Volume 118, Issue 12

Background The goal of Open Payments and the Physician Payments Sunshine Act is to foster transparency and accountability to help stakeholders better understand financial ties between physicians and teaching hospitals and the pharmaceutical and medical device industries. Objective To evaluate the nature of industry relationships among cardiologists using the Open Payments database. Methods The authors used the Centers for Medicare & Medicaid Services Open Payments data for calendar year 2015 to evaluate the financial relationship between cardiologists and medical industries (manufacturers of medications, devices, biologics, and medical supplies). The database used in this specific investigation included general payments reported for 2015. Payments were broken down by totals, type, company, and range. Results In the 2015 calendar year, 81,977 payments were made to 12,078 cardiologists, amounting to $13,906,167.43. The minimum payment made to a cardiologist was $1.16 and the maximum, $2,805,825. The most frequent category was $11 to $50, with 53,722 payments made (65.5%), followed by less than $10, with 12,307 payments made (15.0%). Conclusion Payments to cardiologists were highly variable. Additional studies regarding the effects of these payments may be warranted.

Context Since 2013, prothrombin complex concentrate (PCCs) have been approved in the United States for the reversal of anticoagulation induced by vitamin K antagonists. However, there has been limited investigation into their use in trauma and acute-care surgery (ACS). Objective To investigate the role that 4-factor PCC may have in reversing anticoagulation in the setting of trauma and ACS. Methods All trauma and ACS patients who presented between March 14, 2014, and August 1, 2015, were included in this retrospective descriptive analysis. Patients receiving 4-factor PCC were compared with patients receiving fresh frozen plasma (FFP) alone. The following data were collected from medical records: age, sex, race, international normalized ratio (INR) at admission (baseline) and after reversal, blood products given, dosing of medication, injury severity score, length of stay, thromboembolic event, death during admission, and death within 90 days after admission. Results There were 188 trauma and ACS patients who required reversal of anticoagulation. Of these, 98 patients received FFP and 90 received PCC. Patients who received PCC were at increased risk for death during admission (20% vs 9.2% for FFP group) or within 90 days (39% vs 15%, respectively). Patients in the PCC group had a higher median baseline INR (2.9 vs 2.5 in the FFP group) and a lower postintervention INR (1.4 vs 1.8); consequently, the decrease in INR was greater in the PCC group than in the FFP group (1.5 vs 0.7, respectively). The number of total units of packed red blood cells transfused was significantly higher in patients receiving PCC. Conclusion Patients receiving PCC had worse outcomes than those who received FFP. Given that these differences may have resulted from baseline differences between groups, these results mandate further prospective analysis of the use of PCC in trauma and ACS patients.

Context In 2012, the US wound registry estimated that the cost of managing chronic wounds in the United States exceeded $50 billion. A large percentage of these wounds are venous stasis ulcers of the lower extremity. Evidence suggests that adjuvant osteopathic manipulative treatment (OMT) may provide a benefit by reducing edema and subsequent healing times in venous stasis ulcers of the lower extremity. Objective To determine whether a lymphatic OMT protocol improves wound healing rates among patients with lower-extremity edema. Methods This pilot study was a nonrandomized before-after community trial of lymphatic OMT in patients with lower-extremity wounds and edema. Wound surface area measurements for the preliminary phase were obtained retrospectively. During the intervention period, patients received 10 minutes of OMT twice per week. The OMT protocol, which aimed to improve lymphatic flow, included myofascial thoracic outlet release, doming of the diaphragm, pelvic diaphragm release, popliteal release, and pedal pump (2-3 minutes of continuous pump) performed in sequence. Rates of wound healing were compared between the preliminary (standard therapy), intervention (standard therapy plus OMT), and follow-up (standard therapy) phases. Rates of change in edema (measured using leg volume) were evaluated during the intervention phase. A custom-designed questionnaire was used to assess patients’ satisfaction with their treatment and confidence that its effects on their health were good. Results Eight patients were included in the study. The wound surface area increased during the preliminary phase by a mean of 10 cm 2 /wk and decreased during the intervention phase by a mean of 4.9 cm 2 /wk. Patients’ mean leg volume decreased during the intervention phase. Six patients were “very satisfied” with their treatment. Conclusion The adjunctive OMT protocol may have reduced edema and reversed the trend of wound growth in patients with venous stasis ulcers. Edema reduction is a mainstay of current wound therapy, and any modality that decreases edema may subsequently decrease healing times.

Osteopathic medicine is continuing to move toward competency-based education at undergraduate and graduate levels. Competencies and Entrustable Professional Activities (EPAs) have been implemented to guide educators on the skills and abilities that osteopathic medical students and residents should be able to perform as physicians. Unfortunately, many of these skills have not been well described, and the threshold of “competence” or “entrustability” for each of these tasks remains elusive. The author presents an approach to measuring competence in the domain of osteopathic manipulative medicine using a milestone rubric to assess skills related to osteopathic screening, diagnosis, technique, and explanation. This rubric can be applied to all levels of osteopathic training and across many diagnostic and treatment modalities. Clearly defining and assessing the individual skills composing competence in osteopathic manipulative medicine will be increasingly important as medical education continues to evolve and modernize.

Context Some medical educators have noted a decline in classroom attendance. Understanding student preferences for content delivery and the relationship between student attendance and learning outcomes may enhance curricular design and best practices for technology-supported learning. Objective To measure the attendance of first-year osteopathic medical students, evaluate the relationship between classroom attendance and aggregate mean course grades, and characterize factors that influence attendance decisions when recorded lectures are available. Methods In nonmandatory class sessions during the 2015-2016 academic year, student attendance data were collected using audience response technology and were linked to course grades. Pearson product moment and partial correlations, controlling for Medical College Admissions Test scores, were calculated to quantify the relationship between classroom attendance and aggregate mean course grades. Students were surveyed to characterize factors influencing attendance decisions and compare the perceived convenience, efficiency, and effectiveness of classroom attendance vs lecture capture technology. The preferred modality for receiving didactic content was assessed, and open-ended questions were included about the advantages or disadvantages of lecture capture, classroom attendance, and podcasts. Responses were analyzed using open and axial coding. Results A 78% reduction in first-year student classroom attendance was measured from the beginning to the end of the academic year ( P <.001). The correlation between classroom attendance and aggregate mean course grades ( r= 0.17; P= .29) and the partial correlation between them after controlling for admission test scores ( r= 0.18; P= .08) were not significant, except in the Neuromusculoskeletal A course ( r= 0.22; P= .027). Students regarded lecture capture recordings as more convenient, efficient, and effective than classroom attendance, and podcasting was the preferred method of content delivery. Major themes associated with the open-ended questions were effective or ineffective time management, enhanced interaction, learning advantages or challenges, and positive or negative content characteristics. Conclusion First-year classroom attendance decreased significantly during the academic year, but the authors found no significant relationship between attendance and aggregate mean course grades. Students regarded lecture capture recordings as a practical alternative to attending class; however, podcasts were the preferred modality for receiving didactic content. These findings may help in developing learning-centered curricula at colleges of osteopathic medicine.

Sarcoidosis is a granulomatous condition that has a highly variable presentation. One rare presentation of sarcoidosis is cutaneous scalp sarcoidosis. Usually scalp sarcoid presents as a scarring alopecia, but it can be nonscarring. The presence of sarcoidal lesions on the scalp is associated with systemic disease, as are other cutaneous manifestations of sarcoidosis. The authors present the case of a 64-year-old woman with a history of sarcoidosis who presented with alopecia and hypopigmented patches on her scalp. She also had papular sarcoid lesions on her upper back and a history of pulmonary involvement, which is consistent with previous reports in the literature. The condition subsequently improved with topical clobetasol propionate.

While competing in an obstacle course race, a 57-year-old male athlete developed left groin and leg pain. Several days later, infrarenal aortic dissection with clinically worsening left leg ischemia was diagnosed. An emergent repair was performed and consisted of an aorto-uni-iliac endovascular stent graft, an occluder in the left iliac artery, and a right-to-left femoral-femoral artery bypass. To the authors’ knowledge, the present report is the first case of a spontaneous infrarenal aortic dissection in a competitive athlete associated with participation in an extreme athletic event.