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The Long Term Career Outcome Study is a central program of research in the Center for Health Professions Education at the Uniformed Services University. The overarching goal of Long Term Career Outcome Study is to perform evidence-based evaluations before, during, and after medical school, and as such, it represents a form of educational epidemiology. In this essay, we highlighted the findings of the investigations published in this special issue. These investigations span from “before” medical school matriculation to “during” medical school and “after” learners go on to graduate training and practice. Furthermore, we discuss how this scholarship might shed light on improving the educational practices at the Uniformed Services University and potentially elsewhere. We hope that this work demonstrates how research can enhance medical education processes and connect research, policy, and practice.

Introduction Military medical students enter residency through two main pathways: (1) The Uniformed Services University (USU) and (2) the Armed Services Health Professions Scholarship Program (HPSP). The purpose of this study was to compare how these two pathways prepare military medical students for residency. Methods We conducted semi-structured interviews with 18 experienced military residency program directors (PDs) in order to explore their perceptions of the preparedness of USU and HPSP graduates. We used a transcendental phenomenological qualitative research design to bracket our biases and guide our data analysis. Our research team coded each of the interview transcripts. We then organized these codes into themes, which served as the results of our study. Results Five themes emerged from our data regarding the residents’ preparedness: (1) Ability to navigate the military culture, (2) understanding of the military’s medical mission, (3) clinical preparation, (4) ability to navigate the Military Health System (MHS), and (5) teamwork. The PDs described how USU graduates better understand the military’s medical mission and are more easily able to navigate the military culture and the MHS because of their lived experiences during military medical school. They also discussed the various levels of clinical preparation of HPSP graduates, in contrast to the USU graduates’ more consistent skills and abilities. Finally, the PDs believed both groups to be strong team players. Conclusions USU students were consistently prepared for a strong start to residency because of their military medical school training. HPSP students often experienced a steep learning curve because of the newness of the military culture and MHS.

Background Previously, researchers investigated the career accomplishments of USU medical graduates using the data from a USU alumni survey. To better understand if such accomplishments are related to military retention, the current study investigates the relationship between accomplishments (such as military career milestones and academic achievement) and military retention. Methods Utilizing the responses to the alumni survey sent to USU graduates in the Classes of 1980 to 2017, the researchers investigated the relationship between a series of survey items (e.g., military rank, medical specialties, and operation experiences) and military retention. Results Among the respondents who had a deployment history in support of an operational mission, 206 (67.1%) stayed longer than their initial active duty service or planned on staying longer than their current active duty service commitment. Fellowship directors (n = 65, 72.3%) showed a higher retention rate than other positions. The PHS alumni had the highest retention rate (n = 39, 69%) of the military branches, whereas physicians in medical specialties with higher demand (e.g., otolaryngology and psychiatry) showed less promising retention. Conclusions By conducting future research on underlying reasons as to why full-time clinicians, junior physicians, and physicians in medical specialties with higher demand showed less promising retention, stakeholders will be able to identify what needs to be addressed to retain highly skilled physicians in the military.

The fact that up to one-third of the 800,000 yearly cardiovascular disease (CVD) deaths in the United States may be preventable by diet and physical activity makes a compelling case for lifestyle interventions as a primary prevention strategy. The U.S. Preventive Services Task Force (USPSTF) recommends offering or referring adults with CVD risk factors to behavioral counseling interventions to promote a healthy diet and physical activity. Although few US adults have ideal cardiovascular health, there exists a dose-response relationship whereby an increasing number of ideal cardiovascular health metrics is associated with lower CVD and all-cause mortality. The Dietary Approaches to Stop Hypertension (DASH) diet and the Mediterranean diet have proven benefits in reducing CVD. Among individuals without CVD, high levels of physical activity are associated with an approximately 32% reduced risk of CVD death, and moderate levels are associated with approximately a 22% reduction. Resistance exercises confer additional benefits.

As part of the approach to primary prevention of cardiovascular disease (CVD), adults should have their CVD risk estimated using a population-appropriate risk equation. In the United States, the atherosclerotic cardiovascular disease (ASCVD) pooled cohort equations are recommended by the American College of Cardiology/American Heart Association (ACC/AHA) to estimate risk in patients ages 40 to 79 years. A 10-year ASCVD risk estimate of 20% or higher is considered high, and patients having this level of risk should be offered and counseled to receive statin therapy. A 10-year risk estimate of 7.5% to less than 20% is considered intermediate, and clinicians should discuss the potential benefits of statin therapy for primary prevention in the context of the patient's preferences and values. In some situations, use of CVD risk enhancers, particularly coronary artery calcium assessed by computed tomography, may help inform the clinician-patient discussion. All patients should be counseled about healthy lifestyle modifications to reduce CVD risk. The AHA's Life's Simple 7 defines ideal cardiovascular health as no tobacco use; ideal blood pressure, blood glucose, and cholesterol levels; adequate physical activity; weight management; and healthy diet. An 8th component (sleep) was very recently added and 4 of the original components have been updated. These metrics provide goals that can drive efforts toward primordial prevention (ie, keeping risk factors themselves from developing).

Several drugs have shown benefits in primary and secondary prevention of cardiovascular disease (CVD). Aspirin should be used routinely for the secondary prevention of CVD. Low-dose aspirin should not be used for the primary prevention of CVD in adults ages 60 years and older. Aspirin can be considered for primary prevention in adults ages 40 to 59 years with a 10% or greater 10-year CVD risk. Moderate- to high-intensity statin therapy should be prescribed for most patients with known atherosclerotic CVD, those with a low-density lipoprotein (LDL) cholesterol level of 190 mg/dL or higher, and those ages 40 to 75 years with diabetes or with a 10-year risk of CVD of 7.5% or greater. Newer lipid-lowering drugs have shown benefits in lowering LDL cholesterol levels, but at high cost and with limited evidence of reduction of CVD outcomes. Polypills provide a method to deliver multiple proven drugs at lower cost and to a broader population. Sodium-dependent glucose cotransporter 2 inhibitors or glucagon-like peptide 1 receptor agonists should be added to metformin as the preferred second-line drug in the management of diabetes because of their proven ability to improve cardiovascular outcomes. No supplements have proven benefits in CVD prevention. Omega-3 fatty acids and folic acid have shown benefits when consumed in food.

Diabetes, hypertension, tobacco use, and obesity each substantially increases the risk of cardiovascular disease (CVD) and must be controlled as part of CVD prevention. Among patients with diabetes, the reduction of CVD risk from lower A1c goals must be balanced against the risks of hypoglycemia. The American Diabetes Association (ADA) recommends an A1c goal for adults of less than 7% if hypoglycemia can be avoided. A less stringent goal of less than 8% is appropriate in patients with limited life expectancy. A blood pressure (BP) goal of less than 140/90 mm Hg is prudent for all adults younger than 60 years. A goal of less than 140/90 mm Hg also is advised for initiating or intensifying pharmacotherapy in adults 60 years and older with a history of stroke or who are at high cardiovascular risk. BP targets should be individualized to balance the known benefits of lowering BP to 120/80 mm Hg with the risks of morbidity because of hypotension and adverse effects. Varenicline is the most effective drug for smoking cessation, and abstinence rates are increased by combining it with nicotine replacement therapy. Bariatric surgery is the most effective management for long-term weight loss and reduction of obesity-related comorbidities. Social drivers of health are the primary cause of CVD outcomes differences among races and ethnicities.

Introduction The Coronavirus (COVID-19) pandemic has presented a myriad of organizational and institutional challenges. The Uniformed Services University of the Health Sciences, like many other front line hospitals and clinics, encountered a myriad of challenges in fostering and sustaining the education of students enrolled at the nation’s only military medical school. Critical to the function of any academic medical institution, but particularly one devoted to the training of future physicians for the Military Health System, was the ability to rapidly adapt, modify, and create new means of keeping medical students engaged in their core curricula and progressing toward full and timely attainment of established educational goals and objectives. Methods This article highlights some of the particular challenges faced by faculty and students during the first 6 months of the COVID-19 pandemic and describes how they were managed and/or mitigated. Results Six key “lessons learned” were identified and summarized in this manuscript. These lessons may be applicable to other academic institutions both within and outside of the Military Health System. Conclusions Recognizing and embracing these key tenets of academic change management can accelerate the generation of a cohesive, organizational response to the next pandemic or public health crisis.

There are approximately 20 million students in U.S. colleges and universities. Although this population is characterized as having good health, 600,000 students report some form of disability or some type of medical problem, including attention-deficit/hyperactivity disorder, learning disabilities, psychiatric disorders, and chronic illnesses, among others. Physicians can enhance youth transition to an adult model of health care; the use of self-care skills checklists is one recommended method to assist with the transition. Stimulant medications are effective for treating adults with attention-deficit/hyperactivity disorder, but physicians should use caution when prescribing stimulants to college students because of the high rates of medication diversion in this population. Depression, anxiety, posttraumatic stress disorder, sleep problems, and eating disorders are common in college students and can significantly impact performance. Emphasis on immunization of students for influenza, meningococcus, and pertussis is necessary because of the low rates of compliance. Screening and interventions for obesity, tobacco use, and substance abuse are important because of the high prevalence of these problems in college students. Screening for alcohol abuse facilitates identification of students with problem drinking behaviors. Students who are war veterans should be monitored for suicidal ideation and posttraumatic stress disorder. Lesbian, gay, bisexual, transgender, and questioning students are at risk of harassment and discrimination. Caution should be exercised when prescribing medications to college athletes to avoid violation of National Collegiate Athletic Association eligibility rules.

Henoch-Schönlein purpura, now called immunoglobulin A (IgA) vasculitis, is a systemic, immune complex-mediated, small-vessel leukocytoclastic vasculitis characterized by nonthrombocytopenic palpable purpura, arthritis, and abdominal pain. It is the most common vasculitis in children but can also occur in adults. Diagnostic testing is required only to exclude other etiologies of purpura, to identify renal involvement, and, if indicated, to determine its extent with biopsy. Imaging or endoscopy may be needed to assess organ complications. IgA vasculitis spontaneously resolves in 94% of children and 89% of adults, making supportive treatment the primary management strategy. However, a subset of patients experience renal involvement that can persist and relapse years later. Additional complications can include gastrointestinal bleeding, orchitis, and central nervous system involvement. Systematic reviews have shown that steroids do not prevent complications and should not be used prophylactically. However, randomized trials have demonstrated success with high-dose steroids, cyclosporine, and mycophenolate in treating glomerulonephritis and other complications. Long-term prognosis depends on the extent of renal involvement. Six months of follow-up is prudent to assess for disease relapse or remission.

To improve health care, the USA needs to create a longitudinal medical education system that will develop physicians able to lead the transformation of health care toward a focus on the promotion of healthy behaviors aimed at preventing disease. The development of patient-centered care has been an important step in promoting healthy behaviors. However, to truly develop a meaningful relationship with a patient, a physician must first see them as a person, not as a list of diseases. Medical education should develop physicians able to provide person-centered care - moving beyond patient-centered care to focus more broadly on the entirety of the person, for whom being a patient is merely one aspect of their personhood. Restructuring medical education begins with the admission process itself, followed by longitudinal changes at the undergraduate, graduate, and continuing professional development levels that will reinforce the attributes critical for future physicians. The authors view this longitudinal approach through the theoretical framework of situated cognition, exploring personal, environmental, and social factors leading to success; outline several key stages of medical education from matriculation through continuing professional development; and identify potential areas that merit longitudinal efforts to develop future physicians able to promote positive health behaviors.

INTRODUCTION The purpose of this study was to examine Uniformed Services University (USU) women graduates in terms of percent of graduates', specialty choices and practice choices as compared to civilian women who graduate and practice medicine in the USA. This is a perspective that is currently not well understood. MATERIALS AND METHODS We conducted a retrospective cohort study of all USU women graduates (1980-2015) using the 2016 American Medical Association (AMA) Physician Masterfile that included data from the American Board of Medical Specialties (ABMS). To describe USU women graduates' current practice status we queried for: (1) medical school; (2) year of graduation; (3) practice state; (4) primary specialty board; and (5) major professional activity (office-based practice vs. full-time hospital staff). Data were analyzed using descriptive statistics. RESULTS Our findings indicate that the percentage of USU women graduates has increased over time and stands at 29% for the 2010-2015 cohort as compared to 48% for women graduating from all U.S. medical schools. USU women graduates have a slightly higher board certification rate (89%) than the national cohort (88%). USU women graduates also have a higher percentage in family medicine (19%) than the national cohort (14%). USU women graduates practice in 48 states and were equally split between full-time hospital staff and office-based practice which differs from the national cohort that has a much higher proportion in office-based practice (85%). CONCLUSIONS Women are making significant gains in enrollment at USU, obtaining board certification at similar, and in some cases, higher rates than their civilian peers, and practicing in diverse specialties. This study provides a descriptive picture of women's enrollment and practice characteristics from a military-based medical school. Future work could examine underlying factors that may influence their school choice, career experiences, and trajectories. Future research could also focus on women's experiences of mentoring and support to better understand these factors.

This position paper discusses on-going academic remediation challenges within the field of medical education. More specifically, we identify three common contemporary problems and propose four recommendations to strengthen remediation efforts. Selecting or determining what type of remediation is needed for a particular student is akin to analyzing a Gordian knot with individual, institutional and systemic contributors. More emphasis, including multi-institutional projects and research funding is needed. Recommendations regarding language use and marketing of such programs are given.

Cardiovascular disease remains the leading cause of death in the United States and worldwide. Prevention of cardiovascular disease is an achievable goal. A rigorous 2010 analysis by the World Health Organization suggests that reducing risk factors in young adults and maintaining an optimum risk profile through age 50 could prevent 90% of atherosclerotic cardiovascular disease events. Misinformation and poor implementation of proven preventive strategies, misplaced fears of medications, or incorrect understanding of ideal dietary and lifestyle choices all contribute to poor risk profiles. Every patient deserves an individualized prescription for cardiovascular disease prevention incorporating strategies to control modifiable cardiovascular risk factors.

Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling. Pulmonary embolism is the most common serious cause, found in 5% to 21% of patients who present to an emergency department with pleuritic chest pain. A validated clinical decision rule for pulmonary embolism should be employed to guide the use of additional tests such as d-dimer assays, ventilation-perfusion scans, or computed tomography angiography. Myocardial infarction, pericarditis, aortic dissection, pneumonia, and pneumothorax are other serious causes that should be ruled out using history and physical examination, electrocardiography, troponin assays, and chest radiography before another diagnosis is made. Validated clinical decision rules are available to help exclude coronary artery disease. Viruses are common causative agents of pleuritic chest pain. Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, mumps, adenovirus, cytomegalovirus, and Epstein-Barr virus are likely pathogens. Treatment is guided by the underlying diagnosis. Nonsteroidal anti-inflammatory drugs are appropriate for pain management in those with virally triggered or nonspecific pleuritic chest pain. In patients with persistent symptoms, persons who smoke, and those older than 50 years with pneumonia, it is important to document radiographic resolution with repeat chest radiography six weeks after initial treatment.

INTRODUCTION The Uniformed Services University F. Edward Hebert School of Medicine just passed its 45th anniversary, opening in 1972. A goal of the medical school, like those nationally, is the production of high-quality physicians. The purpose of this study is to describe the practice characteristics of our USU graduates and to compare data with the national cohort of U.S. MD graduates. MATERIALS AND METHODS To accomplish this, we performed a retrospective analysis of U.S. graduates (1980-2009). We used the American Medical Association Physician Masterfile to describe our graduates' current practice profile and compare them with the national cohort. In order to ascertain if USU is meeting our goal to provide high-quality physicians, we also compare our findings with national allopathic school data to norm-reference our results. RESULTS Our findings indicate that USU graduates contribute to both primary care and specialty care and they practice in all 50 states. USU graduates continue to serve their nation after their obligation is complete, with 64% continuing to practice in federal hospitals and agencies. USU graduates also have a higher board certification rate (90%) than the national cohort (88%). CONCLUSION Following our 45th anniversary, we provide continuing evidence that USU is keeping its contract with society. We provide evidence that USU continues to meet its obligation to the nation's health care needs by producing high-quality physicians who serve the country in multiple ways after their military obligation is complete, thus extending the definition of staying power. Our study is not without limitations. First, we could not precisely define the cohort to exclude graduates who still had service obligations. Second, the AMA Physician Masterfile had some missing data fields, so nonresponse or misclassification bias is possible in our results. Study strengths include the long period of time and large number of graduates in each cohort.

Multiple strategies have been proposed to improve health care in the United States. These include the development of communities of solution (COSs), implementation of patient-centered medical homes (PCMHs), and lengthening family medicine residency training. There is scant literature on how to build and integrate these ideal models of care, and no literature about how to build a model of care integrating all 3 strategies is available. The Military Health System has adopted the PCMH model and will offer some 4-year family medicine residency positions starting in 2013. Lengthening residency training to 4 years represents an unprecedented opportunity to weave experiential COS instruction throughout a family physician's graduate medical education, providing future family physicians the skills needed to foster a COS in their future practice. This article describes our COS effort to synergize 3 aspects of modern military medicine: self-defined community populations, the transition to the PCMH model, and the initiation of the 4-year length of training pilot program in family medicine residency training. In this way we provide a starting point and general how-to guide that can be used to create a COS integrated with other current concepts in medicine.

Cardiovascular disease remains the leading cause of death in the United States despite a 50% decrease in deaths from myocardial infarction and stroke in the past 30 years associated with improvements in blood pressure and lipid control. The National Health and Nutrition Evaluation Survey found that the least prevalent metrics of cardiovascular health in adults were healthy diets, normal weights, and optimal levels of exercise. A further reduction in rates of cardiovascular disease will require an increase in exercise. Clinicians who encourage exercise in middle-aged patients face several dilemmas. This article reviews exercise-related risks for sudden death and the performance of a global cardiovascular risk assessment. The need for additional preexercise risk stratification with electrocardiogram, graded exercise testing, or echocardiography is outlined. In addition, the optimum choice of medications for hypertension or dyslipidemia treatment and the effects of these medications and aspirin on endurance exercise are reviewed.

Introduction: Finding ways to improve communication and self-reflection skills is an important element of medical education and continuing professional development. This study examines the relationship between self-reflection and educational outcomes. Methods: We correlate performance in a preclinical course that focuses on self-reflection as it relates to contextual elements of patient care (Human Context of Health Care), with educational measures such as overall grade point average, clinical clerkship scores, and Medical College Admission Test (MCAT) scores. Results: Student performance in Human Context of Health Care correlated with MCAT-Verbal scores, MCAT-writing sample scores, clerkship grades, and overall medical school grade point average (R = 0.3; p < 0.001). Conclusion: Writing and self-reflection skills are often neglected in undergraduate medical curricula. Our findings suggest that these skills are important and correlate with recognized long-term educational outcomes.

Background: Residency education requires large numbers of skilled teaching faculty. Potential faculty can often be identified during residency training. Aims: Employ a 4-week immersive faculty development mini-fellowship to enhance the teaching skills of selected PGY-3 residents and study outcomes over 5 years. Methods: PGY-3 residents were competitively selected and completed the 4-week curriculum to increase skills in precepting, small group teaching, large group teaching, learner feedback/assessment, academic career development, and research. Results: Fifteen residents completed the mini-fellowship over the 5-year study period. The curriculum was rated highly by the residents with mean ratings of curriculum components ranging from 4.5 to 4.9 on a 5-point scale. Eight residents (53%) were selected for faculty positions compared to a usual selection rate of 11%. Compared to new faculty without mini-fellowship completion, program directors rated the residents completing the mini-fellowship as better prepared to perform learner feedback (4.1 vs. 3.0, p � 0.01) and to understand the conduct of research (3.6 vs. 2.5 p � 0.01). Conclusions: This study demonstrates short-term success at growing faculty with enhanced teaching skills during residency. While long-term retention in academic medicine cannot be predicted, this program represents one method to mitigate shortages of qualified junior residency faculty.

Declining death rates from heart disease since the 1950s have been largely attributed to secondary prevention. Unfortunately, studies demonstrate remarkable underutilization of secondary prevention plans by health care providers. Health care providers should develop secondary prevention plans for patients who have sustained a myocardial infarction or an acute coronary syndrome. The secondary prevention plan should include four core components: initial patient risk assessment, pharmacologic therapy, therapeutic lifestyle changes and intervention, and psychosocial evaluation.

INTRODUCTION In August, 2011, the F. Edward Hebert School of Medicine extensively revised its four year curriculum, focusing on the theme of “Molecules to Military Medicine.” Since most civilian medical schools undergoing a major curricular reform typically allow three to seven years for full implementation, the fact that its revision was designed and implemented in two years, was itself a momentous achievement. As such, this report will describe some of the key innovations associated with the new curriculum, followed by a summary of some of the leadership lessons that may help guide other programs considering similar types of curricular revision.

Purpose: In 2010, several primary care physician organizations drafted the “Promoting Good Stewardship in Clinical Practice” list for family medicine to advance the appropriate use of 5 commonly ordered treatments and tests. The goal was to achieve excellent patient care while appropriately conserving health care resources. The purpose of this study was to assess knowledge regarding the appropriate use of these treatments and tests among the memberships of the Uniformed Services Academy of Family Physicians (USAFP) and the Council of Academic Family Medicine (CAFM). Methods: An online, cross-sectional survey of all family physician members of the USAFP and the CAFM was conducted. The survey consisted of 5 clinical cases administered as part of a larger omnibus CAFM Educational Research Alliance survey and a separate USAFP membership survey. The primary outcome was correct answers to clinical scenarios. Results: The response rate was 11% (n = 236 of 2165) for members of USAFP and 47% (n = 519 of 1099) for CAFM members, with an overall response rate of 23% (n = 755 of 3264). Overall, respondents answered 78% of cases correctly (USAFP 79%, CAFM 78%; no significant difference). In rank order, respondents were most likely to answer the Papanicolaou test question correctly (90.1%), followed by the low-back pain (86.7%), the dual-energy X-ray absorptiometry screening (85.4%), the sinusitis (66.5%), and the cardiac screening questions (61.4%). Conclusion: Among the family physicians surveyed, knowledge about the appropriate use of commonly overused tests and treatments was high. Two clinical scenarios (sinusitis and cardiac screening) demonstrate areas where further education could improve care and reduce costs.

There is concern regarding the number of US medical graduates choosing careers in primary care. To address this, the American Academy of Family Physicians (AAFP) Future of Family Medicine project has recommended increasing the length of family medicine residency from 3 to 4 years as one way to increase student interest in family medicine. Given increasing training requirements for family physicians, we investigated attitudes within the military regarding 4-year postgraduate training in family medicine.A survey exploring attitudes toward extended training in family medicine was distributed electronically to all 1,659 members of the Uniformed Services Academy of Family Physicians.Most (68%) respondents felt that extending family medicine training to 4 years would not increase interest in family medicine. The mean suggested length for appropriate family medicine training, however, was 3.5 years. Respondent support for increased duration of training increased when coupled with certificates of added qualifications (CAQ).While military family physicians do not believe that extending family medicine residency to 4 years will increase interest in the discipline, they do acknowledge that extending training beyond the current 3-year model would be beneficial. Because of the central role of family physicians within the military health system, military family medicine residencies present an ideal environment for examining educational outcomes using 4-year training models.

Pruritus can be a symptom of a distinct dermatologic condition or of an occult underlying systemic disease. Of the patients referred to a dermatologist for generalized pruritus with no apparent primary cutaneous cause, 14 to 24 percent have a systemic etiology. In the absence of a primary skin lesion, the review of systems should include evaluation for thyroid disorders, lymphoma, kidney and liver diseases, and diabetes mellitus. Findings suggestive of less serious etiologies include younger age, localized symptoms, acute onset, involvement limited to exposed areas, and a clear association with a sick contact or recent travel. Chronic or generalized pruritus, older age, and abnormal physical findings should increase concern for underlying systemic conditions. Initial evaluation for systemic disease includes complete blood count and measurement of thyroid-stimulating hormone, fasting glucose, alkaline phosphatase, bilirubin, creatinine, and blood urea nitrogen. Hodgkin lymphoma is the malignant disease most strongly associated with pruritus, which affects up to 30 percent of patients with the disease. Chest radiography is needed when lymphoma is suspected. A wheal and flare response indicates histamine-induced pruritus in patients with urticaria or an allergic dermatitis. These patients benefit from continuous dosing of a long-acting antihistamine. Second-generation antihistamines, such as cetirizine, loratadine, and fexofenadine, may be more effective because of improved patient compliance.

Although easily examined, abnormalities of the tongue can present a diagnostic and therapeutic dilemma for physicians. Recognition and diagnosis require a thorough history, including onset and duration, antecedent symptoms, and tobacco and alcohol use. Examination of tongue morphology and a careful assessment for lymphadenopathy are also important. Geographic tongue, fissured tongue, and hairy tongue are the most common tongue problems and do not require treatment. Median rhomboid glossitis is usually associated with a candidal infection and responds to topical antifungals. Atrophic glossitis is often linked to an underlying nutritional deficiency of iron, folic acid, vitamin B12, riboflavin, or niacin and resolves with correction of the underlying condition. Oral hairy leukoplakia, which can be a marker for underlying immunodeficiency, is caused by the Epstein-Barr virus and is treated with oral antivirals. Tongue growths usually require biopsy to differentiate benign lesions (e.g., granular cell tumors, fibromas, lymphoepithelial cysts) from premalignant leukoplakia or squamous cell carcinoma. Burning mouth syndrome often involves the tongue and has responded to treatment with alpha-lipoic acid, clonazepam, and cognitive behavior therapy in controlled trials. Several trials have also confirmed the effectiveness of surgical division of tongue-tie (ankyloglossia), in the context of optimizing the success of breastfeeding compared with education alone. Tongue lesions of unclear etiology may require biopsy or referral to an oral and maxillofacial surgeon, head and neck surgeon, or a dentist experienced in oral pathology.

Henoch-Schönlein purpura is an acute, systemic, immune complex-mediated, leukocytoclastic vasculitis. It is characterized by a triad of palpable purpura (without thrombocytopenia), abdominal pain, and arthritis. Most patients have an antecedent upper respiratory illness. More than 90 percent of Henoch-Schönlein purpura cases occur in children younger than 10 years; however, adults with this condition are more likely to experience complications than children. All patients with Henoch-Schönlein purpura develop a purpuric rash, 75 percent develop arthritis, 60 to 65 percent develop abdominal pain, and 40 to 50 percent develop renal disease. Because Henoch-Schönlein purpura spontaneously resolves in 94 percent of children and 89 percent of adults, supportive treatment is the primary intervention. Oral prednisone at 1 to 2 mg per kg daily for two weeks has been used to treat abdominal and joint symptoms. A meta-analysis found that corticosteroid use in children reduced the mean time to resolution of abdominal pain and decreased the odds of developing persistent renal disease. Early aggressive therapy with high-dose steroids plus immunosuppressants is recommended for patients with severe renal involvement. Long-term prognosis depends on the severity of renal involvement. End-stage renal disease occurs in 1 to 5 percent of patients.

Patients often initiate commercial dietary plans to reduce obesity and prevent cardiovascular disease. Such plans include very low-carbohydrate, low-carbohydrate, very low-fat, and Mediterranean diets. Published evidence on several popular diets has made it easier for physicians to counsel patients about the health benefits and risks of such plans. Although the Atkins, Zone, Sugar Busters!, and South Beach diets have data proving that they are effective for weight loss and do not increase deleterious disease-oriented outcomes, they have little evidence of patient-oriented benefits. In contrast, the Mediterranean diet has extensive patient-oriented outcome data showing a significant risk reduction in mortality rates and in rates of fatal and nonfatal myocardial infarction. The American Heart Association released guidelines in 2006 that integrate recommendations from a variety of diets into a single plan. Physicians should emphasize diets that are rich in fruits, vegetables, and healthful fatty acids and that limit saturated fat intake. A stepwise individualized patient approach, with incorporation of one or two dietary interventions every three to six months, may be a practical way to help reduce a patient's cardiovascular disease risk.

Background: Complications of labor epidural anesthesia include a post-dural puncture headache (PDPH). A 2003 meta-analysis described the onset of PDPH as occurring from 1 to 7 days after the procedure. Presented here is the first published case of a PDPH occurring 12 days postpartum. Methods: Twelve days after an uncomplicated labor epidural a patient was awakened by a “crushing” postural headache. The initial diagnosis was “possible subarachnoid hemorrhage.” Lumbar puncture and computed tomography angiogram were normal. Despite medications a severe postural headache persisted and she was referred for an epidural blood patch. Consultants felt the headache onset after 7 days made PDPH impossible. Ultimately a delayed EBP was performed with immediate resolution of her headache. Discussion: Meta-analyses describe that parturients have a 1.5% risk of accidental dural puncture during epidural placement. Onset of the headache occurs as early as 1 or as late as 7 days after the procedure. Epidural blood patch is the most effective treatment for PDPH and a rapid response is diagnostic. Conclusion: Described is the first reported case of a PDPH occurring well outside the normal range of onset 1 to 7 days after epidural anesthesia. The delayed diagnosis and treatment of PDPH in this patient illustrates the limitations of over-rigorous application of pooled analyses to the care of individual patients.

The National Cholesterol Education Program/Adult Treatment Panel (NCEP/ATP) guidelines reviewed in Chapter 2 provide an excellent evidencebased foundation for the management of hyperlipidemia. Using a consistent stepwise approach leads to better patient outcomes. All portions of the lipid profile are important to consider when assessing risk of cardiovascular disease, but it is prudent to first focus on optimizing low density lipoprotein (LDL). Most studies have proven the significant benefits of reducing LDL. Triglycerides (TG) and high density lipoprotein (HDL) are important, but they are secondary targets of therapy. An important exception is the patient with triglycerides greater than 500 mg/dl. In these patients, triglycerides should be reduced first to lower the risk of pancreatitis. Also, unless the LDL is directly measured, a very high triglyceride level makes the measurement and interpretation of LDL cholesterol difficult.

Hyperlipidemia management for primary care : , Hyperlipidemia management for primary care : , کتابخانه دیجیتال جندی شاپور اهواز

Pleuritic chest pain is a common presenting symptom and has many causes, which range from life-threatening to benign, self-limited conditions. Pulmonary embolism is the most common potentially life-threatening cause, found in 5 to 20 percent of patients who present to the emergency department with pleuritic pain. Other clinically significant conditions that may cause pleuritic pain include pericarditis, pneumonia, myocardial infarction, and pneumothorax. Patients should be evaluated appropriately for these conditions before an alternative diagnosis is made. History, physical examination, and chest radiography are recommended for all patients with pleuritic chest pain. Electrocardiography is helpful, especially if there is clinical suspicion of myocardial infarction, pulmonary embolism, or pericarditis. When these other significant causes of pleuritic pain have been excluded, the diagnosis of pleurisy can be made. There are numerous causes of pleurisy, with viral pleurisy among the most common. Other etiologies may be evaluated through additional diagnostic testing in selected patients. Treatment of pleurisy typically consists of pain management with nonsteroidal anti-inflammatory drugs, as well as specific treatments targeted at the underlying cause.

Although most persons with parvovirus B19 infection are asymptomatic or have mild, nonspecific, cold-like symptoms, several clinical conditions have been linked to the virus. Parvovirus B19 usually infects children and causes the classic "slapped-cheek" rash of erythema infectiosum (fifth disease). The virus is highly infectious and spreads mainly through respiratory droplets. By the time the rash appears, the virus is no longer infectious. The virus also may cause acute or persistent arthropathy and papular, purpuric eruptions on the hands and feet ("gloves and socks" syndrome) in adults. Parvovirus B19 infection can trigger an acute cessation of red blood cell production, causing transient aplastic crisis, chronic red cell aplasia, hydrops fetalis, or congenital anemia. This is even more likely in patients with illnesses that have already shortened the lifespan of erythrocytes (e.g., iron deficiency anemia, human immunodeficiency virus, sickle cell disease, thalassemia, spherocytosis). A clinical diagnosis can be made without laboratory confirmation if erythema infectiosum is present. If laboratory confirmation is needed, serum immunoglobulin M testing is recommended for immunocompetent patients; viral DNA testing is recommended for patients in aplastic crisis and for those who are immunocompromised. Treatment is usually supportive, although some patients may require transfusions or intravenous immune globulin therapy. Most patients recover completely.

Graduate medical education program directors struggle with resident trainees who develop problems in academic and personal spheres leading to probation, resignation, or termination of training. These "residents in trouble" generate a disproportionate amount of work and can demoralize faculty and residents. Only two prior studies have identified the prevalence of residents in trouble. In both studies, the prevalence was based on nonvalidated program director self-report. In contrast, our study uses a review of primary data sources to describe the prevalence, types of problems, remediation methods, and outcomes for residents in trouble over the 25-year experience of a residency program.Five primary data sources were reviewed for every trainee who was enrolled from 1978-2003 at the David Grant Medical Center Family Medicine Residency, looking for any of eight types of occurrences previously identified in the literature as marking a resident in trouble.Over this 25-year period, 230 residents entered training and 209 graduated. The prevalence of residents in trouble was 9.1%. The types of problems encountered included divorce, psychiatric illness, substance abuse, attitudinal problems, interpersonal conflict, excessive patient complaints, and insufficient knowledge. A variety of remediation approaches were used, and 90% of the residents in trouble graduated.The 9.1% provides a point of comparison for program directors to know if their residency has a disproportionate rate of problems requiring organizational reform or if they are dealing with the normative experience of a training program. Our program's experience supports five suggestions for the management of residents in trouble.