Volume 125, Issue 3

Context In 2019, emergence of the novel and communicable severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection took scientific communities by surprise and imposed significant burden on healthcare systems globally. Although the advent of this disease piqued the interest of academic centers, healthcare systems, and the general public, there is still much yet to be elucidated regarding epidemiology, pathophysiology, and long-term impacts of coronavirus disease 2019 (COVID-19). It has been established that long COVID-19 can impact multiple organ systems, including the cardiovascular system, unfavorably. Although the pathophysiology of this damage is not well understood, adverse sequelae may range from chest pain and arrhythmias to heart failure (HF), myocardial infarction, or sudden cardiac death. For any postacute COVID-19 patient requiring a surgical procedure, the potential for cardiac injury secondary to long COVID-19 must be considered in the preoperative cardiac examination. Objectives This literature review serves to add to the growing body of literature exploring postacute cardiovascular outcomes of COVID-19, with a focus on presurgical cardiac clearance in the adult patient. Specifically, this review studies the prevalence of cardiovascular symptomatology including chest pain, arrhythmias, blood pressure changes, myo-/pericarditis, HF, cardiomyopathy, orthostatic intolerance, and thromboembolism. Although current evidence is scarce in both quality and quantity, it is the goal that this review will highlight the negative impacts of long COVID-19 on cardiovascular health and encourage providers to be cognizant of potential sequelae in the context of the presurgical examination. Methods For this study, peer-reviewed and journal-published articles were selected based on established inclusion and exclusion criteria to address the question “How does long COVID-19 impact the presurgical cardiac examination of an adult scheduled to undergo a noncardiac procedure?” Inclusion criteria included human studies conducted in adult patients and published in peer-reviewed journals up until May 2024 examining the effects of long-COVID-19 infection on the cardiovascular system. Exclusion criteria eliminated unpublished reports, preprints, duplicate articles, literature regarding coronavirus strains other than COVID-19, studies regarding post-COVID-19 vaccination complications, animal studies, and studies conducted in people younger than 18 years of age. A total of 6,675 studies were retrieved from PubMed and Google Scholar. Following screening, 60 studies were included in final consideration. Results Cardiovascular symptoms of postacute COVID-19 infection were encountered with the following percentages prevalence (total numbers of articles mentioning symptom/total number of articles [60]): chest pain (83.3), arrhythmias (88.3), hypertension (40.0), hypotension (16.7), myocarditis (80.0), pericarditis (51.7), HF (70.0), cardiomyopathy (55.0), orthostatic intolerance (56.7), and thromboembolic events (85.0). Conclusions The presence of persisting COVID symptoms may negatively impact the patient’s physical examination, blood tests, electrocardiogram (ECG), imaging, and/or echocardiogram. Cardiac conditions associated with long COVID require special attention in the context of the presurgical candidate due to an increased risk of sudden cardiac death, myocarditis, stroke, and myocardial infarction – even in those who were healthy prior to acute COVID-19 infection. Until more specific scientific evidence comes to light, care of these patients should be viewed through the prism of the best practices already in use and clinicians should maintain a low threshold to pursue more extensive cardiac workup prior to surgery.

Context Point-of-care ultrasound (POCUS) has diverse applications across various clinical specialties, serving as an adjunct to clinical findings and as a tool for increasing the quality of patient care. Owing to its multifunctionality, a growing number of medical schools are increasingly incorporating POCUS training into their curriculum, some offering hands-on training during the first 2 years of didactics and others utilizing a longitudinal exposure model integrated into all 4 years of medical school education. Midwestern University Arizona College of Osteopathic Medicine (MWU-AZCOM) adopted a 4-year longitudinal approach to include POCUS education in 2017. There is a small body of published research supporting this educational model, but there is not much data regarding how this approach with ultrasound curriculum translates to real-world changes in POCUS use by graduate student clinicians having received this model of education. Objectives The objectives of this study are to determine the frequency of POCUS use by MWU-AZCOM graduates and to assess how a 4-year longitudinal ultrasound curriculum may enhance the abilities of MWU-AZCOM graduates to perform and interpret ultrasound imaging in specific residency programs. Methods The study was approved by the MWU Institutional Review Board (#IRBAZ-5169, approval date October 3, 2022). An anonymous novel 12-question survey was conducted utilizing Research Electronic Data Capture (REDCap), a secure online platform, and distributed to MWU-AZCOM 2021 and 2022 graduates via email. Survey questions were aimed at assessing frequency of use, utilization of different imaging modalities, reasons for utilizing POCUS, barriers/enablers to utilizing POCUS, ultrasound training, and confidence in performing scans and interpreting POCUS imaging. All of the 104 surveys returned were included in the study. Statistical software R version 4.3 was utilized to conduct statistical analyses. Results Of the 484 surveys distributed, 104 were completed (21.5 % response rate). Responses came from residents working in 14 different specialties, 50 in primary care and 54 in nonprimary care. Of all respondents, 85.6 % currently utilize POCUS in their practice on at least a monthly basis and 77.0 % believe that their POCUS training in medical school enriches their current practice in residency. The top five modalities utilized by residents were procedures (89.9 %), cardiac (88.8 %), pulmonary (82.0 %), Focused Assessment with Sonography for Trauma (FAST, 73.0 %), and vascular (71.9 %). Respondents recognized POCUS as a beneficial diagnostic tool (97.8 %) and reported enhancements in physical examination skills (58.4 %) and professional growth (61.8 %). Facilitators for POCUS adoption included cost-effectiveness (82.0 %), diagnostic differentiation (78.7 %), and safety (79.8 %). Barriers included a lack of trained faculty (27.9 %), absence of necessary equipment (26.9 %), and cost of equipment (22.1 %). Participants demonstrated high confidence levels in performing (74.0 %) and interpreting (76.0 %) POCUS, with 43.3 % believing that their POCUS training enhanced their attractiveness as residency candidates. Conclusions This study supports the positive impact of a 4-year longitudinal POCUS curriculum on graduates’ practice. It emphasizes the link between MWU-AZCOM’s curriculum and real-world clinical needs. Addressing identified barriers and advancing hands-on training can further enhance POCUS understanding, ensuring that future physicians are well-prepared to leverage its diagnostic potential across medical specialties.

Context In 2020, the allopathic and osteopathic residency programs were merged into a single residency system, with the Accreditation Council for Graduate Medical Education (ACGME) as the sole accreditor for residencies and fellowships in the United States. As a result of this merger, osteopathic recognition (OR) emerged as a unique approach to promoting osteopathic training and practice. However, there is a lack of data on the effects of OR in residency, specifically university-based residency programs. Objectives The objective of this study is to investigate the impact of OR on retaining and applying osteopathic principles in a mixed cohort of residents in a single-center setting. Methods We conducted a prospective cohort study of allopathic and osteopathic-trained residents at varying years of postgraduate training in family medicine (FM), internal medicine (IM), and combined internal medicine–pediatric residencies at a single site. Participation in both the osteopathic curriculum and study was voluntary. We distributed a presurvey before the residents participated in the curriculum for that year and a follow-up 6 months later as a postsurvey. The surveys measured confidence levels based on a Likert scale and were aligned with the Osteopathic Recognition Milestones Project (ORMP). Statistical analysis with paired t tests and a Wilcoxon signed-rank test was conducted on participants who completed both surveys. Results We had 38 % (18/47) of participants complete both surveys. We observed significant improvements in confidence levels related to osteopathic principles (p=0.036). Residents reported statistically significant gains in their ability to conduct a literature review on osteopathic medicine (p=0.0288). Additionally, there was a trend toward significance in confidence levels regarding the patient’s perception of touch (p=0.0741) and the osteopathic treatment plan (p=0.0635). Notably, content knowledge was significantly improved (p=0.0313) for all participants. Based on the postsurvey responses, we discovered that participants who not only reported higher confidence overall but also had practiced osteopathic manipulative treatment (OMT) in the last month were more likely to state they would practice osteopathic manipulative medicine (OMM) after residency. Conclusions We conducted a prospective cohort study to assess the effects of OR utilizing surveys aligned to the ORMP. We identified knowledge- and confidence-level gains on osteopathic principles and practice (OPP) in a single-center study. Residents in OR are more likely to utilize OMT after residency.

Context Runners often experience acute/chronic pain due to pre-existing structural somatic dysfunction and/or acquired various overuse injuries of the lower extremity, specifically affecting the ligaments, tendons, muscles, and bones. Common structural and function dysfunctions include but are not limited to patellofemoral pain syndrome (PFPS), Achilles tendonitis, iliotibial band syndrome (ITBS), ligamentous and muscle tears, muscle sprains/strains, stress fractures, pes planus, plantar fasciitis, and shin splints. Objectives The purpose of this study is to assess the correlation between acute and chronic pain, overuse injuries, and observational and palpatory findings upon evaluation to establish common trends of somatic dysfunctions and determine possible etiology of the pain/injury. Methods A total of 103 individuals were recruited (54.4% female, 45.6% male) aged 23–67 years old who consistently run at least 1 mile each week. They were categorized based on their weekly mileage – Novice (1–5 miles per week), Moderate (6–15), Advanced (15+) – with the intention to have a diversity of running types and to assess the data at various levels of commitment to running. The average was 7.8 miles/week with the range at 1 to 28 miles per week. The subjects included Touro students and individuals in the community. A history was collected through an anonymous survey on the individual’s running habits, chronic/acute injuries, and any other relevant medical information. Data analyzing investigators were blinded to subjects’ identifying information. Additionally, an osteopathic assessment was performed by two student investigators for reliability purposes and conducted under supervision by a board-certified osteopathic physician. Results Analysis of the data suggested an existing correlation between the number of somatic dysfunctions and years of running. A slight correlation was found between somatic dysfunctions and miles per week, sports injuries, time per week, and lower extremity pain. Finally, statistical correlations were also identified between the presence of pes planus and limb length discrepancy with three distinct muscular hypertonicities. Conclusions Runners’ pains and injuries of the lower extremity are complex, and injury treatment and prevention is equally multifaceted. An association was found between both pes planus and limb length discrepancy with lower extremity muscle hypertonicity, suggesting the interrelated nature of these somatic dysfunctions. The survey concluded that many runners continue to run in pain and/or after significant injury but do not necessarily capitalize on existing support such as fitted shoes, custom arches, and osteopathic treatment that may help to minimize their risk of or treat injury. The intention of the research is to bring awareness to practitioners to the most common somatic dysfunctions such that they can recommend runners to obtain gait analyses and/or osteopathic treatments, which may not only alleviate injuries faster but also prevent future injury.

Context Osteopathic manipulative medicine (OMM) is a unique skill set consisting of physical manipulations that treat the neuromusculoskeletal system. Although OMM can improve patient outcomes such as functionality and pain, as well as increase physician reimbursement, its use is declining. Barriers to its use include a lack of proficiency, support, reimbursement, and time. Knowledge gaps remain as to how OMM training during graduate medical education (GME) affects OMM use. Objectives This study describes relationships between OMM exposure during GME and the use of OMM in practice. Methods An online survey of physicians in a variety of medical fields during late 2022 assessed the impact of OMM education during postgraduate training on its use in clinical practice. Survey data were analyzed to compare training characteristics and OMM use via chi-square tests and binary logistic regression. Results A total of 299 surveys were completed. Respondents who received formal OMM education during residency were more likely (59.8 %) to utilize OMM in medical practice than those who practiced OMM informally (37.8 %, p<0.001) and those who had no OMM exposure during residency (10.3 %, p<0.001). Respondents who trained with more osteopathic attendings (p<0.001) and co-residents (p=0.012) were also more likely to utilize OMM. Those who completed residencies that were accredited by the Accreditation Council for Graduate Medical Education (ACGME) with an Osteopathic recognition track, by the American Osteopathic Association (AOA), and were dually-accredited (ACGME/AOA), were all more likely to utilize OMM (60 %, 56 %, and 53 %, respectively) than those who completed residencies with ACGME accreditation alone (22 %, p<0.01). Conclusions Although OMM can improve patient outcomes, it is underutilized by Doctors of Osteopathic Medicine (DOs) in practice. Lack of training after medical school has been identified as a contributing factor to its disuse. The results of our study illustrate that there is a positive association between OMM education during postgraduate training and OMM use in clinical practice.

Context The pelvic examination is a fundamental tool for the evaluation and diagnosis of women’s health conditions and an important skill for all medical students to learn as future physicians for the early detection of treatable conditions such as infection or cancer. Although the American College of Obstetricians and Gynecologists (ACOG) asserts that performing pelvic examinations under anesthesia for educational purposes should only occur if the patient provides explicit and informed consent, there still have been reports of medical students performing pelvic examinations on anesthetized patients across the country, and many states are now starting to pass bills requiring informed patient consents to conduct pelvic examinations under anesthesia. Objectives The objectives of this study are to evaluate the prevalence of pelvic examinations performed by osteopathic medical students on anesthetized patients without consent while fulfilling their third-year OB-GYN clerkship requirements. Methods The survey was administered and distributed to all osteopathic medical schools in the country via the Student Osteopathic Medical Association’s (SOMA’s) chapter emails, outreach emails, and SOMA’s social media accounts to collect data. Inclusion criteria included third- or fourth-year osteopathic medical students who completed their OB-GYN clerkship rotations when taking the survey. The exclusion criteria included any osteopathic medical student who had not completed their OB-GYN clerkship rotation. We utilized descriptive analysis to summarize the final data. Results We received 310 responses. The final number of responses was 291 after meeting the exclusion criteria. Most osteopathic medical students (94.2 %, n=274) considered the practice of performing pelvic examinations on anesthetized patients without their explicit consent unethical. Among the participants, 40.9 % (n=119) admitted to performing pelvic examinations on patients under anesthesia while on OB-GYN rotations, but most of them (57.1 %, n=68) did so without obtaining prior consent from the patients. Notably, the number of pelvic examinations performed by medical students on patients under anesthesia ranged widely from 1 to 25 with a median number of 10. Moreover, 58.9 % (n=70) indicated that they had not been properly educated to obtain specific consent before performing pelvic examinations under anesthesia. Many participants cited efficiency of practice, lack of policy awareness and personal education by medical students, and failure to refuse to perform pelvic examinations on anesthetized patients as trainees when asked by their seniors or preceptors. Conclusions This study demonstrates that although most osteopathic medical students consider performing pelvic examinations on anesthetized patients unethical, many still admit to practicing pelvic examinations on patients under anesthesia, while on OB-GYN rotations for efficiency of practice, lack of policy awareness and personal education, and being in unique positions in which grades are determined by seniors and preceptors for their willingness to do what is asked even if the practice does not align with their conviction. This study highlights the importance of ongoing research and implementation of policies at institutional and state levels that will procure the value of pelvic examinations while protecting and upholding the ethics of patients’ rights and autonomy of medical students.