FP SUMMER 2022
MISSOURI FAMILY PHYSICIAN VOLUME 41, ISSUE 3
THE DERMATOLOGY issue
Helping PCPs Care for Mental Health Patients and families often feel most comfortable with their primary care provider and prefer to get their mental health care in the primary care setting. The Missouri Child Psychiatry Access Project (MO-CPAP) was created to help ensure PCPs have the resources, tools and support they need, including same-day phone consultations, referral services and ongoing education.
Learn more and enroll for free today at medicine.missouri.edu/mo-cpap.
FP MISSOURI FAMILY PHYSICIAN
EXECUTIVE COMMISSION BOARD CHAIR John Paulson, DO, PhD, FAAFP (Joplin) PRESIDENT John Burroughs, MD (Kansas City) PRESIDENT-ELECT Kara Mayes, MD, FAAFP (St. Louis) VICE-PRESIDENT Afsheen Patel, MD (Kansas City) SECRETARY/TREASURER Lisa Mayes, DO (Macon)
BOARD OF DIRECTORS DISTRICT 1
DIRECTOR ALTERNATE DISTRICT 2 DIRECTOR ALTERNATE DISTRICT 3 DIRECTOR DIRECTOR ALTERNATE DISTRICT 4 DIRECTOR ALTERNATE DISTRICT 5 DIRECTOR ALTERNATE DISTRICT 6 DIRECTOR ALTERNATE DISTRICT 7 DIRECTOR DIRECTOR ALTERNATE DISTRICT 8 DIRECTOR ALTERNATE DISTRICT 9 DIRECTOR ALTERNATE DISTRICT 10 DIRECTOR ALTERNATE DIRECTOR AT LARGE
Arihant Jain, MD (Cameron) Mike Feuerbacher, MD (Maryville) Robert Schneider, DO, FAAFP (Kirksville) Vacant Emily Doucette, MD, FAAFP (St. Louis) Dawn Davis, MD (St. Louis) Lauren Wilfling, MD (St. Louis) Jennifer Scheer, MD, FAAFP (Gerald) Jennifer Allen, MD (Hermann) Natalie Long, MD (Columbia) Amanda Shipp, MD (Versailles) David Pulliam, DO, FAAFP (Higginsville) Justin Cramer, MD, FAAFP (Marshall) Beth Rosemergey, DO, FAAFP (Kansas City) Afsheen Patel, MD (Kansas City) Wael Mourad, MD, FAAFP (Kansas City) Andi Selby, DO (Joplin) Barbara Miller, MD (Buffalo) Douglas Crase, MD (Licking) Vacant Vicki Roberts, MD, FAAFP (Cape Girardeau) Gordon Jones, MD (Sikeston) Jacob Shepherd, MD (Lees Summit) Josephine Glaser, MD (St. Louis) Krishna Syamala, MD (St. Louis)
RESIDENT DIRECTORS Wesley Goodrich, MD, UMKC Kelly Dougherty, MD, Mercy (Alternate)
STUDENT DIRECTORS
CONTENTS 4 The Dermatology Issue 6 A Review of Acne: Pathogenesis and Treatment 8 Updates for Isotretinoin 10 Calciphylaxis and Its Clinical Mimickers 12 Inked Up: Helping Patients Who Inquire About Tattoo Placement or Removal 16 Connecting-the-Dots: A Case of SAPHO Syndrome 21 Preceptor Workforce Program Measure Signed by Governor 22 Learning to Lead in Family Medicine 23 We are All in This Together: State Legislative Conference 24 Winners of the MAFP Poster Contest Recognized 25 MAFP Goes to Washington 26 Conference Prepares Residents and Students for Success 28 Members in the News 29 References 30 30th Annual Fall Conference Schedule and Registration
MARK YOUR CALENDAR October 16, 2022
AAFP DELEGATES
Virtual Knowledge Self-Assessment (KSA): Care of Hospitalized Patients www.mo-afp.org/cme-events/ November 11-12, 2022
Keith Ratcliff, MD, FAAFP, Delegate Kate Lichtenberg, DO, MPH, FAAFP, Delegate Sarah Cole, DO, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate
November 13, 2022
Karstan Luchini, KCU Joplin Abby Crede, UMKC (Alternate)
MAFP STAFF EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE ASSISTANT EXECUTIVE DIRECTOR Bill Plank, CAE MEMBER COMMUNICATIONS AND ENGAGEMENT Brittany Bussey The information contained in Missouri Family Physician is for informational purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed, or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no respsonsibility for the opinion expressed thereon. Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 • p. 573.635.0830 • f. 573.635.0148 Website: mo-afp.org • Email: office@mo-afp.org
MAFP 30th Annual Fall Conference & Annual Meeting Big Cedar Lodge – Ridgedale, MO www.mo-afp.org/cme-events/afc/ MAFP Commission and Board of Directors Meetings Big Cedar Lodge, Ridgedale, MO November 20, 2022 Virtual Knowledge Self-Assessment (KSA): Care of Women www.mo-afp.org/cme-events/ February 13-14, 2023 MAFP Advocacy Day - Courtyard Marriott, Jefferson City, MO www.mo-afp.org/advocacy/advocacy-day/ February 14, 2023 MAFP Board of Directors Meeting Courtyard Marriott, Jefferson City, MO MO-AFP.ORG 3
The Dermatology Issue
Y
John Paulson DO, PhD, FAAFP Board Chair, Joplin
ou’ve just addressed your patient’s diabetes, hypertension, cholesterol, obesity, and tobacco addiction. Your hand hits the door, and you are on the way to the next patient when you hear, “Doc, will you take a look at this and tell me what you think?” They want you to look at an uncommon occurrence on their skin. Some folks will regularly come in for dermatologic issues. But they tend to fall behind all the other complaints and quality measures driving patient care. However, it is our job to ensure that the skin issue is not the manifestation of a more significant systemic disease. As family physicians, we are trained to treat the entire person. We have to be the specialty of everything, including skin. Patients can walk around with internal issues for years without realizing it, but dermatology is perhaps the most visible of all the subspecialties we treat. Family physicians are often the first to
PS -
see dermatologic issues, as with many other issues. While some will require a referral to a dermatologist, most are diagnosed and treated within our walls. This issue of Missouri Family Physician includes fascinating articles about common skin encounters such as tattoos, acne, and prescribing of isotretinoin. It also discusses the rare conditions of SAPHO and calciphylaxis. We hope these articles will supply knowledge to help you provide the best care for your patients and communities.
MAFP is publishing an issue of this magazine dedicated to the Joy of Family Medicine that will be a collection of inspirational stories from our members. Please send your stories, photos, and reasons why you love Family Medicine to marketing@mo-afp.org.
4
MISSOURI FAMILY PHYSICIAN July - September 2022
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A REVIEW OF ACNE:
Pathogenesis and Treatment
6
MISSOURI FAMILY PHYSICIAN July - September 2022
A
cne vulgaris is the most common disease among humans of all ages. It affects almost all age groups, and up to 85% of Caucasian individuals ages 12-25 suffer some degree of Barbara Miller, MD, FAAFP symptomatology.1 In a primary care setting, physicians will likely Freeman Family Medicine treat many patients for acne Residency, Joplin throughout the course of their careers. However, with so many acne treatments available, it can be difficult to know which ones are most effective, or how to combine them. Acne medications also come with side effects, some of which are significant and can negatively Adam Holbrook, OMS3 impact patients. Understanding Kansas City University - Joplin acne’s pathogenesis, the side effects of commonly used medications, and the standard of care as recommended by the American Academy of Dermatology will improve the ability of family physicians to provide optimal care to these patients. Acne is most commonly Matthew Starr, OMS3 caused by Propionibacterium Kansas City University - Joplin acne (P. acnes), an opportunistic bacterium that lives within the follicles on human skin.2 Testosterone and DHT stimulate the proliferation of sebocytes, which produce sebum in sebaceous glands in the skin.3 Sebum and dead skin cells accumulate and clog the follicle, leading to disruption of the follicle wall and inflammation, known as acne. The process is aided by secretory enzymes from P. acnes.2 Most patients with acne have normal circulating levels of androgens, so acne is not correlated with elevated serum androgen levels3; however, acne-prone skin does have a higher androgen receptor density than non-involved skin.2 Disrupting this inflammatory cycle is crucial to treating acne. As acne is so prevalent in the United States, (affecting approximately 50 million people at any given time4), it is important to understand the best way to treat it to prevent scarring and limit impact on mental health. As noted previously, most patients have normal androgen levels, so hormone testing is not recommended in acne patients unless there are additional signs of androgen excess. Additionally, microbiologic testing is likewise not recommended, as the primary culprit is known and treatable with standard acne therapies. However, if patients exhibit signs of gram-negative folliculitis, they might benefit from microbiologic testing.4 In mild disease, acne is most commonly treated initially with topical therapies. First line therapy is benzoyl peroxide, which notably does not confer bacterial resistance. Other options include dapsone 5% gel in adult females for inflammatory acne; topical antibiotics, which should never be used as monotherapy; and retinoids like tretinoin, usually used in combination with topical
antimicrobials.4 If acne is moderate, it is first recommended to treat with topical combination therapy, which consists of benzoyl peroxide with either a retinoid, an antibiotic, or both. For moderate acne which is resistant to topical therapy, and for severe acne, it is appropriate to advance to oral antibiotic therapy. Systemic antibiotics should always be used in combination with topical therapy with benzoyl peroxide plus a retinoid, antibiotic, or both.4 First-line antibiotics for acne treatment are IT IS IMPORTANT tetracyclines, followed TO UNDERSTAND by oral erythromycin or THE BEST WAY azithromycin in patients TO TREAT IT TO in whom tetracyclines are contraindicated, PREVENT such as children and SCARRING AND pregnant women. LIMIT IMPACT ON Treatment resistant MENTAL HEALTH patients may be treated with trimethoprimsulfamethoxazole.4 The American Academy of Dermatology recommends limiting the use of systemic antibiotics to three months or less due to increasing antimicrobial resistance. There is high morbidity and mortality worldwide associated with antimicrobial resistance, and this is increasing at an alarming rate.5 There has been a significant decrease in the efficacy of topical erythromycin on acne lesions over time6, however, treatment-resistant acne does not seem to put patients or the community at risk. Instead, the true danger lies in pathogenic organisms gaining antibiotic resistance due to exposure to antibiotics during acne treatment. For example, 85% of Streptococcus pyogenes cultures in those taking oral antibiotics were resistant to at least one tetracycline antibiotic, compared to 20% in those not taking antibiotics.6 Coagulase-negative staphylococci have also been shown to acquire antimicrobial resistance, and these strains can transfer resistance to Staphylococcus aureus, which is more pathogenic and can cause more serious infection.6 Hormonal agents may also be used to treat acne, especially in women. They may be used as monotherapy or in combination with other therapies. There are four oral contraceptives which have been FDA-approved for acne treatment. Spironolactone, a potassiumsparing diuretic with anti-androgen properties, can also be used in some females.4 Rarely, corticosteroids can be used temporarily in those with severe inflammatory acne who are starting standard acne treatment. In patients with severe acne which is resistant to oral antibiotics or with nodular acne, oral isotretinoin is the recommended treatment, as it has been proven to be very effective. Notably, due to risks of teratogenicity, all women need to be utilizing two forms of birth control and are required to take monthly pregnancy tests throughout the treatment regimen. Monitoring liver function and serum cholesterol and triglyceride levels in all patients at regular intervals throughout treatment is also recommended.4 Following the guidelines outlined by the American Academy of Dermatology will greatly reduce the likelihood of conferring antibiotic resistance to organisms in patients treated for acne. Furthermore, these patients will benefit from treatment that follows the given recommendations, as they are highly effective for most patients. For more information regarding the recommendations from the American Academy of Dermatology, please visit their website or review the reference. References found on page 29. MO-AFP.ORG 7
Before
U
sually, acne vulgaris is a selflimited chronic inflammatory condition of the pilosebaceous unit. The disease is thought to be multifactorial in the pathogenesis-related to Scott Darling DO, RPVI, RVT sebum production, follicular Liberty, MO hyper-keratinization, proliferation of Cutibacterium acnes (formerly propionibacterium acnes) and inflammation leading to clinical findings.2 In more severe or resistant forms of acne isotretinoin (i.e., Accutane, Amnesteem, Sotret, Claravis, Absorica, Myrosan, Zenatane), a vitamin A analog commonly prescribed. Oral isotretinoin (also known as 13-cis-retinoic acid) has been available since 1971 and became FDA-approved for the indication of severe and refractory nodulocystic acne in the United States in 1982. These indications have since been expanded upon to include significant acne that has been unresponsive to therapy and/or resulting in scarring, as well as treatment of other conditions. In June 2009, Roche Pharmaceuticals pulled Accutane from the US market in the face of competition from generic makers of isotretinoin, who now supply more than 95%. Roche cited “High cost from personalinjury lawsuits” as a reason for withdrawal, though they dispute the validity of claims that isotretinoin is related to inflammatory bowel disease (IBD). Physicians and patients are concerned with the side effects of isotretinoin therapy. These side effects include retinoid dermatitis, cheilitis, hypertriglyceridemia, hypercholesterolemia, risk of congenital disabilities, and myalgias, including elevated serum creatinine kinase levels and elevated transaminases. and a controversial association with depression and inflammatory bowel disease.2 8
MISSOURI FAMILY PHYSICIAN July - September 2022
Following the American Academy of Dermatology (AAD) guidelines, the algorithm to treat the typical patient with mild to moderate acne in your office includes a combination of topical medications, like topical retinoids, benzoyl peroxide, and systemic antibiotics. If they have been previously treated but are unresponsive to this regimen, isotretinoin therapy can be considered. Patients have to be compliant with the iPledge Program. Even though we know that isotretinoin is the one drug in the treatment of acne that will work, both physician and patient have to understand the true risks associated with this drug. The patients come in with all kinds of misinformation and concerns. Physicians need to take the time to uncover the reason why the patient does not want to take this drug. Once the barrier has been identified, it can be addressed from a scientific standpoint, thus putting many of those issues to rest. It can be helpful to break these up into more than one visit. The fear of potential side effects can lead to physicians putting up barriers to prescribing this drug, side effects such as inflammatory bowel disease, hypertriglyceridemia and even the potential for pancreatitis. And, of course, pregnancy, which may be the most legitimate concern. Physicians may even have concerns for bone changes, including premature closure of the epiphysis, hyperostosis often involving vertebral bodies and calcification of tendons and ligaments resulting in chronic pain, have occurred after several years of administration at high doses.2 Even though the above listed side effects are a cause for concern, these concerns have to be weighed against overuse of antibiotics and potential antimicrobial resistance. So, in treatment-resistant acne, one should consider using this drug faster and more often. Should we be more hesitant to prescribe isotretinoin in patients with a history of IBD or a family history of IBD? A lot has changed over the last decade. First reported in 1982, in the post-marketing period, several reports of patients developing inflammatory bowel disease following treatment with isotretinoin were published. Inflammatory bowel disease was subsequently listed in the package insert for Accutane as an adverse gastrointestinal effect. Additionally, the potential connection between isotretinoin and IBD
has spurred a number of multi-million-dollar lawsuits. However, over time, extensive population-based database studies have been undertaken that have put this issue to rest. The American Medical Association, the American Academy of Dermatology, the American Acne & Rosacea Society, the Dermatology Organization of New Jersey, and the New Jersey Medical Society all funded an amicus brief that was submitted to the New Jersey Supreme Court. This brief said that there was no real link when you look at the medical literature on inflammatory bowel disease and isotretinoin. Studies continue to improve in quality and support the evidence that no link can be found. The concern for long-term use of antibiotics with inflammatory bowel disease becomes a more significant concern. Isotretinoin is becoming more of a favored product in that situation. Also, if patients say IBD, do they really mean irritable bowel syndrome rather than inflammatory bowel disease? This may be a potential source of confusion. Depression has to be addressed with every patient every month when seeing them for the isotretinoin. It is a central part of the iPledge packet of information given to patients. If patients are on an SSRI or other drug that treats depression, they should be followed in conjunction with the prescriber of these drugs to closely monitor their symptoms of depression. The drug might have to be stopped, and the dose may have to be increased or decreased for a while or remain unchanged. It is imperative to be aware of the symptoms of depression and have a conversation with the patient and the prescriber of the antidepressant. Depression may be a real side effect of the drug in a very small percentage of patients. However, in the last couple of years, two good-sized systematic reviews and metaanalyses looked at the risk of depression in patients treated with isotretinoin. These meta-analyses show no association. In fact, one of the studies that they included showed that depression actually improved when patients were on isotretinoin. As we look at the newer data, many of the barriers are diminishing and going away.4 There are a lot of new studies and discussions regarding higher dosage of isotretinoin. When isotretinoin first came on the market almost 40 years ago, the dosage was at 16 to 20 weeks, usually at about 1 mg/kg. Time has shown that it is relatively easy to clear up a patient’s acne with any dose of Accutane. The art is to optimize how long they will stay in remission after they finish their course of isotretinoin. Thus, it does seem that there is a minimum dose that is needed to get there in order to get that long-term remission. That information came out published by Alison Layton in 1992. She had treated acne patients over a ten-year span with isotretinoin and found that if she got their cumulative dose to above 120 mg/kg total dose, then their relapse rate had been reduced compared to people who did not achieve that dose. Based on this study, the low dose range is pretty well established. The goal is to get patients to at least 120 mg/kg total. The dosing range referred to is 120mg/kg to 150mg/kg. The physician should know that number for every one of their patients. It should be in their chart at the bottom of their history. The numbers in the chart will say, “What is their dose to date and what is their goal dose range.” Other dosing strategies such as aiming for a lower cumulative dose of 40-70mg/kg for more moderate acne versus a more aggressive strategy with 220 mg/kg have been employed to reduce the risk of relapse have been employed. These dosing strategies typically should be balanced with side effects given that isotretinoin may induce acne fulminans type flare, limiting more aggressive dosing strategies. With acne fulminans, isotretinoin may actually be stopped or markedly decreased, and begin oral prednisone for two to
four weeks. The risks and benefits of higher cumulative doses have to once again be balanced with reoccurrences of acne.5 Laboratory abnormalities are often rare, but there are varying practices in monitoring for elevated transaminases and triglycerides. A recent study has suggested that detecting high-grade hypertriglyceridemia and liver function testing abnormalities is noted in fewer than 1% and 0.5%, respectively. No high-grade cholesterol or CBC abnormalities were observed. Though this study was limited by its retrospective nature, it may argue for the reduction in frequency of lipid and liver function test monitoring and argue for elimination of CBC and cholesterol monitoring in this patient population.1
After
After The teratogenicity of isotretinoin continues to be a serious issue with its use in women with childbearing potential.2 Isotretinoin, a vitamin A derivative, is thought to exert its teratogenic effects by inducing hypervitaminosis A and affects formation of crucial structures of the pharyngeal arches. Characteristic features of fetal retinoid syndrome include craniofacial abnormalities such as cleft palate and ear abnormalities, cardiovascular abnormalities including VSD and Tetralogy of Fallot, and neurologic abnormalities including hydrocephalus. Of note, up to 60% of babies born without gross malformations perform poorly on neuropsychological tests and show evidence of intellectual disability, learning disability, and/ or behavioral dysfunction, which may not be evident until later in life. (3) This illustrates why IPledge has a very specific window for urine pregnancy testing in female patients, which must be adhered to stringently. Two forms of birth control are required. Scott Darling, DO, RPVI, RVT, Certified Sports Medicine, has been in private practice in the Liberty, MO, area for over 20 years. References found on page 29. MO-AFP.ORG 9
Calciphylaxis and Its Clinical Mimickers
T
he clinical presentation of Calciphylaxis is that of an ulcer usually in adipose-rich tissues, most often in patients with end-stage renal disease. The morphology is ever changing and unpredictable. Scott Darling DO, RPVI, RVT Calciphylaxis is a “heart Liberty, MO attack” of the skin. The first step of dysregulation leads to calcification of the small and medium-sized vessels of the dermis and subcutaneous tissues. This causes local thrombi that cut off circulation to the skin leading to ulceration from necrosis.2 The damaged skin eventually recovers by scarring. However, during this recovery process, the skin is exposed to the outside environment. This places it at high risk of infection, leading to significant mortality in patients due to the extremely prolonged healing time of these ulcers. The one-year mortality is not clearly estimated but can be as high as 50% and even higher.13, 14, 15 Early on, Calciphylaxis usually presents as painful skin nodules or indurated plaques that are very firm to palpation and often associated with an overlying livedoid pattern or mottling. In contrast, most lesions in other forms of vasculopathy are not painful. With time the painful skin nodules and plaques can transition into livedo reticularis and then continue to evolve to a true retiform 10
MISSOURI FAMILY PHYSICIAN July - September 2022
purpura. From there, this will evolve into eschar and necrotic ulcerative plaques that we see in calciphylaxis. Unfortunately, patients are often not diagnosed in the early stages. Colleen Gabel, MD, identified the main clinical mimickers in a recent study that can be initially misdiagnosed for calciphylaxis in 75% of patients.1 This is a large portion of calciphylaxis patients that are being misdiagnosed for a disease with such high morbidity and mortality. The mimickers are venous stasis, cellulitis, peripheral vascular disease, hematoma and nonspecific skin issues. The specialties that most often interact with calciphylaxis are Emergency Medicine, Primary Care and Inpatient Internal Medicine. Diagnosis was found to be delayed by almost a month for those misdiagnosed, leading to unnecessary delayed care such as unnecessary courses of antibiotics. The longer calciphylaxis progresses, the larger the ulcers can grow, requiring a much longer healing period for the ulcers, thus elevating the risk of infection and potential sepsis in patients who are already in a fragile health state. The longer calciphylaxis progresses, the more challenging it is to diagnose clinically. The two main risk factors for calciphylaxis are: 1. End-stage renal disease, 75% of all calciphylaxis patients have this and we call it nephrogenic calciphylaxis.3, 4, 15 2. Warfarin. In patients treated with Warfarin for a prolonged time with ulceration, calciphylaxis should be on top of the differential diagnosis.5,6,7 Early signs of calciphylaxis should be reviewed on a regular basis with the inpatient teams. In the outpatient setting, it is important to refer these patients to an academic medical center with more experience and a good
dermatopathologist who is familiar with interpreting calciphylaxis biopsies and has understanding of the nuances between it and other types of vasculopathies. The role of Dermatopathology in interpreting incisional biopsy specimens that contain adipose tissue can influence treatment decisions. Some inpatient teams may not want to treat for a certain dermatologic condition until they have biopsy evidence. Biopsies at the end of the day are subjective interpretative tests. Research has shown that sensitivity of the initial biopsy is 50% which is not good.11 Sometimes patients undergoing a second biopsy had a diagnosis of calciphylaxis in the end. Biopsies for these patients with calciphylaxis have significant morbidity because they may trigger or worsen the condition and tend to have poor healing.11 This has suggested that clinical diagnosis should be considered “valid” in these patients, as well as good communication with other teams and having many other valid points to support the diagnosis of calciphylaxis. In the past, inpatient nephrologists can be encountered that may not want to start IV sodium thiosulfate or different insurance companies have not wanted to cover IV sodium thiosulfate without a biopsy. Since a paper has already documented that biopsies have low sensitivity, biopsies do typically not find calcification in small and medium-sized dermal and subcutaneous vessels. A recent JAAD article found that only 23% of patients had medium vessel calcification with fibrin thrombi, so there is a lot of variability.11 Another method in the diagnostic arsenal to help diagnose calciphylaxis in which biopsy has not yielded a result is imaging. There is no standardized imaging tool that can be used, but different options for imaging have been explored. Dr. Kroshinsky did a paper earlier on that looked at the role of radionuclide bone scans for diagnosing calciphylaxis and found they had pretty good sensitivity and specificity.18 Patients with calciphylaxis will have a higher amount of tracer uptake in the areas where the plaques and nodules are. This radiotracer uptake is higher in the earlier calciphylaxis stages than when they are ulcerated. There is also a decrease in radiotracer uptake when these patients start IV sodium thiosulfate therapy. Some people may suggest CT scans where you can see patterns of calcification in the subcutaneous tissues. There may be some use in combination with ultrasound to rule out peripheral vascular disease. If CT scan shows calcification and Doppler ultrasound shows normal perfusion, it is supportive of calciphylaxis over peripheral vascular disease. Special considerations in non-rich adipose tissue sites, which would include concern for calciphylaxis on the penis, and there is a contraindication to getting contrast, then plain film x-rays looking for subcutaneous calcifications can help establish the diagnosis.19 Inclusion of other lab parameters can suggest calciphylaxis such as elevated calcium phosphate products, pretty significant altered values and mineral parameters in general. A previous study with Dr. Kroshinsky found that lupus anti-coagulants and combined thrombophilia are seen in patients with end stage renal disease compared to patients with end stage renal disease in general without calciphylaxis. These are not as specific when compared to biopsy and imaging options. Treatment options are multimodal with involvement of many different specialties, including close involvement with pathology and a cardiologist if there needs to be a change in anti-coagulation and pain management due to significant pain associated with this disease. The focus needs to be on early initial treatment with sodium thiosulfate done IV or intralesional. Sodium thiosulfate intralesional may be beneficial for patients that may not have
end-stage renal disease or are not getting dialysis in general. A study showed that three weekly infusions might be a barrier to care. Other things to consider are normalizing metabolic parameters. Wound care is extremely important. Infections are the number one cause of mortality in these patients. Use of topical antibiotics as needed, non-stick dressings, and topical debridement are all very helpful. Warfarin has been implicated in calciphylaxis. Therefore, switching to a non-warfarin anti-coagulant can be helpful as well. Other beneficial medications are pentoxifylline and sildenafil. Pain management should not be overlooked. Many of these patients have excruciating pain impacting their quality of life. Pain management should be consulted early on in the treatment plan. The biggest issue with calciphylaxis is starting treatment. Waiting for weeks for a positive biopsy can create a big delay. Prompt diagnosis may make an earlier initiation of treatment possible, mitigating progression to late-stage disease.8,16 If the patient is placed on IV sodium thiosulfate, there is no obligation to keep the patient on the infusion, which can always be stopped. Nephrology and dialysis team check for side effects like metabolic acidosis. The concern for side effects should not delay treatment. Sodium thiosulfate can also be used intralesional if there are concerns about side effects of IV treatment. To prevent ulcers, ideally begin early treatment with sodium thiosulfate. Special site presentations in non-adipose-rich tissue including, acral areas or on the penis, can be associated with higher mortality that is more than three times higher.9 Acral and penile biopsy sites become more difficult. Therefore, clinical presentations of calciphylaxis like tenderness and retiform changes use other clues such as intact distal pulses compared to patients with peripheral vascular disease combined with imaging for these special sites help obtain a diagnosis of calciphylaxis. Non-nephrogenic calciphylaxis disorder is not related to kidney dysfunction. These patients do not have true uremia but have the “4 W’s” in common according to Dr. Knitwear: Women, White, Over Weight and using Warfarin.6 This less classic presentation presents in patients with normal mineral parameters. One common thread in non-nephrogenic calciphylaxis is vitamin K which may have a role in the pathogenesis. Vitamin K regulates calcification in the body in general. Non-nephrogenic calciphylaxis patients may have co-morbidities, including liver disease, obesity and gastric bypass, and these patients may have deficiencies in vitamin K. Further research is needed. If consulted on a patient with existing peripheral vascular disease that is worsening, then calciphylaxis should always be at the forefront in the differential diagnosis and consider imaging over biopsy. Scott Darling, DO, RPVI, RVT, Certified Sports Medicine, has been in private practice in Liberty, MO, for over 20 years. References found on page 29.
THE BIGGEST ISSUE WITH CALCIPHYLAXIS IS STARTING TREATMENT
MO-AFP.ORG 11
Inked Up Helping Patients Who Inquire About Tattoo Placement or Removal
T
Sarah Cole, DO, FAAFP Mercy Family Medicine Residency, St. Louis
12
ihe number of people choosing to apply tattoos has increased globally in recent years, with 35% of Americans reporting having at least one tattoo.1 People have tattoos placed for a variety of personal, cosmetic, cultural or even medical reasons, such as for radiation therapy or to alert health personnel to medical conditions in case of emergency. Some people may consult their family physician before or after tattoo placement, making it important for FPs to have an understanding of different types of tattoos and their potential complications. Some tattoos, such as adhesive decals or henna, are temporary. Adhesive or decal tattoos remain superficially on the epidermis and tend to rub off within days. Henna contains a tannin dye molecule that is painted on the skin where it is absorbed by epidermal cells and fades within a few weeks due to natural exfoliation and cell cycle. Temporary tattoos can cause skin reactions such as contact dermatitis or hypersensitivity response. The Food and Drug Administration (FDA) regulates these as cosmetics and helpful information for patients can be found at https://www.fda.gov/cosmetics/cosmetic-products/ temporary-tattoos-hennamehndi-and-black-henna-fact-sheet. Other tattoos may be permanent. Permanent tattoos are typically achieved by puncturing the epidermis with a needle to deposit pigment in the dermal layer, inciting a chronic immune-mediated reaction whereby macrophages absorb the pigments but cannot break them down. Macrophages thus become trapped in the dermal layer, releasing the pigments upon cell death at which time they are reabsorbed by the next generation of dermal macrophages thus permanently locking the tattoo design in place.2
MISSOURI FAMILY PHYSICIAN July - September 2022
Tattoo inks primarily contain a carrier, often ethyl alcohol, and pigments, usually composed of either metals or organic compounds. Different colors are comprised of different pigments.3 A tattoo’s toxicology and ease of future removal depends on its color, with black being the easiest to remove.4 While the FDA regulates the inks and pigments used in tattoos, state or local authorities may regulate the practice of application or removal. Missouri’s Office of Tattooing, Body Piercings, and Branding sets and regulates standard practices for tattooists and their establishments, including cleaning and sterilization, in Missouri.5 Some potential complications of tattoo placement are localized and selflimited. Redness, swelling, peeling and itching, for example, are common in the first few days following application and often managed with waterbased creams or lotions. Additional skin reactions including cellulitis, allergic reaction, photosensitivity or psoriasis may require medical attention. Risk factors for cellulitis include improper hygiene during tattoo application/ after-care or bacterial contamination of tattoo inks.6 The American Academy of Dermatology (AAD) offers tips to patients on caring for tattooed skin.7 • If tattooed skin feels dry, apply a water-based lotion or cream to the tattoo. Petroleum-based products, such as petroleum jelly, can cause the ink to fade. • Protect the tattoo from the sun. Ultraviolet (UV) light can fade some tattoo inks. When in the sun, protect the tattoo by applying a broadspectrum, water-resistant sunscreen with a Sun Protection Factor (SPF) of 30 or more. Apply the sunscreen 15 minutes before going outside and reapply at least every two hours. • Stay out of tanning beds and away from sunlamps. These devices may also fade the ink in tattoos and can increase the risk of skin cancer. In some people, the UV light may also react with the tattoo ink, causing a painful skin reaction. • See a physician if you have a skin reaction or if your tattooed skin is changing in any way. The patient’s skin may have a bad reaction to the ink in a tattoo. This can happen immediately after getting a tattoo or years later. A change could also be a sign of skin disease. • When considering a new tattoo, consider getting it on skin that is free of moles. A tattoo can make it more difficult to see the earliest signs of skin cancer. When caught early, skin cancer, including melanoma, the deadliest form of skin cancer, is highly treatable. Systemic or more significant complications may also occur. Transient lymphadenopathy may occur after initial placement. One systematic review suggested association but not causation between tattooed skin and cutaneous cancers.4 There are some case reports of first-degree burns in people undergoing MRI who have tattoos with metallic pigments though one prospective study of 330 people aged 18 to 66 years with tattoos undergoing a total of 585 MRIs measured this risk to be low at 0.17%.8 Tattooing has been associated with increased transmission of both Hepatitis B and C, particularly when the tattoo is applied in a home, prison or potentially nonsterile setting.9,10 The United States Preventive Services Task Force (USPSTF) recommends screening for Hepatitis B infection in adolescents and adults at increased risk but does not name tattoos as a risk factor and the 2013 USPSTF guideline to offer Hepatitis C screening to persons receiving unregulated tattoos was replaced in 2020 with the recommendation to offer Hepatitis C screening to all persons age 18 to 79 years old.11,12 Some people with tattoos may later wish to have them removed. Based on safety and efficacy, the AAD recommends laser removal over most other methods including dermabrasion or excision.13 The FDA has not approved creams or ointments for tattoo removal and recommends laser removal by a dermatologist.14 Laser is more effective for certain tattoo colors or pigments than others so knowing the type of ink used may be helpful. The AAD recommends consultation with a dermatologist prior to tattoo removal to determine which type of laser may work best. References found on page 29.
In summary, five top tips for patients regarding tattoos may include: • Consider having tattoos placed on an area of skin free of moles. A tattoo can make it harder to detect early signs of skin cancer. Discuss with your family doctor ways to reduce risk of skin cancer or detect it early. • Select a tattooist and establishment who adhere to Missouri state rules and regulations regarding tattoos and their placement. • Mild skin reactions can usually be managed by applying a water-based cream or lotion and protecting the tattooed area from sun and ultraviolet light. Contact your family doctor if you develop symptoms of more serious skin reactions, which might include rash, pus, pain or fever. • Prior to tattoo placement, review with your family doctor if you are at increased risk for other, more serious complications from tattoos. • If you want a tattoo removed, ask your family doctor for the best way to go about doing so.
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C O SMETICS FACTS From the U.S. Food and Drug Administration
Tattoos and Permanent Makeup There are several types of tattoos you may be seeing, including some that are permanent and others that are temporary. People get tattoos for various reasons, such as beauty, self-expression, or cultural events. Whatever your reason for choosing to get a tattoo, the U.S. Food and Drug Administration (FDA) reminds you to know the facts before you make the decision to get a tattoo.
Types of Tattoos Permanent Tattoo: A needle inserts colored ink into your skin. Permanent tattoos last a lifetime. Permanent Makeup: This is a type of permanent tattoo. A needle inserts colored ink into your skin to look like eyeliner, lip liner, eyebrows, or other makeup. Henna: Plant dye called henna or mehndi is used to stain your skin. A henna tattoo lasts for 3 days up to a few weeks. Black Henna: This type of tattoo may or may not contain henna and may contain hair dye or other dye to make it darker and longer lasting.
The U.S. Food and Drug Administration (FDA) reminds you to get the facts before you make the decision to get a tattoo.
Decal Temporary Tattoos: Some decal tattoos have a backing that is removed with water when applying the design directly to your skin. Others have a backing that sticks to your skin. Decal tattoos may last for a day or up to a week or more.
Tattoo Risks Tattoos can have health effects, and some of these effects can last a lifetime. Tattoo risks include: • Infections and serious illness from unclean tattoo tools, practices, or products. • Allergic reactions to the inks or stains can cause skin problems, such as rashes. • Other skin problems, like increased chance of sunburn, rashes, redness, or scarring. • Swelling and burning of some permanent tattoos when you get an MRI test. If you have questions about safety practices at tattoo parlors, contact the state or local health department that regulates them in your area. In addition, be sure to tell your healthcare provider about any tattoos you have before undergoing any type of medical procedure.
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June 2015
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CONNECTING THE D•O•T•S ••••••••••••••••••••••••••••••••••
A Case of SAPHO Syndrome
Ryan Muehling, MD, PGY-3, Chief Resident Department of Family & Community Medicine University of Missouri-Columbia
Andrea Gilmore, MD, PGY-1 Department of Dermatology
University of Missouri-Columbia
Kevin Frazer, MD Fayette, MO
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S
ynovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome is an inflammatory disease characterized by dermatologic and osteoarticular manifestations. The symptoms are variable in severity and timing of presentation. As the condition is rare, there is limited literature describing its epidemiology, pathophysiology, and treatment. Similarly, establishing the diagnosis can be challenging as there are no wellvalidated diagnostic criteria. The following case report highlights the workup and differential diagnosis clinicians may work through before arriving at a diagnosis of SAPHO syndrome. This case of SAPHO syndrome emphasizes that a thorough history and physical exam are paramount in making the diagnosis.
two weeks with continued worsening of chest pain and swelling, the patient followed up with computed tomography (CT) of the chest, which showed sclerosis of the left side of the manubrium with mature periosteal reaction, as visualized in Figure 2.
CASE PRESENTATION •••••••••••••••••••••••• A male of Cherokee descent in his 30’s with no significant past medical history presented to his primary care provider and reported swelling at the medial aspect of his left clavicle. There was no known trauma and although the discomfort was gradually increasing over the previous year, it acutely worsened in the two weeks prior to clinic presentation. The patient works in construction and reported the pain was most severe at the end of the day. He took no medications and had not tried any other remedies for the pain and swelling. He also described the muscles of his left upper extremity and neck as seeming tight. He reports smoking one pack of cigarettes daily. The patient also had concerns of skin lesions on his bilateral hands and feet at the initial visit. He described these as a “stress-induced psoriasis” for which he had previously seen a dermatologist. The patient denied ever having complete resolution of the lesions, but notes the lesions improved in the colder months of the year, suggesting the possibility of polymorphous light eruption (PMLE). On presentation he had acral crops of pustules and scaly erythematous fissuring/patches on his hands and feet, as illustrated in Figure 1.
Figure 1: Acral crops of pustules on patient’s hands
INVESTIGATIONS ••••••••••••••••••••••••••• Radiographs were obtained of both clavicles, which returned as normal. The patient was prescribed NSAIDs, encouraged to use ice, and counseled on stretching exercises for muscular stiffness. After
Figure 2: CT chest showing mature appearing periosteal reaction along the lateral aspect of the manubrium on the left as well as mild sclerosis of the left side of the manubrium and head of the left clavicle.
The findings were consistent with a diagnosis of sternocostoclavicular hyperostosis (SCCH). The patient was seen by a dermatologist due to continued worsening of the skin lesions. Given treatment failure and recurrence of lesions, a punch biopsy was performed. Results indicated the presence of dermal eosinophils and lack of significant spongiosis, likely representing palmoplantar pustulosis pathology (PPP). The patient was prescribed clobetasol 0.05% cream and Acitretin, an oral retinoid. He was seen by dermatology again one month later. He reported minimal transient improvement in his hands and feet while taking the Acitretin and clobetasol. The condition became debilitating to the point he required filing for short-term disability.
DIFFERENTIAL DIAGNOSIS ••••••••••••••••••• After confirmation of PPP and associated SCCH, he was referred to rheumatology. Given the biopsy results proving palmoplantar pustulosis and failure of therapy with oral retinoid, rheumatology confirmed the most likely diagnosis of SAPHO syndrome. The patient’s chest pain was initially most concerning to him. In an individual with musculoskeletal occupational risk factors, costochondritis or Tietze syndrome are possibilities, especially with the localized nature of the chief complaint and timeline of worsening throughout the day. Costochondritis is inflammation of the costochondral junctions of the ribs at the anterior chest wall.1 It causes sharp, aching, or pressure-like pain over the area that is often reproducible, but without swelling.1 Costochondritis is a selflimiting condition, but given the progressive swelling and pain, it is important to obtain imaging to rule out a more serious underlying process such as a fracture or neoplasm. Tietze syndrome should also be considered given the swelling of his clavicle. Tietze syndrome is similar to costochondritis in pain and location, but causes swelling in addition to the pain. It is commonly caused by infectious, rheumatologic, or neoplastic processes, thus reinforcing the need to obtain imaging of his chest wall.1 The differential would also include focal muscle spasms as he works in construction and puts significant strain on his muscles. Although the specific etiology of muscle spasms remains to be elucidated, continuous contractions of the affected muscles can result in significant localized pain.2 Working through an individual presenting with SAPHO syndrome can be challenging. The presentation is usually insidious in onset MO-AFP.ORG 17
and includes nonspecific complaints. Osteoarticular manifestations may present as escalating pain, swelling, restricted movement, and morning stiffness.3 Reported locations can be widespread, but the anterior chest wall and spine are the most common locations for involvement.3 A thorough history and physical exam is imperative to evaluate the symptoms and direct the next steps in workup, which often includes imaging. Radiographs are useful for ruling out acute fractures. However, only 41% to 55% of individuals with SCCH have radiographic findings.4 CT can better detect pathology, especially in the sternoclavicular area.4 SCCH is a chronic inflammatory condition characterized by erythema, swelling, and pain at the sternoclavicular joint.4 It is a type of hyperostosis, which is an excessive growth or thickening of bone tissue. SCCH often has a relapsing and remitting course, with no clear etiology given the rarity of the condition. In SCCH, nonspecific inflammation of the sternoclavicular ligaments develops and involves surrounding soft tissue. An erosive arthritis develops, as well as subsequent endosteal and periosteal bone formation eventually leading to hyperostosis and soft tissue ossification.4 Although SCCH can present on its own, half of cases have associated cutaneous manifestations such as acne or palmoplantar pustulosis (PPP). What initially appeared as two simultaneous but distinct problems now began to appear as one linked problem. The patient’s cutaneous concerns were also complexing given the conflicting information on past diagnosis versus what the patient was currently experiencing. An apparent PMLE is high on the differential given that it is the most common photosensitive disorder, and involves the development of pruritic erythematous vesicles, plaques, or pustules that develop hours after exposure to ultraviolet light.5 PMLE is most severe with the first sun exposure of the year, and interestingly, the intensity of the eruptions will fade with subsequent ultraviolet light exposure or with decreased exposure. Another diagnosis to consider is dyshidrotic eczema, which is a chronic, relapsing condition characterized by eruptions of pruritic vesicles on the palms and soles. The cause of dyshidrotic eczema remains unknown. The patient’s recurrent, waxing and waning palmar and plantar distribution, suggested dyshidrotic eczema.6 Other conditions on the differential would be allergic and irritant contact dermatitis, especially with his occupation of construction work and excessive sweating in the outdoor heat. Fungal infections and vesiculobullous diseases should remain on the differential. Referral to dermatology is key as a biopsy of the lesions can provide important etiological information.
TREATMENT ••••••••••••••••••••••••••••••• Due to the debilitating nature of the patient’s condition, and previous treatment failure, Rheumatology recommended initiation of the TNF-α inhibitor, adalimumab. Treatment of SAPHO syndrome focuses on the current presenting complaints, rather than the syndrome as a whole. PPP is rare, and there are not well agreed upon consensus recommendations for management given no randomized, controlled trials have been performed. Both topical (glucocorticosteroids, retinoids, vitamin D derivatives, emollients, and keratolytic agents) and systemic therapies (Acitretin, cyclosporine, methotrexate, tetracycline, hydroxyurea, colchicine, and itraconazole) are employed in an attempt to control PPP.7 Phototherapy may also be tried. The patient’s failure to improve highlights how difficult it can be to treat PPP. Phototherapy and photochemotherapy (the addition of psoralen) are well-tolerated options for the treatment of PPP. It does 18
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require a significant time commitment on the part of the patient as many therapies are done three to four times a week, but it can have excellent results. Psoralen plus ultraviolet A photochemotherapy (PUVA), narrow band ultraviolet B (NB-UVB), excimer light therapy, and photodynamic light (PDT) therapy are all options. They work by suppressing cutaneous T cells and cytokines that drive many dermatologic conditions.8 Guselkumab is a monoclonal antibody that binds to IL-23 and inhibits its interaction with its receptor. It has shown promise in the treatment of PPP.9 SCCH treatment is mainly focused on pain control. NSAIDs and glucocorticoids are a common first line agent, but significant improvement is not usually seen.4 Additionally, long term glucocorticoids are not a realistic option for many due to the many negative side effects. Methotrexate, sulfasalazine, and cyclosporine have been proposed as treatment options, but with varying results.4 TNF-α inhibitors and intravenous bisphosphonates may be promising options, but have not been well studied in the literature yet.4,10
OUTCOME AND FOLLOW-UP ••••••••••••••••• Adalimumab was initiated and patient reported drastic improvement in symptoms. He experienced near complete resolution of the clavicular joint pain and improvement of palmoplantar pustulosis for approximately two months. Despite adherence with adalimumab every other week, the patient noticed pustular changes in the hands and feet, as well as the left parasternal pain and fullness. With no clear literature on SAPHO medication titration, the adalimumab was increased to weekly and his condition improved once again. One year after initiation of the TNF-α inhibitor, the SAPHO syndrome remained fairly stable, yet routine monitoring of labs discovered a positive QuantiFERON gold test. Patient is currently holding the TNF-α inhibitor in order to complete 4 weeks of latent TB treatment. Rheumatology is planning to then resume the biweekly dosing.
DISCUSSION ••••••••••••••••••••••••••••••• SAPHO syndrome was first recognized in the literature in 1987 as a group of osteoarticular and dermatologic conditions.11 Apart from what is included in the acronym SAPHO syndrome, other osteoarticular findings could include chronic recurrent multifocal osteomyelitis (CRMO), chronic nonbacterial osteomyelitis, and mandibular sclerosing osteomyelitis.12 Cutaneous findings are also quite varied, and may not coincide with the onset of osteoarticular manifestations. Cutaneous involvement was found to occur with musculoskeletal symptoms in less than 30% of patients. It preceded the musculoskeletal symptoms in 40% to 68% of patients.3 PPP is the most common cutaneous manifestation of SAPHO syndrome, but other neutrophilic dermatoses include acne conglobata, acne fulminans, hidradenitis suppurativa, pyoderma gangrenosum, and Sweet’s syndrome.3 Pustular psoriasis is difficult to distinguish from PPP, and there is some debate as to if this should be included in SAPHO syndrome.3 As with the etiology of SAPHO syndrome, the epidemiology also remains unknown as most of the current understanding relies on case reports. SAPHO syndrome has been reported in a wide range of ages, from 15 months to late adulthood.13 Few populations have data on incidence, with an annual incidence of less than 1 in 10,000 in white individuals and 0.00144 in 100,000 in Japanese individuals.13 To our knowledge, there have been no reported cases
of SAPHO syndrome in an individual with Cherokee heritage. There are currently no validated diagnostic criteria for SAPHO syndrome. However, Benhamou et al. developed criteria which are commonly used by clinicians. The presence of 1 of the following 4 inclusion criteria is sufficient for diagnosis of SAPHO syndrome: osteoarticular manifestations in acne conglobata, acne fulminans, or hidradenitis suppurativa; osteoarticular manifestations in PPP; hyperostosis (of the anterior chest wall, limbs or spine) with or without dermatosis; and CRMO involving the axial or peripheral skeleton with or without dermatosis.14 Kahn et al. also proposed a set of diagnostic criteria with the presence of one of the following leading to a diagnosis: multifocal osteitis with or without skin manifestations; sterile acute or chronic joint inflammation associated with either pustules or psoriasis of palms and soles, or acne, or hidradenitis; sterile osteitis in the presence of one of the following skin manifestations: pustular psoriasis, palmo-plantar
psoriasis, acne conglobata, acne fulminans, or follicular occlusion triad.15,16 Although slightly different, these sets of diagnostic criteria share the common overarching themes of osteoarticular and dermatologic manifestations. The exact cause of SAPHO syndrome remains unknown, but is thought to result from autoinflammation, as proinflammatory cytokines have been implicated in the theorized pathogenesis.12 Other theories include genetic susceptibility or an infectious etiology, as bacteria have been isolated from osteitis lesions, including Propionibacterium acnes, Staphylococcus aureus, Haemophilus parainfluenzae, and actinomycetes.12 Regardless of the exact etiology of SAPHO syndrome, it remains perplexing to clinicians and presents an excellent learning opportunity in the workup of a patient. References found on page 29.
LEARNING POINTS/ TAKE HOME MESSAGES •••••••••••••••••••••••••••••••••••••••••••• • SAPHO syndrome is rare and can be a difficult diagnosis to make, as there are no agreed upon diagnostic criteria and it can present with numerous different complaints. High suspicion and a thorough workup are essential. • Once a musculoskeletal or cutaneous manifestation is diagnosed in a patient, the clinician can begin working towards a unifying diagnosis that includes both. Although it is possible to have two separate processes ongoing, the manifestations of SAPHO syndrome are unique enough to lead one to consider an overarching syndrome. • Treatment of SAPHO syndrome is focused on the presenting complaints and may require several different options given the lack of consensus recommendations. MO-AFP.ORG 19
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MISSOURI FAMILY PHYSICIAN July - September 2022
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L to R behind Governor Mike Parson (seated): Ed Kraemer, MD, University of Missouri Kansas City; Kelly Dougherty, MD, PGY1, Mercy FMR, St. Louis; Rep. Brenda Shields, District 11, St. Joseph; Kathy Pabst, MBA, CAE, MAFP Executive Director.
Preceptor Workforce Program Measure Signed by Governor
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our actions mattered and made a difference. SB 718 was signed by the Governor and we now have a preceptor workforce program (tax credit) in Missouri. This bill is a great step forward to recruit medical students to practice in rural/underserved areas, as well as provide a tax credit to primary care physicians who precept them. Governor Mike Parson signed this measure on June 18, 2022, in his office with legislators and supporters looking on. SB 718 is an omnibus bill related to higher education and the preceptor tax credit was added during the final weeks of session. The preceptor workforce program bill is also included on another Truly Agreed To and Finally Passed omnibus bill, HB 2331, which is awaiting the Governor’s signature as well. The preceptor workforce program provides a tax credit to primary care physicians who precept medical students and physician assistants, and physician assistants (PA) who precept PA students. Primary care (family medicine, internal medicine, pediatrics, psychiatry, or OB/GYN) physicians and physician assistants are eligible for a tax credit if they serve as a community-based faculty
preceptor for medical students or physician assistants for at least 120 hours. These hours are accrued by precepting one or multiple students. A primary care physician or physician assistant can apply for up to three $1,000 tax credits annually. The tax credit cannot be applied to past taxes due or be transferred to future taxes. Preceptors cannot be compensated for precepting in order to be eligible for this tax credit. There are a maximum of 200 $1,000 tax credits available each year. These tax credits are funded by an increased professional license fee of $7 for all physicians and $3 for physician assistants. Many thanks to Representative Brenda Shields (District 11, St. Joseph) and Senator Dan Hegeman (District 12, Crosby) for being fierce advocates for this issue. It’s been a collaborative effort of presenting testimony and contacting legislators by our members, many supportive individuals, and other healthcare organizations throughout the legislative session. We would like to also thank all of you who contacted your legislators to let them know your support for this legislation. MO-AFP.ORG 21
Learning to Lead in Family Medicine
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he AAFP’s Annual Chapter Leadership Forum (ACLF) and National Conference of Constituency Leaders (NCCL) drew 406 attendees to an in-person conference in Kansas City, April 28-30. ACLF is the AAFP’s leadership development program for chapter-elected leaders, aspiring leaders, and chapter staff. Your MAFP team learned about chapter governance, member services, education, and advocacy. Your elected leaders who attended were: John Paulson, DO, PhD, FAAFP, Board Chair John Burroughs, MD, President Afsheen Patel, MD, Vice President Lisa Mayes, DO, Secretary/Treasurer
In addition, your MAFP staff attended: Kathy Pabst, MBA, CAE, Executive Director, Bill Plank, CAE, Assistant Executive Director, and Brittany Bussey, Member Communications and Engagement Coordinator. The conference kicked off with an opening session and plenary with AAFP’s senior leadership. They gave updates on the Academy and addressed current issues of critical importance and breakout sessions that covered governance, communications, advocacy, media relations, and membership issues. A practical, engaging conversation with Valorie Burton, CEO of the Coaching and Positive Psychology Institute, equipped attendees with a survival toolkit to face any challenge that comes their way. Even though Brittany and Bill have been with the MAFP for over two years, this was their first opportunity to meet, network, and learn from other chapter staff in person. 22
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Brittany found her time at the conference extremely valuable. “I participated in several breakout sessions where I learned tangible ways to improve my role in supporting the Missouri Academy,” Brittany said. “I made many great connections with other chapter leaders and physicians across the country. I walked away from this experience more confident in my ability to support our family physicians!” Bill was impressed with how chapter board members, executives, and staff from across the country came together for the betterment of family medicine. “The topic-focused breakout sessions with staff from other chapters were fantastic. In addition to finally meeting them in person, it’s always helpful to work together to find solutions to issues we all face. The engagement of physician leadership to learn about a wide range of topics from AAFP and other chapters was equally impressive.” NCCL is the AAFP’s premier policy development event for underrepresented constituencies. This includes women, minorities, new physicians, international medical graduates (IMG), and lesbian, gay, bisexual, transgender, queer/questioning, and others (LGBTQ+) physicians or physicians who support LGBTQ+ issues. MAFP sent a full delegation to the NCCL: Women – Barbara Miller, MD, FAAFP, Joplin IMG – Jennifer Allen, MD, Hermann LGBTQ – Theresa Drallmeier, MD, St. Louis Minority – Ngozi Wilkens, MD, MPH, FAAFP, St. Louis New Physician – John Heafner, MD, St. Louis
In addition to participating in leadership sessions, NCCL delegates write, debate, and vote on resolutions related to medical practice and patient health. The AAFP’s website describes the National Conference of Constituency Leaders as a leadership development event that empowers change makers to catalyze positive change in family medicine. Chapter delegates voted on issues that were discussed by reference committees devoted to practice enhancement, organization and finance, the health of the public and science, education, and advocacy. Ngozi Ada Wilkins, MD, MPH, FAAFP, Minority Delegate, served on the Reference Committee for Practice Enhancement. “It was awesome to see passionate family physicians in action, advocating for change that benefits our patients, our colleagues, and our specialty. We are all change-makers, but this was most evident at this conference,” Dr. Wilkins said. “Be the change you want to see.” Other issues addressed by the committee included administrative simplification and for the AAFP to update practice management resources to include a clinical leadership toolkit “specifically addressing collaborative practice with nonphysician providers.” “Advocacy has always felt daunting to me,” said Barbara Miller, MD, FAAFP, “but this conference created an open space for those with different levels of experience and viewpoints to come together in a constructive way. We were encouraged to bring ideas AND act on them, and given experienced mentors to shape them appropriately.” Dr. Miller co-authored two resolutions, which were adopted. The first clause resolved was that the AAFP advocate that CMS make salary and compensation freely and publicly available by physician gender, years of experience, geography, hours, and scope of work. This resolution aims to make this information available so that women (and others) can negotiate for compensation, knowing what their male counterparts are making, to resolve the persistent gap between pay for men and women. The second resolved statement asked that the AAFP financially support and advocate for the development of a toolkit and list of best practices for family physicians in caring for the mental health of children and adolescents and likewise support the development of a training curriculum for family medicine residents. “Many physician leaders spoke passionately about the need for both of these actions and shared heartbreaking stories about the need for improved pediatric psychiatric care with an agreement that primary care physicians will need to be prepared to step into that gap,” Dr. Miller said. “This was my first experience with the AAFP’s advocacy arm, and it was truly an honor to represent the women who serve as family physicians in Missouri,” Dr. Miller continued. “I will continue advancing these and other important issues for women in medicine.” In 2023, the conference will be held Tuesday-Thursday, May 9-11, in Kansas City. If you are interested in serving as a delegate to the National Conference of Constituency Leaders, email Kathy Pabst at kpabst@mo-afp.org with your constituency preference and eligibility.
Kathy Pabst, MBA, CAE, introduces the keynote speaker at the AAFP State Legislative Conference, Washington, DC.
We are All in This Together: State Legislative Conference
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efore starting the Family Medicine Advocacy Summit (FMAS), the MAFP delegates participated in the AAFP State Legislative Conference in Washington, DC, for a full day of sessions focusing on state issues. In a new effort by the AAFP to hold federal and state advocacy conferences together, this prelude to the FMAS conference was a great introduction to our federal advocacy efforts during the following days. MAFP advocacy commission co-chairs Keith Ratcliff, MD, FAAFP, and Peter Koopman, MD, FAAFP, were in attendance, along with Kathy Pabst, MBA, CAE, MAFP Executive Director. Bill Plank, CAE, MAFP Assistant Executive Director, and Brian Bernskoetter, MAFP governmental consultant, also attended. They learned best practices on issues that other states are facing. The MAFP was given a shout-out on this national stage for the successful passage of the preceptor workforce program (tax credit) that was signed by the Governor (see page 21). State-specific issues and presentations included up-to-date primary care investment/spend legislation strategies. The MAFP introduced this measure in the Missouri legislature in 2020, but due to COVID-19 and other factors, it has yet to be revived. Stay tuned for new efforts in 2023! We all know the importance of vaccines, and a panel discussion reported on efforts by other states and the challenges the COVID-19 vaccine has created for all immunization efforts. Kathy Pabst served as the luncheon host and introduced the keynote speaker, Wendy Underhill, Director for Elections and Redistricting, at the National Conference of State Legislatures. The afternoon followed with conversations about advocacy and member engagement, scope of practice, and a roundtable discussion on our state chapter legislative experiences. MO-AFP.ORG 23
Winners of the MAFP Poster Contest Recognized This year, the resident and student poster contest was held at the Transition to Practice Conference for Family Medicine Residents and Students. There were 11 entries from Missouri’s medical students and residents.
THIS YEAR’S WINNERS WERE: First Place (Tie): Effect of Addition of Obstetric Hemorrhage Bundle on Rate of Diagnosis of Postpartum Hemorrhage Authors: Rebecca Aguayo, MD, Sonia Hussain, MD, University of Missouri Kansas City Family Medicine Residency First Place (Tie): Echogenic Foci on US and NIPS Availability Prior to L2US Screening Authors: Bailey Englund, DO, Zahn Raubenheimer, MD, University of Missouri Kansas City Family Medicine Residency Third Place: Middle School Medical Explorers (MedEx) Curriculum Authors: Morgan Murray, MD, PGY2, University of Missouri of Kansas City Family Medicine Residency, and Aliyah Tolentino, High School Student The judges scoring the posters identified two posters that were equal in quality, content, and presentation. Posters were judged on their relevance to family medicine, study design, and presentation. Each first-place poster winner will split a $300 gift card among the poster authors. The thirdplace prize is $100. Congratulations to our family medicine residents and students who participated in this annual scholarly activity!
MAFP Distributes Masks to Vulnerable Populations in Missouri
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he MAFP distributed 1,000 high-quality, high-filtration masks to help limit the spread of COVID-19 and other respiratory illnesses among our most vulnerable populations in partnership with the American Academy of Family Physicians and Project N95. Recipients were in underserved areas from the bootheel to urban areas to the state’s center. Masks, packaged with adult and child sizes, were sent to non-profit organizations and free clinics across the state.
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MAFP delegates meet with Senator Josh Hawley’s Legislative Aide. Pictured left to right: Kathy Pabst, MBA, CAE, MAFP Executive Director; Keith Ratcliff, MD, Washington; Kara Mayes, MD, St. Louis; Peter Koopman, MD, Columbia; Tyler Fagan, Senator Hawley’s Legislative Aide; John Burroughs, MD, Liberty; Sarah Cole, DO, St. Louis; Bill Plank, CAE, MAFP Assistant Executive Director
MAFP Goes to Washington
T
he AAFP’s Family Medicine Advocacy Summit was held May 22-24 in Washington, DC, for personal meetings with our elected leaders. The AAFP provided timely information to prepare us for our conversations on behavioral health integration in primary care, telehealth, and improving access to primary care through Medicaid parity. Sessions on advocacy 101, key contact training, a policy panel, the political outlook, and the role of advocacy and social media provided a foundation for our activities the next day. This year’s MAFP delegation included: John Burroughs, MD, Liberty, MAFP President Sarah Cole, DO, FAAFP, St. Louis, MAFP COD Alternate Delegate Peter Koopman, MD, FAAFP, Columbia, MAFP COD Alternate Delegate and Advocacy Commission Co-Chair Kara Mayes, MD, FAAFP, St. Louis, MAFP President-Elect Keith Ratcliff, MD, FAAFP, Washington, MAFP COD Delegate and Advocacy Commission Co-Chair Kathy Pabst, MBA, CAE, MAFP Executive Director Bill Plank, CAE, MAFP Assistant Executive Director The MAFP’s delegation met with the health policy directors for Senator Roy Blunt and Senator Josh Hawley. On the House of Representatives side of the Capitol, we met with staff in the offices of Congressman Emanual Cleaver, Congresswoman Vicky Hartzler, and Congressman Blaine Luetkemeyer. Not only were these meetings important, but also the opportunity starts a relationship to be their primary contact on health care issues.
Key points that were discussed during our meetings included: •
As the public health emergency draws to a close, the ongoing pay disparity between Medicaid and other payers continues to threaten primary care practices with financial instability (especially in rural and underserved communities). Medicaid payment rates must be raised, and federal Medicaid regulations strengthened.
•
Reminded lawmakers and their staffs that family physicians are often the first point of contact for patients navigating the health care system. One-third of the care for serious mental illness and a quarter of prescriptions for serious
mental illness takes place in a primary care setting. To support primary care practices undertaking this work, the Academy is calling for a Medicare add-on code for primary care physicians who have the capacity to provide integrated behavioral health services. •
For the 90% of family physicians now practicing telehealth, an automatic return to pre-COVID telemedicine policies should not occur. To avoid such a setback, members repeated the AAFP’s support for legislation to remove Medicare geographic and originating site restrictions permanently. This would allow all Medicare patients to access virtual care and federally qualified health centers and rural health clinics to permanently provide telehealth services.
Kara Mayes, MD, FAAFP, attended and shared her experience. “Last year I was able to attend the Family Medicine Advocacy Summit virtually, but 2022 was my first opportunity to be in Washington, DC to advocate for family medicine. We heard from several excellent speakers over the course of the conference. The AAFP Governmental Relations staff gave information on advocacy in general, along with the specific asks of the AAFP. We had background information on the relevant topics from experts outside of AAFP. There was even a discussion of the current political climate in the Capitol. All of the speakers throughout the day were engaging and knowledgeable! The following day we were able to meet with staff from the offices of our Missouri senators and several representatives. The in-person interactions were much more engaging than our virtual meetings last year. Getting to take a few days away from the office is always reinvigorating. I look forward to attending again next year!” MO-AFP.ORG 25
Conference Prepares Residents and Students for Success
T
he MAFP and the Family Health Foundation of Missouri (FHFM) hosted the Transition to Practice conference for family medicine residents and students again this year. Held on June 9-10 at Lodge at Old Kinderhook, Camdenton, this conference included hands-on procedures and sessions to help medical students choose family medicine and current residents become better family physicians. A hands-on wilderness session was held on Thursday evening with MAFP resident board member Morgan Murray, MD, PGY2, at the University of Missouri Kansas City Family Medicine Residency. Little did we know, the skills learned from this session would be applied to a real-life wilderness emergency the same evening. Following the one-and-a-half-hour training session at Ha Ha Tonka State Park Visitor Center, the MAFP team decided to enjoy the park’s beauty and walk the trail to the spring. However, upon starting the hike, MAFP Board Chair John Paulson, DO, approached us about needing materials from the wilderness medicine session. The MAFP team sprang into action, interrupting Dr. Murray’s dinner to ask her to assist in helping an athletic young lady who had dislocated her knee during her physical exercise routine. Dr. Murray’s quick response and guidance provided the essential tools to carry her out of the trail on a makeshift gurney of two sticks and a tarp carried by four men. This is family medicine at its finest – patients first and ensuring they receive the care needed! Thank you to Dr. Paulson, Dr. Murray, and the MAFP team for assisting in a time of need. The following day started with an opening keynote session from Todd Shaffer, MD, MBA, FAAFP, about how family medicine works for you. As past president of MAFP and current AAFP board member, Dr. Shaffer shared his knowledge and experience about family medicine and the role our organizations play in practice. This session was a prelude to Kathy Pabst encouraging family medicine residents and students to become more engaged in advocacy. Whether it is a brief meeting over a cup of coffee or testimony during a capitol hearing, 26
MISSOURI FAMILY PHYSICIAN July - September 2022
the voices of all MAFP members are part of a unified effort to represent our patients and issues important to family physicians. MAFP Assistant Executive Director Bill Plank led a session on how MAFP members can get involved in the various MAFP commissions. The residents and students then elected the alternate resident and alternate student board members. We are pleased to report Kelly Dougherty, MD, PGY1, Mercy FMR was elected as the alternate resident director and Abby Crede, MS3 at UMKC was elected the alternate student director. Congratulations! Breakout sessions for residents and students targeted specific areas of interest to them. Students learned how to make their application stand out when applying to residency and prepare for the residency interview, even in a virtual environment.
Kelly Dougherty, MD, PGY1 Mercy FMR
Abby Crede, MS3 UMKC
Todd Shaffer, MD, MBA, FAAFP, Kansas City, and AAFP Board Member, inspired the attendees to become involved in their profession
Residents were provided with key legal points to consider when negotiating their employment contracts, scope of practice for residents, and moonlighting strategies. Struggling with work/life balance is a challenge, and learning to manage both takes dedication and commitment. Jacob Shepherd, MD, FAAFP, and Amanda Shipp, MD, shared their struggles, how they overcame them, and what they are doing to move forward. Part of this challenge is medical school and residency’s financial aspect, which can be overwhelming. Joni Adamson with Missouri Health Professional Placement Services (MHPPS) highlighted opportunities for loan repayment and financial guidance for a secure future. In an era of social media and instant news everywhere, Dr. Shepherd provided key takeaways to the attendees about social media strategies and tactics. Residencies and employers search social media accounts for applicants, and posts should always comply with HIPAA and residency/employer policies. Dr. Paulson, along with Barbara Miller, MD, KCUGMEC Freeman Program Family Medicine Residency in Joplin, both taught hands-on procedures for knee and shoulder injections. Dr. Shaffer shared an impromptu POCUS session for those interested in learning more about this procedure. The conference wrapped up with a light and relaxing Missouri Mingle reception. Nine exhibitors promoted their residency program or health facility to the attendees. This was an opportunity to meet with and learn more about residency and employment options in Missouri. Attendees shared how they appreciated the opportunity to learn more about family medicine, network with other students, and gain skills to help them in their careers. This conference would not have been a success without our sponsors. Thank you to the FHFM! Your donations to the Foundation matter. Learn more by visiting www.mo-afp.org/foundation/. A special thank you to the MHPPS, Missouri Society of the American College of Osteopathic Family Physicians, and Rehab Specialty Medical for supporting this conference!
ATTENDING THE CONFERENCE MADE ME WANT TO PARTICIPATE IN THE ORGANIZATION AND MAKES ME EXCITED
NOT ONLY WERE THE PRESENTATIONS VERY INTERESTING AND INFORMATIVE, THE SPEAKERS WERE ALL INCREDIBLY KIND AND EAGER TO HELP
NO OTHER ORGANIZATION SUPPORTS MEDICAL STUDENTS LIKE THE MAFP, NOR TO THE INCREDIBLE EXTENT AS THE MAFP. THIS IS SOMETHING TO BE TRULY PROUD OF, AS IT DOES MAKE A DIFFERENCE
I CAME AWAY WITH MORE CONFIDENCE AND EXCITEMENT FOR MY FUTURE CAREER AND HAVE GAINED NEW INTEREST IN THE POLICY INFLUENCING SIDE OF MEDICINE
I ENJOYED MEETING PEOPLE THAT ARE EXCITED ABOUT FAMILY MEDICINE, AND I APPRECIATE HOW WELCOMING EVERYONE WAS MO-AFP.ORG 27
MEMBERS IN THE NEWS
DO YOU HAVE NEWS TO SHARE? Email it to office@mo-afp.org for review. We love to hear from our members!
Missouri Resident Selected as AAFP Foundation FM Leads Emerging Leader Institute Recipient The AAFP Foundation Family Medicine Leads program recently selected Nicholas DeVetter, DO, as one of the 2022 Family Medicine Leads (FM Leads) Emerging Leader Institute Scholars. Dr. DeVetter is a PGY1 at A.T. Still University Kirksville College of Osteopathic Medicine. Selected students receive a $1,000 scholarship to attend the AAFP National Conference of Family Medicine Residents and Medical Students and can continue learning and networking after the conference through additional Institute programming. “We’re excited to welcome these outstanding residents and medical students to the Emerging Leader Institute,” says David R. Smith, MD, MPH, FAAFP, AAFP Foundation Board of Trustees President. “These scholars have demonstrated tremendous leadership potential, and we look forward to providing special mentoring and educational opportunities to help them grow.” Congratulations to Dr. DeVetter and all of the 2022 Scholars!
KCU Outstanding Student Scholarship Don “Michael” Kulasekera, DO, was awarded the 2022 KCU Outstanding Student scholarship from the Family Health Foundation of Missouri. Each year, six top graduating Missouri medical students who are entering a Missouri family medicine residency are awarded certificates and scholarships of $500 each. Pictured: Barbra Miller, MD, FAAFP, Don “Michael” Kulasekera, DO, and John Paulson, DO, PhD, FAAFP
FMED Honors Track Group A group of students and faculty leaders are pictured at a recent Family Medicine Honors Track workshop in Joplin, MO. From left to rightBarbara Miller MD, FAAFP, Honors Track faculty leader, Ethan Weeks, Alexander Marx, Abigail Witt, and Kirsten Daniel, and Mariam Akhtar, MD, Honors Track faculty leader.
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References A Review of Acne: Pathogenesis and Treatment — pages 10-11 1.
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Zouboulis, C.C. et al. (2005). What is the pathogenesis of acne? Experimental Dermatology, 14, 143-152. https://onlinelibrary.wiley.com/doi/pdf/10.1111/ j.0906-6705.2005.0285a.x Kumar, B. et al. (2015). New insights into acne pathogenesis: Exploring the role of acne-associated microbial populations. Dermatologica Sinica, 34(2), 67-73. https://www.sciencedirect.com/science/article/pii/S1027811715001457 Kurokawa, I. et al. (2009). New developments in our understanding of acne pathogenesis and treatment. Experimental Dermatology, 18, 821-832. https:// onlinelibrary.wiley.com/doi/pdf/10.1111/j.1600-0625.2009.00890.x Acne Clinical Guideline. American Academy of Dermatology. https://www.aad. org/member/clinical-quality/guidelines/acne Frieri, M., Kumar, K., Boutin, A. (2016). Antibiotic resistance. Journal of Infection and Public Health, 10(4), 369-378. https://www.sciencedirect.com/ science/article/pii/S1876034116301277 Humphrey, S. (2012). Antibiotic Resistance in Acne Treatment. Skin Therapy Letter, 17(9). https://www.skintherapyletter.com/acne/antibioticresistance/?amp
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Updates for Isotretinoin — pages 16-17 1.
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Barbieri JS, Shin DB, Wang S, Margolis DJ, Takeshita J, The Clinical Utility of Laboratory Monitoring During Isotretinoin Therapy for Acne and Changes to Monitoring Practices Over Time, Journal of the American Academy of Dermatology.(2019), doi.https://doi.org/10.1016/j.jaad.2019 06.025 Bolognia J., In Schaffer, J.V. & In Cerroni, L (2018) Dermatologv. Browne H, Mason G,Tang T. Retinoids and Pregnancy: an update. The Obstetrician & Gynecologist 2014;16:7-11 Singer S, Tkachenko E, Sharma P, Barbieri JS, Mostaghimi A Pshchiatric Adverse Events in Patients Taking Isotretinoin as Reported in a Food and Drug Administration Database from 1997 to 2017. JAMA Dermatol. Doi:10.1001/ Jamadermalol.2019.1416 Layton, A. Guidelines for Optimal use of Isotretinoin in Acne. JAAD 1992.27/6,Part 2,S2-S7
Calciphylaxis and its Clinical Mimickers — pages 18-19 1.
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Gabel CK, Blum AE, François J, Chakrala T, Dobry AS, Garza-Mayers AC, Ko LN, Nguyen ED, Shah R, John JS, Nigwekar SU, Kroshinsky D. Clinical mimickers of calciphylaxis: A retrospective study. J Am Acad Dermatol. 2021 Dec;85(6):15201527. doi: 10.1016/j.jaad.2021.03.035. Epub 2021 Mar 17. PMID: 33744358. Essary L.R.Wick M.R.Cutaneous calciphylaxis. An underrecognized clinicopathologic entity. Am J Clin Pathol. 2000; 113: 280-287 Wilmer W.A. Magro C.M. Calciphylaxis: emerging concepts in prevention, diagnosis, and treatment. Semin Dial. 2002; 15: 172-186 Brandenburg V.M. Kramann R. Specht P. Ketteler M.Calciphylaxis in CKD and beyond. Nephrol Dial Transplant. 2012; 27: 1314-1318 Nigwekar S.U. Kroshinsky D. Nazarian R.M. et al.Calciphylaxis: risk factors, diagnosis, and treatment. Am J Kidney Dis. 2015; 66: 133-146 Nigwekar S.U.Wolf M. Sterns R.H. Hix J.K. Calciphylaxis from nonuremic causes: a systematic review. Clin J Am Soc Nephrol. 2008; 3: 1139-1143 Allegretti A.S. Nazarian R.M. Goverman J. Nigwekar S.U. Calciphylaxis: a rare but fatal delayed complication of Roux-en-Y gastric bypass surgery. Am J Kidney Dis. 2014; 64: 274-277 Sahu K.K. Lal A. Mishra A.K. Chastain I. Calciphylaxis: challenges in the diagnosis and management. J Fam Med Prim Care. 2019; 8: 4044-4045 Karpman E. Das S. Kurzrock E.A. Penile calciphylaxis: analysis of risk factors and mortality. J Urol. 2003; 169: 2206-2209 Kroshinsky D. Cotliar J. Hughey L.C. Shinkai K. Fox L.P. Association of dermatology consultation with accuracy of cutaneous disorder diagnoses in hospitalized patients: a multicenter analysis. JAMA Dermatol. 2016; 152: 477480 Dobry A.S. Nguyen E.D. Shah R. Mihm M.C. Kroshinsky D. The role of skin biopsy in diagnosis and management of calciphylaxis: a retrospective analysis. J Am Acad Dermatol. 2020;https://doi.org/10.1016/j.jaad.2020.05.101 Baby D. Upadhyay M. Joseph M.D. et al. Calciphylaxis and its diagnosis: a review. J Fam Med Prim Care. 2019; 8: 2763-2767 Weenig R.H. Sewell L.D. Davis M.D. McCarthy J.T. Pittelkow M.R. Calciphylaxis: natural history, risk factor analysis, and outcome. J Am Acad Dermatol. 2007; 56: 569-579 Fine A. Zacharias J. Calciphylaxis is usually non-ulcerating: risk factors, outcome and therapy. Kidney Int. 2002; 61: 2210-2217
Inked Up: Helping Patients Who Inquire About Tattoo Placement or Removal — pages 6-9 1.
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Baranska A, Shawket A, Jouve M, Baratin M, Malosse C, et al. Unveiling skin macrophage dynamics explains both tattoo persistence and strenuous removal. The Journal of Experimental Medicine, 2018. Timko AL, Miller CH, Johnson FB, Ross EV. In Vitro Quantitative Chemical Analysis of Tattoo Pigments. Arch Dermatol. 2001;137(2):143–147. Muñoz-Ortiz, Juliana et al. “Dermatological and Ophthalmological Inflammatory, Infectious, and Tumoral Tattoo-Related Reactions: A Systematic Review.” The Permanente journal vol. 25 20.225. 26 May 2021. https://www.aad.org/public/everyday-care/skin-care-basics/tattoos (accessed 5/24/22) Missouri Secretary of State: Code of State Regulations. Rules of Department of Commerce and Insurance Division 2267—Office of Tattooing, Body Piercing, and Branding. https://pr.mo.gov/tattooing.asp (accessed 5/22/2022) Dieckmann R, Boone I, Brockmann SO, Hammerl JA, Kolb-Mäurer A, Goebeler M, Luch A, Al Dahouk S. The Risk of Bacterial Infection After Tattooing. Dtsch Arztebl Int. 2016 Oct 7;113(40):665-671. Callaghan MF, Leff AP et al. Safety of Tattoos in Persons Undergoing Tattoos. N Engl J Med 2019; 380:495-496. Jafari S, Buxton JA, Afshar K, Copes R, Baharlou S. Tattooing and risk of hepatitis B: a systematic review and meta-analysis. Can J Public Health. 2012 MayJun;103(3):207-12. Tohme RA, Holmberg SD. Transmission of hepatitis C virus infection through tattooing and piercing: a critical review. Clin Infect Dis. 2012 Apr;54(8):116778. US Preventive Services Task Force. Screening for Hepatitis B Virus Infection in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA Dec 15, 2020. 324(23):2415-2422. US Preventive Services Task Force. Screening for Hepatitis C Virus Infection in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2020;323(10):970–975. Gurnani P, Williams N, Al-Hetheli G, Chukwuma O, Roth R, Fajardo F, Nouri K. Comparing the efficacy and safety of laser treatments in tattoo removal: A systematic review. J Am Acad Dermatol. 2020 Aug https://www.fda.gov/consumers/consumer-updates/tattoo-removal-optionsand-results (accessed 5/25/22)
Connecting the Dots: A Case of SAPHO Syndrome
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— pages 12-15 Proulx AM, Zryd TW. Costochondritis: Diagnosis and Treatment. AFP. 2008 Sep 15;80(6):617–20. Bordoni B, Sugumar K, Varacallo M. Muscle Cramps. In: StatPearls [Internet]. StatPearls Publishing; 2021. The SAPHO Syndrome. Semin Arthritis Rheum. 2012 Dec 1;42(3):254–65. Carroll MB. Sternocostoclavicular hyperostosis: a review. Ther Adv Musculoskelet Dis. 2011 Apr;3(2):101–10. Serena Lembo AR. Polymorphic Light Eruption: What’s New in Pathogenesis and Management. Frontiers in Medicine [Internet]. 2018 [cited 2021 Jul 13];5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6139322/ Soutor C, Hordinsky M. Clinical Dermatology. McGraw Hill Professional; 2013. 352 p. Freitas E, Rodrigues MA, Torres T. Diagnosis, Screening and Treatment of Patients with Palmoplantar Pustulosis (PPP): A Review of Current Practices and Recommendations. Clin Cosmet Investig Dermatol. 2020;13:561. Salman KE, Altunay İK, Salman A. The efficacy and safety of targeted narrowband UVB therapy: a retrospective cohort study. Turkish Journal of Medical Sciences. 2019;49(2):595. Murakami M. Guselkumab for the treatment of palmoplantar pustulosis [Internet]. Vol. 20, Expert Opinion on Biological Therapy. 2020. p. 841–52. Available from: http://dx.doi.org/10.1080/14712598.2020.1760244 Yachoui R, Kreidy M, Parker BJ. Treatment-Refractory Sternocostoclavicular Hyperostosis. Clin Med Res. 2017 Jun;15(1-2):37. Chamot AM, Benhamou CL, Kahn MF, et al. [Acne-pustulosis-hyperostosisosteitis syndrome. Results of a national survey. 85 cases]. Rev Rhum Mal Osteoartic. 1987 Mar;54(3):187–96. Liu S, Tang M, Cao Y, et al. Synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome: review and update. Ther Adv Musculoskelet Dis [Internet]. 2020 [cited 2021 Jul 14];12. Available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC7236399/ Rukavina I. SAPHO syndrome: a review. J Child Orthop. 2015 Feb;9(1):19. Benhamou CL, Chamot AM, Kahn MF. Synovitis-acne-pustulosis hyperostosis-osteomyelitis syndrome (SAPHO). A new syndrome among the spondyloarthropathies? Clin Exp Rheumatol. 1988 Apr;6(2):109–12. Kahn MF, Khan MA. The SAPHO syndrome. Baillieres Clin Rheumatol. 1994 May;8(2):333–62. Kahn MF. Psoriatic arthritis and synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome. Curr Opin Rheumatol. 1993 Jul;5(4):428–35.
https://www.statista.com/statistics/721567/number-of-tattoos-unitedstates/ (accessed 5/22/2022)
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13.50 anticipated Live Category 1 CME credits Scan the code to register online or visit www.mo-afp.org/cme-events/afc/ Friday, November 11, 2022 - Topics
Saturday, November 12, 2022 - Topics
Primary Care Call to Action for VTE Management: Sharpen Your Skills in the Recognition, Treatment, and Secondary Prevention
The Importance of Sleep Health
Don't Pull Your Hair Out! Hair Loss and Alopecia The Role of the Family Physician in the Neurodiagnostic Evaluation of Children with Neurodevelopmental Disorders Treatment Strategies for Basal Insulins to Manage Time-in-Range and Glucose Variability to Improve Outcomes in Patients with Diabetes Is the Most Powerful Healthcare Tool in Your Patient's Pocket? A Review of Connected Healthcare Technology Hyperbaric Oxygen Therapy for the Family Physician: How, When, and Why To Consider for the Patient The Role and Utility of Mineralocorticoid Receptor Antagonists in Diabetic Kidney Disease
Getting Ahead of the Curve: Identifying and Managing Obesity in Primary Care Can Team-Based Care and Novel Therapies Improve Outcomes in Moderate-to-Severe Pediatric Atopic Dermatitis? New Strategies and Best Practices in the Management of Pediatric Facial and Truncal Acne Lifestyle Medicine and Sports Medicine
Sunday, November 13, 2022 Commission Meetings MAFP Board Meeting Application for CME credit has been filed with the American Academy of Family Physicians. Determination of credit is pending.
The Family Health Foundation of Missouri (FHFM) will hold an auction during the 2022 Annual Fall Conference, November 11-12, 2022, at Big Cedar Lodge, Ridgedale, MO. Auction items will be available at the conference and on a virtual platform for those who are unable to attend our annual gathering. With the goal of raising $5,000, the FHFM is counting on your generosity to help fund its scholarship program, tobacco/nicotine cessation program for 4th and 5th graders, and leadership development of residents and medical students. If you are interested in donating an item for the auction, visit https:// moafp.formstack.com/forms/auction for details.
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MISSOURI FAMILY PHYSICIAN July - September 2022
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Too many Americans are experiencing suicide and mental health crises without the support and care they need. In 2020 alone, the US had one death by suicide about every 11 minutes — and for people aged 10-34 years, suicide is a leading cause of death. Moving to an easy-to-remember, 3-digit dialing code will provide greater access to life-saving services.
Providing 24/7, free and confidential support to people in suicidal crisis or emotional distress works! The Lifeline helps thousands of people overcome crisis situations every day. Call 988 for mental health help.