Treatment of Chronic Insomnia in Adults.

Insomnia affects 30% of the U.S. population, with 5% to 15% meeting criteria for chronic insomnia. It can negatively impact quality of life, decrease productivity, increase fatigue and drowsiness, and put patients at higher risk of developing other health problems. Initial treatment focuses on nonpharmacologic therapies such as cognitive behavior therapy, which improves negative thought patterns and behaviors through sleep restriction, stimulus control, and relaxation techniques. Other nonpharmacologic treatments include exercise, mindfulness, and acupuncture. If these approaches are ineffective, pharmacologic agents may be considered. Medications such as benzodiazepines and Z-drugs are often prescribed for insomnia but should be avoided, if possible, due to short- and long-term risks associated with their use. Melatonin receptor agonists are safer and well tolerated but have limited effectiveness. Dual orexin receptor antagonists are effective in patients who have sleep maintenance insomnia or difficulty with sleep onset. Evidence for the use of antihistamines to treat insomnia is generally lacking, but doxylamine is effective for up to four weeks.

Arrhythmias and Sudden Cardiac Death.

Ventricular tachyarrhythmias remain a major cause of sudden cardiac arrest (SCA) that leads to sudden cardiac death (SCD). Primary prevention strategies to prevent SCD include promoting a healthy lifestyle, following United States Preventive Service Task Force recommendations related to cardiovascular disease, and controlling comorbid conditions. For a patient experiencing SCA, early cardiopulmonary resuscitation and defibrillation should be performed. Implantable cardioverter defibrillators are more effective at secondary prevention compared with drug therapy but medications such as amiodarone, beta-blockers, and sotalol may be helpful adjuncts to reduce the risk of SCD or improve a patient's symptoms (eg, palpitations and inappropriate defibrillator shocks).

Family Medicine Musculoskeletal Medicine Education: A CERA Study.

BACKGROUND AND OBJECTIVES: Musculoskeletal (MSK) concerns constitute up to 40% of primary care outpatient visits. Despite Accreditation Council for Graduate Medical Education (ACGME) family medicine program requirements for musculoskeletal medicine and sports medicine training, previous studies have shown that family medicine residency graduates do not have adequate training to manage common musculoskeletal conditions. Factors for this may include deficiencies in education at both the undergraduate and graduate medical education training levels. METHODS: A Council of Academic Family Medicine Educational Research Alliance survey of 287 family medicine program directors assessed the current state of the delivery of musculoskeletal medicine education. Opinions were gathered on the scope and delivery of training requirements as well as potential areas for further curricular attention. RESULTS: Two hundred eighty-seven program directors responded to the survey (response rate 41.53%). Most (72.60%) were in university based or affiliated programs and had a fellowship-trained primary care sports medicine physician (59.85%) curricular lead. A majority (77.4%) did not feel that PGY-1 residents enter residency with the physical exam skills needed to evaluate common musculoskeletal (MSK) conditions , and most (81.15%) did not feel that there should be changes to the current ACGME requirements. An area highlighted for further investment is faculty development in point-of-care ultrasound (39.85%). CONCLUSIONS: Although program directors believe that current ACGME MSK curricular requirements are likely appropriate, they do not feel residents arrive with the examination skills needed to evaluate common MSK conditions.Therefore, further attention can be given to medical student education in musculoskeletal exam skills prior to residency. Future research should develop objective measures using multiple assessors-students, residents, teaching faculty, and patients-to assess both the baseline and graduating competency in MSK medicine of our residents.

Common Upper-Extremity Injuries.

Primary care and sports medicine physicians will undoubtedly encounter upper-extremity injuries on a regular basis in their practice. Athletes have injuries most commonly to the shoulder, elbow, wrist, and hand as a result of a fall onto an outstretched arm. This article aims to educate physicians about sports-related upper-extremity injuries. Common mechanisms of injury, classic physical examination, and radiographic findings are reviewed. General guidelines for treatment as well as indications for referral to a sports medicine or orthopedic specialist are included in the discussion.

Common Prescription Medications Used in Athletes.

Athletes of various skill levels commonly use many different types of medications, often at rates higher than the general population. Common medication classes used in athletes include analgesics such as nonsteroidal anti-inflammatory drugs and acetaminophen, inhalers for asthma and exercise-induced bronchoconstriction, antihypertensives, antibiotics, and insulin. Prescribers must be aware of the unique considerations for each of these medications when using them in patients participating in physical activity. The safety, efficacy, impact on athletic performance, and regulatory restrictions of the most common medications used in athletes are discussed in this article.

Forward Feeding in Graduate Medical Education: Results of a National Survey.

BACKGROUND AND OBJECTIVES: "Forward feeding" is defined as the sharing of information regarding learner behaviors and performance outside of formal institutional committee structures. The purpose of this study was to establish baseline opinions and policies of forward feeding in family medicine residency programs. METHODS: Data for this study were obtained as part of the 2015 CERA Program Directors Fall Survey. Program directors indicated whether they felt that faculty should and do engage in forward feeding. Respondents were asked to rate the importance of various types of information about learners (academic performance, clinical performance, professionalism, physical health, and mental health), reasons for promoting, and concerns regarding forward feeding on a 5-point Likert scale. RESULTS: The overall response rate was 49% (227/461). Most agreed that faculty should (87%) and do (83%) engage in forward feeding. Concerns regarding professionalism and clinical performance were reported as most important to share. The most important reason identified for forward feeding was the early identification of struggling residents, followed by the ability to direct teaching to the resident's specific needs, and improving the quality of feedback. Fear of creating bias was the most commonly cited concern for engaging in forward feeding, followed by fear of violating confidentiality and difficulty maintaining confidentiality. Fear of litigation was the least common concern. CONCLUSIONS: Despite concerns, the majority of program directors feel that faculty should and do engage in forward feeding. Our study confirms the importance of clinical performance and professionalism as two important themes of information shared by attendings about residents.

Post-concussion syndrome and pre-existing mood disorder: A case report.

Sport-related concussions in youth and adolescent athletes most commonly resolve within one week without residual symptoms, with athletes resuming full participation following return to play guidelines. A small percentage of athletes have persistent symptoms that cause significant morbidity, some of whom are ultimately diagnosed with post-concussion syndrome. In these athletes, symptoms in the emotional domain can be more prolonged than other domains, with athletes reporting anxiety and depression months to years following injury. A prior personal or family history of pre-existing mood disorder or attention-deficit/hyperactivity disorder increases the risk of a prolonged duration of symptoms. In this case series, we discuss two cases of post-concussion syndrome in adolescent athletes with a past personal or family history of attention-deficit/hyperactivity disorder, anxiety, and depression treated by a combination of cognitive behavioral therapy and medication with ongoing persistent symptoms. There is increased need for mental health screening in all athletes to identify individuals at risk for post-concussion syndrome. Early identification of at-risk individuals allows the interdisciplinary care team to discuss expectations for the athlete and family regarding duration of symptoms.

Perspectives of Family Medicine Clerkship Directors Regarding Forward Feeding: A CERA Study.

BACKGROUND AND OBJECTIVES: Forward feeding signifies sharing information about learners for purposes of professional and academic advancement, and promotes progression toward a competency-based educational continuum. The aim of this study is to assess reasons for difficulty or failure of the family medicine clerkship and investigate utilization and methods of forward feeding. Reasons behind medical school policies regarding forward feeding are also evaluated. METHODS: Data were collected through the 2013 Council of Academic Family Medicine (CAFM) Educational Research Alliance (CERA) Family Medicine Clerkship Director survey. Directors rated reasons for clerkship difficulty or failure on a 6-point Likert scale. They also reported if they utilized forward feeding, to whom, and the communication method used. Finally, they were asked about factors influencing institutional policy toward forward feeding, including threats of litigation. RESULTS were compared between public and private schools, and based on tenure as clerkship director. Analyses were performed using chi-square or Fisher's exact test. RESULTS: Knowledge deficits were the most common reason for clerkship difficulty and failure, followed by professionalism difficulties. Over half of respondents engage in forward feeding, and almost all pass this information to other clerkship directors. Concern for student privacy and faculty bias were noted as two important factors influencing school policy. While almost half of respondents felt that litigation fears influenced their school's approach to forward feeding, few were aware of any related litigation. CONCLUSIONS: Forward feeding is only utilized by half of clerkship directors. More studies regarding the potential impacts of this practice are warranted.