Depression: Screening and Diagnosis.

Depression affects an estimated 8% of persons in the United States and accounts for more than $210 billion in health care costs annually. The U.S. Preventive Services Task Force (USPSTF) and American Academy of Family Physicians recommend screening for depression in the general adult population. Additionally, the USPSTF recommends screening children and adolescents 12 to 18 years of age for major depressive disorder. All screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The two-item and nine-item Patient Health Questionnaires (PHQs) are commonly used validated screening tools. The PHQ-2 has sensitivity comparable with the PHQ-9 in most populations; however, the specificity of the PHQ-9 ranges from 91% to 94%, compared with 78% to 92% for the PHQ-2. If the PHQ-2 is positive for depression, the PHQ-9 or a clinical interview should be administered. Screening all postpartum women for depression is recommended by the USPSTF, American Academy of Family Physicians, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists. Women should be screened for depression at least once during the perinatal period using the PHQ-2, PHQ-9, or Edinburgh Postnatal Depression Scale. In older adults, the Geriatric Depression Scale is also an appropriate screening tool for depression. If screening is positive for possible depression, the diagnosis should be confirmed using Diagnostic and Statistical Manual of Mental Disorders, 5th ed., criteria.

Zany Over Zika Virus: An Overview of Diagnosis and Treatment Modalities.

Zika virus has been a recent international public health concern with outbreaks occurring in the Americas, Caribbean, and Pacific. The zoonotic infection is primarily spread to humans by the bite of an infected Aedes mosquito. The virus also can be transmitted via bodily fluids, sexual intercourse, and maternal-fetal vertical transmission. Asymptomatic presentation is common. If symptoms do occur, individuals display a low-grade fever, maculopapular rash, arthralgia, or conjunctivitis 2 to 7 d after infection. Infection is concerning due to its associated fetal effects in pregnant women and relationship with Guillain-Barre syndrome. Diagnosis should be suspected in individuals with the appropriate symptomatology and exposure history. Diagnostic tests for the Zika virus are available and vary based on symptom duration. Treatment is supportive, and surveillance is suggested for all pregnant women. Prior infection is thought to provide immunity toward future exposures. Prevention and education is key in decreasing the spread of disease.

Wilderness Travel in Nonpregnant Females: Differences in Physiology, Counseling, and Common Issues.

Interest in wilderness travel has been increasing in women of all ages and can lead to multiple health benefits. In order to optimize a woman's experience in the wilderness, providers should be aware of both common and special conditions unique to women that may be impacted by wilderness travel. Both anatomic and physiologic differences set women apart from men and should be carefully considered in a wilderness setting. Special conditions pertaining to women in the wilderness include high altitude exposure and temperature sensitivity. Before wilderness travel, each patient should complete a physical examination, review medical history with a provider, and receive an overview of counseling for their desired area of travel.

Tick-Borne Illnesses.

Tick-borne diseases are prevalent throughout the United States. These illnesses are caused by a variety of different pathogens that use ticks as vectors, including bacteria, viruses, rickettsia, and protozoa. Some of the most common illnesses caused by ticks are Lyme disease, Rocky Mountain spotted fever, babesiosis, ehrlichiosis, anaplasmosis, tularemia, Colorado tick fever, tick-borne relapsing fever, and Powassan disease. Unique skin changes, fever, and influenza-like symptoms may indicate tick-borne disease. Early diagnosis can be difficult as well as nonspecific and can resemble overtraining syndrome. Diagnosis is important to facilitate early treatment to decrease morbidity and mortality and should often be initiated before a definitive diagnosis is made. Treatment guidelines are published by the Centers for Disease Control and Prevention. As tick-borne diseases increase and their geographic regions expand, it is important for providers to distinguish the often overlapping and diverse presentations of these diseases.

Phenotypic predictors of suicide subtypes from pre-to postdeployment in active duty military personnel.

Military service members are at increased risk for suicide, but there are few strategies for detecting those who are at highest risk after a deployment. Using all available data collected from 4119 Military service members before and after their deployment to Iraq for Operation Iraqi Freedom, we tested whether predeployment characteristics clustered together to predict postdeployment suicidal risk. Latent class analysis showed that three classes best characterized the sample at predeployment. Class 1 had significantly higher scores on PTSD severity pre- and postdeployment than Classes 2 and 3 (Ps < .001). At postdeployment, Class 1 also had a greater proportion of endorsement of lifetime and past year suicidal ideation than Classes 2 and 3 (Ps < .05) and a greater proportion of lifetime suicide attempts than Class 3 (P < .001). Class 1 also had a greater proportion of endorsement of past-30-days intention to act on suicidal thoughts than Classes 2 and 3 (Ps < .05) and past-30-days specific plan for suicide than Classes 2 and 3 (Ps < .05). The study showed that based only on predeployment data, it is possible to determine which service members might be at highest risk for suicidal ideation and behavior at postdeployment.

Prevalence of Fibromyalgia Syndrome in Active-Duty Military Personnel.

OBJECTIVE: Previous research with civilian populations has found strong associations between fibromyalgia (FM) and posttraumatic stress disorder (PTSD). We undertook this study to investigate the prevalence of FM in military service members with and without PTSD. METHODS: Participants were active duty military personnel recruited into either an epidemiologic cohort study of service members before a military deployment or 1 of 3 PTSD treatment trials. Instruments used to document FM and PTSD included the PTSD Checklist-Stressor-Specific Version, the PTSD Symptom Scale-Interview, and the 2012 American College of Rheumatology FM questionnaire. RESULTS: Across the 4 studies, 4,376 subjects completed surveys. The prevalence of FM was 2.9% in the predeployment cohort, and the prevalence was significantly higher in individuals with PTSD (10.8%) compared with those without PTSD (0.8%). In the treatment trials, all of the participants met criteria for PTSD before starting treatment, and the prevalence of FM was 39.7%. CONCLUSION: The prevalence of FM in active duty service members preparing to deploy is similar to that reported for the general population of the US but is higher than expected for a predominantly male cohort. Furthermore, the prevalence of FM was significantly higher in service members with comorbid PTSD and was highest among those seeking treatment for PTSD. Further investigation is needed to determine the factors linking PTSD and FM.

Screening for depression.

In the United States, depression affects up to 9 percent of patients and accounts for more than $43 billion in medical care costs. The U.S. Preventive Services Task Force recommends screening in adolescents and adults in clinical practices that have systems in place to ensure accurate diagnosis, effective treatment, and follow-up. It does not recommend for or against screening for depression in children seven to 11 years of age or screening for suicide risk in the general population. The Patient Health Questionnaire (PHQ)-2 and PHQ-9 are commonly used and validated screening tools. The PHQ-2 has a 97 percent sensitivity and 67 percent specificity in adults, whereas the PHQ-9 has a 61 percent sensitivity and 94 percent specificity in adults. If the PHQ-2 is positive for depression, the PHQ-9 should be administered; in older adults, the 15-item Geriatric Depression Scale is also an appropriate follow-up test. If these screening tests are positive for depression, further evaluation is needed to confirm that the patient's symptoms meet the Diagnostic and Statistical Manual of Mental Disorders' criteria for diagnosis.

Identifying suicidal subtypes and dynamic indicators of increasing and decreasing suicide risk in active duty military personnel: Study protocol.

OBJECTIVES: Several recent studies have demonstrated that posttraumatic stress disorder (PTSD) and insomnia treatments are associated with significant reductions in suicidal ideation (SI) among service members. However, few investigations have evaluated the manner in which suicide risk changes over time among military personnel receiving PTSD or insomnia treatments. This paper describes the study protocol for a project with these aims: (1) explore potential genetic, clinical, and demographic subtypes of suicide risk in a large cohort of deployed service members; (2) explore subtype change in SI as a result of evidence-based psychotherapies for PTSD and insomnia; (3) evaluate the speed of change in suicide risk; and (4) identify predictors of higher- and lower-risk for suicide. METHODS: Active duty military personnel were recruited for four clinical trials (three for PTSD treatment and one for insomnia treatment) and a large prospective epidemiological study of deployed service members, all conducted through the South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONG STAR Consortium). Participants completed similar measures of demographic and clinical characteristics and subsets provided blood samples for genetic testing. The primary measures that we will analyze are the Beck Scale for Suicide Ideation, Beck Depression Inventory, and the PTSD Checklist for DSM-IV. DISCUSSION: Results from this study will offer new insights into the presence of discrete subtypes of suicide risk among active duty personnel, changes in risk over time among those subtypes, and predictors of subtypes. Findings will inform treatment development for military service members at risk for suicide.

STRONG STAR and the Consortium to Alleviate PTSD: Shaping the future of combat PTSD and related conditions in military and veteran populations.

The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid conditions in military personnel and veterans. This manuscript outlines the consortia's state-of-the-science collaborative research model and how this can be used as a roadmap for future trauma-related research. STRONG STAR was initially funded for 5 years in 2008 by the U.S. Department of Defense's (DoD) Psychological Health and Traumatic Brain Injury Research Program. Since the initial funding of STRONG STAR, almost 50 additional peer-reviewed STRONG STAR-affiliated projects have been funded through the DoD, the U.S. Department of Veterans Affairs (VA), the National Institutes of Health, and private organizations. In 2013, STRONG STAR investigators partnered with the VA's National Center for PTSD and were selected for joint DoD/VA funding to establish the Consortium to Alleviate PTSD. STRONG STAR and the Consortium to Alleviate PTSD have assembled a critical mass of investigators and institutions with the synergy required to make major scientific and public health advances in the prevention and treatment of combat PTSD and related conditions. This manuscript provides an overview of the establishment of these two research consortia, including their history, vision, mission, goals, and accomplishments. Comprehensive tables provide descriptions of over 70 projects supported by the consortia. Examples are provided of collaborations among over 50 worldwide academic research institutions and over 150 investigators.

Point-of-Care Ultrasound in Family Medicine Residencies 5-Year Update: A CERA Study.

BACKGROUND AND OBJECTIVES: In 2014, family medicine residency programs began to integrate point-of-care ultrasound (POCUS) into training, although very few had an established POCUS curriculum. This study aimed to evaluate the resources, barriers, and scope of POCUS training in family medicine residencies 5 years after its inception. METHODS: Questions regarding current training and use of POCUS were included in the 2019 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency program directors, and results compared to similar questions on the 2014 CERA survey. RESULTS: POCUS is becoming a core component of family medicine training programs, with 53% of program directors reporting establishing or an established core curriculum. Only 11% of program directors have no current plans to add POCUS training to their program, compared to 41% in 2014. Despite this increase in training, the reported clinical use of POCUS remains uncommon. Only 27% of programs use six of the eight surveyed POCUS modalities more than once per year. The top three barriers to including POCUS in residency training in 2019 have not changed since 2014, and are (1) a lack of trained faculty, (2) limited access to equipment, and (3) discomfort with interpreting images without radiologist review. CONCLUSIONS: Training in POCUS has increased in family medicine residencies over the last 5 years, although practical use of this technology in the clinical setting may be lagging behind. Further research should explore how POCUS can improve outcomes and reduce costs in the primary care setting to better inform training for this technology.

Trauma-Informed Care Training in Family Medicine Residency Programs Results From a CERA Survey.

BACKGROUND AND OBJECTIVES: Experiences of psychological trauma are common among primary care patient populations, and adversely affect patients' health and health care utilization. Trauma-informed care (TIC) is a framework for identifying and responding to patients' experiences of psychological trauma to avoid retraumatization. The purpose of this study was to evaluate the current state of TIC training in family medicine residency programs in the United States in order to identify opportunities for and barriers to TIC training. METHODS: Items addressing the four core domains of TIC were incorporated into the 2017 Council of Academy Family Medicine Educational Research Alliance (CERA) survey of program directors. The items assessed the presence, content, and sufficiency of TIC curriculum, as well as barriers to further integration of TIC training. RESULTS: Approximately 50% of programs responded to the survey. Of 263 respondents, 71 (27%) reported TIC training in their curriculum, but the majority devoted less than 5 hours annually to core content. The content most commonly addressed recognizing signs of trauma, most frequently using didactic formats. Overall, just over one-half of the programs reported that their curriculum met patients' TIC needs "somewhat" (48.5%) or "a great deal" (4.6%). Lack of a champion followed by lack of time were the most commonly cited barriers to integrating TIC training. CONCLUSIONS: Despite the acknowledged importance of effects of trauma in health care, this study identified insufficient exposure to training in the core TIC domains in family medicine residency programs, underscoring a need for greater integration of TIC training during residency.

A stepwise approach to pediatric asthma.

Two guidelines and several recent studies are available to guide your care. This review--with handy figure--puts it all at your fingertips.

Perceived clinical skill degradation of Army family physicians after deployment.

BACKGROUND AND OBJECTIVES: Deployment away from regular clinical practice is necessary for Army family physicians, but no current information identifies specific procedures or clinical encounters where they feel less comfortable after deployment. This study identifies specific clinical areas and amount of perceived degradation in skills after deployment to combat zones. METHODS: Active duty Army family physicians were invited to participate in a web-based and anonymous survey rating comfort level performing clinical encounters or procedures prior to and after military deployment. Participants rated their comfort level using a 5-point Likert scale. The analysis included descriptive statistics about each physician's deployment history. The composite data for each clinical encounter or procedure were analyzed with McNemar's Chi-Square test. RESULTS: A total of 179 eligible Army family physicians (54% of total) fully completed the instrument, with 39% deploying once and 10% deploying more than five times in their career. Deployments ranged from 1 to >24 months, with 42% having a last deployment of 12 months duration. With statistical significance, providers reported being less comfortable post-deployment with managing first-trimester bleeding, ACLS codes, acute abdominal pain, asthma exacerbations, central line placement, chest pain, COPD exacerbations, CVA/hypertensive emergency, lumbar puncture, neonatal fevers, pediatric codes, sepsis/septic shock, and vaginal delivery. These physicians reported statistically significant increased comfort with the care of major trauma after deployment. CONCLUSIONS: Family physicians deploying to support combat operations feel less comfortable with critical clinical skills across the spectrum of care. Refresher training could be provided with standardized approach to these needs with a goal of maintaining full scope primary care providers.

Point of Care Ultrasound in Family Medicine Residency Programs: A CERA Study.

BACKGROUND AND OBJECTIVES: Point-of-care (POC) ultrasound is increasingly used by clinicians across multiple medical specialties. Current perceptions and prevalence of POC ultrasound practice and training in family medicine residency programs has not been described. METHODS: Questions were included in the 2014 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency directors. The survey included questions regarding current use and current curricula regarding POC ultrasound. It also asked rank order questions of perceived benefits and perceived barriers to expanding such training. RESULTS: Fifty percent (n=224) of residency program directors completed the 2014 CERA survey. Few programs (2.2%) reported an established ultrasound curriculum. However, 29% indicated they have started a program within the past year, and 11.2% reported starting the process of establishing such training. Ultrasound assistance for procedural guidance was the most commonly reported (44%) use out of seven POC examples. The three leading perceived benefits of POC ultrasound were: making a more rapid diagnosis, the potential to save health care costs, and the potential to improve patient outcomes. The three leading barriers to expanding training were a lack of appropriately trained faculty, limited access to ultrasound equipment, and a lack of comfort in interpreting images without radiologist review. CONCLUSIONS: A small, but rapidly growing, number of family medicine residencies currently use POC ultrasound. Further research is needed to explore how POC ultrasound can improve patient outcomes in the ambulatory setting and to develop appropriate training methods for this technology.

Reducing tobacco use in adolescents.

After steadily decreasing since the late 1990s, adolescent smoking rates have stabilized at levels well above national goals. Experts recommend screening for tobacco use and exposure at every patient visit, although evidence of improved outcomes in adolescents is lacking. Counseling should be provided using the 5-A method (ask, advise, assess, assist, and arrange). All smokers should be offered smoking cessation assistance, including counseling, nicotine replacement therapy, bupropion therapy, or combination therapy. Pharmacotherapy of any kind doubles the likelihood of successful smoking cessation in adults; however, nicotine replacement therapy is the only pharmacologic intervention that has been extensively studied in children. Community interventions such as smoking bans and educational programs have been effective at reducing smoking rates in children and adolescents. Antismoking advertising and tobacco sales taxes also help deter new smokers and motivate current smokers to attempt to quit.

Smallpox vaccine: contraindications, administration, and adverse reactions.

Since the terrorist attacks of September 11, 2001, and the anthrax exposures in the following weeks, concern that smallpox could be used as a biologic weapon has increased. Public health departments and the U.S. military have begun the process of vaccinating soldiers and civilian first-responders. Smallpox vaccination carries some serious risks: approximately one in 1 million primary vaccinees and one in 4 million revaccinees will die from adverse vaccine reactions. The most serious side effects of smallpox vaccine include progressive vaccinia, postvaccinial central nervous system disease, and eczema vaccinatum. Some of these reactions can be treated with vaccinia immune globulin or cidofovir. Proper patient screening and site care are essential. Family physicians must learn to screen potential vaccinees for contraindications (e.g., immunodeficiency, immunosuppression, certain skin and eye diseases, pregnancy, lactation, allergy to the vaccine or its components, moderate or severe intercurrent illness) and to treat vaccine-associated adverse reactions.