Molecular Characterization and Detection of 16SrIII Group Phytoplasma Associated with Huanglongbing Symptoms.

When huanglongbing (HLB) was found in Brazil in 2004, 'Candidatus Liberibacter americanus' was infecting most of the trees while 'Ca. L. asiaticus' was present in a minor proportion. Currently, 'Ca. L. asiaticus' is the predominant bacterium associated with HLB in citrus trees in São Paulo (SP) and Minas Gerais (MG) States, the major citrus-growing regions in Brazil. A phytoplasma from the 16SrIX group was associated with HLB symptoms in Brazil in 2007, in plants free of Liberibacter spp. In this report, HLB samples testing negative for 'Ca. L. asiaticus', 'Ca. L. americanus', and 16SrIX phytoplasma were infected with 16SrIII phytoplasmas. Coinfection with 'Ca. L. asiaticus' and 16SrIII was also found. The 16S ribosomal RNA (rRNA) gene sequences from 22 samples were obtained and sequenced, confirming that the 16SrIII group phytoplasma is associated with HLB symptoms in SP and MG States. Ten single-nucleotide polymorphisms (SNPs) were found in the 1,427-bp 16S rRNA gene sequences from 16SrIII phytoplasmas from citrus, whereas none was detected in 16S rRNA gene sequences among 16SrIX phytoplasma from citrus. Ribosomal protein (rp) rpsSrplVrpsC gene sequences were amplified with 16SrIII group-specific primers, sequenced from a subset of nine samples, and assembled into three groups based on eight SNPs. SNPs in 16S rRNA gene and rp gene sequences are common in 16SrIII phytoplasmas from other hosts and this phytoplasma group is widespread in South America. 16SrIII phytoplasmas highly related are commonly found in Melia azedarach, a widespread tree in Brazil and Argentina. The finding of a new phytoplasma associated with HLB symptoms belonging to the 16SrIII group reinforces the need to develop diagnostic tools to assess HLB-associated microbiomes.

An accurate, simple prognostic model consisting of age, JAK2, CALR, and MPL mutation status for patients with primary myelofibrosis.

In most patients with primary myelofibrosis, one of three mutually exclusive somatic mutations is detected. In approximately 60% of patients, the Janus kinase 2 gene is mutated, in 20%, the calreticulin gene is mutated, and in 5%, the myeloproliferative leukemia virus gene is mutated. Although patients with mutated calreticulin or myeloproliferative leukemia genes have a favorable outcome, and those with none of these mutations have an unfavorable outcome, prognostication based on mutation status is challenging due to the heterogeneous survival of patients with mutated Janus kinase 2. To develop a prognostic model based on mutation status, we screened primary myelofibrosis patients seen at the MD Anderson Cancer Center, Houston, USA, between 2000 and 2013 for the presence of Janus kinase 2, calreticulin, and myeloproliferative leukemia mutations. Of 344 primary myelofibrosis patients, Janus kinase 2V617F was detected in 226 (66%), calreticulin mutation in 43 (12%), and myeloproliferative leukemia mutation in 16 (5%); 59 patients (17%) were triple-negatives. A 50% cut-off dichotomized Janus kinase 2-mutated patients into those with high Janus kinase 2V617F allele burden and favorable survival and those with low Janus kinase 2V617F allele burden and unfavorable survival. Patients with a favorable mutation status (high Janus kinase 2V617F allele burden/myeloproliferative leukemia/calreticulin mutation) and aged 65 years or under had a median survival of 126 months. Patients with one risk factor (low Janus kinase 2V617F allele burden/triple-negative or age >65 years) had an intermediate survival duration, and patients aged over 65 years with an adverse mutation status (low Janus kinase 2V617F allele burden or triple-negative) had a median survival of only 35 months. Our simple and easily applied age- and mutation status-based scoring system accurately predicted the survival of patients with primary myelofibrosis.

The complete genome sequence of 'Candidatus Liberibacter americanus', associated with Citrus huanglongbing.

Liberibacter spp. form a Rhizobiaceae clade of phloem-limited pathogens of limited host range. Two obligately parasitic species have been sequenced: 'Candidatus Liberibacter asiaticus', which causes citrus huanglongbing (HLB) worldwide, and 'Ca. L. solanacearum', which causes potato "zebra chip" disease. A third (proposed) species, Liberibacter crescens, was isolated from mountain papaya, grown in axenic culture, and sequenced. In an effort to identify common host determinants, the complete genomic DNA sequence of a second HLB species, 'Ca. L. americanus' strain 'São Paulo' was determined. The circular genome of 1,195,201 bp had an average 31.12% GC content and 983 predicted protein encoding genes, 800 (81.4%) of which had a predicted function. There were 658 genes common to all sequenced Liberibacter spp. and only 8 genes common to 'Ca. L. americanus' and 'Ca. L. asiaticus' but not found in 'Ca. L. solanacearum'. Surprisingly, most of the lipopolysaccharide biosynthetic genes were missing from the 'Ca. L. americanus' genome, as well as OmpA and a key regulator of flagellin, all indicating a 'Ca. L. americanus' strategy of avoiding production of major pathogen-associated molecular patterns present in 'Ca. L. asiaticus' and 'Ca. L. solanacearum'. As with 'Ca. L. asiaticus', one of two 'Ca. L. americanus' prophages replicated as an excision plasmid and carried potential lysogenic conversion genes that appeared fragmentary or degenerated in 'Ca. L. solanacearum'.

Does Inclusion of Emergency Medicine (EM) Residents in ECG Screening for STEMI Change the Time to Catheterization Lab Activation?

BACKGROUND: Emergency medicine physicians must rapidly obtain and interpret an electrocardiogram (ECG) to quickly identify life-threatening cardiac emergencies such as ST-elevation myocardial infarction (STEMI). Although ECG interpretation is a critical component of residency education, few high-powered studies exploring the accuracy of resident ECG interpretation exist. OBJECTIVES: This study aims to evaluate whether or not the inclusion of Third Year Emergency Medicine Resident ECG interpretations is noninferior to attending-only ECG interpretations in regard to time to STEMI activation. METHODS: This was a retrospective noninferiority study of STEMI activation times before and after the inclusion of Third Year Emergency Medicine Resident resident ECG interpretations into the workflow at an academic, urban tertiary care center between November 2020 and April 2022, excluding prehospital activations. The primary outcome was the proportion of successful STEMI activations initiated within 5 minutes of ECG completion. An absolute decrease of 10% between groups was chosen as the noninferiority margin. RESULTS: In the attending-only group, 26 (66.7%) cases resulted in successful STEMI activations compared to 31 cases (77.5%) in the combined group. The proportion of successful STEMI activations did not differ with resident screening, X 2 = 1.15, P = 0.28. The absolute difference between groups' successful activations was an increase of 11%, which lies within the noninferiority margin (+11%, 95% confidence interval, -8.68% to 30.7%). Average times to STEMI activation in the attending-only and combined groups were 7.59 minutes (Standard Deviation [SD], 10.19) and 5.13 minutes (SD, 6.95), respectively. Average door-to-balloon times for those undergoing Percutaneous Coronary Intervention were 72.74 minutes (SD, 20.76) in the attending-only group and 89.90 minutes (SD, 67.74) in the combination group. Two sample t-test showed no statistically significant difference between the 2 groups for average time to STEMI activation (difference = 2.46 minutes, 95% CI, -1.46 to 6.38) and average door-to-balloon time (difference = 17.16, 95% CI, -39.73 to 5.41). CONCLUSION: The inclusion of emergency medicine PGY-3 residents in the ECG screening workflow is noninferior to attending-only interpretation of ECGs with regard to STEMI activation time.

Does the Electrocardiogram Machine Interpretation Affect the Ability to Accurately Diagnose ST-Elevation Myocardial Infarction by Emergency Physicians?

INTRODUCTION: An ST-elevation myocardial infarction (STEMI) can portend significant morbidity and mortality to the patient and therefore must be rapidly diagnosed by an emergency medicine (EM) physician. The primary aim of this study is to determine whether EM physicians are more or less likely to accurately diagnose STEMI on an electrocardiogram (ECG) if they are blinded to the ECG machine interpretation as opposed to if they are provided the ECG machine interpretation. METHODS: We performed a retrospective chart review of adult patients over 18 years of age admitted to our large, urban tertiary care center with a diagnosis of STEMI from January 1, 2016, to December 31, 2017. From these patients' charts, we selected 31 ECGs to create a quiz that was presented twice to a group of emergency physicians. The first quiz contained the 31 ECGs without the computer interpretations revealed. The second quiz, presented to the same physicians 2 weeks later, contained the same set of ECGs with the computer interpretations revealed. Physicians were asked "Based on the ECG above, is there a blocked coronary artery present causing a STEMI?" RESULTS: Twenty-five EM physicians completed two 31-question ECG quizzes for a total of 1550 ECG interpretations. On the first quiz with computer interpretations blinded, the overall sensitivity in identifying a "true STEMI" was 67.2% with an overall accuracy of 65.6%. On the second quiz in which the ECG machine interpretation was revealed, the overall sensitivity was 66.4% with an accuracy of 65.8 % in correctly identifying a STEMI. The differences in sensitivity and accuracy were not statistically significant. CONCLUSION: This study demonstrated no significant difference in physicians blinded versus those unblinded to computer interpretations of possible STEMI.

Managing Postpartum Complications in the Emergency Department.

Postpartum patients may present to the emergency department with complaints ranging from minor issues, requiring only patient education and reassurance, to severe, life-threatening complications that require prompt diagnosis and multidisciplinary consultation and management. At times, vague presentations or overlapping conditions can make it difficult for the emergency clinician to recognize an emergent condition and initiate proper treatment. This issue reviews the major common emergencies that present in postpartum patients, by chief complaint, including hemorrhage, infection, pre-eclampsia, eclampsia, headache, and cardiopulmonary conditions, and reviews the most recent evidence and guidelines.

Citrus Sudden Death Is Transmitted by Graft-Inoculation and Natural Transmission Is Prevented by Individual Insect-Proof Cages.

Citrus sudden death (CSD) transmission was studied by graft-inoculation and under natural conditions. Young sweet orange trees on Rangpur rootstock were used as indicator plants. They were examined regularly for one or two characteristic markers of CSD: (i) presence of a yellow-stained layer of thickened bark on the Rangpur rootstock, and (ii) infection with the CSD-associated marafivirus. Based on these two markers, transmission of CSD was obtained, not only when budwood for graft-inoculation was taken from symptomatic, sweet orange trees on Rangpur, but also when the budwood sources were asymptomatic sweet orange trees on Cleopatra mandarin, indicating that the latter trees are symptomless carriers of the CSD agent. For natural transmission, 80 young indicator plants were planted within a citrus plot severely affected by CSD. Individual insect-proof cages were built around 40 indicator plants, and the other 40 indicator plants remained uncaged. Only two of the 40 caged indicator plants were affected by CSD, whereas 17 uncaged indicator plants showed CSD symptoms and were infected with the marafivirus. An additional 12 uncaged indicator plants became severely affected with citrus variegated chlorosis and were removed. These results strongly suggest that under natural conditions, CSD is transmitted by an aerial vector, such as an insect, and that the cages protected the trees against infection by the vector.

Scope-assisted release of the cubital tunnel.

We report on a technique of endoscopic release of the cubital tunnel, which is a modification of Bruno and Tsai's technique. This article covers the history, complications, indications, and postoperative management of ulnar nerve entrapments treated endoscopically, with a special focus on our technique. This minimally invasive alternative to transposition requires no mobilization of the ulnar nerve, which could potentially reduce iatrogenic trauma to the nerve and its vascularity.

Partial chromosome sequence of Spiroplasma citri reveals extensive viral invasion and important gene decay.

The assembly of 20,000 sequencing reads obtained from shotgun and chromosome-specific libraries of the Spiroplasma citri genome yielded 77 chromosomal contigs totaling 1,674 kbp (92%) of the 1,820-kbp chromosome. The largest chromosomal contigs were positioned on the physical and genetic maps constructed from pulsed-field gel electrophoresis and Southern blot hybridizations. Thirty-eight contigs were annotated, resulting in 1,908 predicted coding sequences (CDS) representing an overall coding density of only 74%. Cellular processes, cell metabolism, and structural-element CDS account for 29% of the coding capacity, CDS of external origin such as viruses and mobile elements account for 24% of the coding capacity, and CDS of unknown function account for 47% of the coding capacity. Among these, 21% of the CDS group into 63 paralog families. The organization of these paralogs into conserved blocks suggests that they represent potential mobile units. Phage-related sequences were particularly abundant and include plectrovirus SpV1 and SVGII3 and lambda-like SpV2 sequences. Sixty-nine copies of transposases belonging to four insertion sequence (IS) families (IS30, IS481, IS3, and ISNCY) were detected. Similarity analyses showed that 21% of chromosomal CDS were truncated compared to their bacterial orthologs. Transmembrane domains, including signal peptides, were predicted for 599 CDS, of which 58 were putative lipoproteins. S. citri has a Sec-dependent protein export pathway. Eighty-four CDS were assigned to transport, such as phosphoenolpyruvate phosphotransferase systems (PTS), the ATP binding cassette (ABC), and other transporters. Besides glycolytic and ATP synthesis pathways, it is noteworthy that S. citri possesses a nearly complete pathway for the biosynthesis of a terpenoid.

Does the Removal of Textbook Reading from Emergency Medicine Resident Education Negatively Affect In-Service Scores?

INTRODUCTION: In-service exam scores are used by residency programs as a marker for progress and success on board exams. Conference curriculum helps residents prepare for these exams. At our institution, due to resident feedback a change in curriculum was initiated. Our objective was to determine whether assigned Evidence-Based Medicine (EBM) articles and Rosh Review questions were non-inferior to Tintinalli textbook readings. We further hypothesized that the non-textbook assigned curriculum would lead to higher resident satisfaction, greater utilization, and a preference over the old curriculum. METHODS: We collected scores from both the allopathic In-training Examination (ITE) and osteopathic Emergency Medicine Residency In-service Exam (RISE) scores taken by our program's residents from both the 2015-2016 and 2016-2017 residency years. We compared scores pre-curriculum change (pre-CC) to scores post-curriculum change (post-CC). A five-question survey was sent to the residents regarding their satisfaction, preference, and utilization of the two curricula. RESULTS: Resident scores post-CC were shown to be non-inferior to their scores pre-CC for both exams. There was also no significant difference when we compared scores from each class post-CC to their respective class year pre-CC for both exams. Our survey showed significantly more satisfaction, utilization, and preference for this new curriculum among residents. CONCLUSION: We found question-based learning and Evidence-Based Medicine articles non-inferior to textbook readings. This study provides evidence to support a move away from textbook readings without sacrificing scores on examinations.

The Impact of a Concierge Medicine Model on Door to Doctor Time and Patient Flow in an Urban Emergency Department.

INTRODUCTION: Emergency Department (ED) crowding negatively impacts patient outcomes, patient satisfaction, and patient safety. One solution involves introducing a Concierge Physician (CP) whose sole purpose is to provide a brief initial assessment (BIA) and aid patient navigation through the ED. The goal of this study was to quantify the impact of a CP on patient flow dynamics in an urban ED setting. METHODS: We performed a retrospective observational cohort study in an urban academic ED over a 6-month period. Initially, the CP was present in the treatment area during weekdays; during the last half of the observation period, an additional CP was added to the waiting room on weekends. We identified four major milestones in the ED visit with regards to patient throughput. Adult patients presenting to the ED with a triage level of Urgent (ESI 3) were analyzed for this study. Data were stratified based on the patient's ultimate disposition (admitted or discharged) and presented as means with predictive analysis. RESULTS: Between August 2016 and January 2017, the ED evaluated 42,397 adult patients. Of those, 26,976 (64%) were triage level Urgent (3). Of the level 3 patients, 10,279 (38%) received a BIA from a CP. Patients evaluated by a CP were seen approximately 30 mins faster (40% reduction in Door to Doctor time), but stayed 30 mins longer in the ED on average, because the medical decision-making process took >1 hr longer when the patient was initially evaluated by a CP. CONCLUSION: Adapting a concierge medicine model to rapidly evaluate patients resulted in a dramatically reduced Door to Doctor time, but an increase in overall time spent in the ED. This discrepancy was a direct result of the delay in physician disposition.

The abundant extrachromosomal DNA content of the Spiroplasma citri GII3-3X genome.

BACKGROUND: Spiroplama citri, the causal agent of citrus stubborn disease, is a bacterium of the class Mollicutes and is transmitted by phloem-feeding leafhopper vectors. In order to characterize candidate genes potentially involved in spiroplasma transmission and pathogenicity, the genome of S. citri strain GII3-3X is currently being deciphered. RESULTS: Assembling 20,000 sequencing reads generated seven circular contigs, none of which fit the 1.8 Mb chromosome map or carried chromosomal markers. These contigs correspond to seven plasmids: pSci1 to pSci6, with sizes ranging from 12.9 to 35.3 kbp and pSciA of 7.8 kbp. Plasmids pSci were detected as multiple copies in strain GII3-3X. Plasmid copy numbers of pSci1-6, as deduced from sequencing coverage, were estimated at 10 to 14 copies per spiroplasma cell, representing 1.6 Mb of extrachromosomal DNA. Genes encoding proteins of the TrsE-TraE, Mob, TraD-TraG, and Soj-ParA protein families were predicted in most of the pSci sequences, in addition to members of 14 protein families of unknown function. Plasmid pSci6 encodes protein P32, a marker of insect transmissibility. Plasmids pSci1-5 code for eight different S. citri adhesion-related proteins (ScARPs) that are homologous to the previously described protein P89 and the S. kunkelii SkARP1. Conserved signal peptides and C-terminal transmembrane alpha helices were predicted in all ScARPs. The predicted surface-exposed N-terminal region possesses the following elements: (i) 6 to 8 repeats of 39 to 42 amino acids each (sarpin repeats), (ii) a central conserved region of 330 amino acids followed by (iii) a more variable domain of about 110 amino acids. The C-terminus, predicted to be cytoplasmic, consists of a 27 amino acid stretch enriched in arginine and lysine (KR) and an optional 23 amino acid stretch enriched in lysine, aspartate and glutamate (KDE). Plasmids pSci mainly present a linear increase of cumulative GC skew except in regions presenting conserved hairpin structures. CONCLUSION: The genome of S. citri GII3-3X is characterized by abundant extrachromosomal elements. The pSci plasmids could not only be vertically inherited but also horizontally transmitted, as they encode proteins usually involved in DNA element partitioning and cell to cell DNA transfer. Because plasmids pSci1-5 encode surface proteins of the ScARP family and pSci6 was recently shown to confer insect transmissibility, diversity and abundance of S. citri plasmids may essentially aid the rapid adaptation of S. citri to more efficient transmission by different insect vectors and to various plant hosts.

Transtracheal 2-d ultrasound for identification of esophageal intubation.

This prospective, blinded, observational, efficacy study is one of the first to evaluate ultrasound in detecting esophageal intubation, a significant source of morbidity and mortality. We utilized a convenience sample of patients undergoing elective surgery during July 2004 in an urban teaching hospital. Trained Emergency Physician sonographers performed transtracheal ultrasounds of intubations to identify esophageal intubation. In 35 of the 40 patients enrolled, there was intubation of the trachea, whereas esophageal intubation occurred in five patients. Sonographers correctly identified all five esophageal intubations, for a sensitivity of 100% (95% confidence interval [CI] 48-100). Ultrasound correctly identified 34 of 35 tracheal intubations and misidentified one resulting in a specificity of 97% (95% CI 90-100). It seems that transtracheal ultrasound may be an efficacious adjunct for detecting esophageal intubation.

Effectiveness of 2-hour Troponin in High-risk Patients With Suspected Acute Coronary Syndrome.

BACKGROUND: Research has shown the safety and effectiveness of drawing a standard troponin level at presentation and again at 2 hours in only low-risk patients. Because high-sensitivity troponins are not currently approved in the United States, we studied the utility of a standard troponin that is presently in use. Our goal was to determine if 2-hour standard troponin would be safe and effective in the evaluation of a high-risk cohort of patients never studied previously. METHODS: We conducted a single-center prospective observational study of adult patients presenting to the emergency department with signs and symptoms suggestive of acute coronary syndrome. Patients were defined as high risk if the attending physician planned to admit or transfer the patient to the observation unit. History, Electrocardiography, Age, Risk factors, Troponin scores were calculated on all patients to provide verification that the individuals were high risk. The primary outcome was a composite of 30-day myocardial infarction, death, cardiac arrest with return of spontaneous circulation, or dysrhythmia. The secondary outcome was 30-day revascularization. RESULTS: We included a total of 122 patients with an average follow-up of 112 days (minimum 30 days). A total of 86% of cases had History, Electrocardiography, Age, Risk factors, Troponin scores ≥4. The primary outcome was met in 22 (18%) patients, and the secondary outcome occurred in 7 (5.7%) patients. The negative predictive value of negative 2-hour troponins along with no significant delta troponin rise was 98.7%. CONCLUSIONS: Discharging patients thought to be high risk who have negative troponins at 0 and 2 hours and no delta troponin rise appears safe. No deaths occurred in follow-up. Larger studies are warranted.

JAK2V617F detection and allele burden measurement in saliva vs. peripheral blood in patients with myelofibrosis.

We previously demonstrated that peripheral blood (PB) is a reliable source for testing JAK2V617F mutation in patients with myelofibrosis (MF); saliva has also been tested to detect such mutation, however its diagnostic accuracy as compared to PB has not been validated. In this study, we prospectively tested 167 patients with MF for JAK2V617F mutation, using both saliva and PB collected at the same time from each patient. The concordance between the 2 sources was 96%, with a sensitivity of 100% and a specificity of 90%. The only factor associated with false positivity on saliva was ongoing transfusion dependency. JAK2V617F testing using saliva is a simple, non-invasive, and potentially a more reliable method than PB for measuring JAK2 status and assessing V617F allelic burden in patients with transfusion dependency.

Spiroplasma citri, a plant pathogenic molligute: relationships with its two hosts, the plant and the leafhopper vector.

Spiroplasma citri, the type species of the genus Spiroplasma (Spiroplasmataceae, Mollicutes), is restricted to the phloem sieve tubes and transmitted by phloem sap-feeding insects, as is characteristic of the phytopathogenic mollicutes. The spiroplasmas are the only mollicutes showing motility and helical morphology, apparently mediated by a contractile fibrillar cytoskeleton bound to the inner surface of the spiroplasmal membrane. MreB genes, which are involved in cell-shape determination, have been identified in S. citri. Identified genes of other functional groups are those involved in the transmission of S. citri by the leafhoppers and genes coding for lipoproteins, including spiralin, bound to the outer surface of the spiroplasma membrane. S. citri mutants that are unable to use fructose induce only mild and delayed symptoms. Fructose utilization by the sieve tube-restricted wild-type spiroplasmas is postulated to deprive the companion cells of fructose, thereby impairing sucrose loading into the sieve tubes.

Pediatric nerve agent poisoning: medical and operational considerations for emergency medical services in a large American city.

Most published recommendations for treatment of pediatric nerve agent poisoning are based on standard resuscitation doses for these agents. However, certain medical and operational concerns suggest that an alternative approach may be warranted for treatment of children by emergency medical personnel after mass chemical events. (1) There is evidence both that suprapharmacological doses may be warranted and that side effects from antidote overdosage can be tolerated. (2) There is concern that many emergency medical personnel will have difficulty determining both the age of the child and the severity of the symptoms. Therefore, the Regional Emergency Medical Advisory Committee of New York City and the Fire Department, City of New York, Bureau of Emergency Medical Services, in collaboration with the Center for Pediatric Emergency Medicine of the New York University School of Medicine and the Bellevue Hospital Center, have developed a pediatric nerve agent antidote dosing schedule that addresses these considerations. These doses are comparable to those being administered to adults with severe symptoms and within limits deemed tolerable after inadvertent nerve agent overdose in children. We conclude that the above approach is likely a safe and effective alternative to weight-based dosing of children, which will be nearly impossible to attain under field conditions.

Aspects of residency programs' web sites important to student applicants.

OBJECTIVES: To determine which components of a residency Web site (RWS) are important to residency applicants. METHODS: The authors performed a cross-sectional observational study of residency applicants. All applicants were invited to participate and were provided with a nine-question survey. Applicants were asked questions regarding the importance and impact of RWSs on the residency application process. They were also asked to rate items regarding content and aesthetics, and then rank all items in order of importance. Descriptive statistics are reported. Rank-order displays were determined using the Condorcet choice method. RESULTS: One hundred eighty-eight (82%) of the applicants responded to the survey. Seventy-eight percent of the respondents reported that information provided in an RWS influenced their decision to apply to a particular program (41% decided not to apply to at least one program based on the quality of its RWS). Applicants believed that presentation of the residency curriculum was most important. Information about the hospital and its affiliates, faculty and resident information, and research activities followed in the rank order. Least important to applicants were the aesthetic quality of the site, faculty/resident photographs, and educational resource materials. The authors report additional areas of content that applicants thought would be useful to view. CONCLUSIONS: The content, and not necessarily the aesthetic quality, of an RWS is important to residency applicants. The residency program Web site would seem to be an important factor in the applicant's decision to apply. The applicant's perspective provides training program directors and administrators with focused direction in Web site development or for upgrading existing RWSs for use by future applicants.

Emergency medicine-trained physicians are proficient in the insertion of transvenous pacemakers.

STUDY OBJECTIVE: The insertion and management of a temporary transvenous pacemaker can be a lifesaving procedure in the emergency department setting. We compare the success and complication rates associated with temporary transvenous pacemaker insertion between physicians trained in either emergency medicine or cardiology. METHODS: This was a retrospective medical record review of all patients with a billing code for temporary transvenous pacemaker insertion at our institution between July 1999 and December 2002. Patients were excluded if the temporary transvenous pacemaker was not supervised by an attending physician or was placed under fluoroscopy or if the indication for pacing was asystole. Cases were reviewed by 2 physicians certified in emergency medicine and categorized by the specialty training of the attending physician providing direct supervision. RESULTS: During the review period, 10 emergency medicine faculty and 8 cardiologists directly supervised 141 of the 158 temporary transvenous pacemaker insertions in 154 patients. Twenty-four were placed for asystole, 4 were placed under fluoroscopy, and 13 were placed without direct attending supervision, leaving a total of 117 cases (30 emergency medicine, 87 cardiology) for review. The procedure was successful 97% (95% confidence interval [CI] 90% to 100%) of the time for emergency medicine faculty and 95% (95% CI 91% to 100%) of the time for cardiology faculty. Complications were seen in 23% (95% CI 7% to 39%) of the temporary transvenous pacemakers inserted by emergency medicine attending physicians and 20% (95% CI 11% to 28%) of the temporary transvenous pacemakers inserted by cardiologists. There was no statistical difference in errors between the specialties, and no complication resulted in death or prolonged disability. CONCLUSION: Physicians trained in emergency medicine perform temporary transvenous pacemaker insertions in the acute care setting with a proficiency similar to that of their counterparts in cardiology.

Shock index in the first trimester of pregnancy and its relationship to ruptured ectopic pregnancy.

UNLABELLED: The shock index (SI), the ratio of heart rate to systolic blood pressure, has been reported to be a useful tool in the evaluation of trauma patients presenting to the emergency department (ED). OBJECTIVES: To determine the range of values for SI seen in first-trimester patients presenting to the ED, and to estimate the ability of the SI to predict ruptured ectopic pregnancy (EP). METHODS: This was a prospective cohort study enrolling all patients in the first trimester of pregnancy presenting to the ED with abdominal pain and/or vaginal bleeding. Patients had a SI calculated based on their presenting vital signs, and were followed longitudinally to determine a final diagnosis. Ectopic pregnancies were categorized based on surgical pathology. Mean levels for SI were determined for each group, and ruptured EPs were compared with all other pregnancies using a receiver operating characteristic (ROC) curve. RESULTS: The study enrolled 280 patients, 24 ruptured EPs, 28 unruptured EPs, and 228 non-EPs. The means for SI were 0.67 (95% CI = 0.65 to 0.68) for non-EPs, 0.64 (95% CI = 0.61 to 0.67) for unruptured EPs, and 0.84 (95% CI = 0.77 to 0.9) for ruptured EPs. The ROC curve for SI, heart rate, mean arterial pressure, and systolic blood pressure demonstrated areas under the curve (AUCs) of 0.84 (95% CI = 0.78 to 0.88), 0.74 (95% CI = 0.67 to 0.79), 0.63 (95% CI = 0.67 to 0.79), and 0.70 (95% CI = 0.64 to 0.77), respectively. CONCLUSIONS: The range of values for SI for patients being evaluated for pain and/or vaginal bleeding within the first trimester of pregnancy, who do not have a ruptured EP, are within the previously reported range of 0.5-0.7 for nonpregnant patients. A SI > 0.85 made the diagnosis of ruptured EP 15.0 (95% CI = 5.6 to 40.4) times more likely. This study suggests that SI could impact directly on the diagnostic and therapeutic course of the patient.