Robust and Comprehensive Targeted Metabolomics Method for Quantification of 50 Different Primary, Secondary, and Sulfated Bile Acids in Multiple Biological Species (Human, Monkey, Rabbit, Dog, and Rat) and Matrices (Plasma and Urine) Using Liquid Chromatography High Resolution Mass Spectrometry (LC-HRMS) Analysis.

Bile acids (BAs) are biomolecules synthesized in the liver from cholesterol and are constituents of bile. The in-vivo BA pool includes more than 50 known diverse BAs which are unconjugated, amino acid conjugated, sulfated, and glucuronidated metabolites. Hemostasis of bile acids is known to be highly regulated and an interplay between liver metabolism, gut microbiome function, intestinal absorption, and enterohepatic recirculation. Interruption of BA homeostasis has been attributed to several metabolic diseases and drug induced liver injury (DILI), and their use as potential biomarkers is increasingly becoming important. Speciated quantitative and comprehensive profiling of BAs in various biomatrices from humans and preclinical animal species are important to understand their significance and biological function. Consequently, a versatile one single bioanalytical method for BAs is required to accommodate quantitation in a broad range of biomatrices from human and preclinical animal species. Here we report a versatile, comprehensive, and high throughput liquid chromatography-high resolution mass spectrometry (LC-HRMS) targeted metabolomics method for quantitative analysis of 50 different BAs in multiple matrices including human serum, plasma, and urine and plasma and urine of preclinical animal species (rat, rabbit, dog, and monkey). The method has been sufficiently qualified for accuracy, precision, robustness, and ruggedness and addresses the issue of nonspecific binding of bile acids to plastic for urine samples. Application of this method includes comparison for BA analysis between matched plasma and serum samples, human and animal species differences in BA pools, data analysis, and visualization of complex BA data using BA indices or ratios to understand BA biology, metabolism, and transport.

Emergency medicine resident involvement in EMS.

Emergency Medical Services (EMS) activities are a required component of Emergency Medicine (EM) residency training. To determine resident involvement with EMS, all 135 Accreditation Council for Graduate Medical Education-accredited and 34 American Osteopathic Association-accredited EM residencies were surveyed in June 2005 regarding the EMS activities required of their residents. One hundred twelve surveys were completed (66% response rate). Observing with ground EMS is required in 88% (n = 98) of residencies; working as an EMS provider is required in 28% (n = 31). Helicopter-based EMS involvement is uncommon, only 16% (n = 18) require observing and 21% (n = 23) require working as a provider. Most residencies (60%, n = 67) allow optional helicopter observation. Insufficient time is the most common reason for limiting EMS activities. Residents routinely provide on-line medical command (79%, n = 88). Most residencies (72%, n = 81) require lecturing to prehospital personnel; a minority require serving as Advanced Cardiac Life Support (38%, n = 42) or Advanced Trauma Life Support (13%, n = 14) instructors. Disaster training is required of most residents (73%, n = 82), whereas providing medical care at a mass gathering is not frequently required (28%, n = 31). Except for reviewing EMS patient care reports (54%, n = 60), quality improvement activities are rarely required. Serving as a medical director or assistant medical director for an EMS service is seldom required (6%, n = 7), and most residencies (63%, n = 70) do not specifically provide financial support for EMS physician-related training.

The value of internship in graduate medical education: survey of emergency medicine residents and program directors.

OBJECTIVE: To assess the opinions of emergency medicine (EM) residents and program directors about the value of completing a nonrequired 1-year internship before entering an EM residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME). METHODS: An eight-question, self-administered online survey was e-mailed to EM residents who had completed a nonrequired internship before entering ACGME-accredited residency programs. A separate, six-question survey was e-mailed to program directors of ACGME-accredited programs that do not require an internship who had ever had a resident who had completed a nonrequired internship. RESULTS: Forty-six (27 [59%] osteopathic, 19 [41%] allopathic) of 113 residents and 40 of 124 program directors responded to the survey questions. Less than 4% of residents completed a separate nonrequired 1-year internship. The most common reason for completing a nonrequired internship was to obtain licensure by the American Osteopathic Association (19 [41%]). Most residents believed that they were more proficient with history-taking and physical examinations (38 [83%]) and procedures (34 [74%]) during the first year of residency than their colleagues who did not complete an internship, but this percentage decreased over time. The program directors had similar opinions. Most osteopathic residents who completed the internship for osteopathic licensure would not have done so if it were not required. Most (39 of 40) program directors would not recommend taking a nonrequired internship. CONCLUSION: Completing a 1-year internship before entering an EM residency program may better prepare physicians for their first year of residency in terms of basic clinical competancy, but further study is needed in this area.

Collegiate-based emergency medical services (EMS): a survey of EMS systems on college campuses.

INTRODUCTION: Collegiate-based emergency medical systems (CBEMS) are a unique model for the delivery of prehospital care. The National Collegiate Emergency Medical Services Foundation (NCEMSF) was founded to serve as a resource for CBEMS groups. The purpose of this investigation is to describe the current state of CBEMS organizations. METHODS: The NCEMSF maintains a Web-based, data collection system to gather data on CBEMS organizations. Collegiate-based emergency medical services are defined as emergency medical services in a university or college campus setting. The abstracted data from the NCEMSF registry were analyzed using descriptive statistics. RESULTS: The NCEMSF registry contained data on 175 groups, and 145 groups were identified as providing CBEMS. The levels of service provided by the groups were: (1) first responder, 8.3%; (2) basic life support (BLS) 66.2%; (3) intermediate life support (ILS) 4.8%; (4) advanced life support (ALS), 9.7%; and (5) combination BLS/ALS, 8.3%. Transport capabilities were provided by 31.7% of the CBEMS. The average response time was estimated at 2.6 minutes (95% confidence interval (CI), 2.35-2.91 minutes). Early defibrillation using a automated external defibrillator (AED) or ALS was available by 75.9% (95% CI, 68.8-83.0) of CBEMS. Service to the community beyond the campus was provided by 21.3% of CBEMS groups. Forty-eight percent of the services operate 24 hours/day, seven days/week. The average call volume per year was 568 responses (95% CI, 315-820), and the groups averaged 29 (95% CI, 25-34) members. During the past five years, an average of 4.3 new CBEMS groups were formed per year. Eleven of the CBEMS are based at international schools.

Participation in the RACS sentinel node biopsy versus axillary clearance trial.

BACKGROUND: The Royal Australasian College of Surgeons (RACS) SNAC trial is a randomized controlled trial of sentinel node biopsy (SNB) versus axillary clearance (AC). It opened in May 2001 and is recruiting rapidly with good acceptance by consumers. METHODS: A study of eligibility and treatment choices was conducted between November 2001 and September 2002 for women presenting with early breast cancer to 10 centres participating in the trial. RESULTS: More than half of the 622 women (54%) were ineligible for trial entry because they had large (> 3 cm) or multicentric cancers. Participation was offered to 92% of eligible women and was taken up by 63%. The commonest reason for not participating was the desire to choose treatment rather than have it randomly allocated. Despite this there is a great acceptance of clinical trials because very few women (4% of those eligible) gave 'lack of interest in clinical trials' as the reason for non-participation. Few women who declined trial participation chose to have SNB alone (4.5% of those eligible). CONCLUSION: Sentinel node biopsy may become the standard of care for managing small breast cancers, but a significant number of patients will still require or choose axillary dissection. Results from large randomized trials are needed to determine the relative benefits and harms of SNB compared with AC. Surgeons must carefully discuss options for management with their patients.

Osteopathic emergency physician training and use of osteopathic manipulative treatment.

Previous studies of osteopathic manipulative treatment (OMT) have examined its use in several clinical settings, but no study to date has been specific to emergency medicine. This article examines the use of OMT in the practice of emergency medicine by osteopathic physicians. Osteopathic physicians who identified their practice as emergency medicine were surveyed to determine OMT use, including techniques used, graduate medical education, and factors affecting usage. Use of OMT was common (55%), with a large minority (28%) of osteopathic physicians reporting daily or weekly usage. Techniques most often used include soft tissue treatment, high velocity/low amplitude treatment, and muscle energy treatment. Factors affecting usage include residency training, undergraduate medical experiences, and practice environment. These findings indicate that further investigation into the indications and efficacy of OMT in emergency medicine is warranted.

Comparison of rural and urban ambulance crashes in Pennsylvania.

OBJECTIVE: To describe and compare the characteristics of, and associated injuries caused by, ambulance crashes that occur in rural versus urban areas. METHODS: Crash data collected by the Pennsylvania Department of Transportation were obtained for ambulance crashes from 1997 to 2001. Crash demographics (e.g., location of crash, road conditions, and intersection type) and injuries reported by police were analyzed to determine differences, if any, between crashes occurring in rural and urban areas. RESULTS: 311 rural and 1,434 urban ambulance crashes were identified. Day and time of crash, light conditions, and road type were similar. Rural crashes were more likely to occur on snowy roads (13% vs. 5%) and at nighttime without street lighting (25% vs. 4%). Operator error was the most common cause of crashes (75% for rural; 93% for urban), whereas vehicle or environmental conditions more frequently affected rural drivers (25% vs. 7%). Urban crashes were more likely to involve angled collisions with other vehicles (54% vs. 19%), intersections (67% vs. 26%), and occur at a stop sign or signal (53% vs, 14%). Rural crashes often involved striking a fixed object (33% vs. 7%). Urban crashes more often involved more than one vehicle (88% vs. 56%) and more than four people total (35% vs. 23%). Pedestrian involvement was rare in both groups (< 5%). Injury severity was similar between both types of crashes, although rural crashes more frequently did not involve any injuries (33% vs. 20%). Alcohol and/or drug use by drivers was rare (< 1%). CONCLUSION: Rural ambulance crashes usually do not involve other vehicles and are more often due to environmental or vehicle factors. Urban ambulance crashes typically involve intersections, other vehicles, and traffic signals. Although more people and vehicles are often involved in urban ambulance crashes, the severity of injuries sustained are similar.

Comparison of crashes involving ambulances with those of similar-sized vehicles.

OBJECTIVE: To describe the characteristics and associated occupant injuries of motor vehicle collisions (MVCs) involving ambulances as compared with MVCs involving similar-sized vehicles. METHODS: Motor vehicle crash data in Pennsylvania from 1997-2001 were analyzed to compare the characteristics of crashes involving ambulances with those involving vehicles of a similar size. Crash demographics (e.g., location of crash, roadway conditions, intersection type) and associated injuries were examined and compared using chi-square tests and Fisher's exact test. RESULTS: 2,038 ambulance MVCs and 23,155 crashes involving similar-sized vehicles were identified. Weather and road surface conditions were similar, but ambulance MVCs occurred with increased frequency on evenings and weekends. Ambulances were more likely to be involved in four-way intersection crashes (43% vs. 23%, p = 0.001), angled collisions (45% vs. 29%, p = 0.001), and collisions at traffic signals (37% vs. 18%, p = 0.001). More people were involved in ambulance MVCs (p = 0.001), with 84% of ambulance MVCs involving three or more people and 33% involving five or more people. Injuries were reported in more ambulance MVCs (76% vs. 61%, p = 0.001). Pedestrian involvement was rare (< 5% in both groups). CONCLUSION: Ambulance crashes occur more frequently at intersections and traffic signals and involve more people and more injuries than those of similar-sized vehicles.