Skye Barbic

Point-of-care Ultrasonography for the Diagnosis of Acute Cardiogenic Pulmonary Edema in Patients Presenting With Acute Dyspnea: A Systematic Review and Meta-analysis

OBJECTIVES Acute dyspnea is a common presenting complaint to the emergency department (ED), and point-of-care (POC) lung ultrasound (US) has shown promise as a diagnostic tool in this setting. The primary objective of this systematic review was to determine the sensitivity and specificity of US using B-lines in diagnosing acute cardiogenic pulmonary edema (ACPE) in patients presenting to the ED with acute dyspnea. METHODS A systematic review protocol adhering to Cochrane Handbook guidelines was created to guide the search and analysis, and we searched the following databases: PubMed, EMBASE, Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, and the Cochrane Database of Systematic Reviews. References of reviewed articles were hand-searched, and electronic searches of conference abstracts from major emergency medicine, cardiology, and critical care conferences were conducted. The authors included prospective cohort and prospective case-control studies that recruited patients presenting to hospital with symptomatic, acute dyspnea, or where there was a clinical suspicion of congestive heart failure, and reported the sensitivity and specificity of B-lines in diagnosing ACPE. Studies of asymptomatic individuals or in patients where there was no suspicion of ACPE were excluded. The outcome of interest was a diagnosis of ACPE using US B-lines. A final diagnosis from clinical follow-up was accepted as the reference standard. Two reviewers independently reviewed all citations to assess for inclusion, abstracted data, and assessed included studies for methodologic quality using the QUADAS-2 tool. Contingency tables were used to calculate sensitivity and specificity. Three subgroup analyses were planned a priori to examine the effects of the type of study, patient population, and lung US protocol employed. RESULTS Seven articles (n = 1,075) were identified that met inclusion criteria (two studies completed in the ED, two in the intensive care unit [ICU], two on inpatient wards, and one in the prehospital setting). The seven studies were rated as average to excellent methodologic quality. The sensitivity of US using B-lines to diagnosis ACPE is 94.1% (95% confidence interval [CI] = 81.3% to 98.3%) and the specificity is 92.4% (95% CI = 84.2% to 96.4%). Preplanned subgroup analyses did not reveal statistically significant changes in the overall summary estimates, nor did exclusion of three potential outlier studies. CONCLUSIONS This study suggests that in patients with a moderate to high pretest probability for ACPE, an US study showing B-lines can be used to strengthen an emergency physicians working diagnosis of ACPE. In patients with a low pretest probability for ACPE, a negative US study can almost exclude the possibility of ACPE. Further studies including large numbers of ED patients presenting with undifferentiated dyspnea are required to gain more valid and reliable estimates of test accuracy in ED patients.

Emerging Guidelines for Patient Engagement in Research

There is growing recognition that involving patients in the development of new patient-reported outcome measures helps ensure that the outcomes that matter most to people living with health conditions are captured. Here, we describe and discuss different experiences of integrating patients as full patient research partners (PRPs) in outcomes research from multiple perspectives (e.g., researcher, patient, and funder), drawing from three real-world examples. These diverse experiences highlight the strengths, challenges, and impact of partnering with patients to conceptualize, design, and conduct research and disseminate findings. On the basis of our experiences, we suggest basic guidelines for outcomes researchers on establishing research partnerships with patients, including: 1) establishing supportive organizational/institutional policies; 2) cultivating supportive attitudes of researchers and PRPs with recognition that partnerships evolve over time, are grounded in strong communication, and have shared goals; 3) adhering to principles of respect, trust, reciprocity, and co-learning; 4) addressing training needs of all team members to ensure communications and that PRPs are conversant in and familiar with the language and process of research; 5) identifying the resources and advanced planning required for successful patient engagement; and 6) recognizing the value of partnerships across all stages of research. The three experiences presented explore different approaches to partnering; demonstrate how this can fundamentally change the way research work is conceptualized, conducted, and disseminated; and can serve as exemplars for other forms of patient-centered outcomes research. Further work is needed to identify the skills, qualities, and approaches that best support effective patient-researcher partnerships.

An Analysis of Altmetrics in Emergency Medicine

OBJECTIVES Alternative-level metrics (Altmetrics) are a new method to assess the sharing and spread of scientific knowledge. The primary objective of this study was to describe the traditional metrics and Altmetric scores of the 50 most frequently cited articles published in emergency medicine (EM) journals. Since many articles related to EM are published in other journals, the secondary aim of this study was to describe the Altmetric scores of the most frequently cited articles relevant to EM in other biomedical journals. METHODS A structured search of the Institute for Scientific Information Web of Science version of the Science Citation Index Expanded was conducted. The 200 most frequently cited articles in the top 10 EM journals (2011 Journal Citation Report) were identified. The 200 most frequently cited articles from the rest of the medical literature, matching a predefined list of keywords relevant to the specialty of EM, were identified. Two authors reviewed the lists of citations for relevance to EM and a consensus approach was used to arrive at the final lists of the top 50 cited articles. The Altmetric scores for the top 50 cited articles in EM and other journals were determined. Descriptive statistics and Spearman correlation were performed. RESULTS The highest Altmetric score for EM articles was 25.0; the mean (±SD) was 1.9 (±5.0). The EM journal with the highest mean article Altmetric score was Resuscitation. The main clinical areas shared for articles from EM articles were trauma (mean ± SD = 11.0 ± 15.6, median = 11.0) and cardiac arrest (mean ± SD = 2.7 ± 5.8, median = 0). The highest Altmetric score for other journals was 176.0 (mean ± SD = 23.3 ± 40.8). The other journal with the highest mean article Altmetric score was the New England Journal of Medicine. The main clinical areas shared for articles were critical care (mean ± SD score = 36.5 ± 47.4, median = 36.5), sepsis (mean ± SD = 24.6 ± 48.8, median = 12.0), cardiology (mean ± SD = 19.2 ± 35.6, median = 7.0), and infectious diseases (mean ± SD = 17.0 ± 12.7, median = 17.0). Spearman correlation demonstrated weakly positive correlation between citation counts and Altmetric scores for EM articles and other journals. CONCLUSIONS This study is the first analysis of Altmetric scores for the top cited articles in EM. We demonstrated that there is a mild correlation between citation counts and Altmetric scores for the top papers in EM and other biomedical journals. We also demonstrated that there is a gap between the sharing of the top articles in EM journals and those related to EM in other biomedical journals. Future research to explore this relationship and its temporal trends will benefit the understanding of the reach and dissemination of EM research within the scientific community and society in general.

An exploration of Canadian emergency physicians' and residents' knowledge of computed tomography radiation dosing and risk

OBJECTIVE The objective of this study was to measure the current knowledge of Canadian emergency physicians and emergency medicine residents regarding computed tomography (CT) radiation dosing and its associated risks. METHODS Three focus groups were conducted as the qualitative element of this study. Cognitive debriefing was carried out to ensure the validity and reliability of the focus group findings and to aid with survey development. A 26-item electronic survey was developed and pilot tested for distribution to the membership of the Canadian Association of Emergency Physicians. RESULTS Eighteen emergency medicine physicians and three emergency medicine residents participated in the focus groups. Four major themes emerged: 1) physician knowledge of risks associated with CT, 2) risk management strategies, 3) communication, and 4) knowledge translation. The survey response rate was 49.8% (638 of 1,281). The mean respondent age was 40.9±9.9 years, and 70.7% were male. Of all respondents, 82.5% were actively practicing attending physicians, 56.4% of all respondents practiced in urban academic emergency departments, and the average time practicing was 10.7±9.6 years. Radiography and CT were correctly identified by 92.2% and 95.1% of respondents, respectively, as sources of ionizing radiation, whereas magnetic resonance imaging and ultrasonography were selected by 1.0% and 0.5%, respectively. With respect to the lifetime attributable risk (LAR) of malignancy due to CT, 82.2% of participants correctly identified that abdominal CT increases the risk of cancer by 0.2 to 2%, whereas 51.3% correctly identified that the LAR increases twofold in a 7- year-old boy. When asked to identify populations at risk for potential harm due to ionizing radiation, 92.2% of respondents identified children, 80.3% identified pregnant women, and 71.4% identified women of reproductive age. A minority (37.2%) reported communicating the potential risks of CT to a majority of their patients. Electronic platforms were identified by 74.8% of respondents as their preferred method of knowledge translation on this topic. CONCLUSIONS Canadian emergency medicine physicians and emergency medicine residents demonstrated identifiable gaps in knowledge surrounding CT radiation dose and risk.

What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey

Objective Lack of consensus on the definition of mental health has implications for research, policy and practice. This study aims to start an international, interdisciplinary and inclusive dialogue to answer the question: What are the core concepts of mental health? Design and participants 50 people with expertise in the field of mental health from 8 countries completed an online survey. They identified the extent to which 4 current definitions were adequate and what the core concepts of mental health were. A qualitative thematic analysis was conducted of their responses. The results were validated at a consensus meeting of 58 clinicians, researchers and people with lived experience. Results 46% of respondents rated the Public Health Agency of Canada (PHAC, 2006) definition as the most preferred, 30% stated that none of the 4 definitions were satisfactory and only 20% said the WHO (2001) definition was their preferred choice. The least preferred definition of mental health was the general definition of health adapted from Huber et al (2011). The core concepts of mental health were highly varied and reflected different processes people used to answer the question. These processes included the overarching perspective or point of reference of respondents (positionality), the frameworks used to describe the core concepts (paradigms, theories and models), and the way social and environmental factors were considered to act. The core concepts of mental health identified were mainly individual and functional, in that they related to the ability or capacity of a person to effectively deal with or change his/her environment. A preliminary model for the processes used to conceptualise mental health is presented. Conclusions Answers to the question, ‘What are the core concepts of mental health?’ are highly dependent on the empirical frame used. Understanding these empirical frames is key to developing a useful consensus definition for diverse populations.

Test position and hip strength in healthy adults and people with chronic stroke.

OBJECTIVE To determine if peak torques generated by the hip flexors and extensors are dependent on test position in healthy adults and in people with chronic stroke. DESIGN Cross-sectional study. SETTING Motor performance laboratory. PARTICIPANTS Volunteers were 10 young (20.7+/-1.5y), 10 older adults (62.1+/-7y), and 10 stroke survivors (60.6+/-10y) who were an average of 5 years poststroke. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Isokinetic (60 degrees /s) peak concentric hip flexor and extensor torques (in Nm/kg) generated in supine and standing positions. RESULTS Peak flexor torques measured in standing were generally higher than in supine (P=.018); a pattern evident in all groups, but significant only in stroke. An interaction between test position and group for hip extensor strength (P=.016) reflected 2 distinct patterns in which torques were highest in standing among the young subjects and highest in supine after stroke. CONCLUSIONS Isokinetic hip flexor and extensor strength measured in standing and supine are comparable in young and older healthy people. In chronic stroke, the test position may over or underestimate maximum peak torque depending on the muscle group tested, particularly on the side ipsilateral to the lesion. These findings may have implications for predicting functional ability from strength measurements.

Emotional vitality: concept of importance for rehabilitation.

OBJECTIVES To (1) provide a framework for the conceptualization of emotional vitality as an important construct for rehabilitation professionals; (2) outline the existing scope and breadth of knowledge currently available regarding the definition and measurement of emotional vitality in persons with chronic health conditions; and (3) identify the extent to which the components can be mapped to the International Classification of Functioning, Disability and Health (ICF). DESIGN Activities included a scoping review of the literature, and a Delphi mapping exercise using the ICF. SETTING Not applicable. PARTICIPANTS Not applicable. INTERVENTION Not applicable. MAIN OUTCOME MEASURE Not applicable. RESULTS The results of this study suggest that emotional vitality is a complex latent construct that includes (1) physical energy and well-being, (2) regulation of mood, (3) mastery, and (4) engagement and interest in life. Existing literature supported the presence of all 4 components of the construct. The mapping exercise showed that 3 of these components could be readily mapped to the Body Function chapter of the ICF (energy, mood, mastery). CONCLUSIONS Emotional vitality may influence both the physical and emotional adaptation to living with a chronic illness or disability and should be included in both assessment and treatment planning to optimize rehabilitation outcomes. Future research is needed to refine the definition and identify optimal methods of measuring this construct.

Testing a modification of cognitive adaptation training: streamlining the model for broader implementation.

Cognitive adaptation training (CAT) is a home-based, manualized treatment that utilizes environmental supports to improve target behaviors and functional outcomes in persons with schizophrenia. Although clinical trials have shown CAT to be effective across functional, clinical, and treatment adherence domains, when the intervention is withdrawn clients experience significant declines. The aim of the current study was to test a modified version of CAT, which decreases the duration of intensive CAT intervention while utilizing ongoing case management-supported CAT to maintain the fundamental components of the treatment. Twenty-three people participated in an outcome study of the modified version of CAT, evaluating improvements after 4months of CAT specialist intervention and after an additional 5months of case manager support. Analysis revealed significant improvements in adaptive functioning, psychiatric symptomatology, and goal attainment, which were maintained throughout case management follow-up. This suggests that an intervention that has previously demonstrated good functional outcomes in randomized trials might sustain its impacts in an abbreviated format with support from existing case managers.

Measuring the bright side of being blue: a new tool for assessing analytical rumination in depression.

Background Diagnosis and management of depression occurs frequently in the primary care setting. Current diagnostic and management of treatment practices across clinical populations focus on eliminating signs and symptoms of depression. However, there is debate that some interventions may pathologize normal, adaptive responses to stressors. Analytical rumination (AR) is an example of an adaptive response of depression that is characterized by enhanced cognitive function to help an individual focus on, analyze, and solve problems. To date, research on AR has been hampered by the lack of theoretically-derived and psychometrically sound instruments. This study developed and tested a clinically meaningful measure of AR. Methods Using expert panels and an extensive literature review, we developed a conceptual framework for AR and 22 candidate items. Items were field tested to 579 young adults; 140 of whom completed the items at a second time point. We used Rasch measurement methods to construct and test the item set; and traditional psychometric analyses to compare items to existing rating scales. Results Data were high quality (<1% missing; high reliability: Cronbachs alpha  = 0.92, test-retest intraclass correlations >0.81; evidence for divergent validity). Evidence of misfit for 2 items suggested that a 20-item scale with 4-point response categories best captured the concept of AR, fitting the Rasch model (χ2 = 95.26; df  = 76, p = 0.07), with high reliability (rp = 0.86), ordered response scale structure, and no item bias (gender, age, time). Conclusion Our study provides evidence for a 20-item Analytical Rumination Questionnaire (ARQ) that can be used to quantify AR in adults who experience symptoms of depression. The ARQ is psychometrically robust and a clinically useful tool for the assessment and improvement of depression in the primary care setting. Future work is needed to establish the validity of this measure in people with major depression.

Emotional vitality in family caregivers: content validation of a theoretical framework

PurposeEmotional vitality may play an important role in determining whether informal caregivers are able to successfully adopt and persist in their roles. This study describes a content validation of a conceptual model of emotional vitality in informal caregivers.MethodsA secondary content analysis was performed on transcripts of 30 caregivers who were interviewed about their quality of life in relation to assuming the role of informal caregiver for a family member who had experienced a recent stroke. Caregivers discussed changes in their own health, relationships, roles, finances, participation, and mood after assuming the caregiving role. Using a thematic inductive approach, two raters independently coded the presence and frequency of physical, emotional, and social impacts associated with the caregiving role in order to further develop and validate a conceptual model of caregiver emotional vitality.ResultsThe interviews provided information that affirmed the relevance of four themes relevant to caregiver emotional vitality previously identified: physical health and well-being; mood regulation; sense of control/mastery of new skills; and participation in meaningful activity. An additional theme of support and recognition from others also emerged.ConclusionsAdopting the informal caregiving role results in major impacts to the caregiver’s physical, emotional, and social health. Five core domains appear to meaningfully contribute to emotional vitality of caregivers and may influence their ability to persist in this role over time. Many of the factors that influence emotional vitality in caregivers are potentially modifiable. This new model offers new opportunities for rehabilitation specialists and allied health professionals to develop skill-building interventions that may help caregivers successfully adapt and thrive in the caregiving role.