Volume 120, Issue 9

Context Hepatosteatosis (HS) is prevalent worldwide and can be measured via ultrasonographic (US) hepatic-renal (H/R) echo-intensity ratio. Objective To examine the incidence of HS in rural communities of the Ecuadorian Chimborazo region and to validate portable US as an effective method of disease screening in rural settings. Methods Sagittal right liver/kidney B-mode US was performed in individuals from 4 villages using a portable US scanner equipped with a 3.5-MHz curvilinear probe. National Institutes of Health ImageJ software was used to computerize tissue echogenicity in both renal cortex and hepatic parenchyma offline. Regions of interest of 900 pixels were used for measuring pixel intensity of the right renal cortex and hepatic parenchyma when calculating the H/R ratio. The difference in pixel intensity between liver parenchyma and renal cortex was analyzed using an unpaired t test. The intraclass correlation coefficient was used to test intra- and interobserver reliability for computerizing the H/R ratio. Results Forty patients were enrolled in the study (32 women and 8 men; mean age, 40 years). The mean (SD) H/R ratio of study patients was 3.61 (2.32), moderately higher than normal (normal, H/R <1.5). A significant difference was found in mean (SD) pixel value between hepatic parenchyma and renal cortex (52.82 [15.34] vs 19.93 [10.39]; P <.001). Thirty-four patients (85%) had an H/R ratio greater than 1.5. The intra- and interobserver reliability of computerizing H/R ratio was excellent ( r =0.940; P <.01). Conclusion These findings suggest that HS is moderately present in persons in remote communities of Ecuador. The mean H/R ratio was greater than that in the diagnostic criteria for the disease. Portable US imaging may benefit these communities as an efficient method for the HS screening and diagnosis in rural areas.

Intermittent fasting (IF) is an increasingly popular strategy for weight loss and improved metabolic health. IF regimes involve deliberate implementation of fasting windows ranging from 12 to 72 hours. During these fasting windows, individuals reduce their caloric intake by 75% to 100%. Such strategies show promise and are increasingly socially popular, but many effects are not completely understood. Specifically, the effects of time-restricted feeding (TRF), a specific form of IF in which participants undergo daily fasting periods lasting about 16 hours, is among the most popular yet under-studied regimens. This review finds that TRF may produce mild weight loss and improved function of insulin. TRF also likely produces cardiovascular effects, such as decreased blood pressure and fasting blood triglycerides. TRF, like other forms of IF, may encourage fat loss specifically when combined with exercise. The manuscripts identified in this narrative literature review were analyzed for the potential benefit for patients with type 2 diabetes mellitus, and limitations of summarized content were noted. While these studies support some suspected benefits of TRF, they also legitimize the need for future TRF studies, since conclusions are greatly limited by a paucity of evidence.

Context While existing data demonstrate that osteopathic physicians (ie, DOs) in primary care are more likely than allopathic physicians (ie, MDs) to practice in rural areas, no data exist on practice patterns of DO surgical subspecialists, such as ophthalmologists. Michigan has a relatively high number of DOs and, formerly, the most osteopathic ophthalmology residency programs in the United States. Analyzing the distribution of ophthalmologists in Michigan may reveal patterns and predict trends about the geographic distribution of DO surgical subspecialists across the country. Objective To compare geographic distributions of DO and MD ophthalmologists in Michigan and identify differences in community size and type (eg, urbanized area, urban cluster, or rural area) of practice. Methods A list of Michigan's ophthalmologists practicing in 2018 was developed using the Centers for Medicare and Medicaid Services, the American Osteopathic College of Ophthalmology, and the American Medical Association data sets. DOs and MDs were then analyzed by determining where each ophthalmologist practiced, identifying the size and type of community in which they practiced, and finally by comparing the percentage of DOs and MDs who practiced in various community sizes and each community type as defined by the US Census Bureau. An χ 2 analysis was used to determine whether a difference existed in practice locations. Results A total of 643 ophthalmologists practiced in Michigan in 2018, including 85 DOs and 558 MDs. A greater proportion of DOs worked in rural areas and urban clusters (57 [67%]), whereas a greater proportion of MDs worked in urbanized areas (368 [66%]). Of DOs, 28 (33%) practiced in cities with a population of at least 50,000 vs 371 MDs (66%). Fourteen DOs (16%) practiced in communities with a population of at least 100,000 vs 207 MDs (37%). χ 2 analysis showed a significant difference in the geographic distribution of ophthalmologist DOs and MDs ( P <.01). Conclusion Higher proportions of DOs practice ophthalmology in smaller, more rural Michigan communities compared with MDs, implying that a subgroup exists that tends to serve underserved areas.

Context Chronic pain (CP) is a common and serious medical condition, with an estimated 100 million people affected in the United States. In the 1990s, opioids were increasingly prescribed to manage chronic pain, and this practice contributed to the opioid epidemic of the 21st century. To combat this epidemic, multidisciplinary approaches to chronic pain management are being researched and implemented. Objective To evaluate the clinical effectiveness of an 8-week mindfulness-based stress reduction (MBSR) course implemented in a semi-rural population with chronic pain. Methods Participants were recruited from a community-based teaching hospital in Corvallis, Oregon, for a pre-post study. Participants aged 34 to 77 years who reported having chronic pain lasting for at least 1 year before enrollment were included. Participants took an 8-week group MBSR course in 2.5-hour weekly sessions taught by an experienced MBSR instructor. Techniques were self-practiced between sessions with a goal of 30 minutes per day, 6 days per week. Pre- and postsurvey measurements of pain, depression, and functional capacity were taken via online surveys using the patient health questionnaire (PHQ-9), the Pain Catastrophizing Scale (PCS), and a shortened version of the Modified Oswestry Disability Index (MO). Participants were asked about their satisfaction with the program content, instructor, timing, and location. Results Twenty-eight participants were included in the study . Paired t tests found significant improvements in PHQ-9, PCS, and MO percent scores from before to after the course. PHQ-9 scores decreased by a mean of 3.7 points (95% CI, −5.5, −1.8), PCS scores decreased by a mean of 4.6 points (95% CI: −7.2, −2.0), and MO percent score decreased by a mean of 9.4% (95% CI: −14.2%, −4.6%). Results showed an overall downward shift in the distribution of depression, disability, and pain scores after the course. Conclusions MBSR classes were found to benefit participants with chronic pain and depression in this setting, fostering significant improvement in participant perceptions of pain, mood, and functional capacity.

Pathophysiological mechanisms and cascades take place after a mild traumatic brain injury (mTBI) that can cause long-term sequelae, including chronic traumatic encephalopathy in patients with multiple concurrent TBIs. As diagnostic imaging has become more advanced, microanatomical changes present after mTBI may now be more readily visible. In this narrative review, the authors discuss emerging diagnostics and findings in mTBI through advanced imaging, electroencephalograms, neurophysiologic processes, Q2 biochemical markers, and clinical tissue tests in an effort to help osteopathic physicians to understand, diagnose, and manage the pathophysiology behind mTBI, which is increasingly prevalent in the United States.

Context Upper abdominal or chest pain, tenderness, or sensation of the presence of a mass may lead to general surgery (GS) service referral. These symptoms may be related to rib somatic dysfunction (SD). Objective To describe rib SD in the GS setting and help build a foundation for additional osteopathic manipulative treatment (OMT) research in surgical care. Methods The authors retrospectively reviewed and analyzed the electronic medical records of patient encounters in a GS outpatient clinic or private office in Bronx, New York. Included patients had emergency department or inpatient GS consultations with the diagnosis of rib SD (ICD-9 739.8 or ICD-10 M99.08) initially made by the GS service from February 1, 2016, to January 31, 2019. Six-month follow-up data were also reviewed. Results Twelve patients had rib SD as the underlying cause of their chief concern upon presentation to the GS service. Only 1 also had an underlying operative GS disease. The GS service treated 11 patients (91.7%) with OMT; 1 patient refused OMT. Time spent on OMT ranged from 5 to 30 minutes, with a median of 10 minutes and a mean (SD) of 12.7 (9.05) minutes. The OMT techniques used included balanced ligamentous tension, counterstrain, muscle energy, myofascial release, rib-raising, and soft tissue. All patients who received OMT demonstrated improvement, and 3 patients required osteopathic manipulative medicine/neuromuscular medicine follow-up. Conclusions Rib somatic dysfunction may contribute to patient referral to a GS service, and OMT performed by general surgeons may help provide optimal surgical care.

Context Patients with severe traumatic brain injury (TBI) often have multiple autonomic disturbances that interfere with normal gastrointestinal motility. Many of the pharmacologic agents used in the intensive care unit (ICU) also adversely affect gastrointestinal motility. The body is further subjected to excessive levels of sympathetic discharge in states of traumatic injury and extreme stress, which can interfere with the proper absorption of fluids and nutrients. Objective To determine whether mesenteric lift, an osteopathic manipulative treatment technique, is effective in relieving constipation in patients with TBI who are intubated in the ICU. Methods This retrospective medical record review examined the effect of mesenteric lift on intubated patients with significant TBI who were unable to have a bowel movement within 72 hours of admission. The primary endpoint was the return of normal bowel function within 24 hours. A control group consisted of intubated patients with TBI during the same period who did not receive mesenteric lift. Results Of patients who received mesenteric lift, 77% experienced bowel movements (n=27 of 35), compared with 36% (n=16 of 44) in the control group ( P =.01). Conclusion The application of mesenteric lift to intubated patients with severe TBI in the intensive care unit significantly increased patients’ ability to resume normal bowel function and expel waste.

Context Concussions can cause cognitive impairment, somatic symptoms, and behavioral changes. Symptoms may vary in severity, depending on the degree of traumatic force. Due to the biomechanical nature of this trauma, cranial somatic dysfunctions may commonly be seen in patients with concussion. Objective To determine whether patients were more likely to have nonphysiologic cranial somatic dysfunctions than physiologic cranial somatic dysfunctions after sustaining a concussion. Methods College athletes who had a concussion based on the Immediate Post-Concussion Assessment and Cognitive test were evaluated by a physician within 1 week of the injury. Patients were evaluated for somatic dysfunctions of the cranium. Cranial somatic dysfunctions were documented; test scores and force vectors were compared with the type of strain pattern using SPSS, with P <.05 demonstrating statistical significance. Results Sixteen patients were included in the study: 10 with nonphysiologic cranial strain somatic dysfunctions and 6 with physiologic dysfunctions. Compared with lateral forces, forces of impact with anterioposterior vectors were associated 1.5 times more often with nonphysiologic rather than physiologic cranial somatic dysfunctions ( P =.697). An analysis of specific cranial strain patterns and impact force vectors showed no statistical significance ( P =.096). Conclusion There was no statistically significant association showing that concussion patients were more likely to have nonphysiologic cranial somatic dysfunctions compared with physiological cranial somatic dysfunctions. However, nonphysiologic cranial somatic dysfunctions did show a trend toward association with concussion. Further studies are needed to better understand the potential association between concussion and cranial somatic dysfunctions.

Context Concussion, a type of mild traumatic brain injury, is a disruption in normal brain function due to head injury. New-onset symptoms from concussion vary, likely depending on the areas of the head and neck affected; they can be severe and debilitating. Current treatment options are limited and difficult to individualize. Osteopathic manipulative medicine (OMM) can aid musculoskeletal restrictions that can potentially improve concussion symptoms. Objective To assess concussion symptom number and severity in participants with concussion who received either OMM or an educational intervention. Methods A randomized controlled trial was conducted at the New York Institute of Technology Academic Health Care Center. Patients presenting to the center with concussion-like symptoms due to recent head injury within the previous 7 days provided consent and were randomized into 2 intervention groups, receiving either 1 OMM treatment (n=16) or 1 concussion education intervention (n=15). Participants were assessed before and after the intervention with the validated Symptom Concussion Assessment Tool fifth edition (SCAT-5) for quantification of number of symptoms and their severity. Collected data were analyzed using the Mann-Whitney U test and the repeated-measures analysis of variance. Results Thirty-one participants were enrolled in the study; after 1 control participant was excluded due to incomplete data, 30 patient records were analyzed. The OMM intervention group had a significant decrease in symptom number ( P= .002) and symptom severity ( P =.001) compared with the concussion education group. Conclusion When used in the acute setting, OMM significantly decreased concussion symptom number and severity compared with concussion education. This study demonstrates that integration of OMM using a physical examination–guided, individualized approach is safe and effective in the management of new-onset symptoms of uncomplicated concussions. (Clinicaltrials.gov No. NCT02750566)

Context Impaired sleep quality is among many symptoms observed in patients with a concussion and may predispose a patient to a prolonged recovery course and a later return to their daily activities. Studies have suggested that osteopathic manipulative treatment (OMT) may play a role in improving sleep quality. Objective To investigate how OMT may play a role in the management and overall healing process in patients with a concussion by improving sleep quality. Methods Data were collected from a randomized, controlled study on OMT and concussion (of which this study represents 1 arm) to investigate the effects of OMT vs concussion education counseling on sleep quality in student athletes with a concussion. Student athletes with no medical history of neurodegenerative disease who presented to the New York Institute of Technology College of Osteopathic Medicine Academic Healthcare Center with a concussion following a sport-related injury were enrolled in the study. Participants received OMT intervention or standard counseling on how to care for a concussion during their first and second visits. Participants rated their symptoms, including sleep quality, on the validated scale Sport Concussion Assessment Tool 5th Edition at 3 consecutive visits during 1 week. The mean sleep quality score within and between the OMT and education groups before each of 2 interventions and at the third visit were compared and analyzed using the Mann-Whitney U test. Results Thirty participants were enrolled in the study. Total symptom data showed a stronger, significant correlation with sleep scores than with other symptoms. Participants receiving OMT (n=16) reported overall 80% and 76% improvement in sleep quality from pre-OMT values to their second and third visits, respectively. Participants who had an educational intervention (n=14) reported a 36% and 46% improvement from pre-OMT values to their second and third visits, respectively. Conclusion The beneficial relationship trend between OMT and sleep quality in patients with a concussion was not statistically significant. Owing to the limitations of this study, further research with a larger population and sham control participants is warranted. (Clinicaltrials.gov No. NCT02750566)