A practical approach for implementation of a basal-prandial insulin therapy regimen in patients with type 2 diabetes

Background

Osteopathic philosophy is consistent with an emphasis on primary care and suggests that osteopathic physicians may have distinctive ways of interacting with their patients.

Methods

The National Ambulatory Medical Care Survey (NAMCS) was used to derive national estimates of utilization of osteopathic general and family medicine physicians during 2003 and 2004 and to examine the patient characteristics and physician-patient interactions of these osteopathic physicians. All analyses were performed using complex samples software to appropriately weigh outcomes according to the multistage probability sample design used in NAMCS and multivariate modeling was used to control for potential confounders.

Results and discussion

When weighted according to the multistage probability sample design used, the 6939 patient visits studied represented an estimated 341.4 million patient visits to general and family medicine specialists in the United States, including 64.9 million (19%) visits to osteopathic physicians and 276.5 million (81%) visits to allopathic physicians. Osteopathic physicians were a major source of care in the Northeast (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.42–6.08), providing more than one-third of general and family medicine patient visits in this geographic region. Pediatric and young adult patients (OR, 0.64; 95% CI, 0.45–0.91), Hispanics (OR, 0.63; 95% CI, 0.40–1.00), and non-Black racial minority groups (OR, 0.39; 95% CI, 0.18–0.82) were less likely to visit osteopathic physicians. There were no significant differences between osteopathic and allopathic physicians with regard to the time spent with patients, provision of five common preventive medicine counseling services, or a focus on preventive care during office visits.

Conclusion

Osteopathic physicians are a major source of general and family medicine care in the United States, particularly in the Northeast. However, pediatric and young adult patients, Hispanics, and non-Black racial minorities underutilize osteopathic physicians. There is little evidence to support a distinctive approach to physician-patient interactions among osteopathic physicians in general and family medicine, particularly with regard to time spent with patients and preventive medicine services.     

Osteopathic manipulative treatment and its relationship to autonomic nervous system activity as demonstrated by heart rate variability: a repeated measures study

Background

Osteopathic manipulative treatment (OMT) and ultrasound physical therapy (UPT) are commonly used for chronic low back pain. Although there is evidence from a systematic review and meta-analysis that OMT generally reduces low back pain, there are no large clinical trials that specifically assess OMT efficacy in chronic low back pain. Similarly, there is a lack of evidence involving UPT for chronic low back pain.

Methods

The OSTEOPAThic Health outcomes In Chronic low back pain (OSTEOPATHIC) Trial is a Phase III randomized controlled trial that seeks to study 488 subjects between August 2006 and June 2010. It uses a 2 × 2 factorial design to independently assess the efficacy of OMT and UPT for chronic low back pain. The primary outcome is a visual analogue scale score for pain. Secondary outcomes include back-specific functioning, generic health, work disability, and satisfaction with back care.

Conclusion

This randomized controlled trial will potentially be the largest involving OMT. It will provide long awaited data on the efficacy of OMT and UPT for chronic low back pain.

Trial registration

http://www.clinicaltrials.gov, NCT00315120     

Chronic Inflammatory Disease and Osteopathy: A Systematic Review

Background

Chronic inflammatory diseases (CID) are globally highly prevalent and characterized by severe pathological medical conditions. Several trials were conducted aiming at measuring the effects of manipulative therapies on patients affected by CID. The purpose of this review was to explore the extent to which osteopathic manipulative treatment (OMT) can be benefi-cial in medical conditions also classified as CID.

Methods

This review included any type of experimental study which enrolled sub-jects with CID comparing OMT with any type of control procedure. The search was conducted on eight databases in January 2014 using a pragmatic literature search approach. Two independent re-viewers conducted study selection and data extraction for each study. The risk of bias was evaluated according to the Cochrane methods. Heterogeneity was assessed and meta-analysis performed where possible.

Results

10 studies met the inclusion criteria for this review enrolling 386 subjects. The search identified six RCTs, one laboratory study, one cross-over pilot studies, one observation-al study and one case control pilot study. Results suggest a potential effect of osteopathic medicine on patients with medical pathologies associated with CID (in particular Chronic Obstructive Pul-monary Disease (COPD), Irritable Bowel Syndrome, Asthma and Peripheral Arterial Disease) com-pared to no treatment or sham therapy although data remain elusive. Moreover one study showed possible effects on arthritis rat model. Meta-analysis was performed for COPD studies only show-ing no effect of any type of OMT applied versus control. No major side effects were reported by those receiving OMT.

Conclusion

The present systematic review showed inconsistent data on the effect of OMT in the treatment of medical conditions potentially associated with CID, however the OMT appears to be a safe approach. Further more robust trials are needed to determine the direction and magnitude of the effect of OMT and to generalize favorable results.     

Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial

Background

The Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) is a registered, double-blinded, randomized, controlled trial designed to assess the efficacy of osteopathic manipulative treatment (OMT) as an adjunctive treatment in elderly patients with pneumonia.

Methods

406 subjects aged ≥ 50 years hospitalized with pneumonia at 7 community hospitals were randomized using concealed allocation to conventional care only (CCO), light-touch treatment (LT), or OMT groups. All subjects received conventional treatment for pneumonia. OMT and LT groups received group-specific protocols for 15 minutes, twice daily until discharge, cessation of antibiotics, respiratory failure, death, or withdrawal from the study. The primary outcomes were hospital length of stay (LOS), time to clinical stability, and a symptomatic and functional recovery score.

Results

Intention-to-treat (ITT) analysis (n = 387) found no significant differences between groups. Per-protocol (PP) analysis (n = 318) found a significant difference between groups (P = 0.01) in LOS. Multiple comparisons indicated a reduction in median LOS (95% confidence interval) for the OMT group (3.5 [3.2-4.0] days) versus the CCO group (4.5 [3.9-4.9] days), but not versus the LT group (3.9 [3.5-4.8] days). Secondary outcomes of duration of intravenous antibiotics and treatment endpoint were also significantly different between groups (P = 0.05 and 0.006, respectively). Duration of intravenous antibiotics and death or respiratory failure were lower for the OMT group versus the CCO group, but not versus the LT group.

Conclusions

ITT analysis found no differences between groups. PP analysis found significant reductions in LOS, duration of intravenous antibiotics, and respiratory failure or death when OMT was compared to CCO. Given the prevalence of pneumonia, adjunctive OMT merits further study.     

Muscle functional magnetic resonance imaging and acute low back pain: a pilot study to characterize lumbar muscle activity asymmetries and examine the effects of osteopathic manipulative treatment

Background

Muscle functional magnetic resonance imaging (mfMRI) measures transverse relaxation time (T2), and allows for determination of the spatial pattern of muscle activation. The purposes of this pilot study were to examine whether MRI-derived T2 or side-to-side differences in T2 (asymmetries) differ in low back muscles between subjects with acute low back pain (LBP) compared to asymptomatic controls, and to determine if a single osteopathic manipulative treatment (OMT) session alters these T2 properties immediately and 48-hours after treatment.

Methods

Subjects with non-specific acute LBP (mean score on 1-10 visual analog score = 3.02 ± 2.81) and asymptomatic controls (n = 9/group) underwent an MRI, and subsequently the LBP subjects received OMT and then underwent another MRI. The LBP subjects reported back for an additional MRI 48-hours following their initial visit. T2 and T2 asymmetry were calculated from regions of interest for the psoas, quadratus lumborum (QL), multifidus, and iliocostalis lumborum/longissimus thoracis (IL/LT) muscles.

Results

No differences were observed between the groups when T2 was averaged for the left and right side muscles. However, the QL displayed a significantly greater T2 asymmetry in LBP subjects when compared to controls (29.1 ± 4.3 vs. 15.9 ± 4.1%; p = 0.05). The psoas muscle also displayed a relatively large, albeit non-significant, mean difference (22.7 ± 6.9 vs. 9.5 ± 2.8%; p = 0.11). In the subjects with LBP, psoas T2 asymmetry was significantly reduced immediately following OMT (25.3 ± 6.9 to 6.1 ± 1.8%, p = 0.05), and the change in LBP immediately following OMT was correlated with the change in psoas T2 asymmetry (r = 0.75, p = 0.02).

Conclusion

Collectively, this pilot work demonstrates the feasibility of mfMRI for quantification and localization of muscle abnormalities in patients with acute low back pain. Additionally, this pilot work provides insight into the mechanistic actions of OMT during acute LBP, as it suggests that it may attenuate muscle activity asymmetries of some of the intrinsic low back muscles.     

Impact of Osteopathic Treatment on Pain in Adult Patients with Cystic Fibrosis – A Pilot Randomized Controlled Study

Background

Pain is a common complication in patients with cystic fibrosis (CF) and is associated with shorter survival. We evaluated the impact of osteopathic manipulative treatment (OMT) on pain in adults with CF.

Methods

A pilot multicenter randomized controlled trial was conducted with three parallel arms: OMT (group A, 16 patients), sham OMT (sham treatment, group B, 8 patients) and no treatment (group C, 8 patients). Medical investigators and patients were double-blind to treatment for groups A and B, who received OMT or sham OMT monthly for 6 months. Pain was rated as a composite of its intensity and duration over the previous month. The evolution of chest/back pain after 6 months was compared between group A and groups B+C combined (control group). The evolution of cervical pain, headache and quality of life (QOL) were similarly evaluated.

Results

There was no statistically significant difference between the treatment and control groups in the decrease of chest/back pain (difference = −2.20 IC95% [−4.81; 0.42], p = 0.098); also, group A did not differ from group B. However, chest/back pain decreased more in groups A (p = 0.002) and B (p = 0.006) than in group C. Cervical pain, headache and QOL scores did not differ between the treatment and control groups.

Conclusion

This pilot study demonstrated the feasibility of evaluating the efficacy of OMT to treat the pain of patients with CF. The lack of difference between the group treated with OMT and the control group may be due to the small number of patients included in this trial, which also precludes any definitive conclusion about the greater decrease of pain in patients receiving OMT or sham OMT than in those with no intervention.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01293019","term_id":"NCT01293019"}}NCT01293019     

Osteopathic manipulative treatment for pneumonia

The pneumonias due to infection continue to be a meaningful threat to the health and viability of persons, particularly those in high risk groups: children, the aged and the debilitated. Noll and colleagues provide us with the results of a well-designed and well-executed multi-institutional controlled clinical trial to evaluate the efficacy of osteopathic manipulative treatment (OMT) in the treatment of pneumonia. The data obtained indicate that by intention-to-treat analysis, the addition of OMT to conventional care did not improve the designated outcomes when compared to conventional care only. A disappointing but important finding. However, by per-protocol analysis, the addition of OMT or of light touch decreased length of hospital stay, the duration of intravenous antibiotics and the incidence of respiratory failure and death relative to conventional care only. Further study is called for to explain these surprising results. Meeting the need for randomized clinical trials of the role and efficacy of OMT is a responsibility of high priority for the osteopathic profession in this age of evidence-based medicine. The American Osteopathic Association (AOA) needs to consider reinstating a dues-generated financial set-aside both to increase its support of osteopathic research and to initiate a program of physician-investigator career development awards to recruit and help establish osteopathic clinical investigators in a career in translational and clinical research.     

The immediate effect of individual manipulation techniques on pulmonary function measures in persons with chronic obstructive pulmonary disease

Background

The use of manipulation has long been advocated in the treatment of chronic obstructive pulmonary disease (COPD), but few randomized controlled clinical trials have measured the effect of manipulation on pulmonary function. In addition, the effects of individual manipulative techniques on the pulmonary system are poorly understood. Therefore, the purpose of this study was to determine the immediate effects of four osteopathic techniques on pulmonary function measures in persons with COPD relative to a minimal-touch control protocol.

Methods

Persons with COPD aged 50 and over were recruited for the study. Subjects received five, single-technique treatment sessions: minimal-touch control, thoracic lymphatic pump (TLP) with activation, TLP without activation, rib raising, and myofascial release. There was a 4-week washout period between sessions. Protocols were given in random order until all five techniques had been administered. Pulmonary function measures were obtained at baseline and 30-minutes posttreatment. For the actual pulmonary function measures and percent predicted values, Wilcoxon signed rank tests were used to test within-technique changes from baseline. For the percent change from baseline, Friedman tests were used to test for between-technique differences.

Results

Twenty-five subjects were enrolled in the study. All four tested osteopathic techniques were associated with adverse posttreatment changes in pulmonary function measures; however, different techniques changed different measures. TLP with activation increased posttreatment residual volume compared to baseline, while TLP without activation did not. Side effects were mild, mostly posttreatment chest wall soreness. Surprisingly, the majority of subjects believed they could breathe better after receiving osteopathic manipulation.

Conclusion

In persons with COPD, TLP with activation, TLP without activation, rib raising, and myofascial release mildly worsened pulmonary function measures immediately posttreatment relative to baseline measurements. The activation component of the TLP technique appears to increase posttreatment residual volume. Despite adverse changes in pulmonary function measures, persons with COPD subjectively reported they benefited from osteopathic manipulation.     

Ethnomedicine and ethnobotany of fright,a Caribbean culture-bound psychiatric syndrome

Background

Plant species have long been used as principal ingredients of traditional medicine in far-west Nepal. The medicinal plants with ethnomedicinal values are currently being screened for their therapeutic potential but their data and information are inadequately compared and analyzed with the Ayurveda and the phytochemical findings.

Methods

The present study evaluated ethnomedicinal plants and their uses following literature review, comparison, field observations, and analysis. Comparison was made against earlier standard literature of medicinal plants and ethnomedicine of the same area, the common uses of the Ayurveda and the latest common phytochemical findings. The field study for primary data collection was carried out from 2006-2008.

Results

The herbal medicine in far-west Nepal is the basis of treatment of most illness through traditional knowledge. The medicine is made available via ancient, natural health care practices such as tribal lore, home herbal remedy, and the Baidhya, Ayurveda and Amchi systems. The traditional herbal medicine has not only survived but also thrived in the trans-cultural environment with its intermixture of ethnic traditions and beliefs. The present assessment showed that traditional herbal medicine has flourished in rural areas where modern medicine is parsimoniously accessed because of the high cost and long travel time to health center. Of the 48 Nepalese medicinal plants assessed in the present communication, about half of the species showed affinity with the common uses of the Ayurveda, earlier studies and the latest phytochemical findings. The folk uses of Acacia catechu for cold and cough, Aconitum spicatum as an analgesic, Aesculus indica for joint pain, Andrographis paniculata for fever, Anisomeles indica for urinary affections, Azadirachta indica for fever, Euphorbia hirta for asthma, Taxus wallichiana for tumor control, and Tinospora sinensis for diabetes are consistent with the latest pharmacological findings, common Ayurvedic and earlier uses.

Conclusions

Although traditional herbal medicine is only a primary means of health care in far-west Nepal, the medicine has been pursued indigenously with complementing pharmacology and the Ayurveda. Therefore, further pharmacological evaluation of traditional herbal medicine deserves more attention.     

OTC analgesics and drug interactions: clinical implications

Background

Preventive care in the United States has been a priority, especially for children under 18 years of age. The objective of this analysis was to determine which predisposing, enabling, and need factors affect access to preventive health care for children.

Methods

Data were obtained from the National Survey of Children's Health (NSCH), a cross-sectional study of children in the United States. The current analysis examined whether predisposing, enabling, and need factors included in Andersen's Socio-Behavioral Model significantly affect having received preventive medical care among children 3–17 years of age. Logistic regression was used to compute odds ratios and 95% confidence intervals.

Results

63,924 out of 85,151 subjects were reported as having received preventive medical care. After stratifying by geographical region, the following factors were significant for predicting having received preventive care. Age was negatively associated with having received care in all four regions. Household education of less than a college degree and being white (compared to black) were negatively associated with having received care in the Northeast, Midwest, and South. Having fewer than 4 children was negatively associated in Northeast but positively associated in the West with having received care. Being male, having less than 3 children in the household, having less than 3 adults in the household, and being Hispanic were positively associated with having received care in the West only. Not having insurance and having a lower socioeconomic status were negatively associated with having received care; while, having a personal doctor or nurse was positively associated in all four regions. Primary language other than English was negatively associated with having received care in the Northeast only. Currently needing medicine was also positively associated with having received care in all four regions; while, having limited abilities to do things was positively associated in the West only.

Conclusion

Older children whose family resides in Northeast, Midwest, and South regions with low household education and poverty levels experience insufficient preventive health care. Medicaid or SCHIP coverage should be expanded for children who are still uninsured. For children in the West, gender, family size, ethnicity, and their ability to do things should also be considered when providing assistance for receiving preventive care.     

Traumeel S® for pain relief following hallux valgus surgery: a randomized controlled trial

Background

In spite of recent advances in post-operative pain relief, pain following orthopedic surgery remains an ongoing challenge for clinicians. We examined whether a well known and frequently prescribed homeopathic preparation could mitigate post-operative pain.

Method

We performed a randomized, double blind, placebo-controlled trial to evaluate the efficacy of the homeopathic preparation Traumeel S^® in minimizing post-operative pain and analgesic consumption following surgical correction of hallux valgus. Eighty consecutive patients were randomized to receive either Traumeel tablets or an indistinguishable placebo, and took primary and rescue oral analgesics as needed. Maximum numerical pain scores at rest and consumption of oral analgesics were recorded on day of surgery and for 13 days following surgery.

Results

Traumeel was not found superior to placebo in minimizing pain or analgesic consumption over the 14 days of the trial, however a transient reduction in the daily maximum post-operative pain score favoring the Traumeel arm was observed on the day of surgery, a finding supported by a treatment-time interaction test (p = 0.04).

Conclusions

Traumeel was not superior to placebo in minimizing pain or analgesic consumption over the 14 days of the trial. A transient reduction in the daily maximum post-operative pain score on the day of surgery is of questionable clinical importance.

Trial Registration

This study was registered at ClinicalTrials.gov. # NCT00279513     

The contribution of traditional healers' clinics to public health care system in Addis Ababa, Ethiopia: a cross-sectional study

Background

In practically every human culture, the use of arthropods as medicinal resources has been reported. In Mexico, the Mayan people mainly use plants but occasionally also animals and minerals in their medicine. This article is the first to report the traditional use of the tarantula Brachypelma vagans by medicine men in the Chol community, an ancient indigenous group that inhabits the southeastern part of Mexico. We also describe the utility of such arachnids in traditional medicine.

Methods

This study was carried out in different Chol communities in the states of Chiapas and Campeche (southeastern Mexico) from 2003 until 2007. We interviewed the local medicine men, patients and non-Chol people in each village visited to collect information about the rituals involved and the effectiveness of this traditional medicine and also their opinion of this traditional medicine.

Results

In all independent villages, the people who present an illness called 'aire de tarantula' or tarantula wind with symptoms including chest pain, coughing and asthma, were treated by the medicine man (called 'hierbatero') with a tarantula-based beverage. From village to village, the beverage has a similar base composition but some variations occur in additional ingredients depending on the individual medicine man. Like in all traditional Mayan medicine, the ritual of the ceremony consists of drinking the tarantula-based beverage and this is principally accompanied by chants and burning of incense.

Conclusions

The recipe of the tarantula-based beverage and the procedure of this ritual ceremony were fairly constant in all the villages visited. Our work shows that despite the tarantula's bad image in several cultures, in others positive use is made of these spiders, as in modern medicine.     

"Anxiebo", placebo, and postoperative pain

Background

Surgical treatment and its consequences expose patients to stress, and here we investigated the importance of the psychological component of postoperative pain based on reports in the clinical literature.

Discussion

Postoperative pain remains a significant clinical problem. Increased pain intensity with increased demand for opioid medication, and/or a relative unresponsiveness to pain treatment was reported both when the analgesia was administered by means of conventional nurse injection regimes and patient-controlled analgesia (PCA). Both the quality of the analgesia, and the sensitivity of postoperative models for assessing analgesic efficacy could be significantly influenced. The findings could be explained by increased penetration of an algesic anxiety-related nocebo influence (which we chose to call "anxiebo") relative to its analgesic placebo counterpart. To counteract this influence, the importance of psychological effects must be acknowledged, and doctors and attending nurses should focus on maintaining trustful therapist-patient relationships throughout the treatment period. The physical mechanism of anxiebo should be further explored, and those at risk for anxiebo better characterized. In addition, future systemic analgesic therapies should be directed towards being prophylactic and continuous to eliminate surgical pain as it appears in order to prevent the anxiebo effect. Addressing anxiebo is the key to developing reproducible models for measuring pain in the postoperative setting, and to improving the accuracy of measurements of the minimum effective analgesic concentration.

Summary

Anxiebo and placebo act as counterparts postoperatively. The anxiebo state may impair clinical analgesia and reduce the sensitivity of analgesic trials. Ways to minimize anxiebo are discussed.     

Spinal and sacroiliac assessment and treatment techniques used by osteopathic physicians in the United States

Background

Without systematic exposure to biomedical research concepts or applications, osteopathic medical students may be generally under-prepared to efficiently consume and effectively apply research and evidence-based medicine information in patient care. The academic literature suggests that although medical residents are increasingly expected to conduct research in their post graduate training specialties, they generally have limited understanding of research concepts. With grant support from the National Center for Complementary and Alternative Medicine, and a grant from the Osteopathic Heritage Foundation, the University of North Texas Health Science Center (UNTHSC) is incorporating research education in the osteopathic medical school curriculum. The first phase of this research education project involved a baseline assessment of students' understanding of targeted research concepts. This paper reports the results of that assessment and discusses implications for research education during medical school.

Methods

Using a novel set of research competencies supported by the literature as needed for understanding research information, we created a questionnaire to measure students' confidence and understanding of selected research concepts. Three matriculating medical school classes completed the on-line questionnaire. Data were analyzed for differences between groups using analysis of variance and t-tests. Correlation coefficients were computed for the confidence and applied understanding measures. We performed a principle component factor analysis of the confidence items, and used multiple regression analyses to explore how confidence might be related to the applied understanding.

Results

Of 496 total incoming, first, and second year medical students, 354 (71.4%) completed the questionnaire. Incoming students expressed significantly more confidence than first or second year students (F = 7.198, df = 2, 351, P = 0.001) in their ability to understand the research concepts. Factor analyses of the confidence items yielded conceptually coherent groupings. Regression analysis confirmed a relationship between confidence and applied understanding referred to as knowledge. Confidence scores were important in explaining variability in knowledge scores of the respondents.

Conclusion

Medical students with limited understanding of research concepts may struggle to understand the medical literature. Assessing medical students' confidence to understand and objectively measured ability to interpret basic research concepts can be used to incorporate competency based research material into the existing curriculum.     

The epidemiology and medical management of low back pain during ambulatory medical care visits in the United States

Background

Low back pain (LBP) is a common symptom.

Methods

Patient visits attributed to LBP in the National Ambulatory Medical Care Survey (NAMCS) during 2003–2004 served as the basis for epidemiological analyses (n = 1539). The subset of patient visits in which LBP was the primary reason for seeking care (primary LBP patient visits) served as the basis for medical management analyses (n = 1042). National population estimates were derived using statistical weighting techniques.

Results

There were 61.7 million (SE, 4.0 million) LBP patient visits and 42.4 million (SE, 3.1 million) primary LBP patient visits. Only 55% of LBP patient visits were provided by primary care physicians. Age, geographic region, chronicity of symptoms, injury, type of physician provider, and physician specialty were associated with LBP patient visits. Age, injury, primary care physician status, type of physician provider, and shared physician care were associated with chronicity of LBP care. Osteopathic physicians were more likely than allopathic physicians to provide medical care during LBP patient visits (odds ratio [OR], 2.61; 95% confidence interval [CI], 1.75–3.92) and chronic LBP patient visits (OR, 4.39; 95% CI, 2.47–7.80). Nonsteroidal anti-inflammatory drugs (NSAIDs) and narcotic analgesics were ordered during 14.2 million (SE, 1.2 million) and 10.5 million (SE, 1.1 million) primary LBP patient visits, respectively. Drugs (OR, 0.29; 95% CI, 0.13–0.62) and, specifically, NSAIDs (OR, 0.40; 95% CI, 0.25–0.64) were ordered less often during chronic LBP patient visits compared with acute LBP patient visits. Overall, osteopathic physicians were less likely than allopathic physicians to order NSAIDs for LBP (OR, 0.43; 95% CI, 0.24–0.76). Almost two million surgical procedures were ordered, scheduled, or performed during primary LBP patient visits.

Conclusion

The percentage of LBP visits provided by primary care physicians in the United States remains suboptimal. Medical management of LBP, particularly chronic LBP, appears to over-utilize surgery relative to more conservative measures such as patient counseling, non-narcotic analgesics, and other drug therapies. Osteopathic physicians are more likely to provide LBP care, and less likely to use NSAIDs during such visits, than their allopathic counterparts. In general, LBP medical management does not appear to be in accord with evidence-based guidelines.     

Een carrière als specialist ouderengeneeskunde; iets voor de huidige geneeskundestudent?

Background

Due to the rise of older patients with multi-morbidity, we need more elderly care physicians. However, not all available training slots for the elderly care medicine specialty have been fully utilized in recent years. To assess medical student interest in this specialty as well as potential causes for this interest we explored the interest of medical students in the profession of elderly care physician, as well their perception of this profession, both in the ‘old curriculum’ and in a ‘new curriculum’, where the new curriculum had a mandatory elderly care medicine clerkship and more competency-related learning.

Method

At VUmc 120 final year medical students were asked to complete a questionnaire in 2014 about professional preferences and professional characteristics. The same questionnaire had been presented five years earlier, in 2009, to 150 medical students at the end of their final year.

Results

The response rates were 100% and 85% respectively. Of the students in the new curriculum 16,7% considered a career in elderly care medicine. This percentage was 9,4% for students in the old curriculum (p?=?0,087). The characteristics of the profession that appealed most to the students, but were not considered applicable to elderly care medicine were: diagnostics skills, acute complaints, visible results. The professional characteristics that students found to be very much applicable to this specialty, but less attractive for their future profession were: psychosocial, chronic and terminal conditions.

Discussion

We observe a trend that students in the new curriculum are more interested in the profession of elderly care physician, even though this interest remains limited. We recommend that the basic medical training, both in the bachelor phase and in a mandatory elderly care medicine clerkship, focus more on demonstrating that the characteristics students find appealing in the medical profession are indeed present in this speciality. Also, the basic training should concentrate more on guidance and treatment of patients with chronic and terminal conditions.

     

Treatment of specific macrovascular beds in patients with diabetes mellitus

Background

A ubiquitous dilemma in medical education continues to be whether and how to integrate research competencies into the predoctoral curriculum. Understanding research concepts is imbedded in the six core competencies for physicians, but predoctoral medical education typically does not explicitly include research education. In an effort to quickly report academic research findings to the field, this is the second in a series of articles reporting the outcomes of a research education initiative at one college of osteopathic medicine. The first article described the competency model and reported baseline performance in applied understanding of targeted research concepts. This second article reports on the learning outcomes from the inaugural year of a course in basic biomedical research concepts.

Methods

This course consisted of 24 total hours of classroom lectures augmented with web-based materials using Blackboard Vista, faculty moderated student presentations of research articles, and quizzes. To measure changes in applied understanding of targeted research concepts in the inaugural year of the course, we administered a pretest and a posttest to second year students who took the course and to first year students who took an informatics course in the same academic year.

Results

We analyzed 154 matched pretests and posttests representing 56% of the 273 first and second year students. On average, the first year (53) and second year students (101) did not differ in their mean pretest scores. At posttest the second year students showed significant improvement in their applied understanding of the concepts, whereas the first year students' mean posttest score was lower than their mean pretest score.

Conclusions

This biomedical research course appears to have increased the second year students' applied understanding of the targeted biomedical research concepts. This assessment of learning outcomes has facilitated the quality improvement process for the course, and improved our understanding of how to measure the benefits of research education for medical students. Some of the course content and methods, and the outcome measures may need to be approached differently in the future to more effectively lay the foundation for osteopathic medical students to utilize these concepts in the clinical setting.     

Expression and function of proton-sensing G-protein-coupled receptors in inflammatory pain

Background

Chronic inflammatory pain, when not effectively treated, is a costly health problem and has a harmful effect on all aspects of health-related quality of life. Despite the availability of pharmacologic treatments, chronic inflammatory pain remains inadequately treated. Understanding the nociceptive signaling pathways of such pain is therefore important in developing long-acting treatments with limited side effects. High local proton concentrations (tissue acidosis) causing direct excitation or modulation of nociceptive sensory neurons by proton-sensing receptors are responsible for pain in some inflammatory pain conditions. We previously found that all four proton-sensing G-protein-coupled receptors (GPCRs) are expressed in pain-relevant loci (dorsal root ganglia, DRG), which suggests their possible involvement in nociception, but their functions in pain remain unclear.

Results

In this study, we first demonstrated differential change in expression of proton-sensing GPCRs in peripheral inflammation induced by the inflammatory agents capsaicin, carrageenan, and complete Freund's adjuvant (CFA). In particular, the expression of TDAG8, one proton-sensing GPCR, was increased 24 hours after CFA injection because of increased number of DRG neurons expressing TDAG8. The number of DRG neurons expressing both TDAG8 and transient receptor potential vanilloid 1 (TRPV1) was increased as well. Further studies revealed that TDAG8 activation sensitized the TRPV1 response to capsaicin, suggesting that TDAG8 could be involved in CFA-induced chronic inflammatory pain through regulation of TRPV1 function.

Conclusion

Each subtype of the OGR1 family was expressed differently, which may reflect differences between models in duration and magnitude of hyperalgesia. Given that TDAG8 and TRPV1 expression increased after CFA-induced inflammation and that TDAG8 activation can lead to TRPV1 sensitization, it suggests that high concentrations of protons after inflammation may not only directly activate proton-sensing ion channels (such as TRPV1) to cause pain but also act on proton-sensing GPCRs to regulate the development of hyperalgesia.     

Primary Reasons for Osteopathic Consultation: A Prospective Survey in Quebec

Background

Osteopathy is an increasingly popular health care modality to address pain and function in the musculoskeletal system, organs and the head region, as well as functional somatic syndromes. Although osteopathy is recommended principally in guidelines for management of back pain, osteopaths'' scope of practice is wide, albeit poorly defined. In order to understand better the practice of osteopathy, this study aimed to investigate the most common reasons for osteopathic consultations in clinical settings in Quebec.

Methods

A prospective survey of members of the Registre des ostéopathes du Québec was conducted to examine demographics in osteopathic practices, as well as patients'' primary reasons for consultations over a two-week period. The questionnaire was devised following a literature review and refined and verified with two stages of expert input.

Results

277 osteopaths (60.1% response rate) responded to the survey notice. 14,002 patients'' primary reasons for consultations were reported in completed questionnaires and returned by practicing osteopaths. Musculoskeletal pain located in the spine, thorax, pelvis and limbs was the most common reason for consultations (61.9%), with females consulting most commonly for cervical pain and males for lumbar pain. Perinatal and paediatric (11.8%), head (9.1%), visceral (5.0%) and general concerns (4.8%) were the other most common reasons for consultations. Preventive care represented the remaining 0.3%.

Interpretation

The nature of primary reasons for osteopathic consultations, coupled with documented satisfaction of patients with this approach, suggest a future for multidisciplinary collaborative health care including osteopathy. Results of this survey may contribute to informing physicians and others pending regulation of Quebec osteopaths, and also provide direction for future clinical research and guidelines development.     

Hoe denken ouderen over automatische contactloze monitoring? Een systematische literatuurstudie

Introduction

Technologies for contactless monitoring are increasingly used in order to contribute to qualitative and cost-effective care for older persons. The purpose of this systematic literature review is to explore the attitudes and perceptions of older persons towards the use of systems for contactless monitoring.

Methodology

Relevant studies were identified through an extensive search strategy in Medline, Embase and Cinahl for studies published between January 1990 and August 19 2012; using a reference list offered by a group of experts in this field of research and through the exploration of the reference lists of all relevant studies.

Results

Nine studies with a qualitative study design and one study with a combined study design were included in this literature review. Various aspects of the attitudes, perceptions and needs of older persons as potential or actual end-users of contactless monitoring are discussed in five themes. This refers to the perceptions of older persons on the potential usefulness of contactless monitoring, the communication of information obtained through monitoring, several concerns when contactless monitoring is used and the participation and involvement of the person who is monitored. All these facets can influence the willingness of older people to accept these monitoring systems.

Conclusions

This review can offer technology developers and care providers useful information to promote acceptance and successful integration of systems for contactless monitoring into daily practice by ensuring that they meet the needs, concerns and wishes of older persons as their end-users. Further exploration of the attitudes and perceptions of older people towards contactless monitoring through qualitative and quantitative research with a good methodological quality is required.