Study objective Randomized trials suggest that nonoperative treatment of uncomplicated appendicitis with antibiotics-first is safe. No trial has evaluated outpatient treatment and no US randomized trial has been conducted, to our knowledge. This pilot study assessed feasibility of a multicenter US study comparing antibiotics-first, including outpatient management, with appendectomy. Methods Patients aged 5 years or older with uncomplicated appendicitis at 1 US hospital were randomized to appendectomy or intravenous ertapenem greater than or equal to 48 hours and oral cefdinir and metronidazole. Stable antibiotics-first-treated participants older than 13 years could be discharged after greater than or equal to 6-hour emergency department (ED) observation with next-day follow-up. Outcomes included 1-month major complication rate (primary) and hospital duration, pain, disability, quality of life, and hospital charges, and antibiotics-first appendectomy rate. Results Of 48 eligible patients, 30 (62.5%) consented, of whom 16 (53.3%) were randomized to antibiotics-first and 14 (46.7%) to appendectomy. Median age was 33 years (range 9 to 73 years), median WBC count was 15,000/μL (range 6,200 to 23,100/μL), and median computed tomography appendiceal diameter was 10 mm (range 7 to 18 mm). Of 15 antibiotic-treated adults, 14 (93.3%) were discharged from the ED and all had symptom resolution. At 1 month, major complications occurred in 2 appendectomy participants (14.3%; 95% confidence interval [CI] 1.8% to 42.8%) and 1 antibiotics-first participant (6.3%; 95% CI 0.2% to 30.2%). Antibiotics-first participants had less total hospital time than appendectomy participants, 16.2 versus 42.1 hours, respectively. Antibiotics-first-treated participants had less pain and disability. During median 12-month follow-up, 2 of 15 antibiotics-first-treated participants (13.3%; 95% CI 3.7% to 37.9%) developed appendicitis and 1 was treated successfully with antibiotics; 1 had appendectomy. No more major complications occurred in either group. Conclusion A multicenter US trial comparing antibiotics-first to appendectomy, including outpatient management, is feasible to evaluate efficacy and safety.

This diagnostic study evaluates the sensitivity and specificity of point-of-care ultrasonography performed by emergency medical practitioners in identifying retinal detachment, vitreous hemorrhage, and vitreous detachment among patients with ocular symptoms who present to the emergency department.

Financial commitments and the full schedules of medical schools are the current prevailing roadblocks to implementation of ultrasound education. Experiences drawn from current USMED directors in this study may be used to help programs starting their own curricula.

Objectives The goal of this study was to examine the ability of emergency physicians who are not experts in emergency ultrasound (US) to perform lung ultrasonography and to identify B-lines. The hypothesis was that novice sonographers are able to perform lung US and identify B-lines after a brief intervention. In addition, the authors examined the diagnostic accuracy of B-lines in undifferentiated dyspneic patients for the diagnosis of acute heart failure syndrome (AHFS), using an eight-lung-zone technique as well as an abbreviated two-lung-zone technique. Methods This was a prospective, cross-sectional study of patients who presented to the emergency department (ED) with acute dyspnea from May 2009 to June 2010. Emergency medicine (EM) resident physicians, who received a 30-minute training course in thoracic US examinations, performed lung ultrasonography on patients presenting to the ED with undifferentiated dyspnea. They attempted to identify the presence or absence of sonographic B-lines in eight lung fields based on their bedside US examinations. An emergency US expert blinded to the diagnosis and patient presentation, as well as to the residents’ interpretations of presence of B-lines, served as the criterion standard. A secondary outcome determined the accuracy of B-lines, using both an eight-lung-zone and a two-lung-zone technique, for predicting pulmonary edema from AHFS in patients presenting with undifferentiated dyspnea. Two expert reviewers who were blinded to the US results determined the clinical diagnosis of AHFS. Results A cohort of 66 EM resident physicians performed lung US on 380 patients with a range of 1 to 28 examinations, a mean of 5.8 examinations, and a median of three examinations performed per resident. Compared to expert interpretation, lung US to detect B-lines by inexperienced sonographers achieved the following test characteristics: sensitivity 85%, specificity 84%, positive likelihood ratio (+LR) 5.2, negative likelihood ratio (−LR) 0.2, positive predictive value (PPV) 64%, and negative predictive value (NPV) 94%. Regarding the secondary outcome, the final diagnosis was AHFS in 35% of patients (134 of 380). For novice sonographers, one positive lung zone (i.e., anything positive) had a sensitivity of 87%, a specificity of 49%, a +LR of 1.7, a −LR of 0.3, a PPV of 50%, and an NPV of 88% for predicting AHFS. When all eight lung zones were determined positive (i.e., totally positive) by novice sonographers, the sensitivity was 19%, specificity was 97%, +LR was 5.7, −LR was 0.8, PPV was 76%, and NPV was 68% for predicting AHFS. The areas under the curve for novice and expert sonographers were 0.77 (95% CI = 0.72 to 0.82) and 0.76 (95% CI = 0.71 to 0.82), respectively. Conclusions Novice sonographers can identify sonographic B-lines with similar accuracy compared to an expert sonographer. Lung US has fair predictive value for pulmonary edema from acute heart failure in the hands of both novice and expert sonographers.

Despite cigarette price increases after the MSA, income-related smoking disparities have increased. Increasing cigarette prices may no longer be an effective policy tool and may impose a disproportionate burden on poor smokers.

AS 4.4) and physical exam courses (91% agreement, AS 4.5). They agreed that learning US would enhance their medical education (100% agreement, AS 4.7). Following workshops, 100% of subjects agreed that US would enhance their medical education (AS 4.8) and that they wanted more US in their medical curriculum (AS 4.7). Subjects agreed that the student-sponsored US workshops were worthwhile (100% agreement, AS 4.8), taught them something they could not have learn elsewhere in their medical education (99% agreement, AS 4.8), and added something valuable to their medical education (99% agreement, AS 4.6). Subjects agreed that they learned something relevant to their pre-clinical coursework (91% agreement, AS 4.5), which they could use in their future clinical practice (100% agreement, AS 4.8). Nearly all subjects planned to attend future USIG workshops (96% agreement, AS 4.7) and wanted to learn more US after their experience (99% agreement, AS 4.6). Conclusions: Medical students with limited ultrasound in their medical curriculums want to learn ultrasound. They feel ultrasound should be incorporated into their undergraduate medical education and will seek it out if not provided for them. USIGs are a great method to provide immediate access to ultrasound education that is worthwhile and not found elsewhere in the medical curriculum.

Since the first medical student ultrasound electives became available more than a decade ago, ultrasound in undergraduate medical education has gained increasing popularity. More than a dozen medical schools have fully integrated ultrasound education in their curricula, with several dozen more institutions planning to follow suit. Starting in June 2012, a working group of emergency ultrasound faculty at the California medical schools began to meet to discuss barriers as well as innovative approaches to implementing ultrasound education in undergraduate medical education. It became clear that an ongoing collaborative could be formed to discuss barriers, exchange ideas, and lend support for this initiative. The group, termed Ultrasound in Medical Education, California (UMeCali), was formed with 2 main goals: to exchange ideas and resources in facilitating ultrasound education and to develop a white paper to discuss our experiences. Five common themes integral to successful ultrasound education in undergraduate medical education are discussed in this article: (1) initiating an ultrasound education program; (2) the role of medical student involvement; (3) integration of ultrasound in the preclinical years; (4) developing longitudinal ultrasound education; and (5) addressing competency.

Increased levels of CRP or fibrinogen are associated with higher allele-specific medium-sized apo(a) levels in African-Americans but not in Caucasians. These findings indicate that proinflammatory conditions result in a selective increase in medium-sized apo(a) levels in African-Americans and suggest that inflammation-associated events may contribute to the interethnic difference in Lp(a) levels between African-Americans and Caucasians.