Volume 110, Issue 6

Context: Rib raising is an osteopathic manipulative treatment technique used to address restricted excursion of the rib cage and modulate sympathetic nervous system (SNS) activity. However, the physiologic effects of this technique have not been well documented. Objective: To investigate the effects of rib raising on the autonomic nervous system and the hypothalamic-pituitary-adrenal axis using noninvasive biomarkers. Methods: Changes in salivary biomarkers after rib raising were investigated using a pretest-posttest, placebo-controlled design. Healthy adult participants were recruited and randomly assigned to rib raising or placebo (light touch) groups. All participants provided baseline saliva samples and samples immediately and 10 minutes after receiving the rib raising or placebo procedure. Salivary flow rate, α-amylase activity, and cortisol levels were measured for each sample. Results: Twenty-three participants were recruited, of whom 14 completed the study (7 in each group). Subjects who received rib raising had a statistically significant decrease in α-amylase activity both immediately after ( P =.014) and 10 minutes after ( P =.008) the procedure. A statistically significant change in α-amylase activity was not seen in the placebo group at either time point. Changes in salivary cortisol levels and flow rate were not statistically significant in either group. Conclusions: The results of the present pilot study suggest that SNS activity may decrease immediately after rib raising, but the hypothalamic-pituitary-adrenal axis and parasympathetic activity are not altered by this technique. Salivary α-amylase may be a useful biomarker for investigating manipulative treatments targeting the SNS. Additional studies with a greater number of subjects are needed to expand on these results.

Context: Knowledge of the trends and possible differences in the use of antihyperlipidemic medications in US patients with coronary heart disease (CHD) is vital in order to stimulate a positive change in the health of society. Objective: To assess, in the ambulatory setting, the frequency of antihyperlipidemic medication use in US patients with CHD. Design: Retrospective, national, cross-sectional study using data from the 2004 National Ambulatory Medical Care Survey (NAMCS). Methods: Ambulatory medical visits surveyed by the 2004 NAMCS associated with select ICD-9-CM CHD-related diagnoses were included. Use of antihyperlipidemic medications was captured by searching the database for drug names. Demographics assessed for association with antihyperlipidemic therapy included region of the country in which care was provided; patient age group, sex, ethnicity, and race; physician medical degree; and payment type. Statistical analyses used sample weights to determine national estimates. Results: A weighted national estimate of nearly 16 million ambulatory medical care visits was made in the United States in 2004 of patients with one of the selected CHD diagnoses. Use of any form of lipid-lowering therapy was associated with 40.4% of the CHD patients seeking ambulatory-based medical care in 2004. Non-Hispanic/Latino patients with CHD were more than 4.5 times more likely to be receiving lipid-lowering therapy (odds ratio [OR], 4.59; 95% CI, 1.28-16.37). Patients with CHD who had Medicare as their form of payment for healthcare were less likely to be receiving lipid-lowering therapy (OR, 0.50; 95% CI, 0.28-0.91), as were those receiving medical care in the South region of the United States (OR, 0.36; 95% CI, 0.14-0.89). Similar differences in medication use were noted with the statin medication class. Conclusion: In 2004, less than half of the ambulatory medical visits by US patients with CHD were associated with antihyperlipidemic treatment, and most of these patients were treated with one medication (a statin). A CHD patient's reported ethnicity, primary method of payment, and area of the United States in which care was received all demonstrated differences. On the basis of the growing evidence-based medical literature, it is imperative to continue this research to assess changes in future trends and to work with healthcare and policy advocates to strike a positive change for all patients.

Context: Traditionally, an apprenticeship model has been used for the instruction of invasive bedside procedures. Because this approach is subject to nonuniform application, a new model was established to determine the impact of a standardized curriculum on medical students' and residents' medical knowledge and technical skills. Methods: A procedural instruction curriculum for medical students and residents was developed, and a pilot program with the curriculum was incorporated into an internal medicine residency program. Five common procedures in osteopathic and allopathic internal medicine training programs were included: central venous catheterization, knee arthrocentesis, lumbar puncture, paracentesis, and thoracentesis. An initial assessment of participants' baseline knowledge and skills was obtained. Teaching methods included video instruction; discussion of key concepts; faculty-led, hands-on, simulation-based instruction; and individual deliberate practice. Postinstruction knowledge and skills were evaluated, respectively, through a written test and a quantified assessment (ie, checklist) using direct observation. Participants were asked to provide written feedback at the conclusion of each instructional module. Results: A total of 60 participants, all in allopathic medicine, underwent the training component. Fifty-two participants were internal medicine residents (including 2 from an outside program); 4 were trainees in a combined internal medicine–pediatrics residency; and 4 were medical students (1 from an outside program). Participants demonstrated a statistically significant improvement ( P <.001) in medical knowledge, as evidenced by preinstruction vs postinstruction test scores. Comparison of initial baseline procedural checklist scores with postinstruction checklist scores, during participants' performance on the first live patient, also showed statistically significant improvement ( P <.001). Conclusion: A simulation-based, standardized curriculum in invasive bedside procedural instruction significantly improved the medical knowledge and technical skills of novice physicians.

“Soul sickness,” or demoralization , is characterized by feelings of hopelessness and helplessness and a perceived sense of incompetence. This condition typically involves vague, unexplained physical symptoms. Soul sickness can be efficiently diagnosed by asking patients a series of questions about their personal lives. Patients with this condition require a restoration of their morale and hope. Physicians can assist patients in regaining hope by encouraging them to focus on new, adaptive behaviors. As osteopathic physicians, we can use our skills in osteopathic manipulative treatment to manage the demoralization-related physical symptoms of patients.