Alcohol Withdrawal Syndrome: Outpatient Management.

Approximately one-half of patients with alcohol use disorder who abruptly stop or reduce their alcohol use will develop signs or symptoms of alcohol withdrawal syndrome. The syndrome is due to overactivity of the central and autonomic nervous systems, leading to tremors, insomnia, nausea and vomiting, hallucinations, anxiety, and agitation. If untreated or inadequately treated, withdrawal can progress to generalized tonic-clonic seizures, delirium tremens, and death. The three-question Alcohol Use Disorders Identification Test-Consumption and the Single Alcohol Screening Question instrument have the best accuracy for assessing unhealthy alcohol use in adults 18 years and older. Two commonly used tools to assess withdrawal symptoms are the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised, and the Short Alcohol Withdrawal Scale. Patients with mild to moderate withdrawal symptoms without additional risk factors for developing severe or complicated withdrawal should be treated as outpatients when possible. Ambulatory withdrawal treatment should include supportive care and pharmacotherapy as appropriate. Mild symptoms can be treated with carbamazepine or gabapentin. Benzodiazepines are first-line therapy for moderate to severe symptoms, with carbamazepine and gabapentin as potential adjunctive or alternative therapies. Physicians should monitor outpatients with alcohol withdrawal syndrome daily for up to five days after their last drink to verify symptom improvement and to evaluate the need for additional treatment. Primary care physicians should offer to initiate long-term treatment for alcohol use disorder, including pharmacotherapy, in addition to withdrawal management.

Management of Hypertriglyceridemia: Common Questions and Answers.

Hypertriglyceridemia, defined as fasting serum triglyceride levels of 150 mg per dL or higher, is associated with increased risk of cardiovascular disease. Severely elevated triglyceride levels (500 mg per dL or higher) increase the risk of pancreatitis. Common risk factors for hypertriglyceridemia include obesity, metabolic syndrome, and type 2 diabetes mellitus. Less common risk factors include excessive alcohol use, physical inactivity, being overweight, use of certain medications, and genetic disorders. Management of high triglyceride levels (150 to 499 mg per dL) starts with dietary changes and physical activity to lower cardiovascular risk. Lowering carbohydrate intake (especially refined carbohydrates) and increasing fat (especially omega-3 fatty acids) and protein intake can lower triglyceride levels. Moderate- to high-intensity physical activity can lower triglyceride levels, as well as improve body composition and exercise capacity. Calculating a patient's 10-year risk of atherosclerotic cardiovascular disease is pertinent to determine the role of medications. Statins can be considered for patients with high triglyceride levels who have borderline (5% to 7.4%) or intermediate (7.5% to 19.9%) risk. For patients at high risk who continue to have high triglyceride levels despite statin use, high-dose icosapent (purified eicosapentaenoic acid) can reduce cardiovascular mortality (number needed to treat = 111 to prevent one cardiovascular death over five years). Fibrates, omega-3 fatty acids, or niacin should be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis, although this has not been studied in clinical trials. For patients with acute pancreatitis associated with hypertriglyceridemia, insulin infusion and plasmapheresis should be considered if triglyceride levels remain at 1,000 mg per dL or higher despite conservative management of acute pancreatitis.

Successful Management of Severe Exertional Heat Stroke with Endovascular Cooling After Failure of Standard Cooling Measures.

BACKGROUND: Exertional heat stroke (EHS) is a potentially life-threatening emergency requiring rapid reduction in core body temperature. Methods of cooling include cold water immersion, ice packs, cold water lavage, and chilled saline, among others. We report a case of EHS successfully cooled using an endovascular cooling device after traditional cooling methods failed to reduce core body temperature. CASE REPORT: A 24-year old soldier collapsed during a 12-mile foot march while training in southern Georgia. His initial rectal temperature was 43.1°C (109.6°F). External cooling measures (ice sheet application) were initiated on site and Emergency Medical Services were called to transport to the hospital. Paramedics obtained a repeat rectal temperature of 42.4°C (108.4°F). Ice sheet application and chilled saline infusion were continued throughout transport to the Emergency Department (ED). Total prehospital treatment time was 50 min. Upon ED arrival, the patient's rectal temperature was 41.2°C (106.2°F). He was intubated due to a Glasgow Coma Scale score of 4, and endovascular cooling was initiated. Less than 45 minutes later his core body temperature was 37.55°C (99.6°F). He was admitted to the intensive care unit, where his mental status rapidly improved. He was found to have rising liver enzymes, and there was concern for his developing disseminated intravascular coagulation, prompting transfer to a tertiary care center. He was subsequently discharged from the hospital 14 days after his initial injury without any persistent sequelae. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The primary treatment for EHS is rapid reduction of core body temperature. When external cooling methods fail, endovascular cooling can be used to rapidly decrease core body temperature.

Mildly Elevated Liver Transaminase Levels: Causes and Evaluation.

Mild, asymptomatic elevations (less than five times the upper limit of normal) of alanine transaminase and aspartate transaminase levels are common in primary care. It is estimated that approximately 10% of the U.S. population has elevated transaminase levels. An approach based on the prevalence of diseases that cause asymptomatic transaminase elevations can help clinicians efficiently identify common and serious liver disease. The most common causes of elevated transaminase levels are nonalcoholic fatty liver disease and alcoholic liver disease. Uncommon causes include drug-induced liver injury, hepatitis B and C, and hereditary hemochromatosis. Rare causes include alpha1-antitrypsin deficiency, autoimmune hepatitis, and Wilson disease. Extrahepatic sources, such as thyroid disorders, celiac sprue, hemolysis, and muscle disorders, are also associated with mildly elevated transaminase levels. The initial evaluation should include an assessment for metabolic syndrome and insulin resistance (i.e., waist circumference, blood pressure, fasting lipid level, and fasting glucose or A1C level); a complete blood count with platelets; measurement of serum albumin, iron, total iron-binding capacity, and ferritin; and hepatitis C antibody and hepatitis B surface antigen testing. The nonalcoholic fatty liver disease fibrosis score and the alcoholic liver disease/nonalcoholic fatty liver disease index can be helpful in the evaluation of mildly elevated transaminase levels. If testing for common causes is consistent with nonalcoholic fatty liver disease and is otherwise unremarkable, a trial of lifestyle modification is appropriate. If the elevation persists, hepatic ultrasonography and further testing for uncommon causes should be considered.

Prolonged febrile illness and fever of unknown origin in adults.

Fever of unknown origin has been described as a febrile illness (temperature of 101°F [38.3°C] or higher) for three weeks or longer without an etiology despite a one-week inpatient evaluation. A more recent qualitative definition requires only a reasonable diagnostic evaluation. Although there are more than 200 diseases in the differential diagnosis, most cases in adults are limited to several dozen possible causes. Fever of unknown origin is more often an atypical presentation of a common disease rather than an unusual disease. The most common subgroups in the differential are infection, malignancy, noninfectious inflammatory diseases, and miscellaneous. Clinicians should perform a comprehensive history and examination to look for potentially diagnostic clues to guide the initial evaluation. If there are no potentially diagnostic clues, the patient should undergo a minimum diagnostic workup, including a complete blood count, chest radiography, urinalysis and culture, electrolyte panel, liver enzymes, erythrocyte sedimentation rate, and C-reactive protein level testing. Further testing should include blood cultures, lactate dehydrogenase, creatine kinase, rheumatoid factor, and antinuclear antibodies. Human immunodeficiency virus and appropriate region-specific serologic testing (e.g., cytomegalovirus, Epstein-Barr virus, tuberculosis) and abdominal and pelvic ultrasonography or computed tomography are commonly performed. If the diagnosis remains elusive, 18F fluorodeoxyglucose positron emission tomography plus computed tomography may help guide the clinician toward tissue biopsy. Empiric antibiotics or steroids are generally discouraged in patients with fever of unknown origin.

Low-Carbohydrate and Ketogenic Dietary Patterns for Type 2 Diabetes Management.

Background: Type 2 diabetes mellitus (T2DM) has been traditionally considered a chronic, progressive disease. Since 2017, guidelines from the US Department of Veterans Affairs and US Department of Defense have included low-carbohydrate (LC) dietary patterns in managing T2DM. Recently, carbohydrate reduction, including ketogenic diets, has gained renewed interest in the management and remission of T2DM. Observations: This narrative review examines the evidence behind carbohydrate reduction in T2DM and a practical guide for clinicians starting patients on therapeutic LC diets. We present an illustrative case and provide practical approaches to prescribing a very LC ketogenic (< 50 g), LC (50-100 g), or a moderate LC (101-150 g) dietary plan and discuss adverse effects and management of LC diets. We provide a medication management and deprescription approach and discuss strategies to consider in conjunction with LC diets. As patients adopt LC diets, glycemia improves, and medications are deprescribed, hemoglobin A1c levels and fasting glucose may drop below the diagnostic threshold for T2DM. Remission of T2DM may occur with LC diets (hemoglobin A1c < 6.5% for ≥ 3 months without T2DM medications). Finally, we describe barriers and limitations to applying therapeutic carbohydrate reduction in a federal health care system. Conclusions: The effective use of LC diets with close and intensive lifestyle counseling and a safe approach to medication management and deprescribing can improve glycemic control, reduce the overall need for insulin and medication and provide sustained weight loss. The efficacy and continuation of therapeutic carbohydrate reduction for patients with T2DM appears promising. Further research on LC diets, emerging strategies, and long-term effects on cardiometabolic risk factors, morbidity, and mortality will continue to inform practice.

Low-volume Hydrodissection for the Treatment of Chronic Achilles Tendinopathy.

Chronic Achilles tendinopathy (AT) is a common ailment for many active duty service members that adversely affects readiness. Patients present with pain, swelling, and limited functional ability. Kager's fat pad is a mass of adipose tissue that protects the blood vessels supplying the Achilles tendon and preserves its function. A popular hypothesis is that scarring, tethering, and neovascularization play a significant role in the pathogenesis of AT. Current literature supports the effectiveness of high-volume (40-50 mL) hydrodissection, a procedure in which fluid is injected under ultrasound guidance into the tissues surrounding the Achilles tendon to mechanically separate the paratenon from the underlying Kager's fat pad. There may also be a beneficial effect of scar tissue and neoneurovascular breakdown. However, high-volume injections result in short-term discomfort and decreased mobility. Lowering injection volume (2-10 mL) may reduce this morbidity and facilitate use in limited-resource environments. This case report presents a 29-year-old active duty male with recalcitrant post-traumatic AT who achieved significant pain reduction and faster return to full service using low-volume hydrodissection. The use of 10 mL volume has not been described previously and provides additional support for using lower volumes in chronic AT. This technique is a direct adjunctive treatment option with rehabilitation at a military treatment facility or in the operational environment.

Challenges With Engaging Military Stakeholders for Clinical Research at the Point of Care in the U.S. Military Health System.

The DoD has a specific mission that creates unique challenges for the conduct of clinical research. These unique challenges include (1) the fact that medical readiness is the number one priority, (2) understanding the role of military culture, and (3) understanding the highly transient flow of operations. Appropriate engagement with key stakeholders at the point of care, where research activities are executed, can mean the difference between success and failure. These key stakeholders include the beneficiaries of the study intervention (patients), clinicians delivering the care, and the military and clinic leadership of both. Challenges to recruitment into research studies include military training, temporary duty, and deployments that can disrupt availability for participation. Seeking medical care is still stigmatized in some military settings. Uniformed personnel, including clinicians, patients, and leaders, are constantly changing, often relocating every 2-4 years, limiting their ability to support clinical trials in this setting which often take 5-7 years to plan and execute. When relevant stakeholders are constantly changing, keeping them engaged becomes an enduring priority. Military leaders are driven by the ability to meet the demands of the assigned mission (readiness). Command endorsement and support are critical for service members to participate in stakeholder engagement panels or clinical trials offering novel treatments. To translate science into relevant practice within the Military Health System, early engagement with key stakeholders at the point of care and addressing mission-relevant factors is critical for success.

Exertional rhabdomyolysis: an analysis of 321 hospitalised US military service members and its relationship with heat illness.

INTRODUCTION: Exertional rhabdomyolysis is a syndrome of muscle breakdown following exercise. This study describes laboratory and demographic trends of service members hospitalised for exertional rhabdomyolysis and examines the relationships with heat illness. METHODS: We queried the US Armed Forces Health Surveillance Center's Defence Medical Epidemiology Database for hospitalised cases of rhabdomyolysis associated with physical exertion from January 2010 July 2013. Descriptive statistics reported means and medians of initial, peak and minimal levels of creatine kinase (CK). Correlations explored the relationship between CK, creatinine, length of hospital stay (LOS) and demographic data. RESULTS: We analysed 321 hospitalised cases of exertional rhabdomyolysis. 193 (60.1%) cases were associated with heat; 104 (32.4%) were not associated with heat; and 24 (7.5%) were classified as medical-associated exertional rhabdomyolysis. Initial, maximum and minimal CK levels were significantly lower in heat cases: CK=6528 U/L vs 19 247 U/L, p=0.001; 13 146 U/L vs 22 201 U/L, p=0.03; and 3618 U/L vs 10 321 U/L, p=0.023) respectively, compared with cases of rhabdomyolysis with exertion alone. Median LOS was 2 days (range=0-25). In the rhabdomyolysis with exertion alone group and the rhabdomyolysis with heat group, LOS was moderately correlated with maximal CK (Spearman's ρ=0.52, p<0.001, and Spearman ρ=0.38, p<0.001, respectively). There was no significant difference in median LOS between the rhabdomyolysis with exertion alone and rhabdomyolysis associated with heat groups (2 vs 2, p value=0.96). CONCLUSION: Most hospitalisations for exertional rhabdomyolysis were associated with heat illness and presented with lower CK levels than cases without associated heat illness. These data add evidence that rhabdomyolysis with heat illness is a different entity than rhabdomyolysis with exertion alone. Differentiating exertional rhabdomyolysis with and without heat should inform future research on rhabdomyolysis prognosis and clinical management.

Causes and evaluation of mildly elevated liver transaminase levels.

Mild elevations in levels of the liver enzymes alanine transaminase and aspartate transaminase are commonly discovered in asymptomatic patients in primary care. Evidence to guide the diagnostic workup is limited. If the history and physical examination do not suggest a cause, a stepwise evaluation should be initiated based on the prevalence of diseases that cause mild elevations in transaminase levels. The most common cause is nonalcoholic fatty liver disease, which can affect up to 30 percent of the population. Other common causes include alcoholic liver disease, medication-associated liver injury, viral hepatitis (hepatitis B and C), and hemochromatosis. Less common causes include α(1)-antitrypsin deficiency, autoimmune hepatitis, and Wilson disease. Extrahepatic conditions (e.g., thyroid disorders, celiac disease, hemolysis, muscle disorders) can also cause elevated liver transaminase levels. Initial testing should include a fasting lipid profile; measurement of glucose, serum iron, and ferritin; total iron-binding capacity; and hepatitis B surface antigen and hepatitis C virus antibody testing. If test results are normal, a trial of lifestyle modification with observation or further testing for less common causes is appropriate. Additional testing may include ultrasonography; measurement of α(1)-antitrypsin and ceruloplasmin; serum protein electrophoresis; and antinuclear antibody, smooth muscle antibody, and liver/kidney microsomal antibody type 1 testing. Referral for further evaluation and possible liver biopsy is recommended if transaminase levels remain elevated for six months or more.

Sex and Mental Health Disorder Differences Among Military Service Members With Patellofemoral Syndrome.

BACKGROUND: Mental health disorders are associated with persistent knee pain, but the association between these conditions has had little investigation in the military. The purpose of this study was to identify rates of mental health disorders in patients with patellofemoral pain (PFP) and determine differences by sex and whether mental health copresence influences outcomes. METHODS: Eligible patients with a new PFP diagnosis were categorized according to sex and presence of mental health disorders. Outcomes included odds of mental health disorder before/after initial PFP diagnosis based on sex, and knee-related health care use between patients with/without mental health disorders. RESULTS: In 81,832 individuals with PFP (71.1% men; mean age 33; 91.5% active duty), copresence of any mental health disorders was common (18% men; 28% women). Women had more depression and anxiety; men had more post-traumatic stress disorder and substance abuse disorders. Concurrent mental health disorders after initial PFP diagnosis resulted in higher medical costs and odds of a recurrence (OR 1.24; 95% CI 1.20, 1.28; P < .001). CONCLUSION: Mental health disorders are common in military service members seeking care for patellofemoral pain. Differences in prevalence vary by sex, and presence of mental health disorders adversely affected long-term health care outcomes.

PURL: Can viscous fiber lower glycemic markers in type 2 diabetes?

The first meta-analysis to focus on viscous dietary fiber in T2D suggests a potential role for this supplement in improving glycemic control.

Complementary and alternative medicine use among military family medicine patients in Hawaii.

UNLABELLED: Complementary and alternative medicine (CAM) is a growing component of medicine within the U.S. civilian and military populations. Tripler Army Medical Center (TAMC) Family Medicine Clinic represents an overseas medical facility stationed among a diverse ethnic population. The impact that local cultures have on CAM utilization in the military population in overseas medical facilities is unknown. METHODS: Cross-sectional survey. The authors surveyed all volunteer soldiers, family members, and retirees 18 years old or greater enrolled at TAMC Family Medicine Clinic with appointments between September 1 and September 25, 2008. RESULTS: 503 volunteers were surveyed with a response rate of 73% (n = 369). A total of 50.7% reported using at least one CAM therapy within the last year. CAM use was significantly higher among women, Caucasians, and a college level education or greater. CONCLUSION: Prevalence of CAM use is higher within a military family medicine clinic in Hawaii than the prevalence among mainland civilian or other military populations.

Improving Resilience and Combating Burnout in US Army Health Care Teams.

INTRODUCTION: In 2015, the Army Office of the Surgeon General adapted a Veterans Health Administration course for health care teams to implement holistic health practices to improve the resiliency of health care teams and patient care. The Army course Move to Health was piloted in health care teams at 8 military clinics. During the 20-hour course, health care teams learned techniques to improve their resiliency and created action plans to incorporate holistic health into the workplace, a known factor in decreasing burnout. METHODS: A process and outcome evaluation of this course was conducted using a within-group design. Surveys were administered to health care teams at precourse and 2-month follow-up, and 186 participants completed both surveys. RESULTS: Burnout among team members did not significantly change from precourse (52%, n = 96) to follow-up (48%, n = 90). At follow-up, team members described using resiliency building strategies for self-care, significantly improved their self-efficacy to treat patients holistically in the patient-centered care home model, and reported increased satisfaction with patient centered care home (all are p < 0.01). However, 70% (n = 131) of team members reported that they had not completed action plan implementation and did not report improved job satisfaction. DISCUSSION: Informed by the literature, Move to Health combines an individual resiliency intervention with organizational change, facilitating action plans to mitigate burnout. This manuscript explores potential reasons for why burnout did not significantly change within the 2-month period following the intervention. Reducing burnout among health care teams is vital to ensure that optimal health care is provided to the military and its beneficiaries.

Collapse in the Heat - From Overhydration to the Emergency Room - Three Cases of Exercise-Associated Hyponatremia Associated with Exertional Heat Illness.

Exertional heat illness and exercise-associated hyponatremia continue to be a problem in military and recreational events. Symptoms of hyponatremia can be mistaken for heat exhaustion or heat stroke. We describe three cases of symptomatic hyponatremia initially contributed to heat illnesses. The first soldier was a 31-yr-old female who "took a knee" at mile 6 of a 12-mile foot march. She had a core temperature of 100.9°F, a serum sodium level of 129 mmol/L, and drank approximately 4.5 quarts of water in 2 h. The second case was a 27-yr-old female soldier who collapsed at mile 11 of a 12-mile march. Her core temperature was 102.9°F and sodium level was 131 mmol/L. She drank 5 quarts in 2.5 h. The third soldier was a 27-yr-old male who developed nausea and vomiting while conducting an outdoor training event. His core temperature was 98.7°F and sodium level was 125 mmol/L. He drank 6 quarts in 2 h to combat symptoms of heat. All the three cases developed symptomatic hyponatremia by overconsumption of fluids during events lasting less than 3 h. Obtaining point-of-care serum sodium may improve recognition of hyponatremia and guide management for the patient with suspected heat illness and hyponatremia. Depending on severity of symptoms, exercise-associated hyponatremia can be managed by fluid restriction, oral hypertonic broth, or with intravenous 3% saline. Utilizing an ad libitum approach or limiting fluid availability during field or recreational events of up to 3 h may prevent symptomatic hyponatremia while limiting significant dehydration.

Changing trends in residents-as-teachers across graduate medical education.

BACKGROUND: Teaching residents how to teach is a critical part of residents' training in graduate medical education (GME). The purpose of this study was to assess the change in resident-as-teacher (RaT) instruction in GME over the past 15 years in the US. METHODS: We used a quantitative and qualitative survey of all program directors (PDs) across specialties. We compared our findings with a previous work from 2000-2001 that studied the same matter. Finally, we qualitatively analyzed PDs' responses regarding the reasons for implementing and not implementing RaT instruction. RESULTS: Two hundred and twenty-one PDs completed the survey, which yields a response rate of 12.6%. Over 80% of PDs implement RaT, an increase of 26.34% compared to 2000-2001. RaT instruction uses multiple methods with didactic lectures reported as the most common, followed by role playing in simulated environments, then observing and giving feedback. Residents giving feedback, clinical supervision, and bedside teaching were the top three targeted skills. Through our qualitative analysis we identified five main reasons for implementing RaT: teaching is part of the residents' role; learners desire formal RaT training; regulatory bodies require RaT training; RaT improves residents' education; and RaT prepares residents for their current and future roles. CONCLUSION: The use of RaT instruction has increased significantly in GME. More and more PDs are realizing its importance in the residents' formative training experience. Future studies should examine the effectiveness of each method for RaT instruction.

Folliculitis after smallpox vaccination: a report of two cases.

Rashes are frequent and potentially serious adverse consequences of smallpox vaccination. Life-threatening rashes must be differentiated from benign, self-limiting ones. Generalized vaccinia, erythema multiforme, and folliculitis are distinct self-limiting entities but may be difficult to differentiate from one another. Two cases of folliculitis after smallpox vaccination are described. Both patients received anthrax vaccination within 2 weeks before smallpox vaccination. Both presented with a papulopustular rash 9 days after smallpox vaccination. Although the rashes were initially diagnosed as erythema multiforme, the clinical features were more consistent with folliculitis. Self-limiting rashes after smallpox vaccination are common and may be difficult to distinguish from each other. These rashes are clinically distinct, with characteristic features. Improvement in diagnosis may help classify the frequency and risk of rashes after smallpox vaccination. The association of vaccine-associated folliculitis, anthrax vaccine, and other potential antigenic triggers should be further explored.

Maintenance of skills for today's family physician: the SAGE approach to physician learning.

Physicians need practical ways to maintain and augment clinical skills after residency training. The problem is amplified when a physician encounters a new practice environment that requires retraining in particular skills. With their broad scope of practice, family physicians are especially prone to deterioration of infrequently used skills. The SAGE model for lifelong learning provides a simple solution for today's military family physicians. Scan, assess, gather, and experience are four key steps physicians should take when maintaining or upgrading clinical skills. This approach allows physicians to identify available resources and to develop action plans to improve skills. Supervisors must encourage physicians to be honest in self-assessment of patient care skills and should support the acquisition of improved skills. System-based solutions, in keeping with suggestions from the Institute of Medicine, are introduced.