This is why we, and all the members of our U of T team, gladly

dedicated so many hours toward this immensely involved

project. As our valued reader, we thank you for your honest

and vital financial contribution through your purchase of our

textbook.Each book sold makes an important difference.

The 2023 edition features substantial content revisions to

the text, figures, and graphics of all 32 chapters, following a

comprehensive review by our student and faculty editorial

team. Up-to-date, evidence-based medicine studies are also

summarized in highlighted boxes throughout the text. In

particular, the Ethical Legal, and Organizational Medicine

chapter has been thoroughly revised and expanded, and all

chapters reflect the most-updated COV1D-19 guidelines. The

new MCCQE objectives on Clinical Informatics and Health

Sincerely,

rn

L J

Anders W. Erickson, MD/PhD student

Jennifer Parker, MD/PhD student

Editors-in-Chief, Toronto Sotes 2023

+

5 Editorial Toronto Notes 2023

Acknowledgements

We would like to acknowledge the exceptional work of all previous Toronto Notes (formerly MCCQE Notes)

Editors-in-Chief and their editorial teams, lhe 39th edition of this text was made possible with their contributions.

2022 (38th ed.): Yuliya Lytvyn and Maleeha A. Qazi

2021 (37th ed.): Megan Urupals and Matthacus 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 Colrnan and Ron Somogyi

2007 (23rd ed.):Marilyn Heng and Joseph Ari Greenwald

2006 (22nd ed.):Carolyn Jane Shiau and Andrew Jonathan Ibren

2005 (21st ed.):Blair John Normand Leonard and Jonathan Chi-Wai Yeung

2004 (20th ed.): Andrea Molckovsky and KashifS. Pirzada

2003 (19th ed.): Prateek Lala and Andrea Waddell

2002 (18th ed.): Neety Paint and Sunny Wong

2001 (17th ed.):Jason Yue and Gagan Ahuja

2000 (16th ed.):Marcus Law and Brian Kotcnberg

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

n

L J

1992 (8th ed.):Gideon Cohen-Nehemia and Shanthi Vasudevan

+

All former Chief Editors from 1991 (7th ed.) to 1985 (1st ed.)

AL GRAWANY

6 Editorial Toronto Notes 2023

Student Contributors

Editors-in-Chief

Anders Erickson

Jennifer Parker

Clinical Handbook Editors

Justin Lu

Rayoun Ramendra

Copyright Managers

Mercy Danquah

Marta Karpinski

BMC Production Editors

Jennifer Xin Ran Shao

Aimy Meng Yu Wang

Online Content Managers

Jeffrey Lam Shin Cheung

Sandra Lee

Amanda Mac

Muhammad Shahid

BMC ILLUSTRATORS

Viktoriva Khymych Viola Yu Amy Ke Er Zhang

PRIMARY

EBM Editor

Yijithan Sugumar

Associate Editors

Ming Li

Dorrin Zarrin Khat

CHAPTER EDITORS

Ethical, Legal, and

Organizational Medicine

Kenya Costa-Dookhan

Zuhal Mohmand

Dermatology

Natalie Kozlowski

Yuliya Lytvyn

Sara Mirali

Family Medicine

Neda Pirouzmand

Bree Sharma

Maryam Thrava

Paediatrics

Onyinyechukwu Esenwa

Anna Jiang

Raima Rasouli

Mary Xie

Tinting Yang

Psychiatry

Tania Da Silva

Rawaan Elsawi

Rachel Goud

Anestlicsia

Evan Tang

Kathak Vachhani

Emergency Medicine

V'inyas1Iarish

Danny Ma

Kwasi Nkansah

Tsz Ying So

Medical Genetics

Andrew Mazzanti

Public Health and

Preventive Medicine

Jenny Cho

Muhammad Maaz

Palliative Medicine

Manu Sharma

Christine Wu

Medical Imaging

Grace Grafham

Jeffrey Lam Shin Cheung

Clinical Pharmacology

Max Solish

COPY EDITORS

Ethical, Legal, and

Organizational Medicine

Noroh Dakim

Alex German

Dermatology'

Chidalu Edechi

Jaycie Dalson

Family Medicine

Jaskaran Gill

Shiyu Sunny Zheng

Psychiatry'

David Kim

Paediatrics

Tania Da Silva

Priscilla Kim

Ajantha Xadarajah

Yasmeen Razvi

Public Health and

Preventive Medicine

Caitlin Monaghan

HunsterYang

Emergency Medicine

Graham Colby

Sanch Gupta

Lara Murphy

Daniel Shane

Medical Genetics

Anesthesia Ryan Karimi

Max Solish

Janet Tang

Palliative Medicine

Medical Imaging Samuel Wier

Victoria Anthes

Hayley McKee

r T

c. J

Clinical Pharmacology

Fatimah Roble

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7 Editorial Toronto Notes 2023

Student Contributors

MEDICINE

Associate Editors

Karolina Gaebe

Alyssa Li

EBM Editors

Wei Fang Dai

Camilla Giovino

CHAPTER EDITORS

Cardiology and Cardiac

Surgery

I lardil Bhatt

Akachukwu Nwakoby

Jeremy Roslt

Emily Tam

Gastroenterology

Sahibjot Grewal

Anna Lee

Andrew Rogalsky

Hematology

Reid Gallant

Syed Sluhan I laider

Nathan Kuelmc

Nephrology

David Buchan

IJuaqi Li

Respirology

Brian Bursic

Emma Price

Rajiv Tanwani

Neurology

Thomas Milazzo

Maleeha Qazi

Geriatric Medicine

Imnan Khcrani

Saba Manzoor

Infectious Diseases

Christopher Knox

Erika Nakajima

Rachel Tran

Rheumatology

Rachel Goldlarh

Endocrinology Eden Meisels

Maria Samy

Claire Sethuram

COPY EDITORS

Cardiology and Cardiac

Surgery

Shamara Nadarajah

Julianah Oguntala

Calurn Slapnicar

Vivian Tam

Endocrinology

Winston Li

Kathryn Wiens

Hematology

Pedro Boasquevisque

Daniel Lindsay

Brandon Tse

Nephrology

Anders Erickson

Jennifer Parker

Respirology

Andrew Rogalsky

Raza Syed

Gastroenterology

Oliver Chow

Parker McNabb

Neurology

Lauren Kanee

Kristiana Xhima

Rheumatology

Serena Dienes

Tsz Ying So

Infectious Diseases

NicholasChiang

TediIloxha

Geriatric Medicine

Pooja Sankar

SURGERY

Associate Editors

Vrati Mehra

Chunyi Christie Tan

EBM Editor

Arjan Dhoot

CHAPTER EDITORS

General and Thoracic

Surgery

Ryan Daniel

Jacqueline Lim

Smruthi Ramesh

Neurosurgery

Dan Budiansky

Jack Su

Raza Syed

Ophthalmology

Michael Balas

Josh I Ierman

Michelle Lim

Otolaryngology

Alyssa Li

Jessica Trac

Sheila Yu

Urology

Adree Khondker

Shamir Malik

Vascular Surgery

George Elzawy

Raumil Patel

Obstetrics

I Iarsukh Benipal

Emma Sparks

Jane Zhu

Orthopaedic Surgery

John-Petcr Bonello

Kalter 1 Iali

Robert Koucheki

Marc Manzo

Plastic Surgery

Shaishav Datta

Tiffany Ni

Gynaecology

Eliot Winkler

Sarah Zachariah

Rehona Zamani

COPY EDITORS

General and Hioracic

Surgery

Tasnim Abdalla

Audrey Jong

Lisa Vi

Neurosurgery

Bhadra Pandya

Jacob Peller

Ophthalmology

Kevin Chen

Matthew Veitch

Otolaryngology

Ryan Daniel

Siddhartha Sood

Urology

Kellie Kim

Gabriela Leon

r T

L J

Obstetrics

Julia Avolio

I layley Good

Erin Pucrsten

Orthopaedic Surgery

1lannah Drkulec

Anders Erickson

Plastic Surgery

Thomas Milazzo

Jenn Parker

Vascular Surgery

Serena I lope

Gynaecology +

Laura Diamond

Katherine Kim

I Iolsa Zia

AL GRAWANY

S Editorial Toronto Notes 2023

Faculty Contributors, University of Toronto

All of the following contributors have been appointed at the University of Toronto.

PRIMARY

ETHICAL, LEGAL. AND

ORGANIZATIONAL MEDICINE

Andria Bianchi, PhD

Bioethicist, University Health Network

Assistant Professor, Delia Lana School of Public

Health, University of Toronto

Affiliate Scientist, KITE Research Institute,

Toronto Rehab

Education Investigator 2,TIER (The Institute for

Education Research)

Nadia Incardona,MD,MHSc.BSc,CCFP (EM)

Assistant Professor

Department of Family and Community Medicine

Michael Garron Hospital

Chase Everett McMurren, BA, BEd, MD,CCFP

Department of Family and Community Medicine

University of Toronto

ANESTHESIA

Ahtsham Niazi, MBBS,FCARCSI, FRCPC

Department of Anesthesia and

Pain Management,University Health Network

CLINICAL PHARMACOLOGY

Dasid Juurlink, BPhm, MD, PhD, FRCPC

Division of Clinical Pharmacology and

Toxicology, Departments of Medicine and

Paediatrics,Sunnybrook Health SciencesCentre

Cindy Woodland, PhD

Associate Professor,Teaching Stream

Director,Collaborative Speci.tli7.uion in

Biomedical Toxicology

Director, Applied Clinical Pharmacology Program

DERMATOLOGY

Patrick Fleming, Sc ( Nutrition!.MSc (Community

Health),MD, FRCPC,FCDA

Assistant Professor of Medicine,

Department of Medicine,University of Toronto

Dermatologist, York Dermatology & Research Centre

Consultant Dermatologist,

University Health Network

Marissa Joseph, MD,MScCH. FRCPC, FRCPC

Division of Dermatology, Department of Medicine

Women'

s College Hospital and The Hospital for Sick

Children

Kaif Pardhan, BSc MD MMEd FRCPC

Emergency Physician

Sunnybrook Health SciencesCentre & McMaster

Children’

s Hospital

FAMILY MEDICINE

Ruby Alvi, MD,CCFP,MHSc FCFP

Department of Family and Community Medicine

University of Toronto

Chung Kit (Jacks) Lai. MD,CCFP

Department of Family and Community Medicine

Royal Victoria Regional Health Centre

University'of Toronto

Chase Everett McMurren, BA, BEd,MD, CCFP

Department of Family and Community Medicine

University of Toronto

Rachel Walsh, MD, MSc,CCFP

Department of Family and Community Medicine

Sunnybrook Health SciencesCentre

University'of Toronto

MEDICAL GENETICS

Vanda McNiven,MD,MSc,FRCPC

Division of Clinical Genetics and Metabolics &

Division of Hematology and Oncology

Departments of Paediatrics and Medicine

The Hospital for Sick Children,The University Health

Network, and Mount Sinai Hospital

Graeme AM Nimmo,MBBS,MSc, FRCPC,FCCMG

The Fred A Litwin Family Centre in Genetic

Medicine,Department of Medicine

Mount Sinai Hospital and University Health Network

MEDICAL IMAGING

Andrew Brown, MD, MBA,FRCPC

Assistant Professor

Vascular and Interventional Radiology

Department of Medical Imaging

Unity Health Toronto - SL Michaels Hospital

Beniamin Fine, SM.MD, FRCPC

Clinician Scientist, Medical Imaging

Trillium Health Partners, University of Toronto

Kieran Murphy, MB,FRCPC,FSIR

Interventional Neuroradiology,

Professor of Medical Imaging

Ciara O’Brien, MB BCh BAO (MD), FFR RCSI

Staff Radiologist, Abdominal Division

Joint Department of Medical Imaging

University I Iealth Network,Ml Sinai 1 Iospital,

WomensCollege Hospital

Assistant Professor, Department of Medical Imaging, liana Shawn, MD FRCPC

University'of Toronto ‘ ' "

Department of Psychiatry,Sc Michael'

s1Iospital

Assistant Professor Department of Psychiatry

Anastasia Oikonomou,MD,PhD, FRCPC

Associate Professor, University of Toronto PUBLIC HEALTH AND

Division of Cardiothoradc Imaging, PREVENTIVE MEDICINE

Department of Medical Imaging,

~

Jason J Pennington. MD,MSc, FRCSC

Sunnybrook Health SciencesCentre Division of General Surgery, Department of Surgery,

Scarborough Health Network

PAEDIATRICS Assistant Professor,Department of Surgery'

,

Tanvi Agarwal,MD,FRCPC MScCH (c) University'of Toronto

Division of Paediatric Medicine

Department of Paediatrics Andrew Pinto, BSc,MD,CCFP,FRCPC,MSc

The Hospital for SickChildren Department of Family and Community Medicine,

SL Michaels Hospital

Jillian Baker,MD, MSc,FRCPC Department of Family and Community Medicine

Assistant Professor of Pediatrics, University of Toronto University of Toronto

Divisions of Pediatrics and Hematology/Oncologv Dalla Lana School of Public 1Iealth,

Department of Pediatrics,Unity Health Toronto (St University'of Toronto

Michaels Hospital) & TheHospital for Sick Children

Tyler Groves,MSc.MBBS, FRCPC

Department of Paediatrics, Michael Garron Hospital

Giuseppe (Joey) Latino.MD, FRCPC

Department ot Paediatrics

Division of Genetics,Department of Medicine

North York General Hospital

Laila Premji, MD. FRCPC

Division ol Paediatric Medicine,

Department of Paediatrics

The Hospital for SickChildren

Shazeen Suleman MSc,MD, MPH ( FRCPC!

Women and Childrens Health

SL Michaels HospitaL Unity Health Toronto

Janaki Vallipuram,MD. FRCPC

Division of Paediatric Medicine,

Department of Paediatrics

The Hospital for SickChildren,

Markham Stouffville Hospital

PALLIATIVE MEDICINE

Risa Bordman,MD,CCFP(PC),FCFP

Associate Professor

Faculty Development Program Lead,

Office of Education Scholarship

Department of Family & Community Medicine

Adam Rapoport, MD, FRCPC, MHSc

Departments of Paediatrics and Family &

Community Medicine,University of Toronto

Paediatric Advanced Care Team, SickKids

Emily’s House Childrens Hospice

Donna Spaner,MD,CCFP( PC), FCFP, MScCH

Division of PalliativeCare, Department of Family and

Community Medicine

Toronto Grace Health Centre

PSYCHIATRY

Saulo Castel, MD, PhD, FRCPC

Director,Inpatient Services

Sunnybrook Health SciencesCentre

Assisiant Professor Department of Psychiatry

Tamara Milovic,MD, MBA, FRCPC

Psychiatrist,Centre for Addiction and Mental Health

Lecturer, Department ot'

Psychiatry,

University ot Toronto

Jerome Perera,MD, FRCPC

Psychiatrist, North York General IIospital

Clinician Teacher. Department of Psychiatry,

University of Toronto

Jensen Yeung, MD, FRCPC

Division of Dermaiology, Department of Medicine

Women'

sCollege Hospital

EMERGENCY MEDICINE

Mark Freedman, BSc,MD,FRCPC

Department of EmergencyMedicine

Sunnybrook Health SciencesCentre

Laura Hans, MD,CCFP (EM)

Department of Emergency Medicine

SL Michael'

s Hospital

Adam Kaufman,MD CCFPiEM)

Emergency Physician, Michael Garron Hospital,

Toronto East Health Network

.Assistant Professor, Department of Family and

Community Medicine,University of Toronto

Jo Jo Leung, MD,CCFPIEM),MScCH(HPTE)

Emergence Physician, University Health Network and

Trillium Health Partners

Assistant Professor, Department of Family and

Community Medicine, University of Toronto

r T

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9 Editorial Toronto Notes 2023

Faculty Contributors, University of Toronto

MEDICINE

CARDIOLOGY AND CARDIAC SURGERY

Paul Dorian, MD, MSc, FRCPC

Division of Cardiology

St. Michael'

s Hospital

Thiru Yogaparan, MD, FRCP

Division of Geriatric Medicine, Department of

Medicine, Baycrest Ilealth Sciences

Alireza Zahirieh, MD, FRCPC

Division of Nephrology, Department of Medicine

Sunnybrook Ilealth Sciences Centre

HEMATOLOGY

MatthewCheung,MD. FRCPC

Division of Medical Oncology and 1lematology.

Department of Medicine

Sunnybrook Health SciencesCentre

NEUROLOGY

Charles D. Kassardjian,MD, MSc, FRCPC

Division of Neurology, Department of Medicine

St.Michael'

s Hospital

Douglas 1. Ing, MD, FRCPC, FACC

Division of Cardiology

Toronto General Hospital

Alexandra MucciUi,MD, MEd, FRCPC

Division of Neurology, Department of Medicine

SL Michaels Hospital

Bobby Yanagawa, MD, PhD, FRCSC

Division of Cardiac Surgery

St Michael'

s Hospital

Lisa Chodirker, MD, FRCPC

Division of Medical Oncology and Hematology,

Department of Medicine

Sunnybrook Health SciencesCentre Liza Pulcine,MD,MSc, FRCPC

Assistant Prolessor, Fellowship Director

Children'

s Stroke Program

Division of Neurology, Department of Paediatrics,

The Hospital for Sick Children

ENDOCRINOLOGY

Angela Assal, MD, MHSc, FRCPC

Division of Endocrinology and Metabolism,Depart- Helena Dhamko.MD,FRCPC MScCH

Division of Hematology.E>epartment of Medicine

University Health Network

ment of Medicine

Sunnybrook Health SciencesCentre

University of Toronto

RESPIROLOGY

Samir Gupta,MD, FRCPC

Division ofRespirology Department of Medicine

Unity Health Toronto

Zachary Liederman, MD, FRCPC MScCH

Division of Hematology,Department of Medicine

Universitv Health Network

Jeremy Gilbert, MD, FRCPC

Division of Endocrinology and Metabolism

Sunnybrook Health Sciences Centre

Michael Scott,MD,FRCPC

Clinical Hematologist;Adjunct Lecturer,

Division of Medical Oncology and HematologyDepartment of Medicine,Unity Health Toronto,

SL Michael'

s Hospital

Ambrose Lau,MD, MEd, FRCPC

Division ofRespirology,Department of Medicine

University Health Network and

Unity HealthToronto

Assistant Professor, University of Toronto

Adrian Lau,MD, MScCH, FRCPC

Division of Endocrinology and Metabolism

Department of Medicine

Women’s College Hospital

Universityof Toronto

Martina Trinkaus,MD,FRCPC

Division of Hematology,E>epartment of Medicine

SL Michael'

sHospital

Christopher Li,MD, FRCPC, DABSM

Division ofRespirology;Department of Medicine

Unity Health Toronto - SL Michael’s

Maria Wolfs, MD MHSc FRCPC

Division of Endocrinology and Metabolism

St. Michael's Hospital

INFECTIOUS DISEASES

Andrea K.Boggild,BSc,MSc,MD,DTMH,

FRCPC

Tropical Disease Unit,Toronto General Hospital

Division of Infectious Diseases,

University- Health Network

Department of Medicine, University of Toronto

Institute of Medical Science, University of Toronto

RHEUMATOLOGY

Ahmed Omar, MBBCh, MRCP, MSc

Assistant Professor, University of Toronto

Division of Rheumatology, Department of Medicine

Mount Sinai Hospital, University Health Network

GASTROENTEROLOGY

Maria Cino, BSc(Hon), Hon BSc, MSc,MD,

FRCPC CAGF

Division of Gastroenterology,

Department of Medicine

University Health Network - Toronto Western Site

Associate Professor, University of Toronto Arthur Bookman, MD, FRCPC

Division of Rheumatology, Department of Medicine

Paul L Bunce, BSc.MA.MD. FRCPC University 1lealth Network

Division of Infectious Diseases

Department of Medicine

University Health Network

Flavio Habal,MD,PhD,FRCP,FAGA

Division of Gastroenterology

University Health Network,

Toronto Western Division

Associate Professor, University of Toronto

SahilKoppikar. MD FRCPC

Assistant Professor, Division of Rheumatology

Department of Medicine,

Women'

Susan M. Poutancn, MD.MPH, FRCPC sCollege I lospital

Department of Microbiology,

University Health Network & Sinai Health

Division of Infectious Diseases,

Department of Medicine

University Health Network & Mount Sinai Hospital

Piero Tartaro, MD, MScCl I, FRCPC

Division of Gastroenterology,

Department of Medicine

Sunnybrook Health SciencesCentre

Dharini Mahendira, MD, FRCPC, MScCH

Assistant Professor, Division of RheumatologyDepartment of Medicine, St. Michael'

s Hospital

Medha L.Soowamber, MD, MSc, FRCPC

Division of Rheumatology, Department of Medicine

Mount Sinai Hospital

GERIATRIC MEDICINE

Jillian .Alston, MD, FRCPC, MScCH

Division of Geriatrics

Department of Medicine

St. Michael'

s Hospital

NEPHROLOGY

Damien Noone.MB BCh BAO,MSc

Division of Paediatric Nephrology,

Department of Paediatrics

The Hospital tor Sick Children

r i

L J

Vicky Chau,MD, MScCH, FRCPC

Division of Geriatric Medicine,

Department of Medicine

Sinai Health System & University Health Network

+