Case study #1: The Citadel.

This case study explores a graduate program for working professionals that integrates technical leadership and project management, preparing students to earn their Project Management Professional certification.

U.S. military implantable collamer lens surgical outcomes: 11-year retrospective review.

PURPOSE: To examine the long-term efficacy and safety of myopic implantable collamer lens (ICL) implantation in active duty personnel of U.S. military. SETTING: Hospital practice. DESIGN: Retrospective longitudinal observational study. METHODS: 1485 patients (median age 25, interquartile range 22 to 29) underwent ICL surgery. Patients received a preoperative examination including uncorrected distance visual acuity (UDVA), intraocular pressure (IOP), manifest refraction measuring corrected distance visual acuity (CDVA), corneal topography and tomography, qualitative grading of perceived ectatic risk, ophthalmic biometry, and baseline endothelial cell counts (ECCs). Outcome measures included UDVA, IOP, vault size, manifest refraction, CDVA, and ECCs. The long-term follow-up data ware drawn from the U.S. military medical record system. RESULTS: A total of 3105 eyes were evaluated. Patients received ICLs because of either abnormal topography (2111 eyes [68%]) or high myopia (994 eyes [32%]). 94 eyes (80%) maintained UDVA of 20/25 or better up to 8 years postoperatively. The rate of achieving the desired refractive correction was 97% (503 eyes) at 1 year and 90% (81 eyes) at 8 years. Stability of these outcomes was also shown by minimal change in manifest refraction. Documented mean ECC loss was 22% at postoperative year 5. The overall rate of adverse events was 1.2% (36 eyes) including visually significant cataract formation, glaucoma, retinal detachment, and traumatic incision opening. A removal or replacement rate of 4.5% (135 eyes) was observed. CONCLUSIONS: ICL implantation was found to be effective and safe. Vault sizes decreased over time, suggesting an increased risk of cataract formation after 7 years. Further study is necessary to assess long-term clinical significance of ECC decline.

Characteristics of Highly Rated Internal Medicine Attendings Before and After the 2004 Work-Hour Restrictions.

OBJECTIVES: To describe the characteristics of top-rated Internal Medicine attendings and whether they changed after implementation of the 2004 work-hour restrictions. METHODS: Mixed methods study of resident ratings of medicine attendings (Period 1: 1994-1996, n = 250 and Period 2: 2007-2009, n = 152). Residents evaluated 17 attending characteristics. The top 25% of "overall" ratings were classified as "highly rated." Two free-text questions included "What was your attending's best characteristic?" and "How could your attending best improve?" and were coded in duplicate, using grounded qualitative methods. RESULTS: There were no differences in the characteristics of highly rated attendings in the two time periods. Characteristics associated with being a top-rated attending included enthusiasm (odds ratio [OR]: 5.69, 2.78-11.67), balanced teaching style (OR: 3.63, 1.64-8.02), promoting independent thinking (OR: 2.90, 0.96-8.74), fund of knowledge (OR: 2.73, 1.13-6.58), and time management (OR: 1.78, 1.14-2.80). Among the 1,410 utterances, valued attending attributes included helpfulness, promoting independent thinking, and having strong medical knowledge. CONCLUSIONS: The characteristics valued by residents in attendings did not change over time despite a major structural change in work hours and patterns of teaching. These valued characteristics continue to be a strong general fund of knowledge, enthusiasm for teaching, and balance between didactic and bedside approaches.

Capsule-splitting phenomenon during capsulorhexis in pseudoexfoliation.

We present the case of a 78-year-old white woman with a 2+ nuclear sclerotic cataract and pseudoexfoliation syndrome who had cataract extraction with intraocular lens implantation. The initial continuous curvilinear capsulorhexis (CCC) was performed with a cystotome. Due to unusual tearing characteristics, there was concern that the anterior flap was pseudoexfoliative material instead of the lens capsule. Trypan blue was instilled in the anterior chamber, and the staining pattern indicated that the anterior capsule flap had failed to fold on itself initially. A CCC was initiated in the reverse direction and completed without complication. This case illustrates the importance of recognizing the potential for the capsule-splitting phenomenon when performing a CCC in patients with pseudoexfoliation and the important role for capsule staining in these patients.

Maxillomandibular advancement as surgical treatment for obstructive sleep apnea in active duty military personnel: a retrospective cohort.

OBJECTIVE: The objective of our study is to assess the surgical outcomes of active duty military personnel undergoing maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea. METHODS: Pre- and postoperative data on 37 military personnel who underwent MMA were assessed for changes in apnea-hypopnea index (AHI) and minimum oxygen saturation. A surgical success was defined as a reduction of AHI by 50% or a postoperative AHI of <20. RESULTS: 83.7% had an AHI greater than 20 (n = 33; range 7.6-118) with a mean preoperative AHI of 50.5 per hour. The postoperative AHI decreased by 36.3 to a new value of 14.2 (p < 0.001). Most service members experienced a postoperative AHI of less than 20 (n = 28; 76%). Sixteen (43%) had a surgical cure (AHI < 5). The number of surgical successes for this study was 81% (n = 30). The mean minimal nocturnal oxyhemoglobin saturation did not significantly change from preoperative 85% (SD = 6.8%) to postoperative 86% (SD = 7%; p = 0.21). CONCLUSION: MMA represents a viable surgical treatment option for military personnel in whom continuous positive airway pressure is either not tolerated or for those who desire a fully deployable status.

Prevalence and impact of short sleep duration in redeployed OIF soldiers.

STUDY OBJECTIVES: Short sleep duration (SSD) is common among deployed soldiers. The prevalence of SSD during redeployment, however, is unknown. DESIGN: Cross-sectional study of a brigade combat team (n = 3152 US Army soldiers) surveyed 90-180 days after completing a 6-15 month deployment to Iraq as part of Operation Iraqi Freedom (OIF). Survey items targeted sleep habits and comorbid medical conditions. Multivariate logistic regression analyses were performed to calculate adjusted odds ratios of medical comorbidities associated with SSD. SETTING: US Army Infantry Post. SUBJECTS: All soldiers from a redeploying brigade combat team participated in a health assessment between 90 and 180 days upon return to Ft. Lewis from Iraq. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: A total of 2738 (86.9%) soldiers answered questions regarding self-perceived sleep and were included in the analysis. Mean sleep duration was 5.8 ± 1.2 hours. Nineteen hundred fifty-nine (72%) slept ≤ 6 h, but only 16% reported a daytime nap or felt their job performance was affected due to lack of sleep. Short sleep was more common among soldiers who reported combat exposure. After controlling for combat exposure, short sleep duration (SSD) was associated with symptoms of depression, posttraumatic stress disorder, panic syndrome, and with high-risk health behaviors such as abuse of tobacco and alcohol products, and suicide attempts. CONCLUSIONS: SSD is common among redeployed soldiers. Soldiers who experienced combat are at increased risk for persistent SSD and comorbidities associated with SSD. Efforts to reestablish good sleep habits and aggressive evaluation of soldiers with persistent SSD following deployment may aid in the prevention and management of associated medical conditions.

The prevalence, causes, and consequences of experiencing a life crisis during medical school.

BACKGROUND: Little is known about the prevalence, causes, and consequences of experiencing a major life crisis during medical school. PURPOSE: The objective is to describe the prevalence, causes, and consequences through internship of experiencing a major life crisis while enrolled as a medical student at Uniformed Services University (USU). METHOD: USU graduates from 1980 to 1999 were surveyed regarding their experiences at USU and career milestones. Predictor markers were obtained from the USU Admissions, Promotions, and Registrar's office. Outcome data were derived from a survey of intern program directors from the years 1993 to 1999. RESULTS: There were 1,807 (67%) of USU graduates who responded to our survey. There were 394 (22%) who reported experiencing a major life crisis during medical school. Graduates reporting a major life crisis performed slightly poorer in terms of basic science GPAs (2.95 vs. 2.85, p <.001), USMLE exam scores, and performance ratings by their program directors than did graduates who did not experience a crisis. CONCLUSIONS: A large fraction of medical students experience major life crises. The effects of these crises may persist throughout internship.

Racial discordance in spirometry comparing four commonly used reference equations to the National Health and Nutrition Examination Study III.

Diagnosing lung function abnormalities requires application of the appropriate reference equation for a given patient population. Current guidelines recommend the National Health and Examination Study III data set for evaluating patients in the United States. In Caucasian patients, relying on older reference equations, as opposed to those derived from the NHANES III data set, will often result in a different interpretation of a patient's spirometry. The present study assessed whether similar discordance would occur in African-American patients. A cross-sectional analysis of African-American patients undergoing spirometry testing at our hospital was performed. Patients were classified as normal, restricted, obstructed or mixed based upon the ATS/ERS guidelines, using Crapo, Knudson, Morris, Glindmeyer, and NHANES III prediction equations. Differences in classification were evaluated. 4463 subjects were identified, with a mean age of 49.6. Discordance in interpretation was most common when results from prediction equations by Morris, Knudson, and Glindmeyer were compared to NHANES III (24.6%, 26.4%, and 20.1%, respectively). Discordance was less common when comparing Crapo to NHANES III (12.8%). There was a tendency for Knudson, Morris and Glindmeyer to under classify restriction, and for Crapo, Morris, and Glindmeyer to over classify obstruction. There is significant discordance in interpretation when spirometry for African-American patients is referenced to equations published by Crapo, Morris, Knudson, and Glindmeyer, compared to NHANES III.

Effects of surgical weight loss on measures of obstructive sleep apnea: a meta-analysis.

OBJECTIVE: Limited evidence suggests bariatric surgery can result in high cure rates for obstructive sleep apnea (OSA) in the morbidly obese. We performed a systematic review and meta-analysis to identify the effects of surgical weight loss on the apnea-hypopnea index. METHODS: Relevant studies were identified by computerized searches of MEDLINE and EMBASE (from inception to March 17, 2008), and review of bibliographies of selected articles. Included studies reported results of polysomnographies performed before and at least 3 months after bariatric surgery. Data abstracted from each article included patient characteristics, sample size who underwent both preoperative and postoperative polysomnograms, types of bariatric surgery performed, results of preoperative and postoperative measures of OSA and body mass index, publication year, country of origin, trial perspective (prospective vs retrospective), and study quality. RESULTS: Twelve studies representing 342 patients were identified. The pooled mean body mass index was reduced by 17.9 kg/m(2) (95% confidence interval [CI], 16.5-19.3) from 55.3 kg/m(2) (95% CI, 53.5-57.1) to 37.7 kg/m(2) (95% CI, 36.6-38.9). The random-effects pooled baseline apnea hypopnea index of 54.7 events/hour (95% CI, 49.0-60.3) was reduced by 38.2 events/hour (95% CI, 31.9-44.4) to a final value of 15.8 events/hour (95% CI, 12.6-19.0). CONCLUSION: Bariatric surgery significantly reduces the apnea hypopnea index. However, the mean apnea hypopnea index after surgical weight loss was consistent with moderately severe OSA. Our data suggest that patients undergoing bariatric surgery should not expect a cure of OSA after surgical weight loss. These patients will likely need continued treatment for OSA to minimize its complications.

Clinical and lung-function variables associated with vocal cord dysfunction.

BACKGROUND: Vocal cord dysfunction (VCD) is difficult to diagnose. Laryngoscopy while the patient is symptomatic is the accepted standard method to establish a diagnosis of VCD, but patient characteristics and spirometry values are thought to be useful for predicting VCD. We sought to identify clinical and spirometric variables that suggest VCD. METHODS: We performed 2 parallel studies. First, 3 staff pulmonologists (who were blinded to the laryngoscopy results), scored 3 flow-volume loops from each PFT session on the likelihood that the inspiratory curve indicated VCD. We also performed a cross-sectional study of clinical characteristics and spirometric data from all patients who underwent laryngoscopy for any indication, including suspected VCD, over a 3-year period. We compared the laryngoscopy findings to the clinical characteristics, spirometry results, and the pulmonologists' assessments of the flow-volume loops. We used multivariate logistic regression to identify independent predictors of VCD. RESULTS: The pulmonologists agreed about which flow-volume loops predicted VCD (quadratic kappa range 0.55-0.76), but those ratings were not predictive of laryngoscopic diagnosis of VCD. During the study period, 226 patients underwent laryngoscopy. One hundred (44%) were diagnosed with VCD. Independent predictors of VCD included female sex (odds ratio 2.72, 95% confidence interval 1.55-4.75) and obesity (body mass index > 30 kg/m(2)) (odds ratio 2.06, 95% confidence interval 1.12-3.80). With spirometric data from the effort that had the best forced-vital-capacity, multivariate analysis found the ratio of the forced inspiratory flow at 25% of the inspired volume to forced inspiratory flow at 75% of the inspired volume (FIF(25%/75%)) predictive of VCD (odds ratio 1.97, 95% confidence interval 1.12-3.44). The diagnostic performance of these characteristics was poor; the area under the receiver-operating-characteristic curve was 0.68. With the spirometric data from the effort that had the subjectively determined best inspiratory curve, and after controlling for the reproducibility of the inspiratory curves, multivariate analysis found none of the spirometric variables predictive of VCD. CONCLUSIONS: VCD remains difficult to predict with spirometry or flow-volume loops. If VCD is suspected, normal flow-volume loop patterns should not influence the decision to perform laryngoscopy.

An intensivist-directed intensive care unit improves clinical outcomes in a combat zone.

OBJECTIVE: Intensivist-directed intensive care units (ICUs) have been shown to improve clinical outcomes. Numerous barriers exist that limit hospitals adopting this practice. We sought to show this staffing model can be implemented in an austere environment with limited resources resulting in improved outcomes. DESIGN: We conducted a retrospective observational cohort study of consecutive adult patients admitted to the ICU between March 2004 and January 2007. SETTING: This study was conducted in an ICU in a U.S. Army Combat Support Hospital deployed to Afghanistan. PATIENTS: North Atlantic Trade Organization members (U.S. military service members, American civilian contractors, members of the North Atlantic Trade Organization Coalition International Security Assistance Force), members of the Afghanistan National Army and National Police, and local Afghani nationals were included in the study. Both traumatic injuries and medical illnesses were treated. INTERVENTIONS: During the observation period, the ICU was converted from an open model to an intensivist-directed model. MEASUREMENTS AND MAIN RESULTS: Outcomes compared between the two models included ICU and hospital mortality, duration of mechanical ventilation, and ventilator-associated pneumonia rates. During the observation period, there were 2740 admissions, 965 of which were initially admitted to the ICU. We found significant reductions in ICU mortality (6.6% vs. 4.0%, p < 0.001), duration of mechanical ventilation (4.7 +/- 3.9 days vs. 3.1 +/- 2.7 days, p < 0.001), and rates of ventilator-associated pneumonia (42.5% vs. 8.0%; p < 0.001). CONCLUSIONS: Transition to an intensivist-directed ICU in an Army Combat Support Hospital improved outcomes among ICU patients. This study demonstrates the feasibility of using this model in an austere, combat environment.

Discordance in spirometric interpretations using three commonly used reference equations vs national health and nutrition examination study III.

BACKGROUND: Spirometry plays an essential role in the diagnosis and management of pulmonary diseases. The accurate interpretation of spirometric data depends on comparison to a reference population to identify abnormalities in ventilatory function. National guidelines recommended the use of the National Health and Nutrition Examination Study (NHANES) III data set as the preferred reference population for those persons 8 to 80 years of age in the United States. OBJECTIVES: To determine the effect of using NHANES III reference equations, compared to those of Crapo et al (Crapo), Knudson et al (Knudson), or Morris et al (Morris), on spirometric interpretations in non-Hispanic white patients. METHODS: We conducted a cross-sectional study of all white patients undergoing spirometry testing at our hospital from January 2000 through May 2007. Patients were classified as normal, restricted, obstructed, or mixed, based on the American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines, using the Crapo, Knudson, Morris, and NHANES III prediction equations. Differences in the classifications based on the reference data set were evaluated. RESULTS: At total of 8,733 subjects (62.4% male subjects) were identified, with a mean age of 53 years. Discordance was most common when the results from prediction equations by Knudson and Morris were compared to those of NHANES III (45.5% and 35.3%, respectively). Diagnostic recategorizations occurred less frequently when the prediction equations by Crapo were compared with those of NHANES III (15.9%). Relative to NHANES III, the prediction equations by Knudson, Crapo, and Morris tend to overclassify obstruction and underclassify restriction. CONCLUSIONS: There is significant discordance between the prediction equations put forth by Crapo, Knudson, Morris, and the NHANES III. Our data suggest that the diagnostic reclassification of many patients undergoing pulmonary function testing will occur when ATS/ERS guidelines are implemented. Pulmonologists and other physicians interpreting spirometry need to be aware of the presence and nature of these changes.

Persistence of obstructive sleep apnea after surgical weight loss.

STUDY OBJECTIVES: Weight loss may reduce the severity of obstructive sleep apnea (OSA), but persistence of OSA following surgical weight loss has not been defined. We sought to clarify the impact of bariatric surgery on OSA. We hypothesized that, despite substantial weight loss and reductions in the apnea-hypopnea index (AHI), many will have persistent disease. METHODS: Consecutive patients referred for preoperative sleep evaluation underwent polysomnography before and 1 year following bariatric surgery. We compared the effects of weight loss on body mass, OSA, and continuous positive airway pressure requirements. We defined OSA severity using the AHI (normal < 5 events per hour, mild 5 to 14 events per hour, moderate 15 to 29 events per hour, and severe 30 or more events per hour). We identified predictors of OSA severity following weight loss and assessed compliance with therapy. RESULTS: Twenty-four patients (aged 47.9 +/- 9.3 years; 75% women) were enrolled. At baseline, all subjects had OSA, the majority of which was severe. Weight loss reduced body mass index from 51.0 +/- 10.4 kg/m2 to 32.1 +/- 5.5 kg/m2 (p < 0.001) and the AHI from 47.9 +/- 33.8 to 24.5 +/- 18.1 events per hour (p < 0.001). At follow-up, only 1 patient (4%) experienced resolution of OSA. The majority (71%) had moderate or severe disease. The most important predictor of the follow-up AHI was the baseline AHI (R2 = 0.603). All patients with residual OSA required continuous positive airway pressure to ablate apneic events, but the required pressures decreased from 11.5 +/- 3.6 cm H2O to 8.4 +/- 2.1 cm H20 (p = 0.001). Only 6 patients were compliant with continuous positive airway pressure therapy at the follow-up visit. CONCLUSIONS: Surgical weight loss reduces the AHI, but many patients have residual OSA one year after bariatric surgery.

Cancer incidence among pesticide applicators exposed to captan in the Agricultural Health Study.

OBJECTIVE: Captan is a widely used antifungal pesticide whose potential to cause cancer in humans is uncertain. METHODS: We evaluated the incidence of cancer among pesticide applicators exposed to captan in the Agricultural Health Study. Detailed information on pesticide exposure and lifestyle factors was obtained from self-administered enrollment questionnaires completed between 1993 and 1997. RESULTS: Of the 48,986 applicators enrolled 4,383 (9%) had applied captan. Median follow-up time was 9.14 years. Poisson regression analysis was used to estimate relative risks (RR) for cancer subtypes by tertiles of captan exposure. We investigated risk for all cancers combined and sites of cancer for which at least 15 cases occurred among captan-exposed applicators. These sites included cancers of the prostate, lung, and colon, blood-related cancers, and colorectal cancers. During follow-up 2,912 incident primary cases of cancer were identified. No association between the highest tertile of captan exposure (>67.375 intensity-weighted days) and development of all cancers (RR = 0.89; 95% CI, 0.71-1.13) or cancer of any specific site was observed. CONCLUSION: Although our study is limited by low numbers of observed cancer cases and follow-up time of 9.14 years, it does not provide evidence of an increased risk for the development of cancer at the investigated sites.

Identifying medical students likely to exhibit poor professionalism and knowledge during internship.

CONTEXT: Identifying medical students who will perform poorly during residency is difficult. OBJECTIVE: Determine whether commonly available data predicts low performance ratings during internship by residency program directors. DESIGN: Prospective cohort involving medical school data from graduates of the Uniformed Services University (USU), surveys about experiences at USU, and ratings of their performance during internship by their program directors. SETTING: Uniformed Services University. PARTICIPANTS: One thousand sixty-nine graduates between 1993 and 2002. MAIN OUTCOME MEASURE(S): Residency program directors completed an 18-item survey assessing intern performance. Factor analysis of these items collapsed to 2 domains: knowledge and professionalism. These domains were scored and performance dichotomized at the 10th percentile. RESULTS: Many variables showed a univariate relationship with ratings in the bottom 10% of both domains. Multivariable logistic regression modeling revealed that grades earned during the third year predicted low ratings in both knowledge (odds ratio [OR] = 4.9; 95%CI = 2.7-9.2) and professionalism (OR = 7.3; 95%CI = 4.1-13.0). USMLE step 1 scores (OR = 1.03; 95%CI = 1.01-1.05) predicted knowledge but not professionalism. The remaining variables were not independently predictive of performance ratings. The predictive ability for the knowledge and professionalism models was modest (respective area under ROC curves = 0.735 and 0.725). CONCLUSIONS: A strong association exists between the third year GPA and internship ratings by program directors in professionalism and knowledge. In combination with third year grades, either the USMLE step 1 or step 2 scores predict poor knowledge ratings. Despite a wealth of available markers and a large data set, predicting poor performance during internship remains difficult.