Volume 115, Issue 12

Introduction: Direct recommendation from health care professionals has been shown to generally increase colorectal cancer screening rates in the United States. However, data for rural, underserved communities are limited. Objective: To increase colorectal cancer screening rates at a rural community health center (CHC) by increasing health care professionals’ awareness of patients’ screening eligibility. Methods: Participants were health care professionals at a CHC treating patients eligible for colorectal cancer screening (defined as patients aged 50-74 years who visited the CHC between February 24, 2014, and March 15, 2014, and whose electronic medical records [EMRs] had no recording of colorectal cancer screening). For a 3-week period, these participants added electronic reminders to eligible patients’ EMRs. Data reports for the screening rates of each participant, in addition to the overall CHC, were generated 4 weeks after the study period and compared with screening rates in 2013. Results: Five health care professionals volunteered to participate. No statistically significant difference was found in screening rates of participants compared with overall clinic rates between the 2013 ( P =.639) and 2014 ( P =.583) sample dates. No statistically significant difference was found in the overall CHC screening rates ( P =.052), which were 47.69% and 40.84% in 2013 and 2014, respectively. During the study period, 99 eligible patients were seen. An incidental finding revealed a substantial EMR flaw in uniform data system reporting measures: self-reported colorectal cancer screenings by patients, without official documentation provided, were documented in an EMR section that is not retrieved during uniform data system reporting. Conclusion: No associated change in colorectal cancer screening rates was found at the CHC after increasing participants’ awareness of patients’ screening eligibility using electronic flagging. However, colorectal cancer screening results cannot be reported with certainty given that incidental documentation and data collection discrepancies were found.

Context: The establishment of a single accreditation system for graduate medical education in the United States suggests a convergence of osteopathic and allopathic medicine. Objective: To compare the characteristics of medical care provided by osteopathic and allopathic physicians. Methods: Five-year data from the National Ambulatory Medical Care Survey were used to study patient visits for primary care, including those for low back pain, neck pain, upper respiratory infection, hypertension, and diabetes mellitus. Patient status, primary reason for the visit, chronicity of the presenting problem, injury status, medication orders, physician referrals, source of payment, and time spent with the physician were used to compare osteopathic and allopathic patient visits. Results: A total of 134,369 patient visits were surveyed, representing a population (SE) of 4.57 billion (220.2 million) patient visits. Osteopathic physicians provided 335.6 (29.9) million patient visits (7.3%), including 217.1 (20.9) million visits for primary care (9.7%). The 5 sentinel symptoms and medical diagnoses accounted for 233.0 (12.4) million primary care visits (10.4%). The mean age of patients seen during primary care visits provided by osteopathic physicians was 46.0 years (95% CI, 44.1-47.9 years) vs 39.9 years (95% CI, 38.8-41.0 years) during visits provided by allopathic physicians ( P <.001). Osteopathic patient visits were less likely to involve preventive care (OR, 0.55; 95% CI, 0.44-0.68) and more likely to include care for injuries (OR, 1.60; 95% CI, 1.43-1.78). Osteopathic physicians spent slightly less time with patients during visits (mean, 16.4 minutes; 95% CI, 15.7-17.2 minutes) than allopathic physicians (mean, 18.2 minutes; 95% CI, 17.2-19.3 minutes). The most distinctive aspect of osteopathic medical care involved management of low back pain. Therein, osteopathic physicians were less likely to order medication (OR, 0.33; 95% CI, 0.15-0.75) or to refer patients to another physician (OR, 0.47; 95% CI, 0.23-0.94), despite having more visits paid through Worker’s Compensation (OR, 3.63; 95% CI, 1.01-13.07). Osteopathic and allopathic medical care for upper respiratory infection, hypertension, and diabetes mellitus were comparable. Conclusion: Practice patterns of osteopathic physicians generally mirror those of allopathic physicians except that osteopathic physicians deliver more medical care for older patients and at later stages of disease. Osteopathic medicine should be promoted more vigorously among younger and healthier persons. New opportunities may arise for osteopathic physicians to demonstrate a distinctive approach to low back pain as changes emerge in graduate medical education.

Context: Patients receiving femoral nerve blocks for total knee arthroplasty (TKA) have been shown to have a high incidence of postoperative falls, which has been attributed to weakening of the quadriceps muscles. Local injection of analgesic medication that allows for full motor function of the quadriceps and, therefore, better progress through inpatient physical therapy and decreased hospital stay, has been suggested as an option for postoperative pain relief. Objective: To compare the number of inpatient physical therapy sessions and hospital days needed in patients receiving periarticular injection of extended-release bupivacaine liposome vs femoral nerve block after TKA. Methods: Data were retrospectively reviewed from the records of patients who underwent bilateral primary TKA, in which femoral nerve block was administered at the first operation and periarticular injection of an extended-release bupivacaine liposome mixture at the second operation. An average of 2.3 years had passed between the 2 procedures. The number of inpatient physical therapy sessions and hospital days needed were compared between both procedures for each patient. Results: Sixteen patients (14 women) were included in the study, with a mean (SD) age of 63.8 (6.7) years. Compared with femoral nerve block, periarticular injection of analgesic medication resulted in fewer inpatient physical therapy sessions (femoral nerve block: mean [SD], 3.5 [1.3] sessions; periarticular injection: mean [SD], 2.3 [1.0] sessions; P =.002) and fewer hospital days (femoral nerve block: mean [SD], 1.9 [0.6] days; periarticular injection: mean [SD], 1.5 [0.6] days; P <.032). Conclusion: Compared with femoral nerve block, periarticular injection of analgesia was found to quicken postoperative recovery in patients hospitalized for TKA. The use of periarticular injections in patients undergoing TKA could yield substantial cost savings given the high frequency of this procedure.

The structures in the posterolateral corner of the knee, which stabilize the joint, are often involved in injuries to the posterior cruciate ligament. Familiar structures include the anterior cruciate ligament, posterior cruciate ligament, tibial collateral ligament, and menisci. Less familiar are the structures of the posterolateral corner, the most important of which are the fibular collateral ligament, popliteus tendon, and popliteofibular ligament, which resist varus angulation, external rotation, or posterior translation of the tibia. Injury to the posterolateral corner can be assessed with the posterolateral drawer, dial, reverse pivot shift, external rotation recurvatum, and varus stress tests. The purpose of this review is to highlight the posterolateral corner of the knee and injuries to its structures so that physicians can more accurately diagnose these injuries and provide appropriate treatment. Management focuses on restoring the fibular collateral ligament, popliteofibular ligament, and, in certain cases, the popliteus tendon.

Context: With the growing number of osteopathic physicians practicing in the United States and the creation of a single graduate medical education system, a continued need exists for focused education in osteopathic principles, philosophy, and treatment modalities in primarily allopathic residency programs. Objective: To create and integrate a resident-led osteopathic manipulative treatment (OMT) clinic in an allopathic residency program. Methods: After an informal needs assessment on the basis of resident survey data, a resident-led OMT clinic was created within a military allopathic family medicine residency program. A standard operating procedure, resident survey, and scheduling system were created by the residents for approval by the departmental and hospital leadership. Resident survey data pertaining to the time available to perform OMT, education, and faculty supervision of OMT were obtained before the clinic implementation and 1 year after implementation. Results: Nine osteopathic residents were surveyed before the OMT clinic implementation to illustrate a need for continued osteopathic medical education, faculty support, and skill maintenance. Sixteen osteopathic residents were surveyed after the OMT clinic implementation. More residents indicated that the establishment of an osteopathic curriculum was important (3 of 9 in the preclinic survey vs 9 of 16 in the postclinic survey) and that the program promoted the use of OMT (0 of 9 in the preclinic survey vs 13 of 16 in the postclinic survey). Conclusion: A resident-led OMT clinic can be successfully implemented, maintained, and expanded in an allopathic residency program by implementing an OMT curriculum, offering elective rotations, and encouraging regular use of OMT. The current project can be used as a framework for implementing an OMT clinic.

Autoimmune progesterone dermatitis (AIPD) is an uncommon condition in which allergic dermatitis to endogenous progesterone manifests in cyclic cutaneous eruptions. In this case series, we present 3 patients with AIPD, each with unique presentations and medical histories emblematic of the disease. Cyclic dermatitis related to menses in a premenopausal woman should raise high clinical suspicion for AIPD, especially in the primary care or emergency setting. Because of the rarity of this disorder, this case series seeks to describe AIPD to medical providers of young women, as well as present relevant literature related to the disease. We propose clinical considerations for women of reproductive age with AIPD.