Objectives: The objective was to measure the association between returns to an emergency department (ED) within 72 hours and resource utilization, severity of illness, mortality, and admission rate.Methods: This was a retrospective, cross-sectional analysis of ED visits using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1998 to 2006. Cohorts were patients who had been seen in the ED within the past 72 hours versus those without the prior visit. A multivariate model was created to predict adjusted-resource utilization and mortality or admission rate.Results: During the study period, there were 218,179 ED patient visits and a 3.2% 72-hour return rate. Patients with Medicare (3.5%) and without insurance (3.5%) were more likely to return within 72 hours. Visits associated with alcohol (4.1%), low triage acuity (4.0%), or dermatologic conditions (5.9%) were more likely to return. Seventy-two-hour return visits used fewer resources (5.0 [±0.1] vs. 5.5 [±0.1] tests, medications, procedures), were less likely to be Level I triage acuity (17% vs. 20%), and had a similar admission rate (13% vs. 13%) as those not seen within 72 hours. The sample size was too small to evaluate mortality.
Conclusions:Patients who return to the ED within 72 hours do not use more resources, are not more severely ill, and do not have a higher hospital admission rate than those who had not been previously seen. These findings do not support the use of 72-hour returns as a quality or safety indicator. A more refined variation such as 72-hour returns resulting in admission may have more value.
The introduction of ultrasound into medical student education is well underway in many locations around the world, but is still in its infancy or has yet to begin in others. Proper incorporation of ultrasound education into medical training requires planning and resources, both capital and human. In this article, we discuss the state of the art of ultrasound in medical education throughout the world, as well as various methodologies utilized to improve student education and to incorporate ultrasound into every facet of training. Experiences from various educational systems and available evidence regarding the impact of ultrasound education are summarized. Representing multiple societies and specialties throughout the world, we discuss established modern as well as novel education structures and different successful approaches.
In our meta-analysis, lung ultrasound had significantly better sensitivity with similar specificity when compared to chest x-ray for the diagnosis of pediatric community acquired pneumonia.
Competency in clinical ultrasound is essential to ensuring safe patient care. Competency in clinical ultrasound includes identifying when to perform a clinical ultrasound, performing the technical skills required for ultrasound image acquisition, accurately interpreting ultrasound images, and incorporating sonographic findings into clinical practice. In this concept paper, we discuss the advantages and limitations of existing tools to measure ultrasound competency. We propose strategies and future directions for assessing competency in clinical ultrasound.
The mediator accounting for the major relaxant responses to electrical field stimulation of human airways was previously identified as nitric oxide (NO). In the present study, we examined the distribution of the neuronal isoform of the NO-generating enzyme, nitric oxide synthase (bNOS, type I NOS) in nerve fibers of the human airways (trachea, large and small bronchi, bronchioli) as well as in human intrinsic and sensory ganglia of airway innervation by means of quantitative histochemistry (NADPH-diaphorase technique) and immunohistochemistry. Correlation with substance P (SP) and vasoactive intestinal peptide (VIP) was performed by double-labeling immunohistochemistry. NOS-containing nerve fibers were found to be present in the airway smooth muscle, around submucosal glands, around blood vessels and, very rarely, in the lamina propria. The innervation density of airway smooth muscle by NOS-containing nerve fibers decreased significantly from trachea to large-diameter bronchi to small-diameter bronchi, whereas NOS-containing nerve fibers were completely absent from bronchioli. Colocalization of NOS with VIP but not with SP was frequent in these nerve fibers. In airway intrinsic ganglia, the number of NOS-containing neuronal cell bodies increased from 57% in the trachea up to 83% in small bronchi. Around these perikarya, many nerve fibers displaying VIP-immunoreactive (VIP-IR) or SP-IR were found. In the superior vagal sensory (i.e., jugular) ganglion most of the neuronal cell bodies contained either NOS-IR or SP-IR; a colocalization of both was not as frequent. These data contribute to the understanding of the morphologic basis underlying the functional differences of the neural relaxant responses mediated by NO at different levels of the airway tree.
Ultrasound is becoming a fundamental first-line diagnostic tool for most medical specialties and an innovative tool to teach anatomy, physiology and pathophysiology to undergraduate and graduate students. However, availability of structured training programs during medical school is lagging behind and many physicians still acquire all their ultrasound skills during postgraduate training.There is wide variation in medical student ultrasound education worldwide. Sharing successful educational strategies from early adopter medical schools and learning from leading education programs should advance the integration of ultrasound into the university medical school curricula. In this overview, we present current approaches and suggestions by ultrasound societies concerning medical student educa-tion throughout the world. Based on these examples, we formulate a consensus statement with suggestions on how to integrate ultrasound teaching into the preclinical and clinical medical curricula.
The analysis of vertical reverberation artefacts is an essential component of the differential diagnosis in pulmonary ultra-sound. Traditionally, they are often, but not exclusively, called B-line artefacts (BLA) and/or comet tail artefacts (CTA), but this view is misleading. In this position paper we clarify the terminology and relation of the two lung reverberation artefacts BLA and CTA to spe-cific clinical scenarios. BLA are defined by a normal pleura line and are a typical hallmark of cardiogenic pulmonary edema after exclusion of certain pathologies including pneumonia or lung contusion, whereas CTAs show an irregular pleura line representing a variety of parenchymal lung diseases. The dual approach using low frequency transducers to determine BLA and high frequency transducer to determine the pleural surface is recommended.
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