What is the most effective treatment for tinea pedis (athlete's foot)?

Topical therapy is effective for tinea pedis. Topical terbinafine has a 70% cure rate, is available over the counter (OTC), and requires only 1 to 2 weeks of therapy. Two other OTC topicals, tolnaftate and miconazole, require 2 to 4 weeks to achieve slightly lower cure rates, but are considerably less expensive. (Grade of recommendation: A) The most effective treatment for tinea pedis is oral terbinafine 250 mg twice a day for 2 weeks (94% clinical cure rate). However, oral terbinafine is expensive and not approved for this indication. Oral therapy may be required for patients with hyperkerototic soles, severe disease, topical therapy failure, chronic infection or immunosuppression. (Grade of recommendation: B, based on small randomized controlled trials [RCTs] with limited head-to head comparisons of drugs

African American female with renal failure presenting with skin lesions: a case report

Calciphylaxis is a lethal disorder seen in patients with end-stage renal disease and is characterized by painful necrotic skin lesions. The pathophysiology is still unknown. Elevated calcium, phosphorous and parathormone appear to play a role in causing small and medium sized vasculopathy. Diagnosis is delayed, prognosis is poor and mortality remains high. In this article we describe the case of calciphylaxis in a patient with chronic renal failure and multiple medical comorbidities, and discuss diagnostic management, prognosis and treatment options

Treatment of Acute Sciatica

In patients with acute sciatica, bed rest and advice to stay active have similar outcomes on their functional status and perceived improvement. (Strength of Recommendation [SOR]: A) Spinal manipulation increases improvement compared with placebo; also, specific spinal pulling and turning manipulation techniques are more effective than traction. (SOR: A) Nonsteroidal anti-inflammatory drugs (NSAIDs) are similar to placebo in overall improvement. (SOR: A) Epidural steroid injections are unlikely to be beneficial. (SOR: A

The Experience of Discrimination and Black-White Health Disparities in Medical Care

The current study of Black patients focuses on how discrimination contributes to racial disparities in health. The authors used a longitudinal methodology to study how perceived past discrimination affects reactions to medical interactions and adherence to physician recommendations. In addition, they explored whether these reactions and/or adherence mediate the relationship between discrimination and patients' health. The participants in this study were 156 Black patients of low socioeconomic status at a primary care clinic. Patients completed questionnaires on their current health, past adherence, and perceived past discrimination. Then, they saw a physician and rated their reactions to the visit. Four and 16 weeks later they reported on their adherence to physician recommendations and overall health. Perceived discrimination was significantly and negatively associated with patient health, reactions to the physician, and adherence. Path analyses indicated that adherence mediated the relationship between discrimination and patient health, but patient reactions to the interaction did not

An unusual presentation of adenoid cystic carcinoma of the minor salivary glands with cranial nerve palsy: a case study

<p>Abstract</p> <p>Background</p> <p>Adenoid Cystic Carcinoma (ACC) is a rare tumor entity and comprises about 1% of all malignant tumor of the oral and maxillofacial region. It is slow growing but a highly invasive cancer with a high recurrence rate. Intracranial ACC is even more infrequent and could be primary or secondary occurring either by direct invasion, hematogenous spread, or perineural spread. We report the first case of the 5^thand 6^thnerve palsy due to cavernous sinus invasion by adenoid cystic carcinoma.</p> <p>Case presentation</p> <p>A 49-year-old African American female presented to the emergency room complaining of severe right-sided headache, photophobia, dizziness and nausea, with diplopia. The patient had a 14 year history migraine headaches, hypertension, and mild intermittent asthma. Physical examination revealed right lateral rectus muscle palsy with esotropia. There was numbness in all three divisions of the right trigeminal nerve. Motor and sensory examination of extremities was normal. An MRI of the brain/brain stem was obtained which showed a large mass in the clivus extending to involve the nasopharynx, pterygoid plate, sphenoid and right cavernous sinuses.</p> <p>Biopsy showed an ACC tumor with a cribriform pattern of the minor salivary glands. The patient underwent total gross surgical resection and radiation therapy.</p> <p>Conclusion</p> <p>This is a case of ACC of the minor salivary glands with intracranial invasion. The patient had long history of headaches which changed in character during the past year, and symptoms of acute 5^thand 6^thcranial nerve involvement. Our unique case demonstrates direct invasion of cavernous sinus and could explain the 5^thand 6^thcranial nerve involvement as histopathology revealed no perineural invasion.</p

Lack of chart reminder effectiveness on family medicine resident JNC-VI and NCEP III guideline knowledge and attitudes

BACKGROUND: The literature demonstrates that medical residents and practicing physicians have an attitudinal-behavioral discordance concerning their positive attitudes towards clinical practice guidelines (CPG), and the implementation of these guidelines into clinical practice patterns. METHODS: A pilot study was performed to determine if change in a previously identified CPG compliance factor (accessibility) would produce a significant increase in family medicine resident knowledge and attitude toward the guidelines. The primary study intervention involved placing a summary of the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) and the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP III) CPGs in all patient (>18 yr.) charts for a period of three months. The JNC VI and NCEP III CPGs were also distributed to each Wayne State family medicine resident, and a copy of each CPG was placed in the preceptor's area of the involved clinics. Identical pre- and post- intervention questionnaires were administered to all residents concerning CPG knowledge and attitude. RESULTS: Post-intervention analysis failed to demonstrate a significant difference in CPG knowledge. A stastically significant post-intervention difference was found in only on attitude question. The barriers to CPG compliance were identified as 1) lack of CPG instruction; 2) lack of critical appraisal ability; 3) insufficient time; 4) lack of CPG accessibility; and 5) lack of faculty modeling. CONCLUSION: This study demonstrated no significant post intervention changes in CPG knowledge, and only one question that reflected attitude change. Wider resident access to dedicated clinic time, increased faculty modeling, and the implementation of an electronic record/reminder system that uses a team-based approach are compliance factors that should be considered for further investigation. The interpretation of CPG non-compliance will benefit from a causal matrix focused on physician knowledge, attitudes, and behavior. Recent findings in resident knowledge-behavior discordance may direct the future investigation of physician CPG non-compliance away from generalized barrier research, and toward the development of information that maximizes the sense of individual practitioner urgency and certainty

Development of the Resident Wellness Scale for Measuring Resident Wellness

Purpose: Graduate medical education programs have a responsibility to monitor resident wellness. Residents are at risk of burnout, depression, and suicide. Burnout and depression are associated with poor patient care. Many existing tools measure burnout, depression, and general human well-being, but resident wellness is a distinct construct. We aimed to develop an instrument to measure resident wellness directly. Methods: An expert panel from two purposefully different graduate medical education institutions generated a behavior- and experience-based model of resident wellness. The panel and resident leaders from both institutions generated 92 items, which were tested alongside anchor scales measuring burnout, depression, personality, optimism, life satisfaction, and social desirability in a convenience sample of 62 residents. Ten items were selected using a combination of factor analysis, a genetic algorithm, and purposeful selection. The 10-item scale was distributed to 5 institutions at which 376 residents completed it anonymously. Exploratory factor analysis was used to examine the factor structure of the scale. Results: The model of resident wellness aligned with an accepted framework of well-being in the literature. The 10-item Resident Wellness Scale broadly covered the model and correlated meaningfully with anchor scales. The factor structure of the scale suggested sensitivity to meaningful work, life security, institutional support, and social support. Conclusions: This novel Resident Wellness Scale is designed to track residents’ wellness longitudinally. It is sensitive to aspects of resident wellness that have been shown to reduce burnout and depression and appears to be a psychometrically strong measure of resident wellness

An Objective Structured Clinical Examination Case for Opioid Management: Standardized Patient Ratings of Communication Skills as a Predictor of Systems-Based Practice Scores

The Wayne State University Office of Graduate Medical Education (WSUGME) uses an objective structured clinical examination (OSCE) to assess its programs’ contribution to enhancing residents’ communication skills. In response to revisions in Michigan’s opioid-prescribing mandates in 2017, WSUGME developed a pain management case in collaboration with faculty and the Wayne State University School of Medicine to educate residents about these mandates while gauging their skills in Systems-Based Practice (SBP), an Accreditation Council for Graduate Medical Education Core Competency. This study examined whether resident OSCE performance predicted year-end milestones scores in SBP1 (coordinates patient care within various health care delivery settings), SBP2 (works in interdisciplinary teams to enhance patient safety and improve patient care quality), and SBP3 (practices and advocates for cost-effective, responsible care). Participants included two cohorts of first- (PRG-1) and second-year (PRG-2) residents in 6 programs: one cohort from academic year 2018-2019 (n = 33), the other from 2019-2020 (n = 37). Before the OSCE, WSUGME emailed residents the new state prescription requirements. During the simulated encounter, standardized patients rated residents on a validated communication instrument, and WSUGME conducted a linear regression of patient ratings on resident SBP milestone scores. The ratings of communication skills of PRG-1 residents did not predict any of the year-end SBP milestones. However, ratings of communication skills of PRG-2 residents predicted SBP1 and SBP2, though not SBP3, milestones. The OSCE opioid case proved to be a valid measure of PRG-2 residents’ competence gained across the first year but was less meaningful when applied to PRG-1 residents