Objectives-B-lines are a lung ultrasound (LUS) artifact that often indicate pathology. Little is known about the optimal ultrasound machine settings to assess B-lines. We compared settings typically used to evaluate B-lines at our institution with adjusted settings based on recent studies.Methods-In order to determine typical settings for B-line assessment, we retrospectively reviewed LUS images obtained at our institution. We then prospectively performed LUS with both typical and adjusted settings, using curvilinear and phased array probes, in 20 patients presenting to the emergency department with shortness of breath. The prospectively obtained clips were rated for quality and quantity of Blines by 14 clinicians with experience in LUS, with 1 assigned for typical settings "much greater," 2 for typical settings "slightly greater," 3 for both settings "similar," 4 for adjusted settings "slightly greater," and 5 for adjusted settings "much greater."Results-Mean ratings and 95% confidence intervals significantly exceeded the null value of 3 for both B line quality (curvilinear probe: 4.68, 4.50-4.85; phased array probe: 4.02, 3.70-4.35) and B line quantity (curvilinear probe: 4.16, 3.84-4.49; phased array probe: 3.68, 3.41-3.96).Conclusions-B-line quality and quantity were rated higher using adjusted settings based on recently published evidence than when using settings that are typically employed in our institution. Our findings suggest that B-line assessment should be performed with focal zone at the level of the pleura, harmonics off, and gain increased in the far field.

BackgroundClozapine is known to cause fecal impaction and ileus with resultant colonic necrosis due to compression of colonic mucosa. There are rare reports of clozapine causing necrosis of other portions of the gastrointestinal tract unrelated to constipation. We describe a case of acute necrosis of the upper gastrointestinal tract and small bowel to due to clozapine and quetiapine.Case presentationA 66-year-old white man with a past medical history of schizophrenia, maintained on clozapine and quetiapine, presented with hypoxic respiratory failure caused by aspiration of feculent emesis due to impacted stool throughout his colon. His constipation resolved with discontinuation of clozapine and quetiapine, and his clinical condition improved. These medicines were restarted after 2 weeks, resulting in acute gastrointestinal necrosis from the mid esophagus through his entire small bowel. He died due to septic shock with Gram-negative rod bacteremia.ConclusionsClozapine may cause acute gastrointestinal necrosis.

W e read with interest the recent contribution from Kwan and Singh calling for general internists to promote diagnostic excellence. 1 We agree that novel approaches need to be explored and that accurate and timely diagnosis of common conditions-such as CHF and pneumonia-need to be prioritized over the pursuit of the esoteric.

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