Means and ENDS – e-cigarettes, the Framework Convention on Tobacco Control, and global health diplomacy in action.

E-cigarettes are a new and disruptive element in global health diplomacy (GHD) and policy-making. This is an ethnographic account of how e-cigarettes and other Electronic Nicotine Delivery Systems (ENDS) were tackled at the 6th Conference of the Parties to the World Health Organization's Framework Convention on Tobacco Control. It demonstrates how uncertainty about ENDS and differences of opinion are currently so great that ‘agreeing to disagree’ as a consensus position and ‘strategic use of time’ were the principles that ensured effective GHD in this case. Observers representing accredited non-governmental organisations were active in briefing and lobbying country delegates not to spend too much time debating an issue for which insufficient evidence exists, and for which countries were unlikely to reach a consensus on a specific regulatory approach or universally applicable regulatory measures. Equally, the work of Costa Rica in preparing and re-negotiating the draft decision, and the work of the relevant Committee Chair in managing the discussion, contributed to effectively reining in lengthy statements from Parties and focusing on points of consensus. As well as summarising the debate itself and analysing the issues surrounding it, this account offers an example of GHD working effectively in a situation of epistemic uncertainty

From Traditional Library Instruction to Collaborative Instruction: Charting the Course Toward Evidence-Based Practice

This presentation will explore how a library’s academic liaison program led to a strong teaching partnership within an academic division. The goal of the liaison program is to provide an essential link between the University of Southern California’s Norris Medical Library and the University’s academic communities. This goal was achieved when a research support librarian teamed up with a professor of physical therapy to develop a curriculum for physical therapy students. The objective of this teaching alliance was for first-year doctor of physical therapy students to learn basic skills for Evidence Based Practice. The collaboration combined the librarian\u27s expertise in database searching, library instruction, and information literacy with the subject knowledge of the physical therapist. In developing the learning experience the professor of physical therapy requested assistance through the liaison program. Her requests, however, did not fit within traditional teaching methods used by the liaison. The librarian and the professor were able to maintain and enrich the interdisciplinary partnership through flexibility, communication, and cooperation. The collaborators will share how they overcame obstacles, learned to speak each other\u27s language, and quelled colleagues’ concerns that they were abandoning traditional teaching methods. The conceptual basis of the instructional model will be illustrated with specific teaching examples. A student-centered outcome measure to assess the efficacy of the teaching model will be presented

Development and validation of the ACE tool: Assessing medical trainees' competency in evidence based medicine

BACKGROUND: While a variety of instruments have been developed to assess knowledge and skills in evidence based medicine (EBM), few assess all aspects of EBM - including knowledge, skills attitudes and behaviour - or have been psychometrically evaluated. The aim of this study was to develop and validate an instrument that evaluates medical trainees’ competency in EBM across knowledge, skills and attitude. METHODS: The ‘Assessing Competency in EBM’ (ACE) tool was developed by the authors, with content and face validity assessed by expert opinion. A cross-sectional sample of 342 medical trainees representing ‘novice’, ‘intermediate’ and ‘advanced’ EBM trainees were recruited to complete the ACE tool. Construct validity, item difficulty, internal reliability and item discrimination were analysed. RESULTS: We recruited 98 EBM-novice, 108 EBM-intermediate and 136 EBM-advanced participants. A statistically significant difference in the total ACE score was observed and corresponded to the level of training: on a 0-15-point test, the mean ACE scores were 8.6 for EBM-novice; 9.5 for EBM-intermediate; and 10.4 for EBM-advanced (p < 0.0001). Individual item discrimination was excellent (Item Discrimination Index ranging from 0.37 to 0.84), with internal reliability consistent across all but three items (Item Total Correlations were all positive ranging from 0.14 to 0.20). CONCLUSION: The 15-item ACE tool is a reliable and valid instrument to assess medical trainees’ competency in EBM. The ACE tool provides a novel assessment that measures user performance across the four main steps of EBM. To provide a complete suite of instruments to assess EBM competency across various patient scenarios, future refinement of the ACE instrument should include further scenarios across harm, diagnosis and prognosis

Using Biofeedback to Reduce Spatiotemporal Asymmetry Impairs Dynamic Balance in People Post-Stroke

Background. People poststroke often walk with a spatiotemporally asymmetric gait, due in part to sensorimotor impairments in the paretic lower extremity. Although reducing asymmetry is a common objective of rehabilitation, the effects of improving symmetry on balance are yet to be determined. Objective. We established the concurrent validity of whole-body angular momentum as a measure of balance, and we determined if reducing step length asymmetry would improve balance by decreasing whole-body angular momentum. Methods. We performed clinical balance assessments and measured wholebody angular momentum during walking using a full-body marker set in a sample of 36 people with chronic stroke. We then used a biofeedback-based approach to modify step length asymmetry in a subset of 15 of these individuals who had marked asymmetry and we measured the resulting changes in whole-body angular momentum. Results. When participants walked without biofeedback, whole-body angular momentum in the sagittal and frontal plane was negatively correlated with scores on the Berg Balance Scale and Functional Gait Assessment supporting the validity of whole-body angular momentum as an objective measure of dynamic balance. We also observed that when participants walked more symmetrically, their wholebody angular momentum in the sagittal plane increased rather than decreased. Conclusions. Voluntary reductions of step length asymmetry in people poststroke resulted in reduced measures of dynamic balance. This is consistent with the idea that after stroke, individuals might have an implicit preference not to deviate from their natural asymmetry while walking because it could compromise their balance. Clinical Trials Number: NCT03916562

Evaluation of pregnancy outcomes in patients with multiple sclerosis after fingolimod exposure

Background and Methods: Limited data are available on the safety of fingolimod in pregnant women. We estimated the risk of adverse pregnancy outcomes in women with multiple sclerosis (MS) exposed to fingolimod either shortly before or during pregnancy in prospectively collected cases from clinical trials, observational studies, surveillance programs, and spontaneous reports.Results: The prevalence of major malformations among live births does not appear to be significantly higher than those in the general population and the unexposed MS population. Similarly, the prevalence of cardiac malformations observed in this analysis was not significantly different from that of the general population. Proportions of miscarriage were in line with those of the general and unexposed MS population and no specific pattern of birth defects was identified.Conclusions: These data can help inform healthcare professionals and women with MS exposed to fingolimod during conception.</p

Evidence-based practice educational intervention studies: A systematic review of what is taught and how it is measured

Abstract Background Despite the established interest in evidence-based practice (EBP) as a core competence for clinicians, evidence for how best to teach and evaluate EBP remains weak. We sought to systematically assess coverage of the five EBP steps, review the outcome domains measured, and assess the properties of the instruments used in studies evaluating EBP educational interventions. Methods We conducted a systematic review of controlled studies (i.e. studies with a separate control group) which had investigated the effect of EBP educational interventions. We used citation analysis technique and tracked the forward and backward citations of the index articles (i.e. the systematic reviews and primary studies included in an overview of the effect of EBP teaching) using Web of Science until May 2017. We extracted information on intervention content (grouped into the five EBP steps), and the outcome domains assessed. We also searched the literature for published reliability and validity data of the EBP instruments used. Results Of 1831 records identified, 302 full-text articles were screened, and 85 included. Of these, 46 (54%) studies were randomised trials, 51 (60%) included postgraduate level participants, and 63 (75%) taught medical professionals. EBP Step 3 (critical appraisal) was the most frequently taught step (63 studies; 74%). Only 10 (12%) of the studies taught content which addressed all five EBP steps. Of the 85 studies, 52 (61%) evaluated EBP skills, 39 (46%) knowledge, 35 (41%) attitudes, 19 (22%) behaviours, 15 (18%) self-efficacy, and 7 (8%) measured reactions to EBP teaching delivery. Of the 24 instruments used in the included studies, 6 were high-quality (achieved ≥3 types of established validity evidence) and these were used in 14 (29%) of the 52 studies that measured EBP skills; 14 (41%) of the 39 studies that measured EBP knowledge; and 8 (26%) of the 35 studies that measured EBP attitude. Conclusions Most EBP educational interventions which have been evaluated in controlled studies focus on teaching only some of the EBP steps (predominantly critically appraisal of evidence) and did not use high-quality instruments to measure outcomes. Educational packages and instruments which address all EBP steps are needed to improve EBP teaching

Developmental Neurotoxicity of Pyrethroid Insecticides: Critical Review and Future Research Needs

Pyrethroid insecticides have been used for more than 40 years and account for 25% of the worldwide insecticide market. Although their acute neurotoxicity to adults has been well characterized, information regarding the potential developmental neurotoxicity of this class of compounds is limited. There is a large age dependence to the acute toxicity of pyrethroids in which neonatal rats are at least an order of magnitude more sensitive than adults to two pyrethroids. There is no information on age-dependent toxicity for most pyrethroids. In the present review we examine the scientific data related to potential for age-dependent and developmental neurotoxicity of pyrethroids. As a basis for understanding this neurotoxicity, we discuss the heterogeneity and ontogeny of voltage-sensitive sodium channels, a primary neuronal target of pyrethroids. We also summarize 22 studies of the developmental neurotoxicity of pyrethroids and review the strengths and limitations of these studies. These studies examined numerous end points, with changes in motor activity and muscarinic acetylcholine receptor density the most common. Many of the developmental neurotoxicity studies suffer from inadequate study design, problematic statistical analyses, use of formulated products, and/or inadequate controls. These factors confound interpretation of results. To better understand the potential for developmental exposure to pyrethroids to cause neurotoxicity, additional, well-designed and well-executed developmental neurotoxicity studies are needed. These studies should employ state-of-the-science methods to promote a greater understanding of the mode of action of pyrethroids in the developing nervous system