Non-specialist emergency medicine qualifications in Africa: Lessons from the South African Diploma in Primary Emergency Care.

Introduction: Non-specialist emergency medicine qualifications are an important step in developing the specialty of emergency medicine. The Diploma in Primary Emergency Care (Dip PEC) of the Colleges of Medicine of South Africa is one of the oldest registrable qualifications. Reviewing its changing role over time has lessons for academics developing Emergency Medicine training in Africa. Methods: Through a series of meetings and stakeholder engagements, the Council of the College of Emergency Medicine conducted a three year review of the qualification focusing on the curriculum, assessment processes, success rate and role of the qualification in the South African medical context. A survey of the perceptions of graduates over the last six years was also conducted. Results: The survey showed candidate numbers increased dramatically from 2011 to 2017, resulting in an entry cap. Lessons identified included ensuring that the qualification is responsive to the state of development of emergency medicine in the country, needing aligned and valid assessment processes and maintaining the value of the qualification in context. Discussion: Emergency medicine qualifications are dynamic in and of themselves and how they relate to their context. Program designers must prioritize ongoing evaluation from the start.

Fluxes of Atmospheric Greenhouse-Gases in Maryland (FLAGG-MD): Emissions of Carbon Dioxide in the Baltimore, MD-Washington, D.C. area.

To study emissions of CO2 in the Baltimore, MD-Washington, D.C. (Balt-Wash) area, an aircraft campaign was conducted in February 2015, as part of the FLAGG-MD (Fluxes of Atmospheric Greenhouse-Gases in Maryland) project. During the campaign, elevated mole fractions of CO2 were observed downwind of the urban center and local power plants. Upwind flight data and HYSPLIT (Hybrid Single Particle Lagrangian Integrated Trajectory) model analyses help account for the impact of emissions outside the Balt-Wash area. The accuracy, precision, and sensitivity of CO2 emissions estimates based on the mass balance approach were assessed for both power plants and cities. Our estimates of CO2 emissions from two local power plants agree well with their CEMS (Continuous Emissions Monitoring Systems) records. For the 16 power plant plumes captured by the aircraft, the mean percentage difference of CO2 emissions was -0.3 %. For the Balt-Wash area as a whole, the 1σ CO2 emission rate uncertainty for any individual aircraft-based mass balance approach experiment was ±38 %. Treating the mass balance experiments, which were repeated seven times within nine days, as individual quantifications of the Balt-Wash CO2 emissions, the estimation uncertainty was ±16 % (standard error of the mean at 95% CL). Our aircraft-based estimate was compared to various bottom-up fossil fuel CO2 (FFCO2) emission inventories. Based on the FLAGG-MD aircraft observations, we estimate 1.9±0.3 MtC of FFCO2 from the Balt-Wash area during the month of February 2015. The mean estimate of FFCO2 from the four bottom-up models was 2.2±0.3 MtC.

Increased atmospheric ammonia over the world's major agricultural areas detected from space.

This study provides evidence of substantial increases in atmospheric ammonia (NH3) concentrations (14-year) over several of the worlds major agricultural regions, using recently available retrievals from the Atmospheric Infrared Sounder (AIRS) aboard NASA's Aqua satellite. The main sources of atmospheric NH3 are farming and animal husbandry involving reactive nitrogen ultimately derived from fertilizer use; rates of emission are also sensitive to climate change. Significant increasing trends are seen over the US (2.61% yr-1), the European Union (EU) (1.83% yr-1), and China (2.27% yr-1). Over the EU, the trend results from decreased scavenging by acid aerosols. Over the US, the increase results from a combination of decreased chemical loss and increased soil temperatures. Over China, decreased chemical loss, increasing temperatures, and increased fertilizer use all play a role. Over South Asia, increased NH3 emissions are masked by increased SO2 and NOx emissions, leading to increased aerosol loading and adverse health effects.

Alterations in immune function and CYP450 activity in adult male deer mice (Peromyscus maniculatus) following exposure to benzo[a]pyrene, pyrene, or chrysene.

Polycyclic aromatic hydrocarbons (PAHs) are among the most common classes of chemical contaminants found at hazardous waste sites. Deer mice (Peromyscus maniculatus) exhibit a wide geographic distribution throughout North America and have been suggested as a terrestrial biomonitoring species to facilitate comparisons between superfund sites. Chemicals tested were benzo[a]pyrene (BaP; CAS number 50-32-8), pyrene (Pyr; CAS number 129-00-0), and chrysene (Chr; CAS number 218-01-9). Adult male deer mice were exposed via intraperitoneal (i.p.) injection every other day for 11 d to the PAHs (0.3, 1, 3, 10, or 30 mg/kg) or a corn oil carrier control. Both BaP and Chr suppressed the plaque-forming cell (PFC) response at all treatment levels. Pyr exposure (1-30 mg/kg) also resulted in suppression of this response. Macrophage pinocytosis was suppressed only by Chr (3, 10, and 30 mg/kg). Concanavalin A-induced proliferation was stimulated by BaP at all dose levels, by Pyr at 1-30 mg/kg, and by Chr at 30 mg/kg. Chr did not affect pokeweed mitogen (PWM)-induced proliferation; however, BaP (1-30 mg/kg) and Pyr (0.3-30 mg/kg) produced stimulation of this response as compared to respective controls. BaP and Chr stimulated cytochrome P-450 1A1 (CYP1A1) activity (3, 10, or 30 mg/kg) as measured by ethoxyresorufin O-deethylase (EROD) activity, but Pyr did not. These results indicate that immune function endpoints appear to be more sensitive to these PAHs than measured hepatic CYP450 activity.

Effect of zero- to one-dimensional transformation on multiparticle Auger recombination in semiconductor quantum rods.

We study the effect of the zero- to one-dimensional (1D) transformation on multiparticle Auger recombination using a series of elongated semiconductor nanocrystals (quantum rods). We observe a transition from the three- to two-particle recombination process as the nanocrystal aspect ratio is increased. This transition indicates that in the 1D confinement limit, Auger decay is dominated by Coulomb interactions between 1D excitons that recombine in a bimolecular fashion. One consequence of this effect is strongly reduced decay rates of higher multiparticle states that lead to increased optical-gain lifetimes and efficient light amplification due to involvement of excited electronic states.

Intrinsic bending and deformability at the T-A step of CCTTTAAAGG: a comparative analysis of T-A and A-T steps within A-tracts.

Introduction of a T-A or pyrimidine-purine step into a straight and rigid A-tract can cause a positive roll deformation that kinks the DNA helix at that step. In CCTTTAAAGG, the central T-A step has an 8.6 degrees bend toward the major groove. We report the structural analysis of CCTTTAAAGG and a comparison with 25 other representative crystal structures from the NDB containing at least four consecutive A or T bases. On average, more local bending occurs at the disruptive T-A step (8.21 degrees ) than at an A-T step (5.71 degrees ). In addition, A-tracts containing an A-T step are more bent than are pure A-tracts, and hence A-A and A-T steps are not equivalent. All T-A steps examined exhibit positive roll, bending towards the major groove, while A-T steps display negative roll and bend slightly towards the minor groove. This illustrates how inherent negative and positive roll are, respectively, at A-T and T-A steps within A-tracts. T-A steps are more deformable, showing larger and more variable deformations of minor groove width, rise, cup, twist, and buckle. Standard deviations of twist, rise, and cup for T-A steps are 6.66 degrees, 0.55 A, and 15.90 degrees, versus 2.28 degrees, 0.21 A, and 2.99 degrees for A-T steps. Packing constraints determine which local values of these helical parameters an individual T-A step will adopt. For instance, with CCTTTAAAGG and three isomorphous structures, CGATTAATCG, CGATATATCG, and CGATCGATCG, crystal packing forces lead to a series of correlated changes: widened minor groove, large slide, low twist, and large rise. The difference in helical parameters between A-T steps lying within A-tracts, versus A-T steps within alternating AT sequences, demonstrates the importance of neighboring steps on the conformation of a given dinucleotide step.

Effect of pentoxifylline on nitrogen balance and 3-methylhistidine excretion in parenterally fed endotoxemic rats.

Pentoxifylline interrupts early gene activation for tumor necrosis factor, interleukin-1, and interleukin-6 production and improves survival from experimental sepsis. These effects can alter nitrogen loss during critical illness. To determine the dose-dependent influence of pentoxifylline on nitrogen loss, 44 male Sprague-Dawley rats (220 to 265 g) were randomized to receive parenteral nutrition only (PN), PN plus continuous infusion of Escherichia coli 026:B6 lipopolysaccharide (LPS) at 9 mg x kg(-1) x d(-1), or PN plus LPS plus a continuous infusion of pentoxifylline at either 25 (PEN25) or 100 mg x kg(-1) x d(-1) (PEN100) for 48 h. Before randomization, all animals underwent intravenous cannulation and 40 h of PN adaptation. All animals received isocaloric, isonitrogenous PN (160 kcal x kg(-1) x d(-1) and 1.0 gN x kg(-1) x d(-1)) and were kept nil per os except for water ad libitum. Administration of LPS significantly worsened nitrogen balance for all three groups compared with PN control; however, pentoxifylline only modestly improved nitrogen balance compared with LPS (206 +/- 255, -497 +/- 331, -332 +/- 329, and -310 +/- 383 mg/48hr for the PN, LPS, PEN25, and PEN100 groups, respectively; P < 0.001). Pentoxifylline did not significantly change 3-methylhistidine urinary excretion compared with LPS (573 +/- 180, 705 +/- 156, 780 +/- 326, and 683 +/- 266 microg/48 h for the PN, LPS, PEN25, and PEN100 groups, respectively, P not significant). Pentoxifylline, given in therapeutic doses after an endotoxin challenge, modestly, but not significantly, improved nitrogen balance. Urinary 3-methylhistidine excretion was not influenced by pentoxifylline. A dose-dependent effect by pentoxifylline on these markers was not evident.

A comparison of renal phosphorus regulation in thermally injured and multiple trauma patients receiving specialized nutrition support.

To compare phosphorus intake and renal phosphorus regulation between thermally injured patients and multiple trauma patients, 40 consecutive critically ill patients, 20 with thermal injury and 20 with multiple trauma, who required enteral tube feeding were evaluated. Phosphorus intakes were recorded for 14 days from the initiation of tube feeding which was started 1 to 3 days postinjury. Serum for determination of phosphorus concentrations was collected at days 1, 3, 7, and 14 of the study period. A 24-hour urine collection was obtained during the first and second weeks of nutrition support for urinary phosphorus excretion, fractional excretion of phosphorus, renal threshold phosphate concentration, and phosphorus clearance. Average total daily phosphorus intake during the 14-day study for thermally injured patients and multiple trauma patients was 0.99+/-0.26 mmol/kg/d vs 0.58+/-0.21 mmol/kg/d, respectively, p < .001. Serum phosphorus concentration on the third day of observation was significantly lower in the thermally injured group than those with multiple trauma (1.9+/-0.8 mg/dL vs 3.0+/-0.8 mg/dL, p < or = .01). A trend toward hypophosphatemia in the thermally injured group persisted by the seventh day of feeding (2.7+/-1.2 mg/dL vs 3.3+/-0.6 mg/dL, p < or = .04). Differences in urinary phosphorus excretion was not statistically significant between the thermally injured and multiple trauma groups (271+/-213 mg/d vs 171+/-181 mg/d for week 1, and 320+/-289 mg/d vs 258+/-184 mg/d for week 2, respectively). Urinary phosphorus clearance, fractional excretion of phosphorus, or renal threshold phosphate concentrations were also not significantly different between thermally injured and multiple trauma patients. During nutrition support, serum phosphorus concentrations are lower in thermally injured patients compared with multiple trauma patients despite receiving a significantly greater intake of phosphorus. Renal phosphorus regulation does not significantly contribute to the profound hypophosphatemia observed in thermally injured patients when compared with multiple trauma patients during nutrition support.

Effects of binary mixtures of six xenobiotics on hormone concentrations and morphometric endpoints of northern bobwhite quail (Colinus virginianus).

This study investigated the effects of six endocrine disrupters in five different doses (0.1, 0.3, 1, 3, 10 mg/kg or microg/kg) in ethanol administered by oral gavage to bobwhite quail eggs. Six eggs each were in each dose group of coumestrol, ethynyl estradiol, indole-3-carbinol, o,p'-DDE, p,p'-DDE, or TCDD. Eggs were also dosed in two sets. One set was ethynyl estradiol (0, 0.03, 0.1, 0.3, 1.0, 3.0, 10.0 microg/kg) and TCDD (0, 0.003, 0.01, 0.03, 0.1, 0.3 microg/kg). This set was dosed below the air cell with corn oil as vehicle. Also, northern bobwhite quail eggs were injected in ovo with nine binary mixtures of six xenobiotics prior to incubation (coumestrol (0.3 mg/kg), ethynyl estradiol (3.0 microg/kg), indole-3-carbinol (3.0 mg/kg), o,p'-DDE (1.0 mg/kg), p,p'-DDE (1.0 mg/kg), TCDD (0.1 microg/kg)). The mixtures injected were p,p'-DDE+indole-3-carbinol, coumestrol+indole-3-carbinol, TCDD+indole-3-carbinol, p,p'-DDE+o,p'-DDE, p,p'-DDE+ethynyl estradiol, coumestrol+ethynyl estradiol, coumestrol+TCDD, o,p'-DDE+ethynyl estradiol, TCDD+ethynyl estradiol. Eggs were dosed once prior to initiating incubation. Quail were allowed to hatch and were sacrificed at 21 days of age. Blood, measurements, and tissues were collected. Survival was significantly affected by increasing concentrations of TCDD in ethanol as revealed by trend analysis. Survival was also affected significantly by o,p'-DDE in ethanol but not by trend. Survival results of mixtures indicate significant differences among mixture, mixture components, and controls for coumestrol+TCDD, ethynyl estradiol+TCDD, and indole-3-carbinol+TCDD. Some trends from doses of single compounds that are supported by results in the literature were observed for hatchling weight of ethynyl estradiol dosed females, weight gain of indole-3-carbinol dosed males, weight gain and liver somatic index of o,p'-DDE dosed males, spleen somatic index of TCDD dosed males, and weight gain, gonad somatic index and egg gland somatic index of TCDD dosed females. In conclusion, the dose response treatments appeared to have effects beyond effects on survival of in ovo dosed quail. For mixtures, plasma estradiol concentrations were significantly different among coumestrol+ethynyl estradiol, ethynyl estradiol, coumestrol, and vehicle treatments. Liver somatic index among the same treatments was also significantly different. Kidney somatic index among ethynyl estradiol+p,p'-DDE, ethynyl estradiol, p,p'-DDE, and vehicle treatments was significantly different. Plasma estradiol and plasma testosterone ratios were very different among o,p'-DDE+p,p'-DDE, o,p'-DDE, p,p'-DDE, and vehicle treatments. Coumestrol and ethynyl estradiol appear antagonistic for plasma estradiol concentrations and liver somatic index when both chemicals are present together. Ethynyl estradiol and p,p'-DDE appear to act additively on kidney somatic index when combined together. Mixtures of compounds, used in this study indicate effects very different from either or both mixture components, indicating the lack of predictability of chemicals when combined in mixtures.

The Indian Ocean experiment: widespread air pollution from South and Southeast Asia.

The Indian Ocean Experiment (INDOEX) was an international, multiplatform field campaign to measure long-range transport of air pollution from South and Southeast Asia toward the Indian Ocean during the dry monsoon season in January to March 1999. Surprisingly high pollution levels were observed over the entire northern Indian Ocean toward the Intertropical Convergence Zone at about 6 degrees S. We show that agricultural burning and especially biofuel use enhance carbon monoxide concentrations. Fossil fuel combustion and biomass burning cause a high aerosol loading. The growing pollution in this region gives rise to extensive air quality degradation with local, regional, and global implications, including a reduction of the oxidizing power of the atmosphere.

Oxandrolone in trauma patients.

STUDY OBJECTIVE: To determine the effect of oxandrolone administration on nutritional and clinical outcomes after multiple trauma. DESIGN: Prospective, randomized, double-blind, placebo-controlled study. SETTING: Level 1 trauma center in a university teaching hospital. PATIENTS: Sixty-two patients requiring enteral nutrition, 60 of whom completed the study. INTERVENTION: Patients were randomized to receive either oxandrolone 10 mg or placebo twice/day for a maximum of 28 days. MEASUREMENTS AND MAIN RESULTS: Total urinary nitrogen, prealbumin, nitrogen balance, total body water, and body cell mass were measured on day 1 of enteral nutrition and then at day 7, day 10, and study exit. Patients were assessed daily for metabolic and infectious complications. The two groups were similar for demographics and dosage of enteral nutrition. Measurement of total urinary nitrogen at study entry showed both groups to be highly catabolic (oxandrolone 17.2 +/- 4.9, placebo 19.1 +/- 10.8 g/day, NS). On days 7 and 10, total urinary nitrogen increased in both groups; however, there was no significant difference between groups. Nitrogen balance was negative throughout the study in each group. Body cell mass decreased slightly in both groups over the study period. Prealbumin serum concentrations increased significantly in both groups at day 10 and study exit compared with study entry. The groups did not differ significantly for length of hospital stay (oxandrolone 30.8 +/- 17.9, placebo 27.0 +/- 25.7 days), length of intensive care unit stay (oxandrolone 17.1 +/- 7.8, placebo 15.5 +/- 9.7 days), and frequency of pneumonia or sepsis (oxandrolone 48, placebo 43 episodes). CONCLUSION: Oxandrolone 20 mg/day does not have obvious benefit in nutritional and clinical outcomes during the first month after multiple trauma.

1 A crystal structures of B-DNA reveal sequence-specific binding and groove-specific bending of DNA by magnesium and calcium.

The 1 A resolution X-ray crystal structures of Mg(2+) and Ca(2+) salts of the B-DNA decamers CCAACGTTGG and CCAGCGCTGG reveal sequence-specific binding of Mg(2+) and Ca(2+) to the major and minor grooves of DNA, as well as non-specific binding to backbone phosphate oxygen atoms. Minor groove binding involves H-bond interactions between cross-strand DNA base atoms of adjacent base-pairs and the cations' water ligands. In the major groove the cations' water ligands can interact through H-bonds with O and N atoms from either one base or adjacent bases, and in addition the softer Ca(2+) can form polar covalent bonds bridging adjacent N7 and O6 atoms at GG bases. For reasons outlined earlier, localized monovalent cations are neither expected nor found.Ultra-high atomic resolution gives an unprecedented view of hydration in both grooves of DNA, permits an analysis of individual anisotropic displacement parameters, and reveals up to 22 divalent cations per DNA duplex. Each DNA helix is quite anisotropic, and alternate conformations, with motion in the direction of opening and closing the minor groove, are observed for the sugar-phosphate backbone. Taking into consideration the variability of experimental parameters and crystal packing environments among these four helices, and 24 other Mg(2+) and Ca(2+) bound B-DNA structures, we conclude that sequence-specific and strand-specific binding of Mg(2+) and Ca(2+) to the major groove causes DNA bending by base-roll compression towards the major groove, while sequence-specific binding of Mg(2+) and Ca(2+) in the minor groove has a negligible effect on helix curvature. The minor groove opens and closes to accommodate Mg(2+) and Ca(2+) without the necessity for significant bending of the overall helix. The program Shelxdna was written to facilitate refinement and analysis of X-ray crystal structures by Shelxl-97 and to plot and analyze one or more Curves and Freehelix output files.

Sequential single doses of cisapride, erythromycin, and metoclopramide in critically ill patients intolerant to enteral nutrition: a randomized, placebo-controlled, crossover study.

OBJECTIVE: To evaluate the comparative efficacy of enteral cisapride, metoclopramide, erythromycin, and placebo for promoting gastric emptying in critically ill patients with intolerance to gastric enteral nutrition (EN). DESIGN: A randomized, crossover study. SETTING: Adult medical intensive care unit at a university-affiliated private hospital and trauma intensive care unit at a university teaching hospital. PATIENTS: Ten adult, critically ill, mechanically ventilated patients not tolerating a fiber-containing EN product defined as a single aspirated gastric residual volume >150 mL or two aspirated gastric residual volumes >120 mL during a 12-hr period. INTERVENTIONS: Patients received 10 mg of cisapride, 200 mg of erythromycin ethylsuccinate, 10 mg of metoclopramide, and placebo as 20 mL of sterile water every 12 hrs over 48 hrs. Acetaminophen solution (1000 mg) was administered concurrently. Gastric residual volumes were assessed, and plasma acetaminophen concentrations were serially determined by TDx between 0 and 12 hrs to evaluate gastric emptying. MEASUREMENTS AND MAIN RESULTS: Gastric residual volumes during the study were not significantly different between agents. No differences in area under the concentration vs. time curve or elimination rate constant were identified between agents. Metoclopramide and cisapride had a significantly shorter mean residence time of absorption than erythromycin (6.3+/-4.5 [SEM] mins and 10.9+/-5.8 vs. 30.1+/-4.5 mins, respectively [p<.05]). Metoclopramide (9.7+/-15.3 mins) had a significantly shorter time to peak concentration compared with erythromycin and placebo (60.7+/-8.1 and 50.9+/-13.5 mins, respectively [p<.05]). The time to onset of absorption was significantly shorter for metoclopramide vs. cisapride (5.7+/-4.5 vs. 22.9+/-5.7 mins [p<.05]). CONCLUSION: In critically ill patients intolerant to EN, single enteral doses of metoclopramide or cisapride are effective for promoting gastric emptying in critically ill patients with gastric motility dysfunction. Additionally, metoclopramide may provide a quicker onset than cisapride.

The structure of a stable intermediate in the A <--> B DNA helix transition.

The DNA dodecamer CATGGGCCCATG in a crystal structure of resolution 1.3 A has a conformation intermediate between A and B DNA. This trapping of a stable intermediate suggests that the A and B DNA families are not discrete, as previously believed. The structure supports a base-centered rather than a backbone-centered mechanism for the A <--> B transition mediated by guanine tracts. Interconversion between A and B DNA provides another means for regulating protein-DNA recognition.