Evidence-based Literature Research Articles

Utilization of evidence-based tools and medical education literature by Canadian postgraduate program directors in the teaching and assessment of the CanMEDS roles.

BackgroundResearchers have shown that clinical educators feel insufficiently informed about how to teach and assess the CanMEDS roles. Thus, our objective was to examine the extent to which program directors utilize evidence-based tools and the medical education literature in teaching and assessing the CanMEDS roles.MethodsIn 2016, the authors utilized an online questionnaire to survey 747 Canadian residency program directors (PD’s) of Royal College of Physicians and Surgeons of Canada (RCPSC) accredited programs.ResultsOverall, 186 PD’s participated (24.9%). 36.6% did not know whether the teaching strategies they used were evidence-based and another third (31.9%) believed they were “not at all” or “to a small extent” evidence-based. Similarly, 31.8% did not know whether the assessment tools they used were evidence-based and another third (39.7%) believed they were “not at all” or “to a small extent” evidence-based. PD’s were aware of research on teaching strategies (62.4%) and assessment tools (51.9%), but felt they did not have sufficient time to review relevant literature (72.1% for teaching and 64.1% for assessment).ConclusionsCanadian PD’s reported low awareness of evidence-based tools for teaching and assessment, implying a potential knowledge translation gap in medical education research.

The use of the objective structured clinical examination (OSCE) in a practice-based health discipline: Academic and student experience in paramedicine

Abstract:Purpose:Over the past two decades, the discipline of Paramedicine has seen expediential growth as it moved from a work-based training model to that of an autonomous profession grounded in academia. With limited evidence-based literature examining assessment in paramedicine, this paper aims to describe student and academic views on the preference for OSCE as an assessment modality, the sufficiency of pre-OSCE instruction, and whether or not OSCE performance is a perceived indicator of clinical performance.Design/Methods:A voluntary, anonymous survey was conducted to examine the perception of the reliability and validity of the Objective Structured Clinical Examination (OSCE) as an assessment tool by students sitting the examination and the academics that facilitate the assessment. Findings:The results of this study revealed that the more confident the students are in the reliability and validity of the assessment, the more likely they are to perceive the assessment as an effective measure of their clinical performance. The perception of reliability and validity differs when acted upon by additional variables, with the level of anxiety associated with the assessment and the adequacy of feedback of performance cited as major influencers. Research Implications:The findings from this study indicate the need for further paramedicine discipline specific research into assessment methodologies to determine best practice models for high quality assessment.Practical Implications:The development of evidence based best practice guidelines for the assessment of student paramedics should be of the upmost importance to a young, developing profession such as paramedicine.Originality/Value: There is very little research in the discipline specific area of assessment for paramedicine and discipline specific education research is essential for professional growth.Limitations:The principal researcher was a faculty member of one of the institutions surveyed. However, all data was non identifiable at time of data collection. Key WordsParamedic; paramedicine; objective structured clinical examinations; OSCE; education; assessment.

Curricula Innovation to Positively Influence Preference for Working With Older Adults: A Review of the Literature

Few nursing students show preference in working with older adults. The purpose of this study was to review the U.S. nursing education evidence-based literature to determine curricula innovation to positively influence preference for working with older adults. CINAHL, Medline, Ovid Emcare, PsychInfo, and PubMed databases were searched for relevant U.S studies published between 2009 and 2020 using the search terms “nursing students”, “geriatrics OR gerontology OR older adults OR elderly OR aging”, “career OR work”, and “choice OR preference OR attitude”. Nine studies were eligible for inclusion. Nursing education may play a role in influencing how students perceive and prefer to work with older adults. Promising interventions include stand-alone gerontology courses, intergenerational service-learning experiences, and clinical experiences with community dwelling older adults. More evidence-based research with larger sample sizes are needed to determine effective nursing education interventions to improve nursing students’ attitude and preference for working with older adults.

Manual vs Mechanical Oral Hygiene Procedures: Has the Role of the Dental Hygienist in Phase 2 Post-lockdown Really Changed?

Purpose: Some authors have highlighted the danger of intraoral use of rotating instruments which can produce droplets and aerosols. During the Covid lockdown phase, dental operators were limited to providing emergency treatment that could not be postponed. Therefore, it is necessary for the dental team to restart safely to treat neglected oral diseases that may also affect systemic health. The role of the dental hygienist has apparently changed for procedures performed close to the patient's oral cavity, particularly in terms of the droplets and aerosols produced during oral hygiene practices. Through an analysis of the most recent literature on the use of dedicated PPE and changed post-Covid 19 work processes, and a review of the differences between manual causal therapy and mechanical therapy in terms of outcome after oral hygiene treatment, we define how the role of the dental hygienist can change positively. Materials and Methods: Narrative reviews of the literature in terms of PPE adopted and oral hygiene procedures performed were carried out in Pubmed. Results: 188 articles from February 2020 to May 2020 using the search terms 'dentistry' and 'covid-19' were examined. 10 reviews of the literature were performed using the search terms 'mechanical procedures' and 'manual hygiene'. Conclusion: Only continuous update of evidence-based literature on the new standards in oral hygiene procedures and the different results yielded by different procedures can ensure a safe working environment for the dental hygienist while supporting the dentist in this phase of the pandemic.

Evaluating the efficacy of topical vancomycin powder in the treatment of open lower extremity fractures

Introduction Optimal management of lower extremity fractures includes early antibiotics administration, thorough irrigation and debridement, consideration of soft tissue injury, and definitive skeletal management. The purpose of this study was to evaluate the efficacy of topical vancomycin powder in the treatment of open lower extremity fractures. Methods This was a retrospective case control study in which open lower extremity fractures at our institution were reviewed for development of infection (including species and sensitivity if present) and the development of unanticipated wound complications requiring intervention. Patients from 2010-2015 were treated with standard of care consistent with evidence-based literature (IV antibiotics with external fixator, intramedullary nail, etc.). Patients from 2016–18 were additionally treated with vancomycin powder applied directly to the wound before closure. All patients were monitored per the treating surgeon’s standard follow-up protocol and had follow-up of at least two months. Results This retrospective case control study comprised 434 patients. The historical control group (n = 388 patients) and treatment group (n = 46 patients) were similar for age, sex, BMI (body mass index), diabetes, smoking status, and Injury Severity Score (ISS). There were 36 infections (9.28%) in the control group compared to four infections (8.70%) in the vancomycin powder group (p = 0.901). No significant difference was seen after adjusting for age, sex, BMI, diabetes, smoking status, and ISS. The vancomycin powder group experienced significantly more wound complications (15.2%) compared to the control group (6.4%; p = 0.039), which remained significant when adjusting for multiple covariates. Conclusions Topical vancomycin powder did not reduce the infection rate when applied in the surgical site of open lower extremity fractures. Instead, the addition of topical vancomycin powder resulted in significantly more wound complications in patients with open lower extremity fractures.

Medial Hoffa Fracture: Description of a Novel Classification System and Rationale for Treatment Based on Fragment-Specific Fixation Strategy.

This study aims to present a novel classification system and a rationale for treatment of medial Hoffa fractures. We developed a simple comprehensive classification system for medial Hoffa fractures based on the fragment size and presence of fracture comminution. Furthermore, we propose a treatment algorithm based on two pillars: our case series of nine patients presenting medial Hoffa fractures and the best evidence-based pertinent literature. Fracture healing, range of motion, function, and complications were evaluated after a minimum of 6 months follow-up. All fractures healed with no loss of reduction. Knee flexion ranged from 90 - 130° (mean 110°, standard deviation 15.2). Knee extension ranged from 0 - 10° (mean 1°, standard deviation 3.3). Knee function according to the Lysholm score ranged from 74 - 96 points (mean 85, standard deviation 6.3). There were no complications such as infection, fixation failure, or medial femoral condyle osteonecrosis. One patient required hardware removal due to soft tissue irritation and one patient underwent knee mobilization under anesthesia after 8 weeks of fracture fixation due to knee stiffness. The presented rationale for treatment based on the new classification system is a simple and effective strategy on the decision-making process for adequate management of medial Hoffa fractures.

Recruitment Issues in Emerging Adult Populations: Focus on Adult Congenital Heart Disease.

High-quality nursing research is important to healthcare and is precipitated by successful participant recruitment. Young adults aged 18 to 30 years are particularly difficult to recruit due to transitions during this time, which makes it more problematic to locate these individuals and may make it more difficult for them to prioritize the need for participation. This paper includes data from two cross-sectional survey design pilot studies that aimed to enroll young adults with congenital heart disease using a variety of recruitment methods. The number of participants enrolled in these two pilot studies (7 and 22) was much lower than expected but the recruitment challenges encountered were consistent with other research studies that have recruited young adult populations. After presenting these data and a discussion of the relevant literature, we conclude with proposed strategies for research recruitment of young adults for nurse scientists who directly impact evidence-based literature and practice with research contributions.

Dealing children a helping hand withBook of Beasties: The mental wellness card game

Aim(s)Play contributes uniquely to effective learning and the development of children’s socio-emotional skills. This study investigated Book of Beasties: A school-based, socio-emotional intervention centred around a card game which aims to improve children’s emotional literacy and wellbeing through playful learning. Exploratory research was conducted to determine its potential as an effective resource for school staff and other professionals working in school settings with responsibility for supporting pupils’ mental health.MethodA single case study comprised one London primary school. Four children (aged eight to nine years; two boys and two girls) received the intervention. Qualitative data were collected from session observations, a focus group with children and semi-structured interviews with school staff (the delivery agents) and parents/carers. Data were collated and thematically analysed.FindingsIntegrated findings suggested intervention recipients had benefitted in terms of increased socio-emotional skills and wellbeing. Child and adult participants agreed that Book of Beasties was valuable and acceptable and thus socially valid. Specific components which contributed to the intervention’s effectiveness were elicited. These included fantasy elements of the game and sensory-focused activities.LimitationsData were collected from a single, volunteer school. The class teacher (delivery agent) selected the children who received the intervention, potentially biasing the findings.ConclusionsExploratory research indicated that Book of Beasties was a promising resource for practitioners in schools and can contribute to the evidence-based socio-emotional literature. A full evaluation using both quantitative and qualitative methods was recommended to examine intervention effectiveness on socio-emotional outcomes, process issues and potential adaptations.

Alternative Birth Plans and Unintended Maternal and Neonatal Consequences: A Review of the Literature.

Birth plans are an important part of childbirth preparation for many women. The aim of this review was to discuss some common requests, specifically home birth, water birth, placentophagy, lotus birth, vaccination refusal, and vaginal seeding, including evidence-based recommendations, perceived benefits, and potential maternal and neonatal consequences. A literature search for each topic was undertaken using PubMed and Web of Science. For the home birth section, the MeSH terms home AND birth OR childbirth AND outcomes OR complications OR recommendations OR guidelines were used. For the vaccination section, birth OR childbirth OR maternal AND vaccination refusal were searched. For the remainder of the sections, umbilical cord AND nonseverance OR placentophagy OR vaginal seeding OR lotus birth were searched. A total of 523 articles were identified. The abstracts were reviewed by 2 authors (J.R.W. and J.A.R.); 60 of these articles were selected and used for this review. Home birth is currently not recommended in the United States. Immersion in water for labor is acceptable, but delivery should not occur in water. Placentophagy and lotus birth should be discouraged because of risk of neonatal infection. Vaccines should be administered in accordance with national guidelines. Vaginal seeding should be discouraged until more is known about the practice. These evidence-based recommendations provide clear guidance for physicians so that the birthing experience can be enhanced for both mother and neonate without compromising safety. This is an evidence-based literature review of alternative birth plans and recommendations for directive counseling.

Quality Evaluation of the Clinical Trials for Natural Products Used in Cancer: An Evidence-Based Literature Review

The amount of data regarding the use of herbs/herbal products in cancer clinical trials at times creates a great challenge for oncologists to prescribe or counsel patients. It urges critical evaluation of the quality of clinical trials. Herein, for the first time, the clinical trials for herbs used in cancer were critically evaluated on the basis of three widely used scales, i.e., Jadad, Delphi, and Cochrane scales. The literature was collected with the help of online databases, journals, libraries, and books using a number of specific keywords as mentioned in detail in forthcoming sections. A total of 73 clinical trials were extracted, evaluated, and scored for 14 herbs, according to the predefined criteria mentioned below. A major deficiency of “non-blinding of clinical trials” was observed. The principal component analysis revealed four components (PC1–PC4) with a total variability of 68.21%, wherein the highest percentage variability was observed for PC1 loaded with “non-blinding of the clinical trials, no concealment of the treatment allocation, non-blindness of the patient and care provider”, which accounted for 30.81% of the total variability. The next major variability of 14.70% was observed for PC2 loaded with “non-randomization of the studies, non-blinding of the outcome assessors, no proper drop-out procedures, and lack of information regarding baseline characteristics for the groups”. Pearson’s correlation further confirmed a similar correlation pattern for the mentioned deficiencies (p = 0.05). An in-house grading scale was developed, showing a very small portion (16.44%), i.e., 12/73 studies with a good quality, whereas the majority (57.54%) of the studies, i.e., 42/73, were found to be of poor quality. The rules and regulations governing the quality of clinical trials needs to be more stringent and updated for the natural products/herbs used in cancer clinical trials.

A methodology for structured literature network meta-analysis

PurposeLittle attention has been paid to restructuring existing massive amounts of literature data such that evidence-based meaningful inferences and networks be drawn therefrom. This paper aims to structure extant literature data into a network and demonstrate by graph visualization and manipulation tool “Gephi” how to obtain an evidence-based literature review.Design/methodology/approachThe main objective of this paper is to propose a methodology to structure existing literature data into a network. This network is examined through certain graph theory metrics to uncover evidence-based research insights arising from existing huge amounts of literature data. From the list metrics, this study considers degree centrality, closeness centrality and betweenness centrality to comprehend the information available in the literature pool.FindingsThere is a significant amount of literature on any given research problem. Approaching this massive volume of literature data to find an appropriate research problem is a complicated process. The proposed methodology and metrics enable the extraction of appropriate and relevant information from huge quantities of literature data. The methodology is validated by three different scenarios of review questions, and results are reported.Research limitations/implicationsThe proposed methodology comprises of more manual hours to structure literature data.Practical implicationsThis paper enables researchers in any domain to systematically extract and visualize meaningful and evidence-based insights from existing literature.Originality/valueThe procedure for converting literature data into a network representation is not documented in the existing literature. The paper lays down the procedure to structure literature data into a network.

A Drug-Induced Acute Pancreatitis Retrospective Study.

Background and Aims Drugs are considered a relatively rare and understudied cause of acute pancreatitis (AP). The lack of convincing and conclusive data on drug-induced AP (DIAP) complicates the diagnosis as well as the identification of the causative drug. The aim of this study is to document causes of DIAP cases that occurred in the Saguenay-Lac-Saint-Jean (SLSJ) population. Methods We have conducted a retrospective and descriptive population-based study of DIAP cases that occurred between 2006 and 2014 in the six hospitals serving the entire SLSJ population. Cases were selected from the Quebec Ministry of Health hospitalizations registry (MED-ECHO) administrative public database. A medical chart review was performed in an attempt to characterize DIAP hospitalizations and to identify the imputable drugs. Results During the studied period, 75 cases (30.7% male, 69.3% female) were included totaling 90 hospitalizations for DIAP. Among them, 50 causative drugs were identified and were distributed in 17 different drug classes. Recurrent DIAPs were documented in 13 cases, and among them, 6 cases have experimented a positive rechallenge. Six drugs (5-fluorouracil, atorvastatin, bortezomib, nilotinib, rosuvastatin, and triamcinolone) were associated with the highest degree of evidence. The most common causative drugs of DIAP hospitalization were azathioprine (n = 7), followed by atorvastatin (n = 6), hydrochlorothiazide (n = 5), rosuvastatin (n = 4), and codeine (n = 4). Conclusions This study has added new evidences about potentially pancreatitis-associated drugs in literature. This is the first study to report definite 5-fluorouracil- and triamcinolone-induced AP. An updated version of the evidence-based literature review is needed to support the clinicians in the identification of the causative drugs.

Understanding aggressive behaviour in patients with schizophrenia through social cognitive theory: a narrative literature review

Background/AimsStudies have shown that some people diagnosed with schizophrenia are more predisposed to distress than others because of positive and negative symptoms of schizophrenia, leading to aggressive and violent behaviour. Moreover, there is no conclusive evidence to substantiate the reasons for the causes of aggression and what suitable interventions can be used. The aim of this study was to explore evidence-based literature through social cognitive theory to find effective strategies to manage aggression among patients with a diagnosis of schizophrenia.MethodsA background literature review search was conducted from the following databases: Medline, Cinhal and PsychInfo. The Boolean operator OR was used to search for Aggression OR Violence OR Cognitive theory OR Interventions OR Mental illness OR Schizophrenia OR Self-control OR Self-efficacy OR Social learning theory. Suitable papers were hand searched and seven papers were selected.ResultsResearch studies are in favour of social cognitive interventions to manage aggression in patients with schizophrenia as they have fewer side effects and can be used alongside other pharmacological interventions as the second line of treatment. However, findings from these studies should be viewed with caution, resulting from the contradiction that still exists in whether psychotic symptoms are correlated to aggression and violent behaviours among patients with schizophrenia.ConclusionsSocial cognitive models can enable health care professionals to explore the causes of aggression from a broad perspective, using appropriate risk assessment tools to design appropriate strategies.

International Recommendations for the Management of Adults Treated With Ketogenic Diet Therapies.

To evaluate current clinical practices and evidence-based literature to establish preliminary recommendations for the management of adults using ketogenic diet therapies (KDTs). A 12-topic survey was distributed to international experts on KDTs in adults consisting of neurologists and dietitians at medical institutions providing KDTs to adults with epilepsy and other neurologic disorders. Panel survey responses were tabulated by the authors to determine the common and disparate practices between institutions and to compare these practices in adults with KDT recommendations in children and the medical literature. Recommendations are based on a combination of clinical evidence and expert opinion regarding management of KDTs. Surveys were obtained from 20 medical institutions with >2,000 adult patients treated with KDTs for epilepsy or other neurologic disorders. Common side effects reported are similar to those observed in children, and recommendations for management are comparable with important distinctions, which are emphasized. Institutions differ with regard to recommended biochemical assessment, screening, monitoring, and concern for long-term side effects, and further investigation is warranted to determine the optimal clinical management. Differences also exist between screening and monitoring practices among adult and pediatric providers. KDTs may be safe and effective in treating adults with drug-resistant epilepsy, and there is emerging evidence supporting the use in other adult neurologic disorders and general medical conditions as well. Therefore, expert recommendations to guide optimal care are critical as well as further evidence-based investigation.

Architecture as change-agent? Looking for innovation in contemporary forensic psychiatric hospital design

History suggests that departures from accepted design practice can contribute to positive change in the delivery of mental healthcare, the daily experience of hospitalised patients and public perceptions of mental...

A Comprehensive, Evidence-Based Literature Review of the Surgical Treatment of Rectus Diastasis.

Rectus diastasis is a common condition that can result in a protruding abdomen, causing cosmetic and functional disability. Although it is usually repaired during abdominoplasty or herniorrhaphy, there is a lack of consensus with regard to the repair indications and optimal surgical techniques. The goal of this study is to provide an updated review of the surgical techniques used for rectus diastasis repair and their comparative efficacy. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the PubMed, Embase, and Cochrane databases were searched for articles that discussed the surgical management of rectus diastasis and reported on either outcomes, complications, or recurrence rates. Data detailing surgical techniques were extracted, and pooled analyses of complication and recurrence rates were performed, controlling for surgical approach, common variations in technique, and an associated herniorrhaphy. Thirty-seven studies describing 45 techniques were included. An open rectus diastasis repair was performed in 24 of the studies. After controlling for an associated herniorrhaphy, there was no statistically significant difference in surgical complication and recurrence rates between open and laparoscopic approaches (p = 0.165 and p = 0.133, respectively). Although a double-layer suture closure was associated with a significantly lower rate of complications (p = 0.002), no significant difference was found for suture type absorbability. Surgical repair of rectus diastasis is safe and effective through both open and laparoscopic approaches. Although suture type absorbability does not affect complication or recurrence rates, a double-layer suture closure can decrease surgical complications. The pooled analysis of complication and recurrence rates can help improve informed consent and patient education.

A BIBLIYOMETRIC ANALYSIS OF THE 100 TOP-CITED PUBLICATIONS IN HEALTH TOURISM

Objectives: The purpose of this study are: a) to review evidence-based and cumulative information health tourism literature by bibliometric analyses; b) to identifies the current 100 top-cited articles in health tourism ranging from 1970 to 2020 and indexed in Web of Science (WoS). 
 Method: Retrospective analysis was used bibliometric information from the database of WoS. The obtained data analyzed by using VOSviewer through a software package. Statistical analyses were performed using SPSS software version 23.0 (SPSS Inc., Chicago, IL).
 Results: The citation count of the most-cited articles varied from 27 to 361 WoS (1970 – 2020). The most productive year was 2010 and the most productive country is the USA. 65 different journals were detected and the most frequent article was Tourism Management. Total citation time was positively associated with the age of the article (p

A Quality Improvement Approach to Perineal Skin Care: Using Standardized Guidelines and Novel Diaper Wipes to Reduce Diaper Dermatitis in NICU Infants.

Diaper dermatitis (DD) causes discomfort and emotional distress and creates possible sources of infection among newborn intensive care unit infants. Diaper dermatitis remains prevalent despite studies documenting an understanding of prevention and treatment modalities. Standardizing perineal skin care guidelines could reduce DD. Implement perineal skin care guidelines, while introducing novel diaper wipes, to decrease the incidence of DD by 20% within a 1-year period. Our unit reviewed evidence-based literature to develop a standardized perineal care guideline for prevention and treatment, encompassing the use of novel, preservative-free diaper wipes with grapefruit seed extract. The outcome measures were the incidence and duration of DD. Process compliances were monitored. The balancing measure was the rate of fungal skin infection while using preservative-free wipes. Between July 2017 and March 2019, 1070 infants were admitted for 1 or more days, with 11% of those being born at less than 30 weeks of gestational age. After guideline implementation in January 2018, the incidence of DD decreased by 16.7%. The incidence of severe cases dropped by 34.9%, with 3.5 days per 100 patient-days shortened duration. Process compliance was achieved. Neonates tolerated the novel wipes without increased fungal skin infection. The Perineal Skin Care Guidelines could reduce the rate and duration of DD. Newborn intensive care unit infants tolerated the novel diaper wipes. Additional research on wipes containing other types of extracts or ingredients.

Evidence-based assessment of potential therapeutic effects of adjunct osteopathic medicine for multidisciplinary care of acute and convalescent COVID-19 patients

Although the COVID-19 pandemic affects predominantly the respiratory function, epidemiological studies show that multiple systems can be affected. The severe complications of SARS-CoV-2 infection seem to be induced by an inflammatory dysregulation (“cytokine storm”), which can also induce an immunodepression. Several studies highlight beneficial effects of osteopathic medicine on inflammation and immune regulation. A careful review of evidence-based literature brings to the fore significant improvements of osteopathic manipulative treatment (OMT) in adjunction to conventional care. OMT can improve the condition of infected patients by decreasing symptoms and boosting the efficiency of conventional care. OMT might also benefit surviving patients by reducing the long-lasting consequences of the infection as well as improving their quality of life during convalescence. This review should constitute an argument in favor of multidisciplinary care, although further biological and clinical research is essential to better assess the potential beneficial contributions of adjunct osteopathic medicine to conventional care in the fight against pandemics such as COVID-19.

The influence of opioids and nonopioid central nervous system active medications on central sleep apnea: a case-control study.

Opioids are known to contribute to central sleep apnea (CSA), but the influence of nonopioid central nervous system active medications (CNSAMs) on CSA remains unclear. In light of the hypothesized impact of nonopioid CNSAMs on respiration, we examined the relationships between the use of opioids only, nonopioid CNSAMs alone, and their combination with CSA. Among all adults who underwent polysomnography testing at the University of Michigan's sleep laboratory between 2013 and 2018 (n = 10,606), we identified 212 CSA cases and randomly selected 300 controls. Participants were classified into four groups based on their medication use: opioids alone, nonopioid CNSAMs only, their combination, and a reference group, including those who did not use any of these medications. We defined CSA as a binary outcome and as a continuous variable using central apnea index data. Logistic and linear regression were used to examine associations between medication use, CSA diagnosis, and central apnea index. Study participants included 58% men, and mean age was 50 (± 14 standard deviation years. Nearly half of the study participants did not use opioids or nonopioid CNSAMs, 6% used opioids alone, 27% nonopioid CNSAMs alone, and 16% used a combination of these medications. In adjusted analyses, opioids-only users had a nearly twofold increase in CSA odds, whereas those who used a combination of opioids and nonopioid CNSAMs had fivefold higher odds of CSA relative to the reference group. In contrast, the use of nonopioid CNSAMs alone had protective associations with CSA. This report showed increased odds of CSA, particularly among patients with sleep complaints who were prescribed opioids in combination with nonopioid CNSAMs compared with those who did not use any of these medications.