A mixed treatment comparison of selected osteopathic techniques used to treat acute nonspecific low back pain: a proof of concept and plan for further research.

CONTEXT: Back injuries have a high prevalence in the United States and can be costly for both patients and the healthcare system at large. While previous guidelines from the American College of Physicians for the management of acute nonspecific low back pain (ANLBP) have encouraged nonpharmacologic management, those treatment recommendations involved only superficial heat, massage, acupuncture, and spinal manipulation. Investigation about the efficacy of spinal manipulation in the management of ANLBP is warranted. OBJECTIVES: To compare the results in previously-published literature documenting the outcomes of osteopathic manipulative treatment (OMT) techniques used to treat ANLBP. The secondary objective of this study was to demonstrate the utility of using Bayesian network meta-analysis (NMA) to perform a mixed treatment comparison (MTC) of a variety of osteopathic techniques. METHODS: A literature search for randomized controlled trials (RCTs) of ANLBP treatments was performed in April 2020 according to PRISMA guidelines by searching MEDLINE/PubMed, OVID, Cochrane Central, PEDro, and OSTMED.Dr databases; scanning the reference lists of articles; and using the Canadian Agency for Drugs and Technologies in Health grey literature checklist. Each database was searched from inception to April 1, 2020. The following search terms were used: acute low back pain, acute low back pain plus physical therapy, acute low back pain plus spinal manipulation, and acute low back pain plus osteopathic manipulation. The validity of eligible trials was assessed by the single author using an adapted National Institute for Health and Care Excellence methodology checklist for randomized, controlled trials and an extraction form based on that checklist. The outcome measure chosen for this NMA was the Visual Analogue Scale of pain. The NMA were performed using the GeMTC user interface for automated NMA utilizing a Bayesian hierarchical model of random effects. RESULTS: The literature search initially found 483 unduplicated records. After screening and full text assessment, five RCTs were eligible for the MTC, yielding a total of 430 participants. Results of the MTC model suggested that there was no statistically significant decrease in reported pain when exercise, high-velocity low-amplitude (HVLA), counterstrain, muscle energy technique, or a mix of techniques were added to conventional treatment to treat ANLBP. However, the rank probabilities assessment determined that HVLA and the OMT mixed treatment protocol plus conventional care were ranked superior to conventional care alone for improving ANLBP. CONCLUSIONS: While this study failed to provide definitive evidence upon which clinical recommendations can be based, it does demonstrate the utility of performing NMA for MTCs of osteopathic modalities used to treat ANLBP. However, to take full advantage of this statistical technique, future studies should be designed with consideration for the methodological shortcomings found in past osteopathic research.

Does Performing Preplacement Workplace Hair Drug Testing Influence US Department of Transportation Random and Postaccident Urine Drug Test Positivity Rates?

BACKGROUND: Does performing pre-employment hair drug testing subsequently affect the prevalence of positive random and postaccident urine drug tests? METHODS: This cross-sectional study was designed to evaluate the prevalence of positive postaccident and random workplace urine drug tests for companies that perform pre-employment hair and urine drug testing to companies that only perform pre-employment urine drug testing. RESULTS: Fisher exact test of independence indicated no significant difference between pre-employment hair drug testing and overall US Department of Transportation random and postaccident urine drug test positivity rates. CONCLUSIONS: The analysis failed to reject the null hypothesis, suggesting that pre-employment hair drug testing had no effect upon random and postaccident urine drug test positivity rates.

The Addition of Amphetamine to Potentially Sedating Medication Regimens: An Exploratory Investigation of the Impact upon Reaction Time and Sustained Attention.

OBJECTIVES: The addition of amphetamine to a sedating medication may reduce sedation but does it augment reaction time and sustained attention for workers? The purpose of this exploratory study was gain insight into between group differences that would assist hypothesis formation for a subsequent hypothesis testing study. METHODS: This study examined psychomotor vigilance task (PVT) performance for a group taking potentially sedating medications (opiates, benzodiazepines, anticholinergics, barbiturates or polypharmacy) while taking amphetamine to a group not taking amphetamine. Data was assessed using two-way between groups multivariate analysis of variance. RESULTS: Multivariate testing found a (p = .05; η2 = .044) difference in combined PVT measures between the amphetamine use groups. Tests of between-subjects effects established (p = .006; η2 = .042) a difference in the number of minor lapses between the groups. Estimated marginal means of minor lapses revealed that the group taking amphetamine had 2.8 times the mean number of minor lapses than the group not taking amphetamine. A non-statistically significant trend was noted for the estimated marginal means of each sedating medication class and the use or nonuse of amphetamines that appears to correspond with the sedating medication's effect upon the cholinergic component of the attention system. CONCLUSION: Using PVT data, this exploratory study has provided information useful for generating the hypothesis that co-administration of an amphetamine with a sedating medication will result in arousal with a deficit of sustained attention related to the sedating medication's level of effect upon cholinergic activity.

The Difference Between Random and Postaccident Urine Drug Test Concentrations Among Southern Indiana, Western Kentucky, and Eastern Illinois Workers.

INTRODUCTION: If employee drug use plays a significant part in the incidence of workplace accidents, one would anticipate the positivity rates of postaccident drug tests to be higher than the positivity rates for random tests. Past studies examined the difference of a dichotomous outcome between 2 groups. Dichotomous (positive or negative) categorization may have been a source of systemic error, which minimized the difference between random and postaccident groups. METHODS: This is a study exploring the difference of urine drug concentrations between random and postaccident groups. The population consists of employees from various industries in Southern Indiana, Western Kentucky, and Eastern Illinois. Normalization of drug excretion to urinary creatinine concentration was carried out. Preliminary assumption testing was done. Logarithmic transformation was completed. One-way between-groups analysis of variance was performed to investigate random and postaccident drug test differences in urine drug concentrations. RESULTS: There was a statistically significant difference between test groups on the combined dependent variables. The only dependent variables to reach statistical significance, to an alpha level of 0.025, were urine opiate and urine amphetamine concentrations. Higher mean concentration of both drugs was found in the postaccident group. However, the proportion of variances explained by the reason for testing was quite small. CONCLUSIONS: The results of this study are consistent with studies using dichotomous dependent variables, which demonstrated a significantly higher prevalence for positive postaccident urine opiate tests. The study also identified a similar result for postaccident urine amphetamine tests which was not previously known.

A comparison of random and post-accident urine opiate and opioid tests.

Opioid use is associated with poor reaction time, attention, balance and memory posing a potential threat to workplace safety. The purpose of this study is to determine if there is a statistical association between opiate/opioid use and work related accidents as measured by urine drug tests by comparing the proportion of opiate/opioid laboratory positive urine specimens for postaccident verses random samples. The prevalence of laboratory positive opiate/opioid tests, the odds ratio, Fisher's exact probability test and the population attributable risk were calculated for each comparison. This study found a statistically significant difference for opiate/opioid results favoring the post-accident group.

Benzodiazepines and workplace safety: an examination of postaccident urine drug tests.

BACKGROUND: Benzodiazepines were introduced for clinical use since the 1960s and rapidly became the sedative-hypnotic of choice. The purpose of this study was to determine whether benzodiazepine use as measured by drug tests is higher in postaccident drug tests than in random tests. METHODS: This is a case-control study comparing the proportion of benzodiazepine laboratory positive urine specimens for random versus postaccident samples. Any sample that tested positive for 1 or more substances other than benzodiazepines was eliminated from the study to correct for the confounding effect of other potentially impairing substances. The group prevalence of benzodiazepine positive samples was compared via the odds ratio with 95% confidence intervals and the P-values. RESULTS: The study began with 4756 urine samples with 2161 postaccident specimens and 2595 random specimens. A total of 243 of the samples were confirmed positive for drugs other than benzodiazepines. The study was left with 2016 postaccident and 2497 random samples. In the controlled postaccident group, there were 57 positive screens and 17 (29.8%) were confirmed as positive for either a benzodiazepine or benzodiazepine metabolites. In the controlled random group, there were 48 positive screens and 10 (20.8%) were confirmed as positive for either a benzodiazepine or benzodiazepine metabolites. The OR comparing the total confirmed laboratory positive benzodiazepine specimens after controlling for other substances was 2.1150 (0.9663-4.6292) with a P-value of 0.0609. CONCLUSIONS: The results for comparing the total confirmed laboratory positive benzodiazepine tests controlled for other substances, although suggestive of an association, did not achieve statistical significance.

Marijuana and workplace safety: an examination of urine drug tests.

Although the decriminalization of recreational marijuana and medical marijuana laws provide a compassionate answer for treatment-related issues in patients' lives, they leave questions open as to the impact on other realms of life, such as employment and safety. This is a case-control study comparing the proportion of marijuana positive urine specimens for post-accident verses random samples. The marijuana concentration of each sample underwent creatinine normalization to account for in vivo dilution. Any sample that tested positive for one or more substances other than marijuana was eliminated from the study. The prevalence of marijuana violations, the odds ratio and 95% confidence interval of accident involvement and the population attributable risk were calculated. A two-by-two table was created with the remaining data and the data were used to calculate the odds ratio, resulting in a value of 0.814 with a 95% confidence interval between 0.625 and 1.060. The Fisher exact probability test generated a 2-tailed P of .139. The subsequent population attributable risk was found to be -1.83%. These findings fail to reject the null hypothesis, and this study failed to demonstrate a statistically significant difference between the numbers of laboratory positive marijuana urine drug tests for a group of random drug tests compared with a group of post-accident drug tests.

Dilution of urine drug tests: is it random?

BACKGROUND: The purpose of this study was to determine whether the act of in vivo urine dilution is a random phenomenon. METHODS: The sample population was divided into 4 groups for each of the drugs tested. The groups are precreatinine normalization laboratory positive, precreatinine normalization laboratory negative, and postcreatinine normalization laboratory drug positive, and postcreatinine normalization laboratory drug negative. The nonparametric Kruskal-Wallis 1-way ANOVA by ranks with post hoc Mann-Whitney U testing Bonferroni adjustment was used to compare the mean urine creatinine concentration of each group. RESULTS: The Kruskal-Wallis test revealed that each drug had a statistically significant difference in group comparisons. Post hoc testing found that cocaine demonstrated no statistically significant difference between the prenormalization drug positive and negative groups. Amphetamines, marijuana, and opiates did confirm statistically significant differences between the prenormalization drug positive and negative groups. The examination of phencyclidine was limited by the lack of a prenormalization drug positive group; therefore, no definitive findings can be presented. Statistically significant differences were found between the postnormalization drug positive and negative groups for each drug tested. CONCLUSIONS: This study supports the theory that urine dilution is not a random happening and it may adversely affect the integrity of the drug-testing process.

Creatinine normalization of workplace urine drug tests: does it make a difference?

BACKGROUND: This study examines the effect of creatinine normalization on urine drug concentrations of 5 substances (amphetamines, cocaine, marijuana, opiates, and phencyclidine) and how this affects the proportion of reported positives. METHODS: The Wilcoxon matched-pairs signed-ranks test was used to compare the mean prenormalization urinary drug concentration with the mean postnormalization urinary drug concentration. Frequency analysis was performed on dichotomous drug test results and the information was used to complete McNemar testing for each drug to determine the difference of proportions for prenormalization positive drug tests to postnormalization positive drug test. RESULTS: Each drug tested (N = 4460) was found to have a statistically significant increase in mean urinary drug concentration after creatinine normalization with effect sizes ranging from small to medium with cocaine having the largest effect size (r = 0.229) and phencyclidine having the lowest effect size (r = 0.121). The differences in proportion of dichotomous results between study and control groups for drugs tested were compared with the McNemar test. Each drug had a statistically significant (P = 0.0010) increase of positive drug tests. CONCLUSIONS: This result indicates that specimen dilution does affect the number of laboratory-positive results confirmed.

Intra-annual nutrient flux in Pinus taeda.

Intra-annual nutrient (nitrogen, phosphorus, potassium, calcium and magnesium) flux was quantified for Pinus taeda L. at a nutrient-poor, well-drained sandy site in Scotland County, NC, USA where a 2 × 2 factorial of irrigation and nutrition was applied in four replications in a 10-year-old stand with 1200 stems ha(-1). Treatments were applied with the goal of providing optimum nutrition (no nutritional deficiencies) and water availability. Component (foliage, branch, stem and root) nutrient content was estimated monthly for 2 years using nutrient concentration and phenology assessments combined with destructive harvests. Positive flux values indicated nutrient accumulation in the trees while negative values indicated nutrient loss from the trees. Fertilization significantly increased nitrogen, phosphorus, potassium, calcium and magnesium flux 140%, on average, over non-fertilized. Irrigation significantly increased calcium flux 28% while there was no significant irrigation effect on nitrogen, phosphorus, potassium or magnesium. Maximum nutrient fluxes (kg ha(-1) day(-1)) for non-fertilized and fertilized stands were 0.36 and 1.05 for nitrogen, 0.042 and 0.095 for phosphorus, 0.13 and 0.51 for potassium, 0.27 and 0.42 for calcium, and 0.04 and 0.12 for magnesium, respectively. Maximum flux was coincident with ephemeral tissue (foliage and fine root) development and likely would be higher in stands with more foliage than those observed in this study (projected leaf area indices were 1.5 and 3.0 for the non-fertilized and fertilized stands). Minimum nutrient fluxes (kg ha(-1) day(-1)) for non-fertilized and fertilized stands were -0.18 and -0.42 for nitrogen, -0.029 and -0.070 for phosphorus, -0.05 and -0.18 for potassium, -0.04 and -0.05 for calcium, and -0.02 and -0.03 for magnesium, respectively. Minimum fluxes were typically observed in the dormant season and were linked to foliage senescence and branch death. Foliage and branch component nutrient contents were out of phase for nitrogen, phosphorus, potassium and magnesium, indicating nutrient retranslocation and storage in branches prior to foliage development and after foliage senescence. In contrast to current operational fertilizer programs which often target winter application these data suggest the best application times would be during foliage development.

Comparison of random and postaccident urine drug tests in southern Indiana coal miners.

BACKGROUND: This study examines the relationship between the use of 9 classes of substances (amphetamines, barbiturates, benzodiazepines, cocaine, marijuana, methadone, opioids, phencyclidine, and propoxyphene) and coal-mining accidents. METHODS: The control sample (n = 215) made up of miners that presented for random urine drug testing. The study sample (n = 100) consists of miners that presented for postaccident urine drug testing. Nonparametric Mann-Whitney U tests of creatinine normalized urine drug levels were conducted to compare the medians of the groups. RESULTS: The mean drug concentrations were higher in the postaccident group for each drug tested except marijuana. Two-tailed testing demonstrated statistically significant differences for marijuana (P = 0.000), cocaine (P = 0.008), and opiates (P = 0.037). CONCLUSIONS: The study demonstrates statistically significant higher cocaine and opioid concentrations and lower marijuana concentrations in postaccident urine drug tests of coal miners when compared with random tests.

Code Blue Emergencies: A Team Task Analysis and Educational Initiative.

INTRODUCTION: The objective of this study was to identify factors that have a positive or negative influence on resuscitation team performance during emergencies in the operating room (OR) and post-operative recovery unit (PAR) at a major Canadian teaching hospital. This information was then used to implement a team training program for code blue emergencies. METHODS: In 2009/10, all OR and PAR nurses and 19 anesthesiologists at Vancouver General Hospital (VGH) were invited to complete an anonymous, 10 minute written questionnaire regarding their code blue experience. Survey questions were devised by 10 recovery room and operation room nurses as well as 5 anesthesiologists representing 4 different hospitals in British Columbia. Three iterations of the survey were reviewed by a pilot group of nurses and anesthesiologists and their feedback was integrated into the final version of the survey. RESULTS: Both nursing staff (n = 49) and anesthesiologists (n = 19) supported code blue training and believed that team training would improve patient outcome. Nurses noted that it was often difficult to identify the leader of the resuscitation team. Both nursing staff and anesthesiologists strongly agreed that too many people attending the code blue with no assigned role hindered team performance. CONCLUSION: Identifiable leadership and clear communication of roles were identified as keys to resuscitation team functioning. Decreasing the number of people attending code blue emergencies with no specific role, increased access to mock code blue training, and debriefing after crises were all identified as areas requiring improvement. Initial team training exercises have been well received by staff.

Persistent hypothermia after intrathecal morphine: case report and literature review.

PURPOSE: To describe a case of persistent hypothermia following spinal anesthesia with intrathecal morphine. CLINICAL FEATURES: Following elective right total knee arthroplasty under spinal anesthesia with isobaric 0.5% bupivacaine 11 mg, fentanyl 15 µg, and preservative-free morphine 150 µg, a 57-yr-old female (93.5 kg, 151 cm) developed postoperative hypothermia with a nadir rectal temperature of 33.6°C four hours after surgery. At times, her temperature could not be measured by tympanic, temporal arterial, oral, axillary, or rectal routes. In spite of the low temperature, the patient complained of feeling hot and was diaphoretic without shivering. With the exception of her temperature, her vital signs were normal postoperatively, and aside from hyperglycemia, complete blood count, electrolytes, thyroid-stimulating hormone, serum cortisol, troponin, and twelve-lead electrocardiogram were normal. Her temperature did not respond to warming efforts with a forced-air warming blanket, infusion of warmed intravenous crystalloid, and hourly bladder irrigation with warm saline through an indwelling urinary catheter. Normothermia returned after she received a small dose of sublingual lorazepam eight hours after surgery. The remainder of her postoperative stay was uneventful. CONCLUSION: Patients undergoing spinal anesthesia with intrathecal morphine may develop postoperative hypothermia that is resistant to warming measures. This complication may be treated successfully with lorazepam.

Emergency tricuspid valve replacement during pregnancy.

A 36 year-old intravenous drug user at 19 weeks' gestation required emergency tricuspid valve replacement for severe tricuspid regurgitation and cardiogenic shock refractory to medical therapy. Normothermic, pulsatile, high-flow, and pressure cardiopulmonary bypass (CPB) was used in the absence of fetal monitoring. Ten days postoperatively, the patient miscarried. She was discharged from hospital two months following surgery. High-flow (> 3.0 L/min(2)), high-pressure (> 70 mmHg), normothermic CPB using pulsatile flow and blood cardioplegia is thought to offer the best outcome to the fetus, although data to support these claims are not compelling.

High-fidelity simulation in anesthesiology training: a survey of Canadian anesthesiology residents' simulator experience.

PURPOSE: The objective of this survey was to explore Canadian anesthesiology residents' educational experience with high-fidelity simulation and to improve understanding of the factors perceived to have either a positive or a negative effect on residents' learning. METHODS: In 2008, all Canadian anesthesiology residents (n = 599) were invited to complete a ten-minute anonymous online survey. Survey questions were derived from two sources, a literature search of MEDLINE (1966 to present), EMBASE (1980 to present), and the Cochrane and Campbell collaboration libraries and the experience of 25 pilot residents and the lead author. RESULTS: The survey response rate was 27.9% (n = 167). Junior residents (PGY1-3) responded that it would be helpful to have an introductory simulation course dealing with common intraoperative emergencies. The introduction of multidisciplinary scenarios (where nurses and colleagues from different specialties were involved in scenarios) was strongly supported. With respect to gender, male anesthesia residents indicated their comfort in making mistakes and asking for help in the simulator more frequently than female residents. In accordance with the ten Best Evidence Medical Education (BEME) principles of successful simulator education, Canadian centres could improve residents' opportunities for repetitive practice (with feedback), individualization of scenarios, and defined learning outcomes for scenarios. DISCUSSION: Anesthesiology residents indicate that simulation-based education is an anxiety provoking experience, but value its role in promoting safe practice and enhancing one's ability to deal with emergency situations. Suggestions to improve simulation training include increasing residents' access, adopting a more student-centred approach to learning, and creating a safer learning environment.

Accuracy and precision of metered doses of nitroglycerin lingual spray.

PURPOSE: The accuracy and precision of nitroglycerin lingual spray are examined. METHODS: Two hundred and twenty-four bottles of nitroglycerin lingual spray product (0.4 mg nitroglycerin per dose, 75 doses per bottle) were collected from the hospital pharmacy at Vancouver General Hospital. Bottles were placed upright on a level surface. After three priming sprays, each bottle was weighed and an initial measurement was recorded. All measurements were recorded in grams to three decimal places and the bottles were weighed on an analytical balance. Three more sprays were made to simulate those in the patient instruction insert. The scale was set to zero before each measurement, and the bottles were then placed on the scale for five seconds before the final weight was recorded. The three spray weights were averaged to obtain a mean spray weight for each bottle. RESULTS: The manufacturer guarantees a minimum volume of 0.05-0.1 mL per spray. The lower value of 0.05 mL was used for comparison. The weight of 0.05 mL of preparation was calculated, and this was compared to the mean spray weight of all samples tested. A single sample t test revealed a significant difference between the value reported by the manufacturer and the mean of the sample (t((224)) = -23.42, p < 0.0005). CONCLUSION: A significant difference was observed between the expected weight of nitroglycerin solution per metered dose and the mean weight of the study samples. Results of the study indicate that dose delivery may be inaccurate but is fairly precise.

Excessive hypertension and pulmonary edema after electroconvulsive therapy.

A 53-year-old right-handed man was scheduled to receive 6 treatments of electroconvulsive therapy (ECT) for intractable depression. He was being treated for long-standing hypertension with nadolol and had no history of cardiopulmonary disease. Six months previously, he received 6 nondominant, unilateral ECT treatments. During each of these treatments, his blood pressure increased transiently to as high as 250/150, but he experienced no adverse consequence. He commenced the current course of ECT with well-controlled blood pressure (145/90). During his first bilateral treatment, his blood pressure rose to 280/160, and pulmonary edema ensued. Clinically evident pulmonary edema after ECT is an uncommon event that rarely has been described in the literature.