Objectives: Sonographic thoracic B-lines and N-terminal pro-brain-type natriuretic peptide (NT-ProBNP) have been shown to help differentiate between congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The authors hypothesized that ultrasound (US) could be used to predict CHF and that it would provide additional predictive information when combined with NT-ProBNP. They also sought to determine optimal two-and eight-zone scanning protocols when different thresholds for a positive scan were used.Methods: This was a prospective, observational study of a convenience sample of adult patients presenting to the emergency department (ED) with shortness of breath. Each patient had an eight-zone thoracic US performed by one of five sonographers, and serum NT-ProBNP levels were measured. Chart review by two physicians blinded to the US results served as the criterion standard. The operating characteristics of two-and eight-zone thoracic US alone, compared to, and combined with NT-ProBNP test results for predicting CHF were calculated using both dichotomous and interval likelihood ratios (LRs).Results: One-hundred patients were enrolled. Six were excluded because of incomplete data. Results of 94 patients were analyzed. A positive eight-zone US, defined as at least two positive zones on each side, had a positive likelihood ratio (LR+) of 3.88 (99% confidence interval [CI] = 1.55 to 9.73) and a negative likelihood ratio (LR)) of 0.5 (95% CI = 0.30 to 0.82), while the NT-ProBNP demonstrated a LR+ of 2.3 (95% CI = 1.41 to 3.76) and LR) of 0.24 (95% CI = 0.09 to 0.66). Using interval LRs for the eight-zone US test alone, the LR for a totally positive test (all eight zones positive) was infinite and for a totally negative test (no zones positive) was 0.22 (95% CI = 0.06 to 0.80). For two-zone US, interval LRs were 4.73 (95% CI = 2.10 to 10.63) when inferior lateral zones were positive bilaterally and 0.3 (95% CI = 0.13 to 0.71) when these were negative. These changed to 8.04 (95% CI = 1.76 to 37.33) and 0.11 (95% CI = 0.02 to 0.69), respectively, when congruent with NT-ProBNP.Conclusions: Bedside thoracic US for B-lines can be a useful test for diagnosing CHF. Predictive accuracy is greatly improved when studies are totally positive or totally negative. A two-zone protocol performs similarly to an eight-zone protocol. Thoracic US can be used alone or can provide additional predictive power to NT-ProBNP in the immediate evaluation of dyspneic patients presenting to the ED.

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Objective To compare the characteristics of US adults by frequency of emergency department (ED) utilisation, specifically the prevalence of chronic diseases and outpatient primary care and mental health utilisation. Methods We analysed 157 818 adult participants of the 2004-2009 US National Health Interview Survey, an annual nationally representative sample. We defined ED utilisation during the past 12 months as non-users (0 ED visits), infrequent users (1-3 visits), frequent users (4-9 visits) and super-frequent users (≥10 visits). We compared demographic data, socioeconomic status, chronic diseases and access to care between these ED utilisation groups using multivariable logistic regression. Results Overall, super-frequent use was reported by 0.4% of US adults, frequent use by 2% and infrequent ED use by 19%. Patients reporting ≥4 ED visits were more likely to have Medicaid insurance (OR 1.57; 95% CI 1.34 to 1.85 vs private); fair or poor self-reported health (OR 2.98; 95% CI 2.57 to 3.46 vs excellent-very good); and chronic diseases such as coronary artery disease (OR 1.61; 95% CI 1.40 to 1.86), stroke (OR 1.58; 95% CI 1.36 to 1.83) or asthma (OR 1.64; 95% CI 1.46 to 1.85). While patients reporting the ED as their usual source of sick care were more likely to have ≥4 ED visits (OR 7.09; 95% CI 5.61 to 8.95 vs outpatient clinic as source), ≥10 outpatient visits in the past 12 months was also associated with frequent ED use (OR 11.4; 95% CI 9.09 to 14.2 vs no outpatient visits). Conclusions Frequent ED users had a large burden of chronic diseases that also required high outpatient resources. Interventions designed to divert frequent ED users should focus on chronic disease management and access to outpatient services, particularly for Medicaid beneficiaries and other high risk subpopulations.

Mineral-accumulating compartments in developing seeds of Arabidopsis were studied using high-pressure-frozen/ freeze-substituted samples. Developing seeds store minerals in three locations: in the protein storage vacuoles of the embryo, and transiently in the endoplasmic reticulum (ER) and vacuolar compartments of the chalazal endosperm. Energy dispersive x-ray spectroscopy and enzyme treatments suggest that the minerals are stored as phytic acid ( myoinositol-1,2,3,4,5,6-hexa kis phosphate) salts in all three compartments, although they differ in cation composition.

Background Variation in hospitalization rates have been described for decades, yet little is known about variation in emergency department (ED) admission rates across clinical conditions. We sought to describe variation in ED risk-standardized admission rates (RSAR) and the consistency between condition-specific ED admission rates within hospitals. Methods Cross-sectional analysis of the 2009 National Emergency Department Sample, an all-payer administrative claims dataset. We identify the 15 most frequently admitted conditions using Clinical Classification Software. To identify conditions with the highest ED RSAR variation we compared both the ratio of the 75th percentile to the 25th percentile hospital and coefficient of variation between conditions. We calculate Spearman correlation coefficients to assess within-hospital correlation of condition-specific ED RSARs. Results Of 21,885,845 adult ED visits, 4,470,105 (20%) resulted in admission. Among the 15 most frequently admitted conditions, the five with the highest magnitude of variation were: mood disorders (ratio of 75th:25th percentile, 6.97; coefficient of variation, 0.81), nonspecific chest pain (2.68; 0.66), skin and soft tissue infections (1.82; 0.51), urinary tract infections (1.58; 0.43) and COPD (1.57; 0.33). For these five conditions, the within-hospital RSAR correlations between each pair of conditions were greater than 0.4, except for mood disorders, which was poorly correlated with all other conditions (r<0.3). Conclusions There is significant condition-specific variation in ED admission rates across US hospitals. This variation appears to be consistent between conditions with high variation within hospitals.

BackgroundWhile ultrasound (US) has continued to expedite diagnosis and therapy for critical care physicians inside the hospital system, the technology has been slow to diffuse into the pre-hospital system. Given the diagnostic benefits of thoracic ultrasound (TUS), we sought to evaluate image recognition skills for two important TUS applications; the identification of B-lines (used in the US diagnosis of pulmonary edema) and the identification of lung sliding and comet tails (used in the US diagnosis of pneumothorax). In particular we evaluated the impact of a focused training module in a pre-hospital system that utilizes physicians as pre-hospital providers.Methods27 Paris Service D'Aide Médicale Urgente (SAMU) physicians at the Hôpital Necker with varying levels of US experience were given two twenty-five image recognition pre-tests; the first test had examples of both normal and pneumothorax lung US and the second had examples of both normal and pulmonary edema lung US. All 27 physicians then underwent the same didactic training modules. A post-test was administered upon completing the training module and results were recorded.ResultsPre and post-test scores were compared for both the pneumothorax and the pulmonary edema modules. For the pneumothorax module, mean test scores increased from 10.3 +/- 4.1 before the training to 20.1 +/- 3.5 after (p < 0.0001), out of 25 possible points. The standard deviation decreased as well, indicating a collective improvement. For the pulmonary edema module, mean test scores increased from 14.1 +/- 5.2 before the training to 20.9 +/- 2.4 after (p < 0.0001), out of 25 possible points. The standard deviation decreased again by more than half, indicating a collective improvement.ConclusionThis brief training module resulted in significant improvement of image recognition skills for physicians both with and without previous ultrasound experience. Given that rapid diagnosis of these conditions in the pre-hospital system can change therapy, especially in systems where physicians can integrate this information into treatment decisions, the further diffusion of this technology would seem to be beneficial and deserves further study.

Background: The Affordable Care Act initiated several care coordination programs tailored to reduce emergency department (ED) use for Medicaid-enrolled frequent ED users. It is important to clarify from the patient's perspective why Medicaid enrollees who want to receive care coordination services to improve primary care utilization frequently use the ED.

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