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?
Yes, currently based on the CCS Lipid Guidelines, Lp(a) is seen as a risk modifier, and an elevated Lp(a) may increase a patient’s Framingham Risk Score to the next level. Elevated Lp(a) as a risk modifier is weighed similarly to other risk modifiers, such as hsCRP ≥2.0 mg/L, CAC >0 AU, and family history of premature CAD. There is more to be learned about potentially targeting therapies to Lp(a) and possibly adding it to risk calculators, although at the moment, a high Lp(a) confers higher CV risk and thus tighter control of modifiable CV risk factors
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.
A-8 Dying to help: Pearls for symptom control for the non-PC physician - Jean Zigby
Question about cannabis - now that it is fairly easy to obtain, what are your thoughts/recommendations on patients obtaining cannabis products themselves through different outlets? How do you counsel them about these doses or forms?
I counsel them to obtain cannabis of the type (usually CBD oil) that I would recommend from the SQDC. I then have them return with the product obtained for purposes of titration counselling. As cannabis counselling is a rapidly evolving field, I don’t assume I know everything and adapt my counselling to the product the patient will be trying at this time.
B-4 Approach to early cognitive impairment in the office - Fadi Massoud
1) Should a baseline ekg be done before starting a cholinesterase inhibitor? A baseline EKG is not required routinely in all patients. It is recommended in patients with a PMH of heart disease and in those with abnormal PE (bradycardia or irregular heart rythm)
2) Is it safe to start a cholinesterase inhibitor in first degree AV block? Yes. Clinical trials with ChEI included such patients with no major issues.
3) Is it safe to start a cholinesterase inhibitor in QT prolongation? Some studies have shown a potential for QT prolongation with ChEI, especially donepezil. Therefore, I would not recommend starting a ChEI in such patients.
4) Any ongoing ekg monitoring recommended after starting cholinesterase inhibitor? Not if the patient is asymptomatic.
B-8 Tough cases of lower urinary tract symptoms - Peter Chan
1) You mentioned that for men having OAB symptoms in addition to LUTS, we should not worry about adding anticholinergics if they have a PVR of less than 300 cc- so I presume we should be betting a PVR on these patients first before considering antichonergics? You mentioned that for men having OAB symptoms in addition to LUTS, we should not worry about adding anticholinergics if they have a PVR of less than 300 cc- so I presume we should be betting a PVR on these patients first before considering antichonergics? Ideally, yes, if you have the capacity to perform a bladder scan in your clinic. It is a quick, easy and non-invasive assessment. However, in cases when doing a PVR to document an absence of a high PVR is not possible, you may still choose to add anticholinergics for a patient who has no symptoms or signs that suggest urinary retention safely. Finally, if you are using mirabegron, the risk of retention is lower than with anticholinergics but more costly.
2) Is there still a place for a rectal exam in a healthy asymptomatic male ? (Age 50-70) Is there still a place for a rectal exam in a healthy asymptomatic male ? (Age 50-70) While rectal exam for prostate is "inconvenient" for both parties, it still has an important role in the assessment of prostate health. It does give you a quick idea of the prostate volume (when assessing if LUTS is secondary to BPH and if an elevated level of PSA can be explained by a large prostate), presence or absence of nodule and other findings (such as tenderness that may suggest infection/inflammation), etc. Hence the use of digital rectal exam is still strongly recommended on clinical guidelines for the assessment of prostate health. It is true that with the increased access to prostate ultrasound and MRI, more thorough assessment of the prostate can be done by imaging studies. But cost and time to have these imaging studies remain a significant barrier to use these studies routinely for patients.
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
C-5 Down but not out: Mental health disability management in the new age - Fiore Lalla
1) You commented a little bit about this but I’ve had several scenarios where a patient really isn’t doing well at one particular job either due to a toxic environment etc. and has a legitimate adjustment reaction, but needs income and is in the process of studies for a new career or applying for another job where they feel they will be much better suited and they state that this would probably “cure” their symptoms…how do you approach filling out disability forms for these individuals? As you mentioned, if they are well enough to apply for another job they should be well enough to work at least part-time but if they are having major conflict or issues with a co-worker impacting their health this is tricky.
If they are well enough to apply for another job they should be well enough to work at least part-time.
2) I have a rather high functioning patient who has quit their job and is searching for another job, he has severe anxiety. He wants a letter of proof for his future potential employer stating that he has severe anxiety and would benefit from part time employment to reduce possible future episodes of needing time off due to acute adjustment issues related to the underlying anxiety that tends to be exacerbated by a full time/ busy schedule (however it is the nature of his occupation). How would you approach this?

Try to find better job fit than disclose the anxiety problem.
3) If a patient is off work due to mental health issue, i.e. workplace conflict etc., can they go out of town during their time off? Is this considered " vacation" time and therefore should not be taken during the time off for a disability?

Yes they can take vacation if you stipulate why.
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.
E-3 Seeing back pain in the office - Scott Delaney
Is there any role for topical capsaicin in the treatment of back pain?
I honestly have never prescribed it for back pain. Perhaps because most of the patients I see are acute, lumbar strain or disk related pathology. It certainly has a place in neuropathic pain. In terms of acute lumbar back strain, it would not be first line treatment. Not that there would be anything particularly dangerous about using it. They have also used it in chronic soft tissue related back pain but again, that is a different population from what I normally see in the sports medicine clinic.
PL-4.1 Breast cancer screening in average and high risk patients in 2022 - Stephanie Wong
1) The radiology centre I use reports breast density as a percentage. What is the % cutoff in order to order U/S in conjuction with mammography for screening?
If tomosynthesis was used, I would use 75% as a cutoff to trigger adjunct US (ACR Type D patients with extremely dense breast tissue); If not, then 50% should be the cutoff for using adjunct US on top of standard 2D mammography for screening.
2) If a woman gets a digital tomosynthesis, why would a regular mammography be needed as well?
This is a good question. My understanding is that initially many radiologists who were on their learning curve with tomosynthesis and wanted the standard 2D mammographies to be performed as opposed to relying on the tomosynthesis images only. Now most feel comfortable with the synthetic mammography images (which are reconstructed from tomosynthesis and are simply viewed as opposed to scrolled through) as well as the 3D tomosynthesis images (which one needs to scroll through).
PL-4.3 Vaccine Up-date 2022: will the new technologies introduced during the pandemic change the vaccine landscape? - Brian Ward
What frequency of COVID booster vaccines would you recommend for children from age 5 and up?
The booster recommendations for children 5 years of age or older are a bit of a 'mixed bag' in different jurisdictions but many authorities agree that healthy 5-17 year-olds should have an 'up-dated' (ie: bivalent) booster if it has been more than 2 months (CDC) or 6 months (NACI) since the last dose of their primary series. Note that NACI doesn't make a strong a recommendation for the bivalent booster in a child who has already had a full primary series and a monovalent booster shot. They say the additional booster 'may be considered'. My personal feeling is that most healthy (ie: low risk) children who have already had a full primary series and at least one monovalent booster are likely to be well-protected against severe outcomes and may not get much added benefit from an additional bivalent booster. Note: even if someone in this age group had COVID-19 illness at some point ... an up-dated booster is still suggested if it has been at least 3 months since the illness ... particularly for those at higher risk of severe outcomes. As the pandemic drags on ... the frequency of boosters will continue to be a subject of some debate. Most public health people sincerely hope that we will be able to move to a 'once-a-year' up-dated booster schedule that is aligned with the annual influenza campaign ... but we have no idea if SARS-COV-2 will cooperate with this plan.
A-4 Lipid guideline 2021 - George Thanassoulis
1. Can you give the optimal screening frequency in primary prevention if the initial screening does not reveal a need for a statin? Is it different for those at risk for ASCVD, but whose calculation suggests no need for a statin?
Every 5 years. If new risk factors develop, then risk assessment should be performed again.

2. If a statin is indicated as in the guidelines for primary prevention or for a statin-indicated condition, how soon after starting the stain should the non HDL/LDL/Apo B be repeated to ensure that targets have been met?
6 weeks

3. So many elderly patients fit the definition for Chronic kidney disease (a statin-indicated condition).
a) If a 75 year old patient (or older) has CKD by definition and is not on a statin, should a statin be started?

Yes, unless they have < 2 year life-expectancy
b) Up until what age would you start a statin for CKD?

Any age unless < 2 year life-expectancy or major comorbidities that affect quality of life.

c) At what age does the benefit of starting a statin for CKD start to decline?
No data for this specific subgroup but the data for statin benefits in patients > 75 years in general is quite favorable.

4. I see many patients with incidental findings of atheromatous plaque on the aorta and arterial calcification (outside the coronary arteries) on imaging. (I realize coronary artery calcification is a separate issue). Should all these patients be started on a statin, or just the patients with atheromatous plaque on aorta? Does it depend on the age of the patient? If the decision to start a statin is made for atheromatous plaque on the aorta, should a low dose ASA be started as well?
This is increasingly reported as an incidental finding and the evidence is not well-established. My first approach is to evaluate whether the patient should be on a statin based on primary prevention criteria. In many cases, these patients with incidental findings of atherosclerosis have indications for statins based on primary prevention criteria. If no, I decide based on the extent of atherosclerosis reported. When extensive plaque (more than just intimal thickening) is described in the aorta than I will often recommend statins. I don’t consider ASA for these patients, unless there is evidence for extensive atherosclerosis (and patient has a low risk of bleeding)

5. Does the degree of Lp(a) elevation parallel the patient's risk? (eg do I treat a patient with Lp(a) >1000mg/L similar to a patient with Lp(a) 375mg/L, assuming all other Risk Factors are equal?)
First, I only consider Lp(a) to be clinically significant if it reaches > 500 mg/L (or 100 nmol/L). We don’t have a lot of data to answer whether different levels of Lp(a) should be handled differently. The general principle is to optimize all risk factors (diet, exercise, no smoking, blood pressure, diabetes, and lipoproteins). My goal is to get apoB < 0.8 g/L (or LDL-C < 2.0 mmol/L) for all patients with high Lp(a) in primary prevention. In select patients who have extreme elevations of Lp(a) (i.e. >1500 mg/L), it may be reasonable to be more aggressive (apoB < 0.7 g/L or LDL-C < 1.8 mmol/L).

6. Is there ever any benefit/indication to switching statins for either optimization of treatment, or, minimizing side effects?
The evidence is minimal that switching statins has any major effect for efficacy or tolerability. However, in my practice, for patients who have difficulty tolerating statins, I will often try several different statins to find one that is tolerable. Pravastatin seems to lead to less muscle side-effects. The other consideration for side-effects is trying lower doses or alternate day dosing regimens.

7. In terms of lifestyle modifications, what are the main 'soundbites' you share with the patient that are easy to convey and doable?
30 mins of moderate intensity exercise 5 times per week Eat a well-balanced diet (Mediterranean type) 1 serving of fruits and/or vegetables at each meal At least 1 serving of oily fish per week (salmon, cod etc)

8. Given that Framingham is only assessing for short term risk, is there value in Reynold's score, or other calculator to look at lifetime/longer term risk?
Most scores are based on a 10-yr time frame (including Reynold’s). However, there is a Framingham 30-yr risk score that can be used and can be very valuable for younger patients. The alternative is to use calculated vascular age as described in the CCS guidelines.

9. Why do some labs take up to 2 months to report Lp(a) values while others send the results shortly after test is done?
This is a recent problem due to the larger volume of Lp(a) requests seen at the laboratory. This should return back to normal turn-around times (1-2 weeks) in the next few months. Lp(a) measurement is not particularly complicated and doesn’t require more time than other proteins.

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