A Case That Will Take Your Breath Away: Acquired Methemoglobinemia Related to Trimethoprim-Sulfamethoxazole and Phenazopyridine Ingestion for Treatment of Urinary Tract Infection.

Trimethoprim-sulfamethoxazole (TMP-SMX) and phenazopyridine are individually associated with methemoglobinemia through a series of altered reduction-oxidation reactions. We report a case of methemoglobinemia associated with concurrent use of TMP/SMX and phenazopyridine in a 70-year-old woman with recurrent urinary tract infections. She presented to the emergency department for worsening back pain in the setting of recurrent urinary tract infections, concerning for pyelonephritis. During her workup, she became acutely hypoxic. The emergency department provider suspected the presence of abnormal hemoglobin. An arterial blood gas showing elevated levels of methemoglobinemia confirmed the suspicion. The combined use of TMP/SMX and phenazopyridine was thought to be the likely etiology of hypoxia. This case highlights the importance of medication management in the geriatric population, as well as the judicious use of antibiotics for urinary tract infections-a common chief complaint in the primary care setting.

Veterans Health Administration's Physician Assistant Primary Care Residency: An Evaluation of the First 3 Years.

PURPOSE: Results from an evaluation of a 12-month postgraduate Veterans Health Administration (VHA) residency in primary care for physician assistants (PAs). METHODS: Descriptive and open-ended data were collected to describe the experience of faculty and trainees participating in the first 3 years of this pilot residency. Quantitative data were summarized using descriptive statistics. Text data were transcribed and reviewed for common themes across residency sites and respondents. Data were collected at 2 time points-the end of the first year and the beginning of year 4. RESULTS: In the first 3 years of the program, 18 residents were enrolled at 6 sites, with 89% completing the residency. At the second time point, 8 more residents were enrolled. Residents were primarily female (69%). Of the residents completing the program, 56% obtained VHA employment, and 75% of the current residents planned to work for the VHA upon completing the program. Program infrastructure, such as written curriculum, a dedicated administrative staff, and written evaluations for trainees, was more common at the second time point. Recurring themes included the importance of establishing relationships with potential applicants, preceptors, medical center leadership, and trainees to support the program and the importance of securing resources such as space and protected time for faculty. CONCLUSIONS: Although postgraduate residency programs are less common for PAs than for some other health professions, our data suggest that a one-year residency can provide training for new graduates to help solidify their clinical experience and facilitate their transition to practice.

Colorectal cancer screening and surveillance.

Colorectal cancer is the third most common cancer in men and women. The incidence and mortality rate of the disease have been declining over the past two decades because of early detection and treatment. Screening in persons at average risk should begin at 50 years of age; the U.S. Preventive Services Task Force recommends against routine screening after 75 years of age. Options for screening include high-sensitivity fecal occult blood testing annually, flexible sigmoidoscopy every five years with high-sensitivity fecal occult blood testing every three years, or colonoscopy every 10 years. In 2012, the U.S. Multi-Society Task Force on Colorectal Cancer updated its surveillance guidelines to promote the appropriate use of colonoscopy resources and reduce harms from delayed or unnecessary procedures; these guidelines provide recommendations for when to repeat colonoscopy based on findings. Adenomatous and serrated polyps have malignant potential and warrant early surveillance colonoscopy. Patients with one or two tubular adenomas that are smaller than 10 mm should have a repeat colonoscopy in five to 10 years. Repeat colonoscopy at five years is recommended for patients with nondysplastic serrated polyps that are smaller than 10 mm. Patients with three to 10 adenomas found during a single colonoscopy, an adenoma or serrated polyp that is 10 mm or larger, an adenoma with villous features or high-grade dysplasia, a sessile serrated polyp with cytologic dysplasia, or a traditional serrated adenoma are at increased risk of developing advanced neoplasia during surveillance and should have a repeat colonoscopy in three years. More than 10 synchronous adenomas warrant surveillance colonoscopy in less than three years. Colonoscopy may be repeated in 10 years if distal, small (less than 10 mm) hyperplastic polyps are the only finding.

Iron deficiency anemia: evaluation and management.

Iron deficiency is the most common nutritional disorder worldwide and accounts for approximately one-half of anemia cases. The diagnosis of iron deficiency anemia is confirmed by the findings of low iron stores and a hemoglobin level two standard deviations below normal. Women should be screened during pregnancy, and children screened at one year of age. Supplemental iron may be given initially, followed by further workup if the patient is not responsive to therapy. Men and postmenopausal women should not be screened, but should be evaluated with gastrointestinal endoscopy if diagnosed with iron deficiency anemia. The underlying cause should be treated, and oral iron therapy can be initiated to replenish iron stores. Parenteral therapy may be used in patients who cannot tolerate or absorb oral preparations.

Colonoscopy by a family physician: detecting proximal neoplasia in asymptomatic adults.

PURPOSE: Flexible sigmoidoscopy (FS) is considered an adequate screening test in average risk (AR) patients. The purpose of this study was to determine the diagnostic yield of FS in detecting colonic neoplasia between AR and high risk (HR) patients. METHODS: We present a chart review of 559 outpatient colonoscopies performed by a family physician from September 2003 to October 2007. The prevalence of neoplasia and diagnostic yield of FS was compared between groups. RESULTS: The overall prevalence of neoplasia was 23.1% (AR) and 32.8% (HR); p = 0.02. The prevalence of proximal neoplasia not detectable by FS was 10.2% (AR) and 14.5% (HR); p = 0.16. The diagnostic yield of FS in each group was 56%; FS would have missed 44% of polyps regardless of patient risk. CONCLUSIONS: The high rate of colonic neoplasia not detected by FS (44%) suggests that FS alone is inadequate for screening in AR patients.

Assessing colonoscopy training outcomes using quality indicators.

PURPOSE: Training numbers for colonoscopy vary among specialties. Tracking colonoscopy quality indicators for program graduates may provide reliable outcome data to improve educational programs and establish training requirements. The purpose of this study was to measure specific colonoscopy quality indicators for a family medicine graduate to determine if outcome can be used to assess the quality of procedure training and contribute to more objective means of establishing training numbers. METHODS: We present a case series of the first 800 colonoscopies performed by a newly credentialed family physician who had performed 101 procedures during residency training. Procedure reports and medical records were reviewed for all patients receiving a colonoscopy by this physician from September 2003 to September 2007. Selected quality indicators were compared to recommended colonoscopy standards. RESULTS: The overall reach-the-cecum rate was 98.6%. Adenomas were detected in 21.6% of females and 33.7% of males. All polyps measuring less than 2 cm were removed. Epinephrine was used for 3 patients with hemostasis after polypectomy. There were no perforations. CONCLUSIONS: Quality indicators for colonoscopy were met after 101 supervised procedures. Postgraduate tracking of nationally recognized colonoscopy quality indicators can provide valuable outcome data to improve residency training and assist in establishing uniform training requirements among specialties.

Genital co-infection with herpes simplex viruses type 1 and 2: comparison of real-time PCR assay and traditional viral isolation methods.

We report the clinical case of a genital outbreak with both Herpes Simplex Type 1 (HSV-1) and Herpes Simplex Type 2 (HSV-2) during pregnancy. Herpes was presumptively identified by clinical presentation of lesion and Tzanck smear while serotypes were identified by cell culture and polymerase chain reaction (PCR). This case report highlights the need for increased surveillance of both serotypes in genital infection of pregnant women for effective disease management and reduced risk of transmission. Increasing rates of genital infection with HSV-1, the possibility of genital co-infection with HSV-1 and HSV-2 and the non-specificity and lack of sensitivity of traditional viral isolation methods may lead to under-diagnosis of genital HSV-1 infections unless molecular diagnostic methods, such as polymerase chain reaction (PCR) are routinely deployed in the clinical setting.