Volume 115, Issue 5

Context: The American Osteopathic Association requires the integration of osteo-pathic principles and practice in all specialty residency training programs that it accredits, but the 4 residencies with the most integration of osteopathic manipulative medicine (OMM) have differences in training and emphasis on OMM as a primary treatment modality. Objective: To study differences in OMM use for spinal pain between the neuro-musculoskeletal medicine/OMM (NMM/OMM), the family practice/osteopath-ic manipulative treatment (FP/OMT), the integrated FP/OMT and NMM/OMM (FP/NMM), and the internal medicine and NMM/OMM (IM/NMM) specialty residency training programs. Methods: Medical records were reviewed for patient encounters from September 2011 through October 2013 at NMM/OMM, FP/OMT, FP/NMM, and IM/NMM residencies in a family medicine and OMM specialty clinic. Records were screened for a diagnosis of cervicalgia, thoracalgia, lumbago, or backache. The identifed encounters were compared to determine between-specialty differences in the number of chief complaints, non–somatic dysfunction assessments, body regions with diagnosed somatic dysfunction, body regions managed with OMT, and number and type of OMT techniques used. Results: Eighteen residents had 2925 patient encounters that included 1 or more spinal pain diagnoses. Overall, 2767 patients (95%) received OMT. The probability (95% CI) of residents using OMT was 0.99 (0.98-0.99) for the NMM/OMM residents, 0.66 (0.55-0.77) for the FP/OMT residents, 0.94 (0.88-0.97) for the FP/NMM residents, and 0.997 (0.98-1.0) for the IM/NMM residents. The FP/OMT residents were less likely to manage spinal pain using OMT ( P <.001) and documented fewer somatic dysfunction assessments and fewer musculoskeletal assessments ( P <.001), but they documented significantly more non–somatic dysfunction assessments ( P <.001). When using OMT, the FP/OMT residents diagnosed somatic dysfunction in fewer mean (95% CI) body regions (2.9 [2.4-3.5]) than the NMM/OMM (5.5 [4.9-6.2]), the FP/NMM (5.5 [4.8-6.3]), or the IM/NMM (4.6 [3.4-6.0]) residents ( P <.001). The FP/OMT residents also managed fewer mean (95% CI) body regions with OMT (3.5 [3.0-4.1]) than the NMM/OMM (5.7 [5.2-6.3]), the FP/NMM (5.6 [5.0-6.3]), or the IM/NMM (4.7 [3.7-6.0]) residents ( P <.001). Conclusion: Although the FP/OMT residents used OMT less frequently than the other residents during spinal pain encounters, they provided care for a larger number and a wider variety of non–somatic dysfunction assessments.

Background: Lymphatic pump treatment (LPT) is a technique used by osteopathic physicians as an adjunct to antibiotics for patients with respiratory tract infections, and previous studies have demonstrated that LPT reduces bacterial load in the lungs of rats with pneumonia. Currently, it is unknown whether LPT affects drug effcacy. Objective: To determine whether the combination of antibiotics and LPT would reduce bacterial load in the lungs of rats with acute pneumonia. Methods: Rats were infected intranasally with 5×10 7 colony-forming units (CFU) of Streptococcus pneumoniae . At 24, 48, and 72 hours after infection, the rats received no therapy (control), 4 minutes of sham therapy, or 4 minutes of LPT, followed by subcutaneous injection of 40 mg/kg of levofoxacin or sterile phosphate-buffered saline. At 48, 72, and 96 hours after infection, the spleens and lungs were collected, and S pneumoniae CFU were enumerated. Blood was analyzed for a complete blood cell count and leukocyte differential count. Results: At 48 and 72 hours after infection, no statistically significant differences in pulmonary CFU were found between control, sham therapy, or LPT when phosphate-buffered saline was administered; however, the reduction in CFU was statistically significant in all rats given levofoxacin. The combination of sham therapy and levofoxacin decreased bacterial load at 72 and 96 hours after infection, and LPT and levofoxacin significantly reduced CFU compared with sham therapy and levofoxacin at both time points ( P <.05). Colony-forming units were not detected in the spleens at any time. No statistically significant differences in hematologic findings between any treatment groups were found at any time point measured. Conclusion: The results suggest that 3 applications of LPT induces an additional protective mechanism when combined with levofoxacin and support its use as an adjunctive therapy for the management of pneumonia; however, the mechanism responsible for this protection is unclear.

Context: The growth of osteopathic medicine in the United States has led to a vibrant expansion of the profession internationally. Canadian students represent the majority of international applicants and matriculants to US colleges of osteopathic medicine (COMs); however, to our knowledge, no studies have explored this population. Objective: To gain a better understanding of Canadian students attending US colleges of osteopathic medicine by examining their residency training preference, visa preference, intent to practice in the United States or Canada, receptiveness to incorporating osteopathic manipulative medicine into practice, specialty preference, estimated debt incurred, and effect of debt on specialty choice. Methods: A 10-question electronic survey was sent to Canadian osteopathic medical students in the 17 COMs and branch campuses that accept international applicants. The initial survey pool consisted of frst-, second-, third-, and fourth-year medical students (classes of 2014-2017) compiled from a database managed by the Canadian Osteopathic Medical Student Association. Results: Of the 102 students contacted, 66 (65%) completed the survey. Respondents had a strong desire to practice in Canada (44 [67%]) but were considering an Accreditation Council on Graduate Medical Education (ACGME) or dually accredited residency program in the United States (46 [70%] and 15 [23%], respectively) that would sponsor an H1B visa. Respondents were receptive to incorporating osteopathic manipulative medicine into practice (44 [67%]). Most respondents chose non–primary care specialties (40 [61%]) and incurred a debt of more than $200,000 (44 of 65 [68%]); however, debt had a limited infuence on respondents’ choice of specialty (χ 2 3 =1.911; P =.591). Conclusion: Most respondents planned to complete ACGME training, to return to Canada to practice medicine, and to practice in a non–primary care specialty. As a growing population that will play a large role in the expansion and reception of the profession internationally, Canadian osteopathic medical students and US-trained Canadian DOs merit further examination.

Dissemination is an important part of translational research. When the results of high-quality studies reach a wide audience of peers, they provide an evidence base that can guide practice and improve patient care and safety. From proposal to publication, the authors provide the novice researcher with advice on ethics, tips on selecting a journal, a summary of manuscript requirements, and a brief outline of the submission process and outcomes. By demystifying these processes and outlining some of the basic requirements, the authors hope to encourage novice researchers to engage in quality research and prepare them for disseminating their results.

Pulmonary lymphangitic carcinomatosis (PLC) is the diffuse infltration of lymphatic systems by adenocarcinomas. Because of its vague clinical symptoms and absence of malignant features, confrmatory diagnosis requires transbronchial or open-lung biopsy. Tumor spread is postulated to occur by means of retrograde lymphatic permeation with tumor growth along the lymphatic channels and involvement of vascular endothelial growth factor-C in a signaling pathway. The authors describe the case of a 45-year-old woman whose presentation with cough and dyspnea led to diagnosis of pulmonary lymphangitic carcinomatosis with superimposed pulmonary hypertension, tumor thrombotic microangiopathy, and ultimately metastatic signet ring cell gastric adenocarcinoma. Because of the patient’s poor prognosis, she was given palliative care and died 29 days after admission. This case emphasizes the importance of the osteopathic principle of treating the whole patient and evaluating all organ systems. Physicians should be aware of PLC from gastric adenocarcinoma and consider it in patients with pulmonary symptoms who are unresponsive to antibiotics.

Pneumomediastinum occurs as a result of traumatic or iatrogenic causes or in patients with preexisting lung conditions such as interstitial lung disease, asthma, and chronic obstructive pulmonary disease. Spontaneous pneumomedi-astinum (SPM), however, is rarely seen in clinical practice. The authors report the case of a 14-year-old boy who presented to the emergency department with chest discomfort and shortness of breath after a 1600-m run as part of a physical education class. The patient was found to have SPM, was admitted to the pediatric service for monitoring and pain control, and made a full recovery within 24 hours. This case is notable because SPM occurred in the absence of identifable organic causes and as the result of sustained noncontact physical activity. A review of the literature provides background information and highlights pathophysiologic processes of SPM and suggested treatment. Physicians should consider pneu-momediastinum in young patients or runners presenting with chest pain even in the absence of any known inciting event.