Radiographical bony lesions after discontinuation of immunosuppressant therapy: bone involvement in sarcoidosis.

We describe a patient who had failed renal transplant after 13 years, eventually requiring a graft nephrectomy and discontinuation of immunosuppressive therapy, including antithymocyte globulin, tacrolimus and mycophenolate while on steroid avoidance protocol. Within a few months of complete discontinuation of the immunosuppressive medications, she developed lower back pain associated with numbness in her right anterolateral thigh. The radiological imaging demonstrated multiple bony lesions throughout her axial and appendicular skeleton with normal pulmonary findings. A computerised tomography-guided bone biopsy from the left iliac crest revealed fragments of bone with granulomatous inflammation, thus making the diagnosis of extrapulmonary sarcoidosis. Initiating treatment with prednisone resulted in near-complete resolution of symptoms. Long-term immunosuppressive therapy is administered to all renal transplant recipients to help prevent acute rejection and loss of renal allograft. This case highlights that immunosuppressants can conceal the presence of underlying conditions in transplant patients.

Unusual and rare cause of abdominal pain: abdominal desmoid fibromatosis masquerading as a postoperative haematoma.

Desmoid fibromatosis is a rare connective tissue malignancy. It can occur in a variety of locations, including the abdominal wall, extremities and abdominal cavity. There has been an association with development in a prior surgical scar. Common symptoms can vary depending on the location and can include being painless to having pain at the site, functional impairment and bowel obstruction from intra-abdominal masses. In the following report, we discuss a case in which a patient's abdominal pain was attributed to a postoperative haematoma based on CT radiographic features; however, further work-up and biopsy yielded desmoid fibromatosis, a rare locally aggressive malignancy.

A Primary Care Clerkship during the COVID-19 Pandemic, An Educator and Learners' Perspective on Telemedicine, The New Frontier of Clinical education.

This article was migrated. The article was marked as recommended. The COVID-19 pandemic has disrupted the educational experience within medical education. Telemedicine has rapidly ascended to the forefront with healthcare delivery during the pandemic. We discuss our initial perspective with telemedicine as the sole clinical instructive platform within a family medicine clerkship rotation.

High Volume Portal Usage Impacts Practice Resources.

Patient portals have both patient-centered benefits and substantial impacts on practices. Successful implementation of a patient portal can be achieved with a comprehensive team approach. Increased portal usage results in high-volume patient secure messaging. We describe the impact of high patient message volume on our fee-for-service academic family medicine practice. Practice adaptations are necessary to manage volume, length, and complexity of messages. Dedicated staff with specialized training to handle patient messages and ample protected time for providers are important to minimize clerical burden associated with patient portal use.

Acute pancreatitis associated with lisinopril and olanzapine.

PURPOSE: A case of acute pancreatitis associated with lisinopril and olanzapine is described. SUMMARY: A 69-year-old woman came to the emergency department after four days of experiencing epigastric pressurelike pain that radiated to the left lower quadrant and worsened with ingestion of food. She had started lisinopril three months prior for treatment of hypertension and had been taking olanzapine regularly for bipolar disorder. Upon admission, she was afebrile and hemodynamically stable and exhibited tenderness of the epigastric region. Elevated pancreatic enzymes and abdominal computed tomography (CT) imaging findings confirmed the diagnosis of pancreatitis. Common causes of pancreatitis were ruled out, and it was determined that the recent combination of lisinopril and olanzapine was the likely cause. Food and liquids were withheld, and all oral medications were stopped at hospital admission. Her pain resolved completely after two days. She was discharged on hospital day 4, and all of her medications except lisinopril and olanzapine were resumed. During a follow-up visit with her primary care physician, she reported to be doing well and had no systemic complaints. Olanzapine was reinitiated at that time but was discontinued a month later by her psychiatrist, who was concerned about the development of recurrent symptoms of pancreatitis. Valsartan was prescribed to achieve optimal blood pressure control three weeks after discharge. A follow-up CT scan of the abdomen a month later found no residual pancreatic abnormalities. CONCLUSION: The additive effect of two known pancreatitis-causing medications resulted in increased risk and subsequent acute pancreatitis in this patient.

Urinary tract infection in women over the age of 65: is age alone a marker of complication?

BACKGROUND: We were interested to know if our older female patients with urinary tract infections (UTIs) might have differing pathogens or rates of Escherichia coli antibiotic sensitivity and if our physicians managed them in a manner similar or dissimilar to the care provided to younger patients with no complications. METHODS: This was a secondary analysis from patients excluded from a previous retrospective study regarding uncomplicated UTIs. RESULTS: Twenty-six percent of total patients with UTIs were older than 65 and otherwise medically uncomplicated whereas 21% were older patients who did have complicating factors. E. coli was a pathogen in 81% of uncomplicated elders' and 54% of complicated elders' cultures. E. coli sensitivity rate to sulfamethoxazole-trimethoprim (SMX/TMP) in both groups was 86%. Physicians were significantly less likely to prescribe SMX/TMP for complicated older patients with complications than for young patients with an uncomplicated UTI (P = .017); there was a significant trend of physicians to be less likely to prescribe SMX/TMP with advancing age in a patient and complications across all 3 groups (P = .011). Antibiotics rarely needed to be changed after cultures. CONCLUSIONS: The presence of E. coli on culture in patients with a UTI changes based on medical complications, not age. Being medically complex did not result in reduced sensitivity of E. coli to SMX/TMP but was associated with increased rates of the presence of other pathogens. In our setting, treatment employed with SMX/TMP and without the use of culture and sensitivity may be effective for appropriately selected older women. Prospective studies are needed to determine the optimal approach to management.

Assessing adherence to evidence-based guidelines for the diagnosis and management of uncomplicated urinary tract infection.

OBJECTIVE: To assess adherence to evidence-based guidelines for the diagnosis and management of uncomplicated urinary tract infection (UTI) in a family medicine residency clinic setting. PATIENTS AND METHODS: We retrospectively reviewed the medical records of female patients seen in 2005 at the Mayo Clinic Family Medicine Center in Scottsdale, Ariz, who were identified by International Classification of Diseases, Ninth Revision code 599.0 (UTI). We assessed documentation rates, use of diagnostic studies, and antibiotic treatments. Antibiotic sensitivity patterns from outpatient urine culture and sensitivity analyses were determined. RESULTS: Of 228 patients, 68 (30%) had uncomplicated UTI. Our physicians recorded essential history and examination findings for most patients. Documentation of the risk of sexually transmitted disease differed between residents and attending physicians and was affected by patient age. Urine dipstick and urine culture and sensitivity analyses were ordered in 57 (84%) and 52 (76%) patients, respectively. Eighty percent of patients with positive results on urine dipstick analyses also had urine culture and sensitivity analyses. Sulfamethoxazole-trimethoprim (SMX-TMP) was used as initial therapy in 26 patients (38%). Sixty-one percent of SMX-TMP and ciprofloxacin prescriptions were appropriately provided for 3 days. Escherichia coil was sensitive to SMX-TMP in 33 (94%) of 35 cultures. Treatment was not changed in any patient with an uncomplicated UTI because of results of urine culture and sensitivity analyses. Antibiotic sensitivity patterns for outpatients were significantly different from those for inpatients. CONCLUSION: Only 30% of our patients had uncomplicated UTI, making their management within clinical guidelines appropriate. However, of those patients with uncomplicated UTI, less than 25% received empirical treatment as suggested. Urine culture and sensitivity analyses were performed frequently, even in patients who already had positive results on a urine dip-stick analysis. Although SMX-TMP is effective, it is underused. On the basis of these findings, we hope to provide interventions to increase SMX-TMP prescription, decrease use of urine culture and sensitivity analyses, and increase the frequency of 3-day antibiotic treatments at our institution.

Chronic Recurrent Multifocal Osteomyelitis Mimicking Osteosarcoma.

We report a case of an adolescent female who had an initial outside clinical and imaging presentation that was considered highly suspicious for metastatic osteosarcoma. Extensive evaluation led to the diagnosis of chronic recurrent multifocal osteomyelitis. If this etiology had been considered earlier in the patient's clinical course, her diagnostic evaluation may have been less involved and treatment could have commenced sooner. When this entity is a diagnostic possibility along with neoplasm, strong consideration should be given to proceeding directly to open surgical biopsy due to the difficulty in diagnosing this lesion from small percutaneously-obtained biopsy samples.