Artificial Nutrition and Hydration (ANH): Is it Really What you Want?

Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

Abstract
The use of artificial nutrition and hydration (ANH) has become relatively commonplace. With the development of the PEG years ago, the difficulties that surrounded the use of naso-gastric feeding tubes have all but disappeared. However, the clinical, ethical and legal aspects of ANH have replaced issues of procedural techniques and the discomfort experienced by older patients when the nasogastric tubes were used for prolonged periods. Many in the field of aging and long-term care in particular are particularly sensitive to the long-term implications for the patient and family once ANH is implemented. The issues of starting such intervention when its discontinuation may cause moral conflict, legal challenges and for many who are believers religious conundrums must be considered especially when such decisions are being made during a period of crises and clinical uncertainty.
Key Words: artificial nutrition, hydration, long-term care, implications.

Prescribing Antibiotics to Patients with Acne

Shannon Humphrey, MD, FRCPC, FAAD, Clinical Assistant Professor, Director of Continuing Medical Education, Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada.

Abstract
The pathogenesis of acne is tied to Propionibacterium acnes (P. acnes), an anaerobic bacteria. There has been a dramatic rise in resistance to antibiotics that are usually prescribed to treat acne. Given resistance to antibiotic therapy can occur in more pathogenic bacteria than P. acnes, and the fact that a rise in pathogenic P. acnes has been reported, the development of antibiotic resistance in acne is a public health matter globally. Clinical practice guidelines are aiming to curb the further development of antibiotic resistance without detracting from effective management of both inflammatory and non-inflammatory acne.
Key Words: acne vulgaris, antibiotic resistance, benzoyl peroxide, anti-inflammatory, sub-antimicrobial dosing.

Spinal Cord Stimulation for the Management of Neuropathic Pain in Failed Back Surgery Syndrome

Mohammed F. Shamji MD, PhD, FRCSC, Division of Neurosurgery, Toronto Western Hospital, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

Alina Shcharinsky RN (EC), MN, CNN(C), Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada.

Abstract
Chronic pain is a complex disease state associated with substantial individual disability and suffering alongside societal economic impact. The entity of neuropathic pain is a diagnosis of specific clinical characteristics and underlying pathophysiology. Failed back surgery syndrome represents persistent neuropathic leg pain following structurally corrective spinal surgery, often being refractory to escalated pharmacological management. In appropriately selected patients, spinal cord stimulation is a surgical technique that may offer reduced disability and pain, and improved economic outcomes for patients where medical management has been unsuccessful. Contemporary technological advances continue to improve this approach with greater success, lessened morbidity, and expanding indications.
Key Words: failed back surgery syndrome, neuropathic pain, spinal cord stimulation, neuromodulation.

A Case of Large Nasal Vestibular Mass presenting with Nasal Obstruction and Epistaxis

P.K. Shenoy, MD, FRCS, DLO, FACS, ENT Service Chief, Campbellton Regional Hospital, Campbellton, NB, Canada.

Dr. Lyew Warren, MD, FRCSC, Consultant Pathologist, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada.

Abstract
Nasal vestibular mass are not commonly seen in ENT practice. We are presenting a patient with a large right nasal vestibular mass, who complained of nasal obstruction and epistaxis. Differential diagnosis of the similar growths in the nasal vestibule with their pathology and the treatment options, have been reviewed from the literature.
Key Words: Nasal vestibular mass, papilloma, 0 and 30 degree endoscopes, lateral rhinotomy.

Editor's Note, Volume 3 Issue 7

Beyond Rasouli: What has the Supreme Court said about Late-Stage Dementia and Continued Life-maintaining Treatment?

Michael Gordon, MD, MSc, FRCPC, Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

Abstract
With the rapidly increasing numbers of elders in North American Society, the prevalence of those living with dementia is clearly on the increase. According to the most recent document provided by the Alzheimer Society of Canada, The Rising Tide the growth in the numbers of those living with dementia will increase from 480,600 in 2008 (1.5% of Canada's population) to in the year 2038—1,125,200 people with dementia (2.8% of Canada's population).¹ All the challenges that Canadian society faces with this growing population merely mirror the enormous complexities that those living with dementia, their families and health care professional providers must increasingly contend with. Government policy makers must find ways to address this increasing population in which Dementia plays a prominent role. The result of the Supreme Court ruling on the Rasouli case has major potential implication for those facing the later stages of dementia and those under whose care members of this population will be entrusted.
Key Words: dementia, aging population, substitute decision makers.