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Theoretical basis The case learning objectives and discussion questions relate very closely to several theories related to branding, including brand positioning, brand growth, brand management, customer value proposition, brand matrix and brand identity. Research methodology The information provided in this case was gathered by the author through personal interviews and email exchanges with Jordan Boyes, managing broker and owner of Boyes Group Realty Inc. Secondary research was also conducted to gather relevant academic materials, as well as industry and competitor information. Case overview/synopsis Jordan Boyes opened Boyes Group Realty Inc. in 2015 after working as a Realtor® at another private realty firm in Saskatoon, Saskatchewan for several years. They offered buying and selling services in the areas of commercial, residential and farm real estate. Over the past five years, they had experienced strong sales numbers and growth in the number of new agents joining the company. However, Boyes saw untapped potential in the marketplace and wanted to develop a brand strategy that took the best advantage of brand extension opportunities to drive the continued growth of his company. Complexity academic level This case is suitable at the undergraduate level for a branding course, marketing strategy course or services marketing course. The case is best used to apply the concept of developing brand identity and making strategic decisions in a service-based organization.

Background miRNAs are promising biomarkers in oncology as their small size makes them less susceptible to degradation than mRNA in FFPE tissue. We aimed to derive a hypoxia-associated miRNA signature for bladder cancer. Methods Taqman miRNA array cards identified miRNA seed genes induced under hypoxia in bladder cancer cell lines. A signature was derived using feature selection methods in a TCGA BLCA training data set. miRNA expression data were generated for 190 tumours from the BCON Phase 3 trial and used for independent validation. Results A 14-miRNA hypoxia signature was derived, which was prognostic for poorer overall survival in the TCGA BLCA cohort (n = 403, p = 0.001). Univariable analysis showed that the miRNA signature predicted an overall survival benefit from having carbogen–nicotinamide with radiotherapy (HR = 0.30, 95% CI 0.094–0.95, p = 0.030) and performed similarly to a 24-gene mRNA signature (HR = 0.47, 95% CI 0.24–0.92, p = 0.025). Combining the signatures improved performance (HR = 0.26, 95% CI 0.08–0.82, p = 0.014) with borderline significance for an interaction test (p = 0.065). The interaction test was significant for local relapse-free survival LRFS (p = 0.033). Conclusion A 14-miRNA hypoxia signature can be used with an mRNA hypoxia signature to identify bladder cancer patients benefitting most from having carbogen and nicotinamide with radiotherapy.

PurposeMany muscle-invasive bladder cancers are hypoxic, which limits the efficacy of radiation therapy. Hypoxia modification using carbogen and nicotinamide has been tested in a phase 3 trial, Bladder Carbogen Nicotinamide. We present mature follow-up data with biomarker predictions of outcomes.Methods and MaterialsBladder Carbogen Nicotinamide is a prospective, phase 3, multicenter, randomized, 2-arm, nonblinded clinical trial. Participants were randomized to receive radical radiation therapy (RT; control arm) alone or with the addition of carbogen (98% O2; 2% CO2) and nicotinamide (CON). Patients with muscle-invasive or high-grade non–muscle invasive bladder cancer were included. Tumor tissue was collected at entry and was analyzed for tumor necrosis, hypoxia (24-gene signature), and basal and luminal tumor molecular subtypes. Overall survival (OS) and disease-free survival and relationships with biomarker status outcomes are analyzed using multivariable Cox regression and log-rank analysis.ResultsWe analyzed 333 patients with a median follow-up of 10.3 years. The 10-year OS rates were 30% (95% confidence interval [CI], 0.23-0.39) in RT + CON patients and 24% (95% CI, 0.18-0.33) in the RT-alone patients (hazard ratio [HR], 0.80; 95% CI, 0.61-1.04; P = .08). The greatest benefit from CON was seen in patients with tumor necrosis (n = 79; 5-year OS, 53% vs. 33% in patients without tumor necrosis; HR, 0.59; 95% CI, 0.36-0.99; P = .04). Cases with a high hypoxia gene score (n = 75) had a 5-year OS rate of 51%, compared to 34% for a low score (HR, 0.64; 95% CI, 0.38-1.08; P = .09); those with the basal molecular subtype (n = 70) had a 5-year OS rate of 58%, compared to 38% for those with the luminal subtype (HR, 0.58; 95% CI, 0.32-1.06; P = .08).ConclusionsAlthough the improvement in long-term OS in the whole population is not statistically significant, patients selected by necrosis and high hypoxia gene score benefitted from hypoxia modification.

The second Newborn Sequencing in Genomic Medicine and Public Health (NSIGHT2) study was a randomized, controlled trial of rapid whole-genome sequencing (rWGS) or rapid whole-exome sequencing (rWES) in infants with diseases of unknown etiology in intensive care units (ICUs). Gravely ill infants were not randomized and received ultra-rapid whole-genome sequencing (urWGS). Herein we report results of clinician surveys of the clinical utility of rapid genomic sequencing (RGS). The primary end-point-clinician perception that RGS was useful- was met for 154 (77%) of 201 infants. Both positive and negative tests were rated as having clinical utility (42 of 45 [93%] and 112 of 156 [72%], respectively). Physicians reported that RGS changed clinical management in 57 (28%) infants, particularly in those receiving urWGS (p = 0.0001) and positive tests (p < 0.00001). Outcomes of 32 (15%) infants were perceived to be changed by RGS. Positive tests changed outcomes more frequently than negative tests (p < 0.00001). In logistic regression models, the likelihood that RGS was perceived as useful increased 6.7-fold when associated with changes in management (95% CI 1.8-43.3). Changes in management were 10.1-fold more likely when results were positive (95% CI 4.7-22.4) and turnaround time was shorter (odds ratio 0.92, 95% CI 0.85-0.99). RGS seldom led to clinician-perceived confusion or distress among families (6 of 207 [3%]). In summary, clinicians perceived high clinical utility and low likelihood of harm with first-tier RGS of infants in ICUs with diseases of unknown etiology. RGS was perceived as beneficial irrespective of whether results were positive or negative.

INTRODUCTION AND OBJECTIVE:Guideline-recommended management of high risk (HR) prostate cancer (PCa) is radical prostatectomy with pelvic lymph node dissection (RP+PLND) or radiation therapy with/wi...

BACKGROUND AND OBJECTIVES: There are no US Food and Drug Administration–approved therapies for neonatal seizures. Phenobarbital and phenytoin frequently fail to control seizures. There are concerns about the safety of seizure medications in the developing brain. Levetiracetam has proven efficacy and an excellent safety profile in older patients; therefore, there is great interest in its use in neonates. However, randomized studies have not been performed. Our objectives were to study the efficacy and safety of levetiracetam compared with phenobarbital as a first-line treatment of neonatal seizures. METHODS: The study was a multicenter, randomized, blinded, controlled, phase IIb trial investigating the efficacy and safety of levetiracetam compared with phenobarbital as a first-line treatment for neonatal seizures of any cause. The primary outcome measure was complete seizure freedom for 24 hours, assessed by independent review of the EEGs by 2 neurophysiologists. RESULTS: Eighty percent of patients (24 of 30) randomly assigned to phenobarbital remained seizure free for 24 hours, compared with 28% of patients (15 of 53) randomly assigned to levetiracetam (P < .001; relative risk 0.35 [95% confidence interval: 0.22–0.56]; modified intention-to-treat population). A 7.5% improvement in efficacy was achieved with a dose escalation of levetiracetam from 40 to 60 mg/kg. More adverse effects were seen in subjects randomly assigned to phenobarbital (not statistically significant). CONCLUSIONS: In this phase IIb study, phenobarbital was more effective than levetiracetam for the treatment of neonatal seizures. Higher rates of adverse effects were seen with phenobarbital treatment. Higher-dose studies of levetiracetam are warranted, and definitive studies with long-term outcome measures are needed.

The second Newborn Sequencing in Genomic Medicine and Public Health study was a randomized, controlled trial of the effectiveness of rapid whole-genome or -exome sequencing (rWGS or rWES, respectively) in seriously ill infants with diseases of unknown etiology. Here we report comparisons of analytic and diagnostic performance. Of 1,248 ill inpatient infants, 578 (46%) had diseases of unknown etiology. 213 infants (37% of those eligible) were enrolled within 96h of admission. 24 infants (11%) were very ill and received ultra-rapid whole-genome sequencing (urWGS). The remaining infants were randomized, 95 to rWES and 94 to rWGS. The analytic performance of rWGS was superior to rWES, including variants likely to affect protein function, and ClinVar pathogenic/likely pathogenic variants (p < 0.0001). The diagnostic performance of rWGS and rWES were similar (18 diagnoses in 94 infants [19%] versus 19 diagnoses in 95 infants [20%], respectively), as was time to result (median 11.0 versus 11.2days, respectively). However, the proportion diagnosed by urWGS (11 of 24 [46%]) was higher than rWES/rWGS (p = 0.004) and time to result was less (median 4.6days, p < 0.0001). The incremental diagnostic yield of reflexing to trio after negative proband analysis was 0.7% (1 of 147). In conclusion, rapid genomic sequencing can be performed as a first-tier diagnostic test in inpatient infants. urWGS had the shortest time to result, which was important in unstable infants, and those in whom a genetic diagnosis was likely to impact immediate management. Further comparison of urWGS and rWES is warranted because genomic technologies and knowledge of variant pathogenicity are evolving rapidly.

Background: There are no FDA approved therapies for neonatal seizures. Previous studies demonstrated that phenobarbital (PHB) and phenytoin frequently fail to control seizures. There are concerns about the safety of seizure medications in the developing brain. Levetiracetam (LEV) has proven efficacy in children and adults and has an excellent safety profile; therefore, there is great interest in its use in neonates, but randomized studies have not been performed. Methods: The study was a multicenter, randomized, blinded, controlled, phase IIb trial investigating the efficacy and safety of LEV compared with PHB in the first-line treatment of neonatal seizures, and including a dose escalation component. The primary outcome measure was complete seizure freedom for 24 hours after medication administration. Efficacy in seizure control was determined by independent review of the video EEGs by two neurophysiologists. Results: Eighty percent of subjects (24 of 30) randomized to PHB remained seizure free for 24 hours as compared with 28% of subjects (15 of 53) randomized to LEV (p

Continuous video electroencephalography (cEEG) monitoring is the recommended gold standard of care for at-risk neonates but is not available in many Neonatal Intensive Care Units (NICUs). To conduct a randomized treatment trial of levetiracetam for the first-line treatment of neonatal seizures (the NEOLEV2 trial), we developed a monitoring infrastructure at five NICUs, implementing recent technological advancements to provide continuous video EEG monitoring and real-time response to seizure detection. Here, we report on the feasibility of providing this level of care.Twenty-five key informant interviews were conducted with study neurologists, neonatologists, coordinators, and EEG technicians from the commercial EEG monitoring company Corticare. A general inductive approach was used to analyze these qualitative data.A robust infrastructure for continuous video EEG monitoring, remote review, and real-time seizure detection was established at all sites. At the time of this survey, 260 babies had been recruited and monitored for 2 to 6 days. The EEG technician review by the commercial EEG monitoring company was reassuring to families and neonatologists and led to earlier detection of seizures but did not reduce work load for neurologists. Neurologists found the automated neonatal seizure detector algorithm provided by the EEG software company Persyst useful, but the accuracy of the algorithm was not such that it could be used without review by human expert. Placement of EEG electrodes to initiate monitoring, especially after hours, remains problematic.Technological advancements have made it possible to provide at-risk neonates with continuous video EEG monitoring, real-time detection of and response to seizures. However, this standard of care remains unfeasible in usual clinical practice. Chief obstacles remain starting a recording and resourcing the real-time specialist review of suspect seizures.

BACKGROUND: Congenital diaphragmatic hernia remains a complex disease with significant morbidity and mortality. Hypercarbia is a common derangement in this population, which often requires escalating ventilator support. By decreasing airway turbulence and enhancing CO2 removal, inhaled helium-oxygen mixture (heliox) has the potential to improve ventilation and thereby decrease ventilator support and its associated lung injury. METHODS: Retrospective cohort review of all neonates with congenital diaphragmatic hernia treated at Rady Children9s Hospital San Diego during 2011–2015. Clinical characteristics were compared between the infants who were treated with heliox and those who did not receive this intervention. To analyze the effect of heliox in the subgroup that received this treatment, ventilator settings and arterial blood gas values were compared before and after starting heliox by using paired t tests. RESULTS: During the study period, 45 neonates with congenital diaphragmatic hernia were admitted to our neonatal ICU, 28 received heliox, and 27 were analyzed. During heliox treatment, PaCO2 levels decreased from 68 to 49 mm Hg (P CONCLUSIONS: The addition of heliox to the standard practice of permissive hypercapnia facilitated improvement in gas exchange, which allowed a decrease in ventilator settings and oxygen exposure, both of which are known to contribute to lung injury in this population. A prospective trial is needed to more clearly define the acute and long-term impacts of this treatment.

Acquisition of skills early in surgical training represents a significant challenge at present because of training time constraints. The aim of this study was to investigate if an intensive surgical boot camp was effective in transferring skills at the beginning of a surgical training program.New core surgical trainees (n = 58) took part in a 5-day boot camp. There were pretest and posttest assessments of knowledge, technical skills, and confidence levels. The boot camp used simulation and senior surgical faculty to teach a defined range of technical and nontechnical skills.The scores for knowledge (53.8% vs 68.4%, P.01), technical skills (35.9% to 60.6% vs 50.6% to 78.2%, P.01), and confidence levels improved significantly during boot camp. Skills improvements were still present a year later.The 5-day surgical boot camp proved to be an effective way to rapidly acquire surgical knowledge and skills while increasing the confidence levels of trainees.

This is a key chapter in the book, presenting recommendations for how to configure the fiber-to-the-home (FTTH) plant under a large number of real-world conditions and services. Video in both broadcast and Internet protocol TV (IPTV) are covered, as are voice and a number of different data services.

This chapter presents concepts you will need to keep in mind as you design and build your IPTV facility. It covers unicast and multicast, as well as over-the-top (OTT) video. We discuss capacity planning issues for IPTV, which will surely be your biggest bandwidth usage.

This chapter presents an introduction to video which will be of interest to both those carrying radio frequency (RF) broadcast video and those carrying IPTV. The latter portions concentrate on issues related to RF broadcast of video.

The key accessory required for an fiber-to-the-home (FTTH) deployment is a network management platform capable of integrating all management elements into a simple, easy to use and flexible system. Furthermore, this must be integrated into a system which can reliably manage the deployment of services and billing to them accurately. This chapter provides visibility into the management of an FTTH deployment and the services which are provided to the customer.

This chapter presents concepts you will need to keep in mind as you deploy voice service on your network. The emphasis is on the SIP (session initiation protocol), as it is the dominant protocol at the time of writing. We describe how it works, and present some cases in which you may encounter difficulties, suggesting how to avoid them.

The primary competition for fiber-to-the-home (FTTH) will be the cable TV operator's hybrid fiber-coax (HFC) network, possibly with competition from the telephone company's digital subscriber line (DSL) service in areas where they have suitable plant. The prime area of competition today is data speed. Cable operators are able to exceed 100 Mb/s in some places, and have plans to go higher, though how much higher they can go while maintaining expected video service is questionable. If you deploy your network correctly you will win over the cable operator every time, but don't expect him to give up easily—he won't.

This chapter presents concepts you will need to keep in mind as you design and build your outside plant. It covers important physical architectural considerations applicable to any type of passive optical network (PON), and suggests the most economical ways to build plant under different conditions. It also talks about a reasonably accurate way to calculate how much reach you can safely achieve with different PONs.

This chapter defines performance management using standards based definitions and practical considerations in the context of the FTTx access network. A methodology for developing a performance management system to benefit the network operator long term, in the operation of the network, is provided. Applications for the usage of performance management data are presented along with strategies for collecting, managing, and using the data.

This chapter presents several standards that may be incorporated into certain passive optical networks (PONs), depending on what you plan to do with the PON. This is often based on the services you will offer, your present business(es) and your competitive landscape.

This chapter provides a high-level view of challenges an operator must be aware of in the deployment of an access network. Guidelines are provided to various agencies and sources of information which maintain real-time updates on security threats. Topics such as denial of service attacks and management protection are highlighted.

This chapter presents several physical architectures you might consider for a fiber deployment, as well as some discussion of the PON alternatives on a high level.

Acute pancreatitis has a mortality rate of 5-10%. Early deaths are mainly due to multiorgan failure and late deaths are due to septic complications from pancreatic necrosis. The recently described 2012 Revised Atlanta Classification and the Determinant Classification both provide a more accurate description of edematous and necrotizing pancreatitis and local complications. The 2012 Revised Atlanta Classification uses the modified Marshall scoring system for assessing organ dysfunction. The Determinant Classification uses the sepsis-related organ failure assessment scoring system for organ dysfunction and, unlike the 2012 Revised Atlanta Classification, includes infected necrosis as a criterion of severity. These scoring systems are used to assess systemic complications requiring intensive therapy unit support and intra-abdominal complications requiring minimally invasive interventions. Numerous prognostic systems and markers have been evaluated but only the Glasgow system and serum CRP levels provide pragmatic prognostic accuracy early on. Novel concepts using genetic, transcriptomic and proteomic profiling and also functional imaging for the identification of specific disease patterns are now required.

We show protein kinase C-zeta (PKC-ζ) to be a novel predictive biomarker for survival from prostate cancer (P < 0.001). We also confirm that transcription of the PRKC-ζ gene is crucial to the malignant phenotype of human prostate cancer. Following siRNA silencing of PRKC-ζ in PC3-M prostate cancer cells, stable transfectant cell line si-PRKC-ζ-PC3-M(T1-6) is phenotypically nonmalignant in vitro and in vivo. Genome-wide expression analysis identified 373 genes to be differentially expressed in the knockdown cells and 4 key gene networks to be significantly perturbed during phenotype modulation. Functional interconnection between some of the modulated genes is revealed, although these may be within different regulatory pathways, emphasizing the complexity of their mutual interdependence. Genes with altered expression following PRKC-ζ knockdown include HSPB1, RAD51, and ID1 that we have previously described to be critical in prostatic malignancy. Because expression of PRKC-ζ is functionally involved in promoting the malignant phenotype, we propose PKC-ζ as a novel and biologically relevant target for therapeutic intervention in prostate cancer.

The aim of the study was to select surgeons for a higher surgical training in general surgery programme at the Royal College of Surgeons in Ireland (RCSI) using an objective, transparent and fair assessment programme. Thirty-two individuals applied for higher surgical training in general surgery in Ireland in 2006. Sixteen applicants were short-listed for interview and further assessment. All applicants were required to report on their education performance at undergraduate level and their postgraduate professional development. Applicants were scored on their training record during basic surgical training, structures references, clinical experience, approved technical skills courses, validated logbook and consolidation sheet. Assessments of their research and academic surgery included, the award of a higher degree by thesis, and other surgically relevant degree's or diplomas that had been obtained through part-time studies and were awarded by educational establishments recognized by RCSI or the Irish Medical Council. Short-listed applicants completed validated objective assessment simulations of surgical skills, an interview and assessment of their suitability for a career in surgery. The nine individuals who were selected for higher surgical training in general surgery consistently scored higher than those candidates who were not, in post-graduate development (P < 0.001), surgical skills (P < 0.002), interview scores (P < 0.007) and suitability for a career in surgery (P < 0.002). All performance assessment elements except undergraduate education showed high internal reliability alpha = 0.89 and good statistical power (range 0.95-0.99). The statistical power of undergraduate education was 0.7. The objective assessment programme introduced by RCSI for selection of candidates for the programme in higher surgical training in general surgery reliably and consistently distinguished between candidates. Candidates selected for further training consistently outperformed those who were not in good concordance between measures. This common selection process for higher surgical training is now being rolled out for selection into higher surgical training across all surgical specialties in Ireland.

Computer simulations continue to prove to be a valuable tool in physics education. Based on the needs of an Aviation Physics course, we developed the PHYSics of FLIght Simulator (PhysFliS), which numerically solves Newton's second law for an airplane in flight based on standard aerodynamics relationships. The simulation can be used to pique students' interest, teach a number of physics concepts, and teach computational investigation techniques. This paper describes the development and operation of this simulation, illustrates an example study that can be performed using it, and suggests further ideas for its use.

The purpose of this study was to discuss the treatment of a case of spontaneous intestinal herniation per vagina in a patient who had undergone previous transabdominal hysterectomy and to review the related literature.A computer-based search of the English literature from January 1900 to October 2004 with the use of the terms vaginal herniation, vaginal evisceration, and vaginal trauma/injury was performed. Causes, presentation, and treatment were discussed and compared with a recent case that was treated locally in our hospital.Vaginal evisceration was described in the literature as early as 1864; since then100 cases have been reported in the literature. It is more common in menopausal women with previous hysterectomy pelvic or vaginal surgery. Vaginal trauma, as in rough coitus, instrumentation, obstetric injury, is a recognized cause in premenopausal women.Vaginal evisceration is a rare, distressing emergency that requires aggressive resuscitation and urgent surgical intervention.

s / Pancreatology 16 (2016) S1eS63 S32 Conclusion: Repeated FNA or serum CA19-9 levels were helpful in improving the diagnosis.

The access to water and the engineered landscapes accommodating its collection and allocation are pivotal issues for assessing sustainability. Recent mapping, sediment coring, and formal excavation at Tikal, Guatemala, have markedly expanded our understanding of ancient Maya water and land use. Among the landscape and engineering feats identified are the largest ancient dam identified in the Maya area of Central America; the posited manner by which reservoir waters were released; construction of a cofferdam for dredging the largest reservoir at Tikal; the presence of ancient springs linked to the initial colonization of Tikal; the use of sand filtration to cleanse water entering reservoirs; a switching station that facilitated seasonal filling and release; and the deepest rock-cut canal segment in the Maya Lowlands. These engineering achievements were integrated into a system that sustained the urban complex through deep time, and they have implications for sustainable construction and use of water management systems in tropical forest settings worldwide.

Band erosion (BE) into the gastric lumen occurs in 0.2–11% cases of laparoscopic adjustable gastric banding(LAGB) [1,2]. The revision options for failed LAGB in-clude band replacement, conversion to Roux-en-Y gastricbypass, biliopancreatic diversion with duodenal switch, orvertical sleeve gastrectomy (VSG). LAGB revisions can beperformed at band removal or as a staged second procedure[3–5]. VSG has been successfully used as a revision proce-dure for failed gastric banding due to band intolerance,prolapse, or failed weight loss [6]. Laparoscopic transgastricexcision of an eroded band with immediate conversion toVSG has not been previously reported.

Background We investigated whether combinations of serum cytokines, used with logistic disease predictor models, could facilitate the detection of pancreatic ductal adenocarcinoma (PDAC). Methods The serum levels of 27 cytokines were measured in 241 subjects, 127 with PDAC, 49 with chronic pancreatitis, 20 with benign biliary obstruction and 45 healthy controls. Samples were split randomly into independent training and test sets. Cytokine biomarker panels were selected by identifying the top performing cytokines in best fit logistic regression models during multiple rounds of resampling from the training dataset. Disease prediction by logistic models, built using the resulting cytokine panels, was evaluated with training and test sets and further examined using resampled performance evaluation. Results For the discrimination of PDAC patients from patients with benign disease, a panel of IP-10, IL-6, PDGF plus CA19-9 offered improved diagnostic performance over CA19-9 alone in the training (AUC 0.838 vs. 0.678) and independent test set (AUC 0.884 vs. 0.798). For the discrimination of PDAC from CP, a panel of IL-8, CA19-9, IL-6 and IP-10 offered improved diagnostic performance over CA19-9 alone with the training (AUC 0.880 vs. 0.758) and test set (AUC 0.912 vs. 0.848). Finally, for the discrimination of PDAC in the presence of jaundice from benign controls with jaundice, a panel of IP-10, IL-8, IL-1b and PDGF demonstrated improvement over CA19-9 in the training (AUC 0.810 vs. 0.614) and test set (AUC 0.857 vs. 0.659). Conclusions These findings support the potential role for cytokine panels in the discrimination of PDAC from patients with benign pancreatic diseases and warrant additional study.

Study objective: To determine the accuracy and application of pelvic ultrasound performed by emergency physicians in detecting ectopic pregnancy (EP) in complicated first-trimester pregnancies. Methods: We studied consecutive pelvic ultrasounds performed in all women who presented with abdominal pain or vaginal bleeding during the first trimester of pregnancy over a 6-month period. Patients with clinical evidence of incomplete abortion were not included. We compared ultrasound results with subsequent ultrasound findings by the radiology department and correlated them with follow-up diagnoses and outcomes. Results: Of the 136 eligible patients, a final diagnosis was rendered in 125; 11 were lost to follow-up. These ED ultrasound findings were recorded: established intrauterine pregnancy (IUP) with embryonic structures, 87 (70%); indeterminate scan revealing no distinct evidence of IUP or EP, 15 (12%); early intrauterine gestational sac of less than 6 weeks without embryonic structures, 12 (10%); EP, 8 (6%); blighted ovum, 2 (2%); and molar pregnancy, 1 (1%). The initial ED ultrasound determination was consistent with radiology department findings, final outcome, or both in 121 (96%) (95% confidence interval [CI], 91% to 97%). ED ultrasound accurately identified 87 pregnancies with intrauterine embryonic structures, including 5 patients with fetal demise (95% CI, 97% to 100%). Diagnosis of pregnancy location in these 87 patients effectively ruled out EP, with a negative predictive value of 100%. The sensitivity and specificity of ED ultrasound in the detection of EP were 90% and 88%, respectively. Conclusion: Pelvic ultrasonography performed by emergency physicians can be used to rule out EP and make an accurate diagnosis in most patients with complicated first-trimester pregnancies during the initial ED visit. The remaining patients at risk can be identified and a diagnosis made by means of follow-up ultrasound and serial hCG determinations. [Durham B, Lane B, Burbridge L, Balasubramaniam S: Pelvic ultrasound performed by emergency physicians for the detection of ectopic pregnancy in complicated first-trimester pregnancies. Ann Emerg Med March 1997;29:338-347.]