Volume 118, Issue 10

Context Uninsured patients living in rural areas of North Carolina have been inordinately affected by the increasing prevalence of sexually transmitted diseases (STDs) in the midst of severe budget cuts to treatment programs and a shortage of rural primary care physicians. The Campbell University Community Care Clinic, a self-funded, student-run clinic, provides free health care to uninsured residents of rural Harnett County. As a relatively new clinic serving a unique population, epidemiologic research is paramount to the clinic's continued efficacy. Objective To determine which STDs are present in this patient population and to identify demographic groups at higher risk of contracting STDs. Methods This study was a retrospective analysis of patient medical records from March 1, 2015, to March 6, 2018. Records were evaluated to identify STD cases based on diagnostic information, such as primary diagnoses, positive laboratory results, and clinical indicators. Results A total of 449 patient records were analyzed, revealing an STD incidence rate of 5.3%, which represents a higher STD frequency than the national average of 2%. Our results identified human papillomavirus infection and gonorrhea as the most frequent STDs (n=7 [29.2%] and n=6 [25%], respectively), followed by chlamydia (n=4 [16.7%]), herpes simplex virus (n=4 [16.7%]), syphilis (n=2 [8.3%]), hepatitis C virus (n=2 [4.2%]), trichomoniasis (n=1 [4.2%]), and HIV (n=1 [4.2%]) infections. Among racial/ethnic groups, Hispanics had a slightly higher relative risk (RR) for STDs by a factor of 1.3 when normalized to the average frequency. Patients aged 26 to 29 and 30 to 39 years had a significantly higher RR for STDs: 2.1 and 2.0, respectively. Furthermore, female patients had an STD frequency 3 times that of male patients. Conclusion This study reveals noteworthy health risks in a rural uninsured population, including a higher rate of gonorrhea compared with national rates and a higher RR for STDs in certain demographic groups. These findings form a foundation for improvements in care through earlier STD diagnoses, effective treatment, and enhanced patient education.

Context Somatic dysfunctions are a key element of osteopathic practice. The evaluation of somatic dysfunctions is achieved by assessment of the TART (tissue texture abnormality, asymmetry, restriction of motion, tenderness) parameters. The reliability of a diagnostic method is the crux of successful treatment. Interrater reliability of osteopathic palpatory diagnostic tests have been studied on different anatomical areas, but there are no studies on the evaluation of all of the TART parameters on the sacrum. Objective To evaluate the interrater reliability of osteopathic sacral palpatory diagnostic tests. The hypothesis was that 3 trained osteopathy students at the end of their curriculum could achieve at least moderate agreement on osteopathic sacral palpatory diagnostic tests. Methods Three students from the Centre pour l’Étude, la Recherche et la Diffusion Ostéopathiques school in Rome, Italy, at the end of their curriculum participated as raters and received consensus training. Eligible subjects among students of the same school were recruited on a voluntary basis to be tested. All of the raters tested the sacrum by evaluating the TART parameters on every subject for 3 minutes. Raters were blinded to the other raters’ findings. Interrater reliability was evaluated using Fleiss κ statistics. Results Fifty-two subjects (20 women) were enrolled in the study. Mean (SD) age was 25.9 (7.03) years; height, 1.73 (0.09) ms; weight, 68.73 (14.2) kg; and body mass index, 22.66 (3.58). Agreement was fair for tissue texture abnormality (κ=0.28), asymmetry (κ=0.29), restriction of motion (κ=0.32), and tenderness (κ=0.34); agreement was slight for landmark position (κ=0.06) and diagnosis of somatic dysfunction (κ=0.17). Conclusion Results showed a level of agreement ranging from slight to fair in the assessment of the TART parameters among raters, who were in their last year of osteopathy school. The tenderness parameter was the most reliable. Our findings are consistent with other interrater reliability studies carried out in different body regions, contributing to show an overall heterogeneous level of diagnostic reliability in osteopathy.

Context The location of the more superficial thoracic spinous processes is used to help osteopathic physicians locate the deeper and more difficult-to-palpate thoracic transverse processes. In 1979, Mitchell et al proposed the thoracic rule of threes to describe the relationship of the spinous processes to the transverse processes in the thoracic spine. This rule is currently taught at osteopathic medical schools. The rule of threes separates the thoracic vertebrae into 3 distinct groups, each with a different relationship between transverse processes and spinous processes. In 2006, Geelhoed et al proposed a new relationship between the spinous processes and transverse processes for all thoracic vertebrae (ie, Geelhoed's rule). Objective To determine which anatomical relationship—the rule of threes or Geelhoed's rule—is most accurate in locating the transverse processes and to define anatomical relationships between thoracic spinous and transverse processes. Methods The thoracic spinous and transverse processes of 44 formalin-embalmed human cadavers were dissected, marked, and photographed. Six different measurements per vertebra were made between spinous processes and transverse processes in the thoracic spine. Geelhoed's protocol was used to determine the validity of each rule. The measurements were analyzed for additional relationships between thoracic spinous processes and transverse processes. Group 1 consisted of vertebrae T1 to T3 and T12; group 2 consisted of T4 to T6 and T11; and group 3 consisted of T7 to T10. Results Of the 528 vertebrae measured, 0% of the first group vertebrae, 10.8% of the second group vertebrae, and 69.3% of the third group vertebrae followed the rule of threes. In total, 26.7% of vertebrae followed the rule of threes, whereas 62.3% of vertebrae followed Geelhoed's rule. Additional relationships worth noting include the distance between the transverse process and the adjacent caudal transverse process on the same side is approximately 25.4 mm (1 inch), and the distance between the transverse processes of the same vertebra is approximately 50.8 mm (2 inches) for male T3-T10 vertebrae and female T1-T12 vertebrae. Conclusion According to our findings, the rule of threes is not as accurate anatomically as Geelhoed's rule in locating the transverse processes of the thoracic spine. This study suggests osteopathic medical schools should teach Geelhoed's rule rather than the rule of threes.

Concussions have been increasingly reported over the past decade, but the reported incidence likely minimizes the actual numbers of people affected. Associated symptoms include emotional, somatic, and cognitive complaints, which may be prolonged in patients with certain risk factors. Neurologic examination is necessary to exclude upper motor neuron lesions and thus the need for brain imaging. Cervical conditions are often found concurrently with head injury and displays a similar presentation to concussions. Therefore, determining symptom origin can be problematic. Neuropsychological, oculomotor, and balance evaluations expose specific deficits that can be successfully managed with rehabilitation. Osteopathic assessment of the cranium, spine, sacrum, and thorax for somatic dysfunctions allows for prudent interventions. Patients involved in sports may begin an established graduated return-to-play protocol once cleared by their physician. Concurrently, a parallel return-to-learn program, with applicable academic accommodations, is recommended.

Background Arthroscopy is one of the most common procedures performed by orthopedic surgeons. Virtual reality (VR) simulation in general surgery residency training has been increasing over the past decade, but it has seen little use in the field of orthopedic surgery. Objective To determine osteopathic orthopedic surgery residents’ perceived value of having access to a VR simulator before performing an arthroscopic procedure on a live patient. Methods A survey was developed and sent to all US osteopathic orthopedic surgery residency programs to be disseminated to all of their current residents. The survey consisted of 12 questions, which included Likert-type scale responses and yes or no responses. Results Fifty-eight residents out of approximately 507 responded. Forty-one of 57 respondents (72%) were in year 1 of residency when they performed their first arthroscopy, and 53 of 57 (93%) were not very comfortable when they performed their first arthroscopy. With respect to VR simulator exposure, approximately 31of 51 (61%) reported no exposure to a VR simulator, and 40 of 50 (80%) reported that their program did not provide a skills laboratory where they could practice arthroscopy. Of 50 respondents, 37 (74%) believed that a skills laboratory was important, 28 (56%) believed that a resident should perform 1 to 10 arthroscopies in a skills laboratory before performing one in the operating room, 34 (60%) believed that skills acquired in a skills laboratory would transfer to the operating room, and 33 (66%) agreed that every residency program should provide a skills laboratory. However, 29 (58%) believed that a skills laboratory would not improve patient safety. Conclusion Osteopathic orthopedic surgery residents indicated that they would benefit from the addition of an arthroscopic skills laboratory with a VR simulator. Furthermore, they believed that the skills learned in the skills laboratory would transfer to the operating room and would increase their comfort level with the procedure.

With advances in technology and the advent of social media and social networking sites, the way medical education is taught to millennials must evolve. The “flipped classroom,” which occurs when students are exposed to learning materials before their assigned face-to-face class or didactic session, can help engage all learning styles. A flipped classroom paired with simulation-based medical education (SBME) engages millennial learners to acquire the large amount of information required in osteopathic medical school. Using this paired approach in osteopathic medical education can help students meet the requirements outlined by the Accreditation Council for Graduate Medical Education (ACGME). With the single accreditation system for graduate medical education, finalizing in 2020, this article proposes mandating a flipped classroom with SBME to better prepare osteopathic medical students for their training in ACGME-accredited programs.

Despite growing interest in the importance of compassionate communication and patient experience, many physicians still feel unprepared when faced with delivering bad medical news. To address this need, few methods have been developed to offer physicians a structure for these conversations, with the goal of making the dialogues less traumatic for patients and families and less stressful for physicians. The PROGRAM method promotes compassionate communication to help physicians make a connection with their patients, which is central to improving health care quality. The objective of this article is to provide a systemic approach to structuring difficult dialogues with patients and their families.

Cancer of the uterine cervix is the third most common gynecologic cancer diagnosis and cause of death among gynecologic cancers in the United States. Cervical cancer is frequently asymptomatic until it reaches a locally advanced stage. The authors present a case of urinary retention caused by an atypical presentation of invasive cervical cancer mimicking primary urothelial tumor. The patient was evaluated by a multidisciplinary team, with osteopathic structural examination, intraoperative examination, surgical resection, and histopathologic analysis.