2023 On-Demand Asynchronous Course
Accreditation period: December 11, 2023 to March 11, 2024
Go to the On-Demand Refresher Course
HOW IT WORKS:
1) Go to https://learn.course-mcgill.ca/webapp
2) Login with the username and password you used to register.
3) On your Dashboard click on “Access On-Demand Content” to watch recordings and submit questions.
4) Evaluate each presenter for the sessions you have watched on-demand. IMPORTANT: You cannot evaluate speakers again that you have already evaluated during the live course December 4-6, 2023.
5) When you are sure that you do not want to watch any more recordings for accreditation and have submitted all speaker evaluations, you can complete the Global Evaluation.
6) Once the Global Evaluation has been submitted you will see a button to download your certificate for the self-learning course.
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2023 Speaker Responses to Audience Q & A
Plenary 1 - CHF: Using meds wisely - Richard Sheppard
What is the optimal HR we should target for patients with HFrEF?
Target heart should be obtained 1) to avoid symptoms of heart failure and 2) avoid side effects of medications such as dizziness. From bradycardia and hypotension.
With that said, On average HR 70-80 is reasonable.
A heart rate of > 77 bpm on optimally tolerated beta blocker therapy would be consideration for the use of lancora (ivabradine) to help lower the HR further.
Plenary 1 - Highlights of the 2020 Canadian Cardiovascular Society Atrial Fibrillation Guidelines - A practical approach - Mathieu Walker
What would you do if a patient with history of afib taking DOAC and then have a hemorrhagic stroke? Would you make any adjustment to their DOAC therapy?
The decision to resume anticoagulation in a such a patient must be individualized weighing the risks of recurrent bleed with that of stroke. Consultation with a neurologist would be recommended to help with decision making. Patients considered at significant risk of AF related CVA who are considered at significant risk of re-bleed could be considered for left atrial appendage closure device implantation. There is observational data that suggest that patients considered at low risk of recurrent ICH benefit from resumption of anticoagulation for stroke prevention.
Plenary 2 - Contraception: What's new? - Giuseppina Di Meglio
One of my young patient asked if she could have a copper IUD (mainly for contraception) and at the same time COC (for her acne), since the mechanism is different, is it safe to prescribe both?
"Yes, it is safe to use an interauterine contraceptive (either copper IUD or hormonal IUS) and use combined hormonal contraception (CHC) simultaneously.
The mechanism of action of the CHC does not interfere with the mechanism of action of the IUC. "
Workshop A-01 - Medical wearables and devices for patients - Daniel Lalla
How do you balance the fine line between providing personal and medical information to corporations (i.e. medical data farming) and patient confidentiality?
There are documented cases where activity tracking or heart rate tracking for example has resulted in tangible consequences. There is a famous case for many years ago when Nike started to have a monitoring apps and one person was found to be "excessively physically active" at a time when he told his partner that he was at work and it was discovered by their partner that they were having relations with someone else. So having shared Data Tracking is something that can reveal things that we don't want revealed.
On the other hand it amazes me that people constantly don't check their social media settings and reveal information about their activity, purchases, location and much more on a regular basis so it's important to do a few things
(1) inform patients of social media risks, and they are multiple
- mental health issues
- FOMO
- body dysmorphism
- disturbed sleep
- misinformation and more
directly to their health and indirectly via data collection
(2) to opt of of data collection wherever possible. This is frequently phrased as 'sending analytic data' to help programmers etc.. TURN IT ALL OFF, and go into the options when setting up apps. Nobody reads the terms and services and sometimes a few clicks will reduce data collection
(3) assess risk versus benefit, like anything else. Does the person really have anything 'critical' that could result from data collection? Insurability issues? work issues ? confidential activities that could be revealed? Is there a benefit to health - are you recommended this for well-defined objectives (as we discussed in the talk where there is noted benefit) or 'general health improvement' and only a vague idea of why it might help? Will it help you adjust the dose of a medication for example - that could be very valuable
Workshop B-08 - Approach to polyneuropathy - Rami Massie
How does one identify autonomic dysfunction on a physical examination for polyneuropathy?
"The main finding on examination is documenting orthostatic hypotension. In severe cases, you can also see loss of pupillary reflexes.
If we review the different domains affected by the autonomic nervous system:
Gastroparesis: On hx, ask for weight loss, early satiety, frequent post-prandial nausea. Not much on exam. You can ask GI for a gastric transit study.
Bowel and bladder dysfunction: ask for retention, urgency or urge incontinence, or severe constipation or diarrhea or fecal incontinence. Not much on exam. I don't usually check anal tone for this. Urology can document a neurogenic bladder if needed.
Sweating: you can ask for loss of sweating in the feet (expected in all neuropathies as there is usually some autonomic involvement) versus more generalized loss of sweating. Not much on exam. Can be documented on QSART testing in an autonomic lab.
Skin changes: These are not super reliable in my experience as other conditions can confound this. In some small fiber neuropathies, you will see change of skin color and swelling in the feet. Loss of hair too. But other conditions (venous insufficiency, weakness, CHF, renal pbs) can all contribute to this so I would not rely too much on these findings."
Workshop B-08 - Approach to polyneuropathy - Rami Massie
How does one identify autonomic dysfunction on a physical examination for polyneuropathy?
"The main finding on examination is documenting orthostatic hypotension. In severe cases, you can also see loss of pupillary reflexes.
If we review the different domains affected by the autonomic nervous system:
Gastroparesis: On hx, ask for weight loss, early satiety, frequent post-prandial nausea. Not much on exam. You can ask GI for a gastric transit study.
Bowel and bladder dysfunction: ask for retention, urgency or urge incontinence, or severe constipation or diarrhea or fecal incontinence. Not much on exam. I don't usually check anal tone for this. Urology can document a neurogenic bladder if needed.
Sweating: you can ask for loss of sweating in the feet (expected in all neuropathies as there is usually some autonomic involvement) versus more generalized loss of sweating. Not much on exam. Can be documented on QSART testing in an autonomic lab.
Skin changes: These are not super reliable in my experience as other conditions can confound this. In some small fiber neuropathies, you will see change of skin color and swelling in the feet. Loss of hair too. But other conditions (venous insufficiency, weakness, CHF, renal pbs) can all contribute to this so I would not rely too much on these findings."
Workshop C-06 - How to order the appropriate biochemistry laboratory tests or are diagnostic laboratories open bars? - Julie St-Cyr
What kind of follow up / investigations are recommended for a polyclonal hypergammaglobulinopathy finding on SPEP?
The presence of polyclonal gammopathy may be due to infection, liver disease or an autoimmune disease. So as this condition is non-specific I would rely on the clinical picture to guide my investigation.
Workshop E-09 - Adolescent addiction - Nicholas Chadi
How do you counsel a teen that uses cannabinoid substances to treat insomnia?
While some research has suggested some potential beneficial effects of CBD for sleep in adults (though this remains controversial), current research has not shown any benefits of cannabinoids for sleep in adolescents. On the contrary, THC can negatively impact sleep, affecting sleep cycles and reducing REM. It is often useful to understand why young people are turning to cannabinoids, and see if they are trying to "self-medicate" other symptoms, like depressive or anxiety symptoms, which should be explored and addressed. If teens insist on the use of cannabinoids, it is generally recommended to have a non-judgemental conversation, reflecting that there are other options, which are better researched, and that cannabinoids can have harmful effects on the developing brain. Lifestyle behavior recommendations, should also always be shared (regular sleep hours, avoiding screens before bed, avoiding stimulant substances like caffeine or nicotine later in the day, etc.).
Mushrooms are becoming a popular substance for young patients with psychological symptoms like anxiety. Can you comment?
There is indeed increased interest among teens (and adults) in using psychedelic substances to help "treat" mental health symptoms like low mood and anxiety. To date, there is no conclusive evidence on the effectiveness of prescribed or unprescribed psychedelics for the treatment of mental health in youth. If youth report using these substances or are interested in trying, it is usually helpful to explore the reasons why, understand the effects they are seeking and suggest accessing 1st line resources like counseling and/or pharmacotherapy such as SSRIs. There may eventually come a time where there is evidence to support the use of psychedelics in adolescents, but for now, caution is advised, given the possibility that their use could lead to psychotic symptoms and or traumatic experiences if used in risky situations (and/or with other substances).
Workshop E-10 - Obesity Medical Management – Practical tips and a fresh perspective - Jasmine Kler
What would be the minimum work up for a teenager (who you have not seen for many years), comes to your office with the parent claiming that there was a “sudden “onset of obesity in the last 12 months… history and physical is non-contributory… what laboratory testing should be done to rule out a pathophysiological problem?
I can’t comment completely on the Pediatric work up as I only see adults in my practice. However I would be suspicious of an endocrine disorder. Screening for cushings (in adults this would be a dexamethasone suppression test), assessing thyroid function, and a fasting insulin and fasting glucose level to assess for insulin resistance (calculation of HOMA IR) would be on my radar if this were an adult. I would also look for other indicators of metabolic disease ex blood pressure assessment and fasting lipids. A detailed take home food diary, sleep log and activity log may be informative. I would also have on my radar an eating disorder ex. Binge eating disorder or night eating.
To get the minimum of 25 g protein for breakfast, one would have to have 3-4 hard boiled eggs? (each egg seems to have 6-7g/egg) Or less eggs, and add dairy and meats. In other words, if we are going to have a breakfast, it should be a substantial breakfast?
When thinking about getting protein I think the easiest is to track in an app. Non animal foods ex. Whole grains, legumes have some protein too. The key is to make sure there is a protein from a complete source of protein (ex. Egg, dairy, meat, poultry, fish) and then supplementing with a non complete protein to get the 25 g would be ok. I encourage people to learn about this by using an app food tracker, ex. MyFitnessPal, Cronometer, LoseIt etc. Everyone eats differently so it’s important I think for people to troubleshoot this by finding out first what their current protein is and then going from there. Also breakfast does not have to be early morning. It is the time when an individual breaks their fast.
"Your talk was so interesting and I thought of it today when seeing a patient. She is a 45F pt that has been eating 1000-1200cal per day and exercising ++ for 2 years and hovers around BMI of 32, yoyos up and down 5 lb. Really wants to lose more. Do you see any patients privately from other provinces or do you have any colleagues specializing in medically managed weight loss in Montreal?"
I would first confirm if the patient has a medical indication for additional weight loss, ex. blood pressure, metabolics etc. Also my impression is that this is likely a case of over exercise/under nutrition which leads to metabolic slowing. If people can be open minded about reducing the intensity of exercise and shifting to moderate intensity cardio exercise (HR 65-75% age maximal) with some weight training, focus on nutrition and adequate protein, weight maintenance for a period of time that may give a mental break, allow some recomposition, increase the calories a bit - people feel better. I am not seeing patients out of province at this time and unfortunately don't have a recommendation for who to see in Montreal!
