Updating the Military Unique Curriculum for a Ready Medical Force

INTRODUCTION

Previous conflicts have demonstrated the impact of physician readiness on early battlefield mortality rates. To prepare for the lethal nature of today's threat environment and the rapid speed with which conflict develops, our medical force needs to sustain a high level of readiness in order to be ready to "fight tonight." Previous approaches that have relied on on-the-job training, just-in-time predeployment training, or follow-on courses after residency are unlikely to satisfy these readiness requirements. Sustaining the successes in battlefield care achieved in Iraq and Afghanistan requires the introduction of effective combat casualty care earlier and more often in physician training. This needs assessment seeks to better understand the requirements, challenges, and opportunities to include the Military Unique Curriculum (MUC) during graduate medical education.

MATERIALS AND METHODS

This needs assessment used a multifaceted methodology. First, a literature review was performed to assess how Military Unique Curricula have evolved since their initial conception in 1988. Next, to determine their current state, a needs-based assessment survey was designed for trainees and program directors (PDs), each consisting of 18 questions with a mixture of multiple choice, ranking, Likert scale, and free-text questions. Cognitive interviewing and expert review were employed to refine the survey before distribution. The Housestaff Survey was administered using an online format and deployed to Internal Medicine trainees at the Walter Reed National Military Medical Center (WRNMMC). The Program Director Survey was sent to all Army and Navy Internal Medicine Program Directors. This project was deemed to not meet the definition of research in accordance with 32 Code of Federal Regulation 219.102 and Department of Defense Instruction 3216.02 and was therefore registered with the WRNMMC Quality Management Division.

RESULTS

Out of 64 Walter Reed Internal Medicine trainees who received the survey, 32 responses were received. Seven of nine PDs completed their survey. Only 12.5% of trainees felt significantly confident that they would be adequately prepared for a combat deployment upon graduation from residency with the current curriculum. Similarly, only 14.29% of PDs felt that no additional training was needed. A majority of trainees were not satisfied with the amount of training being received on any MUC topic. When incorporating additional training on MUC topics, respondents largely agreed that simulation and small group exercises were the most effective modalities to employ, with greater than 50% of both trainees and PDs rating these as most or second most preferred among seven options. Additionally, there was a consensus that training should be integrated into the existing curriculum/rotations as much as possible.

CONCLUSIONS

Current Military Unique Curricula do not meet the expected requirements of future battlefields. Several solutions to incorporate more robust military unique training without creating any significant additional time burdens for trainees do exist. Despite the limitation of these results being limited to a single institution, this needs assessment provides a starting point for improvement to help ensure that we limit the impact of any "peacetime effect."

Read to Lead: Developing a Leadership Book Club Curriculum for Graduate Medical Education

BACKGROUND

The importance of effective leadership for improving patient care and physician well-being is gaining increased attention in medicine. Despite this, few residency programs have formalized education on leadership in medicine. The most effective ways to train graduate medical education (GME) trainees in leadership are unclear.

METHODS

Our large internal medicine residency program implemented a book club to develop leadership skills in residency. Through independent reading of the selected book and resident-led small group discussions, we facilitated dialogue on the challenges of leading effectively.

RESULTS

A survey-based curricular evaluation demonstrated that 61% of respondents felt that the book club influenced their thoughts about leadership and that 66% of participants would recommend the book club to other residency programs. Lack of time was the main barrier to participation while addition of complementary media or alternative book formats were identified as possible solutions to increase engagement.

CONCLUSIONS

Leadership book clubs are a practical and effective way to teach leadership during residency. More research is needed to identify the best formats for book club discussion and to develop additional tools to foster future physician leaders.

Building Individual and Organizational Wellness Through Effective Followership

Burnout is widespread across the healthcare industry. Physician burnout has been linked to significant decrements in personal wellness, patient satisfaction, patient outcomes, and organizational financial losses. Appropriately, burnout has been identified as an important issue for leaders in the field as it can lead to physician turnover and loss of talent. In this article, we address how burnout is related to followership. We assert that physicians can utilize effective followership to increase wellness not only for themselves, but also for their leaders and organizations.

Learning to Lead: 10 Leadership Lessons From Operation Bushmaster

Medical students at the Uniformed Services University of the Health Sciences participate in a leadership curriculum designed to develop leadership skills. Operation Bushmaster is a 5-day field practicum designed to test these skills. In this article, we describe 10 leadership lessons learned during Operation Bushmaster applicable to all leaders.

Recognizing Gender Parity in Military Medicine: An Analysis of Plenary Speakers and Award Recipients at Military American College of Physicians Chapter Meetings

INTRODUCTION

Despite the advances toward gender parity in medicine, a gap exists in the recognition of women physicians at academic and subspecialty medical conferences as plenary speakers and award winners. Conferences are cornerstones in the practice of medicine because they serve as platforms to showcase physicians' successes and disseminate work. The selection of who is honored at such events can impact an individual's career by creating networks that may lead to future opportunities. Additionally, the trend of who is honored may create expectations in the minds of trainees and early career physicians about what qualities help an individual achieve success. Our group sought to determine whether there was a gender gap in award recognition and speakership opportunities at the American College of Physicians (ACP) annual military chapter meetings.

METHODS

This was a cross-sectional study with data extracted from publicly available conference programs for the Army-Air Force annual ACP meetings and the Navy annual ACP meetings. Five years of data erewere reviewed for invited plenary speakers. Ten years of data were reviewed for award recipients. For an award to be included, it had to have a preset description and criteria for recipient selection. Awards not given annually or awards given for less than 3 years were excluded. Individuals' gender was determined based on the first name and confirmed through internet searches of pronoun descriptors from professional websites. Comparisons were done using Fisher's exact test and chi-square tests when appropriate, with statistical significance set at a two-tailed P-value of <.05.

RESULTS

Women comprised 26-30% of the chapter membership and there was no significant difference in gender distribution between the chapters. Fourteen of the 69 plenary speakers were women (20%), with significantly fewer women presenters in the Navy as compared to men. Thirty-six of the 134 award winners were women (27%), which was not significantly different from the overall chapter gender distributions. While women recipients of lifetime, teaching, research, and medical student awards were not significantly different from chapter gender distribution, women faculty were significantly more likely to receive an award for teaching than for research, with women receiving 13 of the 28 teaching awards (41%), and none of the 10 faculty research awards.

CONCLUSIONS

The military chapter ACP meetings reviewed mirrored civilian data in many ways, although military plenary speaker and award recipient distributions were more representative of the gender distribution of the branches. Review of the nomination process, planning committee selection, and opportunities for diversity training could be optimized to ensure that future conferences have a gender-balanced representation of individuals being honored. Improving upon current practices is important for the growth and retention of women military physicians.

Leadership Training in Graduate Medical Education: Time for a Requirement?

INTRODUCTION

The need for all physicians to function as leaders in their various roles is becoming more widely recognized. There are increasing opportunities for physicians at all levels including Graduate Medical Education (GME) to gain leadership skills, but most of these opportunities are only for those interested. Although not an Accreditation Council for Graduate Medical Education (ACGME) requirement, some US graduate medical education programs have incorporated leadership training into their curricula. Interestingly, the Royal College of Physicians and Surgeons of Canada adopted the Leader role in its 2015 CanMEDS physician training model and requires leadership training. We sought to understand the value of a leadership training program in residency in our institution.

MATERIALS AND METHODS

Our 2017 pilot leadership training program for senior military internal medicine residents consisted of four one-hour sessions of mini-lectures, self-assessments, case discussions, and small group activities. The themes were: Introduction to Leadership, Emotional Intelligence, Teambuilding, and Conflict Management. Participants were given an 18-question survey (14 Likert scale multiple-choice questions and 4 open-ended response questions) to provide feedback about the course. The Brooke Army Medical Center Institutional Review Board approved this project as a Quality Improvement effort.

RESULTS

The survey response rate was 48.1% (26 of 54). The majority of respondents (84.6%) agreed the leadership training sessions were helpful and relevant. Following the sessions, 80.8% saw a greater role for physicians to function as leaders. Most (88.4%) agreed that these sessions helped them understand the importance of their roles as leaders, with 80.8% feeling more empowered to be leaders in their areas, 76.9% gaining a better understanding of their own strengths and weaknesses as leaders, and 80.8% feeling better prepared to meet challenges in the future. After exposure to leadership training, 73.1% indicated a plan to pursue additional leadership development opportunities. All respondents agreed that internists should be able to lead and manage a clinical team, and every respondent agreed that leadership principles should be taught in residency.

CONCLUSIONS

This pilot project supports the premise that leadership training should be integrated into GME. Initial results suggest training can improve leadership skills and inspire trainees to seek additional leadership education. Moreover, much like the published literature, residents believe they should learn about leadership during residency. While more effort is needed to determine the best approach to deliver and evaluate this content, it appears even small interventions can make a difference. Next steps for this program include developing assessment tools for observation of leadership behaviors during routine GME activities, which would allow for reinforcement of the principles being taught. Additionally, our experience has led our institution to make leadership training a requirement in all of our GME programs, and we look forward to reporting future progress. Finally, an ACGME requirement to incorporate leadership training into GME programs nationwide would prove useful, as doing so would reinforce its importance, accelerate implementation, and expand knowledge of best approaches on a national level.

The Rising Physicians Program: A Novel Approach for Mentoring Medical Students

INTRODUCTION

The transition to medical school is a particularly challenging time for new students as they are faced with significant academic responsibilities. Moreover, for many students at the Uniformed Services University they are adjusting to being on active duty in the military. Mentoring has been considered a way to help with the transition and professional development. Prior to 2015, there was no formal mentoring program for new students at the Uniformed Services University.

MATERIALS AND METHODS

In order to address the demands and challenges facing matriculating medical students, the Rising Physicians Program was created. This student initiated program enabled pre-clerkship medical students to connect with residents at the Walter Reed National Military Medical Center via a secure database with resident profiles. Residents were recruited and voluntarily agreed to serve as mentors. Students were then able to access the database and reach out to mentors based on their specific goals. The program was introduced to students during orientation and student participation was completely voluntary. A survey was designed using best survey practices and sent to the 175 students participating in the program for the 2015 academic (class of 2019) year to determine participation and characteristics of the program.

RESULTS

Sixty-four percent (112/175) of the students from the class of 2019 participated in the post-implementation survey. Fifteen percent of the class (26/175) reported participating in the voluntary mentoring program. The three most commonly used communication methods with mentors in precedence were in-person, e-mail, and text messages. The majority of the students found their interactions in this program were beneficial and did not get in the way of their academic performance. The most common topics of discussion were academics (20%), mentor's past experience (22%), military lifestyle (7%), medical school pathways (23%), and specialty selections (23%). Limitations of the program included a lack of U.S. Air Force mentors and mentors within certain residency specialties.

CONCLUSIONS

The Rising Physician Program provides a near-peer mentoring model for new medical students. Students preferred to communicate with their mentors in person, but the flexibility of communication appears to be important. New students have a variety of academic and professional development concerns that could partially be addressed through mentoring by residents.

A Faculty Development Model for Academic Leadership Education Across A Health Care Organization

Academic leadership in undergraduate and graduate medical education requires a specific set of leadership and managerial skills that are unique to academic leadership positions. While leadership development training programs exist for traditional leadership roles such as department chairs, executives, and deans, there are fewer models of leadership training specifically geared for academic leadership positions such as program and clerkship directors, and designated institutional officials. There are academic programs at the national level, but there is sparse literature on the specific decisions required to create such programs locally. With growing regulatory and accreditation requirements as well as the challenges of balancing the clinical and educational missions, effective leadership is needed across the spectrum of academic medicine. To meet this need for the military health care system in the United States, we used Kern's six-step framework for curriculum development to create a 1-week academic leadership course. This paper describes the process of development, implementation, outcomes, and lessons learned following the initial 3 years of courses. Specific discussions regarding who to train, which faculty to use, content, and other elements of course design are reviewed. The course and process outlined in the paper offer a model for other organizations desiring to establish an academic leadership course.

Factors Influencing Selection of Infectious Diseases Training for Military Internal Medicine Residents

Background

Applications to infectious diseases fellowships have declined nationally; however, the military has not experienced this trend. In the past 6 years, 3 US military programs had 58 applicants for 52 positions. This study examines military resident perceptions to identify potential differences in factors influencing career choice, compared with published data from a nationwide cohort.

Methods

An existing survey tool was adapted to include questions unique to the training and practice of military medicine. Program directors from 11 military internal medicine residencies were asked to distribute survey links to their graduating residents from December 2016 to January 2017. Data were categorized by ID interest.

Result

The response rate was 51% (n = 68). Of respondents, 7% were ID applicants, 40% considered ID but reconsidered, and 53% were uninterested. Of those who considered ID, 73% changed their mind in their second and third postgraduate years and cited salary (22%), lack of procedures (18%), and training length (18%) as primary deterrents to choosing ID. Active learning styles were used more frequently by ID applicants to learn ID concepts than by those who considered or were uninterested in ID (P = .02).

Conclusions

Despite differences in the context of training and practice among military trainees compared with civilian colleagues, residents cited similar factors affecting career choice. Interest in global health was higher in this cohort. Salary continues to be identified as a deterrent to choosing ID. Differences between military and civilian residents' desire to pursue ID fellowship are likely explained by additional unmeasured factors deserving further study.

Military Internal Medicine Resident Decision to Apply to Fellowship and Extend Military Commitment

Introduction

Nationally, the number of internal medicine physicians practicing in primary care has decreased amidst increasing interest in hospitalist medicine. Current priorities in the Military Health System include access to primary care and retention of trained personnel. Recently, we have conducted a study of military internal medicine residents' decision to enter infectious disease. As part of our larger effort, we saw an opportunity to characterize factors impacting decision making of internal medicine residents' desire to apply for subspecialty training and to extend active duty service obligations.

Materials and Methods

Questions were developed after discussion with various military graduate medical education and internal medicine leaders, underwent external review, and were added to a larger question set. The survey link was distributed electronically to all U.S. military affiliated residencies' graduating internal medicine residents in December 2016-January 2017. Data were analyzed by decision to apply to fellowship and decision to extend military obligation using Fisher's exact test or Pearon's chi-square test.

Results

Sixty-eight residents from 10 of 11 military residency programs responded, for a response rate of 51%. The majority (62%) applied to fellowship to start after residency completion. Reasons cited for applying to fellowship included wanting to become a specialist as soon as possible (74%), wishing to avoid being a general internist (57%), and because they are unable to practice as a hospitalist in the military (52%). Fellowship applicants were more likely to plan to extend their military obligation than non-applicants, as did those with longer duration of military commitments. No other factors, including Uniformed Services University attendance or participation in undergraduate military experiences, were found to impact plan to extend active duty service commitment.

Conclusion

The majority of graduating internal medicine residents apply for fellowship and report a desire to avoid being a general internist. Prospective fellows anticipate extending their active duty commitment, as do those with longer commitments.

Recognizing the Importance of Leadership: A Recent Graduate Develops a Corpsman

There is a growing interest in leadership development within the field of medicine both within the military and the larger medical community. Recognition of the importance of leadership training during graduate medical education has grown, but many residents and faculty still argue that residency training should focus on clinical skills and medical knowledge. Most graduates of training programs in the military quickly find themselves in formal leadership positions or they must informally lead in their clinical practice. As these new graduates enter practice, they quickly realize the need to be able to effectively lead. In order to highlight some of the leadership challenges that junior military physicians face, Military Medicine is starting a new column called "Leadership Lessons from the Field." This article is the first in the series and discusses a recent graduate's experience in dealing with an underperforming corpsman. The article reviews the importance of emotional intelligence, feedback, and goal setting.

Anonymous Feedback: What Should a Leader Do?

Leaders are required to evaluate and provide feedback to those they lead. This often involves giving feedback on direct observations, but at times can result from feedback brought to them via other pathways. When a leader is given feedback from a subordinate about another subordinate, they must decide how to best proceed. Often they must collect more data in order to make an informed decision. Followers continuously observe how leaders handle feedback from subordinates, which will directly impact mission success and unit morale. The following case highlights one junior officer's challenge related to anonymous feedback she received.

Taking Charge: Moving from Peer to Supervisor

Leadership transitions occur frequently, and these times can be challenging for the individual and those they lead. Leaders must develop new knowledge and skills required of the position. Leaders also assume a new formal leadership role over prior peers. This can be a difficult task for junior leaders. The following article illustrates an example case faced by a junior Navy Medical Corps Officer and how one might respond.

Leadership Training in Graduate Medical Education: A Systematic Review

BACKGROUND

Leadership is a critical component of physician competence, yet the best approaches for developing leadership skills for physicians in training remain undefined.

OBJECTIVE

We systematically reviewed the literature on existing leadership curricula in graduate medical education (GME) to inform leadership program development.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we searched MEDLINE, ERIC, EMBASE, and MedEdPORTAL through October 2015 using search terms to capture GME leadership curricula. Abstracts were reviewed for relevance, and included studies were retrieved for full-text analysis. Article quality was assessed using the Best Evidence in Medical Education (BEME) index.

RESULTS

A total of 3413 articles met the search criteria, and 52 were included in the analysis. Article quality was low, with 21% (11 of 52) having a BEME score of 4 or 5. Primary care specialties were the most represented (58%, 30 of 52). The majority of programs were open to all residents (81%, 42 of 52). Projects and use of mentors or coaches were components of 46% and 48% of curricula, respectively. Only 40% (21 of 52) were longitudinal throughout training. The most frequent pedagogic methods were lectures, small group activities, and cases. Common topics included teamwork, leadership models, and change management. Evaluation focused on learner satisfaction and self-assessed knowledge. Longitudinal programs were more likely to be successful.

CONCLUSIONS

GME leadership curricula are heterogeneous and limited in effectiveness. Small group teaching, project-based learning, mentoring, and coaching were more frequently used in higher-quality studies.

Sepsis Mimicker in an Human Immunodeficiency Virus-Infected Patient

A 22-year-old human immunodeficiency virus-infected male presented with fever, rash, hypotension, and renal insufficiency 18 days following initiation of therapy with an efavirenz-based antiretroviral regimen. Although rash is a common side effect of efavirenz, severe hypersensitivity reactions are rare. Systemic symptoms can include hepatic toxicity and pneumonitis, and in one instance death. Corticosteroids are the mainstay of treatment.

Phase 1/2a Trial of Plasmodium vivax Malaria Vaccine Candidate VMP001/AS01B in Malaria-Naive Adults: Safety, Immunogenicity, and Efficacy

BACKGROUND

A vaccine to prevent infection and disease caused by Plasmodium vivax is needed both to reduce the morbidity caused by this parasite and as a key component in efforts to eradicate malaria worldwide. Vivax malaria protein 1 (VMP001), a novel chimeric protein that incorporates the amino- and carboxy- terminal regions of the circumsporozoite protein (CSP) and a truncated repeat region that contains repeat sequences from both the VK210 (type 1) and the VK247 (type 2) parasites, was developed as a vaccine candidate for global use.

METHODS

We conducted a first-in-human Phase 1 dose escalation vaccine study with controlled human malaria infection (CHMI) of VMP001 formulated in the GSK Adjuvant System AS01B. A total of 30 volunteers divided into 3 groups (10 per group) were given 3 intramuscular injections of 15 μg, 30 μg, or 60 μg respectively of VMP001, all formulated in 500 μL of AS01B at each immunization. All vaccinated volunteers participated in a P. vivax CHMI 14 days following the third immunization. Six non-vaccinated subjects served as infectivity controls.

RESULTS

The vaccine was shown to be well tolerated and immunogenic. All volunteers generated robust humoral and cellular immune responses to the vaccine antigen. Vaccination did not induce sterile protection; however, a small but significant delay in time to parasitemia was seen in 59% of vaccinated subjects compared to the control group. An association was identified between levels of anti-type 1 repeat antibodies and prepatent period.

SIGNIFICANCE

This trial was the first to assess the efficacy of a P. vivax CSP vaccine candidate by CHMI. The association of type 1 repeat-specific antibody responses with delay in the prepatency period suggests that augmenting the immune responses to this domain may improve strain-specific vaccine efficacy. The availability of a P. vivax CHMI model will accelerate the process of P. vivax vaccine development, allowing better selection of candidate vaccines for advancement to field trials.

Q Fever

Q fever is a significant infectious disease threat to US military personnel deployed in the Middle East. Its environmental stability, aerosol transmission, and animal reservoir make it a considerable risk for deployed troops due to its potential for weaponization and risk of natural infection. It presents as a flu-like illness that responds promptly to antimicrobial therapy. Q fever should be suspected in patients presenting with a compatible febrile illness in an endemic area and especially if the individual has been exposed to livestock. Diagnosis is confirmed with serologic blood tests, but empiric therapy should be initiated when Q fever is considered. If left untreated, patients with acute Q fever can develop severe complications as well as chronic disease manifesting several months after the initial infection.

Results of a Formal Mentorship Program for Internal Medicine Residents: Can We Facilitate Genuine Mentorship?

BACKGROUND

Mentorship programs are perceived as valuable, yet little is known about the effect of program design on mentoring effectiveness.

INTERVENTION

We developed a program focused on mentoring relationship quality and evaluated how subsequent relationships compared to preexisting informal pairings.

METHODS

Faculty members were invited by e-mail to participate in a new mentoring program. Participants were asked to complete a biography, subsequently provided to second- and third-year internal medicine residents. Residents were instructed to contact available mentors, and ultimately designate a formal mentor. All faculty and residents were provided a half-day workshop training, written guidelines, and e-mails. Reminders were e-mailed and announced in conferences approximately monthly. Residents were surveyed at the end of the academic year.

RESULTS

Thirty-seven faculty members completed the biography, and 70% (26 of 37) of residents responded to the survey. Of the resident respondents, 77% (20 of 26) chose a formal mentor. Of the remainder, most had a previous informal mentor. Overall, 96% (25 of 26) of the residents had identified a mentor of some kind compared to 50% (13 of 26) before the intervention (P < .001), and 70% (14 of 20) who chose formal mentors identified them as actual mentors. Similar numbers of residents described their mentors as invested in the mentorship, and there was no statistical difference in the number of times mentors and mentees met.

CONCLUSIONS

Facilitated selection of formal mentors produced relationships similar to preexisting informal ones. This model may increase the prevalence of mentorship without decreasing quality.

Whooping cough in 2014 and beyond: an update and review

Pertussis, or whooping cough, has had a dramatic resurgence in the past several years and is the most common vaccine-preventable disease in the world. The year 2012 marked the most cases in the United States in &gt; 50 years. Large outbreaks have occurred in multiple states, and infant deaths have drawn the attention of not only health-care providers but also the media. Although the disease is theoretically preventable by vaccination, it remains a challenge to control. New vaccination strategies have been implemented across different age groups and populations of patients, but vaccine coverage remains dismally low. Acellular vaccines, although safe, do not afford the same long-lasting immunity as the previously used whole-cell vaccine. Ultimately, improvements in the development of vaccines and in vaccination coverage will be essential to decrease the burden of pertussis on society. This article provides a review of pertussis infection and discusses advances related to the epidemiology, diagnosis, treatment, and prevention of infection, as well as continued areas of uncertainty.

Achieving balance on the inpatient internal medicine wards: a performance improvement project to restructure resident work hours at a tertiary care center

PROBLEM

In an era of increasing duty hours restrictions, a growing body of literature describes how fatigue and handoffs affect patient care and educational experience. Although many studies examine these elements independently, there remains little understanding of how they interact. Previously reported interventions have yielded unexpected results that are likely dependent on local factors.

APPROACH

The authors collected data on admissions, emergency department disposition, and team continuity during an 8-day period before and a 12-day period after changing from a night float system to a resident long-call system with a graded transition to a night team. House staff and attendings were surveyed afterwards.

OUTCOMES

The intervention increased the portion of patients admitted to their primary resident from 47% (43/91) to 82% (75/91) (P < .01) and improved the percentage of emergency room admissions performed in less than 90 minutes from 39% (7/18) to 70% (39/44) (P = .02). The percentage of self-reported duty hours violations decreased from 55% (16/29) to 6.8% (3/44) (P < .01). Survey respondents reported an improved sense of patient involvement, quality of care, and handoffs.

NEXT STEPS

Designing a call system around a brief assessment of admission intensity resulted in better alignment of resident resources with workload and improvements in multiple outcomes. Optimization of inpatient work structure appears to be significantly affected by local factors. Future trials assessing work hour balance will need to take work intensity into account and assess a wide variety of potential consequences.

Invasive fungal infections following combat-related injury

Invasive mold infections are a rare complication of traumatic wounds. We examined the incidence and outcomes of these infections in combat wounds. A retrospective chart review from March 2002 through July 2008 of U.S. soldiers returning from Iraq and Afghanistan with traumatic wounds was performed. A confirmed fungal wound infection was defined as growth of a known pathogenic mold and visualization of fungal elements on histopathology. Six cases were identified for an incidence of 0.4 cases/1,000 admissions. The incidence of invasive mold infections increased over time (p = 0.008) with a peak of 5.2 cases/1,000 admissions in 2007. Isolated molds included Aspergillus (n = 4), Bipolaris (n = 2), and 1 each Mucor and Absidia. All patients were male with a mean age of 22. Blast (n = 5) and gunshot wound (n = 1) were the sources of injury. All patients had fever (mean 39.4 degrees C) and leukocytosis (mean white blood cell count 25 x 10(3)/microL). The average acute physiology and chronic health evaluation II score was 22. All patients received antifungal agents, surgical debridement, and 3 required amputation revision. Average length of stay was 97 days. There were no deaths. Invasive mold infections are a rare complication of combat wounds but are associated with significant morbidity and may be increasing in frequency.

Practice guidelines for the diagnosis and management of patients with Q fever by the Armed Forces Infectious Diseases Society

This issue in the series Current Topics in Military Tropical Medicine focuses on Q Fever. Q fever is a zoonotic infection caused by the bacterium Coxiella burnetii. Over 150 confirmed cases have occurred among U.S. military personnel deployed to Iraq since 2007. Acute Q fever is underdiagnosed because of a myriad of possible clinical presentations but typically presents as a flu-like illness. The most common chronic manifestation is endocarditis. Most providers are not familiar with the diagnosis, treatment, or appropriate follow-up of this disease. In order to facilitate the care of patients infected with C. burnetii, the Armed Forces Infectious Diseases Society convened a panel of experts in the field to develop practical guidelines for those caring for infected patients. The recommendations and rationale are reviewed in this article.

Mortality associated with Acinetobacter baumannii complex bacteremia among patients with war-related trauma

We investigated the mortality associated with Acinetobacter baumannii complex bacteremia among a cohort of patients hospitalized for war-related trauma. Despite a high prevalence of multidrug-resistant strains, the 30-day mortality rate was 2%. For relatively young patients with war-related trauma, A. baumannii complex bacteremia appears to be associated with a low risk of death.

Resident run journal club: a model based on the adult learning theory

BACKGROUND

Multiple formats of journal club exist but data is lacking regarding which model is most effective. Many residents are dissatisfied with their current format, which was the case at our institution.

AIM

This article discusses a resident run model, residents' perceptions following its implementation, and recommendations for running a successful journal club. Practice points Journal club formats vary extensively without a clearly superior method. Defining goals is the first step to a successful journal club. Structured review instruments for articles enhance journal club. The presence of subspecialty staff may augment learning. Resident-run models of journal club can be successfully implemented.

METHODS

A resident run model of journal club was developed based on Adult Learning Theory. A 30-question survey was created to assess residents' attitudes and satisfaction with the new model.

RESULTS

All respondents preferred the new model compared to the old model. Residents reported the new model increased their medical knowledge (88%) and they were able to apply the methods learned in journal club to actual patients (82%).

CONCLUSIONS

A resident run model of journal club may be a viable option for those attempting to start or improve their current club.

Positive rK39 serologic assay results in US servicemen with cutaneous leishmaniasis

The rK39 test is a serologic assay for the rapid diagnosis of visceral leishmaniasis (VL). Serum from a North American cohort of 59 otherwise asymptomatic soldiers with cutaneous leishmaniasis (CL) was tested with the rK39 dipstick and ELISA assays, and 10.2% and 28.8% had positive results, respectively. CL is associated with a reactive rK39 assay result in some patients without clinical evidence of VL.

Impact of depression on HIV outcomes in the HAART era

Highly active antiretroviral therapy (HAART) has significantly decreased the morbidity and mortality of persons infected with HIV. The extent of the benefits, however, is not uniform, and certain factors including ethnicity, gender, baseline HIV viral load and CD4+ T lymphocyte count, adherence and intravenous drug abuse are associated with different immunological, virological and clinical outcomes. Mental health illness (MHI) and specifically depression may be associated with worse outcomes, although studies exploring the impact of MHI on HIV outcomes in both the pre-HAART and post-HAART eras have shown mixed results. The objective of the current paper is to review the available literature on the impact of MHI on HIV outcomes in the HAART era.

Q fever: epidemiology, diagnosis, and treatment

Q fever, a zoonosis caused by Coxiella burnetii, is seen throughout the world. Recent reports suggest that its incidence in the United States is increasing, with more than 30 cases reported in the US military. The disease has many acute and chronic manifestations. Endocarditis is the most common form of chronic disease, and recent studies have led to substantial changes in the approach to its diagnosis and treatment. Military and civilian health care professionals need to consider Q fever when evaluating patients with appropriate geographic exposures and clinical presentations to prevent delays in diagnosis and treatment.

Pseudomonas putida war wound infection in a US Marine: a case report and review of the literature

US service members are returning from the war in Iraq and Afghanistan with wound infections due to uncommon bacteria. Pseudomonas putida, a member of the fluorescent group of pseudomonads, primarily causes infection in immunosuppressed hosts and patients with invasive medical devices. P. putida has been implicated in outbreaks often traced to a contaminated fluid and is a rare cause of clinical infection. However, it should be considered a pathogen when isolated from pure culture. The objective of this article is to present a case report of a P. putida war wound infection, review previous P. putida infections, and provide a concise review of the epidemiology, risk factors, and management of infections due to this organism.

Atypical Q fever in US soldiers

Q fever is an emerging infectious disease among US soldiers serving in Iraq. Three patients have had atypical manifestations, including 2 patients with acute cholecystitis and 1 patient with acute respiratory distress syndrome. Providers must be aware of Q fever's signs and symptoms to avoid delays in treatment.

Race and mental health diagnosis are risk factors for highly active antiretroviral therapy failure in a military cohort despite equal access to care

BACKGROUND

Data suggest that African Americans have lower rates of virologic suppression using highly active antiretroviral therapy (HAART), possibly because of socioeconomic status and access to care. In a US Military clinic, where beneficiaries have ready access to no-cost health care, the impact of several variables (including race) on HIV virologic suppression were examined.

METHODS

Retrospective analysis of antiretroviral-naive patients who began HAART between 1997 and 2003. Demographics, viral loads, CD4 cell counts, and mental health diagnoses were analyzed.

RESULTS

The charts of 129 individuals who initiated their first antiretroviral regimen during the period of observation were evaluated. The overall efficacy of reaching viral suppression was 71% at 12 months and 56% at 24 months. HIV suppression was achieved at 12 months by 63% of African Americans and 92% of whites (P = 0.001). Mental health diagnosis was associated with failure at 24 months (38 vs. 61%; P = 0.034). Being white (odds ratio = 3.5, 95% confidence interval [CI]: 1.2 to 10.3; P = 0.022) and lacking a mental health diagnosis (odds ratio = 8.7, 95% CI: 2.4 to 32.1; P = 0.001) were both associated with increased efficacy at 24 months by multivariate analysis.

CONCLUSIONS

African-American race and the presence of a mental health diagnoses were independently associated with antiretroviral failure. Equal access to care yields high efficacy rates with HAART but does not fully equilibrate racial differences in virologic failure.

Acinetobacter pneumonia: a review

Acinetobacter species are becoming a major cause of nosocomial infections, including hospital-acquired and ventilator-associated pneumonia. Acinetobacter species have become increasingly resistant to antibiotics over the past several years and currently present a significant challenge in treating these infections. Physicians now rely on older agents, such as polymyxins (colistin), for treatment. This paper reviews the epidemiology, treatment, and prevention of this emerging pathogen.

Cutaneous and presumed visceral leishmaniasis in a soldier deployed to Afghanistan

Leishmaniasis has been frequently diagnosed in US military personnel returning from duty in Southwest Asia. The majority of cases have demonstrated cutaneous disease, although a few cases of visceral disease have been documented. We present the case of an immunocompetent, HIV-negative, US Army soldier who suffered both visceral and cutaneous manifestations of leishmaniasis after returning from deployment in Afghanistan. Overlap of cutaneous and visceral involvement is rare and has not been reported in our cohort. Latent Plasmodium vivax infection may have been an exacerbating cofactor. We discuss this case and present a review of the literature.

Ingestion of superwarfarin leading to coagulopathy: a case report and review of the literature

Superwarfarins are found in many pesticides, including D-con, Prufe I and II, Ramik, Talon-G, Ratak, and Contrac. Ingestion of can lead to significant morbidity and even mortality. Physicians need to consider this diagnosis in any patient presenting with coagulopathy of unclear etiology. We present a patient with superwarfarin-induced coagulopathy and review previous cases in adults in the literature. The patient is a 60-year-old man who presented to our medical center with painless hematuria. Laboratory studies revealed an elevated prothrombin time (PT) (42.5 seconds), partial thromboplastin time (PTT) (64.6 seconds), and international normalized ratio (INR) of 7. Liver-associated enzymes were normal, and complete blood cell count (CBC) showed no evidence of disseminated intravascular coagulation. Subsequent work-up included the absence of an inhibitor by mixing study and deficiencies of vitamin K-dependent coagulation factors. The patient's warfarin level was negative. A brodifacoum level was positive, confirming superwarfarin-induced coagulopathy. The patient is currently doing well with normal coagulation studies after receiving high doses of vitamin K for several weeks. The cause of his exposure to superwarfarin remains uncertain. Physicians need to be cognizant of this unusual cause of coagulopathy in adults. The appropriate diagnostic work-up and unique features of therapy are discussed.

Hypertensive retinopathy associated with use of the ephedra-free weight-loss herbal supplement Hydroxycut

The use of performance-enhancing and weight-loss supplements is prevalent in the United States, and over the past decade, there has been growing concern with regard to the safety and efficacy of these products. It is well documented that ephedra-based products are associated with adverse reactions, including serious cardiovascular and neurologic injuries. With new restrictions placed on such products, companies are now marketing caffeine-based ephedra-free herbal supplements. Less is known about the potential side effects of these products. We present the case of a 42-year-old, previously healthy man who developed malignant hypertension and hypertensive retinopathy while taking Hydroxycut, a caffeine-based ephedra-free supplement. To our knowledge, this is the first documented case of hypertensive retinopathy associated with the use of Hydroxycut. Given the lack of investigative studies in regard to their safety and efficacy, judicious care should be taken with the use of all herbal supplements, including those designated as ephedra-free.

Transient blindness due to posterior reversible encephalopathy syndrome following ephedra overdose

Posterior reversible encephalopathy syndrome (PRES), also known as reversible posterior leukoencephalopathy syndrome (RPLS), is most often associated with hypertensive emergencies and is characterized by seizures, mental status changes and visual disturbances. We report a case of a previously healthy young man who developed multiorgan failure and transient cortical blindness following ingestion of a performance-enhancing ephedra-based supplement. Neuroimaging findings confirmed the clinical suspicion of PRES. Radiographic abnormalities and neurologic dysfunction subsequently resolved with correction of his systolic blood pressure. This case emphasizes the need for prompt treatment and consideration of toxic ingestions in patients presenting with hypertension-related end-organ dysfunction.

Varicella zoster virus meningitis complicating sodium stibogluconate treatment for cutaneous leishmaniasis

Sodium stibogluconate (Pentostam(R); GlaxoSmithKline) is a pentavalent antimonial compound used in the treatment of leishmaniasis, which has an association with reactivation of varicella zoster virus (VZV). We report the first known case of an immunocompetent adult who developed VZV aseptic meningitis and dermatomal herpes zoster during treatment with sodium stibogluconate.

Incidence of bacteremia after routine tooth brushing

BACKGROUND

The American Heart Association first developed recommendations on antibiotic prophylaxis against infective endocarditis during dental procedures more than 50 years ago. These recommendations were partly based on the fact that bacteremia occurs with dental procedures. Previous studies in the 1970s and earlier demonstrated that patients become bacteremic after tooth brushing. Improved culture techniques suggest that these rates could be higher now. The objective of this study was to determine the current incidence of bacteremia after routine tooth brushing.

METHODS

Thirty military beneficiaries were enrolled in a prospective, institutional review board-approved study after providing informed consent. The incidence of bacteremia after routine tooth brushing for 1 minute using a standardized soft-bristle toothbrush was prospectively measured in 30 healthy adults at three different time points (at baseline and 30 seconds and 20 minutes after brushing). Periodontal Screening and Recording (PSR) scores were recorded for each patient to assess periodontal disease.

RESULTS

Three of 180 blood cultures were positive for Propionibacterium acnes (a known contaminant). The remaining blood cultures were all negative. The average PSR score was 9.8 (standard deviation 3.17) for 17 of 30 subjects.

CONCLUSIONS

The rate of true bacteremia in this study was zero, which is much lower than previous studies. Bacteremia after tooth brushing in a healthy population is a rare occurrence. Data from previous studies may no longer apply to the current population. Results similar to the ones found in this study during other dental procedures could be an impetus to reevaluate infective endocarditis prophylaxis guidelines.