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You must listen to patients and respect their individuality, concerns and preferences. You must be polite and considerate with patients and treat them with dignity and courtesy

Observers… in or out?

What?

A patient came into the clinic for a treatment, and as of most inital consultations, other members of the clinic team like to come and observe the new case. On the way up to the room i asked my patient if this was okay and she said yes. However, it became increasing noticeable towards the end of the case history that she was holding something back from me and i couldnt understand why a i felt i was asking all of the right questions. I decided that it was okay as it takes time to build a rapour with patients and she might not feel 100% comfortable yet.

I followed the usual routine of coming out to speak to my tutor and going back in alone to take the blood pressure before my colleagues were due to join my again. Whilst taking the blood pressure ei again felt uneasy about how agitated she seemed so decided to try and delve a little deeper into what was going on.

She expressed to me that she was really worried about lots of people looking at her in the room as she was feeling anxious especially if she had to take her clothes off as she feels very self conscious about the way she looks and shes she is very overweight and ugly.

So i explained to her that this is a teaching clinic and my colleagues were purely in the room to learn. But we came to the agreement that there would be no further observation that session as i wanted her to feel as comfortable as possible.

So what?

On reflection i could have picked up on this earlier, however i know it would have been difficult for her to say something in front of the others. I felt bad for putting her in the situation where she felt uncomfortable however at the same time i did want her to understand the situation she was putting herself in and that she had signed the document (which explains observers) to say that she was happy for the consultation to go ahead. On the other hand, essentially, if she is not happy, there is no consent to move forward and therefore i would never push a patient back into a situation where they feel self conscious.

Now what?

I understood her point of view and I’m glad we could come to an agreement that suited us all. It meant that i could practice my presentation skills to my peers outside of the treatment room so the experience was still productive for everyone.

Moving forward, i will definitely be paying extra attention to these social cues from patients so if they are uncomfortable we can adapt the situation as soon as possible. This case also made me really reflect on how the biopsychosocial model incorporates itself within every consultation.

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You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them.

2+ points of pain and body insecurity.

What?

In my 3rd year as a practitioner at the ESO teaching clinic i took over a patient who had who had pain in her shoulder, lower back and knee. As it was a takeover i did virtually a repeat case history to make sure i had good understanding of her presenting complaints as well as her medical history and systemic health. She described all three pains as different as were due to their own separate onsets and each took it in turns to be more restrictive to her lifestyle. From there we continued with the examination and moved on to treatment. I felt quite a lot of pressure to make sure I was addressing all the areas that were causing her discomfort. I didn’t have much time to do this and felt rushed through to try and do techniques everywhere. I felt flustered but continued as I was trying I do what i thought was best for her.

However, when the patient came back, she expressed that she had priorities in terms of what she needed treatment on that week as she felt like trying to do everything at the same time was too much for her and she had some anxieties in being completely undressed in front of others, especially if there are observers in the room as she was slightly overweight.

Furthermore, I adapted my management plan for the patient so that it addressed what she communicated to me. I had to listen to her concerns about the environment for her treatment we agreed that the instances of observations would be minimised where ever possible, however it is a teaching clinic so this is the nature of the appointments here.

So what?

At first i felt embarrassed that my communication skills were not clearer when we originally met and that I hadn’t given her the opportunity to tell me her priorities for her pain but also her concerns regarding dignity. Seeing her in an emotionally vulnerable situation talking about her insecurities made me realise that i am not only doing this to help peoples pain but to create a safe environment for them to open up and express their feelings.

Now What?

This opened my eyes to the idea that i didn’t ask the right questions in the initial consultation. I reflected with the tutor on how i could have avoided this mis communication in the first instance. Therefore, moving forwards i will always be asking my patients clearing what they hope to gain from the treatment as well as what their priorities are if there is more than one point of pain and not moving on until we have worked together to create a clear management plan that we have been agreed on.

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Abstract

Objective

Analogous to medical professionals, allied healthcare manual therapies such as osteopathy, chiropractic and physical therapy/physiotherapy rely on patient centred communication skills to optimise positive outcomes of clinical encounters. The objective of this review is to identify how communication skills are taught and learned within these specific professions.

Methods

CINAHL, AMED, PubMED, ERIC and PsychINFO were searched in April 2018 (search years: inception-2018). Papers were independently selected by two researchers. A narrative synthesis of results was formulated.

Results

Six papers on how patient centred communication skills are being developed in the undergraduate manual therapy healthcare professions were identified. All excluding one paper reported interventions used in undergraduate physical therapy/physiotherapy. The additional paper provided a summary of teaching methods used in undergraduate physical therapy/physiotherapy university programmes across the United Kingdom. Training programmes employed a combination of instruction, modelling and problem-based learning. Only one paper measured the effectiveness of their training to identify if the changes in the students' patient centred communication skills were observable.

Conclusion

There is little evidence to indicate communication skills training is being provided to chiropractic and osteopathy students. However, communication skills training is being provided to physical therapists/physiotherapists and is varied in the types of teaching techniques used, the duration of teaching and the timing of teaching around clinical placements.

View full text

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Learning and teaching of patient-centred communication skills in allied healthcare manual therapy students: A systematic review

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Analogous to medical professionals, allied healthcare manual therapies such as osteopathy, chiropractic and physical therapy/physiotherapy rely on patient centred communication skills to optimise positive outcomes of clinical encounters. The objective of this review is to identify how communication skills are taught and learned within these specific professions.

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You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them.

In the second term of my fourth year i receive some really nice feedback from a patient that was sent straight to the reception team and head of clinic. This filled me with confidence that i was not only communicating well with my patients and doing what was best for them, but my techniques were effective.

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You must give patients the information they want or need to know in a way they can understand.

Autism

What?

In the 1st term of 4th year as a practitioner at the ESO teaching clinic i have an initial consultation with a male in his mid 30’s. The first thing he said when i asked him how i could help was that he was autistic. This wasn’t his presenting complaint however it highlighted how prominent his diagnosis was in his life.

I took this on board but didn’t draw too much attention to it as i didn’t feel that it was connected to his posture induced myalgia. When we moved to examination and treatment i realised that when i was palpating i had to be very clear and literal about the things i was saying. For example i would normally say “does this hurt?” The first time and then subsequently say “what about this?” Moving forward (purely out of habit). However he couldn’t make the relationship between all the different statements and was answering what do you mean quite a lot.

I also found myself needing to explain the techniques i was using in further detail, for example a sternal recoil. Previously, when i have used this with patients i explained it as increasing pressure on the chest and then a quick release whilst working with their breathing. This is what i did with him, but he still seemed very taken aback (more so than i would expect) when the technique was performed.

So what?

I reflected that from prior knowledge i also knew that those with autism don’t react well when something happens that they weren’t expecting. Therefore, this wasn’t the correct technique to utilise for my patient.

I had to be very pedantic about explaining every detail of what i would like to do to gain proper consent from the patient and also explain where my hands where when he couldn’t see them and where i was going to place them so he didn’t jump.

Now what?

I know now that I wont be using these kind of techniques with him any more as if i did i wouldn’t be properly adapting to the needs of my patient and treating them on a individual case basis.

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Offers clear and readable explanations of the complex ethical issues raised by alternative medicine

Relies on case studies, scientific evidence and other objective sources to provide valuable guidance

Provides an important source for patients faced with a choice of therapies

Advised reading for decision-makers entrusted with health funding

Table of contents (7 chapters)

About this book

This book reveals the numerous ways in which moral, ethical and legal principles are being violated by those who provide, recommend or sell 'complementary and alternative medicine' (CAM). The book analyses both academic literature and internet sources that promote CAM. Additionally the book presents a number of brief scenarios, both hypothetical and real-life, about individuals who use CAM or who fall prey to ethically dubious CAM practitioners. The events and conundrums described in these scenarios could happen to almost anyone. Professor emeritus of complementary medicine Edzard Ernst together with bioethicist Kevin Smith provide a thorough and authoritative ethical analysis of a range of CAM modalities, including acupuncture, chiropractic, herbalism, and homeopathy. This book could and should interest all medical professionals who have contact to complementary medicine and will be an invaluable reference for patients deliberating which course of treatment to adopt.

Authors and Affiliations

University of Exeter, Exeter, United Kingdom

Edzard Ernst

School of Science, Engineering and Technology, Abertay University, Dundee, United Kingdom

Kevin Smith

About the authors

Edzard Ernst has researched all aspects of alternative medicine for more than 20 years. He and his team have published well over 1 000 peer-reviewed papers and many books on the subject. His work has been awarded more than a dozen prizes, including the John Maddox Prize 2016. He retired about three years ago and is emeritus professor of the University of Exeter. He continues to play an active role in the public debate on alternative medicine.

Kevin Smith is a senior lecturer at Abertay University, Scotland. He researches and teaches in the related areas of bioethics and genetics. He has published a number of highly regarded academic papers in medical ethics, on subjects ranging from the ethics of gene therapy to the ethics of homeopathy.

Bibliographic Information

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Offers clear and readable explanations of the complex ethical issues raised by alternative medicine Relies on case studies, scientific evidence and other objective sources to provide valuable guidance Provides an important source for patients faced with a choice of therapies Advised reading for decision-makers entrusted with health funding Table of contents (7 chapters) This book reveals the numerous ways in which moral, ethical and legal principles are being violated by those who provide, recommend or sell 'complementary and alternative medicine' (CAM).

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You must receive valid consent for all aspects of examination and treatment and record this as appropriate.

You’re going to crack my rib!?

What?

At the end of 3rd year during one of our clinic sessions i had a patient come in who i had seen a few times before. Her working diagnosis was rib head dysfunction. I had previously used a supine HVT technique on her rib head to resolve the problem, the patient felt instant relief at the time but on return said although it had gotten a lot better there was still a little bit of residual pain in the area. After examination i decided that i felt another HVT was necessary for a restricted area through her thoracic spine. I explained that we were going to use the same technique as we did last week but on the vertebrae as opposed to the rib head itself to loosen off an area that wasn’t moving optimally. At that moment my tutor came in to observe the technique.

I asked the patient if they were okay to continue they said yes and so i started to cross their arms over their chest when my tutor asked me to stop and take a step back. He said to the patient, so what technique are you having done now and why? The patient struggled to answer his questions and thus the tutor said that i haven’t explained it properly.

So what?

At first i felt quite upset as i was happy with my initial explanation and felt as though she should have been able to answer the tutors question easily. I felt that it made me look stupid and as though i was trying to cut corners in the tutors mind - which wasn’t the case at all. But with time i have realised that actually that some patients could feel pressure to have techniques done due to being in the professional environment and quick explanations that they don’t want to admit they don’t understand.

Now what?

Therefore, i went over the consent process again and explained in more detail the aims of the technique as well as the side effects. Going forward i need to remember that patients don’t have the same training as us and have other things going on in their lives so they don’t always remember techniques that we did on them 1+ weeks ago.

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More than words : an investigation into the patient experience of informed consent in osteopathy

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RESEARCH QUESTION: What are the experiences of informed consent in a New Zealand clinical osteopathic consultation for six patients? ABSTRACT: Medical informed consent is described as permission to perform mutually agreed upon examination and treatment after understanding the risks and benefits of multiple options.

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You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath.

Are you actually doing anything?

What?

I treated a patient at the ESO clinic at the end of my third year. I hadn’t used many cranial techniques up until this point as it was never something i had felt confident with - plus it’s difficult for some tutors to give you the freedom to explore those kinds of techniques.

Nevertheless, the patient presented with non-specific lower back pain with a history of kidney stones 15 years ago. She also presented with headaches and expressed that she felt very stressed as she’d recently been going through a very stressful divorce. I decided to use cranial techniques, aiming to effect the HPA axis.

The pituitary gland is located on the sphenoid so part of my examination was to assess the spheno-basilar synchondrosis (SBS), to understand whether there was a connection. I determined that the patient had a torsion of the SBS and so wanted to treat accordingly.

I explained to the patient that i wanted to do a very subtle technique that works with some of the bones in the cranium and will affect a system that they wont be able to control or feel. They were open to the idea and i started my technique.

About 5 minutes in, the patient opened her eyes and and questioned me… “are you actually doing anything?”…

I was taken aback by this question as i felt so concentrated in what I was doing but i did my best to explain that like the vascular system, the reciprocal tension membrane wasn’t something that a person can consciously feel for themselves. I explained that even though my hands weren’t moving- i was working on an innate system and the bones in the skull. The patient looked bewildered but didn’t question me any further.

So what?

On reflection, i didn’t feel like i explained this process very well as i felt like i was taken off guard and didn’t prepare enough for justifications of my technique. I need to remember that because i’m surrounded by osteopathy and its principles in my everyday life, all of my friends understand this terminology like everyday language - but thats not the case for the general public. However, i do think my treatment was very osteopathic and a holistic way of managing their case - so that is a positive aspect to take forward.

Now what?

I need to move forward by gaining confidence around performing cranial techniques on patients and possibly even practicing on my peers who are unaware of the mechanism of cranial to improve justification and ensure the people’s i am explaining to will give honest feedback on their levels of understanding from what i’m saying.

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You must recognise and work within the limits of your training and competence.

Abdominal Pain

What?

A 27 year old female patient attending the ESO teaching clinic presenting with right hip and lower abdominal pain with a sudden onset yesterday. After taking a case history and osteopathic examination i had a working hypothesis for her hip pain, however i was unable to be clear on her abdominal pain with such a sudden onset. With the assistance of my tutor we conducted a urine test to try and rule out infection and a visceral abdominal screening assessment. However, i could so identify the cause of the pain and felt she needed a second opinion to understand what was truly going on. After expressing these feeling toot my tutor be both decided that i would discuss with the patient an alternative approach to osteopathy (in the form of imaging) to rule out any red flags and have a better understanding of what is causing her pain.

So what?

I believe i made the right decision to refer this patient and acknowledge my limitations otherwise i might not have been acting in the best interests of the patient. Although i feel confident in the visceral screening skills i learnt at Boxley, i have only utilised them a few times and never when there was a possible pathological cause. I decided before i go any further and possibly cause her harm she needed to be referred to a specialist.

Now what?

This experience really made me appreciate how important it is that I keep my knowledge and skills up to date but also how important it is to be able to draw a line and admit that the judgement of another health care professional is more of value to the patient. The safest outcome for everyone is to act with honestly and give other options to provide the best patient care.

Recognising and respecting the limits of my training and competence is crucial in osteopathic practice. It involves having a clear understanding of my knowledge and skills while acknowledging their limitations. It also requires honesty with patients about what I can and cannot provide in terms of care, and referring them to specialists when needed. Continuous professional development and humility are important for expanding my expertise, learning from mistakes, and staying updated with advancements. By prioritising patient safety and well-being, I ensure ethical practice and maintain trust with my patients.

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Abstract

Urinary tract infection (UTI) is the most common bacterial infection independent of age. It is also one of the most common causes of hospitalizations for infections among elderly people and the most common indication for antibiotic prescriptions in primary care. Both diagnostics and management of lower and infections provide challenges in clinical practice due to their high prevalence and recurrence, and worldwide increase of . The clinical symptoms of UTI are often uncharacteristic or asymptomatic. The accurate diagnosis and early treatment are crucial due to risk of and long-term consequences. Currently the diagnosis of urinary tract infection is based on the presence of clinical symptoms in combination with the results of nitrite strip test indicating the presence of bacteria in urine and semi-quantitative measurement of is the gold standard in UTI diagnostics it is both time-consuming and costly. Searching for novel biomarkers of UTI has attracted much attention in recent years. The article reviews several promising serum and urine biomarkers of UTI such as leukocyte , interleukins, , heparin-binding protein, , , soluble triggering receptor expressed on myeloid cells-1, α-1 microglobulin (α1Mg) and upper urinary tract antibiotic resistance septicaemia xanthine oxidase myeloperoxidase tetrazolium nitroblue test (TNB). white blood cells count in urine. Although urine culture esterase, C-reactive protein, procalcitonin elastase alpha (1)-proteinase inhibitor, lactofferin, secretory immunoglobulin A

Introduction

Urinary tract infection (UTI) is the most common infection of bacterial etiology across all age groups. It is also one of the most common causes of hospitalisation for infection among elderly people [1] and the most common cause of antibiotics prescriptions in a primary care. UTI also constitutes over 30% of all infectious complications in patients after kidney transplantation [2]. Diagnostics and effective treatment of both lower and upper urinary tract infections still provide significant challenges for clinical practice due to their frequent appearance, recurrence and a worldwide increase of antibiotic resistance. (See Table 1.)

UTIs may give uncharacteristic symptoms or they could be asymptomatic or dominated by the symptoms of kidney abscess and urosepsis with associated kidney failure that may even lead to death. Pyelonephritis and kidney scaring develop in approximately 50% children with feverish urinary tract infection. The worst clinical course is frequently observed in immunocompromised patients. However, if an adequate therapy is early initiated, overall prognosis is good. An accurate diagnosis and early treatment are crucial also due to a risk of long-term consequences, including chronic kidney disease [3], [4].

The location of the infection, i.e. an involvement of the lower or upper urinary tract need to be quickly established but that is not always possible based on clinical symptoms [5], [6], [7]. Typically, lower UTI (L-UTI) manifests with dysuria, frequent and difficult or painful urination. In most cases clinical symptoms of upper UTI (U-UTI) are dominated by fever, shivering and side pain [8].

The choice of therapy is dependent on the location of the infection, its severity and a type of pathogen. The duration of therapy recommended for uncomplicated UTI is shorter compared to complicated UTI that involves the kidneys [9]. U-UTI requires therapy with an antibiotic well-penetrating into the kidney parenchyma.

Currently the diagnosis of urinary tract infection is primarily based on the presence of symptoms in combination with the results of fast diagnostic nitrite strip test indicating the presence of bacteria in urine and semi-quantitative measurement of white blood cells count in urine. However, the primary diagnosis is connected with relatively high rate of errors in comparison with the gold standard that is the urine culture [10], [11], [12], [13], [14], [15]. That often leads to unnecessary administration of antibiotics and risk of their adverse events and the development of antibiotic resistance [16], [17].

Urine test and urine culture are standard methods in the diagnostics of UTI. Although urine culture remains the gold standard of UTI diagnostics it is time-consuming and costly [18]. Taking into consideration frequently appearing asymptomatic bacteriuria and a lack of firm evidence of the need for its antibiotic treatment in immunologically competent subjects the differentiation between urinary tract infection and asymptomatic bacteriuria is also very important.

Section snippets

Methods

We searched MEDLINE via OvidSP and the Cochrane Library during 1990 to 2016. We combined the following search terms used by Cochrane to identify original articles related to urinary tract infection: "biomarkers", "urinary tract infection", "pyelonephritis". We then combined the results with methodological filters to find studies best suited to answer our manuscript topic. The filters limited results to, in turn, randomised trials (questions of intervention), cohort and cross sectional studies.

Results

The search for the clinically useful biomarkers of UTI has attracted much attention in recent years. A biomarker is defined as a parameter that can be objectively measured and assessed in normal and pathological processes as well as pharmacological responses to a therapy [19]. In this review the candidate biomarkers of UTI that has been studied in humans have been reviewed. Six hundred twenty four citations were identified with the initial search from which 54 original articles were selected

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed. This study was supported by the Medical University of Lodz grant No. 503/1-151-02/503-01.

Acknowledgments

This research did not receive any specific grant from finding agencies in the public, commercial, or not-for-profit sectors.

Urinary tract infections

D.L. Peterson
"Collateral damage" from cephalosporin or quinolone antibiotic therapy

M.R. Gillings
Evolutionary consequences of antibiotics use for the resistome, mobilome and microbial pangenome

Urinary tract infections

Biomarkers and surrogate endpoints: preferred definitions and conceptual framework

View full text

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Urinary tract infection (UTI) is the most common bacterial infection independent of age. It is also one of the most common causes of hospitalizations for infections among elderly people and the most common indication for antibiotic prescriptions in primary care.

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You must be able to conduct an osteopathic patient evaluation and deliver safe, competent and appropriate osteopathic care to your patients.

Mock CCA

What?

In February 2023 i had my mock CCA exam which involved consultations with one new patient as well as one returning patient. This is a process put in place so we can be as prepared as possible for our final CCA exam which is 2 new patients and one continuing. Both patients went smoothly and attached is my feedback for the new patient.

So what?

The practice exam really helped to boost my confidence and also my autonomy in the clinical decision making process but also the shared decision making process with my patients. It was odd to not have somebody question what i was doing and why it might be that diagnosis and not another. It made me realise how useful it is to bounce my ideas of someone else in a diagnosis discussion and whilst making the decision on whether to treat or not. On the other hand, i enjoyed having the responsibility and a snippet of what it will be like in clinic every day when i’m qualified.

Now what?

I will continue to maintain and expand my levels of knowledge, skills and professionalism to acquire the best results i can at the final CCA exam in June. I will make sure practically that i have practiced all of the testing routines to be prepared for presenting complaints in any regions of the body.

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Development, Implementation, and Evaluation of a Hybrid Electronic Medical Record System Specifically Designed for a Developing World Surgical Service - World Journal of Surgery

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You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.

I’m embarrassed because your notes are embarrassing…

What?

Recently I was in clinic for around Christmas and one of my colleagues had taken time off for holidays so when I arrived at the clinic I found that I was covering their patient. I took the file for the patient to try and familiarise myself with the case notes. I found myself getting very frustrated as the notes seemed nearly illegible because the students handwriting was so bad… I found it very unprofessional to expect someone else you cover your patients and such badly written notes.

I had to ask another of our colleagues to contact them to give me an overview of the case and otherwise I felt it would have comprised the patients care.

Even then I felt like time was wasted in the appointment re asking questions because I could trust the notes in front of me- therefore there wasn’t so much time for TTT which was frustrating for both myself and the patient.

So what?

I was able to reflect upon how my notes are laid out and written so the most prevalent pieces of information are at the top so it would be easy for anyone to pick the patients case up and feel confident going into the appointment. This also made me think to the future as to what environment I would like to work in. To avoid this situation in the future I would definitely want to work in a place with electronic notes so handwriting is not a factor I have to worry about as at the moment I am a student and I know there are times I will feel out of my comfort zone/embarrassed in front of patients however I done not want to feel like that if I am helping out a colleague as it gives people a bad first impression.

Now what?

In terms of my time at the ESO I will ensure that if I need to take any time out of clinic I will make sure I have either organised my patients case with somebody prior to their consultation or i have written up a patient summary and put it at the front of the patients file so whoever picks it up has a clear idea of what is going on and how to move forward with the treatment and management plan.

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Author notes

G. L. Laing

Present address: Department of Surgery, Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg Metropolitan Hospital Complex, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Post-Net Suite #156, Private Bag X918, Pietermanitzburg, 3200, South Africa

Authors and Affiliations

1. Department of Surgery, Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg Metropolitan Hospital Complex, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Post-Net Suite #156, Private Bag X918, Pietermanitzburg, 3200, South Africa

J. L. Bruce, N. L. Allorto & D. L. Clarke

2. Department of Anesthetics and Critical Care, University of KwaZulu-Natal, Pietermanitzburg, South Africa

D. L. Skinner

3. School of Clinical Medicine, University of KwaZulu-Natal, Pietermanitzburg, South Africa

C. Aldous

Corresponding author

Correspondence to G. L. Laing.

# data[].attributes.attachment_link.title
Development, Implementation, and Evaluation of a Hybrid Electronic Medical Record System Specifically Designed for a Developing World Surgical Service - World Journal of Surgery

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Background The Pietermaritzburg Metropolitan Trauma Service previously successfully constructed and implemented an electronic surgical registry (ESR). This study reports on our attempts to expand and develop this concept into a multi-functional hybrid electronic medical record (HEMR) system for use in a tertiary level surgical service.

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You must respond effectively and appropriately to requests for the production of written material and data.

What?

In terms of referral letters i have actually only written 3 in my time at the ESO. I found the experiences very anxiety driven as i was aware someone with my more thorough training than myself would be reading them. However, it is important to use my knowledge to support the patient through their ongoing journey of care or investigation even if that is not within the realms of osteopathy.
For one patient in particular i had to do an emergency referral as she attended the clinic presenting with left shoulder pain, arm pain and chest pain. Her blood pressure was 180/90. As her husband was already there to drive her i wrote an emergency referral and sent her to hospital straight away. I was very happy with how i handled this situation as i stayed calm and wrote clearly and concisely so that the healthcare professionals receiving the information were having no doubt about what we thought was going on.
I have personally not been required to provide any copies of case notes in my 4 years at the clinic. However, I know moving into the work place that this is something that may be required of me on a day to day basis.

So what?

Responding effectively and appropriately to requests for the production of written material and data is a crucial responsibility in my role as an osteopath. It requires efficient organisation and attention to detail to ensure timely and accurate responses. This could be in the form of referral letters for patients who i think need care that osteopathy cannot provide or on the request for clinical case notes/files for the purpose of insurance or legal issues.

Now what?

When faced with such requests, I will prioritise professionalism and adhere to legal and ethical guidelines. This includes verifying the accuracy of the information, maintaining patient confidentiality, and providing clear and concise written material. I understand the importance of meeting deadlines and responding promptly to fulfill the needs of patients, colleagues, and other stakeholders.

By handling requests for written material and data effectively and appropriately, I will uphold the integrity of my profession and maintain the trust of those who rely on my services. This commitment ensures that information is shared responsibly, respecting privacy and confidentiality, and contributing to the overall quality of patient care.

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Oxford Textbook of Interventional Cardiology

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You must take action to keep patients from harm.

Forgetful patients aren’t good for their health

During my 4th year as a student at the ESO teaching clinic i had a 89 year old female patient who presented with left shoulder pain. She explained that she had been lifting lots of shopping herself as her husband has been ill and she feels she has pulled the muscles in her shoulder. Obviously there was reservations as it was her left shoulder and she was an older lady - but due to a clear onset, mechanical provocation and lack of medication for any illnesses with the input of the tutor i decided she was safe to treat.

On return she said that she was now feeling a pain in the left shoulder that radiated down the arm as well as a degree of chest pain and shortness of breath. I took her blood pressure and it was 180/90, I took it again, 176/86, i then asked my colleague to take it and check it and he got figures around the same levels. She then disclosed to me that she’d forgotten to tell me but 6 months ago she when the hospital for a work up on her heart and they discovered a narrowing artery around her heart which they gave her medication for, which she since has started opting not to take…

I was very alarmed that she had ‘forgotten’ to let me know this vital information…

We then did an emergency referral to her GP/A&E and told her to get seen right away. She seemed frustrated that we didn’t want to treat her but i explained the situation in detail and the importance of seeking immediate medical attention.

The next week i saw she had booked back in and i felt very apprehensive in the run up to the appointment. When she came in she said that she was very grateful that we made the decision for her to go and get seen - they checked her blood pressure and it was the same as our values so they were worried and then did an ECG, chest X-ray and blood tests. However, she said that they couldn’t find anything of note so they told her she would be fine. I asked specifically about this narrowing artery around the heart that had been mentioned previously but she said they didn’t say anything.

I was still sceptical about the situation as of course I wasn’t there to understand any of her results and i could only reply on her interpretation of what the doctors said and even with that she had two new hearing aids which she had previously explained have been troublesome!

Even still the tutor advised me that there was no more that we could do for her in terms of referrals if she has had all the tests done so we should treat her shoulder pain. Furthermore, i told her she definitely needed to speak to her GP to find a solution for not taking the medication she was prescribed for her heart.

So what?

I didn’t feel most comfortable moving forward but her shoulder symptoms did start to improve. I just felt uneasy that we didn’t have any answers and I know older people do naturally have higher blood pressures sometimes however hers was off the of anything that could have been excused. Even so I am glad we referred her and she got all the necessary tests done to ensure she was in reasonable health.

Now what?

At first I wasn’t sure what I could of exactly done differently moving forwards- but I think the most important point to take from this scenario would be to the taking of the case history and making sure I give her patient as many prompts as possible, (especially when they are older and have longer medical histories), to think about anything they have been through or had advice for previously. Secondly, I think I made the right decision to refer and I will now feel confident in future to go through this process and with the ongoing advice I gave her to do my duty as a healthcare practitioner in keeping her from harm.

This instance has stressed the importance of following through with questioning in the case history and on every return giving the patient the opportunity to present new information. In future i will be very vigilant with this.

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Oxford Textbook of Interventional Cardiology

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Cardiac catheterization and coronary angiography remain the key tools in the management of patients with coronary heart disease. Interventional cardiology is now routinely performed outside of major cardiac centres, often in small district hospitals. General training in cardiology rarely offers more than the opportunity to assist a more senior operator to perform angioplasty procedures, so a textbook for the non-specialist has become essential reading.

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You must take action to keep patients from harm.

What?

I completed a safeguarding course on child abuse and female genital mutilation (FGM).

So what?

Learning about these topics openned my eyes to situations that i had never thought about before.

Now what?

I will be alert to signs and indications to that if i need to i can take action appropriately.

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You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation.

A coat of paint wouldn’t go a miss…

The ESO teaching clinic is a certified clinic that has to comply with a certain amount of legislation to represent one, the osteopathic profession, and second, the education of osteopathy. However, i cannot vouch for the fact that it is the cleanest or most pleasant place to be.

Some of the clinic rooms have cracks in the wall or the paint is peeling off, they don’t have good ventilation and some of the material chairs have stains on them that I would feel sceptical about sitting on!

When I observe my colleagues I notice things about their room set up which would make me feel uneasy as a patient for example the room being cluttered with chairs or the bin overflowing with couch roll.

So what?

I think that the clinic doesn’t give off the most professional environment and I understand that it is a teaching clinic that tries to break even more than make a profit but there are definitely things that us students can do to maximise the space we have. For example, make sure the patient is facing the most pleasant side of the room. If any chairs aren’t being used, remove them, make sure the couch is completely cleaned between every patient and neatly lay our couch role to create a more professional environment.

Now what?

I will continue to clean as much as possible for my individual patients and change chairs to make sure there’s no stains etc. if there is any feedback welcomed at the clinic I would also make a point of saying the a coat of white paint wouldn’t go a miss!

In future when going to work at a clinic I will make sure to gain an understanding of what is my responsibility in terms of cleaning and what is the clinic’s responsibility to I can ensure all of the hygiene standards are up to scratch for everyone who walks through the doors!

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You must act with honesty and integrity in your professional practice.

Scar work

What?

A patient came to see me in my fourth at the ESO clinic for a post natal consultation. We diagnosed her with neurogenic TOS due to breastfeeding posture and compression patterns she was creating due to the way she was carrying her son. The patient was happy with the explanation and management plan and was excited about the prospects of her pain and discomfort being reduced.

The treatment plan was going well and with every treatment she found her pain to be less frequent and intense until its complete resolution. She is now continuing to come in as she has requested an alternative kind of treatment.

She came in and told me that her c-section scar was very painful on pressure and also felt numb at times. She has had one previous pregnancy and c-section before this and knows that it took a long time for the surrounding skin to feel normal again however she felt that after 6 months, this scar had not progressed the same way as before. The patient requested if i could do some work on the scar to help it heal/become less bumpy.

I instantly felt a bit worried as I hadn’t been asked anything like this before. However, i decided this wasn’t a moment that i should “fake it till i make it,” and i told the patient that I wasn’t personally very familiar with anything i could do for scars from any of my training but i will do some research and when she comes back next time i will happy to have a discussion about her options going forward whether the be osteopathic in nature or otherwise.

By the time she had come back to the clinic i had explored information provided by the internet and books as well as some of my tutors at Boxley.

One of my tutors specifically provides scar work in her clinic so she pointed me in the direction of some techniques based on the work of Sharon Wheeler.

I explained to my patient that i had done some research and i had practiced some techniques for scar work that may be beneficial to her however i do not claim to be a professional in this field and if she did want to see someone who has lots more experience then i would be happy to put them in touch. Our conversation also explored the progression on scars, especially c-section scars and other options for Keloid scarring like, steroid creams/injections or cryotherapy.

Following the conversation the patient explained to me that although she was aware that I wasn’t experienced in scar work that she trusted me as i had been honest with the limits of my training previously and would like to commence the treatment on an experimental basis.

So what?

I am very happy that i decided to tell the truth about not knowing about scar treatment and take the time to do research and if not this could have been detrimental to the patient. This gave me time to really educate myself about firstly whether or not this was something accessible to me as an osteopath but also how. It shows that even though we have a very broad curriculum at the ESO there is still lots that we haven’t been taught and that we can go on courses for in the future.

Due to the initiative i took, i have a well structured basis of shared decision making and informed consent with my patient. Every appointment we have had from this consultation i check in with the patient to she if she is happy with her progression and whether she wants to continue this type of treatment moving forward.

Now what?

Acting with honesty and integrity is a fundamental aspect of my professional practice as an osteopath. It requires providing transparent and accurate information to my patients, admitting my limitations, and seeking guidance when necessary. Upholding ethical principles, treating patients with respect and empathy, and maintaining confidentiality are integral to maintaining integrity. Regular reflection allows me to assess my actions and make improvements to ensure the trust and well-being of my patients. By embodying honesty and integrity, I contribute to a healing environment and uphold the highest standards of professionalism in osteopathy.

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Sharon Wheeler - Integrating Scar Tissue into the Fascial Web

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You must establish and maintain clear professional boundaries with patients, and must not abuse your professional standing and the position of trust which you have as an osteopath.

Friends and family

What?

Over the years as an osteopathic student - every time one of your friends or family see you they always ask if you can have a look at their back, shoulder, knee, neck etc… or your opinion on their symptoms.

As a student or member of staff at the ESO you can get free treatments from the 3rd/4th year students therefore its common to sometimes be treating your friends who turn into your patients.

So what?

I have always found it difficult to create a professional front with my close family and friends as its difficult to maintain the objectivity that is required as an osteopathy.

I had this experience with my mother when i was practicing on her during the March 2020 lockdown. I was questioning her about her complaint to try and narrow down the DDx’s. It suddenly crossed my mind that there was a possibility that maybe i should be exploring systemic/pathological diagnosis but i had been previously blinded by this as i just assume my loved ones are in good health. However, i had not taken the time do carry out a proper case history with past medical history and systemic questioning because of these assumptions and the basis that it was an informal situation.

As i know her so well i also felt that consent was very poor as there was too much comfort in our relationship.

I was very inappropriate and irresponsible of me to let my family member put their trust in me without doing a full case history which could have resulted in information that meant that OMT was contraindicated.

Now what?

Moving forward i have said that i will not treat family of friends without being in the correct setting and in the same format to with i would use with any other patient in clinic.

If i can avoid treating my family i probably will and i would send them in the direction of a trusted colleague so my relationships do not have any bias on the diagnosis.

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An update on the pathophysiology of osteoarthritis

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You must be open and honest with patients, fulfilling your duty of candour.

I think you were too honest.

What?

In the first term of my 4th year at the ESO clinic I encountered a tutor that I had never met before. I had heard stories about him with made me a bit worried as I heard he was very strict and didn't hold back if he thought your ideas or what you were doing was wrong.

On introduction, I was pleasantly surprised that he had been made out to be a lot worse that he was in terms of strictness and confrontation however his personality was definitely very black or white and his answers were blunt and to the point… no messing around.

I appreciated his honesty and it was something I really respected about him as I want to always have productive feedback so I can improve and be the best osteopath I possible can be.

However, one day in clinic I had a patient in the clinic with L hip OA and Knee OA as well as degenerative changes in the spine due to previous surgery. I was happy with my examination and treatment/management plan with the patient which was based in shared decision making. My tutor entered the room when I was in the middle of my treatment to check on the patient progress and to see if I needed any assistance with patient management. He asked whether it was okay it he felt the range of motion through my patients hips to assess for himself. At first I felt a little offended as I felt he was doing this as he didn't trust my judgement however, I left him to it as I am obviously aware that I do not have anywhere as near as much experience as he does.

He then asked me to demonstrate the explanation of the diagnosis and management plan in front of the patient so he could give me feedback which I appreciated as that was what I wanted from the session. After I finish my explanation I asked the patient if they have any further questions but they didn't. My tutor then took over and, I felt, quite confrontationally said "you just need to be aware that osteoarthritis will never get any better to you need to accept that you will be in pain for the rest of your life."

I felt so angry that he had said this as I could tell this made the patient feel awful and defeated. There was no reason for him to 'rain on their parade' in such a way, when they were feeling so positive previously about how osteopathic treatment was helping their quality of life.

So what?

The thing that frustrated me more was that he wasn't lying. Obviously we know that once degenerative changes have occurred there is no way for them to be reversed - hence he was being open and honest. On the way hand, the criticism of this OPS is that, was it necessary to be that open and honest with the patient?

We know that research presents a placebo effect within osteopathic manipulative treatment, so who's to say that my patient will never be pain free ever again. What is the point in claiming to treat the symptoms of degenerative changes if my tutor uses his blatant honestly to crush any remaining hope my patient has left for their quality of life.

Now what?

I understand that being open and honest with patients, fulfilling the duty of candour, is crucial in healthcare. Adhering to the principles of candour not only promotes patient-centered care but also fosters a collaborative and supportive environment. It demonstrates our commitment to acting in the best interest of patients, ensuring that they are well-informed about their health, and that any adverse events or errors are promptly disclosed. Embracing the duty of candour serves as a reminder of the ethical obligation we have as healthcare professionals to prioritize honesty, integrity, and the well-being of those under our care. It demonstrates our commitment to acting in the best interest of patients, ensuring that they are well-informed about their health, and that any adverse events or errors can be promptly disclosed. However, I do believe there is a flaw in being closed minded and black and white about this topic. Its important to be realistic with the patient about prognosis although in my practice I don't believe it is right to act in the same manner as my tutor and compromise the biopsychosocial factors of the case.

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Author links open overlay panelAli Mobasheri a b c d e f, Mark Batt c

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An update on the pathophysiology of osteoarthritis

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Osteoarthritis (OA) is one of the most common forms of arthritis. There is accumulating evidence to suggest that OA is an inflammatory disease of the …

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You must have a policy in place to manage patient complaints, and respond quickly and appropriately to any that arise.

ESO Complaint Policy

What?

As a student practitioner at the ESO teaching clinic, i am aware that there is a patient complaint policy available at the clinic reception as well as on the clinic website. During my time in practice i have never received a complaint from a patient.

So what?

If i ever get one, i would make sure to gain full understanding as to why the complaint was made and put actions in places to either modify the next appointment or discussing with the patients the other options available to them.

Now what?

It would also be a learning opportunity for me to improve my patient management and apply it to future situations.

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You must have a policy in place to manage patient complaints, and respond quickly and appropriately to any that arise.

Complaint response practice

The following attachment is taken from an assignment i submitted - the personal information included is purely fictional and do not reveal/represent a real patient

What?

During my second year at the ESO, one of our assignments wad to write a response letter to a patient complaint after a treatment session. It was a letter from a x saying that they felt they have been deceived when we knew their son would be fine anyway without treatment.

So what?

When starting to engage with the assignment it seemed very easy and straightforward. However as i started Tod look further into the OPS i realised there were many points that needed to be covered with explanation as to why i (hypothetically) used techniques and backing them up with existing published literature.

Now what?

This assignment resulted very helpful and has given me a good structure to use in the future should i ever need it. I now feel comfortable with the steps i would need to take.

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You must respect your patients’ rights to privacy and confidentiality, and maintain and protect patient information effectively.

Family members& extra information…

What?

In my 4th year at the ESO clinic I had a patient takeover for a women in her early 70's who struggled with OA in her hips and knees as well as carpal tunnel. Over the treatments I began to build up a rapport with the patient and she opened up to me about lots of things in her life, including about the life of her grand daughter. She explained to me how she was being bullied at school and was having a rough time with it, she refused to eat in front of the other girls and would cry most days about being picked on. As I didn't know her granddaughter very well I took a very passive position not he matter and listened however she did ask me how I thought I would feel and the support I would like as I was much closer to her in age. I kept my answers very brief, generalised and two sided and assured her that everyone is different and there is no right way to support someone, its on an individualised basis. Every time she would come in she would give me updates on what was happening and I think it was therapeutic for my patient to talk about it in an environment where nobody else knew anything so she could get her feelings out.

About six months later I was observing one of my colleagues in headaches clinic and she had a new patient coming in. The patient was a 16 year old female presenting with migraines amongst other headaches. The case history ran in the same fashion as usual and we began to uncover patterns to her headaches that coincided with the stress of attending school. Suddenly something clicked in my brain- the last name was the same, description the same, sporting background the same and her mother (my patients daughter) was a spitting image of my patient, just younger. So this was the granddaughter that I has been hearing about all this time.

I suddenly felt a split responsibility- felt that the information I knew about her background was a very important feature in the onset and maintenance of her [resenting complaint. However, I could speak up and break the confidentiality of the sessions I had with my patient. This made me feel really split and I didn't know what to do.

So what?

I thought about it for a good while until I decided what to do. When my colleague finished her case history she asked us observers whether we had any questions for the patient they we felt they had missed. I took this opportunity to ask her a little more about he daily patterns of the headaches and when she gave me clear indications it was related school I moved onto asking her about her support system at school and whether she had a good group of friends etc… her mother laughed instantly and then opened up a conversation about that she was having trouble with some of the girls there etc…

I was very happy that I was able to discreetly open this conversation so that I wasn't breaking anyones confidentiality or trust by claiming to know the information already. This was important as I didn't want to make my patients granddaughter feel uncomfortable either.

Now what?

Respecting patients' privacy and confidentiality, and effectively safeguarding their information, is crucial in healthcare. It builds trust, maintains relationships, and ensures data security. Patient information, including personal details, medical history, and treatment plans, must be handled with the utmost care and discretion. By upholding these principles, healthcare providers prioritise patient well-being and preserve their autonomy, contributing to a stable and ethical healthcare system.

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Carpal tunnel syndrome during the third trimester of pregnancy: prevalence and risk factors - Archives of Gynecology and Obstetrics

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You must treat patients fairly and recognise diversity and individual values. You must comply with equality and anti-discrimination law.

Religious clothing and the importance of gender.

What?

In my 4th year as a student at the ESO student clinic, i was in a session of maternity clinic where i accountered a new patient. On the system it said her date of birth as normal and i looked it up to gauge the age range of my patient before she came in. The date meant that she was 48 years old. I instantly believed there to be a mistake and went to reception to ask them to clarify her d.o.b when she came in to the clinic so they could amend it on the system. How could a pregnant women possibly be that old….

I was wrong…

My patient presented to the clinic as a 48 year old women 7 months pregnant with twins through a rigorous IVF process. My patient expressed that it had been an incredible mission to get to this point but she was so excited to finally give birth to her babies.

She presented with bilateral neurogenic TOS and carpal tunnel. Her midwife and GP were aware of this but said they weren’t prepared to do anything about it whilst she was a high risk pregnancy.

An agreement was made with the patient that she would come in weekly for treatment to try and make the rest of her pregnancy as comfortable as possible. She had never had these symptoms before pregnancy and it was hopeful that they would disappear once she had given birth.

We were managing to keep her symptoms at bay following a couple of weeks of treatment and she was very happy but eager to get them out.

Another aspect of my patients person was that she was a Muslim and she wore a head scarf. This in itself of course was no issue at all. However, because we were working around her shoulders and neck, she felt comfortable enough to remove her head scarf. My patient and myself had a chat about this and she said she was comfortable however there would have to be an assurance between us that no men would enter the room and see her and in her religion they must have their heads covered in front of any man apart from their husband. I then was not only in a professional position of trust but a personal trust that a male wouldn’t walk through the door unexpectedly.

So what?

This relationship with my patient made me reflect on the fact that even through there are adjustments that must take place to make her feel safe this couldn’t get in the way of the quality of treatment that i provided her with.

If i was ever in a group that had a male tutor i either communicated the situation with them and they didn’t enter the room whilst i was treating or i switched to a group with a female tutor if they weren’t comfortable with the situation.

This goes against many of my morals of gender and beliefs against the idea that a man is superior to a women so i had to separate my views on her religion and the way they view women in society to respect that she believes differently to myself and make sure i didn’t let that interfere with my treatment and management plan of the patient.

Now what?

If I’m have situations like this in future, as i’m sure i will, at the ESO clinic i would continue in the same way i have so far, but in clinic post graduate, i will ensure to my patient that no one else will be entering the room apart from the two of us and ensure my communication is clear as well as not asking my patient to remove any clothing especially religious unless absolutely necessary.

I believe it is important in our job to have an understanding of lots of different backgrounds so we can be empathetic to as many situations and lifestyles as possible.

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Authors and Affiliations

1. Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Programa de Pós-Graduação Em Ginecologia, Obstetrícia E Mastologia, Av. Prof. Mário Rubens Guimarães Montenegro, s/n. Bairro: UNESP, Campus de Botucatu, Botucatu, São Paulo, Brazil

Gladys Alexandra Dias de Oliveira

2. Department of Public Health, Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Programa de Pós-Graduação Em Saúde Coletiva, Av. Prof. Mário Rubens Guimarães Montenegro, s/n. Bairro: UNESP, Campus de Botucatu, Botucatu, São Paulo, CEP: 8618687, Brazil

João Marcos Bernardes, Elisiane de Souza Santos & Adriano Dias

Contributions

GADO-protocol/project development, data collection or management and manuscript writing/editing. JMB-manuscript writing/editing. ESS-data collection or management and manuscript writing/editing. AD-protocol/project development, data analysis and manuscript writing/editing.

Corresponding author

Correspondence to Adriano Dias.

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Carpal tunnel syndrome during the third trimester of pregnancy: prevalence and risk factors - Archives of Gynecology and Obstetrics

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Purpose To estimate the prevalence of indicative signs and symptoms of carpal tunnel syndrome (CTS) during the third trimester of pregnancy; assess the severity of symptoms and functional impairment; evaluate associated factors; and to evaluate the complaint of CTS in pregnant women through ultrasonography (USG).

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You must uphold the reputation of the profession at all times through your conduct, in and out of the workplace.

Social media influencer….

What?

One of my class mates has social media accounts as many of us do, however her instagram in particular has a public setting meaning that anyone with the app can access her profile and see the pictures she posts. I feel that some of her pictures and posts are somewhat inappropriate and could give off the wrong idea if come across by patients, colleagues or even employers.

So what?

I think it to be unprofessional to share revealing photos of yourselves for your patients to see on social media as you are their healthcare provider.

Now what?

I wouldn’t ever have a public social media account just in case my patients ever tried to find me and felt offended by any of my posts. Observing this of my colleague has made me more conscious that not only are we representing ourselves but we are representing the profession of osteopathy as a whole.

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Prices 2023 - ESO - European School of Osteopathy

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You must be honest and trustworthy in your professional and personal financial dealings.

Clinic prices and policies

As a student at the ESO - i have not come across any financial dealings in terms of business so therefore this OPS hasn’t been covered yet. However, i am aware that at the ESO clinic they have consultation pricing and charging policies clearly laid out on their website.

I know this is important to have your clinic policies clearly available to all of your patients to minimise the chances of running into any problems.

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As a registered charity and teaching clinic, the ESO Clinic is able to offer very competitive pricing

Our consultation fees can be found below. Re-consultation patients, i.e those who have not visited the Clinic for more than six months, will be charged as a New Patient. Please allow approximately 1hr 20mins for a new patient consultation - returning patient appointments 40mins. To book or for further information please call 01622 685989.

Concessions

Our daytime concessions provide reduced price osteopathic consultations for Blue Light cardholders, Carers and partner organisations - please click for details.

NUS/Students

Daytime concessions provide reduced price osteopathic consultations for students who are over the age of 18 and in full-time education. Documentary evidence must be provided in order to qualify.

Refer a friend

Share the benefits of osteopathic treatment with a friend or relative and receive your next osteopathic treatment for just £12 - your friend will also qualify for a reduced price for their first consultation. Find out more here.

Thank You Scheme

Our Thank You scheme allows patients to receive one reduced price osteopathic consultation after six treatments completed. Simply ask our Reception team to stamp your appointment card to qualify.

Cancellation Policy

The European School of Osteopathy is part of a registered charity and every Clinic appointment is subsidised to keep treatment fees to a minimum. To help keep our consultation fees low, and to enable us to offer appointments to others, we ask patients to provide as much notice as possible if they need to cancel. PLEASE NOTE: A £14 charge will apply for appointments cancelled with less than 24 hours notice. If appointments are cancelled with late notification twice in a row, we will request payment in advance for future appointments.

If you would like to support the ESO, there are various ways you can get involved ... and it doesn't have to cost a penny! To find out more please click here

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Prices 2023 - ESO - European School of Osteopathy

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As a registered charity and teaching clinic, the ESO Clinic is able to offer very competitive pricing Our consultation fees can be found below. Re-consultation patients, i.e those who have not visited the Clinic for more than six months, will be charged as a New Patient.

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Business Plan

Reflection:

In my 3rd year as a student at the ESO, one of our assignments meant that we had to create a business plan for a prospective future clinic. This involved us creating a plan down to the core details about how we would go about starting up our own business-the finances we would need to start up and our yearly NET income.

I did enjoy the process as it was the first time i could take time to actually imagine how the i would run my own practice. Indirectly, it was provided me with good knowledge and consideration, maintaining a high standard of adherence to this OPS.

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You must support colleagues and cooperate with them to enhance patient care.

Better together

What?

During one of my clinic sessions, one of my colleagues observed me and prior to my new patient, asked me if i wanted to receive feedback from her on how i perform and some recommendations as to how i can improve my practice. I agreed to this as i wanted to improve wherever possible.

So what?

My colleague gave my a list of written feedback that took during my session that they noted down during my session including all different aspects of the appointment from case history taking to examination and patient management. It enabled me to explore and improve on things that i would not have reflected on prior to this experience.

No what?

Since the start of 3rd year I have always tried to observe my colleagues as much as possible especially during new patient consultations and give feedback for them to improve on. I do this because i really appreciate when others dot his for me as i find it a very useful learning tool to improve and refine my professional skills, therefore i want them to have the same opportunities. In future i will continue the process for my colleagues and ask others to do the same for me more regularly.

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The effects of psychological meaning-centered therapies on quality of life and psychological stress: A metaanalysis | Palliative & Supportive Care | Cambridge Core

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You must consider the contributions of other health and care professionals, to optimise patient care.

The C Word

What?

In my 3rd term of 3rd year I had a patient who was given to me by a 4th year before they graduated. After a couple of months of treatment to maintain function and pain relief in her symptomatic and imaged grade 1 spondylolisthesis she had some family trauma. She told me that her daughter had been diagnosed with cancer and she was trying o remind string to her family and that she'd gone into a practical mode to organise grand children and house cleaning etc to relive pressures on her daughter but she hadn't had the the time or space herself to truly come to terms with the diagnosis, so constantly feels like she is always moments from having breakdowns.

As her practitioner I had formed a great rapport with this patient and we got on very well, so I felt deeply saddened to hear this news as I also treat a few other of her family members. However, I knew that I was not trained professionally to help her deal with the emotions she was experiencing so I decided that she needed this treatment time to decompress her feeling but when I saw her next I would provide her with the information of different options of talking therapies so help her through this tricky time.

So what?

I felt deeply saddened by this experience but I went away and did some research into support groups as well as one-on-one in person or remote talking therapies to think about and have a look through.

The reason I felt this was important was that there are many links between that emotions of a person and the reflection of that on their pain intensity It is important that all WHO models are addressed in patients to optimise their health and healing time. I felt that if nothing way done, her back pain would get worse and then starts the cyclical pattern of her feeling helpless because everything feels like it is going wrong.

I presented her with the information in her next session and she was very grateful. She Agreed that she did need tot think about other aspects of her health as if she wasn't at her peak she couldn't be as helpful to others. She also wanted to seek some advice about diet management and nutrition for her daughter whilst she was undergoing chemotherapy. I explained to her that I don't have expertise in this are but could give her the contact details of someone I knew that did.

Now what?

Recognising that healthcare is a team effort allows us to harness the collective expertise, skills, and perspectives of various professionals involved in a patient's care. Collaboration among healthcare professionals facilitates a holistic approach, ensuring that patients receive well-rounded, multidimensional care that addresses their diverse needs which is the very core of what osteopathy stands for. By valuing and incorporating the insights of others, we can tap into a wealth of knowledge and experiences, ultimately leading to better patient outcomes. Embracing a team-based approach not only enhances the quality of care but also promotes a supportive and harmonious working environment, fostering a culture of mutual respect and shared responsibility. By acknowledging and leveraging the contributions of our colleagues, we can collectively optimise patient care and work towards the common goal of improving overall health and well-being. This multimodal approach has been so important in the maintenance of any of the patients I see at the ESO clinic.

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The effects of psychological meaning-centered therapies on quality of life and psychological stress: A metaanalysis | Palliative & Supportive Care | Cambridge Core

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The effects of psychological meaning-centered therapies on quality of life and psychological stress: A metaanalysis - Volume 16 Issue 5

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Covid 19 Outbreak Control Scenario Planning Sept 2020

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You must ensure that any problems with your own health do not affect your patients. You must not rely on your own assessment of the risk to patients.

CORONAVIRUS!

What?

I started my 3rd year of the ESO whilst still in the midst of the COVID-19 pandemic. There was lots of PPE equipment around clinic and we had to be even more prepared to keep everything clean and sanitary for not only our patients but ourselves. I knew that if i contracted coronavirus i would not only put those around me at risk in my personal life but this would have a grave effect on someone of my patients - especially the elderly ones and those with serious conditions.

In November 2022, i started to fell flu like symptoms and generally just exhausted - at first i though it might have just been stress from the course and studying and exams and generally being spread thin however my boyfriend pushed me to test for COVID and it came back positive. I felt shocked as I had managed to stay away from all of it for the previous 2 years and now i had got it when everyone was a little less worried.

As soon as i knew i rang the clinic and let them know what had happened and followed their protocol to not come in.

So what?

I felt split as i was very worried about missing out on clinic hours and experience and that i would fall behind. On the other hand there was no way i had the energy to treat and even if i do it would have been so irresponsible of my to put my patients, tutors and colleagues at risk.

I believe it is so important to be on peak form yourself before treating others who aren’t at optimal health - because otherwise you cant give them the full experience that one they are paying for but second they need.

No what?

Covid is not so much of an issue in our society at the moment as there has since been vaccinations circulating globally - however if you were to contract that or any other flus that you shouldn’t put your patients at risk as we must ‘do no harm’.

In my future as a student practitioner and a qualified practitioner i will make sure that if i am ill in any way, if i cant provide my patient with the care I would on a normal day then i should not be putting them at risk of picking up any illnesses (if they are contagious).

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You must inform the GOsC as soon as is practicable of any significant information regarding your conduct and competence, cooperate with any requests for information or investigation and comply with all regulatory requirements.

Are you a criminal?

What?

During my 4th year at the ESO, the GOsC came to the university on our careers day to give us a talk on the benefits and requirements for registering with the GOsC.

One of the steps is obtaining a DBS check so they can check any existing criminal history due to working with members of the public some one which are vulnerable people.

So what?

DBS check means that the GOsC will receive a copy of the disclosure if you have any convictions or cautions to your name. I instantly felt worries as i have had a speeding ticket and parking fine in the past and i didn’t know if these were shown on a DBS check and might have a negative impact on my application.

However, i did some further research and realised those things are not listed as an act of criminal offence and will not influence my registration process.

No what?

By being aware of the paperwork required by the GOsC to move forward with an application added even more importance to the conduct of a person wishing to become an osteopath and the weight we carry as healthcare professionals. If at any point any of my paperwork is requested i will make sure to provide what is required as soon as possible and always cooperate with the requirements of the GOsC to ensure the process is carried out simple, smoothly and efficiently.

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You must support patients in caring for themselves to improve and maintain their own health and wellbeing.

Have you really been doing your exercises?

What?

I had a patient coming in before christmas who i prescribed a course of exercises for. Further into the management plan it came to light that they weren’t engage with the exercises given and were completely relying on the treatment.

I generally try my best to create lifestyle changes that will slot easily into my patients daily routines so that they can quickly develop habits which will aid their recovery journey as well as making positive changes in the long run.

When i became suspicious that the patient wasn’t doing their exercises, I asked them to show me how they were doing them- this provided a bit of an awkward environment as they quite obviously couldn’t remember what i had given them even though they had paper copies of the exercises.

We then had a discussion about not being reliant on treatment and having to engage in some sort of activity outside the treat,ent room otherwise they cant expect to get any better.

So what?

I felt very disheartened by the situation at the time as i feel that i always put a lot of effort in to providing my patients with the best knowledge and tools for outside the treatment room. However on reflection, i cannot expect everyone to have the same outlook on their health as i do, and some patients have a lot more going on in their lives than i do and that could get it the way of any routine changes that might be difficult to implement if they are already busy.

Now what?

Moving forward i will still strive to provide the best and most ad hoc advice for my patients to overall help them make positive lifestyle changes.

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JMIR Mhealth Uhealth. 2018 Mar; 6(3): e47.

Monitoring Editor: Casimiro Dias

Reviewed by M Khazaeepool, Jonathan Rawstorn, and Emer O'Leary

Rob Argent, BSc (Hons), 1, 2, ³ Ailish Daly, BSc (Hons), ¹ and Brian Caulfield, BSc, MSc, PhD 2, ³

¹ Beacon Hospital, Dublin, Ireland

Abstract

Adherence to home exercise in rehabilitation is a significant problem, with estimates of nonadherence as high as 50%, potentially having a detrimental effect on clinical outcomes. In this viewpoint, we discuss the many reasons why patients may not adhere to a prescribed exercise program and explore how connected health technologies have the ability to offer numerous interventions to enhance adherence; however, it is hard to judge the efficacy of these interventions without a robust measurement tool. We highlight how well-designed connected health technologies, such as the use of mobile devices, including mobile phones and tablets, as well as inertial measurement units, provide us with the opportunity to better support the patient and clinician, with a data-driven approach that incorporates features designed to increase adherence to exercise such as coaching, self-monitoring and education, as well as remotely monitor adherence rates more objectively.

Keywords: patient compliance, rehabilitation, exercise therapy, biomedical technology, review

Introduction

The success of certain medical interventions depends largely on patient adherence to advice and prescribed rehabilitation regimes. After injury or surgery, many patients are given specific exercises to do unsupervised at home to aid their recovery, for example after knee replacement. These exercises are specifically targeted at certain muscle groups or joints, rather than global physical activity, for example a straight leg raise for quadriceps strength or a heel slide for knee range of movement. Evidence suggests that noncompliance to these home exercises in musculoskeletal cohorts can be between 30% and 50%, making it a significant issue that places additional burden on patients and health care providers, and may be partially to blame for poor clinical outcomes [ 1, 2]. Clinicians who fail to consider patient adherence in rehabilitation programs may unnecessarily alter their treatment approach, face persistent patient complaints; or refer patients for alternative opinion, thereby contributing to possible unnecessary surgical intervention and additional health care costs [ 1]. Adherence is currently defined by the World Health Organization (WHO) as "the extent to which a person's behaviour...corresponds with agreed recommendations from a health care provider" [ 3]. The majority of research into adherence relates to medication, and this definition has been developed to encompass a multitude of health-related behaviors [ 3], however, it does not yet include exercise prescription. In this viewpoint, we aim to comment on the current evidence in patient adherence to prescribed home exercise programs, the factors affecting these adherence rates, and then discuss design opportunities that connected health interventions provide to improve adherence rates.

The term connected health describes the use of a variety of technologies to inform and aid health care delivery in a data-driven manner with the individual at the center. It covers a broad domain, including digital, mobile health and telehealth and ensures all stakeholders are connected with data that is accurate and timely [ 4]. Mobile technology, including smartphones and tablets can support connected health solutions by providing access to a number of features within the device, including inertial measurement units (IMUs), cloud computing, and back-end development including machine-learning classification [ 5]. Equally, various methods such as telerehabilitation using videoconferencing [ 6], or motion capture using camera systems [ 7] have been employed with the aim to better support patients in their rehabilitation and improve their adherence. But what are the design features that can be harnessed in new connected health solutions that will impact adherence to exercise?

Adherence to Exercise Programs

An Operational Definition of Adherence in Exercise Science

Although medical adherence has been defined by the WHO, it is arguable that there is more than one factor to consider when specifically defining exercise adherence. To form a definition, the authors of this paper have considered on a macro level, the requirements needed to demonstrate strong adherence. Clinicians first need to know whether the patient is exercising, then whether they are exercising to the required amount of repetitions and sets, and finally whether they are performing the correct technique with relation to load, velocity, and alignment. The following operational definition has been built specifically relating to exercise, adapted from the WHO definition, and defines exercise adherence as "the extent to which an individual corresponds with the quantity and quality of exercise, as prescribed by their healthcare professional." Those who perform their exercises to the required repetitions may not be deemed adherent should their technique be erroneous or incorrect, as these individuals will not be gaining maximum benefit from their exercise program.

The Effect of Adherence on Outcome

In an exercise rehabilitation context among the musculoskeletal population, strong adherence enhances the effectiveness of the intervention and is suggested to reduce persistent, disabling complaints [ 11]. Patients who fail to adhere to the prescribed exercise program may extend the duration of their treatment, negatively impact on the therapeutic relationship, and make treatment less effective [ 12]. It can also impact health care providers with increased waiting times and poor efficiency [ 11], while poor adherence rates may also potentially have a role to play in nonsignificant outcomes of research papers [ 13]. A number of studies have also linked strong exercise adherence to improved treatment outcome in patients experiencing neck and back pain and osteoarthritis symptoms [ 14- 16].

Measuring Adherence

Factors Affecting Adherence

Self-Efficacy

Self-efficacy has been strongly linked as a psychological factor affecting treatment adherence. It is a term used to describe an individual's belief in their own capability to achieve a task that will produce a targeted result. It is situation-specific and depends on the activity, but it is considered that a person has a general level of self-efficacy across tasks [ 28]. Four strands of efficacy information are proposed within the concept; mastery experiences based on past and current successful performance, social observation learning from those around the individual, persuasive information particularly from influential people in the individual's life, and emotional states considering the mood the individual is in [ 29]. Self-efficacy has been closely linked with a positive association of adherence in orthopedic and musculoskeletal cohorts [ 24, 30, 31]. It is worth noting however, that one study found that self-efficacy did not predict adherence in the home or clinic setting, although this was assessed in a sports rehabilitation context, and therefore may not be generalized to other cohorts [ 32]. When designing connected health solutions, there is an opportunity to use interventions to improve self-efficacy within the technology design. Methods such as machine learning with biofeedback, interactive education using videos and weblinks, and self-monitoring similar to that used in commercially available fitness trackers, have the potential to improve the self-efficacy and ultimately the adherence of users.

Threat and Beliefs

The beliefs a patient holds regarding their condition are also said to be a direct factor affecting adherence, and the decisions made by patients are based on their own beliefs, personal experiences, and the information they receive [ 33]. This study noted that those who did not perceive their injury to be serious demonstrated lower levels of adherence, and in fact, the authors suggested that enhancing participants' level of threat to further injury or disability would improve adherence, although this is a questionable technique in the wider context of patient management. Indeed, others have stated that providing too much information to patients and overloading them will also negatively affect adherence, as patients can become confused [ 2]. Enhanced threat can also have other negative implications, such as hemophiliac patients who may have had a threat of increased bleeding and arthropathy with physical activity [ 34], and therefore treatment should be about correcting falsely construed beliefs and tailoring individual care, rather than solely modifying the threat appraisal for all patients. This individualized care is an important consideration in the design of connected health solutions, as the end user needs to be considered and technology should be used to augment the clinician's management, rather than to replace in a one size fits all approach that may incorrectly adjust a user's beliefs. Symptoms also need to be perceived to have a sufficient effect on quality of life to encourage adherence [ 35], with another viewpoint that the beliefs a patient holds places them in a similar category as consumers, who want to take their own decisions when confronted with a particular condition [ 8].

Social Support

The social support network of the patient has also been suggested as a possible factor in adherence [ 2, 41]. This network can be friends and family members, as well as support from the therapist. In the sporting population, significant findings were made that both social support as task appreciation, and emotional support from friends and family predict adherence in both the clinic and home setting [ 32]. Further exploratory work in the sporting population made suggestions that those who made use of social support displayed greater adherence and recommended that in this setting, the coach and wider support network are involved in the rehabilitation pathway to offer support and motivation [ 42]. Connected health solutions have the potential to offer social support through online forums or networks where users are able to interact with others in a similar situation, wherever they may be. It is not impossible to foresee a social network built into many mobile health technologies to enhance patient experience and improve adherence. A recently published systematic review found relatively strong evidence that social support can predict adherence, but as discussed earlier, highlighted the challenge of measurement of adherence as a significant limitation across the field [ 18].

Design Considerations for Connected Health Solutions

Overview

When designing future connected health solutions, it is important to have an understanding of the range of possible cognitive, behavioral, and practical barriers that can have an effect on a patient's willingness to adhere to their program [ 45]. The use of mobile devices connected with a form of sensing platform (camera or IMU) in home-based exercise rehabilitation have the potential to provide the clinician with a greater amount of actionable data, which will assist in the management of each case and shift to a more proactive approach to health care. By understanding the factors discussed previously, it is possible to build features and interventions in to new solutions with the aim of enhancing patient adherence and ultimately, clinical outcome.

Coaching

By incorporating regularly combined strategies of supervision, feedback, and reinforcement as a design consideration, it is possible to offer the greater coaching input that a patient receives in clinic with their health care professional but in the convenience of their home environment. When physiotherapists provide positive feedback, and monitor both performance of exercises and the progression of symptoms, adherence rates have been found to be higher [ 2]. The design of connected health interventions can then offer supervision in the form of remote monitoring via online cloud-based portals. This coaching system can be augmented with remote communication using platforms such as videocalling, instant messaging, or email to offer further coaching components. Telerehabilitation has been extensively researched by a Canadian group who in one study of postoperative knee replacement patients found telerehabilitation in the form of videoconferencing to be as effective as usual care and had the potential to increase access to services [ 6].

Task appreciation, when patients are complimented for their achievements, particularly for adherence [ 47], is particularly applicable in the gamification of health interventions to further compliment a user's achievements. Whether this is via rankings, rewards, in-exercise games, or simply augmenting the experience with an avatar type feedback, the user can enjoy a more immersive experience within a connected health technology, potentially impacting on their adherence.

Education

Education is also an intervention to improve adherence; it is multifactorial and can affect perceived barriers and the patients' beliefs/perceived threats that are discussed above. Studies using solely education are few and far between, but in a systematic review, no statistically significant findings were made on 2 fair quality studies, but the provision of written information in supplement to verbal instruction did improve adherence compared with verbal instruction alone [ 19]. A recent symposium piece also concluded that patients rarely need just more education, they need assistance with behavior change in an integrated program [ 51], perhaps suggesting that clinicians should be more aware of the psychological theories discussed previously. Whether Web-, tablet-, or mobile phone-based, connected health solutions can easily offer educational material in a variety of formats, including more interactive methods such as videos that would not have been available in the past to patients.

Conclusions

Adherence to home exercises in rehabilitation is a significant problem, and the reasons for this are multifactorial, covering both psychological and situational factors that vary between each individual, and that need to be considered by clinicians in the design of personalized exercise programs. Techniques discussed in this paper can be built into connected health solutions with the aim to improve self-efficacy and ensure the patient feels better supported in their rehabilitation; this may have an effect on adherence rates and will provide clinicians with more meaningful data to base their clinical decision on. Furthermore, published research needs to investigate the impact of these solutions on adherence rates, as this is sparse at present, yet this is understandable given the difficulties in measuring adherence discussed within the paper.

Connected health technology has the potential to make an impact in the way we manage health and can provide a platform for a far more proactive method of management utilizing numerous interventions to further improve adherence, and ultimately rehabilitation outcomes for patients. There is an emerging market in the use of sensing systems to support patients in their rehabilitation, particularly around adherence to home exercise, although the published research is still in its infancy. These systems have the ability to include many of the design features discussed in this viewpoint within the developed system and have the ability to utilize ubiquitous and cost-effective hardware in the form of mobile phones and tablets. It may then also be possible for these systems to provide a more objective method of measuring adherence across clinical populations.

Acknowledgments

This project is part of the Connected Health Early Stage Researcher Support System Initial Training Network and has received funding from the European Union's Horizon 2020 research and innovation program under the Marie Sklodowska-Curie grant agreement no 676201.

Abbreviations

IMU

inertial measurement unit

WHO

World Health Organization

Footnotes

Conflicts of Interest: None declared.

References

25. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. Br Med J. 2008 Sep 29;337:a1655. doi: 10.1136/bmj.a1655. [[ PMC free article] [ PubMed] [ CrossRef] Google Scholar]

28. Bandura A. Self-Efficacy: The Exercise of Control. New York: Freeman; 1997. [ Google Scholar]

47. Meichenbaum D, Turk DC. Facilitating Treatment Adherence: A Practitioner's Guidebook. New York: Plenum Press; 1987. [ Google Scholar]

Articles from JMIR mHealth and uHealth are provided here courtesy of JMIR Publications Inc.

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Patient Involvement With Home-Based Exercise Programs: Can Connected Health Interventions Influence Adherence?

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Adherence to home exercise in rehabilitation is a significant problem, with estimates of nonadherence as high as 50%, potentially having a detrimental effect on clinical outcomes. In this viewpoint, we discuss the many reasons why patients may not adhere ...

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You must respect your patients’ dignity and modesty.

Inappropriate underwear

What?

In my second term of 4th year at the ESO clinic, i treated a 35 year old female presenting with bilateral hip pain and odd neurological symptoms down the leg. I began testing, working through the routines as i precisely would in other cases and the patient had removed her leggings in order for us to do some sensory testing through the dermatomes of the lower limb. Her underwear was not revealing but with the nature of hip circumduction i can understand it might feel a little odd for those who are not used to osteopathy. When i had finished all of my testing i still felt i didn’t have a good idea of what was going on and so i wanted to go and find my tutor t see if he was able to provoke any pain or retest the things that i had done.

I was about to leave and then i stopped myself and asked my patient is she would be happy to put her leggings back on. She had expressed that she felt comfortable dressed down with myself and my female colleague in the room, however i knew my tutor would want to conduct so supine general articulation through the hips and i wanted to ensure that neither of them felt like they were in an uncomfortable situation.

Then when my tutor came in the examination continued, i could see that she felt comfortable and he managed to illicit some pain so we could put together a diagnosis and management plan for treatment.

So what?

This has made me reflect a lot about whether it is necessary to remove clothing at all with testing and treatment. Patients will 9 times out of 10 feel more comfortable with their clothes on and maybe that would give us more accurate results from our testing. It is possible that we have always been taught to dress our patients down as much as possible to see more of the body and be more holistic for the purposes of our learning in the cognitive stage and not necessarily what we should always do going forward in practice.

Now what?

Moving forward i will only be asking my patient to remove especially necessarily items of clothing, with awareness as to how comfortable they are and also taking into consideration of which regions of the body we are working with and the genders of those who will be coming in and out of the room. Also, i will make it very clear to my patients that they can bring in shorts to wear for subsequent treatments if that would make them feel more comfortable.

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You must make sure your beliefs and values do not prejudice your patients’ care.

My patients comments make me feel uncomfortable

What?

I am currently treating a woman in clinic (as a 4th year student) who is 71 and presents with medial knee pain and upper trapezius pain which she says is bought on by stress, which was difficult at the moment as her husband is not very well. She has no notable systemic concerns.

I first treated her as a cover patient for one of my colleagues as they were ill, however the patient was very unhappy to have to explain her case again. At reception she complained about the arrangements here but we all explained calmly that this is a teaching clinic and the nature of the way things work here, if she doesn’t like it then it is her choice to seek treatment somewhere else.

Nevertheless, after the treatment, she specifically requested for me to be her practitioner and not to have anyone else.

In the weeks following that she kept returning and i came to learn more and more about her and she became comfortable with me. She started making what i felt was inappropriate comments regarding people’s ethnicity. I decided to ignore the subject completely, and move on with the conversation about her treatment. I decided if this was to arise again, i would gently tell her that i didn’t find the kind of language she was using appropriate and that if it happened again she would have to see somebody else for treatment.

So what?

The was already concerning for me as i felt that i had pressure to adapt my diary around her as opposed to her coming in when i can fit her in - but i still didn’t want that to affect her right to proper care. However, i felt very angry that she was making certain comments and that she felt that i wanted to hear them- i certainly didn’t!!! Although, on the other hand, i did feel sorry for her as i know comments like hers always stem from ignorance.

Now what?

After speaking with my tutor, it all felt a little lighter on my shoulders- however my tutor said “unfortunately, there are lots of people that still think this this in our world, we just have to deal with it,” and to be honest i don’t want to just have ‘to deal with it’. Moving forward, if this continues i have decided that i will make it clear that there is no place for those comments in my treatment room and if it does persist i will pass this on to people higher up in clinic management.

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Sports Hernia: Symptoms, Treatment, Recovery & Diagnosis

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You must keep your professional knowledge and skills up to date.

Gilmores groin or sports hernia?

What?

At the end of my third year of studying at the ESO teaching clinic i had a session with a tutor who wanted to make a point and make us aware of some common instances of nomenclature in the world of medical diagnosis and treatment options that keep evolving based on new evidence.

This was because i had a takeover of a patient who had previously been diagnosed with Gilmores groin and i was unsure of what this was. I did my research and it turned out to be a condition that had been referred to in our lectures as sports hernia.

So what?

My lack of knowledge over this updated versions of the diagnosis caused me confusion. I also felt awkward and unprepared when I had to explain the diagnosis to the patient for a second time using an alternative name even though it meant the same thing. This made me realise how important it is to keep our knowledge up to date especially in osteopathy where we often have to collaborate with other healthcare professionals.

Now what?

I will make sure that with every diagnosis will not only be up to date which the range of possible treatment options and osteopathic techniques but also the variations of ways to say the same conditions and what is most widely used in recent research.

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Overview

What is a sports hernia (athletic pubalgia)?

A sports hernia (also called athletic pubalgia, sportsman's hernia and Gilmore's groin) is an injury (usually a tear) in the muscles and/or tendons in your lower abdomen or groin that causes chronic pain. People who have a sports hernia can also experience nerve irritation from the injury, which can contribute to the pain and sensitivity of the affected area. The name "sports hernia" is misleading because there is no actual hernia involved. Healthcare professionals prefer to use the term "athletic pubalgia."

A sports hernia most often happens to people who play sports that require sudden changes of direction or severe twisting movements, but you don't have to be playing a sport to get a sports hernia.

Where do sports hernias occur on the body?

Sports hernias happen in the soft tissue of your lower abdomen or groin area. Specific soft tissues that are commonly affected include:

Your oblique muscles in your lower abdomen.

Your tendons that attach your oblique muscles to your pubic bone (part of your pelvis).

Your tendons that attach your thigh muscles to your pubic bone (part of your pelvis).

What is the difference between a sports hernia and a hernia?

Despite its name, a sports hernia is not actually a hernia. Healthcare professionals prefer to call a sports hernia "athletic pubalgia." Although a hernia and a sports hernia symptoms are similar, the pain of a sports hernia is caused by soft tissue damage, such as a tear, in the lower abdomen or groin. A muscle or tendon is usually torn. The pain from a hernia is due to a gap in your abdominal muscle that causes your intestine or other soft tissue to protrude through, creating a bulge under the skin.

A sports hernia (athletic pubalgia) can lead to a hernia, but in that case, the traditional hernia is considered a separate injury from the athletic pubalgia.

Which sports cause sports hernias?

Sports that involve repetitive, forceful motions, especially twisting your pelvis, can damage or cause a tear in the soft tissue of your lower abdomen or groin (a sports hernia). Sports that are most likely to cause a sports hernia include:

How common are sports hernias?

Approximately 5% of adult athletes experience sports hernias every year. Sports hernias are more common in people who play sports that involve frequent and forceful twisting and turning.

Who do sports hernias affect?

Athletes who play sports that involve sudden, forceful movements, especially twisting of the pelvis, are most likely to get a sports hernia. Males are much more likely to get a sports hernia than females. Athletes between the ages of 26 and 28 most commonly develop a sports hernia. It is rare for older people and children to get sports hernias. You don't have to be an athlete to get a lower abdomen or groin injury (sports hernia), but it is more common in athletes.

Symptoms and Causes

What causes a sports hernia (athletic pubalgia)?

A sports hernia (athletic pubalgia) happens when the deep layers of your lower abdominal wall or the tendons that attach muscles to your pelvis weaken or tear. The following situations can cause or contribute to a sports hernia:

Forceful and repetitive hip movements, like twisting, kicking, jumping and cutting/slicing.

Vigorous and unsafe abdominal and hip exercises.

Weakness in the abdominal muscles and a lack of proper sports conditioning.

An imbalance in strength between your hip and abdominal muscles.

What are the symptoms of a sports hernia?

The main symptom of a sports hernia is ongoing (chronic) pain in your lower abdomen and/or groin. The following descriptions and situations of the pain more specifically apply to a sports hernia:

You experience sudden and intense pain at the time of the injury.

The pain is ongoing (chronic) and feels dull or burning.

It's difficult to pinpoint the exact area of the lower abdomen and groin that the pain is coming from.

The pain radiates downward to your scrotum and/or inner thigh.

You feel pain when you're exerting yourself, especially when sprinting, twisting, kicking or sitting up.

You feel pain in your groin when you cough or sneeze.

You have to stop participating in your sport or significantly cut back on your physical activity because of the pain.

The pain may go away after you've rested, but it comes back during sports activities.

Diagnosis and Tests

How is a sports hernia (athletic pubalgia) diagnosed?

Sports hernias can be difficult to diagnose because many conditions and injuries can cause pain in your groin area, such as hip-joint osteoarthrosis, rectal or testicular pain, or a fracture of the pelvis. In addition, you can feel pain in your groin area from injuries that originate in other parts of your body such as your leg. This is known as referred pain. It happens because you have many nerves in your groin area that extend to other areas.

To diagnose a sports hernia, your healthcare provider will do a thorough examination of your symptoms and history and perform a physical exam. They may also have you undergo imaging procedures to either confirm athletic pubalgia or rule out other possible injuries.

What tests are used to diagnose a sports hernia?

Your healthcare provider will ask you questions about your symptoms and history to see if you could have a sports hernia. They will then give you a physical exam to assess your injury and pain. They will probably ask you to do a sit-up and/or flex your abdomen against resistance. If you have a sports hernia, these exercises will be painful.

Because a sports hernia is a broad condition and you could have other conditions that are causing your groin pain, your healthcare provider may have you undergo imaging tests. These can include:

These imaging tests will help your healthcare provider determine if you have a sports hernia (athletic pubalgia) or something else.

Management and Treatment

How is a sports hernia (athletic pubalgia) treated?

In general, the goals of sports hernia treatment and rehabilitation are to relieve pain, restore range of motion, restore strength, return function and return to sports and activities. Treatment plans for a sports hernia depend on many factors such as the severity of the injury, your age, your health, and what level of activity you want to return to. Sports hernias can be treated with non-surgical treatment or surgery. If you have a sports hernia, your healthcare provider will most likely have you go through non-surgical treatment first to see if that fixes your sports hernia before turning to surgery.

Types of non-surgical treatment for sports hernias include:

Rest: Within the first seven to 10 days after the initial injury that caused the sports hernia, rest and ice can help.

Physical therapy: Two weeks after your injury, your healthcare team may have you do physical therapy. These exercises will help to improve your strength and flexibility in your abdominal and inner thigh muscles.

Anti-inflammatory medications: Anti-inflammatory medications such as ibuprofen and naproxen help reduce swelling and pain. Your healthcare provider may suggest taking this kind of medication for your treatment.

Corticosteroids: Commonly referred to as steroids, corticosteroids are a type of anti-inflammatory drug. Your healthcare provider may recommend a cortisone injection if standard anti-inflammatory medications are not working.

If you are still experiencing pain two to six months after non-surgical treatment, surgical treatment is usually needed to fix your sports hernia. The specific kind of surgery depends on which muscles or tendons are injured and the severity of the injury. General types of surgical treatment include:

Laparoscopic surgical procedure: Laparoscopic surgery involves small cuts (incisions) and a slender tool that has a tiny camera at the end of it. The surgeon is able to insert the camera tool into a small incision to "see" inside the body. They will insert other surgery tools into other small incisions to perform the surgery. Laparoscopic surgery is minimally invasive.

Open surgical procedure: Open surgery involves cutting the skin and tissues open so that the surgeon can see the area that they are performing surgery on.

Surgical rehabilitation: After surgery, your healthcare team will develop a physical therapy and rehabilitation plan specific to your needs to help you regain your strength and stamina.

Do sports hernias heal on their own?

A sports hernia usually requires formal treatment other than rest, so it is unlikely that a sports hernia will heal on its own. Physical therapy, anti-inflammatory drugs and/or corticosteroids are often needed to treat a sports hernia. In some cases, surgery is needed. A groin injury that is not a sports hernia, such as a mild muscle strain, could heal on its own.

What type of physical therapy is needed for a sports hernia?

The overall goal of physical therapy to manage a sports hernia is to improve strength and flexibility in your abdominal muscles and hips without making the injury and pain worse. Your healthcare team will tailor your physical therapy plan to be as specific to your sport and your injury as possible.

Common physical therapy methods for sports hernias include:

Core exercises.

Stretching.

Swimming.

Yoga.

Posture stability.

Using medicine balls.

Using resistance bands.

Prevention

Can I prevent a sports hernia (athletic pubalgia)?

Sports hernias (athletic pubalgia) can be difficult to prevent because of the stress and strain placed on the pelvis and hips in certain sports. Your healthcare team may recommend a sports hernia prevention program if you are at high risk for a core muscle or tendon injury due to the type of sport you play. A sports hernia prevention program may include:

Abdominal and core strengthening exercises.

Exercises to strengthen the hip muscles.

Exercises to improve flexibility and minimize strain across the lower abdominal area where core muscle injuries often occur.

Outlook / Prognosis

How long does it take to recover from a sports hernia?

The treatment and recovery for a sports hernia (athletic pubalgia) depend on the type and severity of the injury. In general, people who have a sports hernia and go through physical therapy treatment experience significant improvement in their symptoms after six to eight weeks of physical therapy.

Approximately 90% of surgeries, both open and laparoscopic, to fix sports hernias (athletic pubalgia) are considered successful. With post-surgery physical therapy and rehabilitation, people with a sports hernia can usually fully return to their sport or activities between six and 12 weeks.

In some cases, the affected tissue can tear again once you return to sports activity. If this happens, surgical repair will most likely need to be repeated.

Living With

When should I see my healthcare provider?

If you're experiencing symptoms of a sports hernia (athletic pubalgia) be sure to contact your healthcare provider. Sports hernias do not generally heal on their own, so you'll likely need treatment.

If you're in the process of treating your sports hernia and experience new or worsening symptoms, be sure to contact your healthcare team.

What questions should I ask my doctor?

It may be helpful to ask your healthcare provider the following questions after you've been diagnosed with a sports hernia (athletic pubalgia):

What kind of sports hernia (athletic pubalgia) do I have?

What is my treatment plan?

Will I need surgery?

How long will it take to recover?

When can I resume exercise and sports?

How can I prevent this from happening again?

A note from Cleveland Clinic
While we all experience pain from time to time, chronic pain is not normal. Be sure to see your healthcare provider if you are experiencing ongoing pain in your lower abdomen or groin. Sports hernias don't usually heal on their own, so you will likely need treatment in order to feel better. Even though it can be upsetting to have to take a break from playing your sport, it is important to follow your healthcare team's instructions for sports hernia recovery and allow your body to heal before returning to sports and exercise.

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Sports Hernia: Symptoms, Treatment, Recovery & Diagnosis

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A sports hernia (also called athletic pubalgia, sportsman's hernia and Gilmore's groin) is an injury (usually a tear) in the muscles and/or tendons in your lower abdomen or groin that causes chronic pain. People who have a sports hernia can also experience nerve irritation from the injury, which can contribute to the pain and sensitivity of the affected area.

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You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

Year 4 - CEX 2

With my tutors feedback it is easier to understand how to improve - he expressed to me that in an exam the examiners can not mark us on the effectiveness of our techniques but only the way they look to the outside eye and thats something i need to work on as another layer of the CCA exam.

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Functional Role of Milk Fat Globule-Epidermal Growth Factor VIII in Macrophage-Mediated Inflammatory Responses and Inflammatory/Autoimmune Diseases

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You must be aware of your wider role as a healthcare professional to contribute to enhancing the health and wellbeing of your patients

Increase milk intake? Really?

What?

I recently have been treating a patient with polymyalgia rheumatica (PMR), and she has been doing very well. She has also been seeing other health professionals as she is currently trying to reduce her dose of steroids.

She has explained that she has recently ‘ballooned’ in size - but i can see that this is fluidly and not fatty and she knows that this is an associated symptom of trying to reduce her intake of her prescribed steroids (under the supervision of her rheumatologist. When she expressed these concerns to her consultant the advice given was to limit her consumption of carbohydrates and sugars and increase milk intake.

From prior knowledge i know that milk is an inflammatory food and so I wasn’t sure what the consultant rheumatologist was trying to achieve with this advice. Also, my patient has quite an obsessive, disciplined personality and i didn’t want her to completely cut out sugars/carbs because in the long term they are needed for normal body function. I have made the decision that my knowledge is very limited on the topic of nutrition and so i referred my patient to a local nutritionist that i know from working in a local multidisciplinary practice a sports massage therapist. I felt that she would be able to give my patient more informed advice about how to go forward.

I felt this was a positive next step and i have done lots of work osteopathically with her and mechanically she is moving very well after our course of treatments together.

So what?

I felt very frustrated as i felt that she had been given counterproductive advice, however I couldn’t comment too much as i am aware my knowledge in nutrition is limited. Luckily i believe i made the right decision by using the resources around me to enhance my patients health by realising the limits of my own training.

Now what?

Moving forward, for my own knowledge i am going to enrol in a course to expand my knowledge and be able to give my patients the best care i possibly can. However, until then i will be making sure i utilise other healthcare professionals around me to ensure a multidisciplinary approach as recommended by the NICE guidlines.

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Inflammation involves a series of complex biological processes mediated by innate immunity for host defense against pathogen infection. Chronic inflammation is considered to be one of the major causes of serious diseases, including a number of autoimmune/inflammatory diseases, cancers, cardiovascular diseases, and neurological diseases. Milk fat globule-epidermal growth factor 8 (MFG-E8) is a secreted protein found in vertebrates and was initially discovered as a critical component of the milk fat globule. Previously, a number of studies have reported that MFG-E8 contributes to various biological functions including the phagocytic removal of damaged and apoptotic cells from tissues, the induction of VEGF-mediated neovascularization, the maintenance of intestinal epithelial homeostasis, and the promotion of mucosal healing. Recently, emerging studies have reported that MFG-E8 plays a role in inflammatory responses and inflammatory/autoimmune diseases. This review describes the characteristics of MFG-E8-mediated signaling pathways, summarizes recent findings supporting the roles of MFG-E8 in inflammatory responses and inflammatory/autoimmune diseases, and discusses MFG-E8 targeting as a potential therapeutic strategy for the development of anti-inflammatory/autoimmune disease drugs.

1. Introduction

Inflammation is the first-line of defense protecting our bodies from harmful stimuli, including pathogen invasion, irritants, and apoptotic or damaged cells [ 1, 2]. The features of inflammation include heat, pain, redness, swelling, the recruitment of various immune cells to the inflammatory tissues, the destruction of tissues, and the dysfunction of organs. Inflammation is categorized as either acute or chronic. Acute inflammation is an immediate immune response at the injured or infected sites, whereas chronic inflammation that develops from continuous inflammatory stimuli involves prolonged immune responses that can last for several weeks to years and is characterized by cycles of active inflammation, tissue injury, and healing. More importantly, chronic inflammation is a major causative factor of a number of inflammatory/autoimmune diseases, including rheumatoid arthritis, systemic lupus erythematosus, asthma, psoriasis, atherosclerosis, diabetes mellitus, and Alzheimer's disease [ 3- 6]. The inflammatory response is a complex biological process that actively involves many types of inflammatory immune cells. Among these immune cells, macrophages, a type of white blood cell that is developed in the myeloid cell lineage, are key players in the inflammatory response. Once macrophages are activated by inflammatory stimuli, they initiate inflammatory responses and produce inflammatory mediators such as nitric oxide (NO), prostaglandin E ₂ (PGE ₂), reactive oxygen/nitrogen species (ROS/RNS), and proinflammatory cytokines such as tumor necrosis factor-alpha (TNF- α), interleukin-1 beta (IL-1 β), and IL-6 through activating intracellular signaling cascades composed of different types of kinases and transcription factors [ 7- 15]. Macrophages are activated and then turn on host defense mechanisms in various ways, such as recognizing pathogen-associated molecular patterns (PAMPs) through pattern recognition receptors (PRRs), phagocytosing pathogens through receptor-mediated endocytosis, and receiving various molecular signals released from other immune cells. Interestingly, recent studies have demonstrated that macrophages are activated and play a crucial role for host defense in inflammatory responses and inflammatory/autoimmune diseases via direct phagocytic engulfment of damaged or apoptotic cells through the formation of macrophage-damaged/apoptotic cell complexes mediated by a "molecular bridge," such as milk fat globule-epidermal growth factor 8 (MFG-E8).

An unknown cDNA sequence and its corresponding protein were first identified in 1990, and its DNA sequences were revealed in mouse mammary epithelial cells [ 16]. This gene was named MFG-E8 because it was highly concentrated in milk fat globules and its amino acid sequences were similar to those of both epidermal growth factor (EGF) and blood coagulation factor V/VIII. MFG-E8, also known as lactadherin or secreted epidermal growth factor repeat and discoidin domain-containing protein 1 (SED-1), is a secreted protein that was initially found as a bridging molecule between damaged or apoptotic cells and phagocytic cells such as macrophages through the release of "eat-me signals" that lead to the macrophage-mediated phagocytic clearance of damaged or apoptotic cells [ 17- 19]. Given its role in clearing damaged/apoptotic cells from various tissues, MFG-E8 has been considered to be an essential regulator of the progression of many inflammatory/autoimmune diseases, and a variety of fields, including pharmacology, molecular medicine, and innate immunity, have begun to study its effects in several experimental animal models of inflammatory/autoimmune diseases [ 20, 21].

In this review, we provide a general introduction to MFG-E8 as a mediator of damaged/apoptotic cell clearance and discuss the roles of MFG-E8 in macrophage-mediated inflammatory responses and inflammatory/autoimmune diseases. Moreover, we further discuss the targeting of MFG-E8 as a potential therapeutic strategy for various inflammatory/autoimmune diseases. The aim of this review is to increase the understanding of the roles of MFG-E8 in macrophage-mediated inflammatory responses in order to provide new insights that can aid in the development of anti-inflammatory drugs for the treatment of macrophage-mediated inflammatory/autoimmune diseases.

2. Structure and Functions of MFG-E8

2.1. Structure and Posttranslational Modification of MFG-E8

MFG-E8 is a 46 kDa secreted glycoprotein consisting of an N-terminal signal peptide that directs MFG-E8 into the extracellular environment, EGF repeats, and discoidin domains (Figure 1(a)) [ 19]. The EGF repeats and discoidin domains were named because of their sequence similarities to EGF and blood coagulation factor V/VIII, respectively. Both the EGF repeats and discoidin-like domains have two similar copies (EGF repeat-1 and EGF repeat-2 and discoidin domain-1 and discoidin domain-2, resp.), and these bimotif structures facilitate the recognition and scavenging of apoptotic cells from tissues [ 19]. The second EGF repeat contains a highly conserved arginine-glycine-aspartate (RGD) motif, which is critical for binding with the -integrin of phagocytic cells. The two discoidin-like domains recognize apoptotic cells through their interaction with anionic phosphatidylserine/phosphatidylethanolamine (PS/PE) (Figure 1(a)) and also bind with collagen through their homologous sequences present in the collagen receptors DDR1 and DDR2, which mediate the turnover of the extracellular matrix [ 22]. Two isoforms of murine MFG-E8, a long and short form generated by alternative splicing, have been identified [ 23]. The main difference between these two forms is that the long form contains proline/threonine-rich repeats (P/T) between its EGF repeat-2 and discoidin domain-1, while the short form does not (Figure 1(b)). The structure of human MFG-E8 is simpler than that of murine MFG-E8. Human MFG-E8 has two discoidin domains similar to murine MFG-E8 but only has one EGF repeat (Figure 1(c)). Two isoforms of human MFG-E8 have been reported as splicing variants. Isoform 1 differs from the canonical MFG-E8 because it is missing amino acid sequences from 1 to 75 and isoform 2 is even shorter than isoform 1, missing amino acid sequences 291-342 of the canonical MFG-E8. MFG-E8 is structurally and functionally homologous to DEL-1 (developmental endothelial locus-1), which plays critical role in the phagocytosis of apoptotic cells [ 24]. DEL-1 binds with PS and integrins on apoptotic cells to induce phagocytic activity.

MFG-E8 is highly glycosylated in vivo [ 23, 51- 53]. Although MFG-E8 has been found to be glycosylated on both N- and O-glycosylation sites, O-glycosylation only occurs on the threonine residues in the P/T-rich repeat regions in the long form. The glycosylation sites can easily be modified to facilitate the interaction between apoptotic cells and macrophages, and this interaction delivers signals to the macrophages to consume the apoptotic cells [ 53]. MFG-E8 is phosphorylated as well. Using the CRISPR/Cas9 genome editing technique, mass spectrometry, and biochemical analysis, MFG-E8 has been identified to be phosphorylated on the serine 42 residue by Fam20C kinase [ 54].

2.2. Expression and Localization of MFG-E8

MFG-E8 is a peripherally secreted glycoprotein that mediates the phagocytosis of apoptotic cells. It shows ubiquitous pattern of expression in various types of cells and tissues. MFG-E8 is secreted from dendritic cells, including bone marrow-derived immature dendritic cells, follicular dendritic cells in the germinal center, and Langerhans cells in the skin [ 55, 56]. MFG-E8 is also expressed and secreted from bone marrow-derived macrophages and peritoneal macrophages after activation. It has been reported that bone marrow-derived immature dendritic cells secrete 30-fold more MFG-E8 than bone marrow-derived macrophages in the presence of granulocyte-macrophage colony-stimulating factor (GM-CSF) [ 55]. GM-CSF also increases the secretion of MFG-E8 from macrophages [ 26, 55], which is enhanced by fractalkine (CX3CL1) [ 25, 37].

Intensive immunohistochemical staining studies have revealed MFG-E8 expression and localization in various types of tissues. MFG-E8 is expressed around and on the apical surface of the alveolar epithelium of involuting mammary glands and the MFG-E8 secreted from the nascent cells was localized to the lumen and the apical surfaces of the epithelium [ 57]. Another immunostaining study of mouse and rat eyes showed that MFG-E8 is expressed in the inner layer of photoreceptor cells and in retinal pigment epithelial cells [ 58]. MFG-E8 expression has also been found in intestinal tissues. The abundant expression of MFG-E8 was observed in the cytoplasmic and extracellular regions of the lamina propria and the mononuclear cells of the injured colonic mucosa in the intestinal tissues of mice with acute colitis [ 20]. MFG-E8 has also been detected in skin tissue and is expressed in the spinous layer of murine skin and is also localized in the cells between the basal and surface layers of neoplastic skin tissue [ 59].

2.3. Regulation of MFG-E8 Expression

Since altered expression of MFG-E8 causes disruptions of homeostasis and is correlated with a number of diseases, the tight regulation of MFG-E8 expression is critical. A number of studies have identified various factors that modulate the expression of MFG-E8. Taking advantage of the function of MFG-E8 binding with the apoptotic cells to be phagocytosed and removed by macrophages, an in vitro study clearly showed that the coculture of macrophages with apoptotic cells highly induced MFG-E8 levels as compared to macrophage culture alone [ 29]. Some molecules of the innate immune system have been reported to regulate MFG-E8 expression. Fractalkine, also known as chemokine C-X3-C motif ligand 1 (CX3CL1) and neurotactin in mice, is primarily expressed in endothelial cells and has the function of chemoattracting immune cells and promoting the strong adhesion of leukocytes to activated endothelial cells. It has been shown that fractalkine induces MFG-E8 expression in microglial cells through its cellular receptor CX ₃CR1 [ 25]. Granulocyte monocyte-colony stimulating factor (GM-CSF), a white blood cell growth factor, is a cytokine that differentiates stem cells into granulocytes and protects against tumors and infection. Jinushi et al. reported that GM-CSF is required for MFG-E8 expression in antigen presenting cells (APCs) for MFG-E8-mediated uptake of apoptotic cells in GM-CSF-triggered immunity [ 26]. In addition, the expression of MFG-E8 in macrophages isolated from various organs in GM-CSF-deficient mice was dramatically decreased. MFG-E8 expression is upregulated during lactation when prolactin hormone production is high in the mammary glands and circulated in the blood [ 27, 60]. Based on this observation, an in vitro study was performed to determine whether prolactin could regulate MFG-E8 expression which clearly showed that prolactin upregulated MFG-E8 expression in mammary epithelial cells and macrophages via the prolactin receptor [ 27, 28]. Peroxisome proliferator-activated receptor-delta- (PPAR-) δ, a member of the nuclear receptor proteins, is a transcriptional sensor for apoptotic cells, and PRAP- δ-deficient mice have been shown to develop autoimmune diseases due to the accumulation of apoptotic cells in the body. It has been reported that PPAR- δ induces the expression of opsonin genes, including MFG-E8, to remove apoptotic cells and to maintain self-tolerance by macrophages [ 29]. MFG-E8 expression is also known to be downregulated by several factors. Lipopolysaccharide (LPS) is a component of the cell wall of gram negative bacteria that induces inflammatory responses in innate cells, such as macrophages. It was reported that the expression levels of MFG-E8 in the serum, spleen, and other organs of mice injected with LPS were significantly decreased [ 33, 34], and, in accordance with this observation, LPS downregulated MFG-E8 expression in mouse peritoneal macrophages and the macrophage-like cell line, Raw264.7, via toll-like receptor 4 (TLR4)/CD14 signaling pathways [ 34]. The expression of gap junction protein plays a critical role in controlling the growth of a variety of transformed cells, likely regulating the expression of a number of growth factors. The gap junction protein connexin 43 was reported to be a negative regulator of MFG-E8 expression and has been shown to inhibit the growth of glioma cells through the suppression of MFG-E8 expression [ 35].

Interestingly, MFG-E8 is differentially expressed and secreted in some disease conditions. The expression of MFG-E8 in humans and in some animal models is reduced in autoimmune disease [ 18], rheumatoid arthritis (RA) [ 36], sepsis [ 34, 37- 40], acute colitis [ 20], atherosclerosis [ 41], ischemia/reperfusion (I/R) injury [ 42], and Alzheimer's disease [ 43]. In contrast, MFG-E8 expression is elevated in other disease conditions, such as lung fibrosis [ 22], melanoma [ 30], breast cancer [ 31], and systemic lupus erythematosus (SLE) [ 32]. The regulation of MFG-E8 expression is summarized in Table 1.

2.4. Mechanism of Action and Functions of MFG-E8

The most remarkable function of MFG-E8 is the phagocytosis and removal of apoptotic cells. The recognition of apoptotic cells is thought to be accomplished by the release of so-called "eat-me" signals from apoptotic cells, which recruit phagocytes such as macrophages and dendritic cells, leading to the clearance of dying cells [ 61, 62]. One of the major characteristics of apoptotic cells is to expose PS as an "eat-me" signal from its inner membrane leaflet to the external membrane surface, which is the key process for apoptotic cells to be recognized and engulfed by phagocytes. Although several receptors and soluble proteins that recognize PS on apoptotic cells have been reported, the mechanisms through which they clear apoptotic cells have been poorly understood. MFG-E8 was first reported to bind with PS and mediate the phagocytosis of apoptotic cells by peritoneal macrophages [ 19]. MFG-E8 produced from activated peritoneal macrophages binds with the PS of apoptotic cells through its C-terminal discoidin domains and also attaches to the -integrin expressed on activated macrophages through the terminal RGD motif of the EGF repeats (Figure 2). The formation of this MFG-E8-mediated complex mediates conformational changes in integrin that triggers signal transduction, leading to cytoskeletal rearrangements in the macrophages that enhance the phagocytic capacity of apoptotic cells. The deletion of C-terminal discoidin domains results in a loss of the ability to bind with PS in the membrane of apoptotic cells [ 53], and a point mutation of the RGD motif in the EGF repeat inhibits phagocytosis through the masking of PS in apoptotic cell membranes [ 63]. There is evidence that the levels of MFG-E8 are critical for its function. The phagocytosis of apoptotic cells is enhanced by low levels of human MFG-E8 (hMFG-E8), whereas high levels of hMFG-E8 inhibit phagocytosis in a dose-dependent manner [ 32]. Similar to its role in the clearance of apoptotic cells, MFG-E8 also removes a variety of unwanted molecules, debris, and microvesicles from different organs. MFG-E8 has been reported to remove excessive collagen in lung tissues, binding with collagen through its two discoidin domains, and facilitating collagen uptake by alveolar macrophages [ 22]. MFG-E8 is also involved in the clearance of defective red blood cells (e.g., sickle cells), mediating phagocytosis by macrophages in the blood. This role suggests that MFG-E8 has an important function in protecting the body from diseases due to abnormal red blood cells, such as sickle cell anemia.

MFG-E8-deficiency results in the impairment of the ability to remove apoptotic cells and disrupts the homeostasis of bodily functions. New insights have been gained through the in vivo study of MFG-E8 −/− mice, which have been generated by deleting exons 4 to 66 of the MFG-E8 gene [ 18]. In wild-type mice, a large number of lymphocytes generated from the bone marrow form germinal centers in the spleen and lymph nodes. During germinal center formation, a massive number of cells undergo apoptosis, a process that is highly regulated. In MFG-E8 −/− mice, multiple enlarged germinal center and splenomegaly are observed, indicating that MFG-E8 is critical for the appropriate apoptosis of lymphocytes during the development of the immune organs. MFG-E8 is also critical for the phagocytosis of apoptotic epithelial cells in the mammary glands, which is important for its involution. MFG-E8 −/− mice were observed to have macrophages with an impaired ability to clear apoptotic epithelial cells due to the lack of MFG-E8 and the inefficient redevelopment of the mammary glands, leading to impairment of mammary gland involution [ 64]. Therefore, MFG-E8 plays a crucial role in the recognition and removal of apoptotic cells by phagocytosis, and its deficiency results in a breakdown in self-tolerance and homeostasis.

3. MFG-E8 in Inflammatory Responses and Inflammatory/Autoimmune Diseases

3.1. Role of MFG-E8 in LPS-TLR4 Signaling

TLR4 is the biological receptor for LPS, one of the most abundant and pathogenic molecules in the cell walls of gram negative bacteria. LPS-triggered TLR4 signaling activates inflammatory responses through the activation of nuclear factor kappa B (NF- κB) and mitogen-activated protein kinase (MAK) signaling pathways, leading to the induction of proinflammatory cytokines such as tumor necrosis factor-alpha (TNF- α), interleukin-1 beta (IL-1 β), and IL-6, as well as inflammatory mediators such as nitric oxide (NO), reactive oxygen/nitrogen species (ROS/RNS), and prostaglandin E ₂ (PGF ₂). It has been demonstrated that MFG-E8 expression is regulated by the LPS-TLR4 signaling pathway. In vitro and ex vivo studies clearly show that LPS downregulates the expression of MFG-E8 in both Raw264.7 murine macrophage cell lines and peritoneal macrophages [ 37, 39]. This observation was confirmed in vivo by cecal ligation and puncture (CLP) sepsis animal models. The splenic mRNA expression of MFG-E8 was reduced in the CLP sepsis mice injected with LPS in a dose-dependent manner, and this reduction was significantly attenuated by the administration of polymyxin B, which neutralizes LPS. In addition, this suppression of splenic mRNA expression of MFG-E8 in CLP sepsis animals was not observed in TLR4-mutated or CD14 −/− mice [ 34], strongly indicating that MFG-E8 expression is negatively regulated by LPS through the TLR4 signaling pathway. Moreover, MFG-E8 has also been reported to have an anti-inflammatory role in LPS-TLR4-mediated inflammatory responses during the phagocytosis of apoptotic cells. In coculture conditions of macrophages with apoptotic cells, MFG-E8 decreased the LPS-induced production of proinflammatory cytokines from macrophages through the suppression of the activities of intracellular signaling molecules, including p38, extracellular signal-regulated kinase (ERK)1/2, and c-Jun N-terminal kinase (JNK) in the mitogen-activated protein kinase (MAPK) signaling pathway as well as the activity of p65 in the NF- κB signaling pathway [ 33]. In accordance with this observation, MFG-E8 suppressed inflammation in sepsis and ischemia/reperfusion conditions with LPS-TLR4 signaling by reducing the production of proinflammatory cytokines such as TNF- α, IL-1 β, and IL-6 [ 21, 40]. Moreover, the uptake of apoptotic cells significantly suppressed LPS-induced inflammatory responses not only through decreasing the production of proinflammatory cytokines including TNF- α and IL-12, but also by increasing the production of the anti-inflammatory cytokine IL-10. This anti-inflammatory action was mediated by PPAR-d, which can induce the expression of MFG-E8 and other types of opsonins [ 29]. MFG-E8 also shows a direct anti-inflammatory role independent of the phagocytic engulfment of apoptotic cells. Recombinant MFG-E8 lowered intestinal inflammation by directly regulating TLR4 signaling through its binding with integrin , and the phagocytosis of apoptotic cells was not involved in this MFG-E8-mediated suppression of inflammation [ 20]. Another study revealed the direct anti-inflammatory function of MFG-E8 through a different mechanism. MFG-E8 suppressed inflammatory responses and in turn the production of TNF- α in macrophages through the STAT-3-mediated activation of suppressor of cytokine signaling 3 (SOCS3), which is a negative regulator of the LPS-induced TLR4 signaling pathway by the inhibition of NF- κB p65 [ 65]. These findings strongly support the anti-inflammatory role of MFG-E8 in the LPS-TLR4 signaling pathway, and this MFG-E8-mediated anti-inflammatory function is achieved through the phagocytosis of apoptotic cells as well as the direct inhibition of LPS-TLR4 signaling independent of the phagocytosis of apoptotic cells (Figure 3).

3.2. Role of MFG-E8 in Inflammatory/Autoimmune Diseases

3.2.1. SLE

The expression level of MFG-E8 has been thought to correlate with the pathogenesis of SLE. MFG-E8 −/− mice showed many unengulfed apoptotic cells in the germinal centers of the spleen, and autoimmune disease was induced in these mice with symptoms similar to that of human SLE, indicating that MFG-E8 has a critical role in removing apoptotic cells and that the complete loss of MFG-E8 causes SLE-like autoimmune disease [ 18]. Interestingly, an in vitro study demonstrated that MFG-E8-mediated engulfment of apoptotic cells shows a bell-shaped efficiency curve in response to MFG-E8 at increasing concentrations in the macrophages isolated from MFG-E8 wild-type mice [ 32], indicating that the ability of macrophages to engulf apoptotic cells is also inhibited by high levels of MFG-E8. This could be explained by the bridge model for the engulfment of apoptotic cells by macrophages. High levels of MFG-E8 can saturate both apoptotic cells and macrophages, leading to the masking of the bridging between apoptotic cells and macrophages, thereby inhibiting the engulfment of apoptotic cells [ 32]. The correlation between MFG-E8 and SLE has also been studied in humans. The serum level of MFG-E8 was found to be higher in SLE patients as compared to very low or undetectable levels in healthy controls; in addition, the medical treatment of SLE resulted in significantly lower levels of MFG-E8 in patients [ 32]. Genetic variations in the MFG-E8 gene have also been studied in SLE patients. One study compared single nucleotide polymorphisms in the coding region of MFG-E8 between healthy controls and SLE patients and found that genetic polymorphisms on MFG-E8 residue 76(Met) allele predisposed participants to SLE in a recessive manner, while the variation of the MFG-E8 residue 76(Leu) allele was negatively associated with SLE [ 66].

3.2.2. Rheumatoid Arthritis and Osteoarthritis

Some studies have demonstrated that MFG-E8 plays a role in inflammatory degenerative bone diseases such as RA and osteoarthritis (OA). The expression of MFG-E8 is downregulated in inflammatory conditions and has also been found to be downregulated in the sera of RA patients, while an in vitro study revealed that MFG-E8 suppresses inflammatory responses by suppressing the production of proinflammatory cytokines. Moreover, the expression of MFG-E8 is decreased in arthritic mice, and the loss of MFG-E8 exacerbated arthritis and led to more severe bone loss in mice by inducing the production of proinflammatory cytokines and the infiltration of pathogenic neutrophils in the inflamed joints [ 36]. MFG-E8 is also expressed in human and mouse osteoclasts and modulates their development and function. Genetic deletion of the MFG-E8 gene and antibody-mediated neutralization of MFG-E8 clearly induced osteoclastogenesis and enhances inflammation-induced bone loss, whereas local administration of MFG-E8 prevented bone loss in mice [ 67]. This observation was confirmed by another in vivo study showing that the loss of MFG-E8 in mice resulted in low bone mass and promoted ovariectomy-associated bone loss by inducing osteoclastogenesis [ 68].

3.2.3. Sepsis

Sepsis is a high lethal systemic inflammatory disease characterized by the increase in proinflammatory cytokines and the accumulation of apoptotic cells. It has been reported that MFG-E8 is correlated with sepsis. During sepsis, a large number of immune cells undergo apoptosis due to the impairment of apoptotic cell clearance, which then induces secondary necrotic cell development that dysregulates proper immune function and induces the production of proinflammatory cytokines [ 69- 71]. Therefore, studying the function of MFG-E8 could lead to promising therapeutic approaches that facilitate the clearance of apoptotic cells by MFG-E8 in sepsis. Miksa et al. induced a CLP sepsis model in rats and assessed the protein levels of MFG-E8 as well as thymocyte apoptosis. In these rats, the MFG-E8 protein levels were decreased in the spleen and liver by 48% and 70%, respectively, and thymocyte apoptosis was increased 1.6-fold. Moreover, inhibition of MFG-E8 in these rats completely abolished the apoptosis of thymocytes [ 39]. The regulation of MFG-E8 expression in sepsis was also confirmed by another study, which found that MFG-E8 protein levels in CLP rats were decreased in the spleen and the blood, where the clearance of apoptotic cells was impaired, and that the administration of immature dendritic cell- (IDC-) derived exosomes containing MFG-E8 facilitated the phagocytosis of apoptotic cells leading to a reduction in mortality [ 40]. It has been reported that MFG-E8 is constitutively expressed in the macrophages of the intestinal lamina propria in mice and that intestinal MFG-E8 expression was decreased in murine models of sepsis [ 38]. From these studies, it is clear that MFG-E8 expression is downregulated in sepsis, which contributes to the impairment in the clearance of apoptotic cells. The production of proinflammatory cytokines during sepsis is a critical cause of mortality and morbidity in sepsis animal models and in sepsis patients. MFG-E8 has been reported to negatively regulate the production of proinflammatory cytokines in inflammatory/autoimmune diseases and therefore could play a crucial role in sepsis by modulating the inflammatory response. The administration of IDC-derived exosome containing MFG-E8 significantly suppressed the expression of proinflammatory cytokines, including TNF- α, IL-6, and High Mobility Group Box (HMGB1), in CLP sepsis animals [ 39, 40]. In addition, the administration of fractalkine in CLP sepsis animals suppressed the increase in blood lactate levels, liver injury, and proinflammatory mediators, which is associated with decreased MFG-E8 levels [ 37]. Several in vivo studies have demonstrated that MFG-E8 ameliorates the symptoms of sepsis in animal models. The administration of both MFG-E8-containing exosome and recombinant MFG-E8 significantly increased the survival rate by 80% in a CLP sepsis rat model [ 39, 40]. Moreover, the survival rate of sepsis was dramatically reduced in MFG-E8-deficient mice as compared to wild-type mice [ 40]. Although the role of MFG-E8 in sepsis has not been fully elucidated and requires further investigation, these studies strongly suggest that MFG-E8 plays a pivotal role in sepsis via the phagocytosis of apoptotic cells and the modulation of proinflammatory cytokine production, leading to anti-inflammatory effects and survival benefits.

3.2.4. Ischemia/Reperfusion Injury

Ischemia/reperfusion (I/R) injury induces massive apoptotic cell death of the target organ as well as remote organs and also results in the inappropriate clearance of apoptotic cells [ 72- 74]. I/R injury is another inflammatory/autoimmune disease characterized by the production of reactive oxygen species [ 75], cytokine secretion [ 76], complement activation [ 77, 78], mitochondrial dysregulation [ 79], activated leukocyte recruitment [ 80, 81], eicosanoid production [ 82, 83], and cell necrosis and apoptosis [ 84, 85]. An in vivo study using a mouse intestinal I/R injury model found that the expression levels of MFG-E8 mRNA and protein were significantly decreased in the spleen and lung by 50% and 60%, respectively, and that the administration of recombinant MFG-E8 in diseased mice dramatically improved the signs of I/R injury, including the increased levels of proinflammatory cytokines such as TNF- α, IL-1 β, and IL-6, as well as histological markers of organ damage such as serum lactate levels, LDH, ALT, AST, and creatinine, resulting in an increase in the survival rate [ 42]. In addition, the administration of recombinant MFG-E8 decreased the accumulation of apoptotic cells in mouse lungs affected by I/R injury [ 42]. One recent in vivo study using a renal I/R mouse model further revealed that MFG-E8 expressed in macrophages and dendritic cells of the kidneys was reduced in the experimental mice, while the administration of recombinant MFG-E8 attenuated the signs of renal I/R injury, including renal function, histological tubular injury, and the induced levels of proinflammatory mediators such as IL-1 β, IL-6, macrophage inflammatory protein-2, and myeloperoxidase [ 21]. These findings strongly indicate that MFG-E8 prevents organ damage under I/R conditions through its anti-inflammatory properties and could be an efficient therapeutic tool in I/R injury.

3.2.5. Atherosclerosis

MFG-E8 is also expressed in both normal and atherosclerotic arteries in humans and has been reported to play a role in the phagocytic clearance of apoptotic cells by macrophages. The physiological role of MFG-E8 in the development of atherosclerosis was examined by reconstituting wild-type or Mfg-e8-deficient bone marrow into irradiated atherosclerosis-susceptible mice. MFG-E8-deficiency in a murine model of atherosclerosis resulted in the mice accumulating apoptotic debris due to decreased apoptotic cell phagocytosis, leading to the acceleration of atherosclerosis [ 41]. MFG-E8-deficiency also regulated the expression of cytokines and the activity of immune cells. MFG-E8-deficiency significantly downregulated the expression of the anti-inflammatory cytokine IL-10 in the spleen, while the expression of interferon- γ was increased in the spleen and arteries of the atherosclerotic mice reconstituted with Mfg-e8-deficient bone marrow [ 41]. Moreover, MFG-E8-deficiency reduced the suppressive functions of regulatory T-cells in the experimental mice [ 41]. This study suggests that the lack of MFG-E8 promotes the accumulation of apoptotic cells in atherosclerosis and suppresses the protective anti-inflammatory responses, thereby leading to acceleration of disease development.

4. MFG-E8-Targeted Drug Development

4.1. Inhibitors and Drugs Targeting MFG-E8

A number of studies have directly targeted MFG-E8 or indirectly intervened in MFG-E8 signaling in various diseases. A humanized monoclonal antibody specific for MFG-E8/lactadherin, Angiolix, showed potential for the treatment of breast and ovarian cancers [ 86]. Moreover, several studies have reported that the direct targeting of MFG-E8 suppresses the proliferation and invasion of vascular smooth muscle cells as well as the apoptosis of arterial endothelial cells [ 87- 89]. Several studies have also found that MFG-E8 and its signaling are indirectly regulated by some natural products, drugs, and inhibitors. Polyphenol polymers, including resveratrol and the grape-seed proanthocyanidin extract procyanidin, which are found in many products, significantly reduced the expression of MFG-E8 induced by advanced glycation end products in arterial endothelial cells [ 90], leading to significant inhibition of apoptosis in arterial endothelial cells [ 88, 89]. Some antidisease drugs have also shown anti-MFG-E8 activity. Enalapril is an angiotensin converting enzyme inhibitor that is commonly used in the treatment of hypertension and heart diseases. Enalapril dramatically reduced MFG-E8 levels in the aorta of experimental hypertensive rats, with concomitant reductions in indices of arterial stiffness and the pulse wave velocity [ 91]. Although this study did not specify the type of cells in which MFG-E8 expression was decreased by Enalapril, it is clear that reduction of MFG-E8 ameliorates the symptoms of hypertension. β-receptor blockers, another agent used in hypertensive and heart disease, have also been shown to suppress MFG-E8 expression in vascular smooth muscle cells and help maintain vascular smooth muscle cell quiescence [ 92]. It has been reported that MFG-E8 production is increased by insulin and glucose in adipocytes [ 93], implying that MFG-E8 expression could be regulated by antidiabetic drugs. Glibenclamide is a drug used for the treatment of type 2 diabetes through the regulation of plasma glucose levels. It may be possible to use glibenclamide to target MFG-E8 expression and its substantial effects in inflammatory responses and inflammatory diseases. The potential of antidiabetic drugs to target MFG-E8, however, is unknown and molecular and cellular mechanism studies of MFG-E8 in diabetes need to be further investigated. Fluvastatin, a 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor, is a drug used for the treatment of hyperlipidemia. It has been reported that circulating microparticles mediated by MFG-E8 are associated with endothelial dysfunction [ 94- 97]. Interestingly, the levels of these microparticles released from the TNF- α-activated cultured human coronary artery endothelial cells are decreased by fluvastatin, leading to improved endothelial functions, suggesting a relationship between antihyperlipidemic inhibitors and the suppression of MFG-E8 signaling [ 98]. However, the studies regarding how MFG-E8 is associated with hyperlipidemia need to be further investigated in molecular and cellular levels.

4.2. MFG-E8 Targeting in Macrophage-Mediated Inflammatory/Autoimmune Diseases

As discussed in Section 3, a number of studies have successfully shown that MFG-E8 plays a crucial role in inflammatory responses and inflammatory/autoimmune diseases, suggesting that the specific targeting of MFG-E8, whether to inhibit or induce its expression, could be a potential strategy to treat and prevent these diseases. Sepsis is a life-threatening inflammatory/autoimmune disease that arises when the body's responses to pathogenic infection injure its own tissues and organs, leading to morbidity and mortality. Miksa et al. investigated the role of MFG-E8 using a sepsis animal model induced in rats by cecal ligation and puncture. MFG-E8 protein levels were decreased in these rats, and the injection of dendritic cell-derived MFG-E8-containing exosomes significantly attenuated the systemic inflammatory responses in these experimental models of sepsis [ 39]. Yang et al. also reported that short peptides derived from MFG-E8 and flanking its RGD motif alleviated the symptoms of organ injury in sepsis, as reflected by the decreased plasma levels of markers of organ injury such as aspartate aminotransferase and proinflammatory cytokines, including IL-6 and TNF- α [ 44]. These studies strongly suggest that the administration of MFG-E8 could be a potential therapeutic for the prevention and treatment of sepsis. The phagocytosis of viable neurons is critical for brain pathology and inhibition of this process is beneficial. MFG-E8 expression is upregulated in microglial cells, and deficiency in its expression suppresses the phagocytosis of neurons and brain atrophy after focal brain ischemia [ 49], indicating that targeting MFG-E8 could be beneficial for brain ischemic injuries. A Japanese group has reported the role of MFG-F8 in colitis using an experimental animal model. The intrarectal administration of recombinant MFG-E8 in trinitrobenzene sulfonic acid-induced colitic mice significantly suppressed colon shortening, body weight loss, and histological inflammation [ 45]. This group further confirmed the anticolitic action of MFG-E8 using butyric acid in a different experimental model of colitis. Butyric acid attenuated the symptoms of experimental colitis induced by the administration of dextran sodium sulfate in C57BL/6N mice and wild-type mice, but this attenuation of symptoms was not observed in MFG-E8 −/− mice [ 46]. These two studies strongly suggest that MFG-E8 is involved in the pathogenesis of colitis and that the administration of MFG-E8 could be a therapeutic approach in the treatment of intestinal inflammatory diseases, including colitis. MFG-E8 was reported to be a critical player in arterial wall inflammatory remodeling during aging, hypertension, diabetes mellitus, and atherosclerosis. The exogenous addition or endogenous overexpression of MFG-E8 promotes the proliferation of vascular smooth muscle cells, whereas the silencing of MFG-E8 or the inhibition of its receptor results in the reduced proliferative ability of these cells [ 47]. These findings suggest that MFG-E8 could be a potential therapeutic agent for the age-associated increase in the proliferation of aortic vascular smooth muscle cells during arterial wall inflammatory remodeling. The phagocytic clearance of apoptotic cells is a crucial process for the prevention of inflammation and autoimmunity. Glucocorticoids ameliorate the symptoms of SLE in mice by enhancing the clearance of apoptotic cells, and the inhibition of MFG-E8 expression via RNA interference or genetic knockout significantly suppressed the phagocytosis-enhancing effects of glucocorticoids in these SLE mice, indicating that the MFG-E8-dependent induction of apoptotic cell clearance is critical for the anti-inflammatory effect of glucocorticoids (Table 2) [ 48]. Atherosclerosis is an inflammatory vascular disease characterized by artery wall thickening as a result of the invasion and accumulation of inflammatory immune cells and is considered to be one of the major complications of type 2 diabetes. Unlike other inflammatory/autoimmune diseases described above, the serum level of MFG-E8 was found to be high in patients with type 2 diabetes mellitus and was positively correlated with carotid-femoral pulse wave velocity. The inhibition of MFG-E8 expression by RNA interference in artic endothelial cells significantly ameliorated atherosclerosis, but the exogenous administration of recombinant MFG-E8 exacerbated the symptoms of atherosclerosis in experimental diabetic mice through the intracellular signaling molecules ERK and monocyte chemoattractant protein 1 [ 50]. Although it is still required to investigate the molecular and cellular mechanisms by which MFG-E8 expression is upregulated in this disease condition, this study suggests that MFG-E8 plays an important role in atherosclerosis in patients with type 2 diabetes mellitus and that targeting MFG-E8 could be a therapeutic approach for the treatment of atherosclerosis in type 2 diabetes mellitus. Taken together, it is clear that although MFG-E8 plays different roles depending on the clinical scenario, the selective targeting of MFG-E8 could be a promising strategy for the prevention and treatment of inflammatory/autoimmune diseases.

5. Conclusions and Perspectives

Inflammation is an essential biological process that protects our body from invasion by pathogens. However, uncontrolled and chronic inflammation leads to inflammatory/autoimmune diseases. Macrophages are major effector immune cells that govern inflammatory responses through various mechanisms. There is increasing evidence that the insufficient clearance of apoptotic or damaged cells is one of the main etiologies of inflammatory/autoimmune diseases, and a number of studies have demonstrated not only that MFG-E8 plays a key role in macrophage-mediated inflammatory responses, but also that the targeted inhibition or administration of MFG-E8 can ameliorate the symptoms of inflammatory/autoimmune diseases. In spite of these promising studies supporting the possibility of MFG-E8 as a therapeutic target for the treatment of inflammatory/autoimmune diseases, few drugs have been developed for these diseases. Targeting MFG-E8 could be a novel and promising strategy for the prevention and treatment of macrophage-mediated inflammatory/autoimmune diseases.

Competing Interests

The author declares that there is no conflict of interests regarding the publication of this paper.

Acknowledgments

The author thanks Professor Jae Youl Cho (Sungkyunkwan University, Korea) for his kind assistance to read the paper critically and support English edition.

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Functional Role of Milk Fat Globule-Epidermal Growth Factor VIII in Macrophage-Mediated Inflammatory Responses and Inflammatory/Autoimmune Diseases

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Inflammation involves a series of complex biological processes mediated by innate immunity for host defense against pathogen infection. Chronic inflammation is considered to be one of the major causes of serious diseases, including a number of autoimmune/inflammatory diseases, cancers, cardiovascular diseases, and neurological diseases.

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CEX Year 4 Feedback

It was a very stressful situation with having lots of patients prepared and then not turning up because there was a big accident in Maidstone meaning lots of roads were shut and people were stuck in traffic as a consequence.

As i was prepared for all of the patients it meant that i could adapt to the situation well however i had a to reflect greatly on what this means for when i am in practice as i am going to have to be prepared for a lot more than 4 patients in a row at any one time and then be prepared for the disappointment if someone doesn’t turn up for their appointment whether that’s within their control or otherwise.

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The Rolfe reflection cycle is a learning process that uses your own experiences and situations you reflect on and improve your practice. It is based on 3 main questions “what?”, “so what?” And “now what?”.

Each of the questions make reference to a different stage of the process. The reflection starts with asking yourself what happened in the situation, what was the problem/experience and what role did you take?

After this come self reflection regarding your actions and more personal thoughts towards the outcome. The last stage is is then to analyse the consequences of the prior steps and think about what you could do to improve/ alter your actions/process moving forward.

Personally i think this reflective model is the most appropriate one for me as i find it useful to be proactive in making quick and pragmatic improvements to my practice, preventing unnecessary overthinking and stress.

As healthcare professionals using reflective practice is equally important and useful on both personal and professional levels. It helps to consolidate all the information that comes from any one situation and helps us to clarify what is required of us. It aids the learning process by exploring the situation on a descriptive level, verbalising your thoughts and then finally analysing the outcome.