Immersion-Induced Mitral Regurgitation: A Novel Risk Factor for Swimming-Induced Pulmonary Edema.

Immersion pulmonary edema, more commonly referred to as swimming-induced pulmonary edema (SIPE), is a well-documented condition believed to be a result of immersion physiologic condition that is characterized by a peripheral-to-central redistribution of blood volume. It disproportionally affects young, healthy athletes with no clinically overt cardiovascular or pulmonary conditions. We present four cases of healthy athletes with previously documented SIPE, who participated in Institutional Review Board-approved clinical studies that examined the pathophysiologic condition and prevention of SIPE. During standard recumbent echocardiography, trivial mitral regurgitation was observed in all four individuals. Acute exacerbation of their mitral regurgitation was observed during immersion with both immersed resting and immersed exercise echocardiography, contributing to the development of SIPE. These observations demonstrate that the occurrence of subclinical or trivial mitral valve regurgitation during dry rest is a novel risk factor for SIPE. We propose the use of immersion echocardiography as a useful investigative tool for otherwise healthy individuals with SIPE and no previously explainable cause.

Developing a model for effective leadership in healthcare: a concept mapping approach.

PURPOSE: Despite increasing awareness of the importance of leadership in healthcare, our understanding of the competencies of effective leadership remains limited. We used a concept mapping approach (a blend of qualitative and quantitative analysis of group processes to produce a visual composite of the group's ideas) to identify stakeholders' mental model of effective healthcare leadership, clarifying the underlying structure and importance of leadership competencies. METHODS: Literature review, focus groups, and consensus meetings were used to derive a representative set of healthcare leadership competency statements. Study participants subsequently sorted and rank-ordered these statements based on their perceived importance in contributing to effective healthcare leadership in real-world settings. Hierarchical cluster analysis of individual sortings was used to develop a coherent model of effective leadership in healthcare. RESULTS: A diverse group of 92 faculty and trainees individually rank-sorted 33 leadership competency statements. The highest rated statements were "Acting with Personal Integrity", "Communicating Effectively", "Acting with Professional Ethical Values", "Pursuing Excellence", "Building and Maintaining Relationships", and "Thinking Critically". Combining the results from hierarchical cluster analysis with our qualitative data led to a healthcare leadership model based on the core principle of Patient Centeredness and the core competencies of Integrity, Teamwork, Critical Thinking, Emotional Intelligence, and Selfless Service. CONCLUSION: Using a mixed qualitative-quantitative approach, we developed a graphical representation of a shared leadership model derived in the healthcare setting. This model may enhance learning, teaching, and patient care in this important area, as well as guide future research.

Transitions of Care in an Era of Healthcare Transformation.

In the practice of modern emergency medicine (EM), transitions of care (TOC) have taken a prominent role, and during this time of healthcare reform, TOC has become a focal point of improvement initiatives across the continuum of care. This review includes a comprehensive examination of various regulatory, accreditation, and policy-based elements with which EM physicians interact in their daily practice. The content is organized into five domains: Accreditation Council for Graduate Medical Education (ACGME), The Joint Commission, Affordable Care Act, National Quality Forum (NQF), and accountable care organizations. This review is meant to be a synthesis of TOC material, tailored for EM physicians and the teams that make these departments run. We include (1) relevant current regulations and standards from various entities that are most likely to affect the day-to-day practice of EM; (2) examination of the consequences of these regulations and standards and how they can be used to shape EM practice and clinical decision making; and (3) comparison of interventions aimed at improving TOC, including evidence from current literature, practical examples, and proposals. Emergency departments must develop, implement, and monitor TOC programs and processes that can facilitate seamless and efficient care as patients transfer between settings. This report provides a framework for that effort and is designed to help EM physicians continue to take the lead in improving TOC to help shape the future of modern practice.

A first step toward understanding best practices in leadership training in undergraduate medical education: a systematic review.

PURPOSE: To characterize leadership curricula in undergraduate medical education as a first step toward understanding best practices in leadership education. METHOD: The authors systematically searched the PubMed, Education Resources Information Center, Academic Search Complete, and Education Full Text databases for peer-reviewed English-language articles published 1980-2014 describing curricula with interventions to teach medical students leadership skills. They characterized educational settings, curricular format, and learner and instructor types. They assessed effectiveness and quality of evidence using five-point scales adapted from Kirkpatrick's four-level training evaluation model (scale: 0-4) and a Best Evidence Medical Education guide (scale: 1-5), respectively. They classified leadership skills taught into the five Medical Leadership Competency Framework (MLCF) domains. RESULTS: Twenty articles describing 24 curricula met inclusion criteria. The majority of curricula (17; 71%) were longitudinal, delivered over periods of one semester to four years. The most common setting was the classroom (12; 50%). Curricula were frequently provided to both preclinical and clinical students (11; 46%); many (9; 28%) employed clinical faculty as instructors. The majority (19; 79%) addressed at least three MLCF domains; most common were working with others (21; 88%) and managing services (18; 75%). The median effectiveness score was 1.5, and the median quality of evidence score was 2. CONCLUSIONS: Most studies did not demonstrate changes in student behavior or quantifiable results. Aligning leadership curricula with competency models, such as the MLCF, would create opportunities to standardize evaluation of outcomes, leading to better measurement of student competency and a better understanding of best practices.