Introduction of a Maternal-Fetal Medicine Tele-Ultrasound Program in Rural Alberta.

OBJECTIVES: We established a program of Maternal-Fetal Medicine (MFM) telemedicine that is safe and acceptable. Since December 2019, a multi-disciplinary team has been planning this quality improvement project. METHODS: We performed a pilot study to investigate the feasibility of using telemedicine and tele-ultrasound to enable prompt MFM consultations for patients in remote locations. We began with the training of sonographers followed by implementation in a small pilot. Interim analysis of the acceptability and feasibility of the program was done through patient surveys, images audit, and review of neonatal outcomes. RESULTS: Our background epidemiologic data showed that in Alberta, between 2017 and 2022, 460 patients travelled >6 hours, and 5038 travelled >2 hours from home to reach their site of birth. Patients were appropriately triaged to delivery/consultation at the tertiary level center based on diagnosis/suspicion of anomalies, such as abnormally invasive placenta, intrauterine growth restriction, hydrops, and partial agenesis of the corpus callosum, all of which were confirmed postdelivery. There was no neonatal mortality, and the single stillbirth was related to an unpreventable peri-viable co-twin demise. The patient survey demonstrated that for >85% of respondents the program reduced costs and stress. Ultrasound image audit found improvement and consistency in image quality after 3 months of training combined with supervision. CONCLUSION: MFM telemedicine is feasible and can be safe with adequate supervision. Additional support and resources are needed to scale and spread this quality improvement initiative.

The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature.

BACKGROUND: A small proportion of chiropractors, osteopaths, and other manual medicine providers use spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial. OBJECTIVES: We convened a Global Summit of international scientists to conduct a systematic review of the literature to determine the efficacy and effectiveness of SMT for the primary, secondary and tertiary prevention of non-musculoskeletal disorders. GLOBAL SUMMIT: The Global Summit took place on September 14-15, 2019 in Toronto, Canada. It was attended by 50 researchers from 8 countries and 28 observers from 18 chiropractic organizations. At the summit, participants critically appraised the literature and synthesized the evidence. SYSTEMATIC REVIEW OF THE LITERATURE: We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and the Index to Chiropractic Literature from inception to May 15, 2019 using subject headings specific to each database and free text words relevant to manipulation/manual therapy, effectiveness, prevention, treatment, and non-musculoskeletal disorders. Eligible for review were randomized controlled trials published in English. The methodological quality of eligible studies was assessed independently by reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials. We synthesized the evidence from articles with high or acceptable methodological quality according to the Synthesis without Meta-Analysis (SWiM) Guideline. The final risk of bias and evidence tables were reviewed by researchers who attended the Global Summit and 75% (38/50) had to approve the content to reach consensus. RESULTS: We retrieved 4997 citations, removed 1123 duplicates and screened 3874 citations. Of those, the eligibility of 32 articles was evaluated at the Global Summit and 16 articles were included in our systematic review. Our synthesis included six randomized controlled trials with acceptable or high methodological quality (reported in seven articles). These trials investigated the efficacy or effectiveness of SMT for the management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. None of the trials evaluated the effectiveness of SMT in preventing the occurrence of non-musculoskeletal disorders. Consensus was reached on the content of all risk of bias and evidence tables. All randomized controlled trials with high or acceptable quality found that SMT was not superior to sham interventions for the treatment of these non-musculoskeletal disorders. Six of 50 participants (12%) in the Global Summit did not approve the final report. CONCLUSION: Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.

Guideline implementation in the Canadian chiropractic setting: a pilot cluster randomized controlled trial and parallel study.

Background: Feasibility and pilot studies are recommended prior to embarking on large-scale costly confirmatory trials. The objectives were to determine the feasibility of conducting a cluster randomized controlled trial (C-RCT) to evaluate a complex knowledge translation (KT) intervention to improve the management of people with neck pain, and to identify challenges and potential solutions to conducting a fully powered C-RCT in the chiropractic setting. Methods: Pilot C-RCT involving a nationally representative sample of chiropractors and patients. We invited 400 chiropractors and 150 patients to participate. Clinicians were randomized to receive either an online theory-based KT educational and brief action plan (BAP) intervention (intervention group) or a copy of a clinical practice guideline (control group). Study-related challenges were ascertained via mid-study phone interviews and end-of-study feedback questionnaires. Analyses focused on descriptive estimates of likely recruitment, retention, and adherence rates, and documentation of potential barriers. Results: In total, 47 chiropractors (12%) agreed to participate and were randomized after resampling. Fifteen withdrew from the study, leaving a total of 32 (8%) participants. Eleven chiropractors in the intervention group completed the webinars and e-learning modules, two partially completed them and three did not register. Participating chiropractors recruited a total of 29 patients. Sixty-three percent (n = 7) of intervention and 56% (n = 10) of control group patients completed all outcome measures at both baseline and 3-months follow-up, attended follow-up visits and performed home exercises. Patients in the intervention group reported significant reductions in pain (mean 1.6, 95% CI 0.26-2.94, P = 0.027) and disability scores (9.8, 95% CI 3.68-15.91, P = 0.033) from baseline to 3-month follow-up. Key barriers to participation reported by chiropractors included lack of time, difficulties in recruiting patients, problems with the administration of study questionnaires, concern that the clinician-patient relationship might be jeopardized, and lack of assistance from office staff. Over half (55%) of the respondents in the intervention group encountered some difficulty registering or completing the educational modules. Conclusion: Recruitment of clinicians and patients for a trial of a complex intervention can be challenging, and retention of participants after enrolment may be low. Future trials of this nature likely require multiple recruitment strategies to achieve desired sample sizes. Moreover, time-constraint issues are perceived particularly by clinicians as a major barrier to both study enrolment before, and protocol adherence during, their actual participation in a trial. Trial registration: The study was registered at, NCT02483091, on 17th June 2015.

Is Ultrasound Useful for Further Evaluation of Homogeneously Hyperattenuating Renal Lesions Detected on CT?

OBJECTIVE: The purpose of this study was to evaluate the ability of ultrasound (US) to characterize hyperattenuating cysts detected as indeterminate hyperattenuating renal lesions on unenhanced and single phase enhanced CT. MATERIALS AND METHODS: A total of 107 consecutive homogeneously hyperattenuating renal lesions underwent gray-scale and Doppler US at our institution between 2010 and 2013. Two radiologists who were unaware of the final diagnosis retrospectively evaluated US images for visibility and diagnosis (simple cyst, intermediate complexity cyst, cystic or solid mass showing internal flow on Doppler US, or indeterminate). A third radiologist assessed lesion size, location, and distance to skin on CT and US. US visibility was compared using chi-square and independent t tests. Consensus US interpretation was compared with reference standard diagnoses, and accuracy for diagnosis of hyperattenuating cysts was tabulated. RESULTS: Mean lesion size ± SD was 20 ± 16 mm (range, 6-96 mm) and mean distance to skin on CT was 62 ± 25 mm (range, 18-125 mm). In all, 89.7% (96/107) of the lesions were visible on US, including all lesions that were 15 mm or larger. Nonvisible lesions were smaller than visible ones (10.0 ± 3.6 mm vs 20.7 ± 16.3 mm, p = 0.03) regardless of location (p > 0.05). CT overestimated lesion distance to skin compared with US (46.6 ± 18.6 mm, p < 0.001). Final diagnoses for US visible lesions (n = 96) were hyperattenuating cyst (n = 66), Bosniak IIF cyst (n = 13), and cystic or solid neoplasm (n = 15); two patients were lost to follow-up. Of the 66 hyperattenuating cysts, 54 (81.8%) appeared as simple cysts on US with sensitivity and specificity for diagnosis of hyperattenuating cyst of 81.8% (95% CI, 75.6-84.3%) and 92.9% (95% CI, 78.1-98.7%), respectively. The other 12 (18.2%) hyperattenuating cysts appeared complex. Two of the 13 Bosniak IIF lesions were incorrectly classified as simple cysts with US. Including the 11 (10%) nonvisible lesions reduced sensitivity and specificity for diagnosis of hyperattenuating cyst to 73.0% (95% CI, 66.9-75.9%) and 89.7% (95% CI, 74.2-97.2%), respectively. CONCLUSION: US can further characterize hyperattenuating cysts presenting as indeterminate hyperattenuating renal lesions on CT in the majority of cases.

A proposed in vitro model for investigating the mechanisms of 'joint cracking': a short report of preliminary techniques and observations.

Joint "cracking" is common but not a clearly understood audible phenomenon. In this brief report we propose an in-vitro model to potentially assist in revealing a mechanism for, and therefore source of, this phenomenon. Using a suction cup under tension and de-nucleated fluid to simulate synovial fluid, an audible release with intra-articular cavity formation was elicited. This was followed by a refractory period during which no audible crack could be elicited until the observed cavity had slowly reabsorbed back into the joint fluid. Conversely, if regular fluid containing pre-existing nuclei was used, a cavity formation occurred but with neither an audible release nor subsequent refractory period. With this simple in-vitro model, we were able to reproduce the characteristic audible release, cavity formation and related refractory period typically observed in related experiments in human joints. This simple in-vitro model may be of use in helping to discern both the timing and precise nature of other yet to be discerned mechanisms related to joint cracking.

Le « craquement ¼ des articulations est un phénomène sonore commun, mais mal compris. Dans ce court rapport, nous proposons un modèle in vitro pouvant aider à révéler un mécanisme, et par conséquent une source, pour ce phénomène. À l'aide d'une ventouse sous tension et d'un fluide énucléé ayant pour but de simuler la synovie, on a entendu un son provenant de la cavité intraarticulaire, suivi d'une période réfractaire au cours de laquelle on n'a pas obtenu de craquement sonore jusqu'à ce que la cavité observée se soit réabsorbée lentement dans le liquide articulaire. À l'inverse, lorsqu'on utilisait le liquide régulier contenant les noyaux préexistants, il se produisait une perforation de la cavité, mais sans son ni période réfractaire. Ce modèle in vitro simple a permis de reproduire le son, la cavité et la période réfractaire connexe caractéristiques qu'on observe en général lors d'expériences connexes sur des articulations humaines. Ce modèle in vitro simple peut aussi servir à discerner à la fois le moment et la nature précise d'autres mécanismes qu'on n'a pas encore perçus concernant le craquement des articulations.

Disinfection of the Radiologist Workstation and Radiologist Hand Hygiene: A Single Institution Practice Quality Improvement Project.

PURPOSE: The purpose of this study was to evaluate the workstation disinfection rates and hand hygiene of radiologists and trainees at shared departmental workstations and assess the impact of education and reminder placards on daily habits. METHODS: A 10-question survey was administered to all staff radiologists, fellows, and residents at our institution. The questions pertained to workstation disinfection, hand hygiene habits, and accessibility to disinfectant wipes and hand sanitizer stations. Subsequently, a short educational PowerPoint presentation was emailed to the department and small reminder placards were placed at each workstation. A follow-up survey was administered. Chi-square and Wilcoxon signed-rank tests were used to analyse the results. RESULTS: The percentage of participants who disinfect their workstations 1-2 times/week, 3-4 times/week or everyday increased from 53.4% (45 of 84 participants) to 74.3% (55 of 74 participants; P = .01), while the number who disinfect their workstation <1 time/week or never decreased from 46.4% (39 of 84 participants) to 25.7% (19 of 74 participants; P = .01). Hand washing before working at the workstation increased from 41.6% (35 of 84 participants) to 48.7% (36 of 74 participants; P = .76) and hand washing after working at the workstation increased from 50.0% (42 of 84 participants) to 56.8% (42 of 74 participants; P = .49). CONCLUSIONS: At our institution, the implementation of daily reminder placards at each workstation and the administration of an educational PowerPoint presentation improved the rate of radiologist workstation disinfection.

Testing the feasibility of a knowledge translation intervention designed to improve chiropractic care for adults with neck pain disorders: study protocol for a pilot cluster-randomized controlled trial.

BACKGROUND: Neck pain in adults is common and a leading cause of physical disability. Recently, a guideline was developed for the management of non-specific neck pain (NSNP) with an aim to improve the quality of the delivery of chiropractic care. One key guideline recommendation is to undertake multimodal care for patients with NSNP. The aim of this pilot study is to determine the feasibility of implementing a multifaceted knowledge translation intervention by promoting the use of multimodal care by chiropractors managing patients with NSNP. METHODS/DESIGN: The design is a cluster-randomized controlled pilot and feasibility trial. Chiropractors in private practice in Canada will be approached to participate in the study. Thirty consenting chiropractors will be randomized to receive either a theory-based educational intervention in the experimental group or simply a printed copy of the guideline in the control group. Each chiropractor will recruit five neck pain patients (a total of 150 patients) into the study. Development of the multifaceted intervention was informed by the results of a related qualitative study based on the Theoretical Domains Framework and consists of a series of three webinars, two online case scenarios, a self-management video on Brief Action Planning, and a printed copy of the practice guideline. Primary feasibility outcomes for both chiropractors and patients include rates of (1) recruitment, (2) retention, and (3) adherence to the intervention. A checklist of proxy measures embedded within patient encounter forms will be used to assess chiropractors' compliance with guideline recommendations (e.g. exercise and self-care prescriptions) at study onset and at 3 months. Secondary outcomes include scores of behavioural constructs (level of knowledge and self-efficacy) for recommended multimodal care. Clinical outcomes include pain intensity and neck pain-specific disability. Analyses from this study will focus on generating point estimates and corresponding 95 % confidence intervals for parameters of a priori interest (recruitment, retention, adherence, pain intensity, Neck Disability Index). DISCUSSION: Results of this study will inform the design of a larger cluster-randomized controlled trial aimed at evaluating the effectiveness of the theory-based tailored intervention and increasing the use of multimodal care by chiropractors managing patients with NSNP. TRIAL REGISTRATION: https://clinicaltrials.gov/, NCT02483091.

Is There an Association between STARD Statement Adherence and Citation Rate?

Purpose To determine if adherence to the Standards for Reporting of Diagnostic Accuracy (STARD) is associated with postpublication citation rates. Materials and Methods A comprehensive search of PubMed, EMBASE, and Cochrane Library databases was performed to identify published articles that have evaluated adherence of diagnostic accuracy studies to the STARD statement. These were included if the number of STARD items reported ("STARD result") could be obtained for each evaluated study. The date of publication, journal impact factor, and citation rate (citations per day) were extracted for the diagnostic accuracy studies. Univariate correlations were performed to identify any association between STARD result, impact factor, and citation rate. Multivariate regression analysis was performed to explore the effect of impact factor on postpublication citation rates. Results The authors were able to obtain the STARD results for 1002 "original" diagnostic accuracy studies from eight different "STARD evaluation" articles. The median impact factor was 3.97 (interquartile range [IQR]: 2.32-6.21), the median STARD result was 15 of 25 items (IQR: 12-18), and the median citation rate was 0.007 citations per day (IQR: 0.0032-0.017). The authors identified a weak positive correlation between STARD result and citation rate (r = 0.096; 95% confidence interval [CI]: 0.034, 0.157), a moderate positive correlation between impact factor and citation rate (r = 0.58; 95% CI: 0.535, 0.617), and a weak positive correlation between impact factor and STARD result (r = 0.13; 95% CI: 0.064, 0.186). Multivariate analysis accounting for journal clustering effects revealed that, when impact factor is partialed out, the positive correlation between citation rate and STARD result does not persist (r = 0.029; 95% CI: -0.033, 0.091). Conclusion There is a positive correlation between completeness of reporting, as evaluated with STARD, and citation rate as well as impact factor. When adjusted for impact factor, the positive correlation between completeness of reporting and citation rate does not persist. (©) RSNA, 2016 Online supplemental material is available for this article.

Evaluation of apparent diffusion coefficient and MR volumetry as independent associative factors for extra-prostatic extension (EPE) in prostatic carcinoma.

BACKGROUND: To assess mean apparent diffusion coefficient (ADC) and MR-derived tumor volume (Vt) as associative factors for extra-prostatic extension (EPE) in prostate cancer (PCa). METHODS: With institutional review board approval, 73 consecutive patients diagnosed with PCa at trans-rectal ultrasound biopsy underwent preoperative multi-parametric (T2W+DWI+DCE) 3 Tesla MRI before radical prostatectomy between 2012 and 2014; 52% (38/73) patients had EPE. Clinical parameters including: age, prostate serum antigen (PSA), digital rectal examination (DRE) and percentage positive cores (PPC) were recorded. Two blinded radiologists subjectively evaluated for EPE using PI-RADS with T2W-MRI. A third blinded radiologist recorded: mean ADC (mm(2) /s) of tumor and tumor volume on ADC and T2W (derived from planar volumetry). VtMAX (the largest volume on ADC or T2W) was documented. Multivariate and receiver operator characteristic analyses were performed. RESULTS: There were no significant differences in age, DRE, or Gleason score between groups (P = 0.52, 0.06, 0.61, 0.36). PSA approached significance being higher with EPE (12.9 ± 12.6 versus 8.2 ± 7.4; P = 0.06). PPC was higher with EPE (60.9 ± 21.9% versus 38.3 ± 21.6%; P < 0.01) with an area under the curve (AUC) of 0.78 and sensitivity/specificity = 75.7/75% when PPC ≥ 45%. AUC for T2W-MRI was 0.46-0.51 with sensitivity/specificity = 40.0-42.9/48.6-57.1% (R1, R2). Inter-observer agreement was fair, k = 0.39. There was no difference in mean ADC between groups (0.89 ± 0.25 versus 0.88 ± 0.19 [EPE] mm(2) /s), P = 0.70. T2W-Vt, ADC-Vt, and VtMAX were larger with EPE (5.1 ± 7.4, 5.8 ± 6.5, 6.3 ± 7.4 cm(3) versus 1.6 ± 1.8, 1.8 ± 1.3, 2.1 ± 1.8), P < 0.01. VtMAX AUC was 0.77 with sensitivity/specificity = 78.4/73.5% when VtMAX ≥ 2.1 cm(3) which outperformed all other parameters (P > 0.05) except PPC (P = 0.6) for the diagnosis EPE. CONCLUSION: MR volumetry and percentage of positive core biopsies are associated with EPE; whereas, in this study, other clinical and MR parameters including mean ADC and subjective T2W-MR analysis were not useful for assessment of EPE.

Evaluation of the European Society of Urogenital Radiology (ESUR) PI-RADS scoring system for assessment of extra-prostatic extension in prostatic carcinoma.

INTRODUCTION: To evaluate extra-prostatic extension (EPE) comparing PI-RADS to non-standardized reporting. MATERIALS AND METHODS: With IRB approval, 145 consecutive patients underwent radical prostatectomy (RP) and multi-parametric (T2W+DWI+DCE) MRI between 2012 and 2013. Eighty patients (66.3% with EPE) were staged without PI-RADS and 65 patients (64.6% with EPE) were staged using a 5-point PI-RADS scoring system. Studies were reported by fellowship-trained radiologists in routine clinical practice. Individual PIRADS scores were assessed using ROC to determine the score which optimized sensitivity/specificity. Diagnostic accuracy for EPE was compared with/without PI-RADS using the McNemar test. Subgroup analysis by radiologist experience was performed using Spearman correlation and chi-square. RESULTS: Area under ROC curve for EPE using PI-RADS was 0.62 and optimal sensitivity/specificity was achieved with PI-RADS score ≥ 3. Compared to non-standardized reporting, sensitivity for EPE improved with PI-RADS (59.5% [49.1-68.2] vs. 24.5% [16.7-31.2]), p=0.01; with no difference in specificity (68.0% [50.5-82.6]) vs. (75.0% [60.1-87.6]), p=0.06. Overall accuracy improved with PI-RADS (62.7% [49.6-73.6] vs. 42.0% [31.7-50.7%]), p=0.006. Diagnostic accuracy was better among experienced radiologists without PI-RADS (p=0.005); however, there was no difference in accuracy by reader experience using PI-RADS (p=0.24). CONCLUSION: The PI-RADS criteria for EPE improves sensitivity without reducing specificity. PI-RADS may reduce differences in accuracy by reader experience.

The Chiropractic Hospital-Based Interventions Research Outcomes Study: Consistency of Outcomes Between Doctors of Chiropractic Treating Patients With Acute Lower Back Pain.

OBJECTIVE: The aim of this study was to determine if effectiveness differs between community-based doctors of chiropractic administering standardized evidence-based care that includes high-velocity low-amplitude spinal manipulative therapy (SMT) for acute low back pain (LBP). METHODS: A secondary analysis of randomized controlled trial and observational pilot study data was performed with nonrandom allocation to 4 DCs. Patients included those with Quebec Task Force categories less than or equal to 2 and acute LBP of 2 to 4 weeks' duration. The intervention provided was clinical practice guidelines-based care including high-velocity low-amplitude SMT. Primary outcomes included changes from baseline in modified Roland Disability Questionnaire (RDQ) at 24 weeks. Comparisons of simple main effects at 24 weeks and of marginal main effects in repeated-measures analyses were performed. RESULTS: Between groups, adjusted point-specific differences in RDQ change were minimally clinically important but not statistically significant at 24 weeks (largest pairwise difference, -3.1; 95% confidence interval, -6.3 to 0.1; overall P = .10). However, in optimal analyses that considered the repeated nature of the measurements for each outcome, significant differences in marginal mean RDQ changes were found between groups (largest pairwise difference, -3.8; 95% confidence interval, -4.9 to 2.6; overall P = .03). CONCLUSIONS: Overall, DCs differed modestly in their effectiveness in improving LBP-specific disability. The point estimates mirrored typically reported effect sizes from recent systematic reviews of SMT; however, confidence limits did not exclude clinically negligible effects.

False positive and false negative diagnoses of prostate cancer at multi-parametric prostate MRI in active surveillance.

MP-MRI is a critical component in active surveillance (AS) of prostate cancer (PCa) because of a high negative predictive value for clinically significant tumours. This review illustrates pitfalls of MP-MRI and how to recognise and avoid them. The anterior fibromuscular stroma and central zone are low signal on T2W-MRI/apparent diffusion coefficient (ADC), resembling PCa. Location, progressive enhancement and low signal on b ≥1000 mm²/s echo-planar images (EPI) are differentiating features. BPH can mimic PCa. Glandular BPH shows increased T2W/ADC signal, cystic change and progressive enhancement; however, stromal BPH resembles transition zone (TZ) PCa. A rounded morphology, low T2 signal capsule and posterior/superior location favour stromal BPH. Acute/chronic prostatitis mimics PCa at MP-MRI, with differentiation mainly on clinical grounds. Visual analysis of diffusion-weighted MRI must include EPI and appropriate windowing of ADC. Quantitative ADC analysis is limited by lack of standardization; the ADC ratio and ADC histogram analysis are alternatives to mean values. DCE lacks standardisation and has limited utility in the TZ, where T2W/DWI are favoured. Targeted TRUS-guided biopsies of MR-detected lesions are challenging. Lesions detected on MP-MRI may not be perfectly targeted with TRUS and this must be considered when faced with a suspicious lesion on MP-MRI and a negative targeted TRUS biopsy histopathological result. KEYPOINTS: • Multi-parametric MRI plays a critical role in prostate cancer active surveillance. • Low T2W signal intensity structures appear dark on ADC, potentially simulating cancer. • Stromal BPH mimics cancer at DWI and DCE. • Long b value trace EPI should be reviewed • Targeted biopsy of MR-detected lesions using TRUS guidance may be challenging.

Fast tracking the design of theory-based KT interventions through a consensus process.

BACKGROUND: Despite available evidence for optimal management of spinal pain, poor adherence to guidelines and wide variations in healthcare services persist. One of the objectives of the Canadian Chiropractic Guideline Initiative is to develop and evaluate targeted theory- and evidence-informed interventions to improve the management of non-specific neck pain by chiropractors. In order to systematically develop a knowledge translation (KT) intervention underpinned by the Theoretical Domains Framework (TDF), we explored the factors perceived to influence the use of multimodal care to manage non-specific neck pain, and mapped behaviour change techniques to key theoretical domains. METHODS: Individual telephone interviews exploring beliefs about managing neck pain were conducted with a purposive sample of 13 chiropractors. The interview guide was based upon the TDF. Interviews were digitally recorded, transcribed verbatim and analysed by two independent assessors using thematic content analysis. A 15-member expert panel formally met to design a KT intervention. RESULTS: Nine TDF domains were identified as likely relevant. Key beliefs (and relevant domains of the TDF) included the following: influence of formal training, colleagues and patients on clinicians (Social Influences); availability of educational material (Environmental Context and Resources); and better clinical outcomes reinforcing the use of multimodal care (Reinforcement). Facilitating factors considered important included better communication (Skills); audits of patients' treatment-related outcomes (Behavioural Regulation); awareness and agreement with guidelines (Knowledge); and tailoring of multimodal care (Memory, Attention and Decision Processes). Clinicians conveyed conflicting beliefs about perceived threats to professional autonomy (Social/Professional Role and Identity) and speed of recovery from either applying or ignoring the practice recommendations (Beliefs about Consequences). The expert panel mapped behaviour change techniques to key theoretical domains and identified relevant KT strategies and modes of delivery to increase the use of multimodal care among chiropractors. CONCLUSIONS: A multifaceted KT educational intervention targeting chiropractors' management of neck pain was developed. The KT intervention consisted of an online education webinar series, clinical vignettes and a video underpinned by the Brief Action Planning model. The intervention was designed to reflect key theoretical domains, behaviour change techniques and intervention components. The effectiveness of the proposed intervention remains to be tested.

Computed tomography for non-traumatic headache in the emergency department and the impact of follow-up testing on altering the initial diagnosis.

The purpose of this study was twofold: (1) to determine the incidence of positive computed tomography (CT) findings in patients presenting to the emergency department (ED) with non-traumatic headache at our institution and (2) to examine follow-up exams, including lumbar puncture, non-enhanced CT, CT angiogram, CT venogram, and magnetic resonance imaging (MRI), to see how often the use of further testing changes the diagnosis. With IRB approval, 865 patients were identified through ED requisitions for CT head with the indication of headache during the calendar year 2011. Exclusion criteria included head trauma, prior intracranial surgery, focal neurologic symptoms, and known intracranial mass. CT results were divided into three categories: P0, P1, and P2. Negative studies were graded as P0. Positive studies were subdivided into clinically insignificant or P1 and clinically significant or P2. Clinically significant was defined as requiring medical treatment. Subsequently, the electronic medical records and picture archiving and communication system (PACS) were reviewed to determine the incidence of follow-up exams, including lumbar puncture or imaging. The secondary tests were divided into the same P0, P1, and P2 categories. There were 254 positive studies: P1 clinically insignificant (27.1 %, 235/865) and P2 clinically significant (2.2 %, 19/865). Of 257 follow-up exams performed, the majority were lumbar punctures (36.0 %) or CT angiograms (29.5 %). In 19/257 exams or 7.4 %, the additional testing changed the clinically insignificant (P0/P1) diagnosis to a significant (P2) result. At our institution, there was a 2.2 % incidence of significant positive CT findings in patients presenting to the ED with non-traumatic headache. Follow-up testing was variable and resulted in a 7.4 % increase in the severity of diagnosis compared to the initial negative CT scan.

Magnetic resonance enterography in post-operative inflammatory bowel disease.

OBJECTIVE: To describe the role of magnetic resonance enterography (MRE) in patients with inflammatory bowel disease (IBD), and to review the expected post-operative appearance, as well as, potential surgical complications in this unique patient population. CONCLUSION: MRE compares favorably to CT Enterography (CTE) in terms of overall diagnostic accuracy and may provide better functional assessment of the small bowel through cine-MRI, diffusion-weighted imaging and dynamic contrast-enhancement. In the post-operative population, MRE provides critical information including: normal post-surgical anatomy, chronic strictures vs. active inflammation and disease/treatment-related complications. The post-operative IBD patient undergoes frequent repeated imaging and MRE may significantly reduce cumulative radiation dose while providing similar or improved diagnostic accuracy compared to CTE. MRE should be considered as an alternative imaging modality in this population.

The effect of waiting time on pain intensity after elective surgical lumbar discectomy.

BACKGROUND CONTEXT: Waitlists are commonly used in Canada to manage access to surgical procedures such as elective surgical lumbar discectomy (ESLD). The timing of enrollment onto the waitlist is important as this is a proxy measure for the concordance of preferences for surgery between a patient and surgeon. After enrollment, the waiting time to actual surgery extends the duration of preoperative symptoms, which possibly affects the outcome of ESLD. Waiting time also specifically reflects the delay in service delivery imposed by the limited capacity of the health-care system. PURPOSE: To determine if a system-imposed delay in treatment, that is, longer waiting time, for ESLD is associated with a higher odds of experiencing residual postoperative pain. STUDY DESIGN/SETTING: Ambidirectional cohort study with 2-year retrospective and 3-year prospective components, conducted at a major tertiary care center serving a metropolitan area in Canada. PATIENT SAMPLE: Patients aged 16 years or older with sciatica because of herniated lumbar disc, confirmed on advanced imaging, were recruited at the time of waitlist enrollment for ESLD. Patients with significant comorbidity or emergency indications for surgery were excluded. Of 391 participants, 291 had complete follow-up information at 6 months postoperatively. OUTCOME MEASURE: Intensity of the predominant symptom (worse of either back or leg pain) was assessed on the 11-point numerical rating scale at waitlist enrollment and 6 months postoperatively. Pain scores were highly skewed and therefore categorized into four ordinal levels defined by quartiles. METHODS: For the primary analysis, time to surgery from waitlist enrollment was dichotomized based on a predetermined clinically meaningful cut-point of 12 weeks. Ordinal logistic regression was used to compare the odds of experiencing higher pain intensity between wait groups. Control of confounders was achieved using both propensity scores and conventional multivariable modeling. RESULTS: In unadjusted analyses, long-wait patients were 80% more likely than short-wait patients to experience higher ordinal pain intensity at 6 months; unadjusted proportional odds ratio (POR)=1.8 (95% confidence interval [CI], 1.2-2.8). The association held after controlling for all imbalances in measured confounders, with long-wait patients still being 70% more likely to report worse pain; adjusted POR=1.7 (95% CI, 1.0-2.8). CONCLUSIONS: A waiting time of 12 weeks or more after waitlist enrollment for ESLD is associated with a modest likelihood of experiencing worse pain at 6 months postoperatively. This result was not because of differences in measured confounders. Future studies are encouraged to identify other, as-of-yet unmeasured, variables that might be associated with both longer waiting times and worse outcomes among ESLD patients. Until then, in jurisdictions where highly constrained access to ESLD is managed through waitlists, the expected waiting time for the operation could be an informative deciding criterion for patients with otherwise unresolved preferences for operative treatment.

Acute sciatica and progressive neurological deficit secondary to facet synovial cysts: A report of two cases.

OBJECTIVE: To describe two patients with lumbar facet synovial cysts causing sciatica and progressive neurological deficit. CLINICAL FEATURES: A 52-year-old female with bilateral sciatica and a neurological deficit that progressed to a foot drop; and a 54-year-old female with worsening sciatica and progressive calf weakness were seen at a major tertiary care centre. Diagnostic imaging studies revealed the presence of spinal nerve root impingement by large facet synovial cysts. INTERVENTIONS AND OUTCOMES: Activity modification, gabapentinoid and non-steroidal anti-inflammatory medications were unsuccessful in ameliorating either patient's symptoms. One patient had been receiving ongoing lumbar chiropractic spinal manipulative therapy despite the onset of a progressive neurological deficit. Both patients eventually required surgery to remove the cyst and decompress the affected spinal nerve roots. CONCLUSION: Patients with acute sciatica who develop a progressive neurological deficit while under care, require prompt referral for axial imaging and surgical consultation. Primary care spine clinicians need to be aware of lumbar facet synovial cysts as a possible cause of acute sciatica and the associated increased risk of the patient developing a progressive neurological deficit.

Case study: chronic recurrent multifocal osteomyelitis in the femoral diaphysis of a young female.

Chronic recurrent multifocal osteomyelitis (CRMO) is relatively uncommon. Even though the name suggests it is the result of infection, this is not likely the case. Instead it is more likely the result of genetic, autoimmune, or autoinflammatory causes. Although CRMO has a benign course and responds well to anti-inflammatory medications, it can have a very aggressive clinical and imaging presentation overlapping with infectious osteomyelitis and malignancy. Therefore, radiologists and clinicians need to be aware of its clinical and imaging presentation to avoid morbidity associated with more aggressive treatment. We present the case of a ten-year-old female with CRMO as a solitary expansile-mixed lytic and sclerotic lesion in the distal femoral diaphysis. The diaphyseal location and mixed lytic and sclerotic appearance are less common and have an aggressive imaging appearance. We also review the pathophysiology, imaging findings, and therapeutic approach to this uncommon but clinically important condition.