Professional barriers and facilitators to using stratified care approaches for managing non-specific low back pain: a qualitative study with Canadian physiotherapists and chiropractors

Background: Recent clinical practice guidelines for the management of non-specific low back pain (LBP) recommend using stratified care approaches. To date, no study has assessed barriers and facilitators for health professionals in using stratified care approaches for managing non-specific LBP in the Canadian primary care setting. This study aimed to identify and contrast barriers and facilitators to using the stratified care approaches for non-specific LBP among Canadian physiotherapists and chiropractors. Methods: Individual telephone interviews, underpinned by the Theoretical Domains Framework (TDF), explored beliefs and attitudes about, and identified barriers and facilitators to the use of stratified care approaches for managing non-specific LBP in a purposive sample of 13 chiropractors and 14 physiotherapists between September 2015 and June 2016. Interviews were digitally recorded, transcribed verbatim and analysed by two independent assessors using directed content analysis. Results: Three and seven TDF domains were identified as likely relevant for physiotherapists and chiropractors, respectively. Shared key beliefs (and relevant domains of the TDF) for both physiotherapists and chiropractors included: lack of time, cost, and expertise (Environmental Context and Resources); and consulting more experienced colleagues and chronic patients with important psychological overlay (Social Influences). Unique key domains were identified among physiotherapists: incompatibility with achieving other objectives (Goals), and chiropractors: confidence in using stratified care approaches (Beliefs about Capabilities); intention to use stratified care approaches (Intentions); awareness and agreement with stratified care approaches (Knowledge); assessment of readiness for change and intentional planning behaviour (Behavioural Regulation); and improving the management of non-specific LBP patients and the uptake of evidence-based practice (Beliefs about Consequences). Conclusions: Several shared and unique barriers and facilitators to using the stratified care approaches for non-specific LBP among Canadian physiotherapists and chiropractors were identified. Findings may help inform the design of tailored theory-based knowledge translation interventions to increase the uptake of stratified care approaches in clinical practice. © The Author(s). 2019

Impact of maternal bariatric surgery on offspring perinatal cardiac function: A prospective study

Objective To assess perinatal cardiac function in offspring of women with previous bariatric surgery and examine its association with maternal glucose control. Design Prospective study. Setting Maternity unit, UK. Population Fifty-four fetuses/neonates; 29 of post-bariatric surgery women and 25 of women without surgery. Methods Prospective, longitudinal observational study of pregnant women with and without previous bariatric surgery, matched for early pregnancy body mass index. Cardiac function of all offspring was assessed by two-dimensional conventional, spectral tissue Doppler and speckle-tracking echocardiography at 35–37 weeks of gestation and at 5–7 weeks of age. Maternal glycated haemoglobin (HbA1c) was measured at 27–30 weeks of gestation. Maternal demographics and fetal/infant cardiac function indices were compared between the groups. Correlation coefficient (r) is reported. Main outcome measures Fetal/infant cardiac function indices. Results Compared with no-bariatric neonates, offspring of post-bariatric women were smaller at birth (birthweight centiles: 64.96 ± 36.41 versus 40.17 ± 27.99; p = 0.007). There were no significant differences in fetal/infant cardiac function indices and perinatal cardiac changes, between groups. There was a positive correlation between maternal HbA1c and fetal left ventricular (LV) longitudinal strain (r = 0.33) and LV longitudinal strain rate (r = 0.29), suggesting an inverse relation between HbA1c and fetal LV systolic function, but this was mainly seen in offspring of women with no previous bariatric surgery (r = 0.56 and r = 0.50, respectively). Conclusions Maternal bariatric surgery does not appear to inadvertently affect the offspring cardiac performance. We found an inverse correlation between maternal HbA1c levels and fetal LV systolic function but this was mainly seen in the no-bariatric pregnancies

The Wonder of Colors and the Principle of Ariadne

The Principle of Ariadne, formulated in 1988 ago by Walter Carnielli and Carlos Di Prisco and later published in 1993, is an infinitary principle that is independent of the Axiom of Choice in ZF, although it can be consistently added to the remaining ZF axioms. The present paper surveys, and motivates, the foundational importance of the Principle of Ariadne and proposes the Ariadne Game, showing that the Principle of Ariadne, corresponds precisely to a winning strategy for the Ariadne Game. Some relations to other alternative. set-theoretical principles are also briefly discussed

Orientational Ordering in Spatially Disordered Dipolar Systems

This letter addresses basic questions concerning ferroelectric order in positionally disordered dipolar materials. Three models distinguished by dipole vectors which have one, two or three components are studied by computer simulation. Randomly frozen and dynamically disordered media are considered. It is shown that ferroelectric order is possible in spatially random systems, but that its existence is very sensitive to the dipole vector dimensionality and the motion of the medium. A physical analysis of our results provides significant insight into the nature of ferroelectric transitions.Comment: 4 pages twocolumn LATEX style. 4 POSTSCRIPT figures available from [email protected]

Ferroelectric and Dipolar Glass Phases of Non-Crystalline Systems

In a recent letter [Phys. Rev. Lett. {\bf 75}, 2360 (1996)] we briefly discussed the existence and nature of ferroelectric order in positionally disordered dipolar materials. Here we report further results and give a complete description of our work. Simulations of randomly frozen and dynamically disordered dipolar soft spheres are used to study ferroelectric ordering in non-crystalline systems. We also give a physical interpretation of the simulation results in terms of short- and long-range interactions. Cases where the dipole moment has 1, 2, and 3 components (Ising, XY and XYZ models, respectively) are considered. It is found that the Ising model displays ferroelectric phases in frozen amorphous systems, while the XY and XYZ models form dipolar glass phases at low temperatures. In the dynamically disordered model the equations of motion are decoupled such that particle translation is completely independent of the dipolar forces. These systems spontaneously develop long-range ferroelectric order at nonzero temperature despite the absence of any fined-tuned short-range spatial correlations favoring dipolar order. Furthermore, since this is a nonequilibrium model we find that the paraelectric to ferroelectric transition depends on the particle mass. For the XY and XYZ models, the critical temperatures extrapolate to zero as the mass of the particle becomes infinite, whereas, for the Ising model the critical temperature is almost independent of mass and coincides with the ferroelectric transition found for the randomly frozen system at the same density. Thus in the infinite mass limit the results of the frozen amorphous systems are recovered.Comment: 25 pages (LATEX, no macros). 11 POSTSCRIPT figures enclosed. Submitted to Phisical Review E. Contact: [email protected]

“I think there has to be a mutual respect for there to be value”: Evaluating patient engagement in a national clinical trial on de-implementation of low value care

Abstract Background The evaluation of patient engagement in research is understudied and under-reported, making it difficult to know what engagement strategies work best and when. We provide the results of an evaluation of patient engagement in a large Canadian research program focused on the de-implementation of low-value care. We aimed to evaluate the experience and impact of patient engagement in the study. Methods An online cross-sectional survey was administered using Microsoft Forms to (1) researchers and study staff and (2) patient partners. The survey was developed following iterative reviews by the project’s patient partnership council and evaluation committee. Survey content areas included opinions on patient engagement to date, including challenges to engagement and suggestions for improvement. Patient partners also evaluated the partnership council. Descriptive statistics including counts and percentages described Likert scale survey items, while open comments were analyzed using descriptive content analysis. Results The survey response rate was 46% (17/37). There were positive attitudes about the value of patient engagement in this project. There was also a high degree of willingness to be involved with patient engagement in future projects, whether as a patient partner or as a researcher including patients on the research team. Most patient partners felt their contributions to the project were valued by researchers and study research staff. Open comments revealed that a co-design approach and full inclusion on the research team were integral to demonstrating the value of patient partner input. Areas for improvement included more frequent and ongoing communication among all team members, as well as earlier training about patient engagement, particularly addressing role expectations and role clarity. Conclusions Our data revealed that despite some challenges, team members recognized the value of patient engagement in research and agreed project decisions had been impacted by patient partner input. Ongoing communication was highlighted as an area for improvement, as well as earlier training and ongoing support for all team members, but particularly researchers and study staff. In response to evaluation data, the team has reinstated a quarterly newsletter and plans to use specific patient engagement planning templates across study sites for all project activities. These tools should help make expectations clear for all team members and contribute to a positive patient engagement experience. Findings can inform patient engagement planning and evaluation for other health research projects.Plain English Summary Evaluating patient engagement in research is often not done or not reported, making it hard to know what engagement strategies work best and when. Here, we provide the results of an evaluation of patient engagement in a Canadian Institutes for Health Research (CIHR) Strategy for Patient Oriented Research (SPOR) Innovative Clinical Trial Multi-Year Grant. The project focuses on strategies to reduce two low-value care practices (pre-operative testing in low-risk day surgery and imaging for low back pain). An online survey was sent to project researchers, study staff and patient partners to get their opinions on the patient engagement in the project. Generally, there were positive attitudes about the value of patient engagement in the project. Both patient partners and research study staff were very willing to be involved with patient engagement in future projects. Most patient partners felt their contributions to the project were valued by researchers and study research staff. An important part of showing the value of patient partners was working together to design the project and making sure that the patient partners were considered full members of the research team. Areas for improvement included better communication among all team members and earlier training about patient engagement with a focus on patient roles and expectations. The results from this survey will be used to improve the patient engagement in this project but will also help patient engagement planning and evaluation for other health research projects

Methods for the sampling and analysis of marine aerosols: results from the 2008 GEOTRACES aerosol intercalibration experiment

Atmospheric deposition of trace elements and isotopes (TEI) is an important source of trace metals to the open ocean, impacting TEI budgets and distributions, stimulating oceanic primary productivity, and influencing biological community structure and function. Thus, accurate sampling of aerosol TEIs is a vital component of ongoing GEOTRACES cruises, and standardized aerosol TEI sampling and analysis procedures allow the comparison of data from different sites and investigators. Here, we report the results of an aerosol analysis intercalibration study by seventeen laboratories for select GEOTRACES-relevant aerosol species (Al, Fe, Ti, V, Zn, Pb, Hg, NO3-, and SO42-) for samples collected in September 2008. The collection equipment and filter substrates are appropriate for the GEOTRACES program, as evidenced by low blanks and detection limits relative to analyte concentrations. Analysis of bulk aerosol sample replicates were in better agreement when the processing protocol was constrained (+/- 9% RSD or better on replicate analyses by a single lab, n = 7) than when it was not (generally 20% RSD or worse among laboratories using different methodologies), suggesting that the observed variability was mainly due to methodological differences rather than sample heterogeneity. Much greater variability was observed for fractional solubility of aerosol trace elements and major anions, due to differing extraction methods. Accuracy is difficult to establish without an SRM representative of aerosols, and we are developing an SRM for this purpose. Based on these findings, we provide recommendations for the GEOTRACES program to and macro-nutrients to the open ocean (Okin et al. 2011) and is a key component of the international GEOTRACES program (GEOTRACES Planning Group 2006). A priority of the GEOTRACES program is to quantify both major and trace elements (e. g., Al, Fe, Ti, V, Zn, Pb, and Hg) and species such as nitrate and sulfate in marine aerosols. Therefore, marine aerosol samples collected during GEOTRACES cruises must follow sampling protocols that permit the collection and analysis of as many elements and compounds as possible, while meeting the constraints associated with basin-wide oceanographic cruises (e. g., space limitations, high-frequency sampling, etc.)

Below the Belt? Territory and Development in China’s International Rise

China’s internationalization has been heralded by some as a new era of South–South cooperation. Yet such framings of development are pitched at an abstract space of the ‘global South’ which conceals more than it reveals. With some theory moving towards ontologies of ‘global development’, we need to capture both the connectedness and the local specificity of increasingly diffuse processes. This article sets out a more fine-grained understanding of how political territories and processes are imagined and produced by and through China’s internationalization, focusing on infrastructure as a ‘technology’ of territorialization. Much of the focus on China’s internationalization has been on state-to-state relations, but this obscures the ‘omni-channel politics’ that China practises. Using a critical literature review and illustrative case study, this article develops the idea of omni-channel politics to posit a view of ‘twisted’ territories in which political processes and development outcomes are more complex and contingent

Exploring factors influencing chiropractors’ adherence to radiographic guidelines for low back pain using the Theoretical Domains Framework

Background The inappropriate use of lumbar spine imaging remains common in primary care despite recommendations from evidence-based clinical practice guidelines to avoid imaging in the absence of red flags. This study aimed to explore factors influencing ordering behaviours and adherence to radiographic guidelines for low back pain (LBP) in chiropractors in Newfoundland and Labrador (NL), Canada. Methods We conducted two focus groups in December 2018 with chiropractors in different regions of NL (eastern, n = 8; western, n = 4). An interview guide based on the Theoretical Domains Framework (TDF) served to identify perceived barriers to, and enablers of, target behaviours of guideline adherence and managing LBP without X-rays. We conducted thematic analysis of chiropractors’ statements into relevant theoretical domains, followed by grouping of similar statements into specific beliefs. Domains key to changing radiographic guideline adherence, LBP imaging behaviours, and/or informing intervention design were identified by noting conflicting beliefs and their reported influence on the target behaviours. Results Six of the 14 TDF domains were perceived to be important for adherence to radiographic guidelines and managing non-specific LBP without imaging. Participating chiropractors reported varying levels of knowledge and awareness of guidelines for LBP imaging (Knowledge). Many chiropractors based their decision for imaging on clinical presentation, but some relied on “gut feeling” (Memory, attention, and decision processes). While chiropractors thought it was their role to manage LBP without imaging, others believed ordering imaging was the responsibility of other healthcare providers (Social/professional role and identity). Contrasting views were found regarding the negative consequences of imaging or not imaging LBP patients (Beliefs about consequences). Communication was identified as a skill required to manage LBP without imaging (Skills) and a strategy to enable appropriate imaging ordering behaviours (Behavioural regulation). Chiropractors suggested that access to patients’ previous imaging and a system that facilitated better interprofessional communication would likely improve their LBP imaging behaviours (Behavioural regulation). Conclusion We identified potential influences, in six theoretical domains, on participating chiropractors’ LBP imaging behaviours and adherence to radiographic guidelines. These beliefs may be targets for theory-informed behaviour change interventions aimed at improving these target behaviours for chiropractors in NL

Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework

Background: The Theoretical Domains Framework (TDF) was developed to investigate determinants of specific clinical behaviors and inform the design of interventions to change professional behavior. This framework was used to explore the beliefs of chiropractors in an American Provider Network and two Canadian provinces about their adherence to evidence-based recommendations for spine radiography for uncomplicated back pain. The primary objective of the study was to identify chiropractors’ beliefs about managing uncomplicated back pain without xrays and to explore barriers and facilitators to implementing evidence-based recommendations on lumbar spine xrays. A secondary objective was to compare chiropractors in the United States and Canada on their beliefs regarding the use of spine x-rays. Methods: Six focus groups exploring beliefs about managing back pain without x-rays were conducted with a purposive sample. The interview guide was based upon the TDF. Focus groups were digitally recorded, transcribed verbatim, and analyzed by two independent assessors using thematic content analysis based on the TDF. Results: Five domains were identified as likely relevant. Key beliefs within these domains included the following: conflicting comments about the potential consequences of not ordering x-rays (risk of missing a pathology, avoiding adverse treatment effects, risks of litigation, determining the treatment plan, and using x-ray-driven techniques contrasted with perceived benefits of minimizing patient radiation exposure and reducing costs; beliefs about consequences); beliefs regarding professional autonomy, professional credibility, lack of standardization, and agreement with guidelines widely varied (social/professional role & identity); the influence of formal training, colleagues, and patients also appeared to be important factors (social influences); conflicting comments regarding levels of confidence and comfort in managing patients without x-rays (belief about capabilities); and guideline awareness and agreements (knowledge). Conclusions: Chiropractors’ use of diagnostic imaging appears to be influenced by a number of factors. Five key domains may be important considering the presence of conflicting beliefs, evidence of strong beliefs likely to impact the behavior of interest, and high frequency of beliefs. The results will inform the development of a theorybased survey to help identify potential targets for behavioral-change strategies