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Frequently Asked Questions about Psoriasis

Frequently Asked Questions about Psoriasis

WHAT IS PSORIASIS?

Psoriasis is a common but chronic skin condition that causes inflammation and scaling (red elevated patches and flaking silvery scales). The patches can be itchy or sore, causing discomfort and pain. Psoriasis causes skin cells to rise to the surface and shed at a very rapid rate. On average, people with psoriasis shed their skin cells every 3 to 4 days, while people without the condition have a turnover rate of about every 30 days.1,2,3,4

Current Concepts in the Surgical Treatment of the Degenerative Spine

Teaser: 

Dr. Safraz Mohammed1 Dr. Robert Ravinsky2 Dr. Albert Yee3

1University of Ottawa, Neurosurgery, Ottawa Civic Hospital, Ottawa, ON.
2,3University of Toronto, Division of Orthopaedics, Department of Surgery; Holland Musculoskeletal Program and Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON.

CLINICAL TOOLS

Abstract: Degenerative conditions of the spine are a major cause of disability, and represent a large economic burden on the health care system. In this review, we have described some of the most common degenerative pathologies of the lumbar spine—low back pain, spinal stenosis, degenerative spondylolisthesis, lumbar disc herniation and cauda equina syndrome—and the diagnostic approach and immediate management from the perspective of the primary care physician. We have emphasized clinical pearls seen in these conditions and specific indications for surgical referral, as well as red flags that should prompt urgent referral for life-threatening entities, such as malignancy and infection.
Key Words: degenerative spine, surgery, lumbar disc herniation, spinal stenosis, spondylolisthesis, radiculopathy.

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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1. Evaluate for hip and knee joint pathology, and vascular pathology, especially in older patients presenting with unilateral radiating leg symptoms.
2. Spine surgery is more successful in treating leg dominant pain symptoms than back dominant mechanical pain symptoms.
3. Screen every patient presenting with a lumbar spine complaint for concomitant cervical and thoracic stenosis, in particular looking for evidence of cord compression (i.e. myelopathy). Be suspicious in patients with bilateral leg symptoms.
Clinicians should ensure that a focused history and a thorough physical examination is performed to help place patients with low back pain into several key categories: (a) nonspecific low back pain (Pattern I or II), (b) back pain potentially associated with radiculopathy leg symptoms (Pattern III) or leg claudication from structural spinal stenosis (Pattern IV), or (c) back pain potentially associated with another specific spinal cause (i.e. red flags). The history should also include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain.3
Unless there are red flag symptoms or signs, routine imaging or other diagnostic tests in patients with acute nonspecific low back pain is not required.3
Diagnostic imaging and special investigations in patients with low back pain in the presence of severe or progressive neurologic deficits or when serious underlying conditions are suspected on the basis of history and physical examination.
Surgery can be helpful for patients with leg dominant symptoms (sciatica/radiculopathy, Pattern III) or leg claudication from spinal stenosis (Pattern IV). There is a limited role for surgery for back pain dominant symptoms in the absence of specific structural correlative pathology (i.e. Pattern I or II).3
Approximately 15% of patients with lumbar spinal stenosis will have concurrent cervical or thoracic canal stenosis. One must screen for the presence of upper motor neuron signs and symptoms. Degenerative lumbar stenosis always presents without upper motor findings but may occasionally have focal root compression signs.
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The Blamed Bladder

Teaser: 

Lauren Campbell, PT, MScPT, MCPA,1 Jessica Nargi, PT, MScPT, MCPA,2

1Registered Physiotherapist, Pelvic Health Physiotherapy on Bay, Toronto, ON.
2 Registered Physiotherapist, Pelvic Health LifeMark Physiotherapy, Toronto, ON.

CLINICAL TOOLS

Abstract: Bladder pain syndrome/interstitial cystitis (BPS/IC) is associated with symptoms of urgency, frequency, and pain in the bladder or pelvis, in the absence of infection or disease. While manual therapy skills performed by a specialized pelvic floor physiotherapist can improve pain and symptoms by as much as 75-80%,23 treatment strategies need to look beyond, because the persistent nature of this condition suggests there is also dysfunction occurring within the peripheral and central nervous systems. Other symptom-improving treatments include bladder retraining, neurophysiology-based pain education, mindfulness meditation, and a variety of other strategies to help quiet their hypersensitive nervous systems.
Key Words: bladder pain syndrome, interstitial cystitis, pelvic floor physiotherapy, biopsychosocial framework, neurophysiology-based pain education, central sensitization.

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.

Identify research and treatment for BPS/IC need to be beyond the bladder.
Understand a pelvic physiotherapist's assessment and treatment framework for BPS/IC.
Understand the importance of tissue dysfunction and central sensitization in BPS/IC.
Use a biopsychosocial framework when approaching BPS/IC
The bladder is likely not "at fault" and given the persistent nature of symptoms, one must consider the whole body.
Pelvic floor physiotherapy is MORE than manual treatment and exercise prescription
Physiotherapists have an excellent knowledge base, dynamic skill set, and also have the time required to educate and help implement behavioural modifications.
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.
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Many older patients of mine have metal implants in their limbs following some form of reconstructive surgery. It is the age of the bionic person.

With so many "snowbirds" and with security metal detectors almost everywhere, there is often an expressed concern about whether having a metal implant in the hip or knee might delay you or lead to problems when you pass through airport or cruise security metal detectors.

I recently had a comparable experience when flying, which I do quite often. I had acquired a MedicAlert bracelet, which also is a common accoutrement of many older patients. As I passed through the security arch having already removed all my usual triggers (phone, wallet, belt, watch), the alarm went off—I realized that the Medic-Alert bracelet, whose clasp is such that it is very difficult to open, clearly for safety reasons, was the culprit. I mentioned it to the agent—who took his wand and clearly identified the source of the alarm, and when he finished the rest of the scan, he let me through without any problems.

I was curious and perused the medical literature on the subject, given the high prevalence of seniors with metal in their bodies—part of the contemporary miracle of modern medicine. I recall a time when severe knee and hip arthritis left seniors either completely immobilized or chronically racked by significant, often life-altering pain.
It is not that the surgery is "easy," and it's not always successful, but for many, it can have a dramatic and long-lasting beneficial effect. No less important than the surgery itself is that there seems to be a very flexible ceiling on age—with some very elderly individuals found suitable for surgery—depending on what other medical conditions exist.
Many of the articles that discuss the issue remark on a practice in the past, when patients with metal hardware in their bodies often provided the security agents with letters or cards attesting to their condition. However, it is now felt that these are not needed nor heeded, as there is no way of verifying the veracity of the author—and the backup metal detector or full body scan will do the trick more effectively and assuredly.

What most of the articles on the subject suggest is that the traveller should alert the security agent right up front about the issue rather than waiting for the detector to go off. I thought of having the clasp on my MedicAlert bracelet changed to one that could be more readily opened and closed but decided that the security of a bracelet that could not readily inadvertently fall off was more important than the minor inconvenience of a manual security scan.

Some things, we often say, just "come with the territory." Travel has become more complicated because of issues of security. There is no doubt that the recent tragic bombing of a passenger plane in the Middle East will result in either more intense scrutiny of travellers or some new directives on screening—just when things seemed to be easing up in North American airports.

Medicine has become more complicated because of novel treatments that, although life enhancing or life saving (such an internal heart pacemaker which also has metal wires), may cause some modicum of inconvenience at the security gate when people travel.

This seems to be a small price to pay to achieve both desirable ends—being able to walk unattended through a security gate after restorative surgery, and making sure that fellow travellers are safe in their travels.

Still, during those years when I was studying medicine all this would have been in the realm of wild imagination.

This article was originally published online at http://www.cjnews.com/living-jewish/travel/do-metal-implants-hinder-your-ability-to-travel

 

Cervical Radiculopathy: Diagnosis and Management

Teaser: 

Heidi Godbout, MD,1 Sean Christie, MD, FRCSC,2

1Dalhousie University, Dept. Surgery (Neurosurgery), Dept. Medical Neurosciences.
2Associate Professor, Dalhousie University, Dept. Surgery (Neurosurgery).

CLINICAL TOOLS

Abstract: Neck and arm pain are common reasons to seek medical attention, especially in the working population. However, there are several diagnostic pitfalls that must be avoided. Appropriate, conservative management will lead to improvement in a significant number of patients. Knowing when to refer a patient as well as what imaging modalities are indicated is crucial to managing cervical radiculopathy in the primary care setting. The purpose of this review is to help primary care physicians diagnose, investigate and treat cervical radiculopathy and to know when a surgical referral is appropriate.
Key Words: Cervical radiculopathy, neurological exam, imaging, conservative treatment, surgery.

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.

1. Cervical pain is a common clinical problem; pure cervical radiculopathy is much less frequent.
2. The natural history of cervical radiculopathy is favorable; most patients improve within 3 months.
3. Imaging is only required if there are indications of sinister, non-mechanical pathology or when surgery is being contemplated.
4. Surgery produces beneficial results in 85-90% of cases.
1. A well-constructed musculoskeletal and neurological history and physical examination can distinguish between mechanical neck pain, cervical radiculopathy, cervical myelopathy or shoulder pathology.
2. C5-6 and C6-7 are the most common levels affected.
3. C6 radiculopathy leads to numbness in the thumb and weakness in wrist extension.
4. C7 radiculopathy leads to numbness in the middle finger and triceps weakness.
5. Spurling's manoeuver can be used to reproduce radicular symptoms. It should not be used when myelopathy is suspected.
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The Role of Nutraceuticals in Atopic Dermatitis

The Role of Nutraceuticals in Atopic Dermatitis

Teaser: 

Jacky Lo, MD,1 Joseph M. Lam, MD, FRCSC,2

1 is a resident in the Family Medicine Residency at the University of British Columbia. He was previously a registered dietitian at the College of Dietitians in BC.
2is a pediatric dermatologist and a clinical assistant professor in the Departments of Pediatrics and Dermatology at the University of British Columbia.

CLINICAL TOOLS

Abstract: Atopic dermatitis (AD) is a chronic relapsing and remitting dermatosis with no definitive cure. Because treatment often remains challenging, the use of nutraceuticals has been gaining popularity as an alternative therapy.
Key Words: Nutraceuticals, atopic dermatitis, prevention, treatment.
The use of prebiotics in formula fed infants may reduce the incidence of AD up until two years of life.
The use of prenatal and/or postnatal probiotics, especially with Lactobacillus rhamnosus and Bifidobacterium, has been shown to reduce the incidence of AD. However, the evidence for its long-term effects appears to be inconsistent.
There is conflicting evidence regarding the use of vitamin D alone and zinc in the treatment of AD.
Routine supplementation of vitamin E alone and selenium does not appear to be beneficial in the treatment of AD.
While the use of fish oil has not been shown to have any statistically significant benefit in the treatment of AD, its use has been associated with improved quality of life, reduction in area affected in a pooled analysis of two studies and pruritus in one study.
Education plays an important in the management of AD and emphasis should be made to explore patients' reasons for turning to alternative therapies.
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Navigating the Gender Spectrum: A General Overview of Transgender Health Care

Navigating the Gender Spectrum: A General Overview of Transgender Health Care

Teaser: 

Dr. Adam C. Millar, MD, MScCH, FRCPC,

Mount Sinai Hospital, Assistant Professor, Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Abstract:Transgenderism is common, with quoted prevalence rates of between 0.5-1% of the population.1,2,3 The term "transgender" reflects a broad spectrum of identities, including agender, pangender, genderqueer and genderfluid. Although there is increased public recognition of transgender issues, many physicians remain uncomfortable managing matters of transgender health. There is a paucity of high quality, long term randomized controlled trials on many transgender health topics, requiring physicians to rely largely on consensus guidelines. Integration of transgender-related subject matter into medical school curricula is one of the first steps towards enabling future physicians to increase their comfort in transgender health care.
Key Words: Transgender, trans, testosterone, estrogen, androgen blockade.

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.

1. Transgenderism is not limited to the binary gender constructs of male and female. The term "transgender" includes a broad spectrum of identities, including agender, pangender, genderfluid and genderqueer.
2. Lack of physician comfort with medical management of the transgender patient has been linked to increased rates of refusal of medical care, as well as verbal harassment and in extreme cases physical assault.
3. Due in part to a lack of large randomized controlled trials, many transgender guideline recommendations are based on expert opinion and relatively low quality evidence.
Rather than assume one's gender identity, it is advisable to ask the patient how they identify, and what pronouns are preferred.
There are no specific hormonal targets during transition therapy. Instead, treatment targets are defined by the patient's goals and overall sense of well-being.
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.