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Part 3: Using Your EMR Effectively

Part 3: Using Your EMR Effectively

Teaser: 

Ian PUN, MD,

Family Physician, Scarborough, Ontario. OSCAR McMaster EMR user since 2010.

CLINICAL TOOLS

Abstract: The leading-edge generation of EMR usage comprises extended interconnectivity to other healthcare databases, expanded communication between providers and their patients and integration of medical diagnostic and support devices ready for remote monitoring. These features are being developed and will become widely adopted in the near future.
Key Words: EMR, OSCAR McMaster EMR, OLIS, HRM, Cancer Care registry, vaccine cold chain.
Have your EMR connect to government websites so information is directly pushed into your EMR.
Health Card databases (HCV), OHIP billing database (MCEDT), Cancer database (CCO SAR), lab database (OLIS), Hospital databases (HRM) and outpatient lab databases (HL7).
Connect medical devices to your EMR.
Communicate with your colleagues electronically through secure means.
Set up your EMR to have working functionality with the CCO SAR, HRM, OLIS and lab databases.
Communicate online with your referring and consulting colleagues.
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Lessons to be Learned from History and the Perspective of Grandparents and Vaccination of Children

Lessons to be Learned from History and the Perspective of Grandparents and Vaccination of Children

Teaser: 

Michael Gordon, MD, MSc, FRCPC,

Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Abstract: The progress of medicine over previous decades includes benefits in the world of vaccination against especially childhood disease. It is therefore surprising to witness the growing and vociferous opposition to childhood vaccination, especially for measles. This poses substantial personal and public health risks. It is important to understand the reasons that anti-vaccination sentiment has taken hold among many often highly educated parents.
Key Words: Vaccination, anti-vaxxers, polio, measles vaccine.
The public are not always convinced by the best of medical evidence.
Medicine is always evolving—the public does not always understand the process.
The history of vaccination is long with many great heroes some of whom were not medical or scientific professionals.
Trying to convince people who believe vaccination causes childhood diseases may not respond to more and more evidence as their belief is almost religious in nature.
Sometimes it is the perspective of those old enough to remember the scourge of childhood infectious illnesses who can play a role in helping their children who may oppose vaccination come to their parental senses.
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Managing Adolescent Idiopathic Scoliosis (AIS) in Primary Care

Managing Adolescent Idiopathic Scoliosis (AIS) in Primary Care

Teaser: 

Paul J. Moroz, MD, MSc, FRCSC,1 Jessica Romeo, RN (EC), MN, BScN,2Marcel Abouassaly, MD, FRCSC,3

1Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario.
2Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario.
3Fellow in Pediatric Orthopedic Surgery at the Children's Hospital of Eastern Ontario, Ottawa, Ontario.

CLINICAL TOOLS

Abstract: Adolescent Idiopathic Scoliosis (AIS) is a condition requiring early detection for appropriate management. Bracing can be effective in preventing curve progression so failing to detect a small AIS curve in a growing child could result in losing the opportunity to avoid a major surgical procedure. Doubts about cost-effectiveness have ended most school screening programs and assessment is now provided mainly by primary care providers. The ability to conduct a quick effective scoliosis examination is important for the busy practitioner. This article illustrates the main features of the screening test, offers guides for imaging, and outlines appropriate tips for specialist referral.
Key Words: Adolescent Idiopathic Scoliosis (AIS), diagnosis, physical exam, Adams Forward Bend Test, primary care.

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1. This can be done with a patient's gown open or closed at the back.
2. The measurement is performed with the examiner sitting and observing the patient from behind. It can be done at the same time as the AFBT, since the examiner is in the same position.
3. With the patient standing erect in bare feet and with the knees extended, the examiner rests his/her hands on top of the iliac crests with fingers extended and palms parallel to the floor. With both the patient's feet flat on the floor, the relative levels of the hands give a surprisingly sensitive estimate of significant LLD (Figure 2).
4. There are alternative methods to measure leg lengths with the patient supine by using a tape measure. These techniques require familiarity with pelvic and ankle landmarks, are time consuming and are remarkably prone to measurement errors.
IMAGING FOR SUSPECTED SPINAL DEFORMITY
1. Radiation exposure using modern radiographic techniques, including digital radiography, is significantly lower than in the past.5
2. Radiologists' reports may use terms related to the spine that can be misleading and worrisome. Cobb angles less than 10 degrees should not be described as scoliosis but rather as "spinal asymmetry" since the term "scoliosis" may prompt an unnecessary referral to a specialist.
3. If imaging is indicated, it is best done at a centre where the patient will be seen in consultation. Radiologists at these centres have the experience to accurately interpret imaging results and correctly report spinal deformity. This also avoids the unfortunate situation where inadequate imaging done elsewhere must be repeated at the referral centre, significantly increasing the patient's radiation dose.
4. Never order a "scoliosis series". It is an obsolete term that referred to pre-operative assessment films. It is still found on some x-ray requisition forms and may be ordered in a misguided attempt to provide the surgeon with as much information as possible. Since the vast majority of patients seen by the spine surgeon will not require surgery, this option is needlessly expensive and the added radiation may be harmful to the patient.
5. The authors allow patients to take smart phone or tablet images of their own spinal x-rays. This engages the patient and their parents or guardians in the management. Take account of all regulatory and privacy issues regarding patient's recording of even their own images.
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Diagnosis and Management of Cervical Myelopathy

Teaser: 

Sean Christie, MD, MSc, FRCSC,1 Aaron S. Robichaud, MD,2

1Associate Professor, Department of Surgery (Neurosurgery), Department of Medical Neurosciences, Dalhousie University, Halifax, Nova Scotia.
2Clinical Fellow, Department of Surgery (Neurosurgery), Department of Medical Neurosciences, Dalhousie University, Halifax, Nova Scotia.

CLINICAL TOOLS

Abstract: Cervical myelopathy is a degenerative disease that occurs secondary to direct spinal cord compression and compromise of spinal vasculature through a process of gradual spinal canal narrowing. Patients generally present with signs and symptoms of long tract compromise. Once myelopathy is suspected on clinical grounds, MRI is the test of choice to confirm canal stenosis and cord injury. Treatment involves surgical decompression, anteriorly and/or posteriorly of the spinal. Despite optimal management in this patient population, outcomes may be poor and are usually limited to halting progression of the disease rather than relieving deficits already present.
Key Words: Cervical myelopathy, cervical stenosis, degenerative spine disease, spondylosis.

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Cervical spondylotic myelopathy is a degenerative disease that results from compression of the spinal cord with subsequent cord injury and impaired conduction along the tracts contained within it.
Myelopathy is a clinical diagnosis based on signs and symptoms of spinal cord dysfunction and should not be used to refer to isolated imaging findings of spinal cord degeneration or stenosis.
MRI is the most sensitive test to identify cervical canal stenosis and injury to the cord and should be arranged when myelopathy is found on clinical evaluation to identify a specific diagnosis and guide management.
Surgical decompression can prevent progression of cervical spondylotic myelopathy, and in some patients improve gait and hand function.
Cervical myelopathy can be differentiated from radiculopathy on clinical exam by the presence of upper motor neuron signs as a result of injury to the spinal cord, which will be absent in radiculopathy.
MRI is helpful in working up cervical spondylotic myelopathy as it allows visualization of the elements causing compression, provides an estimate of the extent of stenosis through loss of CSF space surrounding the cord, and allows identification of cord injury manifest as hyperintense signal change in the cord on T2 weighted imaging.
Patients with symptomatic cervical myelopathy should be referred to a spine surgeon for evaluation and management.
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Non-Muscle-Invasive Bladder Cancer: Review of Diagnosis and Management

Non-Muscle-Invasive Bladder Cancer: Review of Diagnosis and Management

Teaser: 

Neil Pugashetti,1 Shabbir M.H. Alibhai,3 Stanley A. Yap,1,2

1Department of Urology, University of California, Davis, Sacramento, CA.
2Division of Urology, Department of Surgery, VA Northern California Health Care System, Sacramento, CA, USA.
3Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

CLINICAL TOOLS

Abstract: Non-muscle-invasive bladder cancer (NMIBC) represents the large majority of newly diagnosed bladder tumors and represents a significant burden to both patients and the healthcare system. Although the initial standard treatment for all non-muscle-invasive tumors is surgical resection, there exist a wide variety of both surgical and medical treatment modalities based upon the tumor's specific stage and grade. Ensuring a proper diagnosis is key, and management should be tailored to the individual in order to reduce cancer recurrence and prevent progression of disease.
Key Words: Bladder cancer, non-muscle-invasive, diagnosis, treatment.

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Non-muscle-invasive bladder cancer consists of papillary tumors (Ta), tumors invading the submucosal lamina propria (T1), and flat lesions known as carcinoma in situ (CIS).
Proper management is key given the significant risk of tumor recurrence or progression to muscle-invasive disease.
Many treatment modalities exist including transurethral resection, intravesical chemotherapy, intravesical immunotherapy, and radical cystectomy; treatment choice depends on a variety of factors including tumor stage and grade.
The gold standard for the complete work-up of hematuria is office cystoscopy and imaging of the upper urinary tract.
Initial standard treatment of non-muscle-invasive bladder tumors is TURBT; at the time of resection, sampling of muscle surrounding the lesion is important to accurately assess depth of invasion.
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Rituals in Death and Dying: Modern Medical Technologies Enter the Fray

Teaser: 

Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

Abstract

In the absence of immortality, the human species has over the millennia developed rites and rituals to help in the passing of life to honor the person who is dying or has died or in some way demonstrate their "courage" and perseverance as well as duty even in the face of almost certain death. The centuries old traditions of the gathering of loved ones, the chanting of prayers, the ritual religious blessings are in the process of being replaced by the "miracles" of modern medical technology.

Key Words: Cross-cultural death, death, dying, rituals.

A Pain in the Neck

Image Description
Teaser: 

Dr. Hamilton Hall, MD, FRCSC,1 Greg McIntosh, MSc,2 Dr. Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,3 Dr. Pierre Côté, DC, PhD,4

1Professor, Department of Surgery, University of Toronto. Medical Director, CBI Health Group, Executive Director of the Canadian Spine Society, Toronto, ON.
2Masters in Epidemiology, University of Toronto, Faculty of Medicine. Director of Clinical Research for CBI Health Group and research consultant to the Canadian Spine Society.
3Family Physician practising Sport and Exercise Medicine, Toronto Rehabilitation Institute, University Health Network. Appointed at the University of Toronto, Department of Family and Community Medicine, Associate Clinical Professor.
4Canada Research Chair in Disability Prevention and Rehabilitation; Associate Professor, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT); Director, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation.

CLINICAL TOOLS

Abstract: Neck pain is common and disabling. Associated with poor posture, sedentary work and stress it is long lasting and recurrent. Most neck pain is mechanical from the structural elements within the cervical spine and can be referred to a number of remote locations. Radicular arm dominant pain is infrequent. Neck pain is diagnosed on history and confirmed with the physical examination. Routine imaging is inappropriate and the Canadian C-spine rules are recommended. Management focuses on education, range of movement exercises with associated postural improvement and strengthening exercises; neck braces should not be used.
Key Words: cervical spine, neck pain, Canadian C-spine rules, range of movement, exercise.

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

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Most neck pain is benign mechanical pain and serious pathology is uncommon.
Neck pain is longer lasting and more disabling than generally recognized.
Referred neck pain can be felt on top the shoulders, between the shoulder blades, along the jaw, in the front of the chest and as a headache.
Nerve root involvement is unusual but when it occurs typically affects C5, C6 or C7.
Routine imaging is unproductive.
Management is based on education, range of movement exercises and strengthening.
A careful history to locate the site of the dominant symptoms and a physical examination to assess posture and rule out radiculopathy will identify common mechanical neck pain.
The need for an x-ray should be based on the Canadian C spine rules.
Improving mechanical neck pain starts with educating the patient about the favourable prognosis and increasing the range of neck movement: a cervical collar is contraindicated.
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A Lump on the Foot

A Lump on the Foot

Teaser: 

Francesca Cheung, MD CCFP,1 Jeffrey Law and Lindsey Chow, 2

1Family physician with a focused practice designation in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Institute for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.
2Third year medical students from the University of Western Ontario.

CLINICAL TOOLS

Abstract: Kaposi's sarcoma (KS) is an angioproliferative tumour that requires infection by Human Herpesvirus 8 (HHV-8). It most commonly affects elderly men of Mediterranean/Eastern European backgrounds and HIV-infected patients. KS presents clinically as lesions on the skin, but may also arise in the gastrointestinal tract, lungs, and lymph nodes. There is no definitive cure for KS; therapeutic goals are to decrease the size of the lesions, prevent progression and improve function. Management depends on the type of KS, extent of disease and overall health of the patient. Observation is acceptable if the patient is asymptomatic; HAART is often sufficient to control lesions in HIV-infected patients. Cryotherapy and local excision can be used to treat solitary symptomatic lesions. Radiation therapy can be used for advanced and extended KS and in those patients for whom surgery is contraindicated. Intra-lesional injection of interferon alpha-2a or chemotherapeutic agents like vincristine have been reported to be effective in treating nodular KS lesions, but may be associated with inflammation and discomfort. Systemic chemotherapy such as pegylated liposomal doxorubicin is indicated when KS is widespread or rapidly progressive. The prognosis for KS is generally great with most patients dying from unrelated causes.
Key Words: Kaposi's Sarcoma, HHV-8, HIV/ AIDS.

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

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Kaposi’s sarcoma is a common tumour affecting HIV-infected patients. Classic Kaposi’s sarcoma most commonly affects elderly men of Mediteranean/Eastern European background.
Environmental and genetic factors are believed to predispose patients to Kaposi’s sarcoma. KS requires the infection of HHV-8. Chronic immune-suppression contributes to KS development.
KS presents with red/purple macules, plaques and nodules on the skin. Lesions may also arise in the oral cavity, gastrointestinal tract and lungs. Lesions affecting lymph nodes cause lymphedema. Consider KS in an HIV-infected patient who presents with erythematous and/or violaceous nodules or plaques.
Management of KS depends on the type of KS, extent and location of lesions and overall health of the individual. Observation is sufficient for asymptomatic patients. For patients with EKS, HAART is recommended and may be the only therapy needed.
Local control of KS lesions can be achieved through cryotherapy, local excision, intra-lesional injection of chemotherapeutic agents or radiation therapy.
Distant spread of KS can be controlled through systemic chemotherapy.
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Adjunctive Skincare for Acne

Adjunctive Skincare for Acne

Teaser: 

Shannon Humphrey, MD, FRCPC, FAAD,

Director of Continuing Medical Education, Clinical Instructor, Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada.

CLINICAL TOOLS

Abstract: While topical therapy remains a key therapeutic approach in the clinical management of AV, it can be associated with side effects that may compromise the stratum corneum and impair patient adherence. The use of adjunctive cleansers and moisturizers can help mitigate treatment side effects and subsequently enhance therapeutic efficacy. Providing patient-specific skin care recommendations, including product selection and proper use, is an important part of the clinical management of AV and may adjunctively augment the efficacy of topical medications in reducing acne lesions.
Key Words: acne vulgaris, adherence, cleansers, moisturizers.
Irritation resulting from topical medications and the emergence of bacterial resistance to both topical and oral antibiotics remain significant barriers to good treatment adherence.
Providing patient-specific skin care recommendations, including product selection and proper use, is an important part of the clinical management of AV and may adjunctively augment the efficacy of topical medications in reducing acne lesions.
Alleviating dryness and improving skin comfort by using a moisturizer concomitantly with retinoid therapy could enhance treatment efficacy.
The adjunctive use of appropriate gentle soap-free cleansers and non-comedogenic moisturizers that also restore SC barrier function, provide SPF protection, and reduce side effects of topical acne therapy is recommended and is preferred by patients and will likely improve treatment adherence.
Topical dapsone gel is antimicrobial and antineutrophilic and new fixed-dose retinoid-based combination therapies are available and this allows us to improve adherence with therapy and target multiple pathogenic mechanisms with one treatment.
Oleosome technology enables the delivery of broad-spectrum UVA/UVB sun protection (SPF 30). This technology effectively reduces the concentration of filters being applied to the skin, reducing the potential for skin sensitivity reactions.
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Are Evidence-Based Medicine and Anecdotal Medicine at Odds with Each Other?

Are Evidence-Based Medicine and Anecdotal Medicine at Odds with Each Other?

Teaser: 

For any physician beyond 70 years old, of which I am one, evidence-based medicine as currently configured and taught is a concept that came to us somewhat late in our careers. Despite having a solid scientific education in high school and then later at University even though the latter also exposed me fortunately to a wide range of liberal arts subjects, evidence-based medicine was a late addition to how I configured and digested medical knowledge.

I studied medicine at the University of St. Andrews (Dundee campus), which is a very old and venerable University and medical school. Dundee which was a remnant of the industrial revolution and pre-war depression during the 1960s when I was there as a medical student and had not risen from the ashes of the end of its core industry, the turning of imported jute into carpet backings: the industry was outflanked by the new synthetic materials that replaced jute in the carpet industry. It was a poor city, with a substantial working class of factory workers and construction workers, with those whose livelihood was from the trades. Because of its connection to the famous University across the Tay estuary and a thriving College of Art and some other fine educational facilities it also had a significant educated and fairly well-off financially tier to its population.

Medicine was taught in the very old Dundee medical building in the then traditional manner: we had lots of lectures. The lecture halls were very steep with wooden benches and long desks, laboratories with either microscopes for pathology, electrophysiological gizmos that still made recordings on paper that was covered in essence with soot and frequent visits to the autopsy room. Our professors and lecturers varied from well-known authorities who bored us half to death as they in essence read from their only occasionally updated notes, or from their own textbooks if they had written one, to some younger lecturers who tried to bring more excitement into the class, but still provided mostly information/knowledge that one could get from the standard textbooks on the subject they were talking about. When we started our clinical rotations, it was in small groups and as we gathered around the patient with our instructors we listened intently to their knowledge and occasional pearls of clinical and experiential wisdom. What was often heard was, "in my experience" or "it is known that" but virtually never, "the evidence shows" or "the latest meta-analysis of the recent studies on…" reveal that. The idea of using what would now be called evidence-based medicine did not really exist: it entered my own vocabulary and construct of knowledge and translation into practice 15 or 20 years after my graduation in 1966.

In the early days of the EBM craze I often felt a hiatus in my teaching and learning when most of the educational sessions I attended were peppered with "evidence" often applied to the new medium of the PowerPoint presentation. I realized what I was missing were the "stories" of medicine. I recalled vividly our professor of Medicine who was the Physician to the Royal Family when they sojourned in Scotland: he was a great story-teller. When he gave a lecture, with an anecdote not infrequently with a vivid background of history and geography as its anchor, it was never forgotten with the essential points embedded in the story that became very personal and meaningful as it related to individual people, and not just "groups of study subjects".

With this in mind I was delighted to see a recent article in the New York Times entitled "Why Doctors Need Stories" (http://opinionator.blogs.nytimes.com) Even though the focus in this article was on mental health issues and psychiatry, the essence of the article was the importance of stories woven into how doctors practice medicine. For patients it is very important to not just know the "science" and "evidence" of medicine but to understand the physician's personal view and experience with whatever the illness is. Patients very commonly after a physician explains the "evidence" ask, "What in your experience is the best thing to do". That is the question that physicians must be able to answer beyond the "evidence" as personal observations and experience matter a lot not just to practicing physicians, but also to the individual patients they care for. Abraham Varghese the renowned physician author of Cutting for Stone, captures the importance of touch as part of the physician's instruments of care and emphasizes this through the importance of his many narratives in his Ted Talk on the subject (http://www.ted.com).

At the end of the day, our patients need not just our knowledge, but our wisdom which is beyond the recitation of the "evidence" from the world of science: what they also need are our narratives, our individual and collections of personal observations and experiences. It is those stories, which may include us as the subjects of the tales, to confirm our humanity to our patients, but also give them a link from the science of medicine to the people to whom medicine is meant to serve.