Volume 123, Issue 2

Context Simple reaction times (SRTs), measured in milliseconds (msec), are equal to the sum of subject-dependent latencies that occur during cognitive processing and neuromuscular responses to a preprogrammed stimulus presented to a subject. SRTs have the advantage of being a relatively pure, neurologically driven motor/sensory task that provides a clinician with a generalized assessment of functional deficits. SRTs are easily obtained, and studies have reported that the average number of finger-taps during a 10-s interval can be utilized to distinguish between patients with mild traumatic brain injury (TBI) and healthy controls. Objectives A stimulus/response SRT protocol, utilizing an iPad-based tool, was utilized to see if differentiation and quantification of individual components of cognitive latency (CL) and neuromuscular latency (NL) from a subject’s total SRT could be accomplished. The study hypothesis was that cognitive latencies, related to a specific cognitive challenge, would remain constant even as latencies due to neuromuscular challenges changed. Methods Two categories of SRT tests were utilized. The first was a simple finger tapping test (FTT), without any cognitive involvement, that was designed to quantify pure NL. The second test was a choice test (CT) that was characterized by the addition of a cognitive task to the FTT. The objective of the FTT was for the subject to simply tap a single target positioned on the iPad screen as fast as possible over an interval of 10 s. Measurement of the SRT began when a target was displayed and ended when the target was tapped. Two levels of challenge for the FTT and CT tests were presented to the subjects: a small random displacement (SD) of the target of up to 6 mm, and a large random displacement (LD) of the target of up to 24 mm. It was expected that the magnitude of the SRT (FTT) would be directly related to the magnitude of the displacement of the target due to kinematic response characteristics of the hand and arm. Results To validate the study hypothesis, CL for both small and large displacements was calculated by subtracting the respective NL from the total SRT. Utilizing a repeated measures t-test analysis utilizing SPSS, a significant difference between CL (SD) and CL (LD) at p=0.696 was not observed. Conclusions Differentiation and quantification of individual components of CL and NL from a subject’s total SRT was accomplished. An Apple iPad Pro was selected as a platform for our study because: (1) it is readily available, affordable, and programmable; (2) it meets a requirement for portability; and (3) it allows the modification/addition of test parameters to meet future needs. The ability to quantify the extent of cognitive and neuromuscular dysfunction in the TBI patient is an essential component of developing an effective treatment plan.

Context Point-of-care ultrasound (POCUS) has widespread utilization in multiple clinical settings. It has been shown to positively influence clinician confidence in diagnosis and can help appropriately manage patients in acute care settings. There has been a growing trend of increased emphasis on incorporating POCUS training in the first 2 years of the medical school curriculum. Objectives This article aims to analyze the clinical use of POCUS in acute settings and how training early in medical school may strengthen clinician confidence and utilization. Methods An anonymous 10-question survey on POCUS use was conducted via a secure online platform and distributed to board-certified practicing physicians (MDs and DOs) with educational agreements with Midwestern University (MWU) across acute care specialties. This included preceptors within the MWU graduate medical education clinical consortium. Survey questions were aimed at assessing frequency of use, machine type, reasons for utilizing POCUS, initial ultrasound training, confidence in performing/interpreting POCUS, and perceived impact on patient outcomes. Surveys less than 50% complete were excluded. All surveys returned were more than 50% complete and thus included in the study. Statistical analyses were conducted utilizing the statistical software R version 4.0. Results Surveys were sent out to 187 participants with 68 responses (36.4% response rate). The survey results demonstrated a relationship between learning POCUS earlier in one’s medical career (medical school, residency, or fellowship) to increased use in acute settings when compared to learning POCUS during clinical practice. Of the 68 respondents, 65 (95.6%) indicated that they agree or strongly agree that POCUS use improves patient care, and 64 (94.1%) indicated that they agree or strongly agree that the use of POCUS can improve patient outcomes. Conclusions Our survey of acute care physicians indicated that most respondents utilize POCUS daily or weekly (90.8%), and this was related to fewer years of practice (under 10 years from medical school graduation, 94.6%). Moreover, POCUS was utilized primarily in acute care settings for procedures (25%, n=17/68 respondents). These survey results indicate that early integration of POCUS education in osteopathic medical school curricula and throughout fellowship training could likely enhance POCUS utilization in acute care settings.

Context Shoulder and neck pain are leading causes of disability worldwide. Rotator cuff pathology has strong associations with such pain and is extensively targeted by healthcare practitioners. A dysfunctional lower trapezius muscle has also been shown to contribute to neck and shoulder pain, yet it is often overlooked. Objectives This systematic review analyzes those with a history of, or who are currently managing, shoulder or neck pain to indicate differences in measures of lower trapezius function when compared to subjects without that pain. Methods Studies with no age restrictions were included in the study. Studies could determine lower trapezius muscle function with any quantifiable measurement tool or clinical assessment. If the study included a control group (no pain) and a comparator group (pain), and if lower trapezius muscle function was assessed in both, the study was typically included. The significance of the lower trapezius muscle function change was summarized in these pain patients. From a final total of 18 studies identified, level of muscle activity, muscle activation, time to onset, muscle strength, and muscle thickness were reported. Results The 18 included articles involved 485 participants with shoulder and/or neck pain and 455 without. Half of the shoulder pain studies (6/12), and all of the neck pain studies (6/6), demonstrated that the lower trapezius had a noticeable impact. The lower trapezius muscle in participants with shoulder and neck pain tended to show decreased muscle strength, and decreased time to onset/latency. Conclusions The findings from this systematic review should be taken into consideration when assessing and treating patients with shoulder and neck pain. Future studies that define the type and duration of shoulder and neck pain, as well as prospectively assessing lower trapezius muscle function in those with and without that pain, are needed.

Context Osteopathic manipulative treatment (OMT) has been utilized by osteopathic clinicians as primary or adjunctive management for dizziness caused by neuro-otologic disorders. To our knowledge, no current systematic reviews provide pooled estimates that evaluate the impact of OMT on dizziness. Objectives We aimed to systematically evaluate the effectiveness and safety of OMT and analogous techniques in the treatment of dizziness. Methods We performed a literature search in CINAHL, Embase, MEDLINE, Allied and Complementary Medicine Database (AMED), EMCare, Physiotherapy Evidence Database (PEDro), PubMed, PsycINFO, Osteopathic Medicine Digital Library (OSTMED.DR), and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to March 2021 for randomized controlled trials (RCTs) and prospective or retrospective observational studies of adult patients experiencing dizziness from neuro-otological disorders. Eligible studies compared the effectiveness of OMT or OMT analogous techniques with a comparator intervention, such as a sham manipulation, a different manual technique, standard of care, or a nonpharmacological intervention like exercise or behavioral therapy. Assessed outcomes included disability associated with dizziness, dizziness severity, dizziness frequency, risk of fall, improvement in quality of life (QOL), and return to work (RTW). Assessed harm outcomes included all-cause dropout (ACD) rates, dropouts due to inefficacy, and adverse events. The meta-analysis was based on the similarities between the OMT or OMT analogous technique and the comparator interventions. The risk of bias (ROB) was assessed utilizing a modified version of the Cochrane Risk of Bias Tool for RCTs and the Cochrane Risk of Bias in Non-randomized Studies – of Interventions (ROBINS-I) for observational studies. The quality of evidence was determined utilizing the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. Results There were 3,375 studies identified and screened, and the full text of 47 of them were reviewed. Among those, 12 (11 RCTs, 1 observational study, n=367 participants) met the inclusion criteria for data extraction. Moderate-quality evidence showed that articular OMT techniques were associated with decreases (all p<0.01) in disability associated with dizziness (n=141, mean difference [MD]=−11, 95% confidence interval [CI]=−16.2 to −5.9), dizziness severity (n=158, MD=−1.6, 95% CI=−2.4 to −0.7), and dizziness frequency (n=136, MD=−0.6, 95% CI=−1.1 to −0.2). Low-quality evidence showed that articular OMT was not associated with ACD rates (odds ratio [OR]=2.2, 95% CI=0.5 to 10.2, p=0.31). When data were pooled for any type of OMT technique, findings were similar; however, disability associated with dizziness and ACD rates had high heterogeneity (I 2 =59 and 46%). No studies met all of the criteria for ROB. Conclusions The current review found moderate-quality evidence that treatment with articular OMT techniques was significantly associated with decreased disability associated with dizziness, dizziness severity, and dizziness frequency. However, our findings should be interpreted cautiously because of the high ROB and small sample sizes in the eligible studies.

Context Sociological research has linked racism and discrimination among children to poorer health outcomes and social conditions later in life. Objectives Given the change in the political climate in the United States, highly publicized deaths of Black men and women by police, and the rise in hate crimes against Asian Americans from 2016 through 2020, our primary objective was to assess trends in racial or ethnic discrimination among children in the United States. Methods We conducted a cross-sectional analysis of the National Survey of Children’s Health (NSCH), a nationally representative survey, utilizing data from 2016 to 2020. We calculated yearly population estimates of whether a child had experienced discrimination based on race/ethnicity via a parent-reported item. We further divided the estimates by race/ethnicity and plotted linear trends over time. Results Data from the NSCH show that racial/ethnic discrimination reported by parents of children who are minorities increased from 6.7% in 2016 to approximately 9.3% in 2020. Indigenous children were reported to experience discrimination at high rates ranging from 10.8% in 2016 to 15.7% in 2020, as well as Black children ranging from 9.69% in 2018 to 15.04% in 2020. The percent of Asian, Hawaiian or Pacific Islander, and Hispanic children reported to have experience discrimination was between 4.4 and 6.8% during this time. Conclusions Discrimination negatively impacts the developmental experiences of children, disproportionately affecting those identifying as Indigenous and Black. Therefore, addressing harmful stereotyping of Indigenous and Black cultures is necessary, especially in media targeted toward children. Providing culturally competent healthcare, critically in the Indigenous and Black pediatric population, may improve long-term outcomes by reducing discriminatory barriers to healthcare access.

Diabetes is a complex condition that is largely self-managed. Decades of scientific evidence has proved that early glycemic control leads to improved microvascular and macrovascular outcomes in people with diabetes mellitus. Despite well-established management guidelines, only about half of the patients with diabetes achieve glycemic targets, and only one in five patients achieve metabolic control (blood pressure, lipid, and glucose targets), and both patients and physicians find themselves stuck in a rut called therapeutic inertia (TI). The authors present several practical strategies that can be tailored to different practice settings and facilitate reducing TI.