Canadian Primary Care Today

The Evolving Approach to Breast Cancer Screening and Treatment in Canada: Implications for Primary Care Providers

Greydon Arthur — 2024-12-19

Nearly 30,000 Canadians are diagnosed with breast cancer annually, and while its mortality has decreased by over 55% since the 1970s due to modernized screening technologies and advances in systemic therapy, 5,500 Canadians are estimated to die of the disease every year. Primary care providers are critical through all steps of a patient’s breast cancer journey, from facilitating routine screening, to identifying breast cancer risk factors, ensuring expedient referrals, and recognizing acute or chronic treatment toxicities and their impact on overall physical and psychological health.

The Spectrum of Management for Psoriasis: From the Known to New Alternatives

Jaggi Rao — 2024-12-19

Psoriasis is a chronic, immune-mediated systemic condition characterized by inflammatory changes that may involve the skin and joints. It is relatively common, with a prevalence rate of 2–4% in North America, and a global prevalence rate of up to 11.4%. Years ago, affected patients may have ranged in age from 18–39 to 50–69 due to bimodal distribution. While initially thought to be a dermatologic disease, it is now a recognized multisystem condition with a genetic predisposition. The complex pathophysiology is thought to originate from dysregulation between the innate and adaptive immune systems. T-lymphocytes, dendritic cells, cytokines such as interleukin (IL) 23, IL-17, and tumor necrosis factor (TNF) have all been implicated in and contribute to the inflammatory sequelae. The chronicity and pathogenesis of disease may predispose patients to significant functional impairments, associated comorbidities such as metabolic syndrome and cardiovascular disease, and diminished quality of life. This has prompted novel approaches to management with the introduction of biologics and small molecule therapies that address the underlying immune dysregulation.

There are multiple clinical manifestations including plaque psoriasis, guttate psoriasis, erythrodermic psoriasis, and pustular psoriasis. Among the most common is plaque psoriasis which typically presents as symmetrically distributed, well demarcated, erythematous, scaly plaques or patches that may be pruritic. Common sites of involvement include the extensor surfaces of the elbows, knees, the trunk, gluteal cleft, and scalp. Guttate psoriasis is typically preceded by upper respiratory infections and represents approximately 2% of all cases of psoriasis. It involves several small (<1 cm) confetti-like papules and plaques. A severe, although uncommon form is erythrodermic psoriasis which results in widely distributed erythema, scales and exfoliation of a large surface area of the skin. Due to the widespread loss of the epidermal, dermal barrier and associated risk of fluid loss, electrolyte disturbances and infection, it is considered a dermatologic emergency. Pustular psoriasis is also an uncommon, potentially severe, clinical variant, with possible complications secondary to acute widespread erythema and development of multiple pustules.

The Family Physician’s Unique Role in Heart Failure Management

Grace L. Chua — 2024-12-19

Heart failure (HF) is an epidemic with a prognosis that is worse than some cancers. Prevention, early diagnosis, coordination, and implementation of guideline-directed medical therapy (GDMT) are imperative to stem this tsunami wave. The family physician stands in a unique, critical, and first-line position to be able to offer all 3. Their understanding and implementation of these roles are crucial for success in the battle against HF. This review offers a perspective on the role of family physicians in managing HF.

Update on Insomnia for Primary Care

Atul Khullar — 2024-12-19

Insomnia is a common clinical issue with varying definitions depending on the source. The DSM-V defines insomnia disorder as one or more of: difficulty initiating sleep, maintaining sleep, or early morning wakening with an inability to fall back asleep.

These problems occur despite adequate time allowed for sleep (7 hours), cause dysfunction, and are not attributed to another disorder. The DSM-V then classifies insomnia as either episodic (at least 1 month but less than 3 months), persistent (lasting 3 months or more) and recurrent (2 or more episodes within a year), and considers potential contributing comorbidities.

According to the International Classification of Sleep Disorders (ICSD-3) classification system, symptoms must occur at least 3 times per week, and insomnia is categorized as either short term or chronic. Short-term insomnia disorder in this paradigm (ICSD-3) occurs when the sleep problems have lasted more than 1 but less than 3 months, while chronic insomnia disorder occurs when symptoms persist for more than 3 months.

Adult ADHD: What It Is and How to Assess and Treat It

Lawrence Martin — 2024-12-19

4.4% of the adult population, and is also prevalent in 10% of those with depressive or anxiety disorders and in 20% of those with chronic low mood. Among patients referred for treatment-resistant depression, one in three may have undiagnosed ADHD. Overall, ADHD is poorly understood, significantly undertreated, and a common reason for poor response to treatment in mood and anxiety disorders.

ADHD is not a consequence of poor parenting, indulged laziness, or excessive consumption of sugar or food dyes. It is a neurodevelopmental disorder, a “hardwiring” problem, marked by delayed maturation of the Prefrontal Cortex and allied subcortical regions that constitute the “adult” brain.

When we are young, we have limited self-control: we take what we want, say what we think, get excited, cry, and live in the moment. As our brains mature, we learn to control our behaviours, manage our emotional reactions, prioritize tasks, plan, and follow through on those plans. In individuals with ADHD, this maturation is delayed and too often remains incomplete.