Volume 121, Issue 1

Context In 2013, the US Food and Drug Administration issued a warning regarding the use of azithromycin and the risk of fatal dysrhythmias after a 14-year retrospective analysis showed increased risk of cardiovascular-related death in patients who had taken a 5-day course of azithromycin compared with those who took amoxicillin, ciprofloxacin, or no antibiotics. At the authors’ institution, pneumonia is the most common diagnosis for which azithromycin is used as a treatment for patients who are hospitalized. Objective To compare corrected QT (QTc) interval measurements on electrocardiogram (ECG) before and after inpatient azithromycin treatment for pneumonia. Methods The authors retrospectively reviewed the medical records of 642 patients age 18 years and older who were diagnosed with pneumonia and treated with azithromycin at an academic teaching hospital between January 1, 2017 and December 31, 2017. Patients who had an ECG performed both before and after azithromycin treatment were included and divided into 2 groups: those who had 1 dose of azithromycin (Group 1) and those who had 2 doses (Group 2). Patients were excluded if they had a baseline QTc interval on initial ECG greater than or equal to 500 ms, any signs of ischemia or myocardial infarction, any initial dysrhythmia or underlying ECG abnormalities, or absence of pre- and post-ECG results. Outcomes measures included a comparison of QTc intervals on ECG before and after azithromycin, and an analysis of the percentage of patients with a QTc interval measurement greater than 500 ms on ECG after azithromycin treatment. Our primary outcome measurement was the QTc interval measurement on ECG before and after azithromycin in patients treated with azithromycin for community acquired pneumonia. Our secondary outcome measurement was the percentage of patients with a QTc interval measurement of greater than 500 ms on ECG after azithromycin treatment. A Wilcoxon signed-rank test was used to evaluate repeated QTc measures of our primary outcome in Group 1 and Group 2. Our secondary outcome was reported as a percentage of total patients with a QTc interval of greater than 500 ms after azithromycin doses on ECG. Results Of 642 patients, 142 had available pre- and post-EGC results available; 100 were included in Group 1 (1 dose) and 42 in Group 2 (2 doses). Mean QTc interval differences after 1 dose of azithromycin exhibited an increase compared to baseline values (424 vs 477 ms). A Wilcoxon signed-rank test indicated a significant QTc prolongation after 1 dose of azithromycin (mean rank, 43.76; Z=−4.921; P <.001). QTc interval differences after 2 doses of azithromycin did not reach statistical significance when compared to baseline values (422 vs 444 ms). A total of 10 patients (10%) in Group 1 and 4 patients (9.5%) in Group 2 had a QTc interval >500 ms after azithromycin. There were no documented dysrhythmias during hospitalization in this study period. Conclusion QTc interval increases were observed during inpatient azithromycin therapy for pneumonia, but were not found to be associated with cardiac dysrhythmias during hospitalization.

Context The Reporting Items for Practice Guidelines in Health Care (RIGHT) Statement was developed by a multidisciplinary team of experts to improve reporting quality and transparency in clinical practice guideline development. Objective To assess the quality of reporting in clinical practice guidelines put forth by the Society of Interventional Radiology (SIR) and their adherence to the RIGHT statement checklist. Methods In March 2018, using the 22 criteria listed in the RIGHT statement, two researchers independently documented adherence to each item for all eligible guidelines listed by the SIR by reading through each guideline and using the RIGHT statement elaboration and explanation document as a guide to determine if each item was appropriately addressed as listed in the checklist. To qualify for inclusion in this study, each guideline must have met the strict definition for a clinical practice guideline as set forth by the National Institute of Health and the Institute of Medicine, meaning they were informed by a systematic review of evidence and intended to direct patient care and physician decisions. Guidelines were excluded if they were identified as consensus statements, position statements, reporting standards, and training standards or guidelines. After exclusion criteria were applied, the two researchers scored each of the remaining clinical practice guidelines (CPGs) using a prespecified abstraction Google form that reflected the RIGHT statement checklist (22 criteria; 35 items inclusive of subset questions). Each item on the abstraction form consisted of a “yes/no” option; each item on the RIGHT checklist was recorded as “yes” if it was included in the guideline and “no” if it was not. Each checklist item was weighed equally. Partial adherence to checklist items was recorded as “no.” Data were extracted into Microsoft Excel (Microsoft Corporation) for statistical analysis. Results The initial search results yielded 129 CPGs in the following areas: 13 of the guidelines were in the field of interventional oncology; 16 in neurovascular disorders; five in nonvascular interventions; four in pediatrics; 25 in peripheral, arterial, and aortic disease; one in cardiac; one in portal and mesenteric vascular disease; 37 in practice development and safety; three in spine and musculoskeletal disorders; 14 in venous disease; five in renal failure/hemodialysis; and five in women’s health. Of the 46 guidelines deemed eligible for evaluation by the RIGHT checklist, 12 of the checklist items showed less than 25% adherence and 13 showed more than 75% adherence. Of 35 individual RIGHT statement checklist items, adherence was found for a mean (SD) of 22.9 items (16.3). The median number of items with adherence was 21 (interquartile range, 7.5–38). Conclusion The quality of reporting in interventional radiology guidelines is lacking in several key areas, including whether patient preferences were considered, whether costs and resources were considered, the strength of the recommendations, and the certainty of the body of evidence. Poor adherence to the RIGHT statement checklist in these guidelines reveals many areas for improvement in guideline reporting.

Context Chronic orchialgia is a frustrating urologic condition that is commonly refractory to conservative modes of therapy. Microscopic spermatic cord denervation is a proven solution for patients who do not achieve relief from nonsurgical treatments. However, current widely used techniques require additional training in microsurgery. Objective To describe an adaptation and improvement of spermatic cord microdenervation technique that leveraged the robotic surgical training common for new urologists and is also accessible for urologists not specifically trained in microsurgery. Methods Robotic-assisted microdenervation of the spermatic cord was performed in three patients using a fluorescence vascular imaging tool to improve visualization of vascular structures (Firefly™; Innovative Surgical, Sunnyvale, CA, USA), along with a tissue matrix allograft to allow for better healing (AminoFix™; MiMedx ® , Marietta, GA, USA). Results All three patients (100%) experienced postoperative resolution of their chronic orchialgia, and none reported any new pain. Conclusion Utilization of robotic-assisted surgery offers more urologists the ability to use familiar techniques to treat chronic orchialgia when conservative measures are unsuccessful.

Context Nationwide Children’s Hospital (NCH) has a large pediatric residency program with 43 residents in the categorical pediatric program and 10 residents in the Internal Medicine-Pediatrics (IM-Peds) program per class. Of the 43 categorical pediatric residents, four are in the osteopathic recognition track (ORT) and continue their osteopathic education throughout residency. There is currently a lack of data examining the effect of an ORT, and specifically a pediatric ORT, on a residency program. Objective To evaluate the impact of an ORT osteopathic recognition track on an overall residency program’s perceptions of osteopathic manipulative treatment (OMT) and to evaluate allopathic (MD) resident perception of osteopathic educational sessions. Methods An anonymous survey was conducted in June 2017 and distributed to 141 residents (both categorical and IM-Peds) to gather baseline information regarding perceptions and knowledge of OMT. Based on the initial results, a four-part case-based educational series was implemented during the 2018–2019 academic year to teach osteopathic principles to MD residents. A second survey was distributed following each session. Results For the initial survey, 59 (41.8%) residents responded. Survey results demonstrated that resident perceptions of OMT as an efficacious treatment option increased after starting their residency at NCH (p=0.04), and 25 of 43 (58.1%) MD residents stated an interest in learning OMT skills. A total of 140 attendees were present at the four educational sessions. One hundred and thirty-eight residents (98.5%) found the educational sessions beneficial and 132 (94.2%) stated they would refer a patient for OMT. Conclusion ORT residents make a significant impact on their colleagues’ perceptions and knowledge of OMT. This study suggests that further efforts to highlight the clinical applications of OMT in pediatric patients would be welcomed by residents.

The coronavirus disease 2019 (COVID-19) pandemic had an overwhelming impact on both clinical practices and learning environments. On March 17th, 2020, the American Association of Colleges of Osteopathic Medicine and Commission on Osteopathic College Accreditation issued a statement recommending a “pause” in medical student participation in-person at clinical sites. In response, the Family Medicine Department at the Rowan University School of Osteopathic Medicine recognized the need to evolve the traditional curriculum and quickly transitioned to an online format, incorporating telemedicine into the clerkship. This new model enabled 44 third-year medical students to obtain high-quality, offsite, virtual education and learn new skills.

Context Concussion is among the most common injuries in athletes. Over the past 10 years, concussion knowledge has expanded, and guidelines for management have changed. Recent changes include recommendations against strict mental and physical rest after sustaining a concussion, a better recognition of preexisting conditions predisposing protracted concussion recovery, and the addition of preliminary patient counseling and education about the expected course of concussion recovery. Objective To assess the impact of changes in concussion management on the duration of symptoms in middle school and high school athletes after sustaining a first-time, sports-related concussion. Methods A retrospective review was performed of medical records of athletes who sustained a concussion between 2016 and 2018 and were treated by the same primary care physician (J.M.N) using the revised approach to concussion management described. Patients were included if they were 11 to 18 years old and had a diagnosis of first-time concussion sustained while playing organized sports. Athletes who sustained a concomitant injury or sustained a concussion outside of organized sports were excluded from the study; athletes lost to follow-up or with incomplete forms were also excluded. Each athlete’s length of symptomatic time from his or her concussion was calculated. This data was then compared with a previously-published data set of athletes who sustained a concussion between 2011 and 2013, with the same inclusion criteria but a different approach to concussion management. Results A total of 110 male and 72 female athletes (N=182) met the study’s eligibility criteria. Collectively, athletes of both sexes from the 2016–2018 data set reported a higher incidence of preexisting conditions associated with prolonged concussion recovery compared with the data set of 2011–2013 athletes. However, both sexes from the 2016–2018 data set also reported a shorter median duration of concussion symptoms compared with the 2011–2013 athletes (median duration 5 vs. 11 days for male athletes and 7 vs. 28 days for female athletes, respectively; p<0.001). Conclusion Recent changes in concussion management have led to decreased duration of symptoms among 11- to 18-year-old athletes with first-time, sports-related concussions. These management changes include advocating for early activity, recognizing preexisting conditions, and educating athletes about the realities of concussion recovery.

Context Updated data on the use of Osteopathic Manipulative Treatments (OMT) by osteopathic physicians in the United States is overdue. This data would provide an up-to-date point of reference for evaluating the current use of OMT as a distinguishing feature of the osteopathic profession. Objective To determine the prevalence of OMT use, barriers to its use, and factors that correlate with increased use. Methods The American Osteopathic Association (AOA) distributed its triannual survey on professional practices and preferences of osteopathic physicians, including questions on OMT, to a random sample of 10,000 osteopathic physicians in August 2018 through Survey Monkey (San Mateo, CA). Follow-up efforts included a paper survey mailed to nonrespondents one month after initial distribution and three subsequent email reminders. The survey was available from August 15, 2018 to November 5, 2018. The OMT questions focused on frequency of OMT use, perceived barriers, and basic demographic information of osteopathic physician respondents. Statistical analysis (including a one sample test of proportion, chi-square, and Spearman’s rho) was performed to identify significant factors influencing OMT use. Results Of 10,000 surveyed osteopathic physicians, 1,683 (16.83%) responded. Of those respondents, 1,308 (77.74%) reported using OMT on less than 5% of their patients, while 958 (56.95%) did not use OMT on any of their patients. Impactful barriers to OMT use included lack of time, lack of reimbursement, lack of institutional/practice support, and lack of confidence/proficiency. Factors positively correlated with OMT use included female gender, being full owner of a practice, and practicing in an office-based setting. Conclusion Our data suggest that OMT use among osteopathic physicians in the US continues to decline. Barriers to its use appear to be related to the difficulty that most physicians have with successfully integrating OMT into the country’s insurance-based system of healthcare delivery. Follow-up investigations on this subject in subsequent years will be imperative in the ongoing effort to monitor and preserve the distinctiveness of the osteopathic profession.

Context Low back pain is one of the most frequent diagnoses in primary care, and prescription pain medication is commonly used for management. Osteopathic physicians may use osteopathic manipulative treatment (OMT) as an additional tool to help alleviate pain. Objective To determine if nonpharmacological options can improve back pain with the use of OMT. Methods Two groups were studied: patients receiving OMT but not using prescribed pain medications (OMT-only group) and patients who received prescribed pain medication and began receiving OMT after three months of pharmacologic therapy (OMT + medication group). All patients were enrolled in the study for one year. The amount of time between treatments was determined by the physician performing the OMT and the patient’s pain improvement. The Keele STarT survey and Oswestry Disability Index tool were used at each appointment to assess the patient’s functionality and pain. Results Thirty-six patients enrolled in the study: 26 in the OMT-only group and 10 in the OMT + medication group. Each group reported improvement in low back pain (LBP) according to both scales used. The OMT-only group reported improvement according to the Keele STarT survey (30% relative decrease in the mean score) and the Oswestry Disability Index tool (18% relative decrease in disability index), while patients in the OMT + medication group also reported improvement according to the Keele STarT survey (29.5% relative decrease in the mean score) and the Oswestry Disability Index tool (18% relative decrease in disability index). A decrease in Cyclobenzaprine usage was also observed in the OMT + medication group. Conclusion Both groups showed significant decreases in overall pain, and this similar effect in each group may indicate a lack of need for medications when OMT is used. Additional research on efficacy of OMT in this patient population is needed with larger, multicenter, randomized trials.

Context There is a paucity of research assessing the efficacy of osteopathic manipulative treatment (OMT) in patients with vertigo. Objective To assess the feasibility of conducting a randomized, controlled trial comparing OMT and vestibular rehabilitation therapy (VRT), alone or in combination, in patients with vertigo and somatic dysfunction. Methods Volunteers with vertigo who were also diagnosed with somatic dysfunction (SD) were prospectively enrolled in a blinded, randomized, controlled cohort comparative effectiveness study and assigned to 1 of 4 groups: OMT alone, VRT alone, a combination of OMT and VRT (OMT/VRT), or a nonintervention control group. Participants between 18 and 79 years of age were included if they had experienced symptoms of vertigo for at least 3 months’ duration, demonstrated somatic dysfunction, and could participate in computerized dynamic posturography (CDP) testing, tolerate manual therapy and exercises, and communicate effectively in English or Spanish. A total of 3 treatments lasting 45 minutes each were administered 1 week apart to each participant. OMT in this study consisted of counterstrain, myofascial release, balanced ligamentous tension, soft tissue, HVLA, and articulatory techniques. Comparisons were made between composite scores (CS) assessed with computerized dynamic posturography (CDP), dizziness handicap inventory (DHI), optometric evaluation, and osteopathic structural examinations collected before the first treatment, after the third/final treatment, and 3 months after the final treatment. (ClinicalTrials.gov number NCT01529151) Results A total of 23 patients were included in the study: 7 in the OMT group, 5 in the VRT group, 6 in the OMT/VRT group, and 5 in the control group. The OMT/VRT group demonstrated significant improvement in DHI score (P=0.0284) and CS (P=0.0475) between pre- and 3-month posttreatment measures. For total severity, improvements were significant in the OMT group both from pretreatment to immediate posttreatment measures (P=0.0114) and from pretreatment to 3-month posttreatment measures (P=0.0233). There was a statistical difference between the OMT and control groups from pretreatment to 3-month posttreatment DHI scores (P=0.0332). Also, there was a statistical difference in DHI score between VRT and control from pre- to 3-month posttreatment scores (P=0.0338). OMT/VRT statistically and clinically improved visual acuity in patients’ right eyes from pre- to posttreatment (P=0.0325). In all participants, vergence dysfunction was prevalent (5; 21.7%) in addition to vertical heterophoria (15; 65.2%). Conclusion A combination of OMT and VRT significantly reduced vertigo and improved balance 3 months after treatment (P<0.05). There was a high prevalence in vergence and vertical heterophoria, which are not typical screening measurements used by physical therapists and physicians to assess vertigo patients. With a small sample size, this study demonstrated the feasibility of an interdisciplinary team evaluating and treating patients with vertigo in a community setting. A larger study is needed to assess the efficacy of OMT/VRT in vertigo patients.

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.

Context Term neonates treated with therapeutic hypothermia (TH) may experience delays in acquiring skills for oral feeding, thus prolonging hospital admission. Objective To determine whether osteopathic manipulative treatment (OMT) can decrease the overall length of stay (LOS) for term neonates by accelerating the transition to full oral feeds. Methods A pilot study was conducted to compare LOS in term neonates treated with OMT to matched historical controls. Eligibility criteria were gestational age greater than or equal to 37 weeks, mild to moderate encephalopathy, absent seizure activity, and no brain injury on magnetic resonance imaging. Treated neonates had OMT twice between day of life four and seven, then twice per week on nonconsecutive days until hospital discharge. Secondary outcomes were to compare the number of days with nasogastric tube in both OMT and historically matched control groups and to characterize somatic dysfunction patterns in the primary affected areas of the craniosacral mechanism. Results Twelve of 28 neonates treated with TH between October 2017 and August 2018 met eligibility criteria for the study and were matched 3:1 to 36 historical controls. On average, mothers of neonates who received OMT were older than the historical control mothers (31.3 years [SD, ±6.0] vs. 27.4 [SD, ±4.5]; p=0.02) Nineteen of the 36 historical control neonates, but no neonates in the OMT group, were intubated for a median of two days (interquartile range 1, 4). The mean LOS in the OMT group was 9.1 vs. 11.6 days for historical controls (p=0.048); however, in a sensitivity analysis excluding intubated neonates from the historical controls, the difference was 9.1 vs. 10.1 days (p=0.21). All neonates were orally feeding at discharge. Neonates given OMT had between two and four treatments lasting 8–20 minutes. By the final treatment, the craniosacral mechanism’s intraosseous and cranial base compressions and physiologic motion were improved. There were no adverse effects noted during OMT sessions. Conclusion Our findings suggest that OMT performed on term neonates treated with TH may decrease the amount of time needed to acquire the necessary skills for oral feeding. Although this result was not statistically significant, it may be clinically significant. A larger prospective clinical trial may have the power needed to detect a statistically significant reduction in LOS and number of days to full oral feeds in this patient population.

Bariatric surgery is an effective treatment for patients with morbid obesity. However, as safe and common as bariatric procedures have become, multiple complications can still result. These complications vary depending on the type of procedure performed (malabsorptive or restrictive) and are often nutritional derangements from the altered malabsorptive surface of the gastrointestinal tract and decreased capacity of the stomach. Deficiencies in vitamin D after malabsorptive procedures such as the Roux-en-Y gastric bypass can result in subsequent hypocalcemia and bone demineralization, and anemias can also present after surgery from inadequate vitamin B 12 and iron absorption. Because of the prevalence of these deficiencies, baseline micronutrient testing and postoperative screening are recommended in many cases. Additionally, supplemental treatment often requires higher doses than those recommended for healthy adults. The purpose of this narrative review is to outline the various nutrient deficiencies that can result from bariatric procedures and report previously-published recommendations for screening and medical treatment of patients with these deficiencies. This review is directed toward primary care practitioners because of their unique position in delivering continuity of care and the frequency with which they will encounter patients who have undergone bariatric surgery and are seeking counseling regarding weight loss modalities.

Context The combination of osteoarthritis and rheumatoid arthritis affects nearly one-fourth of Americans. Many of the risk factors for arthritis are lifestyle related, such as obesity, physical activity, dietary behaviors, and alcohol and tobacco use. Objective To analyze lifestyle behaviors of patients with vs. those without arthritis. Methods A cross-sectional analysis of 2017 Behavioral Risk Factor Surveillance System (BRFSS) data was conducted on patients with and without a history of arthritis. Physical activity, smoking status, alcohol use, and dietary behaviors were extracted. Logistic regression models were constructed to calculate adjusted risk ratios (ARRs). All confidence intervals (CIs) were reported at 95%. Results The median response rate for the 2017 BRFSS survey was 45.1% (sample n=292,808; population N=118,751,156). The overall prevalence of arthritis was 44% (n=128,850). Respondents with arthritis were significantly more likely to be physically inactive than nonarthritic respondents, with a significant gender interaction (male absolute risk reduction [ARR], 1.2 [CI, 1.15–1.25]; female ARR, 1.29 [CI, 1.24–1.33]). Those with arthritis were also more likely to be current smokers (ARR 1.1; CI, 1.05–1.15) and less likely to have attempted to quit smoking in the last 12 months (ARR, 0.91; CI, 0.87–0.96). Finally, men with arthritis were more likely to drink alcohol heavily (ARR, 1.14; CI, 1.02–1.27]). Conclusion Patients with arthritis were more likely to be women, White, current smokers, and physically inactive, and to have poor mental health, lower education levels, and difficulty paying for healthcare and medications than those without arthritis. Further efforts should be made to address these findings through resource allocation in the care of patients with arthritis. Practitioners should also seek increased understanding of the psychological, social, and economic impacts of physical activity and smoking in patients with arthritis.