Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE): Protocol for a Multisite Pragmatic Clinical Trial.

BACKGROUND: Physical therapy (PT) is frequently used for the management of low back pain (LBP) within the US Departments of Defense (DOD) and Veterans Affairs (VA). However, variations in PT practice patterns and use of ineffective interventions lower the quality and increase the cost of care. Although adherence to the clinical practice guidelines (CPGs) can improve the outcomes and cost-effectiveness of LBP care, PT CPG adherence remains below 50%. The Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE) trial will evaluate the effectiveness of an active PT CPG implementation strategy using an education, audit, and feedback model for reducing pain, disability, medication use, and cost of LBP care within the DOD and VA health care systems. DESIGN: The RESOLVE trial will include 3,300 to 7,260 patients with LBP across three DOD and two VA medical facilities using a stepped-wedge study design. An education, audit, and feedback model will be used to encourage physical therapists to better adhere to the PT CPG recommendations. The Oswestry Disability Index and the Defense and Veterans Pain Rating Scale will be used as primary outcomes. Secondary outcomes will include the LBP-related medication use, medical resource utilization, and biopsychosocial predictors of outcomes. Statistical analyses will be based on the intention-to-treat principle and will use linear mixed models to compare treatment conditions and examine the interactions between treatment and subgrouping status (e.g., limb loss). SUMMARY: The RESOLVE trial will provide a pragmatic approach to evaluate whether better adherence to PT CPGs can reduce pain, disability, medication use, and LBP care cost within the DOD and VA health care systems.

The Safety of Maternal and Fetal MRI at 3 T.

OBJECTIVE. The purpose of this study was to evaluate the effects of clinical 3-T MRI during pregnancy on fetal growth and neonatal hearing in neonates at low risk of congenital hearing impairment or of brain or chromosomal abnormalities. MATERIALS AND METHODS. This single-center retrospective case-control study included consecutively born healthy neonates exposed in utero to 3-T MR during MRI for maternal or fetal indications and born between January 2008 and March 2015. Each exposed neonate was randomly matched 1:2 by birth date to healthy control neonates who had not been exposed to MR. Infant birth weights were compared by unpaired t test. Hearing impairment between groups was compared by Fisher exact test. RESULTS. There was no significant difference in mean birth weight between the MR-exposed (3398 g) and control (3510 g) neonates (p = 0.06). There was no significant difference in prevalence of hearing impairment (p = 0.55) between the MR-exposed (0% [0/81]) and control (1.8% [3/162]) groups. CONCLUSION. This study showed no adverse effects with regard to neonatal hearing or fetal growth in healthy neonates who were variably exposed to 3-T MR in utero during MRI for various clinical maternal or fetal indications at any gestational age.

Gabapentin: Change is in the Wind.

In the midst of a national opioid crisis, Americans have a heightened awareness of the potential for prescription drugs that can be abused. One drug-gabapentin-is frequently prescribed in long-term care facilities for seizures and postherpetic neuralgia, and its use is a growing concern globally. Approved for two uses, but used off-label for many others, gabapentin can induce euphoria at high doses. In older adults, clinicians prescribe it for seizures, pain, migraine, and aggression associated with dementia, among other things. Gabapentin's rapid onset of action, side effect profile, limited drug-drug interactions, and extensive pharmacokinetic data in renal impairment have made prescribers comfortable using it in older adults. This gabapentinoid-a cousin to the Schedule V drug pregabalin-has seen widespread recreational abuse and has led to its reclassification in the United Kingdom and in several U.S. states. Consultant pharmacists need to be aware that the evidence behind off-label use is scant; withdrawal is likely after as few as three weeks of treatment; and drug diversion is possible, even likely. In addition, it is the tenth-most prescribed medication in the United States.

External iliac artery occlusion in a paediatric patient following handlebar trauma.

Arterial occlusion following blunt trauma is an uncommon occurrence. We report an unusual case of delayed external iliac artery occlusion in a young male following blunt abdominal injury. He was successfully treated with thromboendarterectomy and saphenous vein patch repair. There have only been a handful of documented cases occurring in the paediatric population. All patients presenting with groin injury from this mechanism should be carefully investigated and monitored for risk of vascular injury.