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June 21 st | 5:30 – 8:00 pm 4 Mainpro-C Credits From Top to Bottom
June 21st| 5:30 – 8:00 pm
4 Mainpro-C Credits
From Top to Bottom
Top 8 Ways to Use SCOPE Option #4
Number 8!
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Agenda5:45 Welcome and Introductions
5:50 Approach to Headaches
6:20 Diagnostic Imaging Appropriateness Web Based Tool
6:35 Patient Education & Lifestyle Factors
6:45 Break-Out Session - Neurology
7:15 Practical Issues in Hypertension, Diabetes, Renal Disease
7:40 Break-Out Session – Nephrology
7:55 Closing Remarks
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4
HEADACHE
NEUROLOGY
An Approach to Headache Med ic ine
Dr. Jenn i fe r Robb lee , MD MSc FRCP C55
Approach to MigrainesDiagnosis
Treatment
Medication Overuse Headaches
Facial PainTrigeminal Neuralgia
Trigeminal Autonomic Cephalgia
Sinusitis
Red Flags
OUTLINE
Pop u la t i on w i t h M ig ra i ne15%
90%
3R
D
WHY DO
WE CARE?
Rec u r ren t m ig ra i ne su f f e re r s seek
p r ima r y c a re o r e m e r g e n c y c a re
3 rd mos t p reva len t d i sab i l i t y
wo r l d w id e ag es 15 -49
MacGregor, 20177
…
….
MIGRAINE WITHOUT AURA
ICHD-3 CRITERIA
B. 4 - 72H
Untreated
C. 2 / 4 FEATURES:
1 - Unilateral
2 - Pulsating
3 - Moderate to Severe
4. Worse with or Avoid activity
D. 1 / 2 FEATURES
1 - Nausea &/or Vomiting
2 - Photophobia & Phonophobia
E.
NO BETTER
DIAGNOSIS
WWW.ICHD-3.ORG
A.
≥5 ATTACKS
8
P
O
U
N
D
ulsating
ne to Three Days
nilateral
ausea ± Vomiting
isabling Intensity
POUNDing Criteria
Sensitivity = 95%
Specificity = 78%
3/5 predicts migraines (LR 3.5)
4/5 is highly predictive (LR 24)
MacGregor, 2017; Michael et al., 19939
WWW.ICHD-3.ORG
…
….MIGRAINE WITH AURA
-Reversible
-Can be without Headache
-Gradual ± Consecutive
-Lasts 5 to 60 min
VISUAL SENSORY LANGUAGE
30%
of migraine! 10
8%
92%
EPISODIC
MIGRAINE
< 15 d ays p e r mon th
…
….MIGRAINE WITH AURA
CHRONIC
MIGRAINE
≥ 15 d ays p e r mon th
8 d ay s = M ig ra i ne
A t l eas t 3 mon ths
**MUST RULE OUT MEDICATION OVERUSE**Lipton et al 2016 (AMPP & CaMEO) 11
12
13
A
B
C
UNCLEAR
MENSTRUAL MIGRAINE
Botox*, Topiramate, Valproate, Propranolol, Metoprolol
Amitriptyline, Venlafaxine
Candesartan
Gabapentin, Flunarizine, Diamox, Verapamil
…
….MIGRAINE PROPHYLAXIS
Frovatriptan
*Botox: Only for Chronic Migraine
EAP Eligibility: Fail 3 Meds†
†Topiramate, Beta blocker, TCA, Verapamil, Flunarizine, or Gabapentin
Silberstein 201514
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V1
V2
V3
…
….TRIGEMINAL NEURALGIA
Unilateral Face pain
Sharp/Electric/Burning
V2 & V3 > V1
Can include tooth pain
“Paroxysm”
Often triggered
Numbness → Secondary cause?
MRI with trigeminal nerve protocol
Carbamazepine
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TRIGEMINAL AUTONOMIC CEPHALGIAS
Cluster
HeadacheParoxysmal
Hemicrania
SUNCT/SUNAHemicrania
Continua
Side locked + Severe sharp + V1 Face pain
Ipsi ANS: Red eye, ptosis, flushing, tearing, rhinorrhea…
15-180min
Verapamil
2-30min
Indomethacin
≥3 month
Indomethacin
1-600sec
Lamotrigine
17
3%
88%
ACUTE
RHINO-
SINUSITIS
Migraine can cause Face & Sinus Pain ± congestion
Migraine misdiagnosis as Sinusitis is ~42%
Chronic Sinusitis rarely causes painEross et al., 2007; Lal et al., 2015
FINAL DIAGNOSIS OF 100 PATIENTS WITH
SELF-DESCRIBED “SINUS HEADACHE”
MIGRAINEMore likely if:
-Fever
-Anosmia
-Purulent discharge
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Acute Rhinosinusitis
“PODS”
Gryglas , 2016. Lal et al., 2015. Desrosiers et al., 2011. Cady et al., 2005.
• Facial Pain/pressure
• Nasal Obstruction**
• Purulent/discolored Discharge**
• Hyposmia/anosmia (Smell)
Diagnosis = ≥ 2 PODS & >7d
**O or D is needed
CT not recommended
Chronic Rhinosinusitis
“CPODS”
• Facial Congestion
• Facial Pain/pressure
• Nasal Obstruction
• Purulent/discolored Drainage
• Hyposmia/anosmia (Smell)
Diagnosis = ≥2 CPODS & ≥8-12wks
Documented sinus inflammation
***BUT***
Think migraine first if
face pain & congestion
~90% = migraine
~50% migraine sufferers have
congestion & rhinorrhea
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THANK YOU!
D r. J e n n i f e r R o b b l e e , M D M Sc FRC PC
To r o n t o We s t e r n H o s p i t a l ( P) 4 1 6 - 6 0 3 - 5 8 0 0 x 2 9 9 4 ( F) 4 1 6 - 6 0 3 - 5 7 6 8 ( E) h e a d a c h e @u h n . c a
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Top 8 Ways to Use SCOPE Option #4
Number 7!
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Diagnostic Imaging Appropriateness (DI-APP) Project
Headache Pathway Overview
June 21, 2017
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Agenda
• Project Overview
• Headache Pathway Development Team
• Headache Pathway
• Next Steps
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Reasons for Action
• Variability in images ordered for common clinical scenarios1,2
(e.g. right modality and when)
• Uncertainty regarding imaging decisions (e.g. CT vs. MRI) resulting from rapid technological advances
• Lack of integration between community primary care providers and hospital-based imaging specialists
– Opportunity to advance provincial primary care strategy: Patients First: Action Plan for Health Care by “delivering better coordinated and integrated care in the community, closer to home” 3
1. In 2011 approximately 800 MRI/CT requisitions were collected across UHN, St. Joseph’s Healthcare Hamilton, Thunder Bay Regional Health Sciences Centre, St. Joseph’s Health Care London and the clinical indications were cross-referenced with the Ontario MRI/CT Referral Guidelines to assess variability with guidelines.
2. You, J. J., Purdy, I., Rothwell, D. M., Przybysz, R., Fang, J., & Laupacis, A. (2008). Indications for and results of outpatient computed tomography and magnetic resonance imaging in Ontario. Canadian Association of Radiologists journal= Journal l'Association canadienne des radiologistes, 59(3), 135-143.
3. Patients First: Action Plan for Health Care, February 2015
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Approach
• Develop imaging pathways for primary care providers that outline if, when and what imaging is needed for common primary care presentations of:
• Imaging pathways should be based on:
– Best evidence
– Clinical experience
– Ontario population & resources
– Preferred terminology
– Primary care feedback
Headache Low back pain
TIA/Stroke Knee pain
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Thunder Bay
BarrieToronto
HamiltonLondon
OttawaKingston
Sudbury
Oshawa
\
Critical Partnerships
• Started as a radiology-focused initiative
• Partnered with primary care champions and representative organizations
• Ontario College of Family PhysiciansDon’t Just Do Something, Stand There
• Inter-professional Spine Assessment and Education Clinics (ISAEC)
• Ontario Association of Radiologists
• Choosing Wisely Canada
• Health Quality Ontario
• Centre for Effective Practice
Provincial Partners
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Dr. Frank Martino, Chief of Family Medicine, William Osler Health System – Brampton (Panel Lead)
Dr. Peter Hutten-Czapski, Family Physician, Family Health Team– Haileybury, Ontario
Dr. Sharla Lichtman, Family Physician, North York General Hospital – North York, Ontario
Dr. Stuart Murdoch, Chief of Family Practice , Royal Victoria Hospital – Barrie, Ontario
Dr. Matt Orava, Family Physician, Royal Victoria Hospital – Barrie, Ontario
Dr. Adam Steacie, Family Physician at Upper Canada Family Health Team – Brockville, Ontario
Dr. David Tannenbaum, Family Physician-in-Chief, Mt. Sinai Hospital – Toronto, Ontario
Dr. Eric Bartlett, Neuroradiologist, Joint Department of Medical Imaging – Toronto, Ontario
Dr. Laura Howlett, Chief Radiologist, Grey Bruce Health Services – Owen Sound, Ontario
Dr. Omar Islam, Neuroradiologist, Kingston General Hospital – Kingston, Ontario
Dr. Andrew Leung, Neuroradiologist, London Health Sciences Centre – London, Ontario
Dr. Amy Lin, Neuroradiology Fellow, University Health Network – Toronto, Ontario
Dr. Vladislav Miropolsky, Radiologist, Cambridge Memorial Hospital – Cambridge, Ontario
Dr. Apurva Patel, Neuroradiology Fellow, London Health Sciences Centre – London, Ontario
Dr. Sapna Rawal, Neuroradiologist, Joint Department of Medical Imaging – Toronto, Ontario
Dr. Sean Symons, Neuroradiologist, Sunnybrook Health Sciences Centre – Toronto, Ontario
Dr. Cheryl Jaigobin, Neurologist, University Health Network– Toronto, Ontario
Dr. Christine Lay, Neurologist, Women’s College Hospital – Toronto, Ontario
Dr. Jason Lazarou, Neurologist, Mt. Sinai Hospital – Toronto, Ontario
Dr. Eric Monteiro, Otolaryngology Fellow, Mt. Sinai Hospital – Toronto, Ontario
Dr. Shariq Mumtaz, Neurologist, Oshawa Clinic – Oshawa, Ontario
Dr. Manish Shah, Otolaryngologist, North York General Hospital – North York, Ontario
Dr. Peter Tai, Neurologist, University Health Network/Mt. Sinai Hospital – Toronto, Ontario
Dr. Ian Witterick, Otolaryngologist-in-Chief, Mt. Sinai Hospital – Toronto, Ontario
Fam
ily
Ph
ysic
ian
sR
adio
logi
sts
Spec
ialis
ts
Headache Imaging Pathway Development Team
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Demo of Headache Pathway
http://pathways.coralimaging.ca/demo-v2/main.html
Compatible with laptop, PCs, smartphones and tablets
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Assessing Pathway Acceptance
Pathways were evaluated by primary care providers who did not participate in development (n=55)
92% agreed/strongly agreed that the pathway recommendations are
relevant and applicable to their patient population
84% agreed/strongly agreed that the pathways could help facilitate
communication with patients
70% agreed/strongly agreed that the pathways could help to change
their practice
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Next Steps
Feedback from Primary Care
• User Acceptance Testing
• Evaluation of user-friendliness, flow, and layout of tool
Pathways Pilot
• Primary Care Setting
• Evaluation of impact and effectiveness of pathways
Broad Dissemination
Pathways Pilot:
• Provide tool to pilot group of community-based PCPs in order to contain outcomes for the purpose of evaluation
• Evaluation to include physician survey to identify:
– User-friendliness
– When and how tool was used
– When and why tool was not used
– Value to practice
– Affect on decision-making
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Expectations from Pilot Participants
• Participants are expected to commit to the duration of the pilot project for 6 months
• Participants are expected to use the tool for the duration of the pilot
• Participants are expected to conduct interviews and surveys for evaluation purposes
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Contact Information
If interested in participating in the DI-APP Tool pilot please contact:
Jennifer Catton
Manager, Strategy & Quality
Joint Department of Medical Imaging
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Top 8 Ways to Use SCOPE Option #4
Number 6!
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SCOPE Headache Neurology:Migraine Lifestyle & Education
Shawna Kelly, NP-Adult, MN, CNN(C)Nurse Practitioner, SCOPE Headache Neurology Program
What we have learned from your headache patients…
Number of Days/Month with
Headache = 20
Number of Days/Month with Headache = 20
Average Age = 43
Headache Disability Score = 61 (Very Severe Impact)
Very Severe Impact >60
Substantial Impact > 55
Minimal Impact <49
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
66% 31%
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Migraine
Management
PharmacologicTherapy
Lifestyle Modifications,
Behavioural Therapy
Education, Support, & Close
Follow Up
Multifaceted Approach to Migraine Management
(Dodick, 2006)
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Risk Factors for Migraine Progression
Nonmodifiable Modifiable
Age (20 to 40) Female Sex (3:1) Head Trauma Genetic Disposition Low socioeconomic
status
Attack Frequency Acute medication overuse Obesity Caffeine overuse Stress Management (i.e. MBSR) Sleep disturbances (i.e. sleep
apnea) Mood Disorders (i.e.
Depression/Anxiety) Other pain syndromes Lifestyle (dietary
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79.7
65.1
57.353.2
49.8
43.738.4 38.1 37.8 35.7
30 30.326.9
22
5
Migraine Triggers
Per
cen
tag
e
Kelman, 2007
Modifiable
So how do we determine what our patients triggers are??
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**IMPORTANT: Headache means any paininvolving any part of head &/or face
Type to enter text
Month / Year: ____________________
KNC Headache Clinic
Pre-Consultation Diary
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Left, Right, Both?
Severity out of 10
Duration
Pain meds used
Left, Right, Both?
Severity out of 10
Duration
Pain meds used
Left, Right, Both?
Severity out of 10
Duration
Pain meds used
Left, Right, Both?
Severity out of 10
Duration
Pain meds used
Left, Right, Both?
Severity out of 10
Duration
Pain meds used
___________________’s Headache Diary
Identify your triggers:
1) ↑ /↓ Sleep, 2) Skipping meals, 3) Alcohol, 4) Bright light, 5) Noise
6) Smells/perfumes, 7) Stress, 8) Dehydration, 9) Weather
10) Caffeine, 11) Exercise/Activity, 12) Positions?, 13) Others?
Do your headaches have nausea or vomiting? _____________
Think of all the medications you’ve tried. Include doses.
*Menstruating females
Please circle the date in
shaded box if you had
your period that day!
} Fill the date in
the shaded box
KNC Headache Clinic 399 Bathurst Street Toronto Western Hospital Toronto ON M5T 2S8 (P) 416-603-5800 x2994 (F) 416-603-5768
Headache Diary
Diagnostic diaries have significant clinical utility and have proved helpful in:
• Determining headache pathogenesis• Understanding the headache history (i.e.
frequency)• Evaluating response to pharmacologic
therapy• Understanding the relationship between
migraine and triggers (i.e. sleeping behaviours, menstrual cycle)
• Improving communication between patient & provider
• Empowering patients to be actively involved in care
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Migraine
Management
PharmacologicTherapy
Lifestyle Modifications,
Behavioural Therapy
Education, Support, & Close
Follow Up
Multifaceted Approach to Migraine Treatment
(Dodick, 2006)
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Patient Education Library
• All to be uploaded to SCOPE website for SCOPE providers/patients to utilize!
• Currently being reviewed by UHN patient education for content/language
• UHN Monthly Talk – Headache with patient partner
• Date: August 25th, 2017 (all patients, providers, community welcome!)
KNC Headache Clinic
May 2017
Headache and Migraine: Lifestyle Modifications
& Resources
Rest Your Brain -Sleep Hygiene Principles
-Stress Reduction Techniques
Exercise Your Brain Physical Activity
Goal: 3x/week for 20-30 Minutes
Feed Your Brain -Eat Breakfast Everyday with 12-15g of Protein -Avoid Skipping Meals
-Identify & Avoid Triggers
Hydrate Your Brain -8-10 glasses of water/day -Avoid artificial sweeteners
-Limit caffeine to 2 cups/day
KNC Headache Clinic
May 2017
Migraine Treatment: Supplements
KNC Headache Clinic
May 2017
Rest Your Brain Sleep Disorders and Sleep Hygiene Principles
KNC Headache Clinic
May 2017
Medication Overuse Headache (MOH)
Correct Use Medication Overuse
Migraine
Medication
Relief Short-term Relief
More Medication
Rebound Headache
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Support & Close Follow-Up
I am always available for a email/call for SCOPE providers and your patients!
[email protected] 437-997-5880
How do the SCOPE providers want to utilize the Headache Neurology Services??
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Process Mapping Exercise:
Current State Future StateVs.
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Danielle is 32-year-old woman presenting to your office reporting headache almost every day over the past year. Her “backgroundheadache” is mild but becomes moderate-severe at least 4 days/week, lasting 4-6 hours in duration and is interfering with her function at work. For the past 4 months she has been taking acetaminophen 1000 mg BID with minimal relief. She reports nausea, dizziness and neck pain. She reports no photophobia, however reports going into a quiet/dark room during her severe episodes.
Lifestyle – drinks 3-4 coffee 5 days/week, skips breakfast regularly, sleeps 5 hours/night, catches up on the weekend sleeping 9+ hours
Her CBC, Ferritin and TSH levels were normal. She had no fever, weight loss, diplopia, or tinnitus. Headaches are not exacerbated by Valsalva maneuver or positional change. Her physical examination was normal.
Vignette
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= START (Patient presenting with worsening headache)
= STEP (i.e. headache assessment)
= DECISION POINT (i.e. refer to neurology)
= STEP UNCLEAR (i.e. referral process)
= STOP (Diagnosis and patient on appropriate treatment)49
Top 8 Ways to Use SCOPE Option #4
Number 5!
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Breakout
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= START (Patient presenting with worsening headache)
= STEP (i.e. headache assessment)
= DECISION POINT (i.e. refer to neurology)
= STEP UNCLEAR (i.e. referral process)
= STOP (Diagnosis and patient on appropriate treatment)52
Top 8 Ways to Use SCOPE Option #4
Number 4!
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When Should I refer a patient with low eGFR?
Practical Issues In Hypertension, Diabetes, Renal Disease
Dr. Christopher T Chan
Divisional Director of Nephrology (UHN)
R Fraser Elliott Chair in Home Dialysis (UHN)
Professor of Medicine (U of T)
Faculty/Presenter Disclosure
• Faculty: Christopher T Chan
• Relationships with commercial interests:– Grants/Research Support: Baxter, Medtronic, NxStage, Intelomed
– Speakers Bureau/Honoraria: N/A
– Consulting Fees: N/A
– Other: N/A
CFPC CoI Templates: Slide 1
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Learning Objectives
• Definition of eGFR
• Impact of low eGFR on clinical outcomes
• When should I refer?
• Brief overview in partnership
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Cases
• A) 65 yo man with hypertension, Cr 150 umol/L, urinalysis 2+ proteinuria
• B) 35 yo man with diabetes (5 years), Cr 125 umol/L, urinalysis 2+ proteinuria
• C) 95 yo man with past history of hypertension, Cr 125 umol/L
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In 2002, CKD = eGFR < 60 ml/min per 1.73 m2 + kidney damage
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Concerns?
59
New Definition
60
Validation
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De
ath
(%
)
0 6 12 18 24 30 36 42 48 54 60
Months
0
5
10
15
eGFR ≥ 60
eGFR < 60HR, 0.73; 95% CI, 0.54, 1.00
HR 0.94; 95% CI 0.78 to 1.13
P-interaction = 0.02
Trandolapril
Placebo
In patients with reduced GFR<60cc/min, there was a significant 27% reduction in death
Solomon SD, et al. Circulation 2006; 114:26-31.
The PEACE-eGFR substudy
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The role of proteinuria
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The revised definition
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Screening
• The following tests for CKD are indicated
– CBC
– Electrolytes/Cr/eGFR
– Urine ACR or protein to creatinine ratio
– Glucose
– Urine microscopy + Urinalysis
– Renal Ultrasound
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Other tests to consider
66
Primary Prevention of CKD
• BP target: < 140/90– Caveat – DM (from certain guidelines)
• DM:– Glycemic control
– ACEi / ARB
• Proteinuria– ACEi / ARB
• Lipid control – Statin + Ezetimibe
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Dietary Modification
• Adherence to a low salt diet
– (<100 mmol or 2300 mg / day)
– Normal dietary intake
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Lifestyle Modification
• Cessation of smoking
• Regular exercise
• Fluid intake
– There is NO convincing evidence to date that pushing oral fluid intake beyond 2-2.5L per day is beneficial to kidney health
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Summary
70
Evidence Summary
• CKD is associated with increased risk of death from any cause , CV events and progression to ESRD
• The risk of adverse outcomes increases with stages of CKD
• At every stage of CKD, the presence of proteinuria increases the risk of adverse events
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Cases
• A) 65 yo man with hypertension, Cr 150 umol/L, urinalysis 2+ proteinuria
• B) 35 yo man with diabetes (5 years), Cr 125 umol/L, urinalysis 2+ proteinuria
• C) 95 yo man with past history of hypertension, Cr 125 umol/L
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What would work best?
• Leverage existing infrastructure
– Phone contact triage
• eConsult eCommunication
• Combination
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Strengths and Weaknesses
• Access
• Timely Communication
• BUT….
• Increase work flow
• Redundancy
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SCOPE – UHN Nephrology Partnership
• Timely access to nephrology
– Referral
– Commnication
• Common Issues
– DM, Hypertension, CKD
• Primary Care Sub-specialty Care
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Comments &Questions?
References
• CSN guidelines – CMAJ 179: 1154-1162, 2008
• KDIGO – Kidney International 80:17-28, 2011
• KHA-CARI – Nephrology18:340-350, 2013
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Top 8 Ways to Use SCOPE Option #4
Number 3!
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Breakout
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Breakout Session
1. For which renal conditions do you have difficulty getting
consultation?
2. Were we to initiate a central intake process, what would
make the referral process easiest for you to use?
3. Would you access consultation for your nephrology
questions through secure e-mail if we made this available?
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Top 8 Ways to Use SCOPE Option #4
Number 2!
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Closing Remarks
Dr. Pauline Pariser
82
ONEID Bundle
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and/or eConsult?
They are all coming your way!
Sign-up before leaving today!
83
Top 8 Ways to Use SCOPE Option #4
Number 1!
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Thank You!
