Lung ultrasound training and evaluation for proficiency among physicians in a low-resource setting

Background Lung ultrasound (LUS) is helpful for the evaluation of patients with dyspnea in the emergency department (ED). However, it remains unclear how much training and how many LUS examinations are needed for ED physicians to obtain proficiency. The objective of this study was to determine the threshold number of LUS physicians need to perform to achieve proficiency for interpreting LUS on ED patients with dyspnea. Methods A prospective study was performed at Patan Hospital in Nepal, evaluating proficiency of physicians novice to LUS. After eight hours of didactics and hands-on training, physicians independently performed and interpreted ultrasounds on patients presenting to the ED with dyspnea. An expert sonographer blinded to patient data and LUS interpretation reviewed images and provided an expert interpretation. Interobserver agreement was performed between the study physician and expert physician interpretation. Cumulative sum analysis was used to determine the number of scans required to attain an acceptable level of training. Results Nineteen physicians were included in the study, submitting 330 LUS examinations with 3288 lung zones. Eighteen physicians (95%) reached proficiency. Physicians reached proficiency for interpreting LUS accurately when compared to an expert after 4.4 (SD 2.2) LUS studies for individual zone interpretation and 4.8 (SD 2.3) studies for overall interpretation, respectively. Conclusions Following 1 day of training, the majority of physicians novice to LUS achieved proficiency with interpretation of lung ultrasound after less than five ultrasound examinations performed independently.

Body checking in non-elite adolescent ice hockey leagues: it is never too late for policy change aiming to protect the health of adolescents

ObjectivesThe objective of this study is to evaluate the effect of policy change disallowing body checking in adolescent ice hockey leagues (ages 15–17) on reducing rates of injury and concussion.MethodsThis is a prospective cohort study. Players 15–17 years-old were recruited from teams in non-elite divisions of play (lower 40%–70% by division of play depending on year and city of play in leagues where policy permits or prohibit body checking in Alberta and British Columbia, Canada (2015–18). A validated injury surveillance methodology supported baseline, exposure-hours and injury data collection. Any player with a suspected concussion was referred to a study physician. Primary outcomes include game-related injuries, game-related injuries (>7 days time loss), game-related concussions and game-related concussions (>10 days time loss).Results44 teams (453 player-seasons) from non-body checking and 52 teams (674 player-seasons) from body checking leagues participated. In body checking leagues there were 213 injuries (69 concussions) and in non-body checking leagues 40 injuries (18 concussions) during games. Based on multiple multilevel mixed-effects Poisson regression analyses, policy prohibiting body checking was associated with a lower rate of injury (incidence rate ratio (IRR): 0.38 (95% CI 0.24 to 0.6)) and concussion (IRR: 0.49; 95% CI 0.26 to 0.89). This translates to an absolute rate reduction of 7.82 injuries/1000 game-hours (95% CI 2.74 to 12.9) and the prevention of 7326 injuries (95% CI 2570 to 12083) in Canada annually.ConclusionsThe rate of injury was 62% lower (concussion 51% lower) in leagues not permitting body checking in non-elite 15–17 years old leagues highlighting the potential public health impact of policy prohibiting body checking in older adolescent ice hockey players.

0472 Do the Subjective Effects of Hypnotic Medications Result in Unblinding of Treatment Assignment in Hypnotic Randomized Clinical Trials?

Introduction Some hypnotic medications have obvious subjective effects, including therapeutic effects (i.e., anti-insomnia effects), and side effects (i.e., feelings of impairment/intoxication). Information is lacking regarding whether the subjective effects of hypnotics result in unblinding of treatment assignment (active drug versus placebo) in hypnotic randomized clinic trials (RCTs), thus undermining internal validity of study results. In response, we now report the ‘best guesses’ of clinical trial participants, versus study coordinators, versus study physicians in the study Reducing Suicidal Ideation Through Insomnia Treatment (REST-IT). Methods Eighty-nine of the 103 participants in the REST-IT study completed their ‘best guess’ regarding which randomized treatment they had been assigned. REST-IT was a blinded RCT, comparing zolpidem controlled release (CR) versus placebo at bedtime given over 8 weeks in adults with major depressive disorder who also had insomnia and suicidal ideation, and who also received open label fluoxetine. At the conclusion of study participation, the study participants, the study coordinators and the study physician each independently recorded their ‘best guess’ regarding which treatment arm the patient had been assigned. The study physicians and the study coordinators had access to the participants’ Insomnia Severity Index scores when the ‘best guess’ was made. Results Patients guessed correctly 58.4% of the time, coordinators 53.9% of the time, and physicians 49.4% of the time. The percentage guessed correctly did not differ significantly between groups. Physicians most often guessed placebo (56.2%) while study coordinators most often guessed zolpidem-CR (55.1%). Agreement between pairs of study participants with the study coordinators and the study physician was moderately high, with all kappa values 0.49- 0.57, and all kappa differences between zolpidem and placebo with p-values >0.8. Conclusion The blind was maintained in this RCT of zolpidem-CR versus placebo, especially for the physicians. Our results may not apply to other hypnotics or other RCT designs. Support NIMH MH095776, MH095780, MH95778

Abstract MP40: U-shaped Association Of Altitude With Prevalence Of Hypertension Among Tibetan Residents

Background: Tibet has a disproportionately higher prevalence of hypertension, compared to other regions of China. This may be related to long-term exposure to the high altitude. The aim of our study is to evaluate associations of altitudes with prevalence of hypertension among residents aged 15 years and older in Tibet, China. Method: A total of 11,407 Tibet residents in the 5 th National Health Services Survey (NHSS) in 2013-2015 were included in this study. Physician diagnosed hypertension was determined based on self-report. County level altitude was identified and assigned to all residents in a county. Association between altitude and hypertension prevalence was assessed by two logistic regression models: model 1 adjusted for age and gender, and model 2 additionally adjusted for marital status, education, smoking, drinking, exercise, distance to a medical institute, area of residency, and body mass index (BMI). Non-linear relationship between altitude and prevalence of hypertension was explored by restricted cubic spline analyses. Sensitivity analysis were performed by restricting residents in rural and/or nomadic areas. Result: The prevalence of self-reported hypertension is 15.7%, the medication adherence rate is 14%, and the control rate is 10.3%. Compared to residents without physician diagnosed hypertension, those with hypertension were closer to a hospital, older, having lower education level, and less likely to be a smoker or live in an urban area. Altitude showed a U shape relationship with the prevalence of hypertension with a turning point at around 3,800 meters. For residents living more than 3,800 meters above sea level, a 1,000 meters increase in altitude was associated with 2.05 (95% confidence interval: 1.62-2.61) times higher odds of having physician diagnosed hypertension, after adjusting for age and gender. When further controlling for all covariates, the OR dropped to 1.87 (1.46-2.41) but still significant. For residents living below the altitude of 3,800 meters, 1000 meters’ increase was associated 0.55 (95% CI: 0.33-0.92) less likelihood of having physician diagnosed hypertension. Conclusion: The burden of self-reported hypertension was high among Tibet residents. Altitude was in a U-shaped association with the prevalence of hypertension with a turning point at around 3,800 meters.

Ability of verbal autopsy data to detect deaths due to uncontrolled hyperglycaemia: testing existing methods and development and validation of a novel weighted score

ObjectivesVerbal autopsy (VA) is a useful tool to ascertain cause of death where no other mechanisms exist. We aimed to assess the utility of VA data to ascertain deaths due to uncontrolled hyperglycaemia and to develop a weighted score (WS) to specifically identify cases. Cases were identified by a study or site physician with training in diabetes. These diagnoses were also compared with diagnoses produced by a standard computer algorithm (InterVA-4).SettingThis study was done using VA data from the Health and Demographic Survey sites in Agincourt in rural South Africa. Validation of the WS was done using VA data from Karonga in Malawi.ParticipantsAll deaths from ages 1 to 49 years between 1992 and 2015 and between 2002 and 2016 from Agincourt and Karonga, respectively. There were 8699 relevant deaths in Agincourt and 1663 in Karonga.ResultsOf the Agincourt deaths, there were 77 study physician classified cases and 58 computer algorithm classified cases. Agreement between study physician classified cases and computer algorithm classified cases was poor (Cohen’s kappa 0.14). Our WS produced a receiver operator curve with area under the curve of 0.952 (95% CI 0.920 to 0.985). However, positive predictive value (PPV) was below 50% when the WS was applied to the development set and the score was dominated by the necessity for a premortem diagnosis of diabetes. Independent validation showed the WS performed reasonably against site physician classified cases with sensitivity of 86%, specificity of 99%, PPV of 60% and negative predictive value of 99%.ConclusionOur results suggest that widely used VA methodologies may be missing deaths due to uncontrolled hyperglycaemia. Our WS may offer improved ability to detect deaths due to uncontrolled hyperglycaemia in large populations studies where no other means exist.

P022: Physician reporting of medically unfit drivers: barriers and incentives

Introduction: Most medically unfit drivers are not reported to licensing authorities. In BC, physicians are only obligated to report unfit drivers who continue to drive after being warned to stop. This study investigates barriers to and incentives for physician reporting of medically unfit drivers. Methods: We used an online survey to study physician-reported barriers to reporting medically unfit drivers and their idea of incentives that would improve reporting. Email invitations to participate in the survey were sent to all physicians in BC through DoctorsofBC and to all emergency physicians (EPs) in the UBC Department of Emergency Medicine. Results: We received responses from 242 physicians (47% EPs, 40% GPs, 13% others). The most common barrier to reporting was not knowing which unfit drivers continue to drive (79% of respondents). Other barriers included lack of time (51%), lack of knowledge of the process, guidelines, or legal requirement for reporting (51%, 50%, 45% respectively), fearing loss of rapport with patients (48%), pressure from patients not to report (34%), lack of remuneration (27%), and pressure from family members not to report (25%).EPs were significantly less likely than other physicians to cite loss of rapport, pressure from patients, or pressure from family as barriers, but more likely to cite not being aware of drivers who continue to drive after being warned, lack of knowledge (regarding legal requirements to report, guidelines for determining fitness, and the reporting process), and lack of time. Factors that would increase reporting unfit drivers included better understanding of criteria for fitness to drive (70%), more information regarding how to report (67%), more information on when to report (65%), and compensation (43%).Free text comments from respondents identified other barriers/incentives. Reporting might be simplified by telephone hotlines or allowing physician designates to report. Physicians feared legal liability and suggested the need for better medico-legal protection. Loss of patient rapport might be minimized by public education. Failure of response from licensing authorities to a report (long wait times, lack of feedback to physician) was seen as a barrier to reporting. Conclusion: We identified barriers to physician reporting of medically unfit drivers and incentives that might increase reporting. This information could inform programs aiming to improve reporting of unfit drivers.