Report of the Task Force on Residency Training Information (2000-2001), American Board of Emergency Medicine.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. We present the fourth annual report on the status of US emergency medicine residency programs.

Report of the Task Force on Residency Training Information (1999-2000), American Board of Emergency Medicine.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. We present the third annual report on the status of US emergency medicine residency programs. [American Board of Emergency Medicine. Report of the Task Force on Residency Training Information (1999-2000), American Board of Emergency Medicine. Ann Emerg Med. May 2000;35:481-498.]

Report of the Task Force on Residency Training Information (1998-1999), American Board of Emergency Medicine.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. We present the second annual report on the status of US emergency medicine residency programs. [American Board of Emergency Medicine: Report of the Task Force on Residency Training Information (1998-1999), American Board of Emergency Medicine. Ann Emerg Med May 1999;33:529-545.]

Report of the Task Force on Residency Training Information, American Board of Emergency Medicine.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. Before the compilation of this report, this information has not been widely available.

Improved precision of newborn screening for congenital adrenal hyperplasia using weight-adjusted criteria for 17-hydroxyprogesterone levels.

OBJECTIVE: To evaluate the efficacy and efficiency of weight-adjusted threshold levels for 17-hydroxyprogesterone (17-OHP) in screening newborn infants for 21 hydroxylase deficiency-congenital adrenal hyperplasia (21-OH-D-CAH). DESIGN: Analysis of the number of false-positive reports and diagnoses in infants, of 21-OH-D-CAH with the use of two strategies. Before October 1993, separate criteria for definite abnormal 17-OHP levels were established and implemented for 41,846 infants on the basis of birth weight: either less than 2200 gm (17-OHP level, 90 ng/ml) or 2200 gm or more (40 ng/ml). To reduce the burden of follow-up testing in low birth weight infants, criteria for definite abnormal 17-OHP results were statistically determined for four, rather than two, birth weight divisions: 1299 gm or less (17-OHP level > or = 165 ng/ml), 1300 to 1600 gm (> or = 135 ng/ml), 1700 to 2200 gm (> or = 90 ng/ml), and more than 2200 gm (> or = 40 ng/ml). These criteria were applied to the next 149,684 infants screened, and rates of false-positive test results and of false-positive diagnoses of 21-OH-D-CAH were compared. RESULTS: Before implementation of four-tiered weight-adjusted 17-OHP criteria, 205 definite abnormal reports yielded four confirmed cases of 21-OH-D-CAH (positive predictive value = 2%; incidence of 21-OH-D-CAH = 1 in 10,461). With the revised criteria, 61 of 149,684 infants had definite abnormal results and 14 cases of 21-OH-D-CAH were confirmed (positive predictive value, 20%; incidence of 21-OH-D-CAH, 1 in 10,692). No undetected severe cases of 21-OH-D-CAH have been subsequently reported. CONCLUSIONS: Weight-adjusted criteria for 17-OHP levels in screening for 21 -OH-D-CAH markedly reduced the number of false-positive results requiring immediate follow-up testing, particularly among low birth weight infants. Increased specificity afforded by these criteria was not accompanied by diminished sensitivity in detecting severe cases. Long-term follow-up of this screened cohort will determine whether the goals of newborn screening for 21-OH-D-CAH are adequately and efficiently fulfilled by this approach.

An ergonomic perspective on accommodation in accessibility for people with disability.

While accessibility has increasingly become a concern in today's society, the implementation of this concern has failed to address many issues. This paper discusses the components of exclusivity, safety, and reasonability in accessibility. Common problems in the implementation of these factors are addressed. These elements in both design for accessibility and evaluation of accessibility, constitute the principle of accommodation in accessibility. The application of ergonomic principles to improve the accommodation of accessibility is proposed.

Randomized multicenter trial comparing synchronized and conventional intermittent mandatory ventilation in neonates.

OBJECTIVE: To compare synchronized intermittent mandatory ventilation (SIMV) and conventional intermittent mandatory ventilation (IMV) in neonates. STUDY DESIGN: Prospective, multicenter, randomized clinical trial. SETTING: Level III neonatal intensive care units at six university or children's hospitals. PATIENTS: Three hundred twenty-seven infants receiving conventional IMV for respiratory distress syndrome, pneumonia, or meconium aspiration pneumonitis were randomly assigned a 7.5 +/- 6 hours of age to either continue with IMV or change to SIMV. Infants assigned to each mode of ventilation had similar birth weight (BW), gestational age, and Apgar scores at birth, and similar oxygenation indexes at randomization. They received similar surfactant therapy and had similar incidence of sepsis, seizures, secondary pneumonia, and necrotizing enterocolitis. In the infants with BW less than 1000 gm, more infants receiving IMV had surgical ligation of their patent ductus arteriosus than did those receiving SIMV (27 vs. 7 %; p = 0.02). ANALYSIS: Data was analyzed overall for all infants and also separately within three BW groups: less than 1000 gm, 1000 to 2000 gm, and more than 2000 gm. The 1000 to 2000 gm BW group was further analyzed in subgroups weighing 1000 to 1499 gm and 1500 to 2000 gm. RESULTS: In all infants, at 1 hour after randomization, the infants receiving SIMV had a lower mean airway pressure than those receiving IMV (8.08 +/- 2.15 vs. 8.63 +/- 2.59; p<0.05), with similar fractions of inspired oxygen and oxygenation indexes. Infants whose BW was 1000 to 2000 gm at 0.5 hour required a lower fraction of inspired oxygen with SIMV than with IMV (0.52 +/- 0.20 vs. 0.62 +/- 0.27; p<0.05) and had better oxygenation at 1 hour, as shown by lower oxygenation indexes with SIMV than with IMV (6.14 +/- 4.17 vs. 9.42 +/- 8.41; p = 0.01). Infants whose BW was 1000 to 2000 gm received a lower number of unit doses of sedative/analgesic drugs per infant during the first 4 days of SIMV than did infants receiving IMV (3.8 +/- 3.4 vs 6.3 +/- 5.5 unit doses; p = 0.02). Infants whose BW was more than 2000 gm had a shorter duration of mechanical ventilation with SIMV than with IMV (median, 72 vs 93 hours; p = 0.02). Three of the forty-six infants receiving IMV but none of the 47 infants receiving SIMV required extracorporeal membrane oxygenation. In the infants with BW less than 1000 gm, fewer infants treated with SIMV required supplemental oxygen at 36 weeks of postconceptional age than did those treated with IMV (47 vs 72%; p<0.05). In 83 infants whose lungs were mechanically ventilated for 14 days or longer, all with BW less than 2000 gm, those treated with SIMV regained their BW earlier than those treated with IMV (median, 21.5 vs 29 days; p<0.01). There were no differences in the rates of death, intraventricular hemorrhage (grades III and IV), air leak, need for pharmacologic paralysis, or need for supplemental oxygen at 28 days. CONCLUSIONS: We found that SIMV was at least as efficacious as conventional IMV, and may have improved certain outcomes in BW-specific groups.

Improving estimates of HIV-1 seroprevalence among childbearing women: use of smaller blood spots.

OBJECTIVES: Nationwide, human immunodeficiency virus type 1 (HIV-1) seroprevalence surveys using dried neonatal blood specimens are critical to estimating HIV-1 seroprevalence among childbearing women. However, the noninclusion of blood specimens deemed "quantity not sufficient" (QNS) for HIV-1 antibody testing potentially introduces bias. In Wisconsin beginning in 1990, we modified the survey protocol to reduce QNS rates and assess bias introduced by QNS specimens. METHODS: The HIV-1 antibody assay was modified to use four 1/8-in blood spots when a single 1/4-in blood spot could not be obtained. Both methods obtain identical blood volumes for testing. RESULTS: During a 27-month period, 7396 (4.8%) of 154,683 specimens were deemed QNS using 1/4-in blood spots. Of these, 6590 (89%) were of sufficient quantity to be tested using four 1/8-in blood spots; 6 (0.09%) specimens tested with 1/8-in blood spots were HIV-1 Western blot assay positive compared with 44 (0.03%) of 147,287 1/4-in specimens (odds ratio = 3.0; 95% confidence interval = 1.2, 7.4). CONCLUSIONS: Because noninclusion of QNS specimens potentially introduces bias, incorporating the results of HIV-1 antibody testing of QNS specimens using four 1/8-in blood spots can improve the accuracy of HIV-1 seroprevalence estimates in these serologic surveys.

Laboratory quality control issues related to screening newborns for cystic fibrosis using immunoreactive trypsin.

We have incorporated the IRT assay for CF to our newborn screening program, relying heavily on electronic data processing to optimize the test results in order to provide the most reliable data possible from the specimen at hand. We have established an internal cut-off of 100 ng/mL and an external referral of 180 ng/mL; this virtually eliminates the possibility that analytical imprecision will result in misidentifying a positive patient specimen. The relationship between IRT levels and various mutant forms of CF are not well established, and it is possible that various forms of CF may exhibit different levels of IRT in the first few days of life. We believe that IRT screening for CF could be a useful procedure for early identification of potential CF. However, by comparison with other newborn screening tests, its sensitivity, 90%, presents a concern. The expectation for PKU, hypothyroidism, MSUD, and galactosemia screening is 100% sensitivity. A false-negative usually results in litigation. The use of IRT in routine newborn screening will require considerable education of the general public and physicians receiving test results. Our program, along with many others, is anxiously watching the developments in the area of gene testing. We feel the relatively inexpensive IRT, used for mass screening can be successfully coupled with the more definitive (and expensive) gene test on a selected population to identify CF at the earliest possible age in a more effective manner. It is possible that in the near future gene probe tests will be applied in a cost effective manner to the initial filter paper specimen.

The galaxy luminosity function and the redshift-distance controversy (A Review).

The mean relation between distance and redshift for galaxies is reviewed as an observational question. The luminosity function for galaxies is an important ingredient and is given explicitly. We discuss various observational selection effects that are important for comparison of the linear and quadratic distance-redshift laws. Several lines of evidence are reviewed, including the distribution of galaxy luminosities in various redshift ranges, the luminosities of brightest galaxies in groups and clusters at various redshifts, and the Tully-Fisher correlation between neutral hydrogen velocity widths and luminosity. All of these strongly favor the linear law over the quadratic.

Dual-channel continuous-flow system for determination of phenylalanine and galactose: application to newborn screening.

We describe a dual-channel AutoAnalyzer (Technicon) system for the simultaneous measurement of phenylalanine and galactose from blood specimens on filter-paper. Using a single 1/4-in.-diameter (6-mm) specimen, we measure both components fluorometrically at a rate of 70/h. Analytical recovery with the method and the linearity of measurements vs sample concentration are excellent through the ranges of interest, 0-200 mg/L for phenylalanine and 0-800 mg/L for galactose. Carryover at the critical values during screening, 40 mg/L for phenylalanine and 100 mg/L for galactose, is essentially zero. The dual-channel system provides the means to incorporate a low-incidence test, i.e., galactosemia (incidence 1/70 000), into an existing program for phenylalanine analysis, for which the higher rates (phenylketonuria, incidence 1/11 500) easily justify the cost of mass screening.

Two new species of Myxozoa, Myxobolus inaequus sp. n. and Henneguya theca sp. n. from the brain of a South American knife fish, Eigemannia virescens (V.).

Two new species of Myxozoa from the brain of the green knife fish Eigemannia virescens are described: Myxobolus inaequus sp. n. has an unusually large spore body and extremely unequal polar capsules, and Henneguya theca sp. n. has an attenuated spore encased in a sheath not previously described in other Myxozoa . Only spores of the two species were observed, and infections caused no obvious pathological changes in the brain.

Pathogenicity and histopathology of an unusually intense infection of white grubs (Posthodiplostomum m. minimum) in the fathead minnow (Pimephales promelas).

A massive infection of metacercariae, particularly of the white grub (Posthodiplostomum m. minimum), was found in fathead minnows (Pimephales promelas) taken in November, 1979 from a commercial baitfish farm in Missouri. More than 2000 metacercariae were found in one fish 6 cm long. Low-grade mortality was occurring, and histologic sections showed that an intensive inflammatory response had resulted from the infection. The body cavity also contained a large volume of ascitic fluid with many blood cells, of which 92% were leucocytes. Moderate numbers of metacercariae caused a lesser inflammatory response.

Arsenic uptake and loss in the American oyster, Crassostrea virginica.

In addition to a control Crassostrea virginica was treated with 3 and 5 µg As kg(p-1) for 16 wks at ambient seawater salinity and temperature to determine the potential of C. virginica as an indicator of arsenic pollution. Prior to spawning, as much as 10.3±1.5, 12.7±2.7, and 14.1±3.7 µg As g(p-1) dry weight were accumulated in the total soft parts of oysters after treatment with ambient (control), 3 and 5 µg As kg(-1), respectively. Immediately after spawning, an increase in tissue arsenic concentration was observed in all treatments up to week 12, after which a decrease in tissue arsenic concentrations occurred despite continuous addition of arsenic to the seawater. During the uptake period, a significant inverse relationship existed between dry weight and tissue arsenic concentration, whereas a significant direct relationship was apparent between dry weight and tissue content. Arsenic concentration in the total soft parts is not significantly related to seawater arsenic concentration over the range of concentrations used in this study. In all three treatments, arsenic uptake as concentration (µg g(p-1)) is not a significant linear function of time. Weight loss was significant but gradual during the first 16 wks of treatment and did not change significantly during the depuration period (wks 17-25). Tissue arsenic concentrations increased significantly in oysters from all three treatments during the depuration period. Generally, arsenic body burdens increased with increases in phytoplankton concentration and it appears that food contributes more to arsenic uptake than seawater arsenic concentrations. Since a relationship between tissue arsenic concentration and seawater arsenic concentration does not appear to exist, C. virginica would not be a good biological indicator of arsenic concentration in its environment.

Characterization of a C3/C3b regulatory protein in normal human serum.

A protein which alters the activity of C3 and C3b has been isolated from normal human serum by sequential column chromatography. In purified form, at normal serum concentration, this protein fixes to cell-bound C3b. It cannot bind to C3d. After fixation, it prevents the inactivation of C3b by beta 1H and C3bINA in both the classical and alternative pathway C5 convertases. Independent of this action, fixation to C3b also markedly enhances the subsequent activity of C5. At higher concentrations, however, this protein is capable of blocking the activation of C3 by both pathway C3 convertases. This material, therefore, appears to represent a potent means of regulating several critical aspects of the biologic activity of the complement system.

A comparison of hard and soft glass blood-drawing tubes.

The authors examined both hard and soft glass evacuated blood-drawing tubes for possible effects on clinical chemistry measurements. Using routine laboratory procedures, no clinically or statistically significant difference could be detected in 34 analytes using 66 different methods. A special high-precision study utilizing an adaption of the NBS round-robin procedures for calcium, magnesium, sodium, and potassium detected no difference between paired sera when drawn or stored for 72 hours, or both, in the two types of glass. The authors conclude that the type of glass used in production of the evacuated blood-drawing tubes does not affect the clinical chemistry results obtained.

The parasitic coelenterate, Polypodium hydriforme USSOV, from the eggs of the American acipenseriform Polyodon spathula.

No significant differences in macro- and micromorphology were found between the parasitic stolon and free-living polyps of Polypodium sp. obtained from infected eggs of the North American acipenseriform fish Polyodon spathula and corresponding developmental stages of Polypodium hydriforme Ussov, parasitic in the Volga sterlet (Acipenser ruthenus). Therefore, both the American and the European forms of Polypodium belong to the species P. hydriforme Ussov.