A-2 C-CHANGE Guideline update 2022: Bringing together Canada's CV focused guidelines - Rahul Jain & Sheldon Tobe
I started checking Lp(a) one time only, since hearing your talk at last year’s Refresher Course. How do you use that information? (Eg patient with few to no risk factors but very high Lp(a)- does that push the patient to a higher risk catergory?) How is it weighted among the other risk factors we calculate in the Framingham Calculator? Do you think it will one day be added to the Framingham Calculator?
A-3 CKD and cysts: Where two worlds meet - Irith Lebovich
1) Do we need Bosniak classification for every complex cyst?
The Bosniak classification allows us to predict the likelihood that a cyst is malignant - so it is important to have access to this information as this will guide follow-up and the decision to refer to a urologist.
2) A young female adult 21 year old, HTA on medication, no family history because she was adopted, no cause for HTA a part of obesity.do we need to do IRM to look for cyst because of her age( ultrasound normal)
Wonderful and challenging question. The obesity in this young woman's case may explain the hypertension. If there was otherwise nothing to explain it, although most of us would probably not push further with a MRI, I wouldn't say it's unreasonable. It makes logical sense.
A-5 Controversial cases in thrombosis: The clot thickens - Carolyne Elbaz
1) When is a FU DUS indicated for VTE and how would results affect treatment duration?
Not indicated in guidelines. If the patient’s symptoms are not improving it is probably a good idea to repeat the ultrasound to make sure there is no progression. Sometimes an ultrasound can help establish a new baseline after treatment especially if the anticoagulation is discontinued in case there are new symptoms and we want to evaluate for the presence of new thrombus.
2) A patient with arterial blood cloth with anti phospholipids under Coumadin do we need to bridge with Innohep when the I r is under 2?
I think any patient with antiphospholipid antibodies and arterial events should be followed in a hematology clinic for this reason
A-6 Migraine toolkit 2022 update - Robert Altman
1) For patients who mainly have migraines associated with menstrual cycles- and the occasional migraine triggered by stress. Would the primary treatment be COC- i.e lolo, alesse? If they do not want to start a contraceptive medication what is the next best option?
Yes, that is a viable option. Alternatively can try the "menstrual migraine prophylaxis protocol" whereby the patient takes EC-NAPROXEN 500mg PO BID -2/+3 days related to the anticipated date of menstruation. Obviously this works if the person is "regular" and on schedule every month. In summary it would mean taking b.i.d. naproxen for a total of 5 days or (10 tablets) monthly; 2 before and 3 days into the menstruation. You can alternate naproxen with frovatriptan or naratriptan which are "slower onset" triptans which tend to work better for this clientele who usually have a longer more protracted course.
2) I have 27 yr old female patient on OCP who has a history of migraines, and recently started to develop aura with her migraines. Do I need to stop her OCP ?
Not uncommon to develop visual aura with estrogen containing compounds – in fact I have seen it de novo with OCP, with HRT and in pregnancy. I usually educate the patient about the negligibly increased relative risk of stroke and make a joint decision (stroke risk is about 2-3 per 100,000– which in a young female demographic, non-smoker with no other cardiovascular risk factors is extremely low). Usually if younger no other risk factors I have been tending to keep the OCP on board, however the patient – or physician is overly anxious then switch to progesterone only or barrier contraception. In > age of 35, smoker or menopausal – would avoid estrogen.
C-1 Alcohol use disorder and withdrawal- how to help my patient in the clinic setting - Vanessa Pasztor
Do you know what is the protocol to refer someone for inpatient rehab? I have a patient with PAWSS 4 + poor social support. Can I refer them directly to CHUM in this case, or is FOSTER an option for these patients if they have comorbidities (diabetes, CKD , HTN etc)?
Thank you for the question. Yes this sounds like a good patient who would need in patient medical detox before going to a rehab centre. He can be referred to the CHUM or he can call by himself. They will see him in clinic first and assess the next best steps whether admission or outpatient detox with them. If he does get admitted for the detox then they can help him with outpatient resources such as fosters etc after he leaves the hospital. https://www.chumontreal.qc.ca/repertoire/medecine-toxicomanies
D-1 Updates on breast cancer pathology and treatment - Stephanie Wong
A 54 yr old patient of mine with a history of DCIS right breast in 2010 had a recent finding of a 4 mm solid mass vs complicated cyst on left breast u/s this year - Birads 3- Suggestion is made to repeat u/s in 6 months. Is this a safe approach ? The patient is concerned that she needs followup sooner.
"For this patient, BIRADS III findings suggest a less than 3% likelihood that this is something worrisome or that would need biopsy down the line. Given this probably benign finding, repeating US at 6, 12, 24 months (standardized intervals) will document stability and allow the radiologists to declare this patient’s finding as “benign”. Thus, she will get a right US at 6 months, then should have bilateral mammographic screening and right breast diagnostic US at 12 months, and bilateral mammographic screening and right breast US at 24 months, after which hopefully nothing will change and she can continue her annual bilateral mammograms."
D-5 Common ocular emergencies - Marino Discepola
Regarding corneal abrasion , why doesn't patching help? I had a personal experience when I had a corneal abrasion and an ophthalmology resident at JGH refused to patch and I was in excruciating pain and dysfunctional until I found an optometrist who did applied a patching lense and it helped reduce the pain instantly. I am wondering what is the evidence behind that ophthalmologist refuse to patch while optometrist agrees to do it.
There is no proof that an occlusive patch does anything for healing or for pain control. From your question, I am wondering if the optometrist applied a bandage contact lens. This would help with the pain, but there is a risk of a corneal infection with the contact lens in place. That would be the drawback.

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