Journal of Osteopathic Medicine

Endometriosis is defined as the presence of endometrial-like glands and stroma outside of the uterus. There are three types of endometriotic lesions: superficial or peritoneal endometriosis, ovarian endometrioma, and deep infiltrating disease. Endometriosis not only occurs in the pelvis but also can be found in extrapelvic sites such as the gastrointestinal tract, upper abdominal viscera, genitourinary tract, abdominal wall, diaphragm, and thoracic cavity. After thorough history and physical examination is performed, imaging, such as ultrasound or magnetic resonance imaging (MRI), should be obtained if there is high suspicion for deep-infiltrating endometriosis to better assess visceral involvement. Endometriosis can be suspected based on symptoms, physical examination findings, and imaging. However, a definitive diagnosis requires histopathologic confirmation. Treatment options include expectant, medical, and surgical management. Endometriosis is largely a quality-of-life issue, and treatment should be tailored accordingly with empiric medical therapy frequently utilized. Medical management focuses on symptom improvement. Surgical management with excision of endometriosis is preferred over ablation or fulguration of endometriotic lesions. In the case of deep or extrapelvic endometriosis, treatment with a multidisciplinary team with experience in the treatment of advanced-stage endometriosis is essential to minimizing morbidity and increasing long-term success.

This case report details the presentation, diagnosis, and management of a newborn Native American male with non-Herlitz junctional epidermolysis bullosa (JEB), a rare diagnosis specifically in the Native American population. Genetic analysis revealed a homozygous mutation in the COL17A1 gene. The management involved multidisciplinary care and highlighted the challenges in treatment, including pain management, wound care, and ethical considerations surrounding adoption within Indigenous communities. This case highlights the importance of tailored interventions and the need for further research into the genetic diversity and prevalence of epidermolysis bullosa (EB) among the Native American population.

Context Urinary incontinence (UI) in the powerlifting community has been a hot topic due to its noticeability during competition and the burden it places on female athletes who experience it. UI is even experienced in those we least expect: young, high-performing, females with no history of pregnancy. Current studies have utilized primarily survey methodology, thus there is a lack of clinical information on this topic. Furthermore, the top athletes are underrepresentedbecause previous surveys were open to anyone reporting themselves as a powerlifter, regardless of competition level. Objectives The objectives of this study were to determine whether UI in elite female powerlifters is correlated with any musculoskeletal diagnoses and to further evaluate potentially contributing factors for UI within this group. Methods Subjects underwent an osteopathic structural examination and then completed two surveys: the Incontinence Severity Index (ISI/Sandvik Test for Urinary Incontinence) and the Study Questionnaire. Results In total, there were 31 female participants, all of whom were in the top 2 % of powerlifters in the world between the ages of 20 and 30 years old (as of May 21, 2023) and reside in the United States. The survey results displayed a moderately positive relationship between age (rho=0.449, where rho refers to Spearman’s rho), history of pelvic floor examination (rho=0.413), and self-care practice with ISI (rho=0.340). Other survey information such as weight class, height, best total in competition, number of years training, average duration of training day, confidence in ability to contract pelvic floor muscles, history of abdominal or pelvic surgery, history of urinary tract infection (UTI), and sexual activity status all had rho values less than 0.300. With atlantoaxial (AA) rotation to the right, there was an increase in ISI score (p=0.009). Similarly, with AA rotation to the left, there was a decrease in ISI score (p=0.030). All patients with severe ISI had nonphysiologic sacral dysfunctions (p=0.051). Severe ISI-scored participants were more likely to yield a dysfunctional clavicle upon screening (p=0.027). There was a strong correlation between increasing severity of UI and findings of a restricted right clavicle and/or AA rotation to the right (p=0.010). In addition, there were only two individuals with both a restricted right clavicle and AA rotation to the right, and these two individuals both scored severe on the ISI (p=0.012). A pelvic diaphragm dysfunction was present in 74.2 % of the participants. Extension diagnoses of the lumbar spine were found in those with mild UI over those with severe UI (p=0.012). Most other diagnoses were largely unremarkable due to a wide distribution across all ISI scores. Conclusions Our study revealed a relationship between UI and somatic dysfunctions in this population. These findings may help providers, especially in the fields of primary care, sports medicine, and urogynecology, to expand treatment options for UI in this group in the future. Survey results yielded a positive relationship of moderate strength between age, history of pelvic floor exination, and engaging in leakage prevention practices with ISI. No survey category was found to have a relationship of high strength with ISI. These findings contribute to our knowledge on factors that do (or do not) contribute to incontinence severity.

Overhead sports place a significant amount of stress on the shoulder. There are a variety of activities and sports with overhead athletes including both throwing (baseball, softball, football, cricket) and nonthrowing (tennis, swimming, volleyball) sports. Although all of these overhead motions can lead to pathology, a large focus has been on the consequences of overhead throwing. Overhead-throwing sports place forces on the joints, muscles, tendons, and ligaments that vary through the spectrum of athletes, as does the potential injuries that may be caused by these forces. The primary joints that are commonly injured in overhead sports are the shoulder and the elbow. The goal of this article is to discuss the impact of overhead motions on the shoulder, with a primary focus on throwing, as well as to highlight the osteopathic approach to assessment, treatment, management, and prevention.

Injury to the elbow is very common in the throwing athlete and can potentially lead to long absences from play and, in the most severe scenarios, medical retirement. The throwing motion is a highly complex series of movements through the entire kinetic chain that results in very high angular velocities and valgus forces at the elbow joint. The repetitive nature of overhead throwing in combination with the high levels of accumulated force at the elbow puts both pediatric and adult athletes at risk of both acute and chronic overuse injuries of the elbow. This review provides an update on common injuries in the throwing athlete and covers clinical presentation, diagnosis, and treatment of these injuries.

Context Dystonia is a movement disorder that causes involuntary muscle contractions leading to abnormal movements and postures, such as twisting. Dystonia is the third most common movement disorder in the United States, with as many as 250,000 people affected. Because of its complexity, dystonia presents a significant challenge in terms of management and treatment. Despite limited research, osteopathic manipulative treatment (OMT) has been considered as an adjunctive treatment due to its inexpensive and noninvasive nature, as opposed to other modalities such as botulinum toxin injections, deep brain stimulation (DBS), and transcranial magnetic stimulation, which are often expensive and inaccessible. OMT treatments performed in case studies and series such as balanced ligamentous tension/articular ligamentous strain (BLT/ALS), muscle energy (ME), high-velocity low-amplitude (HVLA), and myofascial release (MFR) have shown reduction of pain and muscle hypertonicity, including in patients with dystonia. Objectives The studies reviewed in this paper provide a snapshot of the literature regarding the current evidence of OMT’s role for dystonia. Methods A medical reference librarian conducted a thorough literature search across multiple databases including PubMed and Google Scholar to find articles relevant to the use of OMT for dystonia. The search employed a combination of Medical Subject Headings (MeSH) terms and keywords related to osteopathic medicine and dystonia to ensure precise retrieval of relevant articles within the last 20 years. Despite limited research on the topic, all four relevant reports found in the literature were selected for review. Results Of the four relevant reports, case series and studies highlighted the potential benefits of OMT in managing dystonia, particularly cervical dystonia and foot dystonia. OMT has shown promising results addressing pain, stiffness, and impaired motor function. In cases of foot dystonia in Parkinson’s disease, OMT has helped improve gait and reduce pain by targeting somatic dysfunctions (SDs) associated with dystonia, such as abnormalities in foot progression angle (FPA) and musculoskeletal imbalances. Also, OMT has been found to alleviate symptoms of cervical dystonia, including tremors, muscle spasms, and neck stiffness. These interventions performed in case studies and series led to improvements in gait biomechanics in foot dystonia and overall symptom severity in patients with cervical dystonia. Conclusions Currently, botulinum toxin, oral medications, physical therapy, and rehabilitation are commonly utilized in managing dystonia. The studies reviewed in this paper suggest that these treatments may lead to improvements in pain and muscle hypertonicity in patients with dystonia. It is important to investigate whether factors such as the type of dystonia (eg, focal vs. segmental) and its underlying cause (eg, idiopathic, trauma, infection, autoimmune, medication side effects) influence treatment outcomes. Further research is recommended to explore the role of OMT in managing dystonia.

Peripheral artery disease (PAD) is an atherosclerotic disease that contributes to significant morbidity and mortality, including loss of limb, myocardial infarction (MI), stroke, and death. Treatment options are often underutilized. A major limiting factor in PAD care is the ability to efficiently identify and screen at-risk patients. A PAD patient screening and clinician decision support tool was created to improve access to high-quality, evidence-based care to drive improved clinical outcomes. The tool identifies known PAD risk factors and presenting symptoms, in combination with objective data obtained via the ankle-brachial index (ABI). The tool utilizes this data to drive PAD diagnosis, risk assessment, and treatment, and it is adaptable across multiple care settings, by varied health professions. The implementation of a PAD screening and treatment toolkit enhances anticoagulation and PAD stewardship, and it has been integrated into use across various care settings.

Context This is a follow-up to the original published article, Effects of the Strong Hearts Program after a Major Cardiovascular Event in Patients with Cardiovascular Disease. Objectives This study evaluated the long-term efficacy of the Strong Hearts program up to 2 years after program completion. Methods All study participants who initially completed the Strong Hearts program between 2020 and 2021 (n=128) were contacted at 12 months and 24 months following the date of program completion. A phone survey was conducted to see if any significant post-cardiovascular events or readmissions to the hospital occurred, and self-reported dates of any occurrences were recorded. Hospital readmissions and cardiac-related procedures were cross-referenced with the hospital’s electronic medical record. A chi-square goodness-of-fit analysis was utilized to compare the observed rates of categorical outcomes vs. expected rates yielded from the empirical literature. Results The rate of all-cause readmission at 6 months post-program completion was 2/120 (1.7 %), compared to the expected rate of 50 %, χ ² (1) = 112.13, p<0.001. The readmission rate at 1 year post-program completion was 17/120 (14.2 %), vs. the expected rate of 45 %, χ ² (1) = 46.09, p<0.001, and at 2 years post-program completion, the readmission rate was 24/120 (20.0 %) compared to the expected rate of 53.8 %, χ ² (1) = 56.43, p<0.001. Ten participants (8.3 %) had a subsequent cardiac procedure within 2 years of completing the program, including two requiring percutaneous coronary intervention (1.7 %) and eight requiring coronary artery bypass grafting (CABG, 6.7 %), compared to the expected rates of 13.4 and 57.74 %, χ ² (1)=153.08, p<0.001, respectively. Mortality at 2 years post-program completion was 2/128 (1.6 %), compared to 23.4 %, χ ² (1)=34.13, p<0.001. Conclusions Efficacy of the Strong Hearts program continued at 6 months, 1 year, and 2 years post-program completion in terms of all-cause readmission, subsequent cardiac event, and all-cause mortality.

Context There is an increasing number of medical school graduates opting for surgical specialties, and the osteopathic applicant match rate for urology is lower than that of allopathic applicants. Factors influencing this may include a lack of interest, perceived challenges in matching into urology, insufficient urology mentorship, limited research opportunities, and inadequate osteopathic representation in urology. Objectives The objective of this survey is to assess osteopathic medical students’ perspectives on pursuing urology and enhancing preclinical exposure to and knowledge of urology. Methods A 20-question survey addressing experiences and the factors influencing osteopathic medical students’ specialty selection and their interest in and perception of urology was designed by the investigators on Research Electronic Data Capture (REDCap) software. This survey was distributed via email listserv to all current osteopathic medical students attending Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine over 2 months. Responses were collected and analyzed utilizing Fisher’s exact test. Results Among 150 respondents, 91 % found mentors crucial in selecting a medical specialty, 95 % emphasized the importance of early exposure, and 68 % lacked familiarity with urology, with more M1 students unfamiliar with urology compared to M2 (70.4 % vs. 59 %). A larger proportion of combined M1 and M2 (preclinical) students are considering urology as a specialty compared to M3 and M4 (clinical) students who are actively on rotations (56.5 % vs. 28.6 %; p=0.0064). Also, a greater percentage of males are considering urology compared to females (64.2 % vs. 42.7 %; p=0.0164). Among those considering urology (n=75), 57.3 % lack awareness of urology’s scope, and 84 % report no preclinical discussions with urologists. Those students who report that they are considering urology value early exposure significantly more than others (98.7 % vs. 78.7 %; p=0.0001). They also express greater interest in having a core urology course (73.3 % vs. 38.7 %; p<0.0001). More urology-considering students are interested in extracurricular urology-related workshops, seminars, or conferences (61.3 % vs. 17.3 %; p<0.0001). Students who are considering urology as a specialty show greater interest in having a mentorship program (85.3 % vs. 28 %; p<0.0001). Conclusions Results suggested that increased urology exposure during the preclinical years is important. Urology elective offerings and urology mentorship are of high interest among those considering urology. However, additional investigation is needed to determine the impact of preclinical urology curricula implementation on urology match outcomes.

Context In 2019, emergence of the novel and communicable severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection took scientific communities by surprise and imposed significant burden on healthcare systems globally. Although the advent of this disease piqued the interest of academic centers, healthcare systems, and the general public, there is still much yet to be elucidated regarding epidemiology, pathophysiology, and long-term impacts of coronavirus disease 2019 (COVID-19). It has been established that long COVID-19 can impact multiple organ systems, including the cardiovascular system, unfavorably. Although the pathophysiology of this damage is not well understood, adverse sequelae may range from chest pain and arrhythmias to heart failure (HF), myocardial infarction, or sudden cardiac death. For any postacute COVID-19 patient requiring a surgical procedure, the potential for cardiac injury secondary to long COVID-19 must be considered in the preoperative cardiac examination. Objectives This literature review serves to add to the growing body of literature exploring postacute cardiovascular outcomes of COVID-19, with a focus on presurgical cardiac clearance in the adult patient. Specifically, this review studies the prevalence of cardiovascular symptomatology including chest pain, arrhythmias, blood pressure changes, myo-/pericarditis, HF, cardiomyopathy, orthostatic intolerance, and thromboembolism. Although current evidence is scarce in both quality and quantity, it is the goal that this review will highlight the negative impacts of long COVID-19 on cardiovascular health and encourage providers to be cognizant of potential sequelae in the context of the presurgical examination. Methods For this study, peer-reviewed and journal-published articles were selected based on established inclusion and exclusion criteria to address the question “How does long COVID-19 impact the presurgical cardiac examination of an adult scheduled to undergo a noncardiac procedure?” Inclusion criteria included human studies conducted in adult patients and published in peer-reviewed journals up until May 2024 examining the effects of long-COVID-19 infection on the cardiovascular system. Exclusion criteria eliminated unpublished reports, preprints, duplicate articles, literature regarding coronavirus strains other than COVID-19, studies regarding post-COVID-19 vaccination complications, animal studies, and studies conducted in people younger than 18 years of age. A total of 6,675 studies were retrieved from PubMed and Google Scholar. Following screening, 60 studies were included in final consideration. Results Cardiovascular symptoms of postacute COVID-19 infection were encountered with the following percentages prevalence (total numbers of articles mentioning symptom/total number of articles [60]): chest pain (83.3), arrhythmias (88.3), hypertension (40.0), hypotension (16.7), myocarditis (80.0), pericarditis (51.7), HF (70.0), cardiomyopathy (55.0), orthostatic intolerance (56.7), and thromboembolic events (85.0). Conclusions The presence of persisting COVID symptoms may negatively impact the patient’s physical examination, blood tests, electrocardiogram (ECG), imaging, and/or echocardiogram. Cardiac conditions associated with long COVID require special attention in the context of the presurgical candidate due to an increased risk of sudden cardiac death, myocarditis, stroke, and myocardial infarction – even in those who were healthy prior to acute COVID-19 infection. Until more specific scientific evidence comes to light, care of these patients should be viewed through the prism of the best practices already in use and clinicians should maintain a low threshold to pursue more extensive cardiac workup prior to surgery.

Context Deep organ-space infection (OSI) following gynecologic surgery is a source of patient morbidity and mortality. There is currently conflicting evidence regarding the use of bowel preparation prior to gynecologic surgery to reduce the rates of infection. For the additional purpose of improving patient recovery at our own institution, a retrospective cohort study compared the rate of deep OSI in patients who received oral antibiotic bowel preparation per Nichols–Condon bowel preparation with metronidazole and neomycin. Objectives The primary aim of this study was to compare the rate of deep organ-space surgical site infection in gynecologic surgery before and after institution of an oral antibiotic bowel preparation, thus assessing whether the preparation is associated with decreased infection rate. The secondary objective was to identify other factors associated with deep organ-space site infection. Methods A retrospective cohort study was performed. Demographic and surgical data were collected via chart review of 1,017 intra-abdominal surgeries performed by gynecologic oncologists at a single institution from April 1, 2019 to December 1, 2021. Of these, 778 met the inclusion criteria; 444 did not receive preoperative oral antibiotic bowel preparation, and 334 did receive preoperative bowel preparation. Odds ratios (ORs) were calculated, and a logistic regression model was utilized for categorical variables. Multivariable regression analysis was performed. Results A total of 778 patients were included. Deep OSI rate in patients who did not receive oral antibiotic bowel preparation was 2.3 % compared to 0.3 % (OR 0.13, confidence interval [CI] 0.06–1.03, p=0.02) in patients who did. Receiving oral antibiotic bowel preparation predicted absence of deep OSI (OR 0.04, CI 0.00–0.87, p=0.04). Laparotomy (OR 20.1, CI 1.6–250.2, p=0.02) and Asian race (OR 60.8, CI 2.6–1,380.5, p=0.01) were related to increased rates of deep OSI. Conclusions Oral antibiotic bowel preparation predicts a reduced risk of deep OSI. This preparation is inexpensive and low-risk, and thus these clinically significant results support a promising regimen to improve surgical outcomes, and provide guidance for prospective larger studies.

Context The pelvic examination is a fundamental tool for the evaluation and diagnosis of women’s health conditions and an important skill for all medical students to learn as future physicians for the early detection of treatable conditions such as infection or cancer. Although the American College of Obstetricians and Gynecologists (ACOG) asserts that performing pelvic examinations under anesthesia for educational purposes should only occur if the patient provides explicit and informed consent, there still have been reports of medical students performing pelvic examinations on anesthetized patients across the country, and many states are now starting to pass bills requiring informed patient consents to conduct pelvic examinations under anesthesia. Objectives The objectives of this study are to evaluate the prevalence of pelvic examinations performed by osteopathic medical students on anesthetized patients without consent while fulfilling their third-year OB-GYN clerkship requirements. Methods The survey was administered and distributed to all osteopathic medical schools in the country via the Student Osteopathic Medical Association’s (SOMA’s) chapter emails, outreach emails, and SOMA’s social media accounts to collect data. Inclusion criteria included third- or fourth-year osteopathic medical students who completed their OB-GYN clerkship rotations when taking the survey. The exclusion criteria included any osteopathic medical student who had not completed their OB-GYN clerkship rotation. We utilized descriptive analysis to summarize the final data. Results We received 310 responses. The final number of responses was 291 after meeting the exclusion criteria. Most osteopathic medical students (94.2 %, n=274) considered the practice of performing pelvic examinations on anesthetized patients without their explicit consent unethical. Among the participants, 40.9 % (n=119) admitted to performing pelvic examinations on patients under anesthesia while on OB-GYN rotations, but most of them (57.1 %, n=68) did so without obtaining prior consent from the patients. Notably, the number of pelvic examinations performed by medical students on patients under anesthesia ranged widely from 1 to 25 with a median number of 10. Moreover, 58.9 % (n=70) indicated that they had not been properly educated to obtain specific consent before performing pelvic examinations under anesthesia. Many participants cited efficiency of practice, lack of policy awareness and personal education by medical students, and failure to refuse to perform pelvic examinations on anesthetized patients as trainees when asked by their seniors or preceptors. Conclusions This study demonstrates that although most osteopathic medical students consider performing pelvic examinations on anesthetized patients unethical, many still admit to practicing pelvic examinations on patients under anesthesia, while on OB-GYN rotations for efficiency of practice, lack of policy awareness and personal education, and being in unique positions in which grades are determined by seniors and preceptors for their willingness to do what is asked even if the practice does not align with their conviction. This study highlights the importance of ongoing research and implementation of policies at institutional and state levels that will procure the value of pelvic examinations while protecting and upholding the ethics of patients’ rights and autonomy of medical students.

Context Osteopathic manipulative medicine (OMM) is a unique skill set consisting of physical manipulations that treat the neuromusculoskeletal system. Although OMM can improve patient outcomes such as functionality and pain, as well as increase physician reimbursement, its use is declining. Barriers to its use include a lack of proficiency, support, reimbursement, and time. Knowledge gaps remain as to how OMM training during graduate medical education (GME) affects OMM use. Objectives This study describes relationships between OMM exposure during GME and the use of OMM in practice. Methods An online survey of physicians in a variety of medical fields during late 2022 assessed the impact of OMM education during postgraduate training on its use in clinical practice. Survey data were analyzed to compare training characteristics and OMM use via chi-square tests and binary logistic regression. Results A total of 299 surveys were completed. Respondents who received formal OMM education during residency were more likely (59.8 %) to utilize OMM in medical practice than those who practiced OMM informally (37.8 %, p<0.001) and those who had no OMM exposure during residency (10.3 %, p<0.001). Respondents who trained with more osteopathic attendings (p<0.001) and co-residents (p=0.012) were also more likely to utilize OMM. Those who completed residencies that were accredited by the Accreditation Council for Graduate Medical Education (ACGME) with an Osteopathic recognition track, by the American Osteopathic Association (AOA), and were dually-accredited (ACGME/AOA), were all more likely to utilize OMM (60 %, 56 %, and 53 %, respectively) than those who completed residencies with ACGME accreditation alone (22 %, p<0.01). Conclusions Although OMM can improve patient outcomes, it is underutilized by Doctors of Osteopathic Medicine (DOs) in practice. Lack of training after medical school has been identified as a contributing factor to its disuse. The results of our study illustrate that there is a positive association between OMM education during postgraduate training and OMM use in clinical practice.

Context Chronic pain may affect the relationship between patients and their treating physicians. Objectives This study was designed to compare four aspects of physician communication and physician empathy reported by patients with chronic pain and in chronic pain-free controls. Methods A cross-sectional study was conducted within a national pain research registry from July 2020 through January 2024. Patients with chronic low back pain of greater than 3 months duration were matched to chronic pain-free controls utilizing propensity scores derived from a logistic regression model based on 11 variables that included sociodemographic characteristics, cigarette smoking status, history of comorbid medical conditions, and duration of the current patient-physician relationship. Patients reported on the primary outcomes of physician communication utilizing the Communication Behavior Questionnaire (CBQ) and physician empathy utilizing the Consultation and Relational Empathy (CARE) measure. Group means were compared for each aspect of physician communication (patient participation and patient orientation, effective and open communication, emotionally supportive communication, and communication about personal circumstances) and physician empathy, and Cohen’s d statistic was utilized to assess the clinical relevance of between-group differences. Secondary exploratory analyses were also performed to compare patients treated by osteopathic physicians vs. allopathic physicians and to determine whether study group X physician type interaction effects were present. Results The 387 patients in each study group were matched within a caliper width of 0.001 on the propensity score. Overall, patients ranged from 21 to 79 years of age (mean, 50.7 years; standard deviation [SD], 15.1 years), and 617 (79.7 %) of them were female. Patients in the chronic pain group reported poorer scores for all aspects of physician communication and physician empathy than the chronic pain-free controls. All between-group differences were clinically relevant. There were no differences in physician communication or physician empathy according to physician type in the exploratory analyses, and study group X physician type interaction effects were not observed. Conclusions In this cross-sectional study, patients with chronic pain reported having physicians with poorer communication and less empathy than chronic pain-free controls. Longitudinal research is needed to more clearly determine the temporal relationship between patients’ chronic pain and physician communication and physician empathy during medical encounters.

Context Underserved communities in southeastern Ohio and Appalachia face significant healthcare accessibility challenges, with the Midwest offering a lower density of healthcare providers compared to coastal regions. Specifically, underserved communities in southeastern Ohio and Appalachia are disadvantaged in otolaryngology care. Objectives This analysis aims to identify factors that lead otolaryngologists to a respective practice location, and if any of that influence comes from where otolaryngologists completed their medical education. Methods The proportion of otolaryngologists who performed medical school, residency, and/or fellowship in Ohio was analyzed utilizing a three-sample test for equality. Multivariate logistic regression and Pearson prediction models were produced to analyze the impact of performing medical training (medical school, residency, and fellowship) in Ohio. Results Going to medical school in Ohio significantly increases the odds of going to an otolaryngology residency in the state (p<0.001). Moreover, between medical school and residency, medical school was a significantly better predictor of otolaryngologists practicing in Appalachia (Δ Bayesian Information Criterion [BIC]>2) and southeast Ohio (ΔBIC>10). Medical school in state was also a better predictor of percent rural and median household income than residency (ΔBIC>10). The multivariate model of medical school and residency was significantly better than either predictor alone for the population (ΔBIC>2). All models predicting percent rural were significantly improved with the addition of a Doctor of Osteopathy (DO) degree (ΔBIC>10). Conclusions Where physicians complete their medical training (medical school, residency, and fellowship) in state has a significant impact on predicting their future place of practice. This study found that the location of such training has a positive predictive nature as to whether that physician will practice in a rural and underserved area in the future. Notably, the addition of being licensed as a DO also increased the probability of that physician practicing in a rural area.

Context Public interest in sport-related medical conditions is known to be affected by social media and pop cultural coverage. The purpose of this project was to assess the relationship between popular culture concerning chronic traumatic encephalopathy (CTE) and analyze of how often this topic was searched on the internet. Objectives The objective of this study was to investigate deviations in public interest following player incidents of CTE and the effects that the media has had on public interest in CTE. Methods To determine our primary objective, we utilized Google Trends to extract the monthly relative search interest (RSI) in CTE between January 2002 and October 2022. To assess the increase in RSI following a major event, an autoregressive integrated moving average (ARIMA) to predict RSI from March 2012 was created through the end of the period, and calculated the differences between the actual and forecasted values. Results Data indicate that RSI increased over time, specifically following the release of the movie Concussion . The peak in RSI (100) over this timespan was following the release of Aaron Hernandez’s autopsy results in 2017, which was 87.8 (95 % CI: 8.7–15.7) higher than forecasted, showing a 720.3 % increase in RSI. While research was published regarding CTE in 2005, the first major spike in search interest occurred after Junior Seau died in 2012. Increasing public interest in CTE continued when media exposure conveyed autopsies of former NFL players, the movie Concussion , and the release of The Killer Inside: The Mind of Aaron Hernandez . Given this increased interest in CTE, we recommend that media broadcasters become more educated on brain injuries, as well as the movement of Brain Injury Awareness Month and Concussion Awareness Day. Conclusions There has been an increase in public interest in CTE from 2004 through 2022 with surges following media releases of events involving NFL players. Therefore, physicians and media broadcasters must create partnerships to better educate the public about head injuries and the effects of CTE.

Migraines make up a significant number of office visits every year, yet their pathophysiology and etiology remain largely elusive. This case report presents a 33-year-old patient who originally presented to the emergency department (ED) as a stroke alert and was later determined to have migraine with aura. The patient experienced an acute onset of headache, dizziness, and new-onset expressive aphasia. Before administration of a migraine cocktail, osteopathic manipulative treatment (OMT) was performed and was able to fully resolve all of her symptoms. In an effort to explain the outcomes in this case, a review of the current literature was performed, which provides an interesting perspective on the interplay of the musculoskeletal system and neuroanatomy. The literature establishes that somatic dysfunctions in the cervical vertebrae and trapezius may play a role in migraines and provide rationale for the use of OMT.

Context The biopsychosocial approach to managing low back pain (LBP) has the potential to improve the quality of care for patients. However, LBP trials that have utilized the biopsychosocial approach to treatment have largely neglected sexual activity, which is an important social component of individuals with LBP. Objectives The objectives of the study are to determine the effects of manual therapy plus sexual advice (MT+SA) compared with manual therapy (MT) or exercise therapy (ET) alone in the management of individuals with lumbar disc herniation with radiculopathy (DHR) and to determine the best sexual positions for these individuals. Methods This was a single-blind randomized controlled trial. Fifty-four participants diagnosed as having chronic DHR (>3 months) were randomly allocated into three groups with 18 participants each in the MT+SA, MT and ET groups. The participants in the MT+SA group received manual therapy (including Dowling’s progressive inhibition of neuromuscular structures and Mulligan’s spinal mobilization with leg movement) plus sexual advice, those in the MT group received manual therapy only and those in the ET group received exercise therapy only. Each group received treatment for 12 weeks and then followed up for additional 40 weeks. The primary outcomes were pain, activity limitation, sexual disability and kinesiophobia at 12 weeks post-randomization. Results The MT+SA group improved significantly better than the MT or ET group in all outcomes (except for nerve function), and at all timelines (6, 12, 26, and 52 weeks post-randomization). These improvements were also clinically meaningful for back pain, leg pain, medication intake, and functional mobility at 6 and 12 weeks post-randomization and for sexual disability, activity limitation, pain catastrophizing, and kinesiophobia at 6, 12, 26, and 52 weeks post-randomization (p<0.05). On the other hand, many preferred sexual positions for individuals with DHR emerged, with “ side-lying ” being the most practiced sexual position and “ standing ” being the least practiced sexual position by females. While “ lying supine ” was the most practiced sexual position and “ sitting on a chair ” was the least practiced sexual position by males. Conclusions This study found that individuals with DHR demonstrated better improvements in all outcomes when treated with MT+SA than when treated with MT or ET alone. These improvements were also clinically meaningful for sexual disability, activity limitation, pain catastrophizing, and kinesiophobia at long-term follow-up. There is also no one-size-fits-all to sexual positioning for individuals with DHR.

Context Few osteopathic physicians (Doctors of Osteopathic Medicine [DOs]) utilize osteopathic manipulative treatment (OMT) in their clinical practice, although all DOs are trained to do so. The reasons why many do not utilize OMT are not entirely clear. Anecdotally, these authors have observed that if a physician utilizes OMT, it is because they witnessed the efficacy for themselves in real-life clinical diagnoses found on patients or volunteers. This study seeks to explore this phenomenon. Objectives This study seeks to explore the relationship between witnessing the efficacy of OMT and the future use of OMT in clinical practice. Methods Surveys were sent to DOs who work with Des Moines University’s College of Osteopathic Medicine (COM) clinical students as well as osteopathic medical students enrolled at the Des Moines University’s COM. Survey data were analyzed by separating physicians into cohorts based on their use of OMT and students into cohorts based on their interest in utilizing OMT in future practice. Results DOs who practice OMT reported at least one, and often multiple, instances of witnessing the efficacy of OMT on real-life patients or volunteers while in their first 2 years of medical school. Those who do not utilize OMT reported few opportunities to witness the efficacy of OMT on a real-life patient. For physicians, 96.1 % of those who utilize OMT in their practice had the opportunity to see it work positively during the first 2 years of medical school, whereas only 7.4 % who do not utilize OMT had the opportunity. These findings are mirrored in the experience of current osteopathic medical students who are interested and uninterested in utilizing OMT in their future practice. Conclusions These findings emphasize the importance of exposing our medical students to some type of ‘real-life’ experience early in their careers; the data show that these experiences can be very beneficial in expanding the interest in utilizing osteopathic manipulative medicine (OMM) in future practice. COMs can consider the implementation of programs that provide this experience to students, including extracurricular activities dedicated to the use of OMT.

Context Since William Garner Sutherland’s inception of osteopathic cranial manipulative medicine (OCMM), osteopathic physicians have practiced with the knowledge that cranial sutures exhibit motion. We hypothesize that the complexity of suture interdigitation in humans may provide clues to elucidate the concept of OCMM. Objectives We compared the interdigitation of sagittal, coronal (left and right), and lambdoid (left and right) sutures in computed tomography (CT) scans of humans and five nonhuman primate species ( Gorilla gorilla , Pongo pygmaeus , Pan troglodytes , Hylobates lar , and Nasalis larvatus ). Methods Human ages are evenly distributed between 10 and 65 years of age, with an equal number of males (n=16) and females (n=16) in the sample. Nonhuman primates are all females, and the sample includes juveniles (n=6) and adults (n=34). Sutures were evaluated on a scale ranging from 0 to 3 (0: fused sutures; 1: no interdigitation; 2: low complexity; and 3: representing the highest degree of interdigitation and complexity). Results Based on ordinary least squares linear regression, we found no significant relationship between suture interdigitation and age in humans. Chi-square tests were utilized to assess sex differences within humans, species-level differences, and differences between humans and nonhuman primates across all five sutures. Humans exhibited a statistically significant greater degree of suture complexity than all five nonhuman species across all five sutures. Conclusions These findings indicate that human suture interdigitation is more complex than their closest living relatives (African apes) and other primates (Asian monkeys and apes). We theorize that this would enable subtle movement and serve to transmit forces at the cranial sutures from dietary or ethological behaviors, similar to the pattern observed in other mammals. While humans have a softer diet compared to other living primates, the uniqueness of human craniofacial growth and extended developmental period could contribute to the necessity for complex cranial sutures. More studies are needed to understand variation in human and nonhuman sutural complexity and its relationship to cranial motion.

Sexual abuse scandals in recent years have eroded some of the trust that is foundational for the physician–patient relationship. A closer analysis of some of these stories of abuse from the standpoint of medical professionalism, primarily utilizing the example of Larry Nassar, DO, yields potential ways in which instances of abuse may be reduced or eliminated. The goal of this paper is to elicit lessons that can be learned from these tragic sequences of events so that physicians, healthcare institutions, physician practices, medical boards, and even patients themselves can introduce measures that help prevent future stories like these.

In the past decade, the rise of state legislation that allows for advanced practice provider (APP) independence has grown steadily across the country. Most recently, Montana has enacted House Bill 313, which allows for physician assistant independent practice in primary care services. This is a concerning trend because there is a multitude of studies that demonstrate worsened patient outcomes and increased healthcare expenditures for care delivered by nonphysicians. There are also many unintended consequences that are likely to occur due to this inappropriate expansion of scope of practice for APPs. In this commentary, we outline the ramifications that are likely to occur in states such as Montana that enact legislation that expands the scope of practice for nonphysicians.

Context Prescribing medications is one of the physicians’ most important professional activities throughout their careers. Lack of confidence and competency to prescribe may lead to preventable medical errors. The prevalence of prescription errors among new graduate physicians has been widely studied. Studies have linked this to inadequate foundational pharmacology education and work environment, among other factors. Suggestions were made for different educational interventions to increase the physicians’ confidence and competency in prescribing to reduce the risk of medical errors. However, many of these studies were about students or graduates of medical schools other than osteopathic medical schools. Objectives This study analyzed the self-reported confidence of graduating seniors in the United States osteopathic medical schools in their current ability to prescribe safely and independently and the possible associated factors. Methods This study analyzed secondary data on the graduating seniors’ surveys published by the American Association of Colleges of Osteopathic Medicine (AACOM) from the 2012/2013 to 2020/2021 academic years. Data were analyzed utilizing SPSS version 26.0 and MedCalc version 22.009, and statistical inferences were considered significant whenever p≤0.05. Results The aggregated data show that 38,712 Doctor of Osteopathic Medicine (DO) seniors responded to the AACOM survey, representing 72.1 % of expected graduates during the study period. Most of the DO graduating seniors (70.8 %) reported feeling confident in their current abilities to independently write safe and indicated orders and to prescribe therapies or interventions in various settings. The percentage of respondents who perceived the time devoted to clinical pharmacology instruction as appropriate increased systematically over these reported years. A positive correlation was found between the percentage of students who reported the time dedicated to clinical pharmacology as excessive and the percentage of students who reported being confident in prescribing. A statistically significant positive correlation was found between the percentage of students who agreed that the first two years of medical school were well organized and the percentage of students who reported being confident in prescribing. A statistically significant correlation was found between the percentage of students who agreed with statements about frequent interactions with the attendee, testing at the end of each rotation, and being prepared for Comprehensive Osteopathic Medical Licensing Examination Level 2-Cognitive Evaluation (COMLEX Level 2-CE) during the required clerkships and the percentage of students who reported being confident in independent prescribing. Conclusions During this study period, most osteopathic medical graduating seniors (70.8 %) felt confident about their current prescribing abilities; the rest did not, which can increase the risk of preventable medical errors. The prescription confidence may be boosted by more organization for the first 2 years, increasing the time devoted to clinical pharmacology education, and developing more interactive courses during the required clerkships in clinical education.

Context Over the past several decades, orthopedic surgery has seen a substantial increase in the number of surgeons completing fellowship training. Doctors of Osteopathic Medicine (DOs) continue to advance their orthopedic education through subspecialty fellowship training. DOs have represented between approximately 6 % and 15 % of American Orthopaedic Foot and Ankle Society (AOFAS) fellows. Although historical representation has been considered strong, the fellowship match years 2020 and 2021 have seen a decline in osteopathic orthopedic surgeons participating in foot and ankle fellowships. This deviates from the recent trends of increasing participation across orthopedic subspecialities. Objectives To investigate and review the trends of orthopedic foot and ankle fellowship training. Methods Data was reviewed from the AOFAS regarding number of fellows matched and degree obtained. Data from the Federation of State Medical Boards (FSMB), American Orthopaedic Foot and Ankle Society (AOFAS) and Association of American Medical Colleges (AAMC) were reviewed for physician trends and match statistics. Results Fellowship match years 2020 and 2021 have seen a decline in osteopathic orthopedic surgeons participating in foot and ankle fellowships, with only roughly 3% of AOFAS fellows being osteopathic trained. Conclusions Orthopedic surgery has the highest rate of subspecialty training of all surgical specialties. Although there is hope for an increasing osteopathic presence in orthopedic surgery, recent literature has pointed to potential for continued bias in opportunities for osteopathic students. We hope that increased participation of osteopathic graduates in orthopedic surgery training programs will result in the continued expansion of osteopathic orthopedic surgeons completing fellowship training, including in foot and ankle surgery.