Development of Osteopathic Neuromusculoskeletal Medicine (ONMM) residency curriculum guidelines to meet Accreditation Council for Graduate Medical Education (ACGME) milestones.

CONTEXT: A memorandum of understanding was reached between the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), and the American Association of Colleges of Osteopathic Medicine (AACOM) in 2014 outlining the course for a single accreditation system for graduate medical education. This process was completed in 2020 and has included the transition of AOA-accredited neuromusculoskeletal and Osteopathic Manipulative Medicine (OMM) programs into programs now termed "Osteopathic Neuromusculoskeletal Medicine" (ONMM) under the single accreditation system. Progress through ONMM residency is evaluated on the basis of 15 ACGME milestones that encompass six core competencies. However, there are no curricular guidelines to help guide the achievement of these milestones. OBJECTIVES: The primary purpose of this study was to develop a proposed structure and content for an ONMM residency curriculum that is based on (1) the alignment of residency curriculum with ACGME milestones in one ACGME-accredited ONMM residency program, and (2) the perceived needs of residents and faculty for an ONMM residency curriculum. METHODS: A mixed-methods exploratory sequential approach with embedded design was utilized. Qualitative analysis of didactics curriculum content for the past 2 years was coded according to themes identified in the residency curriculum content, which were further coded according to ACGME milestones. Curriculum topics identified in qualitative analysis were utilized to create a questionnaire that was administered to residents and faculty (n=24) in the ONMM residency program to examine the perceived importance of each curriculum topic based on a five-point Likert scale. Open-ended questions were embedded in the questionnaire that asked how faculty and residents define ONMM and what they believe should be the purpose of an ONMM residency curriculum. RESULTS: Five themes were identified in qualitative analysis of curriculum: (1) OMM laboratory topics; (2) faculty-led activities and lecture topics; (3) resident-led activities and lecture topics; (4) research; and (5) training courses and volunteer activities. The most important perceived curriculum topics for faculty and residents were osteopathic structural examination, orthopedic exam, direct and indirect methods, osteopathic cranial manipulative medicine, pediatric OMT, common upper and lower extremity injuries, and low back pain. Each of these topics aligned well with ACGME milestones. Residents reported that integrative medicine topics such as acupuncture were a significantly more important OMM laboratory topic (mean=3.58, SD=0.996) compared to faculty (mean=2.33, SD=0.985), t (22)=-3.091, p=0.005. Study participants most commonly described ONMM in terms of the specialized knowledge required for the discipline (n=19, 79.2%) and the Tenets of Osteopathy (n=17, 70.8%), and they felt that the purpose of an ONMM residency curriculum should be to gain knowledge (n=20, 83.3%) and become a competent physician (n=19, 79.2%). CONCLUSIONS: The present findings were applied to the development of proposed ONMM residency curriculum guidelines and submitted to the American Academy of Osteopathy (AAO) for consideration. They are presented here as a resource for ONMM residencies to develop a program curriculum in alignment with individual program needs.

A New Taxonomy for Technology-Enabled Diabetes Self-Management Interventions: Results of an Umbrella Review.

BACKGROUND: A 2017 umbrella review defined the technology-enabled self-management (TES) feedback loop associated with a significant reduction in A1C. The purpose of this 2021 review was to develop a taxonomy of intervention attributes in technology-enabled interventions; review recent, high-quality systematic reviews and meta-analyses to determine if the TES framework was described and if elements contribute to improved diabetes outcomes; and to identify gaps in the literature. METHODS: We identified key technology attributes needed to describe the active ingredients of TES interventions. We searched multiple databases for English language reviews published between April 2017 and April 2020, focused on PwD (population) receiving diabetes care and education (intervention) using technology-enabled self-management (comparator) in a randomized controlled trial, that impact glycemic, behavioral/psychosocial, and other diabetes self-management outcomes. AMSTAR-2 guidelines were used to assess 50 studies for methodological quality including risk of bias. RESULTS: The TES Taxonomy was developed to standardize the description of technology-enabled interventions; and ensure research uses the taxonomy for replication and evaluation. Of the 26 included reviews, most evaluated smartphones, mobile applications, texting, internet, and telehealth. Twenty-one meta-analyses with the TES feedback loop significantly lowered A1C. CONCLUSIONS: Technology-enabled diabetes self-management interventions continue to be associated with improved clinical outcomes. The ongoing rapid adoption and engagement of technology makes it important to focus on uniform measures for behavioral/psychosocial outcomes to highlight healthy coping. Using the TES Taxonomy as a standard approach to describe technology-enabled interventions will support understanding of the impact technology has on diabetes outcomes.

Complementarity of Digital Health and Peer Support: "This Is What's Coming".

Purpose: This study examined integration of peer support and a Food and Drug Administration-cleared, diabetes management app (DMA) in diabetes self-management support as a scalable model for those with type 2 diabetes mellitus (T2DM). Methods: Two lay health Coaches delivered telephone-based self-management support to adults (N = 43) with T2DM recruited through a primary group practice. Those eligible were offered no-cost access to DMA for the entire 6-month study. Coaches introduced DMA and contacted individuals by phone and text with frequency dependent on participant needs/preferences. DMA supported monitoring of blood glucose, carbohydrate intake, and medication use, as well as messaging personalized to participants' medication regimens. Clinical data were extracted from DMA, electronic medical records, and Coaches' records. Structured interviews of 12 participants, 2 Coaches, and 5 project staff were analyzed using deductive pre-identified codes (regarding adoptability, patterns of use, value added, complementarity, and sustainability) utilizing standard procedures for qualitative analysis. Results: Of the 43 participants, 38 (88.4%) enrolled in DMA. In general, participants used both DMA and lay health coaches, averaging 144.14 DMA entries (structured, e.g., medications, and free form, e.g., "ate at a restaurant" and "stressed") and 5.86 coach contacts over the 6-month intervention. Correlation between DMA entries and coach contacts (r = .613, p < 0.001) was consistent with complementarity as were participants' and coaches' observations that (a) DMA facilitated recognition of patterns and provided reminders and suggestions to achieve self-management plans, whereas (b) coaching provided motivation and addressed challenges that emerged. Mean hemoglobin A1c (A1c) declined from 9.93% to 8.86% (p < 0.001), with no pattern of coaching or DMA use significantly related to reductions. Staff identified resources to coordinate coach/DMA interventions as a major sustainability challenge. Conclusions: DMA and peer support for diabetes management are compatible and complementary. Additional practice integration research is needed for adoption and scale-up.

A Framework for Optimizing Technology-Enabled Diabetes and Cardiometabolic Care and Education: The Role of the Diabetes Care and Education Specialist.

PURPOSE: The purpose of this article is to present a framework for optimizing technology-enabled diabetes and cardiometabolic care and education using a standardized approach. This approach leverages the expertise of the diabetes care and education specialist, the multiplicity of technologies, and integration with the care team. Technology can offer increased opportunity to improve health outcomes while also offering conveniences for people with diabetes and cardiometabolic conditions. The adoption and acceptance of technology is crucial to recognize the full potential for improving care. Understanding and incorporating the perceptions and behaviors associated with technology use can prevent a fragmented health care experience. CONCLUSION: Diabetes care and education specialists (DCES) have a history of utilizing technology and data to deliver care and education when managing chronic conditions. With this unique skill set, DCES are strategically positioned to provide leadership to develop and deliver technology-enabled diabetes and cardiometabolic health services in the rapidly changing healthcare environment.

Can the Palatability of Healthy, Satiety-Promoting Foods Increase with Repeated Exposure during Weight Loss?

Repeated exposure to sugary, fatty, and salty foods often enhances their appeal. However, it is unknown if exposure influences learned palatability of foods typically promoted as part of a healthy diet. We tested whether the palatability of pulse containing foods provided during a weight loss intervention which were particularly high in fiber and low in energy density would increase with repeated exposure. At weeks 0, 3, and 6, participants (n = 42; body mass index (BMI) 31.2 ± 4.3 kg/m²) were given a test battery of 28 foods, approximately half which had been provided as part of the intervention, while the remaining half were not foods provided as part of the intervention. In addition, about half of each of the foods (provided as part or not provided as part of the intervention) contained pulses. Participants rated the taste, appearance, odor, and texture pleasantness of each food, and an overall flavor pleasantness score was calculated as the mean of these four scores. Linear mixed model analyses showed an exposure type by week interaction effect for taste, texture and overall flavor pleasantness indicating statistically significant increases in ratings of provided foods in taste and texture from weeks 0 to 3 and 0 to 6, and overall flavor from weeks 0 to 6. Repeated exposure to these foods, whether they contained pulses or not, resulted in a ~4% increase in pleasantness ratings. The long-term clinical relevance of this small increase requires further study.

Evidence-Based mHealth Chronic Disease Mobile App Intervention Design: Development of a Framework.

BACKGROUND: Mobile technology offers new capabilities that can help to drive important aspects of chronic disease management at both an individual and population level, including the ability to deliver real-time interventions that can be connected to a health care team. A framework that supports both development and evaluation is needed to understand the aspects of mHealth that work for specific diseases, populations, and in the achievement of specific outcomes in real-world settings. This framework should incorporate design structure and process, which are important to translate clinical and behavioral evidence, user interface, experience design and technical capabilities into scalable, replicable, and evidence-based mobile health (mHealth) solutions to drive outcomes. OBJECTIVE: The purpose of this paper is to discuss the identification and development of an app intervention design framework, and its subsequent refinement through development of various types of mHealth apps for chronic disease. METHODS: The process of developing the framework was conducted between June 2012 and June 2014. Informed by clinical guidelines, standards of care, clinical practice recommendations, evidence-based research, best practices, and translated by subject matter experts, a framework for mobile app design was developed and the refinement of the framework across seven chronic disease states and three different product types is described. RESULTS: The result was the development of the Chronic Disease mHealth App Intervention Design Framework. This framework allowed for the integration of clinical and behavioral evidence for intervention and feature design. The application to different diseases and implementation models guided the design of mHealth solutions for varying levels of chronic disease management. CONCLUSIONS: The framework and its design elements enable replicable product development for mHealth apps and may provide a foundation for the digital health industry to systematically expand mobile health interventions and validate their effectiveness across multiple implementation settings and chronic diseases.

Eco-virological survey of Aedes mosquito larvae in selected dengue outbreak areas in Malaysia.

UNLABELLED: BACKGROUND & OBJECTIVESI: Transovarial transmission of dengue virus in the Aedes vectors is now a well-documented phenomenon reported from many parts of the endemic areas in the world, which played an important role in initiating and maintaining the outbreak in human populations. This study investigated the factors affecting breeding habitats and the relationship with transovarial dengue virus in larvae of Aedes aegypti and Ae. albopictus. METHODS: Larval surveillance was conducted in dengue outbreak areas in Malaysia from 2008 until 2009. Sampling was carried out based on habitat type, water condition (substrate type), canopy coverage, temperature and pH at breeding habitats. RT-PCR was performed to detect presence of transovarial dengue virus in larvae collected in the study areas. RESULTS: A total of 789 breeding habitats were identified during this study and the majority of these breeding sites were plastic containers (57.46%). Aedes albopictus dominated most of the water condition surveyed, while Ae. aegypti indicated preference toward habitats with clear water. Aedes aegypti was selective in selecting ovipositional sites compared to Ae. albopictus where shaded areas were shown to be the most preferred. From a total of 363 mosquito larvae pools, 23 (6.3%) pools were positive for dengue virus where 18 of them were from Ae. albopictus and five were from Ae. aegypti mosquito larvae pools. INTERPRETATION & CONCLUSION: This study indicated the presence of transovarial transmission of dengue virus in immature Ae. aegypti and Ae. albopictus in the field. This study also showed that combination of water conditions, canopy coverage, temperature and pH of breeding habitats were the factors affecting the larval population. The study suggested that larval survey programme could serve as a tool not only to monitor the local dengue vector distribution but also to provide objective information for taking appropriate action by the community against dengue vectors.

Integration of a mobile-integrated therapy with electronic health records: lessons learned.

BACKGROUND: Responses to the chronic disease epidemic have predominantly been standardized in their approach to date. Barriers to better health outcomes remain, and effective management requires patient-specific data and disease state knowledge be presented in methods that foster clinical decision-making and patient self-management. Mobile technology provides a new platform for data collection and patient-provider communication. The mobile device represents a personalized platform that is available to the patient on a 24/7 basis. Mobile-integrated therapy (MIT) is the convergence of mobile technology, clinical and behavioral science, and scientifically validated clinical outcomes. In this article, we highlight the lessons learned from functional integration of a Food and Drug Administration-cleared type 2 diabetes MIT into the electronic health record (EHR) of a multiphysician practice within a large, urban, academic medical center. METHODS: In-depth interviews were conducted with integration stakeholder groups: mobile and EHR software and information technology teams, clinical end users, project managers, and business analysts. Interviews were summarized and categorized into lessons learned using the Architecture for Integrated Mobility® framework. RESULTS: Findings from the diverse stakeholder group of a MIT-EHR integration project indicate that user workflow, software system persistence, environment configuration, device connectivity and security, organizational processes, and data exchange heuristics are key issues that must be addressed. CONCLUSIONS: Mobile-integrated therapy that integrates patient self-management data with medical record data provides the opportunity to understand the potential benefits of bidirectional data sharing and reporting that are most valuable in advancing better health and better care in a cost-effective way that is scalable for all chronic diseases.

Current sedation and anesthesia practices among dentists: a statewide survey.

INTRODUCTION: The purpose of this survey was to describe the current sedation training and practices among dentists in the state of Virginia, and to determine what areas of sedation training may need to be improved or maintained. METHODS: A survey was developed by two faculty members at the VCU School of Medicine and School of Dentistry, focused on sedation practices of dentists within the state of Virginia. The survey contained several key domains: background, education and training, implementation in practice, and continuing education. The survey consisted of thirty questions. RESULTS: Four hundred and thirty nine dentists responded of the 1,982 (22% response rate) surveys were completed and used in analysis. Almost half of the dentists that responded use oral medication to administer sedation within their office and of those 67% re-dose the oral sedative medication to the patient. Over 75% of dentists indicated that they have had some type of sedation related emergency in their office; despite this number, 11% reported that they do not practice for sedation emergency scenarios. Over 70% of dentists reported that they solely monitor their patient during simultaneous sedation and dental treatment, while others reported having a dental assistant (20%) or other medical provider (10%) assisting with monitoring while they are providing dental care. CONCLUSION: With 75% of dentists that responded to the survey practicing sedation, experiencing some type of medical emergency related to sedations, and 4% of these not using any type of patient monitoring system, all providers offering sedation should follow the monitoring guidelines set forth by the ADA and/or AAPD. With an increase in demand from patients for sedation services during dental procedures, additional training should be recommended to dentists to assure that they have the skills and knowledge necessary to rescue a patient should a medical emergency arise.

Aedes larval population dynamics and risk for dengue epidemics in Malaysia.

Early detection of a dengue outbreak is an important first step towards implementing effective dengue interventions resulting in reduced mortality and morbidity. A dengue mathematical model would be useful for the prediction of an outbreak and evaluation of control measures. However, such a model must be carefully parameterized and validated with epidemiological, ecological and entomological data. A field study was conducted to collect and analyse various parameters to model dengue transmission and outbreak. Dengue prone areas in Kuala Lumpur, Pahang, Kedah and Johor were chosen for this study. Ovitraps were placed outdoor and used to determine the effects of meteorological parameters on vector breeding. Vector population in each area was monitored weekly for 87 weeks. Weather stations, consisting of a temperature and relative humidity data logger and an automated rain gauge, were installed at key locations in each study site. Correlation and Autoregressive Distributed Lag (ADL) model were used to study the relationship among the variables. Previous week rainfall plays a significant role in increasing the mosquito population, followed by maximum humidity and temperature. The secondary data of rainfall, temperature and humidity provided by the meteorological department showed an insignificant relationship with the mosquito population compared to the primary data recorded by the researchers. A well fit model was obtained for each locality to be used as a predictive model to foretell possible outbreak.

Aedes larval population dynamics and risk for dengue epidemics in Malaysia

Early detection of a dengue outbreak is an important first step towards implementing effective dengue interventions resulting in reduced mortality and morbidity. A dengue mathematical model would be useful for the prediction of an outbreak and evaluation of control measures. However, such a model must be carefully parameterized and validated with epidemiological, ecological and entomological data. A field study was conducted to collect and analyse various parameters to model dengue transmission and outbreak. Dengueprone areas in Kuala Lumpur, Pahang, Kedah and Johor were chosen for this study. Ovitraps were placed outdoor and used to determine the effects of meteorological parameters on vector breeding. Vector population in each area was monitored weekly for 87 weeks. Weather stations, consisting of a temperature and relative humidity data logger and an automated rain gauge, were installed at key locations in each study site. Correlation and Autoregressive Distributed Lag (ADL) model were used to study the relationship among the variables. Previous week rainfall plays a significant role in increasing the mosquito population, followed by maximum humidity and temperature. The secondary data of rainfall, temperature and humidity provided by the meteorological department showed an insignificant relationship with the mosquito population compared to the primary data recorded by the researchers. A well fit model was obtained for each locality to be used as a predictive model to foretell possible outbreak.

Functional endothelialized microvascular networks with circular cross-sections in a tissue culture substrate.

Functional endothelialized networks constitute a critical building block for vascularized replacement tissues, organ assist devices, and laboratory tools for in vitro discovery and evaluation of new therapeutic compounds. Progress towards realization of these functional artificial vasculatures has been gated by limitations associated with the mechanical and surface chemical properties of commonly used microfluidic substrate materials and by the geometry of the microchannels produced using conventional fabrication techniques. Here we report on a method for constructing microvascular networks from polystyrene substrates commonly used for tissue culture, built with circular cross-sections and smooth transitions at bifurcations. Silicon master molds are constructed using an electroplating process that results in semi-circular channel cross-sections with smoothly varying radii. These master molds are used to emboss polystyrene sheets which are then joined to form closed bifurcated channel networks with circular cross-sections. The mechanical and surface chemical properties of these polystyrene microvascular network structures enable culture of endothelial cells along the inner lumen. Endothelial cell viability was assessed, documenting nearly confluent monolayers within 3D microfabricated channel networks with rounded cross-sections.

Computerized learning technologies for diabetes: a systematic review.

BACKGROUND: The objective of this study was to evaluate computerized learning technology interventions that can empower patients in the self-management of diabetes and support diabetes education over a distance. METHODS: We searched Medline (1966-2006), CINAHL (1982-2006), and the Cochrane Central Register of Controlled Trials (first quarter 2007) databases. We also reviewed reference lists from included studies to identify additional studies. We included 25 articles representing 21 randomized controlled trials that evaluated a computerized learning technology and measured the outcome of patient care. We extracted patient sample, intervention, educational content topics, outcome measures, and statistical significance. RESULTS: Of 21 eligible trials, 18 trials (85.7%) reported significant positive outcomes. Almost 44% (43.8%) of the outcomes demonstrated significant improvements (49 of 112 outcomes). CONCLUSIONS: Patient self-management behaviors are important in chronic disease management, and initial evidence suggests that computerized learning technology interventions can play a significant role in the future.

Resorbable polymer microchips releasing BCNU inhibit tumor growth in the rat 9L flank model.

Sustained local delivery of single agents and controlled delivery of multiple chemotherapeutic agents are sought for the treatment of brain cancer. A resorbable, multi-reservoir polymer microchip drug delivery system has been tested against a tumor model. The microchip reservoirs were loaded with 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU). BCNU was more stable at 37 degrees C within the microchip compared to a uniformly impregnated polymeric wafer (70% intact drug vs. 38%, at 48 h). The half-life of the intact free drug in the microchip was 11 days, which is a marked enhancement compared to its half-life in normal saline and 10% ethanol (7 and 10 min, respectively) [P. Tepe, S.J. Hassenbusch, R. Benoit, J.H. Anderson, BCNU stability as a function of ethanol concentration and temperature, J. Neurooncol. 10 (1991) 121-127; P. Kari, W.R. McConnell, J.M. Finkel, D.L. Hill, Distribution of Bratton-Marshall-positive material in mice following intravenous injections of nitrosoureas, Cancer Chemother. Pharmacol. 4 (1980) 243-248]. A syngeneic Fischer 344 9L gliosarcoma rat model was used to study the tumoricidal efficacy of BCNU delivery from the microchip or homogeneous polymer wafer. A dose-dependent decrease in tumor size was found for 0.17, 0.67, and 1.24 mg BCNU-microchips. Tumors treated with 1.24 mg BCNU-microchips showed significant tumor reduction (p=0.001) compared to empty control microchips at two weeks. The treatment showed similar efficacy to a polymer wafer with the same dosage. The microchip reservoir array may enable delivery of multiple drugs with independent release kinetics and formulations.