Development of a Patient Decision Aid for Syncope in the Emergency Department: the SynDA Tool

Objectives

The objective was to develop a patient decision aid (DA) to promote shared decision making (SDM) for stable, alert patients who present to the emergency department (ED) with syncope.

Methods

Using input from patients, clinicians, and experts in the field of syncope, health care design, and SDM, we created a prototype of a paper‐based DA to engage patients in the disposition decision (admission vs. discharge) after an unremarkable ED evaluation for syncope. In phase 1, we conducted one‐on‐one semistructured exploratory interviews with 10 emergency physicians and 10 ED syncope patients. In phase 2, we conducted one‐on‐one directed interviews with 15 emergency care clinicians, five cardiologists, and 12 ED syncope patients to get detailed feedback on DA content and design. We iteratively modified the aid using feedback from each interviewee until clarity and usability had been optimized.

Results

The 11 × 17‐inch, paper‐based DA, titled SynDA, includes four sections: 1) explanation of syncope, 2) explanation of future risks, 3) personalized 30‐day risk estimate, and 4) disposition options. The personalized risk estimate is calculated using a recently published syncope risk‐stratification tool. This risk estimate is stated in natural frequency and graphically displayed using a 100‐person color‐coded pictogram. Patient‐oriented questions are included to stimulate dialogue between patient and clinician. At the end of the development process, patient and physician participants expressed satisfaction with the clarity and usability of the DA.

Conclusions

We iteratively developed an evidence‐based DA to facilitate SDM for alert syncope patients after an unremarkable ED evaluation. Further testing is required to determine its effects on patient care. This DA has the potential to improve care for syncope patients and promote patient‐centered care in emergency medicine.

     

Bedside Sonography Performed by Emergency Physicians to Detect Appendicitis in Children

Objective

The aim of this study was to evaluate the ability of emergency physicians with various levels of point‐of‐care ultrasound (POCUS) experience to detect appendicitis with POCUS among children visiting a pediatric emergency department (ED).

Methods

A prospective cohort study was conducted in an urban, tertiary care pediatric ED. Children aged 2 to 18 years old who presented with acute abdominal pain suggesting appendicitis were included. Patients were excluded if they had a history of appendectomy or hemodynamic instability requiring resuscitation or were transferred with proven diagnosis of appendicitis. Participating physicians had various levels of POCUS experience. Four of the 22 physicians were experienced in bowel sonography while the others had basic experience in abdominal POCUS. All the participating physicians received a 1‐hour didactic and practical training session on appendix ultrasound. The treating physician performed POCUS following initial physical examination, before further radiologic evaluation. POCUS examinations were recorded as positive for appendicitis, normal, or inconclusive, with normal or inconclusive studies considered negative. Final outcomes were determined by pathology and/or operative reports for surgical cases and telephone follow‐up at 3 weeks for those who did not have surgery. The primary analysis was a simple proportion for sensitivity and specificity for POCUS. Expecting a sensitivity of 80% based on previous studies, we calculated that a sample size of 50 cases would provide a 95% confidence interval (CI) ranging from 66% to 90%.

Results

Of the 140 approached patients, 121 accepted to participate and were recruited. After four patients were excluded for missing POCUS data, 117 patients were included in the primary analysis, of whom 51 (44%) had appendicitis. Twenty‐two physicians performed between one and 20 POCUS procedures. The POCUS was positive in 39, negative in nine, and inconclusive in 69 patients. POCUS was interpreted as positive in 27 of 51 appendicitis for a sensitivity of 0.53 (95% CI = 0.40–0.66). A negative or inconclusive POCUS was reported for 54 of 66 patients without appendicitis (specificity = 0.82; 95% CI = 0.71–0.89).

Conclusion

This study shows limited sensitivity and specificity of POCUS for appendicitis in children, with a high proportion of inconclusive examinations, when performed by emergency physicians with various level of experience in POCUS.

     

Clinical audits to improve critical care: Part 2: Analyse,benchmark and feedback

Clinical audits are an essential part of the cycle designed to ensure that patients receive the best quality of care. By measuring the care delivered against established best practice standards, it becomes possible to identify shortcomings and to plan targeted strategies and processes for continuous improvement. The success of a clinical audit depends upon defined goals, motivation of stakeholders, appropriate tools and resources, and clear communication.In part 1 of this series, an overview of the structures and processes needed to prepare and collect data for clinical audits in the critical care setting was provided [A.J. Ullman, G. Ray-Barruel, C.M. Rickard, M. Cooke, Clinical audits to improve critical care: Part 1 Prepare and collect data, Aust Crit Care, 2017, in press]. In part 2, we discuss how to analyse the collected audit data, benchmark findings with internal and external data sets, and feedback audit results to critical care clinicians to promote evidence-based practice and improve patient outcomes.     

Semi-automatic detection of myocardial trabeculation using cardiovascular magnetic resonance: correlation with histology and reproducibility in a mouse model of non-compaction

Background

The definition of left ventricular (LV) non-compaction is controversial, and discriminating between normal and excessive LV trabeculation remains challenging. Our goal was to quantify LV trabeculation on cardiovascular magnetic resonance (CMR) images in a genetic mouse model of non-compaction using a dedicated semi-automatic software package and to compare our results to the histology used as a gold standard.

Methods

Adult mice with ventricular non-compaction were generated by conditional trabecular deletion of Nkx2–5. Thirteen mice (5 controls, 8 Nkx2–5 mutants) were included in the study. Cine CMR series were acquired in the mid LV short axis plane (resolution 0.086?×?0.086x1mm³) (11.75 T). In a sub set of 6 mice, 5 to 7 cine CMR were acquired in LV short axis to cover the whole LV with a lower resolution (0.172?×?0.172x1mm3). We used semi-automatic software to quantify the compacted mass (M_c), the trabeculated mass (M_t) and the percentage of trabeculation (M_t/M_c) on all cine acquisitions_. After CMR all hearts were sliced along the short axis and stained with eosin, and histological LV contouring was performed manually, blinded from the CMR results, and M_t, M_c and M_t/M_c were quantified. Intra and interobserver reproducibility was evaluated by computing the intra class correlation coefficient (ICC).

Results

Whole heart acquisition showed no statistical significant difference between trabeculation measured at the basal, midventricular and apical parts of the LV. On the mid-LV cine CMR slice, the median M_t was 0.92 mg (range 0.07–2.56 mg), M_c was 12.24 mg (9.58–17.51 mg), M_t/M_c was 6.74% (0.66–17.33%). There was a strong correlation between CMR and the histology for M_t, M_c and M_t/ M_c with respectively: r²?=?0.94 (p?<?0.001), r²?=?0.91 (p?<?0.001), r²?=?0.83 (p?<?0.001). Intra- and interobserver reproducibility was 0.97 and 0.8 for M_t; 0.98 and 0.97 for M_c; 0.96 and 0.72 for M_t/M_c, respectively and significantly more trabeculation was observed in the M_c Mutant mice than the controls.

Conclusion

The proposed semi-automatic quantification software is accurate in comparison to the histology and reproducible in evaluating M_c, M_t and M_t/ M_c on cine CMR.

     

Developing research priorities for nurses working in the gynaecology setting in Western Australia

Background

Nurses working in clinical settings are instrumental to translating research into practice. The Delphi approach has been used by clinicians worldwide to set research agendas relevant to their clinical work.

Living with multiple losses: Insights from patients living with pressure injury

Background

Pressure injury is a common problem. Its prevention and treatment is predominantly focussed on views, perceptions and knowledge of healthcare staff rather than on patient experience, particularly those patients living in their own homes.

Lung real time three-dimensional imaging in critically ill ventilated patients: a global diagnosis concordance study

Lung ultrasound (LUS) increases clinical diagnosis performance in intensive care unit (ICU). Real-time three-dimensional (3-D) imaging was compared with two-dimensional (2-D) LUS by assessing the global diagnosis concordance. In this single center, prospective, observational, pilot study, one trained operator performed a 3-D LUS immediately after a 2-D LUS in eight areas of interest on the same areas in 16 ventilated critically ill patients. All cine loops were recorded on a computer without visible link between 2-D and 3-D exams. Two experts blindly reviewed cine loops. Four main diagnoses were proposed: normal lung, consolidation, pleural effusion and interstitial syndrome. Fleiss κ and Cohen’s κ values were calculated. In 252 LUS cine loops, the concordance between 2-D and 3-D exams was 83.3% (105/126), 77.6% (99/126) and 80.2% (101/126) for the trained operator and the experts respectively. The Cohen’s κ coefficient value was 0.69 [95% Confidence Interval (CI) 0.58–0.80] for expert 1 meaning a substantial agreement. The inter-rater reliability was very good (Fleiss’ κ value?=?0.94 [95% CI 0.87–1.0]) for 3-D exams. The Cohen’s κ was excellent for pleural effusion (κ=?0.93 [95% CI 0.76–1.0]), substantial for normal lung diagnosis (κ?=?0.68 [95% CI 0.51–0.86]) and interstitial syndrome (κ?=?0.62 [95% CI 0.45–0.80]) and fair for consolidation diagnoses (κ?=?0.47 [95% CI 0.30–0.64]). In ICU ventilated patients, there was a substantial concordance between 2-D and 3-D LUS with a good inter-rater reliability. However, the diagnosis concordance for lung consolidation is poor.     

A cross-sectional survey of factors associated with the uptake of smoking cessation aids among smokers and ex-smokers

Background: A cross-sectional survey was conducted in Germany via the online panel PsyWeb with the aim of assessing factors associated with the uptake of smoking cessation aids among smokers and ex-smokers.

Methods: Of the 10,000 panel members invited to participate in the survey, 624 took part.

Main Outcome Measures: Outcomes were measured via questionnaires to assess the uptake of smoking cessation aids, health literacy, readiness to change smoking behavior, and the Fagerström Test for Nicotine Dependence.

Results: There was no association between gender or educational status and use of smoking cessation aids according to chi-square tests of independence. Logistic regression showed that health literacy, degree of tobacco dependence, and readiness to change were significantly associated with the uptake of smoking cessation aids. Smokers with a high degree of nicotine dependence, high readiness to change, and low health literacy were more likely to use aids.

Conclusion: The survey results can be used to develop psychological approaches and interventions to promote smoking cessation, e.g., interventions to increase readiness to change among smokers may increase the uptake of aids. Moreover, the results may help to improve patient care by disseminating information on effective aids and thereby promoting smoking cessation among relevant patient groups.     

Therapeutic Benefit and Gene Network Regulation by Combined Gene Transfer of Apelin,FGF2, and SERCA2a into Ischemic Heart

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