Volume 116, Issue 8

Intussusception is an extremely rare diagnosis in adults, with an etiologic process identified in the majority of cases. The authors describe an unusual case of mucosa-associated lymphoid tissue (MALT) lymphoma as the underlying cause of ileocecal intussusception in an elderly woman. The patient presented with complaints of abdominal pain of variable intensity that had increased in severity over the past several months. A contrast-enhanced computed tomographic scan revealed evidence of ileocecal intussusception, and a subsequent exploratory laparotomy revealed high-grade bowel obstruction. Early recognition of intussusception is critical to appropriate management and resolution.

Context: Pain is one of the most common postpartum complaints by women in the United States, and the pain varies in its location. Research on intervention strategies for postpartum pain has focused primarily on the lower back, but pain management for other types of postpartum pain remains unclear. Objective: To investigate the effects of osteopathic manipulative treatment (OMT) on postpartum pain; the location, quality, and timing of pain; and the difference in pain between vaginal and cesarean delivery. Methods: Postpartum patients who reported having pain were recruited at St Barnabas Hospital in Bronx, New York. The short-form McGill Pain Questionnaire was administered along with a screening questionnaire. Second- or third-year residents in neuromusculoskeletal medicine and osteopathic manipulative medicine examined patients and then diagnosed and managed somatic dysfunction with OMT for approximately 25 minutes. The short-form McGill Pain Questionnaire was again administered after OMT. Paired t tests and McNemar tests were used to analyze changes before and after OMT for continuous and categorical variables, respectively. Differences in visual analog scale (VAS) pain scores between patients who had vaginal vs cesarean delivery were tested using analysis of variance, and group differences in pain location were tested using a Pearson χ 2 test. Results: A total of 59 patients were included in the study. The mean VAS score for pain was 5.0 before OMT and 2.9 after OMT ( P <.001). The VAS scores before OMT significantly differed between patients who had a vaginal delivery and those who had a cesarean delivery ( P <.001), but the mean decrease in VAS score was similar in both groups. Decreases in low back pain (34 [57.6%] before and 16 [27.1%] after OMT), abdominal pain (32 [54.2%] before and 22 [37.3%] after OMT), and vaginal pain (11 [18.6%] before and 5 [8.5%] after OMT) were reported after OMT ( P <.05). Conclusion: Preliminary results demonstrate that OMT is efficacious for postpartum pain management. The lack of a control group precludes the ability to make causal claims. Future studies are needed to solidify OMT efficacy and generalizability.

Introduction: Minimalist running entails using shoes with a flexible thin sole and is popular in the United States. Existing literature disagrees over whether minimalist running shoes (MRS) improve perceived severity of injuries associated with running in traditional running shoes (TRS). Additionally, the perceived injury patterns associated with MRS are relatively unknown. Objectives: To examine whether injury incidence and severity (ie, degree of pain) by body region change after switching to MRS, and to determine if transition times affect injury incidences or severity with MRS. Methods: Runners who were either current or previous users of MRS were recruited to complete an Internet-based survey regarding self-reported injury before switching to MRS and whether self-reported pain from that injury decreased after switching. Questions regarding whether new injuries developed in respondents after switching to MRS were also included. Analyses were calculated using t tests, Wilcoxon signed rank tests, and Fischer exact tests. Results: Forty-seven runners completed the survey, and 16 respondents reported injuries before switching to MRS. Among these respondents, pain resulting from injuries of the feet ( P =.03) and knees ( P =.01) decreased. Eighteen respondents (38.3%) indicated they sustained new injuries after switching to MRS, but the severity of these did not differ significantly from no injury. Neither time allowed for transition to MRS nor use or disuse of a stretching routine during this period was correlated with an increase in the incidence or severity of injuries. Conclusion: After switching to MRS, respondents perceived an improvement in foot and knee injuries. Additionally, respondents using MRS reported an injury rate of 38.3%, compared with the approximately 64% that the literature reports among TRS users. Future studies should be expanded to determine the full extent of the differences in injury patterns between MRS and TRS.

Symptomatic obstructive sleep apnea (OSA) affects 2% of women and 4% of men, but the prevalence of asymptomatic OSA is significantly higher. Several ophthalmic conditions are associated with OSA, including floppy eyelid syndrome, glaucoma, nonarteritic anterior ischemic optic neuropathy, papilledema, keratoconus, and central serous chorioretinopathy. The purpose of this review is to provide primary care physicians with a general knowledge of the signs, symptoms, and management of the ophthalmic diseases associated with OSA.

Context: Medical residency education relies heavily on the use of written and oral testing as a means of assessing a learner’s knowledge acquisition. In the United States, osteopathic emergency medicine residents take an annual specialty-based resident in-service examination (RISE) for this purpose. Their performance on the RISE helps direct educators’ approach to teaching and training. Objectives: To determine the correlative strength of residents’ cumulative performance on a series of weekly in-house quizzes with their performance on the RISE. Methods: In this prospective study, emergency medicine residents took a series of 15 quizzes between August 2013 and January 2014. The quizzes were administered using slides integrated with an audience-response system. Quizzes comprised questions gathered from various question banks and commercial test review resources specific to the specialty of emergency medicine. Effort was made to select questions covering topics tested on the RISE. Scores from each of the quizzes were recorded, and these data were analyzed for correlation with residents’ scores on the RISE. Results: Sixteen emergency medicine residents from all 4 postgraduate years participated in the study. For various reasons (vacation, illness, away rotations), not all 16 residents participated in each quiz. The mean participation rate over all 15 quizzes was 76.7%, with a mean quiz score of 57.8%. A correlation analysis was conducted between the achieved RISE score and the mean quiz score (excluding any quizzes not taken). Graphical analysis revealed a sufficiently linear relationship between the 2 variables, with no outliers. Both variables were normally distributed, as assessed by the Shapiro-Wilks test ( P >.05). A strong positive correlation was found between RISE score and mean quiz score ( r [14]=0.75; P =.001), with the mean quiz score over the quizzes taken explaining about 57% of the variance in the achieved RISE score. Conclusions: The results of this study imply that performance on weekly didactic quizzes may be strongly predictive of RISE performance and as such tracking these data may provide insight to educators and learners as to the most effective direction of their educational efforts.

Background: Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement conventional management of musculoskeletal disorders, including those that cause low back pain (LBP). Osteopathic manipulative treatment is defined in the Glossary of Osteopathic Terminology as “The therapeutic application of manually guided forces by an osteopathic physician (U.S. Usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction. OMT employs a variety of techniques” ( eAppendix ). Somatic dysfunction is defined as “Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements. Somatic dysfunction is treatable using osteopathic manipulative treatment.” These guidelines update the AOA guidelines for osteopathic physicians to utilize OMT for patients with nonspecific acute or chronic LBP published in 2010 on the National Guideline Clearinghouse. 1 Methods: This update process commenced with literature searches that included electronic databases, personal contact with key researchers of OMT and low back pain, and Internet search engines. Early in the process, the Task Force on the Low Back Pain Clinical Practice Guidelines discovered the 2014 systematic literature review conducted by Franke et al 2 ; this study serves as the basis for this updated guideline and further builds upon the literature used to support the previous guidelines. Findings from other eligible studies published after the search parameters of the Franke et al systematic review were also incorporated. Results: The authors of the systematic review identified 307 studies. Thirty-one were evaluated and 16 were excluded. Of the 15 studies included in the review, 6 were retrieved from Germany, 5 from the United States, 2 from the United Kingdom, and 2 from Italy. Two additional studies published after the Franke et al review were also included. Osteopathic manipulative treatment significantly reduces pain and improves functional status in patients, including pregnant and postpartum women, with nonspecific acute and chronic LBP. Franke et al found that in acute and chronic nonspecific LBP, moderate-quality evidence suggested that OMT had a significant effect on pain relief (mean difference [MD], −12.91; 95% CI, −20.00 to −5.82) and functional status (standard mean difference [SMD], −0.36; 95% CI, −0.58 to −0.14). More specifically, in chronic nonspecific LBP, the evidence suggested a significant difference in favor of OMT regarding pain (MD, −14.93; 95% CI, −25.18 to −4.68) and functional status (SMD, −0.32; 95% CI, −0.58 to −0.07). When examining nonspecific LBP in pregnancy, low-quality evidence suggested a significant difference in favor of OMT for pain (MD, −23.01; 95% CI, −44.13 to −1.88) and functional status (SMD, −0.80; 95% CI, −1.36 to −0.23). Conversely for nonspecific LBP postpartum, Franke et al found that moderate-quality evidence suggested a significant difference in favor of OMT for pain (MD, −41.85; 95% CI, −49.43 to −34.27) and functional status (SMD, −1.78; 95% CI, −2.21 to −1.35). 2 Conclusion: The conclusions of Franke et al further strengthen the findings that OMT reduces LBP. In a 2005 systematic review conducted by Licciardone et al 3 and the basis of the LBP guidelines published in 2010, it was determined that OMT reduces pain more than expected from placebo effects alone, and these results had the potential to last beyond the first year of treatment. Franke et al specifically stated that clinically relevant effects of OMT were found for reducing pain and improving functional status in patients with acute and chronic nonspecific LBP and for LBP in pregnant and postpartum women 3 months after treatment. Larger randomized controlled trials with robust comparison groups are needed to further validate the effects of OMT on LBP. In addition, more research is needed to understand the mechanics of OMT and its short- and long-term effects, as well as the cost-effectiveness of such treatment.