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Abstract Background In 2008 the Council of Emergency Medicine Residency Directors delineated consensus recommendations for training in biliary ultrasound for the “detection of biliary pathology”. Objectives While studies have looked at the accuracy of emergency provider performed clinical ultrasound (ECUS), we sought to evaluated if ECUS could be diagnostic for acute cholecystitis and thus obviate the need for follow-up imaging. Method We reviewed all ECUS performed between 2012 and 2017 that had a matching radiology performed ultrasound (RADUS) and a discharge diagnosis. 332 studies were identified. The sensitivity and specificity of both ECUS and RADUS were compared to the patient’s discharge diagnosis. The agreement between the ECUS and RADUS was assessed using an unweighted Cohen’s Kappa. The time from patient arrival to diagnosis by ECUS and RADUS was also compared. Results Using discharge diagnosis as the gold standard ECUS was 67% (56–78%) sensitive, 88% (84–92%) specific, NPV 90% (87–95%), PPV 60% (50–71%), +LR 5.6 (3.9–8.2), −LR 0.37 (0.27–0.52) for acute cholecystitis. RADUS was 76% (66–87%) sensitive, 97% (95–99%) specific, NPV 95% (092–97%), PPV 86% (76–95%), +LR 25.6 (12.8–51.4), and −LR 0.24 (0.15–0.38). ECUS was able to detect gallstones with 93% (89–96%) sensitivity and 94% (90–98%) specificity leading to a NPV 90% (85–95%), PPV of 95% (92–98%), +LR 14.5 (7.7–27.4), −LR 0.08 (0.05–0.13). The unweighted kappa between ECUS and RADUS was 0.57. The median time between obtaining ECUS vs. RADUS diagnosis was 124 min. Conclusions ECUS can be beneficial in ruling out acute cholecystitis, but lacks the test characteristics to be diagnostic for acute cholecystitis.

Abstract Objectives Ultrasound measurement of the optic nerve sheath diameter (ONSD) is a rapid, non-invasive means to indirectly assess intracranial pressure. Previous research has demonstrated the ability of emergency physicians to measure ONSD accurately with bedside ultrasound when compared to CT scan or MRI, however the reliability of this measurement between two or more operators has been called into question (Hassen et al. in J Emerg Med 48:450–457, 2015; Shirodkar et al. in Ind J Crit Care Med 19:466–470, 2015). Given the need for accurate and precise measurement to use this as a screening exam, we sought to determine the inter-rater reliability between ONSD measurements obtained in real time by fellowship-trained emergency ultrasound physicians. Methods Three ultrasound fellowship-trained emergency physicians measured bilateral ONSD of 10 healthy volunteers using a high-frequency linear transducer. The physicians were blinded to the other scanners’ measurements, and no instructions were given other than to obtain the ONSD. Each sonographer measured the ONSD in real time and it was recorded by a research coordinator. All measurements were recorded in millimeters. Intraclass correlation coefficients (ICCs) were calculated to estimate the inter-rater reliability. Results A total of 60 measurements of ONSD were obtained. The average measurement was 4.3 mm (3.83–4.77). Very little variation was found between the three physicians, with a calculated ICC of 0.82 (95% confidence interval 0.63–0.92). Conclusions ONSD measurement obtained by ultrasound fellowship-trained emergency medicine physicians is a reliable measurement with a high degree of correlation between scanners.

Ectopic pregnancies develop outside of the uterus and lead to significant maternal morbidity and mortality if they rupture. As the primary diagnostic tool for these presentations, ultrasound has a growing list of signs and measurements that help distinguish between intrauterine and ectopic pregnancies, the latter being exceedingly rare once a woman has entered her second trimester. The present case reports a series of Emergency Department visits by a woman carrying a second-trimester pregnancy—deemed intrauterine on transabdominal ultrasound due to gestational age and location—who developed massive hemoperitoneum and was diagnosed with a ruptured 15-week tubo-ovarian pregnancy on laparotomy. The discussion describes the sonographic findings that could have helped make the proper diagnosis, most notably mantle distance—the thickness of the myometrium surrounding the gestational sac—which would have correctly identified this pregnancy as ectopic.

Type III interferons (IFN-lambdas(λ)) are important cytokines that inhibit viruses and modulate immune responses by acting through a unique IFN-λR1/IL-10RB heterodimeric receptor. Until now, the primary antiviral function of IFN-λs has been proposed to be at anatomical barrier sites. Here, we examine the regulation of IFN-λR1 expression and measure the downstream effects of IFN-λ3 stimulation in primary human blood immune cells, compared with lung or liver epithelial cells. IFN-λ3 directly bound and upregulated IFN-stimulated gene (ISG) expression in freshly purified human B cells and CD8+ T cells, but not monocytes, neutrophils, natural killer cells, and CD4+ T cells. Despite similar IFNLR1 transcript levels in B cells and lung epithelial cells, lung epithelial cells bound more IFN-λ3, which resulted in a 50-fold greater ISG induction when compared to B cells. The reduced response of B cells could be explained by higher expression of the soluble variant of IFN-λR1 (sIFN-λR1), which significantly reduced ISG induction when added with IFN-λ3 to peripheral blood mononuclear cells or liver epithelial cells. T-cell receptor stimulation potently, and specifically, upregulated membrane-bound IFNLR1 expression in CD4+ T cells, leading to greater antiviral gene induction, and inhibition of human immunodeficiency virus type 1 infection. Collectively, our data demonstrate IFN-λ3 directly interacts with the human adaptive immune system, unlike what has been previously shown in published mouse models, and that type III IFNs could be potentially utilized to suppress both mucosal and blood-borne viral infections.

Abstract Background Traditional landmark thoracostomy technique has a known complication rate up to 30%. The goal of this study is to determine whether novice providers could more accurately identify the appropriate intercostal site for thoracostomy by ultrasound guidance. Methods 33 emergency medicine residents and medical students volunteered to participate in this study during routine thoracostomy tube education. A healthy volunteer was used as the standardized patient for this study. An experienced physician sonographer used ultrasound to locate a site at mid-axillary line between ribs 4 and 5 and marked the site with invisible ink that can only be revealed with a commercially available UV LED light. Participants were asked to identify the thoracostomy site by placing an opaque marker where they would make their incision. The distance from the correct insertion site was measured in rib spaces. The participants were then given a brief hands-on training session using ultrasound to identify the diaphragm and count rib spaces. The participants were then asked to use ultrasound to identify the proper thoracostomy site and mark it with an opaque marker. The distance from the proper insertion site was measured and recorded in rib spaces. Results The participants correctly identified the pre-determined intercostal space using palpation 48% (16/33) of the time, versus the ultrasound group who identified the proper intercostal space 91% (30/33) of the time. On average, the traditional technique was placed 0.88 rib spaces away (95 CI 0.43–1.03), while the ultrasound-guided technique was placed 0.09 rib spaces away (95 CI 0.0–0.19) [P = 0.003]. Conclusions The ability to accurately locate the correct intercostal space for thoracostomy incision was improved under ultrasound guidance. Further studies are warranted to determine if this ultrasound-guided technique will decrease complications with chest tube insertion and improve patient outcomes.

http://dx.doi.org/10.5007/1807-9288.2015v11n2p3 Originally written as an invited presentation for Feira Nordestina do Livro in Recife, but not presented there when funding fell through, this essay considers three entangled senses of the book in its time—historical, presentational, and experiential— considering the book as a vehicle in which “time is articulated and re-synchronized through various material practices.” As a result of having written about the book, especially in relation to new technologies and digital media, for over a quarter of a century, this essay is to some extent haunted by past formulations of these questions. In speculating about the future of the book, the essay begins from the premise that the future of some things is to be more like themselves, that is, self-similar, but then proceeds to a parable that reflects the life of most books since the dawn of the age of print in which some circulate and disappear from use, others are treasured for reasons of art, of literary, historical, or practical value, still others are kept as a hedge against time or otherwise move through generations of this world, fading and renewed, forgotten and remembered by turns.

An American author of digital hypertexts and innovative fictions reflects upon reflection. Benjamin’s notion of the dialectical image as well as the suspended present tense of Foucault’s heterotopic networked time inform reflections upon how Michael Joyce’s earlier digital and print fictions explore a punctuated temporality where the future and the past intermix and a newness bursts forth. Finally in discussing current collaborative work via speculations by physicist and artist Dominique Peysson, the time reversal mirror of the physicist Mathias Fink is offered as a way to consider the multinaéité of the technical body in networked space.

We report on a project to introduce interactive learning strategies (ILS) to physics classes at the Université Pierre et Marie Curie, one of the leading science universities in France. In Spring 2012, instructors in two large introductory classes, first-year, second-semester mechanics, and second-year introductory electricity and magnetism, enrolling approximately 500 and 250 students, respectively, introduced ILS into some, but not all, of the sections of each class. The specific ILS utilized were think-pair-share questions and Peer Instruction in the main lecture classrooms, and University of Washington Tutorials for Introductory Physics in recitation sections. Pre- and postinstruction assessments [Force Concept Inventory (FCI) and Conceptual Survey of Electricity and Magnetism (CSEM), respectively] were given, along with a series of demographic questions. Since not all lecture or recitation sections in these classes used ILS, we were able to compare the results of the FCI and CSEM between interactive and noninteractive classes taught simultaneously with the same curriculum. We also analyzed final exam results, as well as the results of student and instructor attitude surveys between classes. In our analysis, we argue that multiple linear regression modeling is superior to other common analysis tools, including normalized gain. Our results show that ILS are effective at improving student learning by all measures used: research-validated concept inventories and final exam scores, on both conceptual and traditional problem-solving questions. Multiple linear regression analysis reveals that interactivity in the classroom is a significant predictor of student learning, showing a similar or stronger relationship with student learning than such ascribed characteristics as parents’ education, and achieved characteristics such as grade point average and hours studied per week. Analysis of student and instructor attitudes shows that both groups believe that ILS improve student learning in the physics classroom and increase student engagement and motivation. All of the instructors who used ILS in this study plan to continue their use.

The article provides information on ecumenical attributes of Methodism in Czechoslovakia. According to World Service Report, Methodism is to render greatest service in reviving vital religion within the Russian Orthodox Church. Its mission is to promote evangelical and social work and sincere purpose to cooperate with all existing Christian bodies. Moreover, this ecumenical approach is in keeping with policy for European missions that was adopted by the Methodist Episcopal Church.

We report results of numerical experiments which show that a family of simple one dimensional particle systems with long-range interactions, when subjected to a certain class of inelastic interaction, evolve towards states which are highly ordered in phase space, displaying particle motions which are periodic and synchronized in relative phase. For the case of a self-gravitating system, the resulting states show a remarkable stability when the inelastic interactions are turned off, with the phase space order persisting on the longest times we simulate, and much longer than the time-scale expected for relaxation of non-equilibrium states of this long-range system to thermal equilibrium. This appears to provide a novel example of ergodicity breaking in long-range systems. We propose some simple heuristic arguments which predict reasonably well properties of the synchronized states. We enlarge our study to a broader class of long-range interacting systems, where the phenomenon of synchronisation is still present, but only for systems less than a critical size. We conclude with a discussion of avenues for further investigation. [ABSTRACT FROM AUTHOR]

The relation between halo mass, M, and concentration, c, is a critical component in our understanding of the structure of dark matter halos. While numerous models for this relation have been proposed, almost none of them attempt to derive the evolution of the relation analytically. We build on previous efforts to model the c–M relation as a function of physical parameters such as the peak height, ν, and the effective power spectrum slope, , which capture the dependence of c on halo mass, redshift, and cosmology. We present three major improvements over previous models. First, we derive an analytical expression for the c–M relation that is valid under the assumption of pseudo-evolution, i.e., assuming that the density profiles of halos are static in physical coordinates while the definition of their boundary evolves. We find that this ansatz is highly successful in describing the evolution of the low-mass end of the c–M relation. Second, we employ a new physical variable, the effective exponent of linear growth, , to parameterize deviations from an Einstein–de Sitter expansion history. Third, we combine an updated definition of with the additional dependence on and propose a phenomenological extension of our analytical framework to include all halo masses. This semianalytical model matches simulated concentrations in both scale-free models and ΛCDM to 5% accuracy with very few exceptions and differs significantly from all previously proposed models. We present a publicly available code to compute the predictions of our model in the python toolkit Colossus, including updated parameters for the model of Diemer and Kravtsov. [ABSTRACT FROM AUTHOR]

We describe how a simple class of out-of-equilibrium, rotating, and asymmetrical mass distributions evolve under their self-gravity to produce a quasi-planar spiral structure surrounding a virialized core, qualitatively resembling a spiral galaxy. The spiral structure is transient, but can survive tens of dynamical times, and further reproduces qualitatively noted features of spiral galaxies such as the predominance of trailing two-armed spirals and large pitch angles. As our models are highly idealized, a detailed comparison with observations is not appropriate, but generic features of the velocity distributions can be identified to be the potential observational signatures of such a mechanism. Indeed, the mechanism leads generically to a characteristic transition from predominantly rotational motion, in a region outside the core, to radial ballistic motion in the outermost parts. Such radial motions are excluded in our Galaxy up to 15 kpc, but could be detected at larger scales in the future by GAIA. We explore the apparent motions seen by external observers of the velocity distributions of our toy galaxies, and find that it is difficult to distinguish them from those of a rotating disk with sub-dominant radial motions at levels typically inferred from observations. These simple models illustrate the possibility that the observed apparent motions of spiral galaxies might be explained by non-trivial non-stationary mass and velocity distributions without invoking a dark matter halo or modification of Newtonian gravity. In this scenario the observed phenomenological relation between the centripetal and gravitational acceleration of the visible baryonic mass could have a simple explanation. [ABSTRACT FROM AUTHOR]

Mistreatment of trainees is common in the clinical learning environment. Resident mistreatment is less frequently tracked than medical student mistreatment, but data suggest mistreatment remains prevalent at the resident level. To address resident mistreatment, the authors developed an Educational Advance to engage emergency medicine residents and faculty in understanding and improving their learning environment. The authors designed a small-group session with the following goals: 1) Develop a shared understanding of mistreatment and its magnitude; 2) Recognize the prevalence of resident mistreatment data and identify the most common types of mistreatment; 3) Relate study findings to personal or institutional experiences; and 4) Generate strategies for combating mistreatment and strengthening the clinical learning environment at their home institutions. Design was a combination of presentation, small group discussion, and facilitated discussion. Results were presented to participants from a previously administered survey of resident mistreatment. Public humiliation and sexist remarks were the most commonly reported forms. Faculty were the most frequent perpetrators, followed by residents and nurses. A majority of respondents who experienced mistreatment did not report the incident. Session participants were then asked to brainstorm strategies to combat mistreatment. Participants rated the session as effective in raising awareness about resident mistreatment and helping departments develop methods to improve the learning environment. Action items proposed by the group included coaching residents about how to respond to mistreatment, displaying signage in support of a positive learning environment, zero tolerance for mistreatment, clear instructions for reporting, and intentionality training to improve behavior.

Background Proximal interphalangeal joint (PIPJ) dislocations represent a significant proportion of hand clinic visits and typically require frequent follow-ups for clinical assessment, orthotic adjustments, and physiotherapy. There are a large number of treatment options available for PIPJ dislocations, yet no prospective or controlled studies have been carried out, largely due to the diversity of the various types of injuries. Methods We retrospectively reviewed all the PIPJ dislocations in our institution over a five-year period and directly compared the different splinting techniques that we have used over this time frame. Results There were a total of 77 dislocations of the PIPJ (57 men and 20 women) that were included in our study. We found that our management has shifted gradually from complete immobilisation to controlled early mobilisation with figure-of-eight splints. Following treatment, the range of motion of the PIPJ in the figure-of-eight group was significantly greater than that in the other three methods (P