Mpox: Rapid Evidence Review.

Mpox (formerly monkeypox) is a DNA virus of the Orthopoxvirus genus, similar to smallpox. Although mpox was endemic to the Democratic Republic of the Congo and parts of Africa, increasing numbers of cases were reported worldwide in 2022. More than 30,000 cases have been reported in the United States, and worldwide 98% of cases are found in men who have sex with men. Transmission is primarily through contact with skin lesions. The rash of mpox is often vesiculopustular and may be localized to the anogenital region or distributed on the face, trunk, limbs, palms, and soles. Two vaccines are available for pre- or postexposure prophylaxis. Jynneos (smallpox and mpox vaccine, live, nonreplicating) is a live, attenuated vaccine that is safe for patients who are immunocompromised. ACAM2000 (smallpox [vaccinia] vaccine, live) is a live vaccinia virus vaccine that should be given only to immunocompetent, nonpregnant people and should be avoided in those with skin conditions such as atopic dermatitis. For most people infected with mpox, the disease is mild and self-limiting. Antiviral treatments such as tecovirimat, cidofovir, or brincidofovir may be considered for use in individuals who have or are at high risk of severe disease. Possible complications of mpox include anogenital pain, bacterial superinfections of skin lesions, dehydration secondary to oral lesions, encephalitis, keratitis, and respiratory distress. To date, 38 deaths have been reported in the United States.

Multiple Sclerosis: A Primary Care Perspective.

Multiple sclerosis (MS) is a demyelinating disorder of the central nervous system and the most common cause of nontraumatic neurologic disability in young adults. Types of MS include relapsing-remitting (most common), secondary progressive, and primary progressive. Clinically isolated syndrome and radiologically isolated syndrome are additional categories for patients with findings concerning for MS who do not yet meet the diagnostic criteria for the disease. Symptoms of MS depend on the areas of neuronal involvement. Common symptoms include sensory disturbances, motor weakness, impaired gait, incoordination, optic neuritis, and Lhermitte sign. A patient history, neurologic examination, and application of the 2017 McDonald Criteria are needed to diagnose MS accurately. Patients with MS should be treated by a multidisciplinary team that may include physical and occupational therapists, speech and language therapists, mental health professionals, pharmacists, dietitians, neurologists, and family physicians. Steroids are the mainstay of treatment for the initial presentation of MS and relapses. Patients who do not adequately respond to steroids may benefit from plasmapheresis. Patients with MS who smoke tobacco should be strongly encouraged to quit. Disease-modifying therapy has been shown to slow disease progression and disability; options include injectable agents, infusions, and oral medications targeting different sites in the inflammatory pathway. Symptom-based care is important to address the bowel and bladder dysfunction, depression, fatigue, movement disorders, and pain that often complicate MS.

Acute Respiratory Distress Syndrome: Diagnosis and Management.

Acute respiratory distress syndrome (ARDS) is noncardiogenic pulmonary edema that manifests as rapidly progressive dyspnea, tachypnea, and hypoxemia. Diagnostic criteria include onset within one week of a known insult or new or worsening respiratory symptoms, profound hypoxemia, bilateral pulmonary opacities on radiography, and inability to explain respiratory failure by cardiac failure or fluid overload. ARDS is thought to occur when a pulmonary or extrapulmonary insult causes the release of inflammatory mediators, promoting inflammatory cell accumulation in the alveoli and microcirculation of the lung. Inflammatory cells damage the vascular endothelium and alveolar epithelium, leading to pulmonary edema, hyaline membrane formation, decreased lung compliance, and decreased gas exchange. Most cases are associated with pneumonia or sepsis. ARDS is responsible for one in 10 admissions to intensive care units and one in four mechanical ventilations. In-hospital mortality for patients with severe ARDS ranges from 46% to 60%. ARDS often must be differentiated from pneumonia and congestive heart failure, which typically has signs of fluid overload. Treatment of ARDS is supportive and includes mechanical ventilation, prophylaxis for stress ulcers and venous thromboembolism, nutritional support, and treatment of the underlying injury. Low tidal volume and high positive end-expiratory pressure improve outcomes. Prone positioning is recommended for some moderate and all severe cases. As patients with ARDS improve and the underlying illness resolves, a spontaneous breathing trial is indicated to assess eligibility for ventilator weaning. Patients who survive ARDS are at risk of diminished functional capacity, mental illness, and decreased quality of life; ongoing care by a primary care physician is beneficial for these patients.

Hand-Foot-and-Mouth Disease: Rapid Evidence Review.

Hand-foot-and-mouth disease is caused by human enteroviruses and coxsackieviruses. Outbreaks can occur in the spring to fall and are common in North America, and most cases occur in patients younger than 10 years. Hand-foot-and-mouth disease is transmitted by fecal-oral, oral-oral, and respiratory droplet contact. Patients present with a low-grade fever, a maculopapular or papulovesicular rash on the hands and soles of the feet, and painful oral ulcerations. Lesions usually resolve in seven to 10 days; however, in rare cases, patients may have neurologic or cardiopulmonary complications. The differential diagnosis for childhood rashes and oral enanthems is broad and includes erythema multiforme, herpes, measles, and varicella. Treatment is supportive and directed toward hydration and pain relief as needed with acetaminophen or ibuprofen. Oral lidocaine is not recommended, and antiviral treatment is not available. The best methods to prevent the spread of hand-foot-and-mouth disease are handwashing and disinfecting potentially contaminated surfaces and fomites.

Evaluation of Jaundice in Adults.

Jaundice in adults can be an indicator of significant underlying disease. It is caused by elevated serum bilirubin levels in the unconjugated or conjugated form. The evaluation of jaundice relies on the history and physical examination. The initial laboratory evaluation should include fractionated bilirubin, a complete blood count, alanine transaminase, aspartate transaminase, alkaline phosphatase, ?-glutamyltransferase, prothrombin time and/or international normalized ratio, albumin, and protein. Imaging with ultrasonography or computed tomography can differentiate between extrahepatic obstructive and intrahepatic parenchymal disorders. Ultrasonography is the least invasive and least expensive imaging method. A more extensive evaluation may include additional cancer screening, biliary imaging, autoimmune antibody assays, and liver biopsy. Unconjugated hyperbilirubinemia occurs with increased bilirubin production caused by red blood cell destruction, such as hemolytic disorders, and disorders of impaired bilirubin conjugation, such as Gilbert syndrome. Conjugated hyperbilirubinemia occurs in disorders of hepatocellular damage, such as viral and alcoholic hepatitis, and cholestatic disorders, such as choledocholithiasis and neoplastic obstruction of the biliary tree.

Herpes Zoster and Postherpetic Neuralgia: Prevention and Management.

Herpes zoster, or shingles, is caused by reactivation of varicella zoster virus, which causes chickenpox. There are an estimated 1 million cases in the Unites States annually, with an individual lifetime risk of 30%. Patients with conditions that decrease cell-mediated immunity are 20 to 100 times more likely to develop herpes zoster. Patients may present with malaise, headache, low-grade fever, and abnormal skin sensations for two to three days before the classic maculopapular rash appears. The rash is usually unilateral, confined to a single dermatome, and typically progresses to clear vesicles that become cloudy and crust over in seven to 10 days. Herpes zoster can be treated with acyclovir, valacyclovir, or famciclovir, ideally within 72 hours of the development of the rash. Postherpetic neuralgia is the most common complication, occurring in about one in five patients. It is defined as pain in a dermatomal distribution sustained for at least 90 days after acute herpes zoster. Treatment is focused on symptom control and includes topical lidocaine or capsaicin and oral gabapentin, pregabalin, or tricyclic antidepressants. The varicella zoster virus vaccine decreases the incidence of herpes zoster and is approved for adults 50 years and older. The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends this vaccine for adults 60 years and older, except for certain immunosuppressed patients.

The Associations Between Clerkship Objective Structured Clinical Examination (OSCE) Grades and Subsequent Performance.

Construct: We investigated the extent of the associations between medical students' clinical competency measured by performance in Objective Structured Clinical Examinations (OSCE) during Obstetrics/Gynecology and Family Medicine clerkships and later performance in both undergraduate and graduate medical education. BACKGROUND: There is a relative dearth of studies on the correlations between undergraduate OSCE scores and future exam performance within either undergraduate or graduate medical education and almost none on linking these simulated encounters to eventual patient care. Of the research studies that do correlate clerkship OSCE scores with future performance, these often have a small sample size and/or include only 1 clerkship. APPROACH: Students in USU graduating classes of 2007 through 2011 participated in the study. We investigated correlations between clerkship OSCE grades with United States Medical Licensing Examination Step 2 Clinical Knowledge, Clinical Skills, and Step 3 Exams scores as well as Postgraduate Year 1 program director's evaluation scores on Medical Expertise and Professionalism. We also conducted contingency table analysis to examine the associations between poor performance on clerkship OSCEs with failing Step 3 and receiving poor program director ratings. RESULTS: The correlation coefficients were weak between the clerkship OSCE grades and the outcomes. The strongest correlations existed between the clerkship OSCE grades and the Step 2 CS Integrated Clinical Encounter component score, Step 2 Clinical Skills, and Step 3 scores. Contingency table associations between poor performances on both clerkships OSCEs and poor Postgraduate Year 1 Program Director ratings were significant. CONCLUSIONS: The results of this study provide additional but limited validity evidence for the use of OSCEs during clinical clerkships given their associations with subsequent performance measures.

Diagnosis and management of kawasaki disease.

Kawasaki disease is an acute, systemic vasculitis that predominantly affects patients younger than five years. It represents the most prominent cause of acquired coronary artery disease in childhood. In the United States, 19 per 100,000 children younger than five years are hospitalized with Kawasaki disease annually. According to U.S. and Japanese guidelines, Kawasaki disease is a clinical diagnosis. Classic (typical) Kawasaki disease is diagnosed based on the presence of a fever lasting five or more days, accompanied by four out of five findings: bilateral conjunctival injection, oral changes such as cracked and erythematous lips and strawberry tongue, cervical lymphadenopathy, extremity changes such as erythema or palm and sole desquamation, and polymorphous rash. Incomplete (atypical) Kawasaki disease occurs in persons with fever lasting five or more days and with two or three of these findings. Transthoracic echocardiography is the diagnostic imaging modality of choice to screen for coronary aneurysms, although other techniques are being evaluated for diagnosis and management. Treatment for acute disease is intravenous immunoglobulin and aspirin. If there is no response to treatment, patients are given a second dose of intravenous immunoglobulin with or without corticosteroids or other adjunctive treatments. The presence and severity of coronary aneurysms and obstruction at diagnosis determine treatment options and the need, periodicity, and intensity of long-term cardiovascular monitoring for potential atherosclerosis.