Evaluation of Using 3D Printing to Design and Build OMM Spinal Models for Teaching and Education

INTRODUCTION: Understanding spinal mechanics is the foundation for osteopathic manipulative medicine (OMM) training. With such knowledge, osteopathic physicians may confidently diagnose and treat spinal somatic dysfunctions. However, a dynamic and objective teaching tool to educate students on spinal mechanics has not been established. While 3D printing is gaining utility in academia, it is only just beginning to be employed within osteopathic educational settings. A literature review found a single study exploring the use of 3D printing to educate students on rib mechanics. Our study makes use of 3D printing to develop a functional model to teach and test students on spinal mechanics. OBJECTIVE: The primary objective of this study is to develop a working OMM model of the spine for educational and testing purposes. DESIGN/METHODOLOGY: This was a design-and-build project consisting of three phases. The primary endpoint was to have a model that could emulate rotational and sidebending motions of the human spine. The secondary endpoint included modifying the model to artificially create constraints on the system representing somatic dysfunction. The initial model was made from sponges and Lego blocks. It replicated sidebending and rotational motion while lacking a realistic human endfeel. The second model maintained the Lego base but incorporated 3D printing to manufacture manipulatable vertebrae. This corrected for the lack of human end-feel, but lacked sidebending capabilities. The final model incorporated both 3D printing and an adjustable cradle to create reproducible somatic dysfunctions. The natural feel of the spine was created by applying springs to recreate the natural recoil of paraspinal muscles and ligaments. Synthetic skin was also placed over the mechanism to generate a more realistic feel. RESULTS/FINDINGS: The final constructed model served to accurately demonstrate sidebending and rotational components of Fryette’s Laws of spinal motion. The ability to maneuver the cradle base into various positions enabled more thorough testing of somatic dysfunctions. For example, to demonstrate a Type I somatic dysfunction which is sidebent right and rotated left, the cradle base is translated to the left and the left cradle screw is lowered. FUTURE DIRECTION: The future directions of this project are multifaceted. In terms of the model itself, a comparison of the spring constant between paraspinal connective tissue and the springs used could gain extra palpatory realism. Additionally, while Type II somatic dysfunction can be inferred by sidebending and rotating the vertebral model to the same side, flexion and extension are unable to be tested with the current design. Future studies will also assess the subjective experience and diagnostic accuracy of osteopathic clinical faculty to determine the validity of the tool. The model can then be integrated as an educational tool during the first two years of OMM training, and subjective and objective student feedback will be collected. Eventually, the goal is for the model to be used as a means to standardize testing of students’ diagnostic skills across osteopathic medical schools

An investigation of oral sex as a risk factor for recurrent vaginitis: a case study

Background: Recurrent Vaginitis is defined as having three or more confirmed episodes within a year. Recurrence rates of vaginitis have been reported in up to 60% of previously infected women. The most common bacterial cause is due to Gardnerella vaginalis, while Candida albicans is the most common fungal cause; both microorganisms can cause opportunistic infections when imbalances occur in the vaginal environment. Commonly known risk factors include multiple sex partners, unprotected sex, douching, recent antibiotic use, and estrogen therapy. Case Presentation: A healthy 34-year-old female is complaining of recurrent episodes of vaginitis since the birth of her son two years ago. Vaginal irritation is typically accompanied by thick off-white vaginal discharge. She attributes her recurring symptoms to her intrauterine device (IUD) placed six-weeks postpartum. Symptoms occur after sexual intercourse, approximately once or twice a month. Her husband has incorporated oral sex into their routine sexual practice to help counteract the reduced libido she developed since having their son. She is married and monogamous with her husband. She has no prior history of sexually transmitted infection. She denies fevers, unintentional weight change, menstrual irregularity, rash or genital lesions, dyspareunia, or urinary complaints. Her vital signs are within normal range. A pelvic exam reveals mild suprapubic tenderness, erythema of the vaginal introitus, and thick off-white vaginal discharge with slight odor. No abnormal masses or cervical motion tenderness are noted on the bimanual exam. Urinalysis shows leukocyte esterase. Urine pregnancy test is negative. Vaginal swabs for gonorrhea and chlamydia are negative. Clue cells are seen on saline wet mount, and pseudohyphae with budding yeast are noted on potassium hydroxide preparation. For her concurrent bacterial vaginosis and Candidal vaginitis, she is prescribed a week of oral metronidazole 500 mg twice daily, and one dose of oral fluconazole 150 mg, respectively. Additionally, her husband is advised to thoroughly gargle with mouthwash prior to engaging in oral sex. On follow-up, the patient reports no further postcoital vaginitis episodes. Discussion: Current data is inconsistent regarding whether oral sex is considered a risk factor for recurrent vaginitis. The lack of research in this area could be due to the sensitive nature of discussing detailed sexual practices with patients, but these discussions provide a significant part of a patient’s history. Anecdotal evidence from our patient case prompted further investigation into the interactions between oral sex and recurrent vaginitis. An extensive literature review suggests that dysbiosis in vaginal flora resulting in vaginitis may be due to the direct inoculation of oral microbes, or the indirect effects of their byproducts. Furthermore, studies have shown that the use of mouthwash can effectively eliminate oral flora known to impact the vaginal microbiota. We plan to conduct a meta-analysis to further investigate the effects of varying vaginal and oral flora compositions on many aspects of the vaginal environment. A future case-control study can also be done to investigate the effectiveness of using mouthwash prior to oral sex for the prevention of recurrent vaginitis

A nine-year longitudinal case study of a 27-year-old male with neurocysticercosis presenting with new onset seizures

Background: Taenia solium is a cestode endemic to regions of Latin America, Asia, sub-Saharan Africa and Oceania, and serves as the most common cause of acquired epilepsy in the world. T. solium eggs are transmitted fecal-orally when a human or pig host ingests contaminated food or water. Larvae hatch from the intestines and invade into muscle, tissue, or organs, forming cysts called cysticerci. Cysticerci involving the central nervous system is termed neurocysticercosis (NCC). Patients with NCC typically remain asymptomatic for 3-5 years in the viable stage until the host’s immune response is activated in the degenerating stage. Immune-mediated degradation of cysticerci and subsequent inflammation and edema in the nonviable stage may manifest as new onset seizures, headache, and other neurological deficits caused by increasing intracranial pressure. The diagnosis of NCC in non-endemic areas is based on clinical symptoms, history of travel to an endemic region, and presence of classic ring-enhancing lesions on neuroimaging. Case Description: A healthy 27-year-old male presents with new onset seizures. The first episode was witnessed by his wife who stated he was washing dishes before he fell to the ground convulsing. The seizure spontaneously resolved upon arrival of the ambulance. The patient denies symptoms of fever, fatigue, unexplained weight change, headaches, focal neurologic deficit, visual changes, cough, rash, recent illness, or head trauma. Further history is noncontributory except for note of travel to China four years ago to visit his in-laws. Vital signs are within normal range. In the Emergency Department, he suffers another witnessed seizure and is treated with lorazepam. He is disoriented and combative in his postictal state necessitating sedation with intubation. A CBC, CMP, troponin, HIV, toxicology, and tuberculosis screen are largely normal. Lumbar puncture reveals elevated leukocytes with normal glucose and protein levels. Parasitology report and blood cultures remain negative throughout the visit. Computerized tomography (CT) scan and contrasted magnetic resonance imaging (MRI) of the brain show a 3-4 millimeter calcified, ring-enhancing lesion in the right frontal lobe with surrounding edema. He is diagnosed with NCC based on symptoms, travel history, and neuroimaging findings. Conclusion/Discussion: This is an uncomplicated nine-year longitudinal case study of a patient with NCC presenting with new onset seizures four years after traveling to China. Symptomatic management at the time of diagnosis included dexamethasone for brain edema and levetiracetam for prevention of further seizures. Antiparasitics, which can be used in viable or degenerating stages, were not utilized in our patient due to the evidence of a nonviable calcified cysticercus on imaging. The patient ultimately opted for surgical removal of the lesion to definitively treat his seizures. A six-month postoperative MRI confirmed resolution of abnormal findings, at which point the patient was weaned off levetiracetam. Nine years later, the patient remains seizure-free and without complications

A seemingly low risk patient develops urosepsis as a complication of transrectal prostate biopsy: A case study

Background: Prostate cancer (PCa) is the most common cancer in men, and the second most common cause of cancer deaths in the United States. Approximately 1 million Americans undergo prostate biopsies annually, with 97% undergoing the transrectal prostate biopsy (TRPB). While TRPB is reliable and relatively low risk, nearly 7% of patients develop infectious complications, with 3% requiring hospitalization due to sepsis. Risk factors for developing infection post-TRPB include antibiotic resistance, \u3e10 biopsy cores, diabetes mellitus, indwelling catheter, and African-American ethnicity. Identifying risk factors, considering a transperineal biopsy approach, and utilizing pre-procedural practices like rectal sterilization, screening urinalysis, prophylactic antibiotics, or rectal culture can significantly minimize infectious complications. Case Description: A healthy 66-year-old Asian male, with a family history of prostate cancer, complains of worsening nocturia. He denies fever, fatigue, weight change, back or abdominal pain, hematuria, dysuria, polydipsia, or history of recurring infections. Vitals including body mass index (BMI) are within normal range. The prostate is enlarged and non-tender on digital rectal exam. His prostate-specific antigen rose from 2.4 to 5.8 in a year, and a prostate MRI indicated high suspicion for cancer. Following rectal enema prep, urinalysis screen, and betadine sterilization, ultrasound-guided TRPB was performed. Antibiotic prophylaxis included intravenous ciprofloxacin and ceftriaxone followed by three days of oral cefdinir. Twelve biopsies were sampled, and the patient was discharged home in good condition. The following evening, he developed fever, chills, and malaise. He was disoriented in the Emergency Department, with a temperature of 101.2 Fahrenheit, blood pressure 150/82, heart rate 109, respiratory rate 24, and 94% oxygen saturation. Urinalysis revealed leukocytes, blood, glucose, and protein. HbA1c was 6.4%. His condition improved with IV fluid resuscitation, empiric vancomycin and aztreonam in the ED, and meropenem during the remainder of his hospitalization. Peripheral blood cultures confirmed pan-sensitive E. coli. He was discharged home on oral cefuroxime 500mg BID for thirteen more days, and experienced no further complications. Prostate pathology reports confirmed adenocarcinoma, for which he successfully completed radiation therapy. Discussion: Recognizing risk factors as well as following proper infection prevention protocols are essential in minimizing potential TRPB-related complications. While the number of biopsy cores may have contributed to our patient’s progression of urosepsis, he was otherwise seemingly low risk for post-procedural infection at first glance. However, a thorough retrospective review of the patient’s history brings into question whether his borderline diabetic HbA1c level played a role in his unfortunate outcome. This consideration stems from a study demonstrating a progression of altered inflammatory and immune responses in both prediabetic and diabetic patients, highlighting that biochemical changes responsible for diabetic-related complications are evident to a degree in prediabetics. Further studies are needed to explore prediabetes as a direct risk factor for post-procedural infectious complications. Depending on these results, infection-prevention strategies currently in place for diabetics (i.e. rectal cultures and broader antibiotic coverage) may prove helpful for certain prediabetic patients as well. Until then, these potential suggestions exist on speculation alone

Differential Diagnostic Considerations in a Patient With New Onset Apathy: A Case Study on Frontal Lobe Glioblastoma Multiforme

This case study involves a 50 year-old previously healthy female presenting with a two-week history of clinically significant apathy. The patient and her family assume her symptoms are due to a potential underlying psychiatric condition; however, neurologic and systemic disorders should also be considered when evaluating a patient with sudden personality change. After a thorough history and physical exam, further evaluation with neuroimaging is performed due to suspicion of neurological etiology. A sizable ring-enhancing lesion in the frontal lobe is noted on MRI, and a diagnosis of glioblastoma multiforme (GBM) is confirmed with biopsy. GBM, or grade 4 astrocytoma, is an aggressive primary brain tumor with a poor prognosis. Neurological deficits can develop quickly over days to weeks, and may vary depending on tumor location. Most GBMs are located supratentorial, with the majority in the frontal or temporal lobes. Sudden personality or mood changes are highly indicative of GBM located in the frontal lobe due to its role in managing executive functions, such as initiating and focusing on tasks, emotional control, and organization. After maximal surgical resection of the tumor, radiation, and chemotherapy, a patient with GBM may prolong their survival from 3-months to 15-months; therefore prompt diagnosis and early initiation of treatment is imperative. Working with a highly skilled multidisciplinary care team is also important in coordinating an individualized treatment plan for patients with GBM