An Exploration of Emergency Physicians' Attitudes Toward Patients With Substance Use Disorder.

OBJECTIVES: Much is known about some healthcare professionals' attitudes toward patients with substance use disorders, but few studies have specifically looked at emergency department (ED) physicians. Individuals with substance use disorders are more likely to be people who chronically, frequently use the ED, and thus ED physicians are in a unique position to provide early identification and intervention for people struggling with addiction. The purpose of this study was to understand ED physicians' attitudes toward patients with substance use disorder with the aim of decreasing stigma and improving the care of ED patients with substance use disorder. METHODS: An anonymous Qualtrics survey was emailed to 115 emergency physicians in the Johns Hopkins Health System. The survey contained (1) demographics and (2) the medical condition regard scale, http://links.lww.com/JAM/A67. Participants were offered a $10 Amazon gift card to complete the survey. RESULTS: The response rate was 50% (n = 58) and the completion rate was 43% (n = 50). Physicians had lower regard for patients with substance use disorders than other medical conditions with behavioral components. Of note, 54% of respondents indicated that they at least "somewhat agree" that they "prefer not to work with patients with substance use who have pain." CONCLUSIONS: A significant portion of our study population had low regard for patients with substance use. Future research is needed to determine significant contributing factors and develop interventions to mitigate negative attitudes among ED physicians toward patients with substance use disorder.

Interobserver agreement in the evaluation of B-lines using bedside ultrasound.

PURPOSE: We evaluated agreement among trained emergency physicians assessing the degree of B-line presence on bedside ultrasound in patients presenting to the emergency department (ED) with acute undifferentiated dyspnea. We also determined which thoracic zones offered the highest level of interobserver reliability for sonographic B-line assessment. MATERIALS AND METHODS: We evaluated a prospective convenience sample of adult patients presenting with dyspnea to an academic ED. Two consecutive bedside lung ultrasounds were performed on 91 patients by a pair of physician-sonographers. The lung ultrasounds were structured 10-zone thoracic sonograms, documented as videos. Sonographer pairs were expert/expert (>100 lung ultrasounds performed) or expert/novice pairs (novices performed 5 supervised examinations after structured training) and blinded to clinical data. Sonographers reported B-line concentration with 3 assessment methods: (1) normal (<3 B-lines) or abnormal (≥3 B-lines); (2) ordinal (normal, mild, moderate, or severe), and (3) counting B-lines (0-10; >10) in each zone. All statistical analyses were performed using SPSS version 18.0 (Chicago, IL) and Stata 12.1 (College Station, TX). We evaluated interrater and intrarater agreement using Intraclass correlation coefficients (ICCs). RESULTS: The right and left anterior/superior lung zones showed substantial agreement in all assessment methods and demonstrated best overall agreement (ICC for right: counting, ordinal, and normal/abnormal, 0.811 [0.714-0.875], 0.875 [0.810-0.917], and 0.729 [0.590-0.821], respectively). Furthermore, both expert/expert pairs and expert/novice pairs showed substantial agreement in the right and left anterior/superior thoracic zones (expert/expert, 0.904 and 0.777, respectively; expert/novice, 0.862, and 0.834, respectively). Second best agreement was found for the lateral/superior lung zones (right: counting, ordinal, and normal/abnormal, 0.744 [0.612-0.831], 0.686 [0.524-0.792], and 0.639 [0.453-0.761], respectively; and ICC left: counting, ordinal, and normal/abnormal, 0.671 [0.501-0.782], 0.615 [0.417-0.746], and 0.720 [0.577-0.815], respectively). When comparing agreement to distinguish "normal vs abnormal" B-line findings, our results showed significant agreement in all zones with the exception of the right and left inferior/lateral lung fields and left posterior lung. Reinterpretation by 2 experts of all their own randomized video clips at a later date showed agreement of 0.697 (n=733 zones) and 0.647 (n=266) zones for ordinal assessment of B-line concentration. CONCLUSION: Interrater agreement was best in the anterior/superior thoracic zones followed by the lateral/superior zones for both expert/expert and expert/novice pairs. Agreement in the lateral/inferior lung zones was overall inferior. Intrarater agreement was highest at extreme high or low numbers of B-lines.

Diagnostic and functional imaging of thymic and mediastinal involvement in lymphoproliferative disorders.

Lymphoproliferative disorders of the anterior mediastinum may involve the thymus or lymph nodes as part of disseminated disease or as an isolated site. Imaging is crucial in managing patients with mediastinal lymphoma and is employed in pretreatment assessment, midtreatment evaluation of response, posttreatment restaging, and surveillance during follow-up. For decades, computed tomography (CT) has been the standard imaging technique, although in the last years, positron emission tomography (PET)-CT and magnetic resonance imaging (MRI) have been introduced. We discuss the role of different imaging techniques in the assessment of patients with mediastinal lymphoma, focusing on novel aspects of PET-CT and diffusion-weighted/MRI.