Volume 120, Issue 12

Context Robust methodology and ethical reporting are paramount for quality scientific research, but recently, that quality in addiction research has been questioned. Avenues to improve such research quality include adherence to reporting guidelines and proper usage of clinical trial registries. Reporting guidelines and clinical trial registries have been shown to lead researchers to more ethical and transparent methodology. Objectives To investigate the reporting guideline and clinical trial registration policies of addiction research journals and identify areas of improvement. Methods We used Google Scholar Metrics’ h-5 index to identify the top 20 addiction research journals. We then examined the instructions for authors from each journal to identify whether they required, recommended, or made no mention of trial registration and reporting guidelines, including the Consolidated Standards of Reporting Trials (CONSORT), Meta-Analysis of Observational Studies in Epidemiology (MOOSE), Quality of Reporting of Meta-analyses (QUOROM), Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Standards for Reporting Diagnostic Accuracy Studies (STARD), Strengthening the Reporting of Observational Studies in Epidemiology (STROBE), Animal Research: Reporting of In Vivo Experiments (ARRIVE), Case Reports (CARE), Consolidated Health Economic Evaluation Reporting Standards (CHEERS), Standards for Reporting Qualitative Research (SRQR), Standards for Quality Improvement Reporting Excellence (SQUIRE), Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT), Consolidated Criteria for Reporting Qualitative Research (COREQ), Transparent Reporting of a Multivariate Prediction Model for Individual Prognosis or Diagnosis (TRIPOD), Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P), and the International Committee of Medical Journal Editors (ICMJE) guidelines. We performed the same analysis regarding requirements for clinical trial registration. Results Of the 20 journals included in this study, 10 journals (50%) did not require adherence to any reporting guidelines. Trial registration followed a similar trend; 15 journals (75%) did not mention any form of trial or systematic review registration, and ClinicalTrials.gov was only recommended by only 1 journal (5%). Conclusions Among top addiction medicine journals, required adherence to reporting guidelines and clinical trial registry policies remains substandard. A step toward fulfilling the National Institute on Drug Abuses’ call for improvement in transparency and reproducibility within addiction research should include all journals adopting a strict reporting guideline and clinical trial registry adherence policy.

Context Cases of heart failure with preserved ejection fraction (HFpEF) exacerbations continue to affect patients' quality of life and cause significant financial burden on our healthcare system. Objective To identify risk factors for readmission in patients discharged with a diagnosis of HFpEF. Methods Electronic health records of patients over 18 years of age with a primary diagnosis of HFpEF treated between August 1, 2017 and March 1, 2018 in a community hospital were retrospectively reviewed. The study population included patients with HFpEF greater than 40% who were screened but did not qualify for the ongoing CONNECT- HF trial being conducted by Duke Clinical Research. To be included, subjects had to fall into 1 of 2 classifications (NYHA Class II-IV or ACC/AHA Stage B-D) and have a life expectancy greater than 6 months. Patients were excluded if they had terminal illness other than HF, a prior heart transplant or were on a transplant list, a current or planned placement of a left ventricular assist device, chronic kidney disease requiring hemodialysis, inability to use mobile applications, or inability to participate in longitudinal follow up. Readmission rate was analyzed at 30 and 90 days along with patients’ demographics and associated comorbidities, including peripheral vascular disease, anemia, pulmonary hypertension, arrythmia, and valvular heart disease. Patients were risk stratified using the LACE index readmission score and the Charlson comorbidity index. Results Of the 492 cases of HFpEF identified during the 7-month study period, 212 patients were included. The majority of patients were women (126; 59.4%), had a median body mass index above 30 kg/m 2 (123; 58%), and had pulmonary hypertension (94; 44.3%), anemia (146; 68.8%), and arrhythmia (101, 47.6%). Forty-five (21.2%) patients were readmitted for HFpEF within 90 days of initial discharge; 32 of those (71.1%) were readmitted within 30 days of initial discharge. Patients with higher LACE and Charlson comorbidity index scores were more likely to be readmitted within 90 days. Peripheral vascular disease ( P =.002), tricuspid regurgitation ( P =.001), pulmonary hypertension ( P =.049), and anemia ( P =.029) were risk factors associated with readmissions. Use of ACEi/ARBs ( P =.017) was associated with fewer readmissions. Conclusion Anemia, peripheral vascular disease, pulmonary hypertension, and valvular heart disease are not only postulated mechanisms of HFpEF, but also important risk factors for readmission. These study findings affirm the need for continued research of the pathophysiology and associated comorbidities of the HFpEF population to improve quality of life and lower healthcare costs.

The candlenut is a highly accessible seed marketed as a natural weight-loss supplement. However, there is little known about the exact mechanism of action for weight loss nor for the many adverse symptoms it causes, such as nausea, vomiting, fatigue, cardiac dysrhythmias, and even death. In this case report, the authors present a 44-year-old woman who developed a second-degree, Mobitz type II atrioventricular block after consumption of a candlenut supplement. She presented to the emergency department with syncope and her cardiac rhythm indicated a second-degree heart block soon after ingesting candlenuts recommended by her treating physician. Interestingly, a detectable digoxin concentration obtained on hospital day 2 was measured but of unclear significance given no obvious exposure to a cardioactive glycoside. The patient's rhythm normalized on hospital day 2 and she was discharged uneventfully.

Context There is strong evidence that social support—particularly perceived social support—functions as a protective factor for health. Few studies have investigated how medical students perceive the types of social support they experience. Objective To determine how osteopathic medical students perceive social support, understand the factors that influence their perceptions, and explore how group participation in a cocurricular, academic program could affect student perceptions. Methods In this cross-sectional study of 983 medical students at a multicampus osteopathic medical school in the Midwest, potential respondents were invited by email in March 2018 to participate in a self-reported evaluation of their perceived social support using a 40-question Interpersonal Support Evaluation List (ISEL). The demographic variables included gender, race, age, current phase in medical school, Hispanic heritage, campus assignment, and hometown population type. A total score for each type of social support and a summative score for overall perceived social support were calculated. Descriptive statistics were applied to provide a summary of the distribution of study variables. Bivariate analyses were conducted using student t test and analysis of variance (ANOVA) statistic to determine distribution of 4 social support constructs and overall social support by all the study variables; α < .05 was considered statistically significant. Linear regression analysis was performed to determine the association between all study variables and 4 social support constructs. Pairwise interactions were calculated to determine whether the association differed by any of the study variables. Results Self-esteem support was the lowest type of perceived social support overall in the total sample (mean [SD], 23.5[2.0]). Hispanic students reported lower overall mean perceived social support than those who did not identify as Hispanic (100 vs 104; P =.04). Older study participants had higher mean tangible support compared with their younger counterparts (26.25 vs. 25.60, P =.018; t [264]=1.18). Older study participants also had higher mean appraisal support compared with their younger counterparts (26.57 vs. 25.92, P =.06; t [266]=1.27). Female medical students reported lower levels of belonging support overall (mean [SD] 26.79, [2.10]). Students from rural hometowns reported a higher sense of belonging support than any other group. Female students from suburban and urban hometowns reported lower levels of belonging support compared with women from rural hometowns (Adj. β=−0.96, P =.01). Students who participated in the rural and urban underserved program had higher self esteem support compared with those who did not participate in the rural and urban underserved program (Adj. β=−1.30, P =.05). Students in the clinical phase of medical education reported lower levels of belonging support than students in the preclinical phase (26.14 vs. 26.69, P =.05; t[256]=1.07). Conclusions It is critical to understand the ways medical students experience social support and the factors that contribute to it. Longitudinal studies following medical students over time would contribute to a more complete understanding of social support in medical students as they move from preclinical to the clinical phases of medical school.

Context Undergraduate student interest in becoming a physician continues to rise, but so too does the difficulty of earning acceptance to medical school. In this competitive environment, little is known about premedical students’ knowledge of their medical school options. Moreover, as undergraduate students’ emotional health continues to decline, little is known about whether premedical students experience or are at increased risk for the burnout symptoms reported by medical students and other physicians in training. Objective To examine premedical undergraduate students’ knowledge of osteopathic medicine, assess how they learned of osteopathic medicine, and collect information about any reported feelings of burnout. Methods In this institutional review board-approved study, we electronically distributed an anonymous survey to 342 premedical undergraduate students at a midsize, public research undergraduate institution. The survey included 56 questions. Students were surveyed on their preference of medical schools, knowledge of osteopathic medicine, and experience with burnout via the Maslach Burnout Inventory which measures exhaustion, cynicism, and professional efficacy. Of those who completed the survey, only those who confirmed that they currently considered themselves to be premedical students were included in our analysis. A 2×2 factorial analysis of variance (ANOVA) test was applied to assess main and interaction effects amongst respondents who preferred osteopathic or allopathic programs, whether they learned of osteopathic medicine programs by their own research, and their scores on the 3 measures of the Maslach Burnout Inventory: exhaustion, cynicism, and professional efficacy. Bivariate and factorial analyses were completed using SPSS v26 software (IBM). All tests were 2-tailed and used a .05 standard P value. Results Of 342 students to whom the survey was sent, 160 (46.8%) responded, and only 92 (26.9%) considered themselves premedical students. Of the 160 students analyzed in our study, 80 (50%) reported first learning of osteopathic medicine through their own research. A 2×2 factorial ANOVA revealed a significant interaction effect for cynicism in respondents who reported learning of osteopathic medicine programs on their own. Conversely, when respondents reported learning of osteopathic medicine programs from another source, they also reported significantly lower cynicism ( F [1,1]5.23, P =.03) and exhaustion ( F [1,13] 5.79, P =.02) scores. Of the 92 respondents, only 2 students (2.2%) answered all questions regarding general osteopathic medical knowledge correctly. Conclusion The results of this study suggest that among premedical students, knowledge of osteopathic medicine may be incomplete and may be impeding medical school applications. Furthermore, respondents who reported interest in osteopathic medical schools and learned of this option through their own research seemed to experience greater burnout. Based on these findings, increased outreach and education have the potential to not only better inform students of the osteopathic profession, but also to reduce burnout.

Context In the transition of osteopathic programs to the single-accreditation graduate medical education (GME) system, residents are required to demonstrate skill in a set of core competencies identified by the Accreditation Council of Graduate Medical Education (ACGME) prior to graduation. Included in those core competencies are interpersonal and communication skills along with professionalism. Objectives To assess strengths and weaknesses of residents’ interpersonal communication skills and professionalism in the Grandview/Southview Medical Center (Dayton, OH) osteopathic general surgery program using the validated Communication Assessment Tool (CAT). Methods From November 2014 to June 2018, all patients who presented for an appointment at the Cassano General Surgery Clinic were asked by a medical assistant to complete a CAT questionnaire following their encounter with a resident physician. Patients at Cassano, an outpatient office-based facility directed to the underserved local community, are seen first by an intern, then by a 4 th or 5 th year resident and later by an attending physician. Patients 18 years of age or older were included; patients were excluded if they were unable to understand or read English. Patient demographics were collected, including age, gender, race/ethnicity, and previous exposure to this resident physician. Each resident's name was replaced on the CAT with a number for data analysis. The resident variables collected for this study included year of training, gender, and native language. Results The mean response for all CAT items was 4.5 out of 5, indicating that responses to resident performance were largely positive. Patients responded to 4 of the 14 CAT items with only excellent , very good , or good responses and no fair or poor responses. Four items had only 1 fair or poor response. The remaining 6 items received more than 1 fair or poor response: “greeted me in a way that made me feel comfortable” (#1), “talked in terms I could understand” (#8), “encouraged me to ask questions” (#10), “involved me in decisions as much as I wanted” (#11), “showed care and concern” (#13), and “spent the right amount of time with me” (#14). Conclusions Attending surgeons evaluate residents in multiple areas from a doctor's perspective, but there is a potential lack of correlation between that evaluation and a patient's experience, which is paramount in osteopathic medicine. Patient responses to the CAT questionnaire can be used by program directors to identify deficiencies in milestone/competency achievement and facilitate improvement both individually and programmatically for residents according to ACGME standards.

Context While recent streamlining of the graduate medical education process signals an important change from the traditional dichotomy between doctors of osteopathic medicine (DOs) and US-trained doctors of medicine (USMDs), this new uniformity does not continue into the process for licensure, including state medical licensing verification of training (VOT) forms for DOs, MDs, and foreign medical graduates (FMGs). Wide variability remains. Objective To document the differences in the performance metrics program that directors are required to disclose to state medical licensing boards for DOs and FMGs compared with USMDs. Methods VOT forms were collected from all osteopathic and allopathic licensing boards for all US states, Washington DC, and US territories. The authors then reviewed VOT forms for questions pertaining to trainee performance only in states where VOT forms differed for DOs, USMDs, and FMGs. Licensing board questions were categorized as relating to disciplinary action, documents placed on file, resident actions, and nondisciplinary actions by the program. Results Fifty-six states and territories were included in the study (50 US states; Washington, DC; and 5 US territories). Most states and territories (46; 82.1%) used the same VOT form for DOs and USMDs. All states and territories except New York used the same form for FMGs and USMDs (55; 98.2%). Of the 14 states with an osteopathic board, Nevada used Federation Credentials Verification Service (FCVS) for DOs only, and 8 states used a unique osteopathic VOT form. Of these 8 osteopathic boards, 3 VOT forms did not ask any questions regarding resident performance during training. Of the remaining 5 forms, all asked about disciplinary actions. Ten states and 1 territory (US Virgin Islands) required the FCVS for both USMDs and FMGs, but not for DOs, while New York required FCVS only for FMGs. Nevada required FCVS only for DOs. Conclusion Although VOT requirements for FMGs and USMDs were mostly the same within states, performance metric question sets varied greatly from state to state and within states for osteopathic vs allopathic licensing boards. Implementation of a standardized VOT form for all applicants that includes academic performance metrics may help ensure that medical licensure is granted to all physicians who demonstrate academic competency during training, regardless of their degree.

Context One potential way to address critical current and future projected health care workforce shortages is through comprehensive programs that could potentially inspire high school students to pursue osteopathic medical careers in underserved areas. Objective To determine whether a comprehensive, 5-week enrichment program could promote interest among rural high-school students in careers osteopathic medicine. Methods In May 2018, 116 high school students with a grade point average of 2.8 or higher from rural areas, including New Mexico and its surrounding rural areas in the US-Mexico border region, enrolled in а 5-week program offering American College Testing (ACT) preparation and biomedical sciences enrichment at Burrell College of Osteopathic Medicine (BCOM). During the program, students were offered more than 150 hours of interactive in-class lectures and hands-on activities with laboratories focusing on college preparedness, health sciences, and motivating students to pursue osteopathic medical career and practice medicine in rural areas. Clinically-oriented sessions covering osteopathic philosophy and osteopathic manipulative medicine were included. After completion, a voluntary and anonymous survey was sent to students who completed the program students through QualtricsXM©. Blinded ACT scores were collected from participants’ schools, along with college enrollment status information. Results Of 116 enrolled students, 106 (91.4%) completed the program successfully. In their postcompletion survey responses, students reported that they had gained a realistic perception of the field of medicine and were motivated to attend college (mean [standard error, SE] score on 5-point Likert scale over 2 questions, 4.8 [0.06]) and osteopathic medical school (mean [SE], 4.7 [0.1]). Participants also felt more informed about physician shortage in rural areas (mean [SE], 4.7 [0.07]) and appeared to be inspired to practice medicine in rural areas (mean [SE], 4.6 [0.09]). Students also reported feeling better prepared to take the ACT after finishing this program (mean [SE], 4.9 [0.04]). Finally, we were able to collect the ACT scores of 51 participants (48.1%) who completed the program; the mean ACT score was 24.3, compared with a reported national mean of 20.7 on a scoring scale of 1-36. We also performed a follow-up inquiry showing that 78 of the 81 participating students (96%) who had graduated from high school were enrolled in college or university and 59 (73%) had elected in science, technology, engineering, mathematics, or health majors. Conclusion Rural high school pipeline programs could be a tool to motivate high school students to attend college and ultimately to develop physicians who are interested to practice in medically underserved areas.

Context Chronic non-cancer pain (CNCP) is associated with disability, poor quality of life (QOL), and failure to return to work (RTW). Osteopathic manipulative treatment (OMT) or osteopathic manual therapy (OMTh) are increasingly offered to patients with CNCP; however, the existing systematic reviews and meta-analyses in the literature that explore the effectiveness of OMTh have major limitations. Objective To systematically evaluate the quality of evidence documenting the effectiveness of OMTh for patients with CNCP using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and to evaluate the efficacy of OMTh in patients with CNCP through a meta-analysis of pooled data from previous studies. Methods We searched online the databases Ovid, MEDLINE, Embase, OSTMED.DR, EMCare, Allied and Complementary Medicine Database (AMED), Physiotherapy Evidence Database (PEDro), and Cochrane Central Register of Controlled Trials (CENTRAL), as well as the bibliographic references of previous systematic review articles evaluating OMTh for pain severity, disability, QOL, or RTW outcomes. Eligibility included randomized controlled trials methodology, CNCP patients 18 years or older, use of previously validated assessment tools, use of OMTh as an active or combination intervention, and presence of a control or comparison group. We pooled studies based on the homogeneity between OMT comparator treatment and outcomes. Risk of bias was assessed with the Cochrane risk of bias tool and the quality of evidence was determined with GRADE. Results Sixteen randomized controlled trials (n=1158 patients) were eligible for data extraction. Moderate quality evidence showed that OMTh vs. standard care was significantly associated with a reduction in pain [standardized mean difference (95% CI)=[−.37 (−.58, −.17)] and disability [−.28 (−.46, −.10)], as well as improved QOL [.67 (.29, 1.05)]. Moderate quality evidence showed that OMTh plus exercise vs. exercise only was significantly associated with reduction in pain severity [−1.25 (−1.67, −.83)] and disability [−1.15 (−1.57, −.74)]. Moderate quality evidence showed that using visceral OMTh vs. general OMTh was significantly associated with reduction in pain severity [−.74 (−1.09, −.39)] and disability [−.52 (−.91, −.13)]. In comparison to physiotherapy, gabapentin, and OMTh plus gabapentin, OMTh did not show any significant effect for any of the outcomes. OMTh vs. standard care did not show significant improvement in RTW at 12 weeks, although the effect was significant at 8 weeks after OMTh. Conclusion Moderate quality evidence suggests that OMTh is effective for CNCP patients. There was a significant association between visceral OMTh and reduced pain severity and disability. More robust, high-quality randomized controlled trials with larger sample sizes are required to further explore the effectiveness of the OMTh in the management of CNCP.

Iliohypogastric neuralgia is an uncommon etiology of lower abdominal pain caused by entrapment of the iliohypogastric nerve. Conventional management consists of medications, injections, and surgery; previous literature has not explored the use of osteopathic manipulative medicine for management of iliohypogastric neuralgia. Here, the author discusses the case of a 72-year-old woman who presented with 2 years of right lower abdominal pain, having failed multiple treatments, including exploratory laparoscopy and appendectomy. Following management of the patient's somatic dysfunctions with osteopathic manipulative treatment and a heel lift, her iliohypogastric neuralgia was significantly improved.

Context Osteopathic manipulative medicine (OMM) is considered beneficial in the treatment of pregnant women, but few studies have outlined the presenting complaints and diagnoses that warrant consideration and utilization of osteopathic manipulative treatment (OMT) in this population. Objective To describe the characteristics of pregnant patients receiving OMM at a neuromusculoskeletal medicine (NMM)/OMM specialty outpatient clinic, for the purpose of identifying patients who would benefit from referral to NMM specialty clinics or to be considered for treatment by DOs in non-NMM specialty clinics. Methods Electronic health records were reviewed from a single clinic for a 3-year period from October 2015 through September 2018 for patient encounters involving patients with an International Classification of Diseases 10 th Revision code for pregnancy. Data regarding patient demographics, payment methods, presenting complaints, treatment modalities, regions treated, and assessment diagnoses were collected and analyzed. Results Records showed 465 clinical encounters with 194 pregnant patients (mean [SD] number of encounters per patient, 2.4 [2.0]). The most common presenting complaints involved the back (371; 55.4%), hip and pelvis (99; 14.8%), neck (62; 9.3%), and head (54; 8.1%). The most common clinical assessments were lumbar and thoracic spine neuromusculoskeletal diagnoses (420; 53.0%). There were 2604 somatic dysfunction assessments documented; lumbar (409; 15.7%) and sacral (396; 15.2%) somatic dysfunction were most commonly assessed. There were 2518 OMT techniques documented, and muscle energy was most frequently used (406; 16.1%). Conclusions This data, which documents the most frequent presenting complaints of pregnant patients in an NMM/OMM clinic, may be used by clinicians to better understand the role of OMM as an obstetric adjunctive treatment approach and to identify conditions to investigate in future outcome studies.

Mastitis affects breastfeeding mothers everywhere and management obstacles often lead to cessation of breastfeeding. Breastfeeding mastitis is commonly managed with antibiotics despite lack of clear infectious etiology. With the emerging problem of antibiotic resistance, novel managements are required. We present the case of a 34-year-old woman with 6 pregnancies and 3 children (gravida 6, parity 3) who had 5 cases of mastitis within 6 months treated with multiple courses of antibiotics. The patient underwent with osteopathic manipulative treatment (OMT) to the affected breast over 2 sessions and was taught how to perform self-myofascial release. Techniques are shown in an accompanying Supplemental Video. As of this report, the patient had been symptom free for 1 year. Future research, including a clinical trial of OMT, is required to determine whether osteopathic physicians can effectively manage recurrent lactational mastitis.

Context Following the emergence of the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), researchers sought safe and effective treatment modalities. Remdesivir is currently being evaluated for clinical efficacy and safety in patients with COVID-19. Objective To describe the clinical outcomes of COVID-19 patients following treatment with remdesivir at a community hospital. Methods A retrospective review of medical records was conducted in August 2020 for all patients given remdesivir while hospitalized for severe COVID-19 between May 1 and August 19, 2020. A convenience sample of consecutive patients with treatment including remdesivir, antibiotics, convalescent plasma, dexamethasone, or a combination of multiple drugs was included in the analysis. Patients receiving remdesivir were administered a 5-day treatment course. Patients with a glomerular filtration rate of less than 30 mL/min, those with liver function tests 5 times the normal reference range, and those who were pregnant were excluded from treatment with remdesivir. Differences in between men and women were detected with χ 2 and independent samples t tests. The degree to which presenting symptoms influenced patient outcomes was analyzed with a stepwise logistic regression. Results Among the 76 patients who received remdesivir, the mean (95% confidence interval, CI) age was 63 years (59.8–66.2). Thirty-six (47.4%) were men and 40 (52.6%) were women. Forty-nine (64.5%) were White and 27 (35.5%) were nonWhite. The majority of patients (54; 71.1%) had at least 1 comorbid condition, with hypertension being the most common (43; 56.6%). The mean (95% CI) length of stay for patients who received remdesivir was 10.09 days (8.6–11.6) and the mean (95% CI) duration of oxygen therapy was 9.42 days (8.0–10.8). A total of 14 (18.4%) patients given remdesivir were admitted to the intensive care unit (ICU) with an mean (95% CI) length of stay of 9.29 days (5.6–13.0). Women administered remdesivir were more likely to be admitted to the ICU (11 [27.5%] vs 3 [8.3%]; P =.031). The mortality rate was 14 patients (18.4%), with no statistically significant difference observed between men (5; 13.9%) and women (9; 22.5%; P =.33). No significant difference was seen amongst sexes for duration of oxygen therapy (men, 8.0 days [6.2–9.8] vs women, 10.76 days [8.8–12.8]; P =.051) or length of stay (men, 8.61 days [6.7–10.5] vs women, 11.43 days [9.3–13.5]; P =.058). There was no statistically significant difference in pooled racial groups (White vs nonWhite) for in-hospital mortality, number admitted to the ICU, days spent in the ICU, duration of oxygen use, or length of stay. Conclusion Remdesivir may show clinical efficacy for the treatment of severe COVID-19 in a community setting. Although this was a small-scale study with limited patients, it represents a point of reference for the use of remdesivir at other community hospitals.

In this case report, the authors discuss a patient with a rare entity, Kikuchi Fujimoto Disease, which exhibited unique osteopathic structural examination findings, including enlarged cervical lymph nodes in conjunction with a Chapman reflex (CR). This report highlights the critical importance of histological examination of the lymph nodes. Additionally, it reminds physicians to consider the ways in which CR can potentially contribute to the diagnostic process.