Articles: ninos.
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Axial spondyloarthritis is an immune-mediated inflammatory condition involving the sacroiliac joints, spine, and peripheral joints. It affects approximately 1% of adults in the US and is associated with impaired physical function and reduced quality of life. ⋯ Axial spondyloarthritis predominantly affects the sacroiliac joints and spine but is also associated with extraskeletal manifestations such as uveitis, psoriasis, and inflammatory bowel disease. Physical therapy and NSAIDs are first-line treatments, but most patients require therapy with biologics (anti-TNF or anti-IL-17 agents) or JAK inhibitors to achieve improvement in signs and symptoms, inflammation control, and reduced progression of structural damage.
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The outpatient continuity clinic experience is a crucial component of internal medicine residency training. While in many contexts the teaching physician must be physically present for key parts of the patient encounter, some outpatient environments qualify for use of the Primary Care Exception Rule (PCER), which allows indirect supervision of residents for low-complexity visits. Despite pervasive use of the PCER in resident continuity clinics, the literature regarding its effects on various stakeholders is limited. ⋯ We also suggest best practices for its use: to wit, we advise against using the PCER when the history and/or physical exam is critical to the diagnosis and/or management of the patient's chief concern, and advocate for competency-based, rather than time-based, benchmarks for resident supervision under it. We make recommendations for PCER reform, most importantly expanding the PCER to moderate-complexity visits once competency-based assessments have been instituted. We conclude with future directions for research to improve application of the PCER.