bluuebunny/crossref_metadata_2025 huggingface dataset:
Resistance Exercise in the Context of Type 1 Diabetes
Authors: Yardley Jane E.
Published: July 2023

Exercise and physical activity are associated with many benefits for individuals with type 1 diabetes (T1D), including increased longevity and a decrease in the incidence/severity of diabetes-related complications. Unfortunately, these activities (and aerobic exercise in particular) also increase the risk of hypoglycemia and glycemic variability, both of which act as barriers to being more active in this population. Resistance exercise is an often-overlooked activity, as historically it has been seen in training reserved for elite athletes. For individuals with T1D, it is associated with a multitude of benefits including a reduced risk of hypoglycemia during activity. With improved insulin formulations and rapid increases in technology to manage T1D, people with this condition are living longer, healthier lives. This article describes the many reasons why resistance exercise should be a part of this longevity.
Improving Access to Endocrinologists through Provider-to-Provider eConsultations
Authors: Keely Erin , Liddy Clare
Published: July 2023

Access to specialty healthcare care remains a major issue for many Canadians. Not only are wait times long, but other barriers contribute to inequitable access. These include the patient’s ability to attend appointments (e.g. related to transportation difficulties and/or cost), and the ability of some patients to participate in an appointment (e.g. due to cognitive impairment, mobility challenges, loss of wages, or degree of comfort with a new provider).

Informal consultations between healthcare providers have always played a role in healthcare access. The “call a colleague” approach works well when a practitioner is able to contact a colleague by telephone and an established network of specialists exists; however, it is inefficient, does not facilitate record-keeping for medico-legal purposes and follow-up, and is not remunerated. One way to help address these obstacles is through inter-provider electronic consultations (eConsults).
The evolving role of OCT in pathologic myopia
Authors: Greve Mark , Seamone Mark , Shen Carl
Published: July 2023

The global burden of myopia represents a significant public health concern that is expected to continue to increase in the near future. It is estimated that 50% of the world’s population will be affected by myopia by 2050, with a disproportionately high prevalence in Asia. High myopia, where the spherical equivalent refractive error is equal to or higher than 6.00 diopters, is expected to increase in prevalence from 2.7% to 10% during this period. The severity of myopia is of paramount concern to clinicians as higher levels are associated with pathologic myopia (PM) and increased risk of vision loss. Pathologic myopia, as recently defined by the International Myopia Institute, is an excessive axial elongation associated with myopia that leads to structural changes in the posterior segment of the eye that can lead to loss of best-corrected visual acuity. These structural changes and their complications include posterior staphyloma, myopic choroidal neovascularization, myopic maculopathy, myopic traction maculopathy, dome shaped maculopathy, optic disc changes and glaucoma associated with myopia, and retinal detachments.

The advent of optical coherence tomography (OCT) has facilitated the characterization, diagnosis, and management of several of these complications associated with PM and will be the focus of this article. Imaging the highly myopic eye represents a crucial step in the identification of these complications and poses its own unique challenges. Researchers have demonstrated the advantage of 3D cube scans in the detection of pathology compared to 1- and 5-line rasters. Using vertical scanning patterns aligning where the radius of curvature is larger relative to the horizontal plane of the myopic eye can minimize associated artifacts. Wide scans, facilitated by emerging technologies such as swept- source OCT and ultra wide-field OCT, are useful in cases of PM where the pathology can initiate peripherally.
Methods to treat myopia progression in pediatric patients
Authors: Wan Michael J.
Published: July 2023

Myopia is an enormous, and growing, public health issue across the globe. The prevalence of myopia has doubled in just the past 50 years and it is estimated that approximately half of the world’s population (4.8 billion people) will be affected by 2050. The increase has been especially pronounced in individuals of East Asian descent, where 80-90% of young adults are now myopic. Myopia is now the most common cause of visual impairment and the second most common cause of blindness worldwide.

While often considered a “correctable” cause of vision loss, people with myopia have an increased lifetime risk of complications, such as macular degeneration and retinal detachment, which can cause long-term visual impairment or even blindness. Although all levels of myopia are associated with an increased risk of complications, the risk is substantially greater in people with high myopia (defined by the World Health Organization as a refractive error of ≤-5 diopters ). In addition to a large burden of visual impairment, myopia also has a significant global economic cost, estimated to be $250 billion per year in lost productivity, which is almost certain to rise.

With these factors in mind, preventing the progression of myopia is a global public health priority. The purpose of this article is to review the currently available methods to treat myopia progression in children.
Cataract surgery in the myope: What you should know
Authors: Teichman Joshua
Published: July 2023

Improvements in technology have led to an increased safety profile in cataract surgery. Accordingly, in recent decades there has been an increasing clinical focus on providing improved refractive outcomes.

Initially using manual keratometers and ultrasound biometry, advances in intraocular lens (IOL) formulae lead to increased precision and accuracy of IOL calculations. This manifested in the form of decreased requirement for spectacle correction, usually at a distance target.

Later, optical biometry supplanted ultrasound as a more accurate method for the measurement of axial length and anterior chamber depth; it may also be useful in the measurement of lens thickness and white-to-white limbal distance. Newer biometers have built-in topographers with accurate keratometry.

It is beneficial to have an experienced ultrasonographer to perform testing in myopes, but it should be noted that posterior staphyloma can cause issues for the most experienced technicians. Some of the newer optical biometers capture a small OCT image at the time of testing to be used to test for foveal alignment, which is especially important in staphylomatous eyes.

More accurate testing, combined with newer-generation IOL formulae, has resulted in further improvement in the accuracy and precision of IOL calculation and increased spectacle independence for patients, commonly at distance. Moreover, newer intraocular lenses including multifocal and trifocal IOLs have increased the probability of spectacle independence at both distance and near. Furthermore, extended range of vision IOLs can provide distance and intermediate vision, with less dysphotopsia than current multifocal lenses.

Despite these advances, there are patient populations in which special attention is required to achieve improved refractive outcomes. Patients with increased axial length (myopes) have suffered from systematic errors in IOL calculation. Initially, modifications to previously developed IOL formulae were developed to compensate for this. The Wang-Koch correction (including its newer-generation correction) to various formulae would be an example of this.

Currently, the newest generation of IOL formulae perform better, without correction, than the previous generation of formulae, with or without correction.
Uveitis following COVID-19 vaccination
Authors: Derzko-Dzulynsky Larissa , Emami Seema , Pereira Austin
Published: July 2023

The advent of SARS-CoV-2 (COVID-19) vaccines markedly reduced adverse outcomes associated with COVID-19 infection. With over 12 billion doses of COVID-19 vaccines administered globally as of June 2022, reports have emerged of ocular sequelae following immunization. Vaccination remains the most effective way to reduce the risk of COVID-19-related morbidity and mortality. However, it is important for ophthalmologists to understand the potential adverse events related to SARS-CoV-2 vaccination to provide opportunity for appropriate patient counselling and diagnosis. This review outlines the reported associations between COVID-19 vaccination and uveitis, including proposed mechanisms and recommendations for treating ophthalmologists.
Clinical utility of OCTA
Authors: Choudhry Netan , Orr Samantha , Khan Mohammad Ali
Published: July 2023

Optical coherence tomography angiography (OCTA) is a novel technology that can produce images of blood flow with unprecedented resolution of all the vascular layers of the retina and choroid in a rapid, non-invasive fashion. The technology dates back to 2005, when researchers demonstrated that blood flow could be visualized using swept-source OCT (SS-OCT) based on properties of the Doppler signal. Since then, advancements have led to the technology becoming widely available for the clinical community, aiding in patient diagnosis and monitoring. This review article will highlight examples of ophthalmic diseases where OCTA has important clinical utility; specifically, diabetic retinopathy, age-related macular degeneration, retinal vein occlusions, white-dot syndromes, and early research into neurodegenerative diseases.
Refractive surgery for myopia: review of options and the decision-making process
Authors: Bostan Cristina , Talajic Julia , Choremis Johanna
Published: July 2023

Many options now exist for patients seeking surgical correction of myopia. The challenge lies in selecting the right procedure for the right patient. This article provides an overview of current refractive surgery options and discusses the clinical and imaging considerations in decision-making.
Clinical applications of optical coherence tomography (OCT) in glaucoma
Authors: Saheb Hady , Salimi Ali
Published: July 2023

Visual field (VF) testing has been the mainstay for diagnosing and monitoring glaucoma. However, relying solely on VF can delay the patient’s diagnosis in the early stages of the disease, as the structural changes are known to precede the functional changes and VF defects may not be clinically detectable until at least 25-35% of retinal ganglion cells (RGCs) are lost. This concept highlights the importance of alternative diagnostic modalities such as optical coherence tomography (OCT). OCT’s ability to reliably segregate and quantify the thickness of retinal layers has allowed earlier detection of glaucoma, up to 6 years before the onset of any detectable VF loss. Compared to VF, OCT is less time-consuming and is less dependent on the patient’s cooperation and test-taking ability. There are a few commercially available spectral domain OCT (SD-OCT) machines that are routinely used in glaucoma clinics. These devices are fundamentally similar with comparable performance, but their scanning protocols and segmentation algorithms are not analogous; thus, the measured parameters may not necessarily be interchangeable between devices and the values should be interpreted relative to the normative databases specific to each machine. In this review, we present the clinical applications of OCT imaging in glaucoma and share some clinical pearls and pitfalls.
An Approach to Optic Neuropathies
Authors: Patel Vivek R.
Published: July 2023

Optic neuropathies are varied in their clinical presentations, etiologies, recommended diagnostic investigations, and treatments. This article aims to provide a practical framework to guide the evaluation of a patient suspected of an optic neuropathy.
Strategies for the Management of Ocular Surface Disease in Glaucoma
Authors: Trask William , Muzychuk Adam
Published: July 2023

Ocular surface disease (OSD) is a common ophthalmological concern, with a prevalence in the Canadian population estimated at 25%. Amongst glaucoma patients, up to 60% report symptoms of OSD and up to 78% have clinical signs. Surface symptoms significantly reduce glaucoma-related quality-of-life (QOL), and there is emerging evidence to suggest that treatment of OSD may in fact improve intraocular-pressure (IOP) control and contribute to disease stabilization. The treatment of OSD in glaucoma has been receiving increasing attention, however specific recommendations remain sparse.

Ocular surface disease is known to represent a complex milieu of genetic predisposition, adnexal and periorbital status, environmental factors, systemic diseases, and medications (topical and systemic), amongst other predisposing factors. Effective management of this condition therefore demands that treatment be targeted to the specific clinical context. A 2020 study of Canadian glaucoma specialists found that, although 97% identified optimization of ocular surface disease as important for improving patient QOL, only 22.2% felt this was currently being managed adequately in the subspecialty clinic setting. Moreover, although all participants felt comfortable modifying topical hypotensive regimens to improve surface disease, only 61.1% were confident identifying patients who would benefit from topical steroids, and just 30.5% felt knowledgeable regarding the use and dispensation of autologous serum tears, which are increasingly deployed for treatment-resistant OSD in dry-eye practices. There is, therefore, an unmet need for clarity in the treatment algorithm to optimize OSD in glaucoma patients. Here, we discuss the therapeutic approach to these patients and present a suggested algorithm to guide management.
Genetics of retinal degeneration in 2023
Authors: Héon Elise , Vincent Ajoy , Tayyib Alaa
Published: July 2023

Inherited retinal degenerations (IRDs) are of great interest with the development of novel therapies, thereby allowing this group of conditions to be “actionable” for the first time.

A molecular diagnosis can be obtained in nearly 70% of cases of IRD, with over 300 IRD-linked genes having been identified to date. Numerous animal models of different genetic subtypes of IRDs replicated the human phenotypes enough to develop and test novel therapies to improve outcomes for IRD patients. The first gene replacement therapy indicated for IRD, Luxturna (voretigene neparvovec-rzyl), was approved by Health Canada in October 2020 and is now available to patients with vision loss due to inherited retinal dystrophy caused by confirmed biallelic RPE65 mutations. Clinicians from Ontario, Quebec and Alberta can now access this treatment through their province’s public health plan.

This article aims to review some basic information and present new knowledge about IRDs to allow clinicians to better understand diagnosis and disease management.
Keratoconus Management: Navigating Patient Options
Authors: Vosoughi Amir R. , Rocha Guillermo
Published: July 2023

Keratoconus (KC) is a condition which results in progressive corneal thinning. It was first discovered by Dr. John Nottingham in 1854 who described it as “conical cornea” due to the outward bowing appearance caused by the condition. The prevalence of KC is between 0.2 and 4,790 per 100,000 people. KC does not have a gender predilection. It is believed to appear more commonly in South Asian and Middle Eastern populations.

Keratoconus typically begins in the second and third decades of life although it can develop at any time. The clinical symptoms of the condition include blurred and distorted vision. Patients may present with higher-order aberrations (HOA) ̶ the most characteristic of which is coma ̶ resulting in blurred and double vision. The common signs of KC include corneal protrusion and thinning, prominent corneal nerves, Fleischer ring, Vogt’s striae, and scissors reflex on retinoscopy. The most frequently encountered phenotype is oval cones in the central cornea. The primary diagnostic tool for KC is corneal topography, although pachymetry, including epithelial mapping and corneal tomography, are often performed in conjunction with each other as they aid with early detection and the monitoring of KC progression. 

Advancements in clinicians’ knowledge of KC and expertise in its treatment, have led to novel therapies. Stopping disease progression is now possible and improving patients’ quality of vision is feasible in many cases.

Preventive measures halting progression and management of mild and moderate forms of KC are reviewed. Treatment of severe KC will also be briefly reviewed.
From Social Media to Peer Review: How Can we Evaluate Medical Content for Misinformation and Bias?
Authors: McAlister Chryssa , Chiu Hannah , Hatamnejad Amin
Published: July 2023

Traditionally, ophthalmologists stay current by referring to peer reviewed papers found on scientific databases, such as PubMed, where rigorous publication standards reduce the potential for bias. We now access medical information from diverse online sources and social media allowing for fast-paced dissemination of content. Access to this rapidly evolving online information has allowed us to be more versed in our specialized knowledge than ever before. However, the rise of social media use in medicine may challenge the traditional methods aimed to limit misinformation and bias. How can we identify and evaluate bias when we access information from multiple disparate online sources in 2023?
Management of recurrent corneal erosions: A stepwise approach
Authors: Yang Yelin
Published: July 2023

Recurrent corneal erosions syndrome (RCES) is a common disorder characterized by recurring episodes of corneal epithelial breakdown. Symptoms include pain, tearing or redness typically worse upon awakening or overnight during rapid eye movements (REM) sleep. Severe episodes can last for days, leading to epithelial defects and corneal scarring. Recurrences can be frequent and debilitating for patients. The aim of this review is to summarize the current medical and surgical methods available to treat RCES.
Anti-VEGF therapy in pregnancy and breastfeeding
Authors: Basilious Amy , Muni Rajeev H. , Juncal Verena R.
Published: July 2023

Anti-vascular endothelial growth factor (VEGF) is the mainstay of treatment for several visually debilitating diseases and is considered the standard of care for a number of conditions which may affect younger patients, including women of childbearing age. These commonly include, but are not restricted to, diabetic macular edema (DME), proliferative diabetic retinopathy (PDR) and myopic choroidal neovascularization (CNV). As in other areas of medicine, pregnant and breastfeeding women are often excluded from clinical trials due to the unknown side effect profile of new drugs. This lack of evidence regarding the safety of anti-VEGF agents in pregnancy and breastfeeding introduces challenges for clinicians seeking to counsel these patients, particularly because anti-VEGF injections may be often used for an extended period of time, depending on the nature of the retinal disease. As a precaution, anti-VEGF injections are generally not recommended for women who are either pregnant or breastfeeding, given that they are considered Category C drugs and there is limited data regarding their excretion in human breast milk. Therefore, treatment of this group of patients is typically managed on a case-by-case basis, balancing the potential patient benefits with safety concerns for the infant.
Medical management of glaucoma for the pregnant and breastfeeding patient
Authors: Sarohia Gurkaran S. , Palakkamanil Mathew M.
Published: July 2023

Glaucoma is a progressive optic neuropathy which is relatively uncommon in childbearing age, with a reported prevalence of 0.16% between the ages of 18-40 years. Glaucoma management among pregnant patients presents a challenging scenario to the treating physician. Even with its low prevalence in the United Kingdom, a country-wide survey has revealed that approximately 26% of ophthalmologists reported having treated a pregnant patient with glaucoma. Perhaps due to this low prevalence, 31% of these ophthalmologists reported uncertainty about managing glaucoma in this population. When treating pregnant or breastfeeding patients, one must consider the benefit of treatment for the mother while weighing this against the risks the treatment may pose for the mother and fetus/child. This highlights the importance of having a review which can serve as a reference for physicians when managing glaucoma in pregnant and/or breastfeeding patients.
Approach to management of inflammatory bowel disease-related arthritis
Authors: Choi May Y. , Mosher Dianne
Published: July 2023

The most common extraintestinal manifestation of inflammatory bowel disease (IBD) is arthropathy. These conditions have been reported in up to 50% of patients with IBD and are more common in Crohn’s’ disease (CD), particularly colonic disease, and in females.

IBD-associated arthritis is classified as a type of spondyloarthritis (SpA). The treatment is dependent on the type of SpA involvement, which can be subdivided into peripheral and/or axial disease. The treatment approach consists of a combination of non-pharmacological and pharmacological therapies managed by a multidisciplinary team and is based on collaborative decisions between gastroenterology and rheumatology. In light of rapidly expanding therapeutic armamentaria for both immune-mediated arthritis and IBD, this paper will provide an overview of an approach to the treatment of arthritis associated with IBD, considering recommendations by recent guidelines and novel therapies.
Malnutrition assessment in patients with inflammatory bowel disease
Authors: Gold Stephanie L. , Raman Maitreyi
Published: July 2023

Inflammatory bowel disease (IBD) affects over 6.8 million people worldwide and is highly associated with the development of malnutrition. Malnutrition in patients with Crohn’s disease (CD) and ulcerative colitis (UC) is often due to the following: decreased oral intake; food avoidance; side effects of medications; malabsorption; chronic enteric losses; altered anatomy from luminal surgery; and increased nutritional needs in the setting of active inflammation and a high catabolic state. Approximately 20%-80% of patients with IBD are estimated to be malnourished at some point during their disease course; this wide range is likely secondary to significant heterogeneity in the definition of malnutrition in the literature, and due to the lack of robust, validated tools to identify individuals who are malnourished. While malnutrition is traditionally thought of as under- nutrition or protein calorie malnutrition, there are other nutrition phenotypes of significance in patients with IBD including micronutrient deficiencies, sarcopenia and obesity (over-nutrition). Malnutrition is associated with poor outcomes in patients with IBD, including a high number of disease flares; impaired response to biologics; increased surgical complications; hospitalizations; and impaired quality of life, independent of disease activity. Given the significant prevalence of malnutrition, the impact it can have in patients with IBD, and its responsiveness to therapeutic interventions, it is crucial to accurately assess the nutritional status of patients at the time of diagnosis and regularly thereafter.
Surgical approaches to perianal Crohn's disease
Authors: De Buck van Overstraeten Anthony
Published: July 2023

Virtually one-third of patients with Crohn’s disease (CD) develop anal symptoms. In addition to the typical skin tags and chronic fissures, 50% of these patients develop perianal abscesses and fistulas, which are among the most challenging CD phenotypes to treat. They can significantly affect patients’ quality of life (QOL) and result in a significant amount of lost days at school or work, as they often occur in a young, active population.
Advanced combination therapy in IBD
Authors: Solitano Virginia , Jairath Vipul
Published: July 2023

Conventional combination therapy in inflammatory bowel disease (IBD), which consists of an immunosuppressant agent and an anti-TNF agent, is a well-integrated strategy in clinical practice. The landmark SONIC and UC SUCCESS trials demonstrated that combining a thiopurine and infliximab was more effective than monotherapy and was associated with higher corticosteroid-free remission and mucosal healing rates. The primary advantage of this traditional combination therapy derives from the immunomodulator’s effect on the pharmacokinetics of anti-TNFs, with a lower rate of anti-drug antibodies detected in subjects administered combination therapy. Despite the growing therapeutic armamentarium and clinical study development pipeline for IBD, clinical remission rates at one year continue to range from 30% to 50%, indicating that a therapeutic ceiling may have been reached with the use of single agents. In addition, agents that have proven effective for luminal disease may not be helpful for extraintestinal manifestations (EIMs) or for concurrent immune-mediated diseases (IMIDs). In light of this, the concept of advanced combination treatment (ACT), which entails the simultaneous administration of at least two biologic agents, or a biologic and a small-molecule drug, is emerging as a therapeutic approach for patients with refractory IBD, as well as for those with IBD and a concurrent IMID, or IBD with EIMs.
Cutaneous manifestations of inflammatory bowel disease
Authors: Lipson Jennifer
Published: July 2023

As clinicians’ knowledge about the relationship between inflammatory bowel diseases (IBDs) and the integumentary system continues to expand, gastroenterologists and dermatologists need to know about the disease associations involved and understand the impact of treatments on these immune conditions in order to provide care to these medically complex patients.
Vaccine-preventable disease in IBD
Authors: Zhou Felix , Kilby Kyle , Jones Jennifer
Published: July 2023

The increasing prevalence of vaccine-preventable diseases (VPDs) in patients with inflammatory bowel disease (IBD) has given rise to increased awareness of the need to educate clinicians and patients about the critical role of immunization in this patient population. In 2023, it was estimated that in the Canadian population, 320,000 individuals (0.83%) were affected by IBD. Patients with IBD are at risk of vaccine-preventable diseases as the result of several factors, including potentially reduced efficacy and safety of vaccinations in the context of systemic immunosuppressive therapies administered for the management of IBD2 and a state of malnutrition caused by the disease.

Barriers to the administration of vaccinations include: Clinicians’ reluctance to immunize patients with IBD; patient lack of awareness regarding the critical importance of a structured vaccination protocol; gastroenterologists’ assumption that immunization falls under the auspices of the primary care provider (PCP); and limited time and resources.

The objective of this paper is to highlight the need for broader implementation of the 2021 Canadian Association of Gastroenterology (CAG) Guidelines concerning both live and inactivated vaccines in patients with IBD. This overview focuses on commonly encountered VPDs for which administration of live and non-live vaccines may be required and for which an IBD-specific deviation from the NACI recommendations have been made. The vaccines selected for this brief overview are also commonly administered in clinical practice. Clinicians may experience uncertainty in relation to management of these vaccinations in practice.
Targeting IL23p19 using risankizumab for the management of moderate-to-severely active Crohn's disease
Authors: Ma Christopher
Published: July 2023

Targeting Th17-mediated inflammatory pathways through inhibition of interleukin (IL)-23 has emerged as an important therapeutic mechanism for patients with inflammatory bowel disease. Ustekinumab, a monoclonal antibody blocking both IL-12 and IL-23, was the first agent approved by Health Canada with this mechanism of action, initially for Crohn’s disease (CD) in 2016 and subsequently for ulcerative colitis (UC) in 2020. Over the past decade, there has been increasing attention focused on selectively blocking IL-23, as the key activator of pathogenic Th17 inflammatory cells. Several monoclonal antibodies that target the unique p19 subunit of IL-23 (IL23p19 antagonists) have been developed for psoriasis and psoriatic arthritis, where IL-23 specific blockade results in substantially greater efficacy compared to targeting IL-12/23. The first IL23p19 antagonist, risankizumab, has recently been approved in Canada for the treatment of moderate-to-severely active CD. Here, we describe the mechanism of action of risankizumab and how it differentiates from ustekinumab; review the pivotal clinical trial data that demonstrates the ability of risankizumab to achieve relevant clinical and endoscopic endpoints in both biologic treatment naïve and exposed patients; and summarize key safety data that helps inform decisions about the benefit-risk profile of this novel therapy.
Update in the Management and Treatment of Adult Asthma for Primary Care Physicians
Authors: Kaplan Alan
Published: July 2023

Asthma is a common illness; estimates are that it affects up to 18% of the global population, with rates increasing every year. Approximately 3.8 million Canadians have asthma, and these patients continue to suffer from inadequately controlled disease as well as exacerbations. Although we have more medication choice than ever, mortality rates in Canada have not declined. Our current pharmacologic strategy has been mostly unchanged for years; it starts with an anti-inflammatory medication, usually an inhaled corticosteroid (ICS) to treat the type 2 (T2) inflammation that is most common. When an ICS provides inadequate control, therapy is often stepped up to include an ICS/long-acting beta-agonist (LABA) combination and even additional therapies like leukotriene receptor antagonists or long-acting muscarinic agents (LAMAs). As patients with uncontrolled asthma are at risk for deleterious outcomes, controlling the disease and preventing exacerbations should be the goal for all patients.
Bipolar Disorder in Primary Care: Diagnosis and Management
Authors: Yatham Lakshmi N
Published: July 2023

Primary care physicians play an important role in supporting and providing medical care for individuals with bipolar disorder. This includes correctly identifying bipolar disorder in those presenting with depressive symptoms to primary care settings or seeking psychiatric consultation and advise as needed; initiating treatment for depressive and hypomanic episodes; assessing risk for suicide or aggressive behaviour; referring to emergency services as needed; and providing maintenance care and monitoring for those with an established diagnosis with collaborative or as needed consultative support from psychiatric colleagues. The objective of this article is to provide up-to-date information to aid primary care physicians in achieving the above objectives related to diagnosing and managing patients with bipolar disorder.
The Management of Obesity in 2023: An Update
Authors: Glazer Stephen A
Published: July 2023

In 2015, obesity was declared by the Canadian Medical Association (CMA) and other global health organizations (World Health Organization [WHO], World Obesity Federation and the American Medical Association [AMA]) to be a chronic, relapsing and remitting disease caused by the deposition of adipose tissue in organ systems within the body leading to dysfunction and adverse health outcomes. Obesity should be medically addressed no differently than other chronic illnesses such as diabetes, hypertension or coronary artery disease.
Modern Management of Chronic Kidney Disease in T2MD: A Practical Overview for Primary Care Providers
Authors: Girard Louis
Published: July 2023

The development of chronic kidney disease (CKD) in patients with T2DM (CKD in T2DM) is a common and major comorbidity. Not only is it associated with progressive kidney disease and end-stage kidney disease (ESKD), it is also associated with very high risk for major adverse cardiovascular events (MACE) and heart failure (HF) events. CKD in T2DM is extremely  costly from a health economic perspective; however, most importantly, it results in significant reductions in patient quality of life and survival. For several decades, there has been a lack of new therapeutic options to address residual cardiorenal risk. The traditional pillars of therapy include glycemic control with a HbA1C target of 6.5%, blood pressure control with a blood pressure target of less than 130 mmHg, and the use of renin angiotensin aldosterone inhibitors (RAASi). Recently, several options have emerged that can address residual kidney and cardiovascular risk in these patients, thereby providing organ protection. Importantly, these therapies are grounded in the foundation of solid randomized, controlled clinical trials and are now prevalent in the guidelines that inform the management of CKD in T2DM. The novel pillars for kidney and cardiovascular protection include sodium glucose luminal transported 2 inhibitors (SGLT2i) and finerenone, a non-steroidal mineralocorticoid receptor antagonist (nsMRA). This article highlights practical considerations of these pillars for primary care providers with a focus on kidney protection.
Update on the management of hypertension in 2023
Authors: Rabi Doreen M.
Published: July 2023

Hypertension is the most common condition managed in the primary care setting. It is a potent but modifiable risk factor for cardiovascular disease (CVD) and premature mortality. Currently, approximately 25% of Canadian adults have a diagnosis of hypertension. However, the global community is experiencing challenges with optimizing hypertension management; it is estimated that at least 23% of individuals globally have effectively managed hypertension. Furthermore, if clinicians were able to identify and adequately intervene in these cases, we could prevent 10.8 million deaths per year. This statistic is extremely relevant to Canadian practitioners as our most recent Canadian data suggest that 34% of adults with hypertension are not achieving target blood pressure (BP) due to undertreatment or lack of awareness.

The undertreatment of hypertension is complex. There are a number of structural and environmental drivers of CV risk, and there is increasing recognition that if we are going to be effective at CV risk reduction, we must acknowledge the significant role that social determinants play in the development of risk factors including hypertension, smoking, obesity and diabetes.

The clinical guidance concerning hypertension may inadvertently contribute to the challenges we are seeing globally with hypertension management. There are numerous guidelines available to inform clinicians about how to provide supportive care for individuals with hypertension, and discordance between guidelines and the granularity of guidelines make implementation challenging. While there is disparity between guidelines, as well as differences regarding hypertension nomenclature, there is unanimous agreement that accurate BP measurement, risk-based thresholds for intervention, simplified approaches to pharmacotherapy, and well-structured care are the foundations of effective hypertension management.
Immunization in midlife
Authors: Brown Vivien
Published: July 2023

Midlife is often defined as age 50 and above and is a period of life when patients commonly access the healthcare system, having recognized the need for various preventions. The Women’s Health Initiative (WHI) identified cardiovascular disease (CVD), cancer and osteoporosis as the most common causes of morbidity, disability, and poor quality of life in post-menopausal women. Healthcare professionals routinely screen patients with risk factors for these diseases and offer prevention and treatment to improve their quality of life. However, recommendations for immunizations are often neglected leading to unnecessary morbidity and mortality in our aging population. In Canada, it is estimated that 20,000 hospitalizations related to influenza occur each year and that 4,000 to 8,000 Canadians die from influenza-related complications alone. Vaccines can prevent the debilitating and fatal effects of infectious disease, yet clinical evidence has revealed an adult immunization gap. Midlife screening and intervention should serve as an immunization checkpoint, providing an opportunity for healthcare professionals to optimize quality of care and health maintenance in older patients.
Diagnosis and management of irritable bowel syndrome
Authors: Guo Howard , Turbide Christian
Published: July 2023

Irritable bowel syndrome (IBS) is a common gastrointestinal (GI) disorder estimated to affect 10% of the Canadian population. Despite its high prevalence, IBS remains a challenging condition to diagnose and manage due to its varied clinical presentations. Patients with IBS often experience a range of distressing symptoms, including abdominal pain, bloating, disordered bowel habits and psychological distress, which significantly impact their quality of life (QOL). As a result, patients with IBS are more likely to be high-frequency medical consulters, leading to an increased burden on healthcare systems. This article aims to provide a practical overview of IBS, including its diagnostic criteria, workup and management strategies.
Principles of anxiety management for family physicians
Authors: McIntosh Diane
Published: July 2023

Family practitioners (FPs) play an essential role in mental healthcare delivery, providing triage, diagnosis, patient referral, and treatment. They are usually are patient’s first—and often their only—contact with mental healthcare services, due to the lack of access to psychiatric care. As such, FPs are commonly tasked with collecting and evaluating a broad range of symptoms that can be categorized as anxiety. The symptoms of anxiety have become increasingly ubiquitous, particularly due to the impact of the COVID-19 pandemic, leading many front-line providers to understandably feel anxious concerning optimal methods to assess and support these patients.

This article provides clinical pearls, supported by current empirical research, for assessing, diagnosing and treating patients presenting with anxiety.
Acute and prophylactic treatment of migraine
Authors: Marzoughi Sina , Spacey Sian
Published: July 2023

Migraine is a chronic neurological disorder that causes significant disability in patients and has a substantial economic impact in Canada. Effective treatment for migraine will improve our patients’ quality of life; additionally, it will reduce the economic burden generated by healthcare visits and employee absenteeism.

The novel treatments in migraine target calcitonin gene-related peptide (CGRP), a neuropeptide which plays a role in the initiation of a migraine attack. Although our current understanding of migraine pathophysiology is incomplete, it is believed to involve the trigeminal nerve and its connections with the cerebral vasculature with nociceptive signals activated through a variety of neuropeptides including CGRP, substance P and nitric oxide.

As a result of an improved understanding of migraine pathophysiology, the past several years have seen the advent of a variety of new therapeutic options in both the acute and prophylactic management of migraine. Although these agents represent additional options in the clinician’s arsenal, they have, in addition, introduced challenges in determining their cost-effectiveness. In this review, we provide an update on new acute and prophylactic migraine therapies and how they integrate into current practice from a primary care perspective.
A new era in the management of irritable bowel syndrome with constipation (IBS-C)
Authors: Marshall John , Brenner Darren , Liu Louis
Published: July 2023

In Canada, there is significant Irritable bowel syndrome (IBS) burden which negatively impacts health care utilization, economic productivity, and most importantly patients’ quality of life and psychosocial wellbeing. In this panel discussion, experts in the diagnosis and treatment of IBS discuss new strategies for diagnosing IBS-C, clinical trial data for novel therapies in IBS-C and appropriate choices of therapies according to individual patient characteristics. Methods for achieving treatment success and patient satisfaction are also discussed.
Assessment of measurement-based care to improve outcomes in patients with allergic rhinitis in an open-label, prospective study
Authors: Ellis Anne K. , Keith Paul K. , Boursiquot Jean-Nicolas , Francoeur Bruno , Kanani Amin
Published: July 2023

Background
Despite available treatments for allergic rhinitis (AR), patients are often dissatisfied with their treatment and experience uncontrolled symptoms. Measurement-based care is the systematic use of standardized measurements used during office visits to inform treatment decisions. The Improving Symptom Control of Allergic Rhinitis (ICAR) study determined if the assessment and management of AR through measurement-based care could improve patient outcomes.
Methods
ICAR was a real-world, open-label, prospective, multicenter study conducted in Canada between September 2021 and December 2021. Enrolled adult patients (n=503) with AR were categorized as treatment-naïve, uncontrolled despite AR treatment, or requiring a treatment switch due to adverse effects. AR symptoms and symptom control were assessed by the patient using the Rhinitis Control Assessment Test (RCAT) and, by both the patient and the clinician, on a visual analog scale (VAS) at baseline and after 4 weeks of 10 mg daily oral rupatadine.
Results
The majority of patients were uncontrolled (36%) or partially controlled (51%) at baseline, while 20% were treatment-naïve, 32% were uncontrolled despite treatment, and 30% needed treatment switch.At baseline, 66% of patients were taking non-sedating antihistamines, and 78% indicated they were dissatisfied with their treatment.
The overall RCAT score improved by 66%, from an average standard deviation (SD) of 16 (5.2) at baseline to 24 (3.8) at follow-up (P<0.0001). Scores for all individual RCAT items significantly improved (P<0.0001), with a 65% improvement in congestion frequency, a 61% improvement in sneezing frequency, and a 68% improvement in symptom control. Overall RCAT scores significantly improved from baseline by 67% in treatment-naïve patients; 64% in patients uncontrolled despite treatment; 51% in patients needing treatment switch; 55% in patients with asthma; 62% in patients with urticaria; 54% in patients with eczema/atopic dermatitis; 40% in patients with nasal polyps; and 52% in patients with no comorbidities (P<0.0001).
The patient VAS score improved from a mean SD of 6.5 (2.4) units at baseline to 2.6 (2.2) at follow-up; the clinician VAS score improved from 6.6 (2.2) units to 2.0 (2.2).
Conclusion
The ICAR study demonstrated that rupatadine, an antihistamine that also has anti-platelet-activating factor effects, significantly improves AR symptom control when used daily and monitored objectively by measurement-based care.
Evaluation of physicochemical parameters and phenolic compounds of craft beer subjected to forced aging
Authors: Marin Aline Tiecher , Fronza Emanoelly Cristiny Prates , Santos Liliane dos , Pastre Silmara , Hey Albimara , Pereira Ricardo Aparecido
Published: July 2023

Beer is the most consumed alcoholic beverage in the world, obtained by cooking barley malt with the addition of hops and brewer's yeast. The craft beer market has been growing, and, at the same time, the demand for studies on nutritional issues, compounds, and chemical reactions. The forced aging analysis assesses the long-term stability of the drink to simulate the reality of storage. During the shelf life, the drink may undergo reactions that alter the physical-chemical characteristics, color, and flavor. Thus, this research aimed to evaluate changes in phenolic compounds and physical-chemical parameters of beers subjected to the forced aging process. After production, beer samples remained at 50 °C for 1, 3, 6, 9, and 13 days. Afterward, color-EBC analyses were performed through reading at 430 nm, pH, dry extract, phenolic compounds’ content, and physical-chemical analyses in the Beer Analyzer® equipment. The most significant results were related to color, which showed a darkening during the experiment; the pH was more alkaline during aging, and the total phenolic compounds dropped over the days. The results obtained can be related to changes due to storage temperature and product instability after bottling.
Fruit colour progression in grapefruit with relation to carotenoid and Brix-acid ratio
Authors: Chahal T S , Varinder Singh  , PPS Gill  , SK Jawandha  , Vikramjit Singh
Published: July 2023

In citrus, fruit colouration is considered one of the criteria to assess the optimum harvest maturity. The present study the fruit colour variations, β-carotene and its relation to soluble Brix/acid ratio (B/A ratio) during development in four grapefruit varieties viz. Marsh Seedless, Flame, Rio Red and Redblush were investigated. Among different grapefruit varieties, the highest peel colour coordinate a* value and β-carotene content were recorded in cv. Flame at 270 days after full bloom (DAFS). The peel β-carotene concentration varied from 3.61 to 61.42 μg.g-1 during fruit development. L*coordinate showed a declining pattern in the pulp, while it increased in peel till 270 DAFS. Likewise, b* values also increased in both peel and pulp. Chroma (C*) and B/A ratio values of fruit increased with maturity, while the hue angle (h°) decreased. L*a*b*colour coordinates showed a strong correlation with B/A ratio compared to β-carotene content. At the final fruit harvest, the higher value for L* coordinate in peel and pulp was noted in ‘Redblush’ and ‘Marsh Seedless’. In contrast, the highest b* coordinate was observed in the peel and pulp of the Marsh Seedless variety. Overall, a* coordinate was observed to be the most reliable colour parameter to determine the maturity index in the studied varieties of grapefruit.
Escolas cívico-militarizadas no Brasil: um estado do conhecimento no Brasil
Authors: Miranda Edna Mara Corrêa , Silva Francisco Thiago
Published: July 2023

Este artigo tem por objetivo apresentar um estado do conhecimento acerca das pesquisas realizadas no Brasil sobre as escolas cívico-militares. Constitui-se comodesdobramento de dissertação que investigou o currículo das escolas militarizadas no Distrito Federal defendida em maio de 2021 no Programa de pós-Graduação em Educação- Modalidade Profissional (PPGE-MP) na Faculdade de Educação da Universidade de Brasília- UnB. Orientou-se em torno de dissertações e teses de mestrado e doutorado localizados nos Bancos de Teses e Dissertações dos sites Google Acadêmico, Rede Scielo, Banco de Dados da Capes – Biblioteca Digital de Teses e Dissertações (BDTD) e um Repositório Institucional. Foram encontrados quinze trabalhos, sendo uma tese e quatorze dissertações. Constatou-se que somente as regiões centro-oeste e sudeste já realizaram pesquisas sobre a temática, evidenciando que até o presente momento poucos pesquisadores se interessaram pelo assunto. A militarização das escolas públicas demonstrou ser elemento de reflexão de campos do conhecimento que estão além da Educação, como, por exemplo, Psicologia, Ciências Sociais e Antropologia, contudo ainda não ficou constatada nas pesquisas inventariadas a celeuma da diferenciação entre instituições militares e militarizadas, ponto nevrálgico das políticas e debates para a área.