Philadelphia College of Osteopathic Medicine
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Anatomical Variations of the Xiphoid Process: Clinical and Osteopathic Implications of Bifid Morphology
No full textIntroduction The xiphoid process is the ossified extension of the lower sternum in the chest midline of human adults. Natural variation in this structure results in the less common bifurcated morphology. Recognizing these variations is crucial for accurate imaging interpretation, resuscitation interventions involving chest compressions, and considerations in Osteopathic Manipulative Medicine (OMM).
Objective The primary objective of this study was to explore the distribution of the bifid xiphoid process over a multi-year analysis. A secondary objective was to compare bifurcated xiphoid processes to other morphological variations and assess potential clinical implications, including OMM considerations for musculoskeletal and visceral dysfunctions.
Methods A case study was conducted over three years (2021-2024) to analyze the distribution of bifid xiphoid variants in a sample of cadavers (n=32) at a large medical education institution. The dependent variable was binarized (bifid or normal), and univariate analyses were performed on height and width measurements. Statistical comparisons were made across the three years to assess trends in morphological variation.
Results Among the 33 cadavers examined, 15 (45.5%) exhibited a bifid xiphoid process, while 12 (36.4%) had a normal xiphoid process, and 6 (18.2%) were marked as unavailable due to missing data. Quantitative analysis revealed that the mean height of bifurcated xiphoid processes was 39.7 mm (SD = 11.7), compared to 34.2 mm (SD = 11.2) for normal xiphoid processes. Similarly, the mean width of bifurcated xiphoid processes was 29.7 mm (SD = 6.2), whereas normal variants had a mean width of 20.5 mm (SD = 8.4). These findings suggest that bifid xiphoid processes tend to be both longer and wider than their non-bifid counterparts. The implications of this bony landmark for mediastinal pressure, OMM techniques such as myofascial release and thoracic diaphragm mobilization, and surgical considerations are discussed.
Conclusion This expanded study provides a broader dataset on xiphoid process morphology, reinforcing the significance of anatomical variation in clinical practice. The findings aid in improving imaging interpretation, guiding surgical planning, and enhancing anatomical education. Furthermore, understanding xiphoid variability is essential for osteopathic physicians, as structural differences may influence thoracic mobility, diaphragmatic function, and somatic dysfunctions requiring OMM interventions. Future research should explore the physiological effects of xiphoid bifurcation and its potential clinical impact
Case study of bone-anchored hearing aid
Full text linkIntroduction: A 74-year-old female cadaver from a medical school gross anatomy lab was found to have a Bone-Anchored Hearing Aid (BAHA). A BAHA is utilized in patients who suffer from conductive hearing loss in order to bypass dysfunctions of the outer and middle ear and directly transmit the sound waves to the cochlea. The most common etiologies of conductive hearing loss include cerumen impaction, middle ear effusion, congenital malformation, and ossicular chain fixation.
Methods: An assisted hearing device was observed during a routine medical gross anatomy course dissection. Permissions were obtained from the body donation program and the donor\u27s family to allow documentation and publication of the case for medical education. The device was then removed, photographed, and measured. The external, middle, and internal ear, temporal bone, ear canal, and tympanic membrane were observed for any wires or anatomical anomalies.
Results: The bone-anchored hearing aid consisted of two magnets anchored just superior to the mastoid process, posterior to the left external acoustic meatus on the skull. The magnets were anchored with 5 bone screws beneath the dermis, allowing a transducer device to magnetically adhere to the skull. No wires were detected entering the middle ear or cochlea.
Examination of the left tympanic membrane revealed a significant rupture, characterized by a tricuspid valve-like appearance.
No pathology or medical assistive devices were observed in the right skull or ear.
Discussion: The medical device embedded into the left skull was devoid of wires entering the cochlea. This indicates that the device was anchored to the bone and served as a bone-anchored hearing aid. Perforation of the tympanic membrane was the likely reason the patient required a hearing device. The most common etiology of a ruptured tympanic membrane is middle ear effusion, which typically occurs in childhood. This case study provides valuable insight into the various treatments available for hearing loss. Hearing aids promote a patient’s ability to engage with the world, prevent social isolation, and avoid cognitive deterioration. Therefore, spreading awareness about how different hearing devices function is important for both patient and clinician understanding and management
A systemic review of efficacy, ratings and top football gear for concussion prevention in 2024
Full text linkIntroduction: Concussions in football pose significant health risks, requiring the implementation of effective protective gear to reduce the incidence of head injuries. Helmets and mouthguards are standard equipment, but their true effectiveness remains debated.
Objective: This study aimed to systematically evaluate the efficacy of modern football protective gear, specifically helmets and mouthguards, in the prevention of concussions.
Methods: Following PRISMA guidelines, a comprehensive search was conducted in PubMed, Cochrane Library, Google Scholar, and Embase. A total of 3,894 studies were reviewed, and 35 studies met the inclusion criteria. Independent reviewers analyzed the studies to determine the impact of helmets and mouthguards on concussion rates, reconciling discrepancies through a third-party decision. No funding or third-party data collection was required.
Results: The analysis revealed that helmets incorporating MIPS and TPU cushioning were effective in reducing concussion rates by 40%. However, the efficacy of headgear and mouthguards was inconsistent across studies. Headgear was found to slightly increase the risk of concussion, while mouthguards provided minimal protection, reducing concussion incidence by 19% in some studies but lacking statistical significance in others.
Conclusion: Helmets are the most effective piece of protective gear in reducing the risk of concussions in football. While mouthguards may offer some protective benefit, their impact on concussion prevention remains limited. Further research is necessary to explore alternative measures, such as policy changes, to improve concussion prevention strategies in football
Perforated Duodenal Ulcer in a Patient with Multiple Endocrine Neoplasia Type 1: A Case Report
Full text linkIntroduction: Multiple Endocrine Neoplasia Type 1 (MEN1) is a hereditary syndrome characterized by tumors of the parathyroid, pancreas, and pituitary gland. Among its gastrointestinal manifestations, gastrinomas are particularly concerning due to their association with Zollinger-Ellison syndrome (ZES), which leads to excessive gastric acid secretion and peptic ulcer disease (PUD). These symptom overlaps can lead to misdiagnosis of MEN1 as peptic ulcer disease and gastroenteritis. Additionally, while ulcers are a well-recognized consequence of gastrinomas and MEN1, perforation remains a rare but life-threatening complication.
Case Presentation: A 36-year-old female initially presented with diffuse abdominal pain, nausea, vomiting, and diarrhea. She had a history of peptic ulcer disease and H. Pylori overgrowth and was initially treated for both, but her worsening symptoms led to further evaluation. CT imaging of her abdomen later revealed free intraperitoneal air, and an exploratory laparotomy confirmed a 3-mm perforated duodenal ulcer distal to the Ligament of Treitz. The ulcer was surgically resected with primary stapled intestinal anastomosis, and the patient was managed postoperatively with intravenous proton pump inhibitors and broad-spectrum antibiotics. Upon further questioning, the patient disclosed a family history of MEN1—her mother had undergone a Whipple procedure for a pancreatic tumor. Genetic testing confirmed MEN1 in the patient. Although the patient had no prior clinical manifestations of MEN1, her history of PUD and H. Pylori overgrowth prompted serum gastrin testing, which revealed significantly elevated levels of 327 pg/mL (reference range: \u3c 100 pg/mL), confirming gastrinoma-associated hypergastrinemia. The delayed diagnosis, initially attributed to benign peptic ulcer disease and gastroenteritis, underscores the need for early recognition of MEN1-associated gastrointestinal pathology.
Discussion: This case highlights the importance of a proactive diagnostic approach in MEN1 patients with gastrointestinal symptoms. Key management considerations can include early serum gastrin testing, a lower threshold for abdominal imaging in high-risk patients, routine endoscopic surveillance for ulcer detection, and acid suppression therapy with dietary modifications. Multidisciplinary coordination among endocrinologists, gastroenterologists, and surgeons is essential for timely intervention and improved patient outcomes. By implementing these measures, clinicians can significantly reduce the morbidity and mortality associated with peptic ulcer complications in MEN1 patients
Topical antibiotics, over-the-counter products, and standard gauze dressings: a review of postoperative surgical site infection and wound healing management
Full text linkProper wound healing and prevention of surgical site infections (SSI) are critical in postoperative patient care. According to the CDC, SSIs account for almost twenty percent of all healthcare-associated infections and cause an annual cost of an estimated $3.3 billion annually. Wound healing time, as well as cosmetic results, also play an important role in postoperative wound care. Currently there is not a consensus standard of care for topical treatments to address these issues. This study aims to explore various topical treatments that prevent SSI and encourage effective healing.
A search was conducted on PubMed using the algorithm: ([Vaseline] OR [Aquaphor] OR [Mupirocin] OR [Bacitracin]) AND ([Postoperative wound care] OR [Surgical wound] OR [Incision]). Inclusion criteria included full text primary articles published from 2010 to 2025. Exclusion criteria included duplicates, reviews, animal studies, and studies not pertaining to postoperative wound care. Five-hundred and seventy three full-text articles were retrieved. Following screening and exclusion, 15 articles underwent review.
A comprehensive review of the included studies resulted in 5 papers investigating postoperative infection rates, 9 papers analyzing postoperative wound healing, and 1 that encompassed both. Those studies examining SSIs presented mixed data regarding effectiveness of topical antibiotics compared to over the counter treatments. One study concluded that VE-silicone and mupirocin dressings are effective in preventing SSIs and another concluded that generally topical antibiotics lower the risk of SSIs compared to nonantibiotic ointment. However, the other four studies were not able to provide enough evidence to conclude whether antibiotic or nonantibiotic ointment was more effective in preventing SSIs. Among the 10 studies that evaluated postoperative wound healing, authors evaluated different combinations of healing, healing time, number of dressing changes, and cosmetic results. These papers studied various topical dressings and all but one concluded that applying a topical ointment postoperatively promotes wound healing
Statin-Associated Immune Mediated Necrotizing Myopathy: A Case Report
Full text linkBackground: Statins are a widely used class of drugs that have been found to be safe and effective in treating hypercholesterolemia. Used for both primary and secondary prevention, statins inhibit HMG-CoA reductase, inhibiting a vital step in cholesterol production. Statin-associated muscle symptoms (SAMS) are a clinical spectrum defined as muscle pain, discomfort, and/or weakness with or without elevated CK levels. This spectrum ranges from minimal myalgias to severe statin-associated immune-mediated necrotizing myopathy (IMNM). It is known that myocytes have upregulated levels of HMG-CoA reductase in the presence of statin use. While the exact pathophysiology of statin associated IMNM has yet to be elucidated, it is proposed that the antibodies targeted against HMG-CoA reductase damage the myocytes in which HMG-CoA reductase is upregulated. For those with severe deficits, rehabilitation can be helpful to restore and preserve function as severe proximal muscle weakness can result in reduced mobility, difficulty with activities of daily living thus preventing a safe return home.
Case description: This patient is a 58-year-old male with a past medical history including hypertension, hyperlipidemia, hypothyroidism, pre-diabetes, IBS, and OSA presented to Tower Health Rehabilitation Hospital with the diagnosis of SINAM. Prior to his symptoms, he was independent, living alone, working as a mail carrier. In August 2024, he had elevated liver function tests with minor stiffness. Three months later, his liver function tests worsened, and he was having increased stiffness and lower extremity weakness. His weakness progressed and in January 2025, began affecting his bilateral proximal upper extremities. At this time, he was admitted to Reading Hospital with suspected statin induced myopathy and concern for rhabdomyolysis given his markedly elevated CK levels. His statin was discontinued and was recommended to follow up as an outpatient with Neurology for EMG testing. Myositis antibodies were sent, and his HMG-CoA reductase antibodies resulted positive. One month later, he was evaluated by out-patient neurology and his symptoms were markedly worse- he had multiple falls at home and was unable to stand up without a two person assist. Given his difficulty ambulating, he was admitted as an inpatient for prompt immunologic treatment. His symptoms minimally improved following completion of IVIG and IV Solumedrol. He was started on daily Prednisone and was admitted for inpatient rehabilitation given his significant change from baseline functional status.
Discussion: Diagnosis can be difficult, especially considering the gradual onset of vague symptoms potentially presenting years after statin initiation. It is known that early intervention with medical therapies including IVIG and IV steroids are vital to preserving and improving muscle function, so swift diagnosis is key for maximal patient recovery. Statin-associated IMNM is a rare complication of statin use but should be considered in all statin users presenting with proximal weakness affecting functioning regardless of statin onset time. Treating this diagnosis requires a multi-disciplinary approach to facilitate restoring function and quality of life
Utilizing maxillofacial injury severity score (MFISS) in postmortem head gunshot imaging for surgical planning and preventative treatment assessment
Full text linkGunshot injuries to the head represent a major clinical and forensic challenge due to their complexity and multifaceted nature of the trauma. Various pre-operative methods exist to assess extent of craniofacial damage and patient outcomes. One such method is the Maxillofacial Injury Severity Score (MFISS). The MFISS is a trauma scoring system used by craniofacial reconstructive surgeons to categorize the degree of facial trauma based on hard and soft tissue damage. The system is broken down into three hard tissue and one soft tissue classification. All classifications are scored on a 0 to 3 scale ranging from no damage to intense trauma respectively.
While techniques such as the MFISS offer a framework for assessing craniofacial trauma, its current application may not fully address the clinical and forensic complexities associated with these injuries. Utilizing postmortem cases may help address this gap because they can provide a source of variable degrees of craniofacial trauma cases that can be observed, measured, and analyzed.
This study hypothesizes that applying the MFISS to postmortem head gunshot imaging will provide valuable data for preventative treatment strategies and enhance the accuracy of injury assessment utilizing computed tomography (CT). The research uses a sample of 36 postmortem Computed Tomography (CT) scans from the New Mexico Decedent Image Database (NMDID). Three-dimensional hard and soft tissue reconstructions were created for each case utilizing the medical imaging software Horos (Horosproject.org). The two-dimensional CT images were used to track projectile pathway through the skull and the and the three-dimensional reconstructions were examined to establish a total MFISS score.
A regression analysis was performed on the data utilizing the Statistical Package for the Social Sciences version 30 (IBM SPSS Statistics) to assess reliability of the Maxillofacial Injury Severity Score in determining likelihood of survivability of head gunshot trauma victims. The results of the regression analysis indicate a statistical significance in identifying likelihood of survivability when considering the total classification score. Total MFISS score, not individual classification zone, provides the most reliable assessment of gunshot trauma survivability
Thoracolumbar Vertebral Morphology in Hox9 Mice
No full textBackground and Rationale
Shifts in vertebral count and identity have occurred multiple times across mammalian evolution, including in primates. Understanding the development of the spine and the vertebrae that contribute to it is crucial for looking at changes in locomotor patterns in primates, such as bipedality in humans. During development, two halves of separate somites (the building blocks of vertebrae) contribute to one vertebra and each part is under different developmental regulation. In anthropology, individual characteristics like centrum height, articular facet shape, or spinous process shape are used to determine vertebral identity of fossil specimens, typically without consideration of the underlying development. Therefore, it is important to determine features that may be developmentally linked or independent.
Hypothesis
Since different somites contribute to the centrum and spinous process and articular facets, we hypothesize that when there is a shift in transitional vertebra, placement height and width of the centrum will be unmodified while the spinous process will modify. Genetic modification of Hox9 in mice results in the correlated modification of spinous process shape and placement of the transitional vertebra independent of alternation in lumbar number, mimicking changes observed in hominoids.
Methods
3DSlicer was used to assess morphological differences in the vertebrae across the thoracolumbar transition of mice with Hox9 gene modifications compared to wild type C57Blk6 mice. Centrum thickness, centrum height, and cranial and caudal angle measurements were taken from microCT scans by two independent observers. Changes in the appearance of the spinous process were noted separately, with a particular focus on vertebrae T10 and T11. Data were analyzed using the articular facet definition based on where the facet changes from coronal to sagittal orientation.
Results
In mice with a Hoxc9 allele knocked out, we observed a corresponding shift in spinous process angle, articular facet shape, and anterior/posterior centrum width. Cranial/caudal centrum height was independent of articular facet shape. These results partially support our hypothesis and indicate that the centrum may have contribution from two somites.
Significance
These results indicate that centrum height may not be a complete indicator of vertebral identity and location of the transitional vertebra
The Different Effects Between Trimethylamine and Trimethylamine N-oxide on H9c2 Myoblast Cells
Full text linkBackground: Trimethylamine (TMA) is a gut-derived metabolite of choline and L-carnitine that is converted to trimethylamine N-oxide (TMAO) in the liver. Elevated plasma TMAO levels are strongly associated with an increased risk of cardiovascular disease. Previous studies suggest that TMA and TMAO promote inflammation, oxidative stress, and dysregulation of cholesterol metabolism, contributing to pro-atherosclerotic changes in blood vessels. We hypothesize that high levels of TMA and TMAO induce cardiac cell damage through oxidative stress and mitochondrial dysfunction.
Goals/Methods: This study utilizes H9c2 myoblast cells to investigate the effects of TMA and TMAO on cardiac cell function. Cells were treated with different concentrations of TMA or TMAO (0.001uM-500mM) to assess dose-dependent effects on cell viability using the colorimetric Cell Counting Kit-8. Additionally, mitochondrial membrane potential (MMP) and intracellular reactive oxygen species (ROS) levels were measured using MT-1 and DCFDA fluorescence assays, respectively. All data were presented as means ± SE. The data was analyzed by student t-test. p\u3c 0.05 are considered to be statistically significant.
Results: Higher concentrations (10-500 mM) of TMA or TMAO dose-dependently reduced cell viability. TMA (80 mM) significantly attenuated H9c2 cell viability to 25.3 ± 2.1% (n=8) compared to the control. In contrast, TMAO exerted similar effects (26.9 ± 7.3%, n=5) at a higher concentration (250 mM). The ROS levels remained unchanged in TMA-treated cells at 80 mM (104 ± 20.7%, n=3), whereas TMAO (250 mM) showed a 44.53 ± 0.78 fold increase in ROS production. Additionally, TMA (80 mM) slightly reduced MMP to 94.0 ± 5.1% (n=2), while TMAO (250 mM) significantly reduced MMP to 74.8 ± 2.8% (n=2).
Conclusion: The data suggest that higher doses of TMA and TMAO reduced H9c2 cell viability. In contrast to TMAO, TMA showed higher potency. TMAO-induced cell damage is mediated by increased ROS production and MMP reduction. However, TMA\u27s mechanism of cell damage remains unclear, as ROS levels and MMP were not significantly altered. Further studies are needed to elucidate the precise mechanisms underlying TMA-mediated cytotoxicity
Understanding the Association Between Mental Health and Medication Adherence in Adolescents with Chronic Kidney Disease
Full text linkBackground
Adolescents with CKD often face significant mental health challenges that may affect their medication adherence. Despite the high prevalence of mental health concerns (specifically internalizing symptoms) in this population, the association between the severity of these symptoms and medication adherence remains underexplored.
Methods
The current cross-sectional study included adolescents with CKD who were prescribed an antihypertensive medication and completed the Behavior Assessment System for Children, 2nd edition Self-report (BASC-SRP-2). Antihypertensive medication adherence was objectively evaluated over 2 weeks using the MEMS cap. We used the BASC-SRP-2 depression, anxiety, somatization, and internalizing scales and classified participants into sub-clinical (T-score \u3c 60) and at-risk (T-score ≥ 60) groups. We examined the associations between the selected BASC-SRP-2 domains and medication adherence using Wilcoxon rank-sum tests. Adjusted associations were evaluated with logistic regression models dichotomizing adherence as \u3c 75% or ≥75% (covariates were age, race, sex, and income).
Results
The analyzed sample included 103 adolescents with CKD (M age = 15.4 years, SD = 2.44, 52% male, 44% White, 43% Black/African American, 14% Other; and (\u3c 50,000–100,000+: 35%) Table 1 provides information on the proportion of the sample at risk for elevated symptoms of the selected BASC-SRP domains. Medication adherence was significantly lower among adolescents with at-risk depression and internalizing problems compared to the sub-clinical group. Neither anxiety nor somatization were significantly associated with lower adherence. After adjusting for covariates, neither depression nor internalizing symptoms were significantly associated with adherence.
Conclusion
Adolescents with CKD may be at risk for high levels of mental health problems. When adolescents have At-risk levels of depression and internalizing problems, they may have significantly lower medication adherence compared to adolescents with subclinical symptoms. However, these associations were no longer significant after controlling for key demographic variables, which may be attributed to the smaller sample size. These results show the critical importance of addressing mental health problems in adolescents with CKD, which could improve adherence outcomes