Qualitative Assessment CIH Institutions' Engagement With Underserved Communities to Enhance Healthcare Access and Utilization.

Background: In North America, there is a notable underutilization of complementary and integrative health approaches (CIH) among non-White and marginalized communities. Objectives: This study sought to understand how CIH educational instutitions are proactively working to redress this disparity in access and utilization among these communities. Methods: We conducted interviews with 26 key informants, including presidents, clinicians, and research deans across 13 CIH educational institutions across the US and Canada. Thematic analysis included deductive codes based on the interview guide during interview scripts review. Results: Six themes were identified: (1) CIH institutions often had a long and varied history of community engaged care through partnerships to increase access and utilization; (2) CIH institutions' long-standing community outreach had been intentionally designed; (3) CIH institutions provided an array of services to a wide range of demographics and communities; (4) addressing healthcare access and utilization through community partnerships had a strong positive impact; (5) funding, staffing and COVID-19 were significant challenges that impeded efforts to increase CIH access through community engaged work; (6) identified gaps in community partnerships and services to increase access and utilization were recognized. Conclusion: These findings underscore significant efforts made to enhance healthcare access and utilization among marginalized, underserved, and racial and ethnic communities. However, barriers such as funding constraints, resource allocation, and the need for proper measurement and accountability hinder proactive initiatives aimed at redressing disparities in CIH utilization within these communities.

Building Bridges Toward Common Goals - A Call for Greater Collaboration Between Public Health and Integrative, Complementary and Traditional Health Providers.

This commentary makes the case for greater collaboration between public health professionals and integrative, complementary and traditional health practitioners (ICTHP). Previous partnerships have been successful, and more such collaborative work is needed to help overcome division, enhance the health workforce, and move all involved toward shared goals. ICTHP providers may be uniquely able to work across ideological differences and engage individuals and communities who are less trusting of public health, including those who are vaccine hesitant. Diverse partnerships can be difficult to maintain, but the application of equitable processes may aid their success. In the face of highly complex public health challenges, partnerships with ICTHP are critical.

Delay in the diagnosis of paediatric brain tumours: a systematic review.

PURPOSE: A delay in obtaining a diagnosis has been associated with inferior outcomes across several cancer types, including paediatric brain tumours. However, no clear evidence exists in this population. We aimed to quantify the reported pre-diagnostic symptom interval (PSI) as the time from onset of first symptoms to diagnosis in the literature, in addition to evaluating the relationship between delay and outcomes, including survival. METHODS: A systematic review of the literature was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, Wiley Online Library, Web of Science and EMBASE databases were searched. We considered all sources published between 1st January 2010 and 5th November 2022. Children and adolescents aged under 21 years, with new symptomatic primary brain tumour diagnoses, were included. RESULTS: Of 3123 studies identified, 11 were included for analysis. Owing to study heterogeneity, a quantitative meta-analysis was not feasible; however, a narrative synthesis was performed. The median reported PSI varied widely, ranging between 28 and 760.8 days. We failed to identify a significant association between prolonged PSI and inferior overall survival. Few factors were consistently associated with prolonged PSI, amongst them only tumour grade and patient age. CONCLUSION: Delayed diagnosis of paediatric brain tumours was not associated with inferior survival within this review. This 'waiting time' paradox appears to result from several confounding factors including tumour biology, patient population and key systematic factors that were inconsistently reported. Diagnostic interval clearly presents a complex variable, reflected further by disparity in the reporting of delay within the literature. Ultimately diagnostic interval is unlikely to provide a meaningful representation for all tumour types and should not detract from sharp clinical acumen and prompt diagnosis.

A Pragmatic Historical Assessment Tool: A New Systematic Framework for the Collation and Evaluation of Documented Empirical Effectiveness and Safety of Traditional Plant Medicines in the European Materia Medica.

INTRODUCTION: Traditional plant medicines (TPMs) are plant-derived therapeutic products prepared and applied according to longstanding medical customs. Around the world they are widely used in primary and preventative health care. The World Health Organization (WHO) calls in its Traditional Medicine Strategy 2014-2023 for Member States to provide a regulatory framework so that the formal contribution of traditional therapeutics can be advanced in national systems of health care. Evidence of effectiveness and safety is paramount for the regulatory integration of TPMs; however, a presumed lack of such "evidence" is one obstacle for full integration. The consequential health policy question is how to systematically evaluate therapeutic claims relating to herbal remedies when the extant evidence is predominantly based on historical and contemporary clinical usage, i.e., is empiricist in nature. This paper introduces a new method along with several illustrative examples. METHOD: Our research design employs a longitudinal, comparative textual analysis of standard textbooks of the professional European medical literature from the early modern period (1588/1664) onwards to today. It then triangulated these intergenerationally documented clinical observations on two exemplars (Arnica and St. John's Wort) with corresponding listings in multiple qualitative and quantitative sources. A Pragmatic Historical Assessment (PHA) tool was developed and tested as a method to systematically collate the large amount of pharmacological data recorded in these judiciously selected sources. The evidential validity of longstanding professional clinical knowledge could thus be compared with therapeutic indications approved in official and authoritative sources (pharmacopoeias, monographs) and with those supported by contemporary scientific research (randomised-controlled trials [RCTs], experimental research). RESULTS: There was high congruency between therapeutic indications that are based on repeated empirical observations from professional patient care (empirical evidence), those approved in pharmacopoeias and monographs, and modern scientific evidence based on RCTs. The extensive herbal triangulation confirmed parallel records of all main therapeutic indications of the exemplars across all qualitative and quantitative sources over the past 400 years. CONCLUSIONS: Historical clinical medical textbooks and contemporary phytotherapeutic equivalents are the key repository of repeatedly evaluated therapeutic plant knowledge. The professional clinical literature proved to be a reliable and verifiable body of empirical evidence that harmonised with contemporary scientific assessments. The newly developed PHA tool provides a coding framework for the systematic collation and evaluation of empirical data on the effectiveness and safety of TPMs. It is suggested as a feasible and efficient tool to extend evidence typologies that substantiate therapeutic claims for TPMs as part of an evidence-based regulatory framework that formally integrates these medically and culturally important therapeutics.Traditionelle pflanzliche Arzneimittel sind aus Pflanzen gewonnene Heilmittel, die gemäß langjähriger medizinischer Praxis zubereitet und angewendet werden. Weltweit sind sie in der primären und präventiven Gesundheitsversorgung weit verbreitet. Die Weltgesundheitsorganisation (WHO) ruft in ihrer Traditional Medicine Strategy 2014­2023 die Mitgliedstaaten dazu auf, regulatorische Rahmenbedingungen zu schaffen, welche den formellen Beitrag traditioneller Therapeutika in den nationalen Gesundheitssystemen fördern. Der Nachweis von Wirksamkeit und Sicherheit ist von zentraler Bedeutung für die regulatorische Integration traditioneller pflanzlicher Arzneimittel, doch das angebliche Fehlen solcher "Nachweise" ist eine der Hürden für die vollständige Integration. Daraus ergibt sich die gesundheitspolitische Frage, wie man therapeutische Anwendungsgebiete pflanzlicher Heilmittel systematisch evaluieren kann, wenn die vorliegende Evidenz überwiegend auf deren historischer und aktueller klinischen Verwendung beruht, also empirischer Natur ist. In dieser Arbeit wird eine neue Methode mitsamt veranschaulichenden Beispielen vorgestellt.Unser Forschungsansatz beruhte auf einer longitudinalen, vergleichenden Textanalyse von Standard-Lehrwerken der europäischen medizinischen Fachliteratur ausgehend von der frühen Neuzeit (1588/1664) bis heute. Die über Generationen dokumentierten klinischen Beobachtungen wurden anhand von zwei Beispielen (Arnika and Johanniskraut) mit den diesbezüglichen Angaben in unterschiedlichen qualitativen und quantitativen Quellen trianguliert. Ein Pragmatisch­Historisches Auswertungstool (PHA) wurde als Methode entwickelt und getestet, um die großen Mengen der in diesen kritisch ausgewählten Quellen enthaltenen pharmakologischen Daten systematisch zu erfassen. Die Evidenzvalidität des langjährigen klinischen Fachwissens konnte so mit den therapeutischen Anwendungsgebieten verglichen werden, die in offiziellen und autoritativen Quellen (Pharmakopöen, Monografien) zugelassen sind, sowie mit denjenigen, die durch zeitgenössische wissenschaftliche Forschung gestützt werden (randomisierte kontrollierte Studien [RCTs], experimentelle Forschung).Es bestand ein hohes Maß an Kongruenz zwischen den therapeutischen Anwendungsgebieten, welche auf wiederholte empirische Beobachtung aus der professionellen Patientenversorgung beruhen (empirische Evidenz), den zugelassenen Indikationen in Pharmakopöen und Monographien sowie der aktuellen wissenschaftlichen Evidenz basierend auf klinischen Studien. Die umfassende pflanzenbezogene Triangulation bestätigte parallele Aufzeichnungen aller wesentlichen Anwendungsgebiete der untersuchten Beispiele in allen qualitativen und quantitativen Quellen über die letzten 400 Jahre hinweg.Historische Lehrbücher für klinische Medizin und zeitgenössische phytotherapeutische Äquivalente sind die wichtigsten Quellen von wiederholt evaluiertem therapeutischem Wissen zu Heilpflanzen. Die klinische Fachliteratur erwies sich als zuverlässiger und verifizierbarer Korpus empirischer Evidenz, der mit aktuellen wissenschaftlichen Untersuchungen übereinstimmte. Das neu entwickelte PHA-Verfahren bietet ein Kodierungs­Instrument für das systematische Erfassen und Auswerten empirischer Daten zur Wirksamkeit und Sicherheit von traditionellen pflanzlichen Arzneimitteln. Das PHA­Verfahren wird als praktikables und effizientes Instrument zur Erweiterung der Evidenz­Typologien empfohlen, indem es therapeutische Indikationen für traditionelle pflanzliche Arzneimittel untermauern kann, so dass diese medizinisch und kulturell wichtigen Therapeutika in einen evidenz-basierten regulatorischen Rahmen integriert werden können.

Surgical management of anterior sacral meningoceles: an illustrated case series and review of the literature.

BACKGROUND: Anterior sacral meningocele (ASM) is an uncommon variant of spinal dysraphism. Surgical correction for this condition is challenging and optimal corrective approaches are uncertain. OBJECTIVE: To share our experience of managing this rare condition using the posterior trans-sacral approach and provide a contemporary review of the literature. METHODS: Retrospective review of case notes, operative records, and imaging of eligible patients treated via the posterior trans-sacral approach between 2006 and 2020 at our regional neurosciences centre. RESULTS: Three patients, two females and one male with a mean age of 30 years (range 16-38), were treated. Presenting symptoms included lower abdominal pain and recurrent miscarriages. Patients underwent corrective surgery using the posterior approach involving a sacral laminectomy, durotomy and closure of the communicating fistula. A single patient required reoperation due to early recurrence. Another patient proved challenging because of a very large sacral fistula and required two procedures due to the development of high-pressure headaches secondary to a recurrence. All patients improved symptomatically postoperatively and remained symptom free at the last clinic follow-up and have been discharged. Following review of the literature, only two other non-syndromic cases have been described. CONCLUSIONS: ASM is an uncommon congenital abnormality, typically presenting with mass effect symptoms secondary to a presacral cystic mass. Surgical management using a posterior approach to close the meningeal sac is feasible and less invasive than an anterior approach. Long term clinical outcomes in our series were satisfactory.

Cannabis use patterns in drug-resistant and pharmacoresponsive epilepsy: Single tertiary referral center survey investigation.

This study sought to identify differences in cannabis use and perceptions about cannabis in mitigating seizure-related symptoms in patients with epilepsy, and to evaluate differences in these patterns between drug-resistant versus pharmacoresponsive epilepsy. A collection of self-report surveys completed by patients with epilepsy (n = 76) were used to retrospectively compare differences in those with drug-resistant versus pharmacoresponsive epilepsy regarding 1) proportion who used cannabis, 2) frequency of use, 3) method of use, and 4) reason for use. A Cochran-Armitage test for trend indicated that of patients who used cannabis, a higher proportion of patients in the drug-resistant group used more frequently than in the pharmacoresponsive group. Almost half (48%) of those in the drug-resistant group reported daily use compared to approximately a third (36%) of those in the pharmacoresponsive group. Additionally, no patient in either group reported that cannabis was harmful in relation to seizure-related symptoms. Results from this study highlight the need for epilepsy providers to formally assess patients' perceptions and use of non-prescribed cannabis to inform clinical care decisions, particularly in the drug-resistant epilepsy population.

Definitions of Chronic Low Back Pain From a Scoping Review, and Analyses of Narratives and Self-Reported Health of Adults With Low Back Pain.

Among those with low back pain (LBP), individuals with chronic LBP (CLBP) face different treatment recommendations and incur the majority of suffering and costs. However, the way CLBP has been defined varies greatly. This study used a scoping review and qualitative and quantitative analyses of data from LBP patients to explore this variation. CLBP in most recent randomized controlled trials (RCTs) was defined by duration of pain, most commonly ≥3 months. However, individuals with LBP most often define CLBP by frequency. CLBP has also been defined using a combination of duration and frequency (16% of RCTs and 20% of individuals), including 6% of recent RCTs that followed the NIH Pain Consortium research task force (RTF) definition. Although not a defining characteristic of CLBP for individuals, almost 15% of recent RCTs required CLBP to have a healthcare provider diagnosis. In our LBP sample moving from ≥3 months to the RTF definition reduced the CLBP group size by 25% and resulted in a group that used more pain management options and reported worse health across all outcome measures. A pain duration definition offers ease of application. However, refinements to this definition (eg, RTF) can identify those who may be better intervention targets. PERSPECTIVE: This article presents the definitions used for CLBP by researchers and individuals, and the impact of these definitions on pain management and health outcomes. This information may help researchers choose better study inclusion criteria and clinicians to better understand their patients' beliefs about CLBP.

Longitudinal Associations of PROMIS-29 Anxiety and Depression Symptoms With Low Back Pain Impact in a Sample of U.S. Military Service Members.

INTRODUCTION: The Impact Stratification Score (ISS) is a measure of the impact of chronic low back pain (LBP) consisting of nine Patient-Reported Outcomes Measurement Information System (PROMIS-29) items, but no studies have examined the ISS or its association with psychological symptoms in military samples. This study examines longitudinal associations between psychological symptoms and the ISS among military service members. MATERIAL AND METHODS: The study involved secondary data analysis of a sample of active duty U.S. military service members aged 18-50 years with LBP (n = 733). Participants completed the PROMIS-29 at three time points during treatment: baseline (time 1, T1), week 6 of treatment (time 2, T2), and week 12 of treatment (time 3, T3). The impact of LBP was quantified using the ISS (ranging from 8 = least impact to 50 = greatest impact). Psychological symptoms were assessed as PROMIS-29 anxiety and depression scores. Separate autoregressive cross-lagged models examined reciprocal associations of ISSs with anxiety, depression, and emotional distress scores from T1 to T3. RESULTS: Within each time point, the ISS was significantly and positively correlated with anxiety and depression. In autoregressive cross-lagged models, anxiety and depression predicted the ISS at the next time point and associations were similar in magnitude (e.g., anxiety T2 to ISS T3: ß = 0.12, P < .001; depression T2 to ISS T3: ß = 0.12, P <.001). The ISS did not predict future depression or emotional distress scores at any time point, but the ISS at T2 was significantly, positively associated with anxiety scores at T3 (ß = 0.07, P = .04). CONCLUSION: Psychological symptoms consistently and prospectively predict the impact of LBP as measured by the ISS among service members undergoing pain treatment. The ISS may also be associated with future anxiety but not depression. PROMIS-29 anxiety and depression items may be useful adjunctive measures to consider when using the ISS to support LBP treatment planning and monitoring with service members.

Incorporating Complementary and Integrative Health Providers in the Public Health Pandemic Response: Lessons from COVID-19 and Recommendations for the Future from a Multidisciplinary Expert Panel.

Complementary and integrative health (CIH) providers, such as chiropractors and naturopathic doctors, have been an underutilized public health asset in the response to the COVID-19 pandemic. This article seeks to inform how they can be better integrated into future responses to public health emergencies. The authors convened an expert panel of ten CIH and public health practitioners and researchers for a daylong discussion of how the CIH workforce could be better mobilized during future crises. In this article, the authors summarize the key barriers identified in the discussion and make recommendations on how they can be overcome.

A Scoping Review of Chronic Low Back Pain Classification Schemes Based on Patient-Reported Outcomes.

BACKGROUND: In 2014, the National Institutes of Health Pain Consortium Research Task Force recommended that patients with chronic low back pain (CLBP) be stratified by its impact on their lives. They proposed the Impact Stratification Score (ISS) to help guide therapy and facilitate study comparability. The ISS has been evaluated as a continuous measure, but not for use as a stratification or classification scheme. OBJECTIVES: Identify the characteristics of successful schemes to inform the use of the ISS for stratification or classification. STUDY DESIGN: Scoping review of the peer-reviewed literature. METHODS: Search of PubMed, CINAHL, and APA PsycInfo to identify patient self-report-based classification schemes applicable to CLBP. Data were captured on the methods used for each scheme's development, the domains covered, their scoring criteria and what the classification has successfully measured. The study was reviewed and approved by the RAND Human Subjects Protection Committee (2019-0651-AM02). RESULTS: The search identified 87 published articles about the development and testing of 5 classification schemes: 1) The Subgroups for Targeted Treatment (STarT) Back Screening Tool, 2) Multiaxial Assessment of Pain, 3) Graded Chronic Pain Scale, 4) Back Pain Classification Scale, and 5) Chronic Pain Risk Score. All have been shown to be predictive of future outcomes and the STarT Back has been found useful in identifying effective classification-specific treatment. Each scheme had a different classification scoring structure, was developed using different methods, and 3 included domains not found in the ISS. LIMITATIONS: Expanding the search to other databases may have identified more classification schemes. Our minimum number of publications inclusion criterion eliminated dozens of cluster analyses, some of which may have eventually been replicated. CONCLUSIONS: The methods used to develop these successful classification schemes, especially those that use straightforward scoring schemes, should be considered for use in the development of a scheme based on the ISS.

Decompressive craniectomy for intracranial hypertension in vaccine-induced immune thrombotic thrombocytopaenia: a case series.

BACKGROUND: Vaccines have been key in preventing COVID-19 infections and the AstraZeneca (AZ) vaccine has been widely used. However, increased rates of thromboembolic events were identified in recipients and, subsequently, a syndrome of vaccine-induced immune thrombotic thrombocytopaenia (VITT) was described whereby recipients presented with venous sinus thromboses, haemorrhagic infarctions, and - consequently - raised intracranial pressure. National guidance recommended decompressive craniectomies for refractory intracranial hypertension. We describe our neurosurgical experience in managing a cohort of patients with VITT. CLINICAL PRESENTATION: Four patients were included (three females and one male); median age was 46 years. All patients presented with a constellation of headache, focal neurological deficit(s), altered consciousness, and/or seizure at a median 11 d post-vaccine. Pre-operatively, median GCS was 7 and the median platelet count was 28 × 109/L. Mean craniectomy size was 13 cm × 10 cm. All four cases tested positive for anti-PF4 antibodies. Median length of stay was 9 d (range: 2-25). Of the four who were operated upon, two survived to hospital discharge, and one of these subsequently died at a peripheral hospital. CONCLUSIONS: VITT-related sinus thromboses and associated infarcts are rare complications of the AZ vaccine. Neurosurgical management involves treating intracranial hypertension however survival outcomes in our cohort were poor. In our series, decompression was performed in deteriorating patients however prophylactic decompression, in the presence of extensive venous sinus thrombosis, should be considered on a case-by-case basis. As vaccination programmes accelerate across the world, neurosurgeons are likely to be increasingly involved in managing intracranial hypertension in patients with VITT-related sinus thromboses.

Health-Related Quality of Life Among United States Service Members with Low Back Pain Receiving Usual Care Plus Chiropractic Care vs Usual Care Alone: Secondary Outcomes of a Pragmatic Clinical Trial.

OBJECTIVE: This study examines Patient-Reported Outcome Measurement Information System (PROMIS®)-29 v1.0 outcomes of chiropractic care in a multi-site, pragmatic clinical trial and compares the PROMIS measures to: 1) worst pain intensity from a numerical pain rating 0-10 scale, 2) 24-item Roland-Morris Disability Questionnaire (RMDQ); and 3) global improvement (modified visual analog scale). DESIGN: A pragmatic, prospective, multisite, parallel-group comparative effectiveness clinical trial comparing usual medical care (UMC) with UMC plus chiropractic care (UMC+CC). SETTING: Three military treatment facilities. SUBJECTS: 750 active-duty military personnel with low back pain. METHODS: Linear mixed effects regression models estimated the treatment group differences. Coefficient of repeatability to estimate significant individual change. RESULTS: We found statistically significant mean group differences favoring UMC+CC for all PROMIS®-29 scales and the RMDQ score. Area under the curve estimates for global improvement for the PROMIS®-29 scales and the RMDQ, ranged from 0.79 to 0.83. CONCLUSIONS: Findings from this pre-planned secondary analysis demonstrate that chiropractic care impacts health-related quality of life beyond pain and pain-related disability. Further, comparable findings were found between the 24-item RMDQ and the PROMIS®-29 v1.0 briefer scales.

Initial Choice of Spinal Manipulation Reduces Escalation of Care for Chronic Low Back Pain Among Older Medicare Beneficiaries.

STUDY DESIGN: We combined elements of cohort and crossover-cohort design. OBJECTIVE: The objective of this study was to compare longterm outcomes for spinal manipulative therapy (SMT) and opioid analgesic therapy (OAT) regarding escalation of care for patients with chronic low back pain (cLBP). SUMMARY OF BACKGROUND DATA: Current evidence-based guidelines for clinical management of cLBP include both OAT and SMT. For long-term care of older adults, the efficiency and value of continuing either OAT or SMT are uncertain. METHODS: We examined Medicare claims data spanning a five-year period. We included older Medicare beneficiaries with an episode of cLBP beginning in 2013. All patients were continuously enrolled under Medicare Parts A, B, and D. We analyzed the cumulative frequency of encounters indicative of an escalation of care for cLBP, including hospitalizations, emergency department visits, advanced diagnostic imaging, specialist visits, lumbosacral surgery, interventional pain medicine techniques, and encounters for potential complications of cLBP. RESULTS: SMT was associated with lower rates of escalation of care as compared to OAT. The adjusted rate of escalated care encounters was approximately 2.5 times higher for initial choice of OAT vs. initial choice of SMT (with weighted propensity scoring: rate ratio 2.67, 95% confidence interval 2.64-2.69, P < .0001). CONCLUSION: Among older Medicare beneficiaries who initiated long-term care for cLBP with opioid analgesic therapy, the adjusted rate of escalated care encounters was significantly higher as compared to those who initiated care with spinal manipulative therapy.Level of Evidence: 3.

Barriers to the Engagement of Complementary and Integrative Health Providers in Public Health Responses to COVID-19: Recommendations From a Multidisciplinary Expert Panel.

OBJECTIVE: The purpose of this project was to explore barriers to the involvement of complementary and integrative health (CIH) providers in the public health response to COVID-19 and potential solutions for future involvement in public health crises. METHODS: An expert panel of 10 people, which included doctors of chiropractic, naturopathic doctors, public health practitioners, and researchers from the United States, was convened for a day-long online panel discussion. Facilitators asked panelists how CIH practitioners could contribute and be mobilized. We summarized themes and recommendations from the discussion. RESULTS: Despite their skills and resources, few CIH providers participated in public health efforts like testing and contact tracing during the COVID-19 pandemic. Panelists described that CIH professionals may not have participated in those efforts due to the CIH providers possibly not having sufficient public health training and limited contact with public health professionals, as well as policy and financial challenges during the pandemic. Panelists proposed solutions to these barriers, including more public health training, stronger formal relationships between CIH and public health organizations, and improved financial support for both CIH care and public health efforts. CONCLUSION: Through an expert panel discussion, we identified barriers that hindered the involvement of CIH providers in the public health response to the COVID-19 pandemic. During future pandemics in the United States, public health planners should recognize CIH providers as part of the existing labor resource, with clinical expertise and community-level connections that can be called upon in a crisis. During future events, CIH professional leaders should be more proactive in seeking out a supportive role and sharing their knowledge, skills, and expertise.

Long-Term Medicare Costs Associated With Opioid Analgesic Therapy vs Spinal Manipulative Therapy for Chronic Low Back Pain in a Cohort of Older Adults.

OBJECTIVES: The purpose of this study was to compare Medicare healthcare expenditures for patients who received long-term treatment of chronic low back pain (cLBP) with either opioid analgesic therapy (OAT) or spinal manipulative therapy (SMT). METHODS: We conducted a retrospective observational study using a cohort design for analysis of Medicare claims data. The study population included Medicare beneficiaries enrolled under Medicare Parts A, B, and D from 2012 through 2016. We assembled cohorts of patients who received long-term management of cLBP with OAT or SMT (such as delivered by chiropractic or osteopathic practitioners) and evaluated the comparative effect of OAT vs SMT upon expenditures, using multivariable regression to control for beneficiary characteristics and measures of health status, and propensity score weighting and binning to account for selection bias. RESULTS: The study sample totaled 28,160 participants, of whom 77% initiated long-term care of cLBP with OAT, and 23% initiated care with SMT. For care of low back pain specifically, average long-term costs for patients who initiated care with OAT were 58% lower than those who initiated care with SMT. However, overall long-term healthcare expenditures under Medicare were 1.87 times higher for patients who initiated care via OAT compared with those initiated care with SMT (95% CI 1.65-2.11; P < .0001). CONCLUSIONS: Adults aged 65 to 84 who initiated long-term treatment for cLBP via OAT incurred lower long-term costs for low back pain but higher long-term total healthcare costs under Medicare compared with patients who initiated long-term treatment with SMT.

Acute Sigmoid Sinus Compromise Following Skull Base Procedures: Is a "Laissez-Faire" Approach Best?

Objective Venous sinus compromise (VSC) of the sigmoid sinus can manifest as either venous sinus thrombosis, stenosis, or a combination of the two. It may occur following retro and presigmoid craniotomy, even in the absence of overt intraoperative sinus injury. Currently, the optimal management of VSC in the perioperative period is not well established. We report our incidence and management of VSC following skull base surgery around the sigmoid sinus. Patients and Methods A retrospective chart review of all patients undergoing presigmoid, retrosigmoid, or combined approach by the senior author from 2014 to 2019 was performed. Main Outcome Measures Charts were reviewed for patient demographics, surgical details, details of venous sinus compromise, and patient outcomes. Statistical analyses were performed using R 3.6.0 (R Project). Results A 115 surgeries were found with a total of 13 cases of VSC (overall incidence of 11.3%). Nine cases exhibited thrombosis and four stenosis. There were no statistically significant differences between the groups with (group 1) or without (group 2) VSC. Operation on the side of the dominant sinus did not predispose to postoperative VSC. Five patients received antiplatelet medication in the perioperative period. There was no difference in outcomes in the group that did not receive antiplatelet medication versus those who did. Conclusion Acute iatrogenic sigmoid sinus compromise can be managed expectantly. We believe that the treatment for each instance of VSC must be individualized, considering the symptoms of the patient, rather than applying a universal algorithm.

Income as a Predictor of Self-Efficacy for Managing Pain and for Coping With Symptoms Among Patients With Chronic Low Back Pain.

OBJECTIVES: The purpose of this study was to evaluate pain self-efficacy (PSE) and coping self-efficacy (CSE) for people with chronic low back pain (CLBP), and to assess whether lower income may be associated with less PSE and CSE in the United States. METHODS: We conducted a cross-sectional study using survey data collected between June 2016 and February 2017 from n = 1364 patients with CLBP from chiropractic clinics in the United States to measure the relationship between income and both types of self-efficacy. We created 4 multivariate models predicting PSE and CSE scores. We used both a parsimonious set of covariates (age, sex) and a full set (age, sex, education, neck pain comorbidity, catastrophizing, and insurance). We also calculated effect sizes (Cohen's d) for unadjusted differences in PSE and CSE score by income. RESULTS: Lower income was associated with lower PSE and CSE scores across all 4 models. In the full models, the highest-income group had an average of 1 point (1-10 scale) higher PSE score and CSE score compared to the lowest income group. Effect sizes for the unadjusted differences in PSE and CSE scores between the highest and lowest income groups were 0.94 and 0.84, respectively. CONCLUSIONS: Our findings indicate that people with lower income perceive themselves as less able to manage their pain, and that this relationship exists even after taking into account factors like health insurance and educational attainment. There is a need to further investigate how practitioners and policymakers can best support low-income patients with chronic pain.

Measuring the Appropriateness of Spinal Manipulation for Chronic Low Back and Chronic Neck Pain in Chiropractic Patients.

STUDY DESIGN: RAND/UCLA Appropriateness Method (RUAM) applied to chiropractic manipulation for patients with chronic low-back pain (CLBP) and chronic neck pain (CNP). OBJECTIVE: Determine the rate of appropriate care provided by US chiropractors. SUMMARY OF BACKGROUND DATA: Spinal manipulation has been shown effective for CLBP and CNP but may not be appropriate for all patients with these conditions. METHODS: Ratings of the appropriateness of spinal and cervical manipulation previously developed by two RUAM expert panels were applied to data abstracted from random samples of patient charts from chiropractors in six US regions to determine the appropriateness of manipulation for each patient. RESULTS: Of 125 chiropractors sampled, 89 provided charts that could be abstracted. Of the 2128 charts received, 1054 were abstracted. Charts received but not abstracted included 460 that were unusable (e.g., illegible), and 555 did not have CLBP or CNP. Across the abstracted charts 72% had CLBP, 57% had CNP, and 29% had both; 84% of patients with CLBP and 86% with CNP received manipulation. Patients with CLBP who had minor neurologic findings, sciatic nerve irritation, or no joint dysfunction were significantly less likely to receive manipulation. Patients with CNP who had substantial trauma etiology, no joint dysfunction, or no radiographs were significantly less likely to receive manipulation. Most manipulation for CLBP (64%) was appropriate and most manipulation for CNP (93%) was for patients where appropriateness was uncertain or equivocal. The proportions of patients receiving inappropriate manipulation for either condition were low (1%-3%) as were the numbers of patients presenting to these chiropractors for which manipulation was inappropriate. CONCLUSION: Chiropractors in this US sample tend to provide manipulation to very few patients with CLBP or CNP for which it is inappropriate. However, more research is needed to determine which patients with CNP benefit from manipulation.Level of Evidence: 4.

Neurosurgery activity levels in the United Kingdom and republic of Ireland during the first wave of the covid-19 pandemic - a retrospective cross-sectional cohort study.

The impact of Covid-19 on surgical patients worldwide has been substantial. In the United Kingdom (UK) and the Republic of Ireland (RoI), the first wave of the pandemic occurred in March 2020. The aims of this study were to: (1) evaluate the volume of neurosurgical operative activity levels, Covid-19 infection rate and mortality rate in April 2020 with a retrospective cross-sectional cohort study conducted across 16 UK and RoI neurosurgical centres, and (2) compare patient outcomes in a single institution in April-June 2020 with a comparative cohort in 2019. Across the UK and RoI, 818 patients were included. There were 594 emergency and 224 elective operations. The incidence rate of Covid-19 infection was 2.6% (21/818). The overall mortality rate in patients with a Covid-19 infection was 28.6% (6/21). In the single centre cohort analysis, an overall reduction in neurosurgical operative activity by 65% was observed between 2020 (n = 304) and 2019 (n = 868). The current and future impact on UK neurosurgical operative activity has implications for service delivery and neurosurgical training.