Examining the influence of pain and fatigue on neurocognitive functioning in adolescents and young adults with sickle cell disease.

Pain and fatigue are among the most common and impactful complications of sickle cell disease (SCD). Individuals with SCD are also more likely to have neurocognitive deficits. Previous studies have suggested that pain and fatigue might influence neurocognitive functioning in patients with SCD. However, these studies are limited by small sample sizes and inadequate measurement of cognitive performance. The present study aimed to investigate the relationship between pain and fatigue with neurocognitive functioning using performance-based measures of neurocognition. Pain and fatigue were not associated with neurocognitive performance. Implications and directions for future research are discussed.

Lifestyle and subsequent meningioma in childhood cancer survivors: A report from the St. Jude Lifetime Cohort study.

BACKGROUND: Lifestyle is associated with meningioma risk in the general population. AIMS: We assessed longitudinal associations between lifestyle-associated factors and subsequent meningiomas in childhood cancer survivors. METHODS AND RESULTS: Childhood cancer survivors age ≥18 years in the St. Jude Lifetime Cohort Study were evaluated for body composition, self-reported physical activity, cardiopulmonary fitness, muscle strength, smoking, and alcohol consumption at baseline. Time to first meningioma analyses were performed, adjusted for sex, age at diagnosis and baseline assessment, treatment decade, and childhood cancer treatment exposures. The study included 4,072 survivors (47% female; [mean (SD)] 9 (6) years at diagnosis; 30 (8.5) years at the start of follow-up, with 7.0 (3.3) years of follow-up). 30% of the participants were survivors of acute lymphoblastic leukemia and 29% of the participants had received cranial radiation. During follow-up, 90 participants developed ≥1 meningioma, of whom 73% were survivors of acute lymphoblastic leukemia, with cranial radiation being the strongest risk factor (relative risk [RR] 29.7, 95% confidence interval [CI] 10.6-83.2). Muscle strength assessed by knee extension was associated with a lower risk of developing a meningioma in the adjusted analyses (RR 0.5, 95% CI 0.2-1.0, p = 0.04 for quartiles 3-4 vs. 1). No other lifestyle-associated variable was associated with subsequent meningioma. CONCLUSION: Independent of cranial radiation, muscle strength was associated with a lower risk of developing a subsequent meningioma in childhood cancer survivors.

Use of Vacuum-Assisted Closure to Reduce the Likelihood of Wound Complications After Limb-Sparing Resection of Pediatric Primary Bone Sarcomas of the Femur.

BACKGROUND: Limb-sparing surgery is the standard of care for primary bone tumors. However, such procedures are associated with high rates of wound complications, specifically in lower-extremity surgeries. Therefore, identifying and implementing interventions to minimize the likelihood of wound complications after limb-sparing resection of the lower extremity is crucial. METHODS: Patients who underwent limb-sparing osteosarcoma or Ewing sarcoma resection during a 7-year period at a single institution were retrospectively reviewed. Data were collected on 39 patients who underwent limb-sparing resection of the femur. Patient demographics, tumor characteristics, and perioperative and postoperative data were extracted and analyzed. Patients who underwent resection before April 2017 received conventional postoperative incision dressings. Starting in April 2017, patients received vacuum-assisted closure (VAC) with the 3 M™ Prevena VAC system after surgical closure. Eighteen patients received conventional postoperative incision dressing, and 21 received incisional wound VAC. A wound complication was defined as any Clavien-Dindo classification greater than 0 within a 28-day postoperative period. RESULTS: Patients who received postoperative incisional wound VAC had lower rates of wound complications than those who received conventional incision dressings (14% vs. 50%; p = 0.035). Additionally, patients in whom wound complications developed had a longer average hospital stay than those without wound complications (5 days vs. 4 days; p = 0.029). CONCLUSIONS: Wound complications prolong the hospital stay and can delay adjuvant chemotherapy for bone tumors. The use of postoperative incisional wound VAC is associated with less likelihood of wound complications and should be considered in any high-risk surgical closure. LEVEL OF EVIDENCE: Level III Treatment Study.

Lifestyle and Subsequent Malignant Neoplasms in Childhood Cancer Survivors: A Report from the St. Jude Lifetime Cohort Study.

INTRODUCTION: This study aimed to assess longitudinal associations between lifestyle and subsequent malignant neoplasms (SMNs) in young adult childhood cancer survivors. METHODS: Members of the St. Jude Lifetime Cohort (SJLIFE) aged ≥18 years and surviving ≥5 years after childhood cancer diagnosis were queried and evaluated for physical activity, cardiorespiratory fitness (CRF), muscle strength, body mass index (BMI), smoking, risky drinking, and a combined lifestyle score. Time to first SMN, excluding nonmalignant neoplasms and nonmelanoma skin cancer, was the outcome of longitudinal analysis. RESULTS: Survivors (n = 4072, 47% female, 29% smokers, 37% risky drinkers, 34% obese, and 48% physically inactive) had a mean (SD) time between baseline evaluation and follow-up of 7.0 (3.3) years, an age of 8.7 (5.7) years at diagnosis, and an age of 30 (8.4) years at baseline lifestyle assessment. Neither individual lifestyle factors nor a healthy lifestyle score (RR 0.8, 0.4-1.3, p = 0.36) were associated with the risk of developing an SMN. CONCLUSIONS: We did not identify any association between lifestyle factors and the risk of SMN in young adult childhood cancer survivors.

Chronic postsurgical pain in children and young adults with cancer and choice of regional anesthesia for amputation and limb-sparing surgery.

BACKGROUND: Patients undergoing limb amputation (LA) or limb-sparing (LS) for lower extremity oncologic diagnoses are at similar risk for chronic postsurgical pain of neuropathic nature (CPSP/NP). Regional anesthesia (RA) techniques are pre-emptive measures to prevent the occurrence of the CPS/NP. However, recommendations for epidural (EP) versus peripheral nerve blocks (PNBs) lack in pediatric literature. AIMS: This study investigates the incidence and duration of CPSP/NP and describes NP-directed regimens. METHODS AND RESULTS: Data on demographics, use of EP or PNB, duration of CPSP/NP, and NP-directed medication were retrospectively collected for LA and LS between 2009 and 2019. Mixed effects logistic regression was used to compare the odds of CPSP/NP between EP and PNB. Cox PH model with adjustment for clustering due to multiple surgeries on patients was used to quantify rate of pain relief between surgery groups (LA vs. LS) and RA groups (EP vs. PNB). The incidence of CPSP/NP was 36 (23.8%) after 165 surgeries (150 patients). The odds of CPSP/NP after PNB were 2.5 times those of CPSP/NP after EP (p = .11). The rate of pain relief at any instant after the EP was 1.2 times that after PNB (p = .3). The rate of pain relief for LS with EP was 1.9 times that of pain relief for LA with EP, a statistically significant difference (p = .03). Gabapentin was used (94.5%), with addition of amitriptyline (24.2%) and both amitriptyline and methadone (12.7%). CONCLUSION: The LS with the EP group had a significantly higher rate of relief of CPSP/NP than LA with EP. Odds of CPSP/NP after PNB were 2.5 times those of CPSP after EP.

Dexmedetomidine and Propofol at End of Life in Pediatric Oncology: Trends in Palliative Sedation Therapy.

Context: Palliative sedation therapy (PST) can address suffering at the end of life (EOL) in children with cancer; yet, little is known about PST in this population. Objectives: We sought to describe the characteristics of pediatric oncology patients requiring PST at the EOL. Methods: A retrospective review was completed for pediatric oncology patients who required PST at a United States academic institution over 10 years, including demographics, disease characteristics, EOL characteristics, and medications for PST and symptom management. Results: PST was utilized in 3% of patients at the EOL. Of 24 study participants receiving PST, 83% (n = 20), 12.5% (n = 3), and 4.2% (n = 1) received dexmedetomidine, propofol, or both, respectively. The most frequent diagnosis for patients receiving PST was acute myelogenous leukemia (20.8%, n = 5). All patients were followed up by the palliative care team, and two-thirds (66.6%, n = 16) were also followed up by the pain management service; 79% (n = 19) were enrolled in hospice, and 98.5% (n = 23) had a Physician Orders for Scope of Treatment in place. Pain was the most common refractory symptom leading to PST initiation (33.3%, n = 8), followed by neuroagitation and dyspnea. PST was initiated a median of 2.5 days before death. A third of deaths occurred in the intensive care unit (33.3%, n = 8). Conclusions: PST was rare in this study; dexmedetomidine was used as first-line treatment for PST in patients at the EOL with refractory symptoms. Its place in PST protocols in pediatric oncology should be validated with prospective studies. Our study suggests the potential value of collaboration between palliative care and pain specialists in the context of PST.

Decreasing Burnout and Improving Work Environment: The Impact of Firgun on a Pediatric Hematopoietic Cell Transplant Team.

PURPOSE: Oncology teams are challenged by BO, which may be alleviated by meaningful recognition. In this study, firgun-altruistic acknowledgment-was implemented on a pediatric hematopoietic cell transplant unit to evaluate its impact on staff and work environment. METHODS: In this longitudinal, mixed-methods pilot study, interdisciplinary inpatient hematopoietic cell transplant providers received web-based firgun education. Electronic administration of validated surveys occurred at baseline and 8 weeks, including Perceived Stress Scale, Professional Quality of Life Scale, Maslach Burnout Inventory, Workplace Civility Index, Areas of Work Life Survey, and WHO-5. Weekly e-mails reminded participants to practice and log firgun. Wilcoxon signed test for paired data compared pre/post results. Interviews conducted at project completion were coded using MaxQDA software. RESULTS: Forty-two participants enrolled; 25 completed pre/post surveys; eight were interviewed. At study end, participants reported feeling less nervous and stressed (P = .008), and less difficulty coping (P = .01; Perceived Stress Scale), while noting increased acknowledgment of others' work (P = .04) and seeking constructive feedback (P = .04; Workplace Civility Index). Marked BO was not evident overall on the Maslach Burnout Inventory; however, emotional exhaustion subscale mean (SD) scores improved from pre (19.4 [8.6]) to post (16 [6.3; P = .02]) and individual items illustrated decreased fatigue (P = .008), frustration (P = .04), and feeling "at the end of my rope" (P = .001). Postintervention participants noted increased receipt of recognition (P = .02; Areas of Work Life Survey), decreased feeling "bogged down" (P = .02), decreased affective stress (P = .04), and negative pre-occupations (P = .04; Professional Quality of Life Scale). Qualitative analysis revealed themes of improved confidence at work and enhanced feelings of trust and teamwork. CONCLUSION: Firgun is a tool that can potentially reduce BO and stress in interdisciplinary providers, facilitate teamwork, and promote positive work environments in clinical oncology and beyond.

Improving visitors' hand hygiene compliance in a pediatric oncology unit.

BACKGROUND: Hand hygiene (HH) is the single most important method to prevent infections. We aim at improving HH compliance by visitors to a pediatric oncology unit. METHODS: A performance improvement project implemented several Plan-Do-Study-Act cycles in July-November 2018. At baseline, a wall-mounted alcohol-based hand sanitizer dispenser was available at the unit entrance. Cycle 1 (visual cue), cycle 2 (visual cue plus verbal symptom screen), and cycle 3 (visual cue, symptom screen, plus HH verbal instructions) were tested. Patient care associates (PCA) positioned at the entrance implemented the cycles and recorded data about visitor's estimated age, day and time of observations, and covert HH compliance monitoring. Participating PCAs were surveyed regarding process feasibility. RESULTS: Of 1230 (97%) analyzed observations; 204 (17%) were baseline, 293 (24%) in cycle 1, 374 (30%) in cycle 2, and 359 (29%) in cycle 3. The visitors' HH compliance significantly increased to 16.0%, 22.5%, and 48.5% in cycles 1, 2, and 3, respectively, from a baseline of 4.9% (P < .001). Visitors were more likely to perform HH when directly instructed (cycle 3) compared to baseline (adjusted OR = 19.77, 95% CI, 10.30-42.09, P < .001). Although the surveyed PCAs agreed the process is easy and fast, they reported few barriers. CONCLUSIONS: Direct verbal instructions for HH were the most effective in improving visitors' HH compliance.

Compassionate de-escalation of life-sustaining treatments in pediatric oncology: An opportunity for palliative care and intensive care collaboration.

Context: Approximately 40%-60% of deaths in the pediatric intensive care unit (PICU) are in the context of de-escalation of life-sustaining treatments (LSTs), including compassionate extubation, withdrawal of vasopressors, or other LSTs. Suffering at the end of life (EOL) is often undertreated and underrecognized. Pain and poor quality of life are common concerns amongst parents and providers at a child's EOL. Integration of palliative care (PC) may decrease suffering and improve symptom management in many clinical situations; however, few studies have described medical management and symptom burden in children with cancer in the pediatric intensive care unit (PICU) undergoing de-escalation of LSTs. Methods: A retrospective chart review was completed for deceased pediatric oncology patients who experienced compassionate extubation and/or withdrawal of vasopressor support at EOL in the PICU. Demographics, EOL characteristics, and medication use for symptom management were abstracted. Descriptive analyses were applied. Results: Charts of 43 patients treated over a 10-year period were reviewed. Most patients (69.8%) were white males who had undergone hematopoietic stem cell transplantation and experienced compassionate extubation (67.4%) and/or withdrawal of vasopressor support (44.2%). The majority (88.3%) had a physician order for scope of treatment (POST - DNaR) in place an average of 13.9 days before death. PC was consulted for all but one patient; however, in 18.6% of cases, consultations occurred on the day of death. During EOL, many patients received medications to treat or prevent respiratory distress, pain, and agitation/anxiety. Sedative medications were utilized, specifically propofol (14%), dexmedetomidine (12%), or both (44%), often with opioids and benzodiazepines. Conclusions: Pediatric oncology patients undergoing de-escalation of LSTs experience symptoms of pain, anxiety, and respiratory distress during EOL. Dexmedetomidine and propofol may help prevent and/or relieve suffering during compassionate de-escalation of LSTs. Further efforts to optimize institutional policies, education, and collaborations between pediatric intensivists and PC teams are needed.

Efficacy of implementing intermittent STOP THE BLEED® reviews on long term retention of hemorrhage control skills of first year medical students.

CONTEXT: Some medical schools integrate STOP THE BLEED® training into their curricula to teach students how to identify and stop life threatening bleeds; these classes that are taught as single day didactic and hands-on training sessions without posttraining reviews. To improve retention and confidence in hemorrhage control, additional review opportunities are necessary. OBJECTIVES: To investigate whether intermittent STOP THE BLEED® reviews were effective for long term retention of hemorrhage control skills and improving perceived confidence. METHODS: First year osteopathic medical students were asked to complete an eight item survey (five Likert scale and three quiz format questions) before (pretraining) and after (posttraining) completing a STOP THE BLEED® training session. After the surveys were collected, students were randomly assigned to one of two study groups. Over a 12 week intervention period, each group watched a 4 min STOP THE BLEED® review video (intervention group) or a "distractor" video (control group) at 4 week intervals. After the 12 weeks, the students were asked to complete an 11 item survey. RESULTS: Scores on the posttraining survey were higher than the pretraining survey. The median score on the five Likert scale items was 23 points for the posttraining survey and 14 points for the pretraining survey. Two of the three knowledge based quiz format questions significantly improved from pretraining to posttraining (both p<0.001). On the 11 item postintervention survey, both groups performed similarly on the three quiz questions (all p>0.18), but the intervention group had much higher scores on the Likert scale items than the control group regarding their confidence in their ability to identify and control bleeding (intervention group median = 21.4 points vs. control group median = 16.8 points). CONCLUSIONS: Intermittent review videos for STOP THE BLEED® training improved medical students' confidence in their hemorrhage control skills, but the videos did not improve their ability to correctly answer quiz-format questions compared with the control group.

Characteristics and treatment of geriatric patients in an osteopathic neuromusculoskeletal medicine clinic.

CONTEXT: Osteopathic manipulative medicine (OMM) is an adjunctive treatment approach available to geriatric patients, but few studies provide details about presenting conditions, treatments, and response to osteopathic manipulative treatment (OMT) in that patient population. OBJECTIVES: To provide descriptive data on the presentation and management of geriatric patients receiving OMT at an outpatient osteopathic neuromusculoskeletal medicine (ONMM) clinic. METHODS: Data were retrospectively collected from electronic health records (EHR) at a single outpatient clinic for clinical encounters with patients over 60 years of age who were treated with OMT between July 1, 2016, and June 30, 2019. Records were reviewed for demographic information, insurance type, presenting concerns, assessments, regions treated, OMT techniques used, and treatment response. RESULTS: There were 9,155 total clinical encounters with 1,238 unique patients found during the study period. More women than men were represented for overall encounters (6,910 [75.4%] vs. 2,254 [24.6%]) and unique patients (850 [68.7%] vs. 388 [31.3%]; both p<0.001). The mean (standard deviation, SD) number of encounters per patient per year was 4.5 (4.0) and increased with increasing age by decade (p<0.001). Medicare was the most common primary insurance (7,246 [79.2%]), with private insurance the most common secondary insurance (8,440 [92.2%]). The total number of presenting concerns was 12,020, and back concerns were most common (6,406 [53.3%]). The total number of assessments was 18,290; most were neuromusculoskeletal (17,271 [94.5%]) and in the thoracolumbar region (7,109 [38.9%]). The mean (SD) number of somatic dysfunction assessments per encounter was 5 (1.7); the thoracic region was the most documented and treated (7,263 [15.8%]). With up to 19 technique types per encounter, the total number of OMT techniques documented across all encounters was 43,862, and muscle energy (7,203 [16.4%]) was the most documented. The use of high-velocity, low-amplitude (HVLA) declined as age increased (p<0.001). The overall treatment response was documented in 7,316 (79.9%) encounters, and most indicated improvement (7,290 [99.6%]). CONCLUSIONS: Our results showed that geriatric patients receiving OMT at our clinic were predominately presenting for neuromusculoskeletal concerns associated with back, neck, and extremity conditions, consistent with national epidemiological data for this population. The most common OMT techniques were also consistent with those used nationally by osteopathic medical students and practicing physicians. Future longitudinal studies are needed to determine the length of time improvement persists and the overall health impact experienced by geriatric patients receiving OMT.

Characteristics and Management of Pregnant Patients From a Neuromusculoskeletal Medicine/Osteopathic Manipulative Medicine Clinic.

CONTEXT: Osteopathic manipulative medicine (OMM) is considered beneficial in the treatment of pregnant women, but few studies have outlined the presenting complaints and diagnoses that warrant consideration and utilization of osteopathic manipulative treatment (OMT) in this population. OBJECTIVE: To describe the characteristics of pregnant patients receiving OMM at a neuromusculoskeletal medicine (NMM)/OMM specialty outpatient clinic, for the purpose of identifying patients who would benefit from referral to NMM specialty clinics or to be considered for treatment by DOs in non-NMM specialty clinics. METHODS: Electronic health records were reviewed from a single clinic for a 3-year period from October 2015 through September 2018 for patient encounters involving patients with an International Classification of Diseases 10th Revision code for pregnancy. Data regarding patient demographics, payment methods, presenting complaints, treatment modalities, regions treated, and assessment diagnoses were collected and analyzed. RESULTS: Records showed 465 clinical encounters with 194 pregnant patients (mean [SD] number of encounters per patient, 2.4 [2.0]). The most common presenting complaints involved the back (371; 55.4%), hip and pelvis (99; 14.8%), neck (62; 9.3%), and head (54; 8.1%). The most common clinical assessments were lumbar and thoracic spine neuromusculoskeletal diagnoses (420; 53.0%). There were 2604 somatic dysfunction assessments documented; lumbar (409; 15.7%) and sacral (396; 15.2%) somatic dysfunction were most commonly assessed. There were 2518 OMT techniques documented, and muscle energy was most frequently used (406; 16.1%). CONCLUSIONS: This data, which documents the most frequent presenting complaints of pregnant patients in an NMM/OMM clinic, may be used by clinicians to better understand the role of OMM as an obstetric adjunctive treatment approach and to identify conditions to investigate in future outcome studies.

Osteopathic Manipulative Medicine Practice Patterns of Third-Year and Fourth-Year Osteopathic Medical Students: An Educational Research Project.

CONTEXT: Colleges of osteopathic medicine (COMs) are required to provide hands-on osteopathic manipulative medicine (OMM) training during clerkship years, but this can be challenging given that students are in a variety of clinical sites and often train with allopathic physicians. OBJECTIVE: To identify student OMM practice patterns documented on required OMM practice logs detailing 10 OMM treatments each semester as part of a 3-semester third- and fourth-year clerkship curriculum and to determine whether these practice patterns varied by supervisor type (osteopathic vs allopathic) and semester. METHODS: The OMM practice logs from 2 class years were retrospectively reviewed for patient and supervisor characteristics and OMM treatment details. Semesters included 2 third-year semesters and an extended fourth-year semester. RESULTS: Between July 2015 and March 2018, 1018 OMM practice logs were submitted detailing 10,150 treatments involving 4655 clinical (45.9%) and 5474 volunteer (53.9%) patients. Logs contained up to 10 treatments per log; 26.0% included only clinical patients, 17.4% included only volunteer patients, and 56.6% included both. Significantly more clinical patients (1708 [36.7%]) were treated during the first semester of the third year than the other 2 semesters (P<.001). The supervisor's credentials were identified as an osteopathic physician for 6639 treatments (65.4%) and an allopathic physician for 768 (7.6%). No difference was found in the proportion of clinical to volunteer patients supervised by osteopathic or allopathic physicians (P=.34). Neuromusculoskeletal complaints accounted for 10,847 (90.7%) chief complaints, and nonneuromusculoskeletal complaints accounted for 1115 (9.3%). The most commonly treated body regions were the thoracic (6255 [61.4%]), cervical (4932 [48.4%]), and lumbar (4249 [41.7%]). More body regions were treated on clinical patients than on volunteer patients (mean, 2.7 vs 2.6, respectively; P=.04). Commonly used techniques were muscle energy (6570 [64.5%]); high-velocity, low-amplitude (4054 [39.8%]); soft tissue (3615 [35.5%]); balanced ligamentous tension/indirect techniques (2700 [26.5%]); and myofascial release (1944 [19.2%]). CONCLUSION: More than 80% of students documented OMM practice on clinical patients for their required OMM practice logs. Both osteopathic and allopathic physicians provided supervision. Chief complaints and types of osteopathic manipulative treatment used were consistent with current clinical practice. Areas identified for enhanced didactic education included OMM for nonneuromusculoskeletal complaints.

Reliability of the DIERS Formetric 4D Spine Shape Parameters in Adults without Postural Deformities.

The DIERS formetric 4D provides a safe method to monitor and track the progression of postural deformities over time. However, further evaluation of reliability is necessary. Reference values are also needed to indicate postural change. The current study examined the reliability of spine shape parameters produced by the formetric 4D in adults without postural abnormalities and established reference values to determine when real change occurs. Thirty participants were scanned during 1 week. Intraclass correlation coefficients (ICCs) were calculated for 40 spine shape parameters for scans with participants stationary between scans, scans with repositioning between scans, and between days. Within-day and between-day standard error of measurement (SEM), absolute relative SEM, and smallest detectable change (SDC) were reported. ICC for stationary scans was excellent for 29 parameters, good for 10 parameters, and fair for 1 parameter. With repositioning, ICC was excellent for 27 parameters, good for 12 parameters, and fair for 1 parameter. Between days, ICC was excellent for 26 parameters, good for 10 parameters, and fair for 4 parameters. Within-day SEM% was greater than 10% for 6 parameters. Within-day SDC ranged from 1.80 to 25.03 units for a single scan and from 0.97 to 17.93 units for 6 scans. Between-day SEM% was greater than 10% for 9 parameters. Between-day SDC ranged from 1.44 to 28.24 units for a single scan and from 1.05 to 22.2 units for 6 scans. Thirty-six of the 40 spine shape parameters from the DIERS formetric 4D reliably distinguished between participants over time. Reference values were established that can be used to track patient postural change over time. Future research should investigate the clinical relevance of these 40 spine shape parameters and determine when a clinically important change in posture occurs.

Developing Neuraxial and Regional Pain Procedural Skills Through Innovative 3-Dimensional Printing Technology.

CONTEXT: Various forms of simulation-based training, including training models, increase training opportunities and help assess performance of a task. However, commercial training models for lumbar puncture and epidural procedures are costly. OBJECTIVE: To assess medical students' and residents' perception of 3-dimensional (3D)-printed lumbar, cervical, and pelvic models for mastering joint injection techniques and to determine the utility of ultrasonography-guided needle procedure training. METHODS: Osteopathic medical students and residents used in-house 3D-printed gel joint models during an injection ultrasonography laboratory for mastering lumbar epidural, caudal epidural, sacroiliac, and facet joint injection techniques. After the laboratory, they answered a 17-item survey about their perception of the importance of the models in medical education and future practice. The survey also evaluated comfort levels with performing joint injections after using the models, overall satisfaction with the models, and likelihood of using models in the future. RESULTS: Thirty-six medical students and residents participated. Both students and residents agreed that 3D-printed models were easy to use, aided understanding of corresponding procedures, and increased comfort with performing joint injections (all P<.001). Most participants (35 [97.2%]) believed that the models were reasonable alternatives to commercial models. Over half felt capable of successfully performing cervical or pelvic (22 [61.1%]) and lumbar epidural (23 [63.9%]) injections. The majority of participants (34 [94.4%]) would like to use the models in the future for personal training purposes. Overall, 100% believed that the 3D-printed models were a useful tool for injection training. CONCLUSIONS: Results suggest that 3D-printed models provided realistic training experience for injection procedures and seemed to allow participants to quickly master new injection techniques. These models offer a visual representation of human anatomy and could be a cost-saving alternative to commercial trainers.

Automated Measurement of Head Movement Synchrony during Dyadic Depression Severity Interviews.

With few exceptions, most research in automated assessment of depression has considered only the patient's behavior to the exclusion of the therapist's behavior. We investigated the interpersonal coordination (synchrony) of head movement during patient-therapist clinical interviews. Our sample consisted of patients diagnosed with major depressive disorder. They were recorded in clinical interviews (Hamilton Rating Scale for Depression, HRSD) at 7-week intervals over a period of 21 weeks. For each session, patient and therapist 3D head movement was tracked from 2D videos. Head angles in the horizontal (pitch) and vertical (yaw) axes were used to measure head movement. Interpersonal coordination of head movement between patients and therapists was measured using windowed cross-correlation. Patterns of coordination in head movement were investigated using the peak picking algorithm. Changes in head movement coordination over the course of treatment were measured using a hierarchical linear model (HLM). The results indicated a strong effect for patient-therapist head movement synchrony. Within-dyad variability in head movement coordination was found to be higher than between-dyad variability, meaning that differences over time in a dyad were higher as compared to the differences between dyads. Head movement synchrony did not change over the course of treatment with change in depression severity. To the best of our knowledge, this study is the first attempt to analyze the mutual influence of patient-therapist head movement in relation to depression severity.

Assessing likelihood of using the Bruininks-Oseretsky test of motor proficiency to predict preclinical performance of dental students.

Objective: The acquisition of motor skills is a key competency for the practice of dentistry, and innate abilities have been shown to influence motor performance. Thus, finding the most efficient manual dexterity tests may predict performance of dental students. The current study used the Bruininks-Oseretsky Test of Motor Proficiency, to assess motor skills of first year (D1) and second year (D2) dental students. Materials and methods: Three fine motor subsets of the BOT-2-fine motor precision, fine motor integration, and manual dexterity-were administered to D1 and D2 dental students in 2017 and 2018. The BOT-2 subset scores of D1 students were compared with those of D2 students, who had preclinical dental experiences. For D2 students, we tested for correlations between BOT-2 subset scores and performance scores in a preclinical operative dentistry course. Results: No differences were found between D1 and D2 students for any BOT-2 subtest scores (all Ps > .09). No correlations were found between total scores of each BOT-2 subtest and the operative dentistry course for D2 students (all Ps > .20). Conclusions: Our results suggested the BOT-2 was not predictive of manual skills of dental applicants or preclinical dental students. Although we assumed students would perform well with instruction, practice, and feedback, we were unable to determine whether innate abilities influenced acquisition of manual dexterity skills. More research about the acquisition of technical clinical skills in dentistry is required.

Ultrasonographic Evaluation of the Effect of Osteopathic Manipulative Treatment on Sacral Base Asymmetry.

CONTEXT: Patients with low back pain (LBP) may receive osteopathic manipulative treatment (OMT) to resolve or manage their pain. The indication for OMT for patients with LBP is the presence of somatic dysfunction, diagnosed using palpatory examination. Because palpatory findings commonly have poor interexaminer reliability, the current study used ultrasonography (US) to establish pre-OMT and post-OMT musculoskeletal measurements of relative asymmetry between pelvic and sacral bony landmarks. OBJECTIVE: To document objective musculoskeletal changes that occur in response to OMT using US and to compare palpatory assessment of landmark asymmetry with US assessment. METHODS: Sixty men and women aged 20 to 55 years with at least 1 episode of LBP in the past 2 weeks were assigned to a seated control, walking control, or OMT group (20 participants per group). Participants received an initial, bilateral US measurement of the skin to posterior superior iliac spine (SPSIS), skin to sacral base position (SBP), and sacral sulcus depth (SSD). Participants in seated control and OMT groups received a palpatory assessment of SBP and SSD prior to initial US assessment. After assessment, the seated control group sat in a waiting room for 30 minutes, the walking control group walked for 5 minutes, and the OMT group received OMT to address sacral base asymmetry using predominantly direct techniques for a maximum of 20 minutes. Participants then received a second US assessment of the same structures. RESULTS: Body mass index (BMI) was correlated with SPSIS (r=0.5, P=.001) and SBP (r=0.6, P<.001). More participants in seated control (75%) and OMT (65%) groups had an increase in asymmetry from first to second US assessment for SPSIS compared with participants in the walking control group (35%, P=.05). No significant differences were found between groups for absolute asymmetry or total change in asymmetry (all P>.10). The κ was -0.1 (95% CI, -0.2 to 0.03) for SBP and -0.01 (95% CI, -0.1 to 0.1) for SSD. CONCLUSION: Musculoskeletal changes in SPSIS and SBP measurements related to OMT could not be readily identified using US. The SPSIS and SBP measurements were dependent on BMI, which may have affected the accuracy of US to detect small changes in asymmetry. Qualitative palpatory assessments did not correlate with US measurements. Further study is needed to identify US measurements that demonstrate change with OMT. (ClinicalTrials.gov number NCT02820701).

Appraisal of the DIERS method for calculating postural measurements: an observational study.

BACKGROUND: Surface topography is increasingly used with postural analysis. One system, DIERS formetric 4D, measures 40 defined spine shape parameters from a 6-s scan. Through system algorithms, a set of spine shape parameter values from 1 of 12 recorded images obtained during a scan becomes the DIERS-reported value (DRV) for postural assessment. The purpose of the current study was to compare DRV with a standard average value (SAV) calculated from all 12 images to determine which method is more appropriate for assessing postural change. METHODS: One mannequin and 30 human participants were scanned over 5 days. Values from each image and the DRV for 40 defined spine shape parameters were exported, and mean DRV, mean SAV, mean DRV, and within-scan variance were calculated. Absolute difference and percent change between mean DRV and mean SAV were calculated for the mannequin and humans. Inter-method reliability was calculated for humans. Within-scan variance for each parameter was tested for significant variability. RESULTS: For all spine shape parameters on the mannequin, absolute difference (< 0.6 mm, 0.1°, or 0.1%) and percent change (< 2.90%) between mean DRV and mean SAV for each parameter were small. Nine parameters on human participants had a large percent change (> 7%). Absolute difference between mean DRV and mean SAV for those nine parameters was small (≤ 0.87 mm or 0.61°). Absolute difference for all other parameters ranged from 0.02 to 6.98 mm for distance measurements, from 0.01 to 1.21° for angle measurements, and from 0.15 to 0.22% for percentage measurements. Inter-method reliability between DRV and SAV was excellent (0.94-1.00). For the mannequin, within-scan variance was small (< 1.62) for all parameters. For humans, within-scan variance ranged from 0.05 to 36.04 and was different from zero for all parameters (all P < 0.001). CONCLUSIONS: The minimal variability observed in the mannequin suggested the DIERS formetric 4D instrument had high within-scan reliability. The DRV and SAV provided comparable spine shape parameter values. Because within-scan variability is not reported with the DRV, the clinical usefulness of current DRV values is limited. Establishing an estimate of variance with the SAV will allow clinicians to better identify a clinically meaningful change.

Comparison of Autonomic Function before and after Surgical Intervention in Patients with Temporal Lobe Epilepsy.

BACKGROUND AND PURPOSE: Refractory temporal lobe epilepsy (TLE) is commonly associated with imbalances in cardiovascular (CV) parasympathetic and sympathetic functions, which are treated using TLE surgery. We investigated the effect of hemispheric lateralization of seizure foci on autonomic CV functions before and after TLE surgery. METHODS: The study was conducted on patients with left TLE (LTLE, n = 23) and right TLE (RTLE, n = 30) undergoing unilateral TLE surgery. To assess the autonomic CV functions, changes in the heart rate (ΔHR) and blood pressure (BP) were measured using a standardized battery of autonomic reactivity tests before surgery and at 3 and 6 months after surgery. RESULTS: Before surgery, ΔHR and the expiration to inspiration ratio (E:I) during the deep breathing test were higher in the LTLE group than in the RTLE group (both p < 0.001), but both outcomes were comparable between the groups at 3 and 6 months. ΔHR decreased at 3 and 6 months (p < 0.001 and 0.01, respectively) compared with preoperative values. The E:I at 3 months in the LTLE group was lower (p = 0.04) than the preoperative values. Decrease in systolic BP during the head-up tilt test was greater in the LTLE group than in the RTLE group (p = 0.002) before surgery. The maximum increase in diastolic BP during the cold pressor test was lower in the RTLE group at 6 months than that before surgery (p = 0.001) and in the LTLE group (p = 0.002). CONCLUSIONS: We found that hemispheric lateralization of seizure foci in the temporal lobe had a differential effect on autonomic CV functions before surgery. Before surgery, parasympathetic reactivity was higher in the LTLE group, and sympathetic reactivity was higher in the RTLE group. After surgery, autonomic CV functions were comparable between the groups, suggesting that TLE surgery stabilizes autonomic CV functions.