warts. The most well-studied are destructive therapies such as salicylic acid and cryotherapy. There are side effects from treatments such as pain, blistering, scarring and dyspigmentation from cryotherapy. HPV vaccination in children is useful in preventing certain subtypes of genital warts and those that may cause cancer.
Warts often spontaneously resolve with 33% clearing within the first 6 months, 66% within the first 2 years, and 90% within the first 5 years.
Treatment can hasten resolution of warts and often involve destructive therapies such as salicylic acid and cryotherapy.
HPV subtypes causing cancer are rare. Vaccination can significantly decrease the chance of acquiring HPV subtypes that cause genital warts and cervical, anal, oropharyngeal, penile, vulvar, and vaginal cancer.
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Related Terms: Dermatology, warts, common warts, plantar warts, flat warts, mosaic warts, filiform/digitate warts, epidermodysplasia verruciformis, condyloma acuminata
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Spine Infections

Teaser: 

Jessica Albanese, MD,1 Brett Rocos, MB, ChB, MD, FRCS (Tr & Orth),2

1 Adult Spine Fellow, Division of Spine Surgery, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA.
2 Assistant Professor of Orthopaedic Surgery, Division of Spine Surgery, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA.

CLINICAL TOOLS

Abstract: Though they have significant morbidity and mortality, spine infections are a rare cause of back pain. Because they are uncommon, it is important to recognize the signs and symptoms of a spine infection, to establish the diagnosis, and to treat appropriately, guided by culture results, with antibiotic therapy. Surgical intervention is indicated in cases of significant neurologic deficit, significant spinal deformity, instability, and/or failed medical management.
Key Words:spinal infection, spondylodiscitis, discitis, vertebral osteomyelitis, epidural abscess, back pain.

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

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Patients with spine infections often present with back pain and may have radicular pain, neurologic deficits, or constitutional signs and symptoms of infection
Workup begins with laboratory studies including, CBC, CRP, and ESR
The gold standard for imaging is MRI
Definitive diagnosis may require CT-guided biopsy and culture
The mainstay of treatment is at least 6 weeks of antibiotic therapy guided by culture results
Surgical intervention is indicated in cases of progressive neurologic deficit or spinal deformity, instability, or failed medical management
Spinal infections can present insidiously
Refer early if patients present with back pain and unexplained fever
Prompt identification with MRI improves likelihood of recovery
Antibiotic treatment for 6 weeks is recommended
Surgery is useful for neurological deficit or instability
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Related Terms: Back Health, spinal infection, spondylodiscitis, discitis, vertebral osteomyelitis, epidural abscess, back pain