King C.,Fort Belvoir Community Hospital |
Nathan S.D.,Advanced Lung Disease and Lung Transplant Program
Current Opinion in Pulmonary Medicine | Year: 2013
PURPOSE OF REVIEW: The interstitial lung diseases (ILDs) frequently result in considerable disability and reduced survival in affected patients. Unfortunately, they are often poorly responsive to available therapies. Comorbidities, both pulmonary and nonpulmonary, frequently accompany ILDs and contribute to adverse outcomes. RECENT FINDINGS: Multiple comorbidities, including gastroesophageal reflux disease, venous thromboembolism, coronary artery disease, sleep-disordered breathing, depression, emphysema, pulmonary hypertension, and lung cancer contribute to the morbidity and mortality of fibrotic lung disease. SUMMARY: The identification and treatment of comorbidities may improve morbidity and potentially impact mortality in patients with ILD. A high index of suspicion and an awareness of the spectrum of comorbidities are important in optimizing outcomes in this group of patients. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Hersch E.C.,U.S. Army |
Oh R.C.,Fort Belvoir Community Hospital
American Family Physician | Year: 2014
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 fluoro-deoxyglucose 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. © 2014 American Academy of Family Physicians.
Woll M.,U.S. Army |
Brisson P.,Fort Belvoir Community Hospital
Military Medicine | Year: 2013
Background: The mission of a Forward Surgical Team (FST) is to provide immediate lifesaving surgery to wounded U.S. and coalition forces. The degree of humanitarian surgical care provided to civilians is a topic of controversy. Methods: From May 2011 to November 2011, the surgeons of the 126th FST provided humanitarian surgical care to Afghan civilians. Results: The FST surgeons provided 553 surgical evaluations on 511 Afghan civilians. Of the patients, 95% were male and 38% were children. Forty percent of the clinic visits involved wound care and 20% involved a general surgery diagnosis. Seventeen percent involved an orthopedic diagnosis and 23% involved various surgical subspecialty diagnoses. Of the patients, 11% required a procedure necessitating the use of anesthesia. Interviews with Afghan patients and civic leaders identified a positive impact. Conclusion: This is the first report of humanitarian surgical care provided by surgeons of a FST in Afghanistan. Time and resource investment was minimal with no evidence of a negative impact on the primary mission of the FST. © Association of Military Surgeons of the U.S. All rights reserved.
Bynum W.E.,Fort Belvoir Community Hospital |
Lindeman B.,Johns Hopkins University
Academic Medicine | Year: 2016
Understanding and addressing the issue of learner mistreatment is among the most pressing challenges facing academic medicine today. Despite the fact that residents have a significant influence on the clinical learning environment and may be both recipients and perpetrators of mistreatment, the resident perspective on the issue of learner mistreatment is notably sparse in the medical education literature. In this Commentary, the authors provide a resident response to recent data showing that mistreatment is subjective and may occur on a spectrum from incident-based mistreatment to environmental-based mistreatment. They focus on specific factors from the learning environment that may increase a learner's tendency to feel mistreated or have a suboptimal learning experience, including team cohesion, marginalization, peer-on-peer mistreatment, witnessing mistreatment, hierarchies, interdepartmental mistreatment, acculturation of uncivil behaviors, and residents themselves. This is followed by a discussion of proposed solutions to mitigate the negative impact of these influences and build safe learning environments, collaborative teams, empathic teachers, and resilient learners. © 2016 by the Association of American Medical Colleges.
Bynum W.E.,Fort Belvoir Community Hospital |
Goodie J.L.,Uniformed Services University of the Health Sciences
Medical Education | Year: 2014
Context: Shame and guilt are subjective emotional responses that occur in response to negative events such as the making of mistakes or an experience of mistreatment, and have been studied extensively in the field of psychology. Despite their potentially damaging effects and ubiquitous presence in everyday life, very little has been written about the impact of shame and guilt in medical education. Methods: The authors reference the psychology literature to define shame and guilt and then focus on one area in medical education in which they manifest: the response of the learner and teacher to medical errors. Evidence is provided from the psychology literature to show associations between shame and negative coping mechanisms, decreased empathy and impaired self-forgiveness following a transgression. The authors link this evidence to existing findings in the medical literature that may be related to unrecognised shame and guilt, and propose novel ways of thinking about a learner's ability to cope, remain empathetic and forgive him or herself following an error. Results: The authors combine the discussion of shame, guilt and learner error with findings from the medical education literature and outline three specific ways in which teachers might lead learners to a shame-free response to errors: by acknowledging the presence of shame and guilt in the learner; by avoiding humiliation, and by leveraging effective feedback. Conclusions: The authors conclude with recommendations for research on shame and guilt and their influence on the experience of the medical learner. This critical research plus enhanced recognition of shame and guilt will allow teachers and institutions to further cultivate the engaged, empathetic and shame-resilient learners they strive to create. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.
Yancey J.R.,Fort Belvoir Community Hospital |
Thomas S.M.,U.S. Air force
American Family Physician | Year: 2012
Chronic fatigue syndrome is characterized by debilitating fatigue that is not relieved with rest and is associated with physical symptoms. The Centers for Disease Control and Prevention criteria for chronic fatigue syndrome include severe fatigue lasting longer than six months, as well as presence of at least four of the following physical symptoms: postexertional malaise; unrefreshing sleep; impaired memory or concentration; muscle pain; polyarthralgia; sore throat; tender lymph nodes; or new headaches. It is a clinical diagnosis that can be made only when other disease processes are excluded. The etiology of chronic fatigue syndrome is unclear, is likely complex, and may involve dysfunction of the immune or adrenal systems, an association with certain genetic markers, or a history of childhood trauma. Persons with chronic fatigue syndrome should be evaluated for concurrent depression, pain, and sleep disturbances. Treatment options include cognitive behavior therapy and graded exercise therapy, both of which have been shown to moderately improve fatigue levels, work and social adjustment, anxiety, and postexertional malaise. No pharmacologic or alternative medicine therapies have been proven effective. © 2012 American Academy of Family Physicians.
Hardin C.A.,Fort Belvoir Community Hospital
Dermatology online journal | Year: 2013
The divided or kissing nevus is an unusual congenital melanocytic nevus. By definition, these nevi appear on skin that separates during embryological development. These lesions have been reported on the eyelids, fingers, and rarely the penis. We describe an 18 year old uncircumcised male who presented with an asymptomatic darkly pigmented patch on the glans penis. He reported that the lesion had appeared recently and was enlarging. Physical examination revealed a second symmetric lesion on the adjacent foreskin. Punch biopsy of the lesion on the glans penis showed abundant intradermal melanocytes devoid of mitoses and atypia, consistent with an intradermal melanocytic nevus. Based on the benign histologic nature and clinical exam, the lesion was diagnosed as a divided or kissing nevus of the penis. Proposed treatments include excision and grafting as well as Nd:YAG laser therapy. However, these patients may be safely monitored with regular follow-up skin examinations because there is minimal risk of malignant transformation.
Lin K.W.,Georgetown University |
Yancey J.R.,Fort Belvoir Community Hospital
Journal of the American Board of Family Medicine | Year: 2016
Objective: The goal of this study was to evaluate the quality of evidence supporting primary care-relevant Choosing WiselyTM recommendations using the Strength of Recommendation Taxonomy (SORT). Methods: All Choosing Wisely "top 5" lists published by American medical specialty societies through June 2014 were reviewed for relevance to primary care. Both authors independently applied SORT to generate an evidence letter grade for each of the included recommendations, relying on citations supplied by the nominating organizations. Results: Of 310 recommendations, 224 were identified as being relevant to primary care. We rated 43 (19%) as SORT level of evidence A, 57 (25%) as B, and 124 (55%) as C. Conclusion: We found that a majority of primary care-relevant Choosing Wisely recommendations are based on expert consensus or disease-oriented evidence. Further research is warranted to strengthen the evidence base supporting these recommendations in order to improve their acceptance and implementation into primary care.
Brisson P.,Fort Belvoir Community Hospital
American Journal of Tropical Medicine and Hygiene | Year: 2012
Compliance with malaria chemoprophylaxis by military service members (MSMs) is notoriously low, ranging from 30% to 56%. Our objective was to determine the rate of compliance and reasons for non-compliance with malaria chemoprophylaxis among healthy US MSMs in Afghanistan. An eight-question, anonymous online survey was used to collect data regarding the compliance of healthy MSMs with malaria chemoprophylaxis. E-mail surveys were sent to 1,200 MSMs; 528 (44%) MSMs completed the survey. One-time daily doxycycline was the most commonly prescribed chemoprophylaxis (90%); 60% (N = 318) responded that they were compliant with their chemoprophylaxis as prescribed, whereas 40% (N = 221) indicated that they were not compliant. Compliance with daily dosing was 61% and weekly dosing was 38%. The most common reasons for non-compliance were gastrointestinal effects (39%), forgetfulness (31%), and low perception of risk (24%). Malaria chemoprophylaxis compliance by healthy MSMs in Afghanistan is poor. Side effects, forgetfulness, and lack of education are contributing factors. Commanders bear the primary responsibility for the health of their soldiers, and the individual MSM bears personal responsibility; however, additional public health interventions could possibly have a positive impact on prevention. Copyright © 2012 by The American Society of Tropical Medicine and Hygiene.
Bynum W.,Fort Belvoir Community Hospital
Academic Medicine | Year: 2014
The last 20 years have seen an unprecedented technological revolution, including the development of the personal computer. The new technologies that have emerged during this age of innovation have allowed human beings to connect widely with one another through electronic media and have made life more efficient and streamlined. Likewise, this technological renaissance has helped to define medicine as one of the most innovative professions by providing physicians with diagnostics and interventions that are more accurate, efficacious, and safe, to the benefit of physicians and the public. However, in both life and the practice of medicine, these new technologies have had the unintended consequence of reducing the value of direct human connection and threaten to isolate individuals in spite of advancing society.In this commentary, the author argues that human beings need to make a more concerted effort to connect with each other through both enhanced communication technologies and direct human contact. Likewise, leaders in medicine need to embrace and promote technological advancement while at the same time working to maintain the human connection that physicians have with their patients and teaching learners to do the same. Doing so will prevent physicians from becoming automated medical kiosks that offer sound, innovative medical advice but that lack the personality, compassion, and emotion that will lead to better health.