J Am Osteopath Assoc
· 2020 Jan · PMID 31930395
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A 20-year-old male swimmer presented to the emergency department with right arm pain and swelling several days after a weight training session following swim team practice. The initial diagnosis was muscle strain, and th...A 20-year-old male swimmer presented to the emergency department with right arm pain and swelling several days after a weight training session following swim team practice. The initial diagnosis was muscle strain, and the patient was discharged. The next day, he was evaluated by his swim team physician, who ordered right upper extremity duplex ultrasonographic imaging, which revealed no flow and thrombosis in the subclavian and axillary veins, and Paget-Schroetter syndrome was diagnosed. He subsequently had a mechanical thrombectomy and catheter-directed thrombolysis was initiated with placement of a lytic catheter for continuous infusion of tissue type plasminogen activator.
J Am Osteopath Assoc
· 2020 Jan · PMID 31904778
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CONTEXT: Burnout is a psychological syndrome that results from prolonged exposure to stressful work activities and includes 3 dimensions: emotional exhaustion (EE), depersonalization (DP), and low sense of personal accom...CONTEXT: Burnout is a psychological syndrome that results from prolonged exposure to stressful work activities and includes 3 dimensions: emotional exhaustion (EE), depersonalization (DP), and low sense of personal accomplishment (PA). Burnout is a widespread problem in numerous professions but is particularly high among medical students, residents, and early-career physicians compared with college graduates of similar age. However, minimal research has addressed burnout in osteopathic medical students. OBJECTIVE: To assess levels of burnout in osteopathic medical students and to examine the relationship among burnout, perceived stress, sleep quality, and smartphone use. METHODS: This study used a cross-sectional study design and an anonymous, electronic questionnaire service to administer the Maslach Burnout Inventory, the Perceived Stress Scale-4, the Pittsburgh Sleep Quality index, and the Smartphone Addiction Scale Short Version. RESULTS: A total of 385 participants (mean [SD] age, 25 [2.4] years; 208 [54.0%] women; 286 [74.3%] white; 138 [35.8%] second-year osteopathic medical students [OMSs]) completed the survey. Of the 385 participants, 9 (2.3%) reported high EE, 67 (17.4) reported high DP, and 310 (80.5) reported a high level of low PA. When comparing dimensions of burnout by gender, only levels of PA differed by gender, with men reporting higher levels of burnout compared with women (χ12=5.2, P=.022). Further, levels of DP differed by year in medical school (χ 2=17.3, P=.008), with post-hoc comparisons showing differences between OMS I and OMS III (F=4.530, df=3, P=.004). Linear regression models showed that higher perceived stress (standardized β=0.5, P<.001), poorer sleep quality (standardized β=0.2, P=.001), and higher smartphone addiction scores (standardized β=0.1, P<.001) were associated with higher EE. Similarly, higher perceived stress (standardized β=0.2, P<.001), poorer sleep quality (standardized β=0.2, P=.001), and higher smartphone addiction scores (standardized β=0.2, P=.001) were associated with higher DP. Only higher perceived stress was associated with higher levels of low PA (standardized β=-0.4, P<.001). CONCLUSIONS: These findings suggest independent associations with EE, DP, perceived stress, sleep quality, and smartphone use. Additional research with a larger, more diverse sample is needed to confirm these findings. If confirmed, wellness interventions can be designed to target 2 modifiable factors: sleep quality and smartphone use.
J Am Osteopath Assoc
· 2020 Jan · PMID 31904776
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PURPOSE: To observe the changes of the retinal nerve fiber layer (RNFL) thickness and the optic disc vessel density (VD) in preclinical diabetic retinopathy (DR) and the relationship between RNFL changes and VD, as well...PURPOSE: To observe the changes of the retinal nerve fiber layer (RNFL) thickness and the optic disc vessel density (VD) in preclinical diabetic retinopathy (DR) and the relationship between RNFL changes and VD, as well as to investigate the influencing factors on peripapillary vessel density. METHODS: This was a cross-sectional study. Thirty-four eyes of 34 type 2 diabetes mellitus (T2DM) patients diagnosed with preclinical diabetic retinopathy (DR) were included in our study, with twenty-three eyes of 23 healthy subjects set up as normal controls. History of diabetes, hypertension, and dyslipidemia was recorded in detail. All participants underwent color fundus photography (CFP), RNFL around the optic disc, and OCT angiography (OCTA) over the optic disc. The 4.5 mm × 4.5 mm Angio Disc scan mode was performed with all participants by using the OCTA instrument. The relationship between changes of RNFL in the four quadrants (superior, inferior, temporal, and nasal) and VD changes was analyzed. RESULTS: Vessel density was significantly lower in the superior ( = −2.27) and temporal ( = −2.02) peripapillary sectors of diabetic eyes compared to normal eyes ( < 0.05). The retinal nerve fiber layer (RNFL) was significantly thinner in the temporal quadrant ( < 0.001) of diabetic eyes compared to normal eyes. Pearson correlation coefficient analysis showed a significant positive correlation between vessel density and RNFL thickness in the peripapillary region in the temporal ( = 0.468, < 0.01) and superior ( = 0.612, < 0.01) sectors. Multiple linear regression analysis showed that glycated hemoglobin (HbA1c) ( = −1.50, < 0.01) and the duration of diabetes ( = −0.33, =0.03) were associated with peripapillary vessel density. CONCLUSIONS: Preclinical DR presented optic disc microcirculation changes. Temporal RNFL thinning is an early sign of retinal neurodegeneration and is associated with temporal peripapillary vessel density reduction. The duration of diabetes and HbA1c are risk factors for peripapillary vessel density reduction in patients with preclinical DR.
Gimpel JR, Belanger SI, Knebl JA
… +7 more, LaBaere RJ, Shaffer DC, Shannon SC, Shears T, Steingard SA, Turner MD, Williams DG
J Am Osteopath Assoc
· 2020 Jan · PMID 31904773
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BACKGROUND: Osteopathic distinctiveness is a result of professional education, identity formation, training, credentialing, and qualifications. With the advancement of a single graduate medical education (GME) accreditat...BACKGROUND: Osteopathic distinctiveness is a result of professional education, identity formation, training, credentialing, and qualifications. With the advancement of a single graduate medical education (GME) accreditation system and the continued growth of the osteopathic medical profession, osteopathic distinctiveness and professional identity are seen as lacking clarity and pose a challenge. SUMMIT: To achieve consensus on a succinct definition of osteopathic distinctiveness and to identify steps to more clearly define and advance that distinctiveness, particularly in professional self-regulation, a representative group of osteopathic medical students, residents, physicians, and members of the licensing, GME, and undergraduate medical education (UME) communities convened the 2019 United States Osteopathic Medical Regulatory Summit in February 2019. Key features of osteopathic distinctiveness were discussed. Growth in the profession; changes in health care delivery, technology, and demographics within the profession and patient communities; and associated challenges and opportunities for osteopathic medical practice and patients were considered. CONSENSUS: Osteopathic medicine is a distinctive practice that brings unique, added value to patients, the public, and the health care community at large. A universal definition and common understanding of that distinctiveness is lacking. Efforts to unify messaging that defines osteopathic distinctiveness, to align the distinctive elements of osteopathic medical education and professional self-regulation across a continuum, and to advance research on care and educational program outcomes are critical to the future of the osteopathic medical profession. RECOMMENDATIONS: (1) Convene a task force of groups represented at the Summit to develop a succinct and consistent message defining osteopathic distinctiveness. (2) Demonstrate uniqueness of the profession through research demonstrating efficacy of care and patient outcomes, adding to the public good. (3) Harmonize GME and UME by beginning to align entrustable professional activities with UME milestones. (4) Convene representatives from osteopathic specialty colleges and certification boards to define curricular elements across GME, certification, and osteopathic continuous certification. (5) Build on the Project in Osteopathic Medical Education and Empathy study.
J Am Osteopath Assoc
· 2020 Jan · PMID 31904772
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Of the 13 subtypes of Ehlers-Danlos Syndromes (EDSs) identified in the 2017 international classification of EDSs, 12 have a recognized, associated genetic mutation. However, hypermobile EDS (hEDS) currently has no identi...Of the 13 subtypes of Ehlers-Danlos Syndromes (EDSs) identified in the 2017 international classification of EDSs, 12 have a recognized, associated genetic mutation. However, hypermobile EDS (hEDS) currently has no identifiable associated gene. Therefore, patients with hEDS are identified through a set of clinical diagnosis guidelines and criteria, which are meant to differentiate hEDS from other hypermobile joint conditions and other EDSs subtypes. In this article, the authors provide an overview of hEDS symptoms and comborbidities, current treatment options, and the clinical criteria currently guiding the standard of care.
J Am Osteopath Assoc
· 2020 Jan · PMID 31904771
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Lateral strain is a type of nonphysiologic cranial dysfunction that occurs at the sphenobasilar synchondrosis. In this dysfunction, the sphenoid and occiput rotate in the same directions along 2 vertical axes. There is c...Lateral strain is a type of nonphysiologic cranial dysfunction that occurs at the sphenobasilar synchondrosis. In this dysfunction, the sphenoid and occiput rotate in the same directions along 2 vertical axes. There is currently no consensus on the nomenclature for this cranial dysfunction. In this article, the authors provide a standard nomenclature for lateral strains using the historical writings of pioneers in osteopathic medicine, including William Gardner Sutherland, DO, Anne L. Wales, DO, and Harold Magoun, DO. The authors establish the following consensus: (1) Lateral strains are named for the side to which the basisphenoid shifts; (2) The more prominent greater wing of the sphenoid is on the same side to which the basisphenoid shifts; (3) In vault and fronto-occipital holds, the holds form a parallelogram shape, with the index fingers pointing to the same side as the more prominent greater wing; and (4) The hand that is on the side of the prominent greater wing will shift anteriorly while the hand on the opposite side will shift posteriorly.
Smith E, Foxx-Orenstein A, Marks LA
… +1 more, Agrwal N
J Am Osteopath Assoc
· 2020 Jan · PMID 31904770
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The nonpharmacologic management of irritable bowel syndrome focuses on dietary modification through the concept of food sensitivity or intolerance. Currently, testing for food allergies is not recommended in the absence...The nonpharmacologic management of irritable bowel syndrome focuses on dietary modification through the concept of food sensitivity or intolerance. Currently, testing for food allergies is not recommended in the absence of a clinical history consistent with an immunoglobulin E-mediated reaction. Objective means of determining food sensitivity, such as individualized diets, are being studied, but testing for food sensitivity is limited to certain food groups. Diets such as the low-FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet may provide benefit.
J Am Osteopath Assoc
· 2019 Dec · PMID 31841130
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Topical imiquimod is commonly used in the nonsurgical management of actinic keratosis and superficial basal cell carcinoma. Although adverse effects have been limited primarily to local irritation, another rare adverse r...Topical imiquimod is commonly used in the nonsurgical management of actinic keratosis and superficial basal cell carcinoma. Although adverse effects have been limited primarily to local irritation, another rare adverse reaction is erythema multiforme. We present a case of erythema multiforme involving the oral mucosa, trunk, and extremities that followed broad application of topical imiquimod for the management of suspected superficial basal cell skin cancers and actinic keratosis. The patient had used imiquimod previously without complication. Cessation of use and systemic corticosteroids resulted in prompt clearance.
J Am Osteopath Assoc
· 2019 Dec · PMID 31790129
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The use of opioids for chronic pain management is extraordinarily common despite substantial evidence of only modest benefits, when compared with nonopioid analgesics. Opioid use is also associated with serious risks, in...The use of opioids for chronic pain management is extraordinarily common despite substantial evidence of only modest benefits, when compared with nonopioid analgesics. Opioid use is also associated with serious risks, including overdose and death. A growing body of evidence suggests that opioids are involved in significant drug interactions that often go unrecognized in clinical practice. Understanding opioid-involved drug interactions is of great practical importance for all health care professionals caring for patients with chronic pain. In this article, we describe the mechanisms of opioid-involved drug interactions and their potential consequences, which have major public health implications. Additionally, this article provides practical strategies to aid health care professionals in avoiding and mitigating opioid-involved drug interactions in order to obtain a favorable balance in the risk-benefit ratio associated with opioid use. These strategies include using osteopathic principles for chronic pain management, separating the times of administration of the opioid(s) from the nonopioid(s) involved in the interaction, changing the opioid(s) adversely affected by the interaction, changing the nonopioid(s) causing the interaction, and partnering with pharmacists in clinical practice.
J Am Osteopath Assoc
· 2019 Dec · PMID 31790128
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The opioid epidemic in the United States is one of the largest modern health crises in the nation's history. The crisis has been cultivated in academic journals, driven by the medical-pharmaceutical complex, and fueled b...The opioid epidemic in the United States is one of the largest modern health crises in the nation's history. The crisis has been cultivated in academic journals, driven by the medical-pharmaceutical complex, and fueled by campaigns representing the most prestigious health care organizations and advocacy groups. Comprehensive guidelines for proper prescribing have been released in addition to state-sponsored prescription drug-monitoring programs (PDMPs) in response to overprescribing habits. When considering opioid treatment for a patient, physicians should document a thorough history of pain, give an appropriate physical examination, and complete a risk assessment using the proper diagnostic tools. Considering the osteopathic philosophy and approach to chronic pain, physicians should account for an integrative treatment approach for improved patient outcomes when considering applying the osteopathic philosophy to chronic pain management. A successful treatment plan can integrate cognitive behavioral therapy and promote self-healing by treating somatic dysfunctions with osteopathic manipulative treatment. This literature review discusses how to treat patients with chronic pain and how to properly use and prescribe opioids. The researchers analyzed the history and current status of the opioid epidemic, examined opioid management in the outpatient setting, reviewed the current domestic and international opioid prescribing guidelines, and discussed the incorporation of the osteopathic philosophy to manage chronic pain.
J Am Osteopath Assoc
· 2019 Dec · PMID 31790127
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CONTEXT: Discogenic low back pain is the most common type of low back pain and is a major cause of morbidity worldwide. Current nonoperative treatment options are limited in efficacy and lack evidence of long-term pain r...CONTEXT: Discogenic low back pain is the most common type of low back pain and is a major cause of morbidity worldwide. Current nonoperative treatment options are limited in efficacy and lack evidence of long-term pain relief; thus, there is an unmet clinical need for an effective treatment for patients with discogenic pain. Amniotic membrane and umbilical cord (AMUC) particulate may be useful in relieving pain and inhibiting the degenerative cascade in patients with discogenic pain by reducing inflammation. OBJECTIVE: To evaluate the effectiveness of AMUC particulate for discogenic pain. METHODS: Six months of conservative therapy failed in patients who had discogenic pain confirmed by magnetic resonance imaging and provocative discography. They subsequently received intradiskal injection of 50 to 100 mg of AMUC particulate for cervical, lumbar, and lumbosacral disks. RESULTS: A total of 11 patients with 20 disks were included. Before treatment, all patients reported severe pain, and 10 patients took opioids daily. After treatment, the median reported pain relief was 40%, 50%, and 75% at 1-month (n=6), 3 months (n=8), and 6 months (n=5), respectively. Complete pain relief was noted in 1 patient; however, 2 patients (18%) reported no pain relief at 1 and 3 months. No adverse events, repeated procedures, or complications occurred. CONCLUSION: This preliminary evidence suggests that a single intradiskal injection of AMUC particulate is safe and may provide symptomatic pain relief in some patients with discogenic pain.
J Am Osteopath Assoc
· 2019 Dec · PMID 31790126
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CONTEXT: Information about the characteristics of patients who use osteopathic manipulative treatment (OMT) is limited. OBJECTIVE: To determine the scope of conditions being managed with OMT and describe the characterist...CONTEXT: Information about the characteristics of patients who use osteopathic manipulative treatment (OMT) is limited. OBJECTIVE: To determine the scope of conditions being managed with OMT and describe the characteristics of patients who receive OMT. METHODS: Researchers conducted a longitudinal, observational study on the use and effectiveness of OMT at 17 clinics where clinicians (ie, osteopathic and allopathic physicians and Canadian-trained osteopaths) provided OMT. Adult patients receiving OMT completed questionnaires immediately before, immediately after, and daily for 7 days after treatment. Data collected from patients included demographic information, chief complaint(s) and their severity, and health-related quality of life. Physical examination findings, treatment, and medical diagnosis documentation were extracted from medical records. Census data were used to assess whether patients were representative of the population of the county where the clinic was located. RESULTS: Data were collected from 927 patients at 1924 office visits. A majority of patients were women (690 [75%]), white (854 [96%]), and not Hispanic or Latinx (707 [95%]). The mean (SD) age was 51.9 (15.9) years. When compared with census data, the sample had higher percentages of women, people aged 65 years and older, people who identified as white, people who were high school and college graduates, and people with higher household incomes than that of the county population. The most common chief complaints from patients were pain or discomfort in the lower back (311 [34%]) and neck (277 [30%]), which corresponded with the most common medical diagnoses. Patients reported that OMT, surgery, and medications were the most helpful treatments they had used previously for their chief complaint(s). Before receiving OMT, patients' health-related quality of life was significantly worse (P≤.05) than that of the general US population. CONCLUSIONS: Adult patients receiving OMT are being treated primarily for musculoskeletal pain conditions, are not representative of the population of the county where the clinic was located, and have worse health-related quality of life than that of the general population. Information about the characteristics of patients who use OMT is important for defining osteopathic distinctiveness and identifying potential areas for increasing the use of OMT. (ClinicalTrials.gov number NCT02395965).
Wu CA, Simon AJ, Modrich MA
… +3 more, Stacey MW, Matyas BT, Shubrook JH
J Am Osteopath Assoc
· 2019 Dec · PMID 31790125
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CONTEXT: In 2015, Solano County's Medi-Cal insurer implemented a new policy to taper patients using high-dose opioids (≥120-mg morphine equivalent dose) to a safer level to follow best practices to address the opioid epi...CONTEXT: In 2015, Solano County's Medi-Cal insurer implemented a new policy to taper patients using high-dose opioids (≥120-mg morphine equivalent dose) to a safer level to follow best practices to address the opioid epidemic. OBJECTIVE: To evaluate the effect of the 2015 Solano County Medi-Cal prescribing policy, gain insight into the patient experience of undergoing opioid tapering, and generate hypotheses for further study. METHODS: Using a case series approach, researchers completed medical record reviews of affiliated clinical records, Solano County Vital Statistics, and California's prescription monitoring program in 2018. After exclusions, eligible patients were asked to participate in a comprehensive qualitative interview. RESULTS: Medical record reviews of 38 patients found the majority were not using opioids using them at a morphine equivalent dose of 90 mg or less. The reviews also found that mental illness and obesity prevalence were higher than Solano county baseline levels. Furthermore, naloxone was not prescribed to any of the 38 patients. Researchers reached 15 of the 38 patients by phone, and ultimately 6 completed the interview process. Themes and emergent concepts from interviews identified a lack of empathetic connection with health care professionals, poor understanding of overdose risks, persistent pain, and confirmed naloxone underuse. CONCLUSION: Safer prescribing policies may take multiple years to fully implement and need to be employed across the jurisdiction to minimize doctor-shopping and adverse effects on patients with chronic pain. Approaching pain management through the social-ecological model can address potential root causes of addiction and establish a framework for doctors to provide compassionate care, community leadership, and advocacy for these patients.
Mort SC, Díaz SR, Miller C
… +3 more, Bowlby M, Henderson D, Beverly EA
J Am Osteopath Assoc
· 2019 Dec · PMID 31790124
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CONTEXT: Recreational use of opioids is a growing problem in the United States, particularly in the Midwest. Educators have called for inclusion of pain- and opioid-specific courses in health professional school curricul...CONTEXT: Recreational use of opioids is a growing problem in the United States, particularly in the Midwest. Educators have called for inclusion of pain- and opioid-specific courses in health professional school curricula, yet more research is needed to address future prescribers' beliefs, experiences, and postgraduate plans related to opioids. OBJECTIVE: To examine health professional students' perceived severity of the opioid crisis and opioid-related beliefs, experiences, and postgraduate plans. METHODS: Using a descriptive, cross-sectional design, researchers evaluated health professional students from 3 academic programs (nurse practitioner [NP], physician assistant [PA], and doctor of osteopathic medicine [DO]) using a 25-item survey that assessed perceived opioid crisis severity and opioid-related beliefs, experiences, and postgraduate plans. Demographics of respondents were assessed using descriptive statistics and frequencies. Responses were compared between academic programs with 1-way analysis of variance or Kruskal-Wallis tests, and relationships between students' experiences and postgraduate plans were assessed. RESULTS: A total of 491 students (mean [SD] age, 27.2 [5.4] years; 62.7% female; 68.2% DO students) participated in the survey (response rate, 40.4%). The opioid crisis was perceived to be severely impacting the health care system (mean [SD] score, 79.7 [16.8] out of 100), and most respondents (415 [84.5%]) reported that opioid use affected their communities. Clinical experience varied by program, with NP students (75 [81.5%]) reporting the most experience treating acute overdose. Most respondents (317 [64.6%]) agreed that their postgraduate practice would involve caring for patients addicted to opioids; however, only 232 students (47.3%) felt confident in their ability to treat patients with addiction. Experiences managing acute overdose and handling drug-seeking behavior were positively associated with a belief that postgraduate work would involve working with patients with addiction (U=38,275.5, Z=5.92, P<.001; U=25,346.0, Z=4.94, P<.001) and confidence in treating patients with opioid addictions (U=36,806.5, Z=4.96, P<.001; U=23,765.5, Z=3.66, P<.001). CONCLUSION: Although health professional students had similar beliefs and perceptions regarding the opioid crisis, there were notable differences between academic programs. Students with clinical opioid experiences were more likely to plan on working with patients addicted to opioids and be confident in treating these patients. Thus, the inclusion of experiential learning in the medical curricula may be beneficial for both students and their future patients.