Volume 117, Issue 6

Background Efficiency and fiscal responsibility are important to the equal, safe, and effective delivery of care in the emergency department, where all presenting patients must be evaluated for emergent conditions. Health care professionals’ understanding of the costs of care is a first step to developing rational approaches for the efficient distribution of the finite resources hospitals and emergency departments have at their disposal to reduce costs to patients and health care systems. Objective To determine emergency department health care professionals’ knowledge of the costs to patients of routine care delivered in the emergency department. Methods An internet-based survey of currently practicing emergency medicine health care professionals with various levels of training (physicians, residents, physician assistants, and nurse practitioners) was conducted to evaluate their ability to identify the cost of care for 3 common presentations to the emergency department: abdominal pain, dyspnea, and sore throat. Results Four hundred forty-one emergency medicine health care professionals participated. In the 3 cases presented, correct costs were determined by 43.0%, 32.0%, and 40.1% of participants, respectively. Geographic region was not related to cost determination. Larger institution size was related to greater cost chosen ( P =.01). Higher level of training was significantly correlated with perceived understanding of cost ( P <.001); however, it was not related to accurate cost assessment in this study. Conclusion Emergency medicine health care professionals have an inadequate understanding of the costs associated with care routinely provided in the emergency department.

Context The substantial functional impairment associated with migraine has both physical and emotional ramifications. Mood disorders are often comorbid in patients with migraine and are known to adversely affect migraine activity. Objectives To explore the effects of osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-trained osteopaths) on pain and mood disorders in patients with high-frequency migraine. Methods Retrospective review of the medical records of patients with high-frequency migraine who were treated with OMTh at the Headache Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Santa Lucia from 2011 to 2015. Clinical assessments were made using the Headache Disability Inventory (HDI), the Headache Impact Test (HIT-6), the Hamilton Depression Rating Scale (HDRS), and the State-Trait Anxiety Inventory (STAI) forms X-1 and X-2. Results Medical records of 11 patients (6 women; mean age, 47.5 [7.8] years) with a diagnosis of high-frequency migraine who participated in an OMTh program met the inclusion criteria and were included in the study. When the questionnaire scores obtained at the first visit (T0) and after 4 OMTh sessions (T1) were compared, significant improvement in scores were observed on STAI X-2 (T0: 43.18 [2.47]; T1: 39.45 [2.52]; P <.05), HIT-6 (T0: 63 [2.20]; T1: 56.27 [2.24]; P <.05), and HDI (T0: 58.72 [6.75]; T1: 45.09 [7.01]; P <.05). Conclusion This preliminary study revealed that patients with high-frequency migraine and comorbid mood disorders showed significant improvement after four 45-minute OMTh sessions. Further investigation into the effects of OMTh on pain and mood disorders in patients with high-frequency migraine is needed.

The One Health concept focuses on the interrelationship between the health of humans, animals, and the environment. There is a delicate balance among these relationships, and when an imbalance exists, the effects can be catastrophic. Such an imbalance occurred in 2010, when elevated lead exposure in rural communities in northwestern Nigeria resulted in the deaths of an estimated 400 children younger than 5 years in a 12-month period. Before the children became ill, waterfowl began to die in great numbers, a connection that would not be realized until much later. This review covers toxicodynamics and the neurotoxic effects of lead in the developing central nervous system, the role that animals can play in recognizing lead exposure and contamination, and environmental sources of lead exposure. The experiences in Nigeria may be especially pertinent to the emerging problems associated with lead exposure and poisoning in the United States.

Duchenne muscular dystrophy (DMD) is a deadly and incurable disease typically diagnosed in early childhood. Presently, the delay between a caregiver's initial concern and the primary care physician obtaining creatine kinase levels—the most important screening test—is more than a year. It is imperative to diagnose DMD as soon as possible because early treatment has the potential to double the patient's lifespan. In addition, because of geographic and economic disadvantages, multidisciplinary DMD treatment centers are not readily available to all patients. Therefore, the challenge of early diagnosis and treatment coordination rests with the primary care physician. The present review provides osteopathic primary care physicians with current and relevant information regarding DMD diagnosis and management.

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

Hypoxic-ischemic encephalopathy is caused by neonatal asphyxia and can lead to mortality or long-term neurodevelopmental morbidity in neonates. Therapeutic hypothermia (TH) is one of the few effective ways to manage mitigating neurologic sequelae. The authors describe the case of a neonate who had a perinatal hypoxic insult and sustained no long-term sequelae after being treated with TH. It is important that osteopathic physicians who provide obstetric and gynecologic, perinatal, and emergency medical care are able to recognize a perinatal hypoxic event, understand the stratification of hypoxic-ischemic encephalopathy risk factors, and implement early TH protocols.

Pediatric limp is a relatively common condition in primary care and can be challenging to diagnose and manage. Common causes of painful pediatric limp include transient synovitis, septic arthritis, osteomyelitis, and trauma. The authors present the case of an 11-year-old girl with a painful limp and anterior ankle pain of unclear origin. Osteopathic structural examination revealed a somatic dysfunction known as continuum distortion , 1 of 6 fascial alterations identified in the fascial distortion model. Myofascial release was applied, providing rapid, complete resolution of symptoms. This case demonstrates that osteopathic physicians may consider the fascial distortion model framework when identifying causes of pain in patients.