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Clinical Images: Cercarial Dermatitis

Clinical Images: Cercarial Dermatitis

Teaser: 

Kerry Gardner, MD,1 Joseph M. Lam, MD, FRCPC,2

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

CLINICAL TOOLS

Abstract: Cercarial dermatitis (swimmers' itch) consists of urticarial papules that form when the larvae of avian parasitic flatworms penetrate the skin. Cercarial dermatitis is common in the summer months where heaviest recreational swimming occurs, and when the temperature is ideal for amplified schistosome development.
Key Words: cercarial dermatitis (swimmers' itch), non-communicable, water-borne disease.
Cercarial dermatitis usually occurs with exposure to fresh water, but can occur with shallow salt water exposure as well.
The eruption typically occurs on uncovered skin 12-24 hours (up to 8 days) after exposure.
The eruption is self-limited, lasting 4-10 days (up to 20 days).
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Related Terms: Dermatology, cercarial dermatitis (swimmers' itch), non-communicable, water-borne disease
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Clearing Up Acne Treatment for the Primary Care Physician

Teaser: 

Darcy Russell,1 Joseph M. Lam, MD, FRCPC,2

1Medical Undergraduate Program, University of British Columbia, Vancouver, BC.
2Clinical Assistant Professor, Department of Pediatrics and Dermatology, University of British Columbia, BC.

CLINICAL TOOLS

Abstract: Acne vulgaris is a common skin condition encountered in family practice and can cause significant distress during adolescence. Treatment options discussed include topical benzyl peroxide, topical retinoids, oral and topical antibiotics, hormonal therapy, and isotretinoin. The following review article provides up-to-date recommendations for treating mild to severe pediatric acne.
Key Words: acne vulgaris, adolescence, treatment, pathogenesis.
The differential diagnosis for acne in adolescence includes corticosteroid induced acne, folliculitis, keratosis pilaris, papular sarcoidosis, perioral dermatitis, pseudofolliculitis barbae, and tinea faceie.
Acne may be classified as mild, moderate or severe based on the number and type of lesions involved as well as the total surface area involved.
Acne therapy is targeted at treating as many pathogenic factors as possible.
Topical fixed-dose combination therapies can be used for all types and severities of acne in children 9 years of age and older.
Both topical and oral antibiotics work by inhibiting P acnes protein synthesis and decreasing inflammation.
Do not be afraid of isotretinoin. It can be used first line in patients with severe nodular and/or inflammatory acne, acne conglobata, and recalcitrant acne.12 It is the only treatment that targets all four pathogenic factors implicated in acne vulgaris and can permanently decrease acne.
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Related Terms: Dermatology, acne vulgaris, treatment, pathogenesis
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Five Things to Know about Cauda Equina Syndrome

Teaser: 

Drew A. Bednar, MDCM, FRCS(C), FAAOS,

Clinical Professor of Orthopedic Surgery, Adult Spine Surgeon, McMaster University, Hamilton, ON.

CLINICAL TOOLS

Abstract: Cauda Equina Syndrome (CES) is a rare progressive syndrome of pain and neurological deficits below the waist caused by massive central lumbar disc prolapse. The most common clinical presentation is highly variable with multifocal mixed polyradicular deficits. Loss of bladder and/or bowel control can be subtle and is frequently not the patient' chief complaint. These symptoms must be aggressively sought by the assessing physician. While delays of a few hours in the diagnosis and management may not be deleterious, definitive lumbar MRI imaging and (if positive) surgical care referral are emergent.
Key Words: Cauda Equina Syndrome; Presentation; Diagnosis; Outcome.

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 CES patient often presents with rapidly escalating, poorly controlled pain. There may be daily or even more frequent physician visits.
While standing, the CES patient commonly adopts a "sciatic scoliosis": forward bending at the waist and leaning to either side as they attempt to decompress themselves. They may limp or need walking aids. These features help distinguish them from drug-seekers or malingerers.
Since patients are distracted by extreme pain, they may not reliably volunteer a history of bladder/bowel disturbance.
Cauda Equina Syndrome is an acute or subacute pathology caused specifically by massive central prolapse of a lumbar disc. Decompensation lumbar spinal stenosis is not Cauda Equina Syndrome.
Cauda Equina Syndrome most commonly presents with complaints of back or leg pain. These differ from common sciatica in being rapidly progressive, difficult to control with analgesics and often associated with considerable locomotor impairment.
The neurological examination in Cauda Equina Syndrome most commonly finds a mixed pattern of incomplete polyradicular deficits in the distribution of multiple lumbar and sacral nerve roots involving either of the legs and/or the saddle (perineum). The classically described complete flaccidity with loss of all motor control from the waist down is extremely rare.
Patients presenting with CES will not commonly volunteer complaints of incontinence or urinary retention as they are often overwhelmed by the magnitude of their pain. The assessor must specifically ask about bowel/bladder function and when indicated, test these by bladder scanning or catheterizing and a digital rectal examination.
As a rapidly evolving syndrome of neurological deterioration, CES warrants emergent imaging investigation and referral. Although the literature is not precise on the critical time point, it is widely accepted that patients should receive surgical intervention within 24 to 48 hours.
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Related Terms: Back Health, cauda equina syndrome, presentation, diagnosis, outcome
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Faits en bref : Aperçu de la nycturie

Faits en bref : Aperçu de la nycturie

Teaser: 

Références

  1. Gilbert J. Nocturia and Diabetes. Journal of Current Clinical Care Educational Supplement. 017.
  2. Shapiro C. Nocturia & Sleep. Journal of Current Clinical Care Educational Supplement. 2017.
  3. Elterman D. Nocturia & Urology. Journal of Current Clinical Care Educational Supplement. 2017.
  4. Von Ruesten A, Weikert C, Fietze I, Boeing H. Association of sleep duration with chronic diseases in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam study. PLoS One. 2012;7(1):e30972.
  5. InterAct Consortium, Scott RA, Langenberg C, et al. The link between family history and risk of type 2 diabetes is not explained by anthropometric, lifestyle or genetic risk factors: the EPIC-InterAct study. Diabetologia. 2013;56(1):60-9.
  6. Redeker NS, Adams L, Berkowitz R, et al. Nocturia, sleep and daytime function in stable heart failure. J Card Fail. 2012;18(7):569-75.
  7. Morris JL, Sereika SM, Houze M, Chasens ER. Effect of nocturia on next-day sedentary activity in adults with type 2 diabetes. Appl Nurs Res. 2016; 32:44-46.
  8. Destors M, Tamisier R, Sapene M, et al. Nocturia is an independent predictive factor of prevalent hypertension in obstructive sleep apnea patients. Sleep Med. 2015;16(5):652-8.
  9. Ayik S, Bal K, Akhan G. The association of nocturia with sleep disorders and metabolic and chronic pulmonary conditions: data derived from the polysomnographic evaluations of 730 patients. Turk J Med Sci. 2014;44(2):249-54.
  10. Bliwise DL, Foley DJ, Vitiello MV, Ansari FP, Ancoli-Israel S, Walsh JK. Nocturia and disturbed sleep in the elderly. Sleep Med. 2009;10 (5):540–8.
  11. Stanley, N. The underestimated impact of nocturia on quality of life. Eur Urol. 2005;4(Suppl):17-19.
  12. Denys MA, Cherian J, Rahnama'i MS, O'Connell KA, et al. ICI-RS 2015-Is a better understanding of sleep the key in managing nocturia? Neurourol Urodyn. 2016 Sep 21 (in press).
  13. Hajduk IA, Strollo PJJ, Jasani RR, Atwood CWJ, Houck PR, Sanders MH. Prevalence and predictors of nocturia in obstructive sleep apnea-hypopnea syndrome--a retrospective study. Sleep. 2003;26(1):61-64.
  14. Yalkut D, Lee LY, Grider J, Jorgensen M, Jackson B, Ott C. Mechanism of atrial natriuretic peptide release with increased inspiratory resistance. J Lab Clin Med. 1996;128(3):322-328.
  15. McIntyre R. Nocturia and marjor Depressive Disorder. Journal of Current Clinical Care Educational Supplement. 2017.
  16. Breyer BN, Shindel AW, Erickson BA, Blaschko SD, Steers WD, Rosen RC. The association of depression, anxiety and nocturia: a systematic review. J Urol. 2013;190(3):953-7.
Related Terms: Urogenital Disorders, nocturia, nocturnal polyuria, Desmopressin

Movement as Medicine in Osteoarthritis

Teaser: 

Dr. Zahra Bardai MD CCFP (COE) MHSc FCFP,

Community Family Physician, Lecturer, University of Toronto, Assistant Clinical Professor (Adjunct), Department of Family Medicine, McMaster University, Hamilton, ON.

CLINICAL TOOLS

Abstract: Osteoarthritis is a prevalent health condition that affects millions of people worldwide. Increasingly, there has been a growing body of international recommendations emphasizing non-pharmacologic interventions using physical activity to modify joint mechanics. Discussion will focus on pathophysiology of joint mechanics as it relates to physical activity as well as the use of specific clinical strategies that can be incorporated into physical activity counseling in osteoarthritis management.
Key Words: Osteoarthritis, Physical Activity, Exercise Vital Sign, Exercise Prescription.
Osteoarthritis is a leading source of nonfatal health burden
Non-pharmacologic treatments of osteoarthritis focus on modifiable factors in joint mechanics
Osteoarthritis is a structural and functional failure of joints
Movement and physical activity have protective effects on osteoarthritic joints
The Exercise Vital Sign should become incorporated into assessments for preventative health and chronic disease including osteoarthritis.
The Exercise Prescription tool can help clinicians formally prescribe exercise as a treatment for their patients.
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Related Terms: Arthritis, Sports Medicine, osteoarthritis, physical activity, Exercise Vital Sign, Exercise Prescription

Back Education: Does it Work for Patients?

Teaser: 

Dr. Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,

Family Physician practising Sport and Exercise Medicine at the Toronto Rehabilitation Institute, University Health Network. She is appointed at the University of Toronto, Department of Family and Community Medicine as an Associate Clinical Professor.

CLINICAL TOOLS

Abstract: Back education or “Back Schools” are used both as a method of prevention and, in conjunction with traditional rehabilitation and exercise programs, as a component in treatment of recurrent or persistent low back pain. It is challenging to evaluate the effectiveness of this educational effort. Models have varied from brochures, booklets and simple office conversations to formal scheduled classes. Content has ranged from purely mechanical instruction to complex cognitive behavioural therapy. Essential to success is the ability to integrate the instructions into activities of daily living. The composition of those lessons remains the subject of continuing debate.
Key Words: Back School, education, body mechanics, prevention, pain management.

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
Back education programs do not reduce the frequency or severity of future back pain attacks.
The educational message should be consistent, frequent and stress self-management.
Group education is useful but the message must be tailored to the individual.
Information must be integrated into the patient's daily routine.
Back education should be part of rehabilitation and is probably most effective during the sub-acute phase of recovery when the pain is still present but not so distracting that it prevents learning.
Comprehensive back school includes spinal anatomy, instruction in proper body mechanics, individualized pain control techniques plus the recognition and treatment of pain disorder through cognitive behavioural therapy when required.
The back program should follow the precepts of adult education with frequent interaction, problem solving, practical applications and a focus on participation.
A successful back school educates the patient about the benign nature of back pain and provides the tools to transfer knowledge about back hygiene into practice in the patient's life.
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: Back Health, Back School, education, body mechanics, prevention, pain management

Quick Facts about Nocturia

Quick Facts about Nocturia

Teaser: 

References

  1. Gilbert J. Nocturia and Diabetes. Journal of Current Clinical Care Educational Supplement. 017.
  2. Shapiro C. Nocturia & Sleep. Journal of Current Clinical Care Educational Supplement. 2017.
  3. Elterman D. Nocturia & Urology. Journal of Current Clinical Care Educational Supplement. 2017.
  4. Von Ruesten A, Weikert C, Fietze I, Boeing H. Association of sleep duration with chronic diseases in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam study. PLoS One. 2012;7(1):e30972.
  5. InterAct Consortium, Scott RA, Langenberg C, et al. The link between family history and risk of type 2 diabetes is not explained by anthropometric, lifestyle or genetic risk factors: the EPIC-InterAct study. Diabetologia. 2013;56(1):60-9.
  6. Redeker NS, Adams L, Berkowitz R, et al. Nocturia, sleep and daytime function in stable heart failure. J Card Fail. 2012;18(7):569-75.
  7. Morris JL, Sereika SM, Houze M, Chasens ER. Effect of nocturia on next-day sedentary activity in adults with type 2 diabetes. Appl Nurs Res. 2016; 32:44-46.
  8. Destors M, Tamisier R, Sapene M, et al. Nocturia is an independent predictive factor of prevalent hypertension in obstructive sleep apnea patients. Sleep Med. 2015;16(5):652-8.
  9. Ayik S, Bal K, Akhan G. The association of nocturia with sleep disorders and metabolic and chronic pulmonary conditions: data derived from the polysomnographic evaluations of 730 patients. Turk J Med Sci. 2014;44(2):249-54.
  10. Bliwise DL, Foley DJ, Vitiello MV, Ansari FP, Ancoli-Israel S, Walsh JK. Nocturia and disturbed sleep in the elderly. Sleep Med. 2009;10 (5):540–8.
  11. Stanley, N. The underestimated impact of nocturia on quality of life. Eur Urol. 2005;4(Suppl):17-19.
  12. Denys MA, Cherian J, Rahnama'i MS, O'Connell KA, et al. ICI-RS 2015-Is a better understanding of sleep the key in managing nocturia? Neurourol Urodyn. 2016 Sep 21 (in press).
  13. Hajduk IA, Strollo PJJ, Jasani RR, Atwood CWJ, Houck PR, Sanders MH. Prevalence and predictors of nocturia in obstructive sleep apnea-hypopnea syndrome--a retrospective study. Sleep. 2003;26(1):61-64.
  14. Yalkut D, Lee LY, Grider J, Jorgensen M, Jackson B, Ott C. Mechanism of atrial natriuretic peptide release with increased inspiratory resistance. J Lab Clin Med. 1996;128(3):322-328.
  15. McIntyre R. Nocturia and marjor Depressive Disorder. Journal of Current Clinical Care Educational Supplement. 2017.
  16. Breyer BN, Shindel AW, Erickson BA, Blaschko SD, Steers WD, Rosen RC. The association of depression, anxiety and nocturia: a systematic review. J Urol. 2013;190(3):953-7.
Related Terms: Urogenital Disorders, nocturia, nocturnal polyuria, Desmopressin
Disclaimer: 
This article was published as part of THE LATEST IN THE DIAGNOSIS AND MANAGEMENT OF NOCTURIA eCME resource. The development of THE LATEST IN THE DIAGNOSIS AND MANAGEMENT OF NOCTURIA eCME resource was supported by an educational grant from Ferring Inc.

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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Related Terms: Dermatology, Dermatofibromas, pilomatricomas, mastocytomas, spider angiomas, terra firma-forme dermatitis

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

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

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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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Related Terms: Men’s Health, Women’s Health, Disorders of sex development, intersex, gender identity, sex differentiation, ambiguous genitalia

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.

Pre-test CME Quiz Post-test CME Quiz
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.
Related Terms: Back Health, spinal control, low back pain, kinematics, stability, wearables