Lymphatic osteopathic manipulative treatment reduces duration of deltoid soreness after Pfizer/BioNTech COVID-19 vaccine

Pfizer-BioNTech BNT162b2 is one of the three U.S. Food and Drug Administration (FDA)-approved vaccines for the prevention of COVID-19. Its most common side effect, injection site pain, occurs because of locally recruited inflammatory mediators and is mitigated by the lymphatic system. Side effects may discourage individuals from receiving vaccines; therefore, reducing the duration of injection site pain can promote vaccination compliance. Osteopathic manipulative treatments (OMT) can directly affect the physiology underlying muscle soreness; however, there is currently no literature that supports the use of OMT in this scenario. In this case report, an otherwise healthy male presented with acute left deltoid soreness after receiving the Pfizer COVID-19 vaccine. The pain began 5 h prior to the visit. Three hours after being treated with lymphatic OMT, the severity of the pain was significantly reduced and was alleviated 8h after onset in comparison to the median duration of 24–48 h. He received his second dose 3 weeks later. This case report can provide future studies with the groundwork for further investigating the role of OMT in treating postvaccination muscle soreness, which can improve patient satisfaction and potentially promote vaccination compliance.

A novel movement system screen for primary care providers: a multisite, observational study

Context Movement of the human body is essential for the interaction of an individual within their environment and contributes to both physical and emotional quality of life. Movement system disorders (MSDs) are kinesiopathologic conditions that result from either altered movement patterns, trauma, or pathology. A screening tool may facilitate earlier diagnosis and treatment of acute MSDs. This tool could prevent progression to chronic conditions, leading to better patient outcomes and quality of life. Objectives Our study evaluated whether a screening tool would be able to accurately screen individuals for MSDs, explore comorbidities that may predict the prevalence of MSDs, and identify why people do not discuss these problems with their primary care provider (PCP). Methods A multisite, observational study in a primary care setting. Data were analyzed to determine the psychometric properties of the screening question. Logistic regression was performed to explore the relationship of comorbidities with MSDs. Thematic analysis was performed to explore why patients do not discuss these issues with their PCP. Results The point prevalence of MSDs was determined to be 78%. The sensitivity of the screening question was determined to be good (70%). Arthritis, obesity, sleep disorders, and gastroesophageal reflux disease (GERD) were significant predictors for an MSD. Thematic analysis regarding why patients do not discuss the MSD with their physician revealed: (1) the perceived lack of importance of the problem; (2) the lack of access to healthcare, and (3) the acuity of the problem. Conclusions Screening for an MSD and associated comorbidities could prevent the transition of acute conditions to chronic conditions. If PCPs can identify predictors and factors associated with an MSD, they may be able to screen for MSDs more effectively. Earlier identification of MSDs may facilitate earlier treatment and prevent costs associated with resulting chronic disorders and persistent pain and disability.

Cranial manipulation affects cholinergic pathway gene expression in aged rats

Context Age-dependent dementia is a devastating disorder afflicting a growing older population. Although pharmacological agents improve symptoms of dementia, age-related comorbidities combined with adverse effects often outweigh their clinical benefits. Therefore, nonpharmacological therapies are being investigated as an alternative. In a previous pilot study, aged rats demonstrated improved spatial memory after osteopathic cranial manipulative medicine (OCMM) treatment. Objectives In this continuation of the pilot study, we examine the effect of OCMM on gene expression to elicit possible explanations for the improvement in spatial memory. Methods OCMM was performed on six of 12 elderly rats every day for 7 days. Rats were then euthanized to obtain the brain tissue, from which RNA samples were extracted. RNA from three treated and three controls were of sufficient quality for sequencing. These samples were sequenced utilizing next-generation sequencing from Illumina NextSeq. The Cufflinks software suite was utilized to assemble transcriptomes and quantify the RNA expression level for each sample. Results Transcriptome analysis revealed that OCMM significantly affected the expression of 36 genes in the neuronal pathway (false discovery rate [FDR] <0.004). The top five neuronal genes with the largest-fold change were part of the cholinergic neurotransmission mechanism, which is known to affect cognitive function. In addition, 39.9% of 426 significant differentially expressed (SDE) genes (FDR<0.004) have been previously implicated in neurological disorders. Overall, changes in SDE genes combined with their role in central nervous system signaling pathways suggest a connection to previously reported OCMM-induced behavioral and biochemical changes in aged rats. Conclusions Results from this pilot study provide sufficient evidence to support a more extensive study with a larger sample size. Further investigation in this direction will provide a better understanding of the molecular mechanisms of OCMM and its potential in clinical applications. With clinical validation, OCMM could represent a much-needed low-risk adjunct treatment for age-related dementia including Alzheimer’s disease.

Pediatric unilateral knee swelling: a case report of a complicated differential diagnosis and often overlooked cause

Lyme disease is the most common vector-borne illness in the United States. However, Lyme arthritis is a diagnosis that is often missed, even in children, who are the population with the highest incidence of Lyme disease. Lyme arthritis, which presents in the later stage of Borrelia burgdorferi infection, needs to be recognized and managed promptly, especially in endemic areas or when exposure to ticks is known. We present a case of a 3-year-old female presenting to the emergency department with a history of limping for 2 weeks. The mother of the child recognized a tick bite. However, the child was not taken to seek care expeditiously, because she had not developed any rashes. Test results demonstrated that the patient was IgG positive and IgM negative for Lyme disease, with Western blot confirming the diagnosis of Lyme arthritis. Most patients presenting with Lyme arthritis do not recall having a tick bite, making it difficult to differentiate it from other pediatric conditions. When this diagnosis is missed, it can result in long-term morbidity, which is generally refractory to intravenous antibiotic therapy, oftentimes requiring synovectomy. Hence, this underscores the importance of the consideration of Lyme arthritis as a differential diagnosis in patients presenting with joint effusion.

The effectiveness of the metabolic map in promoting meaningful learning

Context Many medical students and practicing physicians view biochemistry, especially its metabolic pathways, as a challenging topic given the depth of material. Medical biochemistry educators aim to help prepare future physicians to apply knowledge of metabolism to disease processes. Research confirms that study tools promote critical thinking and help to connect biochemistry concepts to health and disease processes. Objectives To explore whether the Pathways of Human Metabolism Map as a study tool helps to connect basic metabolic pathways to clinical applications. Methods We provided the Pathways of Human Metabolism Map to our first-year osteopathic medical students and conducted a survey to assess their perceptions. Our survey questions aimed to explore the effectiveness of utilizing the metabolic map for connecting the basic metabolic pathways to clinical applications on their studies. Students were surveyed at the end of the course utilizing a Qualtrics survey encompassing Likert scale questions as well as open-ended responses. Results The results of our comprehensive survey questions revealed the unique perceptions of students. Analysis of our data implicates that study tools like the metabolic map inspire meaningful learning. Conclusions Our data show that students who utilized the metabolic map in their studies reported that utilizing the map improved their understanding of medical biochemistry. Our research results suggest that providing study aids like the metabolic map encourages students to minimize rote memorization and promotes integration with clinical context. Our results provide a support for study strategies that implement meaningful learning in medical education.

Glycemic control is associated with lower odds of mortality and successful extubation in severe COVID-19

Context Corticosteroids, specifically dexamethasone, have become the mainstay of treatment for moderate to severe COVID-19. Although the RECOVERY trial did not report adverse effects of corticosteroids, the METCOVID (Methylprednisolone as Adjunctive Therapy for Patients Hospitalized with COVID-19) study reported a higher blood glucose level in patients receiving methylprednisolone. Objectives This study aims to analyze the association between corticosteroids and COVID-19–related outcomes in patients admitted to the medical ICU (MICU) for COVID-19 pneumonia. Methods This is an observational study of 141 patients admitted to the MICU between March 18 and June 7, 2020. Data on demographics, laboratory and imaging studies, and clinical course were obtained, including data on corticosteroid use. Bivariate analyses and logistic regression were performed between patient characteristics and mortality and successful extubation. Results Of the 141 patients, 86 required mechanical ventilation, 50 received steroids, and 71 died. Regarding demographics, patients had a median age of 58 (interquartile range [IQR] 48, 65), Hispanic (57.4%, n=81), and non-Hispanic Black (37.5%, n=53). The most prevalent comorbidities were hypertension (49.6%, n=70) and diabetes (48.2%, n=68). Lower blood glucose levels on admission (125.5 vs. 148 mg/dL, p=0.025) and lower peak blood glucose levels on corticosteroids (215.5 vs. 361 mg/dL, p=0.0021) were associated with lower prevalence of mortality. Patients who were successfully extubated had a lower admission blood glucose (126.5 vs. 149 mg/dL, p=0.0074) and lower peak blood glucose on corticosteroids (217 vs. 361 mg/dL, p=0.0023). Conclusions Lower blood glucose on admission and lower maximum blood glucose on corticosteroids were associated with lower odds of mortality and successful extubation, regardless of preexisting diabetes. Hyperglycemia may be negating any potential benefit of corticosteroid therapy. These findings suggest that glucose control could be a parameter that impacts the outcome of patients receiving corticosteroids for COVID-19 pneumonia.

AOA ophthalmology and otolaryngology program closures as a model to highlight challenges of maintaining GME in high need areas

Context While 90% of former American Osteopathic Association (AOA) residency programs transitioned to Accreditation Council for Graduate Medical Education (ACGME) accreditation, surgical subspecialty programs such as ear, nose, and throat (ENT, 62%) and ophthalmology (47%) struggled to gain accreditation. Doctors of Osteopathic Medicine (DOs) actively participate in serving underserved communities, and the loss of AOA surgical specialty programs may decrease access to surgical care in rural and nonmetropolitan areas. Objectives To determine the challenges faced by former AOA-accredited surgical subspecialty programs during the transition to ACGME accreditation, particularly ENT and ophthalmology programs in underresourced settings. Methods A directory of former AOA ENT and Ophthalmology programs was obtained from the American Osteopathic Colleges of Ophthalmology and Otolaryngology-Head and Neck Surgery (AOCOO-HNS). A secured survey was sent out to 16 eligible ENT and ophthalmology program directors (PDs). The survey contained both quantitative and qualitative aspects to help assess why these programs did not pursue or failed to receive ACGME accreditation. Results Twelve of 16 eligible programs responded, com-prising six ophthalmology and six ENT PDs. Among the respondents, 83% did not pursue accreditation (6 ophthalmology and 4 ENT programs), and 17% were unsuccessful in achieving accreditation despite pursuing accreditation (2 ENT programs). Across 12 respondents, 7 (58%) cited a lack of hospital/administrative support and 5 (42%) cited excessive costs and lack of faculty support as reasons for not pursuing or obtaining ACGME accreditation. Conclusions The survey results reflect financial issues associated with rural hospitals. A lack of hospital/administrative support and excessive costs to transition to the ACGME were key drivers in closures of AOA surgical specialty programs. In light of these results, we have four recommendations for various stakeholders, including PDs, Designated Institutional Officials, hospital Chief Medical Officers, and health policy experts. These recommendations include expanding Teaching Health Center Graduate Medical Education to surgical subspecialties, identifying and learning from surgical fields such as urology that fared well during the transition to ACGME, addressing the lack of institutional commitment and the prohibitive costs of maintaining ACGME-accredited subspecialty programs in underresourced settings, and reconsidering the Centers for Medicare & Medicaid Services (CMS) pool approach to physician reimbursement.

Advances in the therapeutic approach of pudendal neuralgia: a systematic review

Context Although pudendal neuralgia (PN) has received growing interest over the last few years, diagnosis remains difficult, and many different therapeutic approaches can be considered. Objectives This article aims to provide an overview of the possible treatments of PN and investigate their efficacies. Methods Utilizing PubMed and ScienceDirect databases, a systematic review was carried out and allowed identification of studies involving patients with PN, as defined by Nantes criteria, and their associated treatments. Relevant data were manually reported. Results Twenty-eight articles were selected, totaling 1,013 patients (mean age, 49 years) and six different types of interventions. Clinical outcomes, most frequently quantified utilizing the Visual Analog Scale (VAS), vary greatly with both the therapy and time after intervention (from 100 to <10%). However, neither peri nor postoperative serious complications (grade > II of Clavien–Dindo classification) are reported. Although surgery seems to provide a higher proportion of long-term benefits, identifying the most efficient therapeutic approach is made impossible by the multitude of outcome measurements and follow-up frequencies. It should also be noted that literature is sparse regarding randomized controlled trials with long-term follow-up. Conclusions Although there are a number of modalities utilized for the treatment of PN, there are no current recommendations based on treatment efficacies. This seems to be largely in part caused by the lack of standardization in outcome quantification. Future research in this field should focus on prospective cohort studies with high levels of evidence, aimed at assessing the long-term, if not permanent, benefits of available therapies.

Bursting the bubble: hereditary spherocytosis masking poor glycemic control

Hemoglobin A1c (HbA1c) is a very common measure utilized to diagnose diabetes and to monitor the level of glycemic control during the course of management. Despite the high utility of HbA1c, it has some limitations. Physiological conditions that affect the lifespan of red blood cells (RBCs) can falsely elevate or lower HbA1c results. In this case report, we present a case of a patient who was found to have hereditary spherocytosis (HS) after developing nephrotic range proteinuria. The patient had diabetes that was previously thought to be well controlled, but his HS was masking his poor glycemic control. This case highlights the importance of understanding the limitations of the HbA1c in managing patients with diabetes.