Volume 111, Issue 6

Although the usual perspective on return to play for athletes is recovery from injury, an unheralded aspect on return to play involves potentially contagious skin infections. An estimated 8.5% of health conditions and injuries related to high school sports and 21% of health conditions and injuries related to college sports involve infectious diseases of the skin. In about half of these cases, the head, face, or neck is affected. The infectious agents are common microorganisms, including methicillin-resistant and methicillin-sensitive Staphylococcus and Streptococcus bacteria, herpes viruses, and tinea fungi. The challenge for physicians is to provide proper treatment to patients within the return-to-play guidelines of a sport's governing body, resulting in rapid resolution of the condition, minimization of time spent out of the sport, and minimization of communicable spread of the disease.

The authors ask for reader support of the Osteopathic Graduate Medical Education Development Initiative, which assists nonteaching hospitals in starting new osteopathic training programs.

Context: Falls, many of which are caused by balance problems, are a leading cause of injuries in elderly persons. Few studies have investigated osteopathic manipulative treatment (OMT) for patients with balance problems. Objective: To test whether an OMT protocol with an emphasis on cranial manipulation can improve vestibular balance control structures and postural stability in a healthy elderly population. Design: A pilot prospective clinical trial. Setting: Research laboratories of the University of North Texas Health Science Center Texas College of Osteopathic Medicine in Fort Worth. Patients: Forty healthy elderly patients aged 65 or older were enrolled and separated into an OMT group and a control group. Owing to the recruitment process and limited time for the study, the first 20 patients to enroll were in the OMT group, and the next 20 were in the control group. Patients were excluded if they had a condition that could impair balance. Intervention: The OMT protocol comprised 7 OMT techniques applied weekly by the same osteopathic physician before balance tests. Patients in the control group received no treatment. Main Outcome Measures: Patients were asked to stand on a force plate and to perform 3 balance tests: (1) eyes open, (2) eyes closed, and (3) a modified Romberg test. The center of pressure between their feet was recorded for 30 seconds. The average center of pressure displacement for each test was used to determine anteroposterior (AP) sway and mediolateral (ML) sway. Balance tests were performed each week for 4 weeks. Tests were performed at the same time of day as the first test. Results: Changes in AP sway values between visits 1 and 4 were as follows: eyes open, -0.72 and 0.75 mm for the control and OMT groups, respectively; eyes closed, -0.49 and 0.44 mm; and Romberg test, -0.17 and 0.52 mm. The changes in ML sway values between visits 1 and 4 were as follows: eyes open, -0.58 and 0.07 mm for the control and OMT groups, respectively; eyes closed, -0.21 and 0.03 mm; and Romberg test, -0.15 and 0.39 mm. The OMT group had significantly reduced sway for the eyes-open test after 4 visits ( P =.001). Conclusion: The OMT protocol used in the present study improved the postural stability of healthy elderly patients, as measured by changes in sway values. (ClinicalTrials.gov number NCT01153412)

Context: Infections due to methicillin-resistant Staphylococcus aureus (MRSA), especially community-acquired MRSA, have increased substantially during the past decade. The optimal protocols for screening patients, particularly during pregnancy, have not been determined. Objectives: To determine the incidence of nasopharyngeal carriage of MRSA in pregnancy as well as whether there was a correlation between positive maternal screening test results and an increased risk of adverse maternal or neonatal outcomes, including neonatal carriage of MRSA. Methods: The authors conducted a retrospective review of medical records from Rockford Memorial Hospital in Illinois between December 14, 2007, and July 14, 2008. All patients, who were pregnant women admitted to the hospital, and their newborns had nasopharyngeal swabs collected for MRSA detection. Numbers of neonatal intensive care unit admissions and results of neonatal sepsis evaluations were noted. Maternal postoperative infections and anesthesia-related complications were noted and compared to those of control patients. Apgar scores at birth were compared with those of a control group. Results: Of 1045 patients who were tested, 31 patients (2.9%) had positive results for MRSA. By comparison, the hospital-wide MRSA prevalence for this period was 7.9% (569 positive results of 7206 patients tested). This prevalence was substantially higher than that noted for the study population. Twenty-three of the 31 patients (74%) delivered at our institution and thus comprised the study group. A control group comprised 46 patients with negative results of MRSA screening. No positive results of neonatal MRSA screening tests were noted in either group, and no statistically significant difference between the 2 groups existed in 5-minute Apgar scores, neonatal intensive care unit admissions, or neonatal sepsis evaluations. Positive MRSA-screening test results were associated with a statistically significant decrease in the provision of regional anesthesia to the pregnant women ( P =.05). Conclusion: Maternal nasopharyngeal carriage of MRSA was not associated with adverse maternal or neonatal outcomes, including neonatal MRSA carriage. Regional anesthesia was provided less frequently to MRSA-positive individuals. Further studies in larger groups of patients are needed to help determine the optimal management of MRSA-positive patients during pregnancy.

Context: The Comprehensive Osteopathic Medical Licensing Examination-USA (COMLEX-USA) currently assesses osteopathic medical knowledge via a series of 3 progressive cognitive examinations and 1 clinical skills assessment. In 2009, the National Board of Osteopathic Medical Examiners created the Fundamental Osteopathic Medical Competencies (FOMC) document to outline the essential competencies required for the practice of osteopathic medicine. Objectives: To measure the distribution and extent to which cognitive examination items of the current series of COMLEX-USA assess knowledge of each of the medical competencies included in the FOMC document. Methods: Eight graduate medical education panelists with expertise in competency-based assessment reviewed 1046 multiple-choice examination items extracted from the 3 COMLEX-USA cognitive examinations (Level 1, Level 2-Cognitive Evaluation, and Level 3) used during the 2008-2009 testing cycle. The 8 panelists individually judged each item to classify it as 1 of the 6 fundamental osteopathic medical competencies described in the FOMC document. Results: Panelists made 8368 judgments. The majority of the sample examination items were classified as either patient care (3343 [40%]) or medical knowledge (4236 [51%]). Panelists also reported these 2 competencies as being the easiest to define, teach, and assess. The frequency of medical knowledge examination items decreased throughout the COMLEX-USA series (69%, 43%, 40%); conversely, items classified as interpersonal and communication skills, systems-based practice, practice-based learning and improvement, and professionalism increased throughout the 3-examination series. Conclusion: Results indicate that knowledge of each of the 6 competencies is being assessed to some extent with the current COMLEX-USA format. These findings provide direction for the enhancement of existing examinations and development of new assessment tools.

A 37-year-old white woman presented with acute bilateral hamstring pain after hiking. She had a creatine kinase level of 11,144 U/L. Rhabdomyolysis was diagnosed and the patient was admitted for intravenous fluid hydration. The patient continued to have exercise-induced myalgias and elevations in her creatine kinase level. Rheumatologic causes were ruled out and results from electromyogram testing were nondiagnostic. A muscle biopsy revealed a mitochondrial myopathy. The 22 mitochondrial DNA and transfer RNA genes were sequenced. An A-to-G transition was found at nucleotide position 4281 in the transfer RNA isoleucine gene. The patient was placed on a regimen of riboflavin, vitamin C, and coenzyme Q10, which provided mild relief. The patient returned to the emergency department 2 more times after vigorous exercise, with creatine kinase levels as high as 2800 U/L. At last follow-up, the patient was using a fentanyl citrate transdermal patch, which enabled her to perform moderate exercise without pain.

A limited number of cases have been reported in the medical literature in which aortic dissection occurs with an aberrant right subclavian artery and a common carotid trunk. The authors report the case of a 59-year-old man who presented to the emergency department with sudden onset pain of 30 minutes duration on the right side of the buttocks. After presentation, the patient developed chest pain, which radiated to the back. Computed tomography angiogram revealed a Stanford type A aortic dissection that extended down to the bifurcation of the iliac arteries. He was also found to have an aberrant right subclavian artery with a retroesophageal tract and a common trunk of the common carotid arteries. The patient was transferred to a tertiary care center and underwent surgery for aortic arch replacement. The authors also discuss the embryologic development of these vascular abnormalities.