Knowledge Translation in Emergency Medicine: proceedings of a concensus conference

  The November 2007 issue of Academic Emergency Medicine is a theme issue on knowledge translation in emergency medicine. The issue includes the presentations from the May 2007 conference entitled Knowledge Translation in Emergency Medicine: Establishing a Research Agenda and Guide Map for Evidence Uptake.
Full text is available free online.  PubMed Records

From: Executive Summary: Knowledge Translation in Emergency Medicine: Establishing a Research Agenda and Guide Map for Evidence Uptake:
Knowledge translation (KT) describes any process that contributes to the effective and timely incorporation of evidence-based information into the practices of health professionals in such a way as to effect optimal health care outcomes and maximize the potential of the health care system. The 2007 Academic Emergency Medicine Consensus Conference was conceived to stimulate the development of a KT research agenda and a coordinated initiative within the specialty of emergency medicine (EM). This article provides an executive summary of the consensus conference initiative by describing the overriding themes that emerged as central to the KT enterprise for EM, as well as the specific research recommendations that received the greatest support.

Selected titles: The Knowledge Translation Paradigm: Historical, Philosophical, and Practice Perspectives;  Responsiveness to Change: A Quality Indicator for Assessment of Knowledge Translation Systems;  Some Theoretical Underpinnings of Knowledge Translation;  Guideline Implementation Research: Exploring the Gap between Evidence and Practice in the CRUSADE Quality Improvement Initiative; Evidence-based Reviews and Databases: Are They Worth the Effort? Developing Evidence Summaries for Emergency Medicine; Funding Opportunities in Knowledge Translation: Review of the AHRQ’s “Translating Research into Practice” Initiatives, Competing Funding Agencies, and Strategies for Success; Development of the Capacity Necessary to Perform and Promote Knowledge Translation Research in Emergency Medicine; Development of the Capacity Necessary to Perform and Promote Knowledge Translation Research in Emergency Medicine; Informatics and Knowledge Translation; The Emergency Physician and Knowledge Transfer: Continuing Medical Education, Continuing Professional Development, and Self-improvement; Graduate Medical Education and Knowledge Translation: Role Models, Information Pipelines, and Practice Change Thresholds; Toward Improved Implementation of Evidence-based Clinical Algorithms: Clinical Practice Guidelines, Clinical Decision Rules, and Clinical Pathways; Knowledge Translation at the Macro Level: Legal and Ethical Considerations; Qualitative Data Collection and Analysis Methods: The INSTINCT Trial; The Utility of a Quality Improvement Bundle in Bridging the Gap between Research and Standard Care in the Management of Severe Sepsis and Septic Shock in the Emergency Department

The Dietary Supplements Labels Database: brands, ingredients, and references

  Here is a new database from the U.S. National Library of Medicine.  From the Web site:
The Dietary Supplements Labels Database offers information about ingredients in more than two thousand selected brands of dietary supplements. It enables users to determine what ingredients are in specific brands and to compare ingredients in different brands. Information is also provided on the health benefits claimed by manufacturers. These claims by manufacturers have not been evaluated by the Food and Drug Administration. Companies may not market as dietary supplements any products that are intended to diagnose, treat, cure or prevent any disease.

Ingredients of dietary supplements in this database are linked to other National Library of Medicine databases such as MedlinePlus® and PubMed® to allow users to understand the characteristics of ingredients and view the results of research pertaining to them, including the following characteristics:
– Uses in humans
– Adverse effects
– Mechanism of action
The Database can be searched by brand names, uses noted on product labels, specific active ingredients, and manufacturers.
                                              FAQ      Glossary    Related Resources

Evidence-Based Treatment of Adult Whiplash Associated Disorder Grades 1-4 of the Cervical Spine

   A new clinical practice guideline on whiplash disorders is now available for review, and feedback is invited:
Evidence-Based Treatment of Adult Whiplash Associated Disorder Grades 1-4 of the Cervical Spine       

Clinical Practice Guideline Feedback    Feedback must be received by November 29th, 2007.

From the Canadian Chiropractic Association Web site:
On behalf of the Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory and Educational Accreditation Boards, you are encouraged to review this draft of the Guideline and provide your feedback. Once you have reviewed the documents, you are invited to submit your feedback to any of the 28 stakeholder organizations involved in the Guideline development process. Click on the link that appears at the end of this page “Clinical Practice Guidelines Feedback” to fill-out a user–friendly questionnaire and submit your comments. This draft Guideline has been developed to the highest standards and represents an important evolution in providing members with objective, evidence-based guidance on clinical practice issues.

One of the key aspects of the Guideline development process is feedback from practicing chiropractors who will be using the information in a clinical practice setting. We hope that every practitioner will take this opportunity to review the draft and provide important feedback for the refinement of the Guideline. Please take some time to contribute your expertise to this valuable development process. The finalized Guideline will be published in the Journal of the Canadian Chiropractic Association.
Clinical Practice Guidelines (CCA Web site)

Do chiropractors adhere to guidelines for back radiographs?: A study of chiropractic teaching clinics in Canada

   From the October 15, 2007 issue of Spine [subscription required]:

Ammendolia CD, Cote PD, Hogg-Johnson SP, Bombardier CM. Do chiropractors adhere to guidelines for back radiographs?: A study of chiropractic teaching clinics in Canada. Spine 2007; 32(22):2509-2514.

Key Points
* There is high adherence to radiography guidelines for a new episode of low back pain among chiropractic teaching clinics.
* There is low radiography use rate for this patient population in this setting.
* There is a high red flag rate among patients with low back pain attending chiropractic teaching clinics

Study Design: Clinical cohort.
Objectives: To measure the adherence to 3 radiography guidelines for low back pain in chiropractic teaching clinics.
Summary of Background Data: Evidence-based guidelines for low back pain suggest that plain radiography should be restricted to patients with suspected serious disease. Among primary healthcare providers who can request radiographs, chiropractors are thought to have utilization rates that exceed what is recommended by practice guidelines. It is uncertain whether this gap between evidence and practice begins in undergraduate training.
Methods: We screened 1241 consecutive patients with a new episode of low back pain who presented to any of the 6 out-patient teaching clinics of the Canadian Memorial Chiropractic College between January 2004 and September 2004. We collected information about red flags and radiography recommendations from patients and chiropractic trainees using self-administered questionnaires. Radiography recommendations were compared with criteria used in 3 radiography guidelines. Adherence was measured as the proportion of patients without red flags who were not recommended for radiography.
Results: Of the 503 eligible patients, 448 (89.1%) agreed to participate in the study. Radiography was recommended for 12.3% of patients. According to the selected radiography guidelines, the proportion of patients with red flags ranged from 45.3% to 70.5%. The proportion of patients without red flags who were not recommended for radiography ranged from 89.4% (95% confidence interval, 85.5%-93.2%) to 94.7% (95% confidence interval, 90.9%-98.5%) for the selected guidelines.
Conclusions: The results suggest a strong adherence to radiography guidelines for patients with a new episode of low back pain who presented to chiropractic teaching clinics. Although a high proportion of patients had red flags, radiography utilization was lower than rates reported in previous studies suggesting that adherence to guidelines may help prevent unnecessary radiography.

Pharmaceutical education: gifts from industry and lifelong learning

   From the August 15, 2007 issue of the American Journal of Pharmaceutical Education [Open Access]:

Hanson AL, Bruskiewitz RH, DeMuth JE. Pharmacists’ perceptions of facilitators and barriers to lifelong learning. Am J Pharm Educ 2007; 71(4):67.

OBJECTIVES: To reevaluate facilitators of and barriers to pharmacists’ participation in lifelong learning previously examined in a 1990 study.
METHODS: A survey instrument was mailed to 274 pharmacists who volunteered to participate based on a prior random sample survey. Data based on perceptions of facilitators and barriers to lifelong learning, as well as self-perception as a lifelong learner, were analyzed and compared to a similar 1990 survey.
RESULTS: The response rate for the survey was 88%. The top 3 facilitators and barriers to lifelong learning from the 2003 and the 1990 samples were:
(1) personal desire to learn;
(2) requirement to maintain professional licensure; and
(3) enjoyment/relaxation provided by learning as change of pace from the “routine.”
The top 3 barriers were:
(1) job constraints;
(2) scheduling (location, distance, time) of group learning activities; and
(3) family constraints (eg, spouse, children, personal). Respondents’ broad self-perception as lifelong learners continued to be highly positive overall, but remained less positive relative to more specific lifelong learning skills such as the ability to identify learning objectives as well as to evaluate learning outcomes.
CONCLUSIONS: Little has changed in the last decade relative to how pharmacists view themselves as lifelong learners, as well as what they perceive as facilitators and barriers to lifelong learning. To address factors identified as facilitators and barriers, continuing education (CE) providers should focus on pharmacists’ time constraints, whether due to employment, family responsibilities, or time invested in the educational activity itself, and pharmacists’ internal motivations to learn (personal desire, enjoyment), as well as external forces such as mandatory CE for relicensure.  PubMed  Record

Piascik P, Bernard D, Madhavan S, Sorensen TD, Stoner SC, TenHoeve T. Gifts and corporate influence in doctor of pharmacy education. Am J Pharm Educ 2007; 71(4):68.

OBJECTIVES: To explore the nature of corporate gifts directed at PharmD programs and pharmacy student activities and the perceptions of administrators about the potential influences of such gifts.
METHODS: A verbally administered survey of administrative officials at 11 US colleges and schools of pharmacy was conducted and responses were analyzed.
RESULTS: All respondents indicated accepting corporate gifts or sponsorships for student-related activities in the form of money, grants, scholarships, meals, trinkets, and support for special events, and cited many advantages to corporate partner relationships. Approximately half of the respondents believed that real or potential problems could occur from accepting corporate gifts. Forty-four percent of respondents agreed or strongly agreed that corporate contributions could influence college or school administration. Sixty-one percent agreed or strongly agreed that donations were likely to influence students.
CONCLUSIONS: Corporate gifts do influence college and school of administration and students. Policies should be in place to manage this influence appropriately.  PubMed Record 

And this just in:

Ellis RA, Goodyear P, Brillant M, Prosser M. Student experiences of problem-based learning in pharmacy: conceptions of learning, approaches to learning and the integration of face-to-face and on-line activities.  Adv Health Sci Educ Theory Pract 2007 Jul 12; [Epub ahead of print; subscription required]

This study investigates fourth-year pharmacy students’ experiences of problem-based learning (PBL). It adopts a phenomenographic approach to the evaluation of problem-based learning, to shed light on the ways in which different groups of students conceive of, and approach, PBL. The study focuses on the way students approach solving problem scenarios in class, and using professional pharmacy databases on-line. Qualitative variations in student approaches to solving problem scenarios in both learning situations are identified. These turn out to be associated with qualitatively different conceptions of PBL and also with levels of achievement. Conceptions and approaches that emphasis learning for understanding correlate with attaining higher course marks. The outcomes of the study reinforce arguments that we need to know more about how students interpret the requirements of study in a PBL context if we are to unravel the complex web of influences upon study activities, academic achievement and longer-term professional competence. Such knowledge is crucial to any theoretical model of PBL and has direct practical implications for the design of learning tasks and the induction of students into a PBL environment.

Rate your disgust sensitivity

  Do you want to know what disgusts you and why the things that disgust you disgust you?  Well, the BBC is here to help. Take this test created by the BBC Science & Nature’s Human Body and Mind. From the site:

Test your sensitivity to disgust and take part in a real science experiment. It has 20 questions and should take between 5-10 minutes. The questionnaire is split into two sections. Section one consists of 19 questions. Section two consists of a single vote. It was developed by Dr Val Curtis of the London School of Hygiene and Tropical Medicine.

Take the test and see if you can do it with a straight face. At then end of the test you will be enlighted about why these things disgust you. (Why is there not a “nobody’s” response to the question about who you would allow to use your toothbrush?)

More tests:
Explore your memory;  What’s your brain sex?;  What’s your personality type?;  Spot the fake smile (I only got 12 out of 20 correct!)

Institutional academic-industry relationships

  From the October 17, 2007 issue of JAMA:

Campbell EG, Weissman JS, Ehringhaus S, Rao SR, Moy B, Feibelmann S et al. Institutional academic-industry relationships. JAMA 2007; 298(15):1779-1786.

Context: Institutional academic-industry relationships have the potential of creating institutional conflicts of interest. To date there are no empirical data to support the establishment and evaluation of institutional policies and practices related to managing these relationships.
Objective: To conduct a national survey of department chairs about the nature, extent, and consequences of institutional academic-industry relationships for medical schools and teaching hospitals.
Design, Setting, and Participants: National survey of department chairs in the 125 accredited allopathic medical schools and the 15 largest independent teaching hospitals in the United States, administered between February 2006 and October 2006.
Main Outcome Measure: Types of relationships with industry. Results A total of 459 of 688 eligible department chairs completed the survey, yielding an overall response rate of 67%. Almost two-thirds (60%) of department chairs had some form of personal relationship with industry, including serving as a consultant (27%), a member of a scientific advisory board (27%), a paid speaker (14%), an officer (7%), a founder (9%), or a member of the board of directors (11%). Two-thirds (67%) of departments as administrative units had relationships with industry. Clinical departments were more likely than nonclinical departments to receive research equipment (17% vs 10%, P = .04), unrestricted funds (19% vs 3%, P < .001), residency or fellowship training support (37% vs 2%, P < .001), and continuing medial education support (65% vs 3%, P < .001). However, nonclinical departments were more likely to receive funding from intellectual property licensing (27% vs 16%, P = .01). More than two-thirds of chairs perceived that having a relationship with industry had no effect on their professional activities, 72% viewed a chair’s engaging in more than 1 industry-related activity (substantial role in a start-up company, consulting, or serving on a company’s board) as having a negative impact on a department’s ability to conduct independent unbiased research.
Conclusion: Overall, institutional academic-industry relationships are highly prevalent and underscore the need for their active disclosure and management.

Is continuing medical education a drug-promotion tool? Yes and No

  From the October 2007 issue of Canadian Family Physician:

Marlow B. Is continuing medical education a drug-promotion tool? NO. Can Fam Physician 2007; 53(10):1650-1652.
CLOSING ARGUMENTS:

• Industry practices in relation to continuing medical education and continuing professional development have changed dramatically in the last 10 years.
• Accrediting bodies, such as the College of Family Physicians of Canada, have introduced measures in their accreditation standards that prevent promotion in accredited educational activities.
• Physician organizations and industry leaders have established guidelines and codes that have been adopted widely and that clearly define the relationship between industry and physicians. These guidelines and codes ensure that accredited medical education and continuing professional development programs are balanced and unbiased.

Steinman MA, Baron RB. Is continuing medical education a drug-promotion tool? YES. Can Fam Physician 2007; 53(10):1650-1653.
CLOSING ARGUMENTS:

• Medical education is an important part of drug companies’ promotional strategy to increase sales of their products.
• Many continuing medical education (CME) programs are funded wholly or in part by drug and device manufacturers.
• Despite various mechanisms to protect against commercial influence, financial conflicts of interest faced by CME providers and speakers can affect course content in favour of sponsors’ products.
• To minimize commercial bias, physicians should seek CME programs with less industry sponsorship and with rigorous mechanisms to mitigate conflicts of interest.

Ethical, professional, and legal obligations in clinical practice: a series

 The five short articles in this series are based on discussions held in this UK author’s surgical unit. He writes, While our unit dealt with these issues from a surgical perspective, the obligations of clinical practice apply to all practitioners and the series could be easily modified for other clinical specialties. Even though these articles are a few years old, it seems to me that they are still relevant and may be of interest to some of you. Free full text is available.

Click on this  PubMed Related Articles link to retrieve the series. Click on the PubMed links after each article to view the MeSH terms used to index the articles. There are also links to specific MeSH terms under each article listed below.

Gore DM. Ethical, professional, and legal obligations in clinical practice: a series of discussion topics for postgraduate medical education. Introduction and topic 1: informed consent. Postgrad Med J 2001;77:238–9.  PubMed Record
MeSH terms: Informed Consent; Liability, Legal; Ethics, Medical

Gore DM. Ethical, professional, and legal obligations in clinical practice: a series of discussion topics for postgraduate medical education. Topic 2: consent and legal competence. Postgrad Med J 2001;77:318–19.  PubMed Record
MeSH Terms: Mental Competency; Confidentiality

Gore DM. Ethical, professional, and legal obligations in clinical practice: a series of discussion topics for postgraduate medical education. Topic 3: resuscitation decisions in adult patients. Postgrad Med J 2001;77:388–9.  PubMed Record
MeSH Terms: Resuscitation Orders; Decision Making

Gore DM. Ethical, professional, and legal obligations in clinical practice: a series of discussion topics for postgraduate medical education. Topic 4: Confidentiality. Postgrad Med J 2001;77(909):443-4.  PubMed Record
MeSH Terms: Confidentiality; Ethics, Medical; Patient Advocacy

Gore DM. Ethical, professional, and legal obligations in clinical practice: a series of discussion topics for postgraduate medical education. Topic 5: disclosing confidential information. Postgrad Med J 2001;77(910):512-3.  PubMed Record
MeSHTerms: Death Certificates; Automobile Driving; Physician-Patient Relations; Truth Disclosure

Predictors of inappropriate antibiotic prescribing among primary care physicians

   In this retrospective cohort study that included 852 primary care physicians in Quebec, authors Cadieus, Tamblyn, Dauphinee and Libman (of Montreal) found that international medical graduates, physicians with high practice volumes and those who were in practice longer were more likely to prescribe antibiotics inappropriately. The study was published in the October 9, 2007 issue of the Canadian Medical Association Journal [Open Access]

Cadieux G, Tamblyn R, Dauphinee D, Libman M. Predictors of inappropriate antibiotic prescribing among primary care physicians. Can Med Assoc J 2007; 177(8):877-883.

Background: Inappropriate use of antibiotics promotes antibiotic resistance. Little is known about physician characteristics that may be associated with inappropriate antibiotic prescribing. Our objective was to assess whether physician knowledge, time in practice, place of training and practice volume explain the differences in antibiotic prescribing among physicians.
Methods: A historical cohort of 852 primary care physicians in Quebec who became certified between 1990 and 1993 was followed for their first 69 years of practice (19901998). We evaluated whether inappropriate antibiotic prescribing had occurred during the study period (19901998) for viral (prescription of antibiotics) and bacterial (prescription of second-or third-line antibiotics given orally) infections. We used logistic regression to estimate the independent contributions of time in practice, practice volume, place of medical training and scores on licensure examinations. Physician sex and visit setting were controlled for, as were patient age, sex, education, income and geographic area of residence.
Results: A total of 104 230 patients who received a diagnosis of a viral infection and 65 304 who received a diagnosis of a bacterial infection were included in our study. International medical graduates were more likely than University of Montreal graduates to prescribe antibiotics for viral respiratory infections (risk ratio [RR] 1.78, 95% confidence interval [CI] 1.302.44). Inappropriate antibiotic prescribing increased with time in practice. Physicians with a high practice volume were more likely than those with low practice volume to prescribe antibiotics for viral respiratory infections (RR 1.27, 95% CI 1.091.48) and to prescribe second-and third-line antibiotics as first-line treatment (RR 1.20, 95% CI 1.061.37). Physician scores on licensure examinations were not predictive of inappropriate antibiotic prescribing. Interpretation: International medical graduates, physicians with high-volume practices and those who were in practice longer were more likely to prescribe antibiotics inappropriately. Developing effective interventions will require increased knowledge of the mechanisms that underlie these predictors of inappropriate antibiotic prescribing.  PubMed Record   CBC News   Globe & Mail