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Carpal tunnel syndrome (CTS) is caused by compression of the median nerve as it travels through the carpal tunnel. Patients commonly experience pain, paresthesia, and, less often, weakness in the distribution of the median nerve. Provocative maneuvers, such as the Phalen test and Tinel sign, have varying sensitivity and specificity for the diagnosis of CTS. Thenar atrophy is a late finding and highly specific for CTS. Although patients with a classic presentation of CTS do not need additional testing for diagnosis, electrodiagnostic studies can confirm the diagnosis in atypical cases, exclude other causes, and gauge severity for surgical prognosis. An abnormal nerve conduction study is useful for ruling in CTS, but a normal test does not necessarily exclude it. Over-the-counter analgesics, such as nonsteroidal anti-inflammatory drugs and acetaminophen, have not shown benefit for CTS. Patients with mild to moderate CTS initially may be offered nonsurgical treatments, such as splinting or local corticosteroid injections. Night-only splinting is as effective as continuous wear. A neutral wrist splint may be more effective than an extension splint. In patients with recent onset of CTS, corticosteroid injections provide slightly greater improvement of symptoms compared with splinting at 6 weeks, with similar outcomes at 6 months. Patients with severe CTS, including objective weakness or sensory deficits, should be offered surgical decompression. Endoscopic and open carpal tunnel release techniques are equally effective.

Background and Objectives: Physicians are increasingly confronted with patients' interrelated psychosocial and physiological issues. To assist physicians in managing the psychosocial needs of patients, integrated behavioral health (IBH) has become increasingly common. This study was completed in a large, Midwestern family medicine residency program where the authors sought to (1) identify physicians' perceptions of IBH implementation and areas of needed IBH improvement, and (2) recognize educational needs to be addressed when providing behavioral health training to resident physicians., Methods: The authors utilized a pre/post design to measure physician perception of access and quality of an integrated behavioral health program. For quantitative data, we performed standard descriptive statistics, likelihood ratio χ2 tests, independent sample t test, and linear mixed-model analysis. For qualitative data, we completed phenomenological analysis, derived from a focus group., Results: Physician satisfaction with access and quality of behavioral health services significantly improved after the implementation of the IBH (P<.01). Perception of behavioral health management also improved, including the commitment of the residency program to mental health well-being, benefit from consultations with BHPs, and physician ownership of managing patients' mental health needs. Themes from the focus group indicated a desire for increased communication with BHPs, as well as additional assessment and intervention skills to manage psychiatric disorders., Conclusions: Family physicians value IBH in supporting patients' behavioral health treatment, and resident physicians hone behavioral health management skills through collaborating with BHPs and completing behavioral health training. Residencies should increase focus on teaching essential skills in behavioral health management.

Introduction: Given the recent reports of e-cigarette, or vaping, product use-associated lung injury (EVALI) and harm of e-cigarettes, the authors evaluated changes in the use and perception of e-cigarettes as tobacco use cessation tools in 2019 relative to 2016. The authors also evaluated the sources family physicians most commonly use to receive information regarding e-cigarettes., Methods: A cross-sectional online survey of 248 community family physicians in Kansas was conducted from October 2019 to December 2019. An 11-item questionnaire measured the participants' perceptions of recommending e-cigarettes to patients for tobacco cessation. A mixed method approach was used to collect, analyze, and interpret the data. Standard descriptive statistics, Likelihood-Ratio/Fisher's exact tests, and immersion-crystallization methods were used to analyze the data., Results: The response rate was 59.3% (147/248). The proportion of the family physicians who did not recommend e-cigarettes for tobacco use cessation was significantly higher in 2019 than in 2016 (86% vs. 82%; χ 2 [1, n = 261] = 12.31; p < 0.01). Several reasons regarding respondents' perceptions of e-cigarettes as tobacco use cessation tools were reported. The medical literature and news media were the top sources where family physicians accessed e-cigarettes information., Conclusion: Most family physicians did not recommend e-cigarettes for tobacco cessation. Opinions regarding the efficacy and safety of e-cigarettes were influenced by information sources. Future, larger studies would be beneficial to further determine family physicians' beliefs and practices regarding e-cigarettes as tobacco use cessation products., (© 2020 The University of Kansas Medical Center.)

Hidradenitis suppurativa is a chronic folliculitis affecting intertriginous areas. Onset generally occurs in young adulthood to middle adulthood (18 to 39 years of age). Females and blacks are more than twice as likely to be affected. Additional risk factors include family history, smoking, and obesity. Hidradenitis suppurativa is associated with several comorbidities, including diabetes mellitus and Crohn disease. The clinical presentation of hidradenitis suppurativa ranges from rare, mild inflammatory nodules to widespread abscesses, sinus tracts, and scarring. Quality of life is often affected, and patients should be screened for depression. Treatment includes wearing loose-fitting clothes, losing weight if overweight, and smoking cessation. Topical clindamycin alone can be effective for patients with mild disease. Patients with moderate disease can be treated with oral antibiotics, such as tetracyclines, in addition to topical clindamycin. Adalimumab, a tumor necrosis factor alpha inhibitor, is effective for patients with moderate to severe hidradenitis suppurativa. Surgical procedures are often necessary for definitive treatment and include local procedures, such as punch debridement and unroofing/deroofing. Wide excision is indicated for patients with severe, extensive disease and scarring.

Background: The medical literature reports that many medical trainees experience burnout. The primary goal of this study was to determine how the prevalence of burnout and other forms of emotional distress among the University of Kansas School of Medicine (KUSM) medical students compared to the previously published data., Methods: We conducted a cross-sectional survey of 379 medical students. Between July and September 2018, we surveyed 872 KUSM medical students on the three campuses (Kansas City, Salina, and Wichita) of KUSM. The survey included items on demographic information, burnout, symptoms of depression, fatigue, quality of life, and self-reported general health. The authors used standard descriptive summary statistics, Kruskal-Wallis test/one-way analysis of variance, chi-square test, correlation, and multivariate logistic regression model to analyze the data., Results: The overall response rate was 43.5% with 48% of the students reporting manifestations of burnout. Burnout, depression, and fatigue were lowest during the first year of training and increased as year in training progressed. In multivariate models, only year in training was associated with increased odds of burnout, symptoms of depression, and fatigue. Nearly 46% of the students screened positive for depression, and 44.6% reported high levels of fatigue in the past week., Conclusion: Even though KUSM students have a lower prevalence of burnout than the national rate (48% vs. 55.9%), this prevalence is high enough to warrant new interventions. Because burnout and other emotional distress increase over the course of medical school no matter what campus the students attend, interventions should be both longitudinal and global across all campuses., Competing Interests: Conflict of InterestThe authors declare that they have no conflict of interest., (© International Association of Medical Science Educators 2019.)

Human papillomavirus infection is the precursor for the development of cervical cancer and is detectable in 99.7% of squamous cell carcinoma and adenocarcinoma cases. Early detection of precancerous lesions with Papanicolaou testing remains the primary mechanism for cancer prevention. Once cervical cancer is diagnosed, treatment may involve surgery, radiation therapy, chemotherapy, or a combination. The choice of therapy depends on the stage of disease, lymph node involvement, patient comorbidities, and risk factors for recurrence. Early-stage, microinvasive disease may be treated with surgery alone if margins are negative and there is no lymph node involvement; adjuvant chemoradiation should be considered for other early-stage disease. Locally advanced disease is often treated with chemoradiation. The addition of bevacizumab, an antivascular endothelial growth factor monoclonal antibody, to combination chemotherapy improves survival among patients with recurrent, persistent, or metastatic cervical cancer. Disease stage and lymph node involvement are the most prognostic factors. Pregnancy status and desire to preserve fertility should be considered when developing a treatment strategy. After treatment, close follow-up with a gynecologist-oncologist for pelvic examinations at regular intervals is recommended to assess for recurrence.

Carpal tunnel syndrome, the most common entrapment neuropathy of the upper extremity, is caused by compression of the median nerve as it travels through the carpal tunnel. Classically, patients with the condition experience pain and paresthesias in the distribution of the median nerve, which includes the palmar aspect of the thumb, index and middle fingers, and radial half of the ring finger. Additional clues include positive physical examination findings, such as the flick sign, Phalen maneuver, and median nerve compression test. Although patients with typical symptoms and signs of carpal tunnel syndrome do not need additional testing, ultrasonography and electrodiagnostic studies are useful to confirm the diagnosis in atypical cases and rule out other causes. If surgical decompression is planned, electrodiagnostic studies should be obtained to determine severity and surgical prognosis. Conservative treatment may be offered initially to patients with mild to moderate carpal tunnel syndrome. Options include splinting, corticosteroids, physical therapy, therapeutic ultrasound, and yoga. Nonsteroidal anti-inflammatory drugs, diuretics, and vitamin B6 are not effective therapies. Local corticosteroid injection can provide relief for more than one month and delay the need for surgery at one year. Patients with severe carpal tunnel syndrome or whose symptoms have not improved after four to six months of conservative therapy should be offered surgical decompression. Endoscopic and open techniques are equally effective, but patients return to work an average of one week earlier with endoscopic repair.

Objective: To compare self-reported safe sleep data from a community social service agency and primary care centers., Design, Settings, and Participants: Cross-sectional Pregnancy Risk Assessment Monitoring System (PRAMS)-based survey data from a community social service agency and survey data from primary care centers were compared using descriptive statistics. There were 166 community survey respondents, average age of 25 years (SD = 5.4 years), and 79 primary care center respondents, average age of 24 years (SD = 5.4 years). Two binary logistic regressions were performed to examine the association between demographic differences and safe sleep position/bed sharing., Results: Safe sleep position responses did not differ significantly between the community-based (n = 126, 85%) and primary care center-based (n = 62, 79%) samples, χ(2)(1) = 0.79, P = .372. Reported bed sharing was significantly higher in the community sample (n = 54, 36%) than the health care center sample (n = 4, 5%), Fisher's exact test, P< .001. Black race was determined to be significantly associated with increased unsafe sleep positioning (OR = 2.86, P = .022). The community center cohort was the only significant predictor of bed sharing (OR = 25.40, P = .002)., Conclusion: Differences in reported safe sleep environments may be due to knowledge variances of safe sleep guidelines, or clinic-based respondents may have been more likely to provide socially desirable responses. The comparison data further highlight the need for continued targeted effort to improve safe sleep behaviors to improve infant health outcomes., (© The Author(s) 2015.)

Dizziness is a common and challenging condition seen in the primary care office. Because dizziness is a vague term that can include a wide array of medical disorders, it is important to use a stepwise approach to differentiate between causes. This article focuses on vertigo and its four most common causes: benign paroxysmal peripheral vertigo, vestibular neuritis, vestibular migraine, and Meniere's disease., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Acute otitis externa (AOE) is most often infectious in origin, and can be easily treated with a combination of topical antibiotic and steroid preparations. Systemic antibiotics are rarely needed for AOE. Chronic otitis externa (COE) can be more difficult to treat, but if an underlying cause can be identified this condition can often be successfully managed. In both AOE and COE, prevention is fundamental. If patients are able to avoid precipitating factors, future episodes can often be averted., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Low health literacy is associated with poor health outcomes. Research is needed to understand the mechanisms and pathways of its effects. Computer-based assessment tools may improve efficiency and cost-effectiveness of health literacy research. The objective of this preliminary study was to assess if administration of the Short Test of Functional Health Literacy in Adults (STOFHLA) through a computer-based medium was comparable to the paper-based test in terms of accuracy and time to completion. A randomized, crossover design was used to compare computer versus paper format of the STOFHLA at a Midwestern family medicine residency program. Eighty participants were initially randomized to either computer (n = 42) or paper (n = 38) format of the STOFHLA. After a 30-day washout period, participants returned to complete the other version of the STOFHLA. Data analysis revealed no significant difference between paper- and computer-based surveys (p = .9401; N = 57). The majority of participants showed "adequate" health literacy via paper- and computer-based surveys (100% and 97% of participants, respectively). Electronic administration of STOFHLA results were equivalent to the paper administration results for evaluation of adult health literacy. Future investigations should focus on expanded populations in multiple health care settings and validation of other health literacy screening tools in a clinical setting.

Purpose: Breastfeeding is a potential solution to improve health outcomes for adolescent mothers and infants. Adolescence is a risk factor for low breastfeeding rates and is associated with a higher risk for perinatal complication. This study investigated facilitators and barriers to adolescent breastfeeding initiation and duration in an urban setting., Methods: Four, 1-hour focus groups were conducted. Twenty-nine (N = 29) adolescent mothers and pregnant adolescents participated and described attitudes toward breastfeeding, attitudes among family and friends, current knowledge, and barriers and facilitators for breastfeeding., Results: Four themes emerged, including the following: behavioral histories of breastfeeding, community assets, social support, and barriers. Participants identified positive histories and community resources such as local hospitals and social services as facilitators. Lifestyle, independence, lack of support from family and primary care providers, social stigma/embarrassment, and difficulty with breastfeeding techniques were described as barriers., Conclusion: A comprehensive and integrated primary care and public health community effort is needed to support and improve adolescent breastfeeding. Further examination of integrated interventions focused on adolescent breastfeeding behaviors through an environmental approach is needed.