RESUMEN
INTRODUCTION: U.S. Army internists serve in a variety of provider roles during deployment, many of which vary from the traditional responsibilities of a general internist or internal medicine subspecialist. There is significant interest in defining specific clinical and procedural skills in which Army internists may require refresher training after deployment, but information to quantify and clarify these needs is lacking. MATERIALS AND METHODS: An online, anonymous survey was created to assess Army internists' experience and comfort level with specialty-specific problems and procedures before and after deployment. This survey was distributed via the Army Central Simulation Committee to all U.S. Army internists eligible for deployment. The survey was available online from January 11, 2012, to March 9, 2012. RESULTS: Ninety-seven of all 115 (84%) U.S. Army internists eligible for deployment responded. The reported comfort level with core clinical problems in general internal medicine before and after deployment did not change, with the exception of decreased comfort with the performance of advanced cardiac life support (87% versus 76% comfortable, p = 0.035), evaluation and management of anemia (92% versus 83% comfortable, p = 0.039), and comfort with preoperative risk stratification and mitigation (81% versus 65% comfortable, p = 0.017). Providers' reported comfort level performing core internal medicine procedures decreased, including significant decreases with lumbar puncture (p < 0.001), arterial line placement (p = 0.02), ultrasound-guided central line placement (p = 0.01), ultrasound-guided thoracentesis (p = 0.004), and arthrocentesis (p = 0.01). Despite a reported deceased comfort with certain core clinical problems and procedural skills, only 10 of 68 (13%) respondents reported being offered refresher skills training following deployment. CONCLUSION: Although Army internists' comfort with core general internal medicine clinical problems remains largely unaffected by deployment, confidence in core internal medicine procedures suffers because of limited opportunities to practice these skills in the deployed setting. Skills training and assessment in procedures required for individual provider practice should be a primary focus of reintegration after deployment.
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Competencia Clínica/normas , Medicina Interna/educación , Personal Militar/estadística & datos numéricos , Guerra , Adulto , Actitud del Personal de Salud , Femenino , Humanos , Medicina Interna/métodos , Medicina Interna/normas , Masculino , Evaluación de Necesidades , Médicos/psicología , Médicos/normas , Autoeficacia , Autoinforme , Encuestas y Cuestionarios , ViajeRESUMEN
BACKGROUND: Given the pathogenesis of obstructive sleep apnea (OSA), anesthesiologists may be in a unique position to rapidly identify patients who are at risk for undiagnosed OSA in the perioperative period. Identification is the first step in prompt diagnosis and potential prevention of OSA related comorbidities. Patients who exhibit unanticipated difficult mask ventilation (DMV) during induction of general anesthesia may be at risk of having undiagnosed OSA. OBJECTIVE: To determine the association of OSA in patients with difficult mask ventilation under general anesthesia. METHODS: Ten patients were identified over a 2-year period at the time of anesthetic induction as being difficult to mask ventilate and were then enrolled in this prospective pilot study. After enrollment and informed consent, the patients were referred to the sleep study center for full overnight polysomnography to evaluate for the presence and severity of OSA. RESULTS: Of our cohort, 9/10 patients exhibited polysomnographic evidence of OSA, while the last subject tested positive for sleep disordered breathing. Eighty percent (8/10) of subjects espoused snoring, but only 10% (1/10) reported witnessed apneas. Average DMV was 2.5, and higher grades of DMV were associated with more severe OSA. CONCLUSION: In this study, difficult mask ventilation was predictive of undiagnosed OSA. Anesthesiologists may be in a unique position to identify patients at risk for OSA and prevention of related comorbidities.
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Anestesia General , Máscaras Laríngeas/estadística & datos numéricos , Apnea Obstructiva del Sueño/diagnóstico , Adulto , Anciano , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Polisomnografía/métodos , Polisomnografía/estadística & datos numéricos , Valor Predictivo de las Pruebas , Prevalencia , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Síndromes de la Apnea del Sueño/diagnóstico , Síndromes de la Apnea del Sueño/epidemiología , Apnea Obstructiva del Sueño/epidemiologíaRESUMEN
BACKGROUND: Vocal cord dysfunction (VCD) is difficult to diagnose. Laryngoscopy while the patient is symptomatic is the accepted standard method to establish a diagnosis of VCD, but patient characteristics and spirometry values are thought to be useful for predicting VCD. We sought to identify clinical and spirometric variables that suggest VCD. METHODS: We performed 2 parallel studies. First, 3 staff pulmonologists (who were blinded to the laryngoscopy results), scored 3 flow-volume loops from each PFT session on the likelihood that the inspiratory curve indicated VCD. We also performed a cross-sectional study of clinical characteristics and spirometric data from all patients who underwent laryngoscopy for any indication, including suspected VCD, over a 3-year period. We compared the laryngoscopy findings to the clinical characteristics, spirometry results, and the pulmonologists' assessments of the flow-volume loops. We used multivariate logistic regression to identify independent predictors of VCD. RESULTS: The pulmonologists agreed about which flow-volume loops predicted VCD (quadratic kappa range 0.55-0.76), but those ratings were not predictive of laryngoscopic diagnosis of VCD. During the study period, 226 patients underwent laryngoscopy. One hundred (44%) were diagnosed with VCD. Independent predictors of VCD included female sex (odds ratio 2.72, 95% confidence interval 1.55-4.75) and obesity (body mass index > 30 kg/m(2)) (odds ratio 2.06, 95% confidence interval 1.12-3.80). With spirometric data from the effort that had the best forced-vital-capacity, multivariate analysis found the ratio of the forced inspiratory flow at 25% of the inspired volume to forced inspiratory flow at 75% of the inspired volume (FIF(25%/75%)) predictive of VCD (odds ratio 1.97, 95% confidence interval 1.12-3.44). The diagnostic performance of these characteristics was poor; the area under the receiver-operating-characteristic curve was 0.68. With the spirometric data from the effort that had the subjectively determined best inspiratory curve, and after controlling for the reproducibility of the inspiratory curves, multivariate analysis found none of the spirometric variables predictive of VCD. CONCLUSIONS: VCD remains difficult to predict with spirometry or flow-volume loops. If VCD is suspected, normal flow-volume loop patterns should not influence the decision to perform laryngoscopy.
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Laringoscopía , Parálisis de los Pliegues Vocales/fisiopatología , Adulto , Estudios Transversales , Femenino , Volumen Espiratorio Forzado , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Espirometría , Capacidad Vital , Parálisis de los Pliegues Vocales/diagnósticoRESUMEN
A case of vocal cord dysfunction (VCD) is presented, followed by a discussion of the clinical characteristics, pathogenesis, diagnosis, and management of this disorder. Special emphasis is given to clinical pearls and pitfalls for the practicing allergist. VCD is a common condition that mimics asthma. Dyspnea, cough, and chest tightness are frequent manifestations of the disease. A high degree of clinical suspicion is required to recognize VCD and diagnosis is made most confidently by laryngoscopy. The mainstay of treatment for VCD is reassurance, speech therapy, and treatment of associated comorbidities including gastroesophageal reflux disease, postnasal drip syndrome, and psychiatric conditions.
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Enfermedades de la Laringe/diagnóstico , Enfermedades de la Laringe/terapia , Pliegues Vocales/fisiopatología , Adulto , Asma/diagnóstico , Diagnóstico Diferencial , Femenino , Humanos , Enfermedades de la Laringe/fisiopatología , LaringoscopíaRESUMEN
A case of allergic bronchopulmonary aspergillosis (ABPA) is presented, followed by a discussion of the clinical characteristics, pathogenesis, diagnosis, and management of this disease. Special emphasis is given to clinical pearls and pitfalls for the practicing allergist. ABPA is a hypersensitivity response to Aspergillus antigens in the lung and is distinct from other forms of Aspergillus pulmonary disease. Episodic bronchospasm, expectoration of mucous plugs, and fleeting pulmonary infiltrates are common manifestations of the disease. Several diagnostic schemes for ABPA have been described with varying criteria, which uniformly includes asthma and positive immediate skin-prick test to Aspergillus fumigatus. The mainstay of treatment for ABPA is corticosteroids, which are normally effective.