Samuel Alan Stewart

Prophylactic radiotherapy for the prevention of procedure-tract metastases after surgical and large-bore pleural procedures in malignant pleural mesothelioma (SMART): a multicentre, open-label, phase 3, randomised controlled trial

Summary Background The use of prophylactic radiotherapy to prevent procedure-tract metastases (PTMs) in malignant pleural mesothelioma remains controversial, and clinical practice varies worldwide. We aimed to compare prophylactic radiotherapy with deferred radiotherapy (given only when a PTM developed) in a suitably powered trial. Methods We did a multicentre, open-label, phase 3, randomised controlled trial in 22 UK hospitals of patients with histocytologically proven mesothelioma who had undergone large-bore pleural interventions in the 35 days prior to recruitment. Eligible patients were randomised (1:1), using a computer-generated sequence, to receive immediate radiotherapy (21 Gy in three fractions within 42 days of the pleural intervention) or deferred radiotherapy (same dose given within 35 days of PTM diagnosis). Randomisation was minimised by histological subtype, surgical versus non-surgical procedure, and pleural procedure (indwelling pleural catheter vs other). The primary outcome was the incidence of PTM within 7 cm of the site of pleural intervention within 12 months from randomisation, assessed in the intention-to-treat population. This trial is registered with ISRCTN, number ISRCTN72767336. Findings Between Dec 23, 2011, and Aug 4, 2014, we randomised 203 patients to receive immediate radiotherapy (n=102) or deferred radiotherapy (n=101). The patients were well matched at baseline. No significant difference was seen in PTM incidence in the immediate and deferred radiotherapy groups (nine [9%] vs 16 [16%]; odds ratio 0·51 [95% CI 0·19–1·32]; p=0·14). The only serious adverse event related to a PTM or radiotherapy was development of a painful PTM within the radiotherapy field that required hospital admission for symptom control in one patient who received immediate radiotherapy. Common adverse events of immediate radiotherapy were skin toxicity (grade 1 in 50 [54%] and grade 2 in four [4%] of 92 patients vs grade 1 in three [60%] and grade 2 in two [40%] of five patients in the deferred radiotherapy group who received radiotherapy for a PTM) and tiredness or lethargy (36 [39%] in the immediate radiotherapy group vs two [40%] in the deferred radiotherapy group) within 3 months of receiving radiotherapy. Interpretation Routine use of prophylactic radiotherapy in all patients with mesothelioma after large-bore thoracic interventions is not justified. Funding Research for Patient Benefit Programme from the UK National Institute for Health Research.

Applying Social Network Analysis to Understand the Knowledge Sharing Behaviour of Practitioners in a Clinical Online Discussion Forum

Background Knowledge Translation (KT) plays a vital role in the modern health care community, facilitating the incorporation of new evidence into practice. Web 2.0 tools provide a useful mechanism for establishing an online KT environment in which health practitioners share their practice-related knowledge and experiences with an online community of practice. We have implemented a Web 2.0 based KT environment—an online discussion forum—for pediatric pain practitioners across seven different hospitals in Thailand. The online discussion forum enabled the pediatric pain practitioners to share and translate their experiential knowledge to help improve the management of pediatric pain in hospitals. Objective The goal of this research is to investigate the knowledge sharing dynamics of a community of practice through an online discussion forum. We evaluated the communication patterns of the community members using statistical and social network analysis methods in order to better understand how the online community engages to share experiential knowledge. Methods Statistical analyses and visualizations provide a broad overview of the communication patterns within the discussion forum. Social network analysis provides the tools to delve deeper into the social network, identifying the most active members of the community, reporting the overall health of the social network, isolating the potential core members of the social network, and exploring the inter-group relationships that exist across institutions and professions. Results The statistical analyses revealed a network dominated by a single institution and a single profession, and found a varied relationship between reading and posting content to the discussion forum. The social network analysis discovered a healthy network with strong communication patterns, while identifying which users are at the center of the community in terms of facilitating communication. The group-level analysis suggests that there is strong interprofessional and interregional communication, but a dearth of non-nurse participants has been identified as a shortcoming. Conclusions The results of the analysis suggest that the discussion forum is active and healthy, and that, though few, the interprofessional and interinstitutional ties are strong.

An Infobutton For Web 2.0 Clinical Discussions: The Knowledge Linkage Framework

This paper aims to develop an infobutton to automatically retrieve published papers corresponding to a topic-specific online clinical discussion. The knowledge linkages infobutton is designed to supplement online clinical conversations with pertinent medical literature from Pubmed. The project involves three distinct steps: 1) Clinical messages around a specific problem are grouped together into a thread. 2) These threads are processed using Metamap to link the conversations to keywords from the MeSH lexicon. 3) These keywords are used in a novel search strategy to retrieve a set of papers from Pubmed, which are then returned to the user. A pilot study using the messages from 2007 and 2008, was conducted to compare the knowledge linkage search strategy to a vector space model and extended Boolean model. The knowledge linkage model proved to be significantly better in terms of precision (p = 0.013 and 0.003, respectively) and recall (p = 0.351 and 0.013). Pertinent papers were returned to over 55% of the threads. This approach has demonstrated how clinicians can supplement their peer communications with evidence based research. Future work should focus on how to improve the threading and keyword-mapping strategies.

Using Social Network Analysis to Study the Knowledge Sharing Patterns of Health Professionals Using Web 2.0 Tools

Peer communication is a vital component of the knowledge translation process for healthcare practitioners, and emerging web 2.0 tools are providing virtual venues to facilitate this communication. Using social network analysis methods this paper will attempt to explore the communication patterns that emerge out of the Pediatric Pain Mailing List. The analysis will assess the overall health of the communication network, identify users and subjects of interest, and it will isolate potential subgroups that exist within the community. These results will be presented to the user using the VECoN system, developed as part of this project to present the structure of communication networks graphically to the user through the use of social network analysis methods.

Self-Reported Barriers to Healthcare Access for Rheumatoid Arthritis Patients in Rural and Northern Saskatchewan: A Mixed Methods Study.

OBJECTIVES The aim of the present study was to identify potential barriers for access to medical and allied health services from the perspective of rural and Northern Saskatchewan rheumatoid arthritis (RA) patients. METHODS A total of 100 adults with established RA, residing in rural and Northern Saskatchewan, were recruited from two rheumatology practices. Structured interviews with standardized scripts solicited patient perspectives on appointment waiting times, travel required to access medical services and satisfaction with healthcare provision. Thematic analysis was employed for qualitative data. RESULTS Patients-reported concerns regarding waiting time for their first rheumatology appointment. There was reduced access to allied health professionals, with only 53% of the participants having seen a physiotherapist (PT), and only 26% an occupational therapist (OT). Patients had similar driving distances to their family physician, PT, pharmacy and laboratory services but commuted significantly further for rheumatologist and OT services. There were high levels of satisfaction with their rheumatologist and family physician appointments (8.96 and 8.04 on a ten-point scale). Patients with longer travel times had higher satisfaction with their health care appointments: Patients who travelled one, two and more than two hours had satisfaction scores of 0.93, 0.88 and 1.32 points higher on a ten-point scale (p < 0.03). CONCLUSIONS Access to medical services is a concern for this population. Patients were dissatisfied with the waiting time for their first specialist appointment and with decreased access to allied health professionals. Patients travelling longer distances were more satisfied with their health care providers care, suggesting that good patient-care giver relationships helped to ameliorate the difficulties of travelling to their appointments. Copyright

Probing the effect of OSCE checklist length on inter-observer reliability and observer accuracy

Purpose The Objective Structured Clinical Examination (OSCE) is a widely employed tool for measuring clinical competence. In the drive toward comprehensive assessment, OSCE stations and checklists may become increasingly complex. The objective of this study was to probe inter-observer reliability and observer accuracy as a function of OSCE checklist length. Method Study participants included emergency physicians and senior residents in Emergency Medicine at Dalhousie University. Participants watched an identical series of four, scripted, standardized videos enacting 10-min OSCE stations and completed corresponding assessment checklists. Each participating observer was provided with a random combination of two 40-item and two 20-item checklists. A panel of physicians scored the scenarios through repeated video review to determine the ‘gold standard’ checklist scores. Results Fifty-seven observers completed 228 assessment checklists. Mean observer accuracy ranged from 73 to 93% (14.6–18.7/20), with an overall accuracy of 86% (17.2/20), and inter-rater reliability range of 58–78%. After controlling for station and individual variation, no effect was observed regarding the number of checklist items on overall accuracy (p=0.2305). Consistency in ratings was calculated using intraclass correlation coefficient and demonstrated no significant difference in consistency between the 20- and 40-item checklists (ranged from 0.432 to 0.781, p-values from 0.56 to 0.73). Conclusions The addition of 20 checklist items to a core list of 20 items in an OSCE assessment checklist does not appear to impact observer accuracy or inter-rater reliability.Purpose The Objective Structured Clinical Examination (OSCE) is a widely employed tool for measuring clinical competence. In the drive toward comprehensive assessment, OSCE stations and checklists may become increasingly complex. The objective of this study was to probe inter-observer reliability and observer accuracy as a function of OSCE checklist length. Method Study participants included emergency physicians and senior residents in Emergency Medicine at Dalhousie University. Participants watched an identical series of four, scripted, standardized videos enacting 10-min OSCE stations and completed corresponding assessment checklists. Each participating observer was provided with a random combination of two 40-item and two 20-item checklists. A panel of physicians scored the scenarios through repeated video review to determine the ‘gold standard’ checklist scores. Results Fifty-seven observers completed 228 assessment checklists. Mean observer accuracy ranged from 73 to 93% (14.6–18.7/20), with an overall accuracy of 86% (17.2/20), and inter-rater reliability range of 58–78%. After controlling for station and individual variation, no effect was observed regarding the number of checklist items on overall accuracy (p=0.2305). Consistency in ratings was calculated using intraclass correlation coefficient and demonstrated no significant difference in consistency between the 20- and 40-item checklists (ranged from 0.432 to 0.781, p-values from 0.56 to 0.73). Conclusions The addition of 20 checklist items to a core list of 20 items in an OSCE assessment checklist does not appear to impact observer accuracy or inter-rater reliability.

Investigating Cost Implications of Incorporating Level III At-Home Testing into a Polysomnography Based Sleep Medicine Program Using Administrative Data

Objective Obstructive sleep apnea is a common problem, requiring expensive in-lab polysomnography for proper diagnosis. Home monitoring can provide an alternative to in-lab testing for a subset of OSA patients. The objective of this project was to investigate the effect of incorporating home testing into an OSA program at a large, tertiary sleep disorders centre. Methods The Sleep Disorders Centre in Saskatoon, Canada, has been incorporating at-home testing into their diagnostic pathways since 2006. Administrative data from 2007 to 2013 were extracted (10030 patients) and the flow of patients through the program was followed from diagnosis to treatment. Costs were estimated using 2014 pricing and were stratified by disease attributes and sensitivity analysis was applied. Results The overall costs per patient were

The role of radiology in the quantification of digital ulnar deviation in rheumatoid arthritis patients.

627.40, with

Evaluating quality of life and cost implications of prophylactic radiotherapy in mesothelioma: Health economic analysis of the SMART trial

419.20 for at-home testing and

Surgically Positioned Paravertebral Catheters and Postoperative Analgesia After Open Abdominal Aortic Aneurysm Repair

746.20 for in-lab testing. The cost of home management would rise to