Effect of a Mandatory Third-Year Osteopathic Manipulative Treatment Course on Student Attitudes.

CONTEXT: Despite interest by osteopathic medical students in learning and incorporating osteopathic manipulative treatment (OMT) techniques into their future practices, most students indicate that OMT is rarely or never taught during many clinical rotations. OBJECTIVE: To determine whether a mandatory OMT course taken during the third year of medical school would influence students' exposure to OMT, confidence in OMT, intent to continue developing OMT skills, and plan to provide OMT as practicing physicians. METHODS: A mandatory pilot OMT course was implemented in the 2014 third-year curriculum. A survey was then developed to assess students' attitudes toward OMT. Surveys were administered to students whose third year was in 2013 and thus had not taken the course (group 1) and to students who had taken the course in 2014 (group 2). RESULTS: Of the 223 students in group 1, 143 (64%) responded. Of the 213 students in group 2, 112 (53%) responded. Students in group 2 reported greater exposure to OMT compared with students in group 1, higher confidence levels in practicing OMT (61 [54%] vs 71 [50%]), greater intent to continue developing OMT skills, and plan to provide OMT as practicing physicians (91 [81%] vs 94 [66%]). CONCLUSION: A pilot course in OMT increased students' levels of confidence in and intent to provide OMT in their future practices.

Predictive relationship of osteopathic manual medicine grades and COMLEX-USA Level 1 total scores and osteopathic principles and practice subscores.

CONTEXT: Osteopathic manual medicine (OMM) encompasses hands-on diagnosis and treatment as part of patient care. The area of osteopathic principles and practice (OPP) is considered a core competency for students and practitioners of this medical tradition. The Comprehensive Osteopathic Medical Licensing Examination-USA (COMLEX-USA) is a useful tool for assessing candidates' competency. OBJECTIVES: To examine the relationship of COMLEX-USA Level 1 total scores and OPP subscores with OMM course grades, and to determine if these grades are predictive of COMLEX-USA Level 1 OPP performance. METHODS: The authors collected data-COMLEX-USA Level 1 total and OPP subscores, OMM grades (written, practical, and total for first and second academic years), sex, and age-for a cohort of osteopathic medical students at a single institution, and these data were then analyzed by means of correlation analysis. RESULTS: Records were obtained from a second-year class of osteopathic medical students (N=217). The authors' analysis of total scores and OPP subscores on COMLEX-USA Level 1 yielded a statistically significant correlation with all variables. Although the correlations were moderate, second-year written examination grades showed the strongest association with the COMLEX-USA Level 1 OPP subscores (r=0.530) and total scores (r=0.566). CONCLUSION: Performance in the second-year OMM written examination could identify students potentially at risk for poor performance on COMLEX-USA Level 1.

Opioid consumption following outpatient upper extremity surgery.

PURPOSE: After elective outpatient upper extremity surgery, patients' need for opioid analgesic medication may be considerably less than typically dispensed. Our goal for this study was to evaluate pain control and quantify the amount of leftover pain medication. METHODS: We recruited patients scheduled for elective outpatient upper extremity surgery, who met the inclusion criteria, to participate in a phone interview 7 to 14 days after surgery. Information collected included age, gender, procedure performed, analgesic medication and regimen prescribed, satisfaction with pain control, number of tablets remaining, reasons for not taking medication, other analgesic medications used, payer classification, and any adverse drug reactions. RESULTS: A total of 287 eligible subjects consented to participate. Of these, 36 patients failed phone contact and 1 patient canceled surgery, which left 250 patients who completed the study. Oxycodone, hydrocodone, and propoxyphene accounted for over 95% of the prescription medications, with adequate pain control reported by 230 (92%) patients. Patients most frequently received 30 pills. Patients undergoing bone procedures reported the highest medication use (14 pills), whereas patients undergoing soft tissue procedures reported the lowest use (9 pills). Over half of the subjects reported taking the opioid medication for 2 days or less. Medicare patients consumed significantly less medication (7 pills, P < .05) than patients covered by all other types of insurance. Overall, patients consumed a mean of 10 opioid pills, whereas 19 pills per subject were reported unused, which resulted in 4,639 leftover tablets for the entire cohort. CONCLUSIONS: Our data show that excess opioid analgesics are made available after elective upper extremity surgery and could potentially become a source for diversion. A prescription of 30 opioid pills for outpatient surgery appears excessive and unnecessary, especially for soft tissue procedures of the hand and wrist. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.

A prematriculation intervention to improve the adjustment of students to medical school.

BACKGROUND AND PURPOSE: The transition from a baccalaureate program to a medical curriculum can be a difficult period for some students. Our study asked whether providing students with review materials and a means of assessing their degree of preparedness prior to matriculation influenced actual and perceived performance in 1st-year basic science courses. METHODS: Didactic review materials in basic science subjects encountered in the 1st year were made available to prematriculants online. Access to materials for each subject was contingent upon completion of a pretest. Prematriculants were free to use the materials as they saw fit. Once students matriculated, performance in basic science subjects was compared between those who had accessed the materials and those who had not. Students who accessed the materials were also surveyed to determine if they perceived any benefit from their use. RESULTS: More than half of matriculants chose to access the intervention materials. There was no significant difference in MCAT, prerequisite grade point average, or total grade point average between those students who chose to access the intervention materials and those who did not. Students who accessed the intervention materials reported gains in confidence in their ability to perform well in medical school. Those students who accessed the intervention materials had significantly higher examination scores in an early basic science course than those who did not. CONCLUSIONS: An online prematriculation intervention can provide useful background material to interested students. Access to this material increased performance in a 1st-year basic science course and was perceived as valuable by students.

Flexner revisited: the role and value of the basic sciences in medical education.

A central tenet of Flexner's report was the fundamental role of science in medical education. Today, there is tension between the time needed to teach an ever-expanding knowledge base in science and the time needed for increased instruction in clinical application and in the behavioral, ethical, and managerial knowledge and skills needed to prepare for clinical experiences. One result has been at least a perceived reduction in time and focus on the foundational sciences. In this context, the International Association of Medical Science Educators initiated a study to address the role and value of the basic sciences in medical education by seeking perspectives from various groups of medical educators to five questions: (1) What are the sciences that constitute the foundation for medical practice? (2) What is the value and role of the foundational sciences in medical education? (3) When and how should these foundational sciences be incorporated into the medical education curriculum? (4) What sciences should be prerequisite to entering the undergraduate medical curriculum? (5) What are examples of the best practices for incorporating the foundational sciences into the medical education curriculum? The results suggest a broad group of experts believes that an understanding of basic science content remains essential to clinical practice and that teaching should be accomplished across the entire undergraduate medical education experience and integrated with clinical applications. Learning the sciences also plays a foundational role in developing discipline and rigor in learners' thinking skills, including logical reasoning, critical appraisal, problem solving, decision making, and creativity.

Acute stroke care in a neurologically underserved state: lessons learned from the Iowa Stroke Survey.

Prior studies have suggested that stroke care is more fragmented in rural or neurologically underserved areas. The purpose of this study was to determine the availability of diagnostic and treatment services for acute stroke care in Iowa and to identify factors influencing care. Each of the 118 facilities in Iowa with emergency departments was surveyed by telephone. This survey consisted of 10 questions, focusing on the existence of pre-hospital and emergency room acute stroke protocols and the availability of essential personnel and diagnostic and treatment modalities essential for acute stroke care. Of the 118 hospitals with emergency departments, 109 (92.4%) had CT available. Within the subset having CT capabilities, 89.9% (98/109) had intravenous tissue plasminogen activator (IV t-PA) available. Of those facilities with both CT and IV t-PA, 46% (45/98) had around-the-clock in-house physician coverage. Further, 31% (14/45) of sites with CT, t-PA, and an in-house physician had a radiology technician on site. Only 12% (14/118) of centers could offer all essential components. Despite 88% of Iowa hospitals not providing all of these components, only 31% of these hospitals reported protocols for stabilization and immediate transfer of acute stroke patients. These findings indicate that the development of a stroke system is still in its infancy in Iowa. Collaborative efforts are needed to address barriers in rural Iowa and to assist facilities in providing the best possible care. Creativity will be paramount in establishing a functional statewide system to ensure optimum care for all Iowans.

Scaphoid excision and limited wrist fusion: a comparison of K-wire and circular plate fixation.

The purpose of this study was to compare the clinical outcome, union rate, and complications of a consecutive series of Scaphoid excision and limited wrist arthrodesis performed by a single surgeon using distal radius bone graft and K-wires or circular plate fixation. A sequential series of ten patients(11 wrists) who were stabilized with temporary K-wires were compared to 11 patients (11 wrists) who were stabilized with a circular plate. Minimum follow-up was 1 year. One patient in the K-wire group was converted to a wrist fusion. Six of the remaining ten patients in the K-wire fixation group and 8 of the 11 patients in the circular plate fixation group returned for the following blinded evaluations: Quick DASH, analog pain scale, range of motion, grip and pinch strength, plain x-ray, and multi-detector computed tomography evaluation. One non-union occurred in the K-wire group. There were no non-unions in the circular plate fixation group. There was no difference in any of remaining measures or rate of complications. This study shows that equivalent results can be obtained using circular plate fixation compared to K-wires when equivalent bone graft source and fusion technique are used. If K-wire removal requires a return to the OR, circular plate fixation is more cost-effective.

A departmental outcome assessment to evaluate educational achievement.

Defining and addressing outcome objectives is a crucial process in medical science and education. One outcome objective of the Physiology/ Pharmacology Department at Des Moines University is to prepare students to successfully complete Part I of the national licensure examination. This study assesses the effectiveness of the departmental curriculum in helping the students achieve success on Part I of the licensure examination. Standardized discipline examinations were used as the comprehensive final examination for the physiology and pharmacology courses for the classes of 1997, 1998, and 2002 through 2005. The results were assessed by class year and specific topic area as determined by an item keyword description. Student performance on Part I of the National Podiatric Board examination was assessed for each class. Podiatric medical students' performance tended to be similar to or slightly lower than that of the national cohort on the discipline examinations. Topic analysis revealed areas of weakness, which were then addressed in the second-year courses. Student performance on Part I was generally acceptable yet showed marked improvement with the curricular interventions and changes. External assessments provide us with an unbiased means to evaluate the strengths and weaknesses of the curriculum through student performance and to make appropriate adjustments to enhance students' success.

Aging, peripheral nerve injury and nociception: effects of the antioxidant 16-desmethyltirilazad.

Peripheral neuropathies increase with aging, and reactive oxygen species contribute to the symptomatology of neuropathic pain disorders. In this study, we examined age-related differences in the therapeutic efficacy of pre- or post-treatments of the amino-steroidal antioxidant 16-desmethyltirilazad in delaying the onset and/or limiting the duration of tactile-evoked allodynia following the induction of peripheral mononeuropathies in rats. Two different models of nerve injury were utilized to induce allodynia in young and aged rats: (1) the chronic constriction injury (CCI) model of Bennett and Xie [Bennett GJ, Xie Y-K. A peripheral mononeuropathy in rat that produces disorders of pain sensation like those seen in man. Pain 1988;33:87-107]; (2) the partial sciatic nerve ligation (PSNL) model of Seltzer et al. [Seltzer Z, Dubner R, Shir YA. Novel behavioral model of neuropathic pain disorders produced in rats by partial sciatic nerve injury. Pain 1990;43:205-18]. Calibrated von Frey filaments were used to examine changes in paw withdrawal threshold values. The results demonstrated that pre-treating young and aged rats with 16-desmethyltirilazad prior to the induction of peripheral mononeuropathies prevented the onset of neuropathic pain. However, once post-operative tactile allodynia was established, post-treatment therapy was ineffective at reversing the symptoms. These findings support the mediatory role of reactive oxygen species in neuropathic pain disorders, and suggest that the antiallodynic efficacy of antioxidant intervention is dependent on the time course of administration.

Tissue plasminogen activator use: evaluation and initial management of ischemic stroke from an Iowa hospital perspective.

Despite its efficacy for acute ischemic stroke, tissue plasminogen activator (rt-PA) is reported as used in less than 5% of patients with stroke. This study assessed the rate of intravenous rt-PA use in a community hospital and identified factors influencing rt-PA use. A retrospective chart review revealed a total of 464 patients presenting to the emergency department with a primary diagnosis of stroke from January 2000 through June 2002. Records were sorted into 3 groups: those presenting to the emergency department within 3 hours, 3 to 6 hours, and 6 hours or more of symptom onset. Each record was reviewed using National Institute of Neurologic Disorders and Stroke thrombolytic therapy criteria. Primary measures were rate of intravenous rt-PA use and reasons for not receiving rt-PA. Of the 464 patients with stroke who presented to the emergency department during the 30-month period, 99 arrived in less than 3 hours, 22 between 3 and 6 hours, and 343 greater than 6 hours. A total of 13 (2.8% of all patients with stroke or 13% of those presenting within 3 hours) received rt-PA. All patients meeting criteria received rt-PA. Rapidly improving or minor symptoms and difficult to control or elevated blood pressure were the most common reasons for not using rt-PA. Of the patients arriving within the 3-hour window, 14 were excluded by time factors. We conclude from this study that rt-PA can be effectively used in community hospitals and that use likely exceeds previously quoted national rates when based on a more appropriate measure of eligibility criteria as opposed to total presenting patients with stroke.