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The Journal of the American Osteopathic Association ( JAOA ) encourages osteopathic physicians, faculty members and students at colleges of osteopathic medicine, and others within the health care professions to submit comments related to articles published in the JAOA and the mission of the osteopathic medical profession. The JAOA's editors are particularly interested in letters that discuss recently published original research. Letters must be submitted online at http://www.osteopathic.org/JAOAsubmit. Letters to the editor are considered for publication in the JAOA with the understanding that they have not been published elsewhere and are not simultaneously under consideration by any other publication. All accepted letters to the editor are subject to editing and abridgment. Although the JAOA welcomes letters to the editor, these contributions have a lower publication priority than other submissions. As a consequence, letters are published only when space allows.

Context: Intraoperative blood loss during open lumbar spine surgery is associated with adverse events and is a contributor to higher medical costs. Intraoperative hypothermia has been shown to increase blood loss and postoperative allogeneic blood transfusion rates in other realms of orthopedic surgery, but it has not been studied extensively in patients undergoing spine surgery. Objective: To determine whether a clinically relevant association exists between intraoperative core body temperature and blood loss or transfusion rates in adult patients undergoing open lumbar spine surgery. Methods: In this retrospective medical record review, the surgical records of 174 adult patients who underwent open, nonmicroscopically assisted lumbar spine surgery performed by a single surgeon at a single institution were evaluated. Maximum, minimum, and average temperature, hypothermic temperature, and temperature range parameters were compared with intraoperative, total, and net blood loss and blood transfusion parameters. Additional patient demographic and perioperative characteristics were compared with blood loss and transfusion parameters to determine potential confounders. Analysis of variance, Spearman rank correlation, and generalized multiple linear regression analysis were performed to test for an association between temperature and blood loss or allogeneic transfusion rates. Statistical significance was set at P ≤.05. Results: After implementation of exclusion criteria, 160 patient records and 168 surgical procedures were included in the analysis. For patients whose temperature decreased to a hypothermic level at some point during the procedure, hypothermic maximum temperature was protective against blood loss on bivariate analysis ( P ≤.02), but this finding lost significance after multivariate regression analysis ( P >.09). Temperature range was associated with increased blood loss on bivariate analyses ( P <.001) but also lost significance after adjusting for covariates in regression analysis ( P ≥.65). Surgery type ( P ≤.001) and operative time ( P ≤.001) were the most robust predictors of increased blood loss (P=.005) and were significantly associated with temperature ( P <.001). Conclusion: No effect was found on perioperative blood loss from any temperature parameter or hypothermia in adult patients who underwent lumbar spine surgery once covariates were controlled for with multivariate analysis. One possible interpretation of these results is that the effect of temperature on blood loss can be explained by its strong relationship to the confounders of operative time and surgery type. J Am Osteopath Assoc. 2014;114(11):828-838 doi: 10.7556/jaoa.2014.169

This final article in the series on the medical management of ionizing radiation injuries and illnesses focuses on the effects of acute ionizing radiation exposure to one of the largest organ systems of the body—the skin. These injuries may extend beyond the skin into deeper tissues and cause local radiation injury. There are numerous causes of these injuries, ranging from industrial incidents to medical procedures. In the present article, the authors characterize the clinical course, pathophysiologic process, sources of injury, diagnosis, and management of local radiation injury and describe a clinical scenario. This information is important for primary care physicians, to whom patients are likely to initially present with such injuries. J Am Osteopath Assoc. 2014;114(11):840-848 doi: 10.7556/jaoa.2014.170

Context: During the first 2 years of osteopathic medical school, osteopathic manipulative medicine (OMM) courses use an objective professionalism score to measure student timeliness and appropriate dress for learning activities. Objective: To assess for correlations between this score and the numeric course grades of all first- and second-year basic science and clinical courses at a single osteopathic medical school. Methods: The professionalism scores obtained for each of the 7 quarters of the OMM course (2007-2012) were compared with the students' numeric final course grades and combined grade point average (GPA) of all courses in the corresponding quarter. Spearman correlation coefficients were used to determine the strength of the relationship between the professionalism score and the final course grades and the combined GPA. Results: The mean (SD) professionalism score was 98.6% (3.3%), and scores ranged from 23.1% to 100%. Excluding the OMM course, the professionalism score was positively correlated with 29% of first-year course grades and 65% of second-year course grades. The professionalism score was predictive of academic performance in 16 of 23 clinical courses with the highest correlation for Principles of Medicine and Dermatology (ρ=0.28 and ρ=0.25, respectively). The OMM professionalism score was positively associated with GPA for quarters 1, 6, and 7 ( P =.006, P <.001, and P <.001, respectively). Professionalism scores were significantly lower in the second year ( P <.001). Conclusion: Objective measures of professionalism correlated with academic performance in many first- and second-year osteopathic medical school courses, particularly clinical courses in the second-year curriculum. J Am Osteopath Assoc. 2014;114(11):850-859 doi: 10.7556/jaoa.2014.171

Osteopathic manipulative medicine researchers often use sham therapy as the placebo control during clinical trials. Optimally, the sham therapy should be a hands-on procedure that is perceptually indistinguishable from osteopathic manipulative treatment, does not create an effect on its own, and is not a treatment intervention. However, the sham therapy itself may often influence the outcome. The use of cardiovascular variability (eg, beat-to-beat heart rate variability) as a surrogate for the autonomic nervous system is one objective method by which to identify such an effect. By monitoring cardiovascular variability, investigators can assess autonomic nervous system activity as a response to the sham therapy and quickly determine whether or not the selected sham therapy is a true placebo control. The authors provide evidence for assessment of beat-to-beat heart rate variability as one method for assuring objectivity of sham therapy as a placebo control in osteopathic manipulative medicine research. J Am Osteopath Assoc. 2014;114(11):860-866 doi: 10.7556/jaoa.2014.172

Context: The electrocardiographic (ECG) pattern of high-grade stenosis of the left anterior descending coronary artery (LAD) is important clinically because of the high risk of myocardial infarction and cardiac death if the pattern is not recognized. Although the recognition of this pattern is currently widespread, false-positive ECG changes that mimic this pattern are infrequently reported. Objective: To demonstrate that ECG changes from intermittent left bundle branch block (LBBB) and cardiac memory can mimic anterior ischemia. Methods: Medical record review of cardiology patients in whom ECG tracings showed intermittent LBBB and anterior T-wave changes during normal QRS conduction. Patients were included if ECG changes suggestive of high-grade LAD stenosis in leads V2 and V3 met the following criteria: (1) the QRS conduction was essentially normal during periods of absent LBBB; (2) the ST segment took off from an isoelectric point or only slightly elevated from baseline; and (3) the ST segment sloped up gradually with an abrupt and sharp down stroke leading to terminal T-wave inversion. Additional criteria were little or no ST segment elevation, no loss of precordial R waves, and ECG changes suggestive of high-grade LAD stenosis demonstrated in precordial leads V2 and V3. All patients demonstrated intermittent LBBB, and patients were excluded if a ventricular pacemaker was present. The case series began in 2003 and continued until 2011. Results: Sixteen patients (3 male) with intermittent LBBB were identified with ST- and T-wave changes during normal ventricular conduction that matched the pattern described by Hein J.J. Wellens, MD. Of these patients, none had evidence of clinically substantial coronary artery disease. Eleven patients had stress testing with myocardial perfusion imaging, and 5 patients underwent cardiac catheterization. In 1 patient whose ECG pattern showed high-grade LAD stenosis but normal coronary arteries at catheterization, a stress test was later performed, which provoked LBBB. All other patients had spontaneous, intermittent periods of LBBB and normal conduction. Conclusion: The ECG pattern of high-grade LAD stenosis has proven to be an important marker of high-risk patients with chest pain. This pattern may also be seen in patients with a right ventricular pacemaker on resumption of native QRS conduction. Intermittent LBBB is a less obvious cause of a similar ECG pattern that may mimic anterior ischemia due to high-grade stenosis. J Am Osteopath Assoc. 2014;114(11):868-873 doi: 10.7556/jaoa.2014.174

Postural orthostatic tachycardia syndrome (POTS) is associated with many symptoms including orthostatic intolerance, fatigue, palpitations, and cognitive dysfunction. Treatment, which typically consists of exercise, increased dietary sodium and fluids, compression garments, and medications for orthostatic intolerance, frequently produces unsatisfactory results. The authors report the case of a 26-year-old woman who presented with a 6-year history of severe fatigue, orthostatic intolerance, heat intolerance, cognitive dysfunction, and diffuse pain. She had previously injured her jaw on an obstacle course. Results of a standing test were consistent with POTS. After standard medical therapy was unsuccessful, the patient was referred for osteopathic manipulative treatment. At her 18-month follow-up, the patient's symptoms had improved dramatically. Physicians should consider osteopathic evaluation and manipulative treatment when caring for patients with POTS. J Am Osteopath Assoc. 2014;114(11):874-877 doi: 10.7556/jaoa.2014.173