Gouty Toes and Rosacea Nose: Does Enlightenment-Era Art Suggest a Correlation?

Gout, one of the most ancient documented diseases in history, has long captivated artists, yielding a rich collection of artworks. This interest peaked during the Enlightenment era in Europe, a time marked by a surge in gout cases alongside rising wealth, consumerism, and subsequent increased public access to artists. This editorial aims to highlight an intriguing observation of a novel association within several Enlightenment-era paintings depicting individuals suffering from gout and often also portraying the distinctive red noses and cheeks seen in patients with rosacea. Traditionally, both rosacea and gout have been classified as localized inflammatory diseases. However, recent studies challenge this conventional categorization, suggesting that these conditions might be components of systemic inflammatory syndromes. Despite the widespread prevalence of these conditions, their potential interconnectedness and shared pathophysiological pathways remain unexplored. Therefore, the representation of gout and rosacea in historical art could extend beyond mere artistic interest, offering a unique and critical perspective for contemporary medical research.

Emergency Physicians' Experience-Remuneration (E-R) Mismatch: A Canadian Healthcare Irony.

Conventional wisdom suggests that in almost every profession, the most experienced and educated employees are remunerated at a higher rate than the less experienced ones. For example, new-graduate hires most commonly start at the bottom of the pay scale. No profession could reflect the importance of experience and the need for mastery of skills more than emergency medicine (EM), where a split-second decision could mean the difference between life and death. In Canada, however, EM physicians are remunerated as per a common pay scale that does not consider the length of their education, training, or years of practice. Such an unfair experience-remuneration mismatch (E-R mismatch) could lead to job dissatisfaction, burnout, and switching to other specialties. Given the current EM physician shortage in Canada, the E-R mismatch among such physicians could negatively impact patient care and the health system as a whole and prolong the already long wait times. The aim of this editorial is to shed light on this flaw in the Canadian healthcare system and lead to change toward a fair pay system. The creation of a professional and experience-based hierarchy among Canadian EM physicians should be considered a matter of urgency for those developing health-related legislation.

CUT BARB (an Acronym for Fishhook Injuries): Illustrated by the Extraction of a Fishhook From the Auricle Using the Advance-and-Cut Technique.

Fishhook injuries are common within fishing communities. The embedded barb in the tissue prevents the hook from being pulled out until the barb is disengaged. Although the majority of injuries are minor, occasionally fishhook injuries can be serious. Herein, the author developed a novel acronym: CUT BARB (C: consult immediately for critical areas, U: underlying structure injury, T: tetanus immunization, B: barb shape and size, A: antibiotic prophylaxis, R: radiology imaging, B: bait or lure fragments). The aim of the acronym is to aid emergency department (ED) physicians in conducting a comprehensive clinical assessment and reaching a prompt therapeutic decision for embedded fishhook injuries. Additionally, the author is demonstrating the technique via the extraction of a medium-sized single-barbed fishhook embedded in the left auricle of a 60-year-old female using the advance-and-cut technique.

MACE in the Race: A Canadian Perspective on Major Adverse Cardiac Events (MACE) During Running.

The recent tragic deaths of two fit and healthy Canadian physicians during running have shocked the whole Canadian medical community. In order to prevent such loss of precious human lives, the paradox of dying during a life-prolonging activity begets further contemplation and investigation on whether we have been missing something in assessing the risk of major cardiovascular adverse events (MACE) in fit individuals during long-distance running. Additionally, knowing the potential, yet the rare fatal risk of running, physicians are obliged to disclose that fatal risk while prescribing exercise to their patients according to the Supreme Court of Canada Ruling. Further research is urgently needed.

Unified Anatomical Explanation of Diagonal Earlobe Creases, Preauricular Creases, and Paired Creases of the Helix.

Three types of ear creases have been described in the medical literature in association with several cardiovascular and metabolic disorders: diagonal earlobe creases (DELCs) (Frank's sign), preauricular vertical creases, and paired ear creases of the helix (PECH). The exact mechanism of development of such creases, as well as an explanation of their association with cardiometabolic disorders, remains unclear. Herein, the author provides a suggested unified mechanism of development of all three types of auricular creases. In addition, an anatomical explanation linking the associated cardiometabolic disorders and the three types of ear creases to the common culprit of facial visceral adiposity will be given.

Bitemporal Obesity: An Overlooked Sign of Visceral Obesity?

With increasing rates of morbidity and mortality associated with visceral obesity, as well as its related cardiometabolic disorders, physical findings that aid in diagnosing patients at risk for such conditions are extremely useful. This brief report introduces the novel facial physical sign of bitemporal obesity, which the author observed in a patient and suggests to be associated with visceral obesity.

Gestational potential space hypothesis: Evolutionary explanation of human females body fat redistribution.

Homo sapiens, as well as other primates, developed the evolutionary advantage of storing excess energy as body fat, primarily in the readily accessible visceral fat compartment when food is plentiful for use during scarcity. However, uniquely to female humans, a second transient dimorphic phenotypic change begins at menarche and is reversed by menopause. It is the diversion of visceral fat stores from the abdominal cavity to the gluteofemoral region. The evolutionary purpose for this remains unclear. The author proposes the gestational potential space hypothesis: that such fat diversion is for the reproductive purpose of increasing the potential abdominal space available for gestation and reducing the intra-abdominal pressure. This hypothesis is supported by the basic laws of physics and increased rates of maternal and fetal complications experienced by those with visceral adiposity.

Caloric Restriction and Remission of Severe Chronic Spontaneous Urticaria: An Autobiographical Case Report.

In this autobiographical case report, the physician-author-patient is documenting the remission of his own severe chronic spontaneous urticaria (CSU) in response to caloric restriction and subsequent weight loss. To my knowledge, this is the first reported case of CSU remission secondary to weight loss in the literature. CSU is a common debilitating pruritic skin condition that carries a significant economic and psychological burden. Currently, the mainstay of CSU treatment is symptom control, rather than seeking to achieve complete remission. Despite some recent retrospective studies reporting an association between obesity and CSU, there is a paucity of interventional research testing the impact of obesity management on CSU. The case reported herein highlights the need for research able to test the hypothesized association between obesity, particularly visceral obesity, and CSU.

Frank's Sign in Polycystic Ovary Syndrome and Sideburn Adiposity: A Case Report and Illustrated Hypothesis.

The diagnosis of polycystic ovary syndrome (PCOS) remains uniquely dependent on physical examination signs. Diagonal earlobe crease (DELC) also referred to as "Frank's sign, has been associated with several cardiometabolic disorders with further investigations reporting that its occurrence was more prevalent among aging men and thought to a sign of aging skin. However, there is no clear mechanism of development or rationale behind such associations. The author is reporting a novel association between Frank's sign and PCOS in a 23-year-old female patient. The presence of the DELC in young women could alert clinicians to the need to further investigate a diagnosis of PCOS. The author is providing an accompanying hypothesis to suggest possible common pathogenesis that links the two to visceral adiposity of the face.

Sideburns Obesity Syndrome: Is Sideburn Fat the Window to the Heart?

Despite significant advancements in cardiovascular diagnostic technology, physical examination signs remain credible diagnostic indicators of coronary artery disease. Here, we report a case of a 50-year-old male patient with premature coronary artery disease associated with a novel physical sign of bilateral symmetrical bulging of the sideburn areas of the face. The sideburns correspond anatomically to the buccal fat pad which is composed of visceral adipose tissue. Visceral obesity is an established risk factor for cardiovascular disease, independent of total body weight, with some suggestion of a causal association. Therefore, isolated buccal visceral obesity (sideburn obesity syndrome) could be a marker for premature coronary artery disease.

Non-alcoholic fatty kidney disease (NAFKD): A novel disease that explains the etiology of hyperuricemia and gout in metabolic syndrome.

Gout is the most common inflammatory arthritis in adults. It is causally associated with intraarticular deposition of monosodium urate crystals in hyperuricemia. The commonest pathogenesis is renal under-excretion of urate in metabolic syndrome. Despite being the commonest type, the exact etiology of hyperuricemia in metabolic syndrome remains unclear. Historically, common gout was found at increased rates in affluent men, earning its name the 'disease of kings'. It is also rare in premenopausal women. The authors hypothesize that the etiology of common gout is a novel condition termed non-alcoholic fatty kidney disease (NAFKD). The hypothesis offers an explanation of the two prerequisites necessary for the development of NAFKD (that leads to hyperuricemia and gout) as follows: 1) sustained positive energy balance and 2) male sex hormone predominance state. The hypothesis presented herein could guide the prevention and early detection of hyperuricemia and support curative modalities.