Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection.

The most common causes of peptic ulcer disease (PUD) are Helicobacter pylori infection and use of nonsteroidal anti-inflammatory drugs (NSAIDs). The test-and-treat strategy for detecting H. pylori is appropriate in situations where the risk of gastric cancer is low based on age younger than 55 years and the absence of alarm symptoms. Most other patients should undergo upper endoscopy to rule out malignancy and other serious causes of dyspepsia. Urea breath tests and stool antigen tests are most accurate for identifying H. pylori infection and can be used to confirm cure; serologic tests are a convenient but less accurate alternative and cannot be used to confirm cure. Treatment choices include standard triple therapy, sequential therapy, quadruple therapy, and levofloxacin-based triple therapy. Standard triple therapy is only recommended when resistance to clarithromycin is low. Chronic use of NSAIDs in patients with H. pylori infection increases the risk of PUD. Recommended therapies for preventing PUD in these patients include misoprostol and proton pump inhibitors. Complications of PUD include bleeding, perforation, gastric outlet obstruction, and gastric cancer. Older persons are at higher risk of PUD because of high-risk medication use, including antiplatelet drugs, warfarin, selective serotonin reuptake inhibitors, and bisphosphonates.

The Heart of Residency.

Description As part of wellness activities in 2023, our family medicine residents produced individual paintings. Samantha coalesced these 4 × 4 canvases to create this heart. The following quote is also poignant for those of us in family medicine.

Primary Care Physician Supply and Population Health Outcomes in Florida, 2010-2019.

Background: Primary care physicians play vital roles in the prevention and management of chronic disease. With increasing rates of chronic disease and a national primary care physician shortage, the role that primary care physician supply has on health outcomes in Florida is not well understood. The objective of this study was to investigate the relationship between primary care physician supply (PCPS) and population health outcomes of obesity, life expectancy, coronary artery disease hospitalization, and death rate as reported by county in the state of Florida for the years 2010, 2013, 2016, and 2019. Methods: This was a retrospective, cross-sectional study. Secondary data was used from the Florida Department of Health. Numerous population health and social determinants of health variables related to PCPS in the literature were selected for analysis. Correlation and linear regression analyses were conducted using STATA14. Results: The association between PCPS and obesity was the strongest association in this analysis and was significant for each year with an average of 9.25 primary care physicians per 100 000 people needed to decrease the obesity rate by 1%. PCPS was positively correlated with life expectancy for years 2013, 2016, and 2019 and negatively correlated with the death rate in 2010 and 2019. In the multiple regression, PCPS was negatively associated with areas having a high rate of uninsured persons, unemployment, decreased education, and age over 65. Conclusion: Increased supply of primary care physicians in Florida is significantly associated with decreased rates of obesity and death and increased life expectancy. Our results also indicate that areas with higher levels of social vulnerability also have inequitable distributions of PCPS. Therefore, PCPS should be increased, particularly in areas with the highest need, as primary care physicians in the state of Florida play an important role in improving the overall health of the populations they serve.

Treatment of the common cold in children and adults.

The common cold, or upper respiratory tract infection, is one of the leading reasons for physician visits. Generally caused by viruses, the common cold is treated symptomatically. Antibiotics are not effective in children or adults. In children, there is a potential for harm and no benefits with over-the-counter cough and cold medications; therefore, they should not be used in children younger than four years. Other commonly used medications, such as inhaled corticosteroids, oral prednisolone, and Echinacea, also are ineffective in children. Products that improve symptoms in children include vapor rub, zinc sulfate, Pelargonium sidoides (geranium) extract, and buckwheat honey. Prophylactic probiotics, zinc sulfate, nasal saline irrigation, and the herbal preparation Chizukit reduce the incidence of colds in children. For adults, antihistamines, intranasal corticosteroids, codeine, nasal saline irrigation, Echinacea angustifolia preparations, and steam inhalation are ineffective at relieving cold symptoms. Pseudoephedrine, phenylephrine, inhaled ipratropium, and zinc (acetate or gluconate) modestly reduce the severity and duration of symptoms for adults. Nonsteroidal anti-inflammatory drugs and some herbal preparations, including Echinacea purpurea, improve symptoms in adults. Prophylactic use of garlic may decrease the frequency of colds in adults, but has no effect on duration of symptoms. Hand hygiene reduces the spread of viruses that cause cold illnesses. Prophylactic vitamin C modestly reduces cold symptom duration in adults and children.

Herpes zoster and postherpetic neuralgia: prevention and management.

Herpes zoster (shingles) is diagnosed clinically by recognition of the distinctive, painful vesicular rash appearing in a unilateral, dermatomal distribution. An estimated 1 million cases occur in the United States each year, and increasing age is the primary risk factor. Laboratory testing, including polymerase chain reaction, can confirm atypical cases. Treatment with acyclovir, famciclovir, or valacyclovir decreases the duration of the rash. Adjunct medications, including opioid analgesics, tricyclic antidepressants, or corticosteroids, may relieve the pain associated with acute herpes zoster. There is conflicting evidence that antiviral therapy during the acute phase prevents postherpetic neuralgia. Postherpetic neuralgia in the cutaneous nerve distribution may last from 30 days to more than six months after the lesions have healed. Evidence supports treating postherpetic neuralgia with tricyclic antidepressants, gabapentin, pregabalin, long-acting opioids, or tramadol; moderate evidence supports the use of capsaicin cream or a lidocaine patch as a second-line agent. Immunization to prevent herpes zoster and postherpetic neuralgia is recommended for most adults 60 years and older.

COVID-19 disruption to family medicine residency curriculum: results from a 2020 US programme directors survey.

OBJECTIVE: This research project examined the effects of the COVID-19 pandemic on the required curriculum in graduate medical education for family medicine residencies. DESIGN: Our questions were part of a larger omnibus survey conducted by the Council of Academic Family Medicine Educational Research Alliance. Data were collected from 23 September to 16 October 2020. SETTING: This study was set in the USA. PARTICIPANTS: Emails were sent to 664 family medicine programme directors in the USA. Of the 312 surveys returned, 35 did not answer our questions and were excluded, a total of 277 responses (44%) were analysed. RESULTS: The level of disruption varied by discipline and region. Geriatrics had the highest reported disruption (median=4 on a 5-point scale) and intensive care unit had the lowest (median=1 on a 5-point scale). There were no significant differences for disruption by type of programme or community size. CONCLUSION: Programme directors reported moderate disruption in family medicine resident education in geriatrics, gynaecology, surgery, musculoskeletal medicine, paediatrics and family medicine site during the pandemic. We are limited in generalisations about how region, type of programme, community size or number of residents influenced the level of disruption, as less than 50% of programme directors completed the survey.

Erythema ab igne: Toasted Skin Syndrome.

Introduction: Erythema ab igne is a benign skin condition caused by long-term exposure to infrared radiation and/or heat. Erythema ab igne begins as a mild erythema over the previously exposed areas and develops into an erythematous reticulated hyperpigmentation with scaling and telangiectasias. Clinical Findings: A 55-year-old female presented to the primary care clinic with concerns due to the development of a rash on her lower back in the previous 1 to 2 weeks. She had a history of chronic back pain and was using conservative treatment for pain management, including daily use of a heating pad for 15 minutes every hour. Interventions: There is no definitive therapy for erythema ab igne. Elimination of the heat source may reverse the erythema and hyperpigmentation. Outcome: The patient was counseled regarding the importance of limiting and/or discontinuing the use of the heating pad to facilitate resolution of the rash. The patient did not return to the clinic and resolution of the rash was not confirmed.

Comparison of Maternity Care Training in Family Medicine Residencies 2013 and 2019: A CERA Program Directors Study.

BACKGROUND AND OBJECTIVES: Maternity care training is a standard requirement for all family medicine residents, and family physicians play a critical role in the US maternity care workforce. In 2014, the Accreditation Council for Graduate Medical Education (ACGME) updated the required obstetrical experience during family medicine residency training from a volume-based to a competency-based requirement of 200 hours (2 months rotation). This study aimed to determine if family medicine resident maternity care training experience differed after this change in requirements. METHODS: A nationwide survey of family medicine program directors was conducted as part of the 2019 Council of Academic Family Medicine Educational Research Alliance (CERA) survey, replicating a 2013 CERA survey to determine if there was a change in family medicine resident maternity care experience after the ACGME requirements update. RESULTS: The priority programs place on residents' continuity deliveries and family medicine faculty attending deliveries decreased between 2013 and 2019. The reported number of continuity deliveries and vaginal deliveries performed by residents also decreased significantly between 2013 and 2019, yet the program directors' estimate of the number of graduates going on to provide obstetric deliveries or pursue a maternity care fellowship did not change significantly. Programs reporting more than 25% of graduates continuing to conduct vaginal deliveries have reported similar numbers of vaginal deliveries per resident as in 2013. CONCLUSIONS: The majority of family medicine residents are graduating with less delivery experience, and residency programs are placing less priority on continuity deliveries and modeling by family physician faculty following the 2014 ACGME Family Medicine Requirements update. This trend may have major implications on the comprehensive nature of our specialty and further widen gaps in the maternity care workforce. Further studies are needed to determine the impact on the competency of graduating family medicine residents in providing maternity care and for the long-term effects on the maternity care workforce.

Creative Writing in Residency Training.

Description Residents compose notes for medical purposes on a daily basis. As part of wellness, I have done creative writing during didactic time with family medicine residents. I present some of the poems that have been created.

Gastroesophageal Reflux Disease: A General Overview.

Description Gastroesophageal reflux disease (GERD) varies in presentation and the patient's symptoms of regurgitation in the throat or epigastric pain do not necessarily correlate with the severity of their disease. This general overview of GERD will include information on guidelines and diagnostic testing; lifestyle, medical and surgical management; and GERD in special populations. The pathophysiology of GERD is multifactorial, and a step-wise approach will assist physicians in making the diagnosis as GERD has a significant financial burden to the U.S. healthcare system.

Nine SARS-CoV-2 Positive Pregnant Women and Their Infant Delivery Outcomes.

There are scientific reports from around the world describing the cases of COVID-19. This is a case series reporting outcomes of deliveries from nine mothers with positive SARS-CoV-2 testing at Healthcare Corporation of America hospitals in the United States from January to April 2020. Thirty-three percent of the women had cesarean sections. There was only one preterm birth and that infant did have low birth weight and low Apgar scores at one and five minutes. Seven of the nine infants were tested for SARS-CoV-2 and all results were negative. As the COVID-19 pandemic continues across the globe and at a high rate in the United States, more research will be needed to determine the outcomes for pregnant women and their offspring, both at birth and in the future.

Eye Conditions in Infants and Children: Myopia and Hyperopia.

Patients with poor vision screening results should be referred to an ophthalmology subspecialist for further testing to define the refractive error. Refractive errors are influenced by the optical power of the cornea and lens, along with the length of the eye (ie, total of the lens thickness, anterior, and vitreous chamber depth). Refractive errors include myopia, in which the visual image focuses in front of the retina, and hyperopia, in which the visual image focuses behind the retina. Patients with myopia, or nearsightedness, are able to see near objects better than those at a distance. Being outdoors or participation in physical activity outdoors may prevent myopia. Eyeglasses, surgery, and pharmacotherapy also have been studied to correct and prevent progression of myopia. Patients with hyperopia, or farsightedness, have good distance vision but may have more difficulty with reading. Another concern for children with hyperopia is development of strabismus because of refractive error. Eyeglasses and surgery are the management options for hyperopia.

Eye Conditions in Infants and Children: Vision Screening and Routine Eye Examinations.

Vision problems in children are relatively common, with refractive error, strabismus, and/or amblyopia affecting between 5% to 10% of preschool-age children. Amblyopia is most concerning in the pediatric population because the visual system can develop poorly, potentially causing unilateral or bilateral vision impairment, which may or may not be correctable. Because of this, most pediatric vision screening recommendations focus on screening for amblyopia or the risk factors for amblyopia, including anisometropia, high refractive errors, and strabismus. The U.S. Preventive Services Task Force (USPSTF) recommends screening children for amblyopia and its risk factors at least once between ages 3 and 5 years. However, the joint policies of the American Academy of Pediatrics (AAP), American Academy of Ophthalmology (AAO), American Association for Pediatric Ophthalmology and Strabismus (AAPOS), and American Association of Certified Orthoptists (AACO) recommend screening starting in the newborn period and continuing through adolescence. These groups advocate for instrument screening in younger children and children who are developmentally delayed because the use of eye charts can be difficult in these children. In general, children with abnormal screening results should be referred to an ophthalmology subspecialist for further evaluation.

Eye Conditions in Infants and Children: Amblyopia and Strabismus.

Amblyopia is a developmental disorder of the central nervous system. It occurs in infancy or early childhood when the visual system is susceptible to issues that interrupt development. In the United States, up to 2% of infants and children ages 6 to 71 months have amblyopia. Risk factors for amblyopia include hyperopia, astigmatism, and myopia. Risk factors are more common in children who are premature or small for gestational age. Management of amblyopia in children includes optical correction of refractive errors, occlusion therapy (patching), pharmacotherapy, and surgery. Strabismus occurs when one eye can focus on an object or a point but the other eye turns inward toward the nose (esotropia), upward (hypertropia), downward (hypotropia), or outward toward the temple (exotropia). The patient may report diplopia or vision loss and may present with compensating posture such as a head tilt. Nonsurgical (ie, eyeglasses, prisms, onabotulinumtoxinA) and surgical management options are available to manage strabismus.

Eye Conditions in Infants and Children: Accommodations for Children With Vision Impairment.

The effects of vision impairment and blindness on children can last a lifetime. Most children with vision impairments need a multidisciplinary team of teachers, child development specialists, and social workers. Blindness often is associated with other risk factors, disease processes, and/or disabilities. In the United States, the Social Security Administration defines children as legally blind when best corrected visual acuity is less than 20/200. The US law concerning accommodations for children with impairments is part of the Americans with Disabilities Act of 1990 (ADA), and specifically the Individuals with Disabilities Education Act (IDEA), which covers preschool-age and school-age children. Accommodations for children with vision impairment include low vision aids allowing them to stay in mainstream classes and schools.

What is appropriate fetal surveillance for women with diet-controlled gestational diabetes?

No evidence clearly supports the practice of increased fetal surveillance in the pregnancies of women with well-controlled (ie, fasting blood sugar <105 mg/dL) class A1 gestational diabetes (strength of recommendation [SOR]: B, consistent retrospective cohort studies). However, a number of guidelines recommend beginning surveillance of some kind between 32 and 40 weeks based on cumulative risk factors, including gestational diabetes (SOR: C, expert opinion).

Common gastrointestinal symptoms: dysphagia.

Swallowing occurs in 3 phases: oral, pharyngeal, and esophageal. Oropharyngeal dysphagia typically is a result of neuromuscular disorders, such as stroke and parkinsonism, or of mucosal dryness caused by drugs or radiation therapy. Esophageal dysphagia is commonly caused by anatomic defects of the esophagus, such as reflux disease; motility disorders, such as achalasia; or eosinophilic esophagitis. If oropharyngeal dysphagia is suspected, the patient should undergo initial testing with a water or semisolid bolus swallow test. If results are positive, the diagnosis can be confirmed with a videofluoroscopic swallowing study. If esophageal dysphagia is suspected, patients typically undergo endoscopic esophagogastroduodenoscopy. Management of confirmed oropharyngeal dysphagia involves short-term compensation strategies, such as postural changes or food thickening, to minimize the risk of aspiration. This is followed by rehabilitation that may involve swallowing exercises with biofeedback or electrical stimulation of the swallowing muscles. Some patients may need enteral feeding. For esophageal dysphagia, choice of management depends on the etiology; it may include endoscopic dilation, myotomy, injection of onabotulinumtoxinA (formerly called botulinum toxin type A) for structural abnormalities, or topical steroid therapy for eosinophilic esophagitis.

Common gastrointestinal symptoms: irritable bowel syndrome.

The diagnosis of irritable bowel syndrome (IBS) should be considered when patients have had abdominal pain/discomfort, bloating, and change in bowel habits for 6 months. Patients may experience variation between periods of constipation and diarrhea. When evaluating patients with IBS, physicians should be alert for red flag symptoms, such as rectal bleeding, anemia, nighttime pain, and weight loss. Physicians also should consider other medical conditions that manifest similarly to IBS. Clinicians who are confident in diagnosing IBS based on symptoms typically do not obtain many tests unless the patient has red flag symptoms. Various etiologic mechanisms have been proposed for IBS, including abnormal bowel motility, inflammation, altered mucosal permeability, genetic predisposition, and visceral hypersensitivity. Lack of certainty about the etiology makes it difficult to develop effective management approaches; thus, management is directed toward symptom relief. Dietary changes, such as avoiding fermentable carbohydrates, may benefit some patients, especially those with bloating. Constipation-dominant IBS can be managed with antispasmodics, lubiprostone, or linaclotide, whereas diarrhea-dominant IBS can be managed with loperamide or alosetron, though the latter drug can cause ischemic colitis. For long-term therapy, tricyclic antidepressants or selective serotonin reuptake inhibitors have good efficacy. Peppermint oil and probiotics also may provide benefit.

Common Gastrointestinal Symptoms: dyspepsia and Helicobacter pylori.

The most common diagnoses among patients with dyspepsia are functional dyspepsia, gastroesophageal reflux disease, peptic ulcer, and gastric or esophageal cancer. Helicobacter pylori infection is present in many patients with dyspepsia and is etiologic in some conditions. The evaluation of dyspepsia divides patients into 3 categories: 1) for patients taking nonsteroidal anti-inflammatory drugs (NSAIDs), NSAIDs should be discontinued; if symptoms resolve after discontinuation, no further evaluation is needed; 2) for patients with reflux symptoms, proton pump inhibitors (PPIs) should be prescribed without endoscopy unless alarm symptoms are present; and 3) for patients with no NSAID use or reflux symptoms, evaluation depends on risk. Patients older than 55 years or with alarm symptoms are at high risk and should undergo endoscopy. Those 55 years or younger with no alarm symptoms are at low risk. Those patients should be tested for H pylori and treated if results are positive. If symptoms persist after eradication treatment, PPIs should be prescribed for 4 to 6 weeks; if symptoms persist after treatment, endoscopy should be obtained. If H pylori test results are negative, PPIs should be prescribed for 4 to 6 weeks. Endoscopy should be obtained if symptoms persist. There are several regimens for eradication of H pylori. The most effective is sequential therapy with a PPI and amoxicillin for 5 days followed by a PPI, clarithromycin, and tinidazole for another 5 days.

Common gastrointestinal symptoms: risks of long-term proton pump inhibitor therapy.

More than 11 million individuals receive proton pump inhibitor (PPI) prescriptions each year in the United States. Although PPIs are effective treatment for peptic ulcers and esophagitis and provide symptom relief for many other conditions, their use carries risks. They decrease gastric acid and can lower blood levels of drugs whose absorption is acid dependent, including several antiretroviral and cancer therapy drugs. Other drugs, such as digoxin, may be absorbed more extensively when gastric acid is reduced; thus, digoxin toxicity may occur with PPI use. Warfarin's effect also is increased in patients taking PPIs. Decreased gastric acid can lower absorption of vitamin B12, calcium, iron, and magnesium; deficiencies in these nutrients are a concern. Several medical conditions, including Clostridium difficile infection, osteoporotic fractures, and community-acquired pneumonia, are more likely to occur among PPI users. Interstitial nephritis also has been reported. Because of these risks, clinicians should try to use the lowest possible dose of PPI and to discontinue PPI therapy if it is not essential. Step-down regimens can be used to decrease/discontinue treatment; these regimens may prevent or minimize the rebound acid hypersecretion that can occur with abrupt discontinuation. For some patients, occasional treatment with intermittent or on-demand regimens may be sufficient to control symptoms.