Sarcoidosis: Evaluation and Treatment.

Sarcoidosis is a multisystem granulomatous inflammatory disease of unknown etiology that can involve any organ. Ongoing dyspnea and dry cough in a young to middle-aged adult should increase the suspicion for sarcoidosis. Symptoms can present at any age and affect any organ system; however, pulmonary sarcoidosis is the most common. Extrapulmonary manifestations often involve cardiac, neurologic, ocular, and cutaneous systems. Patients with sarcoidosis can exhibit constitutional symptoms such as fever, unintentional weight loss, and fatigue. The early recognition and diagnosis of sarcoidosis are challenging because there is no diagnostic standard for testing, initial symptoms vary, and patients may be asymptomatic. Consensus guidelines recommend a holistic approach when diagnosing sarcoidosis that focuses on clinical presentation and radiographic findings, biopsy with evidence of noncaseating granulomas, involvement of more than one organ system, and elimination of other etiologies of granulomatous disease. Corticosteroids are the initial treatment for active disease, with refractory cases often requiring immunosuppressive or biologic therapies. Transplantation can be considered for advanced and end-stage disease depending on organ involvement.

Virtual Recruitment Effects on Matched Residents in Family Medicine: Experiences From Central Pennsylvania.

Background and Objectives: As a result of the COVID-19 pandemic, interviews during the 2021 US residency match were conducted virtually, a practice again recommended and repeated by many programs in 2022. The impact of virtual interviews on recruitment and match outcomes has recently been of interest, with results showing the virtual format to be mostly well received by applicants due to cost, travel, and scheduling benefits. Few studies have looked at pre/posttransition comparisons of applicant geographic and demographic data. We compared objective match outcomes between in-person and virtual interviews across three residency programs. Methods: We conducted a retrospective cross-sectional analysis of National Residency Matching Program data between 2015-2022 across three family medicine residency programs. Primary outcomes were fill rate, average rank position, distance from program, and percentage of underrepresented in medicine demographic status for matched applicants. We compared aggregate in-person data (2015-2019) to aggregate virtual data (2020-2022) for each program using χ2, Fisher Exact test, or 2-tailed t tests to 95% confidence. Results: Saint Joseph Hospital in Reading, Pennsylvania, a 3-year community-based university affiliated program, had significantly more unfilled positions during virtual recruitment (P=.0058). Mount Nittany Medical Center in State College, Pennsylvania, a 3-year community based university-affiliated program, had a significant difference in distance of matched residents' current address (P=.048). Virtual interviews were not associated with significant differences in average position on rank list, average distance from permanent address zip code, or percentage of underrepresented in medicine (URiM) demographic status for matched applicants. Conclusions: The impact of virtual interviewing on unfilled positions and geographic data is likely site specific and generally small, as some programs had significant structural changes. Further research is needed to confirm the generalizability of these results and explore future comparisons of demographic and geographic characteristics of matched applicants pre/posttransition to the virtual format.

Atopic Dermatitis.

Atopic dermatitis (AD) is a common, chronic relapsing, and remitting inflammatory skin disease that is characterized by erythematous, scaly, and pruritic lesions often located over the flexural surfaces. Treatment goals of AD include the reduction of itching and burning, as well as the reduction of skin changes. Treatment of AD includes emollients and skin care, topical therapies including topical corticosteroids and steroid-sparing therapies, systemic therapies, and phototherapy.

Autoimmune Skin Conditions: Psoriasis.

Psoriasis is a chronic, inflammatory skin condition with significant effect on quality of life. It affects 3.2% of the United States population. Psoriasis is caused by an interaction between genetic and environmental triggers. Associated conditions include depression, increased cardiovascular risk, hypertension, hyperlipidemia, diabetes, nonalcoholic fatty liver disease, Crohn disease, ulcerative colitis, celiac disease, nonmelanoma skin cancers, and lymphoma. Several clinical variants exist, including chronic plaque, guttate, pustular, inverse, and erythrodermic psoriasis. Lifestyle modification and topical therapies, such as emollients, coal tar, topical corticosteroids, vitamin D analogues, and calcineurin inhibitors, are used for limited disease. More severe psoriasis may require systemic therapy with oral or biologic therapy. Individualized management of psoriasis may involve different combinations of treatments. Counseling patients about associated comorbidities is essential.

Autoimmune Skin Conditions: Autoimmune Blistering Disease.

There are many types of autoimmune blistering skin disease. Two of the most common are bullous pemphigoid and pemphigus vulgaris. Bullous pemphigoid is characterized by tense bullae created by a subepidermal split resulting from autoantibodies targeted at the hemidesmosomes at the dermal-epidermal junction. Bullous pemphigoid typically occurs in elderly people and often can be drug-induced. Pemphigus vulgaris is characterized by flaccid bullae because of an intraepithelial split triggered by autoantibodies targeting desmosomes. Diagnosis can be made for both conditions by physical examination, biopsy for routine histology, biopsy for direct immunofluorescence, and serologic studies. Both bullous pemphigoid and pemphigus vulgaris are associated with significant morbidity and mortality and diminished quality of life, making early recognition and diagnosis paramount. Management proceeds in a stepwise approach using potent topical corticosteroids along with immunosuppressant drugs. Rituximab recently has been shown to be the drug of choice for most people with pemphigus vulgaris.

Autoimmune Skin Conditions: Systemic Sclerosis.

Systemic sclerosis (formerly scleroderma) is a relatively rare autoimmune connective tissue disease which symmetrically affects the skin and affects the internal organs. There are two types: limited cutaneous and diffuse cutaneous. Each type is categorized by different clinical, systemic, and serologic findings. Autoantibodies can be used to predict phenotype and internal organ involvement. Systemic sclerosis can affect the lungs, gastrointestinal system, kidneys, and heart. Pulmonary and cardiac disease are the leading causes of death, so screening for these conditions is important. Early management of systemic sclerosis is paramount to prevent progression. Numerous therapeutic interventions for systemic sclerosis exist, but there is no cure. The goal of therapy is to improve quality of life by minimizing specific organ-threatening involvement and life-threatening disease.

Autoimmune Skin Conditions: Cutaneous Lupus Erythematosus.

Cutaneous lupus erythematosus (CLE) is a spectrum of autoimmune skin conditions associated with systemic lupus erythematosus (SLE). CLE and SLE may exist concurrently or independently. Accurate recognition of CLE is crucial because it may herald systemic disease onset. Lupus-specific skin conditions include acute cutaneous lupus erythematosus (ACLE) which manifests as a malar or butterfly rash; subacute cutaneous lupus erythematosus (SCLE); and chronic cutaneous lupus erythematosus, which includes discoid lupus erythematosus (DLE). All three types of CLE present as pink-violet macules or plaques with unique morphology, in areas of sun-exposed skin. Association with SLE differs: ACLE is most closely associated, with SCLE in the middle, and DLE the least so. All types of CLE are pruritic, sting, and burn, and DLE can result in disfiguring scarring. All CLE is exacerbated by UV light exposure and smoking. Diagnosis combines clinical evaluation with skin biopsy. Management focuses on mitigating modifiable risk factors and using pharmacotherapy. UV protection includes use of sun protective factor (SPF) 60 or higher sunscreens containing zinc oxide or titanium dioxide, avoidance of sun exposure, and use of physical barrier clothing. Topical therapies and antimalarial drugs are first-line, followed by systemic therapies (eg, disease-modifying antirheumatic drugs, biologic therapies [eg, anifrolumab, belimumab], or other advanced systemic drugs).

Effects of Early COVID-19 Restrictions on Resident Well-being and Burnout.

BACKGROUND AND OBJECTIVES: The COVID-19 pandemic has contributed to burnout among residents, a population already at increased risk for heightened stress and work-related fatigue. Residency programs were also forced to alter schedules and educational objectives. We assessed how social distancing restrictions (specifically self-isolation) enacted early in the COVID-19 pandemic affected family medicine (FM) resident well-being and burnout. Our FM department created a 2-week reserve rotation as a response to the need to socially distance and protect the residents. We explored how the reserve rotations impacted their experiences. METHODS: A purposive sample of FM residents were recruited in May and June of 2020. Qualitative interviews explored well-being and burnout, changes in education and provision of patient care, and overall adaptation to the pandemic. We employed interpretative phenomenology to analyze the interviews. RESULTS: We interviewed six out of 24 residents before saturation was reached. Qualitative analysis revealed themes related to positive and negative consequences of the pandemic, including uncertainty/fear of the unknown, schedule/life changes, communication, and adapting to a new routine. CONCLUSIONS: The COVID-19 pandemic placed an additional burden on residents, a group already at increased risk for burnout. While uncertainty and disruptions in work and home life were significant stressors, this cohort demonstrated adaptability and resilience that was facilitated by peer support and effective communication. These factors, along with the reserve rotation with decreased clinical responsibilities, led to an improved sense of well-being and decreased feelings of burnout.

Assorted Skin Procedures: Foreign Body Removal, Cryotherapy, Electrosurgery, and Treatment of Keloids.

Clinicians in the primary care setting will encounter various different skin conditions requiring procedural intervention. There are many different procedural approaches to treatment. Knowing which modalities are available and best suited to handle a particular skin lesion allows for flexibility for patient and clinician. Although some treatment modalities may be used more than others, it is helpful to be at least familiar with basic in office skin procedures such as removal of foreign bodies, cryotherapy, electrosurgery, and treatment of keloids, as these procedures are helpful in addressing the wide variety of the most commonly encountered skin issues in primary care.

A guide to the Tx of cellulitis and other soft-tissue infections.

Diagnostic and therapeutic priorities vary for the 8 types of infection reviewed.

Area- and Individual-Level Correlates of Self-Rated Health: Implications for Geographic Health Disparities.

BACKGROUND: Self-rated health (SRH) is a common measure of overall health. However, little is known about multilevel correlates of physical and mental SRH. METHODS: Patients attending primary care clinics completed a survey before their appointment, which we linked to community data from American Community Survey and other sources (n = 455). We conducted multilevel logistic regression to assess correlates of excellent/very good versus good/fair/poor physical and mental SRH. RESULTS: 43.9% of participants had excellent/very good physical SRH, and 55.2% had excellent/very good mental SRH. Physical SRH was associated with age (odds ratio[OR] = 0.82 per 10 years; 95% confidence interval[CI] = 0.72-0.93) and community correlates, including retail establishment density (OR = 0.94, 95% CI = 0.90-0.99) and percent of students eligible for free/reduced lunch (OR = 1.60, 95% CI = 1.08-2.38) (all P < .05). Mental SRH was not associated with any characteristics. CONCLUSIONS: Practitioners in public health, social work, and medicine could use zip codes to intervene in patients and communities to improve physical SRH.