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Aim Upper limb infections secondary to traumatic wounds, animal bites and other causes are a common reason for admission to the plastic surgery service for intravenous antibiotics. This audit investigated the compliance of treatment of upper limb infections with trust guidance. The guidance stipulated an antibiotic treatment duration of five to seven days total and microbiology advice suggested that in cases requiring multiple washouts, this should start from the date of the last surgical washout where pus was present. Method There was retrospective sampling for four months using inpatient lists to include patients admitted for intravenous antibiotics for upper limb infections. Notes were requested by the secretaries and data was collected using patient notes, discharge summaries and electronic drug charts. Results The analysis included twenty-seven suitable patients. All patients had the correct antibiotics prescribed according to guidance, however only 22% of patients had five to seven days total of antibiotics either from the start of therapy or from the date of last infected washout in those who underwent surgical treatment. 14/27 patients had more than seven days total antibiotics. 13/27 patients were discharged with an additional seven days of oral antibiotics regardless of the total duration. Conclusions These infections are significantly over-treated with antibiotics, which has serious potential consequences for antimicrobial resistance. The findings of the audit prompted new trust guidelines to be produced and prescribing guidance was sent to the junior doctors to calculate the total antibiotic duration when preparing discharge summaries. There is a plan for re-audit in a few months’ time.

Mesocosms are outdoor experimental systems designed to separate and test environmental responses, in this case, cumulative effects to field-collected periphyton and macroinvertebrate communities from multiple stressors. This experimental system produces valuable, highly reproducible data, and along with field monitoring, laboratory bioassays and modeling results, provides a strong weight-of-evidence approach for aquatic risk assessment. Through the control of confounding environmental variables, this type of experiment permits the separation of interactions between multiple stressors in complex effluents or due to shifting ambient conditions. The system described is modular and was originally developed to facilitate transport of the entire system to remote or industrial test sites (e.g., for in situ 21-d chronic level testing). However, this setup is also appropriate for long term installations with suitable provision for routine maintenance and losses associated with regular wear-and-tear on equipment. The following protocol details a basic stream mesocosm system setup (e.g., 4 replicate streams per treatment-level) which is the foundation for the more than a dozen stream mesocosm experiments conducted by the authors since the 1990s.

Chironomidae larvae constituted the largest proportion of benthic invertebrates collected from 99 rivers stretching from northern Labrador (latitude 58°N) to northern parts of Ellesmere Island (82°N). We describe 92 species of Chironomidae (mainly larval forms) providing new descriptions, a revision for the adult female of Parametriocnemus boreoalpinus Gowin et Thienemann, a possible new genus (larval form only), and 9 larval forms that may represent a new species. In addition, new geographical distribution records are specified for 1 Nearctic species, 6 species in Canada, 10 for Labrador, and 17 for Nunavut. This work contributes to Environment Canada’s International Polar Year output (2007-2009).

Permafrost soils store between 1,330–1,580 Pg carbon (C), which is three times the amount of C in global vegetation, almost twice the amount of C in the atmosphere, and half of the global soil organic C pool. Despite the massive amount of C in permafrost, estimates of soil C storage in the high latitude permafrost region are highly uncertain, primarily due to under sampling at all spatial scales; circumpolar soil C estimates lack sufficient continental spatial diversity, regional intensity, and replication at the field-site level. Siberian forests are particularly under sampled, yet the larch forests that dominate this region may store more than twice as much soil C as all other boreal forest types in the continuous permafrost zone combined. Here we present above and belowground C stocks from twenty sites representing a gradient of stand age and structure in a larch watershed of the Kolyma River near Cherskiy, Sakha Republic, Russia. We found that the majority of C stored in the top 1 m of the watershed was stored belowground (91 %), with 20 % in the top 10 cm of soil and 42 % in the top 30 cm. Carbon was more variable in surface soils (10 cm; coefficient of variation (CV) = 0.35 between stands) than in the top 30 cm (CV = 0.14) or soil profile to 1 m (CV = 0.12). Combined active layer and deep frozen deposits (surface – 15 m) contained 205 kg C m-2 (yedoma, non-ice wedge) and 331 kg C m-2 (alas), which, even when accounting for landscape-level ice content, is an order of magnitude more C than that stored in the top meter of soil and two orders of magnitude more C than in aboveground biomass. Aboveground biomass was composed of primarily larch (53 %) but also included understory vegetation (30 %), woody debris (11 %) and snag (6 %) biomass. While aboveground biomass contained relatively little (9 %) of the C stocks in the watershed, aboveground processes were linked to thaw depth and belowground C storage. Thaw depth was significantly negatively related to stand age, and variability of soil C in the top 10 cm was related to soil moisture and moss and lichen cover. These results suggest that as the climate warms, changes in stand age and structure may be as important as direct climate effects on belowground environmental conditions and permafrost C vulnerability.

Residents' assessment of their learning environment is an important element of residency accreditation and a strong predictor of resident satisfaction. The authors examined the reliability and validity of a resident/fellow survey and explored the relationship between reported duty hours noncompliance and residents' perceptions of other aspects of their learning environments.The Accreditation Council for Graduate Medical Education (ACGME) administered a 29-item Web-based survey in 2007 and 2008 to 91,073 residents in 5,610 programs. Aggregate data from the survey comprised indicators of substantial compliance or noncompliance. The authors examined relationships among duty hours and aspects of the educational environment, as well as the relationship of the survey results to citations from accreditation reviews.The survey demonstrated a high degree of internal reliability (Cronbach alpha, 0.84). Common factor analysis revealed two factors, educational environment and resident duty hours (eigenvalues of 5.49 and 2.42, respectively). Programs having resident-identified duty hours issues were more likely than those without such issues to have received duty hours citations from residency review committees (odds ratio: 2.04; 95% CI: 1.03, 3.05).The ACGME Resident/Fellow Survey is a reliable, valid, and useful tool for evaluating residency programs. There are strong relationships between duty hours noncompliance and noncompliance in other aspects of the program environment.

Ahead of Print article withdrawn by publisher.

Background: Residency program directors and program coordinators have increasing demands placed on them by accrediting agencies and require educational development specifically tailored to their needs. Description: We created, piloted, and evaluated an educational development program consisting of 10 sessions spanning 1 year for program directors and a parallel set of sessions for program coordinators. Evaluation: On average, more than half the residency programs participated in the sessions. Programs improved in residency activities related to their program's handbook, interviewing, evaluations, rotation descriptions, and program evaluation. They did not improve in educational scholarly activities. Program directors and coordinators indicated that the program improved their skills, and they would recommend the program for others. Conclusions: This 10-session program improved important elements of residency education and was favorably received.

A nurse practitioner educator and a physician educator, experts in teaching clinical breast examination techniques, review the essential steps of the procedure and emphasize breast cancer detection. Photographs show each step of the procedure.

Modernization of specialist training in a competency-based framework is not unique to the United States. In the following commentary, the authors explore the current environment within which graduate medical education (GME) in the United States operates, using the perspective framework developed by Wallenburg and colleagues from the Netherlands: the accountability perspective, the educational perspective, the work-life balance perspective, and the trust-based perspective. In this exploration, they identify factors within and beyond the medical profession that shape GME in the United States and influence the Accreditation Council for Graduate Medical Education, the professional self-regulatory body charged with setting standards and assessing compliance for allopathic GME in the United States. The authors conclude that the modernization of medical education examined by Wallenburg and colleagues must be approached with the needs of future trainees and patients in mind.

In their insightful and provocative analysis in this issue, Drs. Lypson, Hamstra, and Colletti propose that the Accreditation Council for Graduate Medical Education (ACGME), with some modifications in process, might assume the role of unions or other collective bargaining units for residents. They make valid observations about aspects of the ACGME Institutional Requirements that pertain to resident safety and well-being and the environment in which residents learn and participate in care. To understand the nature of these requirements, the authors reiterate the ACGME's role as an educational accreditor and the philosophical basis for its accreditation function. The authors conclude that the ACGME cannot and will not replace resident unions, associations, or other groups where residents perceive the need arising for the presence of these organizations.

Background: Utilization of standardized patients (SPs)in academic medicine is well known, but little has been done with SPs in pharmaceutical education. We present a new application for SPs in pharmacy education, and discuss how resources, costs, and expertise may be shared between the two academic disciplines to maximize SP use. Description: We developed a " pharmacy Objective Structured Clinical Examination (OSCE)" used to evaluate clinical skills associated with pharmacy education and practice. The SPs in pharmacy were more standardized participants, because they could portray a physician, nurse, or patient. Program development, evaluation, and implementation was accomplished in conjunction with the college of medicine' s SP program. Evaluation: Comparable to academic medicine' s OSCE experience, interrater reliability data showed good to excellent agreement between raters and Cronbach' s coefficient alpha ranged between 0.54 and 0.79. Conclusions: This program represents another use of medical SPs tha...

SUMMARY Although the assessment of medical students’ clinical skills through the use of an Objective Structured Clinical Examination (OSCE) is becoming more widespread among American medical schools, there is still a signi® cant number of medical schools that do not utilize this type of examination. The reasons for this are many, including considerations about expense, commitment of faculty time and the logistics of setting up and administering an OSCE program. Although studies have been published on various aspects of the OSCE, there have been very few overviews on how to develop this type of examination from initial needs assessment to implementation. This paper describes the process of developing an OSCE at a American medical school of intermediate size. The development process is divided into seven activity areas: initial preparation, case writing, developing a standardized patient program, procedures for conducting the exam, faculty participation, measurement and evaluation, and ® nancial support. Results of innovations that were tried during the pilot phase of development are discussed.

This study assessed students' attitudes, students' level of confidence and the importance of faculty feedback during an Objective Structured Clinical Examination (OSCE). A survey was administered as one of 15 OSCE stations to 138 sophomore medical students. Eight of the twelve survey items were Likert type items with a follow-up open-ended question. The remaining four items required only an open-ended response. The five surveyors participated in the design of the questionnaire and in training to insure reliable information acquisition and recording. The OSCE was given in five identical tracks in a single day. Each surveyor interviewed either 27 or 28 students during the four-hour period of the track. The Likert responses to the eight items were analyzed and statistical comparisons made for each question. The open-ended responses were analyzed using qualitative summary techniques and compared to the Likert responses. Statistical analyses of the Likert based items showed students had high levels of confidence in their ability to conduct physical examinations and histories, found faculty feedback helpful and informative, but were nervous throughout the examination. The qualitative analysis provided additional information regarding students' feelings about the OSCE, their levels of confidence, their stress levels and the importance of faculty feedback during the examination. Results of the survey suggest curricular changes which could be made in preparation for the OSCE and for a new Introduction to Clinical Medicine course currently in its first year in the College of Medicine.

Breast cancer screening in physicians' daily practices needs greater emphasis. Increasing provider participation in research in this area can be a challenge as demonstrated in our study to test interventions targeting rural health care providers.Recruitment methods for the randomized controlled trial involving 27 counties in the Mississippi River Delta region of Arkansas included the following: introductory letters and return postcards, mailed questionnaires, telephone calls, attendance at local medical staff meetings, and telephoning the primary care offices to set a time to meet the providers at their practice sites. This final recruitment strategy of telephoning the primary care offices and arranging with the office manager to bring a CME/CEU credit program included an on-site demonstration of a CBE technique and a free lunch.Only the final strategy yielded provider participation for the study and was more successful in the experimental than the control counties. Providers in the control group could not receive the education program until after their post-test.Successful approaches to enrolling physicians and nurses in a study involve careful use of their time and providing benefits.

When it struck the US Gulf Coast in 2005, Hurricane Katrina severely disrupted many graduate medical education residency/fellowship programs in the region and the training of hundreds of residents/fellows. Despite the work of the Accreditation Council for Graduate Medical Education in responding to this natural disaster and facilitating communication and transfer of residents/fellows to other unaffected training programs, the storm exposed the gaps in the existing system. Subsequently, the Accreditation Council for Graduate Medical Education, with the aid of its member organizations, including the American Medical Association, developed a new disaster recovery plan to allow for a more rapid, effective response to future catastrophic events. These policies were instrumental in the rapid relocation of 597 residents/fellows from the University of Texas Medical Branch at Galveston after the landfall of Hurricane Ike in September 2008. As a further accommodation to affected trainees, medical certification boards should be as flexible as possible in waiving continuity requirements in the event of a disaster that affects residency/fellowship programs.(Disaster Med Public Health Preparedness. 2010;4:S71-S74)

Retrospective accounts suggest that therapeutic doses of paracetamol can produce severe hepatic injury in patients with putative high-risk conditions, including alcoholism and infectious hepatitis. Metabolism of paracetamol to its hepatotoxic metabolite is enhanced in patients who abuse alcohol, who also have compromised liver defences from depressed hepatic glutathione.To determine the effect of paracetamol on serum liver tests of newly abstinent subjects who abuse alcohol, including subjects with hepatitis C infection.A randomized, double-blind, placebo-controlled study. Adult alcohol abusers with a current drinking episode longer than 7 days received either placebo or paracetamol 4 g/day for 5 days.Of 142 subjects enrolled, 74 received paracetamol and 68 received placebo. Mean ALT activity during treatment increased from 48 to 62 IU/L in the paracetamol group and from 47 to 49 IU/L in the placebo group. Maximum ALT was 238 and 249 IU/L in the paracetamol and control groups respectively. The INR remained unchanged and serum bilirubin decreased in both groups. Subgroup analyses for subjects with alcoholic hepatitis, hepatitis C virus antibody and other subgroups showed no statistical difference between groups.Administration of paracetamol 4 g/day appears safe in newly abstinent patients who abuse alcohol.

The relationship between immunosuppression and oncogenesis can be determined by studying the molecular interactions between tumor-inducing viruses and lymphocytes. We approached this study by using a unique system of two genetically related Leporipoxviruses, malignant fibroma virus (MV), and Shope fibroma virus (SFV). MV induces a syndrome of a highly lethal, disseminated myxosarcoma, severe immune suppression, and replicates in lymphocytes both in vivo and in vitro. In contrast, SFV causes a benign fibromyxosarcoma without immune dysfunction and cannot replicate in lymphocytes. Earlier studies demonstrated that transfer of a 10.8-kb Bam HI piece of MV (fragment "C") to SFV resulted in the ability of SFV to replicate in lymphocytes and suppress immune function. These results suggested that lymphocytotropic replication and immune suppression was located on the left side of fragment C. We extended these studies by generating families of recombinants between MV and SFV by using subfragments of fragment C. The resulting recombinant viruses were analyzed for their ability to replicate in lymphocytes, suppress immune function, and produce tumors. Those recombinants expressing MV-like characteristics were mapped by endonuclease digestion. This study demonstrates that recombinants containing a 3.6-kb Nde I subfragment, as well as those containing an overlapping 1.9-kb Hinc II subfragment, were capable of replicating in lymphocytes, suppressing immune functions, and inducing disseminated tumors in rabbits. Our study has therefore identified a portion of MV DNA sufficient to transfer the unique pathogenicity of MV to SFV, and suggests that control of immune suppression and tumor dissemination may not necessarily be mediated by the same viral genes.

Purpose. This study sought to investigate whether an institution's Graduate Medical Education Committee (GMEC) could develop a system of continuous quality improvement of its residency programs using an annual survey provided by the institution for all residents. Method. Beginning in 2000, residents were surveyed annually about their educational and work environments. The GMEC determined standards of performance for the items on the survey based on four areas commonly cited by the Accreditation Council for Graduate Medical Education: supervision, feedback/evaluation, scholarly time, and duty hours. Residency program directors submitted action plans to improve those areas rated below the standard by the residents in the program. Results. The 2000 survey served as baseline. In 2001, residency programs met the standard for 55.2% of the items, and 18 programs submitted 67 action plans. In 2002, programs met the standard for 80.6% of the items. For the items below standard, programs showed improvement in 14.9% and declined in 4.5% of the items compared with baseline. Six of the 18 programs had accreditation site visits during the study period. Five received no citations in the targeted areas. The sixth program was visited three months after it developed action plans for its six deficient areas. It received citations for two of the six areas. Conclusion. An institution that sponsors residency programs can develop and sustain an effective system to continuously monitor and evaluate its programs and improve the educational quality as evidenced by successful accreditation decisions.

Purpose/Objectives: To test a multimethod approach designed for rural healthcare providers to increase breast cancer screening among low-income, African American, and older women. Design: Two-year experimental pretest/post-test with random as- signment by group. Setting: Primary healthcare providers' offices. Sample: 224 nurses, physicians, and mammography technicians. Methods: Standardized patients to observe and record healthcare providers' performances, followed by direct feedback, newsletters, post- ers, pocket reminder cards, and lay literature about screening to use in clinics. Main Research Variables: Healthcare providers' knowledge and at- titudes as measured by survey responses, skills as measured by a checklist, and the provision of breast cancer screening as measured by mammography facilities' data. Findings: Healthcare providers significantly improved in demonstra- tion of breast cancer screening practice after the intervention. Nurses performed significantly better than physicians on the breast examina- tion during the post-test. More women older than 50 received mammograms in the experimental counties than in the comparison counties. Culturally sensitive lay literature is needed for African Ameri- can women with low literacy. Conclusions: Successful interventions included use of standardized patients to teach healthcare providers in their office settings, prompts such as posters and pocket reminder cards, and easy-to-read newsletters. Implications for Nursing: Physicians and nurses play a powerful role in motivating women to have mammograms and clinical breast exami- nations and to practice breast self-examination. Interventions that help these providers fulfill that role should be implemented. Key Points . . . ➤ As a group, older women with lower income and less educa- tion have lower rates of breast cancer screening despite Medi- care coverage of these services.

Written materials about breast cancer screening for African American women with low literacy skills are needed. Available materials were not at or below third-grade reading levels, were not culturally sensitive, and were not accurate in illustrating correct breast self-examination (BSE) techniques. Focus groups representing the target population helped the authors design a pamphlet describing how to perform BSE and a motivational picture book to help women overcome barriers to screening. The authors chose a food theme for the cover of the pamphlet written at a third-grade level and suggested a photographic version. In the motivational book, two women address barriers to screening and replace myths and fears with facts and actions. Data from 162 women showed that they learned from both the photographic and illustrated versions. Women in the photographic group found significantly more lumps in the silicone models, so the authors chose that version to use in final testing. Finally, nurses pretested a group of patients before they reviewed the materials and post-tested another group after they reviewed them. The group who had reviewed the materials had greater knowledge of and intent to follow the guidelines and received higher scores on BSE techniques.

This paper describes a process by which a traditional gross anatomy course has evolved into a clinically oriented anatomy course. Several clinically oriented teaching methods are described which have been introduced into the gross anatomy course in a step-wise fashion. Emphasis is placed on the use of standardized patients in a small group setting to teach the clinical application of traditional gross anatomical information.

Standardized patients and teaching associates provide, reinforce, and evaluate the teaching of clinical skills to students and health care providers. As new needs and roles emerge for this method of teaching and evaluation, information is needed for recruitment, training, and retention.This article addresses the general characteristics and experiences of 12 Breast Teaching Associate Professionals (BTAPs) in a two-year NCI-funded study aimed to improve breast cancer screening practices of rural primary health care providers in Eastern Arkansas.Areas of focus are demographic characteristics, motivations for serving as BTAPs, their perceptions of the advantages and disadvantages of the BTAP role, and the influence or impact the role had on their own health behaviors or personal lives.The evolving commitment to the value of this method of teaching and to health care education on this campus became stronger for many of the women as participation continued into other projects with further learning and specialization.

The 1995-1998 Delta Project was designed to increase breast cancer screening among disadvantaged African American women with limited literacy skills by educating their health care professionals about breast health. The research team intended to provide onsite training and appropriate educational materials; however, they found no suitable materials. This article presents the results of an assessment of available materials and defines the need for suitable materials.Nineteen organizations that develop cancer-related publications submitted materials intended for African American audiences. Sixty-one documents were examined for readability and cultural sensitivity. The Flesch Reading Ease (FRE), Flesch-Kincaid (F-K), and Cultural Sensitivity Assessment Tools (CSAT) were used in testing.The mean FRE score of 65 yielded a F-K mean grade level of 7.5 (desired level: 3.5). Using CSAT, 16 documents (26%) were eliminated because they had no visuals. Twenty-two publications (37%) were culturally sensitive for all audiences and 19 (31%) were for white audiences. Four (6%) pieces specifically addressed African American women.Printed educational materials on breast cancer do not adequately provide information to undereducated, economically disadvantaged African American women.

In the 6 years since implementation of the common duty hour standards on July 1, 2003, programs and institutions have made changes in education and patient care and have achieved sizable gains in compliance, with the percentage of programs cited for duty hour noncompliance currently hovering around 7 percent. Concurrently, the Accreditation Council for Graduate Medical Education (ACGME) has made enhancements to its processes for monitoring and promoting program and institutional oversight of resident duty hours. In 2003, it piloted a resident survey, and between 2004 and 2006, it surveyed all accredited specialty programs and subspecialty programs with 4 or more fellows. The survey was repeated in 2007 and 2008, with half of the programs included each year, and in 2009, the ACGME surveyed all specialty programs, as well as subspecialty programs with 4 or more fellows. During each administration, the survey found a small number of programs (around 5 percent of those surveyed) in which a significant percentage of residents reported noncompliance with several standards. Follow-up has included resurveying, requests for information on how the problem is being addressed, and assessment during the next site visit. In 2008, the ACGME stepped up compliance measures for this cohort, and between October 2008 and March 2009, it conducted site visits of the programs with annually recurring (“continuous”) and multiyear “significant” noncompliance. Program visits entailed review of a full program information form, with added emphasis on duty hour compliance. The concurrent focused institutional reviews for programs in the chronic (successive year) violator group encompassed a review of program-level citations, monitoring of duty hour compliance, documentation of how the program and institution addressed noncompliance problems, and meetings with residents, with oversampling of residents from programs with duty hour noncompliance and those from procedural and other specialties in which residents are known to work longer hours.

The Introduction to the Medical Profession course gives freshmen medical students their first exposure to basic interviewing techniques. Medical students use the time-in/time-out technique with standardized patients (SPs) prior to interviewing real patients in the clinic or hospital. Small groups of 4-6 students interview 2 SP s under the guidance of a faculty facilitator. Two to three students take turns interviewing each SP as the entire group observes. “Time-out” can be called by the student interviewer or the faculty facilitator at any time during the interview. The action stops, and difficulties with the interview are discussed. Then, “ time-in” is called, and the interview resumes. After the SP is interviewed, he or she is brought out of the patient role to give feedback to each student. The entire session takes approximately 1 hours. An ad hoc advisory committee of course faculty developed 16 cases based on experiences from their clinical practices. Each SP learned 3 different cases so the students were exposed to a variety of common patient complaints. Each faculty facilitator participated in the dry run session with the SP and case author in order to learn the case and facilitation techniques.

The clinical skills of sophomore medical students at the University of Arkansas are being assessed through the use of the Objective Structured Clinical Examination (OSCE). This exam was developed in order to better standardize the evaluation of practical clinical skills. The exam uses standardized patients, who are lay people trained to accurately and consistently portray a patient encounter. Faculty members at UAMS authored clinical cases for 20 patient encounters that test history taking, physical examination and communication skills. Each student interacts with the patient while being assessed in a standardized way, and then is given educational feedback by a faculty member. Students who do not pass the exam, undergo a remediation program prior to entering the junior year.

In response to the current emphasis on health maintenance and disease prevention, the authors developed a comprehensive education program in which sophomore medical students interview a standardized patient about breast problems and risk factors, receive one-on-one instruction from the standardized patient during the clinical breast examination, and practice recommendations for screening and instruction in breast self-examination. In this pilot study sophomore students who underwent the comprehensive education program were compared with students who received the traditional, didactic instruction and practiced on plastic breast models. The students who received the didactic instruction had mean scores on a multiple-choice knowledge-base pretest and posttest of 54.6% and 76.8%, respectively. The students who participated in the comprehensive education program had mean pretest and posttest scores of 51.2% and 78.5%, respectively. All students participated in a practical test of the clinical breast examination during an objective structured clinical examination. The students who had received the didactic instruction scored 69.9% (mean), compared with 84.1% for the students who had had the comprehensive education program. The comprehensive breast education program teaches medical students about risk factors, screening recommendations, and clinical breast examination more effectively than do traditional didactic methods.

To evaluate the frequency of association of angiotensin-converting enzyme (ACE) inhibitor therapy with angioneurotic edema and the frequency of correct diagnosis by treating physicians.Retrospective population-based chart review.Medicare patients identified with 1991 and 1992 MEDPRO data set.51 patients were identified from the MEDPRO data sets. Twenty-four patients (47%) had ACE inhibitor-associated angioneurotic edema of whom 17 (71% of the subgroup) had the medication stopped. Twenty-nine percent of the affected patients were discharged still taking an ACE inhibitor. Twenty-six patients (51% of the total population) had non-ACE inhibitor-associated angioneurotic edema and one patient had an uncertain history.ACE inhibitor therapy is the number one cause of angioneurotic edema in our hospitalized patient population. Recognition of the association of this drug with the condition was not recognized in 29% of cases and the offending agent was continued upon discharge from the hospital.

The purpose of this study was to determine whether exposing mice to ultraviolet radiation (UVR) would alter the pathogenesis of infection with Mycobacterium lepraemurium (MLM), which causes a chronic, progressive, lethal disease in susceptible mouse strains. BALB/c mice were irradiated on dorsal skin with various doses of UVR from FS40 sunlamps 3 days before infection with MLM in the hind footpad. The course of disease was followed by assessing the number of acid-fast bacteria in the footpad, regional lymph node and spleen, and measuring the size of the lesion at the site of MLM infection at various times after infection. Mice were also tested periodically for a delayed-type hypersensitivity (DTH) response by injecting MLM antigen into the uninfecled footpad and measuring footpad swelling 24 hours later. Mice treated with a single high dose of UVR (45 kJ/m2) had significantly more bacteria in the infected footpad, lymph node and spleen than unirradiated control animals. They also had larger lesions at the site of MLM infection and exhibited significant suppression of the DTH response at 3 and 6 months after infection. Injection of mice s.c. in the footpad with MLM 3 d after 45 kJ/m2 UVR reduced the median survival time from 391 to 305 d and after i.v. infection from 171 to 139 d. Dose-response studies indicated that exposing mice to 2.3 kJ/m2 of UVR, which is approximately 1 minimal erythemal dose for this strain, suppressed the DTH response by 50% at 3 months alter infection. Significant increases in the number of bacteria in the footpad, spleen and lymph node were detected with doses of UVR≥5.6 kJ/m2. Mice exposed chronically to UV radiation also showed impaired responses to MLM. Thus, exposing mice to a single or multiple doses of UVR before infection increased the severity of a chronic mycobacterial infection and decreased the immune response to mycobacterial antigens.

The relationship of virus-induced immunological dysfunction and tumor dissemination was studied using two related tumor-causing leporipoxviruses: malignant fibroma virus (MV) and Shope fibroma virus (SFV). Recombinant viruses, produced by transferring MV's 10.7 kb BamHI C fragment to SFV, replicate in lymphocytes and suppress lymphocyte function in vitro. Those recombinants that replicate in lymphocytes and suppress lymphocyte function in vitro share about 3.5 kb from MV's C fragment. Some recombinants mimic MV in producing immune suppression and disseminated virus infection in vivo. Other recombinants, even some that are highly immunosuppressive in vitro (e.g. R71), only variably induce immune suppression in vivo, and do not cause disseminated disease. A segment of DNA from MV that transfers to Shope fibroma virus almost all of MV's virulence in vivo was identified.

SUMMARY 1. Employing field-deployed mesocosms, we examined the effects of 12-h pulse and 20-day press (continuous) exposures of the common agricultural insecticide, imidacloprid, on nymph abundance, emergence patterns and adult body size of Epeorus spp. (Heptageniidae) and Baetis spp. (Baetidae). 2. In press exposures, reduced nymph density was driven by reduced survivorship; in pulse exposures, reduced nymph density may reflect increased emergence because of stress. 3. Once exposed to imidacloprid, Epeorus and Baetis mayflies developed less and emerged smaller than their control counterparts. Concentrations as low as 0.1 l gL )1 (12-h pulse) reduced head length in Baetis and thorax length in Epeorus. 4. In all of the Baetis and Epeorus examined, effects were only found in males. Male survivorship and body size can affect population dynamics. Sublethal doses of this widely applied agricultural insecticide have the potential to reduce reproductive success of mayfly populations.

Objective: To determine if an educational program can improve a physical medicine and rehabilitation resident’s ability to deliver bad news to patients. Design: Preeducation and posteducation assessment of residents’ communication ability with a standardized patient. Setting: Clinical skills center. Participants: 10 rehabilitation residents (PGY-2 to PGY-4). Intervention: Preeducation experience with a standardized patient with a simulated C6 complete spinal cord injury followed by a 1-hour educational lecture using the American Medical Association’s (AMA) Education for Physicians on End-of-Life Care (EPEC) program on communicating bad news to patients. This was followed by a posteducation experience with the original standardized patient. The person monitoring the session then provided feedback to the resident before a novel standardized patient, who simulated a mother of a patient who had been in a persistent vegetative state for over a year. The monitor and the standardized patient used a standardized checklist to assess the resident’s performance. Main Outcome Measures: Monitor checklist of 8 items: score 1 if done and 0 if not done (max=8, min=0). Standardized patient checklist of 7 items rated on a Likert scale: excellent, 5; very good, 4; good, 3; fair, 2; poor, 1 (max=35, min=7). Results: Monitor checklist: the preeducation mean was 2.9 (95% confidence interval [CI], 1.81–3.99); the posteducation mean was 5.4 (95% CI, 4.377–6.423); and the novel case mean was 5.9 (95% CI, 5.044–6.756) (multivariate test [Hotelling trace], P =.002). Standardized patient checklist: the preeducation mean was 31.4 (95% CI, 29.609–33.191); the posteducation mean was 34.2 (95% CI, 33.636–34.764); and the novel case mean was 27.9 (95% CI, 25.577–30.223) (multivariate test [Hotelling trace], P =.001). Resident survey (5-point scale): worthwhile educational experience was 4.9; I will use what I learned in the future was 4.7; and I would participate again if not compensated was 4.4. Conclusions: A 1-hour lecture on delivering bad news to patients using the AMA’s EPEC program produced a significant change in resident behavior in interaction with a standardized patient. Residents felt that it was a worthwhile educational experience that would help them in their future practice.

OBJECTIVE New accreditation requirements for residency training programs require residents to have educational experiences that allow them to demonstrate competency in the following areas: (1) patient care, (2) medical knowledge, (3) practice-based learning and improvement, (4) interpersonal and communication skills, (5) professionalism, and (6) systems-based practice. Residents' competence must be assessed with dependable measures. Residency training program directors (PDs) need assistance in complying with these new requirements. DESCRIPTION Using a survey modified from Michigan State University, we asked PDs to rate their current understanding of and preparation for the general competencies and to provide written comments. PDs of the 47 ACGME-accredited programs received e-mailed instructions to complete the Web-based survey. Twenty-four PDs (51%) complied by the deadline. The mean ratings were calculated from a five-point scale (1 = strongly disagree, major impediment or least useful, 5 = strongly agree, not an impediment, or most useful). PDs felt they were informed (3.45) and understood (3.67) the requirements, but they were not well prepared to meet them (2.95). The perceived impediments to implementation included amount of PD time (2.27), amount of residents' protected time for the curriculum (2.30), amount of residency support staff (2.73), lack of expertise in curriculum development (2.73) and evaluation (2.41), and lack of funding for resources other than personnel (2.91). PDs rated types of assistance that would be helpful: developing workshops or presentations on curriculum development and evaluation techniques (3.82), developing curricula (4.14), providing one-on-one consultation (4.23), receiving examples of materials, methods, and ideas from other programs (4.41), and describing evaluation methods/instruments (4.50). Written comments stated that time to concentrate on the topic, release time from clinical responsibilities, and technical computer support would be helpful. Of the six competency areas, PDs were most interested in receiving assistance in developing curricular materials for the competencies of systems-based practice (4.50), professionalism (4.36), and practice-based learning and improvement (4.27). PDs were most interested in receiving assistance in developing evaluations for practice-based learning and improvement (4.59), professionalism (4.59), interpersonal and communication skills (4.45), and systems-based practice (4.36). PDs responded that they currently use written faculty evaluations to assess all six general competency areas. DISCUSSION Results of the survey indicate that PDs require assistance to comply with the new ACGME requirements. Curricular materials and valid and reliable evaluation methods need to be developed. In order to assist PDs, the following activities are under way: (1) PDs are members of a listserve for sharing ideas and examples of curricular and evaluation materials; (2) PDs attend a monthly seminar series that provides practical information for curricular material development and specific evaluation methods, including indications for use and feasibility; (3) educators from our Office of Educational Development provide individual consultations with each PD; (4) PDs participate in an eight hour workshop with practical sessions for developing curricular materials and evaluations; and (5) two institution-wide assessments are being developed: a patient-satisfaction survey and a 360-degree evaluation to assess communication skills and professionalism.

Many events determine the severity, duration, and predisposition to recurrent herpes simplex virus (HSV) disease. In addition to the various host immune responses, such as local, humoral, and cellular immunity, which influence the outcome of infection and subsequent development of disease, evidence is also accumulating to suggest that intratypic strains of HSV may also play an important role in the outcome, depending on the degree of virulence each strain exhibits. Since it has been suggested that each individual is initially infected and colonized with a strain of virus whose characteristic virulence or avirulence will determine the type of HSV disease that individual will experience, it is suggested that intratypic strains should be considered an important variable in recurrent HSV disease.

Intramedullary Schwann cells have been observed following x-irradiation of lumbosacral spinal cords in immature rats. The present investigation was designed to determine whether or not the development of intramedullary Schwann cells within the spinal cord could be influenced by the portion of the spinal cord exposed to radiation. Three groups of rats were irradiated when three days of age. In one group the irradiated zone was limited to a 5 mm length of mid-thoracic spinal cord (T only), in another group the irradiation was limited to a 5 mm length of lumbosacral spinal cord (L only), and in a third group 5 mm lengths of both mid-thoracic and lumbosacral spinal cord (T/L) were irradiated. All of these animals received a single exposure to 4000 R of soft x-rays (HVL 0.16 mm Al). Sham-irradiated littermates served as control animals. Groups of rats were killed at intervals from 9 through 60 days following irradiation, and the spinal cords were prepared for light microscopic examination. Schwann cells appeared in the lateral portion of the lumbosacral dorsal funiculi of L only and T/L irradiated spinal cords as early as 9 days post-irradiation. By 19 days post-irradiation Schwann cells occupied the lateral, medial, and deep medial portions of the dorsal funiculi in the lumbosacral areas. By 25 days post-irradiation Schwann cells were also observed in the dorsal gray horns. In contrast, Schwann cells were not observed in the midthoracic regions of T only and T/L irradiated rats until 11 days post-irradiation. The accumulation of these cells was not extensive, and, in general, the Schwann cells were confined to the lateral portion of the dorsal funiculi in all animals. These findings indicate that intramedullary Schwann cell development is influenced by the region of spinal cord irradiated in immature rats.

Previous studies have demonstrated the importance of IFN alpha/beta in resistance to primary viral infections. However, the role of IFN gamma in primary infections is unclear. The present studies were undertaken to determine whether IFN gamma induction was an important early host defense against primary HSV infection. The approach was to block the IFN gamma response with antibodies to IFN gamma prior to infection and at various times post-infection (p.i.). The data indicates that treatment of mice with anti-IFN gamma prior to infection enhanced mortality (89% vs 37%). Anti-IFNs given at various times post HSV challenge proved most effective within the first 24 h of infection. The above results suggest for the first time that IFN gamma mediates important host defense(s) early during primary HSV infection. Similar results were obtained using antibody to IFN alpha/beta.

Mice treated from birth with rabbit anti-mouse IgM antiserum (anti-mu), although immunosuppressed in regard to B cell function, may paradoxically be protected when challenged with certain viruses. Our early studies indicated that short term treatment of weanling mice protected against Semliki forest virus, herpes simplex virus, and Coxsackievirus B1. For this study, the murine model of Coxsackievirus B1 infection was chosen to determine if specific anti-mu immunoglobulin (anti-mu Ig) would protect and whether protection could be correlated with antiviral activity in certain organs. Weanling Balb/c mice were treated intraperitoneally (i.p.) with either affinity purified anti-mu Ig or purified normal rabbit (NR) Ig two consecutive days prior to i.p. challenge with Coxsackievirus B1. Mortality of anti-mu Ig treated mice was significantly lower than controls (3.4% vs 89%, P less than 0.001). Importantly, this purified anti-mu-induced protection correlated well with reduced levels of virus in blood and certain organs, especially brain. This decrease was not attributed to interferon (IFN) or virus-specific neutralizing (NT) antibody or enhanced cellular cytotoxicity. Anti-mu treatment appears to inhibit virus replication and/or enhance clearance of virus from target organs. The data indicate that a unique antiviral activity is activated by anti-mu treatment, and can be passively transferred to and protect recipient mice. The murine model of Coxsackievirus disease appears to be well suited for use in the elucidation of the mechanism of this protection.

Common variable hypogammaglobulinemia (immunodeficiency), a disorder characterized by late-onset immunoglobulin deficiency and lack of humoral immunity, has a variable association with bronchiectasis, cholelithiasis, nodular lymphoid hyperplasia, gastrointestinal neoplasia, megaloblastic anemia, and malabsorption. The patient described in this report had all of the above except neoplasia. In addition, he had calcium oxalate renal stones probably secondary to his malabsorption. The first case demonstrating the beneficial effect of home hyperalimentation in patients with severe malabsorption refractory to other treatments is described. Home hyperalimentation overnight allows the patient freedom for daily activities while also being more cost-effective than in-hospital parenteral nutrition.

Schwann cells, peripheral-type myelin and connective tissue elements develop within the dorsal portion of the X-irradiated spinal cord in immature rats. Factors controlling the distribution of these elements within the irradiated site are not fully understood. In the present study [3H]thymidine autoradiography was used to examine proliferative activities of cells in these areas occupied by peripheral nervous system components, and correlative ultrastructural evaluations were made. At 15 and 20 days post-irradiation (P-I), the Schwann cells occupied the dorsolateral portions of the dorsal funiculi, and heavily labeled cells occurred throughout these areas. By 25 days P-I the Schwann cells extended ventrally into the depths of the dorsal funiculi and into the dorsal gray matter, and labeled cells were concentrated in the deeper portions of these areas. Ultrastructurally, the Schwann cells and peripheral-type myelin were more mature in the superficial portions where proliferative activity was diminished. In contrast, much less mature, peripheral-type myelin occurred in the depths where the labeled cells were concentrated. At 30 and 45 days P-I, labeled cells were much less frequent but usually occurred in the depths when observed. Similarly, a dorsal-ventral gradient in maturity of peripheral-type myelin was evident ultrastructurally. By 60 and 90 days P-I, labeling was rare, and mature Schwann cell myelin was present throughout the areas. Astrocytes and their processes were less numerous in regions invaded by Schwann cells, as compared to controls, and studies are in progress to evaluate the relationships between these glial elements and intraspinal peripheral nervous system components.

Schwann cells, Schwann cell myelin, and connective tissue components develop in the spinal cord of the immature rat following exposure to x-rays. For the purposes of this paper, these intraspinal peripheral nervous tissue constituents are referred to as IPNT. A series of investigations are in progress to elucidate factors related to the development of IPNT, and the present study is a light microscopic evaluation of the relationship between the amount of radiation administered (1,000-3,000R) to the lumbosacral spinal cord in 3-day-old rats and the incidence and distribution of IPNT at intervals up to 60 days postirradiation (P-I). The results showed that IPNT was present in only 33% of the rats exposed to 1,000R, whereas its presence was observed in 86% or more of those in the 2,000-, 2,500-, and 3,000R groups. The distribution of IPNT was quite limited in the 1,000R group, where it was restricted to the spinal cord-dorsal root junction and was found in only a few sections within the irradiated area. The distribution was more widespread with increasing amounts of radiation, and IPNT occupied substantial portions of the dorsal funiculi and extended into the dorsal gray matter in the 3,000R group. In all aR mals developing IPNT in the groups receiving 2,000R or more, the IPNT was present in essentially all sections from the irradiated area. Further studies will compare in detail spinal cords exposed to 1,000R in which IPNT is an infrequent, limited occurrence with those exposed to higher doses where IPNT occurs in a more widespread fashion in essentially all animals.