Characterizing the use of osteopathic manipulative medicine in the obstetric population by trimester and indications for use.

CONTEXT: Osteopathic manipulative medicine (OMM) has been shown to successfully alleviate some pregnancy-related pain. However, most of the published data focuses on the third trimester and postpartum period or musculoskeletal indications. OBJECTIVE: To explore OMM use among obstetrical providers and determine the frequency of use by trimester and by clinical indications across multiple types of women's healthcare practices in Southern and Central Maine. METHODS: An anonymous, 43-item survey, presented in English, was emailed to 172 eligible providers (physicians, nurse practitioners, and certified nurse midwives with obstetrics privileges at one of two main delivery centers in southern and central Maine) via an encrypted database system in January 2018. Follow-up email reminders were sent weekly for three weeks. Questions addressed use of OMM for specific indications, knowledge of OMM, and perceived barriers use of OMM. RESULTS: The survey response rate was 73 of 172 (42%); 95% of respondents were physicians (n=69). Due to the low response rate of non-physicians, only data from physicians was included in the study. Data were summarized descriptively as frequencies (n [%]). The highest rates of OMM utilization were during the third trimester (35 [51.5%]) and postpartum (41 [60.3%]) periods, while the lowest rates of utilization were in the intrapartum (eight [11.9%]) and first trimester periods (26 [38.3%]). Osteopathic physicians (n=19) used OMM more frequently in the first, second, and third trimesters, as well as the intrapartum period (10 [52.6%]; 11 [57.9%]; 14 [73.7%]; and six [31.6%], respectively) compared with their allopathic physician (n=50) counterparts (nine [8%]; 15 [30%]; 21 [42%]; and two [4%], respectively). While osteopathic physicians reported higher frequencies of OMM use and referral for non-musculoskeletal indications such as constipation, edema, and nasal congestion (13 [68.4%]; 11 [57.9%]; 10 [52.6%], respectively), musculoskeletal complaints were the most frequently cited indication for OMM use among both osteopathic and allopathic physicians (low back, 67 [97.1%]; pelvis, 65 [94.2%]; coccyx, 50 [72.5%]; and head, 49 [71%]). CONCLUSION: These results suggest that more education is needed about OMM use in the obstetric population, particularly during early trimesters and the intrapartum period, as well as for visceral and lymphatic complaints of pregnancy.

Integrating Screening, Brief Intervention and Referral to Treatment (SBIRT) for Substance Use into Prenatal Care.

OBJECTIVES: Universal screening for substance use during pregnancy, brief intervention, and referral to treatment (SBIRT) is recommended by ACOG and the USPSTF. Here we present the implementation of SBIRT into the electronic health record (EHR) to inform clinical intervention and collect data on the prevalence of substance use during pregnancy at three prenatal clinics. METHODS: A literature-based SBIRT instrument was developed. The tool was integrated into the EHR of a resident Ob/Gyn clinic, an MFM practice, and an Ob/Gyn generalist practice at our institution, an academic, tertiary care medical center in an urban area, and automated reports of aggregate retrospective EHR data were used to monitor patient responses to SBIRT over time. Data reports included patient responses to screening for substance use, brief intervention, and referral to treatment from January to December 2018 RESULTS: An interprofessional team of health care providers and systems analysts guided the SBIRT implementation process. As of December 2018, overall SBIRT performance during prenatal care encounters was 1797/2619 (69%), 432/1350 (32%), and 1290/1518 (85%) in the resident clinic, MFM practice, and generalist practice, respectively. Eighty (5.1%) women in the resident clinic, 2 (0.5%) in the MFM practice and 14 (1%) in the generalist practice reported past or present substance use. CONCLUSIONS FOR PRACTICE: Integrating universal SBIRT into prenatal care using the EHR requires a multi-disciplinary approach. The SBIRT tool facilitates reportable substance use screening, brief intervention, and referral to treatment during prenatal care. Future reports will further characterize substance use in our prenatal practices and inform intervention strategies in this population.

Novel Use of Dual-Lumen Catheter for Irrigation and Drainage After Evacuation of Chronic Subdural Hematoma.

BACKGROUND: Chronic subdural hematoma (cSDH) is an intracranial pathology most commonly affecting elderly patients. Patients may present with worsening headache, seizures, weakness, balance and gait problems, and memory deficits. Even in patients undergoing hematoma evacuation, there is a substantial risk for recurrence. The authors present the first use of an irrigating external ventricular drain in the United States in the perioperative management of a patient with cSDH treated with craniotomy (IRRAS, Stockholm, Sweden). CASE DESCRIPTION: An 82-year-old male presented with right-sided weakness, confusion, and right-sided neglect with expressive aphasia. He was found to have a large 2.5-cm cSDH with a 9-mm left-to-right midline shift. The patient was treated with a minicraniotomy to evacuate the hematoma and placement of an irrigating drain in the subdural space. The patient was discharged home on postoperative day 3 without complication. He was at neurologic baseline 2 weeks later on follow-up. CONCLUSIONS: The use of an irrigating drain for perioperative management of cSDH is a novel means to prevent recurrence and warrants further exploration.

Engaging Individuals with Neurological Conditions and Caregivers in Rural Communities in a Health Research Team.

BACKGROUND: In rural communities, individuals living with neurological conditions, such as stroke, traumatic brain injury (TBI), or spinal cord injury (SCI) and their caregivers face limited resources, decreased support, and a lack of access to health information and research. Little information exists on how to engage these individuals in community-based research. OBJECTIVES: We sought to 1) determine the most effective method(s) for engaging individuals with stroke, TBI, or SCI, and their caregivers in rural communities; 2) determine the perceived value of patient-centered outcomes research (PCOR) in their health care and clinical decision making; 3) to determine their health needs and related research priorities; and 4) to establish a community-based research team to support the development of relevant questions. METHODS: Targeting a population of individuals with stroke, TBI, or SCI and their caregivers, as well as health care providers, 17 in-depth interviews were conducted, followed by seven focus groups, and two half-day meetings to establish a community-based research team and develop a research agenda. RESULTS: Recruitment through trusted community networks was found to be the most beneficial for engaging participants. Participants placed high value on health research, but reported difficulties in accessing health information and in finding the information most relevant to them. A research team was established and research priorities centered on access to care and education. CONCLUSIONS: It is imperative to involve those living with a diagnosis or in an under-resourced community to develop the solutions that will work for them in their settings.