Monday, July 27, 2015

Two New Papers from Biomed Central

Kosloff TM, Elton D, Tao J, Bannister WM. Chiropractic care and the risk of vertebrobasilar stroke: results of a case–control study in U.S. commercial and Medicare Advantage populations. Chiropr Man Ther 2015,23:19  doi:10.1186/s12998-015-0063-x

Background: There is controversy surrounding the risk of manipulation, which is often used by chiropractors, with respect to its association with vertebrobasilar artery system (VBA) stroke. The objective of this study was to compare the associations between chiropractic care and VBA stroke with recent primary care physician (PCP) care and VBA stroke.

Methods: The study design was a case–control study of commercially insured and Medicare Advantage (MA) health plan members in the U.S. population between January 1, 2011 and December 31, 2013. Administrative data were used to identify exposures to chiropractic and PCP care. Separate analyses using conditional logistic regression were conducted for the commercially insured and the MA populations. The analysis of the commercial population was further stratified by age (<45 a="" analysis="" as="" associations="" calculated="" chiropractic="" conducted="" descriptive="" determine="" different="" exposure="" for="" hazard="" manipulative="" measure="" o:p="" odds="" of="" periods.="" proxy="" ratios="" relevance="" secondary="" the="" to="" treatment.="" using="" visits="" was="" were="" years="">
Results: There were a total of 1,829 VBA stroke cases (1,159 – commercial; 670 – MA). The findings showed no significant association between chiropractic visits and VBA stroke for either population or for samples stratified by age. In both commercial and MA populations, there was a significant association between PCP visits and VBA stroke incidence regardless of length of hazard period. The results were similar for age-stratified samples. The findings of the secondary analysis showed that chiropractic visits did not report the inclusion of manipulation in almost one third of stroke cases in the commercial population and in only 1 of 2 cases of the MA cohort.

Conclusions: We found no significant association between exposure to chiropractic care and the risk of VBA stroke. We conclude that manipulation is an unlikely cause of VBA stroke. The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection. We further conclude that using chiropractic visits as a measure of exposure to manipulation may result in unreliable estimates of the strength of association with the occurrence of VBA stroke.

Muramoto M, Matthews E, Ritenbaugh C, Nichter MA. Intervention development for integration of conventional tobacco cessation interventions into routine CAM practice. BMC Compl Altern Med 2015,15:96  doi:10.1186/s12906-015-0604-9

Background: Practitioners of complementary and alternative medicine (CAM) therapies are an important and growing presence in health care systems worldwide. A central question is whether evidence-based behavior change interventions routinely employed in conventional health care could also be integrated into CAM practice to address public health priorities. Essential for successful integration are intervention approaches deemed acceptable and consistent with practice patterns and treatment approaches of different types of CAM practitioners – that is, they have context validity. Intervention development to ensure context validity was integral to Project CAM Reach (CAMR), a project examining the public health potential of tobacco cessation training for chiropractors, acupuncturists and massage therapists (CAM practitioners). This paper describes formative research conducted to achieve this goal.

Methods: Intervention development, undertaken in three CAM disciplines (chiropractic, acupuncture, massage therapy), consisted of six iterative steps: 1) exploratory key informant interviews; 2) local CAM practitioner community survey; 3) existing tobacco cessation curriculum demonstration with CAM practitioners; 4) adapting/tailoring of existing curriculum; 5) external review of adaptations; 6) delivery of tailored curriculum to CAM practitioners with follow-up curriculum evaluation.
Results: CAM practitioners identified barriers and facilitators to addressing tobacco use with patients/clients and saw the relevance and acceptability of the intervention content. The intervention development process was attentive to their real world intervention concerns. Extensive intervention tailoring to the context of each CAM discipline was found unnecessary. Participants and advisors from all CAM disciplines embraced training content, deeming it to have broad relevance and application across the three CAM disciplines. All findings informed the final intervention.

Conclusions: The participatory and iterative formative research process yielded an intervention with context validity in real-world CAM practices as it: 1) is patient/client-centered, emphasizing the practitioner’s role in a healing relationship; 2) is responsive to the different contexts of CAM practitioners’ work and patient/client relationships; 3) integrates relevant best practices from US Public Health Service Clinical Practice Guidelines on treating tobacco dependence; and 4) is suited to the range of healing philosophies, scopes of practice and practice patterns found in participating CAM practitioners. The full CAMR study to evaluate the impact of the CAMR intervention on CAM practitioners’ clinical behavior is underway.



Wednesday, July 15, 2015

Desire2Learn Brightspace Roll-Out

That’s the news for this week. We rolled out our new learning management system, Brightspace. We had an in-service in which Doug Black of our Port orange campus spoke to teaching faculty, while Craig Mencl, also of the Port Orange campus, spoke to clinicians. The idea was to demonstrate how easy to use the system is. After the in-service, a number of us were available for one-on-one sessions with individual faculty, and I am happy to say a good number of people took advantage of that.

Users will quickly find out that is rather easy to upload content. Using the “Module” section, you can organize your course however you like. For me, right now, I am organizing it by modules simply title “Week One,” “Week Two,” etc. Thus, if all you wanted to do was recreate what you have on the portal- and you should provide everything on Brightspace that you did on the portal- that is a matter of a few minutes work (outside of uploading large video files, for example, which have to process over time).
But Brightspace is not a content-delivery system alone. If that is all it did, we could have stayed with the portal. Brightspace offers you the ability to do so much more. You can create discussion boards, develop self-assessments, send out mass or individual communications, have a blog for an individual class, etc. Over the course of this current term, you can get comfortable with the LMS, and be ready to expand what you do the next.

Your sandbox is a good place to experiment with what the system offers. What you do there will affect nothing anywhere else. Feel free to experiment and take advantage of this.
Note: next week I will be away riding RAGBRAI. No post until I return.

Wednesday, June 10, 2015

End of Term Youtube Extravaganza: Binge Watching Edition

What with a longer break than normal coming up, I thought I would provide you with a list of shows to binge watch, starting with the obvious one…

Buffy the Vampire Slayer:  Yep, my foavorite program, of which there were 144 episodes over 7 seasons. The entire first episode is on youtube, as seen here. This is the best show ever put on TV and it is about far more than a young girl fighting vampires.

Firefly:  Another show from Joss Whedon, who created Buffy. This one centers on a group of misfits who live in the future, where science fiction blends with westerns. Weird, funny and brilliant, and it only had one season.

Lost Girl:   Yet another fantasy program, about Bo, a succubus (look it up). This is about the Fae and their world, and it introduces you to perhaps the funniest sidekick in the history of television, the irrepressible Kenzi (played by Ksenia Solo).

House, MD:  Gregory House is a misanthrope. He hates everyone and trusts no one. But he always gets it right, in the end, usually at a cost…

The Bridge:  Dark and twisted, but with great acting, it is a story about a murder investigation involving both US and Mexican police. Stand-out is Diane Kruger as Sonia, who is a woman without empathy- she is literal and does not understand subtext, facial expressions, or other cues to behavior.

Continuum:  A great science fiction program about a woman sent back in time to prevent a terrorist attack. It twists and turns and goes places you do not expect.

Lie to Me:  Tim Roth plays a man who is an expert in reading microexpressions, making it harder for them to get away with lying. But he lacks social skills himself and is protected by his co-workers.

A little light watching for you! Enjoy the break.


Monday, June 1, 2015

New From Biomed Central

Svavarsdóttir NH, Sigurðardóttir AK, Sigurðardóttir A. How to become an expert educator: a qualitative study on the view of health professionals with experience in patient education. BMC Med Educ 2015, 15:87  doi:10.1186/s12909-015-0370-x

Background: Health professionals with the level of competency necessary to provide high-quality patient education are central to meeting patients’ needs. However, research on how competencies in patient education should be developed and health professionals trained in them, is lacking. The aim of this study was to investigate the characteristics of an expert educator according to health professionals experienced in patient education for patients with coronary heart disease, and their views on how to become an expert educator. Methods This descriptive qualitative study was conducted through individual interviews with health professionals experienced in patient education in cardiac care. Participants were recruited from cardiac care units and by using a snowball sampling technique. The interviews were audiotaped and transcribed verbatim. The data were analyzed with thematic approaches, using systematic text condensation. Results Nineteen Icelandic and Norwegian registered nurses, physiotherapists, and cardiologists, who had worked in cardiac care for 12 years on average, participated in the study. Being sensitive to the patient’s interests and learning needs, and possessing the ability to tailor the education to each patient’s needs and context of the situation was described as the hallmarks of an expert educator. To become an expert educator, motivation and active participation of the novice educator and a supportive learning environment were considered prerequisites. Supportive educational resources, observation and experiential training, and guidance from experienced educators were given as examples of resources that enhance competence development. Experienced educators expressed the need for peer support, inter-professional cooperation, and mentoring to further develop their competency. Conclusions Expert patient educators were described as those demonstrating sensitivity toward the patient’s learning needs and an ability to individualize the patient’s education. A supportive learning environment, inner motivation, and an awareness of the value of patient education were considered the main factors required to become an expert educator. The experienced educators expressed a need for continuing education and peer support.

Davis R, Ives J, Dunn M. A systematic review of empirical bioethics methodologies. BMC Med Ethics 2015, 16:15  doi:10.1186/s12910-015-0010-3

Background: Despite the increased prevalence of bioethics research that seeks to use empirical data to answer normative research questions, there is no consensus as to what an appropriate methodology for this would be. This review aims to search the literature, present and critically discuss published Empirical Bioethics methodologies.
Methods: MedLine, Web of Science and Google Scholar were searched between 15/02/12 and 16/06/13 to find relevant papers. These were abstract reviewed independently by two reviewers with papers meeting the inclusion criteria subjected to data extraction.

Results: 33 publications (32 papers and one book chapter) were included which contained 32 distinct methodologies. The majority of these methodologies (n = 22) can be classed as either dialogical or consultative, and these represent two extreme ‘poles’ of methodological orientation. Consideration of these results provoked three central questions that are central to the planning of an empirical bioethics study, and revolve around how a normative conclusion can be justified, the analytic process through which that conclusion is reached, and the kind of conclusion that is sought.
Conclusion: When considering which methodology or research methods to adopt in any particular study, researchers need to think carefully about the nature of the claims they wish to generate through their analyses, and how these claims align with the aims of the research. Whilst there are superficial similarities in the ways that identical research methods are made use of, the different meta-ethical and epistemological commitments that undergird the range of methodological approaches adopted rehearse many of the central foundational disagreements that play out within moral philosophy and bioethical analysis more broadly. There is little common ground that transcends these disagreements, and we argue that this is likely to present a challenge for the legitimacy of the bioethical enterprise. We conclude, however, that this heterogeneity ought to be welcomed, but urge those involved in the field to engage meaningfully and explicitly with questions concerning what kinds of moral claim they want to be able to make, about normative justification and the methodological process, and about the coherence of these components within their work

Schneider M, Evans R, Haas M, Leach M, Hawk C, Long C, Cramer GD, Walters O, Vihstadt C, Terhorst L. US chiropractors’ attitudes, skills and use of evidence-based practice: A cross-sectional national survey. Chiropr ManTher 2015, 23:16  doi:10.1186/s12998-015-0060-0

Background: Evidence based practice (EBP) is being increasingly utilized by health care professionals as a means of improving the quality of health care. The introduction of EBP principles into the chiropractic profession is a relatively recent phenomenon. There is currently a lack of information about the EBP literacy level of US chiropractors and the barriers/facilitators to the use of EBP in the chiropractic profession.
Methods: A nationwide EBP survey of US chiropractors was administered online (Nov 2012-Mar 2013) utilizing a validated self-report instrument (EBASE) in which three sub-scores are reported: attitudes, skills and use. Means, medians, and frequency distributions for each of the sub-scores were generated. Descriptive statistics were used to analyze the demographic characteristics of the sample. Means and proportions were calculated for all of the responses to each of the questions in the survey.

Results: A total of 1,314 US chiropractors completed the EBASE survey; the sample appeared to be representative of the US chiropractic profession. Respondents were predominantly white (94.3%), male (75%), 47 (+/− 11.6) years of age, and in practice for more than 10 years (60%). EBASE sub-score means (possible ranges) were: attitudes, 31.4 (8–40); skills, 44.3 (13–65); and use, 10.3 (0–24). Survey participants generally held favorable attitudes toward EBP, but reported less use of EBP. A minority of participants indicated that EBP coursework (17%) and critical thinking (29%) were a major part of their chiropractic education. The most commonly reported barrier to the use of EBP was “lack of time”. Almost 90% of the sample indicated that they were interested in improving their EBP skills.
Conclusion: American chiropractors appear similar to chiropractors in other countries, and other health professionals regarding their favorable attitudes towards EBP, while expressing barriers related to EBP skills such as research relevance and lack of time. This suggests that the design of future EBP educational interventions should capitalize on the growing body of EBP implementation research developing in other health disciplines. This will likely include broadening the approach beyond a sole focus on EBP education, and taking a multilevel approach that also targets professional, organizational and health policy domains.

Tuesday, May 26, 2015

Resources for Desire2Learn

Because this is a short week following a holiday weekend, this will be a very brief entry. Desire2Learn provides its users a significant amount of support and resources. Here are just a few:  This is a link to the latest updates and news related to the learning management platform.  This is a link to a large number of video clips which can walk you thorugh all the different functions and options you can use in the D2L environment. From start-up to advanced user, there is material here for you.  This is the company's dedicated youtube channel. On this site, you will find a plethora of youtube clips also showing you how to use the product. I find so much information among these clips.  This is Brightspace Training Videos on Demand, even more clips for your use.  This is the Brightspace community, where you can post questions and receive answers from other users.

Monday, May 18, 2015

David Sackett, RIP

On May 13, David Sackett died. He was inarguably the Father of evidence-based medicine, and his work has transformed the practice of healthcare in incalculable ways. He began his work by establishing the first Department of Clinical Epidemiology and Biostatistics in Canada, at McMaster University. McMaster is now renowned as the epicenter of evidence-based care, and we have sent many of our faculty there to take their week-long course in how to teach evidence-based care.

According to the website devoted to the Sackett Symposium, Dr. Sackett was best known for work in three areas: research methods for applied testing of healthcare innovations; use of those methods to evaluate the scientific validity and clinical utility of medical interventions; and education of healthcare clinicians in the use and application of best evidence in practice.
The work at our college has been transformed by his work. We use his approach in what we do- we ask questions, acquire information, appraise that information, apply it, and assess it to determine whether it is working. That cycle repeats itself as time goes on and as our patient either does or does not respond to what we do. What he did, more than anyone before or after, was show how to use research literature and combine it with clinical expertise to benefit the patient, always respecting the patient’s own values. We say this as a mantra now, but it was a seismic shift in how medicine was practiced.

And he acknowledged the evidence-based medicine was not static; it needed to evolve, and it has. He was funny, bold, and at times profane, not afraid to use a select swear word where it was appropriate to make his point. The Users’ Guide to the Medical Literature is based on the series of papers Sackett and others wrote in the 1980s; that book is now in its 3rd edition, and it helps inform Dr. Mike Haneline’s excellent text “Evidence-Based Chiropractic Practice.”
And he was much of the opinion that once you become seen as an expert, you need to stop and do something else. He did, regularly; He shifted from epidemiology, to compliance and then to writing about clinical trials. Once he became good at something, he stopped and moved to a new area.

We owe him a huge debt, which we repay every day when we use the tools he brought to our attention. He will be missed.

Monday, May 11, 2015

The Point of a Professor: NY Times Article

As I was reading the New York Times this morning, I came across this article: The article is entitled “What’s the point of a professor?” It makes the biting point that there is one part of higher education that falls low on the ladder of “meaningful contacts: the professors.” I tend to agree with this article, and I note that this has been an evolutionary change since the days when I entered the chiropractic profession as an instructor at what was then National College of Chiropractic.

The article points out that while students are generally content with their teachers, they are also not very much interested in them as thinkers and mentors. In general, students are enrolled in our courses, but then they rarely have much contact with us outside of class. They show up, they may even engage in the classroom (though that is certainly not always the case), but they do not seek our counsel once class ends. There are many reasons for this, in my opinion. One is that we do not give them reason to seek us outside of class. This is a bit of “hidden curriculum,” in fact, where we may not send welcoming messages. And students view us as means to an end, the end being getting their degree. Thus, we are something to put up with, rather than to truly engage with. There is a bit of a service attitude; students are consumers and we need to make consumers happy. And there is a need to have good reviews in order to receive promotion. Sometimes good reviews can be had by making life easy for students, rather than challenging them.
Beyond that is the wild world of the internet. I have never gone to- and never will- the website What good would come of it? The only reason I can think of to visit that site as a student would be to berate an instructor. In chiroprac6tic education, that could be fore reasons having nothing to do with teaching skills. It could be because of differences in philosophy, for example. But places such as yikyak are growing in size and influence. They place professors into difficult situations- you cannot respond since the system is designed to be anonymous.

In this new world, we need to find ways to reach students. I do not see students myself as a teacher until 9th trimester. By the time I see them, they are nearly gone, so there is little time to develop long-term relationships. I cannot act as a moral exemplar for them save for the 15 weeks I have them in class before they leave the college. We need to find ways to provide such interactions very early in their time at the college. Work for us all.