CONSULTANT’S CORNER
                                           Practical Answers To Your Everyday Questions

                                                                          This month—8 answers:

                                                                     1.     Advising on adult ADHD
                                                                     2.     Dealing with CRPS
      Advising on adult ADHD
                                                                     3.     Disc replacement update

1.   What medications are
     effective for adults with
                                   The key to treating adult
                                   attention deficit hyperactivity
                                   disorder (ADHD) is in making

                                                                            The travelling child—what do
                                                                            you recommend?
                                                                            Looking for Lyme disease
                                   the diagnosis.
     Question submitted by:                                          6.     Is SARS making a
     Laura Chapman, MD             In our practice, we do not               comeback?
     Vancouver, British Columbia
                                   treat for adult ADHD unless
                                   there are current ADHD            7.     Understanding umbilical
                                   symptoms and a clear                     hernias
                                   childhood history of ADHD.
                                   Also, there must be
                                                                     8.     Subclinical hyperthyroidism
                                   significant functional                   help
                                   impairment in multiple areas.
                                                                            better to consider an
                                   Before choosing a medication, it is      antidepressant.
                                   important to rule out other
                                   psychiatric disorders and                Studies have shown that
                                   establish comorbid psychiatric           desipramine, bupropion SR and
                                   diagnoses.                               atomoxetine are antidepressants
                                                                            that are almost as effective as
                                   Stimulants, like methylphenidate         stimulants for adult ADHD.
                                   and dextroamphetamine, remain the
                                   first-line treatment for adult ADHD.     Answered by:
                                                                            Matthew Morgan, BSc, MD
                                   A stimulant should be titrated to a      Senior Psychiatry Resident
                                   dose that maximizes reduction of         Dalhousie University
                                   ADHD symptoms with minimal side-         Halifax, Nova Scotia
                                   effects (e.g., insomnia, hypertension,   Kayhan Ghatavi, MD, FRCPC
                                   weight loss).                            Consultation-Liaison Staff Psychiatrist
                                                                            Dalhousie University
                                   If the patient does not respond/         Halifax, Nova Scotia
                                   tolerate a stimulant or has comorbid
                                   anxiety/mood symptoms, it may be

                                                                     The Canadian Journal of CME / August 2005 23
               Dealing with CRPS

   2.          What is the current
               best management for
                                                Natural history                       Evidence suggests that
                                                                                      physiotherapy should be the first
               complex regional pain            CRPS is characterized by pain,        line of treatment for adolescent
               syndrome?                        trophic changes and autonomic         patients with CRPS.
                                                dysfunction. Typically, on
               Question submitted by:           examination, there is evidence of     Evidence to support specific
               Steve O’Brien, MD                allodynia, hyperalgesia and           pharmacotherapeutic treatments
                                                hyperpathia. The early phase of       is limited. These interventions
               Prince Edward Island
                                                the disorder is characterized by      include the use of non-steroidal
                                                pain that is disproportionate to      anti-inflammatory drugs, tricyclic
               Reflex sympathetic
                                                the degree of trauma. There is        antidepressants, anticonvulsants,
               dystrophy, or complex
                                                evidence of swelling, redness and     steroids, alpha-2 agonists,
               regional pain syndrome
                                                vasomotor instability,                calcium channel blockers,
               (CRPS), is an example of
                                                hyperhydrosis and                     clonidine, capcaisin, calcitonin
               neuropathic pain—pain that is
                                                coolness to the touch.                and opioids.
               mediated by a lesion or
                                                Demineralization begins due to
               dysfunction in the nervous
                                                disuse.                               Surprisingly, the evidence for
               system. Typically, it is
                                                                                      sympathetic blocks and
               precipitated by trauma and
                                                Over time, redness gives way to       sympathectomy is poor. There is
               immobilization. Often, the
                                                cyanosis of the skin, fibrosis        support for spinal cord
               trauma appears minor. It can
                                                affects the joints and                stimulation. Treatment with
               be subclassified as CRPS 1
                                                demineralization becomes              thalidomide and etanercept are
               (without nerve injury) and
                                                pronounced, leading to                under investigation.
               CRPS 2 (with nerve injury).
                                                                                      Finally, the development of pain
                                                Investigations                        management skills is critical for
                                                                                      patients who have to deal with
               It is thought that CRPS
                                                Although tests ranging from           this poorly understood, and often
               occurs as a result of a normal
                                                three-phase bone scans and            misdiagnosed, disorder.
               sympathetic response to
                                                thermography to laser Doppler
               trauma that does not shut off,                                         Answered by:
                                                fluxmetry have been used as
               leading to prolonged                                                   Jeff Ennis, MSW, MD, FRCP(C)
                                                investigative tools in making the     Director
               vasoconstriction and the
                                                diagnosis of CRPS, the key to         East End Multidisciplinary Pain
               continued release of                                                   Management Program
                                                diagnosis is the history and
               proinflammatory mediators.                                             Hamilton, Ontario
                                                physical examination.
               The end result is pain,
               swelling, trophic changes and
               disuse of the affected area.
               Recently, however, the role of
                                                Outcome is improved by early
               the sympathetic nervous
                                                identification of this disorder and
               system in CRPS has been
                                                early treatment. Typically,
               called into question.
                                                treatment focuses on early
                                                physiotherapeutic intervention.

24 The Canadian Journal of CME / August 2005
                                                              CONSULTANT’S CORNER

     Disc replacement update

3.   Can you update us on
     lumbar and cervical
     disc replacement
                              Spinal arthroplasty (cervical
                              and lumbar disc replacement)
                              has been widely used in
                                                                  Limitations of
     surgery for DDD in       Europe for over three decades       • Only a very small, specific
     Canada? What are the     to treat degenerative disc            subgroup of patients with
     outcomes so far? Is      disease (DDD), but only               DDD may be candidates.
     anyone doing it in       recently in selected Canadian
                                                                  • The offending disc has to
     Canada yet?              centres, including Vancouver,
                              Calgary, London, Toronto and          be the primary pain
     Question submitted by:   Montreal.                             source.
     Monique Moreau, MD                                           • It is a complex surgery
     Alliston, Ontario        Over 90% of European                  with serious potential
                              patients with lumbar                  complications.
                              arthroplasty with followup of
                              more than a decade report           • Arthroplasty mimicks
                              satisfaction and pain relief.         spinal biomechanics, but
                                                                    does not reproduce them.
                                                                  • Cost effectiveness has not

                   S   pinal arthroplasty
                       has been widely
                   used in Europe for over
                                                                    yet been addressed.
                                                                  • Long-term durability is not
                                                                    known (only 10 to 15 years
                                                                    for hip implant).
                   three decades.
                              Answered by:
                              Wai P. Ng, MD, PhD,
                              Neurosurgeon and
                              Assistant Professor
                              Divison of Neurosurgery
                              Department of Clinical
                              Neurosurgical Science
                              University of Western
                              London, Ontario

                                                              The Canadian Journal of CME / August 2005 25
                The travelling child—what do you recommend?

   4.           What are the
                recommendations for
                a 10-month-old
                                               A healthy 10-month-old
                                               travelling to Pakistan must have
                                               a thorough pre-travel health
                                                                                     An excellent travel health Web
                                                                                     site to consult is the Public
                travelling to                  assessment, as children under         Health Agency of Canada Travel
                Pakistan? (Hepatitis           two years are at a higher risk for    Medicine Program
                A/B vaccine? Malaria           consequences of travel-related        (
                prophylaxis? What              infections, such as malaria.
                doses? Any good                                                      Answered by:
                Web sites?)                    First, all routine childhood          Jacquie Shackel, RN, BN
                                               primary series vaccinations           Coordinator
                                                                                     Travel Health and Tropical
                Question submitted by:         must be up to date, not               Medicine Services
                Shanti Rao, MD                 forgetting poliomyelitis, hepatitis   Certificate in Travel Health
                Windsor, Ontario               B vaccine, one dose of                Winnipeg Regional Health Authority
                                               measles-mumps-rubella                 Winnipeg, Manitoba
                                               vaccine and three doses of
                                                                                     Pierre J. Plourde, MD, FRCPC
                                               pneumococcal conjugate                Medical Director
                                               vaccine.                              Travel Health and Tropical
                                                                                     Medicine Services
                                               Other recommended                     Winnipeg Regional Health Authority
                                               vaccinations would normally           Associate Professor
                                                                                     Clinical Parasitology and
                                               include hepatitis A and typhoid       Microbiology
                                               vaccines, but, since this child is    University of Manitoba
                                               too young to receive these,           Winnipeg, Manitoba
                                               particular attention needs to be
                                               given to food and water

                                               Referral to a travel
                                               health specialist
                                               would be
                                               recommended for
                                                                     C    hildren under two
                                                                          years are at a higher
                                                                     risk for consequences of
                                               more complex
                                               vaccine decisions,    travel-related infections.
                                               including rabies,
                                               encephalitis and
                                               tuberculosis. As
                                               for malaria,
                                               preventative use of
                                               diethyl-N-toluamide (DEET) and
                                               insecticide-treated bednets are
                                               highly recommended in
                                               conjunction with
                                               chemoprophylaxis with

26 The Canadian Journal of CME / August 2005
                                                                  CONSULTANT’S CORNER

     Looking for Lyme disease

5.   Where is the
     spirochete, borrelia
     burgdorferi, that causes
                                  In Canada, Lyme disease
                                  endemnicity generally
                                  corresponds with those areas
                                                                        Black-legged ticks are occasionally
                                                                        found in other areas of the
                                                                        country, where their appearance
     Lyme disease endemic         where the tick vector has become      usually reflects their sporadic
     in Canada?                   established and can complete its      importation on the backs of
                                  lifecycle and over-winter for         migratory birds. Such occurrences
     Question submitted by:       successive years.                     are unlikely to contribute to the
     John Crawford, MD
                                                                        number of cases of Lyme disease
     Victoria, British Columbia
                                  In Ontario, the black-legged ticks    and rare cases that might arise
                                  (Ixodes scapularis) are endemic at    would hardly be considered
                                  only six localities, namely Point     endemic.
                                  Pelee National Park, Rondeau
                                  Provincial Park, Long Point, Turkey   Answered by:
                                  Point, Presquile Provincial Park      Kevin Forward
                                  and Long Point in Prince Edward       Service Chief
                                                                        Division of Microbiology
                                  County.                               Queen Elizabeth II Health Science
                                  In British Columbia, there are        Professor
                                  several regions where endemic         Departments of Pathology, Medicine
                                  Lyme disease occurs. In these         and Microbiology and Immunology
                                                                        Dalhousie University
                                  regions, the usual vector is the      Halifax, Nova Scotia
                                  western black-legged tick (Ixodes
                                  pacificus). Over the last several
                                  years, black-legged ticks (deer
                                  ticke or Ixodes scapularis) have
                                  been shown to over-winter
                                  in a small area in Nova
                                  Scotia, near the town of

                                  To date, we have
                                  documented three cases of
                                  Lyme disease that appear
                                  to have been acquired in
                                  that area.

                                                                   The Canadian Journal of CME / August 2005 27
                 Is SARS making a comeback?

   6.           What are the odds of
                another outbreak of
                SARS or a similar virus?
                                               It is impossible to give an
                                               accurate prediction about if,
                                               when and where a novel
                                                                                    To be effective, as well as not
                                                                                    unnecessarily burdensome,
                                                                                    screening and additional
                What should the family         respiratory might appear. Even       precautions would need to be
                practice clinic do for         with pandemic influenza, all we      based on the epidemiology of
                protection on an               know for certain is another          any novel virus. Therefore, such
                ongoing basis?                 pandemic will occur. When it         additional steps are not
                                               will occur and how severe it will    recommended prior to the
                Question submitted by:         be cannot be accurately              emergence of a novel virus.
                Barbara Lansing, MD            predicted.
                Calgary, Alberta
                                                                                    In the event of the emergence
                                               Ongoing precautions for              of a novel virus, communication
                                               respiratory infections in a family   regarding epidemiology,
                                               practice or outpatient setting       screening and infection control
                                               should continue to focus on          would come from local public
                                               basic infection control:             health units.

                                               • good handwashing,                  Ease and speed of such
                                               • trying to keep coughing            communications are essential,
                                                 patients from close contact        but experience shows that the
                                                 with other patients and            link between public health and
                                               • good environmental                 family physicians is often less
                                                 cleaning.                          than optimum (fax and regular
                                                                                    mail, rather than electronic
                                                                                           communication, are still

                                      W    ith pandemic
                                           influenza, all we
                                      know for certain is
                                                                                           the norm). Therefore, in
                                                                                           addition to enhancing
                                                                                           basic infection control
                                                                                           steps, ensuring a good
                                                                                           communication link with
                                      another pandemic will                                Public Health should be
                                                                                           part of preparing for the
                                      occur.                                               potential emergence of a
                                                                                           novel respiratory virus.

                                                                                    Answered by:
                                                                                    Robert Strang, MD, MHSc, FRCPC
                                                                                    Medical Officer of Health
                                                                                    Dartmouth, Nova Scotia

28 The Canadian Journal of CME / August 2005
                                                                CONSULTANT’S CORNER

     Understanding umbilical hernias

7.   When does an
     umbilical hernia in an
     infant require surgery?
                               Umbilical hernias (UH) are a
                               relatively common finding in the
                               pediatric population. Children of
                                                                      Compression of the hernia has
                                                                      no benefit in preventing
                                                                      enlargement of the fascial defect
     Is there any role for     African origin, low birth weight       and may, in fact, increase the
     compression of the        or Down’s syndrome have a              risk of complications.
     hernia to prevent         higher prevalence.
                                                                      Answered by:
     enlargement?                                                     Sandeep K. Mayer, MD, FRCSC
                               A UH occurs because the                Pediatric Surgeon
     Question submitted by:    umbilical ring has not fully           Associate Professor
     Rameeta Lad, MD                                                  Departments Surgery & Pediatrics
                               closed. The umbilical ring starts      Centre hospitalier Université de
     Burlington, Ontario
                               to close in the late gestational       Sherbrooke
                               period and continues to close          Sherbrooke, Quebec
                               until mid-childhood in most
                               children. Thus, in 95% of cases,
                               the UH will
                               close by
                               school age
                               (five years old),
                               without any
                                                 I  n 95% of cases, the UH
                                                    will spontaneously close
                                                 by five years old.
                               need for

                               Absolute indications for early
                               surgical repair before five
                               years old are hernia
                               incarceration or
                               strangulation, which
                               occurs exceptionally.

                                                                   The Canadian Journal of CME / August 2005 29
              Subclinical hyperthyroidism help

8.            How do you investigate
              and manage subclinical
              hyperthyroidism (i.e., low
                                               A low thyroid-stimulating
                                               hormone (TSH) with a normal
                                               free T4 level in an
                                                                                 There is evidence that
                                                                                 subclinical hyperthyroidism is
                                                                                 associated with increased
              TSH, normal free T4)?            asymptomatic patient is           incidence of tachycardia, atrial
                                               suggestive of subclinical         fibrillation, impaired diastolic
              Question submitted by:
                                               hyperthyroidism. This is once     relaxation, low bone mass and
              Christiane Proulx, MD
                                               T3 toxicosis is ruled out by a    increase in fractures.
              Port Colborne, Ontario
                                               normal T3 level. Other
                                               considerations include            Although intervention studies
                                               pituitary/hypothalamic disease,   are sparse, most
                                               pregnancy and the use of high-    thyroidologists would treat
                                               dose glucocorticoids and          patients for hyperthyroidism if
                                               dopamine.                         the TSH remains persistently
                                                                                 suppressed (at least > 6
                                               The most common causes of         months) below 0.1 IU/L; most
                                               subclinical hyperthyroidism       would not treat if the TSH is
                                               include exogenous                 between 0.1 IU/L and
                                               levothyroxine therapy, Graves’    0.5 IU/L as the risk of the
                                               disease, thyroiditis, toxic       above complications and the
                                               nodule and toxic multinodular     progression to overt
                                               goiter.                           hyperthyroidism is not high
                                                                                 enough to warrant the
                                               In addition to a history and      side-effects associated with
                                               focused physical examination,     antithyroid agents.
                                               additional investigations
                                               include measurement of
                                                                                 Answered by:
                                               thyroid antibodies and a          Hasnain Khandwala, MD, FRCPC
                                               radioactive iodine uptake and     Assistant Professor of Medicine
                                               scan, which will help find the    Division of Endocrinology
                                               specific cause of the             University of Saskatchewan
                                               hyperthyroidism.                  Saskatoon, Saskathewan

30 The Canadian Journal of CME / August 2005

To top