Toronto Notes 2022

1597 Pages·2022·94.56 MB·english

by  Lytvyn and Qazi

TORONTO NOTES
CCOOMMPPRREEHHEENNSSIIVVEE MMEEDDIICCAALL RREEFFEERREENNCCEE
AANNDD AA RREEVVIIEEWW FFOORR MMCCCCQQEE
Editors-in-Chief • Yuliya Lytvyn & Maleeha A. Qazi
Associate Editors, Primary • Ming Li & Jacqui van Warmerdam
Associate Editors, Medicine • Thomas Chang & Andreea Damian
Associate Editors, Surgery • Winston W. Li & Ashmita Singh
Production Managers • Anders Erickson & Jennifer Parker

TORONTO NOTES
2022
Comprehensive Medical Reference
and a Review for the Medical Council of Canada Qualifying Exam
(MCCQE)
38th Edition
Editors-in-Chief:
Yuliya Lytvyn & Maleeha A. Qazi
Toronto Notes for Medical Students, Inc.
Toronto, Ontario, Canada
2 Editorial Toronto Notes 2022
Thirty-eighth Edition
Copyright © 2022 – Toronto Notes for Medical Students, Inc. Toronto, Ontario, Canada
Typeset and production by Type & Graphics Inc.
ISBN 978-1-927363-94-2 (38th ed.)
All rights reserved. Printed in Toronto, Ontario, Canada. Toronto Notes 2022 is provided for the sole use of the purchaser.
It is made available on the condition that the information contained herein will not be sold or photocopied. No part of this
publication may be used or reproduced in any form or by any means without prior written permission from the publisher.
Every effort has been made to obtain permission for all copyrighted material contained herein. Previous editions copyright
© 1985 to 2022.
Cover illustration: Ariadna Villalbi and Aimy Wang
Illustrations: Biomedical Communications, University of Toronto
Notice:
THIS PUBLICATION HAS NOT BEEN AUTHORED, REVIEWED, OR OTHERWISE SUPPORTED BY THE
MEDICAL COUNCIL OF CANADA NOR DOES IT RECEIVE ENDORSEMENT BY THE MEDICAL COUNCIL AS
REVIEW MATERIAL FOR THE MCCQE PART I. THIS PUBLICATION HAS NOT BEEN AUTHORED, REVIEWED,
OR OTHERWISE SUPPORTED BY THE NATIONAL BOARD OF MEDICAL EXAMINERS U.S.A. NOR DOES IT
RECEIVE ENDORSEMENT BY THE NATIONAL BOARD AS REVIEW MATERIAL FOR THE USMLE.
The editors of this edition have taken every effort to ensure that the information contained herein is accurate and conforms
to the standards accepted at the time of publication. However, due to the constantly changing nature of the medical
sciences and the possibility of human error, the reader is encouraged to exercise individual clinical judgement and consult
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3 Editorial Toronto Notes 2022
Dedicated to all the many contributors and supporters of Toronto Notes,
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Note:
Many of you have wondered about the Toronto Notes logo, which is based on the rod of Asclepius, the Greek god of
medicine. The rod of Asclepius consists of a single serpent entwined around a staff. This icon symbolizes both rebirth, by
way of a snake shedding its skin, and also authority, by way of the staff.
In ancient Greek mythology, Asclepius was the son of Apollo and a skilled practitioner of medicine who learned
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The rod of Asclepius is at times confused with the caduceus, or wand, of Hermes, a staff entwined with two serpents
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As you may have guessed, our logo uses the rod of Asclepius that is modified to also resemble the CN Tower – our way
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Thomas O’Brien, MD
Class of 2009, M.D. Program, University of Toronto
4 Editorial Toronto Notes 2022
Preface – From the Editors
Dear reader, The 2022 edition features substantial content revisions to
the text, figures, and graphics of all 32 chapters, following a
We are grateful to present Toronto Notes 2022 to you. This comprehensive review by our student and faculty editorial
edition is the product of an exceptional effort from the team. Up-to-date, evidence-based medicine studies are also
hundreds of editors and contributors who worked tirelessly summarized in highlighted boxes throughout the text. This year,
with us as we navigated through the challenges posed by the one of our priorities was to include a table of often discussed
on-going COVID-19 pandemic. Together, we have created Landmark Clinical Trials in every chapter. Alongside our
the thirty-eighth edition of Toronto Notes, thus continuing textbook-wide revisions, the Cardiology and Cardiac Surgery,
our organization’s rich tradition of providing an up-to-date, the Geriatric Medicine, and the Infectious Diseases chapters
comprehensive, and concisely written medical resource to our have received substantial expansions to increase their utility
readers. in practice. In addition to content updates, the Toronto Notes
2022 Clinical Handbook chapters now include a section on Do
Thirty-eight years ago, Toronto Notes began as a humble Not Miss Diagnoses to guide your learning during clerkship
initiative, with medical students from the University of Toronto rotations. Toronto Notes prioritizes cultural sensitivity, health
collecting and circulating their notes. Nearly four decades later equity, and strives for accurate representation of our vibrant and
– with annual editions and an ever-expanding vision – Toronto diverse communities. To enhance our team’s editorial lens on
Notes has become one of the most trusted medical review texts; these concepts while editing the chapters, training was provided
it is a resource that is cherished by trainees and physicians by the Anti-Racism and Cultural Diversity Office and Office of
throughout Canada and around the world. Inclusion & Diversity at the University of Toronto.
The Toronto Notes for Medical Students Inc. is a nonprofit We sincerely thank each of our 207 student editors and 101 faculty
corporation whose mission is to provide a trusted medical editors, whose meticulous revisions and shared dedication to
resource in order to give back to our community. This year, the bettering of this text has helped make Toronto Notes 2022
while our global community continued their fight for racial possible. We have learned so much from leading this team, and
justice and battled the COVID-19 pandemic, locally we were are especially grateful to everyone for contributions to Toronto
also devastated by the loss of our colleague, Mohammad Asadi- Notes with challenging time commitments and demands. We
Lari, an MD-PhD student at the Temerty Faculty of Medicine, thank our incredible Associate Editors – Ming Li, Jacqui van
who was a passenger on the Ukrainian Airlines Flight 752 that Warmerdam, Thomas Chang, Andreea Damian, Winston Li
crashed on January 8th, 2021. As a country, we also reeled from and Ashmita Singh – for their tireless leadership, exceptional
the discovery of unmarked graves across Residential Schools in organization, and wonderful teamwork. We, and the success of
Canada, reminding us once again of the discrimination, injustice, this edition, lean on their shoulders. We also thank our Clinical
and racism Indigenous Peoples have faced and continue to Handbook Editors – Benjamin Baker, Cathy Huilin Lu, and
face. Keeping in line with our values and community needs, Chunyi Christie Tan—for their exceptional editorial leadership
all proceeds from Toronto Notes sales are directly donated to and spearheading the work on this resource. We are grateful
support both global and local initiatives. This year we have to our Production Managers – Jennifer Parker and Anders
contributed to a new program by the Community of Support at Erickson – who make Toronto Notes’ operations a reality with
the University of Toronto, the Indigenous Student Mentorship their daily work. We owe a great deal of gratitude to the Editors-
Fund, to support Indigenous students in gaining mentorship in-Chief of the 2021 edition – Megan Drupals and Matthaeus
for careers in medicine. Toronto Notes also supported the Black Ware – for their continued guidance over the past two years.
Health Alliance with their African, Caribbean, Black (ACB) Lastly, we thank our longtime partners at Type & Graphics Inc
COVID-19 Public Awareness Initiative – a collaboration with – especially our backbone, Enrica Aguilera and Maria Garcia —
the Black Medical Students Association of Canada, and the for their years of support and excellent work producing Toronto
Black Youth Helpline. Among other initiatives, we have also Notes 2022. Finally, we thank you for supporting our initiative
supported U of T Medicine class activities, student scholarships by purchasing and reading our product. We hope that you will
and bursaries (such as the Mohammad and Zeynab Asadi-Lari find Toronto Notes 2022 to be a useful companion on your
award), our Daffy annual musical fundraiser for the Canadian medical journey, both now and for years to come.
Cancer Society, and the entirety of our (over twenty-five)
student-led outreach programs that seek to enrich lives in the
community.
Sincerely,
This is why we, and all the members of our U of T team, gladly
dedicated so many hours toward this immensely involved Yuliya Lytvyn, PhD, MD student
project. As our valued reader, we thank you for your honest Maleeha A. Qazi, PhD, MD student
and vital financial contribution through your purchase of our Editors-in-Chief, Toronto Notes 2022
textbook. Each book sold makes an important difference.
5 Editorial Toronto Notes 2022
Acknowledgements
We would like to acknowledge the exceptional work of all previous Toronto Notes (formerly MCCQE Notes)
Editors-in-Chief and their editorial teams. The 38th edition of this text was made possible with their contributions.
2021 (37th ed.): Megan Drupals and Matthaeus Ware
2020 (36th ed.): Sara Mirali and Ayesh Seneviratne
2019 (35th ed.): Taraneh (Tara) Tofighi and Mark Shafarenko
2018 (34th ed.): Tina Binesh Marvasti and Sydney McQueen
2017 (33rd ed.): Jieun Kim and Ilya Mukovozov
2016 (32nd ed.): Zamir Merali and Justin D. Woodfine
2015 (31th ed.): Justin Hall and Azra Premji
2014 (30th ed.): Miliana Vojvodic and Ann Young
2013 (29th ed.): Curtis Woodford and Christopher Yao
2012 (28th ed.): Jesse M. Klostranec and David L. Kolin
2011 (27th ed.): Yingming Amy Chen and Christopher Tran
2010 (26th ed.): Simon Baxter and Gordon McSheffrey
2009 (25th ed.): Sagar Dugani and Danica Lam
2008 (24th ed.): Rebecca Colman and Ron Somogyi
2007 (23rd ed.): Marilyn Heng and Joseph Ari Greenwald
2006 (22nd ed.): Carolyn Jane Shiau and Andrew Jonathan Toren
2005 (21st ed.): Blair John Normand Leonard and Jonathan Chi-Wai Yeung
2004 (20th ed.): Andrea Molckovsky and Kashif S. Pirzada
2003 (19th ed.): Prateek Lala and Andrea Waddell
2002 (18th ed.): Neety Panu and Sunny Wong
2001 (17th ed.): Jason Yue and Gagan Ahuja
2000 (16th ed.): Marcus Law and Brian Rotenberg
1999 (15th ed.): Sofia Ahmed and Matthew Cheung
1998 (14th ed.): Marilyn Abraham and M Appleby
1997 (13th ed.): William Harris and Paul Kurdyak
1996 (12th ed.): Michael B. Chang and Laura J. Macnow
1995 (11th ed.): Ann L. Mai and Brian J. Murray
1994 (10th ed.): Kenneth Pace and Peter Ferguson
1993 (9th ed.): Joan Cheng and Russell Goldman
1992 (8th ed.): Gideon Cohen-Nehemia and Shanthi Vasudevan
All former Chief Editors from 1991 (7th ed.) to 1985 (1st ed.)
6 Editorial Toronto Notes 2022
Student Contributors
Editors-in-Chief Production Managers Clinical Handbook Editors
Yuliya Lytvyn Anders Erickson Benjamin Baker
Maleeha A. Qazi Jennifer Parker Cathy Huilin Lu
Chunyi Christie Tan
Communications Managers Online Content Managers Copyright Managers
Michelle Lim Alex Beomju Bak Wei Fang Dai
Grace Xiaoxi Zhou Jeffrey Lam Shin Cheung Saba Manzoor
Huaqi Li Eric Plitman
Rayoun Ramendra
BMC Production Editors
Ariadna Pomada Villalbi
Aimy Wang
BMC ILLUSTRATORS
Sherry An Jennifer Gu Cassie Hillock-Watling Min Jee Kim Willow Yang
Jennifer Barolet Mimi Guo Alexandra Ho Abeeshan Selvabaskaran Amy Zhang
PRIMARY
Associate Editors EBM Editors
Ming Li Sarah House
Jacqui van Warmerdam Vrati Mehra
CHAPTER EDITORS
Ethical, Legal, and Clinical Pharmacology Family Medicine Paediatrics Psychiatry
Organizational Medicine Mark Khoury Anson Cheung Melanie El Hafid Ava Abraham
Happy Inibhunu Sahar Zarabi Cathy Huilin Lu Anna Jiang Jeanette Hui
Andrew Lagrotteria Amanda Poxon Shakiba Khalkhali Ard- Fiona Moloney
Joseph Kates Rose Dermatology Emily Tam estani
Cindy Na-Young Kang Benjamin Martinez Public Health and
Anesthesia Maria Leis Medical Genetics Preventive Medicine
Carlos Khalil Sara Mirali Yaanu Jeyakumar Palliative Medicine Glen Katsnelson
Isabelle Laksono Nicholas Light Brian Hyung Caleb Tackey
Evan Tang Emergency Medicine Jack Su
Yousuf Ahmed Medical Imaging
Danny Ma Jeffrey Lam Shin Cheung
Jackie Tsang Sabrina Fitzgerald
Kenneth Williams
COPY EDITORS
Ethical, Legal, and Clinical Pharmacology Family Medicine Paediatrics Psychiatry
Organizational Medicine Brian Hyung Leah Bennett Zachary Blatman Jude Sanon
Sahibjot Grewal Robert Lao Tsz Ying So Noel Kim Brian Serapio
Zuhal Mohmand
Dermatology Medical Genetics Palliative Medicine Public Health and
Anesthesia Emma Price Brian Hyung Khizar Abid Preventive Medicine
Matthew McGarr Adrian Witol Robert Lao Kaylee Sohng Zuhal Mohmand
Adanna Odunze Max Solish
Emergency Medicine Medical Imaging Matthaeus Ware
Maria Leis Raza Syed
Mitchell Segal Brian Tsang
7 Editorial Toronto Notes 2022
Student Contributors
MEDICINE
Associate Editors EBM Editors
Thomas Chang Peter Nakhla
Andreea Damian Kyle Seigel
CHAPTER EDITORS
Cardiology and Cardiac Gastroenterology Hematology Nephrology Respirology
Surgery Tedi Hoxha Vanessa Arciero Anshika Jain Kevin Jia Qi Chen
Ahmed Abdelaal Rohit Jogendran Justin Brunet Tiange Li Jenny Sue Hyun Cho
Nitish K. Dhingra Jocelyn Price Reid Gallant Jenny Liao
Lina Elfaki Nathalie Loeb Neurology
Abdullah Malik Geriatric Medicine Juweiriya Ahmed Rheumatology
Dustin Tanaka Jim TC Chen Infectious Diseases Moriam Ahmed Sabrina Campbell
Maggie Li Rawaan Elsawi Keshav Narang Dario Ferri
Endocrinology Dorothy Qian Yici (Andrea) Liu
Lindsey Hatcher Arjuna Maharaj
Kyung Young (Peter) Kim
Alicia Serrano
COPY EDITORS
Cardiology and Cardiac Gastroenterology Hematology Nephrology Respirology
Surgery Miski Dahir Manu Sharma David Buchan Orli Silverberg
Harsukh Benipal Rachel Goldfarb Cimon Song Anna Lee Rajiv Tanwani
Erika Opingari
Geriatric Medicine Infectious Diseases Neurology Rheumatology
Endocrinology Sahibjot Grewal Daniel Teitelbaum Armin Farahvash Xinran Liu
Roslyn Mainland Shamara Nadarajah Rachel Tran Yajur Iyengar Eden Meisels
Christine Wu Golsa Shafa
SURGERY
Associate Editors EBM Editors
Winston W. Li Isra Hussein
Ashmita Singh Lisa Vi
CHAPTER EDITORS
General and Thoracic Neurosurgery Ophthalmology Otolaryngology Urology
Surgery Dan Budiansky Yuri V. Chaban Emily YiQin Cheng Edem (Andy) Afenu
Noor Bakir Zaid Salaheen Anubhav (Avi) Garg Christopher End Adree Khondker
Justin Lu Raza Syed Bryan Wong Smruthi Ramesh
Raumil Patel Plastic Surgery
Audrey Shakespeare Obstetrics Orthopaedic Surgery Shaishav Datta Vascular Surgery
Jessica Trac Ye Rin (Yenah) Seo Anser Daud Max Solish Monish Ahluwalia
Katie Wilkins Robert Koucheki Mithila Somasundaram Lyon Qiao
Gynaecology Wei (Sheila) Yu Geoffrey Schemitsch
Zainab Doleeb
Michelle Lee
Matthew Tersigni
Melissa Tigert
COPY EDITORS
General and Thoracic Neurosurgery Ophthalmology Otolaryngology Urology
Surgery Alyssa Li Arjan Dhoot Isabella Janusonis Wei Fang Dai
Alyssa Li Rachel Tran Glen Katsnelson Kathak Vachhani Tiffany Ni
Saba Manzoor Matthaeus Ware
Orthopaedic Surgery Plastic Surgery Vascular Surgery
Gynaecology Obstetrics Marc Anthony Manzo Khizar Abid Catherine Meng
Sonia Igboanugo Sallie Han Zarian Shahzad Irina Sverdlichenko Sandra Sabongui
Claire Sethuram Julianah Oguntala
8 Editorial Toronto Notes 2022
Faculty Contributors, University of Toronto
All of the following contributors have been appointed at the University of Toronto.
PRIMARY
ETHICAL, LEGAL, AND
ORGANIZATIONAL MEDICINE Kaif Pardhan, BSc MD MMEd FRCPC Giuseppe (Joey) Latino, MD, FRCPC
Andria Bianchi, PhD Emergency Physician Department of Paediatrics
Bioethicist, University Health Network Sunnybrook Health Sciences Centre & McMaster Division of Genetics, Department of Medicine
Assistant Professor, Dalla Lana School of Public Children’s Hospital North York General Hospital
Health, University of Toronto
Affiliate Scientist, KITE Research Institute, David Rosenstein, BSc Arch, MD, CCFP(EM) Laila Premji, MD, FRCPC
Toronto Rehab Emergency Physician, Michael Garron Hospital, Division of Paediatric Medicine,
Education Investigator 2, TIER (The Institute for Toronto East Health Network Department of Paediatrics
Education Research) The Hospital for Sick Children
FAMILY MEDICINE
Chase Everett McMurren, BA, BEd, MD, CCFP Ruby Alvi, MD, CCFP, MHSc FCFP Shazeen Suleman, MSc, MD, MPH (FRCPC)
Department of Family and Community Medicine Department of Family and Community Medicine Women and Children’s Health
University of Toronto University of Toronto St. Michael’s Hospital, Unity Health Toronto
ANESTHESIA Chung Kit (Jacky) Lai, MD, CCFP PALLIATIVE MEDICINE
Ahtsham Niazi, MBBS, FCARCSI, FRCPC Department of Family and Community Medicine Risa Bordman, MD, CCFP(PC), FCFP
Department of Anesthesia and Royal Victoria Regional Health Centre Associate Professor
Pain Management, University Health Network University of Toronto Faculty Development Program Lead,
Office of Education Scholarship
Diana Tamir, MD, FRCPC Chase Everett McMurren, BA, BEd, MD, CCFP Department of Family & Community Medicine
Staff Anesthesiologist Department of Family and Community Medicine
Toronto General Hospital University of Toronto Adam Rapoport, MD, FRCPC, MHSc
Clinical Director of the Acute Pain Service Departments of Paediatrics and Family &
Postgrad Anesthesia Site Assistant Coordinator Rachel Walsh, MD, MSc, CCFP Community Medicine, University of Toronto
Department of Anesthesia and Pain Management Department of Family and Community Medicine Paediatric Advanced Care Team, SickKids
Toronto General Hospital Sunnybrook Health Sciences Centre Emily’s House Children’s Hospice
University of Toronto
CLINICAL PHARMACOLOGY Donna Spaner, MD, CCFP(PC), FCFP, MScCH
David Juurlink, BPhm, MD, PhD, FRCPC MEDICAL GENETICS Division of Palliative Care, Department of Family
Division of Clinical Pharmacology and Hanna Faghfoury, MDCM, FRCPC, FCCMG and Community Medicine
Toxicology, Departments of Medicine and The Fred A Litwin Family Centre in Toronto Grace Health Centre
Paediatrics, Sunnybrook Health Sciences Centre Genetic Medicine, Department of Medicine
Mount Sinai Hospital and University Health PSYCHIATRY
Cindy Woodland, PhD Network Saulo Castel, MD, PhD, FRCPC
Associate Professor, Teaching Stream Director, Inpatient Services
Director, Collaborative Specialization in Graeme AM Nimmo, MBBS, MSc, FRCPC, FCCMG Sunnybrook Health Sciences Centre
Biomedical Toxicology The Fred A Litwin Family Centre in Genetic Assistant Professor, Department of Psychiatry
Director, Applied Clinical Pharmacology Program Medicine, Department of Medicine
Mount Sinai Hospital and University Health Tamara Milovic, MD, MBA, FRCPC
DERMATOLOGY Network Psychiatrist, Centre for Addiction and Mental Health
Patrick Fleming, Sc(Nutrition), MSc(Community Lecturer, Department of Psychiatry,
Health), MD, FRCPC, FCDA MEDICAL IMAGING University of Toronto
Assistant Professor of Medicine, Department of Angela Atinga, MB, BChir, BA, MA (Cantab), FRCR
Medicine, University of Toronto Sunnybrook Health Sciences Centre, Department Jerome Perera, MD, FRCPC
Dermatologist, York Dermatology & of Medical Imaging, Division of Musculoskeletal Psychiatrist, North York General Hospital
Research Centre Imaging Clinician Teacher, Department of Psychiatry,
Consultant Dermatologist, Assistant Professor, Department of Medical Imaging, University of Toronto
University Health Network University of Toronto
Ilana Shawn, MD FRCPC
Marissa Joseph, MD, MScCH, FRCPC, FRCPC Nasir Jaffer, MD, FRCPC Department of Psychiatry, St. Michael’s Hospital
Division of Dermatology, Department of Medicine Division of Abdominal Imaging, Assistant Professor, Department of Psychiatry
Women’s College Hospital and The Hospital for Sick Department of Medical Imaging
Children Mount Sinai Hospital and PUBLIC HEALTH AND
University Health Network PREVENTIVE MEDICINE
Jensen Yeung, MD, FRCPC Joint Department of Medical Imaging Onye Nnorom, MDCM, CCFP, MPH, FRCPC
Division of Dermatology, Department of Medicine University of Toronto Dalla Lana School of Public Health,
Women’s College Hospital University of Toronto
Kieran Murphy, MB, FRCPC, FSIR Department of Family and Community Medicine,
EMERGENCY MEDICINE Interventional Neuroradiology, University of Toronto
Mark Freedman, BSc, MD, FRCPC Professor of Medical Imaging
Department of Emergency Medicine Jason J Pennington, MD, MSc, FRCSC
Sunnybrook Health Sciences Centre Ciara O’Brien, MB BCh BAO (MD), FFR RCSI Division of General Surgery, Department of Surgery,
Staff Radiologist, Abdominal Division Scarborough Health Network
Adam Kaufman, MD CCFP(EM) Joint Department of Medical Imaging Assistant Professor, Department of Surgery,
Emergency Physician, Michael Garron Hospital, University Health Network, Mt. Sinai Hospital, University of Toronto
Toronto East Health Network Women’s College Hospital
Assistant Professor, Department of Family and Com- Assistant Professor, Department of Medical Imaging, Lisa Richardson, MD, MA, FRCPC
munity Medicine, University of Toronto University of Toronto Division of General Internal Medicine
Department of Medicine
Jo Jo Leung, MD, CCFP(EM), MScCH(HPTE) PAEDIATRICS University Health Network
Emergency Physician, University Health Network Julie Johnstone, MD (FRCPC), MScCH
and Trillium Health Partners Division of Paediatric Medicine,
Assistant Professor, Department of Family and Department of Paediatrics
Community Medicine, University of Toronto The Hospital for Sick Children