Practice Change

Trauma as a determinant of health

By Dr. Vanessa Brcic and Dr. Devon Christie on April 18, 2018

What changed our practice was a fundamental recognition of trauma as a determinant of health, and furthermore, that PTSD is only the tip of the iceberg when it comes to trauma. Much lies under the surface for our patients.

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The practice of mindfulness

By Dr. Vincent Hanlon on March 14, 2018

Mindfulness is the awareness that emerges through paying attention to the unfolding of experience moment by moment. This paying attention is done on purpose, in the present moment, and it’s non-judgmental.

Guidelines

By Dr. Duncan Etches on February 21, 2018

In summary, in place of pattern or algorithm driven medicine, clinical experience and ability to determine what is best for our patient lies at the heart of the art of medicine.

Angiotensin Receptor Neprilysin Inhibitor (ARNI) in Heart Failure with Reduced Ejection Fraction (HFrEF): Sacubiltril/Valsartan and the PARADIGM HF Trial

By Doson Chua, PharmD, FCSHP, BCPS(AQ) and Dr. Mustafa Toma on January 10, 2018

Sacubitril/valsartan is the first in class of ARNI and has proven its superiority in reducing mortality and morbidity in HFrEF as compared to the use of ACEI. Sacubitril/valsartan should be considered in patients who are symptomatic despite optimal or maximally tolerated guideline-driven HF therapies consisting of a beta blocker, ACEI/ARB and MRA. Monitoring of patients on sacubitril/valsartan is similar to ACEI.

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Managing your passwords

By Dr. David Topps on November 29, 2017

Ever been frustrated by the number of passwords you have to keep track of in your daily life as a professional? At one time, you might have only a few – some simple ones for unimportant sites, some stronger ones and perhaps a really good one for your most important data.

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Managing opioid use disorder: buprenorphine/naloxone opioid agonist treatment

By By Dr. Christy Sutherland and Emily Wagner on November 15, 2017

I no longer offer rapid methadone tapers to my patients. Buprenorphine/naloxone is now recommended as the first-line opioid agonist treatment for opioid use disorder in British Columbia. This is because of its superior safety profile when compared with methadone as well as an easier transition to take home dosing.

Indications and value of self-administered vaginal swabs for STIs and vaginitis

By Dr. Roberto Leon on November 1, 2017

I came across a publication in the British Medical Journal by Sarah A. Schoeman: Assessment of best single sample for finding chlamydia in women with and without symptoms: a diagnostic test study. Participants took a vaginal swab before a routine gynecological exam, and clinicians then took an endocervical swab during examination.

MOVE an injury not RICE

By Dr. Jennifer Robinson on October 18, 2017

MOVE an injury: Movement, not rest. Options: offer other options for cross training. Vary rehabilitation with strength, balance and agility drills. Ease back to activity early for emotional strength.

Whether or not to use systemic corticosteroids to treat a skin disease

By Dr. Eileen Murray on October 3, 2017

When I started out in dermatology, corticosteroids were the only systemic drug available to treat patients with severe allergic contact dermatitis (ACD), atopic dermatitis (AD), drug reactions and those with bullous diseases. Corticosteroids are potent and excellent immunosuppressive agents. The main problem with systemic use is the high risk of drug interactions, as well as multiple serious acute and long-term side effects.

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The risks of worklessness

By Dr. Taryl Felhaber on September 20, 2017

Why should physicians encourage early and ultimate return to work whenever they can? In a nutshell, because it is usually in the patient’s best interest to remain in the workforce.

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Evaluation of penicillin allergy

By Dr. Jennifer Grant on September 6, 2017

Recent data show that up to 90% of patients with a reported penicillin allergy are mislabelled and of those who are allergic, many beta-lactams can still be safely prescribed due to low risk of cross-reactivity. Mislabelling of penicillin allergy is due to many things including misdiagnosis (confusing a viral exanthema for allergy), purer formulations of antibiotics, loss of allergy and differences in side-chain structure.

Management of Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

By Drs. Christopher Cheung and Kenneth Gin on August 9, 2017

Perioperative management of anticoagulation is challenging as physicians must consider the risks of stroke, systemic embolism, and perioperative bleeding.

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Review of the topic of Autism Spectrum Disorder

By Dr. Anne Antrim on July 18, 2017

The current definition of Autism Spectrum Disorder has 2 criteria: “persistent impairment in reciprocal social communication and social interactions” AND “restricted, repetitive patterns of behavior”. The symptoms must be present from early childhood, but may not manifest till the social demands exceed the capacity of the child to respond.

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Step by step approach to determine the safety of prescribing Hormone Replacement Therapy

By Dr. Roberto Leon on June 20, 2017

One of the most complex decisions that women (and their physicians) occasionally need to take in mid-life is whether to use prescription medications for their menopausal symptoms. Previously known as Hormone Replacement Therapy (HRT), Menopause Hormone Therapy (MHT) is an effective and evidence based treatment for moderate to severe hot flashes and/or night sweats (defined as bothersome enough to interfere with daily activities, impair quality of life and/or interrupt sleep).

Seeking collateral information when clinical practice guidelines deliver strong recommendations for drug therapies on the basis of a single clinical trial

By Cait O'Sullivan on May 31, 2017

When I identify strong drug therapy recommendations of particular relevance to my practice scope, I seek collateral information and there are two resources I routinely incorporate into my literature search. I start with the Cochrane Library and then check to see whether a FDA advisory committee has weighed in on key issues.

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Long-term benzodiazepine use is associated with increased mortality in people with schizophrenia

By Dr. Randall White on May 10, 2017

When psychiatric patients are treated in an emergency department, they are often hypervigilant, manic, or otherwise in an excited, agitated state. The current standard of care to manage acute agitation in adults is using an antipsychotic medication and a benzodiazepine, often loxapine or haloperidol and lorazepam.

Elevated Lipoprotein (a) is a common reason for unexplained premature or recurrent coronary heart disease and stroke

By Dr. Gordon Francis on April 26, 2017

High Lp(a) is a major CVD risk factor that should be measured and acted upon in patients and families where there is history of premature CV events but lack of clear risk factors, and in patients with known CVD and recurrent events despite treatment to LDL-C target.

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Serious illness conversations and capturing advance care planning

By Drs. Charlie Chen and Hayden Rubensohn on April 12, 2017

What is the patient willing to consent to as treatment if his/her condition were to seriously deteriorate? The Serious Illness Conversation Guide developed by Ariadne Labs provides a framework for physicians to engage in care planning with patients in a manner acceptable to the patient.

Outcome-focused cognitive behavioral therapy (CBT)

By Dr. Dan Bilsker on March 8, 2017

Treatment plan should specifically target psychological problems that are barriers to occupational, relationship or emotional function, rather than broadly defined issues. Being able to return to work is a substantial benefit for the individual: staying at home for an extended time is damaging to the individual’s self-esteem, coping ability and psychological health. Practice “positive psychology”, emphasizing the outcomes that determine the meaning and success of one’s life and focus on individual’s strengths to reach goals.

Geriatric urinary incontinence: just ask!

By Dr. Martha Spencer on February 22, 2017

Martha Spencer, MD, FRCPC, Providence Health Care, Clinical Instructor, UBC (biography and disclosures) Disclosures: Education grant from Pfizer to help support my incontinence fellowship in Edmonton, Grant from Pfizer ($10 000) to support start-up costs for the Geriatric Continence Clinic at SPH. Mitigating potential bias: Only published trial data is presented and recommendations are consistent […]

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Symptoms attributed to Chronic Lyme Disease

By Dr. Ric Arseneau on February 8, 2017

The PLEASE trial (Persistent Lyme Empiric Antibiotic Study Europe) was published in the New England Journal of Medicine in March 2016. This randomized, double-blind, placebo-controlled study assessed whether longer-term antibiotic treatment of persistent symptoms attributed to Lyme disease leads to better outcomes than does shorter-term treatment.

Pyogenic granulomas

By Dr. Joseph Lam on January 10, 2017

Pyogenic granulomas or lobular capillary hemangiomas are common acquired vascular tumors accounting for 0.5% of all skin nodules in children. They occur predominantly on the head and neck. Although they are benign vascular proliferations, treatment is often sought because of recurrent episodes of bleeding due to a propensity to superficial ulceration and bleeding.

Chronic Fatigue Syndrome upgraded to disease

By Dr. Ric Arseneau on November 30, 2016

Chronic Fatigue Syndrome (CFS) – also known as Myalgic Encephalomyelitis (ME) and Systemic Exertion Intolerance Disease (SEID) – is a common clinical condition. Yet, it is under- recognized and diagnosed. An estimated 84–91% of patients with the condition remain undiagnosed.

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Prednisolone or pentoxifylline for alcoholic hepatitis

By Dr. Paul Mullins on October 26, 2016

Alcoholic hepatitis (AH), perhaps more accurately described as alcohol-related cholestatic liver failure, is a clinical syndrome with high mortality. In severe AH at 28 days: 30-40%. STOPAH is a UK multi-centre, double-blind, randomized trial in severe AH to assess the effect of Prednisolone and/or Pentoxifylline on mortality at 28 days, and mortality or liver transplantation at 90 days and at one year.

Pyogenic granulomas

By Dr. Joseph Lam on October 25, 2016

Pyogenic granulomas or lobular capillary hemangiomas are common acquired vascular tumors accounting for 0.5% of all skin nodules in children. Although they are benign vascular proliferations, treatment is often sought because of recurrent episodes of bleeding due to a propensity to superficial ulceration and bleeding.

Diagnosing processing disorders

By Dr. Alisa Lipson on September 28, 2016

As a general pediatrician, I see many children whose behaviour and/or development is not emerging as expected. A diagnosis such as autism or learning disability may be the obvious explanation; but frequently it is not so straightforward. Parents come armed with questions about ‘processing disorders’ and and they expect their MD to be knowledgeable.

Recommending a plant-based diet

By Dr. Jan Hajek on August 3, 2016

For diabetes in particular, observational studies suggest that persons who follow a plant-based diet have a lower risk for diabetes, and an RCT demonstrated reductions in HbA1c in patients with diabetes randomized to a vegan diet compared to the standard American Diabetes Association diet.

Part 2: Minimizing the pain of the IUD insertion: all effort required

By Dr. Roberto Leon on July 12, 2016

Up until recently, pain management with IUDs (intrauterine devices) insertion was not commonly performed, as most users were multiparous women and the insertion was reasonably straightforward. However, because the IUDs provide unsurpassed protection against a pregnancy along with many other advantages, its acceptance is dramatically increasing, especially in nulliparous women and adolescents.

Comparing intensive versus standard blood-pressure control: The SPRINT Trial

By Drs. Christopher Cheung and Kenneth Gin on June 22, 2016

Hypertension affects over 1 in 5 Canadians and is one of the leading causes of cardiovascular disease, including coronary artery disease and heart failure. Uncontrolled hypertension is a risk factor for stroke (both ischemic and hemorrhagic), retinopathy, chronic kidney disease (CKD), and peripheral vascular disease. Epidemiologic studies show that the risk of cardiovascular disease increases above a blood pressure of 115/75 mmHg.

Diagnosis and management of congenital cytomegalovirus infection

By Dr. Soren Gantt on June 8, 2016

Approximately 1 out of every 150 live-born infants has congenital CMV infection (cCMV). Of these, most are asymptomatic. However, more than 20% will suffer permanent neurologic sequelae, including hearing loss, intellectual disability, and visual deficits. In fact, cCMV is responsible for 25% of all childhood hearing loss, and is the second most common cause of intellectual disability after Down syndrome.

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Practice Change

Trauma as a determinant of health

The practice of mindfulness

Guidelines

Angiotensin Receptor Neprilysin Inhibitor (ARNI) in Heart Failure with Reduced Ejection Fraction (HFrEF): Sacubiltril/Valsartan and the PARADIGM HF Trial

Managing your passwords

Managing opioid use disorder: buprenorphine/naloxone opioid agonist treatment

Indications and value of self-administered vaginal swabs for STIs and vaginitis

MOVE an injury not RICE

Whether or not to use systemic corticosteroids to treat a skin disease

The risks of worklessness

Evaluation of penicillin allergy

Management of Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation

Review of the topic of Autism Spectrum Disorder

Step by step approach to determine the safety of prescribing Hormone Replacement Therapy

Seeking collateral information when clinical practice guidelines deliver strong recommendations for drug therapies on the basis of a single clinical trial

Long-term benzodiazepine use is associated with increased mortality in people with schizophrenia

Elevated Lipoprotein (a) is a common reason for unexplained premature or recurrent coronary heart disease and stroke

Serious illness conversations and capturing advance care planning

Outcome-focused cognitive behavioral therapy (CBT)

Geriatric urinary incontinence: just ask!

Symptoms attributed to Chronic Lyme Disease

Pyogenic granulomas

Chronic Fatigue Syndrome upgraded to disease

Prednisolone or pentoxifylline for alcoholic hepatitis

Pyogenic granulomas

Diagnosing processing disorders

Recommending a plant-based diet

Part 2: Minimizing the pain of the IUD insertion: all effort required

Comparing intensive versus standard blood-pressure control: The SPRINT Trial

Diagnosis and management of congenital cytomegalovirus infection

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