Acute flank pain from suspected urolithiasis is a common presenting complaint in the Emergency Department. Multiple computed tomography (CT) has traditionally been the standard imaging modality used to diagnose obstructive kidney stones, however point of care ultrasound (PoCUS) can play an important role in the diagnostic algorithm and risk stratification of acute flank pain. Here, we present the case of a 29-year-old female with suspected urolithiasis, who underwent PoCUS that revealed right-sided hydronephrosis and normal left kidney, bladder, and aorta. A subsequent KUB was negative. As the clinical course failed to improve with therapy, an abdominal and pelvic CT was ordered revealing a 5 mm distal obstructing ureteric calculus at the right vesico-ureteric junction and another 5 mm left mid ureteric calculus. To the best of our knowledge, this is the first case in which a patient presenting with acute right-sided flank pain demonstrated unilateral hydronephrosis on PoCUS, but had clinically significant bilateral ureteric stones on CT. Emergency physicians who employ PoCUS for evaluation of flank pain must be aware of its benefits and drawbacks and how they apply to each patient. As such, we have developed a script emergency physicians can use for shared decision-making with renal colic patients when deciding on the appropriate imaging modality.

We report here a systematic study of the molecular content in the neutral envelope of NGC 7027. The measurements were done in September 1991 with the 30-meter IRAM telescope on Pico Veleta (Spain). The frequencies and transitions covered are given in Table 1. Long integrations were performed in each transitions toward the central position of NGC 7027, and for the strongest lines we obtained detailed maps. The results of the observation are given in Table 1 (in units of main beam temperature).

We report high angular resolution mapping of the CO (J=2→1 and 1→0) lines in three evolved planetary nebulae (PNe): NGC 6781, NGC 6772, and VV47. The CO 2→1 observations of the ring-like nebula NGC 6781 provide the most detailed map to date of the kinematic structure of a PN envelope. The data are well explained with a model consisting of a thin, clumpy, ellipsoidal shell, which is open at the ends and is expanding with a velocity proportional to distance from the star. The molecular shell of NGC 6772 appears similar, but the gas is more confined to an equatorial ring and is much more incomplete. The molecular gas in VV 47 is in two clumpy lobes, which are likely to be the only surviving molecular condensations from an earlier, more extended equatorial distribution of the same kind. The average CO excitation temperature of these PNe is found to be >23 K from the CO 2→1/1→0 line ratio, and the mass of molecular gas is estimated to be 0.1, 0.02, and 0.002 M ⊙ in NGC 6781, NGC 6772, and VV 47, respectively. It appears that the ring-like PNe are formed from the dissociation and ionization of neutral ellipsoidal shells; destruction of the envelope begins with the rapid ionization of the least dense polar caps, and continues until the densest molecular material at the nebular waist is fully ionized.

We observe the heating of interstellar material in young supernova remnants (SNR). In addition, when analyzing the soft X-ray background we find evidence for large isolated regions of apparently hot, low density material. These, we infer, may have been heated by supernovae. One such region seems to surround the Sun. This has been modeled as a supernova remnant viewed from within. The most reasonable parameters are ambient density no ~ 0.004 cm−3, radius of about 100 pc, age just over 105 years (Cox and Anderson 1982).

The spiral galaxy NGC 4258 is known for its anomalous Hα and nonthermal radio arms perpendicular to the normal spiral arms (van der Kruit et al., 1972). Several models have been proposed to explain this phenomenon and its origin is most probably to be sought in the past activity of the nucleus of NGC 4258. Most of the characteristics of the anomalous arms, such as the symmetry with respect to the center, or the properties of the emission lines (pure Hα line emission with no continuum, line ratio between Hα and [NII]) are reminiscent of the optical and radio jets currently observed in active galaxies.

There have been several recent changes in perspective on the diffuse interstellar environment, including recognition of a thick disk of warm gas, cosmic rays, and magnetic field. In addition, evidence for a pervasive hot phase driven by supernova disruption has weakened to the point that a quasihomogeneous warm intercloud gas may occupy most of the interstellar volume at midplane, with individual bubbles created by supernovae and OB associations occupying perhaps 10 and 20 per cent respectively. The bubble population is sufficient to explain the high stage ions (0 VI, N V, C IV, perhaps Si IV) found in the disk, though possibly not those found at higher z. The estimated midplane pressure has increased, leaving the thermal pressure inside clouds almost negligible. The reduced porosity of the medium, its greater thickness, and its larger pressure all act to suppress fountain activity, either arising from the disk generally, or from the blowout of superbubbles. Finally, there appears to be a peculiar coincidence between the cloud heating mechanism and the activity determining the interstellar pressure.

The interstellar medium and its hot gas component are very different from common conception.

NGC 604 is by far the brightest HII nebula in the nearby spiral galaxy M33. The gas in this region has about the same metallicity as the gas in the Large Magellanic Cloud (Diaz et al. 1987). In this respect the physical conditions in this nebula may resemble those in 30 Doradus. A one arcmin field centred on the eastern part of the ionized nebula has been observed in CO(2-1) and CO(1-0) using the IRAM 30m antenna and the OVRO interferometer. In CO(1-0) the IRAM and the OVRO data have been combined to produce high resolution maps including the emission at low spatial frequencies. A CO(1-0) map at 7″ resolution (about 25 pc for the distance of M33) has been obtained; maps in both transitions at 12″ resolution have also been produced. The distribution of total line emission (see Figure 1) is characterized by two prominent clouds plus diffuse emission. These clouds are resolved with typical virial masses of a few 105 M⊙. The peak brightness is 8K and the velocity width ΔV1/2 8 km s-1. The CO(2-1)/CO(1-0) brightness temperature ratio is 0.7. Based on LVG models (e.g. Castet et al., 1990) we conclude that the density must be about or at least 1000 cm-3. The virial mass to CO luminosity ratio for these clouds is identical to the one for Galactic GMCs (Solomon et al., 1987). These two molecular clouds are located on the edge of an HI concentration along the HI ridge of a M33 spiral arm feature. From the comparison of sensitive radio continuum VLA maps and an Hα map (Viallefond et al., in preparation) we observe the counterpart of these gas concentrations in the distribution of the extinction; we conclude that one of the two molecular clouds, the brightest on the CO map in Figure 1, must be located inside the ionized halo of NGC 604; the position of this cloud also coincides with the peak of brightness on the near infrared map for the H2 lines obtained by Israel et al. (1990); part of the HI may be photodissociated molecular gas. We suggest that the intense radiation field in NGC 604 compensates the metallicity deficiency to give a NH2/WCO ratio similar to the Galactic one. The diffuse emission is detected over the entire field. The velocity fields as observed with the CO, the HI (data from Deul and van der Hulst, 1988), and the Hα (e.g. Hippelein and Fried, 1984) lines are very similar, the main characteristic is an East-West gradient unrelated with the general rotation of M33. High velocity molecular gas is also detected as a faint blue shifted wing of about 25 km s-1 on the global CO profile; its spatial distribution is diffuse. Finally double peaked profiles are observed in the vicinity of a large optical and radio continuum loop known to be associated with the presence of a Wolf-Rayet star. Obviously the kinematics is perturbed by the recent vigorous formation of massive stars in this unusually bright star forming region of M33.

There have been several recent changes in perspective on the diffuse interstellar environment, including recognition of a thick disk of warm gas, cosmic rays, and magnetic field. In addition, evidence for a pervasive hot phase driven by supernova disruption has weakened to the point that a quasihomogeneous warm intercloud gas may occupy most of the interstellar volume at midplane, with individual bubbles created by supernovae and OB associations occupying perhaps 10 and 20 per cent respectively. The bubble population is sufficient to explain the high stage ions (0 VI, N V, C IV, perhaps Si IV) found in the disk, though possibly not those found at higher z. The estimated midplane pressure has increased, leaving the thermal pressure inside clouds almost negligible. The reduced porosity of the medium, its greater thickness, and its larger pressure all act to suppress fountain activity, either arising from the disk generally, or from the blowout of superbubbles. Finally, there appears to be a peculiar coincidence between the cloud heating mechanism and the activity determining the interstellar pressure.

Schistosomiasis in China has been substantially reduced due to an effective control programme employing various measures including bovine and human chemotherapy, and the removal of bovines from endemic areas. To fulfil elimination targets, it will be necessary to identify other possible reservoir hosts for Schistosoma japonicum and include them in future control efforts. This study determined the infection prevalence of S. japonicum in rodents (0–9·21%), dogs (0–18·37%) and goats (6·9–46·4%) from the Dongting Lake area of Hunan province, using a combination of traditional coproparasitological techniques (miracidial hatching technique and Kato-Katz thick smear technique) and molecular methods [quantitative real-time PCR (qPCR) and droplet digital PCR (ddPCR)]. We found a much higher prevalence in goats than previously recorded in this setting. Cattle and water buffalo were also examined using the same procedures and all were found to be infected, emphasising the occurrence of active transmission. qPCR and ddPCR were much more sensitive than the coproparasitological procedures with both KK and MHT considerably underestimating the true prevalence in all animals surveyed. The high level of S. japonicum prevalence in goats indicates that they are likely important reservoirs in schistosomiasis transmission, necessitating their inclusion as targets of control, if the goal of elimination is to be achieved in China.

Introduction: Point of care ultrasonography (PoCUS) is an established tool in the initial management of hypotensive patients in the emergency department (ED). It has been shown rule out certain shock etiologies, and improve diagnostic certainty, however evidence on benefit in the management of hypotensive patients is limited. We report the findings from our international multicenter RCT assessing the impact of a PoCUS protocol on diagnostic accuracy, as well as other key outcomes including mortality, which are reported elsewhere. Methods: Recruitment occurred at 4 North American and 3 Southern African sites. Screening at triage identified patients (SBP<100 mmHg or shock index >1) who were randomized to either PoCUS or control groups. Scans were performed by PoCUS-trained physicians. Demographics, clinical details and findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. Final chart review was blinded to initial impressions and PoCUS findings. Categorical data was analyzed using Fishers two-tailed test. Our sample size was powered at 0.80 (α:0.05) for a moderate effect size. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. The perceived shock category changed more frequently in the PoCUS group 20/127 (15.7%) vs. control 7/125 (5.6%); RR 2.81 (95% CI 1.23 to 6.42; p=0.0134). There was no significant difference in change of diagnostic impression between groups PoCUS 39/123 (31.7%) vs control 34/124 (27.4%); RR 1.16 (95% CI 0.786 to 1.70; p=0.4879). There was no significant difference in the rate of correct category of shock between PoCUS (118/127; 93%) and control (113/122; 93%); RR 1.00 (95% CI 0.936 to 1.08; p=1.00), or for correct diagnosis; PoCUS 90/127 (70%) vs control 86/122 (70%); RR 0.987 (95% CI 0.671 to 1.45; p=1.00). Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We found that the use of PoCUS did change physicians’ perceived shock category. PoCUS did not improve diagnostic accuracy for category of shock or diagnosis.

Introduction: Point of care ultrasound (PoCUS) is an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). While PoCUS protocols have been shown to improve early diagnostic accuracy, there is little published evidence for any mortality benefit. We report the findings from our international multicenter randomized controlled trial, assessing the impact of a PoCUS protocol on survival and key clinical outcomes. Methods: Recruitment occurred at 7 centres in North America (4) and South Africa (3). Scans were performed by PoCUS-trained physicians. Screening at triage identified patients (SBP<100 or shock index>1), randomized to PoCUS or control (standard care and no PoCUS) groups. Demographics, clinical details and study findings were collected prospectively. Initial and secondary diagnoses were recorded at 0 and 60 minutes, with ultrasound performed in the PoCUS group prior to secondary assessment. The primary outcome measure was 30-day/discharge mortality. Secondary outcome measures included diagnostic accuracy, changes in vital signs, acid-base status, and length of stay. Categorical data was analyzed using Fishers test, and continuous data by Student T test and multi-level log-regression testing. (GraphPad/SPSS) Final chart review was blinded to initial impressions and PoCUS findings. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. There was no difference between groups for the primary outcome of mortality; PoCUS 32/129 (24.8%; 95% CI 14.3-35.3%) vs. Control 32/129 (24.8%; 95% CI 14.3-35.3%); RR 1.00 (95% CI 0.869 to 1.15; p=1.00). There were no differences in the secondary outcomes; ICU and total length of stay. Our sample size has a power of 0.80 (α:0.05) for a moderate effect size. Other secondary outcomes are reported separately. Conclusion: This is the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients. We did not find any mortality or length of stay benefits with the use of a PoCUS protocol, though a larger study is required to confirm these findings. While PoCUS may have diagnostic benefits, these may not translate into a survival benefit effect.

Introduction: Point of Care Ultrasound (PoCUS) protocols are commonly used to guide resuscitation for emergency department (ED) patients with undifferentiated non-traumatic hypotension. While PoCUS has been shown to improve early diagnosis, there is a minimal evidence for any outcome benefit. We completed an international multicenter randomized controlled trial (RCT) to assess the impact of a PoCUS protocol on key resuscitation markers in this group. We report diagnostic impact and mortality elsewhere. Methods: The SHoC-ED1 study compared the addition of PoCUS to standard care within the first hour in the treatment of adult patients presenting with undifferentiated hypotension (SBP<100 mmHg or a Shock Index >1.0) with a control group that did not receive PoCUS. Scans were performed by PoCUS-trained physicians. 4 North American, and 3 South African sites participated in the study. Resuscitation outcomes analyzed included volume of fluid administered in the ED, changes in shock index (SI), modified early warning score (MEWS), venous acid-base balance, and lactate, at one and four hours. Comparisons utilized a T-test as well as stratified binomial log-regression to assess for any significant improvement in resuscitation amount the outcomes. Our sample size was powered at 0.80 (α:0.05) for a moderate effect size. Results: 258 patients were enrolled with follow-up fully completed. Baseline comparisons confirmed effective randomization. There was no significant difference in mean total volume of fluid received between the control (1658 ml; 95%CI 1365-1950) and PoCUS groups (1609 ml; 1385-1832; p=0.79). Significant improvements were seen in SI, MEWS, lactate and bicarbonate with resuscitation in both the PoCUS and control groups, however there was no difference between groups. Conclusion: SHOC-ED1 is the first RCT to compare PoCUS to standard of care in hypotensive ED patients. No significant difference in fluid used, or markers of resuscitation was found when comparing the use of a PoCUS protocol to that of standard of care in the resuscitation of patients with undifferentiated hypotension.

Introduction: Point of care ultrasound (PoCUS) has become an established tool in the initial management of patients with undifferentiated hypotension in the emergency department (ED). Current established protocols (e.g. RUSH and ACES) were developed by expert user opinion, rather than objective, prospective data. Recently the SHoC Protocol was published, recommending 3 core scans; cardiac, lung, and IVC; plus other scans when indicated clinically. We report the abnormal ultrasound findings from our international multicenter randomized controlled trial, to assess if the recommended 3 core SHoC protocol scans were chosen appropriately for this population. Methods: Recruitment occurred at seven centres in North America (4) and South Africa (3). Screening at triage identified patients (SBP<100 or shock index>1) who were randomized to PoCUS or control (standard care with no PoCUS) groups. All scans were performed by PoCUS-trained physicians within one hour of arrival in the ED. Demographics, clinical details and study findings were collected prospectively. A threshold incidence for positive findings of 10% was established as significant for the purposes of assessing the appropriateness of the core recommendations. Results: 138 patients had a PoCUS screen completed. All patients had cardiac, lung, IVC, aorta, abdominal, and pelvic scans. Reported abnormal findings included hyperdynamic LV function (59; 43%); small collapsing IVC (46; 33%); pericardial effusion (24; 17%); pleural fluid (19; 14%); hypodynamic LV function (15; 11%); large poorly collapsing IVC (13; 9%); peritoneal fluid (13; 9%); and aortic aneurysm (5; 4%). Conclusion: The 3 core SHoC Protocol recommendations included appropriate scans to detect all pathologies recorded at a rate of greater than 10 percent. The 3 most frequent findings were cardiac and IVC abnormalities, followed by lung. It is noted that peritoneal fluid was seen at a rate of 9%. Aortic aneurysms were rare. This data from the first RCT to compare PoCUS to standard care for undifferentiated hypotensive ED patients, supports the use of the prioritized SHoC protocol, though a larger study is required to confirm these findings.

Dr David Livingstone died on May 1st 1873. He was 60 years old and had spent much of the previous 30 years walking across large stretches of Southern Africa, exploring the terrain he hoped could provide new environments in which Europeans and Africans could cohabit on equal terms and bring prosperity to a part of the world he saw ravaged by the slave trade. Just days before he died, he wrote in his journal about the permanent stream of blood that he was emitting related to haemorrhoids and the acute intestinal pain that had left him incapable of walking. What actually killed Livingstone is unknown, yet the years spent exploring sub-Saharan Africa undoubtedly exposed him to a gamut of parasitic and other infectious diseases. Some of these we can be certain of. He wrote prolifically and described his encounters with malaria, relapsing fevers, parasitic helminths and more. His graphic writing allows us to explore his own encounters with tropical diseases and how European visitors to Africa considered them at this time. This paper outlines Livingstone's life and his contributions to understanding parasitic diseases.