Brian V. Reamy

Post-Epidural Headache: How Late Can It Occur?

Background: Complications of labor epidural anesthesia include a post-dural puncture headache (PDPH). A 2003 meta-analysis described the onset of PDPH as occurring from 1 to 7 days after the procedure. Presented here is the first published case of a PDPH occurring 12 days postpartum. Methods: Twelve days after an uncomplicated labor epidural a patient was awakened by a “crushing” postural headache. The initial diagnosis was “possible subarachnoid hemorrhage.” Lumbar puncture and computed tomography angiogram were normal. Despite medications a severe postural headache persisted and she was referred for an epidural blood patch. Consultants felt the headache onset after 7 days made PDPH impossible. Ultimately a delayed EBP was performed with immediate resolution of her headache. Discussion: Meta-analyses describe that parturients have a 1.5% risk of accidental dural puncture during epidural placement. Onset of the headache occurs as early as 1 or as late as 7 days after the procedure. Epidural blood patch is the most effective treatment for PDPH and a rapid response is diagnostic. Conclusion: Described is the first reported case of a PDPH occurring well outside the normal range of onset 1 to 7 days after epidural anesthesia. The delayed diagnosis and treatment of PDPH in this patient illustrates the limitations of over-rigorous application of pooled analyses to the care of individual patients.

Henoch-Schönlein purpura.

Henoch-Schönlein purpura is an acute, systemic, immune complex-mediated, leukocytoclastic vasculitis. It is characterized by a triad of palpable purpura (without thrombocytopenia), abdominal pain, and arthritis. Most patients have an antecedent upper respiratory illness. More than 90 percent of Henoch-Schönlein purpura cases occur in children younger than 10 years; however, adults with this condition are more likely to experience complications than children. All patients with Henoch-Schönlein purpura develop a purpuric rash, 75 percent develop arthritis, 60 to 65 percent develop abdominal pain, and 40 to 50 percent develop renal disease. Because Henoch-Schönlein purpura spontaneously resolves in 94 percent of children and 89 percent of adults, supportive treatment is the primary intervention. Oral prednisone at 1 to 2 mg per kg daily for two weeks has been used to treat abdominal and joint symptoms. A meta-analysis found that corticosteroid use in children reduced the mean time to resolution of abdominal pain and decreased the odds of developing persistent renal disease. Early aggressive therapy with high-dose steroids plus immunosuppressants is recommended for patients with severe renal involvement. Long-term prognosis depends on the severity of renal involvement. End-stage renal disease occurs in 1 to 5 percent of patients.

Writing, self-reflection, and medical school performance: the Human Context of Health Care.

INTRODUCTION Finding ways to improve communication and self-reflection skills is an important element of medical education and continuing professional development. This study examines the relationship between self-reflection and educational outcomes. METHODS We correlate performance in a preclinical course that focuses on self-reflection as it relates to contextual elements of patient care (Human Context of Health Care), with educational measures such as overall grade point average, clinical clerkship scores, and Medical College Admission Test (MCAT) scores. RESULTS Student performance in Human Context of Health Care correlated with MCAT-Verbal scores, MCAT-writing sample scores, clerkship grades, and overall medical school grade point average (R = 0.3; p < 0.001). CONCLUSION Writing and self-reflection skills are often neglected in undergraduate medical curricula. Our findings suggest that these skills are important and correlate with recognized long-term educational outcomes.

Lipid disorders in athletes.

The treatment of lipid disorders in athletes presents several unique issues. The effects of exercise on lipid subfractions are explained and the evidence supporting the treatment of dyslipidemia is reviewed. Screening for dyslipidemia with a discussion of novel risk factor assessment is examined. The National Cholesterol Education Program Adult Treatment Panel III treatment guidelines are presented as a template for the management of dyslipidemia in athletes. Special cautions in the use of statins in athletes, as well as complementary and alternative medical treatments are discussed. Treatment regimens must be tailored to both the risk status and sport of each individual athlete.

Family Physicians' Knowledge of Commonly Overused Treatments and Tests

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.

A Novel Approach Using an Electronic Medical Record to Identify Children and Adolescents at Risk for Dyslipidemia: A Study from the Primary Care Education and Research Learning (PEARL) Network

Purpose: We conducted a retrospective analysis to identify children and adolescents in the Primary Care Education and Research Learning practice-based research network (PBRN) who were at risk for dyslipidemia. Methods: Using coding data from an electronic medical record to identify all adults with an underlying diagnosis of hyperlipidemia enrolled to this PBRN, children at risk for dyslipidemia were identified. Results: Enrolled to this network were 189,282 patients, including 55,252 children aged 2 to 18 years. The prevalence of physician-coded hyperlipidemia in the adult population was 1.5%. Two percent of the children enrolled to this PBRN were at risk for dyslipidemia. Conclusion: Using technology within electronic medical records allowed for the identification of children at risk for dyslipidemia and to create clinical reminders that will allow us to improve the efficiency of screening efforts.

Who will be the faculty of the future? Results of a 5-year study growing educators using an immersive third postgraduate year (PGY-3) faculty development mini-fellowship

Background: Residency education requires large numbers of skilled teaching faculty. Potential faculty can often be identified during residency training. Aims: Employ a 4-week immersive faculty development mini-fellowship to enhance the teaching skills of selected PGY-3 residents and study outcomes over 5 years. Methods: PGY-3 residents were competitively selected and completed the 4-week curriculum to increase skills in precepting, small group teaching, large group teaching, learner feedback/assessment, academic career development, and research. Results: Fifteen residents completed the mini-fellowship over the 5-year study period. The curriculum was rated highly by the residents with mean ratings of curriculum components ranging from 4.5 to 4.9 on a 5-point scale. Eight residents (53%) were selected for faculty positions compared to a usual selection rate of 11%. Compared to new faculty without mini-fellowship completion, program directors rated the residents completing the mini-fellowship as better prepared to perform learner feedback (4.1 vs. 3.0, p ≤ 0.01) and to understand the conduct of research (3.6 vs. 2.5 p ≤ 0.01). Conclusions: This study demonstrates short-term success at growing faculty with enhanced teaching skills during residency. While long-term retention in academic medicine cannot be predicted, this program represents one method to mitigate shortages of qualified junior residency faculty.

Prevention of Cardiovascular Disease

Cardiovascular disease remains the leading cause of death in the United States and worldwide. Prevention of cardiovascular disease is an achievable goal. A rigorous 2010 analysis by the World Health Organization suggests that reducing risk factors in young adults and maintaining an optimum risk profile through age 50 could prevent 90% of atherosclerotic cardiovascular disease events. Misinformation and poor implementation of proven preventive strategies, misplaced fears of medications, or incorrect understanding of ideal dietary and lifestyle choices all contribute to poor risk profiles. Every patient deserves an individualized prescription for cardiovascular disease prevention incorporating strategies to control modifiable cardiovascular risk factors.

The Uniformed Services University of the Health Sciences: Developing Career-Committed Military Medical Officers

Effective Date: The first day of the first pay period beginning on or after January 1, 2007. Supercedes Schedules Issued: August 24,2006 Chairman/Administrative Non PHD Maximum

The Military Health System: A Community of Solutions for Medical Education, Health Care Delivery, and Public Health

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