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In 2006, the latest version of a national curriculum for the fourth-year emergency medicine (EM) clerkship was published. Over the past several years, that curriculum has been implemented across multiple clerkships. The previous curriculum was found to be too long and detailed to cover in 4 weeks. As well, updates to the Liaison Committee on Medical Education (LCME)'s form and function document, which guides the structure of a clerkship, have occurred. Combining experience, updated guidelines, and the collective wisdom of members of the national organization of the Clerkship Directors in Emergency Medicine (CDEM), an update and revision of the fourth-year EM clerkship educational syllabi has been developed.

[1] It is well known that ionospheric scintillation has the potential to affect all types of GPS receivers, even dual-frequency military precise-positioning service versions. In a previous effort the degree of degradation to Wide Area Augmentation System (WAAS) operation caused by scintillation, on the basis of simulated data input to an actual WAAS reference receiver under carefully controlled laboratory conditions at Space and Naval Warfare Systems Center, was analyzed and reported [Morrissey et al., 2000]. This degradation is manifested in increased errors for carrier phase and code range measurements and in a higher probability of loss of GPS signal track. However, the results supported the assessment that scintillation should not be a problem for WAAS receivers in the conterminous United States, except perhaps during the very rare occurrence of a “severe geomagnetic storm.” The previous work was briefed in a number of fora, and a detailed report was widely distributed throughout the ionospheric community along with a request for identification of any “gaps” in the results that could be addressed with further testing. From the feedback received, the following tests were conducted: (1) tests with long-duration deep amplitude nulls, corresponding to the GPS signal moving with the ionospheric disturbance; (2) tests with phase scintillation waveforms derived from 50 Hz ionospheric scintillation monitor (ISM) data previously collected by the U.S. Air Force (Philips Laboratory) at Antofagosta, Chile; (3) tests of a modified military single-frequency receiver (Enhanced Miniaturized Airborne GPS Receiver (EMAGR)) side-by-side with the WAAS receiver, with emphasis on maintaining lock at L1; and (4) tests at values of input carrier-to-noise ratio (CNR) lower (i.e., down to 36 dB Hz) than those used in the original tests. The tests with deep amplitude nulls were reported by Morrissey et al. [2002], and the tests with realistic input phase scintillation waveforms were reported at the Ionospheric Effects Symposium (IES) 2002. The current paper is based upon the IES 2002 results as modified by recent testing. Both these amplitude and phase results include EMAGR and low CNR performance.

In an effort to determine if there are significant differences in outcome between elderly (> or = 65 years of age) and younger (< 65 years of age) women with epithelial ovarian cancer we examined the survival of patients with this malignancy who underwent their initial surgical evaluation at the Memorial Sloan-Kettering Cancer Center from January 1987-January 1991. The actuarial median overall survival for the 98 younger patients has not been reached but will exceed 4 years, compared to a median survival of 24 months for the 48 elderly patients (P < 0.0001). For individuals with advanced (stages 3-4) disease, excluding patients with tumors of low malignant potential, the median survival for the younger patient population has also not been reached and will exceed 4 years, compared to 21 months for the older population (P < 0.0001). Even in the limited number of patients with local/regional (stages 1-2) ovarian cancer, there was a statistically significant superior survival for the younger group of patients (P < 0.02). With a single exception, all deaths were believed to be due principally to disease progression, rather than to an unrelated comorbid medical event. We conclude that elderly patients with ovarian cancer experience a significantly inferior survival than younger individuals with this malignancy. Evaluation of larger populations will be required to confirm the results of this analysis and to probe for explanations for the striking survival differences we have observed.

There is evidence of differences between older (or = 65 years of age) and younger (65 years of age) women with ovarian cancer.To evaluate differences in the care of older versus younger patients with ovarian cancer, a retrospective review was conducted of the records of 146 patients who had their initial surgery for ovarian cancer at the Memorial Sloan-Kettering Cancer Center from January 1987-January 1991.There was a significant difference in stage at presentation between the older (48 patients) and younger (98 patients) populations (Stage I/II: older 10%; younger 25%; P0.05). Although there was no statistically significant difference in the distributions of patients according to tumor grade between the two groups, 10% of the younger patients had ovarian cancer of low malignant potential, compared to only 2% of older patients (P0.1). Forty-six percent of the younger patients entered an intensive initial chemotherapy trial compared to only 17% of the older patients (P0.001), principally due to comorbid medical conditions (e.g., heart disease). Finally, whereas the relative number of younger to older patients with ovarian cancer undergoing initial surgery at this institution was 2:1, the relative number of totally new patients to the service (including referral for initial treatment or salvage programs) was 4:1 (P0.001), suggesting that older patients with ovarian cancer are less likely to be referred for secondary experimental programs than for initial treatment.These data suggest that there are major differences between the presentation and treatment strategies of older compared to younger patients with ovarian cancer.