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British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
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British Columbia Medical Journal, October 2010 issue: Full Issue

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British Columbia Medical Journal, October 2010 issue …

British Columbia Medical Journal, October 2010 issue

Please download or visit this entire issue online at http://www.bcmj.org/october-2010

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  • 1. OSTEOARTHRITIS OF THE October 2010; 52: 8 Pages 381- 428 HIP AND KNEE—PART 1 Pathogenesis and nonsurgical management Clinical features and pathogenetic mechanisms Evidence-based guidelines for nonpharmacological treatment Pharmacological treatment Good Guys: Hammy and Hector Proust: Ari Giligson Research team explores new bone and tendon-related treatments Health Canada allows 10 000 unproven remedies onto shelves Screening renal failure patients for tuberculosis www.bcmj.org
  • 2. contents October 2010 Volume 52 • Number 8 Pages 381–428 A R T I C L E S OSTEOARTHRITIS OF THE HIP AND KNEE—PART 1 392 Guest editorial Pathogenesis and nonsurgical management Established 1959 B.A. Masri, MD 393 Clinical features and pathogenetic mechanisms of osteoarthritis of the hip and knee Manal Hasan, MD, Rhonda Shuckett, MD 399 Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee J. Hawkeswood, MD, R. Reebye, MD ON THE COVER: Hip and 404 Pharmacological treatment of osteoarthritis of the hip and knee knee osteoarthritis places Stephen Kennedy, MD, Michael Moran, MBBS a huge burden on society because of the disability associated with it. In Part 1 O P I N I O N S of this double-issue series, we explore the pathogene- sis and nonsurgical man- agement of OA of the hip 384 Editorials Patient self-management, David R. Richardson, MD (384); Type 2 diabetes and knee. In Part 2 (Novem- ber), we examine the surgi- in youth, Susan E. Haigh, MD (385) cal options. Artwork by Jerry Wong. 386 Personal View Nosocomial or iatrogenic infections, Jim Battershill, MD (386); Re: Driver assessment, Robert Shepherd, MD (386); Re: AGM article, Jim Busser, MD (387); Re: Potential allergic drug reaction from residual antibiotics present 30% in livestock, H.C. George Wong, MD (388) 389 Comment All in a day’s work (or perhaps a couple of weeks), Ian Gillespie, MD Cert no. SW-COC-002226 410 Good Guys Hammy and Hector, Sterling Haynes, MD ECO-AUDIT: Environmental benefits of using recycled paper Using recycled paper made with post- 426 Back Page Proust questionnaire: Ari Giligson, MD consumer waste and bleached without the use of chlorine or chlorine compounds results in measurable environmental benefits. We are pleased to report the following savings. 1399 pounds of post-consumer waste used instead of virgin fibre saves: • 8 trees • 760 pounds of solid waste • 837 gallons of water Enter to Win an iPad from • 1091 kilowatt hours of electricity (equivalent: 1.4 months of electric power required by the average home) • 1382 pounds of greenhouse gases (equivalent: www.bcmj.org 1119 miles traveled in the average car) • 6 pounds of HAPs, VOCs, and AOX combined • 2 cubic yards of landfill space 382 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 3. contents #115–1665 West Broadway, Vancouver, BC, Canada V6J 5A4 Tel: 604 638-2815 or 604 638-2814 Fax: 604 638-2917 E-mail: journal@bcma.bc.ca Web: www.bcmj.org D E P A R T M E N T S 390 Recently Deceased Physicians 391 WorkSafeBC Research team explores new bone and tendon-related treatments EDITOR David R. Richardson, MD Kukuh Noertjojo, MD, Craig Martin, MD EDITORIAL BOARD David B. Chapman, MBChB Brian Day, MB 411 Council on Health Promotion Health Canada allows 10 000 unproven remedies onto shelves Susan E. Haigh, MD Lindsay M. Lawson, MD Lloyd Oppel, MD Timothy C. Rowe, MB Cynthia Verchere, MD EDITOR EMERITUS Willem R. Vroom, MD 412 Guidelines for Authors MANAGING EDITOR Jay Draper 413 BC Centre for Disease Control Screening renal failure patients for tuberculosis PRODUCTION COORDINATOR James Johnston, MD, Kevin Elwood, MB Kashmira Suraliwalla EDITORIAL ASSISTANT Tara Lyon 414 Pulsimeter Stephen Lewis AIDS Foundation AfriGrand Caravan (414) COPY EDITOR Barbara Tomlin MWIA conference, Pamela Verma, BSc, Kristin DeGirolamo, BSc Pharm (414) Call for nominations: BCMA and CMA special awards (415) PROOFREADER Ruth Wilson Core-Plus Plan reminder (416) COVER CONCEPT & ART Peaceful Warrior Arts 416 Advertiser Index DESIGN AND PRODUCTION Olive Design Inc. PRINTING 417 Calendar Mitchell Press ADVERTISING 420 Classifieds OnTrack Media Tel: 604 375-9561 bcmj@ontrackco.com 427 Club MD 302–70 E. 2nd Ave. Vancouver, BC V5T 1B1 ISSN: 0007-0556 Advertisements and enclosures carry no endorsement of the BCMA or BCMJ. © British Columbia Medical Journal, 2010. All rights reserved. No part of this journal may be re- Subscriptions produced, stored in a retrieval system, or transmitted in any form or by any other means—elec- Single issue ................................................................................................................................$8.00 tronic, mechanical, photocopying, recording, or otherwise—without prior permission in Canada per year........................................................................................................................$60.00 writing from the British Columbia Medical Journal. To seek permission to use BCMJ material in any Foreign (surface mail) ..............................................................................................................$75.00 form for any purpose, send an e-mail to journal@bcma.bc.ca or call 604 638-2815. Postage paid at Vancouver, BC. Canadian Publications Mail, Product Sales Agreement #40841036. The BCMJ is published 10 times per year by the BC Medical Association as a vehicle for Return undeliverable copies to BC Medical Journal, 115-1665 West Broadway, Vancouver, BC V6J continuing medical education and a forum for association news and members’ opinions. The BCMJ 5A4; tel: 604 638-2815; e-mail: journal@bcma.bc.ca is distributed by second-class mail in the second week of each month except January and August. Prospective authors should consult the “Guidelines for Authors,” which appears regularly in the Jour- US POSTMASTER: BCMJ (USPS 010-938) is published monthly, except for combined issues Janu- nal, is available at our web site at www.bcmj.org, or can be obtained from the BCMJ office. ary/February and July/August, for $75 (foreign) per year, by the BC Medical Association c/o US Agent- Statements and opinions expressed in the BCMJ reflect the opinions of the authors and not nec- Transborder Mail 4708 Caldwell Rd E, Edgewood, WA 98372-9221. Periodicals postage paid at essarily those of the BCMA or the institutions they may be assoicated with. The BCMA does not as- Puyallup, WA. USA and at additional mailing offices. POSTMASTER: Send address changes sume responsibility or liability for damages arising from errors or omissions, or from the use of to BCMJ c/o Transborder Mail, PO Box 6016, Federal Way, WA 98063-6061, USA. information or advice contained in the BCMJ. The BCMJ reserves the right to refuse advertising. www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 383
  • 4. editorials Patient self-management recently attended a patient self- for your health and I am concerned I management seminar. The idea is to involve patients in their own care, thereby increasing the chance about you.”) Next, I got Bob thinking about the issue while encouraging him to be an active part of the solution. I wanted to tell Bob that they will actually make appropri- “Bob, there are two basic factors that he was the only ate lifestyle changes. After complet- involved in weight control. Do you living creature on the ing the course, filled with religious know what they are?” self-management fervor, I was unleash- “No.” planet capable of ed upon my unsuspecting patients. I was taken aback, but sometimes creating mass . . . I found the most applicable issue more groundwork is required. “Well, in my practice to be weight control, so Bob, the two factors are how many when faced with an obese middle- calories you consume—diet—and aged man I launched into action. First how many you burn off—exercise.” I established rapport. “Bob, you are Now it was time to give control back ing, is there any other type of exercise really fat and are going to die.” (I actu- to the patient. “Which of these would you like?” ally started with, “Bob, there is lots of you like to talk about?” “I love to exercise.” evidence that being overweight is bad “We can talk about diet but I don’t “I notice you live by the pool. How eat anything.” about swimming?” “Bob, you’re 5'9" and 300 pounds “I don’t like to get wet.” but you don’t eat anything?” “There’s a gym at the pool, how “That’s right Doc. You would be about using the stationary bike?” surprised by how little I eat and what “My thighs rub.” I do eat is all healthy.” “Elliptical trainer?” I think Bob and I would both be “I get dizzy.” surprised by what he eats. If the patient “Rowing machine?” isn’t ready to talk reasonably about “I don’t like the sound they make, one item then it’s probably better to it creeps me out.” try a different approach, “Well, Bob, In the seminar they did say that since your diet is so good how about sometimes you have to accept that some we talk about your activity level?” patients just aren’t ready to change. “I walk everywhere.” However, I have a problem with this “Everywhere?” whole self-management thing. It feels “Yes, everywhere.” a little like babysitting. Who doesn’t “So let’s get this straight. You know that being overweight isn’t good don’t eat anything and walk every- for you? Have any of you ever had a where but continue to gain weight?” I conversation with a patient like this? wanted to tell Bob that he was the only “Hey Bob, probably no one ever told living creature on the planet capable you this before but being overweight of creating mass and that I wanted to is bad for you.” study him in the lab, but I remember “Really, you’re kidding. Shut the the kind people at the seminar stating front door! Bad for you? I’ve been see- that ridicule isn’t an effective self- ing doctors for years and you’re the management technique. “Well, Bob, first one to tell me. Well, if it’s bad for if you can’t improve your diet and me then I’ll lose weight and take bet- you’re already walking everywhere, ter care of myself. Thanks Doc.” the only solution is to increase your Another life saved. activity a little more. Other than walk- —DRR 384 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 5. editorials Type 2 diabetes in youth ntil recently, type 2 diabetes today’s children will become the first ing the importance of preventing obe- U mellitus was almost unheard of in children, but over the past few years there has been a signif- generation in some time to potentially have a shorter life expectancy than their parents! sity and promoting health. It was esta- blished in 2005 as a cross-government health promotion initiative and their icant increase in incidence of this con- Currently, the economic costs re- mandate involved achieving five goals dition in children and adolescents. It lated to obesity and its consequences by 2010. Three of these related to has occurred too rapidly to be solely are not insignificant but relatively healthier food and exercise habits and attributable to genetic predisposition, small. Without effective intervention, resulted in new guidelines for food indicating that environmental factors though, they may well become stag- and beverage sales in public schools are likely to play a key role in its devel- gering in the future. in BC. These were developed with opment. Preventing childhood obesity in registered dietitians and implemented The hallmark of type 2 diabetes is the first place is obviously the goal in 2008. New recommendations for insulin resistance and the most com- and comes down to a need for com- physical activity in schools were also mon cause of this is overweight and prehensive changes in dietary and introduced in 2008. Their web sites obesity (overweight is defined by a lifestyle habits. This is a very complex and links for parents and families try- body mass index of 25 to 29.9 or waist issue and intervention must take place ing to adopt a healthier lifestyle are circumference of > 80 cm in females at a number of levels—the family, excellent tools. and > 94 cm in males and obesity as a schools and community, the food and There is promise that we can begin BMI > 30 or waist circumference of entertainment industry, policymakers, to stem the tide of childhood obesity, > 88 cm in females and > 102 cm in and government agencies. but it will take a massive shift in our males). About 50% of the Canadian The fast food industry in particu- current habits. Little steps can start at population is overweight or obese. lar needs to get on side and make rad- home! The proportion of obese children has ical changes. For the most part, unfor- —SEH almost tripled in the last 25 years in tunately, they offer “bad” foods. Bad both females and males in all age foods are cheap, heavily promoted, groups except preschoolers. Children and engineered to taste good. They are Liquid Nitrogen of obese parents have a 66% risk of loaded with calories, sugars or refined for Medical Use being obese before adulthood. It is carbohydrate, fat, and salt. Portion Westgen has been providing Liquid Nitrogen estimated that 26% of Canadians age sizes have exploded. “Supersized” to doctors for the past 10 years. We have 2 to 17 (more than 1 in 4) are over- portions of fries, burgers, and pop established a reputation for prompt, quality weight or obese, up from 15% in 1978. are typically two to five times larger service at a reasonable price. We also offer MVE Cryogenic Refrigera- Ninety-five percent of children with than when first introduced. Some fast tors in 10 and 20 litre sizes. These can be type 2 diabetes are obese. food chains have introduced healthier acquired on a one year LEASE TO OWN With the seemingly unabated in- meals, but they are generally more option, a system that allows you to own your crease in prevalence of obesity, type 2 expensive than the standard burger tank after a year of low monthly payments diabetes in youth is emerging as a seri- and fries. which includes free liquid nitrogen for the ous public health concern. It is associ- Regular physical activity is key to lease period. ated with increases in morbidity and achieving and maintaining a healthy MVE Cryogenic mortality from both microvascular weight. It’s recommended that chil- Refrigerators and macrovascular disease, and we dren get at least 60 minutes of physi- • No Stop Charge are now seeing these complications, cal activity daily, and sadly this is • No Cartage Fees • No Dangerous particularly coronary artery disease, often not achieved. Goods Handling appearing in young adults. This child- On a positive note, the ActNowBC Charges hood obesity epidemic means that initiative has led the way in recogniz- • Lease to own option Service provided to practitioners on Vancouver Island, Lower Mainland and Okanagan area. For more information contact Westgen at: 1-800-563-5603 Ext. 150 or 778-549-2761 www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 385
  • 6. personal view “wash your hands in front of each Letters for Personal View are welcomed. patient before examining them.” Also They should be double-spaced and less “get offices on the main floor so older than 300 words. The BCMJ reserves the patients are considered.” Many of our right to edit letters for clarity and length. teachers had seen the 1918 influenza Letters may be e-mailed (journal@bcma .bc.ca), faxed (604 638-2917), or sent epidemic and were still scared stiff of it. through the post. I fully realize that the world moves on, but perhaps we should look back once in a while at what we are leaving Nosocomial or behind. iatrogenic infections For example, we all had a small —Jim Battershill, MD, FRCPC booklet called The Control of Com- North Vancouver ne hears frequently through the municable Disease, which listed meas- O press about nosocomial (hos- pital) or iatrogenic (doctor- induced) diseases these days. I find ures for the practitioner such as immu- nization, placarding, or isolation. Surgical infection (it used to be called Re: Driver assessment this frustrating because when I entered “surgical scarlet fever”) was a cause doctor who never examines medicine in 1946 the antibiotic era was just beginning and we were still indoctrinated in the older measures for horror and embarrassment by all the staff of the hospital. One of my fondest memories is of A his or her patients is doing a poor job. The Office of the Superintendent of Motor Vehicles for disease control. One wonders if practical advice such as “the first thing (OSMV) tests young drivers repeat- some may have been abandoned too the patient does when he/she enters edly. The OSMV does not test older quickly. the office is to look to your hands” and drivers. Dr Jensen wrote, “The physi- The EMR for BC Specialists 7% of General Surgeons 7% of Internists 8% of Dermatologists Implement Accuro®EMR 8% of Neurosurgeons 9% of Otolaryngologists Alternative Specialist Funding Program 10% of Neurologists 13% of Surgical Specialists 13% of Urologists 13% of Ophthalmologists Accuro® EMR will enable physicians to meet the 19% of Endocrinologists 21% of Thoracic Surgeons 22% of Obstetricians & Gynecologists 25% of Orthopaedic Surgeons Alternative Specialist Funding Program (ASFP) 29% of Plastic Surgeons of $5,000 one-time and $250/month 35% of Gastroenterologists 42% of Nephrologists info@optimedsoftware.com 1-866-454-4681 * percentage of BC Specialists www.optimedsoftware.com for Accuro® Demonstration using Accuro®EMR 386 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 7. personal view cian has no authority to have the dri- plaining about the doctor who took ers, the driver’s medical examination, ver’s licence cancelled. The decision away his driver’s licence. He almost destroys the trust between patient and to… deny a licence to operate a motor never comes to see me, so I cannot doctor. The OSMV should require vehicle rests solely with OSMV” examine him. older drivers to have their vision [“Driver assessment and the duty to On the OSMV “Driver’s medical checked by an optometrist by the auto- report.” BCMJ 2010;52:122]. examination” is a request that the doc- mated static perimetry. The OSMV Patients do not understand this. tor check a box “cognitive impairment should examine older drivers and do a The only contact older patients have MMSE score.” The Folstein Mini screen of cognitive ability. The only with the OSMV is a letter requiring Mental Status Examination does not test that assures that a person can drive them to get a medical exam. As far as evaluate executive function. It is pos- safely is a road test. the patients are concerned, this exam sible for a person to score well on the —Robert Shepherd, MD is a routine visit that they happen to MMSE, but have sufficient loss of Victoria have to pay for. Several patients have executive function that he or she left my practice because I required should not drive. References them to have an evaluation at Drive- The OSMV “Driver’s medical 1. Kerr NM, Chew SS, Eady EK, et al. Diag- ABLE (www.driveable.com). examination” requires the doctor to nostic accuracy of confrontation visual One such patient is Mr B., a gen- evaluate visual field. Kerr and col- field tests. Neurology 2010;74:1184- tleman who enjoyed driving. I used to leagues demonstrated that “most 1190. look forward to his visits, and he en- confrontation visual field tests were joyed his visits with me when he insensitive to the identification of Re: AGM article would tell me about the history books field loss.”1 he had been reading. When I asked The current method by which the he Journal’s feature on the An- him to go to DriveABLE, he scored far below normal on “Identification of driving situations.” Now his wife tells OSMV evaluates older drivers is inad- equate to assure safe driving. The cur- rent method by which the OSMV T nual General Meeting [BCMJ 2010;52:290-293] hinted at problems that warrant expansion. me that he sits around at home com- gathers information about older driv- Continued on page 388 “MCI takes care of everything without telling me how to run my practice”. heal thyself. MCI means freedom: I remain independent MCI Medical Clinics Inc. Toronto – Calgary – Vancouver www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 387
  • 8. personal view Continued from page 387 spent $375 000 to date in direct costs Re: Potential allergic While the segue to Zafar Essak and pertaining to Dr Wang. No reference was drug reaction from Caroline Wang bears no comment, to made to her provision of facts, which write that their business took “a lot of she clearly wished accessible to mem- residual antibiotics time” risks losing the merit of the busi- bers. No mention was made of Past present in livestock ness inside its treatment. Highly signifi- President Ian Courtice’s appeal to the agree with the concern about anti- cant to my view were repeated ad homi- nem objections levied by one director at Dr Essak. Those objections, later Board to quickly resolve this matter. On low attendance, Dr Lloyd Op- pel asserted that it was the norm for I biotic use in our livestock ex- pressed in Dr Bill Mackie’s COHP column [BCMJ 2010;52:309]. built upon by other directors, were coun- associations everywhere. The BCMJ’s In addition to the problem of tered by Past President John Turner. managing editor proposed that given antibiotic-resistant organisms, there I found it was this fruitless antag- the many opportunities for input that is a potential of sensitization from onism, more than anything else, that people now have (phone, e-mail, reg- the residual antibiotics in the livestock frustrated remaining attendees. To my ular surveys, elections), the AGM has resulting in subsequent antibiotic view, the standing rules of our AGMs become obsolete, “a dinosaur on the allergy in patients. There could be a should provide that the demeanor of brink of extinction.” With all due res- potential cause of chronic urticaria or any speaker and any items they raise, pect to such opinion holders, the Asso- idiopathic anaphylaxis due to ingestion once criticized, not be subject to repeat ciation might better take low atten- of the livestock containing the resid- objection by the same person. Further dance as a failure to convince members ual antibiotics by sensitive patients objection should have to be levied by that attending matters. This hinges on later on. Research in this area should some other attendee. whether and how well those in charge be carried out. It was learnt that the Association show themselves to be open, account- Antibiotic-resistant organisms and able, and responsive, and to accord potential allergic drug reaction from regular members a meaningful voice. the residual antibiotics in our live- The social program, while important, stock should be of great concern to cannot compensate for the entrenched Health Canada. business portion that I maintain us to —H.C. George Wong, MD have evolved. Vancouver Our recent AGMs return to ques- tions of transparency, accountability, and function. I shall have asked the Enter to Win Board to answer these squarely at its an iPad from September meeting. www.bcmj.org —Jim Busser, MD BCMA Delegate, District 3 Your forum to advance… Specialist Issues Representing BCMA specialists 388 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 9. comment All in a day’s work (or perhaps a couple of weeks) “ o, are you enjoying being short notice because of reporter dead- see more brain injury prevention pro- S BCMA president? What is it like?” To frequent questions such as this, lines. It can be quiet for several weeks and then there will be a flurry of act- ivity all in one day, usually when an grams and more effective methods of assessing brain injury in our emer- gency departments. Regarding the lat- I would say “fascinating, satisfying, issue grabs the media’s attention. ter, I am working on a pilot project challenging, and more.” The BCMA Most reporters are respectful, howev- intended to improve the quality and is a well-integrated group of teams er they do like to polarize the news to consistency of the assessment patients including the Executive Office, Pro- increase the level of audience interest. receive when they present in BC hospi- fessional Relations, Policy and Eco- tal emergency departments after trau- nomics, Negotiations, Communica- matic brain injury. Our small group tions, Finance, Benefits, and Member Most reporters are has met with interested and knowl- Services. The work is varied and can respectful, however they edgeable experts, including represen- change on very short notice. tatives from ICBC, and a second meet- do like to polarize the My practice is compressed into 2 ing is forthcoming to discuss a draft days per week with the remaining time news to increase the assessment flowchart, intake forms, spent at the BCMA office. My patients level of audience patient information forms, and how to and my office assistant, Rosemary, ensure good communication with the interest. have been very understanding and patient’s family doctor. We will then supportive of my taking a turn at this decide on the appropriate terms of ref- leadership. While president-elect, I was invit- erence for any committee work that Once weekly, I meet with the sen- ed to speak to the BCMA staff. During will be carried forward and report that ior staff of the BCMA to keep abreast the question period, someone asked if to the Board of Directors. of Association issues, plus I have other I had a special project to undertake With respect to brain injury pre- meetings with staff, physician mem- during my presidency. For some time vention, the BCMA’s resolution sup- bers, government officials, and indi- I have had an interest in the comput- porting a ban on mixed martial arts viduals from stakeholder organiza- erized assessment of cognitive ability (MMA) fighting in Canada somehow tions. Responding to e-mail and phone and have noticed that there is a wide came to the attention of a Vancouver calls usually has to fit in around the variation in findings and that there are newspaper 2 weeks before it was to other tasks. Media interview requests often long delays in the identification be brought to CMA’s General Council can bump other plans and are often on of significant impairment. I’d like to Continued on page 390 GPAC clinical practice guidelines are now available in iPod Touch and iPhone format — FREE! This free application contains over 30 clinical practice guidelines in abridged format. It serves as a condensed, portable companion to the full clinical practice guidelines found at www.BCGuidelines.ca, where over 50 guidelines are available in a range of formats. Download app from: http://itunes.apple.com/us/app/bc-guidelines/id377956292?mt=8 By BC physicians, for BC physicians www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 389
  • 10. comment Continued from page 389 brain injury. All sport has its own inher- meeting. The story (and subsequent ent risks; however the intent of these ones) generated a visceral reaction from competitive team sports is very differ- Recently many MMA fans and a request to meet ent than the intent of MMA, plus these deceased with an MMA representative. After players are padded and helmeted. And our meeting, in which he wanted us to even though many sanctioned MMA physicians withdraw our resolution, all we could fights have a physician ringside, his or he following physicians agree upon was the common goal that the incidence of brain injuries must be reduced. her presence will not fundamentally reduce the risk of long-term brain damage to a fighter, even if the physi- T have died over the past 9 months; please consid- er submitting a piece for our cian does provide other worthwhile “In Memoriam” section in the The sole intent in an ringside medical care. BCMJ if you knew the deceased With the passing of this resolution well. MMA fight is to disable at CMA’s general council meeting by your opponent, which an 84% majority, it is now up to the Andrews, Dr William John includes by inducing CMA to advocate for a ban with fed- Baldwin, Dr John Henry eral legislators. In Canada, under Sec- Bartok, Dr Katalina a brain injury. tion 83 of the Criminal Code, prize Boxall, Dr Ernest Alfred fighting is illegal with exceptions made Brunton, Dr Lawrence Jackson Not surprisingly, there was debate for boxing (which the CMA voted to Chen, Dr Ferdinand at the BCMA caucus meeting when call for a national ban in 2002) and Chetwynd, Dr John Brian this resolution was first introduced, events authorized by provincial sports Dudley, Dr John Howard and even more debate at CMA’s Gen- commissions. MMA itself has been Duffy, Dr John Peter eral Council when it was presented banned in six provinces and territo- Findlay, Dr Ian Douglas for discussion. My argument among ries, however Ontario reversed its ban Goh, Dr Anthony Poh Seng media, physicians, and interest groups in August after strong lobbying. Our Kalyanpur, Dr Vasant Raghav has always been the concern with the role will be to provide expert opinion Lewis, Dr David John degree of violence in this sport and the to government about the risks to brain MacDonald, Dr Alan Angus risk for brain injury. The sole intent in health, if and when government de- Mackenzie, Dr Conrad an MMA fight is to disable your oppo- cides to consider the Canadian Med- McAdam, Dr Ronald nent, which includes by inducing a ical Association’s recommendation. McCannel, Dr John Arthur brain injury. We know that repeated Debating this issue has been chal- McDaniel, Dr Bernard Minshull brain injuries have long-term debilitat- lenging, eye opening, and at times Milobar, Dr Tony ing effects. Continuing research also frustrating. But being president of the Penny, Dr Helen Angela confirms the increased risk of neuro- BCMA means you don’t back down Percheson, Dr Peter Brady degenerative disease, and at an earlier when the going gets tough. I am proud Pinkerton, Dr Alexander Clyde age, after repeated concussion. We that I stuck to my principles and per- Puttick, Dr Michael Paul Ernest would not be doing our job if we sisted in working with those who had Queree, Dr Terence Candlish didn’t speak up on behalf of the brain objections, and in the end the position Selwood, Dr Michael health of Canadians. of our caucus was validated by a large Smaill, Dr William Donald Critics have wondered (somewhat majority of physician delegates at the Thomas, Dr Ifor Mackay sardonically) why we haven’t also CMA’s annual meeting. Tucker, Dr Frederick Gordon called for a ban on football, hockey, —Ian Gillespie, MD Van Schie, Dr Lisa or baseball, as they too have a risk of BCMA President 390 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 11. worksafebc Research team explores new bone and tendon-related treatments Platelet-rich plasma offers Shock therapy thought to One cause of shoulder mixed success in treating ease pain from calcified pain is calcific rotator cuff tendinopathies supraspinatus tendinopathy tendinopathy, which occurs The concept of using growth factors One cause of shoulder pain is calcific contained in activated platelets to rotator cuff tendinopathy, which occurs in 7% to 17% of rotator help wound healing dates back to the in 7% to 17% of rotator cuff tendinopa- cuff tendinopathies. early 1980s. More recently, the use of thies. Extracorporeal shock wave ther- platelet-rich plasma (PRP) to treat apy (ESWT) has been promoted as an various musculo skeletal disorders, alternative to surgical intervention in experts have demonstrated a lack of including tendinopathies, has increas- treating rotator cuff tendinopathy that agreement regarding the diagnosis of ed tremendously. fails to respond to conventional and fracture nonunions. Tendon healing is a complex pro- more conservative therapies. While While ultrasound has been applied cess involving many growth factors, the mechanism is still unclear, this in treating fractures for half a century, such as platelet-derived, transform- outpatient procedure is thought to pro- its role in fracture healing is not ing, vascular endothelial, insulin-like, vide long-lasting analgesia and stimu- well understood. In January 2010, the and epidermal growth factors, which late the healing process. WorkSafeBC Evidence-Based Prac- are detected in higher concentrations In June 2010, the WorkSafeBC tice Group investigated the effective- in PRP. To date, the respective role of Evidence-Based Practice Group inves- ness of Exogen low-intensity ultra- each type of growth factor requires tigated the effectiveness of ESWT, sound in treating fracture nonunion further exploration. As well, recent using low- and high-level energy shock and found three high-quality system- evidence suggests varying concentra- waves to treat calcific supraspinatus atic reviews12-14 and one large case tion levels of these growth factors in or rotator cuff tendinopathy in gener- series (n = 1317)15 that showed as fol- PRP, depending on the protocol and al. Their findings included two sys- lows: devices used to spin the blood. tematic reviews, one of high quality6 • No high-level primary studies exist In April 2010, the WorkSafeBC and one of low quality,7 three low- to provide evidence of the effective- Evidence-Based Practice Group con- quality RCTs,8-10 and one low-quality ness of low-level ultrasound. ducted a systematic literature review case-control study.11 This included • Low-level evidence, including large of the effectiveness of PRP in treat- some high- and low-quality evidence case series, showed that low-level ing tendinopathies. They found five to suggest high energy ESWT can ultrasound is effective as an adjunct studies of varying quality and design provide pain relief and increased func- to good immobilization, especially investigating the application of PRP tion, as measured by the Constant- when provided by an external in treating chronic patellar tendinosis1 Murley score, among patients suffering immobilizer. and chronic elbow tendinosis,2 during from calcific rotator cuff tendinopa- • Low-level ultrasound may be effec- arthroscopic rotator cuff repair,3 dur- thy. There was no evidence on the tive among patients aged 31 to 60 ing Achilles tendon surgery to pro- effectiveness of ESWT in treating with long bone or scaphoid frac- mote healing,4 and treating Achilles noncalcific rotator cuff tendinopathy. tures; who had comorbid illnesses; tend ino pathy. 5 Lower-quality and who had been treated with other lower-level studies 1-4 showed the Low-intensity ultrasound for drugs, such as steroids, NSAIDs, effectiveness of PRP in treating vari- nonunion fractures appears anticoagulants; or who are current ous tendinopathies. However, the only effective for some smokers. available high-quality evidence show- Fracture healing is a complex process Other adjunct treatments, yet to ed that PRP injection compared to involving various factors that need to be tested for effectiveness, are also saline injection did not result in sig- occur at a specific time and place. available. These include pulsed elec- nificant improvement in pain and US data show up to 10% of healing tromagnetic field stimulation, direct activity.5 These studies could not dis- fractures develop delayed union, current or capacitative coupling, ex- count the value of co-interventions. and a significant proportion of these tracorporeal shockwave stimulation, become nonunions. At present, some Continued on page 416 www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 391
  • 12. Guest editorial Osteoarthritis of the hip and knee, Part 1: Pathogenesis and nonsurgical management ease and the journey of patients with evidence behind these modalities. OA of the hip or knee from diagnosis This article serves not only as a guide to nonoperative treatment and finally for practitioners, but also as a summa- to surgical intervention. This first part ry for patients who are considering in a two-part theme issue on OA of the each of these modalities. The article hip and knee explores the patholge- demystifies these modalities and netic mechanisms and several aspects allows the physician and patient to of nonsurgical management. understand the relative merits of each In the first article here, Drs Hasan treatment, from footwear and weight and Shuckett discuss the epidemiolo- loss to the use of canes. gy of hip and knee OA and factors in In the third article here, Drs Ken- its genesis. The figures that they in- nedy and Moran continue the discus- clude about the burden of disease are sion of nonoperative management, but indeed sobering. The authors discuss this time from the pharmacological the risk factors for OA, allowing us as point of view. They discuss the role of Dr B.A. Masri practitioners to potentially change oral medications as well as joint injec- patients’ behavior at a young age and tions. This sets the stage for their dis- lessen the likelihood of this disease cussion of the indications for surgical with aging. They also discuss clinical intervention, and when to consider steoarthritis (OA) is the presentation and radiographic find- referral to an orthopaedic surgeon. O most common chronic dis- ease affecting British Col- umbians. Family physicians manage patients with osteoarthritis on a daily basis using strategies that range ings, allowing an easier understand- ing of when to suspect OA in a patient and when to proceed to a radiographic review. The authors clearly delineate the indications for plain radiographs By focusing on the earlier stages of OA and considering diagnosis and nonoperative management, all the articles in Part 1 of this theme issue pave the way for the articles in from reassurance to surgical interven- and MRI. With improved access to Part 2, which will discuss surgical tion. Large joint OA, as exemplified MRI, we often see patients presenting modalities. by hip and knee osteoarthritis, places with OA with an MRI as the initial —B.A. Masri, MD, FRCSC a significant burden on society be- radiographic investigation. The take- Professor and Head, cause of the disability associated with home message is that an MRI should Department of Orthopaedics it. Patients affected by OA of the hip be reserved for use when X-rays do University of British Columbia and knee often require surgical inter- not indicate OA. vention. Many modalities for nonoperative With the increasing emphasis on treatment for OA of the hip and knee joint replacement, it is important to exist. In the second article here, Drs consider the entire spectrum of dis- Hawkeswood and Reebye discuss the 392 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 13. Manal Hasan, MBBS, MD, Rhonda Shuckett, MD, FRCPC, Diplomate ABIM Clinical features and patho- genetic mechanisms of osteo- arthritis of the hip and knee Understanding how osteoarthritis develops is critical to treating this disabling disease. steoarthritis (OA) is a non- tween X-ray findings and symptoms O ABSTRACT: Osteoarthritis is a non- inflammatory form of arthritis that inflammatory form of arth- of OA.1 accounts for 25% of visits to primary ritis. A common miscon- OA accounts for 25% of visits to care physicians. When osteoarthritis ception is that OA is due primary care physicians, and 50% of affects the hip and knee, it can lead solely to wear and tear, since OA is NSAID prescriptions.2 It is estimated to major disability and compromised typically a disease of persons in the that up to 80% of the population will quality of life. Diagnosis relies on sixth decade and beyond. “Degenera- have radiographic evidence of OA by clinical symptoms, physical find- tive arthritis” is often used as a syno- age 65, with 60% of those showing ings, and radiographic findings. The nym for OA, but OA is not the result of symptoms and thereby having clinical interplay between mechanical and a bland degenerative process; rather, OA.3 Another study found that by age systemic factors such as congenital OA involves both degenerative and 70 to 74 years, about 33% of men and abnormalities, obesity, and malalign- regenerative processes. 40% of women will have OA with ment may predispose individuals to OA is common and serves as the clinical and X-ray features.4 The life- osteoarthritis of the hip and knee. main source of chronic joint com- time risk of developing symptomatic We must identify these factors and plaints in adults. The morbidity con- knee OA is about 45%, rising to 66% the underlying causes of osteoarth- ferred by OA of the knee and hip in an in obese persons. While there is vari- ritis if we are to develop more pro- ever-aging population is major. Its ation in these numbers, it is clear that gressive early interventions for this high prevalence and huge impact on the morbidity and disability conferred common affliction. quality of life demand that we engage by OA of the hip and knee is enormous in better understanding of OA by con- and demands our attention.5 sidering diagnostic, epidemiological, clinical, and radiographic features. An Symptoms and understanding of how OA is classified physical findings and OA risk factors is also critical. The main symptoms of OA of the knee or hip are pain, stiffness, and altered Diagnosis and function. Initially this tends to be epidemiology worse with weight bearing and ambu- The diagnosis of OA relies on clinical lation. Eventually this can progress to symptoms, physical findings, and radiographic findings. Not all persons Dr Hasan is a rheumatology fellow in the who have radiographic OA have clin- Division of Rheumatology at the University ical disease. Conversely, not all per- of British Columbia, sponsored by the King- sons who have joint pain demonstrate dom of Saudia Arabia. Dr Shuckett is a clin- plain radiographic findings of OA. ical associate professor in the Division of Thus, there is often discordance be- Rheumatology at UBC. www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 393
  • 14. Clinical features and pathogenetic mechanisms of osteoarthritis of the hips and knees pain day and night once cartilage loss al compartment OA of the knees. Less leads to bone-on-bone contact. True commonly, patients may present with hip pain is felt in the groin most com- a valgus or knock-knee deformity, monly, but can also present in the but- indicative of more advanced disease tock and often down the anteromedial in the lateral compartment of the knee. thigh to the knee. Not uncommonly, On occasion, and much less common- patients may present solely with knee ly, patients may present with isolated pain when the problem is in the hip. OA in the patellofemoral joint, which Pain arising from osteoarthritis of the can of itself be very symptomatic. knee is felt right around the knee joint, In the case of the hip, a true cap- and unlike pain caused by hip OA, this sular pattern of limitation is found pain does not typically radiate. with groin or buttock pain (or both) In contrast to inflammatory arthri- and particular pain with internal rota- tides such as rheumatoid arthritis, with tion of the hip. Flexion deformity of their prolonged morning stiffness and the involved hip can be present with worsened pain in the morning, OA advanced OA. Patients will often walk Figure 1. Radiograph of osteoarthritis of tends to worsen as the day progresses. with a limp, and a waddling Trende- the hip showing predominant superolateral The stiffness in OA is termed “inac- lenburg gait may be evident in late joint space narrowing, subchondral sclerosis of whitening of the bone adjacent tivity stiffness” and contrasts with stages. to the joint space, and some marginal the prolonged “morning stiffness” of osteophytes. rheumatoid arthritis. Inactivity stiff- X-ray findings ness in osteoarthritic lower limb joints Standard knee X-rays should include lasts about 5 to 10 minutes and occurs a standing anteroposterior (AP) view when the patient gets up and bears of both knees, plus lateral views. In weight after prolonged immobility. patients with suspected posterolateral On physical examination, a small OA with a mild valgus deformity, a effusion with a fluid bulge sign can be 30 degree flexed standing posteroan- present in OA of the knee. Larger effu- terior (PA) view with the beam sions can occur but are less frequent directed 15 degrees from cephalad to than in the inflammatory arthropathies. caudad may be valuable in showing Synovial fluid analysis after aspira- the disease in the posterior aspect of tion of an OA knee effusion reveals the lateral compartment of the knee.6,7 that the fluid is thick and viscous with In early cases, a standard standing AP a low synovial white blood cell count, view may appear normal or indicate most of which are mononuclear cells. very mild OA, whereas the standing On examination, there may be carti- flexed PA view may show bone- laginous crepitus or a crackling feel- on-bone contact. Patellofemoral OA ing on palpation of the knee with mo- of the knee cap is also a common tion. Eventually there may be coarse finding, best diagnosed on a skyline bone-on-bone crepitus whereby the X-ray view. opposing bone ends, denuded of carti- X-rays of the hips to evaluate for lage, seem to grate against one anoth- OA should include a standing AP er. There is often a loss of range of pelvis view and frog-leg views of the motion of the involved knee or hip, suspected hip joint. It is important to Figure 2. Medial compartment particularly with progression of OA. always order standing X-rays of both osteoarthritis of the knee with medial Loss of cartilage of the knee can knees in the case of suspected knee compartment joint space loss.This marked narrowing is between the medial tibial lead to malalignment of the leg with a OA and an X-ray of the pelvis and not plateau and the medial femoral condyle. varus deformity or bow-legged posi- just the affected hip in the case of sus- The fibula can be seen in its lateral tioning of the leg being evident. This pected hip OA. This will allow for location. angulation of the knee applies to medi- comparison between sides and im- 394 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 15. Clinical features and pathogenetic mechanisms of osteoarthritis of the hips and knees proves the ability to diagnose mild to application. MRI has emerged as an Table 1. Traditional classification of OA moderate disease. excellent modality for detection of OA On plain X-ray evaluation, loss of when the plain radiographs indicate Primary osteoarthritis the radiolucent cartilage, termed joint no disease or mild disease, and the • Idiopathic space narrowing, is seen in OA. In the patient’s symptoms are out of keeping • Generalized hip joint the joint space narrowing with the apparent severity of disease. • Erosive tends to be more in the weight-bearing MRI can detect large focal articular Secondary osteoarthritis superolateral aspect of the joint, again cartilage lesions that cannot be detect- • Due to mechanical incongruity of joint, highlighting the role of mechanics in ed on plain films.6-8 congenital or acquired (e.g., acetabular OA ( Figure 1 ). However, there are dysplasia of hip or internal knee different patterns of OA of the hip, and Classification of OA derangement) it is possible to get more central wear, Traditionally OA has been classified • Due to prior inflammatory disease (e.g., rheumatoid arthritis) particularly in patients with deep sock- as primary or secondary ( Table 1 ).9 • Due to endocrine disorders (e.g., ets or protrusio acetabuli. In the knee, Primary OA denotes generalized or diabetes, acromegaly) main involvement is often in the medi- erosive OA with no identifiable cause. • Due to metabolic disorders (e.g., calcium al joint compartment ( Figure 2 ), but Secondary OA denotes OA caused by pyrrophosphate dihydrate crystals, involvement of other compartments an underlying condition, including hemochromatosis) or of the entire joint is also common. those caused by inflammatory dis- • Miscellaneous (e.g., avascular necrosis) On plain X-ray of an osteoarthrit- eases, trauma, and mechanical factors. Source: Adapted from Brandt KD.9 ic joint, in addition to joint space nar- In a large series of cases of so- rowing, there tends to be subchondral called primary osteoarthritis of the sclerosis or an appearance of whiten- hip, some underlying mechanical Table 2. Classification of OA by cause ing of the subchondral bone. Osteo- developmental variation could be found A. Abnormal concentrations of force on phytes, which reflect a regenerative in most cases to account for the onset normal cartilage process with formation of fibrocarti- of the disease.10 For instance, the sub- • Cartilage surface irregularities (e.g., laginous extensions or hooks at the tle presence of a shallow cup of the intra-articular fractures, meniscal tear) joint margins, are common. Interest- hip, called acetabular dysplasia, is a • Malalignment of the joint (e.g., leg length ingly, the presence of osteophytes in common precursor to OA of the hip. disparity, acetabular dysplasia, congenital hip dislocation) one compartment, such as the lateral In middle-aged men, femoroacetabu- • Loss of ligamentous stability (e.g., compartment in a patient with medial lar impingement (FAI) is thought to anterior cruciate ligament tear) compartment OA, is not indicative of be the most common cause of OA of • Loss of protective sensory feedback (e.g., disease in that compartment. It is sim- the hip. FAI of the pincer type occurs diabetic neuropathy) ply indicative of the body’s reparative most often in middle-aged women. On • Other causes (e.g., obesity, occupational) response to the abnormal stresses and occasion, patients may present with B. Normal concentrations of force on presence of disease in the medial com- symptoms of impingement prior to abnormal cartilage partment. the development of advanced OA. It • Pre-existing arthritis (e.g., rheumatoid The identification of OA on plain thus appears that the term “primary or arthritis) X-rays means there is already full idiopathic OA” is probably a mis- • Metabolic abnormalities (e.g., crystal thickness cartilage loss and even nomer as it applies to the hip or knee, arthropathy) bone-on-bone contact. These radi- and that if we look hard enough an • Genetic (e.g., generalized osteoarthritis of hands) ographic findings occur relatively late underlying structural cause will often in the course of OA. It would be ideal be apparent. C. Normal concentrations of force on to be able to identify OA before gross In the 1970s Mitchell and Cruess normal cartilage supported by stiffened subchondral bone changes are apparent on radiographs. proposed a more pathogenetic classi- • Paget disease Earlier OA detection is important in fication of OA ( Table 2 ). This classi- identifying disease before the pro- fication system assumes that osteo- D. Normal concentrations of force on gressive bone-on-bone stage. Joint arthritis can arise from an intrinsic normal cartilage supported by weakened subchondral bone ultrasound has been applied in studies problem of the cartilage as encoun- • Avascular necrosis to identify OA earlier, but this is more tered after years of chronic inflamma- a research tool than a routine clinical tory arthritis.11 Thus, OA can occur Source: Adapted from Mitchell NS, Cruess RL.11 www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 395
  • 16. Clinical features and pathogenetic mechanisms of osteoarthritis of the hips and knees is gaining increasing recognition as a major structural precursor to hip OA. These are usually asymptomatic before possible progression to OA and can be seen on a screening AP pelvis radi- ograph. Such pre-symptomatic X- rays, however, are not ordered rou- Subtle and asymptomatic anatomic tinely. variations have been associated Genetic factors with hip osteoarthritis. The strongest association between genetic factors and OA applies to gen- eralized osteoarthritis of the hands. Evidence for a correlation between genetics and knee or hip OA is less conclusive.15,16 Physical activity Although the health of cartilage and with (A) normal force on abnormal Gender and the other joint tissues requires regular cartilage. Alternatively, it can occur estrogen connection joint loading, excessive loading may with (B) abnormal concentrations of Women are more likely than men to contribute to OA. While some studies force on normal cartilage. This would have OA, be it generalized OA of the suggest a strong positive relationship implicate mechanical aberrations such hands or OA of the hips and knees.12 between work-related knee bending as malalignment, the post-meniscecto- The increase in OA in menopausal exposure and knee OA, others have my knee, or a cruciate deficient knee. women has led to numerous investi- failed to find a direct relationship The abnormally formed hip mention- gations into the relationship between between the presence of knee OA ed above would fall into this category hormonal factors and OA. The results and habitual physical activity or rec- as well. have been conflicting and inconclu- reational running. 17 A relationship Mitchell and Cruess’s classifica- sive.13,14 Clearly, other health issues between heavy manual work, farming tion system also includes situations are of concern when determining in particular, and hip OA was found in where there is (C) stiffened subchon- whether hormone replacement thera- different studies, but the association is dral bone, as in the case of the rare py is to be considered in the post- still considered a weak one.18 Paget disease, which does indeed pre- menopausal patient. Although it makes sense that high dispose to OA of an involved joint. levels of impact and repeated torsion- Alternatively, they describe situations Congenital/developmental al loading could increase the risk of where (D) weakened subchondreal abnormalities articular cartilage degeneration, this bone, as in avascular necrosis, predis- Local factors that affect the shape of is not borne out consistently in stud- poses to OA. the joint may increase local stress on ies. Still, it would appear prudent to cartilage and contribute to the devel- suggest that anyone with a known Risk factors for OA opment of osteoarthritis, especially in underlying predisposition to OA, such OA is best viewed as the end result of the hip joint. As already mentioned, as abnormal hip or joint anatomy or an interplay between local and sys- subtle and asymptomatic anatomic excessive body weight, avoid repeti- temic factors. Such factors are well variations have been associated with tive impact-loading activities such as outlined in the classification schema hip osteoarthritis. These include ace- jogging. of mechanical factors proposed by tabular dysplasia or epiphysiolysis, Mitchell and Cruess. Several local which are common milder variants of Obesity systemic factors may be operative in congenital hip dislocation and slipped Every step taken in a normal gait places predisposing patients to OA of the hip capital femoral epiphysis, respective- about three times an individual’s body or knee. ly.10 Femoralacetabular impingement weight on lower limb joints. Thus it 396 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 17. Clinical features and pathogenetic mechanisms of osteoarthritis of the hips and knees should not be surprising that obesity tis. An exception to this is the pres- deformity that will challenge accurate and high body mass index have long ence of intra-articular fractures, that leg length measurement. It is key to been recognized as potent risk factors is, fractures that extend though the place the patient’s legs in proper align- for OA, especially medial compart- joint line. The disruption of the carti- ment. There should be an equal dis- ment OA of the knee in females. lage and subchondral bone with an tance between the medial malleoli The Framingham Study found that intra-articular fracture does portend a of the ankles, and the feet should be women who lost about 5 kg had a 50% heightened risk of OA of the involved centred in a neutral position under the reduction in the risk of developing joint in future decades. Trauma of corresponding hips. The apparent leg new symptomatic knee OA.19 Weight- the knees leading to internal knee length is measured from the umbilicus loss interventions have been shown to derangement such as a mensical or to the medial malleolus on each side. decrease pain and disability in estab- major ligamentous tear will predis- A discrepancy usually signals a scol- lished knee OA. The Arthritis, Diet, pose to osteoarthritis. In the case of iosis. The true leg length is measured and Activity Promotion Trial showed the hip, acetabular labral tears, which from the anterior superior iliac spine that weight loss combined with exer- can only be seen on MRI combined to the medial malleolus, and a discrep- cise, but not either weight loss or exer- with an arthrogram, will increase the ancy suggests a true variation between cise alone, was effective in decreasing risk of future OA of the involved hip the two legs. For a true leg length dis- pain and improving function in obese joint. An acetabular labral tear is often crepancy of more than 1 cm, a shoe lift elders who already had symptomatic an indication for hip arthroscopy to or built-up orthotic that adjusts for half knee OA.20 trim the torn fragment. Hip arthros- of the leg length difference is typical- When patients ask their physicians copy is not often done for diagnostic ly recommended. For a large discrep- how they can prevent OA of the knees, purposes because MRI is so effective ancy this may not be readily attainable. weight control is paramount. Unfortu- at picking up lesions. Varus deformities, valgus deform- nately weight loss is challenging in It is thought that blunt trauma such ities, and cruciate ligament tears are established OA of the knee due to the as contact with a dashboard in a motor other factors that can predispose to the limited physical activity possible. vehicle accident can lead to patello- development and progression of knee The relationship between excess femoral syndrome and chondromala- OA. Detailed discussion of such fac- weight and hip OA is less clear. The cia patella. However, whether these tors is beyond the scope of this article. evidence in hip OA is not as compel- pre-OA lesions will progress in future Like the medial compartment and ling as with knee OA.21,22 decades to full thickness confluent the lateral compartment, the patello- In addition, there is evidence that cartilage loss signifying OA has not femoral compartment of the knee is obesity predisposes to osteoarthritis been determined. often afflicted with OA. While injury in non-weight-bearing joints such as is a common factor in medial and lat- the joints of the hand. Clearly excess Alignment, including leg length eral compartment OA, malalignment weight in a biomechanical sense alone Strong evidence suggests that altered is a more common factor in patel- does not explain this finding. Recent mechanics play a role in OA incidence lafemoral OA. Most cases of chon- studies have shown that body fat, par- and progression, and recent studies dromalacia patella that result from ticularly central fat deposits, are bio- are beginning to isolate specific malalignment are nonprogressive, but chemically active and produce sub- mechanical factors that may be of par- some can progress to OA.24 stances such as leptin and adiponectin.23 ticular importance. Such alignment It has also been shown that leptin can problems include a leg length discrep- Conclusions induce the formation of cytokines, ancy of more than 1 cm, which con- OA of the hip and knee is a major such as interleukin-6, which can have fers an increased risk of OA of the hip health care issue in an ever-aging pop- a deleterious effect on chondrocytes on the long leg side. All patients ulation. OA of weight-bearing joints of the cartilage. should be assessed for this. confers major disability and compro- Leg length measurements include mised quality of life. At this time, Trauma the apparent and the true leg length. medical treatment of OA is not as In general, there is a paucity of good To measure leg length, you should sophisticated as the treatment of documentation to support the con- have the patient lie flat on his or her rheumatoid arthritis. All too often we tention that blunt trauma to a joint back on the examining table and en- fail with conservative treatment, and increases the risk of future osteoarthri- sure that there is no hip or knee flexion patients with hip and knee OA progress www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 397
  • 18. Clinical features and pathogenetic mechanisms of osteoarthritis of the hips and knees to total joint arthroplasty. Advances in al. Correlation between radiographically The risk of osteoarthritis with running and joint replacement seem to overshad- diagnosed osteophytes and magnetic aging: A 5-year longitudinal study. J ow advances in more conservative resonance detected cartilage defects in Rheumatol 1993;20:461-468. medical treatment of OA. The better the patellofemoral joint. Ann Rheum Dis 18. Maetzel A, Makela M, Hawker G, et al. we understand the underlying causes 1998;57:395-400. Osteoarthritis of the hip and knee and and mechanisms of OA, the better we 9. Brandt KD. Osteoarthritis: Clinical pat- mechanical occupational exposure—A will be equipped to develop more pro- terns and pathology. In: Kelly W, Harris E, systematic overview of the evidence. J gressive early interventions for this Ruddy S, et al. (eds). Textbook of rheuma- Rheumatol 1997;24:1599-1607. common affliction. As Ilardi and tology. 2nd ed. Philadelphia: Sauders; 19. Felson DT, Zhang Y, Anthony JM, et al. Sokoloff, two pioneers in the study of 1985:1432. Weight loss reduces the risk for sympto- OA, said several decades ago, “Our 10. Stulberg SD, Harris WH. Acetabular dys- matic knee osteoarthritis in women. The treatment of osteoarthritis can be no plasia and development of osteoarthritis Framingham Study. Ann Intern Med more rational than our understanding of the hip. In: Harris WH (ed). The hip. 1992;116:535-539. of its pathogenesis.”25 Proceedings of the Second Open Scien- 20. Messier SP, Loeser RF, Miller GD, et al. tific Meeting of the Hip Society. St Louis: Exercise and dietary weight loss in over- Competing interests CV Mosby; 1974:82. weight and obese older adults with knee None declared. 11. Mitchell NS, Cruess RL. Classification of osteoarthritis: The Arthritis, Diet, and degenrative arthritis. Can Med Assoc J Activity Promotion Trial. Arthritis Rheum References 1977;117:763. 2004;50:1501-1510. 1. Hannan MT, Felson DT, Pincus T. Analy- 12. Srikanth VK, Fryer JL, Zhai G, et al. A 21. Heliovaara M, Makela M, Impivaara O, et sis of the discordance between radi- meta-analysis of sex differences in preva- al. Association of overweight, trauma and ographic changes and knee pain in osteo- lence, incidence and severity of osteo- workload with coxarthrosis. A health sur- arthritis of the knee. J Rheumatol 2000; arthritis. Osteoarthritis Cartilage 2005; vey of 7,217 persons. Acta Orthop Scand 27:1513-1517. 13:769-781. 1993;64:413-518. 2. Lawrence RC, Felson DT, Helmick CG, et 13. Nevitt MC, Felson DT, Williams EN, et al. 22. Karlson EW, Mandl LA, Aweh GN, et al. al. Estimates of the prevalence of arthri- The effect of estrogen plus progestin on Total hip replacement due to osteoarthri- tis and other rheumatic conditions in the knee symptoms and related disability in tis: The importance of age, obesity, and United States. Part II. Arthritis Rheum postmenopausal women: The Heart and other modifiable risk factors. Am J Med 2008;58:26-35. Estrogen/Progestin Replacement Study, 2003;114:93-98. 3. Agency for Healthcare Research and a randomized, double-blind, placebo-con- 23. Simopoulou T, Malizos KN, Iliopoulos D, Quality. Hospitalizations for osteoarthri- trolled trial. Arthritis Rheum 2001;44: et al. Differential expression of leptin and tis rising sharply. Newswise. www.news 811-818. leptin’s receptor isoform (Ob-Rb) mRNA wise.com/articles/hospitalizations-for- 14. Hannan MT, Felson DT, Anderson JJ, et between advanced and minimally affect- osteoarthritis-rising-sharply (accessed al. Estrogen use and radiographic osteo- ed osteoarthritis cartilage; effect on car- 27 July 2010). arthritis of the knee in women. The Fram- tilage metabolism. Osteoarthritis Carti- 4. Kopec JA , Rahman MM, Berthelot ingham Osteoarthritis Study. Arthritis lage 2007;15:872-883. J-M, et al. Descriptive epidemiology of Rheum 1990;33:525-532. 24. Hunter DJ, Zhang YQ, Niu JB, et al. Patel- osteoarthritis in British Columbia, Cana- 15. Zhai G, Ding C, Stankovich J, et al. la malalignment, pain and patellofemoral da. J Rheumatol 2007;34:386-393. The genetic contribution to longitudinal progression: The Health ABC Study. 5. Murphy L, Schwartz T, Helmick CG, et al. changes in knee structure and muscle Osteoarthritis Cartilage 2007;15:1120- Lifetime risk of symptomatic knee osteo- strength: A sibpair study. Arthritis Rheum 1127. arthritis. Arthritis Rheum 2008;59:1207- 2005;52:2830-2834. 25. Ilardi CF, Sokoloff L. The pathology of 1213. 16. Lian K, Zmuda JM, Nevitt MC, et al. Type osteoarthritis: Ten strategic questions 6. Leach RE, Gregg T, Siber FJ. Weight- I collagen alpha1 Sp1 transcription factor for pharmacologic management. Semin bearing radiography in osteoarthritis of binding site polymorphism is associated Arthritis Rheum 1981;11:3-7. the knee. Radiology 1970;97:265-268. with reduced risk of hip osteoarthritis 7. Cibere J. Do we need radiographs to defined by severe joint space narrowing diagnose osteoarthritis? Best Pract Res in elderly women. Arthritis Rheum 2005; Clin Rheumatol 2006;20:27-30. 52:1431-1436. 8. Boegard TL, Rudling O, Petersson IF, et 17. Lane NE, Michel B, Bjorkengren A, et al. 398 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 19. J. Hawkeswood, MD, R. Reebye, MD, FRCPC Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee Education about osteoarthritis, guidance regarding weight loss and exercise, and timely referrals should all be part of early intervention. n order to develop patient-focused The majority of evidence consid- I ABSTRACT: Osteoarthritis is the most common form of arthritis and evidence-based recommendations ered by the panel pertains to knee can lead to signigicant pain and dis- for the management of hip and osteoarthritis, as reflected in this nar- ability. Treatment of osteoarthritis knee osteoarthritis, the Osteoarth- rative review. The hip and knee joints of the knee and hip should aim to ritis Research Society International are very different in structure, load- reduce joint pain and stiffness, (OARSI) convened a panel of 16 ex- ing, and movement. Certainly the maintain or improve mobility, and perts from four medical disciplines: treatment effect of a modality des- optimize patient functioning and primary care, rheumatology, ortho- cribed for one joint may not be the quality of life while limiting the pro- paedics, and evidence-based medicine. same for the other joint. Clarification gression of joint damage. A recent Panel members reviewed existing regarding the nature of supporting expert review of the management of guidelines for the management of hip evidence has been made below when- osteoarthritis by the Osteoarthritis and knee osteoarthritis, a highly prev- ever possible. We also outline the Research Society International sup- alent cause of pain and disability,1 OARSI recommendations and pro- ports a combination of nonpharma- along with data published from 1945 vide additional practical suggestions cological and pharmacological stra- to January 2006.2 for implementing evidence-based, tegies. The review also indicates Treatments were evaluated for ef- conservative management of hip and that patient education is critical in ficacy, safety, and cost-effectiveness. knee OA. the early stages of care, and that Panel members also considered each weight loss and exercise are key to treatment in terms of patient tolerance, OARSI recommendations any nonpharmacological treatment. acceptability, likely adherence, and All patients with hip and knee OA The guidelines are expanded for prac- further logistic issues involved in its should be given information access tical implementation of evidence- administration.3 A subjective “strength and education about the objectives of based, conservative management of of recommendation” (SOR) overall treatment and the importance of hip and knee osteoarthritis. numeric rating (0 to 100 mm on a visu- changes in lifestyle, exercise, pacing al analog scale) was provided for each management strategy based on the Dr Hawkeswood is a fifth-year resident in individual scoring by each of the 16 physical medicine and rehabilitation at the panel members. Mean and standard University of British Columbia. Dr Reebye errors of the mean for each SOR were is a physical medicine and rehabilitation calculated and presented with confi- specialist, a staff physician at G.F. Strong dence intervals. Of the 25 treatments Rehabilitation Centre, and a member of the suggested, 20 involved nonsurgical Division of Physical Medicine and Rehabil- options.3 itation at UBC. www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 399
  • 20. Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee of activities, weight reduction, and led to better scores for weight loss, crease patient activity levels. Physical other measures to unload the dam- physical activity, and pain after 4 medicine and rehabilitation special- aged joint(s). The initial focus should months.5 ists also play an essential role. They are be on self-help and patient-driven Patients with hip and knee OA, trained in all nonsurgical treatment treatments rather than on passive ther- who are overweight, should be en- options and can longitudinally sup- apies delivered by health professionals. couraged to lose weight and maintain port patients faced with complex dis- Subsequently emphasis should be their weight at a lower level. SOR: ease, pain, disability, and resource placed on encouraging adherence to 96% (95% CI 92–100)2 challenges. the regimen of non-pharmacological The entire OARSI panel recom- therapy. SOR: 97% (95% CI 95–99)2 mended encouraging patients to main- General exercise strategy There are two major barriers to the uptake of routine exercise in the osteo- arthritis population: (1) failure on the part of medical practitioners to prop- In patients with knee OA and erly recommend exercise to patients or make appropriate referrals to exer- mild/moderate varus or valgus cise professionals and (2) failure of instability, a knee brace can patients to comply with prescribed exercise programs.8 A survey of osteo- reduce pain, improve stability arthritis patients in Canada revealed and diminish the risk of falling. only one-third had been advised to exercise for their OA; however, 73% had tried exercising in the past.9 A dose-response relationship between compliance and exercise Patient education regarding osteo- tain a healthy body weight.2 Patients effects has been demonstrated in arthritis pathogenesis, clinical course, with knee OA who commenced a low- knee OA, indicating the importance and treatment is needed to promote energy diet reported improved pain, of patient adherence.10 Compliance behavioral modifications and improve stiffness, and functional status after 8 can be improved through professional symptoms. However, such complex weeks of intervention.2,6,7 For each disease education and exercise pres- interventions can be time-consuming kilogram of body weight lost, the knee entation. 11 Initial physiotherapist- and difficult to provide during a single experiences a 4 kg reduction in load supervised classes have been shown visit. Consequently, systematic con- per step and a 4800 kg reduction in to be beneficial as a supplement to servative OA management programs compressive load for each kilometre longer-term home exercises for both are not routinely offered to patients, as walked.7 pain and functioning.12 In general, less than half of those with obesity and Patients with symptomatic hip and physicians should encourage patients OA are advised to lose weight.4 knee OA may benefit from referral to to undertake exercises patients enjoy. In a recent study, patients with a physical therapist for evaluation mild to moderate OA received stan- and instruction in appropriate exer- Pool exercise dardized educational content over the cises to reduce pain and improve func- Patients with hip and knee OA should course of three encounters with a phy- tional capacity. This evaluation may be encouraged to undertake, and con- sician (days 0, 15, and 30) versus usual result in provision of assistive devices tinue to undertake, regular aerobic, care (also involving three encoun- such as canes and walkers, as appro- muscle strengthening and range of ters).5 In the treatment group, the first priate. SOR: 89% (95% CI 82–96)2 motion exercises. For patients with visit focused on informing the patient A global assessment of a patient’s symptomatic hip OA, exercises in water about the disease and outlining treat- medical and functional issues is nec- can be effective. SOR: 96% (95% CI ment. The second visit focused on essary when prescribing therapy for 93–99)2 standardized exercise, and the third osteoarthritis. Physiotherapists play Archimedes recognized that “any visit on weight loss instructions. Com- an essential role in managing hip and object, wholly or partly immersed in a pared with usual care, this program knee osteoarthritis by helping to in- fluid, is buoyed up by a force equal to 400 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 21. Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee the weight of the fluid displaced by patients with hip and knee OA. Pa- bone-on-bone weight-bearing distri- the object.” The depth of water can tients should be given instruction in bution within the joint itself.15 be a useful gauge, and patients with the optimal use of a cane or crutch in Osteoarthritis of the knee often severe symptoms may progress to the contralateral hand. Frames or involves the medial compartment, a more shallow water. Additionally, pa- wheeled walkers are often preferable situation thought to be the result of the tients may find other aspects of the for those with bilateral disease. SOR: natural “bowing” or varus moment water therapeutic, such as the temper- 90% (95% CI 84–96)2 present during normal human gait. ature, added constituents, or pressure Canes are a practical, affordable Alternatively, isolated lateral com- from jets. means to off-load the affected joint, partment OA can result from a valgus The effectiveness of active aquatic improve balance, assist in muscular knee alignment. While multiple high- exercise for the treatment for osteo- compensation, and, hopefully, reduce quality studies are lacking, knee “off- arthritis was recently assessed in a pain symptoms. Patients should be loader” braces have demonstrated Cochrane review that included six instructed to hold the cane in the con- improved pain scores and walking tol- studies of patients with both hip and tralateral hand and take steps with the erance at 1 year, particularly in the knee OA and knee OA only.13 Imme- affected limb and cane in tandem. The medial compartment OA group.22 diately after an exercise period, sig- total length of the cane should equal Compliance can be inconsistent, par- nificant improvements in function, the distance from the upper border of ticularily in the context of obesity where quality of life, and mental health were the greater trochanter to the base of effective fitting can be challenging. found in patients with both hip and the heel. The patient should be able to Every patient with hip or knee OA knee OA, along with pain reduction in stand with the cane with level shoul- should receive advice concerning the knee OA group. The rate of patient ders and elbow flexion at 20 to 30 appropriate footwear. In patients with withdrawal was relatively low (20% degrees. Lastly, patients should ascend knee OA insoles can reduce pain and to 28%) and reports of adverse events stairs with the good leg (“moving up improve ambulation. Lateral wedged (such as increased pain or drug con- is good”) and descend stairs with the insoles can be of symptomatic benefit sumption) were absent.14 affected leg and cane together.20 for some patients with medial tibio- Walkers are typically prescribed femoral compartment OA. SOR: 77% Strengthening exercises for patients who require maximum (95% CI 66–68)2 Muscle weakness is a common assistance with balance. This includes While the degree of observed lat- impairment among patients with knee the elderly, the fearful, and the unco- eral thrust and compressive forces osteoarthritis.15,16 A longitudinal study ordinated. The patient must have good experienced at the knee may be re- suggests that quadriceps weakness grasp and arm strength bilaterally, duced by lateral wedged insoles, the precedes the onset of knee osteoarthri- although forearm supports are avail- primary role of these insoles should tis and hence could increase the risk of able. Unfortunately, patients can be- be to improve pain symptoms.23 Two disease development.17,18 Quadriceps come dependent on walkers and there- prospective RCTs of patients with strengthening, when combined with fore their use should be reserved for medial femorotibial OA showed re- general strength, flexibility, and func- rehabilitation, severe disease, or other duced NSAID use and better compli- tional exercises, has been shown to select circumstances.20 ance in the treatment group using the improve OA symptoms.19 There is, In patients with knee OA and mild/ lateral wedged shoe insert.24,25 Ortho- however, limited evidence to suggest moderate varus or valgus instability, tics should be smaller (between 8 and that stronger muscles can prevent dis- a knee brace can reduce pain, improve 12 mm) and ideally a patient’s toler- ease progression.15 stability and diminish the risk of ance, including gait pattern, should be Any loss of muscle strength may falling. SOR: 76% (95% CI 69–83)2 noted within the first 2 weeks of use.23 be associated with pain, anxiety, lack Braces and orthoses are defined as The clinical status of patients with of motivation, effusion, muscle atro- “any medical device added to a per- hip or knee OA can be improved if phy, and altered joint mechanics.15 son’s body to support, align, position, patients are contacted regularly by Exploring a patient’s physical and immobilize, prevent or correct defor- phone. SOR: 66% (95% CI 57–75)2 emotional barriers to exercise can help mity, assist weak muscles, or improve Regular phone contact with a guide behavioral change and promote function.”21 A knee brace may reduce trained nonclinical professional may long-term adherence to exercise. both the muscular contraction needed help improve a patient’s pain symp- Walking aids can reduce pain in to stabilize the affected knee, and the toms.26 Self-management strategies www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 401
  • 22. Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee for knee and hip OA that provide TENS can help with short-term ment plan will depend on patient patients with opportuntity for educa- pain control in some patients with hip familiarity, preference, and treatment tion and treatment are also deemed or knee OA. SOR: 58% (95% CI 45– response. effective ways to improve pain and 72) 2 disability.27 In British Columbia, the Transcutaneous electrical nerve Conclusions Vancouver Coastal Health Osteoar- stimulation is typically provided by The OARSI guidelines describe num- thri tis Service Integration System physiotherapists, although patients erous useful strategies for the treat- (OASIS) team consists of nurse clini- can purchase their own devices. In ment of hip and knee osteoarthritis. cians, physiotherapists, occupational contrast to electrical muscle stimula- While the literature will continue to therapists, and dietitians, and is de- tion, TENS primarily blocks pain trans- grow in this field, these recommenda- signed to support OA patients (physi- mission. TENS has been well studied tions provide clinicians with a number cian referral is required).28 The BC in knee osteoarthritis, and in some of practical options for managing their Ministry of Health Services web site patients can provide clinically signif- unique patients. Generally speaking, provides other provincial resource icant pain relief, particularly over the treatments receiving lower SOR options.29 short-term (first 2 to 4 weeks of ther- scores require further research to clar- ify ideal candidate patients and to help refine each therapy. Overall, the OARSI guidelines show that early intervention for OA should include In some studies, real acupuncture disease education, guidance on weight is shown to be better than sham loss and exercise, and timely referrals. A global patient assessment will help acupuncture for treating pain, suggesting to shape a comprehensive approach to that acupuncture can be an effective care, and hopefully reduce the need for medications or surgery. treatment for knee osteoarthritis. Competing interests None declared. Some thermal modalities may be apy).30,31 While no serious side effects References effective for relieving symptoms in have been reported,31 conditions in- 1. Lawrence RC, Helmick CG, Arnett FC, et hip and knee OA. SOR: 64% (95% CI volving skin breakdown and pace- al. Estimates of the prevalence of arthri- 60–80)2 maker implantation are contraindica- tis and selected musculoskeletal dis- There is no strong evidence sup- tions. orders in the United States. Arthritis porting the use of thermal modalities; Acupuncture may be of sympto- Rheum 1998;41:778-799. however, these are still included in the matic benefit in patients with knee OA. 2. Zhang W, Moskowitz RW, Nuki G, et al. majority of guidelines for OA man- SOR: 59% (95% CI 47–71)2 OARSI recommendations for the man- agement.3 Thermal modalities are In some studies, real acupuncture agement of hip and knee osteoarthritis, likely still included in most OA treat- is shown to be better than sham part I: Critical appraisal of existing treat- ment guidelines because they are acupuncture for treating pain,3,32 sug- ment guidelines and systematic review accessible, affordable, and often the gesting that acupuncture can be an of current research evidence. Osteo- patient’s first-line choice for manag- effective treatment for knee osteo- arthritis Cartilage 2007;15:981-1000. ing acute pain. Heat may be applied in arthritis. A recent study showed that 3. Zhang W, Moskowitz RW, Nuki G, et al. the form of warm water, heat packs, or acupuncture alone was helpful with OARSI recommendations for the man- wax therapy, and may serve as an pain at 2 and 6 weeks, while adding it agement of hip and knee osteoarthritis, adjunct during stretching or perhaps to advice and exercise recommenda- part II: OARSI evidence-based, expert during painful episodes. Cryotherapy tions delivered by a physiotherapist consensus guidelines. Osteoarthritis typically involves ice packs—a prac- provided no additional benefit.33 As Cartilage 2008;16:137-162. tical consideration for acute episodes with other alternative therapies, the 4. Serdula MK, Mokdad AH, Williamson DF, of inflammation and pain. utility of acupuncture in a manage- et al. Prevalence of attempting weight 402 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 23. Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee loss and strategies for controlling weight. exercise programs on persons with knee 25. Pham T, Maillefert JF, Hudry C, et al. Lat- JAMA 1999;282:1353-1358. osteoarthritis. J Strength Cond Res 2001; erally elevated wedged insoles in the 5. Ravaud P, Boutron I, Roy C, et al. ARTIST 15:337-340. treatment of medial knee osteoarthritis. (osteoarthritis intervention standardized) 15. Bennell K, Hunt M. Muscle and exercise A two-year prospective randomized con- study of standardised consultation ver- in the prevention and management of trolled study. Osteoarthritis Cartilage sus usual care for patients with osteo- knee osteoarthritis: An internal medicine 2004;12:46-55. arthritis of the knee in primary care in specialist’s guide. Med Clin North Am 26. Rene J, Weinberger M, Mazzuca SA, et France: Pragmatic randomised con- 2009:93;161-177. al. Reduction of joint pain in patients with trolled trial. BMJ 2009;338:b421. 16. Ikeda S, Tsumara H, Torisu T. Age-related knee osteoarthritis who have received 6. Christensen R, Astrup A, Bliddal H. quadriceps-dominant muscle atrophy monthly telephone calls from lay person- Weight loss: The treatment of choice for and incident radiographic knee osteo- nel and whose medical treatment regi- knee osteoarthritis? A randomized trial. arthritis. J Orthop Sci 2005;10:121-126. mens have remained stable. Arthritis Osteoarthritis Cartilage 2005;13:20-27. 17. Slemenda C, Heilman D, Brandt K, et al. Rheum 1992;35:511-515. 7. Messier SP, Gutekunst DJ, Davis C, et al. Reduced quadriceps strength relative to 27. Warsi A, LaValley MP, Wang PS, et al. Weight loss reduces knee-joint loads in body weight: A risk factor for knee osteo- Arthritis self-management education overweight and obese adults with arthritis in women? Arthritis Rheum programs: A meta-analysis of the effect osteoarthritis. Arthritis Rheum 2005;52: 1998;41:1951-1959. on pain and disability. Arthritis Rheum 2026-2032. 18. Hootman J, Fitzgerald S, Macera C, et al. 2003;48:2207-2213. 8. Bennell K, Hinman R. Exercise as a Lower extremity muscle strength and 28. Vancouver Coastal Health. OASIS. www treatement for osteoarthritis. Curr Opin risk of self-reported hip or knee osteo- .vch.ca/oasis/services_oasis.htm Rheumatol 2005;17:634-640. arthritis. J Phys Act Health 2004;1:321- (accessed 29 May 2009). 9. Li L, Maetzel A, Pencharz J, et al. Use of 330. 29. BC Ministry of Health. Osteoarthritis in mainstream nonpharmacologic treat- 19. Fransen M, McConnell S. Exercise for peripheral joints—diagnosis and treat- ment by patients with arthritis. Arthritis osteoarthritis of the knee. Cochrane ment. www.bcguidelines.ca/gpac/guide Rheum 2004;51:203-209. Database Syst Rev 2008;(4):CD004376. line_osteoarthritis.html (accessed 29 10. Ettinger WH, Burns R, Messier SP, et al. 20. DeLisa J, Gans B, Walsh N, et al. (eds). May 2009). A randomized trial comparing aerobic Physical medicine and rehabilitation: 30. Brosseau L. Efficacy of transcutaneous exercise and resistance exercise with a Principles and practice. 4th ed. Balti- electrical nerve stimulation for osteo- health education program in older adults more: Lippincott, Williams and Wilkins; arthritis of the lower extremities: A meta- with knee osteoathritis. JAMA 1997; 2004. analysis. Phys Ther Rev 2004;9:213-233. 277:25-31. 21. Deshaies LD. Upper extremity orthoses. 31. Bjordal JM, Johnson MI, Lopes-Martins 11. Campbell R, Evans M, Tucker M, et al. In: Trombly CA, Radomski MV (eds). RA, et al. Short-term efficacy of physical Why don’t patients do their exercises? Occupational therapy for physical dys- interventions in osteoarthritis knee pain. Understanding non-compliance with function. 5th ed. Baltimore: Lippincott, A systematic review and meta-analysis physiotherapy in patients with osteo- Williams and Wilkins; 2002. of randomised placebo-controlled trials. arthritis of the knee. J Epidemiol Com- 22. Brouwer RW, Jakma TS, Verhagen AP, BMC Musculoskeletal Disord 2007;8:51. munity Health 2001;55:132-138. et al. Braces and orthoses for treating 32. Ezzo J, Hadhazy V, Birch S, et al. Acu- 12. McCarthy C, Mills P, Pullen R, et al. Sup- osteoarthritis of the knee. Cochrane puncture for osteoarthritis of the knee: A plementing a home exercise programme Database Syst Rev 2005;(1):CD004020. systematic review. Arthritis Rheum with a class-based exercise programme 23. Yonclas PP, Nadler RR, Moran ME, et al. 2001;44:819-825. is more effective than home exercise Orthotics and assistive devices in the 33. Foster NE, Thomas E, Barlas P, et al. alone in the treatment of knee osteo- treatment of upper and lower limb osteo- Acupuncture as an adjunct to exercise arthritis. Rheumatology 2004;43:880- arthritis: An update. Am J Phys Med based physiotherapy for osteoarthritis of 886. Rehabil 2006;85(suppl):S82-S97. the knee: Randomised controlled trial. 13. Bartels EM, Lund H, Hagen KB, et al. 24. Maillefert JF, Hudry C, Baron G, et al. Lat- BMJ 2007;335:436. Aquatic exercise for the treatment of erally elevated wedged insoles in the knee and hip osteoarthritis. Database treatment of medial knee osteoarthritis: Syst Rev 2007;(4):CD005523. A prospective randomized controlled 14. Wyatt FB, Milam S, Manske RC, et al. study. Osteoarthritis Cartilage 2001;9: The effects of aquatic and traditional 738-745. www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 403
  • 24. Stephen Kennedy, MD, Michael Moran, MBBS, FRCSC Pharmacological treatment of osteoarthritis of the hip and knee A range of oral analgesics, topical treatments, and intra-articular injections can be used to reduce pain and improve function in patients with osteoarthritis of the hip and knee. reatment for hip and knee Evidence for the proposed mechanism T ABSTRACT: Treatment goals for the management of hip and knee osteo- osteoarthritis (OA) aims to is insufficient in vivo, but some stud- arthritis are to reduce pain, maintain reduce pain, maintain or im- ies have reported benefits from gluco- or improve function, and, where pos- prove function, and, where samine in terms of pain relief and even sible, to slow the progress of the possible, to slow the progress of the radiographic progression.1 underlying disease. The benefits and underlying disease. Although no med- Evidence for a positive effect is potential toxicities of pharmacologi- ication has yet been shown to slow the controversial, however, with several cal options should be considered advance of joint pathology in osteo- studies showing no benefit over pla- and treatment should be individ- arthritis, pharmacological manage- cebo.1,2 The Osteoarthritis Research ualized according to patient symp- ment remains an integral component Society International (OARSI) guide- toms, preferences, and a therapeu- of therapy for most patients in the lines state that “treatment with glu- tic agent’s overall safety profile. course of their disease. cosamine and/or chondroitin sulphate When intrusive pain or disability Knowledge of the current evi- may provide symptomatic benefit in persists despite a substantial trial dence can support safe and effective patients with knee OA,” but “if no of nonsurgical therapy, or when con- counseling and prescribing practices, response is apparent within 6 months trolling symptoms requires long- and assist in determining when to treatment should be discontinued.”2 term opioids, high-dose acetamin- refer for surgery. As well as consid- Other guidelines, such as those for the ophen or NSAIDs, and repeated ering the benefits and potential toxi- American Academy of Orthopaedic intra-articular injections, referral cities of pharmacological options, Surgeons, make a recommendation for surgical options should be con- physicians must individualize treat- that physicians not prescribe glu- sidered. ment based on patient symptoms and cosamine.3 Both sets of guidelines are preferences. based on level I evidence.2,3 This disparity in recommend - Glucosamine sulfate and ations is considered to be due to the chondroitin sulfate heterogeneity of existing studies, Glucosamine is one of the most com- particularly with respect to adequacy monly used complementary or alter- native medicine products in North Dr Kennedy is a resident in orthopaedics at America. Typically derived from the the University of British Columbia. Dr ground shells of shellfish or from Moran is a clinical assistant professor and processed grains, glucosamine has head of the Division of Comprehensive proponents who claim it restores gly- Orthopaedics in the Department of cosaminoglycans in arthritic joints Orthopaedics at the University of British and reduces pain and inflammation.1 Columbia in Prince George, BC. 404 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 25. Pharmacological treatment of osteoarthritis of the hip and knee of allocation concealment.2 Little or Higher doses of acetaminophen or sidered.2,3 Gastroprotection is recom- no benefit has been observed when even prolonged use at recommended mended in all eight of the guidelines concealment is adequate.2 Evidence doses are not without risk.2 Although where NSAIDs are considered for the regarding chondroitin sulfate is sim- not common in the studies referenced management of hip or knee OA.2 ilarly inconsistent.2 There is marked by the guidelines above, acetaminophen COX-2 inhibitors are recommended heterogeneity of outcomes between overdose can result in hepatoxicity in all 11 of the guidelines where they trials, and again higher-quality stud- and severe sequelae. Patients should are considered.2 H2-receptor antago- ies with adequate concealment have be counseled and monitored regard- nists do not have similar protective been unable to show significant ben- ing their daily dosage. In the absence qualities, and the GI benefit associat- efit.1,2 of an adequate response, or in the pres- ed with COX-2 agents is lost with con- Overall, the evidence and recom- ence of severe pain or inflammation current low-dose daily acetylsalicylic mendations remain inconsistent for (or both), alternative therapy should acid.2,3 both glucosamine and chondroitin.1-3 be considered. Combining acetamin- Cardiovascular (CV) risk is anoth- We do not recommend prescription of ophen with another medication (e.g., er concern. After rofecoxib was with- these supplements as their benefit ibuprofen) at lower doses of each can drawn from the market due to in- remains unproven, but the risk of their also be effective. creased risk of thrombotic events, a use seems limited to mild stomach number of studies were done to inves- upset and the cost of the pills.1-3 A trial NSAIDs tigate the CV safety of other NSAIDs. of treatment for 6 months would not NSAIDs or nonsteroidal anti-inflam- Celecoxib and valdecoxib do not be unreasonable if a patient expresses matory drugs are among the most appear to have the same risks, and great interest in such products. Future commonly used analgesics in the overall CV risk with COX-2 inhibitors independent high-quality studies are world and are often used as first-line has not been found significantly high- required to further clarify the efficacy medications for joint pain. One UK er than with nonselective NSAIDs.2 of both agents. telephone survey in 2003 reported that Serious vascular events occur at ap- 50% of respondents with osteoarthri- proximately 1% per year on COX-2 Acetaminophen tis were taking NSAIDs.2 inhibitors versus 0.9% on traditional Acetaminophen is a common first-line There is good level I evidence for NSAIDs.2 analgesic for treatment of hip and the analgesic effect of NSAIDs in CV risk is greater in patients with knee osteoarthritis. OARSI found the OA, and meta-analyses of short-term, a history of ischemic heart disease or use of acetaminophen to be a core rec- placebo-controlled randomized trials stroke, or in patients with risk factors ommendation in 16 of 16 guidelines have shown an effect size between 0.23 for heart disease such as hypertension, evaluated.2 Compared with placebo, and 0.32 in terms of reduction in pain.2 hyperlipidemia, diabetes, smoking, or statistically significant effects on pain NSAIDs, however, are associated peripheral arterial disease.2 Caution relief have been demonstrated with- with more adverse effects than acet- should be exercised when prescribing out statistically significant risk of tox- aminophen.2,3 Gastrointestinal (GI) all NSAIDs in these patients.2 icity.3 OARSI guidelines recommend discomfort occurs more frequently Renal toxicity is also a concern in up to 4 g per day as an effective first- and, more importantly, serious com- selected patients. In patients with con- line therapy in patients with mild to plications such as peptic ulcers, perfo- gestive heart failure, pre-existing moderate pain from OA.2 Current rations, and bleeds are more likely to renal insufficiency, or transplanted European League Against Rheuma- occur.2,3 Pooled relative risk compared kidneys, the use of NSAIDs can lead tism (EULAR) recommendations for to placebo is estimated at 270%.2 Risk to acute renal failure. Care should be hip and knee OA suggest that aceta- also increases with age, concurrent taken to screen for clinical or labora- minophen at these doses should be the use of other medications, and duration tory evidence of existing diminished first choice for mild to moderate pain, of therapy. creatinine clearance and considera- and if successful, should be used as In patients at greater GI risk, there tion should be given to follow-up lab the preferred long-term oral anal- is level I evidence that NSAIDs should analysis after treatment is begun. gesic.2 For most patients the differ- be used in combination with a proton Renal clearance decreases significant- ence in pain relief between acetamin- pump inhibitor or misoprostol for ly with age. ophen and NSAIDs is not clinically gastroprotection, or that the use of a In patients with symptomatic hip significant.2 COX-2 selective agent should be con- or knee OA, NSAIDs should be used www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 405
  • 26. Pharmacological treatment of osteoarthritis of the hip and knee at the lowest effective dose and their studies. This compared with 7% of sizes of 0.41 and 0.40, respectively, in long-term use should be avoided if placebo-treated patients.2 weeks 1 and 2.2 Side effects seem lim- possible.2,3 In patients at greater GI There have been no long-term tri- ited to local reactions such as burning, risk, either a COX-2 selective agent or als of the use of opioids for OA, and itching, and rashes.2 Placebo effects a nonselective NSAID in combination ongoing concerns remain about the may be large with topical therapies, with a gastroprotective agent should risks of dependence. Recovery from and one meta-analysis showed evi- be considered.2,3 All NSAIDs should arthroplasty surgery is more difficult dence of possible publication bias be used with caution in patients with for patients on chronic opioid therapy, with underreporting of negative stud- CV risk factors.2 Physicians should and their optimal outcome may be ies.2 However, topical NSAIDs re- continue to choose an NSAID on the compromised.4 main a reasonable option in combina- basis of the agent’s overall safety pro- We feel that strong opioid anal- tion with or as an alternative to other file and the patient’s individual risk gesics should be reserved for patients analgesics. factors. in exceptional circumstances with severe pain who are not candidates for Topical capsaicin Opioids other therapy. Short courses of weak Topical capsaicin creams contain a Weak opioids have increasingly been opioids like codeine or tramadol and lipophilic alkaloid extracted from used recently for the treatment of acetaminophen combinations can be chili peppers that activates and sensi- refractory pain in patients with hip or used for brief exacerbations of pain if tizes peripheral pain and heat recep- knee OA. A number of systematic tolerated.2 When prescribing these, tors by binding and activating specif- reviews and meta-analyses of opioids precautions should be taken: patients ic cation channels.2 Application to the for chronic non-cancer pain, musculo- should be counseled about their use skin causes a burning sensation ini- skeletal pain, and OA have provided and potential for dependence. Non- tially but can lead to effective analge- evidence of efficacy and acceptable pharmacological therapies should con- sia that prevails over the sensation of safety in short-term trials.2 tinue and surgical treatments should burning.2 The efficacy of capsaicin is Analysis of 18 randomized place- be considered. It is highly recom- supported by a meta-analysis of RCTs bo-controlled trials of 3244 OA pa- mended that strong narcotics such as of its use in the treatment of chronic tients showed a moderate effect size morphine, oxycodone, and hydromor- painful conditions, including a single for reduction in pain intensity (0.25).2 phone not be prescribed for osteo- placebo-controlled trial in 70 patients However, there was substantial het- arthritis. Instead, patients should be with knee OA and two RCTs in erogeneity between studies. This was referred for surgical treatment. patients with hand OA.2 The mean not obviously related to the prepara- reduction in pain was 33% after 4 tion used or the quality of the RCTs.2 Topical treatments weeks of therapy.2 Treatment is safe, A systematic review regarding Topical NSAIDs but local burning, stinging, or erythe- acetaminophen and codeine combina- Topical NSAIDs can be effective ma troubles 40% of patients. The tions indicated a small analgesic ben- adjunctive treatments or alternatives burning sensation also prevents ade- efit over acetaminophen alone (approx- to oral analgesics in knee OA.2 A quate blinding with this agent, which imately 5%), but adverse effects were meta-analysis of 13 RCTs, including may influence conclusions based on more frequent.2 Another meta-analysis 1983 patients with hand and knee OA, the available data.2 Despite these of opioids for chronic non-cancer showed topical NSAIDs to be superi- shortcomings, topical capsaicin can pain, including OA, demonstrated that or to placebo in terms of analgesia, be a useful alternative or adjunctive only strong opioids were significantly relief of stiffness, and function, with a treatment in selected patients.2 A typ- more effective in relieving pain than reduced relative risk of adverse GI ical dose is 0.025% cream four times acetaminophen or NSAIDs.2 events compared with oral forms.2 In a day.2 Benefits associated with the use of one large case control study topical opioids, however, are limited by fre- NSAIDs were reported to have no Intra-articular injection quent side effects such as nausea more GI side effects than placebo.2 Techniques for injection (30%), constipation (23%), dizziness Topical NSAIDs are less effective Intra-articular injection of the hip gen- (20%), somnolence (18%), and vom- than oral NSAIDs in the first week of erally requires fluoroscopic or ultra- iting (13%).2 One-quarter of patients treatment, but efficacy is apparent sound guidance to ensure accurate treated with opioids withdrew from within 2 weeks, with pain relief effect placement. 406 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 27. Pharmacological treatment of osteoarthritis of the hip and knee Multiple descriptions exist for cerns in terms of “trial quality, poten- Discordant conclusions in system- intra-articular injection of the knee tial publication bias, and unclear clin- atic reviews of HA have been found joint.5,6 The patient should be supine ical significance.”2 Pooled effects to be due to inclusion of different and relaxed. It is easiest to inject the from poor-quality trials are as much controlled trials, differences in the knee in full extension. All injections as twice those obtained from higher- outcome measures and time points should be performed in a sterile man- quality ones.2 In systematic reviews selected for extraction, and different ner.5,6 It’s helpful to palpate surface landmarks prior to antiseptic cleans- ing and draping. A 25-gauge 11/2 inch needle should be used. One study found the lateral mid-patellar approach to Injection of hyaluronic acid have the greatest accuracy.5 More common, and our method of choice, is preparations into the knee and hip is to use the soft point at the superior lat- commonly used to treat osteoarthritis, but eral pole of the patella between the patella and the femur, with the needle there is considerable ongoing controversy inserted into the suprapatellar pouch about the treatment’s efficacy, cost- at that level. Entry should be deliber- ate and smooth. Joint effusion can effectiveness, and benefit-to-risk ratio. make the process much easier, while factors such as joint degeneration, diminished range of motion, and obe- sity can make insertion more diffi- there is significant heterogeneity be- statistical methods for data synthesis, cult.5,6 If the needle meets an obstruc- tween studies and evidence to suggest which resulted in conflicting esti- tion, pull back slightly and adjust the publication bias and overestimation mates of therapeutic effect.2 trajectory. Aspiration of joint fluid can of effect size.2 No major safety issues were de- be used for confirmation of accurate A Cochrane review of 40 placebo- tected, but in placebo-controlled trials placement. During injection, patient controlled trials with five different minor adverse events such as transient complaints of increased pain should hyaluronan products found statistical- pain at the injection site occurred be considered an indication of possi- ly significant improvements in pain slightly more frequently in patients ble extra-articular placement.5,6 The on weight bearing when results were treated with intra-articular hyaluro- fluid should flow smoothly and cause pooled, but improvements were vari- nan than in those treated with intra- little or no discomfort. If infiltration is able.2 Pain reduction from baseline at articular corticosteroids.2 difficult, reposition and reattempt 5 to 13 weeks varied from 28% to 54% Because of the conflicting evidence injection as necessary. for pain and 9% to 32% for function- from the literature and existing guide- al outcome scores.2 Data to suggest lines, the use of intra-articular HA Viscosupplementation that the higher molecular weight HA is not universally recommended.2,3 Hyaluronic acid (HA) or hyaluronan preparations were more effective than Relief may be gained for patients with is a glycosaminoglycan constituent of lower molecular weight preparations mild to moderate hip or knee OA synovial fluid. Injection of HA prepa- were inconclusive.2 In a randomized symptoms, and results are character- rations into the knee and hip is com- comparison of three injections of high ized by delayed onset but prolonged monly used to treat osteoarthritis, but and low molecular weight HA, there duration.2 The adequacy of clinical there is considerable ongoing contro- were significant improvements of benefit remains somewhat unclear and versy about the treatment’s efficacy, approximately 40% in pain and func- costs are not insignificant—injections cost-effectiveness, and benefit-to-risk tional scores up to 6 months after treat- typically range from $130 to $230 per ratio.2,3 ment.2 However, in another placebo- injection and 3 to 5 weekly injections Numerous studies have examined controlled trial comparing HA with are required. We tend not to recom- the effectiveness of various HA prepa- corticosteroid or saline at 2 weekly mend these injections, particularly in rations and generally show positive intervals, there were no significant patients with moderate to severe dis- effects, but there are significant con- differences between the groups.2 ease, but if patients are given realistic www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 407
  • 28. Pharmacological treatment of osteoarthritis of the hip and knee expectations and have adequate re- may be due to additional mechanisms to-head comparisons exist to support sources, a trial of therapy is not unrea- unrelated to the purely anti-inflamma- any particular choice of corticosteroid, sonable, particularly for mild OA. tory effect. and data are insufficient to state how In terms of toxicity, potential side frequently it is safe to repeat injec- Corticosteroid therapy effects include post-injection flares of tions. More than four times annually Despite the unclear role of inflamma- pain, crystal synovitis, hemarthrosis, is generally not recommended. One tion in the pathogenesis and progres- joint sepsis, articular cartilage atro- indication for these injections is if a sion of osteoarthritis, 11 of 13 existing phy, and steroid-induced arthropathy. patient needs to be active for a short treatment guidelines recommend in- Side effects such as bruising and period of time while awaiting surgery, jection of corticosteroids for OA at lipodystrophy are not uncommon but either because of work or family com- some stage of the disease.2 Multiple can be minimized with careful tech- mitments. The temporary relief, partic- systematic reviews conclude that it is nique. Overall, in 28 controlled trials ularly if the patient is clearly informed effective for relieving pain at least in of intra-articular steroid injections in about its temporary nature, is often the short term (i.e., 1 to 2 weeks).2,3,7 1973 patients with OA of the knee, no appreciated. The efficacy is also supported by evi- serious adverse events were reported dence from a Cochrane systematic as a consequence.2 In cases where Antidepressants review, which examined data from 13 inflammatory or infectious arthritis is Depression and osteoarthritis are both randomized placebo-controlled tri- considered, aspiration and analysis of common and often coexist. Multiple als.2,8 The effect size for pain relief is synovial fluid prior to injection should studies have demonstrated that psy- in the moderate range (0.25) at 2 and also be considered. chosocial factors are equally or more 3 weeks after injection, with a lack of OARSI guidelines state that intra- important than disease-specific fac- evidence for pain relief by 4 weeks articular injections with corticosteroid tors in reports of pain intensity and and 24 weeks after injection.2,8 Evi- can provide short-term symptomatic disability in several conditions, in- dence for hip steroid injection is more relief of knee OA, and should be con- cluding joint pain.9,10 Awareness and limited, and mixed in terms of results.2 sidered, particularly in cases of mod- treatment of depressive symptoms can result in significantly less pain and improved quality of life.9,10 In one study of older adults with arthritis and comorbid depression, treatment of Despite the unclear role of inflammation depression extended beyond improved mood to significant improvement in in the pathogenesis and progression of pain, function, and quality of life.10 osteoarthritis, 11 of 13 existing treatment When to refer guidelines recommend injection of The decision to refer a patient for sur- corticosteroids for OA at some gery is complex, and consensus state- ments fail to agree upon specific stage of the disease. thresholds for referral, but pain and disability are consistently the most important measures considered.11-13 Physical examination is emphasized less and tends not to correlate with the Some randomized controlled trials erate to severe pain not responding decision for surgery.12,13 The ability to have demonstrated better outcomes in to other analgesics and nonpharma- work, give care to dependants, and patients with synovial effusions or cologic modalities.2 Anecdotally we live independently consistently out- other clinical signs of inflammation, have found a small percentage of pa- weigh range of motion or other meas- but this has not been seen universally tients to achieve long-term improve- ures of physical impairment.13 and it remains controversial whether ment. For the most part, however, Generally, referral to an orthopaedic steroid injections should be restricted improvements are short-lived for what surgeon should be made when intru- to these patients.2 The analgesic effect is a chronic problem.7 Too few head- sive pain or disability persists despite 408 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 29. Pharmacological treatment of osteoarthritis of the hip and knee a substantial trial of nonsurgical ther- Competing interests 11. Naylor CD, Williams JI. Primary hip and apy, or when long-term opioids, high- None declared. knee replacement surgery: Ontario crite- dose acetaminophen or NSAIDs, and ria for case selection and surgical priority. repeated intra-articular injections are References Qual Health Care 1996;5:20-30. required to control symptoms. The 1. Block JA, Oegema TR, Sandy JD, et al. 12. Hadorn DC, Holmes AC. The New decision should be personalized and The effects of oral glucosamine on joint Zealand priority criteria project. Part 1: based on each patient’s experience of health: Is a change in research approach Overview. BMJ 1997;314:131-134. the disease, functional goals, and risks needed? Osteoarthritis Cartilage 2010; 13. Arnett G, Hadorn DC. Developing priori- of undergoing elective surgery. 18:5-11. ty criteria for hip and knee replacement: Age, obesity, and comorbidities 2. Zhang W, Moskowitz RW, Nuki G, et al. Results from the Western Canada Wait- have little impact on the benefit from OARSI recommendations for the man- ing List Project. Can J Surg 2003;46:290- joint replacement and rarely should agement of hip and knee osteoarthritis, 296. prevent referral.14 Hip and knee replace- part II: OARSI evidence-based, expert 14. Santaguida PL, Hawker GA, Hudak PL. ment surgeries reliably reduce pain, consensus guidelines. Osteoarthritis Patient characteristics affecting the prog- restore function, and have low mor- Cartilage 2008;16:137-162. nosis of total hip and knee joint arthro- bidity and mortality.15,16 With improv- 3. Richmond J, Hunter D, Irrgang J, et al. plasty: A systematic review. Can J Surg ing joint arthroplasty survivorship, it Treatment of osteoarthritis of the knee 2008;51:428-436. has also become a viable option for (nonarthroplasty). J Am Acad Orthop 15. Schulte KR, Callaghan JJ, Kelley SS, et al. younger patients with disabling dis- Surg 2009;17:591-600. The outcome of Charnley total hip arthro- ease. Decision making in these cases 4. Carroll IR, Angst MS, Clark JD. Manage- plasty with cement after a minimum can be challenging, and orthopaedic ment of perioperative pain in patients twenty-year follow-up. The results of one consultation may be the best way to chronically consuming opioids. Reg surgeon. J Bone Joint Surg Am 1993; determine suitability for surgery. It is Anesth Pain Med 2004;29:576-591. 75:961-975. important to note that there is no age 5. Jackson DW, Evans NA, Thomas BM. 16. Robertsson O, Dunbar M, Pehrsson T, et restriction for joint replacement sur- Accuracy of needle placement into the al. Patient satisfaction after knee arthro- gery, and referral should not be with- intra-articular space of the knee. J Bone plasty: A report on 27,372 knees operat- held because of young age. Joint Surg Am 2002;84:1522-1527. ed on between 1981 and 1995 in 6. Lockman LE. Knee joint injections and Sweden. Acta Orthop Scand 2000;71: Conclusions aspirations: The triangle technique. Can 262-267. Pharmacological treatments for osteo- Fam Physician 2006;52:1403-1404. arthritis of the hip and knee have not 7. Hepper CT, Halvorson JJ, Duncan ST, et been shown to alter the progression of al. The efficacy and duration of intra-artic- disease but may be used in a multitude ular corticosteroid injection for knee of combinations for symptom relief. A osteoarthritis: A systematic review of range of oral analgesics, topical treat- level 1 studies. J Am Acad Orthop Surg ments, and intra-articular injections 2009;17:638-646. of hyaluronic acid or steroids might 8. Bellamy N, Campbell J, Robinson V, et al. be considered. Treatment should be Intra-articular corticosteroid for treat- individualized according to patient ment of osteoarthritis of the knee. symptoms, preferences, and a thera- Cochrane Database Syst Rev 2006;(2): peutic agent’s overall safety profile. CD005328. When intrusive pain or disability per- 9. Vranceanu AM, Barsky A, Ring D. Psy- sists despite a substantial trial of non- chosocial aspects of disabling muscu- surgical therapy, or when controlling loskeletal pain. J Bone Joint Surg Am symptoms requires long-term opioids, 2009;91:2014-2018. high-dose acetaminophen or NSAIDs, 10. Lin EH, Katon W, Von Korff M. Effect of and repeated intra-articular injections, improving depression care on pain and referral for surgical options should be functional outcomes among older adults considered. with arthritis: A randomized controlled trial. JAMA 2003;290:2428-2434. www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 409
  • 30. good guys Hammy and Hector During his career as a rural GP, Dr Haynes referred many difficult orthopaedic cases to the expert care of Dr Hammy Boucher and Dr Hector Gillespie at VGH, including a patient badly injured in a remote plane crash in 1961. Sterling Haynes, MD the pedicles of the lumbar and sacral Don’t want to hear no troubles—jist spine. The procedure was innovative give me the positives,” said Joe. hough Hammy Boucher and and hastened early recovery when a “Here, I’ll help load your stuff in the T his partner Hector Gillespie were both superb orthopaedic surgeons, they were the antithesis of back fusion was necessary. It is still being used today. As a GP in Williams Lake, I re- back of my plane. Then we’ll be off like a dirty shirt to One-Eyed Lake.” Once we were in the air Joe asked each other. Hammy was a hard man, ferred most of my difficult cases to me to find the section of the maps that stern and sometimes distant. He ate up Hammy or Hec. In 1961, on a Tuesday showed One-Eyed Lake. I searched interns and residents at Vancouver (my day off) in May, I was called to go the back of the plane but that topo- General Hospital and Shaughnessy to One-Eyed Lake in the Chilcotin graphical map section was gone. In Veteran Hospital every morning for region, a few miles from the Puntzi the hazy smoke from forest fires we breakfast, at rounds, and later in the US Air Force Base. A light plane had searched, flying at 300 feet west of the day as a nightly snack. Hec was an crashed with three people aboard, Puntzi Mountain US Air Force Base affable, chunky man with a great bed- until we heard and saw a man on a side manner, a good teacher, and the small lake firing shotgun shells. It was football doc for the BC Lions profes- We walked about Cappy. He waved us in and we landed sional football club. Hammy was a half a mile and heard on One-Eyed Lake. tall, powerfully built man as well, but With the US sergeant medic, a PFC screaming, and then we to him orthopaedic surgery was no soldier from Puntzi Mountain, and joking matter. Both men had perfect- saw the front end and two young Native lads, we set down ed the no-touch technique while in the the prop buried in the trail with Cappy in the lead. We surgical theatre—tissue and bone were walked about half a mile and heard the mud. handled only with sterile instruments screaming, and then we saw the front during all procedures. This method end and the prop buried in the mud. I was very difficult to learn by junior and Cappy Lloyd, the radio-telephone was the first one there and the boys residents who didn’t have powerful operator at the One-Eyed Lake Lodge, followed with all the medical equip- hands. Jokesters say an orthopaedic asked me to go to the wreck immedi- ment. The sergeant carried the Thomas surgeon has to be as strong as an ox… ately. I gathered my bag, Thomas splints and mesh metal stretcher. I and twice as smart. Both these men splints, yards of bandaging and dress- managed to pry open the door and were strong but they were very smart ings, and 10 litres of IV fluids, and found Jack, the pilot, dead. Kenny medically as well. Hammy, in 1959, soon I was at the dock by Colonel Joe’s Huston was still strapped in the co- devised and perfected a procedure float plane on Williams Lake. Joe, a pilot’s seat and Jack’s teenage son was called the “Boucher fusion,” which southerner, had been a US fighter pilot sitting on sleeping bags at the back of was a transluminar screw fixation of on the Burma Road in the Second the plane nursing his ankle. Kenny’s World War. Joe was getting ready for scalp was on the dashboard. I remem- Dr Haynes is a retired general practitioner the trip and was gassing up his Cess- ber throwing Kenny’s bagged tomato living in West Kelowna. He has published a na 180 by hand from a 45 gallon drum sandwich on the floor and stuffing his book entitled Wake-Up Call: Tales From a of high octane fuel when I arrived. scalp in the brown bag and putting it Frontier Doctor, available through amazon.ca. “What do ya know good Doc? in my pocket. All five of us managed 410 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 31. good guys council on to gently get Kenny onto the pad- health promotion ded metal wire stretcher, and I placed one leg in a Thomas splint for his badly fractured femur. Then Health Canada allows 10 000 unproven I threaded two intra-catheters into each broken arm’s veins. The two remedies onto shelves young men carried the bottles of ecent industry concerns over The current NHP regulations came saline. Cappy assisted the young lad out of the plane and helped him hobble back to the lodge. A R Health Canada’s backlog of roughly 10 000 so-called nat- ural remedies awaiting pre-market into force in 2004 at which time Health Canada had an estimated 40 000 natural health product applica- few hundred yards along the trail review1 have not gone unheeded by tions to review and provide licences Kenny stopped breathing and I intu- Health Canada. In a move reminiscent for, and manufacturers had 6 years to bated him on the muddy path. Then of a Kafka novel, the nation’s fore- meet Health Canada’s requirements. his sterterous breathing reassured most health protection agency has Health Canada now says it will not be me as we carried Kenny along the decided to address the bottleneck enforcing the now-passed 1 April swampy lakeshore. posed by an already woefully lax 2010 deadline. The agency states that While we were away Colonel screening process by simply exempt- about 60% of applications it received Joe had gassed up the plane in antic- ing products from such review alto- have been processed. For the remain- ipation of flying the injured back to gether for at least a couple of years. ing 11 000 NHP applications received Williams Lake. For more than a decade, products but not yet assessed, Health Canada “Doc, what say we strap Kenny such as herbal, homeopathic, and sim- on 4 August introduced the Natural to one of the pontoons? We don’t ilar remedies have been granted spe- Health Products (Unprocessed Prod- have room in my plane.” cial regulatory status as natural health uct Licence Applications) Regula- “Colonel Joe, are you out of products (NHPs). Manufacturers are tions. These state that these products your mind? I’ll get the RCMP’s permitted to market these NHPs using can remain for sale to Canadians dur- large Beaver aircraft to fly down claims that they produce health bene- ing the 21/2 years the agency believes from Prince George. When you get fits. Currently, the standard proof of it will take to apply the existing weak back to Williams Lake notify the safety and effectiveness that applies review standards for safety, efficacy, hospital matron, Doreen Campbell, to this class of products is far lower and quality. The benefits of this ex- of our problems and we’ll be back than those that apply to regular med- emption will be huge—as far as pro- in three or four hours.” ications. Furthermore, once proper ducers are concerned. Health Canada “OK, Doc.” testing is done, almost all of these recently estimated the retail value of We had a great trip back in the products fail to show compelling proof the unapproved natural health prod- Beaver. My partner, John Hunt, and of efficacy, including products already ucts at between $200 to $930 million.2 I in the War Memorial hospital on the market. Indeed, even after claims The bottom line is that thousands splinted some of the 43 fractures of health benefits are disproved, the of products remain unapproved by and transfused Kenny with six units products continue to be sold. Health Canada but are still openly of blood. I retrieved the scalp from The problem of inadequate stan- sold to unsuspecting Canadians, who my brown sandwich bag and re- dards is compounded by the lack of might well believe that Health Cana- attached it with many stitches. At resources at Health Canada to review da wouldn’t allow anything into stores dawn the next day Kenny was trans- and process a backlog of marketing unless it truly was safe and effective. ferred by an Air-Sea Rescue Grum- applications. At the end of 2009, pharmacy regula- man flying boat to the Richmond This is not to say that unapproved tors concerned for patient health and docks and then to VGH under natural products aren’t on the shelves. safety instructed pharmacies across the care of Hammy. Kenny was to They are, but producers are concerned the county to stop selling unapproved remain a patient in VGH for three that Health Canada might demand natural health products. Health Cana- years. Kenny returned to town with that unapproved products be removed da’s maneuver appears to sidestep no crutches, and after a long 40 from the marketplace. Although such the concerns by neatly declaring those months, married Doreen Campbell, a move might seem to be common same products “approved pending the hospital matron. Ken’s recov- sense to those concerned about review.” ery was due to the great treatment consumer protection, Health Canada The proposal to defer the weak re- provided by Hammy and Hec and appears to have taken a different view process that exists within Health the resident staff of VGH. approach. Continued on page 416 www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 411
  • 32. guidelines for authors (short form) The British Columbia Medical Journal wel- 3. Disclosure. All authors must sign a “Disclo- Permissions come letters, articles, and scientific papers. sure of financial interests” statement and pro- It is the author’s responsibility to obtain written Manuscripts should not have been submitted to vide it to the BCMJ. This helps reviewers deter- permission from both author and publisher for any other publication. Articles are subject to mine whether the paper will be accepted for material, including figures and tables, taken or copyediting and editorial revisions, but authors publication, and may be used for a note to adapted from other sources. Permissions should remain responsible for statements in the work, accompany the text. accompany the article when submitted. including editorial changes; for accuracy of ref- 4. Consent. If the article is a case report or if an erences; and for obtaining permissions. 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Presented at the 52nd Annual system according to the International System of Authorship, copyright, disclosure, Meeting of the Canadian Psychiatric Associ- Units (SI). and consent form ation, Winnipeg, MB, 5 October 2008. When submitting a clinical/scientific/review 2. Kim-Sing C, Kutynec C, Harris S, et al. Breast Abbreviations paper, all authors must complete the BCMJ’s cancer and risk reduction: Diet, physical activ- Except for units of measure, we discourage four-part “Authorship, copyright, disclosure, ity, and chemoprevention. CMAJ. In press. abbreviations. However, if a small number are and consent form.” Personal communications are not included in necessary, use standard abbreviations only, pre- 1. Authorship. All authors must certify in writ- the reference list, but may be cited in the text, ceded by the full name at first mention, e.g., in ing that they qualify as an author of the paper. with type of communication (oral or written) vitro fertilization (IVF). Avoid abbreviations in Order of authorship is decided by the co-authors. communicant’s full name, affiliation, and date the title and abstract. 2. Copyright. All authors must sign and return (e.g., oral communication with H.E. Marmon, an “Assignment of copyright” prior to publica- director, BC Centre for Disease Control, 12 Drug names tion. Published manuscripts become the proper- November 2007). Use generic drug names. Use lowercase for ty of the BC Medical Association and may not Material submitted for publication but not generic names, uppercase for brand names, e.g., be published elsewhere without permission. accepted should not be included. venlafaxine hydrochloride (Effexor). 412 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 33. bc centre for disease control Screening renal failure patients for tuberculosis James Johnston, MD, FRCPC, patients, likely reflecting the uncer- Treatment of LTBI Kevin Elwood, MB, BCh, tain value of current diagnostic strate- Once the diagnosis of LTBI is estab- MRCP, FRCP gies in this group. lished and active disease is ruled out, LTBI prophylaxis should be consid- Scope of problem A diagnostic challenge ered. The current standard of therapy More than 60 years after the develop- Diagnosis of LTBI traditionally relies for LTBI is 9 months of isoniazid ment of effective antimycobacterial on a combination of clinical history, (INH) monotherapy. INH is metabo- therapy, tuberculosis (TB) remains a tuberculin skin test (TST) and chest lized and cleared by the liver, and does significant problem in British Colum- X-ray results. These traditional modal- not require dose adjustment in renal bia. Provincial TB rates exceed the ities, however, have their limitations disease. Preventive regimens have Canadian average, attributable to the in CKD populations. Half of dialysis been associated with neuropsychiatric, disproportionate burden in foreign- patients have some degree of anergy hepatic, and gastrointestinal side effects born and Aboriginal populations. Fur- to TST, so a negative TST cannot effec- in CKD populations. However, the ther reduction in the rates will require tively rule out LTBI. These patients risk of side effects must be weighed targeting populations at high risk of are often frail with thinning skin, mak- against the high risk of active disease, reactivation of latent TB with preven- ing the test technically difficult. Chest so patients require individual assess- tive treatment. X-rays are insensitive unless granulo- ments. Patients with advanced chronic matous abnormalities happen to be kidney disease (CKD) are susceptible present. Guidelines and to tuberculosis infection and disease. The recently developed interferon recommendations CKD is more common in foreign-born gamma release whole blood assays The most recent guidelines address- individuals—a population with high (IGRAs) are a promising diagnostic ing the issue were published by the rates of latent tuberculosis infection addition in CKD populations. There British Thoracic Society. They stress (LTBI). More importantly, however, are two commercially available tests that screening all CKD patients for immunity is impaired in CKD pa- in evaluation, the QuantiFERON-TB LTBI is not supported by current evi- tients through reduced function of Gold (Cellestis, Australia) and T-SPOT dence and would not likely be cost- T and B cells and neutrophils. Once TB assay (Oxford Immunotec, UK). effective. However, targeted testing infected with Mycobacterium tuber- These tests offer several advantages for at-risk patients was recommended. culosis, dialy sis patients have a over the TST: they are highly specific Likewise, the Canadian Tuberculosis 20-fold increased risk of developing in BCG vaccinated individuals, have Committee recommends targeting active disease. Renal transplant pa- inbuilt positive controls to detect aner- testing for LTBI in CKD populations, tients are at even higher risk due to gy, and do not require 48-hour follow- specifically, all recent immigrants and added immunosuppressive therapy. up for reading. Both tests are avail- high-risk populations with CKD The occurrence of an active infectious able for limited indications through requiring dialysis should be screened case of TB in a dialysis unit is highly the BCCDC tuberculosis clinics and with TST (cutoff 10 mm or greater) disruptive, putting both staff and other increasingly elsewhere in the province. followed by IGRA if available. If patients at risk. Early data support IGRA use in either TST or IGRA is positive, pa- As of December 2009, there were CKD populations. When compared tients should be considered to have 2720 patients enrolled in provincial with TST in cross-sectional studies LTBI infection. dialysis programs, while 10 368 pa- and short-term cohorts, these assays Improving the diagnosis of LTBI tients were registered in predialysis appear to have improved sensitivity infection in CKD patients is chal- clinics. To date there is no provincial for LTBI. In particular, IGRAs appear lenging. The currently recommended policy for LTBI screening in CKD to detect prior active disease and are strategy is TST followed by IGRA in associated with TB exposure history. patients with risk factors for LTBI Dr Johnston is a research fellow at the BC Long-term follow-up is still required infection. Alternatively initial screen- Centre for Disease Control. Dr Elwood is to demonstrate improved clinical out- ing with IGRA alone is an option. We the director of TB Control at the BC Centre comes associated with these assays. recommend that clinicians consider for Disease Control. Continued on page 416 www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 413
  • 34. pulsimeter Stephen Lewis AIDS MWIA conference tary general. She was enthusiastic Foundation AfriGrand about the congress both from a local In July more than 600 female physi- and international perspective. “This Caravan cians and students from across the meeting gives [Canadian doctors] a This fall, the Stephen Lewis Founda- world met in Munster, Germany, to very good global perspective… we tion’s Grandmothers to Grandmothers discuss professional issues and topics don’t always have a strong grasp Campaign will bring together more in women’s health. This meeting of what’s happening in sub-Saharan than 240 grandmothers’ groups, stu- marked the 28th International Con- Africa, the Middle East, or Europe.” dents, activists, and community mem- gress of the Medical Women Interna- With many opportunities for present- bers to partake in the AfriGrand Cara- tional Association (MWIA), one of the ing research and current data in these van to raise awareness and funds for oldest professional associations in countries, coupled with time to dis- the AIDS pandemic in sub-Saharan medicine. Founded in 1919, this group cuss issues that were raised, the Africa. has representation from women doc- MWIA Congress provided an excel- During the campaign, the Stephen tors in each continent. lent platform to learn and discuss Lewis Foundation will travel across Dr Ilona Kickbusch of the Gradu- the status of medical care in several the country with African grandmothers ate Institute Geneva, located in Gene- countries. Dr Ross has been an active and teenage granddaughters orphaned va, Switzerland, delivered a powerful member since 1984 and considers the by AIDS. The Caravan will create a keynote address on the conference’s MWIA pivotal in helping protect forum for these women to tell their theme, Globalization in Medicine— women by fighting gender inequality stories, share their strategies, and talk Challenges and Opportunities. Dr and improving women’s health. about their challenges and triumphs in Kickbusch emphasized the impor- Delegates tackled globalization dealing with the ravages of AIDS. It tance of health policy and how it must and health through a series of diverse will also offer Canadians in 40 com- change to accommodate the global- and poignant resolutions that impli- munities the opportunity to be inspir- ization of health care. She insisted that cate women’s health in many sectors. ed by these stories and to join the current policy is disproportionate to One of the most important resolutions movement. The Caravan will pass the severity of the global disease encouraged stronger and more accu- through BC from 29 October until 10 burden. Dr Kickbusch concluded by rate reporting of crimes against women November. encouraging nations to work first on in the international media. The MWIA The AfriGrand Caravan provides their policy and then begin to address also chose a strong stance for legaliz- an opportunity for Canadians across the larger issues. ing homosexuality and allowing refu- the country to hear directly from those Past President Dr Atsuko Heshiki, gee status for homosexuals escaping at the heart of community-based professor emeritus of Saitama Med- victimization in their home countries. efforts to turn the tide of AIDS in ical School in Japan, presented the In addition to their policy work, Africa. results of MWIA’s recent survey of the MWIA serves as a voice for For more information, and to view 615 medical women across the world. women’s health internationally and the full AfriGrand Caravan schedule, “The challenges they face are the works closely with the World Health visit www.stephenlewisfoundation same,” Dr Heshiki remarked. Female Organization (WHO) on its gender .org/caravan.htm. doctors reported that they were gener- and health portfolio. “We worked with Friday, 29 October—Cranbrook ally well supported by their supervi- WHO to help generate their modules Sunday, 31 October—Nelson sors during pregnancy, but childcare to train their staff to include gender in Monday, 1 November—Penticton access was an increasing barrier to all aspects of their work,” said Dr Ross. Wednesday, 3 November—Abbotsford their ability to provide medical serv- The next MWIA Congress is Thursday, 4 November—Burnaby ice. And, while most were satisfied scheduled to take place in summer Friday, 5 November—Vancouver with job equality earlier in their careers, 2013 in Seoul, Korea. For more infor- Monday, 8 November—Nanaimo women in the 40 to 60 age group felt mation visit www.mwia.net. Tuesday, 9 November—Comox Valley there was gender discrimination with —Pamela Verma, BSc Hons, Wednesday, 10 November—Victoria regard to academic promotion. Class of 2012 Of local interest was Burnaby fam- —Kristin DeGirolamo, BSc Pharm, ily physician Dr Shelley Ross, who Class of 2013, UBC Medicine oversaw the event as MWIA’s secre- Pulsimeter continued on page 416 414 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 35. pulsimeter Call for nominations: BCMA and CMA special awards BCMA Silver Medal of Service Dr David M. Bachop Gold cation of the public; service to the peo- BCMA members are encouraged to Medal for Distinguished ple of Canada in raising the standards nominate physicians or laypersons for Medical Service of health care delivery in Canada; serv- the BCMA Silver Medal of Service This award may be made annually to a ice to the profession in the field of med- award. The medal will be presented at British Columbia doctor who is judged ical organization. the BCMA’s Annual General Meeting by the selection committee to have in June 2011. Physician nominees must made an extraordinary contribution CMA Medal of Service have 25 years of membership in good in the field of organized medicine Presented to a CMA member for excel- standing in the BCMA, the CMA, and and/or community service. Achieve- lence in at least two of the following the BC College of Physicians and Sur- ment should be so outstanding as to areas: service to the profession in the geons of British Columbia. Nonmed- serve as an inspiration and a challenge field of medical organization, service ical candidates may be laypersons of to the medical profession in British to the people of Canada in raising the Canadian or foreign citizenship. To be Columbia. Only one award will be standards of medical practice in Canada, eligible for the award, nominees must made in any 1 year and there shall be personal contributions to the advance- meet at least one of the following cri- no obligation on the fund to make the ment of the art and science of medicine. teria: award annually. A letter of nomination Sir Charles Tupper Award for • Long and distinguished service to the including a current curriculum vitae of Political Action BCMA. the candidate should be sent to Ms Awarded to a member of the CMA’s • Outstanding contributions to medicine Lorie Janzen at BCMA, #115–1665 MD-MP Contact Program who has and/or medical/political involve- West Broadway, Vancouver, BC V6J demonstrated exemplary leadership, ment in British Columbia or Canada. 5A4 by 5 April 2011. commitment, and dedication to the cause • Outstanding contributions by a of advancing the policies, views, and CMA Special Awards layperson to medicine and/or to the goals of the CMA at the federal level welfare of the people of British Further information on criteria, includ- ing nomination forms for the CMA through grassroots advocacy efforts. Columbia or Canada. Nominations for the BCMA Silver Special Awards, can be obtained from May Cohen Award for Women Medal of Service may be made by any www.cma.ca/index.cfm/ci_id/1368/ Mentors BCMA member in good standing. Sub- la_id/1.htm (select “About CMA” and Submitted by the mentee and presented mit the candidate’s curriculum vitae “Awards from CMA”). Alternatively, to a woman physician who has demon- and your reasons for nominating the contact the CMA Awards Committee strated outstanding mentoring abilities. individual to the BCMA Membership Coordinator by mail, 1867 Alta Vista Drive, Ottawa, ON K1G 3Y6, or by CMA Award for Excellence in Committee, #115–1665 West Broad- Health Promotion way, Vancouver, BC V6J 5A4 by 30 telephone at 800 663-7336 extension 2243. Nominations and the individ- Awarded for individual efforts or a November 2010. non-health sector organization to pro- ual’s curriculum vitae must be sent to CMA Honorary Membership the CMA by 30 November 2010. mote the health of Canadians at the The BCMA is able to submit nomina- national level or with a national posi- F.N.G. Starr Award tive impact. tions to the CMA for individuals to receive the honor of becoming a CMA Awarded to a CMA member who has achieved distinction in one of the fol- CMA Award for Young Leaders Honorary Member (previously called The CMA will present the Award for CMA Senior Member Award). Candi- lowing ways: making an outstanding contribution to science, the fine arts, or Young Leaders to one student, one res- dates must be age 65 or over and a ident, and one early-career physician member of both the BCMA and the literature (nonmedical); serving human- ity under conditions calling for courage (5 years post-residency) member who CMA for the immediately preceding has demonstrated exemplary dedica- 10 consecutive years, including the or the endurance of hardship in the pro- motion of health or the saving of life; tion, commitment, and leadership in forthcoming year 2011. They must one of the following domains: politi- have distinguished themselves in their or advancing the humanitarian or cul- tural life of his or her community or in cal, clinical, education, research, or medical careers by making a signifi- community service. cant contribution to the community and improving medical service in Canada. to the medical profession. To nominate CMA Medal of Honour Dr William Marsden Award a candidate for CMA Honorary Mem- Bestowed upon an individual who is in Medical Ethics ber Award, send a letter outlining the not a member of the medical profes- Recognizes a CMA member who has reasons for your nomination along with sion who has achieved excellence in demonstrated exemplary leadership, the individual’s curriculum vitae to the one of the following areas: personal commitment, and dedication to the BCMA Membership Committee, #115– contributions to the advancement of cause of advancing and promoting 1665 West Broadway, Vancouver, BC medical research, medical education, excellence in the field of medical ethics V6J 5A4 by 30 November 2010. health care organization, or health edu- in Canada. www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 415
  • 36. pulsimeter cdc advertiser Continued from page 414 Continued from page 413 index early screening in high-risk CKD Core-Plus Plan patients, as anergy may be less of reminder a confounder in those with less The BC Medical Association thanks the following advertisers The open enrollment period for the advanced disease. Once LTBI for their support of this issue of Core-Plus Plan under the BCMA infection is established, prophy- the BC Medical Journal. Health Benefits Trust Fund is under- lactic therapy should be consid- way. The deadline to enroll in this pro- ered in consultation with TB con- AIM Medical Imaging ............... 425 gram, or to make changes to your cov- trol and the patient’s personal erage if you are already participating, physicians. As always, an ounce BC Association of is 31 October 2010. New coverage or of prevention trumps a pound of Clinical Counsellors ................ 384 changes to existing coverage for cure. members who submit the required Cambie Surgery Centre/ plan documents by the deadline will Specialist Referral Clinic ..... 423 be effective 1 January 2011. cohp If you have any questions regard- Carter Auto ........................................ 422 ing the open enrollment period or the Continued from page 411 plans offered under the BCMA Health Canada’s Natural Health Products General Practice Benefits Trust Fund, please visit www Directorate places Canadians in Service Committee .bcma.org/hbtf or contact an HBTF harm’s way by failing to prevent ...................385, 388, 390, 416, 421 Administrator: exaggerated health claims and by Cory St Jean exposing consumers to unneces- Guidelines and Protocols Toll free: 800 665-2262 ext. 2865 sary health risks. Given that med- Advisory Committee ............... 389 Direct: 604 638-2865 ical claims made on behalf of cstjean@bcma.bc.ca NHPs typically exceed the evi- Interior Health ................................. 419 Darlene Laird dence of medical benefit, and that MCI Medical Clinics Inc. ........ 387 Toll free: 800 665-2262 ext. 2818 significant safety issues with vari- Direct: 604 638-2818 ous NHPs continue to be discov- Optimed ............................................... 386 dlaird@bcma.bc.ca ered upon proper scientific test- —Sandie Braid, CEBS ing, many Canadians will wonder Robson Helimagic ........................ 424 Assistant Director, BCMA Insurance if a near-billion-dollar bonanza to industry is worth the price. Society of Specialist —Lloyd Oppel, MD Physicians and Surgeons ...... 388 Chair, Allied Health Practices worksafebc Committee Speakeasy Solutions .................... 424 Continued from page 391 References Westgen ............................................... 385 and orthobiologics, especially the 1. Geddes J. Problems in the natural Wickaninnish Inn .......................... 387 bone morphogenic protein (BMP)-7. health products aisle. Maclean’s 3 Full documents and other system- October 2009. www2.macleans.ca/ atic reviews can be downloaded from 2009/10/03/problems-in-the-natural- www.worksafebc.com/evidence. health-products-aisle/ (accessed 23 —Kukuh Noertjojo, MD, August 2010). MHSc, MSc 2. Gavura S. Health Canada gets out a —Craig Martin, MD, MHSc big rubber stamp. Science-based WorkSafeBC Evidence- Pharmacy [blog] 15 July 2010. http:// Based Practice Group sciencebasedpharmacy.wordpress .com/2010/07/15/health-canada- References g e t s - o u t - a - b i g - r u b b e r- s t a m p / References are available by calling Carmen (accessed 23 August 2010). Prang at 604 244-6224 or toll-free 1 800 967- 5377, extension 6224 or carmen.prang@ worksafebc.com or online at www.bcmj.org. 416 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 37. calendar program runs on Friday afternoons risk manager for CMPA, as well as The BCMJ Calendar section is available from 1 p.m.–5 p.m. and includes great representatives from Harper Grey on the BCMA web site at www.bcma.org. speakers and learning materials. Easton and other members of the Bar Rates: $75 for up to 150 words (maxi- There will be opportunities to partici- from Vancouver. A formal banquet mum), plus GST, for 1 to 30 days; there is pate via videoconference from Royal will follow. Practice-deductible cost no partial rate. If the course or event is Columbian, Surrey Memorial, and including banquet will be $100 per over before an issue of the BCMJ comes Prince George General hospitals. Top- person. Mainpro-1 credits available. out, there is no discount. VISA and ics and dates: 5 Nov (women’s and For more information please visit Master Card accepted. men’s health), 3 Dec (geriatrics), 4 Feb www.minorumedical.com. Reserva- Deadlines: Online: Every Thursday (list- (diagnostics and radiology), 1 Apr tions: Dr Michael M. Myckatyn at ings are posted every Friday). Print: The (ophthalmology/ENT), 6 May (gen- myckatynmd@shaw.ca. first of the month 1 month prior to the eral internal medicine/best topics). To issue in which you want your notice to register and for more information, ADHD CONFERENCE appear, e.g., 1 February for the March visit www.ubccpd.ca, call 604 875- Vancouver, 20–21 Nov (Sat–Sun) issue. We prefer that you send material 5101, or e-mail cpd.info@ubc.ca. The Canadian ADHD Resource Al- by e-mail to journal@bcma.bc.ca. liance is returning to Vancouver for D.A. BOYES SOCIETY their 6th Annual ADHD Conference. MEETING This year’s conference will feature FREE ACCREDITED Vancouver, 28–29 Oct (Thu–Fri) topics dealing with the less frequently ONLINE CME The 36th annual D.A. Boyes Society presented faces of ADHD: ADHD in www.mdBriefCase.com Meeting will provide an update in ob- girls, women, and preschoolers; pa- Looking for convenient and afford- stetrics and gynecology for practising tients with brain injury and those able ways to participate in accredited specialists. To be held at the Morris J. involved with forensics; and patients CPD activities? Let mdBriefCase Wosk Centre for Dialogue, this inter- with mood and rage disorders. Research help! Since 2002, www.mdBriefCase active and innovative CME-CPD on long-term outcomes, ADHD and .com has been the leading provider of program will provide a timely and learning, adult ADHD in primary care online continuing education for Cana- clinically relevant update on selected practice, and the latest information on dian physicians. Our courses are avail- topics in all areas of obstetrics and ADHD within the DSM-V will be cov- able 24/7, making it easy for busy gynecology, including maternal fetal ered. Two free preconference work- physicians to complete their require- medicine, reproductive endocrinology, shops on adult ADHD and ADHD ments. We develop more than 35 on- urogynecology, gynecologic oncolo- medication will be offered. Formats line learning programs each year in gy, and general gynecology. To regis- will include plenaries, workshops, collaboration with leading experts, ter and for more information visit and “meet the expert” sessions where professional societies, and academic www.ubccpd.ca, call 604 875-5101, cases can be discussed. Featured institutions. All of our programs are or e-mail cpd.info@ubc.ca. speakers include Laurence Greenhill, Mainpro-M1 and Maintenance of Cer- Gabrielle Carlson, Rachel Klein, tification (MOC) accredited and we THE MOST RESPONSIBLE Rosemary Tannock, and Steve Hotz. offer easy-to-print certificates. What PHYSICIAN Accreditation for family physicians, are you waiting for? Sign up today and Vancouver, 16 Nov (Tue) specialists, and American physicians, start getting your CME at www.md The Minoru Medical Education and approval for psychologists, has BriefCase.com! Society presents this evening CME at been applied for. For more informa- the Wosk Centre for Dialogue. This tion visit www.caddra.ca or e-mail CME ON THE RUN accredited program addresses the penny.scott@caddra.ca. Various locations, recurring question of which physician 1 Oct–6 May (Fri) is the most responsible in any given COMBINED APLS/ACLS Please join us for our fourth series of situation and who will be left holding Vancouver, 25–27 Nov (Thu–Sat) CME on the Run conferences to be the bag if something goes wrong. APLS: The Pediatric Emergency held at the Paetzold Lecture Hall, Many scenarios will be presented and Medicine Course will run half-day, Vancouver General Hospital, and at discussed. Keynote speaker will be Thursday, 25 November and full-day various videoconference sites. Each Dr Jacques Guilbert from Ottawa, Continued on page 418 www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 417
  • 38. calendar Continued from page 417 in room free. Sea Courses offers group istration at 8:30 a.m.). Dr Weisberg Friday, 26 November. This course is rates, and on all CME sailings your will conduct experiential exercises designed to train physicians to assess companion cruises free. Phone 604 and will address how to use hypnosis. and manage critically ill children dur- 684-7327, toll free 1 888 647-7327, e- Participants will learn how to concep- ing their first hours in the emergency mail cruises@seacourses.com. Visit tualize an integrative medicine ap- department. Participants will take part www.seacourses.com for more CME proach to understanding mind-body in a 2-day format of skills stations and cruises to Baltic & Russia, Rhine, Alas- healing, and will learn new hypnotic case discussion sessions and must ka, China and Yangtze River, South strategies. Participants will gain an then successfully complete the APLS America, Dubai, and the Caribbean. understanding of how their own be- Course Completion Examination. liefs either limit or enhance clinical Please note that this course is intend- FP ONCOLOGY CME DAY effectiveness. Seminar highlights in- ed for experienced clinicians involved Vancouver, 27 Nov (Sat) clude Fundamentals for Powerful and in care of critically ill children. Partic- The BC Cancer Agency’s Family Effective Mind-Body Interventions, ipants are required to have previously Practice Oncology Network invites Psychoneuroimmunology and Hypno- completed at least one PALS or APLS family physicians to take part in its sis: How and Why Mind-Body Medi- course successfully. The ACLS: Pro- annual CME Day—an opportunity to cine Works, Neurobiology: Brain vider Update Course will run on Sat- strengthen oncology skills and knowl- Structure, Mind-Body Interactions urday, 27 November. The ACLS Pro- edge and enhance cancer care for and Hypnotic Strategies, and Master- vider Course provides the knowledge patients and families. This session ing Obstacles: Dealing With the “Dif- and skills needed to evaluate and takes place at the Westin Bayshore ficult” Patient. Attendees will also manage the first 10 minutes of an adult Hotel in Vancouver and is part of the learn how to make use of these skills ventricular fibrillation/ventricular BC Cancer Agency’s Annual Cancer in their practice. For a detailed tachycardia (VF/VT) arrest. Providers Conference, 25–27 November. The brochure and registration form visit are expected to learn to manage 10 program meets the accreditation crite- www.hypnosis.bc.ca. core ACLS cases: a respiratory emer- ria of the College of Family Physi- gency, four types of cardiac arrest cians of Canada and has been accred- 5 EXOTIC CME CRUISES (simple VF/VT, complex VF/VT, PEA, ited for up to 1.5 Mainpro-C credits Various dates and asystole), four types of pre-arrest and 2 Mainpro-M1 credits. This Fam- 16–30 Jan, South America (CME: emergencies (bradychardia, stable ily Practice Oncology CME Day will respirology, cardiology, and psychia- tachycardia, unstable tachycardia, and provide an effective means to learn try); 13–27 Feb, New Zealand (CME: acute coronary syndromes), and stroke. about new oncology resources and gastroenterology); 22–29 Apr, Rhine This 1-day update course is intended support, better understand the BC River (CME: primary care refresher); for experienced clinicians who have Cancer Agency and establish useful 11–23 Jun, UK and Norwegian Fjords previously completed at least one contacts, and benefit from oncology (CME: internal medicine); 29 Oct– ACLS course successfully. Resuscita- updates, including practical and cur- 12 Nov, Istanbul to Luxor (CME: tion simulations that are relevant and rent information. To learn more about rheumatology and neurology). Com- realistic for the learner’s background the network please visit www.bc panion cruises free. Phone 604 684- and current work environment will be cancer.bc.ca/hpi/fpon. Register for 7327, toll free 1 888 647-7327, e-mail used as much as possible. To register this event at www.bccanceragency cruises@seacourses.com. Visit www and for more information, visit www conference.com. .seacourses.com for more CME cruises. .ubccpd.ca, call 604 875-5101, or e- mail cpd.info@ubc.ca. HYPNOSIS—HEALING & PAIN FP ONCOLOGY PRECEPTOR MGMT TRAINING 4 CARIBBEAN CME CRUISES Vancouver, 27 Nov (Sat) Vancouver, 28 Feb–11 Mar (Mon– Various dates The Canadian Society of Clinical Hyp- Fri), and 26 Sep–7 Oct (Mon–Fri) 26 Nov–6 Dec, Sexual Health Medi- nosis (BC Division) presents Hypno- The BC Cancer Agency’s Family cine—This is also a special food and sis for Mind-Body Healing and Pain Practice Oncology Network offers an wine cruise; 26 Dec–2 Jan, Use of Management; Psychoneuroimmunol- 8-week preceptor program beginning Pharmaceuticals; 19–27 Feb, Clinical ogy, Neurobiology, and the Power of with a 2-week introductory session Medicine—Ideal CME for hospital- the Healer’s Beliefs, with Dr Mark B. every spring and fall in the Vancouver ists; 12–19 Mar, Diabetes Manage- Weisberg, PhD, ABPP. The seminar Centre. This program provides oppor- ment—With a limited time spring will be held at Vancouver General tunity for rural family physicians, with break promotion of 3rd and 4th person Hospital from 9 a.m. until 5 p.m. (reg- the support of their community, to 418 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 39. calendar strengthen their oncology skills so that year’s national conference in beauti- BCMJ CRUISE CONFERENCE they may provide enhanced care for ful Vancouver aims to attract geriatri- Rhine River, 22–29 Apr, 2011 local cancer patients and their fami- cians, family physicians, fellows, res- (Fri–Fri) lies. Following the introductory ses- idents, students, and allied health care Cruise your way from Basel, Switzer- sion, participants complete a further 6 professionals. A number of interna- land, to Amsterdam, Netherlands, on- weeks of customized clinic experi- tional keynote presenters have been board the AMA Waterways ms Amale- ence at the Cancer Centre where their secured, including Dr Edward R. Mar- gro. Enjoy castles, cobblestones, cafes, patients are referred. These can be cantonio, associate professor of med- and cathedrals on the free daily shore scheduled flexibly over 6 months. Par- icine, Harvard Medical School, Bos- excursions. Companion cruises free. ticipants who complete the program ton, MA; Dr John E. Morley, Saint Application has been made for 14 are eligible for credits from the Col- Louis University; Dr Cheryl Phillips, hours of CME credits. Faculty for this lege of Family Physicians of Canada. American Geriatrics Society Board Primary Care Refresher include Drs Those who are REAP eligible receive chair and clinical professor, Universi- Matt Blackwood, Shannon Lee Dut- a stipend and expense coverage ty of California; Dr Kaveh G. Shoja- chyn, Lindsay Lawson, Colin Rankin, through UBC’s Enhanced Skills Pro- nia, University of Toronto; and Dr and David Richardson speaking on a gram. For more information or to Roger Y. Wong, University of British true cross-section of the issues seen in apply visit www.bccancer.bc.ca/hpi/ Columbia. The meeting’s comprehen- primary care today, including opiate fpon or contact Gail Compton at 604 sive agenda has resulted in a keen prescribing, ADHD, practical derma- 707-6367. interest for this conference. Abstract tology, COPD and asthma, tuberculo- closing date is 1 December 2010, and sis, chronic back pain, humor in med- CDN GERIATRIC notifications of acceptance will be icine, and more. Book now as this SOCIETY ASM sent via e-mail in January 2011. To cruise is selling quickly. More infor- Vancouver, 14–16 Apr (Thu–Sat) register and for more information visit mation and photos at www.seacours- The 31st Annual Scientific Meeting of www.CGS2011.ca, call 604 875-5101, es.com; to book call 604 684-7327, the Canadian Geriatrics Society will or e-mail cpd.info@ubc.ca. toll free 1 888 647-7327, or e-mail be held at the Four Seasons Hotel. This cruises@seacourses.com. Life’s better here Wanted: A Family Physician Who Lives in the Moment Make a date with yourself. You’ve learned what matters. A walk in the rain. Rich friendships. Time to think and rejoice. Ski. Swim. Hike. Ride your bike. Spend weekends at the cottage. Or, do nothing at all. Here in the sunny BC Southern Interior we don’t talk about work/life balance. We live it. We are looking for Family Physicians for many of our most desirable communities. Family Physicians in Interior Health receive a highly competitive compensation package including generous on-call, recruitment and retention incentives. When can you start? - Dr.Young ician Appointmen ts Family Phys Life’s better here.Visit www.betterhere.ca to find out why. ounds 8:00am R Ashcroft Castlegar Chase Clearwater Fernie Kaslo Lytton Princeton Sorrento 100 Mile 1-877-522-9722 physicianrecruitment @ interiorhealth.ca www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 419
  • 40. classifieds C L A S S I F I E D A D V E RT I S I N G ( l i m i t e d t o 100 words ) Rates: BCMA members $50 + GST per ceding the month of publication, e.g., by issue for each insertion of up to 50 words. 1 November for December publication. Please Each additional word, 50¢ + GST per issue. call if you have questions. Box number $5 + GST. We will invoice on Send material to: Kashmira Suraliwalla • publication. BC Medical Journal • #115-1665 West Non-members $60+ GST per issue for each Broadway • Vancouver, BC V6J 5A4 insertion of up to 50 words. Each additional Canada • Tel: 604 638-2815; fax: 604 638- word, 50¢ + GST. Box number $5 + GST per 2917 • E-mail: journal@bcma.bc.ca issue. Payment must accompany submission. Provincial legislation prohibits ads that dis- Deadlines: Ads must be submitted or can- criminate on the basis of sex. The BCMJ may celled in writing by the first of the month pre- change wording of ads to comply. are guaranteed to be busy. We provide all the practices available positions available administrative and operational support. Enquiries to Paul Foster, 604 592-5527, or e- CURRENT ADS ONLINE PHYSICIAN—NORTH VANCOUVER mail pfoster@denninghealth.ca. All classified ads are available online in an Physician required for the busiest clinic/family easily searchable format at www.bcmj.org/ practice on the North Shore! Our MOAs are known to be the best, helping your day run GP—FORT ST. JAMES classified/list. smoothly. Lucrative 6-hour shifts and no head- GP required for busy family practice. Sur- aches! For more information, or to book shifts rounded by beautiful scenery and hundreds of FP—SIDNEY online, please contact Kim Graffi at kimgraf- lakes, Fort St. James has recreational opportu- Well-established family practice in office fi@hotmail.com or by phone at 604 987-0918. nities for everyone! We are recruiting two full- shared with one other female MD. Admitting time physicians to consult in the clinic and privileges at Saanich Peninsula Hospital, no share ER on-call services and hospital in- CURRENT ADS ONLINE obstetrics or ER required. One in five weekend All classified ads are available online in an patient care. High-income potential! For more call. Great lifestyle in small seaside town near easily searchable format at www.bcmj.org/ information please contact our office manager, Victoria. E-mail practiceinfo@shaw.ca for classified/list. Kathy, at kathy.marchal@northernhealthcare details. .ca or call 250 996-8291. Visit our web site at LOCUM—VANCOUVER www.fsjamesmedicalclinic.com. FAMILY PRACTICE—NORTH VAN Busy walk-in clinic shifts available in Yale- Family practice available in North Vancouver. town and the heart of Kitsilano at Khatsahlano DOCTOR—SURREY Two young associates. Best location in Lower Medical Clinic—voted best independent med- If the overhead cost is stopping you from hav- Mainland. Call 604 985-4104 or e-mail bob ical clinic in Vancouver in the Georgia Straight ing your own practice, or if you are looking to puddicombe@gmail.com. readers’ poll. Contact Dr Chris Watt at have a very busy practice with guaranteed watt1@telus.net. income, we have the right office for you! FP—PENTICTON Located in Surrey on King George Blvd, two GP relocating, busy practice with shared call WALK-IN—VICTORIA blocks from SkyTrain station, next to a phar- Walk-in clinic shifts available in the heart of macy and a dental clinic. Four exam rooms, with six others; no ER, maternity, or night lovely Cook St. Village in Victoria, steps from physician’s office, reception, waiting area, work. Call duties minimal 1/6. Very lucrative the ocean, Beacon Hill Park, and Starbucks. turnkey operation, opportunity for clinical storage, signage, computer networking, plenty For more information contact Dr Chris Watt at of free parking, and more. Lease terms are research, great community, very low overhead. watt1@telus.net. For details e-mail ann3985@hotmail.com or flexible, and the rent is very low and nego- phone 250-809 1701. tiable. For more information please call Mr LOCUM—ABBOTSFORD Zehtab at 604 306-4706, or e-mail mydoctor East Abbotsford walk-in clinic with congenial @shawbiz.ca. FP—RICHMOND staff and pleasant patient population is looking Established family physician’s office, central for a flexible locum physician interested in location, looking for a doctor to take over prac- possible long-term opportunity with excellent GPs/LOCUMS—SURREY tice for free or work part-time. Patients are remuneration. Please call Cindy at 604 504- Very busy walk-in clinic looking for physi- mostly ethnic Chinese, Cantonese/Mandarin. 7145 between 9 a.m. and 2 p.m., Monday to cians/locums to do Monday and Friday morn- Friday. ing shifts from 9 a.m. to 3 p.m. Coverage also E-mail info to s.ostashek@dccnet.com. needed for April Sunday morning shifts from 9 GPs/SPECIALISTS—LOWER a.m. to 3 p.m. or 10 a.m. to 3 p.m. Evenings GP—PRINCE GEORGE from Monday to Friday from 3 p.m. to 8 p.m. MAINLAND Replacement physician needed to take over a Considering a change of practice style or lo- The split is 70/30 with $95 minimum. Also busy general practice in Prince George. Full cation, or considering selling your practice? looking for physicians to move their practice. EMR practice with a diverse patient base. Group of eight established locations within We can do it by a percentage or just flat fee. Available 9 December. For more information Surrey, Delta, and Abbotsford with opportuni- Please contact the manager at 778 688-5898, contact Dr J-P Viljoen at 250 961-4107 or ties for family, walk-in, or specialist physi- or e-mail jobs@chandmedical.com. viljoenjp@hotmail.com. cians. Full-time, part-time, or locum doctors Continued on page 422 420 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 41. Chang Change is possible ge poss sible The Practice Support Program (PSP) helps BC physicians make practice Sup pport Program he elps makke changes by providing focused training sessions that improve practice h b providi f viding d i i i h improve i quality and efficiency and support enhanced delivery of patient care. effic ciency enh hanced patie care. ent PSP current offerings include: Advanced Access/Office Efficiency Shows physicians how to eliminate backlog and open up their appointment schedule so patients can be seen sooner, even on the same day. Group Medical Visits/Patient Self-management Teaches physicians how to provide patients with specific chronic conditions, like diabetes, with care, education, and advice in a group setting that is efficient for the physician and supportive for the patient. Also includes patient self-management techniques and health literacy. Chronic Disease Management Teaches physicians how to use a registry and recall system that enables them to take a proactive approach with their chronic disease patients. Mental Health Helps general practitioners identify patients with significant Axis I disorders, implement appropriate screening tools, make a standardized diagnosis, and develop a care plan for patients using evidence-informed strategies and easy cognitive-behavioural skills tools. Available soon: End-of-Life/Palliative Approach to Care, Prescribing Safety and Quality, Child and Youth Mental Health, Shared Care with Focus on COPD Visit www.pspbc.ca www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 421
  • 42. classifieds Continued from page 420 geous with a stunning floor-to-ceiling view facing north and west. The space is available GPs—RICHMOND FP—KELOWNA Mon, Wed, and Fri (and weekends if desired). Doctors required for shifts at very busy clinic Partner wanted to split general practice 50-50. Call Trish Long at 604 872-3235 (Mon–Thur). (walk-in/family practice); 65/35 split. Please New GP coming to Kelowna would either wish contact Richard at rishar@shaw.ca. to split an existing practice or start a new one GP—NANAIMO with a partner who wants to work half time. FP/WALK-IN—SURREY Like-minded individual would be interested in General practitioner required for locum or per- Physician required for shifts in a busy, happy, high levels of productivity while on, but hav- manent positions. The Caledonian Clinic is lo- and colorful clinic located inside the Guildford ing 6 months per year off. E-mail kelowgp@ cated in Nanaimo on beautiful Vancouver Town Centre Mall. Please feel welcome to gmail.com. Island. Well-established, very busy clinic with drop by, or contact Andrew at 604 588-8764, 24 general practitioners and four specialists. fax 604 588-8761, or e-mail guildfordmedical Two locations in Nanaimo; after-hours walk-in clinic@telus.net. FP—SURREY/GUILDFORD clinic in the evening and on weekends. Com- Lucrative family practice/walk-in in Surrey, near Guildford. Physician needed full-time or puterized medical records, lab, X-ray, and GP/FP—NORTH SHORE part-time. Split 75%. Busy practice. Mostly pharmacy on site. Contact Doris Gross at 250 Busy family practice/walk-in clinic seeking young families. High-income potential. Call 716-5360, or e-mail dorisg@shawcable.com. F/T or P/T physicians. Very spacious clinic, Dr R. Manchanda at 604 580-5541, or e-mail newly renovated, equipped with open source raman_manchanda@hotmail.com. PHYSICIANS—LETHBRIDGE EMR, located across from the SeaBus. Con- Would you like to live in the best place in venient traffic to downtown Vancouver. Offer- LOCUM—FORT ST. JOHN Alberta, close to mountains and lakes? Camp- ing highest percentage splits (up to 72.5%). No GP (or GPA) locum needed July/Aug. Accom- bell Clinic is seeking P/T and F/T physicians; OB or ED mandatory. Flexible hours. Great staff. modation and vehicle provided; 23.3% North- new graduates welcome. Currently we have 16 Please contact Judy Molnar at lowerlonsdale ern Allowance on all billings. ER shifts level 1 family physicians, one pediatrician, and an medical@gmail.com. MOCAP. Twelve-GP clinic, UBC residency internist. Multidisciplinary health care teams training site. Full EMR. Supportive practice include a pharmacist, clinical educators, and FP—SOUTH SURREY environment. Brilliant opportunity for new mental health worker. Fully integrated elec- Large family practice clinic located in South grad looking to get feet wet! E-mail dr.mackey tronic medical records and on-site X-ray, labo- Surrey/White Rock is looking for physicians @fsjmedicalclinic.com, or visit www.fsjmedical ratory service, and pharmacy. Friendly support interested in working either part-time or full- clinic.com. staff and professional management. Excellent time. Our clinics are enhanced family practice start-up conditions and above-average income with full EMR and RN support for chronic dis- ease management. We have very dedicated PSYCHIATRIST—VANCOUVER with very competitive overhead. We welcome long-term staff to support your practice. Days Two psychiatrists looking for a third to share your inquiries. Contact Chris Harty at 403 and hours may be flexible and there is an suite 902–601 W. Broadway. The office is gor- 381-2263 or charty@campbellclinic.ca. opportunity for practice associateship after 1 year. If you are interested in discussing these positions please e-mail our clinic manager at ymcleod@telus.net or call 604 531-1626. Car shopping that’s stress free. GP—TSAWWASSEN The Tsawwassen Medical Clinic, a friendly six-doctor group, has an opening for a family physician in July 2011. This position will appeal to someone looking for an excellent medical group with superior facilities and an excellent staff in a great community just 30 to 35 minutes south of Vancouver. Schools and recreational facilities are excellent as well as easy access to nearby marinas. On-call sched- ule is one in six and hospital and OB involve- ment are available but not necessary. This is a great opportunity for a young doctor to build up his or her practice quickly, as well as taking over the practice of a retiring doctor. Interest- ed applicants please contact Susan at 604 943- 9922 or e-mail info.tmc@eastlink.ca. GP—KITIMAT Brilliant family opportunity for doc to join GP in stunning northwest BC. Kitimat, a marvel of ALL makes and models! industry and nature, needs a fifth GP. New 22- Linda Berti (Honda, BMW, GM, Ford, Subaru, etc.) bed hospital. Refurbished clinic. Great staff. 604.291.2266 Wide variety of work. Specialist cover. Lots of 1.877.311.2266 Lowest prices. government incentive payments. Excellent lindab@cartergm.com No need to negotiate gross income. Friendly, purpose-built town is a safe, healthy environment, and offers the 4550 Lougheed Hwy Quick and convenient. young family an exciting new start. Lots of Burnaby, BC Over the phone, by email or in person ocean and mountain activities including down- hill, cross-country, and heli-skiing; mountain 422 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 43. classifieds hiking and biking; unsurpassed ocean and river minster border, 25 minutes from Vancouver. fishing; wildlife watching; golf; and whitewa- Contact Devon at parhar.assist@ubc.ca or 604 PHYSICIAN—BURNABY ter rafting. Tremendous sporting facilities. 771-1081. Simon Fraser University Health and Coun- Good schools. Affordable housing. No traffic! selling Services is looking for a physician to www.healthmatchbc.com. www.mdwork.com. work 1 or 2 days a week. We are a clinic locat- GP/SPECIALISTS—NEW WEST www.kitimat.com. Apply to hjpmills@uni ed at SFU’s Burnaby campus offering medical GP/specialists needed for well-established, serve.com. and counseling services to SFU students from busy, combination family practice/walk-in Monday to Friday, 9 a.m. to 4:30 p.m. Our clinic, with possibility for long-term associa- staff also includes RNs, counselors, psycholo- PALLIATIVE CARE FELLOWSHIP— tion, part- or full-time. Located in on ground UBC gists, congenial and efficient MOAs, and spe- floor of fully medical building in New West- cialist consults by an allergist and psychiatrist. “Year of Added Competency” training based minster, across RCH emergency ward and in the Lower Mainland of Vancouver or Victo- This position could begin as a locum and SkyTrain. Offering 70% on all billings, 90% progress to a contract position with benefits. ria. This program is jointly accredited by the on all doctors’ notes and legals. Professionally College of Family Physicians and the Royal Contact Dr Patrice Ranger at pranger@sfu.ca managed. E-mail nikarohani@shaw.ca or call or 778 782-4615. College of Physicians and Surgeons of Cana- 778 228-9598. da. For anyone interested in a career in pallia- tive medicine the program provides an excel- ANESTHESIOLOGIST—KAMLOOPS lent academic and clinical grounding, and also FP—PONOKA, AB We are looking for two anesthesiologists to provides excellent training for physicians in Full-time family physician required in Ponoka, join the collegial team at Royal Inland Hospi- any specialty who will be spending their work- AB. Five-doctor clinic, Monday to Friday, tal, a busy tertiary care centre providing anes- ing lives caring for people with life-threaten- paperless medical system, low overhead ex- thesia services for orthopaedics, neurosurgery, ing illness. Funded for physicians eligible for a penses. 1 in 10 ER shifts. Acute and long-term vascular surgery, general surgery, urology, BC licence at R3 level for family physicians, care, surgical, obstetrical, and anesthetist obstetrics, plastic surgery, and ENT. Practice and up to R6 level for specialists from any opportunities. PCN opportunity. Contact Dr involves some pediatrics. Eight-hour shifts. Royal College program. The application dead- Izak van der Westhuizen at 403 704-0326. Call 1 in 10. FRCPC or equivalent required. line for the July 2011–July 2012 academic year Kamloops offers exceptional four-season is 30 November 2010. For program outline and FP—DELTA recreation as well as a vibrant community application details visit www.familymed.ubc Locum/associate for a large family practice lifestyle. Interested? E-mail jane.larocque@ .ca/palliative/Education/Postgrad/addedcom- with after hours and weekend services. Full interiorhealth.ca, call 1 877 522-9722, or visit petency.htm. EMR. Flexible hours. For information, contact www.betterhere.ca. Dr R. Clarke at r_clarke@telus.net. LOCUM/ASSOC— INTERNAL MED—CRANBROOK BURNABY/NEW WEST Golden opportunity: long-term/short-term, PHYSICIANS—VICTORIA General internist required to join three other part-time/full-time, locum/associate needed Two maternity locums and permanent family internists at Cranbrook Regional Hospital. in a multi-physician office with family physi- physician needed in dynamic clinic in a beau- Includes four-bed ICU, cardiac lab, and pul- cians, pediatrician, internal medicine special- tiful heritage building. Opportunities for monary lab. Internists are supported by a strong ist, hearing specialist, sleep specialist, etc. maternity leaves starting October 2010; one hospitalist program. Call 1 in 4. Generous on- Supportive colleagues in beautiful medical for 4 to 6 months and one for 1 year. Multidis- call remuneration. Locum or permanent posi- centre with onsite pharmacy, laboratory, optom- ciplinary clinic with four competent, friendly tion. Interest in respirology an asset. Located etry clinic, dental clinic, and rehab centre with GPs. No call or obstetrics required. Sports in the southeast corner of British Columbia, physiotherapists, massage therapists, and chi- medicine an asset. Complementary practition- Cranbrook offers outstanding outdoor activi- ropractors. Extremely safe, bright, and pleas- ers and therapist; rehabilitation facility ties, urban pursuits, and cultural opportunities. ant work environment. Convenient cafe across attached. Competitive split offered. Please e- Contact 1 877 522-9722, physicianrecruitment the hallway from the medical clinic. Clinic is mail heraldstreethealth@live.com or call 250 @interiorhealth.ca, or visit betterhere.ca. located centrally on the Burnaby/New West- 995-2035. Continued on page 424 www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 423
  • 44. classifieds Continued from page 423 age. Opportunity to pursue specialty interest areas that complement the practice. Will con- INTERNAL MED—NELSON sider locums. Situated in BC’s Okanagan Val- A general internist is needed to service the 30- ley, Vernon is known for its scenic geography, bed hospital and cardiac lab as well as support gentle climate, relaxed lifestyle, and abundant specialty clinics including heart health, dia- recreational and cultural amenities including a betes, pediatrics, and maternity. Located in the newly opened performing arts centre and west Kootenays, Nelson has been consistently recreational complex. Contact 1 877 522-9722, ranked as the number one small town arts com- physicianrecruitment@interiorhealth.ca, or munity in Canada. Residents also enjoy a wide visit betterhere.ca. range of outdoor pursuits. Generous recruit- ment, retention, and on-call incentives. Con- FP—OAKRIDGE tact 1 877 522-9722, physicianrecruitment@ Interested in cutting back on your hours? Two interiorhealth.ca, or visit betterhere.ca. Cutting edge digital family physicians looking for a third FP to dictation systems, share two practices; i.e., you would work 8 INTERNAL MED—WILLIAMS LAKE months per year. These practices are located in customized for you. General internist required. Clinical practice the Oakridge area in prime office space, with including in-patient and out-patient consulta- lab and X-ray in same building. Reply to Save time tions, exercise stress testing, and interpretation drtwilson@shawbiz.ca. Save money of ECG and PFTs. Potential for expansion of service to pacemaker checks and other servic- Utilize cutting edge technology PHYSICIAN—SURREY Improve patient care es as per need and internist’s preferences. The Opportunity in south Surrey. Established clin- growing community of Williams Lake is locat- ic with ownership potential. Shifts available Harness the power of speech to text ed amid sparkling lakes and rolling ranchland Monday and Tuesday morning and Wednes- technology with Speakeasy Solutions and in the heart of the Cariboo Chilcotin region of day, Thursday, and Friday afternoons (40+ per Dragon NaturallySpeaking Version 10. British Columbia. Contact 1 877 522-9722, shift). Flexibility in start and end times for physicianrecruitment@interiorhealth.ca, or shifts. Flexibility for time off—semiretired Call today for a customized visit betterhere.ca. owner will cover. Fastest-growing area in demonstration. Metro Vancouver with good patient mix due to INTERNAL MED—VERNON many new home owners. Friendly, well- 604-264-9109 General internist needed to provide in-patient trained, and supportive staff. Clinic is at inter- www.speakeasysolutions.com and out-patient services as well as ICU cover- section of major highways for quick and easy commute. Come try us out with a shift. Con- income, service of full-time secretary, transcrip- tact Gordon at 604 719-9006 or applemedical tion, electronic billings, telephone, and fax @uniserve.com. included. Phone 604 731-6552 from 9 a.m. to 5 p.m. medical office space SPACE—VANCOUVER CURRENT ADS ONLINE Position/space available for a family doctor or Seeking readers to find what they’re looking walk-in clinic doctor to join our multidiscipli- for in the BCMJ online classified ads. All ads nary clinic on the ground floor of the brand from this issue are available online in an new Vancouver Coastal Health building locat- easily searchable format at www.bcmj.org/ ed at 1669 E. Broadway. The ideal doctor classified/list. would be willing to refer patients for treat- ments of their injuries/accidents, etc. Terms SPACE—VANCOUVER are negotiable and flexible. Our team consists Third person wanted for shared three-office of an experienced chiropractor, physiothera- space. Suitable for psychiatrist or psycholo- pist, massage therapist, acupuncturist, and pain gist. Pooled expenses. North view, Fairmont medicine specialist physician. If interested Medical Building, 750 W. Broadway, 12th please contact Dr Samji at 604 760-0230 or floor. Close to VGH and public transportation. docsuhill@rogers.com. Call 604 872-3422. SPACE—SIDNEY SPACE—LADYSMITH Medical office strata for sale or lease. Located Lease or purchase strata titled professional in the Shoal Centre, amid 500 private senior offices in the beautiful Vancouver Island housing units in Sidney, BC. Just blocks from community of Ladysmith. New construction, the commercial core and located next to Pacif- street-level or second-floor offices with ocean ic Compounding Pharmacy and ample park- views. Ladysmith service area includes com- ing. Open to creative terms. Asking $950 000 munities of Yellowpoint, Saltair, and Chemai- or $20 psf. Ana Kraft—NAI Commercial 250 nus. E-mail randall.taylor@dtzbarnicke.com 880-0800 or ana@naicommercial.ca. for a brochure, or call Randall Taylor at 250 714-4248. Real estate services provided by SPACE—SOUTH GRANVILLE DTZ Barnicke Nanaimo Ltd. Nanaimo, BC. South Granville and 14th location. Nicely improved second-floor space with five offices, SPACE—VANCOUVER conference room, kitchen, and large open area Office available for full-time or part-time psy- facing west. Surrounded by shops, boutiques, chiatrist on W. Broadway. Guaranteed high banks, and cafes. The building is on public 424 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 45. classifieds transit routes; 20-minute drive to the airport for your paper or electronic patient records and 10 minutes to downtown. Five under- ground parking stalls available for monthly miscellaneous with no hidden costs. Contact Sid Soil at DOCUdavit Solutions today at 1 888 711-0083, rent. Nineteen months left on sub-lease, with BILLING SOFTWARE—$199 ext. 105 or e-mail ssoil@docudavit.com. We option for long-term renewal. Gross rent It’s true. Windows XP Practice Software, $199 also provide great rates for closing specialists. $9000. Full commission (2 months) will be per computer. Klinix Assess. You get the com- offered to the successful leasing agent. Rental plete software package of billing, scheduling, BOOK OF POEMS AVAILABLE incentive available to expiration of existing and medical records plus product support and Instinct-Science and Other Poems by Gurdev lease term, 21 March 2012. Interested parties updates for an annual licence fee of $199 per S. Boparai is available through Chapters book- contact Joanne Houser at 604 688-6464 ext. computer. Your satisfaction guaranteed in the store, at www.chapters.ca. 102 or jhouser@disabilityfoundation.org. first 120 days or return Klinix Assess for your money back. No fine print. Demos at www FREE CME SPACE—VANCOUVER .klinix.com. Toll free 1 877 SAVE-199. New state-of-the-art facility with boardrooms vacation properties available for CME events. No charge for PATIENT RECORD STORAGE—FREE physicians; seats up to 35 guests. Easy access FRENCH VILLA Retiring, moving, or closing your family or to underground parking. For further informa- France/Provence. Les Geraniums, a 3-bedroom, 3-bath villa. Terrace with pool and panoramic general practice, physician’s estate? DOCUd- tion contact Lisa at 604 733-4407 or lgarcia@ views. Walk to market town. One hour to Aix avit Medical Solutions provides free storage aimmedicalimaging.com. and Nice. New, independent studio with ter- race also available. 604 522-5196, villavar@ telus.net. FOR RENT—MAUI Our oceanview 1 BR, 2 bath condominium Parental Leave unit can accommodate up to four people in relaxed surroundings. It is located in Kihei Program Reminder across the road from the Kamaole III Beach Park. Facilities include two swimming pools, two hot tubs, two tennis courts, BBQ, and high-speed Internet access. Rates US $120– $180 per day. Call 250 248-9527 or e-mail pstockdill@telus.net. Are you a physician practising medicine in British Columbia? Are you or your spouse having a baby or planning a pregnancy in the period from 1 FOR RENT—WHISTLER April 2010 to 31 March 2011? Plan your next holiday. Beautiful four-bed- If you are, then it is important to take advantage of the Parental Leave room house, 5 minutes from Whistler Village. Quiet, private, ideal for groups of 8 to 10. All Program, one of the negotiated benefits administered by the BCMA. the comforts of home. Contact Beth Watt or Remember that effective 1 April 2010 the program has been improved to Peter Vieira at beth_watt@telus.net or 604 include benefits for male physicians and adoptive parents in addition to 882-1965. pregnancy benefits. Funding has also been improved, allowing an increase in the maximum benefit to $1000 per week. For more information or an NEED A HOLIDAY IN PARADISE? One bedroom beachfront condo in Puerto Val- application package, please contact: Lorie Lynch, PLP Administrator; Toll larta, Mexico, overlooking Mismaloya Bay. free: 800 665-2262 ext. 2882; Direct: 604 638-2882; llynch@bcma.bc.ca Sleeps four. Full kitchen, fully furnished, A/C, —Sandie Braid, CEBS satellite TV. Available weekly or monthly. Call 604 542-1928, or e-mail jorajames@telus.net. Assistant Director, BCMA Insurance FOR SALE—TOFINO Investment opportunity. Shared-titled ownership of beachfront home on spectacular Chesterman Beach. Three bedrooms, 2 baths, fully equip- ped and managed. Surfing, kiting, kayaking, hiking, biking, fishing, whale watching, beach- combing, and storm watching. Many top-class restaurants. Personal use or vacation rental for 13 or 26 weeks per year (25% or 50% owner- ship). This is titled ownership, not time-share. Contact zulubendall@hotmail.com. CURRENT ADS ONLINE Seeking readers to find what they’re looking for in the BCMJ online classified ads. All ads from this issue are available online in an easily searchable format at www.bcmj.org/ classified/list. www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 425
  • 46. back page Proust questionnaire: Ari Giligson, MD The Proust Questionnaire has its origins in a parlor game popularized by Marcel Proust, the French essayist and novelist, who believed that, in answering these questions, an individual reveals his or her true nature. Who are your heroes? What is your most marked Leonardo Da Vinci, Arthur C. Clarke, characteristic? Socrates. My moustache. What is your greatest fear? What technological medical Pain and suffering to the ones I care advance do you most about. anticipate? The paperless medical office—some- What is the trait you most time around 2050. deplore in yourself? Loss of equanimity when angry. What do you most value in your colleagues? What characteristic do your Compassion. favorite patients share? Logic, respect, sincerity. Who are your favorite writers? R. Zelazny, A.C. Clarke, P.K. Dick. What is your favorite activity? Tinkering out in my workshop. What is your greatest regret? What profession might you Not having any regrets. have pursued, if not medicine? On what occasion do you lie? Engineer, sculptor, or astronaut. Only when most appropriate. How would you like to die? Whiling away the eons at the heat Which talent would you most Which words or phrases do you death of the universe. like to have? most overuse? Photographic memory, or being a “Little,” “bit,” and “just.” “supertaster.” What do you consider your Tell us a bit about yourself. Please complete and submit a greatest achievement? Proust Questionnaire—your colleagues will appreciate it. Diplomatically sidestepping uncom- fortable questions. Online E-mail www.bcmj.org/proust- journal@bcma.bc.ca. E-mail questionnaire. Complete and us and we’ll send you a submit it online. blank MS Word document to complete and return. Print www.bcmj.org/proust- Mail Dr Giligson is a general ophthalmologist in questionnaire. Print a copy from 604 638-2858. Call us and solo practice in North Delta, and an associ- our web site, complete it, and we’ll mail you a copy to com- either fax (604 638-2917) or mail plete and return by mail (BCMJ ate clinical professor at the UBC Depart- it (BCMJ 115-1665 West Broad- 115-1665 West Broadway, ment of Ophthalmology. way, Vancouver BC V6J 5A4). Vancouver BC V6J 5A4). 426 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  • 47. BCMA MEMBER DISCOUNTS CLUB MD BCMA discounted ski tickets! Available online in October Enjoying the view 30% off lift tickets* Peak 2 Peak lift! 40% off rental tickets *Lift tickets include unlimited one-day Peak 2 Peak access! 15% off lift tickets E: vlee@bcma.bc.ca P: 604.638.2838 TF: 1 800 665.2262 ext 2838 www.bcma.org/quick-news/club-md-enews www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 427
  • 48. BC Medical Journal Cruise Conference 22–29 April 2011 • Basel, Switzerland to Amsterdam, Netherlands Basel • Breisach • Colmar • Freiburg • Strasbourg • Mannheim • Heidelberg • Rudesheim • Kolbenz • Cologne • Amsterdam Primary Care Refresher Excellent accredited CME AMA Waterways, MS Amalegro Companion cruises free! Itinerary, features, faculty, topics, and more: www.seacourses.com Cruise is selling quickly—call now to avoid disappointment 604 684-7327 1 888 647-7327 cruises@seacourses.com www.seacourses.com

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