Volume 120, Issue 2

Context The OSTEOPATHIC Trial demonstrated substantial improvement in pain intensity, decreased need for rescue medication for pain, and greater likelihood of recovery in patients with chronic low back pain who received 6 osteopathic manipulative treatment (OMT) sessions over 3 months. Objective To assess osteopathic medical care and the effectiveness of OMT for chronic low back pain in a real-world setting without the constraints of a rigid research protocol. Methods An observational study of 445 adults with chronic low back pain who had an established osteopathic physician (ie, DO) or allopathic physician (ie, MD) was conducted within the PRECISION Pain Research Registry from April 2016 through February 2019. Primary outcome measures included a numerical rating scale for low back pain intensity, the Roland-Morris Disability Questionnaire for back-related functioning, and use of nonsteroidal anti-inflammatory drugs or opioids for low back pain. Results A total of 79, 48, and 318 patients, respectively, were treated by DOs who used OMT, DOs who did not use OMT, or MDs. Patients treated by DOs who used OMT reported significantly lesser low back pain intensity (mean numerical rating score, 5.6; 95% CI, 5.1-6.1 vs 6.1; 95% CI, 5.9-6.3; P =.04) and back-related disability (mean Roland-Morris Disability score, 12.4; 95% CI, 11.1-13.8 vs 14.4; 95% CI, 13.7-15.0; P= .009) than patients treated by MDs. Patients treated by DOs who used OMT also reported less frequent use of nonsteroidal anti-inflammatory drugs (multivariate odds ratio, 0.41; 95% CI, 0.24-0.70; P =.001) or opioids (multivariate odds ratio, 0.52; 95% CI, 0.28-0.98; P =.04). There were no significant differences in primary outcomes between DOs who did not use OMT and MDs. Conclusion This study of community-based patients in a pain research registry supports the effectiveness of OMT as an integral component of osteopathic medical care for chronic low back pain. Patients treated by DOs who did not use OMT did not experience better results than patients treated by MDs in any primary outcome measure. Further research is needed to more specifically compare the effects of OMT with other treatment effects that may be attributed to patient-DO interactions during medical encounters.

Background Clinical practice guidelines (CPGs) can positively affect the quality of patient care offered by physicians because they decrease variability in clinical practice and may help reduce unnecessary testing, promoting a more responsible use of resources. Building on existing framework for reporting guideline development, including the work of the Enhancing the Quality and Transparency of Health Research Network, the Reporting Items for Practice Guidelines in Healthcare (RIGHT) Working Group created a 2016 checklist of 35 items considered essential for high-quality reporting of CPGs. Objectives To evaluate how many previously published CPGs in orthopedic surgery met the RIGHT criteria and assess how improvements can be made in future orthopedic CPGs based on any found deficiencies. Methods All 18 CPGs published before January 1, 2018, by the American Academy of Orthopedic Surgeons (AAOS) are publicly available on orthoguidelines.org. Two authors downloaded each file and both of those authors independently scored each CPG using piloted abstraction RIGHT checklist forms. Results Of the 35 RIGHT criteria outlined in 22 checklist items, 23 (65.7%) were met across all AAOS guidelines, 6 (17.1%) were not met by any of the AAOS guidelines, and 6 (17.2%) were met by some of the AAOS guidelines. Conclusion Overall, the AAOS guidelines addressed many important recommendations within the RIGHT checklist. Assessing adherence to the RIGHT checklist can help ensure that future guidelines are more effectively communicated, hopefully assisting end users in efficient implementation and increasing the level of evidence-based patient care.

Objective To assess the attitudes of academic deans at colleges of osteopathic medicine (COMs) and chairs of COMs’ osteopathic manipulative medicine (OMM) departments toward osteopathic recognition under the single graduate medical education (GME) accreditation system. Methods An 11-item Likert-type survey with additional demographic questions was distributed via email to deans and OMM department chairs at 51 COMs and additional locations in September 2017. Items were formulated to assess survey participants’ understanding and beliefs regarding the value and support of the establishment of osteopathic recognition within the single GME accreditation system. Demographic information gathered was limited to role (ie, dean or OMM department chair). Survey items were ranked on a 5-point Likert-type scale from strongly disagree to strongly agree. Results A total of 39 COMs deans and 24 OMM chairs indicated they understood the intent of osteopathic recognition in a single GME accreditation system, but OMM chairs felt less informed about osteopathic recognition than deans (17% vs 3% disagreeing with the statement, “I have been adequately informed about osteopathic recognition”). There was no difference between deans and chairs regarding their attitudes toward osteopathic recognition in residency training programs, though a minority of deans (n=2) disagreed that osteopathic recognition benefits programs and indicated that they did not recommend it for surgical specialties (n=2) or fellowship programs (n=3). Deans and chairs generally agreed on their overall support of osteopathic recognition, the perceptions of osteopathic medical students toward osteopathic recognition, and the value that osteopathic recognition brings to COMs, with 2 deans dissenting on each item. A moderate correlation was found between information of and attitude toward osteopathic recognition for the deans ( r =0.72, n=39), but a much weaker relationship was observed between information and attitude for the chairs ( r =0.37, n=24) (difference between the correlations: z =1.89, P =.06). Conclusion Although the deans and OMM chairs agreed that they support, believe in the value of, and find that osteopathic medical students are interested in osteopathic recognition, there is an opportunity for improvement of deans’ and COMs chairs’ understanding of osteopathic recognition.

Modern medical and technological advances provide highly effective management for the treatment of patients with heart failure with reduced ejection fraction (HFrEF). In this review, the authors propose a 2-step approach to treatment that is straightforward, practical, and thorough. For the patient whose life now includes HFrEF, the physician's first step is to ensure that the patient is taking the 3 key medications ([1] renin-angiotensin inhibitors (angiotensin receptor/neprilysin inhibitors, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers), [2] β-blockers, and [3] mineralocorticoid receptor antagonists) recommended in guideline-directed doses to attain comprehensive receptor blockade. Significant coexisting medical issues are also characteristic in patients with HFrEF. Therefore, the physician's second step is to address the comorbidities of heart failure to fulfill comprehensive patient care. This review presents evidence to implement the management of HFrEF and heart failure comorbidities that will reduce cardiac mortality and hospitalization and to avoid treatments that are of no benefit or may cause harm.

Context Depression is one of the most commonly diagnosed psychiatric disorders, but antidepressant pharmacotherapy often fails to achieve remission, leading health care professionals and researchers to consider various augmentation strategies to improve clinical outcomes. Objective To assess the safety, tolerability, and efficacy of nutraceutical augmentation for depression. Methods Nutraceutical-focused systematic reviews and clinical practice guidelines identified the more commonly studied augmentation strategies for depression. Results S-adenosylmethionine, l -methylfolate, omega-3 fatty acids, and hydroxyvitamin D have sufficient scientific evidence to support their clinical consideration in the stepped care approach to the management of depression. Conclusions Clinical remission is the goal in the management of depression, and nutraceuticals may be part of an overall treatment approach to achieve that outcome.

In this highly digitalized era, sleep disorders are becoming more common and are associated with an increased burden of chronic disease. Shift workers are at an increased risk for both sleep disorders and metabolic syndrome. In this article, the authors outline the connection between circadian discordance, hormonal imbalance, and the development of metabolic syndrome in shift workers. Based on a literature review of animal model studies, observational studies, and clinical trials conducted between August and October of 2018, the authors offer several clinical interventions, including work schedules, light therapy, medications, and dietary habits to improve the circadian synchronicity of shift workers and reduce their risk of morbidity and mortality. It is important for physicians to be familiar with the consequences of shift work and ways to mitigate the risks for this patient population.

A 20-year-old male swimmer presented to the emergency department with right arm pain and swelling several days after a weight training session following swim team practice. The initial diagnosis was muscle strain, and the patient was discharged. The next day, he was evaluated by his swim team physician, who ordered right upper extremity duplex ultrasonographic imaging, which revealed no flow and thrombosis in the subclavian and axillary veins, and Paget-Schroetter syndrome was diagnosed. He subsequently had a mechanical thrombectomy and catheter-directed thrombolysis was initiated with placement of a lytic catheter for continuous infusion of tissue type plasminogen activator.