Volume 123, Issue 12

Context A 25-pound weight limit is currently set on containerized instrumentation sets by the Association of periOperative Registered Nurses (AORN) and the Association for the Advancement of Medical Instrumentation (AAMI), in order to reduce strain on the staff and ensure that the sets are not too crowded in order to preserve sterilization and drying of the instruments. This is pushing companies to reduce the weight and number of instrumentation sets for the operating room. One solution has been to explore the viability of new, lighter materials such as Onyx. Objectives The goal of this study is to evaluate the novel material Onyx as a viable material utilized in reusable total knee arthroplasty (TKA) instrumentation sets utilizing traditional steam sterilization as the sterilization method. Methods Mechanical and biocompatibility tests according to the American Society for Testing Materials (ASTM) and International Organization for Standardization (ISO) 10,993 were run to evaluate the Onyx Material to see if it would be a viable alternative to the stainless and martensitic steel that is currently being utilized. Results Gross warping and cracking after 10 rounds of sterilization was observed. This was qualitatively worse in the Onyx without a carbon fiber component. The Onyx material did not meet biocompatibility standards for its application. Conclusions Onyx was determined to not be a viable material for TKA instruments regarding multiple high-pressure and -temperature sterilizations and cytotoxic cell testing.

Context The United States Medical Licensing Examination (USMLE) Step 1 and Comprehensive Osteopathic Medical Licensing Exam (COMLEX) Level 1 transitioned from a numeric scoring system to a Pass/Fail designation in 2022. This transition intended to decrease stress, improve medical student well-being, and encourage residency program directors to emphasize other aspects of residency applications. Pass/Fail score transitions in the undergraduate medical education curriculum have improved medical student psychological well-being and satisfaction; whether these same benefits translate to the board examination period is unknown. Objectives The objectives of this study are to assess the impact of USMLE Step 1 and COMLEX Level 1 grade scale transition on medical student stress, wellness, board preparation decisions, and future residency selection processes. Investigators hypothesized that students under the Pass/Fail designation would experience less stress during the intensive study period leading up to USMLE Step 1 and COMLEX Level 1 and devote more time to other aspects of their residency applications. Methods To examine the impact on osteopathic medical student (OMS) stress and approach to board preparation, two surveys were administered to Rocky Vista University College of Osteopathic Medicine (RVU-COM) students before (Class of 2023) and after (Class of 2024) the transition to a Pass/Fail designation. All students within the RVU-COM Classes of 2023 and 2024 were invited to participate. The Cohen Perceived Stress Scale (PSS-10) was administered at the beginning of the focused board study period in May 2021 and 2022 to the Class of 2023 and 2024, respectively. The investigator-designed Licensing Exam Questionnaire (LEQ), meant to capture board preparation patterns, residency application perspectives, and wellness during examination preparation, was administered immediately after the board examination deadline in July 2021 and 2022 to the Class of 2023 and 2024, respectively. Statistical analysis included the use of independent t tests (numeric variables) and chi-square tests (categorical data). This project was considered exempt from full Institutional Review Board review. Results Approximately one-third of the Class of 2023 (PSS-10: n=86; LEQ: n=93) and 2024 (PSS-10=89; LEQ: n=92) responded. No difference was detected in mean PSS-10 score, 20.14 (SD=7.3) compared to 19.92 (SD=6.56) for the Class of 2023 and 2024 (p=0.84), respectively. The Class of 2023 reported more weeks studying (mean 6.27 weeks, SD=0.79) vs. the Class of 2024 (mean 5.44 weeks, SD=0.007), p<0.001, more practice examinations taken X 2 (1, n=182)=13.75, p<0.001, and a greater proportion scheduled examinations after June 20 X 2 (1, n=182)=29.01, p<0.001. No difference existed in hours studying per day, sequence of Step 1/Level 1, time between examinations, money spent, or type of study resources utilized. Conclusions The transition of USMLE Step 1 and COMLEX Level 1 to a Pass/Fail designation did not reduce stress for OMSs at a single, multicampus COM. Respondents, however, altered board preparation practices in meaningful ways. As student behaviors and board-study patterns emerge, these insights must be connected to outcomes in the future.

Context Fluoroscopic injection through the rotator cuff interval (RCI) is a common technique for diagnostic arthrography and therapeutic intervention. Ultrasound approaches through the RCI have been less commonly studied, but there is a growing body of literature. Objectives The purpose of this study was to present a standardized technique of ultrasound-guided injection into the glenohumeral joint utilizing the RCI in magnetic resonance imaging (MRI) arthrography (MRA) and to report one medical group’s experience with the technique. Methods A retrospective chart review of all ultrasound-guided injections into the glenohumeral joint utilizing the RCI was performed from July 1, 2014 through June 1, 2021. Data were compiled for age, gender, body mass index (BMI), and prior surgery on the shoulder. The primary endpoint was successful administration of intra-articular dilute gadolinium contrast adequate for radiologic interpretation. A total of 487 injections into the glenohumeral joint via the RCI were performed. One hundred and fifty-five patients had previous shoulder surgery, with the remainder naive to intervention. Results The success rate of injections into the glenohumeral joint was 99.4 %, with only three injections considered unsuccessful. The three unsuccessful injections did not succeed because of a lack of intra-articular contrast media present. This success rate is impressive and promising, particularly when considering that 155 of the patients had previous surgery, which could potentially cause complications, and because these injections were performed over a long period of 7 years. Conclusions Accessing the RCI under ultrasound guidance is a very successful technique for injection within the glenohumeral joint.

Literature describing the integration of osteopathic manipulative treatment (OMT) during prenatal care visits in a resident clinic setting are scarce. Concise and readily accessible resources reviewing OMT in pregnancy are limited. We sought to integrate OMT into routine prenatal care appointments in a family medicine resident clinic setting and create a concise resource for those performing OMT in pregnancy. Musculoskeletal (MSK) pain in pregnancy is common. Specifically, low back pain (LBP) often accompanies pregnancy and may negatively impact sleep, the ability to work, and the ability to complete daily tasks. Treatment options for LBP in pregnancy are limited due to the concern for fetal or maternal harm associated with pharmacologic options or invasive procedures. OMT is a low-risk intervention that has been demonstrated to improve back pain and reduce deterioration of back-specific function in pregnancy. Over a 12-month period, one resident physician offered OMT during routine prenatal care visits in a family medicine resident clinic. During the study period, we identified barriers to integrating OMT along with solutions. Barriers to integrating OMT were noted in three areas: clinic setup and logistics, attending physician awareness of OMT in pregnancy, and treating physician knowledge of OMT in pregnancy. OMT provides pregnant patients with additional treatment options and relief from MSK pain. This may reduce the number of patients with untreated MSK pain and benefit those who are unable to attend additional appointments outside of prenatal care due to financial or logistic barriers. OMT can be integrated into routine prenatal care visits in a training setting by providing complaint-specific OMT and determining how treatments can be performed for each unique examination room and table. Reviewing OMT in pregnancy with the attending physician prior to treatment, contraindications to OMT in pregnancy, and visualizing how treatments will be altered in pregnancy allows for smooth integration.

Context Healthcare-associated infections (HAIs) pose a substantial public health threat. Despite significant strides to curb HAIs in hospital environments, outpatient settings have not received the same degree of attention. Given their emphasis on holistic, patient-centered care, osteopathic family medicine offices are pivotal in both disease prevention and comprehensive patient treatment. The importance of simple yet effective disinfection protocols, such as thorough cleaning between patient appointments, cannot be overstated in these settings because they are integral to minimizing disease transmission. Objectives This study aims to assess the effectiveness of the current disinfection protocols in osteopathic family medicine offices. Methods A cross-sectional study evaluating disinfection practices on 18 examination tables in an osteopathic family medicine office was conducted. Two high-touch surfaces (midtorso region and table edge) were examined. Initial swab samples were collected after morning disinfection by Environmental Services, and terminal swab samples were gathered after day’s-end disinfection by the medical staff. Adenosine triphosphate (ATP) bioluminescence assays were performed utilizing AccuPoint Advanced HC Reader, which quantified ATP, indicating contamination levels in the samples. The higher the ATP levels found in a sample, the greater the amount of biological contamination. All samplers were handled and tested as per manufacturer’s instructions. A preliminary trial was conducted to confirm the internal validity of ATP bioluminescence measurements. The statistical analysis involved Shapiro–Wilk and Wilcoxon signed-rank tests, with significance set at p<0.05. Cohen’s d test was utilized to calculate the effect size, identifying meaningful differences in initial and terminal swab sample relative light units (RLUs). Results The midtorso region demonstrated an 11.1 % increase in failure rate after terminal disinfection when compared to initial disinfection. A Wilcoxon signed-rank test revealed a median estimated pathogen level for the midtorso region that was higher after terminal disinfection (median, 193 RLUs; range, 1–690 RLUs; n=18) compared to initial disinfection (median, 134 RLUs; range, 4–946 RLUs; n=18). However, this increase was not statistically significant, p=0.9124, with a small effect size, d =0.04. The edge showed no change in failure rate after terminal disinfection, maintaining a 100 % failure rate both before and after disinfection. However, the Wilcoxon signed-rank test revealed a slight reduction in the median estimated pathogen levels after terminal disinfection (median, 2095 RLUs; range, 891–5,540 RLUs; n=18) compared to before disinfection (median, 2,257 RLUs; range, 932–5,825 RLUs; n=18). However, this reduction was not statistically significant, p=0.61, with a small effect size, d =0.12. Conclusions The findings from this study reveal a substantial disparity in outcomes between the two sample locations, midtorso and edge. The midtorso demonstrated a relatively low failure rate in both initial and terminal swab samples, indicating successful outcomes. In contrast, the edge consistently displayed a 100 % failure rate, emphasizing the need for more care and attention when cleaning the edge of the examination to ensure better outcomes. By prioritizing adequate disinfection protocols, including thorough cleaning between patients, osteopathic family medicine offices can more effectively prevent disease transmission and promote patient safety.