Volume 125, Issue 8

Context Oklahoma has one of the highest per capita rates of mental health needs in the United States; however, 72 of the 77 counties are designated as Health Professional Shortage Areas (HPSAs) in mental health services. In October 2022, after a year of planning, the Oklahoma Child and Adolescent Psychiatry and Mental Health Access Program (OKCAPMAP) was launched to deliver mental health and psychiatric consultation services to primary care providers across the state. Project planning incorporated a provider recruitment committee to target providers in rural communities and other areas with barriers to mental health services. Objectives This study’s primary objective was to determine if, after 18 months of activity, provider enrollment aligned with this mission. Methods We conducted a cross-sectional analysis of data from OKCAPMAP. We report the number and type of enrolled providers and information extracted from consultation requests including generalized patient demographics and the mental health conditions for which the request was made. We then utilized the sum of providers pooled at the zip code tabulation area (ZCTA) level to measure correlations with the Social Deprivation Index (SDI), frequency of child abuse filings, and other barriers associated with access for individuals seeking treatment. Results As of April 30th, 2024, OKCAPMAP had enrolled 384 providers in 37 of the 77 counties of Oklahoma. Correlations of providers enrolled at the ZCTA showed significant (p<0.01) positive relationships with frequency of child abuse filings ( R =0.39), percent of rented households (R=0.36), those with high housing cost burden ( R =0.27), percent of households lacking a vehicle ( R =0.19), single parent household ( R =0.17), and the SDI ( R =0.10). Conclusions OKCAPMAP data show successful recruitment of providers where there are high rates of pediatric trauma and in areas where household access to psychiatric services may be limited. By creating an accessible framework to provide free mental health consultations to pediatric-serving primary care providers in these areas, OKCAPMAP will likely have a significant impact on families and communities across Oklahoma.

Context Osteopathic listening tests are diagnostic tools utilized in manual therapies, but their impact on physiological markers of the autonomic nervous system (ANS), such as heart rate (HR) and heart rate variability (HRV), remains unclear. This study examines these effects to clarify the role of listening tests within osteopathic practice. Objectives This study aims to evaluate the influence of osteopathic listening tests on HR and HRV markers, including the root mean square of successive differences (rMSSD) and the low-frequency/high-frequency (LF/HF) ratio, in healthy participants, and to contextualize the findings within existing osteopathic research on ANS modulation. Methods 51 osteopathic students were randomized into three groups: (1) an osteopathic test group (OTG) receiving listening tests; (2) a light pressure group (LPG) experiencing non-therapeutic light pressure; and (3) a control group (CG) receiving no intervention. Measurements of HR, rMSSD, and LF/HF ratio were collected during the first and last 30 s of the protocol utilizing validated software. Data from 48 participants were analyzed after excluding artifacts. Results No significant changes in HR, rMSSD, or LF/HF ratio were observed in any group during the protocol. For OTG, the HR changed minimally (69.17 ± 9.58 beats per minute [bpm] to 69.10 ± 10.24 bpm; p=0.884), while the rMSSD and LF/HF ratio also showed no significant alterations (p=0.064 and p=0.106, respectively). Similar null findings were observed in the LPG and CG, suggesting that neither osteopathic tests nor light pressure induced measurable effects on the ANS markers chosen. Conclusions This study found no evidence that osteopathic listening tests influence HR or HRV markers in healthy participants. Although listening tests serve as diagnostic tools for identifying somatic dysfunctions, they do not appear to exert therapeutic effects on ANS regulation. These findings contrast with previous studies on osteopathic manipulative treatment (OMT), which have demonstrated significant modulation of ANS activity. Future studies should investigate the differential effects of diagnostic tests and therapeutic techniques to better define the scope of the osteopathic interventions.

Context Klippel–Feil syndrome (KFS) is a rare congenital abnormality characterized by cervical vertebral fusion. Patients typically present with a triad of short neck, low posterior hairline, and limited cervical range of motion. The location and quantity of vertebral fusions in KFS makes airway management challenging in the field of anesthesia. Anesthesiologists select intubation methods based on perceived difficulty, making this paper essential to the field. Objectives The purpose of this study is to analyze first-attempt intubation success rates of KFS patients by intubation technique and stratified by location and quantity of cervical fusions and a Mallampati score if reported. Methods This is a systematic review of all case reports on PubMed in the last 10 years utilizing the keywords “KFS,” and subsequently screened searching “anesthesia” and “intubation.” Examiners reviewed the remaining 27 articles for fusion abnormalities and intubation techniques utilized. The articles detail fiberoptic, direct, laryngeal mask airway (LMA), and video-guided intubation techniques, and the success rates were analyzed. Results Of the 1234 KFS articles found, 657 were case reports with 157 being in the last 10 years. After review, 27 case reports presenting 30 cases were included. The average age reported was 25.4 ± 21.6 and 73.3 % were female. Direct (n=10), fiberoptic (n=12), video-guided (n=6), and LMA (n=2) were the chosen first-attempt intubation maneuvers. Fiberoptic and video-guided intubations reported 83 % success, while direct and LMA reported 50 % success. Higher success rates were found in patients with two cervical segment fusions (70 %) when compared to three or more fusions (33 %). Inferior vertebral fusions (C5-T1) reported higher success than midcervical fusions (C3-C5), 100 % and 33 %, respectively. Mallampati class 4 had the highest success (100 %), although further analysis showed fiberoptic intubation was utilized in each of these cases, skewing the data. Conclusions Fiberoptic and video-guided intubation in KFS patients offers the highest success rates of intubation. There were limitations in this study due to the number of case reports available. Although there may be confounding variables to consider based on the case presentation and surgery performed, fiberoptic endotracheal intubation should be considered the gold standard when intubating KFS patients.

Context In late 2020, the National Board of Osteopathic Medical Examiners (NBOME) announced that the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) Level 1 would discontinue reporting numeric scores, only providing a Pass/Fail designation. The National Board of Medical Examiners (NBME) changed the core reports for the United States Medical Licensing Examination (USMLE) Step-1 to Pass/Fail in early 2020. Subsequently, residency program directors were reported to migrate toward increased reliance on COMLEX-USA Level 2CE and USMLE Step 2CK scores, the prestige of medical schools, and the status of the authors of letters of reference during their review of residency applicants. Objectives Funded by an American Association of Colleges of Osteopathic Medicine (AACOM) research grant, A.T. Still University – Kirksville College of Osteopathic Medicine (ATSU-KCOM) and the Arkansas College of Osteopathic Medicine (ARCOM) generated a series of five hypotheses to investigate the perceived impact of the transition to Pass/Fail scoring. Methods Both institutional review boards (IRBs) provided exempt status for this study. The hypotheses were examined through surveys distributed to current osteopathic medical students (OMS), recent graduates (classes of 2021 and 2022), academic advisors, and college of osteopathic medicine (COM) curriculum committee members in this cohort study. The investigative process consisted of two surveys: an initial survey to collect data on all five hypotheses and a focused, follow-up survey designed to better understand the impact of the scoring change. The surveys collected respondent feedback based on a Likert Scale. Standard descriptive statistics were assembled and analyzed. Qualitative responses were coded into thematic elements to examine response patterns. Results The initial survey collected responses from 302 respondents (23.2 % response rate) based on a scale from 1 (strongly disagree) to 4 (strongly agree). The survey results revealed the means for the following items based on a 4-point Likert scale (1=Strongly Disagree; 2=Disagree; 3=Agree; 4=Strongly Agree): (1) Increase chances of matching into residency: 2.35; (2) Pass/Fail is a positive change: 2.71; (3) Pass/Fail will reduce competition in competitive residency programs: 1.94; (4) clinical skills will be more strongly considered: 2.60; and (5) new score reports provide a robust analysis of strengths and weaknesses in basic science: 2.24. Almost half (46 %) of the respondents expressed negative sentiments toward the Pass/Fail change. Reasons included more emphasis on COMLEX-USA Level 2CE, decreased motivation to perform on COMLEX-USA Level 1, and the perceived disadvantages that resulted during the residency match process. Conclusions Among the survey respondents, many, especially students, do not view the change as favorable. Respondents cited the primary reasons for their unfavorable perception as a lack of motivation to perform on COMLEX-USA Level 1 and the added stress of performing on COMLEX-USA Level 2CE. Additionally, respondents viewed the change as negatively impacting their audition rotations and subsequent residency competitiveness.

Objectives The objective of this study was to compare longitudinal outcomes of patients with FM, CWP, or localized chronic low back pain (LBP) to determine whether FM is an extreme manifestation of the CWP continuum. Methods A retrospective cohort study was conducted within a national pain research registry from August 2019 to July 2023. A total of 310 participants with FM (and CWP), CWP (without FM), or LBP were followed for 12 months to measure pain intensity, back-related disability, and health-related quality of life (HRQOL). Multivariable analyses were performed with generalized estimating equations (GEEs), including baseline and longitudinal covariates to adjust for potential confounding. Results The mean age of the participants was 52.3 (standard deviation [SD], 13.6) years, and 238 (76.8 %) were female. There were 64 (20.6 %) participants with FM, 56 (18.1 %) with CWP, and 190 (61.3 %) with LBP. There were no differences in pain intensity among the groups. Compared with back-related disability in the LBP group (mean, 12,7; 95 % confidence interval [CI], 11.4–14.1), the FM group (mean, 15.3; 95 % CI, 13.7–17.0; p=0.006) and CWP group (mean, 16.2; 95 % CI, 14.8–17.7; p<0.001) had greater disability. There were no clinically relevant differences in pain and disability between the FM and CWP groups. Compared with the LBP group, the FM group had worse outcomes on five HRQOL scales, and the CWP group had worse outcomes on all seven scales. Clinically relevant HRQOL differences between the FM and CWP groups involved anxiety and depression, with results favoring the FM group. Conclusions These findings do not support the view that FM is an extreme manifestation of the CWP continuum, involving greater pain, disability, or HRQOL deficits.

Context Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. When mild to moderate in severity, nonoperative treatments including osteopathic manipulative treatment (OMT) have been found to be effective. Studies have been carried out to quantify the mechanism of such treatments with cadaver studies, magnetic resonance imaging (MRI), and ultrasound. Objectives This pilot project investigated the mechanism of a previously undescribed technique of nonoperative carpal tunnel treatment, dorsal carpal arch muscle energy (DCA-ME), which focuses on the dorsal arch (trapezium, trapezoid, capitate, and hamate bones) manipulating the bones to redome the arch, round the tunnel, and increase its volume. Although the actual effectiveness of such manipulation in the treatment of CTS can only be assessed and quantified in patients with the disorder, this initial study was carried out to see if it was feasible for physical changes following DCA-ME to be quantified with ultrasound. Methods A pilot study of 25 healthy volunteers with no prior history of CTS or related disorders was undertaken to quantify anatomical changes in carpal tunnel dimensions following OMT of the nondominant wrist, utilizing DCA-ME. The subjects were randomly assigned to either the OMT group (n=14) or the control group (n=11). The control group underwent a sham manipulation. Pre- and postultrasound measurements of carpal tunnel dimensions were made. The study employed a two-group, pre-/postmanipulation design to evaluate the anatomical changes resulting from the OMT manipulation compared to those following the control sham manipulation. Results Comparison of the OMT and control groups revealed a mean increase in carpal tunnel depth from 0.45 mm ± 0.13 mm pre-OMT to 0.48 mm ± 0.13 mm post-OMT (p=0.0146, Cohen’s d =0.214, 95 % CI 0.0068 to 0.0517). There was also a mean increase in cross-sectional area from 1.83 mm 2  ± 0.56 mm 2 pre-OMT to 1.98 mm 2  ± 0.59 mm 2 post-OMT (p=0.0058, Cohen’s d =0.260, 95 % CI 0.0517 to 0.2490). There was no significant difference in canal width (p=0.5973) or transverse carpal ligament length (p=0.2673) following OMT intervention. The control group, which received the sham procedure, demonstrated no significant differences in the transverse carpal ligament length, carpal tunnel width, depth, or cross-sectional area before and after the sham intervention. Conclusions Ultrasound measurements at the narrowest section of the carpal tunnel before and after DCA-ME OMT of healthy asymptomatic wrists demonstrated a significant increase in cross-sectional area as well as depth, with no significant change in the length of the transverse carpal ligament, suggesting that the cause of the increased volume is an alteration of dorsal arch shape. A limitation of the study is the small sample size, inclusion of only healthy wrists, the short period of time between manipulation and measurements, and the difficulty of assuring the same level and angle of ultrasound measurements.