Lifelong Care of Patients After Gender-Affirming Surgery.

Gender-affirming surgery includes a range of procedures that help align a transgender or gender diverse person's body with their gender identity. As rates of gender-affirming surgery increase, family physicians will need to have the knowledge and skills to provide lifelong health care to this population. Physicians should conduct an anatomic survey or organ inventory with patients to determine what health screenings are applicable. Health care maintenance should follow accepted guidelines for the body parts that are present. Patients do not require routine breast cancer screening after mastectomy; however, because there is residual breast tissue, symptoms of breast cancer warrant workup. After masculinizing genital surgery, patients should have lifelong follow-up with a urologist familiar with gender-affirming surgery. If a prostate examination is indicated after vaginoplasty, it should be performed vaginally. If a pelvic examination is indicated after vaginoplasty, it should be performed with a Pederson speculum or anoscope. After gonadectomy, patients require hormone therapy to prevent long-term morbidity associated with hypogonadism, including osteoporosis. The risk of sexually transmitted infections may change after genital surgery depending on the tissue used for the procedure. Patients should be offered the same testing and treatment for sexually transmitted infections as cisgender populations, with site-specific testing based on sexual history. If bowel tissue is used in vaginoplasty, vaginal bleeding may be caused by adenocarcinoma or inflammatory bowel disease. (Am Fam Physician. 2024;109(6):560-565.

Using Ultrasound to Augment Exam Skills Among Clerkship Students.

Introduction: Point-of-care ultrasound (POCUS) is becoming more common as a diagnostic and clinical tool. Some medical schools have incorporated POCUS training in their curriculum. A family medicine clerkship during the third year of undergraduate medical education is appropriate for incorporating musculoskeletal (MSK) education. Musculoskeletal ultrasound (MSKUS) is a potential tool for augmenting this teaching. Methods: Third-year undergraduate family medicine clerkship students were given prework related to ultrasound physics, terminology, and sonographic appearance of MSK structures. This was followed by a 2-hour session in the first week of their clerkship covering the shoulder and knee MSK exams, and incorporated hands-on scanning. Students practiced MSK exams during their 8-week clerkship and POCUS was available in clinic. They were administered a postsession survey to rate the MSKUS curriculum. Objective, structured clinical exam (OSCE) testing, including performance evaluation of the knee examination during the final clerkship week, was compared to prior-year OSCE scores. Results: Third-year medical students felt the use of MSKUS was helpful and enhanced overall understanding of MSK exams. We did not see an improvement in OSCE scores. Students reported a desire for more POCUS training. Conclusion: POCUS is a powerful tool within the clinical and academic setting. We were able to develop a curriculum using MSKUS to augment teaching the shoulder and knee exams to third-year family medicine clerkship students. While we did not see an improvement in OSCE scores evaluating the performance of a knee exam, students reported greater understanding of the exams with the MSKUS instruction added. Students desire more POCUS training in the undergraduate medical curriculum.

Adaptation and External Validation of Pathogenic Urine Culture Prediction in Primary Care Using Machine Learning.

BACKGROUND: Urinary tract infection (UTI) symptoms are common in primary care, but antibiotics are appropriate only when an infection is present. Urine culture is the reference standard test for infection, but results take >1 day. A machine learning predictor of urine cultures showed high accuracy for an emergency department (ED) population but required urine microscopy features that are not routinely available in primary care (the NeedMicro classifier). METHODS: We redesigned a classifier (NoMicro) that does not depend on urine microscopy and retrospectively validated it internally (ED data set) and externally (on a newly curated primary care [PC] data set) using a multicenter approach including 80,387 (ED) and 472 (PC) adults. We constructed machine learning models using extreme gradient boosting (XGBoost), artificial neural networks, and random forests (RFs). The primary outcome was pathogenic urine culture growing ≥100,000 colony forming units. Predictor variables included age; gender; dipstick urinalysis nitrites, leukocytes, clarity, glucose, protein, and blood; dysuria; abdominal pain; and history of UTI. RESULTS: Removal of microscopy features did not severely compromise performance under internal validation: NoMicro/XGBoost receiver operating characteristic area under the curve (ROC-AUC) 0.86 (95% CI, 0.86-0.87) vs NeedMicro 0.88 (95% CI, 0.87-0.88). Excellent performance in external (PC) validation was also observed: NoMicro/RF ROC-AUC 0.85 (95% CI, 0.81-0.89). Retrospective simulation suggested that NoMicro/RF can be used to safely withhold antibiotics for low-risk patients, thereby avoiding antibiotic overuse. CONCLUSIONS: The NoMicro classifier appears appropriate for PC. Prospective trials to adjudicate the balance of benefits and harms of using the NoMicro classifier are appropriate.

Impact of the COVID-19 Pandemic on Exercise Habits Among US Primary Care Patients.

BACKGROUND: To explore how the COVID-19 pandemic has affected exercise habits, we hypothesized that participants' physical activity would have increased by at least 30 min/wk after the onset of the pandemic. METHODS: We distributed an anonymous survey to ambulatory patients at the Family Medicine Clinic, University of Kansas Medical Center to analyze changes in exercise habits and weight. RESULTS: Of the 500 adult patients surveyed, 382 were included. Results were stratified by demographics, including employment status before and during COVID-19. The median change in weekly exercise duration was 0.0 minutes, but the mean change was -25.7 minutes; total exercise duration decreased after the pandemic's onset (paired Wilcox signed rank test P < .001). More individuals reported participation in virtual group classes (6.3% before the pandemic vs 13.1% during the pandemic; McNemar's P < .001). Individuals with home exercise equipment before the pandemic were more likely to acquire more than were those who had none before (Chi square test P < .005). Overall, there is a significant trend in the direction of weight gain (Wilcox signed rank test P < .001). CONCLUSIONS: Most participants decreased physical activity during the unprecedented COVID-19 pandemic, expanding our understanding of how exercise habits change during stressful life events.

Telemedicine Management of Musculoskeletal Issues.

Telemedicine can provide patients with cost-effective, quality care. The coronavirus disease 2019 pandemic has highlighted the need for alternative methods of delivering health care. Family physicians can benefit from using a standardized approach to evaluate and diagnose musculoskeletal issues via telemedicine visits. Previsit planning establishes appropriate use of telemedicine and ensures that the patient and physician have functional telehealth equipment. Specific instructions to patients regarding ideal setting, camera angles, body positioning, and attire enhance virtual visits. Physicians can obtain a thorough history and perform a structured musculoskeletal examination via telemedicine. The use of common household items allows physicians to replicate in-person clinical examination maneuvers. Home care instructions and online rehabilitation resources are available for initial management. Patients should be scheduled for an in-person visit when the diagnosis or management plan is in question. Patients with a possible deformity or neurovascular compromise should be referred for urgent evaluation. Follow-up can be done virtually if the patient's condition is improving as expected. If the condition is worsening or not improving, the patient should have an in-office assessment, with consideration for referral to formal physical therapy or specialty services when appropriate.

Care of the Military Veteran: Selected Health Issues.

According to the U.S. Census Bureau, 18.2 million veterans were living in the United States in 2017, of whom 1.6 million were female. Less than one-half of all veterans receive care at a Veterans Health Administration or military treatment facility, leaving most to receive services from primary care physicians. Injuries and illnesses common among this patient population include musculoskeletal injuries and chronic pain, mental health issues such as posttraumatic stress disorder (PTSD) and moral injury, traumatic brain injury, chemical and noise exposures, and infectious disease concerns. Family physicians should ask about military service and be well informed about the range of veterans' health concerns, particularly PTSD, depression, and suicidality. Physicians should screen veterans for depression using the Patient Health Questionnaire-9 and for PTSD using the PTSD Checklist for DSM-5. Veterans with traumatic brain injury should be screened specifically for comorbid PTSD and chronic pain because the diagnosis informs treatment. Exposures to loud noise, chemicals, and infectious diseases are prevalent and can cause disability. Family physicians can use available resources and clinical practice guidelines such as those from the U.S. Department of Veterans Affairs and Department of Defense to inform care and to assist veterans.

Anomalies associated with failed methotrexate and misoprostol termination.

BACKGROUND: Methotrexate and misoprostol are frequently used in combination for medical termination of pregnancy. Despite their frequent use, published information about low-dose exposures to these known teratogens is sparse and neonatal follow-up data are limited. We present neonatal outcomes in three infants from two different women who had failed medical terminations with methotrexate and misoprostol. CASES: A young gravida 1, para 0, presented with intrauterine pregnancy complicated by first-trimester exposure to oral methotrexate and vaginal misoprostol. Ultrasonography determined that the fetus had intrauterine growth restriction and ventriculomegaly. The infant had growth and developmental delays. A young gravida 4, para 3-0-0-3, also presented after first trimester exposure to methotrexate and misoprostol, and was found to have a twin gestation. The infants were noted to have multiple congenital anomalies, growth restriction, and developmental delay. CONCLUSION: Even single doses of methotrexate and misoprostol used in medical termination of pregnancy can be associated with multiple congenital anomalies.