Monday, April 27, 2015

Three New Papers from the Biomed Central Family of Journals

Joosen MCW, van Beurden KM, Terluin B, van Weeghel J, Brouwers EPM, van der Kilnk JJL. Improving occupational physicians’ adherence to a practice guideline: feasibility and impact of a tailored implementation strategy. BMC Medical Education 2015, 15:82  doi:10.1186/s12909-015-0364-8

Background: Although practice guidelines are important tools to improve quality of care, implementation remains challenging. To improve adherence to an evidence-based guideline for the management of mental health problems, we developed a tailored implementation strategy targeting barriers perceived by occupational physicians (OPs). Feasibility and impact on OPs’ barriers were evaluated. Methods OPs received 8 training-sessions in small peer-learning groups, aimed at discussing the content of the guideline and their perceived barriers to adhere to guideline recommendations; finding solutions to overcome these barriers; and implementing solutions in practice. The training had a plan-do-check-act (PDCA) structure and was guided by a trainer. Protocol compliance and OPs’ experiences were qualitatively and quantitatively assessed. Using a questionnaire, impact on knowledge, attitude, and external barriers to guideline adherence was investigated before and after the training. Results The training protocol was successfully conducted; guideline recommendations and related barriers were discussed with peers, (innovative) solutions were found and implemented in practice. The participating 32 OPs were divided into 6 groups and all OPs attended 8 sessions. Of the OPs, 90% agreed that the peer-learning groups and the meetings spread over one year were highly effective training components. Significant improvements (p < .05) were found in knowledge, self-efficacy, motivation to use the guideline and its applicability to individual patients. After the training, OPs did not perceive any barriers related to knowledge and self-efficacy. Perceived adherence increased from 48.8% to 96.8% (p < .01). Conclusions The results imply that an implementation strategy focusing on perceived barriers and tailor-made implementation interventions is a feasible method to enhance guideline adherence. Moreover, the strategy contributed to OPs’ knowledge, attitudes, and skills in using the guideline. As a generic approach to overcome barriers perceived in specific situations, this strategy provides a useful method to guideline implementation for other health care professionals too.

Jafree SR, Zakar R, Fischer F, Zakar MZ. Ethical violations in the clinical setting: the hidden curriculum learning experience of Pakistani nurses. BMC Medical Ethics 2015, 16:16  doi:10.1186/s12910-015-0011-2

Background: The importance of the hidden curriculum is recognised as a practical training ground for the absorption of medical ethics by healthcare professionals. Pakistan’s healthcare sector is hampered by the exclusion of ethics from medical and nursing education curricula and the absence of monitoring of ethical violations in the clinical setting. Nurses have significant knowledge of the hidden curriculum taught during clinical practice, due to long working hours in the clinic and front-line interaction with patients and other practitioners.

Methods: The means of inquiry for this study was qualitative, with 20 interviews and four focus group discussions used to identify nurses’ clinical experiences of ethical violations. Content analysis was used to discover sub-categories of ethical violations, as perceived by nurses, within four pre-defined categories of nursing codes of ethics: 1) professional guidelines and integrity, 2) patient informed consent, 3) patient rights, and 4) co-worker coordination for competency, learning and patient safety.

Results: Ten sub-categories of ethical violations were found: nursing students being used as adjunct staff, nurses having to face frequent violence in the hospital setting, patient reluctance to receive treatment from nurses, the near-absence of consent taken from patients for most non-surgical medical procedures, the absence of patient consent taking for receiving treatment from student nurses, the practice of patient discrimination on the basis of a patient’s socio-demographic status, nurses withdrawing treatment out of fear for their safety, a non-learning culture and, finally, blame-shifting and non-reportage of errors.

Conclusion: Immediate and urgent attention is required to reduce ethical violations in the healthcare sector in Pakistan through collaborative efforts by the government, the healthcare sector, and ethics regulatory bodies. Also, changes in socio-cultural values in hospital organisation, public awareness of how to conveniently report ethical violations by practitioners and public perceptions of nurse identity are needed.

Ahn K, Jhun HJ. New physical examination tests for lumbar spondylolisthesis and instability: low midline sill sign and interspinous gap change during lumbar flexion-extension motion. BMC Musculoskeletal Disorders 2015, 16:97  doi:10.1186/s12891-015-0551-0

Background: Lumbar spondylolisthesis (LS) and lumbar instability (LI) are common disorders in patients with low back or lumbar radicular pain. However, few physical examination tests for LS and LI have been reported. In the study described herein, new physical examination tests for LS and LI were devised and evaluated for their validity. The test for LS was designated “low midline sill sign”, and that for LI was designated “interspinous gap change” during lumbar flexion-extension motion. Methods The validity of the low midline sill sign was evaluated in 96 patients with low back or lumbar radicular pain. Validity of the interspinous gap change during lumbar flexion-extension motion was evaluated in 73 patients with low back or lumbar radicular pain. The sensitivity, specificity, and positive and negative predictive values of the two tests were also investigated. Results The sensitivity and specificity of the low midline sill sign for LS were 81.3% and 89.1%, respectively. Positive and negative predictive values of the test were 78.8% and 90.5%, respectively. The sensitivity and specificity of the interspinous gap change test for LI were 82.2% and 60.7%, respectively. Positive and negative predictive values of the test were 77.1% and 68.0%, respectively. Conclusions The low midline sill sign and interspinous gap change tests are effective for the detection of LS and LI, and can be performed easily in an outpatient setting.


Monday, April 20, 2015

Pull My Finger

On April 15, a new scientific paper hit worldwide with a major impact. My friend and colleague, Greg Kawchuk of the University of Edmonton, had done what no one before him had ever been able to do. He found out what happened when you crack your knuckle. And on that fateful day, Greg had more than 45 media interviews, including with the New York Times, the BBC and other major newspapers. Greg is a top scientist, and to this day I remember his presentation at an ACC-RAC conference with pleasure- he recreated a famous Olympic iice-dancing routine as part of his presentation, only he used two chiropractors to do the dance. It remains the funnies thing I have ever seen at any conference, ever. But I digress.

In his paper, which has become known as the “Pull my finger” study, he placed the fingers of a chiropractor into a device that literally pulled the finger to the point where a knuckle crack occurred. Even better, the reason he used that chiropractor’s finger was because the chiropractor possessed the unusual ability of being able to have his knuckle crack on demand- no refractory period, etc. Greg was able to use this on all 10 fingers of the participant. With his team, he then took cine-MRI images of the knuckle as it cracked, and was able to visualize the changes taking place. He found not that there was a bubble collapse (the prevailing theory) but that a cavity was formed. You can now see why this garneed such worldwide attention (in a Facebook post of a few moments ago, Greg noted that his aunt said that “it went virus.”).
The actual paper, which is titled “Real-time visualization of joint cavitation,”  is available free for download on the Public Library of Science, or PLoS. It can be found at From Greg’s work, we need to know a new term: tribonucleation. Here is the abstract of this most interesting paper.

Cracking sounds emitted from human synovial joints have been attributed historically to the sudden collapse of a cavitation bubble formed as articular surfaces are separated. Unfortunately, bubble collapse as the source of joint cracking is inconsistent with many physical phenomena that define the joint cracking phenomenon. Here we present direct evidence from real-time magnetic resonance imaging that the mechanism of joint cracking is related to cavity formation rather than bubble collapse. In this study, ten metacarpophalangeal joints were studied by inserting the finger of interest into a flexible tube tightened around a length of cable used to provide long-axis traction. Before and after traction, static 3D T1-weighted magnetic resonance images were acquired. During traction, rapid cine magnetic resonance images were obtained from the joint midline at a rate of 3.2 frames per second until the cracking event occurred. As traction forces increased, real-time cine magnetic resonance imaging demonstrated rapid cavity inception at the time of joint separation and sound production after which the resulting cavity remained visible. Our results offer direct experimental evidence that joint cracking is associated with cavity inception rather than collapse of a pre-existing bubble. These observations are consistent with tribonucleation, a known process where opposing surfaces resist separation until a critical point where they then separate rapidly creating sustained gas cavities. Observed previously in vitro, this is the first in-vivo macroscopic demonstration of tribonucleation and as such, provides a new theoretical framework to investigate health outcomes associated with joint cracking.

Monday, April 13, 2015

Reviewing Manuscripts

On the current home page for BioMed Central blog is an article about peer review. I have had an opportunity to provide hundreds of peer reviews for submitted manuscripts over the course of my career, and I enjoy providing them, while understanding that they take time and a certain amount of skill. But I also know that it is a human process, so it is imperfect and subject to idiosyncrasy.  The blog post here (  rises a number of critical issues.

The first issue relates to training. Should those who provide peer review have some sort of training to do so? This is important, because the quality and depth of peer review ranges a great deal. Consider that at ACC-RAC there may be 200 reviewers involved in vetting the papers that have been submitted. None have any training whatsoever. Certainly, some reviewers will be scientists who have themselves undergone peer review, and may also offer same to various journals, but they will provide their reviews based on the own perceptions about how in-depth they should be, etc. And many others have never done reviewing at all. It does seem that it would be beneficial to provide a base level of training so that individuals would know about how deep to go into their review, would understand they do not need to comment on or correct editing errors (after all, that is what an editor is for), and would be trained to keep comments impersonal. The use of a mentor might help here.
Second, journals could provide checklists for reviewers to use.  And journals could offer some sort of accreditation process for those who review. They could open up the review process (that is, they could publish the reviewers’ comments along with the paper).

And reviewers should be acknowledged for the work they do. I would publish an annual thank you to reviewers, when I edited JMPT. It takes time and is done free, and it is a valuable service. I hope that you will find such opportunities to provide such a service.