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Background: Among adults, weight stigma is associated with markers of poor cardiometabolic health. Although weight-based teasing (WBT) is common among youth with high body weight, few studies have examined its associations with cardiometabolic markers. Owing to unique stressors (e.g., parental deployment and frequent moves), military-dependent youth may be at particularly high risk for obesity, WBT, and poor cardiometabolic health. We, therefore, assessed associations between WBT and cardiometabolic health markers among adolescent military dependents presenting for a weight gain prevention trial. Methods: Participants underwent fasting phlebotomy; had fasting weight, height, and waist circumference measured; and completed assessments of WBT, anxiety, and loss-of-control eating. Multivariate analysis of covariance, adjusting for relevant covariates including demographics and body composition, was used to examine differences in metabolic syndrome (MetS) components (waist circumference, systolic and diastolic blood pressure, high-density lipoprotein cholesterol, triglycerides, and glucose) between youth reporting WBT and youth reporting no WBT. Bootstrapped models examined whether WBT mediated the relationship between BMIz and MetS components. Results: Data from 142 youth (57.7% female; 14.4 ± 1.6 years; 51.2% non-Hispanic White, 20.9% non-Hispanic Black; BMIz: 1.9 ± 0.4) were analyzed. WBT was not significantly associated with any MetS component. Relationships were observed between BMIz and all MetS components (except systolic blood pressure and glucose), although WBT did not significantly mediate these relationships (p's > 0.05). Conclusions: This study did not find support for a relationship between WBT and MetS components in adolescent military dependents at risk for adult obesity. Prospective research is needed to determine whether associations between WBT and adverse cardiometabolic outcomes emerge primarily in adulthood.

Objective Parental military deployment can lead to stress in the family system due to concerns about the deployed service-member's safety and increased responsibilities for those not deployed. Parent-related stress can impact adolescent disordered eating. Given the important role that stress plays in disordered eating and obesity, it is crucial to understand the impacts of unique stressors to which vulnerable populations are exposed. Method We studied 126 adolescent (14.3 ± 1.6 years; 59.5% girls; 44.4% non-Hispanic White; BMI-z, 1.91 ± .39) military dependents prior to entering an obesity and binge-eating disorder prevention trial. The Eating Disorder Examination was used to assess adolescent disordered eating. Parents self-reported their own distress and family deployment history that occurred during the adolescent's lifetime. Results Parental distress interacted with frequency of parental deployments such that for those with high parental distress, more frequent deployment was associated with greater adolescent shape and weight concerns (β = .21, p = .012) and global eating pathology (β = .18, p = .024). Discussion In this hypothesis-generating study, the combination of number of deployments and parental distress may be associated with disordered eating among adolescent military dependents seeking prevention of binge-eating disorder and adult obesity. If these preliminary findings are supported longitudinally, interventions to reduce parental stress related to deployment may be warranted to reduce disordered eating in adolescent dependents.

Stressors unique to military families may place dependents of military service members of both sexes at high-risk for disordered-eating. Yet, there are no data examining sex-related differences in eating pathology and distress among this population. Therefore, we examined disordered-eating attitudes and associated psychosocial characteristics in adolescent military dependents at high-risk for both eating disorders and adult obesity (i.e., BMI ≥ 85th percentile and elevated anxiety symptoms and/or loss-of-control eating). One-hundred-twenty-five (55.2% female) adolescent (12–17 y) military dependents were studied prior to entry in an eating disorder and obesity prevention trial. Youth were administered the Eating Disorder Examination interview to determine disordered-eating attitudes, and completed questionnaires to assess self-esteem, social functioning, and depression. Girls and boys did not differ in BMIz (p = .66) or race/ethnicity (p = .997/p = .55). Adjusting for relevant covariates, girls and boys did not differ significantly with regard to disordered-eating global scores (p = .38), self-esteem (p = .23), or social functioning (p = .19). By contrast, girls reported significantly more symptoms of depression (p = .001). Adolescent male and female dependents at high-risk for eating disorders and adult obesity reported comparable levels of eating-related and psychosocial stress. Data are needed to elucidate how adolescent military dependents respond to intervention and whether sex moderates outcome.

Perceived weight stigma is associated with adverse health indices, such as elevated cortisol, lipid/glucose dysregulation, and poorer self-rated health. This relationship may be particularly relevant for military personnel, given the cultural emphasis on fitness and weight/shape. Therefore, we investigated the relationship between weight stigma and physical health in 117 active duty personnel (66.7% male; 56.4% non-Hispanic White; age: 30.8 ± 7.4 years; BMI: 29.5 ± 2.5 kg/m2). Participants reported weight stigma (general and military-specific), weight bias internalization, and the presence (≥1; n = 55) or absence (n = 62) of medical conditions. Logistic regressions were conducted examining the ability of weight stigma (general or military-specific) and weight bias internalization to predict the presence or absence of medical conditions. General weight stigma was not significantly associated with the presence of a medical condition (p > .05). However, individuals with military-specific weight stigma scores twice that of their peers were over three times more likely (p = .04) to report a medical condition. Weight bias internalization was not significant in any model (ps > .20). Longitudinal studies should prospectively examine the relationship between weight stigma in the military setting and health among service members.

Big data could help identify potential clues about the immediate (and future) impact of coronavirus disease 2019, but it is in short supply.

Background Metabolic syndrome in adolescence has been associated with adverse cardiometabolic outcomes in adulthood. Preliminary data suggest that boys may have worsened metabolic syndrome components compared to girls. Yet, little is known about the physical health of military dependents, a potentially at-risk population. Objective Examine sex differences in metabolic syndrome components in a sample of adolescent military dependents. Methods Participants were adolescents (N = 139; 14.4 ± 1.6 years; 45.3% male; 41.0% non-Hispanic White, 19.4% non-Hispanic Black; BMI-z: 1.9 ± 0.4) at-risk for adult obesity and binge-eating disorder due to an age- and sex-adjusted BMI ≥85th percentile and loss-of-control eating and/or elevated anxiety. A multivariate analysis of covariance was conducted to compare objectively measured metabolic syndrome components across boys and girls. Covariates were age, race, loss-of-control eating status, anxiety symptoms, and BMI-z. Results Metabolic syndrome components differed by sex (P = .01). Boys had higher systolic blood pressure (P = .049), lower high-density lipoprotein cholesterol (P = .01), and higher glucose (P = .001) than girls. Waist circumference, diastolic blood pressure, and triglycerides did not differ between boys and girls (P > .05). Conclusions Future research should prospectively examine these relationships into adulthood. If the current findings are supported, prevention programs should consider targeting cardiometabolic health particularly among male adolescent military dependents.

OBJECTIVE: Adolescent military-dependents may be at higher risk for psychosocial stressors and disordered-eating compared to civilian youths, but the mechanisms underlying these relationships are unclear. Interpersonal theory of disordered-eating proposes that difficult relationships lead to negative affect thereby promoting emotionally-induced eating. Given the unique stressors related to their parents’ careers, the interpersonal model may be particularly relevant to adolescent military-dependents. Therefore, this study examined the prediction of the interpersonal model (that negative emotions mediate the link between multiple aspects of social functioning and emotional-eating) among a cohort of adolescent military-dependents. METHODS: One-hundred-thirty-six military-dependents at high-risk for both adult obesity and binge-eating disorder due to reports of loss-of-control eating and/or anxiety symptoms (56% female, age=14±2y, BMIz=2.0±.4) were studied prior to participation in an excess weight-gain prevention study. Bootstrapping mediation models were conducted to examine depressive symptoms as a potential mediator of the relationship between social functioning and emotional-eating. Analyses were adjusted for age, sex, race, BMIz, the presence of reported loss-of-control eating, and anxiety. RESULTS: Depressive symptoms were a significant mediator of the relationship between multiple domains of social functioning, including general social loneliness, social adjustment related to family and friends, and attachment to father and peers, and emotional-eating (ps < .05). CONCLUSIONS: The interpersonal model of disordered-eating may be important for understanding the development of excess weight-gain and binge-eating disorder among adolescent military-dependents. Prospective data are needed to determine the utility of interpersonal theory in predicting response to intervention and outcomes.

Weight-based teasing (WBT) by family members is commonly reported among youth and is associated with eating and mood-related psychopathology. Military dependents may be particularly vulnerable to family WBT and its sequelae due to factors associated with their parents&rsquo, careers, such as weight and fitness standards and an emphasis on maintaining one&rsquo, s military appearance, however, no studies to date have examined family WBT and its associations within this population. Therefore, adolescent military dependents at-risk for adult obesity and binge-eating disorder were studied prior to entry in a weight gain prevention trial. Youth completed items from the Weight-Based Victimization Scale (to assess WBT by parents and/or siblings) and measures of psychosocial functioning, including the Beck Depression Inventory-II, The Rosenberg Self-Esteem Scale, and the Social Adjustment Scale. Eating pathology was assessed via the Eating Disorder Examination interview, and height and fasting weight were measured to calculate BMIz. Analyses of covariance, adjusting for relevant covariates including BMIz, were conducted to assess relationships between family WBT, eating pathology, and psychosocial functioning. Participants were 128 adolescent military dependents (mean age: 14.35 years old, 54% female, 42% non-Hispanic White, mean BMIz: 1.95). Nearly half the sample (47.7%) reported family WBT. Adjusting for covariates, including BMIz, family WBT was associated with greater eating pathology, poorer social functioning and self-esteem, and more depressive symptoms (ps &le, 0.02). Among military dependents with overweight and obesity, family WBT is prevalent and may be linked with eating pathology and impaired psychosocial functioning, prospective research is needed to elucidate the temporal nature of these associations.

Purpose To describe the breadth of strategies U.S. medical schools use to promote medical student well-being. Method In October 2016, 32 U.S. medical schools were surveyed about their student well-being initiatives, resources, and infrastructure; grading in preclinical courses; and learning communities. Results Twenty-seven schools (84%) responded. Sixteen (59%) had a student well-being curriculum, with content scheduled during regular curricular hours at most (13/16; 81%). These sessions were held at least monthly (12/16; 75%), and there was a combination of optional and mandatory attendance (9/16; 56%). Most responding schools offered a variety of emotional/spiritual, physical, financial, and social well-being activities. Nearly one-quarter had a specific well-being competency (6/27; 22%). Most schools relied on participation rates (26/27; 96%) and student satisfaction (22/27; 81%) to evaluate effectiveness. Sixteen (59%) assessed student well-being from survey data, and 7 (26%) offered students access to self-assessment tools. Other common elements included an individual dedicated to overseeing student well-being (22/27; 82%), a student well-being committee (22/27; 82%), pass/fail grading in preclinical courses (20/27; 74%), and the presence of learning communities (22/27; 81%). Conclusions Schools have implemented a broad range of well-being curricula and activities intended to promote self-care, reduce stress, and build social support for medical students, with variable resources, infrastructure, and evaluation. Implementing dedicated well-being competencies and rigorously evaluating their impact would help ensure appropriate allocation of time and resources and determine if well-being strategies are making a difference. Strengthening evaluation is an important next step in alleviating learner distress and ultimately improving student well-being.

PURPOSE: Six key elements of opioid medication management redesign in primary care have been previously identified. Here, we examine the effect of implementing these Six Building Blocks on opioid-prescribing practices. METHODS: Six rural-serving organizations with 20 clinic locations received support for 15 months during the period October 2015 to May 2017 to implement the Six Building Blocks. Patients undergoing long-term opioid therapy (LtOT) at these study sites were compared with patients undergoing LtOT enrolled in a regional health plan who did not receive care at the study sites but who resided in the same primary care service areas (control group). Outcomes were monthly trend in the proportion of patients undergoing LtOT prescribed a ≥100 morphine equivalent dose (MED) of opioids daily and the total number of patients receiving an opioid prescription. An interrupted time series using difference-indifference analysis was used for tests of significance. RESULTS: The proportion of patients prescribed a ≥100 MED of opioids daily decreased 2.2% (11.8% to 9.6%) among patients at the intervention clinics and 1.3% (14.0% to 12.7%) among patients in the control group. The rate of decrease was significantly greater among study patients than among patients in the control group (P = .018). The rate of decrease in the number of patients on LtOT at intervention clinics increased during the intervention period compared with the preintervention period (P

Purpose: To prospectively examine the relationship between prenatal events, postnatal airway host response and microbiota, and clinical outcomes. Materials and methods: Tracheal aspirates collected at seven days of age from 71 mechanically ventilated infants (median gestational age (GA), 25 weeks [range 23–28]) were simultaneously processed for a 12-plex protein assay and bacterial identification by 16S rRNA sequencing. Phenotypes were determined by unsupervised clustering of the protein analytes. Subject characteristics, microbial communities and clinical factors and outcomes were compared across the phenotype groups. Results: Three clusters were identified: 1 (high protein levels), 2 (high proinflammatory proteins and low anti-inflammatory proteins), and 3 (low protein levels), respectively. Antenatal hemorrhage was most common in cluster 1, while chorioamnionitis characterized cluster 2 and preeclampsia was most prevalent in cluster 3, which was characterized by a predominance of Staphylococcus and relative absence of Ureaplasma. There were higher rates of adverse clinical outcomes in cluster 1. Conclusions: Airway protein profiles in seven days old mechanically ventilated preterm infants are associated with important antenatal events and unique airway microbial communities. These relationships may reveal new mechanisms by which antenatal events impact the course and outcomes of preterm infants.

The use of B-vitamin supplements has increased over the last decade. Although use is widespread in both military and civilian populations, data on patterns of B-vitamin prescription rates are lacking.This study examines trends in B-vitamin prescriptions dispensed by military treatment facilities.We examined data from the Department of Defense Pharmacy Data Transaction Service to determine the nature of several B-vitamin prescriptions dispensed through military treatment facilities from 2007 through 2011. The eight B vitamins examined were B1 (thiamine), B2 (riboflavin), B3 (niacin), B5 (panthenol), B6 (pyridoxine), B7 (biotin), B9 (folic acid), and B12 (cobalamin).The number of B-vitamin prescriptions dispensed from military treatment facilities decreased 7% from 278,972 in 2007 to 260,472 in 2011. Individual vitamin prescription patterns varied widely. Vitamins B6, B9, and B12 were the most frequently prescribed in each year. Vitamin B2 prescriptions quadrupled between 2009 and 2011, and B12 prescriptions showed a steady increase over time. In contrast, vitamins B3, B6, and B9 prescriptions showed a steady decline, and vitamin B7 prescriptions decreased by 66% between 2008 and 2009.No single pattern in B-vitamin prescriptions was observed. The driving forces behind increases in prescribed and non-prescribed dietary supplement use remain speculative.

Background: Art and humanities can enhance undergraduate medical education curricular objectives. Most commonly, art is used to help students learn observational skills, such as medical interviewing and physical diagnosis. Educators concurrently struggle to find ways to meaningfully teach professional values within crowded curricula. Aim: This curriculum aimed to combine art and reflection to actively convey tenets of medical professionalism. Setting: Internal medicine clerkship at a single institution. Participants: Third-year students. Program description: Students reviewed an online module describing attributes of medical professionalism before completing a 4-step written exercise stimulated by viewing a work of art and based on a critical incident from their own experiences. A faculty member reviewed the essays and facilitated small group discussion to normalize the students' emotional responses and generalize their observations to others. Program evaluation: The curriculum was acceptable to students and enthusiastically received by faculty. Efforts to assess the effects and durability of the exercise on student behavior are ongoing. Discussion: Artwork can enhance student reflection on professional values. This model efficiently and creatively meets curricular professionalism objectives.

Introduction The use of energy drinks (ED) or shots (ES) is becoming increasingly popular in U.S. beverage market. In addition, young, physically active males, such as active-duty enlistees represent a prime target for the advertising of ED/ES; however, the exact mechanisms and safety of these products have come under scrutiny. This cross-sectional, exploratory, web-based survey among U.S. service members describes the prevalence of ED/ES use as well as common side effects and safety of these products among self-reported users. Materials and methods A convenience sample of U.S. military members (n = 1,706; response rate = 7%) was used to conduct a cross-sectional, exploratory, web-based survey of ED/ES usage among U.S. military members. Main outcome measures included: (1) prevalence of ED/ES use, (2) perceived effects associated with use, and (3) differences among subgroups. Results Among all respondents, 50% reported consuming ED and 16% reported consuming ES at least once a month. Young, male, enlisted and members of operational military units were significantly more likely to indicate use of ED/ES at least once within the past 30 days than other groups, and were more likely to co-ingest ED and alcohol. Self-reported reasons for using ED included needing an energy boost (77%) and increasing mental alertness (52%). Perceived increases in mental alertness, heart rate, and mental endurance were the most commonly reported effects of ED/ES consumption. About a third (36%) perceived energy beverages and dietary supplements to be safe; while more than half (53%) reported not discussing ED, ES, vitamins/minerals, DS, caffeine, or alcohol use with their healthcare provider(s). Conclusion Military Service members fit the targeted age and gender demographic of many marketing campaigns for ED/ES products, and many perceive these beverages as safe to use. The possible problems associated with overuse/reliance on ED/ES products, particularly relating to operational force readiness, merit further investigation.

The emotional, cognitive, and behavioral health of the nearly two million children of military service members in the United States is important as these children play an integral role in the operational readiness of the armed forces. For example, when a service member's child experiences psychosocial difficulties, these difficulties often impact the service member's personal well-being and ability to focus at work, impairing the service member's ability to focus on the mission. Although military service members and their families (e.g., children and spouses) face many of the same stressors as their civilian counterparts, they also experience additional stressors related to being a military family, including frequent relocation, unpredictable schedule changes, short- and long-term family separation, and threats to service members' safety. Psychosocial functioning and resilience to stress may be influenced by a variety of factors. One important factor that influences parent and child functioning is community support. Community support may be especially important for military families because of the increased significance of social support during stress such as deployment and geographic relocation. Research is promising regarding the protective effects of community support in civilian populations. However, there is a comparable dearth in the literature regarding military families and no validated measures designed specifically to assess the construct of community support in military families. We therefore aimed to develop and examine a new measure, the Community Assessment of Military Perceived Support (CAMPS) and examine its potential relationship with the psychosocial functioning of military parents and their children.The CAMPS was developed and initially tested with both quantitative and qualitative methods. The CAMPS was then used to examine the relationships among perceived community support and child/parent psychosocial symptoms. This cross-sectional correlational study was conducted in a sample of military parents with children between the ages of 2 and 18 years of age who completed an online, anonymous survey.One hundred and fifty-seven military parents completed the CAMPS. Internal consistency was excellent (α = 0.94). More community support as measured by the CAMPS was associated with fewer child and parent psychosocial symptoms (p0.01) and the relationship between perceived military community support and child well-being was mediated by parent well-being (95% confidence interval [-0.19, -0.04]). Together, parent psychosocial functioning and perceived military community support explained 24% of the variance in child psychosocial functioning.The CAMPS is an internally consistent measure that appears to be associated with military parent and child psychosocial functioning. Given the importance of military community support, the CAMPS may have potential as a tool for outcome research and program evaluation. Future research is required to validate the CAMPS in a larger, more diverse military sample. Moreover, longitudinal studies are needed to determine the directionality of the relationship between community military support and psychosocial functioning.

Preterm birth exposes the developing lung to an environment with direct exposure to bacteria, often facilitated by endotracheal intubation. Despite evidence linking bacterial infections to the pathogenesis of bronchopulmonary dysplasia (BPD), systematic studies of airway microbiota are limited. The objective was to identify specific patterns of the early respiratory tract microbiome from tracheal aspirates of mechanically ventilated preterm infants that are associated with the development and severity of BPD. Infants with gestational age ≤34 weeks, and birth weight 500-1250g were prospectively enrolled. Mechanically ventilated infants had tracheal aspirate samples collected at enrollment, 7, 14, and 21 days of age. BPD was determined by modified NIH criteria with oxygen reduction tests; infants without BPD were excluded due to low numbers. Aspirates were processed for bacterial identification by 16S rRNA sequencing, and bacterial load by qPCR. Cross-sectional analysis was performed using 7 day samples and longitudinal analysis was performed from subjects with at least 2 aspirates. Microbiome analysis was performed on tracheal aspirates from 152 infants (51, 49, and 52 with mild, moderate, and severe BPD, respectively). Seventy-nine of the infants were included in the cross-sectional analysis and 94 in the longitudinal. Shannon Diversity, bacterial load, and relative abundance of individual taxa were not strongly associated with BPD status. Longitudinal analysis revealed that preterm infants who eventually developed severe BPD exhibited greater bacterial community turnover with age, acquired less Staphylococcus in the first days after birth, and had higher initial relative abundance of Ureaplasma. In conclusion, longitudinal changes in the airway microbial communities of mechanically ventilated preterm infants may be associated with BPD severity, whereas cross-sectional analysis of airway ecology at 7 days of age did not reveal an association with BPD severity. Further evaluation is necessary to determine whether the observed longitudinal changes are causal or in response to clinical management or other factors that lead to BPD.

Use of energy drinks and energy shots among military personnel is controversial. High amounts of caffeine (the primary active ingredient in these products) may impact performance of military duties. The impact of caffeine overconsumption and potential subsequent side effects that might be experienced by service members with unique roles and responsibilities is a concern. Reported here are the prevalence of use, reasons for use, and side effects associated with consumption of energy drinks and energy shots among several populations of active duty personnel in the US military. A snowball survey was sent to over 10,000 active duty personnel. A total of 586 (∼6% response rate) individuals completed a 30-item electronic survey. Over half of respondents (53%) reported consuming an energy drink at least once in the past 30 days. One in five (19%) reported energy shot consumption in the prior 30 days. One in five (19%) also reported consuming an energy drink in combination with an alcoholic beverage. Age and gender were significantly associated with energy drink consumption. Young male respondents (18-29 years) reported the highest use of both energy drinks and energy shots. Among those reporting energy drink and energy shot use, the most common reasons for consumption were to improve mental alertness (61%) and to improve mental (29%) and physical (20%) endurance. Nearly two-thirds (65%) of users self-reported at least one side effect. The most commonly reported side effects included increased pulse rate/palpitations, restlessness, and difficulty sleeping. Use of energy products among military personnel is common and has the potential to impact warrior health and military readiness.

It is estimated that 20%-40% of advanced medical imaging in the United States is unnecessary, resulting in patient overexposure to radiation and increasing the cost of care. Previous imaging utilization studies have focused on clinical appropriateness. An important contributor to excessive use of advanced imaging may be a physician "knowledge gap" regarding the safety and cost of the tests.To determine whether safety and cost information will change physician medical image decision making.Double-blinded, randomized controlled trial. Following standardized case presentation, physicians made an initial imaging choice. This was followed by the presentation of guidelines, radiation exposure and health risk, and cost information.Approximately half (57 of 112, 50.9%) of participants initially selected computed tomography (CT). When presented with guideline recommendations, participants did not modify their initial imaging choice (P=0.197). A significant reduction (56.3%, P0.001) in CT ordering occurred after presentation of radiation exposure/health risk information; ordering changed to magnetic resonance imaging or ultrasound (US). A significant reduction (48.3%, P0.001) in CT and magnetic resonance imaging ordering occurred after presentation of Medicare reimbursement information; ordering changed to US. The majority of physicians (31 of 40, 77.5%) selecting US never modified their ordering. No significant relationship between physician demographics and decision making was observed.This study suggests that physician decision making can be influenced by safety and cost information and the order in which information is provided to physicians can affect their decisions.

AB Purpose: Dietary supplement (DS) use among US military personnel is widespread. Many consume several different DS with multiple ingredients one or more times each week, representing a potential public health concern. The overall purpose of the study was to assess the knowledge and behaviors of health professionals and physicians regarding patterns of DS use and possible adverse events (AE) associated with DS use. We also determined how providers address the issue of DS with patients and evaluated provider knowledge regarding reporting systems. Methods: Two prospective, cross-sectional, web-based questionnaires were administered. First, health care providers who accessed the Natural Medicines Comprehensive Database to gather evidenced-based information on DS and herbal products were queried. Second, physicians who had graduated from the Uniformed Services University were sent a web-based questionnaire regarding DS knowledge, AE knowledge and reporting, and communication with patients about DS. The frequencies of responses were evaluated. Results: Although 60% of the military physicians who responded to the questionnaires believed they had observed AE in association with a DS, only 18% actually reported them. Three of four physician respondents (approximately 73%) did not know how or where to report AE associated with DS. The majority of physicians (66%) routinely asked most of their patients about DS use, and 65% did not have a reliable source of information for herbal and DS products. Conclusions: Information gaps in DS information and AE reporting were identified. A centralized AE reporting system could serve to identify potentially harmful DS for further evaluation. Health professionals need to remain vigilant for AE associated with DS use and better informed on how to report these events.

Physician interaction with pharmaceutical representatives results in less evidence-based prescribing and increased costs. Many organizations have called for strong conflict of interest policies in academic institutions. Implementing policy without educational interventions may not adequately address the influence of industry on physician prescribing patterns. The objective of this study is to assess the implementation and content of family medicine residency curricula on the physician-pharmaceutical industry relationship.We surveyed US family medicine program directors using the Council of Academic Family Medicine Educational Research Alliance (CERA) platform. The presence of a formal curriculum on the physician-industry interaction and specific curricular elements (ethics of interaction, understanding detailing sessions and advertisements, use of unbiased pharmaceutical information) were the outcome measures of interest.Fifty-two percent (212 of 406) of program directors responded. Forty percent (95% confidence interval [CI]: 33%--46%) reported having a formal curriculum on physician-pharmaceutical industry interactions. The presence of a formal curriculum was more likely in residencies permitting interaction with industry (52% [48/92] versus 30% [36/120]) or with a university affiliation (43% [75/173] versus 19% [7/36]). The use of unbiased sources of information relating to pharmaceutical products and the ethics of the physician-pharmaceutical industry relationship were the most common curricular elements (59% and 55%, respectively).This study shows that less than half of US family medicine programs have a curriculum addressing physician-industry interactions. Further research on the efficacy of and barriers to curriculum creation and implementation is warranted.

To identify health-related behaviors associated with potentially harmful dietary supplements (DS) - body building (BB), weight loss (WL) and performance enhancing (PE), explore common reasons and sources of information for DS use.Based on the 2005 Survey of 16,146 U.S. military personnel, BB users were dichotomized as yes (regular use - taking any supplement of BB at least once a week in past 12 months) or no; similarly defined for WL and PE. Weighted logistic regression models are used.BB, WL and PE were used by 19.4%, 17.0%, and 8.0% of participants, respectively. Significantly more users were overweight or obese: BMI ≥25 (vs. BMI25); heavy drinkers (vs. abstainers); and users of taking steroids in their lifetime (vs. not). Most common reasons of BB, WL, and PE users wanted to increase muscle mass, lose weight, and improve physical performance (BB: 45.8%, WL: 54.8%, PE: 38.5%). Fewer than 30% discussed dietary supplements use with their healthcare providers. The leading source of dietary supplements information (BB: 27.8%, WL: 23.6%, PE: 30.0%) was magazines.The dietary supplements: BB, WL and PE were used by significant proportions of service members, and associated with risk-taking behaviors that may affect overall military readiness and public health.

Handheld computing devices, or personal digital assistants (PDAs), are used often in the health care setting. They provide a convenient way to store and carry either personal or reference information and can be used to accomplish other tasks associated with patient care. This article reports clinical and educational lessons learned from a longitudinal institutional initiative designed to provide medical students with PDAs to facilitate patient care and assist with clinical learning.

The skin biopsy is considered one of the most important tools in dermatology. Two primary reasons a clinician may perform a skin biopsy are either to establish a diagnosis or to evaluate therapy. The objective of this study was to critically assess the value of the skin biopsy as a diagnostic test for inflammatory dermatoses. One hundred consecutive skin biopsy specimens where an inflammatory dermatosis was queried were reviewed. To assess the diagnostic ability of the skin biopsy, the frequency with which a correct diagnosis was made based on histopathological analysis alone was recorded, that is, an initial "blind" diagnosis made without clinical data. Once this was recorded, the clinical history was provided and a posthistory diagnosis reached. The posthistory diagnosis was then compared with the final working diagnosis in the patient case notes. In 55% of cases, histology was able to provide a prehistory specific diagnosis. In 31% of cases, histology was not able to provide a specific diagnosis but could provide a differential diagnosis. In two thirds of these (20 of the 31 cases), the diagnosis was reached posthistory with clinicopathologic correlation. In 12% of cases, histology could only provide a pattern analysis, and in 2% of cases, only a descriptive report could be issued. In 13% of cases, the biopsy provided the final working diagnosis, which had not been considered clinically. The skin biopsy for inflammatory dermatoses is clearly a worthwhile investigative procedure. Prehistory blind histology based on microscopic data provided an accurate diagnosis correlating to the working diagnosis in 53% of cases. The diagnostic boundaries of dermatopathology are such that in an additional 25 cases (25%) a diagnosis was reached with aid of clinical data proving the importance of providing a well-thought-out differential diagnosis. Overall, in 78% of cases, histology with the aid of clinical information was able to provide an accurate diagnosis correlating to the working diagnosis.

Phytophotodermatitis is a phototoxic dermatologic reaction that occurs with exposure to ultraviolet light after contact with certain plant chemicals. Recognition is vital to proper management and avoidance of unnecessary distress for patients. Sun-sensitizing compounds, known as furocoumarins, are found in many plants (limes, celery, and natural grasses) and are excited by ultraviolet A (UVA) irradiation. UVA irradiation induces covalent linkages of nuclear DNA resulting in cutaneous photosensitivity and vesicular skin damage while increasing melanin production. Delayed erythema, hyperpigmentation, and vesicle or bullae formation are hallmarks. Literature review reveals most cases occur during or after vacation in a sunny destination with exposure to citrus fruit or in children playing outdoors in the summer when furocoumarins are abundant. Hyperpigmented lesions typically appear on the hands or around the mouth. Overall incidence is unknown and there appears to be no predilection for race, although typically more easily recognized in the fair skinned. Of concern are the many cases where misdiagnosis of child abuse has occurred with unnecessary legal action taken and emotional distress for innocent families. Phytophotodermatitis is relatively common and easily diagnosed with awareness and a careful history. Accurate diagnosis avoids unnecessary concern by patients and potential misdiagnosis of abuse. Consider phytophotodermatitis when hyperpigmentation in bizarre streaks on sun-exposed areas with vesicles in a nondermatomal distribution is present. Presented is an illustrative case.

Physicians use multiple sources of information to search for answers to clinical questions. These sources include textbooks, journals, colleagues, and electronic resources, including the Internet.To explore what sources are most commonly used by staff military physicians, we distributed a survey asking them to describe sources of medical information they used most frequently while in garrison and while on deployment.Most military physicians use the Internet to access medical information every day while in garrison. The frequency and pattern of use of medical resources differs while on deployment. The most common sources of electronic medical information are general Internet search engines (Google). Open-domain sites (PubMed and MEDLINE) are more commonly used by military surgeons, while filtered secondary information sources (UptoDate, MD Consult) appear to be more commonly used by military primary care physicians. Younger physicians use electronic resources more commonly than do older physicians.Knowing what sources of medical information military physicians use to search for answers to their clinical questions can help guide allocation of medical informatics resources, particularly to deployed military physicians providing in-theater care.

Gastrointestinal lymphoma is an uncommon disease but is the most frequently occurring extranodal lymphoma and is almost exclusively of non-Hodgkin type. Primary gastrointestinal lymphoma most commonly involves the stomach but can involve any part of the gastrointestinal tract from the esophagus to the rectum. Risk factors for the development of gastrointestinal lymphoma include Helicobacter pylori infection, immunosuppression after solid organ transplantation, celiac disease, inflammatory bowel disease, and human immunodeficiency virus infection. Although gastrointestinal lymphoma has a wide variety of imaging appearances and definitive diagnosis relies on histopathologic analysis, certain findings (eg, a bulky mass or diffuse infiltration with preservation of fat planes and no obstruction, multiple site involvement, associated bulky lymphadenopathy) can strongly suggest the diagnosis. Imaging also plays an important role in the detection of complications such as perforation, obstruction, and fistulization. The most commonly used imaging modalities are barium examination and computed tomography (CT). These modalities are complementary, although CT provides a better overall assessment of the disease stage.

Although prior studies have examined the prevalence of dietary supplement use among various populations, data on single vitamins prescribed by health care providers are limited.This study examined trends in single-vitamin supplement (A, C, D, E, K) prescriptions by providers from military treatment facilities from 2007 to 2011.We examined prescription data from the Department of Defense Pharmacy Data Transaction Service to determine trends in the aforementioned single-vitamin supplement prescriptions. Prescription rates per 1,000 active duty personnel were estimated using population data retrieved from the Defense Medical Epidemiology Database (i.e., [number of prescriptions/population size] × 1,000).Across the 5-year period, the number of vitamin D prescriptions per 1,000 active duty personnel increased 454%. In contrast, the number of vitamin A, vitamin E, and vitamin K prescriptions per 1,000 active duty personnel decreased by 32%, 53%, and 29% respectively. Vitamin C prescriptions remained relatively constant. Across all age groups, total single-vitamin supplement prescriptions increased by 180%.Together, prescriptions examined in this study increased steadily from 2007 to 2011, primarily because of the increase in vitamin D prescriptions. The exhibited trend reflects the current general-population pattern of dietary supplement use, with large increases in vitamin D and declines in vitamin E.

The role of testosterone in health and quality of life has become increasingly visible and overtly marketed to the public. Some evidence suggests that testosterone levels in men may be low because of a variety of reasons, including stress and environmental exposures.This study examines trends in testosterone prescriptions dispensed by military treatment facilities (MTFs).We examined data from the Department of Defense Pharmacy Data Transaction Service to determine the nature of androgen prescriptions dispensed through MTFs from 2007 through 2011.The number of androgen prescriptions increased more than two-fold across the military from 19,494 in 2007 to 45,270 in 2011. Most prescriptions (99%) were for men. Androgen prescription rates rose 23% per year from 2007 through 2011 (p0.001, CI 23-24%). The prescription rate for 35- to 44-year-olds increased more than any other age group, with annual increases averaging 33% (p0.001, CI 32-34%).The number of androgen prescriptions within MTFs rose significantly from 2007 through 2011. This is similar to rises in androgen prescriptions seen in civilian medical systems. Clinical indications for the sharp increase in testosterone prescriptions are unknown, and the indications for clinically appropriate testosterone replacement need further clarification.

This study examined a cohort of students attending the Uniformed Services University regarding their attitudes toward medical care in underserved populations. Using the previously validated Medical Student Attitudes Toward the Underserved (MSATU), repeated measures analysis of variance showed that student attitudes toward care in underserved populations was less favorable than limited national data at entry and declined over time (Mean MSATU total score Year 1: 46.2 [SD 10.95]; Year 4: 41.7 [SD 12.3] p < 0.01). Differences in medical school debt, exposure to underserved populations, and the definition of “service” in the context of active duty military status might explain some of our findings. Providing broad service learning opportunities within the curriculum could increase student exposure to underserved populations and strengthen the social contract between community and institution.

This study examined the correlations between physical fitness parameters and standard measures of academic performance in a cohort of students at the Uniformed Services University. Significant positive correlations were noted between the average aerobic fitness score and preclerkship grade point average (GPA; r = 0.37, p < 0.05) and cumulative GPA (r = 0.38, p < 0.05). Positive correlations were also noted between the average overall fitness score and preclerkship GPA (r = 0.34, p < 0.05), medical school cumulative GPA (r = 0.34, p < 0.05), and the score on Step 1 of the national board examination (r = −0.33, p < 0.05). Physical fitness may serve as one indicator to predict which students will succeed in medical school and to identify those who are at risk for poor performance and might benefit from a wellness intervention.

Military medical professionals play a central role in preventing and treating obesity among America's warriors through training, medical care, and their personal example. Unfortunately, medical students in both undergraduate and graduate settings often experience declines in physical fitness. Pedometry has been demonstrated as one means of promoting fitness with 10,000 steps/day generally accepted as a key benchmark. With this in mind, we used pedometry as an incentive during the preclinical years to encourage students to adopt a more active lifestyle. Findings suggest that participants that consistently report meeting the 10,000 steps/day maintained or improved their aerobic fitness.

Objective: With rising health care costs, methods to decrease length of hospital stay without compromising care are necessary. One area that extends length of stay in trauma patients is inpatient anticoagulation to a therapeutic international normalized ratio. The 1998 American College of Chest Physicians guidelines recommend thromboprophylaxis with low-molecular-weight heparin (LMWH) and oral warfarin in this population. The LMWH Expedited Anticoagulation Program (LEAP) was created with the following goals: to decrease the number of inpatient warfarin days and to reduce overall number of hospital days. Methods: Inpatient anticoagulation was initiated with warfarin and LMWH. LEAP included early multidisciplinary collaboration to ensure third-party approval, outpatient primary care physician follow-up, and LMWH self-injection before discharge. Patients were discharged on LMWH (discontinued by primary care provider when a therapeutic international normalized ratio was attained) and warfarin (continued until resolution of orthopedic injuries). From August 2000 to August 2001, adult patients were included in the prospective study. Primary inclusion criteria were blunt acetabular fracture, bilateral lower extremity fracture, and contralateral upper and lower extremity fractures. Patients with similar injuries receiving warfarin for deep venous thrombosis prophylaxis between June 1999 and June 2000 were the control population. Anticoagulation care was similar for the study and control subjects. Results: There were 182 patients evaluated for LEAP inclusion. After initial evaluation, 108 patients were enrolled in LEAP (Injury Severity Score of 13). There were 69 control subjects (Injury Severity Score of 13). The average number of inpatient warfarin days was decreased from 8.8 days to 5.0 days in the control and study populations, respectively (p < 0.0001). The average length of hospitalization was shortened from 17.3 days in the control group to 12.9 days in the study (LEAP) population (p < 0.002). Conclusion: LEAP has successfully decreased the number of inpatient days on warfarin and total hospital days for trauma patients requiring deep venous thrombosis prophylaxis. These results have substantially decreased health care costs and increased available hospital beds in this era of high hospital occupancy.

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.

Medical students are interested in maximizing clinical experiences during preclinical years; we report an exploratory survey of student and faculty interest in a student-run health clinic (SHC) at the Uniformed Services University of the Health Sciences (USU).We distributed via e-mail a questionnaire to explore student and faculty opinions regarding the role of a SHC at the USU.Nearly half of the students (310/669; 46%) and one in five faculty members (78/427; 18%) responded. 227 students stated the USU should have a SHC and 247 students were willing to commit time to a SHC on a weekly or monthly basis. The majority of participants believe work in a SHC would benefit various clinical attributes representative of the Accreditation Council for Graduate Medical Education residency accreditation requirements. However, most participants believe work in a SHC would benefit only students pursuing careers in primary care whereas having less benefit to surgical careers.Our survey suggests that there is sufficient student interest at the USU to explore additional clinical opportunities early in the medical school experience; we furthermore identified a subtle yet profound difference of opinions in students and faculty regarding the benefits of early clinical exposure and different specialties.

Medical school is stressful. Students commonly exhibit changes in dietary and physical activity patterns in response. We tracked measurements of physical fitness over 4 years in a cohort of students at the Uniformed Services University.Validated measures for specific components of physical fitness were measured in 170 students (94% of the Class of 2011) over the course of 4 years. Measurements included: (1) height and weight (body composition), (2) timed push-ups and sit-ups (muscular endurance), and (3) timed run (aerobic endurance). These measurements are part of annual physical readiness testing required for active duty service in the US military.Muscular endurance and aerobic capacity declined significantly over the 4 years of medical school. Changes in physical fitness were most pronounced during the preclinical years. There were inconsistent changes in body composition among students in the Army, Navy, and Air Force. Composite fitness scores declined significantly in Army and Navy students but not in the Air Force.Individual levels of physical fitness decline during medical school. Declines are most notable during the preclinical years. To promote student wellness, medical schools should incorporate student wellness activities as a routine part of the curriculum.

Background: Obesity is a parallel problem in canine and human populations. We describe health perceptions and levels of companion animal attachment in a cohort of dog owners. Methods: As part of a larger trial examining the impact of veterinary counseling on activity levels of dog owners and their pets, owners presenting to a veterinary referral center were asked to self-report perceived levels of health and attachment to their dog (Lexington Attachment to Pets Scale). Owner body mass index and the body conditioning score of the companion dog were also recorded. Results: Heavier pet owners reported a greater sense of attachment to their dogs. Heavier owners also reported lower perceived health and less social support. Conclusions: Increasing body mass index is associated with higher pet attachment, lower perceived health, and less social support. This information can impact wellness counseling for overweight pet owners and canine companions.

Background There are no empirically-grounded criteria or tools to define or benchmark the quality of outpatient clinical documentation. Outpatient clinical notes document care, communicate treatment plans and support patient safety, medical education, medico-legal investigations and reimbursement. Accurately describing and assessing quality of clinical documentation is a necessary improvement in an increasingly team-based healthcare delivery system. In this paper we describe the quality of outpatient clinical notes from the perspective of multiple stakeholders. Methods Using purposeful sampling for maximum diversity, we conducted focus groups and individual interviews with clinicians, nursing and ancillary staff, patients, and healthcare administrators at six federal health care facilities between 2009 and 2011. All sessions were audio-recorded, transcribed and qualitatively analyzed using open, axial and selective coding. Results The 163 participants included 61 clinicians, 52 nurse/ancillary staff, 31 patients and 19 administrative staff. Three organizing themes emerged: 1) characteristics of quality in clinical notes, 2) desired elements within the clinical notes and 3) system supports to improve the quality of clinical notes. We identified 11 codes to describe characteristics of clinical notes, 20 codes to describe desired elements in quality clinical notes and 11 codes to describe clinical system elements that support quality when writing clinical notes. While there was substantial overlap between the aspects of quality described by the four stakeholder groups, only clinicians and administrators identified ease of translation into billing codes as an important characteristic of a quality note. Only patients rated prioritization of their medical problems as an aspect of quality. Nurses included care and education delivered to the patient, information added by the patient, interdisciplinary information, and infection alerts as important content. Conclusions Perspectives of these four stakeholder groups provide a comprehensive description of quality in outpatient clinical documentation. The resulting description of characteristics and content necessary for quality notes provides a research-based foundation for assessing the quality of clinical documentation in outpatient health care settings.

The study's objective was to determine the effectiveness of a social marketing intervention in influencing use of a targeted electronic medical record (EMR) template to document a standard asthma encounter.This quasi-randomized controlled trial used intervention groups exposed to an educational workshop on EMR documentation with embedded social marketing messages aimed at persuading behavior. Conducted in July 2009 to June 2010, participants in the study included third-year medical students. The primary outcome was the number of participants using a target EMR template. (Clinicaltrials.gov identifier: NCT01043113).A total of 155 participants randomized across eight clusters. Following the workshop, intervention groups were more likely to use the target asthma template than the control group (PR 3.97, 95% CI=1.34--11.79). At slightly over 30 days following the workshop, the intervention group continued to use the asthma template more often than the control group (PR 2.40, 95% CI=1.10--5.21). Stratifying by gender, intervention group females used the asthma template more after the interventions than control group females (PR 10.79, 95% CI=1.18--64.27). In follow-up at slightly over 30 days after the intervention, intervention group female participant asthma template use continued to be used more than control group females (PR 2.82, 95% CI=1.58--5.02). There were no significant differences in group use of asthma template use by intervention group males immediately after the intervention compared to control group males (PR 2.55, 95% CI=0.80--8.14) or similarly at slightly over 30 day follow-up (PR 2.18, 95% CI=0.74-6.42).Social marketing can effectively influence medical student use of EMR templates for clinical documentation in a controlled setting.

Financial limitations in low-income populations, those at highest risk for poor health outcomes, may preclude adherence to recommended dietary guidelines. We examine the financial burden of shopping for foods to meet national dietary recommendations in a supermarket compared to eating primarily in a fast-food restaurant.Using a single-parent, low-income model, we obtained whole food costs (healthy) from local supermarkets and from fast-food outlets (convenient). Using cost per calorie as a metric for comparison, we used estimated single-parent, low-income living expenses to determine the relative costs of meeting national dietary guidelines.Average food costs for healthy and convenience diets accounted for 18% and 37% of income, respectively. Dairy products and vegetables accounted for the largest cost percentages of diet costs (36% and 28%, respectively). The cost per calorie of a convenience diet was 24% higher than the healthy diet. Both models resulted in net financial loss over the course of a year for a single-parent, low-income family.Food costs represent a significant proportion of annual income. Diets based heavily on foods from convenient sources are less healthy and more expensive than a well-planned menu from budget foods available from large supermarket chains.

Overweight at any age in childhood increases the risk for overweight in adulthood. The relative risk ranges from 1.9 to 10.1 and increases as children get older. Not all overweight children become overweight adults, however.

Objective: This is a pilot study to describe patterns of nutritional supplement use by recruits entering the U.S. Marine Corps (USMC). Methods: A survey asking USMC recruits to self-report nutritional supplement use was administered upon entry to basic training. Simple descriptive statistics and prevalence ratios were used to describe patterns of supplement use. Results: The response rate was 65%. Half of respondents reported nutritional sports supplement use at some point before boot camp. The five most commonly supplements were: protein powder (43%), postrecovery workout drinks (36%), vitamin supplements (26%), creatine (26%), and nitric oxide (16%). Conclusions: Nutritional supplement use is frequent among recruits entering the USMC. The impact of supplement use on recruit fitness, training, and injury rates is not known.

To the Editor: We appreciate Dr. Walsh's commentary and strongly agree that it is important to publish the actual questions used when survey-based research is published. While we respect his opinion that the questions could have been written differently, great care was taken when drafting these

It is not known whether parental activity levels influence children's physical fitness. Members of the military are required to maintain standards of physical fitness, whereas the civilian population is not. We conducted this study to compare fitness levels of children in military and civilian families.This was a prospective cohort study of third-grade students from two public schools in San Diego County, Calif. Attendees of one school included children of enlisted service personnel. Attendees of the other school included officers' children. Civilian students attended both schools. Students' physical fitness was tested with several standard instruments, including time on a 1-mile run. Independent variables included whether students had civilian or military parents, television viewing habits, and parental military status (enlisted personnel versus officer) as a surrogate marker for socioeconomic status.A total of 170 of 246 (70%) eligible students completed the study. Children of military parents had lower scores on the mile run and lower scores on other measures of fitness than did children of civilian parents. Socioeconomic status (ie, child of officer versus enlisted personnel) was the strongest predictor of poor fitness, with children of enlisted service members scoring lower on all measures of physical fitness than officers' children. More television viewing was associated with lower levels of fitness.Children of military parents did not have a higher fitness level than children of civilian parents. Lower socioeconomic status and more television viewing are associated with lower levels of fitness.

Tattoos are an increasingly prevalent form of self-expression, especially for adolescents. This study was conducted to determine health-risk behaviors associated with tattoos in young men and women entering military service.We surveyed a cohort of 550 military recruits using a modification of the Youth Risk Behavioral Survey (YRBS), a validated instrument used to assess health risk behaviors in adolescents. All individuals entering basic training in the US Marine Corps or the US Air Force from June through September 1999 were eligible to participate. The primary outcome variables of interest were tobacco use, alcohol use, seatbelt use, suicidal behaviors, depression, and physical violence.The survey response rate was 91% (n = 499 of 550). Overall, 27% of respondents had tattoos (n = 125) when entering military service. Women entering military service were more likely to have a tattoo than men. Controlling for age and gender, individuals with tattoos were more likely to smoke, drink heavily, use smokeless tobacco, and ride in a vehicle with someone who had been drinking than non-tattooed individuals.In a population of military recruits, tattoos were associated with predictable adverse health-risk behaviors. This represents an important opportunity for targeted preventive counseling.

This article describes our study of the use of beta blocker drugs in Medicare beneficiaries hospitalized for acute myocardial infarction in West Virginia between 1999 and 2000. We contrasted findings with the responses of practicing cardiologists in the state. The survey asked cardiologists to describe their recent patterns of beta blocker usage, to comment on the severity of generally recognized contraindications to beta blocker administration, and to speculate on reasons why West Virginia's rates of beta blocker use in AMI were lower than rates in most other states. Our study revealed that beta blocker use in AMI declined significantly with patient age, and that rates of use in larger hospitals exceeded those in smaller hospitals. There was little difference attributable to the specialty of the admitting physician. We also observed a positive association between the use of beta blockers in AMI and other appropriate interventions, such as the use of aspirin and revascularization. Cardiologists said they were using more beta blockers in AMI than five years ago, and speculated that high rates of chronic obstructive pulmonary disease and non-specialist physicians were responsible for low rates in West Virginia.

Ascaris lumbricoides are among the medically important worms belonging to the phylum Nematoda (roundworms) that are parasites of the human gastrointestinal tract. Despite current sanitation and hygiene standards in the United States, infection due to intestinal roundworms is not uncommon in children and adults. A high index of suspicion is warranted as patients may present anywhere along a spectrum of illness from asymptomatic to acutely ill. The following is a case presentation and discussion of Ascaris lumbricoides, the common roundworm or intestinal longworm. Arch Fam Med. 2000;9:1193-1194

The efficacy and safety of subcutaneous phytonadione in the treatment of patients with asymptomatic excessive International Normalized Ratio (INR) values secondary to warfarin therapy were evaluated. Patients at an outpatient anticoagulation clinic with an INR of 8 or more but less than 14 were given 1 mg of subcutaneous phytonadione, and patients with an INR of 14 or more but less than 20 received 2 mg. The patients were instructed to withhold warfarin therapy for the next 24 hours and to immediately report any bleeding complications. At subsequent visits, patients with an INR of 8 or more but less than 14 were given an additional 1 mg of subcutaneous phytonadione. Patients with an INR above 4.5 were instructed to withhold warfarin therapy for an additional 24 hours. Seventeen patients received the 1-mg dose (group 1), and four patients received the 2mg dose (group 2). In group 1, the mean INR reduction was 49% at 24 hours and 72% at 48 hours and the INR was below 4.5 in 93% of patients at 48 hours. In group 2, the mean INR reduction was 67% at 24 hours and 85% at 48 hours and the INR was below 4.5 in 100% of patients at 48 hours. In four group-1 patients and one group-2 patient, the INR fell below 2.0 at 48 hours. No patients reported hemorrhagic or thrombotic complications. Subcutaneous phytonadione safely lowered excessively high INR values caused by warfarin therapy.

Streptokinase is an important component in the treatment strategy for acute myocardial infarction. However, physicians need to be aware that some patients may experience allergic reactions to this drug. Prompt recognition and appropriate management of symptoms usually result in recovery from the allergic event without further complication.