Shortages in medical subspecialty care, particularly endocrinology, present a growing challenge in the United States. In Ohio, structural inequities in the rural and Appalachian regions, including fewer healthcare providers, limited facilities, and barriers to transportation and broadband connectivity, contribute to delayed diabetes diagnoses, increased complications, and a higher mortality rate. This study aimed to examine the distribution of endocrinology subspecialists in Ohio and the corresponding prevalence of diabetes. This cross-sectional study utilized public data gathered in 2022 from the Centers for Medicare & Medicaid Services (CMS) and the United States Diabetes Surveillance System (USDSS) to compare the mean prevalence and incidence of diabetes, the mean costs, and the Prevention Quality Indicator (PQI) scores for both short-term and long-term diabetes complications by Appalachian and non-Appalachian counties in Ohio. Of the 263 endocrinologists analyzed in this study, 21 (7.9 %) practiced in counties classified as Appalachian and 242 (92.1 %) practiced in counties classified as non-Appalachian (p<0.001). Moreover, only 9 of 32 (28.1 %) Appalachian counties had at least one practicing endocrinologist compared with 26 (46.4 %) of the non-Appalachian counties (p<0.1). The mean prevalence of diabetes was also significantly higher in Appalachian counties than in non-Appalachian counties (12.3±0.6 % vs. 11.2±0.9 %; p<0.01). In contrast, no statistically significant differences were observed in diabetes-related costs (p=0.4), short-term complications (p=0.2), or long-term complications (p=0.7) between Appalachian and non-Appalachian counties. The regression models found that although a higher density of endocrinologists per 100,000 persons was negatively associated with diabetes prevalence and incidence, none of these relationships reached statistical significance, with diabetes prevalence being the strongest predictor of endocrinologist concentration (Akaike Information Criterion [AIC]=258). This study revealed a dual disparity in Appalachian Ohio, where these counties not only had fewer endocrinologists, but also had a higher prevalence and incidence of diabetes compared to non-Appalachian counties. Targeted strategies are needed to address this critical gap in subspecialty care in these Appalachian communities.

Professionalism in medicine has been historically difficult to define, teach, assess, and remediate. While professionalism is vital to the practice of medicine, the lack of consistency across training and disciplines, combined with the often generalized nature of its description, has caused challenges in academic medicine and has led to the weaponization of its use. It is clear that change in this essential competency in medicine is needed, and change has to begin with an honest self-assessment. The purpose of this report is to present an evidence-based rubric for the assessment of professionalism at the institutional level. The literature on professionalism emphasizes the importance of creating and maintaining a culture of professionalism within an educational community that guides expected behaviors and ensures accountability. This rubric presents expected behaviors within the major areas of the academic enterprise through an osteopathic lens, emphasizing the distinctive wisdom of osteopathic philosophy and the guidance it provides for a new landscape of medical professionalism. Through the Senior Leadership Development Program (SLDP) of the American Association of Colleges of Osteopathic Medicine (AACOM), the authors identified six key areas in which to define osteopathic medical professionalism at the institutional level. These are: Definition and Culture; Prematriculation and Matriculation; Preclinical Curriculum; Clinical Curriculum; Student Affairs, Disciplinary Procedure, and Code of Conduct; Patient Care; and Research. Within each area, five clusters of professionalism were utilized to capture the multi-dimensional nature of cultivating a culture of professionalism within a community: Ethics and Integrity, Respect, Teamwork, Accountability, and Self-Management. A four-tier scale was developed to evaluate participants' performance in theseareas. The result of this report is a multi-dimensional and comprehensive rubric that can be utilized by colleges of osteopathic medicine (COMs) to perform self-assessments of how professionalism is conceptualized at their institution. In addition, the rubric can be utilized by segments of the academic enterprise in focused self-assessment and for change efforts at the programmaticlevel. Osteopathic medical professionalism has the potential to carve a new pathway for the future of professionalism in academic medicine. This institutional self-assessment rubric for COMs is the first step in a change process that can clarify and specify how professionalism is defined, so that appropriate and meaningful teaching, assessment, and remediation can follow. Future research on this rubric will be to conduct formal validation analysis in order to standardize its application in an effort to broaden its use and potential impact.

Child maltreatment impacts an estimated 7.4 per 1,000 children in the UnitedStates. Given the severity of some abusive injuries, children may present to emergency departments (EDs). As such, EDs are primary screening locations for early identification of maltreatment. Our objective was to assess rates of maltreatment among pediatric patients presenting to theED. We performed a cross-sectional analysis of pediatric ED visits utilizing data from the Center for Disease Control's (CDC) National Hospital Ambulatory Medical Care Survey (NHAMCS, 2019-2022). Child maltreatment was identified by International Classification of Diseases (ICD) diagnosis codes of confirmed and suspected maltreatment, examinations performed after sexual assault, problems related to upbringing, malnutrition, and chief complaint codes for 'child abuse,' 'sexual abuse,' or 'rape.' Design-based chi-squared tests and regression models were utilized to determine associations between sociodemographic factors, comorbidities, wait time, and length of stay for these patients. Our sample included 13,896 pediatric visits. After applying sampling weights, 1.4 % of pediatric ED visits (422,755 visits annually) were related to maltreatment. Of these visits, 62.7 % were for examinations after sexual assault, 31.2 % included maltreatment, and 6.1 % were for problems related to upbringing or malnourishment. No significant associations were observed by race, age, insurance, sex, or rurality. When evaluating associations between comorbidities and child maltreatment-related visits, associations of asthma, substance use, and developmental disorders were statistically significant (p<0.05). Additionally, visits for these encounters were 28.0 minutes longer compared to other visits (p=0.040). Our findings show maltreatment-affected children across sociodemographics between 2019 and 2022, with more than 420,000 cases presenting to the ED annually. Our results showed that higher rates of maltreatment were found among children with substance use and developmental disorders. At the hospital level, maltreatment visits were often longer than usual visits, but with shorter boarded time-more arriving via ambulance compared to other visits. This underscores the urgent need for comprehensive education and training for all ED staff on how to recognize and respond to child maltreatment across diverse populations. Taking a comprehensive history as well as implementing evidence-based protocols can help increase sensitivity to child maltreatment in EDs across the UnitedStates.

Heart failure (HF) affects 6.7 million American adults. The gold standard for HF assessment is echocardiography (echo) to determine the ejection fraction (EF). Evaluating the cardiac apex angle may be a possible way to estimate EF; however, there is a lack of investigation into this relationship. This study aimed to evaluate whether a correlation exists between the cardiac apex angle andEF. A new, standardized method was developed to measure the cardiac apex angle, with the apex as the vertex, the inferior ray extending from the vertex to the right heart border, and a superior ray extending to the intersection of the left atrial appendage and ventricle. Cadaveric hearts were assessed and patient data from the Medical Information Mart for Intensive Care (MIMIC-IV) database were retrospectively analyzed. Chest X-rays (CXR) provided the cardiac apex angles, and echocardiogram reports contained matched EF values. In 15 cadaveric hearts, the average apex angle was 47.2°, and the average EF was 48.5 %. Linear regression analysis revealed an R2 value of 0.6543. In the MIMIC-IV cohort of 583 unique patients with matched echocardiograms and CXRs, the average EF was 52.7 %, and the average apex angle was 47.2°, with linear regression analysis revealing an R2 value of 0.7018. This was further broken down by sex and CXR direction. Access to echo may be limited in resource-constrained settings. Utilizing CXRs to estimate EF offers a practical alternative, potentially enabling early diagnosis and standardized treatment. This approach leverages common imaging modalities to bridge diagnostic gaps and improve HF management.

Burnout is a critical issue, with prevalence as high as 76 % among medical students. Associated with decreased empathy, cheating, withdrawal from medical school, and suboptimal patient care, burnout correlates with work hours (WH) and self-harm thoughts (SHT). This study analyzes the correlations of burnout, WH, SHT, and various socioeconomic, demographic, experiential, and behavioral factors among medical students. A cross-sectional analysis was conducted utilizing a 60-question survey distributed to 12 osteopathic and 23 allopathic medical schools in six states (AR, KS, LA, MO, OK, and TX). Data from 137 medical students was analyzed utilizing the Copenhagen Burnout Inventory (CBI). Average burnout scores, weekly WH, and frequency of SHT were calculated for different demographic groups, with multiple linear regression analysis identifying significant predictors of burnout. Key findings include: (1) burnout and SHT rates increased from medical school year 1 (MS1) to MS3years despite varying workloads; (2) female students reported higher burnout while male students had higher SHT rates; (3) married students showed significantly lower SHT rates (2.6 vs. 16.3 %); (4) students experiencing mistreatment had substantially higher burnout scores (48.8 vs. 38.0) and doubled SHT rates (19.3 vs. 7.8 %); (5) self-funded students reported higher burnout and SHT; and (6) religious affiliation was associated with lower SHT prevalence. Regression analysis identified male gender as protective against burnout, while depression/hopelessness, self-funded education, increased WH, and mistreatment were significant risk factors. Medical student burnout varies significantly based on multiple factors, with concerning relationships between burnout, WH, and SHT. Medical schools should prioritize creating supportive learning environments and eliminating student mistreatment, with targeted interventions for vulnerable groups including female students, those with financial strain, and caregivers. Addressing these factors early in medical training may help mitigate burnout throughout physicians' careers, ultimately improving healthcare delivery.

Acute neck and low back pain are common emergency department (ED) presentations, generally treated with nonsteroidal anti-inflammatory drugs (NSAIDs). Osteopathic manipulative treatment (OMT) is a hands-on treatment modality utilized to treat a variety of musculoskeletal conditions. We sought to evaluate the relative efficacies and side effects of hands-on OMT vs. one dose of oral ibuprofen, in the treatment of adult patients presenting with acute neck or backpain. We conducted a prospective randomized controlled trial at a high-volume urban ED. Adult patients with acute neck or low back pain were randomized to 5 min of OMT or oral ibuprofen 400 mg. Primary endpoint was the reduction in pain. Secondary outcomes included patient satisfaction and the rate of adverse events. Thirty-eight patients were enrolled; 35 were included in the final analysis. Twenty patients were randomized to OMT, 15 to ibuprofen. Median pain reduction on the Numeric Rating Scale 11 (NRS-11) scale was 2.0 points for OMT and 1.0 point for ibuprofen (p=0.11) at 30 min; 2.5 points for OMT and 2.0 points for ibuprofen (p=0.22) at 60 min. There was no significant difference between groups. Nor were there any significant differences on the 5-point Pain Relief Scale (PRS-5) scale (p=0.36), or in any of the secondary outcomes. In this small, unblinded, single-center randomized trial, we found no significant difference in utilizing OMT compared to 400 mg of oral ibuprofen for patients with acute neck or low back pain, regarding pain control, patient satisfaction, or side effects.

Whiplash is common after road traffic accidents and affects millions of people worldwide. The incidence of whiplash-associated disorders (WADs) has risen to at least 300 per 100,000 in Western countries, with global emergency room visits estimated at 235-300 per 100,000 annually. The aim of this study was to evaluate an osteopathic intervention for whiplash and determine whether pain, mobility, and quality of life improve with respect to conventional treatment. A randomized, controlled clinical trial (from January 13, 2021 to August 10, 2022) conducted at Hospital San Juan de Dios del Aljarafe, Bormujos (Seville), Spain. The inclusion criteria were patients with WADs grade II, aged 18-55. The exclusion criteria were previous WAD, previous osteopathic treatment, pregnancy, or neurological/rheumatic conditions. Measures included initial and final evaluations at 21days (Visual Analog Scale [VAS], Neck Disability Index [NDI], Whiplash Disability Questionnaire [WDQ]) and WDQ re-administered at 4weeks. The control group followed the hospital's protocol, and the experimental group also received an osteopathic intervention (n=52, 26 in each group). Statistical analysis was performed utilizing Statistical Package for the Social Sciences (SPSS) version 27.0. An intra-subject comparison was conducted with student's t-test for dependent samples and Wilcoxon's test, and inter-group comparisonswere performed utilizing student's t-test for independent samples as well as Mann-Whitney U, and chi-squaredtests. Significant improvements were obtained in the intervention group at 7, 14, and 21days for pain (decrease of two units at each time point; p<0.001), number of pain sites (decrease of one additional unit; p<0.001), and number of medications taken (decrease of one additional unit; p=0.004; p=0.002; p=0.051). The WDQ administered at 4weeks showed a greater improvement in the intervention group (-62.5 [IR:-73.0 to-47.5] vs.-43.5 [-56.3 to-34.0]; p=0.004) and at 21days in the control group (-88.0 [-99.5 to-53.5] vs.-62.0 [-76.3 to-37.8]; p=0.035). The algometer for the left trapezius was better for the intervention group (0.7 [(0.12-1.0] vs. 1.0 [0.5-1.5]; p=0.029). A significant improvement was observed for the intervention group in terms of pain, number of sites, medications taken, and at 4weeks posttreatment in the WDQ. These findings emphasize the significance of a personalized and comprehensive osteopathic approach in the treatment ofWADs.

Allopathic physicians, those with a Doctor of Medicine (MD) degree, may be unfamiliar with training distinctions with a Doctor of Osteopathic Medicine (DO) degree. Concerns about differences in medical training between DO and MD students may lead to biases against DOs as applicants for entry into residency or fellowship programs. This bias may be associated with lower acceptance rates into certain programs, with several competitive specialties matching <1 % of DO applicants. The potential for disparate treatment could lead to shortages in certain specialties. There is a lack of evidence that competency assessments of DO residents differ from those of MDs when it comes to patient care and outcomes. This study aimed to compare Milestone assessments across Accreditation Council for Graduate Medical Education (ACGME) competencies (Patient Care [PC], Medical Knowledge [MK], Practice-based Learning and Improvement [PBLI], Interpersonal and Communication Skills [ICS], Professionalism [PROF], and Systems-based Practice [SBP]) of residents who attended US allopathic (MD) vs. osteopathic (DO) medical schools, hypothesizing that there would be no differences throughout residency. We analyzed Milestone achievements of residents in 3-year programs from the four largest medical specialties in the 2016 and 2017 Match: Family Medicine, Internal Medicine, Pediatrics, and Emergency Medicine. We excluded residents who graduated from international medical schools and programs that exclusively had either osteopathic- or allopathic-trained residents to control for potentially confounding effects. We extracted Milestone data for two cohorts of categorical residents who entered training in July 2016 and July 2017. These cohorts were chosen to avoid the effects of the COVID-19 pandemic and to utilize a single assessment instrument, Milestones 1.0. Milestone scores were compared at the initial and penultimate assessment periods. For each competency domain, by specialty separately, we applied a generalized estimating equations model to account for the correlation among Milestone ratings repeated over time for each resident nested within a training program. Among 13,544 eligible residents, 31 % were DO graduates. At the initial assessment in the 2016 cohort, DOs had lower Milestone means than MDs in eight areas: Family Medicine MK; Internal Medicine MK, SBP, PBLI, and ICS; and Pediatrics PC, SBP, and PROF. DOs had higher Milestone means than MDs in two areas: Emergency Medicine PC and SBP. By the penultimate assessment, DOs had lower Milestone means than MDs in only three areas (Pediatrics PC, MK, and SBP), and higher Milestone means in all 6 areas for Emergency Medicine. On initial assessment in the 2017 cohort, DOs had lower Milestone means than MDs in seven areas: Family Medicine MK; Internal Medicine PC, MK, SBP, PBLI, PROF, and ICS. DOs had higher Milestone means than MDs in one area: Emergency Medicine MK. By the penultimate assessment, the only significant differences were lower Milestone scores for DOs in Family Medicine MK and PBLI. The absolute value of the differences ranged from 0.05 to0.12. Osteopathic- and allopathic-trained residents in four medical specialties demonstrate similar Milestone assessments throughout their training. Small, statistically significant differences found in Milestone assessments favored either MDs or DOs; however, no consistent trends were seen by year or specialty.