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Objective Point-of care-ultrasound (PoCUS) is useful in evaluating unstable emergency department patients. The portability of this technology increases its potential use in prehospital settings, including helicopter emergency medical services (HEMS) programs. Identifying useful applications may support implementing a PoCUS program that develops sonography skills for prehospital providers. The aim of this study was to determine the HEMS patient population that would benefit from prehospital PoCUS for hypotension and how commonly the extended focused assessment with sonography in trauma (E-FAST) for trauma patients or the rapid ultrasound in shock (RUSH) for medical patients could be used by HEMS. Methods A retrospective chart review was performed over a 1-year period of adult patients transported by a midwestern HEMS system. Charts were reviewed for episodes of hypotension. Results The chart review included 216 charts, of which 3 were excluded. Of the 213 cases, 100 were trauma patients, and 113 were medical patients. Of the trauma patients, 51% experienced hypotension, as did 73 of 113 medical patients. Conclusion Fifty percent of HEMS patients may benefit from PoCUS to evaluate for hypotension in flight.

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Black sea bass (Centropristis striata) is an important fish species in both commercial and recreational fisheries of southern New England and the mid-Atlantic Bight. Due to the intense urbanization of these waters, this species is subject to a wide range of anthropogenic noise pollution. Concerns that C. striata are negatively affected by pile driving and construction noise predominate in areas earmarked for energy development. However, as yet, the hearing range of C. striata is unknown, making it hard to evaluate potential risks. This study is a first step in understanding the effects of anthropogenic noise on C. striata by determining the auditory bandwidth and thresholds of this species using auditory evoked potentials (AEPs), creating pressure and acceleration audiograms. These physiological tests were conducted on wild-caught C. striata in three size/age categories. Results showed that juvenile C. striata significantly had the lowest thresholds, with hearing sensitivity decreasing in the larger size classes. Furthermore, Centropristis striata has fairly sensitive hearing relative to other related species. Preliminary investigations into the mechanisms of their hearing ability were undertaken with gross dissections and an opportunistic micro computed tomography image to address the auditory structures including otoliths and swimbladder morphology. Crucially, the hearing range of C. striata, and their most sensitive frequencies, directly overlap with high-amplitude anthropogenic noise pollution such as shipping and underwater construction.

Over the last decade, ocean temperature in the U.S. Northeast Continental Shelf (U.S. NES) has warmed faster than the global average and is associated with observed distribution changes of the northern stock of black sea bass (Centropristis striata). Mechanistic models based on physiological responses to environmental conditions can improve future habitat suitability projections. We measured maximum, resting metabolic rate, and hypoxia tolerance (Scrit) of the northern adult black sea bass stock to assess performance across the known temperature range of the species. A subset of individuals was held at 30°C for one month (30chronic°C) prior to experiments to test acclimation potential. Absolute aerobic scope (maximum – resting metabolic rate) reached a maximum of 367.21 mgO2 kg−1 hr−1 at 24.4°C while Scrit continued to increase in proportion to resting metabolic rate up to 30°C. The 30chronic°C group had a significant decrease in maximum metabolic rate and absolute aerobic scope but resting metabolic rate or Scrit were not affected. This suggests a decline in performance of oxygen demand processes (e.g. muscle contraction) beyond 24°C despite maintenance of oxygen supply. The Metabolic Index, calculated from Scrit as an estimate of potential aerobic scope, closely matched the measured factorial aerobic scope (maximum / resting metabolic rate) and declined with increasing temperature to a minimum below 3. This may represent a critical value for the species. Temperature in the U.S. NES is projected to increase above 24°C in the southern portion of the northern stock’s range. Therefore, these black sea bass will likely continue to shift north as the ocean continues to warm.

Introduction Contrast-enhanced ultrasound (CEUS) using intravascular microbubbles has potential to revolutionize point-of-care ultrasonography by expanding the use of ultrasonography into clinical scenarios previously reserved for computed tomography (CT), magnetic resonance imaging, or angiography. Methods We performed a literature search and report clinical experience to provide an introduction to CEUS and describe its current applications for point-of-care indications. Results The uses of CEUS include several applications highly relevant for emergency medicine, such as solid-organ injuries, actively bleeding hematomas, or abdominal aortic aneurysms. Compared with CT as the preeminent advanced imaging modality in the emergency department, CEUS is low cost, radiation sparing, repeatable, and readily available. It does not require sedation, preprocedural laboratory assessment, or transportation to the radiology suite. Conclusions CEUS is a promising imaging technique for point-of-care applications in pediatric and adult patients and can be applied for patients with allergy to CT contrast medium or with impaired renal function. More high-quality CEUS research focusing on accuracy, patient safety, health care costs, and throughput times is needed to validate its use in emergency and critical care settings.

Oceanic and coastal waters are acidifying due to processes dominated in the open ocean by increasing atmospheric CO2 and dominated in estuaries and some coastal waters by nutrient-fueled respiration. The patterns and severity of acidification, as well as its effects, are modified by the host of stressors related to human activities that also influence these habitats. Temperature, deoxygenation, and changes in food webs are particularly important co-stressors because they are pervasive, and both their causes and effects are often mechanistically linked to acidification. Development of a theoretical underpinning to multiple stressor research that considers physiological, ecological, and evolutionary perspectives is needed because testing all combinations of stressors and stressor intensities experimentally is impossible. Nevertheless, use of a wide variety of research approaches is a logical and promising strategy for improving understanding of acidification and its effects. Future research that focuses on spatial and temporal patterns of stressor interactions and on identifying mechanisms by which multiple stressors affect individuals, populations, and ecosystems is critical. It is also necessary to incorporate consideration of multiple stressors into management, mitigation, and adaptation to acidification and to increase public and policy recognition of the importance of addressing acidification in the context of the suite of other stressors with which it potentially interacts.

Using an 18-month longitudinal follow-up of women receiving healthcare at intervention clinics compared to control clinics, the present study tested four hypotheses related to the effectiveness of a systems change intervention on intimate partner violence (IPV) inquiry, violence reduction and the health and wellbeing of women patients in family medicine clinics. The study also examined participants’ views of the benefits and harms of IPV inquiry. Results showed that the intervention increased IPV inquiry, discussion, and disclosure compared to usual care. Women in intervention clinics made fewer doctor visits, but also received more prescriptions over time. The groups did not differ in change in physical violence, use of safety plans and strategies, connection to the community, patient satisfaction, or quality of health. Over the course of the study, both the intervention and usual care groups adopted more safety behaviors and experienced less violence, suggesting that participating in research interviews may have constituted an unintentional intervention. Small sample size (N = 34), low participation rate (32 %) and attrition (35 %) call for caution in interpreting these results.

The estuaries and continental shelf system of the United States Mid-Atlantic are subject to ocean acidification driven by atmospheric CO2, and coastal acidification caused by nearshore and land-sea interactions that include biological, chemical, and physical processes. These processes include freshwater and nutrient input from rivers and groundwater; tidally-driven outwelling of nutrients, inorganic carbon, alkalinity; high productivity and respiration; and hypoxia. Hence, these complex dynamic systems exhibit substantial daily, seasonal, and interannual variability that is not well captured by current acidification research on Mid-Atlantic organisms and ecosystems. We present recommendations for research priorities that target better understanding of the ecological impacts of acidification in the U. S. Mid-Atlantic region. Suggested priorities are: 1) Determining the impact of multiple stressors on our resource species as well as the magnitude of acidification; 2) Filling information gaps on major taxa and regionally important species in different life stages to improve understanding of their response to variable temporal scales and sources of acidification; 3) Improving experimental approaches to incorporate realistic environmental variability and gradients, include interactions with other environmental stressors, increase transferability to other systems or organisms, and evaluate community and ecosystem response; 4) Determining the capacity of important species to acclimate or adapt to changing ocean conditions; 5) Considering multi-disciplinary, ecosystem-level research that examines acidification impacts on biodiversity and biotic interactions; and 6) Connecting potential acidification-induced ecological impacts to ecosystem services and the economy. These recommendations, while developed for the Mid-Atlantic, can be applicable to other regions will help align research towards knowledge of potential larger-scale ecological and economic impacts.

There is a great need to demonstrate sustained improvement in healthcare-based inquiry, intervention, and prevention provided to patients exposed to intimate partner violence (IPV). We evaluated implementation of the Healthcare Can Change from Within model (HCCW) in three primary care clinics and an emergency department within a large healthcare system, using two other primary care clinics for a usual-care comparison on selected variables. Outcome measures included individual-level variables (staff knowledge and attitudes) and system characteristics (clinic policies, procedures, patient education materials, and IPV documentation in patient records). Doctors and nurses reported increased self-efficacy, understanding of referral resources, and understanding of legal issues; IPV knowledge was unchanged. Intervention clinics implemented new policies and procedures, increased patient education, and increased documentation of IPV screening, an improvement which was sustained at 2-year follow-up. Results suggest HCCW is a promising practice for improving the healthcare response to IPV.

Injury, including unintentional injury and intentional injury, is the leading cause of death in people aged

Health care providers and patients agree that domestic violence presents a serious health issue that falls within the purview of medical care. The patient-physician encounter has the potential to assist domestic violence victims in considering their options of living without violence and playing a critical role in preventing future violence. Despite this possibility, many persons evaluated in the health care system do not experience the benefits of such interactions. This article reviews current research that evaluates physician, patient, and systems barriers to providing care to patients experiencing domestic violence as well as gaps in the current research and suggestions for how these barriers might be overcome. Educational initiatives, implementation of protocols, and increasing environmental cues that prompt patients and physicians to discuss domestic violence may all increase the likelihood of screening and the success of interventions.

We compared distribution and abundance by habitat for age-0, young-of-the-year (YOY) winter flounder, Pseudopleuronectes americanus, in three estuaries (Hammonasset River, Navesink River, and Great Bay-Little Egg Harbor) in the northeastern United States to better define essential fish habitat (EFH). Two replicates of five representative habitats were sampled in most estuaries: eelgrass (Zostera marina), unvegetated areas adjacent to eelgrass, macroalgae, (primarily Ulva lactuca), unvegetated areas adjacent to macroalgae, and tidal marsh creeks. Fish were sampled every two weeks, May through October 1995 and 1996, with a beam-trawl (1-m width, 3-mm mesh net). Abundance of YOY winter flounder was highest in the Navesink River estuary and similar between years, but was significantly lower and differed between years in the Great Bay-Little Egg Harbor and Hammonasset River estuaries. Annual temperature differences appear to influence estuary use by YOY. In the years and estuaries studied, where habitat-related differences in abundance were significant, YOY were found in higher densities in unvegetated areas adjacent to eelgrass. The exception was in the Hammonasset River in 1995 when densities were higher in eelgrass. We conclude that the type of habitat most important to YOY winter flounder varies among estuaries and as a result, care should be taken in defining EFH, based only on limited spatial and temporal sampling.

White muscle tissue RNA concentration was evaluated as an indirect measure of fish growth. Young-of-the-year winter flounder Pseudopleuronectes americanus and tautog Tautoga onitis were grown in short-term caging experiments conducted during 1994 and 1995 within 3 geographically distinct estuarine systems in the NE of the USA: the Hammonasset River along the Connecticut coast of Long Island Sound, the Navesink River located in the Hudson-Raritan Bay estu- ary in northern New Jersey, and Great Bay-Little Egg Harbor estuary in southern New Jersey. Fish were caged in each of 5 habitat types including: eelgrass, macroalgae, unvegetated areas adjacent to eelgrass, unvegetated areas adjacent to macroalgae, and tidal marsh creeks. White muscle tissue RNA concentration (µg per mg wet tissue wt) was measured in winter flounder and tautog recovered from the cages and compared to instantaneous growth rate measurements of these same fish. RNA concentration was significantly correlated with growth rate measured as length (r = 0.83) and weight (r = 0.79) in winter flounder and length (r = 0.69) and weight (r = 0.73) in tautog. In most cases, estu- ary- and habitat-specific differences in growth rate, as determined by RNA concentration, were sim- ilar to those determined by measuring instantaneous growth. These results validate the use of RNA concentration as an indirect measure of growth in young-of-the-year winter flounder and tautog.

The focused abdominal sonography for trauma (FAST) examination is complicated by brightly lit trauma bays, limited time, and body habitus. Recently, new ultrasound (US) technology has become available that improves organ visualization in abdominal scans. Objective: The hypothesis was that a new US mode, tissue harmonic (TH) imaging, improves visualization of critical organ relationships in the FAST examination by making use of previously unused frequencies. The authors performed a blind, prospective observational study to compare the images obtained in typical FAST views with those obtained in standard US and TH modes. Methods: Blunt trauma patients presenting to a level I trauma center between April and September 2000 were enrolled on a convenience basis. Typical FAST views were obtained in standard and TH modes. The emergency ultrasonographer (EU) switched between modes for each view, optimizing the gain each time. Multiple digital still images were made with all indications of the mode used disguised. For each view on a patient, the best image in each mode was selected in a blinded fashion. Three experienced EUs, blinded to the mode used, rated each image pair for resolution, detail, and total image quality as previously defined on a ten-point Likert scale, 10 being the best for each category. Wilcoxon signed-ranks test, 95% confidence intervals (95% CIs), and interobserver correlation were calculated. Results: A total of 76 image groups (39 of Morison's pouch, 20 splenorenal, and 17 bladder) from 52 patients were rated. Tissue harmonics produced improved resolution, detail, and quality when compared with the standard US mode, with median scores of 6.7 vs. 6.0, 6.7 vs. 6.0, and 6.3 vs. 6.0, respectively. The differences of 0.7 (95% CI = 0.4 to 0.93), 0.7 (95% CI = 0.4 to 0.93), and 0.33 (95% CI = 0.17 to 0.67) were statistically significant, with p = 0.0001, 0.0001, and 0.0003, respectively. There was good interobserver agreement (kappa = 0.74; 95% CI = 0.68 to 0.79). Conslusions: Tissue harmonics produced FAST images higher in detail, resolution, and total image quality than standard-mode US images.

A hand-carried ultrasound training session was organized as an initial step in developing a long-term ultrasound education program for family medicine residents and faculty. Comparative effectiveness studies examining the potential benefits, risks, and any possible cost savings associated with this technology will be predicated on having a sufficient number of primary care physicians trained and able to use hand-carried ultrasounds as part of routine care. The proposed training described here is a first step toward this broader conversation and empirical study of hand-carried ultrasound use in family medicine.An 8-hour training consisting of didactic lectures, case review, and hands-on experience imaging standardized patients with ultrasound machines and an ultrasound simulator. The objective of the course was to introduce focused ultrasound acquisition and interpretation of the gall bladder, kidney, heart, and abdominal aorta to family medicine physicians. Participating physicians were evaluated for changes in self-perceived comfort and proficiency with the hand-carried ultrasound before and after the training.Statistically significant changes for most comfort and proficiency items were demonstrated. Importantly, the only item that did not show significant change dealt with basing clinical decisions on information obtained from the device.The subjective improvement suggests this approach is one potentially useful hand-carried ultrasound training framework. Future work should attempt to further develop curricula and address issues such as longitudinal training assessments and certification and the development of competency in the necessary skill sets.

Objective: To evaluate ultrasound error in patients presenting with penetrating injury with a potential for pericardial effusion. Methods: Residents and faculty from an emergency medicine training program at Level 1 trauma center with an active ultrasound program were asked to view digitized video clips of subxiphoid cardiac examinations in patients with chest trauma. Participants were asked to fill out a standardized questionnaire on each video clip asking whether a pericardial effusion was present. Other questions included size of effusion and presence of tamponade. The study also asked participants to rate their confidence in their impressions. Data were analyzed using interquartile ranges and confidence levels. Results: All participants had difficulty distinguishing between epicardial fat pads and true pericardial effusions. The overall sensitivity was 73% and specificity was 44%. Confidence shown by participants in their answers increased with level of training or experience, regardless of whether they were correct or incorrect. Additional views were frequently requested to help decide whether an effusion was present. Conclusions: A serious potential exists for misdiagnosing epicardial fat pads as pericardial effusion in critically ill trauma patients. Emergency physicians need to be aware of this and should consider one of two suggested alternative methods to improve the accuracy of diagnosis.

Objective: To determine a discriminatory level for serum progesterone (SP) in pregnant patients with no definite intrauterine pregnancy (IUP) on endovaginal ultrasonography (US) in the differentiation of ectopic pregnancy from normal IUPs. Methods: A prospective observational study in a convenience sample of women at risk for ectopic pregnancy was performed at an urban teaching hospital from May 1991 until May 1994. Women aged ≥18 years presenting to the ED with a positive pregnancy test in combination with pelvic or abdominal pain, vaginal bleeding, orthostasis, adnexal mass or tenderness, or any historical risk factor for ectopic pregnancy were eligible. Hypotensive or unstable patients were excluded. Endovaginal US was performed and patients with no definite IUP had a serum 3-hCG and SP measured. Results: 314 patients were enrolled, with 14 excluded for lack of follow-up or incomplete SP data, yielding 300 patients. The initial endovaginal US diagnoses included 169 definite IUP, 31 abnormal IUP, 5 definite ectopic pregnancy, and 95 no definite IUP. 68/95 had SP measured, with values of 22.8 ± 13.4 ng/mL (mean ± SD) for IUP; 4.9 ± 6.5 for spontaneous abortion, and 7.5 ± 7.2 for ectopic pregnancy. The mean values were significantly different (2-tailed t-test) for ectopic pregnancy vs IUP and for spontaneous abortion vs IUP. An SP of ≥11 ng/mL (sensitivity 91%; specificity 84%) was post hoc the best cutoff value for suggesting an IUP when the endovaginal US was not definite for IUP. Conclusions: SP cannot reliably discriminate ectopic pregnancy vs spontaneous abortion in pregnant patients with no definite IUP on endovaginal US; however, a low SP (

This article reviews the current technology, literature, teaching models, and methods associated with simulation-based point-of-care ultrasound training. Patient simulation appears particularly well suited for learning point-of-care ultrasound, which is a required core competency for emergency medicine and other specialties. Work hour limitations have reduced the opportunities for clinical practice, and simulation enables practicing a skill multiple times before it may be used on patients. Ultrasound simulators can be categorized into 2 groups: low and high fidelity. Low-fidelity simulators are usually static simulators, meaning that they have nonchanging anatomic examples for sonographic practice. Advantages are that the model may be reused over time, and some simulators can be homemade. High-fidelity simulators are usually high-tech and frequently consist of many computer-generated cases of virtual sonographic anatomy that can be scanned with a mock probe. This type of equipment is produced commercially and is more expensive. High-fidelity simulators provide students with an active and safe learning environment and make a reproducible standardized assessment of many different ultrasound cases possible. The advantages and disadvantages of using low- versus high-fidelity simulators are reviewed. An additional concept used in simulation-based ultrasound training is blended learning. Blended learning may include face-to-face or online learning often in combination with a learning management system. Increasingly, with simulation and Web-based learning technologies, tools are now available to medical educators for the standardization of both ultrasound skills training and competency assessment.

Study objectives: To determine whether bedside endovaginal sonography (EVS) performed by emergency physicians reduces complications associated with ectopic pregnancy (EP) including missed EP and EP rupture. Methods: Our setting was an urban trauma center emergency department. We assembled a prospective convenience sample (n=314) with a historical EP control group (n=56) of women 18 years or older with a positive pregnancy test and any signs, symptoms, or risk factors for EP. Bedside EVS for all subjects and immediate quantitative serum human chorionic gonadotropin determination for patients with no definite intrauterine pregnancy by EVS. Results: Retrospective chart review identified 56 EP patients in the historical control group who had had no bedside EVS. Twenty-four of these patients (43%; 95% confidence interval [CI], 30% to 56%) were discharged from the ED, 12 of whom (50%; 95% CI, 30% to 70%) were later categorized as having ruptured EP. During the prospective study period, 40 patients were diagnosed as having EP; 11 (28%; 95% CI, 14% to 42%) were discharged from the ED ( P =NS), and only 1 (9%; 95% CI, 0% to 26%) of the discharged patients was later determined to have a ruptured EP ( P Conclusion: An EP protocol incorporating bedside EVS performed by emergency physicians significantly reduced the incidence of discharged patients with subsequent EP rupture, compared with historical controls. [Mateer JR, Valley VT, Aiman EJ, Phelan MB, Thoma ME, Kefer MP: Outcome analysis of a protocol including bedside endovaginal sonography in patients at risk for ectopic pregnancy. Ann Emerg Med March 1996;27:283-289.]

Gender differences among a cohort of injured patients seeking emergency medical services were examined with respect to their experiences as perpetrators and/or victims of domestic violence. Contextual issues, including violence initiation, emotional and behavioral responses to partner-initiated violence, and injury frequency and severity were analyzed. Women reported male partner-initiated violence more frequently than men reported female partner-initiated violence. Behavioral responses to partner initiated violence varied. Women were more likely to report using force back and to involve law enforcement. Women were more likely to be injured in a domestic assault over their lifetime, within the last year, and at the time of recruitment. Comparison of injury severity revealed that women reported higher rates of injuries than men in all possible severity categories. Women also reported experiencing more fear than men during partner-initiated violence, as well as being subjected to larger numbers of dominating and controlling behaviors, and greater intimidation secondary to their partner's size. Understanding contextual differences in partner violence for women and men has significant implications for policy development, identification, treatment, and referral of patients identified as living in violent relationships.

Pelvic ultrasonography is a valuable tool for the emergency physician in the evaluation of the wide spectrum of pelvic complaints presenting to the emergency department. The goal of this article is to outline pelvic problems that can be readily identified by the emergency physician using pelvic sonography early in the patient's evaluation. A special emphasis is placed on the sonographic diagnosis of ectopic pregnancy.

To examine the scope of alcohol use among a population of injured adolescents.A convenience sample of injured patients aged 12-18 years seen at a pediatric ED was tested for the presence of alcohol. Injured patients seen within 6 hours of their injuries were asked to submit urine samples for testing using reagent strips. Data were collected from the patient, out-of-hospital emergency care personnel, and parents regarding the circumstances of the injury.Of the 243 injured patients who were tested during an 8-month period, 231 were included in the final analysis. Ninety patients (39%) were alcohol-positive. The mean age of the alcohol-positive group was 16.0 +/- 1.64 years, compared with 15.3 +/- 1.8 years for the alcohol-negative group (p0.003). There was no significant difference between the 2 groups based on race, gender, or injury characteristics. A positive urine alcohol test was found for 18 (33%) of motor vehicle crash victims, 9 (38%) of the motor vehicle drivers, 10 (37%) of the patients who attempted suicide, and 49 (44%) of the assault victims.A substantial percentage of injured adolescent patients were alcohol-positive. The authors recommend the use of alcohol screening when treating injured adolescents.

Forty-two actinomycete strains were isolated by enrichment techniques from soils and other lignocellulose-containing natural habitats. Isolates were screened for their lignocellulose-decomposing abilities using a substrate weight loss – 14C-labeled lignocellulose degradation assay which determined the relative abilities of each isolate to attack lignin versus glucan components of lignocellulose. Six Streptomyces strains were selected for further study, based upon their abilities to decompose significantly both lignin and glucan components of lignocellulose. The selected strains were examined under defined cultural conditions for their abilities to decompose 14C-labeled lignocelluloses prepared from Douglas fir. The 14C-labeled lignocellulose substrates included specifically lignin-labeled or glucan-labeled lignocelluloses, and two [14C]lignin lignocelluloses labeled specifically in only the lignin side chain or ring components. Results showed that the Streptomyces strains decomposed substantial amounts of both lignin and glucan components to 14CO2, and 14C-labeled water-soluble products. As compared with previously described lignocellulose-degrading streptomycetes, these strains were generally more efficient decomposers of the lignin component of lignocellulose, but were similar in their abilities to decompose the glucan component. Characterization of growth on specifically labeled lignins showed that aromatic ring structures within the lignin were cleaved and a substantial percentage of the ring carbons were released as CO2. In contrast, side-chain components were attacked to only a limited degree. These streptomycetes were similar to other recently characterized lignin-decomposing bacteria in their overall abilities to degrade lignin, but their specificity of attack on the structural components of lignin appears to be different.