Volume 115, Issue 6

Context: The percentage of total US residents in the military is lower than ever before. Many civilians, including civilian physicians, have little knowledge of US military actions or the day-to-day experiences and working environments of veterans. Objective: To assess civilian physician knowledge of veterans’ issues using a survey. Methods: A 10-item survey was distributed to physicians at 2 primary care–focused medical conferences in Ohio to determine self-reported levels of comfort and familiarity with veteran-oriented topics. Results: Of 350 surveys that were distributed, 141 surveys were returned. Of the 141 respondents, 101 practiced primary care, 19 practiced internal medicine, 16 practiced other specialties, and 5 did not report a specialty affiliation and were excluded from final analysis. A single respondent reported pediatrics as a specialty but indicated “not applicable“ for all answers. This individual was excluded from final analysis. Overall, physicians reported feeling moderately comfortable with military terminology and uncomfortable with the diagnosis and management of traumatic brain injury. More than half of the respondents indicated that they were not comfortable discussing health-related exposures and associated risks that veterans might experience and that they were unfamiliar with referral and consultation services for veterans. The data collected had a high degree of reliability (Cronbach α=0.88). Respondents of both primary care and internal medicine specialties scored statistically significantly higher than the other respondents in questions on veterans’ medical conditions, military terminology, and military health risks ( P <.05), although these 2 groups scored similarly ( P >.05). Specialty orientation did not affect responses for questions on other topics ( P >.05). Conclusion: The data indicated an overall moderate level of familiarity among civilian physicians with veterans’ issues. The results did not reveal an overall high level of comfort with any issues included in the survey. More research is needed to determine reasons behind the findings and methods to improve civilian physician comfort with various veterans’ issues.

Context: Sleep disorders are frequent clinical presentations, especially among active-duty service members. Medications are one factor that can affect sleep in many ways. Objective: To determine the effect of increasing numbers of medications on the sleep cycle of active-duty service members. Methods: Medical records for active-duty service members who completed enhanced sleep assessments at the Psychiatry Continuity Service at Walter Reed National Military Medical Center from October 1, 2010, through November 30, 2013, were retrospectively reviewed. Data were collected on home sleep study findings, sleep-related self-report instrument scores, and active medications. Results: A total of 135 medical records were reviewed. One hundred patients (74.07%) had an active prescription for a psychoactive drug. Among all patients, the mean (SD) number of active medications per participant was 2.52 (2.09), with 118 patients (82.96%) having an active medication for depression or insomnia. As the number of prescribed medications increased, the percentage of the sleep cycle in deep sleep decreased ( P =.049), the percentage of light sleep increased ( P =.016), the percentage of rapid eye movement sleep decreased ( P =.083), and the first episode of deep sleep was delayed ( P =.056). An increased number of medications had no significant impact on total sleep time ( P >.05). Conclusion: An increasing number of medications did not influence total sleep time but negatively affected the sleep cycle.

Context: A blood alcohol level above 0 g/dL is found in up to 50% of patients presenting with traumatic injuries. The presence of alcohol in the blood not only increases the risk of traumatic injury, but it is also associated with worse outcomes and trauma recidivism. In light of these risks, the American College of Surgeons Committee on Trauma advocates screening for at-risk drinking. Although many institutions use blood alcohol levels to determine at-risk drinking in trauma patients, the Alcohol Use Disorders Identification Test (AUDIT) offers a cheap and easy alternative. Few direct comparisons have been made between these 2 tests in trauma patients. Objective: To compare the utility of blood alcohol level and AUDIT score as indicators of at-risk drinking in trauma patients. Methods: Records for all trauma patients aged 18 years or older who were admitted to a level I trauma center from May 2013 through June 2014 were reviewed in this retrospective cohort study. Inclusion criteria required patients to have undergone both blood alcohol level testing and AUDIT on admission. A blood alcohol level greater than 0 g/dL and an AUDIT score equal to or above 8 were considered positive for at-risk drinking. Performance of both tests was indexed against the National Institute of Alcohol Abuse and Alcoholism (NIAAA) criteria for at-risk drinking. Results: Of 750 patients admitted for trauma, 222 records (30%) contained data on both blood alcohol level and AUDIT score. The patients were predominantly male (178 [80%]) and had a mean (SD) age of 40.1 (16.7) years. Most patients (178 [80%]) had sustained blunt trauma. Ninety-seven patients (44%) had a positive blood alcohol level, 70 (35%) had a positive AUDIT score, and 54 (24%) met NIAAA criteria for at-risk drinking. The sensitivity and specificity of having a positive blood alcohol level identify at-risk drinking were 61% and 62%, respectively. The sensitivity and specificity of having a positive AUDIT score identify at-risk drinking were 83% and 81%, respectively. Conclusion: As a stand-alone indicator of at-risk drinking behavior in trauma patients, the AUDIT score was shown to be superior to blood alcohol level. The utility of obtaining routine blood alcohol levels in trauma patients as a screening tool for at-risk drinking should be reexamined.

Context: Chest wall mobility is strongly related to respiratory function; however, the effect of aging on chest wall mobility—and the level at which this mobility is most affected—remains unclear. Objective: To investigate age-related differences in chest wall mobility and respiratory function among elderly women in different age groups. Methods: This cross-sectional observational study was performed in Himeji City in Hyogo Prefecture and Ayabe City in Kyoto Prefecture in Japan. Inclusion criteria were female sex, age 65 years or older, community resident, and ability to ambulate independently, with or without an assistive device. Thoracic excursion at the axillary and xiphoid levels and at the level of the tenth rib was measured with measuring tape. Respiratory function, including forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV 1 ), was assessed by spirometry, and FVC percent predicted (%FVC), FEV 1 percent predicted (%FEV 1 ), and FEV 1 /FVC were calculated. Chest wall mobility and respiratory function were compared among 4 age groups. Results: Of 251 potential participants, 132 met the inclusion criteria. Participants were divided into 4 age groups: group 1, 65 to 69 years; group 2, 70 to 74 years; group 3, 75 to 79 years; and group 4, 80 years or older. Statistically significant differences were found in thoracic excursion at the axillary level between groups 1 and 4 and between groups 2 and 4 when adjusted for height and weight ( F 4.52 , P =.01). In addition, statistically significant differences were found in the FVC and FEV 1 values between groups 1 and 3 and between groups 2 and 3 (FVC: F 4.97 , P =.01; FEV 1 : F 6.17 , P =.01). Conclusion: Chest wall mobility at the axillary level and respiratory function decreased with age in community-dwelling women aged 65 years or older. Further longitudinal studies are required to clarify the effects of aging on chest wall mobility and respiratory function.

With the commitment on the part of the American Osteopathic Association, the American Association of Colleges of Osteopathic Medicine, and the Accreditation Council for Graduate Medical Education to transition to a single graduate medical education accreditation system by 2020, a legitimate concern exists about the future of pediatric residency training that maintains an osteopathic focus. The authors describe a dually accredited pediatric residency program at one of the nation’s largest children’s hospitals, which may serve as a potential model of how to integrate a robust osteopathic-based education into a general pediatric residency program.

Stiff person syndrome (SPS) is a rare and disabling central nervous system disorder first described in 1956 and characterized by fluctuating rigidity and stiffness, gait impairment, and painful spasms of the axial and limb musculature. Although an underlying mechanism of impaired synaptic γ-aminobutyric acid–ergic inhibition has been proposed, the exact mechanism remains unclear. The glutamic acid decarboxylase antibody, a marker for SPS, is a strong indication of disease and has been reported in approximately 70% of patients. The current treatment of choice is benzodiazepines and baclofen, both of which reduce motor unit potential firing and, therefore, decrease stiffness and spasms. However, patients continue to have substantial disability with pharmacologic therapy alone. This case report demonstrates the potential of osteopathic manipulative treatment as an adjunct to medication in the management of SPS. By decreasing somatic dysfunction and reducing the frequency of exacerbations, osteopathic manipulative treatment may alleviate the symptoms and overall morbidity associated with this disease.