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Answers to your questions from our medical experts

Indications for Iron Injections

When are iron injections indicated? Are there strategies to decrease discomfort ? and optimize beneficial effects? Submitted by: Jana Holden, MD, Leduc, Nova Scotia

The management of Further, there has been an association with should be twofold: to determine the underlying ghluteta©l sarcomas. In the 201t0ioAmnerican cause of the condition and to pprescyribeririongSociety of HemaitoslotgyriEbducuation Program, supplementation. Oral iroCn is tohe preferred ini - Auerbach alndDBallard recnolomamde,nded that “the rcia n dow tial route of supplementation. Intramuscumlar euse of IMeinrjsecctiaons should be abandoned.” om sed us al use (IM) iron injections have beren Cused; howevuetrh, ori erson e o ted. A Referencye for p al rohibi le cop we woouldrdisScourage uthseeir puse for severaalsriena g- 1. Auerbach M, Ballard H: Clinical Use of Intravenous Iron: t f rised print Administration, Efficacy, and Safety. Hematology Am Soc Hematol Nosons. nIMauirtohnocan be pawinfaunl,dcan potentially U ay, vie Educ Program 2010; 338 –347. leave permdanisenptlskin discolouration, and is not Answered by: Dr. Cyrus Hsia more effective or safe than intravenous iron. Dr. Leonard Minuk

Assessing ASA Effect

Are urine tests helpful to assess ASA effect? ? Submitted by: Gail Dangoor, MD, Thornhill, Ontario

There are several tests that can be used to assess In general, a second antiplatelet drug ( e.g. , the effects of ASA on platelet aggregation. Urinary clopidogrel) that acts by a different mechanism is 11-dehydro-thromboxane B2 levels should be added when a patient experiences a myocardial suppressed in the setting of ASA use. However, infarct while on ASA. Tests for ASA resistance are multiple factors can result in thrombotic events in not routinely indicated in clinical practice. patients who are prescribed ASA, including non- compliance, interaction with other drugs, strong Answered by: Dr. Bibiana Cujec thrombotic stimulus, and resistance to the effects of ASA.

The Canadian Journal of Diagnosis / January 2012 19 Experts on Call

Treatment Options for Thrombosed External

Can you recommend practical non-surgical options for acutely thrombosed ? external hemorrhoids? Submitted by: P. Balcar, MD, New Westminster, British Columbia

Hemorrhoids result from dilation of the submu - analgesics and sitz baths. All patients with cosal vascular tissue in the distal . hemorrhoids should be treated with dietary Normally these fibrovascular cushions con - changes aimed at increasing stool bulk. In tribute to resting anal pressure and fecal conti - addition to increased fluid intake, a meta- nence. When one of these cushions becomes analysis reviewing 378 patients found that abnormally large and produces symptoms, we those receiving fiber laxatives displayed call it a . Although the etiology reduced hemorrhoid symptoms compared to remains unclear, it is likely that straining with those receiving nonfiber laxatives. 1 Practically contributes to their development. speaking, sugar-free Metamucil, which con - External hemorrhoids, those located below tains psyllium fiber, is a good choice; start at 1 the dentate line, are prone to , an tbs daily taken in yogurt. This can be increased acutely painful condition. The diagnosis is con - to reach the desired effect of a daily, soft firmed with physical exam. If left untreated, the formed bowel movement. Please note that pain usually resolves in 48 to 72 hours. If the there is no evidence for nonprescription topical patient presents with intolerable pain within 24 preparations containing , anaesthetics, hours of symptom onset, the clot should be , and antiseptics. removed under local anaesthesia with the skin References edges left to heal by secondary intention. 1. Alonso-Coello P, Guyatt G, Heels-Ansdell D, et al : Laxatives for the Those presenting after 24 hours should be Treatment of Hemorrhoids. Cochrane Database Syst Rev. 2005; (4):n.p. 2. Mounsey AL, Halladay J, Sadiq TS: Hemorrhoids. Am Fam Physician treated conservatively, since the pain of surgery 2011; 84(2):204 –210. in addition to the thrombosis is worse than the initial pain. These patients can be given topical Answered by: Dr. Robert Bailey and 0.3% nifedipine cream (with or without lido - Dr. Mike McCall caine cream), which relieves pain through anti- inflammatory and relaxing properties. This can be combined with oral

20 The Canadian Journal of Diagnosis / January 2012 Experts on Call

RAST Testing

Which patients would benefit from RAST testing? ? Submitted by: Julie Torrie, MD, Medicine Hat, Alberta

Radioallergosorbent (RAST) testing is a radioim - hospital settings. 2 RAST testing to environmen - munoassay test to detect specific IgE antibodies tal allergens ( e.g. , pollens, animal dander) is gen - to suspected or known allergens. RAST testing erally not done due to the superior predictive can be used to detect specific antibodies to value of skin prick testing to standardized aller - food, environmental allergens, insect sting gens. In rare circumstances, it may be necessary venom, and -lactam antigens. The presence of to choose RAST testing over allergy skin prick or these antibodβies indicates that a patient is sen - intradermal testing. For example, if the patient sitized to that allergen (may still be clinically tol - recently suffered anaphylaxis, false negative skin erant). This is in contrast to being allergic, which tests may occur due to skin mast cell depletion also entails clinical reactivity. Therefore, the (better to wait a month, then perform skin tests). meaning of a positive RAST test is highly vari - Severe eczema may make interpretation difficult able and is dependent upon the clinical history (a rare situation), and some patients cannot dis - (i.e. , the likely presence of true allergy), the type continue antihistamines for an adequate period of allergen tested, as well as patient-specific fea - of time (these interfere with skin test responses). tures ( e.g. , total IgE level). For antibiotics, RAST Of note, specific IgE antibodies to more specific testing has poor predictive value. In the case of epitopes on certain allergens ( e.g. , Ara h2 vs Ara food and venom testing, the RAST suffers from h8 peanut protein allergens) look to give us even inferior sensitivity compared to skin prick test - more information about clinical reactivity pheno - ing, but use of serial RAST testing in the follow- types, and hopefully we’ll be seeing more of up of these patients over time may aid in clinical these tests in the near future. decision making as to whether tolerance to that References allergen is likely. To this end, “cut-off values” in 1. Sampson HA: Utility of Food-specific IgE Concentrations in Predicting Symptomatic Food Allergy. J Allergy Clin Immunol 2001; certain food specific IgE levels have been devel - 107(5):891 –896. oped. Specific IgE levels above these values are 2. Shek LP, Soderstrom L, Alstedt S, et al : Determination of Food Specific IgE Levels Over Time Can Predict the Development of Tolerance in indicative of a very high likelihood of clinical Cow's Milk and Hen's Egg Allergy. J Allergy Clin Immunol 2004; reactions upon exposure. 1 This can be helpful 114(2):387 –391. when timing oral food challenge in the clinic and Answered by: Dr. Tom Gerstner

22 The Canadian Journal of Diagnosis / January 2012 Experts on Call

Cluster Migraines

What are “cluster migraines” and what is the best treatment and prophylaxis for ? them? Submitted by: Paul Stephan, MD, Scarborough, Ontario

Cluster headaches are characterized by short- Intranasal in the ipsilateral nostril or lived attacks of peri-orbital pain for a period of inhalation of methoxyflurane are also effective. one to two months, followed by a pain-free inter - Triptan therapy commonly used in migraine val that may last up to one year. The chronic headaches is also effective in cluster head- form of cluster headaches is sometimes referred aches. Prophylactic drugs that are effective to as chronic migrainous neuralgia. in treating cluster headaches include pred - Cluster headaches are clinically different from nisone, lithium, methysergide, pizotifen, nifedip - migraines and have a prevalence of approxi - ine, verapamil, nimodipine, indomethacin, and mately 70 per 100,000 population. Males are cyproheptadine. affected more than females, and usual age of Blockade of the greater occipital nerve ipsi - onset is between 20 – and 50 –years –of –age. lateral to the side of attacks, trigeminal sensory The pain during an attack is usually excruci - rhizotomy, and percutaneous radiofrequency ating and starts without any aura. It reaches its trigeminal rhizotomy have been reported to be peak within 15 minutes and lasts from half an successfull as well. hour to two hours. Attacks may recur at the Reference same time each day, and most of the attacks 1. Rana AQ: Synopsis of Neurological Emergencies. Authorhouse, occur in late evening. Bloomington, Indianna, 2009. Lacrimation from the eye or nose on the Answered by: Dr. Abdul Qayyum Rana affected side may be seen in many cases. For acute attacks, ergotamine or inhalation of 100% oxygen for 10 to 15 minutes is very effective. Experts on Call

Treatment of Onychomycosis

What are the current recommendations for treatment of onychomycosis in ? older patients? Submitted by: Anna Byszewski, MD, Ottawa, Ontario

The prevalence of onychomycosis in patients older with dermatophyte onychomycosis, oral from 60 – to 79 –years –of –age has been report - terbinafine gave a mycologic cure rate of 64% ed to be 18.2% in a multicentre Canadian sur - and a clinical efficacy rate of 62% at 18 months vey of 15,000 patients. 1 Elderly patients may from the start of therapy. 2 Importantly, there respond poorly to therapy for onychomycosis were no significant adverse events or clinically because of several factors. These include significant laboratory abnormalities in this slow growth of nails, frequent nail dystrophy, study in which 50 patients received oral and increased co-morbidities, such as periph - terbinafine. eral and diabetes mellitus. In cases where there are contraindications Although there are no current specific rec - or concerns about drug interactions, topical ommendations for treating onychomycosis in 8% ciclopirox olamine nail lacquer could be older patients, it is quite appropriate to give a used. It would be appropriate in cases of three trial of therapy to elderly patients with ony - or less affected nails and less than 50% of chomycosis after proper documentation of the nailplate involvement without lunular (matrix) diagnosis with a KOH preparation and fungal involvement. However, it is much less effective culture and a discussion with the patient about in producing mycologic and clinical cure than potential side effects of systemic therapy and oral terbinafine. It also requires weekly debrid - drug interactions. ing of the affected nails and needs to be Oral terbinafine is the best treatment for der - applied nightly for 48 weeks. matophyte onychomycosis, giving the highest References mycologic and clinical cure. I believe this to be 1. Gupta AK, Jain HC, Lynde CW, et al : Prevalence and Epidemiology of the treatment of choice if there are no con - Onychomycosis in Patients Visiting Physicians’ Offices: A Multicenter Canadian Survey of 15,000 Patients. J Am Acad Dermatol 2000; 43 (2 traindications. Oral terbinafine is given in a Pt 1):244 –ß248. dose of 250 mg o.d. for 12 weeks for toenail 2. Gupta AK, Konnikov N, Lynde CW. Single-blind, Randomized, Prospective Study on Terbinafine and Itraconazole for Treatment of onychomycois and 6 weeks for fingernail ony - Dermatophyte Toenail Onychomycosis in the Elderly. J Am Acad chomycosis. Patients need to be advised that it Dermatol 2001; 44(3):479 –484. can take up to six months for fingernails and Answered by: Dr. Richard Haber one year for toenails to grow out after therapy. In a Canadian study in which oral terbinafine was used in patients 60-years-of-age or

24 The Canadian Journal of Diagnosis / January 2012 Experts on Call

Rubella Immunity in

If it is shown that a mother is immune to rubella, does it need to be checked ? again in subsequent ? Submitted by: Herbert Chang, MD, Coquitlam, British Columbia

Once a woman is shown to be rubella immune, remain susceptible to rubella. Most obstetri - it is not necessary to retest in pregnancy. Up to cians continue to test for rubella immunity dur - 5% of individuals do not seroconvert after ing routine prenatal blood work regardless of a rubella immunization. There are women born in woman’s immune status. Canada (presumably immunized as children) and who have delivered infants and who have Answered by: Dr. Victoria Davis been reimmunized for rubella postpartum yet

Prescribing Methylphenidate for Bipolar Disorder

Please comment on the use of methylphenidate in treating bipolar disorder. ? Submitted by: Reynald Gilbert, MD, Lac Etchemin, Québec

The recommended treatment sequence in bipo - Because of the high risk of switching to hypo - lar depression includes the following: mania or mania, methylphenidate is not recom - mended in treating bipolar patients, except in 1. Optimizing the dose of the current mood the case of children and adolescents who pre - stabilizer regimen sent with both bipolar disorder and ADD. In that 2. Augmenting with triiodothyronine (T3), case, methylphenidate will be prescribed only lithium, or folate after the mood is stabilized on a mood stabilizer. 3. Adding another mood stabilizer Resource 4. Using or adding an atypical antipsychotic 1. Post RM, Altshuler LL: Mood Disorders: Treatment of Bipolar Disorders (Chapter 13.9). In Sadock BJ, Sodock VA, Ruiz P (eds.): Kaplan & 5. Adding an antidepressant to the mood Sadock’s Comprehensive Textbook of Psychiatry. 9th edition. stabilizer. A SSRI antidepressant might Lippincott, Williams, & Wilkins, Philidelphia, 2009, 1743 –1812. be a preferable next adjunct, especially if a patient has a comorbid OCD. The Answered by: Dr. Hany Bissada SNRIs should be used with caution in bipolar illness, because venlafaxine had a higher switch rate than bupropion and the other SSRIs.

26 The Canadian Journal of Diagnosis / January 2012 Experts on Call

Dry Skin and Nummular Eczema

What causes dry skin to progress to nummular eczema in adults? ? Submitted by: R. Lewis, MD, Kamloops, British Columbia

Dry skin, or xerosis, does not progress to num - clinically by erythematous scaly patches with mular eczema. Nummular eczema is an idio - polygonal fissuring and is also known as pathic dermatitis characterized by “coin- eczema craquelé. This usually responds well to shaped” erythematous scaly and crusted a mild topical corticosteroid, such as 1% plaques. It usually responds well to medium hydrocortisone ointment, for the asteatotic potency topical corticosteroids or a topical cal - eczema as well as regular use of emollients for cineurin inhibitor, such as tacrolimus 0.1% the xerosis. ointment. Dry skin, or xerosis, can be associated with Answered by: Dr. Richard Haber asteatotic dermatitis. This is characterized Experts on Call

Complex Regional Pain Syndrome

What are the treatment, prognosis, and return to work (RTW) for complex ? regional pain syndrome (CRPS) Type 1? Submitted by: René Boucher, MD, Edmundston, New Brunswick

The symptoms of typical CRPS consist of valproate, clonazepam, topiramate, and amot - disproportionate extremity pain, swelling, and rigine, are another class of drugs that may be autonomic disturbance. CRPS affects the upper effective. Benzodiazepines and baclofen may extremities slightly more than the lower extrem - be helpful in decreasing muscle spasm. ities. Pain is reported in more than 90% of Individuals requring nerve blocks may require a patients. Motor dysfunction, muscle spasms, short hospitalization. Early diagnosis is impor - tremour, incoordination, and sensory symptoms tant to prevent complications or development to of hypoesthesia, hyperesthesia, and allodynia chronic stage. Children with CRPS have a bet - may occur. ter prognosis compared to adults. Returning to A multimodality approach may be needed to work depends upon many factors, such as indi - manage these patients. Commonly used drugs vidual personality, depression, degree of pain, include opioids, tramadol, acetaminophen, success in pain control, and nature of work, and and nonsteroidal anti-inflammatory drugs. hence, no general statement can be made. Tricyclic antidepressants, including amitriptyline, Patients with chronic problems may develop imipramine, nortriptyline, as well as selective anxiety, hopelessness, and depression. serotonin reuptake inhibitors, including paroxe - tine, can also be used. Anticonvulsants, such as pregabalin, carbamazepine, phenytoin, sodium Answered by: Dr. Abdul Qayyum Rana

Dumping Syndrome

What is the “”? ? Submitted by: J.S. Bradley, MD, Calgary, Alberta

Dumping syndrome is a condition that usually and alterations in the gastrointestinal hormonal exists after a partial gastrectomy. It is character - milieu. Symptoms typically occur soon after ized by the rapid emptying of hypertonic gastric eating. Treatment includes eating small meals contents into the small intestines. This results in throughout the day and avoiding foods that are symptoms of , abdominal cramps, diar - rich in , carbohydrates, and simple sugars. rhea, diaphoresis, lightheadedness, and palpita - tions due to the rapid transfer of plasma volume Answered by: Dr. Richmond Sy

28 The Canadian Journal of Diagnosis / January 2012 Experts on Call

Hypothyroidism in Patients on Amiodarone

What is the epidemiology of hypothyroidism in patients prescribed amiodarone? ? Submitted by: Krieger, MD, Toronto, Ontario

Amiodarone induced hypothyroidism (AIH) patients. AIH usually develops earlier than AIT, occurs more frequently than amiodarone- both in patients with apparently normal thyroid induced thyrotoxicosis (AIT) in iodine-sufficient glands and in patients with pre-existing thyroid areas. In regions of moderately low iodine abnormalities. intake the frequency can be as low as 5%, ver - sus 22% in regions with sufficient iodine intake. Answered by: Dr. Ally Prebtani AIH is more frequent in females and in older Experts on Call

Early Stages of Basal Cell Carcinoma

How can one recognize the early stages of basal cell carcinoma? ? Submitted by: Catherine McCuaig, MD, Montréal, Québec

Basal cell carcinoma is the most common type 3. Raised papules, especially if translucent in of skin cancer. There are several clinical variants appearance or with a rolled border and including nodular, superficial, pigmented, scle - overlying , should suggest a rosing (morpheaform), and cystic. It may be dif - nodular basal cell carcinoma. With time ficult to diagnose basal cell carcinoma in its ear - these may ulcerate liest stages. A high index of suspicion should 4. Scar-like areas, especially if there is no occur in a patient with a history of excessive history of trauma, could suggest a ultraviolet exposure who presents with any of sclerosing basal cell carcinoma the following findings: When in doubt, it is best to biopsy any suspi - 1. Nonhealing lesions, especially if they are cious lesions to make a definitive diagnosis. bleeding 2. Erythematous patches that are persistent Answered by: Dr. Richard Haber (especially on the upper chest and back) could suggest a superficial basal cell carcinoma

Topiramate for Weight Control

Are there any studies regarding the use of topiramate to facilitate weight control ? in patients taking psychotropic medications/antidepressants? Submitted by: Francine Pagé, MD, Ottawa, Ontario

Topiramate is approved for the treatment of with or without binge eating. McElroy et epilepsy in children and adults, as well as for the al suggest the use of topiramate to control psy - prevention of migraine in adults. There is evi - chotropic-associated weight gain.

dence to suggest that topiramate possesses References antibingeing effects, and it is associated with 1. McElroy SL, Guerdjikova A, Keck Jr PE, et al : Antiepileptic Drugs in Obesity, Psychotropic-induced Weight Gain, and Eating Disorders. In: anorexia and weight loss in a wide range of con - McElroy SL, Keck Jr PE, Post RM (eds.): Antiepileptic Drugs to Treat ditions. Placebo controlled data suggests that Psychiatric Disorders. Informa Healthcare, New York, 2008, 283 –309. topiramate may be effective in the treatment of Answered by: Dr. Hany Bissada

30 The Canadian Journal of Diagnosis / January 2012 Experts on Call

Diagnosing Pulmonary

What is the best test for diagnosing a ? ? Submitted by: Christopher Lebos, MD, Montréal, Québec

Depending on institutional experience, a CT Table 1 pulmonary angiogram or a ventilation perfusion Modified Wells Criteria lung scan is the best test to diagnose pul - Criteria Points monary embolism. CT pulmonary angiography Symptoms of DVT 3 has a sensitivity of ~85% for detection of pul - No Alternative Diagnosis that 3 monary embolism and a specificity of ~95%. Better Explains the Symptoms Ventilation perfusion lung scan has similar Pulse > 100 1.5 diagnostic accuracy. The advantage of CT pul - Immobilization (> 3 Days) or 1.5 monary angiography is that it may detect Surgery in Previous 4 Weeks another cause of the patient’s chest pain or Prior History of Pulmonary 1.5 dyspnea — for example, aortic or Embolism or DVT consolidation. The disadvantage is that con - Hemoptysis 1 trast dye is required, and this may cause acute Malignancy 1 kidney injury in patients with underlying renal dysfunction. Contrast should be avoided in embolism. A CT pulmonary angiogram should patients with severely reduced renal function be performed in patients with likely pulmonary (GFR < 30 mL/m 2) or contrast allergy. embolism or unlikely pulmonary embolism with These radiological tests should be com - positive D-dimer. A negative CT pulmonary bined with the clinical probability of pulmonary angiogram excludes the diagnosis of pul - embolism based on the modified Wells criteria. monary embolism, and a positive CT pul - The scores for the criteria in Table 1 should be monary angiogram confirms the diagnosis in added. Pulmonary embolism is likely if the this setting. In general, I reserve ventilation per - summed score is > 4 and unlikely if ≤ 4. fusion lung scans for patients who have con - If pulmonary embolism is unlikely based traindications to CT pulmonary angiography. on this score, serum D-dimer should be per - formed. If the D-dimer is negative, this effec - Answered by: Dr. Bibiana Cujec tively excludes the diagnosis of pulmonary

32 The Canadian Journal of Diagnosis / January 2012 Experts on Call

Predisposing Factors for Helicobacter pylori

What are predisposing factors for H. pylori infection? ? Submitted by: Nafisa Aptekar, MD, Brampton, Ontario

Helicobacter pylori is the most common chron - amongst nursery school children. H. pylori has ic bacterial infection in humans. It is associated also been demonstrated in the oral cavity, sup - with antral , , gastric porting an oral-oral mode of transmission. Race mucosa-associated lymphoid tissue (MALT) has also been examined as a potential risk fac - lymphoma, and gastric adenocarcinoma. The tor for H. pylori infection, as increased rates of majority of individuals with H. pylori are asymp - infection have been noted in African Americans tomatic. In developing countries, the prevalence and Hispanics when compared to Caucasians. of H. pylori is noted to be greater than 80% However, socioeconomic factors may play a before the age of 50 years, while in developed large role in the varied prevalence. Some stud - countries, the prevalence is approximately 50% ies have also found that people with O blood before the age of 60 years. H. pylori prevalence group are more susceptible to H. Pylori infec - varies significantly with age, socioeconomic tion, as well as its gastrointestinal symptoms, status, and country of residence. 1 A predispos - when compared to other ABO groups. 4-5 These ing factor for H. pylori is poor socioeconomic results have been both reproduced and rejected status. Risk factors for the infection include liv - in further studies, making this association ing in housing without paved roads and without controversial. 6 flushing , which are indicators for impov - References erished living conditions associated with poorer 1. Kanbay M, Gur G, Arslan H, et al : The Relationship of ABO Blood sanitation and overcrowding. This supports the Group, Age, Gender, Smoking, and Helicobacter pylori Infection. Dig Dis Sci 2005; 50(7):1214 –1217. fecal-oral mode of transmission. Using a statis - 2. Strebel K, Rolle-Kampczyk U, Richter M, et al : A Rigorous Small Area tical inference model, one study found that Modelling-study for the Helicobacter pylori Epidemiology. Sci Total Environ 2010; 408(18):3931– 3942. more than three children living in a household, 3. Goh KL, Chan WK, Shiota S et al : Epidemiology of Helicobacter pylori more persons per m 2 than average, a home sit - Infection and Public Health Implications. Helicobacter 2011; 16 (Suppl 1):1 –9. uated on a main road, and the use of well water 4. Jaff MS: Relation between ABO Blood Groups and Helicobacter pylori were strongly associated with H. pylori infec - Infection in Symptomatic Patients. Clinical Exp Gastroenterol 2011; 4: 221–226. tion. 2 Living in rural areas has been associated 5. Kanbay M, Gur G, Arslan H, et al : The Relationship of ABO Blood Group, Age, Gender, Smoking, and Helicobacter pylori Infection. with increased H. pylori infection when com - Digestive Diseases and Science 2005; 50(7):1214 –1217. pared to urban areas. 3 Transmission of H. pylori 6. Turkolmez S, Derya C, Fusun A, et al : The Relationship of Helicobacter pylori Positivity with Age, Sex, and ABO/Rhesus Blood Groups in has been determined to occur during early Patients with Gastrointestinal Complaints in Turkey. Helicobacter childhood. Recent studies have supported find - 2007; 12(3):244 –250. ings that infected siblings were a significant risk Answered by: Dr. Robert Bailey and factor for H. pylori infection and have noted that Dr. Jennifer Chaulk the rate of infection was also increased

34 The Canadian Journal of Diagnosis / January 2012 Experts on Call

Diagnosis and Treatment of Pulmonary Fibrosis

How does one diagnose and treat pulmonary fibrosis? ? Submitted by: Nicolas Boudrealt, MD, Etchemin, Québec

In 2011, a number of international respiratory Patients diagnosed with IPF should be societies jointly published updated guidelines referred to a respirologist for monitoring and for the diagnosis and management of idiopathic treatment. Unfortunately, evidence-based, ef- pulmonary fibrosis (IPF). 1 IPF was defined as “a fective treatment options are lacking for IPF. specific form of chronic, progressive fibrosing The recent guidelines recommend against interstitial pneumonia of unknown cause, occur - monotherapy with systemic corticosteroids, ring primarily in older adults, limited to the lungs, colchicine, cyclosporine, interferon gamma, and associated with the histopathologic and/or bosentan, or etanercept. The guidelines radiologic pattern of usual interstitial pneumonia also recommended against the use of a combi - (UIP).” 1 nation of systemic corticosteroids and an Clinically, IPF presents with symptoms of pro - immune modulating agent ( e.g. , azathioprine, gressive dyspnea and , signs of inspirato - cyclophosphamide). There was a weak recom - ry crackles, and, often, clubbing. Pulmonary mendation based on low quality evidence that function studies typically reveal a restrictive some patients might benefit from a trial of treat - defect (low lung volumes) with impaired gas ment with acetylcysteine, pirfenidone, or exchange at rest and during exertion ( e.g. , anticoagulants. Treatment is aimed at avoid- reduced diffusing capacity, hypoxemia). ing lung infections ( e.g. , vaccinations, good Although the natural history of IPF is variable hygiene), medical management of symptomatic and unpredictable, most patients experience a gastroesophageal reflux disorder, and main - steady worsening with progressive decline over taining overall fitness ( e.g. , pulmonary rehabili - months to years in exercise tolerance and lung tation). Supplemental oxygen is recommended function, which may ultimately result in pul - in the setting of severe resting hypoxemia. monary , chronic respiratory failure, Favourable long-term survival has been report - and death. ed for appropriately chosen individuals who Diagnosis is confirmed when other causes of undergo lung transplantation. Ultimately, as the interstitial lung disease are ruled-out and find - disease progresses, palliation of symptoms is ings typical of UIP are seen on a chest high-res - paramount and may require the involvement of olution commuted tomography scan (HRCT). a palliative care specialist for assistance in Those changes include a subpleural predomi - caring for intractable dyspnea and cough . nance of reticular interstitial opacities and hon - Reference eycombing with or without traction bronchiecta - 1. Raghu G, Collard Hr, Egan JJ, et al : An official ATS/ERS/JRS/ALAT sis. In the absence of typical findings or pres - Statement: Idiopathic Pulmonary Fibrosis: Evidence-based Guidelines for Diagnosis and Management. Am J Respir Crit Care Med 2011; ence of atypical findings on HRCT a surgical 183(6):788 –824. lung biopsy is required to confirm the diagnosis showing histological features consistent with a Answered by: Dr. Paul Hernandez UIP pattern.

36 The Canadian Journal of Diagnosis / January 2012 Experts on Call

Examination of Thunderclap Headache

When a patient presents with “thunderclap” headache and the CT is negative, is ? a lumbar puncture mandatory? Submitted by: Sean O’Sullivan, MD, Tillsonburg, Ontario

Subarachnoid hemorrhage is included in the dif - meningitis. Intial investigation in these patients is ferential diagnosis of sudden onset of extremely CT scan of the head, which usually shows severe headache, commonly known as thunder - hyperdensity in the major fissures and sulci or clap headache. This is a neurological emer - around the brain stem. However, in about 5 to gency. Neurological examination may initially be 10% of patients, the CT scan may be normal, normal in these patients. Although meningeal and in these cases, lumbar puncture is required. signs, such as Kernig’s sign and Brudzinsky’s Reference sign may be positive, meningeal signs have low 1. Rana AQ: Synopsis of Neurological Emergencies. Authorhouse, sensitivity and specificity. Also, meningismus is Bloomington, Indiana, USA 2009. 51 –68. not specific to subarachnoid hemorrhage, and Answered by: Dr. Abdul Qayyum Rana these signs may be seen in infection, such as Experts on Call

Treatment for Oral Stomatitis

What solution do you suggest for oral stomatitis resulting from chemotherapy? ? Submitted by: Joslyn Warworuk, MD, Windsor, Ontario

The most common treatment for oral stomatitis most contain at least three ingredients. Usually is to use “magic mouthwash” for symptomatic the formulations are designed to be taken every relief. The constituents of the mouthwash often four to six hours. include an antacid, an antifungal ( e.g. , nys - tatin), an antibiotic ( e.g. , tetracycline), an anti - Answered by: Dr. Richmond Sy histamine, a topical anaesthetic ( e.g. , xylo - caine), and an anti-inflammatory ( e.g. , hydro - cortisone). There are many combinations, but Experts on Call

Methadone for IBS

Can we prescribe a low-dose methadone for an IBS patient with chronic back ? and neck symptoms? What would be the dosage? Submitted by: Michael Mansour, MD, Montréal, Québec

Due to their highly addictive potential, it is not recommended to prescribe narcotics for the Answered by: Dr. Richmond Sy treatment of for patients with irri - table bowel syndrome.

Statin Indications

Is there still an indication for a statin in an 85-year-old patient? ? Submitted by: Sébastien Paquin, MD, Québec, Québec

There is inadequate clinical trial data to address average ages of 50 to 60 years, the absence of this specific question. I would not treat an ele - proof of benefit is not the same as proof of the vated LDL (even > 5.0 mmol/L) in an absence of benefit. Recently, a study of hyper - 85-year-old patient who does not have clinical tension treatment in the elderly found significant evidence of vascular disease ( i.e. , no myocardial benefit from treatment. 2 infarction, stroke, or peripheral arterial disease). References However, if the patient has vascular disease, I 1. Genest J, McPherson R, Frohlich J, et al : 2009 Canadian Cardiovascular Society/Canadian Guideline for the Diagnosis and Treatment of would definitely recommend long-term statin Dyslipidemia and Prevention of in the Adult — therapy with similar targets to a younger patient 2009 Recommendations. Can J Cardiol 2009;25(10):567 –579. 1 2. Beckett NS, Peters R, Fletcher AE, et al : Treatment of Hypertension in (i.e. , LDL < 2.0 or 50% reduction in LDL). Statin Patients 80 Years of Age or Older. N Engl J Med 2008; 358(18): therapy prevents myocardial infarction and 1887 –1898. improves survival in patients with coronary Answered by: Dr. Bibiana Cujec disease. Although data to date has been derived from clinical trials of patients with

40 The Canadian Journal of Diagnosis / January 2012 Experts on Call

HPV Vaccine and Viral Shedding

I have a male patient with venereal warts. I have no place to send the ? sample for strain determination. Will the HPV vaccine protect his future wife from both cervical cancer and wart contraction? Submitted by: Irwin Asbell, MD, Toronto, Ontario

There are no studies that investigate the effect of not been previously exposed to the virus. There viral shedding after a male (or female) that is infect - are studies that demonstrate partial protection ed with human papillomavirus (HPV) has been against the acquisition of the nonvaccine HPV given the HPV vaccine. Published studies look at types that cause approximately 20% of cervical the outcomes in the individuals immunized. Most cancers. 2 As the HPV vaccine has been shown to genital warts are cause by HPV types 6 and 11. be safe and effective in men and women, the vac - The quadrivalent HPV vaccine, which covers types cine, in this case, can at least do no harm and may 6 and 11 (as well as types 16 and 18, the cause of be of benefit. most cervical cancers and precancerous lesions), References is now approved in Canada for men and could be 1. Giuliano AR, Palefsky JM, Goldstone S, et al : Efficacy of Quadrivalent HPV recommended for the patient in this case, as there Vaccine Against Infection and Disease in Males. N Engl J Med 2011; 364(5):401 –411. may be benefits to the individual and his part - 2. Wheeler CM, Kjaer SK, Sigurdsson K, et al : The Impact of the Quadrivalent ner(s). 1 The partner(s) of this individual should also Human Papillomavirus (HPV: Types 6, 11, 16, and 18) L1 Virus-like Particle Vaccine on Infection and Disease Due to Oncogenic Non-vaccine HPV be encouraged to have the HPV vaccine, as it has Types in Sexually Active Women Aged 16 –26 Years. J Infect Dis 2009; been proven to be safe and effective in the reduc - 199(7):936 –944. tion of HPV related disease, especially if they have Answered by: Dr. Victoria Davis

Stimulant Medications and Mood Destabilization

Could stimulant medications used to treat ADHD in the bipolar patient result in ? mood destabilization? Submitted by: Heather Sylvester, MD, Stratford, Ontario

Psychostimulants may precipitate manic or hypo - patient is well stabilized and fully compliant with manic symptoms in undiagnosed or not ade - the prescribed pharmacological treatment for the quately treated bipolar patients. It is preferable not bipolar disorder. Such a decision should be taken to use psychostimulants in patients with a history in consultation with a psychiatrist. of functional psychosis, including bipolar patients, Answered by: Dr. Hany Bissada unless the benefits outweigh the risks and the

The Canadian Journal of Diagnosis / January 2012 41 Experts on Call

Predictors for Myalgias/Myositis

Are there any predictors as to who may get myalgias/myositis with statins? ? Submitted by: Lorne Singer, MD, Kitchner, Ontario

Statin-induced myopathy is more common with to develop myalgias or myositis with statin certain statins, higher statin doses, drug interac - therapy. Statins may also unmask an underlying tions, and patients with genetic predisposition or neuromuscular disorder ( e.g. , polymyositis, certain underlying conditions. mononeuritis multiplex, amyotrophic lateral scle - Statin-induced myopathy is less common with rosis). Of note, the FDA has issued a warning pravachol and rosuvastatin. These statins are not regarding the use of simvastatin 80 mg daily metabolized by the cytochrome P450 (CYP3A4) because of the risk of myositis. Some patients system unlike simvastatin, atorvastatin, or lovas - have a genetic predisposition to statin-induced tatin. Myopathy is more common when a myopathy (variants of the SLCO1B1 gene that statin is given in combination with a fibrate or codes for a peptide that mediates uptake of cyclosporine. Erythromycin, clarithromycin, HIV statins into myocytes and hepatocytes). These protease inhibitors, amiodarone, diltiazem, and patients can be intolerant of any statin, even in verapamil also increase levels of statin and may very small doses. cause myopathy. Likelihood of statin-induced myopathy increases with older age and higher Answered by: Dr. Bibiana Cujec doses. Patients with renal failure, obstructive liver disease, or hypothyroidism are more likely

tatin-induced myopathy is more common with certain Sstatins, higher statin doses, drug interactions, and patients with genetic predisposition or certain underlying conditions.

42 The Canadian Journal of Diagnosis / January 2012 Experts on Call

Safe Levels for Elevating Creatinine Kinase

If someone is on statins with previously normal levels of LFTs and CK, what is ? the safe level to hit when elevating LFTs and CK? Submitted by: Alexander Voros, MD, Pilot Mound, Manitoba

Statins are important medications to prevent done once the CK has decreased. CK levels CVD, but they can have side effects, such as should be monitored in three to six weeks. If myalgias and can be associated with elevations the CK level is less than five times normal, the in liver enzymes or creatinine kinase (CK) levels. statin can be continued and monitored with If myalgias are present without biochemical reassessment in 6 to 12 weeks abnormalities, discontinuing the statin with a With regards to an elevation of transaminase reintroduction when symptoms resolve can levels, these occur relatively rarely. In large often be used to assess whether the statin is studies the elevation of liver enzymes of greater causing the symptoms. Using the lowest effec - than three times elevation occurred in about tive dose and mild symptoms may enable some 3% of individuals. Large elevations in transam - to reach their lipid targets. inase levels are uncommon, and other causes Recently, a consensus group provided some should be sought. Discontinuation of statins guidance on the evaluation of an individual with should be done if there is a 10 times elevation an elevation in CK levels. If the CK is elevated of the transaminase levels.

10 times or more, the statin should be discon - Dx Reference tinued and evaluation of the individual is 1. Mancini GB, Baker S, Bergeron J, et al : Diagnosis, Prevention, and required and treatment may be necessary for Management of Statin Adverse Effects and Intolerance: Proceedings of a Canadian Working Group Consensus Conference. Can J Cardiol rhabdomyolysis. An elevation between 5 and 2011; 27(5):635 –662. 10 times the CK level is considered less severe, Answered by: Dr. Vincent Woo and again the statin should be stopped. Consideration of restarting the statin can be

44 The Canadian Journal of Diagnosis / January 2012