The Role of Nurses and Midwives in Expanding and Sustaining Voluntary Medical Male Circumcision Services for HIV Prevention: A Systematic and Policy Review.

ABSTRACT: Male circumcision reduces men's risk of acquiring HIV through heterosexual sex, and voluntary medical male circumcision (VMMC) is central to HIV prevention strategies in 15 sub-Saharan African countries. Nurses have emerged as primary VMMC providers; however, barriers remain to institutionalizing nurse-led VMMC. Patient safety concerns have hindered task sharing, and regulations governing nurse-performed VMMC are not always supportive or clear. We performed a systematic review on VMMC safety by provider cadre and a desk review of national policies governing the VMMC roles of nurses and midwives. Also, VMMC by nurses is safe and has become standard practice. Countries had multiple policy combinations among different documents, with only one disallowing VMMC by these cadres. Countries with alignment between policies often ensured that nursing workforces were equipped with clinical competencies through national certification. Regulatory clarity and formalized certification for nurse-performed VMMC can increase program sustainability and build nursing capacity to meet other critical basic surgical needs.

' It is a question of determination': a case study of monitoring and evaluation of integrated family planning services in urban areas of Togo.

Background: Integrating family planning into postabortion and postpartum services can increase contraceptive use and decrease maternal and child death; however, little information exists on the monitoring and evaluation of such programs. This article draws on research completed by the EngenderHealth's AgirPF project in three urban areas of Togo on the extent to which monitoring and evaluation systems of health services, which operated within the AgirPF project area in Togo, captured integrated family planning services. Methods: This mixed methods case study used 25 health facility assessments with health service record review in hospitals, large community clinics, a dispensary, and private clinics and 41 key informant interviews with health faculty, individuals working at reproductive health organizations, individuals involved in reproductive health policy and politics, health care workers, and health facility directors. Results: The study found the reporting system for health care was labor intensive and involved multiple steps for health care workers. The system lacked a standardized method to record family planning services as part of other health care at the patient level, yet the Ministry of Health required integrated family planning services to be reported on district and partner organization reporting forms. Key informants suggested improving the system by using computer-based monitoring, streamlining the reporting process to include all necessary information at the patient level, and standardizing what information is needed for the Ministry of Health and partner organizations. Conclusion: Future research should focus on assessing the best methods for recording integrated health services and task shifting of reporting. Recommendations for future policy and programming include consolidating data for reproductive health indicators, ensuring type of information needed is captured at all levels, and reducing provider workload for reporting.

Women in Osteopathic and Allopathic Medical Schools: An Analysis of Applicants, Matriculants, Enrollment, and Chief Academic Officers.

In the 1993-1994 academic year, female enrollment was 34.7% in osteopathic medical schools and 40.2% in allopathic medical schools. To assess progress in female enrollment since that time, the authors examined admission data in the ensuing years, including female applicants, matriculants, and first-year students in osteopathic and allopathic medical schools, as well as female chief academic officers at these institutions. In the 2004-2005 academic year, 50.3% of first-year students in osteopathic medical schools were women; however, by the 2013-2014 academic year, that figure dropped to 44.2%. The percentage rose slightly by the 2016-2017 academic year to 45.9%. Additionally, for the 2016-2017 academic year, allopathic medical schools had a significantly higher proportion of female matriculants than did osteopathic medical schools (49.8% vs 45.9%, respectively; P<.001).

Determining Psychoneuroimmunologic Markers of Yoga as an Intervention for Persons Diagnosed With PTSD: A Systematic Review.

There is a growing body of research on yoga as a therapeutic intervention for psychological symptoms of post-traumatic stress disorder (PTSD) accompanied by speculations on underlying physiologic mechanisms. The purpose of this systematic review is to identify, qualitatively evaluate, and synthesize studies of yoga as an intervention for PTSD that measured physiologic outcomes in order to gain insights into potential mechanisms. The focus is on studies evaluating yoga as a therapeutic intervention for PTSD rather than for trauma exposure, PTSD prevention, or subclinical PTSD. Multiple databases were searched for publications from the past two decades using terms derived from the question, "In people with PTSD, what is the effect of yoga on objective outcomes?" Eligibility criteria included yoga-only modalities tested as an intervention for formally diagnosed PTSD with at least one physiologic outcome. Results of this review confirmed that, though much of the published literature proposes physiological mechanisms underlying yoga's effects on PTSD, very few studies ( n = 3) have actually evaluated physiological evidence. Additionally, several studies had methodological limitations. In light of the limited data supporting yoga's beneficial effects on autonomic nervous system dysregulation, we present a theoretical model of the psychoneuroimmunologic processes associated with PTSD and the effects yoga may have on these processes to guide future research. Gaps in the literature remain for mechanisms related to activation of the hypothalamic-pituitary-adrenal axis and inflammation. Additional rigorous mechanistic studies are needed to guide development of effective yoga interventions for PTSD to augment existing evidence-based PTSD treatments.

Osteopathic Medical Students Entering Family Medicine and Attitudes Regarding Osteopathic Manipulative Treatment: Preliminary Findings of Differences by Sex.

CONTEXT: Factors distinguishing osteopathic physicians from their allopathic counterparts include the use of osteopathic manipulative treatment (OMT), application of osteopathic principles and practice (OPP), and a greater likelihood of entering primary care, specifically family medicine (FM). In the United States, the percentage of entering osteopathic medical students who were female rose from 14.3% in fall 1977 to 44.3% in fall 2015. OBJECTIVES: To investigate the perspectives of female osteopathic medical students as they relate to osteopathic distinctiveness. METHODS: Students at the West Virginia School of Osteopathic Medicine who were eligible to participate in graduation exercises in 2014 or 2015 were asked to complete the school's standard Exit Survey. The research team chose 5 items from the survey to include in the current analysis. Sex had been self-identified at admission, and residency in first postgraduate year was categorized as FM or other specialty. Graduates entering a transitional year or traditional internship were removed from analysis. RESULTS: Analysis was conducted for 308 of the 375 students (82%) expected to graduate in 2014 or 2015. χ2 analysis found no difference by sex in the number of graduates entering FM residencies vs other specialties (P=.727). Statistically significant differences were found in 2 survey items: "Use of OMT will enhance my practice" (P=.005) and "What emphasis do you believe OMT will have in your practice?" (P<.001). Graduating female students responded more favorably to OMT on both items. For the latter item, 91.4% of female and 80.3% of male students indicated OMT would have at least some role in their practices. Sex differences remained after statistically controlling for entry into FM. CONCLUSION: Female graduating osteopathic medical students were more likely to report that OMT will have at least some role in their practices. Future studies of the attitudes and practice patterns of osteopathic physicians should analyze for differences by sex.

Relationship of admissions variables and college of osteopathic medicine variables to performance on COMLEX-USA level 3.

CONTEXT: New accreditation standards require that all US colleges of osteopathic medicine (COMs) publically report the first-time pass rates of graduates on the Comprehensive Osteopathic Medical Licensing Examination-USA (COMLEX-USA) Level 3. Little is known about the extent to which admissions variables or COM performance measures relate to Level 3 performance. OBJECTIVE: To examine the relationship of admissions variables and COM performance to scores on Level 3 and to assess whether a relationship existed between Level 3 scores and sex, curriculum track, year of graduation, and residency specialty in the first postgraduate year. METHODS: Data were analyzed from 4 graduating classes (2008-2011) of the West Virginia School of Osteopathic Medicine in Lewisburg. Relationships were examined between first-attempt scores on COMLEX-USA Level 3 and Medical College Admission Test (MCAT) scores; undergraduate grade point averages (GPAs); GPAs in COM year 1, year 2, and clinical rotation years (years 3 and 4); and first-attempt scores on COMLEX-USA Level 1, Level 2-Cognitive Evaluation, and Level 2-Performance Evaluation. RESULTS: Of the 556 graduates during this 4-year period, COMLEX-USA Level 3 scores were available for 552 graduates (99.3%). No statistically significant differences were found in Level 3 scores based on sex, curriculum track, graduating class, or residency specialty. The strongest relationship between Level 3 scores and any admissions variable was with total MCAT score, which accounted for 4.2% of the variation in Level 3 scores. The strongest relationship between Level 3 scores and COM year performance measures was with year 2 GPA, which accounted for 35.4% of the variation in Level 3 scores. Level 1 scores accounted for 38.5% of the variation in Level 3 scores, and Level 2-Cognitive Evaluation scores accounted for the greatest percentage of variation (45.7%). The correlation of Level 3 scores with passing the Level 2-Performance Evaluation on the first attempt was not statistically significant. CONCLUSION: A weak relationship was found between admissions variables and performance on COMLEX-USA Level 3, suggesting that graduates with lower MCAT scores and undergraduate GPAs may have overcome their early disadvantage. Strong relationships were found between Level 3 scores and year 2 GPAs, as well as scores on COMLEX-USA Level 1 and Level 2-Cognitive Evaluation.

Clearly distinct: outcomes of initiative to increase integration of osteopathic principles and practice at West Virginia School of Osteopathic Medicine.

CONTEXT: In 1992, the West Virginia School of Osteopathic Medicine (WVSOM) created a task force as part of an institution-wide initiative to integrate osteopathic principles and practice (OPP) across its entire curriculum. The goals of the initiative, which was implemented with the graduating class of 1997, were to create a clearly distinct osteopathic curriculum and preserve the use of osteopathic manipulative treatment (OMT) by WVSOM alumni. OBJECTIVE: To evaluate outcomes of the Osteopathic Principles and Practices Integration Project among WVSOM alumni. METHODS: A survey was mailed on a staggered timeline to WVSOM alumni who had graduated at least 5 years earlier. Data from the graduating classes of 1995 and 1996 (preintervention) were compared with data from the graduating classes of 1997 through 2002 (postintervention). RESULTS: After excluding responses from alumni still in residencies, responses from 52 (41.9%) of 124 alumni in the preintervention group and 155 (40.9%) of 379 alumni in the postintervention group were analyzed. Comparisons of preintervention group to postintervention group, based on the chi(2) test, revealed significant improvement in the proportion of alumni who agreed that basic sciences faculty at WVSOM provided exposure to osteopathic philosophy (P=.020); that basic sciences faculty at WVSOM taught OMT (P=.019); and that alumni were exposed to osteopathic philosophy during rotations with DOs (P=.031). Approximately 53% of alumni in both groups reported daily OMT use in treating patients. Posthoc analysis using the McNemar test for correlated proportions revealed that the proportion of all alumni rating themselves as "prepared" in OMT and OPP at the end of the second year of the WVSOM curriculum was 92.7%, significantly higher than the 76.1% rating of preparation at graduation (P<.001). CONCLUSION: Survey results indicate that WVSOM's Osteopathic Principles and Practices Integration Project has created a distinctly osteopathic curriculum and has helped alumni maintain use of OMT in clinical practice.

Relationships between clinical rotation subscores, COMLEX-USA examination results, and school-based performance measures.

At the West Virginia School of Osteopathic Medicine (WVSOM) in Lewisburg, an electronic rating form was created to assist preceptors in evaluating student performance for third- and fourth-year clinical rotations. Multiple preceptors, often in rural locations, rated the clinical performance of 70 students in the WVSOM graduating class of 2005. The current study analyzes these ratings. Using Cronbach alpha, subscore reliability coefficients were obtained for all rotations: clinical knowledge, 0.80; data collection, 0.59; application of knowledge, 0.65; and professionalism, 0.78. For the three required family medicine rotations, which were almost always supervised by osteopathic physicians, reliability of the rating for osteopathic principles and practice (OPP) was 0.44. Intercorrelations among these five subscores ranged from 0.46 to 0.94, all statistically significant at the .01 level. Ratings for the five subscores were compared with 19 measures of student performance in other parts of the WVSOM curriculum, many correlations were significant at the .01 level. Clinical knowledge correlated 0.59 with year 2 grade point average (GPA), 0.51 with years 1 and 2 OPP GPA, 0.50 with Comprehensive Osteopathic Medical Licensing Examination USA Level 2 Cognitive Evaluation, and 0.45 with years 1 and 2 physical diagnosis GPA. Application of knowledge correlated 0.55 with year 2 GPA and 0.50 with the organization score on the college's year 3 objective structured clinical evaluation. Professionalism correlated 0.51 with year 2 GPA and 0.49 with OPP years 1 and 2 written examination score. The average preceptor rating using the new electronic form was 92.6, compared with 96.8 when the previous paper-based form was used for the WVSOM class of 1998 (change significant at .05 level). These moderate correlations provide some support for the validity of the Clinical Education Grade Form.

Relationships between scores on the COMLEX-USA Level 2-Performance Evaluation and selected school-based performance measures.

The Comprehensive Osteopathic Medical Licensing Examination USA Level 2 Performance Evaluation (COMLEX-USA Level 2-PE) is a national multistation performance examination designed to examine students' osteopathic clinical skills. The current study examines the relationship between achievement levels on the COMLEX-USA Level 2-PE and selected school-related variables for the class of 2005 at the West Virginia School of Osteopathic Medicine in Lewisburg, WVa (N=70). Significant (P<.01) correlations between the COMLEX-USA Level 2-PE summary performance and selected academic achievement measures include: weighted Physical Diagnosis grade, 0.41; weighted year 1 and year 2 Osteopathic Principles and Practice grade, 0.37: overall year 2 grade point average, 0.42; the objective structured clinical evaluation (OSCE) Physical Examination score, 0.40; and the OSCE Total Station score, 0.33. While further research is needed, the current study found modest but notable relationships between school-generated academic variables and performance on the COMLEX-USA Level 2-PE, and therefore supports the validity of the COMLEX-USA Level 2-PE examination for assessing the clinical skills of future osteopathic physicians.

Community-based osteopathic manipulative medicine student clinic: changes in curriculum and student confidence levels.

The West Virginia School of Osteopathic Medicine in Lewisburg instituted a free, community-based medical clinic in spring 1995 as part of an institution-wide Osteopathic Principles and Practices Integration Project. Under this initiative, osteopathic medical students are provided with 26 hours of supervised experience in osteopathic palpatory diagnosis and osteopathic manipulative treatment. The educational goal of the clinic is to increase the confidence of osteopathic medical students in their technical abilities in using osteopathic manipulative medicine to diagnose and treat community patients. Based on a variety of results from student-completed surveys, the authors conclude that the osteopathic manipulative medicine student clinic at West Virginia School of Osteopathic Medicine has met its goal of increasing student confidence in the application of these skills.

Relations between academic performance by medical students and COMLEX-USA Level 2: a multisite analysis.

The Comprehensive Osteopathic Medical Licensing Examination-USA (COMLEX-USA) is a national medical licensing examination for physicians earning the doctor of osteopathic medicine (DO) degree. Little has been published regarding the validity of this relatively new, high-stakes examination. The purpose of this study was to examine the validity of COMLEX-USA Level 2, which is given to fourth-year osteopathic medical students and focuses on clinically relevant content. Nineteen osteopathic medical schools were asked to submit Level 2 scores and associated academic information, including predictions by deans or deans' representatives regarding whether each student would pass the examination. Twelve of the 17 schools that had students eligible to take the Level 2 examination provided data for 1254 (80%) of 1577 first-time test takers in March 2000. The overall mean score of study participants was 533.35, with a pass rate of 91.98%. The highest average correlation with COMLEX-USA Level 2 performance was with COMLEX-USA Level 1 scores (r = 0.76), followed by basic science grade point average (GPA) (r = .66), total GPA as a fourth-year student (r = .65), and clinical GPA (r = .36). Students identified as being at highest risk received the lowest mean score (427.54) and were most likely to fail Level 2. COMLEX-USA Level 2 scores are moderately to highly related to academic achievement in osteopathic medical schools.