Critical Appraisal – OT paper with interesting features

Monday morning session on critical appraisal for some lovely Occupational Therapists.

We had picked out an RCT to look at together and it turned out to have some bumps.

Clin Rehabil. 2012 Dec;26(12):1096-104. doi: 10.1177/0269215512444631.

A randomized controlled trial of Cognitive Sensory Motor Training Therapy on the recovery of arm function in acute stroke patients.

Chanubol R1, Wongphaet P, Chavanich N, Werner C, Hesse S, Bardeleben A, Merholz J.
Interesting features:
  • A nice explanation of their power calculation
  • A variation in clarity of the protocols for the intervention and comparison
  • Outcome measures that are probably not that helpful (though better ones were hard to come by)
  • An intention to treat analysis that seems to exclude people who withdrew (?!)
  • An overexcited reaction to a subgroup analysis (they enjoyed this explanation of why that might be an issue)
  • Presentation of results with medians and IQR as well as means
A very good paper for discussion with OTs who have an interest in stroke rehabilitation.

Critical Appraisal – learning from the experts

I was recently lucky enough to spend a weekend locked in a hotel learning about critical appraisal at a two day workshop run by the Critical Appraisal Company.  The plan was to build my knowledge while picking up tips from expert tutors.

Like all good NHS activity it started early both days and had fairly average coffee.  The venue was smart enough and we were well fed.  With the shorter events I run timing is definitely important in terms of fitting in to available slots.  I wonder if anyone has systematically assessed which times of day are best for scheduling sessions aimed at NHS staff?  While I do not offer food and drink at my courses we do need to think about these sort of hygiene factors – how do we minimise barriers to taking the opportunity to learn?

Ahead of the course (from when we paid and for six months afterwards) we were issued with a login for elearning materials – you can see the contents list (they also sell access to these without the face to face training session). We were strongly encouraged to complete these ahead of time and they added hugely to the value of the session in my view.  The elearning takes the form of narrated slides with accompanying handouts.  The tutor on the course mentioned that these will be updated soon but I found them steady and clear.  You can jump from section to section and replay tricky bits.  Something similar would be a great addition to the brief courses I run both for learning before and after (or without any input).  Even in a two day sessions some sections went by very quickly and knowing I could review things later was a great reassurance.

On arrival we were issued with some very slick handouts.  There was a workbook that had examples, exercises and reminders of major points.  Alongside this was a tricky to physically handle A3 book. This consisted of a series of full papers from journals with appropriate IP permissions.  The paper was printed down the middle of the page with boxes either side for practical exercises aimed at pulling out aspects of the paper, checking calculations and building skills.  Finally there was a copy of the new edition of the book (Doctor’s guide to critical appraisal – a buy recommendation from me) by the course tutor (and partner).  Throughout the materials there was cross referencing to the relevant sections of the book and of the elearning.  All in all this was a very slick and integrated set of materials.

The content of the course was very similar to the elearning.  The big difference was the additional degree of elaboration and the use of anecdotes to make it less dry. This was very much in line with the way I try and present similar material. Extensive use was made of clickers to add interactivity and test understanding.  I think this was perhaps a little over done as we ended up running well behind schedule which impacted negatively on the time spent on aspects later in the agenda.  It was interesting to see the extent to which people were still not grasping key concepts. The clickers provided a non threatening way to explain where people were going wrong and bring out helpful illustrations of various learning points. I know colleagues have had some success with online polls and it merits further thought.

With the full weekend to work with the session did include much of the methodological background that I have largely dropped from my sessions.  I could see it was helpful for people but I think elearning and other options will be a better way to cover this in a tighter time scale. The explanation of randomisation techniques was helpful as this was an area I know less well and it may be something that warrants more attention than most librarians slides I have seen tend to give it.

We spent a lot of time looking at two by two contingency tables and this is something I will be adding into my sessions.  At present I cover various CER, EER, ARR, RRR, NNT calculations using an example and point to information on the table method in a handout but I think this is an oversight. So much power is made available to people to check results and I think it warrants some time.

Generally I came away feeling happy about the quality of the sessions I run. I focus hard on the practical application of appraisal – why something matters with a bit less detail about what it is. The course is excellent and I would recommend it for people looking to build their skills. Librarians who have revised their subject should have no concerns about running introductory sessions.  My impression is that librarians attend a lot more trainer the trainer sessions on critical appraisal than they deliver. People should take the plunge!

Improve critical appraisal with this one crazy tip

I spend lots of time training on basic critical appraisal.  I will have run 20 sessions over the past year (I have one more to do this morning before things grind to a halt for Christmas). This is great as they are challenging sessions where I regularly learn new things.  The quick turn over means I can also tweak as I go.

A couple of weeks ago I ran three sessions in as many days and these reinforced a few things.  It also seems timely to think about this as I have had confirmation that I will be attending this weekend long course in March.

I have had to run some of these sessions in constrained time slots (about an hour). In practice this means there is no time for the practical group appraisal exercise which is a shame.  However it also made me really focus on my slides.  A cut down version does away with nearly all the stuff about what the different research methods are and how they are used.  I found this seems to make for a more useful session – we can really focus on what people need to be doing as they read.  For many (most?) attendees the methodology stuff is a low level rehash and their interest is low.  There also isn’t enough time to do much justice to the topic even in a full two hour session. So a refreshed slide deck in prospect for next year.

Another lesson was that I should vary my papers.  I think there is a tendency in this type of training to stick to familiar favourites.  It makes for less preparation and you have the benefit of having heard others observations.  However I think one of the more successful aspects of the course is having experience of a wide range of papers to illustrate the points.  Carrying out more appraisal helps build skills and should make for a more engaging presentation.  Plus it means less repeating anecdotes.

The one crazy tip?  Running a session for a group of palliative care medics one observed:

The last sentence of the introduction is nearly always the research question


Tongue tie and the supplementary concepts

Delivering tailored literature search training for a departmental group is always a great opportunity for learning new things.  Today I helped a multiprofessional group who work in a tongue tie clinic.

This is the (cleaned up) strategy we ended up creating as part of the session:

  1. MEDLINE; (tongue AND tie).ti,ab; 160 results.
  2. MEDLINE; tonguetie.ti,ab; 6 results.
  3. MEDLINE; ankyloglossia.ti,ab; 290 results.
  4. MEDLINE; “tongue tie”.ti,ab; 157 results.
  5. MEDLINE; 1 OR 2 OR 3 OR 4; 398 results.
  6. MEDLINE; breastfeeding.ti,ab; 14979 results.
  7. MEDLINE; (breast AND feeding).ti,ab; 14567 results.
  8. MEDLINE; 6 OR 7; 27717 results.
  10. MEDLINE; BREAST FEEDING/; 27307 results.
  11. MEDLINE; 5 OR 9; 1383 results.
  12. MEDLINE; 8 OR 10; 38085 results.
  13. MEDLINE; 11 AND 12; 109 results.

The keywords are a nice example with some extra results by dropping the space and a solid alternate term in ankyloglossia that has a big impact on total results.

More interesting again is moving to the suject headings.  There is no Tongue Tie/ and it is not immediately clear what to go to from the alternatives offered up.  When in doubt try Pubmed and a tongue tie search in Pubmed returns the following search:

“Ankyloglossia”[Supplementary Concept] OR “Ankyloglossia”[All Fields] OR “tongue tie”[All Fields]

I had not met Supplementary Concept before (or if I have I forget).  When in doubt Google and that brough me to Mesh Record Types which explains these are for chemicals, drugs and rare diseases. Each is linked to a broader descriptor by the Heading Mapped to field (HM).

Sadly HDAS does not include HM in the “more fields” option and I cannot see a likely candidate in the list I tried HW but that came up blank.

For the purposes of my session I used the MeSH browser to look it up and found

Heading Mapped to *Mouth Abnormalities

I did not note the * at the time and wonder if I should have restricted to major terms but given the small numbers of articles involved I think it was fair to go with the whole heading.

Finally I also had a look in Cochrane where there is a protocol Frenotomy for tonguetie in newborn infants (which does not come up if your search for ankyloglossia incidentally). The protocol claims there is Tongue Tie in MeSH – it is an Entry Term but it won’t map to it so not sure myself.

Welcome anyones ideas on how to explain this to people!

Occupational therapy training session thoughts

I ran a session this morning on literature searching for a group of hand therapy specialist occupational therapists.

Looking ahead of time I noted some general sites

OTSeeker a good place to find details of OT interventions

OTCATS for Critically Appraised Topics

and a nice general libguide from Edith Cowan University in Australia

I went with CINAHL for the demonstration but this proved to be a challenge as the subject headings lack detail around the structures of the hand.

We did some interesting searching around trying to retrieve PIPJ (Proximal Interphalangeal Joint Injuries) but it was hard to pin this down through the subject headings at all.

Arthoplast* Rehabilit* proved a nice example of a typo that returns results

I had a nightmare when we found Finger Joint Surgery/ as a subject heading from examining the full record but I was then unable to get CINAHL to map to it.

A mixed bag of a session!

Palliative care training session thoughts

I run tailored search training sessions for different groups of healthcare staff.  After a year or so in post I am starting to see some groups for the second time and finding that I have not always recorded some of the useful things I found out ahead of time.  So I will share some of them here from time to time to help my memory.  Peoples suggestions of other interesting things will be welcome.

The group today were are all doctors working in palliative care.

A good starting point was the NHS Evidence Palliative Care Topic not least as it includes a link to one of the NICE Pathways.

Some web searching retrieved a great site I had used last time and promptly forgotten CareSearch. This Australian site has lots of tips on searching and includes a brilliant tool for launching canned searches on palliative care topics via PubMed.

Some useful tips to help me think about search headings came from a chance find of a slide set by a colleague.

A more general introduction to research for palliative care from the Scottish Partnership for Palliative Care includes literature searching but also lots of helpful contextual information.

Finally the National End of Life Care Intelligence Network includes various publications and tools. What we know now looks a brilliant annual update on changes to the palliative care knowledge base.  Hopefully there having joined Public Health England will not stop this useful work continuing.

During the session we used a search for Fentanyl and Constipation to explore search concepts.

Using Medline I was able to show value in MeSH searching by retrieving additional references for only some small tweaks to the keywords and basic subject headings.

Any other brilliant palliative care search resources I should have mentioned?