Volume 113, Issue 2

Context: Fluzone Intradermal (ID) vaccine was licensed in the United States in May 2011 and uses a microinjection device with a 1.5-mm, 30-gauge needle that delivers a smaller volume and antigen load than the Fluzone Intramuscular (IM) vaccine. The same ID microinjection system has been used in Argentina and Australia since 2010 with documented acceptance by both patients and vaccine administrators. Objectives: To evaluate the acceptability of Fluzone ID influenza vaccine in clinical practice in the United States among patients and vaccine administrators and to compare the ID and IM influenza vaccines in terms of patient preference, preinjection anxiety, postinjection pain, and vaccine selection in future years. Methods: The authors developed 3 surveys—an initial and a follow-up survey for recipients of the ID vaccine and another survey for administrators—to assess opinions of ID administration. Vaccine recipients were surveyed at the time of injection concerning vaccine acceptability, vaccine preference, preinjection anxiety, and postinjection pain. Recipients who had received the IM influenza vaccine within the past 3 years were asked to compare the ID vaccine with their prior IM vaccine experience. Vaccine administrators were also surveyed after administering the ID vaccine at their assigned clinic. Recipients were then surveyed 7 days later. Results: Vaccine clinic participants were offered 3 vaccines: the ID and the IM Fluzone vaccines and Flumist (Medimmune) intranasal vaccine. Of the 367 participants vaccinated, 249 (67.8%) chose the ID vaccine and 117 (31.9%) chose the IM vaccine. Immediately after ID vaccination, 234 of 235 recipients (99.6%) reported being satisfied with the method of administration. One hundred seventy-five of 178 ID vaccine recipients (99.4%) who had also received the IM vaccine in the past 3 years reported being satisfied. Previous IM recipients reported a preference for the ID vaccine over the IM vaccine. They also reported less preinjection anxiety and postinjection pain compared with the IM vaccine administration, both immediately and 7 days after vaccination. All vaccine administrators reported satisfaction with the ID vaccine. Conclusion: The current study demonstrates the overall acceptability of the Fluzone ID vaccine in clinical practice in the United States by both patients and vaccine administrators. Additionally, the study is the first to our knowledge to document a patient preference for ID influenza vaccine over IM influenza vaccine.

Context: Military service members have unique experiences that may contribute to sleep problems in this patient population. Objective: To gather sleep habits and chronic sleep complaints among active-duty service members to identify common characteristics. Methods: The investigators administered a detailed sleep log, the Pittsburgh Insomnia Rating Scale, the Zung Self-Rating Depression Scale, the Epworth Sleepiness Scale, and the Pre-Sleep Arousal Scale to consenting service members referred to a military psychiatric partial hospitalization program. Results: A total of 57 service members participated in this study. Participants reported a mean of less than 5 total hours of sleep and sleep latencies of 30 minutes or more. Tobacco users (n=22) reported nearly a full hour less of total time slept. Service members with combat experience (n=26) reported qualitatively poorer sleep with less total sleep time ( P =.05), greater presleep arousal ( P =.01), and a substantially greater number of troubling dreams ( P =.06) compared with service members without combat experience. Conclusion: Chronic sleep issues are common complaints among military personnel, an anecdotal finding confirmed by the results of this study. These results lend support for more detailed sleep assessments, particularly among combat veterans.

The responsibility of diabetes management and insulin therapy has definitively moved to primary care physicians. Within the primary care setting, there is a growing need for clear, evidence-based guidelines related to the management of insulin therapy. Straightforward algorithms regarding insulin initiation, titration, and follow-up management can help physicians effectively treat patients with type 2 diabetes mellitus. Once 2 oral diabetic drugs have failed in a patient whose disease duration is 7 to 10 years, use of insulin therapy with a basal insulin analog should be considered. For patients who receive maximal basal insulin doses without reaching fasting blood glucose and target glycated hemoglobin levels with basal insulin analogs, a mealtime-insulin intensification approach should be considered. The authors discuss how simplified insulin initiation and titration regimens allow primary care physicians and other health care professionals to care for patients with type 2 diabetes mellitus.

Context: Comprehensive Osteopathic Medical Licensing Examination-USA (COMLEX-USA) Level 1 scores are an important criterion used by residency directors to make residency placement decisions. Objective: To explore the association between scoring at least 600 on COMLEX-USA Level 1 and grade point average (GPA), scores on the Medical College Admission Test (MCAT), and different test preparation strategies. Methods: Third-year osteopathic medical students at Nova Southeastern University were invited to complete a self-administered survey regarding their COMLEX-USA preparation strategies and to provide consent for the researchers to access their preclinical GPA and their MCAT and COMLEX-USA scores. Descriptive analyses were conducted to understand examination preparation procedures and resources used, and bivariate analyses were conducted to identify the statisically significant predictors of scoring 600 or higher. Two separate logistic regressions were also run. The first included all of the statisically significant factors that emerged from the bivariate analyses, and the second examined which candidate predictors remained statistically significant once the effects of GPA and MCAT scores were removed. Results: One hundred twenty-two students completed the survey, and 113 (93%) provided informed consent to access their preclinical GPA and their MCAT and COMLEX-USA scores. In the first regression, scoring 600 or higher was associated with a higher GPA ( P <.02), a higher MCAT score ( P <.05), earlier preparation initiation ( P <.05), and not ranking the Comprehensive Osteopathic Medical Self-Assessment Examination (COMSAE) as the most helpful practice examination ( P <.04). In the second regression, scoring 600 or higher was associated with earlier initiation of examination preparation ( P <.01) and not ranking COMBANK (question bank for COMLEX-USA) as the most helpful question bank ( P <.03). Among the different examination preparation methods, the specific resources ranked as most helpful were First Aid for the USMLE (United States Medical Licensing Examination) (review book), the COMSAE (practice examination); COMBANK (question bank); and Kaplan USMLE (lecture videos). Conclusion: Preclinical GPA and MCAT scores continue to be important predictors of scoring at least 600 on COMLEX-USA Level 1. However, the findings underscore the importance of maintaining a high GPA during the first 2 years of medical school and initiating COMLEX-USA preparation early.

Negative-pressure wound therapy (NPWT) with a vacuum-assisted closure system has been successfully used in the management of various wounds on the trunk and distal extremities, including diabetic foot ulcers. However, reported successful NPWT cases have involved distal wounds that were below the knee. The authors report a case of an elderly diabetic patient with recalcitrant wounds in his left lower extremity from an above-the-knee amputation. The patient had undergone 27 surgical débridement or revision procedures over the course of 3 months. On entering rehabilitation, the patient had a full-thickness wound in his residual limb that measured 9 × 8 cm. The patient received NPWT with a vacuum-assisted closure system, which resulted in a fully healed residual limb. After 120 days, the patient was ready to begin prosthetic restoration.