Volume 118, Issue 2

Sexual assault is a traumatic event with potentially devastating lifelong effects on physical and emotional health. Sexual assault is associated with gastrointestinal, neurologic, and reproductive symptoms, as well as obesity, diabetes, and chronic pain. With 1 in 3 women and 1 in 6 men experiencing some form of unwanted sexual violence in their lifetime, sexual assault is a significant public health problem that necessitates attention in the medical community. This review discusses relevant literature on the neurobiologic changes that occur as a consequence of sexual assault, such as how the brain responds during a traumatic experience and the impact of trauma on memory. Osteopathic considerations for trauma-informed care and practice and how all physicians can better serve patients with a history of sexual assault are also discussed.

Although cannabis use is federally prohibited, medical cannabis is legal in some form in 30 states and the District of Columbia, and recreational use is legal in 8 states and the District of Columbia. The increasing legal acceptance of cannabis has led to a burgeoning industry that is producing an expanding variety of cannabis products. Physicians and other health care professionals should be aware of modern forms of cannabis consumption, as well as variations in tetrahydrocannabinol concentrations, to improve assessment of cannabis use and approach to treatment. This review aims to familiarize clinicians with modern forms of cannabis consumption and enable comparisons between disparate cannabis products.

Background Patient no-shows impede the effectiveness and efficiency of health care services delivery. Objective To evaluate a 2-phase intervention to reduce no-show rates at an integrated care community health center that incorporates a teaching program for osteopathic family medicine residents. Methods The Elmont Teaching Health Center (ETHC) is 1 of 5 community-based health centers comprising the Long Island Federally Qualified Health Centers. In August 2015, the ETHC implemented a centerwide No-Show Rates Reduction Initiative divided into an assessment phase and implementation phase. The assessment phase identified reasons most frequently cited by patients for no-shows at the ETHC. The implementation phase, initiated in mid-September, addressed these reasons by focusing on reminder call verification, patient education, personal responses to patient calls, institutional awareness, and integration with multiple departments. To assess the initiative, monthly no-show rates were compared by quarter for 2015 and against rates for the previous year. Results We recorded 27,826 appointments with 6147 no-shows in 2014 and 31,696 appointments with 5690 no-shows in 2015. No-show rates in the first 3 quarters of 2015 (range, 18.2%-20.0%) were slightly lower than the rates in 2014 (20.1%-23.4%) and then changed by an increasingly wide margin in the last quarter of 2015 (15.3%), leading to a significant year (2014, 2015) by quarter (Q1, Q2, Q3, Q4) interaction ( P =.004). Also, the change observed in Q4 in 2015 differed significantly from Q1 ( P =.017), Q2 ( P =.004), and Q3 ( P =.027) in 2015, while Q1, Q2, and Q3 in 2015 did not significantly differ from one another. Conclusion No-show rates were successfully reduced after a 2-phase intervention was implemented at 1 health center within a larger health care organization. Future directions include dismantling the individual components of the intervention, evaluating the role of patient volumes in no-show rates, assessing patient outcomes (eg, costs, health) in integrative care settings that treat underserved populations, and evaluating family medicine residents’ training on continuity of care and no-show rates.

Context According to the US Department of Housing and Urban Development, nearly 1.5 million people spend at least 1 night in an emergency shelter or transitional housing each year, and more than 500,000 people are homeless on a given night in the United States. To our knowledge, limited data exist regarding the prevalence of homelessness in ED patients by gender (male, female, and transgender) Objective To assess the prevalence of homelessness by gender in 3 EDs in Pennsylvania. Methods From May 2015 through February 2016, patients in 3 EDs were approached to take a 5-question homelessness screening survey. To participate, patients had to be aged at least 18 years, speak English, have capacity to complete the survey, be willing to participate, and not be critically ill. Frequency comparisons were made using χ 2 analysis. Statistical significance was defined as P ≤.05. Results A total of 4395 patients were included in the analysis. The mean (SD) age of the participants was 50.8 (20.5) years; 2557 (58.2%) were women and 3 (0.07%) were transgender. No difference in the rate of homelessness was observed between men and women, with 135 of 1835 men (7.4%) and 173 of 2557 women (6.8%) screening positive for homelessness ( P =.472). Forty of 2557 women (1.6%) and 41 of 1835 men (2.2%) admitted they had slept outside or in an abandoned building, their car, an emergency shelter, or a hotel due to financial hardship in the past 60 days ( P =.26). One transgender patient screened positive for homelessness. The mean age of participants who screened positive for homelessness was 40.9 (15.9) years. Conclusion No significant difference was observed in the rate of homelessness between men and women in this ED population, which defies the perception that this issue primarily affects men. Public health interventions aimed at homeless populations should consider that both men and women may be equally affected by homelessness.

Verrucae plantaris (plantar warts) are common cutaneous lesions of the plantar aspect of the foot that are caused by the human papillomavirus (HPV). Ubiquitous in our environment, asymptomatic infection with HPV occurs frequently, with most infections controlled or cleared by cellular and humoral immune responses. However, certain populations have been observed to manifest plantar warts at higher rates compared with the general population, placing them at increased risk for wart-induced pain and complications. Plantar warts shed HPV, which can then infect other sites in the plantar region or spread to other people. Although controlling risk factors is useful in preventing infection, the pervasive nature of HPV makes these preventive measures frequently impractical. This literature review outlines the current knowledge regarding the relationship between plantar wart pathophysiology, HPV transmission, and epidemiologic characteristics. Given the high propensity for treatment resistance of plantar warts and no established, practical, and reliable method of prevention, HPV prophylaxis for populations that demonstrate high rates of plantar warts may be of benefit in controlling the spread of lesions.

Context Medical schools use a variety of preadmission indices to select potential students. These indices generally include undergraduate grade point average (GPA), Medical College Admission Test (MCAT) scores, and preadmission interviews. Objective To investigate whether the admission indices used by Midwestern University Arizona College of Osteopathic Medicine are associated with the academic and clinical performance of their students. Methods Associations between the prematriculation variables of undergraduate science GPA, undergraduate total GPA, MCAT component scores, and interview scores and the academic and clinical variables of the first- and second-year medical school GPA, Comprehensive Osteopathic Medical Licensing Examination-USA (COMLEX-USA) Level 1 and Level 2-Cognitive Evaluation (CE) total and discipline scores, scores in clinical rotations for osteopathic competencies, COMLEX-USA Level 2-Performance Evaluation passage, and match status were evaluated. Two-tailed Pearson product-moment correlations with a Bonferroni adjustment were used to examine these relationships. Results The traditional predictors of science and total undergraduate GPA as well as total and component MCAT scores had small to moderate associations with first- and second-year GPA, as well as COMLEX-USA Level 1 and Level 2-CE total scores. Of all predictors, only the MCAT biological sciences score had a statistically significant correlation with failure of the COMLEX-USA Level 2-Performance Evaluation examination ( P =.009). Average interview scores were associated only with the osteopathic competency of medical knowledge ( r =0.233; n=209; P =.001), as assessed by clerkship preceptors. No predictors were associated with scores in objective structured clinical encounters or with failing to match to a residency position. Conclusion The data indicate that traditional predictors of academic performance (undergraduate GPA, undergraduate science GPA, and MCAT scores) have small to moderate association with medical school grades and performance on COMLEX-USA Level 1 and Level 2-CE. This finding requires additional research into the value of the interview in the medical school admissions process and the availability of alternatives that allow better prediction and assessment of applicant performance.

Addiction is a public health crisis in the United States. Understanding the cause and providing effective treatment for patients—in particular, those with substance use disorders—is challenging. Research has demonstrated that addiction is not a flaw in one's moral fiber or a disease of choice; rather, it is driven by alterations in neuronal mechanisms, especially those that involve the neurotransmitter dopamine, which plays a critical role in the brain's reward pathway. Much of osteopathic philosophy is based on the concept of total body homeostasis and allostasis. This article discusses the role of achieving dopamine homeostasis as part of a comprehensive biopsychosocial treatment strategy in the effective management of addiction. The authors aim to motivate osteopathic primary care physicians to incorporate osteopathic philosophy into the treatment of patients with substance use disorders.

Neuromyelitis optica is an inflammatory, demyelinating disease of the central nervous system that is characterized by severe relapsing attacks of optic neuritis and transverse myelitis. The current case describes a 29-year-old man with intractable epilepsy and diplegic spastic cerebral palsy who was given the diagnosis of neuromyelitis optica spectrum disorder after presenting with weakness, incontinence, and decreased visual acuity. His symptoms recurred 21 months after initial presentation. Magnetic resonance imaging of his spine revealed arachnoid cysts with regional mass effects. Differentiation of arachnoid cysts from a demyelinating process may be difficult in the early stages of the disease. Close monitoring of patients with neuromyelitis optica spectrum disorder is important, especially in patients with recurrent or refractory symptoms.