Geriatrics https://ubccpd.ca/ en TCMP Article: Spinal stenosis — practice tips https://ubccpd.ca/tcmp-article-spinal-stenosis-practice-tips <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--title--rss.html.twig * field--node--title--resource.html.twig x field--node--title.html.twig * field--node--resource.html.twig * field--title.html.twig * field--string.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--title.html.twig' --> <span class="field field--name-title field--type-string field--label-hidden">TCMP Article: Spinal stenosis — practice tips</span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--title.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--uid--rss.html.twig * field--node--uid--resource.html.twig x field--node--uid.html.twig * field--node--resource.html.twig * field--uid.html.twig * field--entity-reference.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--uid.html.twig' --> <span class="field field--name-uid field--type-entity-reference field--label-hidden"> <!-- THEME DEBUG --> <!-- THEME HOOK: 'username' --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/user/username.html.twig' --> <span>nina.z@ubc.ca</span> <!-- END OUTPUT from 'core/themes/classy/templates/user/username.html.twig' --> </span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--uid.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--created--rss.html.twig * field--node--created--resource.html.twig x field--node--created.html.twig * field--node--resource.html.twig * field--created.html.twig * field--created.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--created.html.twig' --> <span class="field field--name-created field--type-created field--label-hidden">Fri, 04/21/2023 - 16:26</span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--created.html.twig' --> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=1469&amp;2=bookmark" token="XELcjW_ihOCo7Na7Kyrl5V6tMk8OezM-h4bTfJ240jE"></drupal-render-placeholder> <!-- THEME DEBUG --> <!-- THEME HOOK: 'addtoany_standard' --> <!-- FILE NAME SUGGESTIONS: * addtoany-standard--node--resource.html.twig * addtoany-standard--node.html.twig x addtoany-standard.html.twig --> <!-- BEGIN OUTPUT from 'modules/contrib/addtoany/templates/addtoany-standard.html.twig' --> <span class="a2a_kit a2a_kit_size_32 addtoany_list" data-a2a-url="https://ubccpd.ca/tcmp-article-spinal-stenosis-practice-tips" data-a2a-title="TCMP Article: Spinal stenosis — practice tips"><a class="a2a_dd" href="https://www.addtoany.com/share" data-tooltip="Share"><span class="visually-hidden">Share</span><span class="CPD-Icon-Share"></span></a></span> <!-- END OUTPUT from 'modules/contrib/addtoany/templates/addtoany-standard.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--field-topic-audience--rss.html.twig * field--node--field-topic-audience--resource.html.twig * field--node--field-topic-audience.html.twig * field--node--resource.html.twig * field--field-topic-audience.html.twig * field--entity-reference.html.twig x field.html.twig --> <!-- BEGIN OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <div class="field field--name-field-topic-audience field--type-entity-reference field--label-above"> <div class="field__label">Topic &amp; Audience</div> <div class="field__items"> <div class="field__item"><a href="/taxonomy/term/13" hreflang="en">Family Medicine</a></div> <div class="field__item"><a href="/taxonomy/term/15" hreflang="en">Geriatrics</a></div> <div class="field__item"><a href="/taxonomy/term/21" hreflang="en">Internal Medicine</a></div> </div> </div> <!-- END OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--field-learning-activity--rss.html.twig * field--node--field-learning-activity--resource.html.twig * field--node--field-learning-activity.html.twig * field--node--resource.html.twig * field--field-learning-activity.html.twig * field--entity-reference.html.twig x field.html.twig --> <!-- BEGIN OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <div class="field field--name-field-learning-activity field--type-entity-reference field--label-above"> <div class="field__label">Learning Activity</div> <div class="field__items"> <div class="field__item"><a href="/node/750" hreflang="en">This Changed My Practice Articles</a></div> </div> </div> <!-- END OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--field-resource-thumbnail--rss.html.twig * field--node--field-resource-thumbnail--resource.html.twig * field--node--field-resource-thumbnail.html.twig * field--node--resource.html.twig * field--field-resource-thumbnail.html.twig * field--entity-reference.html.twig x field.html.twig --> <!-- BEGIN OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <div class="blazy blazy--field blazy--field-resource-thumbnail blazy--field-resource-thumbnail--rss field field--name-field-resource-thumbnail field--type-entity-reference field--label-hidden field__item" data-blazy=""> <!-- THEME DEBUG --> <!-- THEME HOOK: 'blazy' --> <!-- BEGIN OUTPUT from 'modules/contrib/blazy/templates/blazy.html.twig' --> <div data-b-token="b-02265181839" class="media media--blazy media--bundle--image media--image is-b-loading"> <!-- THEME DEBUG --> <!-- THEME HOOK: 'image' --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/image.html.twig' --> <img alt="XR in MedEd" decoding="async" class="media__element b-lazy" loading="lazy" data-src="/sites/default/files/images/Research%20-%20immersive%20technology%20in%20medical%20education%20-%20hero%20image%20%281%29_0.png" src="data:image/svg+xml;charset=utf-8,%3Csvg%20xmlns%3D&#039;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#039;%20viewBox%3D&#039;0%200%201%201&#039;%2F%3E" width="1600" height="900" /> <!-- END OUTPUT from 'core/themes/classy/templates/field/image.html.twig' --> </div> <!-- END OUTPUT from 'modules/contrib/blazy/templates/blazy.html.twig' --> </div> <!-- END OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--body--rss.html.twig * field--node--body--resource.html.twig * field--node--body.html.twig * field--node--resource.html.twig * field--body.html.twig x field--text-with-summary.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--text-with-summary.html.twig' --> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><p>By&nbsp;<a href="https://thischangedmypractice.com/author/madria01/" title="Posts by Dr. Mark Adrian">Dr. Mark Adrian</a>&nbsp;on April 19, 2023</p> <div>Receive 0.25 Mainpro+ or MOC Section 2* study credits per article. <p>&nbsp;</p> <hr /> <h3>Author</h3> <p>Dr. Mark Adrian (<a href="https://thischangedmypractice.com/bios/#maadrian" rel="noopener" target="_blank">biography, no disclosures</a>)</p> <h3>What care gaps or frequently asked questions I have noticed</h3> <p>Degenerative lumbar spinal stenosis is a radiological finding consisting of narrowing of the spinal canal. It occurs in older adults and if symptomatic, can result in pseudoclaudication (numbness, pain, and weakness) of the lower extremities.1&nbsp;Although the diagnosis is often straightforward, atypical presentations are common as are competing diagnoses. The treatment options are variable and are dependent on the patient’s goals, clinical presentation, and imaging findings.</p> <h3>Data that answers these questions or gaps</h3> <p>Degenerative changes of the spine (disc bulges, hypertrophy(enlargement) of the facet joints, and ligamentum flavum buckling) can result in narrowing of the spinal canal and compression of the spinal nerve roots, cauda equina, spinal veins, and arteries. Patients experiencing symptomatic stenosis can present with a spectrum of symptoms, ranging from minor to disabling symptoms associated with neurological deficits. Degenerative changes of the spine however are ubiquitous in older adults and the degree of stenosis on spinal imaging (even if severe) does not reliably correlate with the presence of symptoms or degree of symptoms.2</p> <p>Hip arthritis, vascular disorders, and peripheral nerve dysfunction are common in the older adult and can mimic symptoms of stenosis. Non-specific lower back pain is common in general population and spinal canal narrowing is common in asymptomatic older adults. Care therefore must be taken to distinguish the source of the symptoms (Tables 1 and 2).</p> <h3>What I recommend (practice tips)</h3> <ol> <li><a id="table"></a>Distinguish the source of the symptoms. A detailed history and physical are required to establish the diagnosis and rule out competing disorders. <ul> <li>The cardinal historical features of symptomatic stenosis are varying degrees of lower extremity symptoms of pain, heaviness, numbness, or stiffness that are&nbsp;triggered by walking&nbsp;(or&nbsp;standing) and&nbsp;relieved by sitting&nbsp;or&nbsp;forward flexed posture&nbsp;(shopping cart sign).</li> <li>Peripheral neuropathies generally present with non-positional burning symptoms in a stocking distribution.</li> <li>Physical examination is usually benign in patients with stenosis, but evaluation of the hips, distal pulses, and reflexes is necessary to rule out competing disorders.</li> </ul> <p>Table 1.&nbsp;Symptoms and causes</p> <table border="1"> <tbody> <tr> <td>PSEUDOCLAUDICATION</td> <td>VASCULAR CLAUDICATION</td> </tr> <tr> <td>Symptoms progress from back/buttock, distally to the lower extremities</td> <td>Symptoms progress from ankle/calf to proximally</td> </tr> <tr> <td>Variable limitation of walking distance (posture dependent)</td> <td>Consistent limitation of walking distance</td> </tr> <tr> <td>Climbing downstairs more symptomatic the upstairs</td> <td>Climbing upstairs more symptomatic than downstairs</td> </tr> <tr> <td>Cycling/stationary bike generally well tolerated</td> <td>Cycling/stationary bike exacerbate symptoms</td> </tr> </tbody> </table> <p><br /> Table 2.&nbsp;Signs and symptoms suggesting hip joint-mediated pain</p> <table border="1"> <tbody> <tr> <td>HIP JOINT-MEDIATED PAIN</td> </tr> <tr> <td>Pain with pivoting</td> </tr> <tr> <td>Pain with transitioning (getting in and out of the car or off the sofa)</td> </tr> <tr> <td>Pain with crossing legs or putting on shoes or socks</td> </tr> <tr> <td>Limp</td> </tr> <tr> <td>Painful and limited hip internal rotation on physical exam</td> </tr> </tbody> </table> </li> </ol> <ol start="2"> <li>Cross-sectional imaging (MRI or CT) is required to establish the diagnosis. Although MRI and CT scans provide complementary information, MRI defines the soft tissues, thecal sac, and nerve roots better than a CT scan. If contra-indicated or not available, a CT scan (from the L2 level to the sacrum) is usually satisfactory. Symptomatic stenosis is positional and MRI and CTs are static investigations, performed supine. To better evaluate for a dynamic spinal deformity that may be contributing to the stenosis, standing spinal x-rays (AP and Lateral) are also recommended, in addition to cross-sectional imaging.</li> <li>In the majority of cases, symptomatic spinal stenosis is a stable (or slowly progressive) condition that can be managed conservatively. Exercises that place the patient in a flexed position should be encouraged (e.g., cycling, skating, cross-country skiing, walking with walking poles, or rolling walker) and are generally tolerated. Exercise should be encouraged to maintain and optimize fitness and function. Instruction in a home exercise program by a physiotherapist in balance, postural exercises (particularly addressing thoracic kyphosis), and hip flexor and hamstring stretching can optimize the spinal biomechanics and potentially “open up” the spinal canal.</li> <li>In some patients with radicular pain, gabapentin can be helpful.<sup>3</sup></li> <li>Epidural steroid injections (ESI) performed in a hospital setting or facility that uses imaging guidance can provide short-term help (3–6 months) in many patients.<sup>4</sup>&nbsp;The degree and duration of the response to epidural injections however are unpredictable. If effective, ESIs can safely be organized on a recurring basis.</li> <li>Referral for a surgical opinion is indicated in patients who are severely disabled with advanced spinal stenosis on imaging, or in the rare cases of rapid progression with neurological deficits, or the development of bowel or bladder dysfunction (cauda equina syndrome).<sup>5</sup></li> </ol> <h3>Will you change your practice?</h3> <p><a class="btn btn-primary" href="https://thischangedmypractice.com/spinal-stenosis/#discussion" rel=" noopener" target="_blank" title="Vote and see how your colleagues are voting">Vote</a></p> <h3>References</h3> <ol> <li>Jensen RK, Jensen TS, Koes B, Hartvigsen J. Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis.&nbsp;Eur Spine J. 2020;29(9):2143-2163. doi:10.1007/s00586-020-06339-1 (View with&nbsp;<a href="https://www.cpsbc.ca/proxyauth/?url=https%3A%2F%2Fsearch.ebscohost.com%2Flogin.aspx%3Fdirect%3Dtrue%26AuthType%3Dcookie%2Cip%2Cuid%26db%3Dmdc%26AN%3D32095908%26site%3Deds-live%26scope%3Dsite" rel="noopener" target="_blank">CPSBC</a>&nbsp;or&nbsp;<a href="https://go.exlibris.link/3LF9Xzhq" rel="noopener" target="_blank">UBC</a>)</li> <li>Kreiner DS, Shaffer WO, Baisden JL, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update).&nbsp;Spine J. 2013;13(7):734-743. doi:10.1016/j.spinee.2012.11.059 (<a href="http://ezproxy.library.ubc.ca/login?url=https://dx.doi.org/10.1016/j.spinee.2012.11.059" rel="noopener" target="_blank">View</a>)</li> <li>Yaksi A, Ozgönenel L, Ozgönenel B. The efficiency of gabapentin therapy in patients with lumbar spinal stenosis.&nbsp;Spine (Phila Pa 1976). 2007;32(9):939-942. doi:10.1097/01.brs.0000261029.29170.e6 (View with&nbsp;<a href="https://www.cpsbc.ca/proxyauth/?url=https%3A%2F%2Fovidsp.ovid.com%2Fovidweb.cgi%3FT%3DJS%26CSC%3DY%26NEWS%3DN%26PAGE%3Dfulltext%26AN%3D00007632-200704200-00003%26LSLINK%3D80%26D%3Dovft" rel="noopener" target="_blank">CPSBC</a>&nbsp;or with&nbsp;<a href="https://go.exlibris.link/N0fgc6f4" rel="noopener" target="_blank">UBC</a>)</li> <li>Cohen SP, Greuber E, Vought K, Lissin D. Safety of Epidural Steroid Injections for Lumbosacral Radicular Pain: Unmet Medical Need.&nbsp;Clin J Pain. 2021;37(9):707-717. doi:10.1097/AJP.0000000000000963 (<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8360670/pdf/ajp-37-707.pdf" rel="noopener" target="_blank">View</a>)</li> <li>Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis.&nbsp;N Engl J Med. 2008;358(8):794-810. doi:10.1056/NEJMoa0707136 (<a href="https://www.nejm.org/doi/pdf/10.1056/NEJMoa0707136?" rel="noopener" target="_blank">View</a>)</li> </ol> <p><a class="btn btn-primary" href="https://thischangedmypractice.com/accreditation?pageid=7826&amp;pagetitle=Spinal+stenosis+%E2%80%94+practice+tips#Spinal%20stenosis%20%E2%80%94%20practice%20tips" rel=" noopener" target="_blank" title="Earn credits and let us know how you will change your practice">Complete a reflective activity</a></p> </div> </div> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--text-with-summary.html.twig' --> Fri, 21 Apr 2023 16:26:44 +0000 nina.z@ubc.ca 1469 at https://ubccpd.ca April 12, 2022: Living at Risk: ethical considerations when caring for older adults with diminished capacity https://ubccpd.ca/april-12-2022-living-risk-ethical-considerations-when-caring-older-adults-diminished-capacity <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--title--rss.html.twig * field--node--title--resource.html.twig x field--node--title.html.twig * field--node--resource.html.twig * field--title.html.twig * field--string.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--title.html.twig' --> <span class="field field--name-title field--type-string field--label-hidden">April 12, 2022: Living at Risk: ethical considerations when caring for older adults with diminished capacity</span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--title.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--uid--rss.html.twig * field--node--uid--resource.html.twig x field--node--uid.html.twig * field--node--resource.html.twig * field--uid.html.twig * field--entity-reference.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--uid.html.twig' --> <span class="field field--name-uid field--type-entity-reference field--label-hidden"> <!-- THEME DEBUG --> <!-- THEME HOOK: 'username' --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/user/username.html.twig' --> <span>abhiraj.virk@ubc.ca</span> <!-- END OUTPUT from 'core/themes/classy/templates/user/username.html.twig' --> </span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--uid.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--created--rss.html.twig * field--node--created--resource.html.twig x field--node--created.html.twig * field--node--resource.html.twig * field--created.html.twig * field--created.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--created.html.twig' --> <span class="field field--name-created field--type-created field--label-hidden">Thu, 04/14/2022 - 16:59</span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--created.html.twig' --> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=1131&amp;2=bookmark" token="zklb7hy5OrvQ4vevlsNXjBpgyj_q0K7zPxTH6uBdQ58"></drupal-render-placeholder> <!-- THEME DEBUG --> <!-- THEME HOOK: 'addtoany_standard' --> <!-- FILE NAME SUGGESTIONS: * addtoany-standard--node--resource.html.twig * addtoany-standard--node.html.twig x addtoany-standard.html.twig --> <!-- BEGIN OUTPUT from 'modules/contrib/addtoany/templates/addtoany-standard.html.twig' --> <span class="a2a_kit a2a_kit_size_32 addtoany_list" data-a2a-url="https://ubccpd.ca/april-12-2022-living-risk-ethical-considerations-when-caring-older-adults-diminished-capacity" data-a2a-title="April 12, 2022: Living at Risk: ethical considerations when caring for older adults with diminished capacity"><a class="a2a_dd" href="https://www.addtoany.com/share" data-tooltip="Share"><span 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--> <!-- BEGIN OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <div class="field field--name-field-link field--type-link field--label-hidden field__item"><a href="https://mediasite.audiovisual.ubc.ca/Mediasite/Play/e944d260ff5848a398573f1cee0ea87c1d">https://mediasite.audiovisual.ubc.ca/Mediasite/Play/e944d260ff5848a398573f1cee0…</a></div> <!-- END OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--body--rss.html.twig * field--node--body--resource.html.twig * field--node--body.html.twig * field--node--resource.html.twig * field--body.html.twig x field--text-with-summary.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--text-with-summary.html.twig' --> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><h4>April 12, 2022</h4> <p>By Dr. Jocelyn Chase</p> <p><a href="https://ubccpd.ca/sites/default/files/documents/Evaluation%20Form%20Apr%2012%2C%202022.pdf">Evaluation Form</a><br /> <a href="https://ubccpd.ca/sites/default/files/documents/DC%20at%20Risk%202022.pptx_.pdf">Powerpoint Slides</a></p> </div> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--text-with-summary.html.twig' --> Thu, 14 Apr 2022 16:59:19 +0000 abhiraj.virk@ubc.ca 1131 at https://ubccpd.ca Nov 28, 2017: Rheumatoid Arthritis https://ubccpd.ca/nov-28-2017-rheumatoid-arthritis <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--title--rss.html.twig * field--node--title--resource.html.twig x field--node--title.html.twig * field--node--resource.html.twig * field--title.html.twig * field--string.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--title.html.twig' --> <span class="field field--name-title field--type-string field--label-hidden">Nov 28, 2017: Rheumatoid Arthritis</span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--title.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--uid--rss.html.twig * field--node--uid--resource.html.twig x field--node--uid.html.twig * field--node--resource.html.twig * field--uid.html.twig * field--entity-reference.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--uid.html.twig' --> <span class="field field--name-uid field--type-entity-reference field--label-hidden"> <!-- THEME DEBUG --> <!-- THEME HOOK: 'username' --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/user/username.html.twig' --> <span>paul.butterwor…</span> <!-- END OUTPUT from 'core/themes/classy/templates/user/username.html.twig' --> </span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--uid.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--created--rss.html.twig * field--node--created--resource.html.twig x field--node--created.html.twig * field--node--resource.html.twig * field--created.html.twig * field--created.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--created.html.twig' --> <span class="field field--name-created field--type-created field--label-hidden">Tue, 11/28/2017 - 23:29</span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--created.html.twig' --> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=540&amp;2=bookmark" token="ErG-DGxSD5TzyRvntlODC-rpjHTdpGcGEKeZQJND2MQ"></drupal-render-placeholder> <!-- THEME DEBUG --> <!-- THEME HOOK: 'addtoany_standard' --> <!-- FILE NAME SUGGESTIONS: * addtoany-standard--node--resource.html.twig * addtoany-standard--node.html.twig x addtoany-standard.html.twig --> <!-- BEGIN OUTPUT from 'modules/contrib/addtoany/templates/addtoany-standard.html.twig' --> <span class="a2a_kit a2a_kit_size_32 addtoany_list" data-a2a-url="https://ubccpd.ca/nov-28-2017-rheumatoid-arthritis" data-a2a-title="Nov 28, 2017: Rheumatoid Arthritis"><a class="a2a_dd" href="https://www.addtoany.com/share" data-tooltip="Share"><span class="visually-hidden">Share</span><span class="CPD-Icon-Share"></span></a></span> <!-- END OUTPUT from 'modules/contrib/addtoany/templates/addtoany-standard.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--field-topic-audience--rss.html.twig * field--node--field-topic-audience--resource.html.twig * field--node--field-topic-audience.html.twig * field--node--resource.html.twig * field--field-topic-audience.html.twig * field--entity-reference.html.twig x field.html.twig --> <!-- BEGIN OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <div class="field field--name-field-topic-audience field--type-entity-reference field--label-above"> <div class="field__label">Topic &amp; Audience</div> <div class="field__items"> <div class="field__item"><a href="/taxonomy/term/13" hreflang="en">Family Medicine</a></div> <div class="field__item"><a href="/taxonomy/term/15" hreflang="en">Geriatrics</a></div> </div> </div> <!-- END OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--field-resource-thumbnail--rss.html.twig * field--node--field-resource-thumbnail--resource.html.twig * field--node--field-resource-thumbnail.html.twig * field--node--resource.html.twig * field--field-resource-thumbnail.html.twig * field--entity-reference.html.twig x field.html.twig --> <!-- BEGIN OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <div class="blazy blazy--field blazy--field-resource-thumbnail blazy--field-resource-thumbnail--rss field field--name-field-resource-thumbnail field--type-entity-reference field--label-hidden field__item" data-blazy=""> <!-- THEME DEBUG --> <!-- THEME HOOK: 'blazy' --> <!-- BEGIN OUTPUT from 'modules/contrib/blazy/templates/blazy.html.twig' --> <div data-b-token="b-85d821dd542" class="media media--blazy media--bundle--image media--image is-b-loading"> <!-- THEME DEBUG --> <!-- THEME HOOK: 'image' --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/image.html.twig' --> <img alt="" decoding="async" class="media__element b-lazy" loading="lazy" data-src="/sites/default/files/images/Rheumatoid%20Arthritis%20thumbnail.jpg" src="data:image/svg+xml;charset=utf-8,%3Csvg%20xmlns%3D&#039;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#039;%20viewBox%3D&#039;0%200%201%201&#039;%2F%3E" width="2560" height="1440" /> <!-- END OUTPUT from 'core/themes/classy/templates/field/image.html.twig' --> </div> <!-- END OUTPUT from 'modules/contrib/blazy/templates/blazy.html.twig' --> </div> <!-- END OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--field-link--rss.html.twig * field--node--field-link--resource.html.twig * field--node--field-link.html.twig * field--node--resource.html.twig * field--field-link.html.twig * field--link.html.twig x field.html.twig --> <!-- BEGIN OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <div class="field field--name-field-link field--type-link field--label-hidden field__item"><a href="https://learning.video.ubc.ca/id/0_dh9ym8rm?width=608&amp;height=402&amp;playerId=23448209">https://learning.video.ubc.ca/id/0_dh9ym8rm?width=608&amp;height=402&amp;playerId=23448…</a></div> <!-- END OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--body--rss.html.twig * field--node--body--resource.html.twig * field--node--body.html.twig * field--node--resource.html.twig * field--body.html.twig x field--text-with-summary.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--text-with-summary.html.twig' --> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><h4>November 28, 2017</h4> <p>Dr. Shahin Jamal</p> </div> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--text-with-summary.html.twig' --> Tue, 28 Nov 2017 23:29:35 +0000 paul.butterworth@ubc.ca 540 at https://ubccpd.ca Sept 12, 2017: Does Cyclobenzaprine work for pain; Should we use statins in the elderly https://ubccpd.ca/sept-12-2017-does-cyclobenzaprine-work-pain-should-we-use-statins-elderly <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--title--rss.html.twig * field--node--title--resource.html.twig x field--node--title.html.twig * field--node--resource.html.twig * field--title.html.twig * field--string.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--title.html.twig' --> <span class="field field--name-title field--type-string field--label-hidden">Sept 12, 2017: Does Cyclobenzaprine work for pain; Should we use statins in the elderly</span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--title.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--uid--rss.html.twig * field--node--uid--resource.html.twig x field--node--uid.html.twig * field--node--resource.html.twig * field--uid.html.twig * field--entity-reference.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--uid.html.twig' --> <span class="field field--name-uid field--type-entity-reference field--label-hidden"> <!-- THEME DEBUG --> <!-- THEME HOOK: 'username' --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/user/username.html.twig' --> <span>paul.butterwor…</span> <!-- END OUTPUT from 'core/themes/classy/templates/user/username.html.twig' --> </span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--uid.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--created--rss.html.twig * field--node--created--resource.html.twig x field--node--created.html.twig * field--node--resource.html.twig * field--created.html.twig * field--created.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--created.html.twig' --> <span class="field field--name-created field--type-created field--label-hidden">Tue, 09/12/2017 - 23:44</span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--created.html.twig' --> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=546&amp;2=bookmark" token="J-722NUUbodRVlTVigu2lEtx5OOLpzQCJ2kP1nkuZpc"></drupal-render-placeholder> <!-- THEME DEBUG --> <!-- THEME HOOK: 'addtoany_standard' --> <!-- FILE NAME SUGGESTIONS: * addtoany-standard--node--resource.html.twig * addtoany-standard--node.html.twig x addtoany-standard.html.twig --> <!-- BEGIN OUTPUT from 'modules/contrib/addtoany/templates/addtoany-standard.html.twig' --> <span class="a2a_kit a2a_kit_size_32 addtoany_list" data-a2a-url="https://ubccpd.ca/sept-12-2017-does-cyclobenzaprine-work-pain-should-we-use-statins-elderly" data-a2a-title="Sept 12, 2017: Does Cyclobenzaprine work for pain; Should we use statins in the elderly"><a class="a2a_dd" href="https://www.addtoany.com/share" data-tooltip="Share"><span class="visually-hidden">Share</span><span class="CPD-Icon-Share"></span></a></span> <!-- END OUTPUT from 'modules/contrib/addtoany/templates/addtoany-standard.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--field-topic-audience--rss.html.twig * field--node--field-topic-audience--resource.html.twig * field--node--field-topic-audience.html.twig * field--node--resource.html.twig * field--field-topic-audience.html.twig * field--entity-reference.html.twig x field.html.twig --> <!-- BEGIN OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <div class="field field--name-field-topic-audience field--type-entity-reference field--label-above"> <div class="field__label">Topic &amp; Audience</div> <div class="field__items"> <div class="field__item"><a href="/taxonomy/term/13" hreflang="en">Family Medicine</a></div> <div class="field__item"><a href="/taxonomy/term/15" hreflang="en">Geriatrics</a></div> </div> </div> <!-- END OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--field-resource-thumbnail--rss.html.twig * field--node--field-resource-thumbnail--resource.html.twig * field--node--field-resource-thumbnail.html.twig * field--node--resource.html.twig * field--field-resource-thumbnail.html.twig * field--entity-reference.html.twig x field.html.twig --> <!-- BEGIN OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <div class="blazy blazy--field blazy--field-resource-thumbnail blazy--field-resource-thumbnail--rss field field--name-field-resource-thumbnail field--type-entity-reference field--label-hidden field__item" data-blazy=""> <!-- THEME DEBUG --> <!-- THEME HOOK: 'blazy' --> <!-- BEGIN OUTPUT from 'modules/contrib/blazy/templates/blazy.html.twig' --> <div data-b-token="b-f006d0abeb6" class="media media--blazy media--bundle--image media--image is-b-loading"> <!-- THEME DEBUG --> <!-- THEME HOOK: 'image' --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/image.html.twig' --> <img alt="" decoding="async" class="media__element b-lazy" loading="lazy" data-src="/sites/default/files/images/Cyclobenzaprine%20thumbnail.jpg" src="data:image/svg+xml;charset=utf-8,%3Csvg%20xmlns%3D&#039;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#039;%20viewBox%3D&#039;0%200%201%201&#039;%2F%3E" width="2560" height="1440" /> <!-- END OUTPUT from 'core/themes/classy/templates/field/image.html.twig' --> </div> <!-- END OUTPUT from 'modules/contrib/blazy/templates/blazy.html.twig' --> </div> <!-- END OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--field-link--rss.html.twig * field--node--field-link--resource.html.twig * field--node--field-link.html.twig * field--node--resource.html.twig * field--field-link.html.twig * field--link.html.twig x field.html.twig --> <!-- BEGIN OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <div class="field field--name-field-link field--type-link field--label-hidden field__item"><a href="https://learning.video.ubc.ca/id/0_2kzbnq5h?width=608&amp;height=402&amp;playerId=23448209">https://learning.video.ubc.ca/id/0_2kzbnq5h?width=608&amp;height=402&amp;playerId=23448…</a></div> <!-- END OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--body--rss.html.twig * field--node--body--resource.html.twig * field--node--body.html.twig * field--node--resource.html.twig * field--body.html.twig x field--text-with-summary.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--text-with-summary.html.twig' --> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><h4>September 12, 2017</h4> <p>Dr. Aaron Tejani</p> </div> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--text-with-summary.html.twig' --> Tue, 12 Sep 2017 23:44:00 +0000 paul.butterworth@ubc.ca 546 at https://ubccpd.ca May 30, 2017: Choosing Wisely - Long Term Care Homes https://ubccpd.ca/may-30-2017-choosing-wisely-long-term-care-homes <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--title--rss.html.twig * field--node--title--resource.html.twig x field--node--title.html.twig * field--node--resource.html.twig * field--title.html.twig * field--string.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--title.html.twig' --> <span class="field field--name-title field--type-string field--label-hidden">May 30, 2017: Choosing Wisely - Long Term Care Homes</span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--title.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--uid--rss.html.twig * field--node--uid--resource.html.twig x field--node--uid.html.twig * field--node--resource.html.twig * field--uid.html.twig * field--entity-reference.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--uid.html.twig' --> <span class="field field--name-uid field--type-entity-reference field--label-hidden"> <!-- THEME DEBUG --> <!-- THEME HOOK: 'username' --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/user/username.html.twig' --> <span>paul.butterwor…</span> <!-- END OUTPUT from 'core/themes/classy/templates/user/username.html.twig' --> </span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--uid.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--created--rss.html.twig * field--node--created--resource.html.twig x field--node--created.html.twig * field--node--resource.html.twig * field--created.html.twig * field--created.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--node--created.html.twig' --> <span class="field field--name-created field--type-created field--label-hidden">Tue, 05/30/2017 - 23:51</span> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--node--created.html.twig' --> <drupal-render-placeholder callback="flag.link_builder:build" arguments="0=node&amp;1=550&amp;2=bookmark" token="zfHj4pB8e9O-_w_EzR7-DUVU4_gqv7VIuReMCmo60xo"></drupal-render-placeholder> <!-- THEME DEBUG --> <!-- THEME HOOK: 'addtoany_standard' --> <!-- FILE NAME SUGGESTIONS: * addtoany-standard--node--resource.html.twig * addtoany-standard--node.html.twig x addtoany-standard.html.twig --> <!-- BEGIN OUTPUT from 'modules/contrib/addtoany/templates/addtoany-standard.html.twig' --> <span class="a2a_kit a2a_kit_size_32 addtoany_list" data-a2a-url="https://ubccpd.ca/may-30-2017-choosing-wisely-long-term-care-homes" data-a2a-title="May 30, 2017: Choosing Wisely - Long Term Care Homes"><a class="a2a_dd" href="https://www.addtoany.com/share" data-tooltip="Share"><span class="visually-hidden">Share</span><span class="CPD-Icon-Share"></span></a></span> <!-- END OUTPUT from 'modules/contrib/addtoany/templates/addtoany-standard.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--field-topic-audience--rss.html.twig * field--node--field-topic-audience--resource.html.twig * field--node--field-topic-audience.html.twig * field--node--resource.html.twig * field--field-topic-audience.html.twig * field--entity-reference.html.twig x field.html.twig --> <!-- BEGIN OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <div class="field field--name-field-topic-audience field--type-entity-reference field--label-above"> <div class="field__label">Topic &amp; Audience</div> <div class="field__items"> <div class="field__item"><a href="/taxonomy/term/13" hreflang="en">Family Medicine</a></div> <div class="field__item"><a href="/taxonomy/term/15" hreflang="en">Geriatrics</a></div> </div> </div> <!-- END OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--field-resource-thumbnail--rss.html.twig * field--node--field-resource-thumbnail--resource.html.twig * field--node--field-resource-thumbnail.html.twig * field--node--resource.html.twig * field--field-resource-thumbnail.html.twig * field--entity-reference.html.twig x field.html.twig --> <!-- BEGIN OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <div class="blazy blazy--field blazy--field-resource-thumbnail blazy--field-resource-thumbnail--rss field field--name-field-resource-thumbnail field--type-entity-reference field--label-hidden field__item" data-blazy=""> <!-- THEME DEBUG --> <!-- THEME HOOK: 'blazy' --> <!-- BEGIN OUTPUT from 'modules/contrib/blazy/templates/blazy.html.twig' --> <div data-b-token="b-0bc31d453d8" class="media media--blazy media--bundle--image media--image is-b-loading"> <!-- THEME DEBUG --> <!-- THEME HOOK: 'image' --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/image.html.twig' --> <img alt="" decoding="async" class="media__element b-lazy" loading="lazy" data-src="/sites/default/files/images/Long%20Term%20Care%20Homes%20thumbnail.jpg" src="data:image/svg+xml;charset=utf-8,%3Csvg%20xmlns%3D&#039;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#039;%20viewBox%3D&#039;0%200%201%201&#039;%2F%3E" width="2560" height="1440" /> <!-- END OUTPUT from 'core/themes/classy/templates/field/image.html.twig' --> </div> <!-- END OUTPUT from 'modules/contrib/blazy/templates/blazy.html.twig' --> </div> <!-- END OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--field-link--rss.html.twig * field--node--field-link--resource.html.twig * field--node--field-link.html.twig * field--node--resource.html.twig * field--field-link.html.twig * field--link.html.twig x field.html.twig --> <!-- BEGIN OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <div class="field field--name-field-link field--type-link field--label-hidden field__item"><a href="https://learning.video.ubc.ca/id/0_wka0tisk?width=608&amp;height=402&amp;playerId=23448209">https://learning.video.ubc.ca/id/0_wka0tisk?width=608&amp;height=402&amp;playerId=23448…</a></div> <!-- END OUTPUT from 'themes/custom/de_theme/templates/field/field.html.twig' --> <!-- THEME DEBUG --> <!-- THEME HOOK: 'field' --> <!-- FILE NAME SUGGESTIONS: * field--body--rss.html.twig * field--node--body--resource.html.twig * field--node--body.html.twig * field--node--resource.html.twig * field--body.html.twig x field--text-with-summary.html.twig * field.html.twig --> <!-- BEGIN OUTPUT from 'core/themes/classy/templates/field/field--text-with-summary.html.twig' --> <div class="clearfix text-formatted field field--name-body field--type-text-with-summary field--label-hidden field__item"><h4>May 30, 2017</h4> <p>Dr. Duncan Etches</p> </div> <!-- END OUTPUT from 'core/themes/classy/templates/field/field--text-with-summary.html.twig' --> Tue, 30 May 2017 23:51:05 +0000 paul.butterworth@ubc.ca 550 at https://ubccpd.ca