Monday, December 16, 2013

Holiday Best Wishes and Some New Work by Palmer People


Dear All: As we head in to the holiday break, I thought I would leave for now with some of the recent work your colleagues have accomplished. Please have a wonderful break, and I will see you in January.

Roecker C, Long CR, Vining R, Lawrence DJ. Attitudes toward evidence-based clinical practice among doctors of chiropractic with diplomate-level training in orthopaedics. Chiropr Man Ther 2013, 21:43 doi:10.1186/2045-709X-21-43

ABSTRACT
Background: Evidence-based clinical practice (EBCP) is a practice model gaining prominence within healthcare, including the chiropractic profession. The status of EBCP has been evaluated in a variety of healthcare disciplines, but little is known regarding the attitudes doctors of chiropractic (DCs) hold toward this model of healthcare. This project examines the attitudes toward EBCP within a specialty discipline of DCs.

Methods: We identified a survey questionnaire previously used to evaluate EBCP among non-chiropractic complementary and alternative practitioners. We adapted this questionnaire for use among DCs and pretested it in 5 chiropractic college faculty. The final version was administered to DCs with diplomate-level training in orthopedics. The survey was emailed to 299 potential participants; descriptive results were calculated.
Results: 144 surveys were returned, resulting in a 48% response rate. The majority of respondents perceived EBCP as an important aspect of chiropractic practice. Respondents also believed themselves to have an above average skill level in EBCP, reported that training originated from their diplomate education, and based the majority of their practice on clinical research.

Conclusion: Doctors of chiropractic with an orthopedic diplomate appear to have favorable attitudes toward EBCP. Further study will help understand EBCP perceptions among general field DCs. A logical next step includes validation of this questionnaire.

 Mansholt BA, Stites JS, Deerby DC, Boesch RJ, Salsbury SA. Essential literature for the chiropractic profession: a survey of chiropractic research leaders. Chiropr Man Ther 2013, 21:33 doi:10.1186/2045-709X-21-33
ABSTRACT

Background: Evidence-based clinical practice (EBCP) is an accepted practice for informed clinical decision making in mainstream health care professions. EBCP augments clinical experience and can have far reaching effects in education, policy, reimbursement and clinical management. The proliferation of published research can be overwhelming—finding a mechanism to identify literature that is essential for practitioners and students is desirable. The purpose of this study was to survey leaders in the chiropractic profession on their opinions of essential literature for doctors of chiropractic, faculty, and students to read or reference.

Methods: Deployment of an IRB exempted survey occurred with 68 academic and research leaders using SurveyMonkey®. Individuals were solicited via e-mail in August of 2011; the study closed in October of 2011.Collected data were checked for citation accuracy and compiled to determine multiple responses. A secondary analysis assessed the scholarly impact and Internet accessibility of the recommended literature.
Results: Forty-three (43) individuals consented to participate; seventeen (17) contributed at least one article of importance. A total of 41 unique articles were reported. Of the six articles contributed more than once, one article was reported 6 times, and 5 were reported twice.

Conclusions: A manageable list of relevant literature was created. Shortcomings of methods were identified, and improvements for continued implementation are suggested. A wide variety of articles were reported as “essential” knowledge; annual or bi-annual surveys would be helpful for the profession

Triano JJ, Budgell B, Bagnulo A, Roffey B, Bergmann T, Cooperstein R, Gleberzon B, Good C, Perron J, Tepe R. Review of methods used by chiropractors to determine the site for applying manipulation. Chiropr Man Ther 2013, 21:36 doi:10.1186/2045-709X-21-36

ABSTRACT
Background: With the development of increasing evidence for the use of manipulation in the management of musculoskeletal conditions, there is growing interest in identifying the appropriate indications for care. Recently, attempts have been made to develop clinical prediction rules, however the validity of these clinical prediction rules remains unclear and their impact on care delivery has yet to be established. The current study was designed to evaluate the literature on the validity and reliability of the more common methods used by doctors of chiropractic to inform the choice of the site at which to apply spinal manipulation.

Methods: Structured searches were conducted in Medline, PubMed, CINAHL and ICL, supported by hand searches of archives, to identify studies of the diagnostic reliability and validity of common methods used to identify the site of treatment application. To be included, studies were to present original data from studies of human subjects and be designed to address the region or location of care delivery. Only English language manuscripts from peer-reviewed journals were included. The quality of evidence was ranked using QUADAS for validity and QAREL for reliability, as appropriate. Data were extracted and synthesized, and were evaluated in terms of strength of evidence and the degree to which the evidence was favourable for clinical use of the method under investigation.
Results: A total of 2594 titles were screened from which 201 articles met all inclusion criteria. The spectrum of manuscript quality was quite broad, as was the degree to which the evidence favoured clinical application of the diagnostic methods reviewed. The most convincing favourable evidence was for methods which confirmed or provoked pain at a specific spinal segmental level or region. There was also high quality evidence supporting the use, with limitations, of static and motion palpation, and measures of leg length inequality. Evidence of mixed quality supported the use, with limitations, of postural evaluation. The evidence was unclear on the applicability of measures of stiffness and the use of spinal x-rays. The evidence was of mixed quality, but unfavourable for the use of manual muscle testing, skin conductance, surface electromyography and skin temperature measurement.

Conclusions: A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care– methods involving pain provocation upon palpation or localized tissue examination. Procedures which involve some indirect assessment for identifying the manipulable lesion of the spine–such as skin conductance or thermography–tend not to be supported by the available evidence.

Monday, December 9, 2013

Books for the Evidence-Based Practitioner

A number of excellent books are now published which provide strong grounding in evidence-based care. I thought I would list several here as a resource for you. They are in no particular order.

1.       Howlett B, Rogo EJ, Shelton TG. Evidence-based Practice for Health professionals: An Interprofessional Approach.  Burlington, MA; Jones and Bartlett, 2014

2.       Blessing JD, Forister JG. Introduction to Research and Medical Literature for Health professionals, 3rd Edition. Burlington, MA; Jones and Bartlett, 2013

3.       Rosser WW, Slawson DC, Shaughnessy AF. Information Mastery: Evidence-Based Family Medicine.  Hamilton, ON; BC Decker Inc, 2004

4.       Brownson RC, Baker EA, Leet TL, Gillespie KN. Evidence-Based Public Health. New York, NY; Oxford Press, 2003

5.       Haneline M. Evidence-Based Chiropractic Practice.  Sudbury, MA; Jones and Bartlett, 2007

6.       Guyatt G, Rennie D, Meade MO, Cook DJ. JAMA Evidence: Users’ Guides to the Medical Literature. A Manual for Evidence-Based Clinical Practice, 2nd edition.  New York, NY; McGraw Hill, 2008

7.       Howick J. The Philosophy of evidence-Based Medicine. Oxford, UK; BMJ Books, 2011

8.       Srauss SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM, 3rd edition. Edinburgh, UK; Elsevier, 2008

9.       Nordenstrom J. Evidence-Based Medicine in Sherlock Holmes’ Footsteps. Malden, MA; Blackwell Publishing, 2007

10.   Crombie IK. The Pocket Guide to Critical Appraisal. Oxford, UK; BMJ Books, 1996

11.   Dagenais S, Haldeman S. Evidence-Based management of Low Back Pain. St. Louis, MO; Elsevier, 2012

Monday, December 2, 2013

Regression Analysis

In a recent issue of the “Newsletter of the International Society for Evidence-Based Health Care,” (Newsletter 13, October 2013), Benkhadra et al (1) provide an interesting discussion of how to make sense of regression analysis. They position this as using an analogy from third-grade math. In their article, they note that for novices to evidence-based practice, the words “regression analysis” or “regression model” can put people off from reading further for simple fear they will not be able to understand what is being said. To help such readers, they provide an example based on simple math. I would like to use their example: they look at using results from a young middle-aged man looking to see if he qualifies for life insurance. In his case, he has elevated cholesterol. And he wonders if this might be due to his drinking alcohol. A study is found (2) that looks at the association between alcohol and cholesterol level, and this study is a regression analysis reporting results as regression coefficients. The value reported is 0.298, with p<0 .05="" confidence="" interval="" no="" o:p="" reported="">

To try to see what this means, the authors ask you to consider a simple “input/output” table, and they ask you to predict what values would come next:
Input=3, output=8
Input=4, output=10
Input=5, output=?
Input=6, output=?

 A moment’s thought shows you that the relation here is that output is equal to ( input x2)+2.  You could now develop a linear regression graph for several different people and show that (y=A*x+B) as the line best fitting this relationship. In the case of the paper we found, the actual measure is (cholesterol= 160+0.2998 x alcohol consumption per week).  This has some implications; for example, when alcohol consumption is 0, cholesterol would be 160, and as alcohol consumption increases, so does cholesterol levels at a predictable rate. This is a linear regression, and is a simple model. Of course, it gets more complex as we increase variables…

 References
1.       Benkhadra K, Asi N, Haydour Q, Murad MH. Making sense of a study using regression analysis: analogy from third grade math. International Society of Health Care for Evidence-Based Health Care, October 2013: 4-6
2.       Porrini M, Simonettim P, Testolin G, Roggi C, Laddomada MS, Tencone MT. Relation between diet composition and coronary disease risk factors. J Epidemiol Community Health 1991;45:148-151

 Links for Further Explanation




 

Monday, November 25, 2013

Holiday Week

This week is a short one, due to our Thanksgiving break. Please accept my best wishes for this holiday season, and I hope you have a chance to relax, spend time with family and eat hearty. I will have various and sundry kids and spouses/significant others in, as well as one grandchild. Rest may not be in the picture… J

Monday, November 18, 2013

New from Biomed Central


Lyness JE, Lurie SJ, Ward DS, Mooney CJ, Lambert DR. Engaging students and faculty:
implications of self-determination theory for teachers and leaders in academic medicine
BMC Medical Education 2013, 13:151 doi:10.1186/1472-6920-13-151

ABSTRACT
Background: Much of the work of teachers and leaders at academic health centers involves engaging learners and faculty members in shared goals. Strategies to do so, however, are seldom informed by empirically-supported theories of human motivation.
Discussion: This article summarizes a substantial body of motivational research that yields insights and approaches of importance to academic faculty leaders. After identification of key limitations of traditional rewards-based (i.e., incentives, or 'carrots and sticks’) approaches, key findings are summarized from the science of self-determination theory. These findings demonstrate the importance of fostering autonomous motivation by supporting the fundamental human needs for autonomy, competence, and relatedness. In turn, these considerations lead to specific recommendations about approaches to engaging autonomous motivation, using examples in academic health centers.
Summary: Since supporting autonomous motivation maximizes both functioning and well-being (i.e., people are both happier and more productive), the approaches recommended will help academic health centers recruit, retain, and foster the success of learners and faculty members. Such goals are particularly important to address the multiple challenges confronting these institutions.

Sim TF, Sherriff J, Hattingh L, Parsons R, Tee LBG. The use of herbal medicines during breastfeeding: a population-based survey in Western Australia
BMC Complementary and Alternative Medicine 2013, 13:317 doi:10.1186/1472-6882-13-317

ABSTRACT
Background: Main concerns for lactating women about medications include the safety of their breastfed infants and the potential effects of medication on quantity and quality of breast milk. While medicine treatments include conventional and complementary medicines, most studies to date have focused on evaluating the safety aspect of conventional medicines. Despite increasing popularity of herbal medicines, there are currently limited data available on the pattern of use and safety of these medicines during breastfeeding. This study aimed to identify the pattern of use of herbal medicines during breastfeeding in Perth, Western Australia, and to identify aspects which require further clinical research.
Methods: This study was conducted using a self-administered questionnaire validated through two pilot studies. Participants were 18 years or older, breastfeeding or had breastfed in the past 12 months. Participants were recruited from various community and health centres, and through advertising in newspapers. Simple descriptive statistics were used to summarise the demographic profile and attitudes of respondents, using the SPSS statistical software.
Results: A total of 304 questionnaires from eligible participants were returned (27.2% response rate) and analysed. Amongst the respondents, 59.9% took at least one herb for medicinal purposes during breastfeeding, whilst 24.3% reported the use of at least one herb to increase breast milk supply. Most commonly used herbs were fenugreek (18.4%), ginger (11.8%), dong quai (7.9%), chamomile (7.2%), garlic (6.6%) and blessed thistle (5.9%). The majority of participants (70.1%) believed that there was a lack of information resources, whilst 43.4% perceived herbal medicines to be safer than conventional medicines. Only 28.6% of users notified their doctor of their decision to use herbal medicine(s) during breastfeeding; 71.6% had previously refused or avoided conventional medicine treatments due to concerns regarding safety of their breastfed infants.
Conclusions: The use of herbal medicines is common amongst breastfeeding women, while information supporting their safety and efficacy is lacking. This study has demonstrated the need for further research into commonly used herbal medicines. Evidence-based information should be available to breastfeeding women who wish to consider use of all medicines, including complementary medicines, to avoid unnecessary cessation of breastfeeding or compromising of pharmacotherapy.
Triano JJ, Budgell B, Bagnulo A, Roffey B, Bergmann T, Cooperstein R, Gleberzon B, Good C, Perron J, Tepe R. Review of methods used by chiropractors to determine the site for applying manipulation

Chiropractic & Manual Therapies 2013, 21:36 doi:10.1186/2045-709X-21-36

ABSTRACT
Background: With the development of increasing evidence for the use of manipulation in the management of musculoskeletal conditions, there is growing interest in identifying the appropriate indications for care. Recently, attempts have been made to develop clinical prediction rules, however the validity of these clinical prediction rules remains unclear and their impact on care delivery has yet to be established. The current study was designed to evaluate the literature on the validity and reliability of the more common methods used by doctors of chiropractic to inform the choice of the site at which to apply spinal manipulation.
Methods: Structured searches were conducted in Medline, PubMed, CINAHL and ICL, supported by hand searches of archives, to identify studies of the diagnostic reliability and validity of common methods used to identify the site of treatment application. To be included, studies were to present original data from studies of human subjects and be designed to address the region or location of care delivery. Only English language manuscripts from peer-reviewed journals were included. The quality of evidence was ranked using QUADAS for validity and QAREL for reliability, as appropriate. Data were extracted and synthesized, and were evaluated in terms of strength of evidence and the degree to which the evidence was favourable for clinical use of the method under investigation.
Results: A total of 2594 titles were screened from which 201 articles met all inclusion criteria. The spectrum of manuscript quality was quite broad, as was the degree to which the evidence favoured clinical application of the diagnostic methods reviewed. The most convincing favourable evidence was for methods which confirmed or provoked pain at a specific spinal segmental level or region. There was also high quality evidence supporting the use, with limitations, of static and motion palpation, and measures of leg length inequality. Evidence of mixed quality supported the use, with limitations, of postural evaluation. The evidence was unclear on the applicability of measures of stiffness and the use of spinal x-rays. The evidence was of mixed quality, but unfavourable for the use of manual muscle testing, skin conductance, surface electromyography and skin temperature measurement.
Conclusions: A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care– methods involving pain provocation upon palpation or localized tissue examination. Procedures which involve some indirect assessment for identifying the manipulable lesion of the spine–such as skin conductance or thermography–tend not to be supported by the available evidence.

 

Monday, November 11, 2013

New Content on Atomic Learning

I thought I would let you know of new training programs recently added to our Atomic Learning website. Please feel free to play around.

Blackboard 9.1 Service Pack 8 – Instructor Training
http://www.atomiclearning.com/bb91_sp8theme

Blackboard 9.1 Service Pack 9 – Instructor Training
http://www.atomiclearning.com/blackboard-servicepack-9-training

Blackboard 9.1 Service Pack 10 – Instructor Training
http://www.atomiclearning.com/bb_sp10

Blackboard 9.1 Service Pack 11 – Instructor Training
http://www.atomiclearning.com/blackboard-sp11-training

Blackboard 9.1 Service Pack 12 – Instructor Training
http://www.atomiclearning.com/blackboard-sp12-training

Blackboard 9.1 Service Pack 13 – Instructor Training
http://www.atomiclearning.com/blackboard-servicepack-13-training






Rapid Web Development Using Bootstrap
http://www.atomiclearning.com/bootstrap-training







 

Monday, November 4, 2013

American Society for Bioethics and Humanities 2013 Conference

At the end of the break week, I was able to attend the annual meeting of the American Society for Bioethics and Humanities. This is a conference I always eagerly look forward to going to. Just to give you a flavor of the scope of material the conference covers, here are the sessions I attended:

  • Delivering Research Ethics Education: Strategies for Training Community Research Partner
  • The Moral Courage of Paracelsus: Medical, Religious, and Social Refor
  • Unfit for the Future: The Need for Moral Bioenhancement
  • A Tribute to Edmund Pellegrino and His Work 
  • Student Paper Award Selections
  •      Bioethics, Human Rights, and Maternal Mortality
  •      More than Informed Consent: Why Research Ethics Needs Religion
  •      Toward a More Patient-Centered Advance Directive for Surgical Patients
  • A Conversation with Amy Gutmann, Chair, Presidential Commission for the Study of Bioethical Issues
  • Student-Led Research Review Panel: An Alternative to IRB Review of Medical Student Projects
  • IRBs in Existential Crisis: Proposals for Evaluating the Efficacy of IRB Oversigh
  • How to Get Fired in Bioethics: A User’s Guide to Succes
  • Difference, Representation, and Inclusion in Bioethics and Humanitie
  • Thinking Through the Ethics of Pregnancy Reduction
  • The Best-Laid Schemes: Do Bioethicists Corrupt Public Policy
  • Climate Change: A Neglected Topic in Bioethic
  • Ethical Issues Surrounding the Use of Social Media Platforms in Disease Surveillance and Epidemiological Researc
  • Gun Control, Ethics, and Public Health
  • Disability Gai
  • Has Bioethics Undermined Medical Ethics
  • Legal Update 2013: Top 10 Legal Developments in Bioethic
  • A Seat at the Table or a Voice in the Void: A Pilot Study of the Factors That Shape Community Members’ Roles on Research Review Board
  • Pay-to-Participate Research: A Worthwhile Innovation
  • Subversive Subjects: Rule-Breaking and Deception in Clinical Trial
  • From Unification, Registration: The Genesis of Research Subject Registrie
  • Randomized Clinical Trials in Maternal-Fetal Surgery: Who Is the Patient and Why It Matter
  • Exploiting Altruism in Human Subjects Research

 

 

Monday, October 28, 2013

Electronic Communication with Students

The latest issue of the publication Online Cl@ssroom  (October 2013) offers the reader some useful information about a number of technological approaches to effective online communication with your students. Most are free for download and use. Among them are:

Jing: This is owned by the same company that produces Camtasia. In Jing, you are given the opportunity to combine audio and visual elements. It captures images, video, animations and so on and then lets you share that captured material on the web. It also allows you to record what is taking place on the screen and then send that to the web. The only limitation is that it only allows you to capture 5 minutes at a time. It works with screencast.com for a hosting site. The url is www.techsmith.com/jing.html and it is free (though upgraded versions do have cost).
VoiceThread: In VoiceThread, you can share a file or something else with your class, and then allow people access to ti and let them comment. Now, the interesting thing here is that they can leave voice files, not just text files; text would simply be like a regular posting board. This is a voice recorder moved to the computer. It also has built-in drawing tools, so imagine posting a complex anatomical chart and letting people leave voice comments as well as their own overlaid drawings. Pretty cool, huh. This is also free (or at cost if upgraded) at www.voicethread.com.

Go Animate:  You have probably seen a Go Animate video in the past few months without realizing you were doing so. The program allows you to make animations to illustrate your educational point. Thus, you end up with a video when you are done. You can choose characters, their features, the backgrounds, and a whole lot more; in fact, you can get buried in making choices to create just the perfect teaching video. The best plan would cost around $58 per year for use. The url for this is www.goanimate.com
There is explosive growth in teaching technologies. The Center for Teaching and Learning is, at the time I write this, in process of obtaining Camtasia, so that one can put voiceover on a PowerPoint presentation. As time goes on, there will be more choices, and the above represent only a few available for your use.

Monday, October 21, 2013

Congratulations, Graduates!

Let me send my congratulations to all graduates of our recent commencement ceremony: to the new DCs, the chiropractic assistants, all new BS degree recipients, and the two new graduates of our clinical master's degree program, both of whom I have worked with closely over the past couple of years. Good on all of you!

Friday, October 4, 2013

End of Term: It Must be Youtube Time Again!


This will be my last post for th current term. I am posting this early because I am scheduled for jury duty next week, and then most of us here in Davenport will be on break. So, please enjoy your time off, and please enjoy these little clips! I'll be back by the start of our new term.
 
1.       Basejumping “The Crack.” This is an amazing clip where you are looking backward at a second jumper while the first flies through a small canyon in his parasuit. Whoa! http://www.youtube.com/watch?v=hhnb9q6c4gA

2.       Mathieu Biche Fools Penn and Teller. I have some familiarity with magic, and I have no idea how he pulled this one off. And neither do Penn and Teller.  He cannot have forced a choice, since he set the trick up randomly. At least, so it seems. This is very, very clever. http://www.youtube.com/watch?v=OpthjI1z2FM

3.       Turtleman. Hey, who doesn’t love the Turtleman? It is clear that Turtleman loves what he does, and brings joy to those he meets. http://www.youtube.com/watch?v=YYEQw34eHtc

4.       Rachel Flowers on the Huge Beast Modular Moog, with Keith Emerson Introducing. Rachel is an amazing musician, who can play several instruments, and here she is allowed to play Keith Emerson’s original Moog, called the Beast. Oh, and she’s blind. http://www.youtube.com/watch?v=x7qujZpMHbA

5.       Rachel Again. So, here she is dueting with herself on flute and keyboards. http://www.youtube.com/watch?v=Qoc5qfJ9Jgw

6.       Firefly: Mal the Negotiator. One of the best but not watched shows ever. http://www.youtube.com/watch?v=NPRlHwwVIug

7.       Gravity. This is the trailer for the new movie. This movie is unlike any you have ever seen. It is intense. Relentless. Mind boggling. http://www.youtube.com/watch?v=OiTiKOy59o4

8.       Doc Martin. One of those great British series, this time about a misanthrope with no bedside manners who has a phobia to blood. Martin Clunes rocks! http://www.youtube.com/watch?v=4i-xXsk-NGg

9.       Mark Cavendish Crashes. Oh, this is scary to see. And you get a sense of how intense a bicycle sprint can be, as those riders are moving at close to 50mph! http://www.youtube.com/watch?v=-RNAYR3KPIg

10.   Subcontrabass Flute. Largest flute ever made, and an odd looking critter. http://www.youtube.com/watch?v=Qmxnp_3KUt0

 

Monday, September 30, 2013

How to Read an Article about Harm

Consider this question: how would you test the idea that smoking causes cancer? The best way to do so would be to develop a clinical trial in which half of the participants were required to smoke three packs of cigarettes per day for five years while the other half did not smoke at all. You could then see if there were differences in the rate of lung cancer between the two groups. But, of course, this is not ethical.

Given that we cannot use clinical trials to answer such questions, we can use other designs, including both a case-control study design and a cohort design.  In a case-control study we would look in the past medical records and exposures of cases (those with lung cancer) and controls (those without), and would find that some in each group were heavy smokers while others were not. We could then calculate the difference in rates of cancer between the two groups. In such case, we would end up with an odds ratio; that is, the odds that exposure to smoking leads to lung cancer. In a cohort study, we would follow people forward in time while allowing them to live their life. None have cancer at the beginning of the study. We would find, years down the road, that some in both groups were heavy smokers while others were not, and again we could calculate the difference in rates of cancer between the two groups. In this case, we would end up with a risk ratio.
Risk is associated with disease incidence; that is, the rate of newly diagnosed conditions in a population. In a case-control study, we are starting with people who already have the condition of interest; therefore, we cannot calculate risk (which requires us to newly diagnose a disease), and instead we look at odds.

When we read an article about harm, we need to understand the specific study design being used. While clinical trials are best, they often cannot be conducted. Cohort studies are stronger than case-control studies, since they allow us to calculate the true disease rate in a group. But in studies of harm, other questions to look at while reading are to ensure that the exposures and outcomes in both groups were measured the same way, that follow-up was long enough, that the exposure precedes the adverse outcome, and that the association between exposure and outcome is strong.
It is important to understand that risk and odds ratios do not tell you how frequently a problem occurs, only that the effect occurs more or less often in the exposed group compared to the unexposed group. This can then tell you whether or not to recommend the patient stop the exposure. Once we know, for example, that smoking is associated with a higher rate of cancer, we can advise patients to stop smoking.

For additional information on harm, please see http://www.cche.net/text/usersguides/harm.asp

Monday, September 23, 2013

It’s a New (Publishing) World Out There

In my younger days as a faculty member at National College of Chiropractic (later National University of Health Sciences) I was involved in developing and publishing textbooks. This was a labor of love, since I knew that the potential pay-off likely would never make up for the time I put into working on each book. And indeed, the fist book I published, Fundamentals of Chiropractic Diagnosis and Management, took nearly 4 years to complete, from conception to final publication. Over the course of my career I was involved with 16 books. But as all of us are well aware, we lived in a radically different world than the one I was lived in back in the day.

Our students do not purchase textbooks like we older folk did. I love books, and I actually loved my old chiropractic texts, and each term I was happy to put out the money to buy them. But with so many information sources now available on line, the textbook market has changed in some highly interesting ways. Here is but one example:  http://jblearning.com/custom/overview/.
Jones and Bartlett, one of many publishing companies, now offers customized course materials. If you use Jones and Bartlett texts for your course, they will provide you the means to build a custom packet of information for your students, drawn directly from the text. When you are done developing the text, which is easy to do online, it will generate either a print or eBook edition.  Put another way, you can take chapters from existing Jones and Bartlett textbooks, select only the ones you wish to use, put them in the order you wish to have your students read them, add in some of your own material, develop your own cover for the book, and then make either the print of eBook copy. You can immediately see the benefit. Your students do not have to buy several textbooks because you need them to read one or two chapters in each; you can just take those chapters and put them in your course book. Instructions for doing so, and a short video clip about this system, can be found at the URL I listed above.

We are seeing this kind of publishing more and more.  Consider the old model, which I admit to using in my own course. I assign a required text, in my case Haneline’s Evidence-Based Chiropractic Practice. I lecture each week using PowerPoint slides drawn from each week’s assigned reading. My guess is that few students actually acquire the text, and likely never read the supporting assigned material. They miss the richness of understanding that reading will bring to the material presented in class. Call me old school, but I always read every assignment I was given. Imagine now being able to use only the chapters you want students to have, at a price reduced from purchasing full textbooks, and even available for their tablet of smart phone? How cool is that?
Jones and Bartlett is hardly the only publisher looking at new models for publication. Elsevier allows you to develop a book containing all the articles you have ever published in Elsevier journals, as but one example. This is not just a vanity project, but if you assign those articles to a class, imagine how nice to have them all in one location, at reasonable cost.

And there is iBookAuthor, and other models that we have been exposed to. Exciting stuff; new horizons for us to conquer.

Monday, September 16, 2013

Clinical Prediction Rules

One of the most important parts of a chiropractor’s daily work with patients is the need to establish a proper and correct diagnosis. Diagnosis is key to the requisite decisions for appropriate care than then follow. As teach students, we generally use heuristic models, where the thinking is linear and directly correlated. That is, students are taught that if a given orthopedic test is positive, it has a specific meaning; if McMurray’s test is positive it means that there is a torn meniscus, for example. As we gather information from an examination, we combine it with our clinical experience and knowledge to close in on what feel is the correct diagnosis. It is for this reason that at Palmer we have focused on training our students to understand the importance of sensitivity and specificity of diagnostic tests, and to derive likelihood ratios from that information.

But this is imperfect at best. Clinical prediction rules (CPR) are designed to try to enhance the accuracy of a clinician’s diagnostic decisions- and the treatment decisions that follow. A clinical prediction rule is defined as “a clinical too that quantifies the individuals contributions that various components of the medical history, physical examination, and basic laboratory results make toward the diagnosis, prognosis, or likely response to treatment in an individual patient.” (1) CPRs are useful in situations where the decision making is complicated and complex.
CPRs a redeveloped using a 3-step process. The first step involves the actual creation or derivation of the rule. Step 2 involves the testing or validation of that new rule, and the final step assesses the impact the rule has had on actual clinical behavior; that is, does it end up making a difference in practice? In order to derive a new rule, it is necessary to locate and identify the factors that might have predictive power. This information could be drawn from the history, physical examination or from lab or other testing. We could then look at a series of patients to see if any of our proposed predictors are present in a large percentage of those patients. Consider, for example, a positive straight leg raise test in patients with prolapsed lumbar discs. To validate a CPR, we need to demonstrate that if we repeatedly apply it with our patients, it leads to the same results (either diagnostically or prognostically). So, in effect, we are now testing the rule in a larger and new population of patients. In the testing process and the research that is done, one can generate either likelihood ratios or odds or risk ratios. These are concepts we are now well aware of.
Here are a couple of relevant CPR papers:
  • Schenk R, Dionne C, Simon C, Johnson R. Effectiveness of mechanical diagnosis and therapy in patients with back pain who meet a clinical prediction rule for spinal manipulation. J Man Manip Ther 2012;20:43-49
  • Stolze LR, Allison SC, Childs JD. Derivation of a preliminary clinical prediction rule for identifying a subgroup of patients with low back pain likely to benefit from Pilates-based exercise. J Orthop Sports Phys Ther 2012;42:425-436
References

1.       McGinn T, Wyer P, Wisnivensky J, et al. Clinical prediction rules. In: Guyatt G, Rennie D, Meade MO, Cook D. Users’ guide to the medical literature, 3rd edition. New York, NY; MgGraw Hill Medical, 2008:491