Tuesday, January 20, 2015

Two New Papers

O’Mara-Eves A, Thomas J, McNaught J, Miwa M, Ananiadou S. Using text mining for study identification in systematic reviews: a systematic review of current approaches. Systematic Reviews 2015, 4:5  doi:10.1186/2046-4053-4-5

Background: The large and growing number of published studies, and their increasing rate of publication, makes the task of identifying relevant studies in an unbiased way for inclusion in systematic reviews both complex and time consuming. Text mining has been offered as a potential solution: through automating some of the screening process, reviewer time can be saved. The evidence base around the use of text mining for screening has not yet been pulled together systematically; this systematic review fills that research gap. Focusing mainly on non-technical issues, the review aims to increase awareness of the potential of these technologies and promote further collaborative research between the computer science and systematic review communities.

Methods: Five research questions led our review: what is the state of the evidence base; how has workload reduction been evaluated; what are the purposes of semi-automation and how effective are they; how have key contextual problems of applying text mining to the systematic review field been addressed; and what challenges to implementation have emerged?
We answered these questions using standard systematic review methods: systematic and exhaustive searching, quality-assured data extraction and a narrative synthesis to synthesise findings.

Results: The evidence base is active and diverse; there is almost no replication between studies or collaboration between research teams and, whilst it is difficult to establish any overall conclusions about best approaches, it is clear that efficiencies and reductions in workload are potentially achievable.
On the whole, most suggested that a saving in workload of between 30% and 70% might be possible, though sometimes the saving in workload is accompanied by the loss of 5% of relevant studies (i.e. a 95% recall).

Conclusions: Using text mining to prioritise the order in which items are screened should be considered safe and ready for use in 'live' reviews. The use of text mining as a 'second screener' may also be used cautiously. The use of text mining to eliminate studies automatically should be considered promising, but not yet fully proven. In highly technical/clinical areas, it may be used with a high degree of confidence; but more developmental and evaluative work is needed in other disciplines.

Finn Y, Cantillon P, Flaherty G. Exploration of a possible relationship between examiner stringency and personality factors in clinical assessments: a pilot study. BMC Medical Education 2014, 14:1052  doi:10.1186/s12909-014-0280-3

Background: The reliability of clinical examinations is known to vary considerably. Inter-examiner variability is a key source of this variability. Some examiners consistently give lower scores to some candidates compared to other examiners and vice versa – the ‘hawk- dove’ effect. Stable examiner characteristics, such as personality factors, may influence examiner stringency. We investigated whether examiner stringency is related to personality factors.

Methods: We recruited 12 examiners to view and score a video-recorded five station OSCE of six Year 1 undergraduate medical students at our institution. In addition examiners completed a validated personality questionnaire. Examiners’ markings were tested for statistically significant differences using non-parametric one way analysis of variance. The relationship between examiners’ markings and examiner personality factors was investigated using Spearman correlation coefficient.
Results: At each station there was a statistically significant difference between examiners markings, confirming the presence of inter-examiner variability. Correlation analysis showed no association between stringency and any of the five major personality factors. When we omitted an outlier examiner we found a statistically significant negative correlation between examiner stringency and openness to experience with a correlation coefficients (rho) of – 0.66 (p = 0.03). Conversely there was a moderate positive correlation between examiner stringency and neuroticism with a correlation coefficient (rho) of 0.73 (p = 0.01).

Conclusions: In this study we did not find any relationship between examiner stringency and examiner personality factors. However, following the elimination of an outlier examiner from the analysis, we found a significant relationship between examiner stringency and two of the big five personality factors (neuroticism and openness to experience). The significance of this outlier is not known. As this was a small pilot study we recommend further studies in this field to investigate if there is a relationship between examiner stringency in clinical assessments and personality factors.


Wednesday, January 14, 2015

The Most Accessed Article on Chiropractic and Manual Therapies for 2014

I apologize for the tardiness of this post; I was out ill the past day or so and am only just back. My colleague Dr. Stephen Perle, an associate editor for Chiropractic and Manual Therapies, tweeted a note indicating that this article, by Bronfort et al and from 2010, was the most accessed article of the past year. I thought it was a good reminder of this important paper.

Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK Evidence Report. Chiropr Osteop 2010;18:3, doi:10.1186/1746-1340-18-3


Background: The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions.

Methods: The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories. The strength/quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs.

Results: By September 2009, 26 categories of conditions were located containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. We identified 49 recent relevant systematic reviews and 16 evidence-based clinical guidelines plus an additional 46 RCTs not yet included in systematic reviews and guidelines.

Additionally, brief references are made to other effective non-pharmacological, non-invasive physical treatments.

Conclusions: Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.

Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.



Monday, January 5, 2015


Welcome back. I hope that all of you had a marvelous break and return to work rested and ready for the new year.

Over the past 2 weeks I have done little work. This is not because I am lazy, as most of you are well aware. It is because like all of you, I work hard and I find that work seems to follow me home, so that even during the evening I am doing work by answering emails, etc. There is little chance for down time as a result. I think we run the danger of allowing work to dictate our life even when we are not at work any longer. So I “labored” hard to try to relax and just spend time with my wife and, where possible, with my kids. I read a lot. I think I finished 7 books. I went to the movies and saw “The Theory of Everything.” I ate well. It was great!
There is a lesson there, I suppose. Work hard, but relax and take personal time. Nothing new, I suppose.  But a good message to take into this new year.

Happy new year to you all!

Monday, December 15, 2014

The Teacher’s Toolkit

In his book “Essential Skills for a Medical Teacher,” (1) Professor Ron Harden discusses what he terms the “teacher’s toolkit.” He likens it to the tools a carpenter has- a set of tools which together help to construct a structure, all of which are necessary but are used for different purposes. Hew views a teacher in similar fashion. The teacher also needs many tools. Among those tools, Harden lists:

Presentation tool:  This would be something like PowerPoint, used to help present content to students.
An audience response system: At Palmer, we have clickers, which are linked to the computer system, but you could equally use nothing more than a set of colored cards, as they do at the McMaster University evidence-based training program.

Simulated patients or simulators: to stand in for real patients during learning exercises.
Video clips: to use to demonstrate concepts and content.

Podcasts: for students to engage with learning at a later time.
Online information sources: we should all be providing this to our students.

Networking tools: can we figure out how to adapt social media platforms to educational purposes.
Peer-to-peer teaching opportunities: so students can support each other.

The point here is simply to note that we have many tools available to use, and we should both use them and use them in ways that optimize learning.
Let me take this opportunity to wish you a very happy holiday season and a great new year. I’ll be back in January, but hope that you are able to enjoy your time away and come back refreshed.

1.       Harden RM, Laidlaw JM. Essential skills for a medical teacher. New York, NY; Churchill Livingstone, 2014

Monday, December 8, 2014

Therapeutic Misconception

Much of the research that is conducted by teaching and clinical faculty at palmer as opposed to that done by our research faculty, is conducted in classroom settings and most often involves either survey research or the use of interview or focus groups. In the former case, where a survey is administered to a class (either on paper or using a tool such as SurveyMonkey), that research is typically exempt from consideration by the IRB because it is is low risk and has little danger for the participant. And when that happens, we often do not collect an explicit consent form from the student participant. His or her consent is implied by simply completing the survey; obviously, they consented if they did go and fill out the survey form.

But in clinical settings, such as the PCCR, consent is critically important. Informed consent documents (ICDs) need to be prepare for each study, and they are complex and complicated instruments. For example, there are 13 elements that must be included in an ICD. It has to be written at an appropriate level (which is usually 8th-grade reading level), and the patient must not be coerced into signing. It can take a great deal of time and energy to prepare ICDs and there is now a growing body of evidence about how well they relay important information to research participants.
But there is a real challenge here as well. So much research occurs in clinical settings. And this blurs the line between what a physician would if allowed to simply treat a patient and what a physician or research is allowed to do if that same patient is a participant in a research project. In the former case, a doctor would do whatever he or she felt was in the patient’s best interests- vary treatment, frequency of visits, etc. But when there is a research protocol, that same doctor cannot vary from it. However, patients, despite being given an ICD which explains this to them, often misunderstand this.  They believe that everything being done to them and for them when they are in research is done because ti si the best thing for them. This is not the case in research.  Studies have shown that when asked, they will tell you that they are getting the best treatment, even when assigned to a placebo group or to a no-treatment group.  This is how Lidz and Appelbaum describe it: “The therapeutic misconception occurs when a research subject fails to appreciate the distinction between the imperatives of clinical research and of ordinary treatment, and therefore inaccurately attributes therapeutic intent to research procedures. The therapeutic misconception is a serious problem for informed consent in clinical research.” (1)

I am always on the look-out for this when new research is planned. Please read more on this to avoid such problems if ever you do research involving patients.

1.       Lidz CW, Appelbaum PS. The therapeutic misconception: problems and solutions. Med Care 2002;40(9Suppl):V55-63

Monday, December 1, 2014

National Collaborating Centre for Methods and Tools

I would like to draw your attention to the National Collaborating Centre for Methods and Tools website (www.nccmt.ca). it is one of several Canadian centers involved in sharing what works in public health. It is based on using evidence to inform the practice of public health and the website provides many tools to assist a healthcare practitioner in doing so. According to their website, their goals are:

·         To develop the organizational capacity and individual skills of those involved in public health to share what works in public health.

·         To identify, develop and evaluate relevant methods and tools for knowledge translation; and to make those methods and tools accessible to people involved in practice, program decision-making, policy-making and research.

·         To identify gaps in methods and tools for sharing what works in public health and to encourage researchers and others to fill these gaps.

·         To build active and sustainable networks that enable practitioners, program decision-makers, knowledge experts, policy-makers and researchers to share what works in public health; and to strengthen partnerships and links with other NCCs and their target audiences.

As you visit each web page on the site, you will find links to a registry of methods and tools used for knowledge translation (that is, from finding evidence, to using it on behalf of a patient). At present there are 188 links on the registry, and it provides a wealth of resources for your use. 
Even better is the page on the Learning Centre (http://www.nccmt.ca/learningcentre/index.php#main3.html). On this page you will find links to many free online educational modules. For example, one module is “Introduction to Evidence-Informed Decision Making,” another is “Quantitative Research designs,” and so on. These are not little module; most will take at least 3 hours to complete, and some will take longer, but they are great training programs.

As we return from Thanksgiving break, this would be a good way to have a refresher about evidence-based practice. I strongly recommend you bookmark this site.

Monday, November 24, 2014

Thanksgiving. Thank You.!

On this occasion of a short week and a time to celebrate thanks, I send mine to you. I am grateful to all who work here, who give so much of their time and their energy. I hope that you enjoy the time off later this week, I hope you are with family (as I will be- 3 children coming, with 3 spouses, 1 grandchild and 1 twin sister to a spouse), and I hope that you are able to eat, relax and catch your breath.

Happy Thanksgiving!