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Primary Care Approach to Degenerative Cervical Myelopathy

Teaser: 

1Ali Moghaddamjou, MD,2Jetan H. Badhiwala, MD,3Michael G. Fehlings. MD, Phd, FRCSC, FACS,

1Division of Neurosurgery, Department of Surgery, University of Toronto, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada. 2Division of Neurosurgery, Department of Surgery, University of Toronto, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada. 3Division of Neurosurgery, Department of Surgery, University of Toronto, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.

CLINICAL TOOLS

Abstract: Degenerative cervical myelopathy is an umbrella term describing all degenerative conditions that present with cervical myelopathy due to compression of the spinal cord. The role of primary care physicians (PCPs) in early identification is vital as delayed diagnosis can lead to irreversible neurological impairment. Patients often present with subtle neurological deficits associated with neck or upper extremity pain. Screening for upper motor neuron signs, gait disturbances, fine motor abnormalities and bowel bladder symptoms is critical. Currently, surgical decompression is the treatment of choice but with future advancements in non-operative treatments, PCPs are expected to play a larger role in treatment plans.
Key Words: degenerative cervical myelopathy, primary care, cervical spondylotic myelopathy, degenerative disc disease.

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PCPs play a vital role in the management of DCM as a delayed diagnosis can lead to irreversible neurological impairment.
A heightened level of awareness with a comprehensive history and a focused physical examination are essential.
With advancements in biomarkers and emerging neuroprotective and regenerative agents, we can expect an increased role in the primary care medical management of DCM patients soon.
The approach to DCM management is multidisciplinary and generally will involve PCPs, spinal surgeon, physiotherapist, pain specialist, and neurologist.
Patients with query bilateral carpal tunnel syndrome should be assessed for DCM.
Patients with moderate to severe DCM or unequivocal progression of mild DCM require surgical treatment while there exists clinical equipoise between structured non-operative therapies and surgical decompression for mild non-progressive cases of DCM.
Clinically monitor patients with mild DCM frequently and carefully for subtle signs of neurological progression
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Related Terms: Back Health, degenerative cervical myelopathy, primary care, cervical spondylotic myelopathy, degenerative disc disease
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Frailty in Adult Spine Surgery—A Clinical Update

Teaser: 

1Eryck Moskven, MD,2Raphaële Charest-Morin, MD, FRCSC,

1PGY 1, Department of Orthopaedics, Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC. 2Clinical Assistant Professor, Combined Neurosurgical and Orthopaedic Spine Program, Vancouver General Hospital, University of British Columbia, Vancouver, BC.

CLINICAL TOOLS

Abstract: Purpose: Frailty is a state of increased vulnerability. This paper reviews the definitions and applicability of frailty tools and discusses the impact of frailty in patients with spinal disease.
Recent Findings: Frailty is a significant risk factor for postoperative adverse-events (AEs), prolonged postoperative length of stay (LOS), adverse discharge disposition, and mortality following spine surgery. Cumulative deficit measures such as the mFI are appropriate risk stratification tools, while phenotypic measures are sensitive to capturing the relationship between spine disease and spine surgery on the frailty trajectory.
Summary: Frailty in patients with spinal disorders is predictive of postoperative adverse outcomes. The role of spine surgery to reverse frailty requires investigation.
Key Words: frailty, spine surgery, adverse outcomes, geriatric.

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Frailty is a state of decreased reserve and increased vulnerability associated with adverse health outcomes.
Clinical frailty measures derived from the cumulative deficit model of frailty such as the mFI are appropriate risk stratification tools for identifying patients at an increased risk of postoperative AEs following spine surgery.
Frailty tools with phenotypic constructs are the most sensitive measures in capturing the relationship between spinal pathology and surgical intervention on the frailty trajectory.
When assessing an elderly patient, the FRAIL acronym is a helpful guide to screen for frailty - F (fatigue), R (resistance/muscular weakness), A (ambulatory difficulty), I (illness and comorbidities), and L (unintentional loss of weight).
Access to a readily available clinical frailty assessment tool on a mobile device, such as the Clinical Frailty Scale (CFS), reduces the need for extensive chart review to calculate and determine frailty severity.
When assessing for surgical candidacy the clinician should evaluate the impact of spinal pathology on health-related quality of life, the magnitude of the proposed surgical intervention and the frailty status.
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Related Terms: Back Health, frailty, spine surgery, adverse outcomes, geriatrics
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Common Myths about mRNA COVID-19 Vaccine

Teaser: 

Zainab Abdurrahman, BSc, MMath, MD, FRCPC (Paediatrics), FRCPC (Clinical Immunology and Allergy)

Assistant Clinical Professor (Adjunct) of Paediatrics, McMaster University, Hamilton, ON.

CLINICAL TOOLS

Abstract: There are many concerns the general population has over the new mRNA vaccines that have been produced and are now being distributed in countries around the world to help curb the spread of COVID-19. This review helps to debunk the myths around some of the more common concerns.
Key Words: COVID-19, vaccines, mRNA, trials, studies.
The mRNA vaccine is safe and effective for the prevention of COVID-19.
The two mRNA vaccines approved for use in Canada are the Pfizer-Biontech and the Moderna vaccine.
The Ministry of Health updated their guidelines indicating that the vaccine is still recommended for those with allergies.
It is important to discuss and dispel the myths that patients may have surrounding the mRNA vaccines.
The vaccine is safe and effective for the prevention of COVID-19.
Despite the safety and efficacy of the vaccine, patients who receive it should be reminded to continue wearing a mask and physically distance and follow public health guidelines.
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Related Terms: Infectious Diseases, COVID-19, vaccines, trials, studies, mRNA
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The COVID-19 Vaccine: Communicating with Patients

Teaser: 

Dr. Marina Abdel Malak

is a Family Medicine Resident at the University of Toronto. She graduated and completed her Bachelor of Science in Nursing and went on to study Medicine. She has a passion for medical education, patient empowerment, and increasing awareness about the relationship between mental, emotional, and physical health.

CLINICAL TOOLS

Abstract: The COVID-19 pandemic has challenged providers and patients in several ways. The news of a vaccine has sparked both hope and doubt among our communities. Healthcare providers are in optimal positions to educate patients about the COVID-19 vaccine, and to dispel myths. This article aims to provide quick facts about the vaccine, tips to navigate around vaccine hesitancy, and resources to share with patients.
Key Words: COVID-19, vaccine, pandemic, resilience.
The COVID-19 vaccine is available and indicated for most patients > 16 years old, in a 2-dose series (with 21 days between first and second dose)
There is a spectrum of 'vaccine hesitancy' among individuals. Tailoring conversations to patients is essential in helping to navigate discussions around receiving vaccines
Data shows that the COVID-19 vaccine is about 95% effective in preventing the virus, with side effects similar to 'routine' vaccines
It is the responsibility of healthcare providers to dispel myths about vaccines, and to empower patients to understand the importance of vaccination when indicated
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: Caregiving, COVID-19, vaccines, pandemic, resilience
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When to Scratch Beyond the Surface of the Diagnosis—A look at Atopic Dermatitis Mimickers and Their Response to Topical Corticosteroids

Teaser: 

Briar Findlay1Joseph M. Lam, MD, FRCPC,2

1 Paediatric Resident, BC Children's Hospital, Vancouver, BC.
2Associate Clinical Professor, Department of Paediatrics, Associate Member, Department of Dermatology, University of British Columbia.

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Abstract: Many dermatoses occur in the pediatric population that can mimic atopic dermatitis based on their morphology or their propensity for triggering itch. This review will highlight some of the common skin conditions that can mimic atopic dermatitis, their typical response to topical corticosteroids and helpful features that can help distinguish these conditions from atopic dermatitis.
Key Words: atopic dermatitis mimickers, topical corticosteroids, chronic inflammatory skin disease, paediatrics.
Many dermatitic eruptions can mimic atopic dermatitis but features such as their typical response to topical corticosteroids can be a helpful distinguishing feature.
Some atopic dermatitis mimickers can worsen with topical corticosteroids and these include periorificial dermatitis and tinea corporis.
Some atopic dermatitis mimickers will only partially improve with topical corticosteroids alone and these include allergic contact dermatitis and molluscum dermatitis.
Other atopic dermatitis mimickers such as psoriasis and seborrheic dermatitis can respond to topical corticosteroids and the correct diagnosis can be made using other morphological or historical features.
AD is a prevalent, chronic and relapsing condition in infancy and childhood.
Morphology, distribution and age of onset can be important in distinguishing between AD and common mimickers.
Response to corticosteroids is not diagnostic for AD as many mimickers may have an initial or complete response to topical corticosteroids; however, corticosteroid usage in some mimickers of AD may lead to complications and unnecessary side effects of topical corticosteroids.
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Related Terms: Dermatology, atopic dermatitis mimickers, topical corticosteroids, chronic inflammatory skin disease, paediatrics
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Community Resources for Management of Back Pain

Teaser: 

1Naazish Shariff, BHSc. Candidate, 2Eugene K. Wai, MD, MSc, CIP, FRCSC,

1Faculty of Health Science, University of Ottawa, Ottawa, ON. 2Head—University of Ottawa Combined Adult Spinal Surgery Program, Associate Professor—Division of Orthopaedic Surgery, University of Ottawa, Cross Appointment to School of Epidemiology and Public Health, Ottawa, ON.

CLINICAL TOOLS

Abstract:Back pain is a community level health problem because of the high prevalence and burden on patients, health care and society. Many aspects of back management, such as exercise and psychosocial stress management, are suitable for a community model of care. Community models for back pain are in their infancy but lessons learned from other chronic diseases can be applied and will be discussed. This review will discuss existing evidence-based community programs, such as Exercise is Medicine® and the Stanford Model, that support exercise and self-management, and their relevance to low back pain.
Key Words: back pain, community model of care, self-management, exercise, lifestyle risk factors.

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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Many aspects of back management such as exercise and promotion of self-management are more suited for a community model of care.
Physicians and other health care providers are important catalysts for change and must support patient engagement.
Health care practitioners should identify resources within their community as well as develop their own local creative solutions.
Evidence-supported models for community involvement in managing chronic diseases are available. This article provides resources enabling practitioners to identify these programs in their community and tailor them for their back pain patients.
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Related Terms: Back Health, back pain, community model of care, self-management, exercise, lifestyle risk factors
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Spinal Injuries among Paediatric Patients

Teaser: 

Dr. Khaled Almansoori, MD, M.Ed, FRCSC,

Adult & Paediatric Spine Surgeon, Department of Orthopaedic Surgery, Advocate Christ Medical Center, Illinois, USA.

CLINICAL TOOLS

Abstract:Due to the distinctive anatomic and biomechanical features of the growing paediatric spine, children are susceptible to unique patterns of spinal injuries. Although clinical examination can help guide management, physicians are often required to rely on advanced imaging. Imaging interpretation can be challenging when considering that abnormal parameters among adults, are often within normal physiological limits in children. In general, spinal injuries in children younger than nine years of age are often managed non-operatively, while adolescents are typically managed by adult treatment principles. With the exception of neurologic injuries, most paediatric spinal injuries demonstrate good to excellent prognosis and outcomes.
Key Words: fracture, injury, spine, paediatric, children.

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

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Due to the unique properties of the growing spine, including greater elasticity, osseous plasticity, presence of growth centers, relatively strong ligaments, and greater joint mobility, paediatric patients are susceptible to unique fracture patterns and injuries.
There are absolute contraindications regarding return to play decisions.
Children under 13 years of age with vertebral body compression fractures can progressively restore their vertebral height until skeletal maturity.
The vast majority of spine injuries among children under nine years of age, even when relatively unstable, can be managed non-operatively.
Pre-adolescent patients with complete spinal cord injuries are at high risk for developing progressive scoliosis and have not been shown to demonstrate any better neurological outcomes when compared to adults.
The cervical spine is the commonest area of spine injuries with the C1-3 vertebral levels being more commonly seen in children under eight years of age.
A standard immobilization board should not be used for children under eight years of age without an occipital recess or 2-3cm of padding to elevate their body relatively to their head.
Adult radiographic spinal parameters are often unreliable in children and severe neurologic injuries can be sustained in spite of normal imaging results.
Clinical examination is fairly unreliable for identifying spinal column injuries among pre-school patients and it is often necessary to rely on advanced imaging.
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Related Terms: Back Health, fracture, injury, spine, paediatric, children
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Epiglottitis: An Under-recognized, Life-Threatening Infection

Members of the College of Family Physicians of Canada may claim one non-certified credit per hour for this non-certified educational program.

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Teaser: 

Dr. Pradeep Shenoy, MD, FRCS, FACS, DLO,1
Marah Mansour2

1ENT & Neck Surgeon, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada.
2Faculty of Medicine, Tartous University, Tartous, Syrian Arab Republic.

CLINICAL TOOLS

Abstract:Acute Epiglottitis is a potentially life threatening infection of the supraglottic structures, epiglottis and aryepiglottic folds causing fatal airway obstruction. Historically described in adults before the 1960s and after the 1960s in the paediatric group causing more mortality and morbidity until the introduction of the H. influenza type B vaccine in 1993. Since then the incidence was described again more in the adult group.6 Prompt diagnosis and treatment will save the patients if failed mortality is as high as 80% in children and 20% in adults.2
Key Words: Epiglottis, H. Influenza Type B, Aspergillus, Kliebsiella, Candida, Fibroptic laryngoscopy, Humidified oxygen therapy, orotracheal intubation, naso-tracheal intubation, tracheostomy thumb sign.
Epiglottits is an acute emergency in ENT practice as mortality is high in children at about 80% and 20% in adults.
Before the 1960s epiglottitis was not seen in the paediatric group.
Since the invention of H. influenza type B vaccine the numbers in the paediatric group has declined though in adults it remains the same as there are other bacteria and fungus involved in immune compromised patients .
Acute epiglottitis is potentially life threatening both in children and adults. Prompt diagnosis with clinical examination complimented with radiographic investigation depending on the severity of cases and early treatment could save the patient
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Related Terms: Otolaryngology, epiglottis, H. Influenza Type B, Aspergillus, Kliebsiella, Candida, Fibroptic laryngoscopy, Humidified oxygen therapy, orotracheal intubation, naso-tracheal intubation, tracheostomy thumb sign
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Virtual Care for Low Back Pain Patients

Teaser: 

Ted Findlay, DO, CCFP, FCFP,1 Dr. Hamilton Hall, MD, FRCSC,2

1 is on Medical Staff with the Calgary Chronic Pain Centre at Alberta Health Services, Calgary Zone in Calgary, Alberta.
2 is a Professor in the Department of Surgery at the University of Toronto. He is the Medical Director, CBI Health Group and Executive Director of the Canadian Spine Society in Toronto, Ontario.

CLINICAL TOOLS

Abstract:The COVID-19 global pandemic has had a rapid and massive impact on health care delivery worldwide. Two of the first public health measures applied in Canada and most other developed nations have been some variety of social distancing and "stay at home" orders, which limit the ability of patients to access non-urgent health care services. Patients with chronic pain including low back pain comprise some of the most disadvantaged populations where ongoing support from their family physician is an essential aspect of management. Virtual patient care has rapidly become one of the primary means to deliver of non-urgent management and is, in many ways, ideally suited for the support of chronic low back pain patients. It will continue to be used not only until face to face appointments are again permitted but may become a permanent feature of continuing care.
Key Words: COVID-19; virtual care; video appointments; low back pain; communication.

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

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1. Virtual patient care is not a new concept, but its use has been accelerated due to the COVID-19 pandemic.
2. Even pre-dating the COVID-19 pandemic, organized medicine in Canada has come out strongly in favor of the delivery of health care by virtual means.
3. There are many on-line resources that can be accessed by patients to help manage their low back pain during pandemic limitations on direct patient contact.
4. Positive patient identification and documentation of consent are requirements for virtual care delivery.
5. Both the physician and the patient have a role to play in ensuring appropriate privacy for the virtual visit.
Have your patient download and test any required communications software prior to their virtual appointment.
Commercial video communication software can be compliant with provincial personal privacy and information protection laws, check with your provincial medical association and/or provincial College of Physicians and Surgeons to be certain that approved software is being used.
Have the patient perform any required clinical measurements and list current medications and any required refills prior to the start of the virtual appointment.
Make sure that unidentified number call blocking does not prevent the virtual appointment from being completed.
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Related Terms: Back Health, COVID-19, virtual care, video appointments, low back pain, communication
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Osteoporosis Prevention: What can we tell patients?

Teaser: 

Dr. Marina Abdel Malak

is a Family Medicine Resident at the University of Toronto. She graduated and completed her Bachelor of Science in Nursing and went on to study Medicine. She has a passion for medical education, patient empowerment, and increasing awareness about the relationship between mental, emotional, and physical health.

CLINICAL TOOLS

Abstract:Osteoporosis (OP) is the leading cause of hip fractures in patients. Primary prevention focusses on engaging in strategies that prevent the development of osteoporosis. Physicians often provide health information to patients on how to optimize their overall wellness, and therefore, ought to educate patients on bone health as well. Offering advice on specific interventions that decrease the risk of developing OP is an effective way to engage patients in maintaining peak bone mass. Physicians should counsel patients on key points such as dietary modifications, physical activity, and decreasing the use of alcohol and smoking. Setting mutual goals with patients and ensuring that they understand the positive impact this will have on their health is critical.
Key Words: Osteoporosis, bone health, health promotion, primary prevention, education.

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

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1) Educating patients about methods to decrease the risk of osteoporosis is a critical role of the physician, as peak bone mass develops in early adulthood
2) CALCIUM (see figure 4) is a mnemonic that can help physicians recall what strategies they can address with patients: calcium/vitamin D intake, aerobic activities, limit alcohol, cut down on smoking, increase balance, use supplements if indicated, and maintain a healthy weight
3) Physicians should provide patients with resources and referrals if appropriate to ensure patients receive adequate information/support in promoting their bone health
Patients should be advised that a vitamin D supplement is required to obtain the 1000-2000 IU daily requirement
A calcium supplement is not always indicated if dietary intake is adequate
Both aerobic and weight-bearing activities are essential for OP prevention
Smoking cessation and limiting alcohol are also factors that impact bone health
Patients should be encouraged to mutually set goals around bone health with their physicians, as this increases the likelihood that their behaviour changes will be successful
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Related Terms: Osteoporosis, osteoporosis, bone health, health promotion, primary prevention, education
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