Purpose: The purpose of this study is to define the prevalence of vitamin B 12 deficiency in a type 2 diabetic population within a primary care practice. Metformin use and advanced age are associated with vitamin B 12 deficiency and often present in type 2 diabetic patients, yet the prevalence of vitamin B 12 deficiency in the diabetic population is unknown.Methods: We conducted a cross-sectional study of 203 outpatient type 2 diabetic patients at a large military primary care clinic. Patients completed a survey and had B 12 levels measured. Patients with borderline B 12 levels also had methylmalonic acid and homocysteine levels drawn. Serum B 12 levels <100 pg/mL or serum B 12 levels of 100 to 350 pg/mL with elevation of serum methylmalonic acid >243 nmol/L or homocysteine >11.9 nmol/L defined B 12 deficiency. Descriptive statistics described frequency and means.2 and student's t tests were used to analyze associations between categorical and continuous variables, respectively. Multivariate logistical regression identified covariates independently associated with B 12 deficiency.Results: Twenty-two percent (n ‫؍‬ 44) of diabetic patients had metabolically confirmed B 12 deficiency. Patients on metformin had lower serum B 12 levels (425.99 pg/mL vs 527.49 pg/mL; P ‫؍‬ .012) and were at increased risk for B 12 deficiency (P ‫؍‬ .04), as defined by a serum B 12 level <350 pg/mL. Prevalence of B 12 deficiency was significantly lower for patients using a multivitamin (odds ratio, 0.31; 95% CI, 0.15-0.63).Conclusions :

Background: Fish oil (⍀-3 fatty acids) has been studied for more than 30 years. However, recent concerns of mercury and environmental toxins have clouded fish oil's potential clinical benefits. This article aims to review practical, evidence-based applications of fish oil for the primary care physician.Methods: PubMed search using key words 'fish oil,' 'docosahexaenoic,' and 'eicosapentaenoic' in title/abstract. Limited to human clinical trials. Articles were further scanned for relevant sources.Results: For secondary prevention of cardiovascular disease, 1 g of fish oil has shown to reduce overall and cardiovascular mortality, myocardial infarction, and sudden cardiac death. Higher doses may be used for its potent triglyceride-lowering effects and for patients with rheumatoid arthritis to reduce nonsteroidal anti-inflammatory use. ⍀-3 fatty acid supplementation of infant formula has shown benefit in infant neural growth and development. With the potential health benefits of fish, women of childbearing age should be encouraged to eat 1 to 2 low-mercury fish meals per week.Conclusions More than 30 years ago, Danish researchers hypothesized that lower rates of heart disease of Greenland Eskimos were associated with higher consumption of whale, seal, and fish.1,2 Since then, from research unraveling the mechanism of ⍀-3 fatty acids, to clinical trials in cardiovascular disease, treatments of hyperlipidemia, rheumatoid arthritis, and the prevention of preterm labor, there have been more than 7000 reports-including nearly 900 human clinical trials on the study of fish oil and ⍀-3 fatty acids. 3,4 However, recent concerns regarding mercury and other environmental toxins have clouded the waters of fish oil research and its potential health benefits. This article will discuss the evidence behind fish oil-emphasizing current, practical information for conditions family physicians can effectively impact today.

BackgroundTeaching residents how to teach is a critical part of residents’ training in graduate medical education (GME). The purpose of this study was to assess the change in resident-as-teacher (RaT) instruction in GME over the past 15 years in the US.MethodsWe used a quantitative and qualitative survey of all program directors (PDs) across specialties. We compared our findings with a previous work from 2000–2001 that studied the same matter. Finally, we qualitatively analyzed PDs’ responses regarding the reasons for implementing and not implementing RaT instruction.ResultsTwo hundred and twenty-one PDs completed the survey, which yields a response rate of 12.6%. Over 80% of PDs implement RaT, an increase of 26.34% compared to 2000–2001. RaT instruction uses multiple methods with didactic lectures reported as the most common, followed by role playing in simulated environments, then observing and giving feedback. Residents giving feedback, clinical supervision, and bedside teaching were the top three targeted skills. Through our qualitative analysis we identified five main reasons for implementing RaT: teaching is part of the residents’ role; learners desire formal RaT training; regulatory bodies require RaT training; RaT improves residents’ education; and RaT prepares residents for their current and future roles.ConclusionThe use of RaT instruction has increased significantly in GME. More and more PDs are realizing its importance in the residents’ formative training experience. Future studies should examine the effectiveness of each method for RaT instruction.

Exertional rhabdomyolysis (ER) is an uncommon condition with a paucity of evidence-based guidance for diagnosis, management, and return to duty or play. Recently, a clinical practice guideline for diagnosis and management of ER in warfighters was updated by a team of military and civilian physicians and researchers using current scientific literature and decades of experience within the military population. The revision concentrated on challenging and controversial clinical questions with applicability to providers in the military and those in the greater sports medicine community. Specific topics addressed: 1) diagnostic criteria for ER; 2) clinical decision making for outpatient versus inpatient treatment; 3) optimal strategies for inpatient management; 4) discharge criteria; 5) identification and assessment of warfighters/athletes at risk for recurrent ER; 6) an appropriate rehabilitative plan; and finally, 7) key clinical questions warranting future research.

Higher peak CK levels predicted longer length of stay. Higher serum Cr significantly correlated with lower CK levels. There did not appear to be any threshold CK for admission or discharge, however, all but one patient were discharged after CK downtrended.

Purpose: Consumption of fish oil has been shown to reduce mortality in patients with cardiovascular disease (CVD). This study aims to determine the frequency and associations of dietary fish prescribing by family physicians.Methods: A 22-item survey mailed to randomly selected Washington State family physicians. Results: Nearly all agreed that nutrition is important in CVD prevention (99%) and felt that they have an essential role in giving dietary advice (92%). The majority (57%) knew of fish oil's effectiveness in secondary prevention of CVD. However, only 17% of respondents were identified as high fish prescribers. Knowledge of fish oil's benefit in sudden death reduction was associated with higher fish prescribers in bivariate (P ‫؍‬ .005) and multivariate analysis (OR ‫؍‬ 2.77; 95th CI: 1.32 to 5.82). High fish prescribers were more likely to report having sufficient time to discuss dietary therapies in bivariate (P ‫؍‬ .018) and multivariate analysis (OR ‫؍‬ 1.43; 95th CI: 1.03 to 1.98).Conclusions

Prevalence of CAM use is higher within a military family medicine clinic in Hawaii than the prevalence among mainland civilian or other military populations.

Exertional heat illness and exercise-associated hyponatremia continue to be a problem in military and recreational events. Symptoms of hyponatremia can be mistaken for heat exhaustion or heat stroke. We describe three cases of symptomatic hyponatremia initially contributed to heat illnesses. The first soldier was a 31-yr-old female who "took a knee" at mile 6 of a 12-mile foot march. She had a core temperature of 100.9°F, a serum sodium level of 129 mmol/L, and drank approximately 4.5 quarts of water in 2 h. The second case was a 27-yr-old female soldier who collapsed at mile 11 of a 12-mile march. Her core temperature was 102.9°F and sodium level was 131 mmol/L. She drank 5 quarts in 2.5 h. The third soldier was a 27-yr-old male who developed nausea and vomiting while conducting an outdoor training event. His core temperature was 98.7°F and sodium level was 125 mmol/L. He drank 6 quarts in 2 h to combat symptoms of heat. All the three cases developed symptomatic hyponatremia by overconsumption of fluids during events lasting less than 3 h. Obtaining point-of-care serum sodium may improve recognition of hyponatremia and guide management for the patient with suspected heat illness and hyponatremia. Depending on severity of symptoms, exercise-associated hyponatremia can be managed by fluid restriction, oral hypertonic broth, or with intravenous 3% saline. Utilizing an ad libitum approach or limiting fluid availability during field or recreational events of up to 3 h may prevent symptomatic hyponatremia while limiting significant dehydration.