Blue Ribbon Committee I Review: Findings and Impact.

OBJECTIVE: Review the subsequent impact of recommendations made by the 2004 American Surgical Association Blue Ribbon Committee (BRC I) Report on Surgical Education. BACKGROUND: Current leaders of the American College of Surgeons and the American Surgical Association convened an expert panel to review the impact of the BRC I report and make recommendations for future improvements in surgical education. METHODS: BRC I members reviewed the 2004 recommendations in light of the current status of surgical education. RESULTS: Some of the recommendations of BRC I have gained traction and have been implemented. There is a well-organized national curriculum and numerous educational offerings. There has been greater emphasis on preparing faculty to teach and there are ample opportunities for professional advancement as an educator. The number of residents has grown, although not at a pace to meet the country's needs either by total number or geographic distribution. The number of women in the profession has increased. There is greater awareness and attention to resident (and faculty) well-being. The anticipated radical change in the educational scheme has not been adopted. Training in surgical research still depends on the resources and interests of individual programs. Financing student and graduate medical education remains a challenge. CONCLUSIONS: The medical landscape has changed considerably since BRC I published its findings in 2005. A contemporary assessment of surgical education and training is needed to meet the future needs of the profession and our patients.

The Blue Ribbon Committee II Report and Recommendations on Surgical Education and Training in the United States: 2024.

OBJECTIVE: An expert panel made recommendations to optimize surgical education and training based on the effects of contemporary challenges. BACKGROUND: The inaugural Blue Ribbon Committee (BRC I) proposed sweeping recommendations for surgical education and training in 2004. In light of those findings, a second BRC (BRC II) was convened to make recommendations to optimize surgical training considering the current landscape in medical education. METHODS: BRC II was a panel of 67 experts selected on the basis of experience and leadership in surgical education and training. It was organized into subcommittees which met virtually over the course of a year. They developed recommendations, along with the Steering Committee, based on areas of focus and then presented them to the entire BRC II. The Delphi Method was chosen to obtain consensus, defined as>80% agreement amongst the panel. Cronbach alpha was computed to assess the internal consistency of three Delphi rounds. RESULTS: Of 50 recommendations, 31 obtained consensus in the following aspects of surgical training (# consensus recommendation /# proposed): Workforce (1/5), Medical Student Education (3/8), Work Life Integration (4/6), Resident Education (5/7), Goals, Structure and Financing of Training (5/8), Education Support and Faculty Development (5/6), Research Training (7/9), and Educational Technology and Assessment (1/1). The internal consistency was good in Rounds 1 and 2 and acceptable in Round 3. CONCLUSIONS: BRC II used the Delphi approach to identify and recommend 31 priorities for surgical education in 2024. We advise establishing a multidisciplinary surgical educational group to oversee, monitor and facilitate implementation of these recommendations.

An exploration of patient and pharmacist willingness to utilize a food insecurity screening tool in supermarket-based pharmacies.

BACKGROUND: Food insecurity (FI) is a disturbance of eating patterns due to lack of resources, preventing consistent access to healthy foods. FI negatively impacts health outcomes and increases care cost. OBJECTIVES: The primary objective was to (a) explore patient willingness to screen with the 2-question Hunger Vital Sign tool and (b) accept education regarding food assistance programs at their community pharmacy. The secondary objective was to gauge pharmacy personnel's comfort with utilizing the screener and providing education. PRACTICE DESCRIPTION: Screenings occurred from February to May 2023 at supermarket-based pharmacies in counties above state average FI prevalence. PRACTICE INNOVATION: This study evaluated responses to a 9-item FI screening questionnaire that was offered to patients presenting to the pharmacy. Personnel offered patients education about resources and documented responses. Pharmacies provided survey responses to detail their experiences. EVALUATION METHODS: This mixed-methods observational pilot study received approval from Idaho State University's institutional review board. Objective 1(a) was assessed by recording the number of patients agreeing or declining to participate. Objective 1(b) was evaluated by recording the number of patients who accepted education. The secondary objective was appraised by gathering survey responses from personnel. Results were analyzed with descriptive statistics. RESULTS: Of patients asked to participate, 163 (73.1%) agreed. Forty-one agreed but did not submit responses. Of patients agreeing, 123 (75.5%) accepted education. Of patients submitting responses, 56 (49.5%) screened as at-risk for FI. Regarding comfort engaging in the innovation, 4 pharmacies (50.0%) reported being comfortable, 3 (37.5%) neither comfortable nor uncomfortable, and 1 (12.5%) uncomfortable. Qualitative information collected from personnel highlighted meaningful interactions and how this will change their approach to pharmacy practice. CONCLUSION: Supermarket-based pharmacists may be able to detect and educate on FI. Patients in the study screened at a higher rate of at-risk for FI than their counties reported. Many patients accepted education regardless of screening results.

Rheological and Solubility Properties of Soy Protein Isolate.

Soy protein isolate (SPI) powders often have poor water solubility, particularly at pH values close to neutral, which is an attribute that is an issue for its incorporation into complex nutritional systems. Therefore, the objective of this study was to improve SPI solubility while maintaining low viscosity. Thus, the intention was to examine the solubility and rheological properties of a commercial SPI powder at pH values of 2.0, 6.9, and 9.0, and determine if heat treatment at acidic or alkaline conditions might positively influence protein solubility, once re-adjusted back to pH 6.9. Adjusting the pH of SPI dispersions from pH 6.9 to 2.0 or 9.0 led to an increase in protein solubility with a concomitant increase in viscosity at 20 °C. Meanwhile, heat treatment at 90 °C significantly improved the solubility at all pH values and resulted in a decrease in viscosity in samples heated at pH 9.0. All SPI dispersions measured under low-amplitude rheological conditions showed elastic-like behaviour (i.e., G' > G″), indicating a weak "gel-like" structure at frequencies less than 10 Hz. In summary, the physical properties of SPI can be manipulated through heat treatment under acidic or alkaline conditions when the protein subunits are dissociated, before re-adjusting to pH 6.9.

Independent pharmacist prescribing of statins for patients with type 2 diabetes: An analysis of enhanced pharmacist prescriptive authority in Idaho.

OBJECTIVES: This study describes the development and patients' perceptions of a community pharmacist-led, statin-prescribing service for patients with diabetes and aims to identify why patients indicated for statin therapy were not prescribed therapy at the time of pharmacist consultation. SETTING: This pilot service began in 4 community-based Albertsons Companies pharmacies located in western Idaho. Patients eligible for the statin-prescribing service had a current diagnosis of type 2 diabetes, were aged between 40 and 75 years, were currently taking medications to manage their diabetes and had no contraindications to statin therapy. PRACTICE DESCRIPTION: Due to recent law changes in Idaho, pharmacists can now prescribe statins and certain other medications without oversight from a medical provider or the need for a collaborative practice agreement. PRACTIVE INNOVATION: Patients were identified and contacted by their local community pharmacist to discuss the statin-prescribing service. Once statin therapy was initiated, patients completed a brief, 7-question survey regarding their perceptions of the service. EVALUATION: This study evaluated the following: number of patients eligible for the prescribing service, number of patients who received a pharmacist-written statin prescription, and patients' perceptions regarding the service. METHODS: Of the 64 patients screened, 18 (28%) were eligible for statin therapy. Of those eligible, 6 (33%) accepted pharmacist services and 4 patients started statin treatment. Two patients were prescribed a statin by the community pharmacist, whereas the other 2 patients contacted their primary care provider and requested a statin prescription at the pharmacist's recommendation. RESULTS: Overall, participating patients (n = 4) reported feeling comfortable and satisfied with all aspects of the protocol and their pharmacist's role as a prescriber. CONCLUSION: This pilot was the first example of community pharmacists independently prescribing statins outside of the clinic setting. The service could target an important health initiative.

Effectiveness of physical therapy treatment in addition to usual podiatry management of plantar heel pain: a randomized clinical trial.

BACKGROUND: Many patients will seek care from a podiatrist for plantar heel pain (PHP), while few of these patients will also be seen by a physical therapist. Physical therapists can provide treatment that is not a part of routine podiatric care for PHP and may provide additional improvement. Therefore, the purpose of this study was to examine the effects of interdisciplinary care for PHP that incorporated physical therapy treatment after initiating podiatric treatment. METHODS: Eligible individuals with PHP that presented to a podiatrist were randomized to receive usual podiatric care (uPOD) or usual podiatric care plus physical therapy treatment (uPOD+PT). The primary outcome was change in foot and ankle ability measure (FAAM) at 6-months. Secondary outcomes included change in numeric pain rating scale (NPRS), patient-reported success, and 6-week and 1-year endpoints. Patient-reported success was defined as the top two global rating of change scale rankings. Primary analysis was intention-to-treat (ITT) using analysis by covariance adjusted to baseline scores, and a secondary per-protocol (PP) analysis was performed analyzing only those who completed treatment. RESULTS: Ninety-five individuals participated and were included in the ITT analysis, and 79 were included in the PP analysis. For the primary outcome of FAAM change from baseline to 6-months, both groups improved significantly (uPOD+PT: 26.8 [95% CI 21.6, 31.9]; uPOD: (20 [15.6, 24.4]), but there was no between-group difference (4.3 [- 1, 9.6]). For secondary outcomes, the uPOD+PT group demonstrated greater improvement in NPRS at 6 weeks (0.9 [0.3, 1.4]) and 1 year (1.5 [0.6, 2.5]) in the ITT analysis. In the PP analysis, the uPOD+PT group demonstrated greater improvement in FAAM at 6 months (7.7 [2.1, 13.3]) and 1 year (5.5 [0.1, 10.8]), NPRS at 6 weeks (0.9 [0.2, 1.6]), 6 months (1.3 [0.6, 2.1]) and 1 year (1.3 [0.6, 2.1]), and in patient-reported success (relative risk [95% CI]) at 6 weeks (2.8 [1.1, 7.1]), 6 months (1.5 [1.1, 2.1]), and 1 year (1.5 [1.1, 1.9]). CONCLUSIONS: There was no significant benefit of uPOD+PT in the primary outcome of FAAM change at 6 months. Secondary outcomes and PP analysis indicated additional benefit of uPOD+PT, mostly observed in individuals who completed treatment. TRIAL REGISTRATION: Prospectively registered May 24, 2013 at www.clinicaltrials.gov (NCT01865734).

Point-of-Care Ultrasound Applications in the Outpatient Clinic.

Although the use of point-of-care ultrasound (POCUS) is well established in the emergency department (ED) and intensive care unit, the use of POCUS in the outpatient clinic setting is still emerging. General practitioners and specialists alike have increasing access to smaller and less expensive US devices that can assist in making timely diagnoses, guiding procedures, and monitoring patients. In this case-based review, we highlight some of the literature on simple-to-apply POCUS applications relevant to ambulatory medicine. The topics discussed include detecting left ventricular systolic dysfunction, ascites, gallstones, and Achilles tendon tears, as well as distinguishing abscess from cellulitis. Although a robust literature surrounds POCUS use in EDs, literature is limited regarding POCUS in the ambulatory setting; however, the literature supports general practitioners learning this skill set to the benefit of their patients. As POCUS moves out of hospital EDs and into the clinics, high-quality research demonstrating comparable accuracy and utility will be needed.

Ultrastructural analysis of 3 hyaluronic acid soft-tissue fillers using scanning electron microscopy.

BACKGROUND: Although hyaluronic acid (HA) specifications such as molecular weight and particle size are fairly well characterized, little information about HA ultrastructural and morphologic characteristics has been reported in clinical literature. OBJECTIVE: To examine uniformity of HA structure, the effects of extrusion, and lidocaine dilution of 3 commercially available HA soft-tissue fillers. MATERIALS AND METHODS: Using scanning electron microscopy and energy-dispersive x-ray analysis, investigators examined the soft-tissue fillers at various magnifications for ultrastructural detail and elemental distributions. RESULTS: All HAs contained oxygen, carbon, and sodium, but with uneven distributions. Irregular particulate matter was present in RES but BEL and JUV were largely particle free. Spacing was more uniform in BEL than JUV and JUV was more uniform than RES. Lidocaine had no apparent effect on morphology; extrusion through a 30-G needle had no effect on ultrastructure. CONCLUSION: Descriptions of the ultrastructural compositions and nature of BEL, JUV, and RES are helpful for matching the areas to be treated with the HA soft-tissue filler architecture. Lidocaine and extrusion through a 30-G needle exerted no influence on HA structure. Belotero Balance shows consistency throughout the syringe and across manufactured lots.

Implications of early and guideline adherent physical therapy for low back pain on utilization and costs.

BACKGROUND: Initial management decisions following a new episode of low back pain (LBP) are thought to have profound implications for health care utilization and costs. The purpose of this study was to evaluate the impact of early and guideline adherent physical therapy for low back pain on utilization and costs within the Military Health System (MHS). METHODS: Patients presenting to a primary care setting with a new complaint of LBP from January 1, 2007 to December 31, 2009 were identified from the MHS Management Analysis and Reporting Tool. Descriptive statistics, utilization, and costs were examined on the basis of timing of referral to physical therapy and adherence to practice guidelines over a 2-year period. Utilization outcomes (advanced imaging, lumbar injections or surgery, and opioid use) were compared using adjusted odds ratios with 99% confidence intervals. Total LBP-related health care costs over the 2-year follow-up were compared using linear regression models. RESULTS: 753,450 eligible patients with a primary care visit for LBP between 18-60 years of age were considered. Physical therapy was utilized by 16.3% (n = 122,723) of patients, with 24.0% (n = 17,175) of those receiving early physical therapy that was adherent to recommendations for active treatment. Early referral to guideline adherent physical therapy was associated with significantly lower utilization for all outcomes and 60% lower total LBP-related costs. CONCLUSIONS: The potential for cost savings in the MHS from early guideline adherent physical therapy may be substantial. These results also extend the findings from similar studies in civilian settings by demonstrating an association between early guideline adherent care and utilization and costs in a single payer health system. Future research is necessary to examine which patients with LBP benefit early physical therapy and determine strategies for providing early guideline adherent care.

Long-term results for incobotulinumtoxinA in the treatment of glabellar frown lines.

BACKGROUND: IncobotulinumtoxinA has been approved for treatment of glabellar frown lines (GFL) in the United States, all major European markets, South Korea, and Argentina and in Russia and Mexico for the treatment of mimic wrinkles and hyperkinetic facial lines, respectively. OBJECTIVES: Prospective, 2-year, open-label, multicenter, repeat-dose, Phase III trial investigating the safety and efficacy of incobotulinumtoxinA for the treatment of GFL. METHODS: Subjects with moderate or severe GFL on the Facial Wrinkle Scale (FWS), enrolled from previous trials, were treated with 20 U of incobotulinumtoxinA per cycle (up to eight treatment cycles, treatment interval at least 85 days). Efficacy was measured according to the investigator-assessed percentage of responders on the FWS (subjects with a score of 0 or 1) at rest and maximum frown on Day 30 of each cycle, subject assessments, and onset and duration of treatment effect. RESULTS: In 796 subjects, 77% to 88% were responders at rest, and 79% to 90% were responders at maximum frown. Onset was rapid; subjects reported effects in the first few days after treatment. No new tolerability or safety concerns were reported. CONCLUSIONS: IncobotulinumtoxinA injections were well tolerated and resulted in efficacy in the treatment of GFL for up to 2 years.

The convergence of medicine and neurotoxins: a focus on botulinum toxin type A and its application in aesthetic medicine--a global, evidence-based botulinum toxin consensus education initiative: part I: botulinum toxin in clinical and cosmetic practice.

BACKGROUND: The U.S. Food and Drug Administration has approved four distinct formulations of botulinum toxin (BoNT) serotypes A and B (BoNTA and BoNTB) for medical use. These four products are indicated for many medical applications, but the three BoNTA formulations are the most widely used worldwide and are the only products approved for aesthetic use. The latest approval of a BoNTA with no complexing proteins (incobotulinumtoxinA) necessitates a review and discussion of differences between available formulations and the effect that these differences may have on clinical practice. OBJECTIVES: To review the history, science, safety information, and current and emerging applications of BoNT in clinical and cosmetic practice and to compare commercially available BoNTA formulations. METHODS AND MATERIALS: Publications, clinical trials, and author experience were used as a basis for an up-to-date review of BoNT and its use in human medicine. The similarities and differences between formulations are presented, and diffusion, spread, equivalency ratios, stability, and storage are discussed. RESULTS: Each commercial formulation has unique characteristics that may influence its use in aesthetic medicine. Familiarity with the similarities and differences between products will aid physicians in making patient care decisions. CONCLUSION: New formulations, emerging uses, and continued research into the science and uses of BoNTA will lead to increasingly refined therapeutic approaches and applications. Continued education is important for physicians to optimize use of the agent according to the most current evidence and approaches.

Multicenter, randomized, phase III study of a single dose of incobotulinumtoxinA, free from complexing proteins, in the treatment of glabellar frown lines.

BACKGROUND: Botulinum toxin type A is a proven, effective aesthetic treatment for glabellar frown lines. IncobotulinumtoxinA (NT 201, Xeomin/Xeomeen/Bocouture, Merz Pharmaceuticals GmbH, Frankfurt, Germany) is a 150-kDa botulinum toxin type A free of complexing proteins. OBJECTIVE: To assess the efficacy and safety of incobotulinumtoxinA in a randomized, double-blind, placebo-controlled, Phase III study in patients with moderate to severe glabellar frown lines. MATERIALS AND METHODS: Two hundred seventy-six patients were randomized 2:1 to receive a single injection of 20 U of incobotulinumtoxinA or placebo, respectively. Efficacy was assessed at day 30 using a Food and Drug Administration-mandated composite endpoint; a responder was defined as a patient with a 2-point or greater improvement in glabellar frown lines on a 4-point scale as assessed by investigator and patient. Safety was assessed periodically through Day 120. RESULTS: Treatment with a single dose of incobotulinumtoxinA was significantly superior to placebo in the treatment of glabellar frown lines at Day 30 using the composite endpoint (p < .001), with investigators and patients assessing glabellar frown lines as significantly more improved after incobotulinumtoxinA injection than with placebo (p < .001). IncobotulinumtoxinA was well tolerated. CONCLUSION: A single dose of 20 U of incobotulinumtoxinA demonstrated efficacy and safety in the treatment of glabellar frown lines using new Food and Drug Administration efficacy variables.

IncobotulinumtoxinA in esthetics.

IncobotulinumtoxinA (Xeomin®/Xeomeen®/Bocouture®/XEOMIN Cosmetic™) is a botulinum toxin type A that differs from other commercially available botulinum toxin type A preparations in that it is free from complexing proteins ([150 kDa]/NT 201). The proven efficacy of incobotulinumtoxinA in various therapeutic indications preceded its use in the field of esthetic medicine, where it is widely approved for the treatment of glabellar frown lines on the basis of positive efficacy and safety findings from a number of clinical trials. Here, we discuss the characteristics of incobotulinumtoxinA and review the clinical data supporting its use in esthetics.

Ableism to Empowerment: Navigating School Structures When Working With Students Who Stutter.

PURPOSE: School-based speech-language pathologists (SLPs) face uniquely complex webs of guidelines and criteria that can undermine their ability to move toward disability-affirming practices. The purpose of this clinical focus article is to present a contrast between ableist and disability-affirming practices in school-based stuttering therapy while highlighting the critical perspectives of students who stutter. Practical examples of disability-affirming stuttering therapy in public school settings are provided. CONCLUSIONS: This clinical focus article outlines practical guidelines and specific examples of affirming collaboration, eligibility decisions, goal choice, and accommodations for students who stutter. These discussions demonstrate how SLPs can adopt updated assessment therapy planning and institutional practices to affirm students who stutter while informing school cultures and society about the dignity and value of stuttered voices. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.21818028.

Leveraging the Short-Term Benefits of Manual Therapy which Includes Exercise Over Exercise Therapy Alone Appears Justified for Knee Osteoarthritis.

Letter to the Editor-in-Chief in response to JOSPT article "The Benefits of Adding Manual Therapy to Exercise Therapy for Improving Pain and Function in Patients with Knee or Hip Osteoarthritis: A Systematic Review with Meta-analysis" by Runge et al. J Orthop Sports Phys Ther 2023;53(1):49-50. doi:10.2519/jospt.2023.0201.

International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework.

SYNOPSIS: This position statement, stemming from the International IFOMPT (International Federation of Orthopaedic Manipulative Physical Therapists) Cervical Framework, was developed based upon the best contemporary evidence and expert opinion to assist clinicians during their clinical reasoning process when considering presentations involving the head and neck. Developed through rigorous consensus methods, the International IFOMPT Cervical Framework guides assessment of the cervical spine region for potential vascular pathologies of the neck in advance of planned interventions. Within the cervical spine, events and presentations of vascular pathologies of the neck are rare but are an important consideration as part of patient examination. Vascular pathologies may be recognizable if the appropriate questions are asked during the patient history-taking process, if interpretation of elicited data enables recognition of this potential, and if the physical examination can be adapted to explore any potential vasculogenic hypothesis. J Orthop Sports Phys Ther 2023;53(1):7-22. Epub: 14 September 2022. doi:10.2519/jospt.2022.11147.

Response to the Letter to the Editor-in-Chief.

Author response to the JOSPT Letter to the Editor-in-Chief "A Second Look at the Risks of Serious Adverse Events with Orthopaedic Manual Therapy, Paracetamol, and NSAID Treatment of Neck Pain" J Orthop Sports Phys Ther 2023;53(6):1-2. doi:10.2519/jospt.2023.0202-R.