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CME Opportunity for Primary Care Providers and Allied Health Professionals working in primary care

Update your knowledge on post-bariatric care and obesity management by attending this series of six ECHO Ontario Bariatric Network (OBN) sessions starting on June 3rd.  Register online at obn.echoontario.ca.  For more information contact ECHOobnadmin@stjosham.on.ca

Return to Driving After Hip Arthroscopy

Amit M. Momaya, Despina Stavrinos, Benjamin McManus, Shannon M. Witting, Benton Emblom, Reed Estes

Clinical Journal of Sport Medicine, Volume 28, No. 3, May 2018

Hip arthroscopy represents one of the most common procedures performed to help alleviate hip pain and improve quality of life. Driving represents one of the most important topics that patients will ask physicians about, especially in the primary care setting after they have been discharged from hospital and are looking to get back to their daily routine. The purpose of this study was to use a modern driving simulator and assess patients’ braking performance after undergoing a right hip arthroscopy.

This prospective study involved 14 patients scheduled to undergo right hip arthroscopy (perfumed by a single surgeon at 1 institution) and a control group (healthy volunteers who denied musculoskeletal problems) of 17 participants to account for a potential learning phenomenon. The two groups did not differ in age, sex, height, weight, and driving experience as measured by years since licensure. The control group did not undergo any type of surgical procedure. All were between the ages of 16 and 60, licensed drivers, and regularly drove using automatic transmission. All participants drove in the simulator initially to establish a baseline, and then at 2, 4, 6, and 8 weeks post-operatively. The following variables were measured:

  • Initial reaction time (IRT): time between stimulus and initiation of release of accelerator
  • Throttle release time (TRT): time from initiation to full release of foot from accelerator
  • Foot movement time (FMT): time between release of accelerator and initial contact with brake
  • Brake travel time (BTT): time to apply 200N of force from initial brake press
  • Braking reaction time (BRT): the sum of IRT + TRT + FMT
  • Total braking time (TBT): the sum of BRT + BTT

The results of the study revealed that the experimental group exhibited significant improvements in INT, TRT, FMT, and BRT at between the pre-operative and 2 weeks post-operative driving sessions in the simulator, however there was no significant change thereafter. There was no significant change in BTT in the experimental group over the 8-week period. No learning phenomenon was noted in the control group.

This study, which was the first to address driving after hip arthroscopy, suggests that most patients may return to driving at the 2 week mark, as indicated by breaking performance. However, there are several limitations to this study. Perhaps the most obvious limitation is that the participants are operating in a simulation and not in an actual vehicle. In addition, despite the fact that all patients in the experimental arm underwent a hip arthroscopy, the procedures themselves differed with respect to degree of soft tissue and bony surgery. For example, an osteoplasty may affect braking performance significantly more than a simple debridement. The relatively small sample size was a barrier to attempt to look at whether these differences existed. Also, it is important to note that currently, there are no single legally mandated or universally accepted numbers for BRTs. While this study provides some evidence for driving after right hip arthroscopy, it is recommended that primary care physicians, surgeons and patients communicate openly with one another to create individualized timelines for safe return to driving.

Sean Mindra, MD, CCFP

PGY3 – Sport and Exercise Medicine, University of Ottawa

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine

POSTPONED: Lung Cancer Screening and Smoking Reduction and Cessation in the Champlain Region

Please note that due to unforeseen circumstances, the Lung Cancer Screening and Smoking Reduction and Cessation conference planned at the Renfrew Groves Park Lodge GEM Hall on Thursday, February 22, 2018 is being postponed. Please stay tuned for a new date and time to be announced.

 

Champlain Regional Cancer Program Presents:  Lung Cancer Screening – An Interactive Learning Event

POSTPONED: Thursday, February 22, 2018 6:00 pm—8:00 pm

(Buffet Diner and Registration will start at 5:30 pm)

Groves Park Lodge GEM Hall 470 Raglan Street North Renfrew, On. K7V 1P5

Cost: $25.00

Register online Now!

www.cancerprimarycare.eventbrite.ca

For more information contact: cancerprimarycare@toh.ca

or  dial: 613-798-5555 x 15811

This program has been accredited by the College of Family Physicians of Canada and the Ontario Chapter for Mainpro+ credits.

Please share poster: Lung CME Poster2

Is there an association between tendinopathy and diabetes mellitus? A systemic review and analysis

Tom A Ranger, Andrea M Y Wong, Jill L Cook, Jamie E Gaida

Ranger TA et al. Br J Sports Med 2016; 50: 982-989

The prevalence of Diabetes in our population is increasing, as is the morbidity and mortality associated with this chronic disease. As a primary care provider, we are well aware of the role ‘lifestyle’ plays in the development and control of Type 2 diabetes mellitus.  For this reason, the guidelines recommend exercise and diet as first line treatment for this condition.  It has been shown that up to 50% of participants who quit exercise as part of their management do so because of musculoskeletal symptoms.  So the question arises: Does tendinopathy, a condition that reduces exercise tolerance, have a role to play in lack of adherence to an exercise program in diabetics?

Earlier studies have shown that hyperglycemia does change the collagen cross-linking of tendons and reduced their proteoglycan content (Reddy, 2003) leading to weakened tendons and predisposing them to tendinopathy.  This study investigated the potential association between diabetes and tendinopathy by systematically reviewing and meta-analysing case control, cross sectional, and studies that considered both of these conditions.  In total 31 studies were selected for the final analysis with good attention paid to exclusion criteria and reduction of bias.  Confounding variables were identified: age, sex, adiposity, statin use and hyperglycemia.  There is observational evidence that statins may induce tendinopathy (Marie I, Arthritis Rheum 2008;59:367-72) as well as an association between adiposity and tendinopathy (Gaida, Arthritis Rheum 2009; 61 840-9).

This systematic review showed that “diabetics had greater than three times the odds of tendinopathy compared to controls; and people with tendinopathy had 1.3 times increased odds of diabetes compared to controls.  Therefore there is evidence of a strong link between diabetes and tendinopathy however cause and effect cannot be established even though there are plausible biological pathways by which high blood glucose can affect tendon structures.” It was also shown that those diabetics with tendinopathy have had a longer duration of diabetes.

Regardless of the cofounders that may exist, the compelling evidence supports the link between diabetes and tendinopathy. This has important clinical implications such as careful monitoring and structuring of load progression when initiating exercise to prevent the development of tendinopathy.  A slower, more graduated approach would be crucial for these patients. As well, those who have tendinopathy and require rehabilitation should ensure tight glycemic control to speed resolution.

“Co-management by medical and allied health practitioners may be indicated for people with tendinopathy and long standing diabetes.”

Keith Morgan BSC, MD, CCFP, Sport Medicine Fellow                               February 2017

Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Med

Cognitive Decline Not Impacted by Cholesterol or Blood Pressure Drugs

With populations aging in much of the world, the decline of mental capacity in later years  is of increasing concern. There has been hope in the medical community that effectively treating hypertension and atherosclerosis could slow or delay this decline.brain

In the HOPE-3 clinical trial, a study of people over the age of 70 taking either blood pressure medication or statins for the prevention of heart disease, neither drug slowed cognitive decline during treatment. These results, presented at the American Heart Association 2016 Scientific Sessions, were disappointing for researchers looking to delay or even prevent the cognitive decline that comes with aging.

However, the findings were encouraging in one respect. There have been persistent concerns among patients and regulators that the use of statins to control cholesterol could negatively impact cognitive function and memory. The trial found that the patients taking statins did not have a larger decline in cognitive ability than other participants.

Patients were randomly assigned to receive either one of three drug regimens (combination blood pressure medication, a statin, or both) or to corresponding placebo groups. At the beginning and end of the study, 1,626 older adults completed several questionnaires and tests of mental processing speed and cognitive function.

While participants in all groups experienced a decline in cognitive function over the time of the study, there was no difference in the amount of this decline between treatment or placebo groups.

Data from the trial seemed to suggest that there might be some prevention of cognitive decline in patients with the highest blood pressure and LDL cholesterol levels at the start of the study, but this would need to be confirmed in other trials, said Jackie Bosch, PhD, of McMaster University, who presented the study results at AHA.

Dr. Bosch indicated that the results of this and other recent studies should put to rest concerns about statins and cognitive decline. “We have the data…that show that there is no adverse effect of statins” on cognition, she concluded.

[This article originally appeared in The Beat.]

Early Screening for Cardiovascular Abnormalities with Preparticipation Echocardiography: Feasibility study

 

Gleason, Kerkhof, Cilia, Lanya, Finnoff, Sugimoto, Corrado

Clin J Sport Medicine 2016; 0: 1-7

Sudden Cardiac Death (SCD) is estimated to occur between 1/40000 – 1/80000 of our young athletes. Although the incidence is uncommon, it remains a concern because the consequences are so tragic.  So how should we screen our young athletes? This article aims to address this.

The traditional H&P often leads to a significant number of false positives and false negatives. The ECG has been mandated by the European Society of Cardiology and the IOC. This has led to a reduction of SCD in Italy by 90% however this effect has not been duplicated in North America. This is likely due to the fact that the etiology of SCD in Europe is arrhythmogenic RV cardiomyopathy whereas in North America the most common cause is structure cardiomyopathy (eg. HOCM). This is not picked up by the standard ECG. There has been an attempt to increase the sensitivity of ECG findings by using the ‘Seattle criteria’, however, there still appears to be some deficits with this method.

The American Heart Association has encouraged the investigation of a feasible and clinically relevant method to meet the shortcomings of the traditional H&P and ECG.

The ESCAPE protocol (Early Screening for Cardiac Abnormality with Pre-participation Echocardiography) attempts to meet this need. Essentially a front-line physician (non-cardiologist) performs an Echo of the heart using a portable ECHO to look for structural abnormalities in their athletes. Three measurements are taken: septal to free wall ratio <1.3; a septal thickness of >15mm, and/or a hypertrophied LV.  It has been shown that there is no significant difference between a cardiologist and a non-cardiologist in gathering these measurements with accuracy.

This study chose to compare the time it takes to perform H&P vs ECG vs Echo as the primary outcome regarding feasibility. They found on average the H+P and ECG took approximately 4 min each and the ECHO averaged approximately 2min 17 sec which is statistically significant. The goal of the ECHO screen is to determine who needs a formal CV workup, not to diagnose HOCM. One of the limitations of this study was its small sample size of n=35. Some barriers to successful implementation of ECHO screening would be physician training, and accessibility to portable ECHOs. However, access to improved diagnostic modalities may improve in the future allowing our screens to be more cost effective, as well as more reliable and accurate.

In summary, the writers felt that the portable ECHO is feasible and accurate if used for CV screening in our athletes. Primary outcome of ‘physician time’ needed to screen is significantly less than that required of an H&P and/or ECG.  Secondary outcomes are also encouraging. This included a reduction of false positive and false negative rates of ECG’s and H&P’s that led to unnecessary testing and costs. They conclude that a directed physical exam, a rhythm strip, and a portable ECHO screen may be the answer to the question, “How do we as healthcare providers best screen athletes at risk for Sudden Cardiac Death?”

View original research (PDF): Early_screening_for_cardiovascular_abnormalities-99503

Article summarized and presented by:

Keith Morgan BSc, MD, CCFP

Sport and Exercise Medicine Fellow

University of Ottawa.

Advisor: Dr. Taryn Taylor, BKin, MSc, MD, CCFP (CAC SEM), Dip Sport & Exercise Medicine

Cancer Care Webinar Series for Primary Care

The Champlain Regional Primary Care Cancer Program presents

Two upcoming presentations for Family Doctors and other Primary Care Providers:

 

Cancer Care Webinar Series for Primary Care

“Early Identification of Palliative Patients”

November 9, 2016

12:15-12:45

 

and

 

“Cancer Update 2016”

December 9, 2016

08:30-1600

 

Meet local experts and learn more about:

Poverty and Health – Update on HPV – What’s new in Cervical Screening and Colposcopy – Lung Nodules Imaging – Prostate Cancer Treatment

Consent and Capacity  – Symptom management – Prevention, Diagnosis and Treatment of Melanoma

EMR and Practice Reports – Emergencies in Cancer Care and more!

Download a poster to post and share!

Register online Now!

www.cancerprimarycare.eventbrite.ca

For more information contact Julie de Loë at 613-798-5555 x 15811 or cancerprimarycare@toh.on.ca

 

Changes in Blood Pressure Medication Temporarily Increase Risk of Serious Falls

Elderly patients who start taking blood pressure medication or change their prescription or dosage have a temporarily increased risk of serious fall-related injury. The findings, published in Circulation: Cardiovascular Quality and Outcomes, included more than 90,000 patients in the United States aged 65 years and older.BP medicine

Between 2007 and 2012, researchers found that 272 of the patients began taking drugs for high blood pressure, 1,508 added a new drug to their existing blood pressure regimen, and 3,113 had the dose of at least one blood pressure drug increased. The likelihood of a serious fall-related injury went up 36% for patients starting a medication regimen, 16% for patients adding a new drug and 13% for patients increasing a dose.

This increased risk dissipated after two weeks following the medication changes. The authors of the study stressed that, due to its observational nature, the research could only show an association between medication changes and fall risk, not determine cause and effect. However, it identifies a time period during which elderly patients may need closer monitoring for short-term side effects.

Aortic Valve Replacement: What’s Next for TAVI?

Aortic stenosis affects more than 100,000 Canadians over the age of 65. Until recently, surgical replacement was the only treatment option, but over the last several years, TAVI, or transcatheter aortic valve implantation (often referred to as transcatheter aortic valve replacement (TAVR) in the US), has emerged as a viable alternative with advantages over surgery. Because the TAVI valve is inserted through a catheter, the incision is small and recovery times can be much shorter than for the open heart surgical procedure.

First introduced in the early 2000s, TAVI is approved in Canada mostly for use in patients who are inoperable or whose condition makes surgery a high risk. As evidence for TAVI’s safety and durability grows and advanced technology comes on the market, the procedure is poised to become much more common.

Extending TAVI to Lower Risk Patients

“We do patients for whom surgery would be high risk, often higher risk patients than at other centres in the province,” said Interventional cardiologist Marino Labinaz, head of the TAVI heart team at the Ottawa Heart Institute.TAVI

The older and sicker high risk patients require hospital stays similar to surgical patients. In Europe, where TAVI is used in a broader range of patients, the time in hospital can be much shorter.

“In low risk patients, we are seeing expedited discharge. There is a trial underway in Vancouver where they are looking at 24-hour discharge,” he said. “Where I see the sweet spot for TAVI in the low-risk patient is in rapid recovery. You’re going to come in, get your TAVI and go home the next day. In our patients, we haven’t reaped the benefit of early discharge yet.”

“The use of TAVI in these patients will be, in part, patient choice. It may also become a societal choice,” he continued, “Because, if you can send a patient home in 24 hours, then TAVI could become very cost effective when compared to a five- to seven-day stay for surgery. This will particularly be true if the cost of the valves comes down.”

TAVI is currently a more expensive option than surgery due to the cost of the valves, but as demand for TAVI grows and as new vendors enter the market and increase competition, costs are expected to decline.

Conscious Sedation Over General Anesthetic

Another emerging benefit of TAVI over surgery is the use of conscious sedation.

“Currently, we give patients a general anesthetic and they are intubated. Conscious sedation means we give them short-acting medication,” he explained. “They are conscious, and they are never intubated. The patient doesn’t have the issue of the anesthetic to recover from, and it saves time so you can do more patients in a day.”

Given the Heart Institute’s emphasis on high-risk patients, conscious sedation is only just getting started in Ottawa.

Improved Technology

One of the limitations of TAVI is the size of the catheter. To fit the valve inside, the catheter has to be larger around than those used in angioplasty for delivering stents.

“From a patient perspective, one of the biggest changes is that the valves are becoming smaller in size,” said Dr. Labinaz. “The first generation devices were very large calibre and we would see higher rates of dissections or occlusions in the arteries. Smaller tubes mean fewer vascular complications.”

Another important advancement is retrievability. Until recently, the cardiologist had only one shot to position and deploy the valve. Poor positioning can impact the seal of the valve and cause leaking—known as paravalvular aortic regurgitation—as well as complications that can require a pacemaker. A retrievable valve allows for real-time adjustments to be made.

“They aren’t yet commercially available here, but there are three valves available on special access from Health Canada that have the ability to be retrieved,” he said. “With two of them, you can deploy the valve to 80% to get an idea how it is positioned and functioning, and then retrieve it. The only completely deployable valve that can be retrieved is the new Lotus valve. We will begin using it this spring.”

“Another advance related to leaking is the addition of flexible sleeves on the outside of the valves that provide a better seal with the calcium and nodules and crevices that can create an uneven surface. Preliminary data is positive.”

One complication of aortic valve replacement that’s common to surgery and TAVI is stroke. Material from the calcium deposits in and around the valve can break away during the procedure and travel up the bloodstream to the brain. For both surgery and TAVI, the rate of stroke is 5 to 10%. On the horizon for TAVI is the use of protective filters in the blood vessels to capture that material. Results so far have been mixed.

Looking Ahead

“TAVI has been a real game changer,” concluded Dr. Labinaz. “We’re getting lots of data now on the durability of the valves in people who have had them for five and 10 years. They have low failure rates and seem to be comparable to the surgical valves.”

“It’s my prediction that TAVI will become a standard way of doing aortic valve replacement in the next five years. In Germany, it already is. Sixty per cent of aortic valve replacements in Germany are now TAVI. That’s the way it’s going. In Canada, cost and funding are the limiting factors.”

Exercise is Medicine

As a leading cause of morbidity and mortality in Canada and worldwide, physical inactivity needs to be addressed by family physicians with their patients. This month, the Canadian Academy for Sport and Exercise Medicine (CASEM) released a position statement on physical activity prescription1, providing guidance on the use of exercise as a therapeutic intervention for the prevention and management of many chronic diseases. Prescribing exercise effectively has been proven to increase physical activity (PA) and lead to positive outcomes in hypertension, diabetes, mental health, and cognitive function in older adults, so we owe it to our patients to acquire this skill.

To initiate a brief intervention in clinic, asking two questions can inform further counseling: (1) ‘On average, how many days/week do you engage in moderate or greater physical activity (like a brisk walk)?’ and (2) ‘On those days, how many minutes do you engage in activity at this level?’ Using these two pieces of information can provide the exercise vital sign: the amount of minutes of moderate-vigorous activity per week. The goal is 150 minutes of exercise per week with of moderate intensity exercise (causes increased breathing or sweating but allows the patient to still be able to maintain a conversation2). Moving forward, incorporating a written prescription, PA measurement and tracking (e.g. with a smart phone or pedometer), and clinical follow-up are key components to induce behaviour change (see Resources below).

Before starting an exercise program, individuals can self-screen with the Physical Activity Readiness Questionnaire (PAR-Q+) tool3 which will direct them to a physician for further evaluation if there are concerns. Patients who should receive medical clearance include: 1) those with signs or symptoms of cardiovascular (CV), metabolic, or renal disease; 2) inactive patients with said diseases; and 3) stable CV, metabolic, or renal patients wishing to progress from moderate to vigorous intensity exercise4. These patients should be referred to a qualified exercise professional for consideration of a thorough physical exam and exercise test. Otherwise, healthy individuals can gradually begin a light-moderate exercise regimen at home and progress as tolerated. Patients in the Champlain LHIN can make use of the Heart Wise Exercise program to find locations in the community that provide exercise classes suitable for individuals with or at risk of developing a cardiovascular or chronic health issue.

Key messages for patients during the discussion of the health benefits of physical activity1:

–        Exercise is more effective than medication for the treatment of stroke and as effective for the secondary prevention of coronary heart disease and diabetes.

–        A 150 min of moderate-to-vigorous physical activity (MVPA) accumulated per week can reduce the risk of most major chronic diseases by 25–50%.

–        A 15 min of MVPA per day (or 75 min/week) is associated with a ∼15% relative mortality risk reduction, and benefits increase with the dose.

Physical Activity Recommendations as per CSEP Guidelines5

Frequency ≥5d/wk of moderate exercise, or ≥3d/wk of vigorous exercise
Intensity Moderate (brisk walk, water aerobics) and/or vigorous
Time 30-60min/d of moderate or 20-60min/d of vigorous exercise (≥10min per session)
Type Regular, purposeful exercise that involves major muscle groups and is continuous
Progression Increase 5-10min per session every 1-2wk

 

References

  1. Thornton JS, Fremont PF et al. Physical Activity Prescription: A Critical Opportunity to Address a Modifiable Risk Factor for the Prevention and Management of Chronic Disease: A Position Statement by the Canadian Academy of Sport and Exercise Medicine. Clin J Sport Med. 2016;26(4):259-65
  2. Reed JL, Pipe AL. The talk test: a useful tool for prescribing and monitoring exercise intensity.Curr Opin Cardiol. 2014;29(5):475–80
  3. Warburton DE, Jamnik VK, Bredin SSD, et al. The 2015 Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and electronic Physical Activity Readiness Medical Examination (ePARmed-X+). Health Fitness J 2015;8:53–6.
  4. Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM’s Recommendations for Exercise Preparticipation Health Screening. Med Sci Sports Exerc 2015; 47: 2473–9
  5. Canadian Society for Exercise Physiology. Canadian Physical Activity Guidelines. Ottawa, Canada: Canadian Society for Exercise Physiology, 2011. http://www.csep. ca/guidelines (accessed 31 Jul 2016).

Resources:

Heart Wise Exercise Program: http://www.champlainhealthline.ca/displayservice.aspx?id=23256 or http://heartwise.ottawaheart.ca/

Exercise prescription pad: http://www.exerciseismedicine.org/canada/assets/page_documents/EIMC_Pad_ENnewlogo_v3.0_1_copy.pdf

Pedometers: https://www.stepscount.com/

 

Advisor: Dr. Taryn Taylor, BKIN, MSc, MD, CCFP (SEM), Dip Sport Med

Ryan Shields, MD, MSc, CCFP

PGY-3 Sport and Exercise Medicine