BACKGROUND: Traditionally performed using a subxiphoid approach, the increasing use of pointof-care ultrasound in the emergency department has made other approaches (parasternal and apical) for pericardiocentesis viable.The aim of this study is to identify the ideal approach for emergency-physicianperformed ultrasound-guided pericardiocentesis as determined by ultrasound image quality, distance from surface to pericardial fl uid, and likely obstructions or complications. METHODS:A retrospective review of point-of-care cardiac ultrasound examinations was performed in two urban academic emergency departments for the presence of pericardial eff usions.The images were reviewed for technical quality, distance of eff usion from skin surface, and predicted complications.RESULTS: A total of 166 pericardial effusions were identified during the study period.The mean skin-to-pericardial fl uid distance was 5.6 cm (95% confi dence interval [95% CI] 5.2-6.0 cm) for the subxiphoid views, which was signifi cantly greater than that for the parasternal (2.7 cm [95% CI 2.5-2.8cm], P<0.001) and apical (2.5 cm [95% CI 2.3-2.7 cm], P<0.001) views.The subxiphoid view had the highest predicted complication rate at 79.7% (95% CI 71.5%-86.4%),which was signifi cantly greater than the apical (31.9%; 95% CI 21.4%-44.0%,P<0.001) and parasternal (20.2%; 95% CI 12.8%-29.5%,P<0.001) views. CONCLUSIONS:Our results suggest that complication rates with pericardiocentesis will be lower via the parasternal or apical approach compared to the subxiphoid approach.The distance from skin to fl uid collection is the least in both of these views.

To the editorDesmoid tumors, also known as aggressive fibromatosis, are local tumors of mesenchymal origin that may cause significant morbidity due to their infiltrative nature.1,2 Risk factors for...

The number of phishing attacks has increased each year, becoming more sophisticated and creating the need for practical training in identifying these scams. A recent study explored the potential of training staff at a university to recognize phishing attacks through either facts or utilizing stories shared by peers or experts. The study found that facts from an expert, rather than stories from experts or peers, remain the most effective form of training. Here we replicate and extend this study by targeting current college students. The results show that college students respond differently than university staff and are more receptive to social stories or facts from peers. These results indicate the importance of taking the target demographic into account when designing and conducting phishing training.

Saturated and unsaturated fatty acids make up 85% of the total hair lipid content and are found in the cuticle and cortical cell membrane complex. Although these lipids only make up 2-6% of the hair's overall weight, they play a crucial role in keeping hair healthy, influencing shine, feel, manageability, and strength. The objective of this work was to understand the mechanisms of how these lipids are lost on exposure to external stressors, such as chemical treatments, washing, and UV exposure and to understand how their loss impacts hair strength. The experimental approach was to measure these lipids and oxidation products, lipid peroxides (LPOs) and correlate their loss with fatigue strength measurements. The results show lipids are lost over time by washing, exposure to chemical treatments, such as coloring, and environmental insults, such as UV, and it was confirmed that a mechanism of degradation is via oxidation of unsaturated lipids to form LPOs. In addition, it was shown that replenishment of these lipids is possible by incorporating lipids, such as fatty alcohols (FaOHs), into a gel network with anionic surfactants to create a delivery system that can efficiently penetrate FaOHs into hair and increase internal strength as measured by fatigue.

Medical graduates entering residency often lack confidence and competence in procedural skills. Implementation of ultrasound (US)-guided procedures into undergraduate medical education is a logical step to addressing medical student procedural competency. The objective of our study was to determine the impact of an US teaching workshop geared toward training medical students in how to perform three distinct US-guided procedures. Cross-sectional study at an urban academic medical center. Following a 1-h didactic session, a sample of 11 students out of 105 (10.5 %) were asked to perform three procedures each (total 33 procedures) to establish a baseline of procedural proficiency. Following a 1-h didactic session, students were asked to perform 33 procedures using needle guidance with ultrasound to establish a baseline of student proficiency. Also, a baseline survey regarding student opinions, self-assessment of skills, and US procedure knowledge was administered before and after the educational intervention. After the educational workshop, students’ procedural competency was assessed by trained ultrasound clinicians. One-hundred-and-five third-year medical students participated in this study. The average score for the knowledge-based test improved from 46 % (SD 16 %) to 74 % (SD 14 %) (p < 0.05). Students’ overall confidence in needle guidance improved from 3.1 (SD 2.4) to 7.8 (SD 1.5) (p < 0.05). Student assessment of procedural competency using an objective and validated assessment tool demonstrated statistically significant (p < 0.05) improvement in all procedures. The one-day US education workshop employed in this study was effective at immediately increasing third-year medical students’ confidence and technical skill at performing US-guided procedures.

BACKGROUND:Diagnosing pericardial effusion is critical for optimal patient care. Typically, clinicians use physical examination findings and historical features suggesting pericardial effusion to determine which patients require echocardiography. The diagnostic characteristics of these tools are not well described. The objective of this study is to determine the prevalence of historical features and sensitivity of clinical signs to inform clinicians when to proceed with echocardiogram.METHODS:A retrospective review of point-of-care echocardiograms performed over a two and a half year period in two emergency departments were reviewed for the presence of a pericardial effusion. Patient charts were reviewed and abstracted for presenting symptoms, historical features and clinical findings. The prevalence of presenting symptoms and historical features and the sensitivity of classic physical examination findings associated with pericardial effusion and tamponade were determined.RESULTS:One hundred and fifty-three patients with pericardial effusion were identified. Of these patients, the most common presenting complaint was chest pain and shortness of breath. Patients had no historical features that would suggest pericardial effusion in 37.5% of cases. None of the patients with pericardial effusion or pericardial tamponade had all of the elements of Beck's triad. The sensitivity of Beck's triad was found to be 0 (0%-19.4%). The sensitivity for one finding of Beck's triad to diagnose pericardial tamponade was 50% (28.0%-72.0%).CONCLUSION:History and physical examination findings perform poorly as tests for the diagnosis of pericardial effusion or pericardial tamponade. Clinicians must liberally evaluate patients suspected of having a pericardial effusion with echocardiography.

Koji Kondo's Mario Soundtrack Andrew Schartmann New York, NY: Bloomsbury Academic, 2015. Foreword, preface, acknowledgments, introduction, and notes. 208 pp. $10.75 paper. ISBN: 978162898532Sound Play: Video Games and the Musical Imagination William Cheng New York, NY: Oxford University Press, 2014. Acknowledgments, foreword, notes, and index. 262 pp. $26.95 paper. ISBN: 9780199969968Game audio has always been an integral part of game play, first attracting players to place their quarters into the coin slots of early arcade games and later not only providing important game play feedback but also creating immersive environments for gaming at home. We have, however, begun the serious academic study of game audio only during the last decade or so. Andrew Schartmann's and William Cheng's new books make varied and welcome entries into this bourgeoning field.Andrew Schartmann, currently finishing a doctorate in music theory at Yale University, provides his engaging and wellwritten book as he continues to examine early game audio. In Koji Kondos Mario Soundtrack, he offers a complete analysis of the 1985 Super Mario Bros. soundtrack. The first section of the book, Contexts, begins with a brief discussion of the game industry in the 1970s and 1980s leading up to the release of Super Mario Bros. (SMB). Here, Schartmann emphases how SMB and the Nintendo Entertainment System (NES) were poised to have a major impact in the game scene. After an equally short discussion of how the NES produced audio and Koji Kondo's compositional style, Schartmann then turns his attention to the music and sounds of the game.In the second, longer portion of the book, Music Schartmann thoroughly analyzes-both musically and contextually-each track of game music and the sound effects as a part of the game play. Schartmann often compares the musical themes of SMB with other classical pieces in similar styles. Although his writing can be enjoyed by anyone, Schartmann's concise focus on the SMB game soundtrack and the NES audio methods make it particularly accessible to those who are not necessarily experts in the field-but rather lovers of the iconic game and its audio. Perhaps the most distinguished discussion in the book addresses the sound effects and their function in the game, to which Schartmann gives brilliant contemplation. Particularly intriguing here is his question about the flagpole slide at the end of the level. Schartmann asks, Why does the sound rise as Mario slides down (p. 105)?Although Schartmann's direct style makes the book a quick read, he could have strengthened it. Online links to audio samples might have served most readers better than the western musical notation he provides. Although his target audience often seems to be anyone who loves SMB, Schartmann at times lapses into musical theory jargon beyond the average musicand Mario-loving reader with whom he seems most interested in connecting. Still, the concise nature of Schartmann's focus on the sounds in SMB and his clear writing make this an excellent read for any lover of this classic NES game. …

BACKGROUND:Goal-directed ultrasound protocols have been developed to facilitate efficiency, throughput, and patient care. Hands-on instruction and training workshops have been shown to positively impact ultrasound training.OBJECTIVES:We describe a novel undifferentiated chest pain goal-directed ultrasound algorithm-focused education workshop for the purpose of enhancing emergency medicine resident training in ultrasound milestones competencies.METHODS:This was a cross-sectional study performed at an academic medical center. A novel goal-directed ultrasound algorithm was developed and implemented as a model for teaching and learning the sonographic approach to a patient with undifferentiated chest pain. This algorithm was incorporated into all components of the 1-day workshop: asynchronous learning, didactic lecture, case-based learning, and hands-on stations. Performance comparisons were made between postgraduate year (PGY) levels.RESULTS:A total of 38 of the 40 (95%) residents who attended the event participated in the chest pain objective standardized clinical exam, and 26 of the 40 (65%) completed the entire questionnaire. The average number of ultrasounds performed by resident class year at the time of our study was as follows: 19 (standard deviation [SD]=19) PGY-1, 238 (SD=37) PGY-2, and 289 (SD=73) PGY-3. Performance on the knowledge-based questions improved between PGY-1 and PGY-3. The application of the novel algorithm was noted to be more prevalent among the PGY-1 class.CONCLUSION:The 1-day algorithm-based ultrasound educational workshop was an engaging learning technique at our institution.

Nearly two decades ago, significant concern about the environmental impacts of aquaculture production gave rise to environmental certification schemes as a means to ensure production adhered to less impactful environmental standards. Currently, some governments with more robust regulations are also engaging by creating national voluntary sustainability certification schemes. While its likely that the majority of aquaculture standards originated independently of one another, they generally overlap on the main impact issues but with differing requirements for compliance, making it difficult to differentiate more unique or robust schemes. Differentiation and encouragement of the adoption of the more rigorous standards is one means to encourage the industry to lessen environmental and social impacts. One confounding factor in benchmarking studies is the lack of a consistent methodology making wider comparisons difficult. Here we created a tool for standards comparison that began with a broad reaching set of factors based on the FAO Technical Guidelines on Aquaculture Certification and the International Principles for Responsible Shrimp Farming. Our analysis first compared if the factors were addressed (the breadth of the scheme), as well the mechanism by which compliance was required (the scheme depth), a proxy for how rigorously each factor was addressed. This analysis compared 112 factors divided into five impact areas (community, environment, food safety, feed and marine resource use, and supply risk), for three national shrimp aquaculture certification schemes including Indonesia, Thailand, and Vietnam, and three global schemes including Aquaculture Stewardship Council, Global Aquaculture Alliance and GLOBALG.A.P. The global schemes were found to be of greater breadth and depth than the national schemes. As an analysis tool, the breadth–depth (B–D) graphical analysis was compared to more rigorous statistical methods including multiple analysis of variance and cluster analysis. Overall, the B–D analysis provided a relatively simple means to assess rigor (breadth and depth) of multiple certification standards when compared using a broad baseline set of factors. It was further observed that the global certification programs overlapped in breadth and depth largely because of an uneven application across the five impact areas. The use of this analysis can be implemented to better understand similarities and differences between standards, and can be foundational in developing and adjusting schemes to ensure they are unique and operating at different levels of rigor, which can be a roadmap towards increasing the sustainability of aquaculture production.

Through the observation of their four-year-old son's use of an iPad 2, the researcher and his wife attempted to better understand the perceptions, use, and motivations of young children both as parents and researchers, through an intrinsic, ethnographic case study. The study of this individual case may help parents and educators make informed decisions about technology use and the culture of young children who are digital, touch-screen natives. This case study should further help fill a void in the research base among younger children's use of touch-screen technology in a transparent and natural environment, the home. In general, the technology was seen as a tool of entertainment and was highly engaging to a fault. Content selection showed limitations due to content filters and marketing in addition to the limited control of written language and verbal articulation by the primary participant. Further questions for research include the following: What are the affects of intentional scaffolding, guided interaction, and direct instruction among toddlers and touch-screen technology? How does providing access to technology to children with demographic differences affect issues of social equality? How do Internet content filters influence content selection for populations with limited language command versus those with proficient language command?

Rebuilding Britain: Planning for a Better Future, Hugh Ellis and Kate Henderson, Bristol, Policy Press, 2014, 120 pp., £14.99, ISBN: 978-1-4473-17593Contemporary Britain is beset by crisis: from housing and demographic crises, to the urban and global financial crisis, to perhaps the biggest crisis of all, looming catastrophic climate change - all seemingly rendered impossible to resolve by a crisis in democratic decision-making. This short, readable and passionately argued book punches well above its weight in attempting to address these 21st century challenges head on. Hugh Ellis and Kate Henderson identify the central problem as one of a failure of national and regional planning for the future. Inspired by the early town planning tradition, notably the Garden City movement, they point to the forgotten art of utopian thinking and call on the British planning system to reinvent itself as a renewed force for progressive social change.The book is written in an engaging and informative style that treads carefully between well-referenced academic textbook, pragmatic policy prescription and unabashedly political polemic. Ellis and Henderson break their argument down into four easily digestible parts: first laying out their vision for re-engaging planning in utopian thinking, introducing the history of the early town planning movement and its co-evolution with anarchist and utopian ideas; second, making the empirical case for why we need to think big again, with subchapters on social, economic, political and environmental crises; third, suggesting practical solutions borrowed from utopian history and contemporary exemplars in sustainable urbanism, such as Freiburg and Malmo; before finally bringing the argument full circle by considering the contradictions and potential of realising utopia.Common ownership and democratic control of land is presented as the key to unlocking the potential of planning, in a section entitled 'the lie of the land!' The authors argue that land ownership is the elephant in the room: the foundation of all wealth creation and the scarce resource, concentrated so unequally in the hands of neo-feudal landowners. Drawing on pragmatic utopian experiments in land reform from British history, notably the Garden City movement, the authors argue for a new system of cooperative ownership and land value capture in urban development, whereby all surpluses, the 'unearned increment', are recycled back into the local area for community benefit rather than siphoned off by absentee landlords as profit. This comes as no surprise: Ellis and Henderson are the current head of policy and chief executive, respectively, of the Town and Country Planning Association (TCPA), the modern heir of Ebenezer Howard's Garden Cities Association.Achieving such a vision is problematic in our so-called post-political or post-democratic society, in which public services have been privatised and outsourced and our planning system transformed into an unaccountable, narrowly technocratic enterprise concerned above all with economic growth and efficiency (Allmendinger and Haughton, 2012). A particularly shocking consequence revealed in the book is that Britain is the only country in northwest Europe that lacks a national plan or even a regional planning framework, which are convincingly argued to be essential prerequisites for tackling the huge multi-scalar challenges of national infrastructure redevelopment, regional socioeconomic redistribution and climate change adaptation.Despite the obvious ideological and institutional challenges to the practical uptake of their ideas, Ellis and Henderson make an impassioned plea for rediscovering the lost art of planning as a future-oriented purposive activity with political vision. Cutting through these utopian ambitions is a tension between temporal process and spatial form, procedure and end state - which can also be seen in planning theory: in the shift from modernist technocratic blueprint plan-making towards a postmodern concern with mediating partnerships, consulting stakeholders and facilitating collaborative planning processes. …