Uniformed Medical Students and Residents in Emergency Medicine.

"Uniformed medical students and residents" refers to medical school enrollees and physicians in training who are obligated to serve in the military after graduation or training completion. This is in exchange for 2 forms of financial support that are provided by the military for individuals interested in pursuing a career in medicine. These programs are offered namely through the Uniformed Services University of Health Sciences (USUHS) and the Health Professions Scholarship Program (HPSP). Uniformed medical school graduates can choose to serve with the military upon graduation or to pursue residency training. Residency can be completed at in-service programs at military treatment facilities, at out-service programs, at civilian residency training programs, or via deferment programs for residency training at civilian programs. Once their residency training is completed, military physicians should then complete their service obligation. As such, both USUHS and HPSP students should attend a basic officer training to ensure their preparedness for military service. In this article, we elaborate more on the mission, requirements, application, and benefits of both USUHS and HPSP. Moreover, we expand on the officer preparedness training, postgraduate education in the military, unique opportunities of military medicine, and life after completion of military obligation.

Bedside method to estimate actual body weight in the Emergency Department.

BACKGROUND: Actual body weight (ABW) is important for accurate drug dosing in emergency settings. Oftentimes, patients are unable to stand to be weighed accurately or clearly state their most recent weight. OBJECTIVE: Develop a bedside method to estimate ABW using simple anthropometric measurements. METHODS: Prospective, blinded, cross-sectional convenience sampling of adult Emergency Department (ED) patients. A multiple linear regression equation from Derivation Phase (n = 208: 121 males, 87 females) found abdominal and thigh circumferences (AC and TC) had the best fit and an inter-rater correlation of 0.99 and 0.96, respectively: Male ABW (kg) = -47.8 + 0.78 ∗ (AC) + 1.06 ∗ (TC); Female ABW = -40.2 + 0.47 ∗ (AC) + 1.30 ∗ (TC). RESULTS: Derivation phase: Number of patients (%) with a body weight estimation (BWE) > 10 kg from ABW for males/females were: 7 (6%)/1 (1%) for Patients, 46 (38%)/28 (32%) for Doctors, 38 (31%)/24 (27%) for Nurses, 75 (62%)/43 (49%) for 70 kg/60 kg convention, and 14 (12%)/8 (9%) using the anthropometric regression model. For validation phase (55 males, 44 females): Gold standard ABW mean (SD) male/female = 83.6 kg (14.3)/71.5 kg (18.9) vs. anthropometric regression model = 86.3 kg (14.7)/73.3 kg (15.1). R(2) = 0.89, p < 0.001. The number (%) for males/females with a BWE > 10 kg using the anthropometric regression model = 8 (15%)/11 (27%). CONCLUSIONS: For male patients, a regression model using supine thigh and abdominal circumference measurements seems to provide a useful and more accurate alternative to physician, nurse, or standard 70-kg male conventional estimates, but was less accurate for use in female patients.

Bedside estimation of patient height for calculating ideal body weight in the emergency department.

BACKGROUND: Ideal body weight (IBW), which can be calculated using the variables of true height and sex, is important for drug dosing and ventilator settings. True height often cannot be measured in the emergency department (ED). OBJECTIVES: Determine the most accurate method to estimate IBW using true height-based IBW that uses true height estimated by providers or patients compared to true height estimated by a regression formula using measured tibial length, and compare all to the conventional 70 kg male/60 kg female standard IBW. METHODS: Prospective, observational, double-blind, convenience sampling of stable adult patients in a tertiary care ED from September 2004 to April 2006. Derivation set (215 patients) had blinded provider and patient true height estimates and tibial length measurements compared to gold-standard standing true height. A validation set (102 patients) then compared the accuracy of IBW using true height calculated from the regression formula vs. IBW using gold-standard true height. Regression formula for men tibial length-IBW (kg) = 25.83 + 1.11 × tibial length; for women tibial length-IBW = 7.90 + 1.20 × tibial length; R(2) = 0.89, p < 0.001. Inter-rater correlation of tibial length was 0.94. RESULTS: Derivation set: percent within 5 kg of true height-based IBW for men/women = PATIENT: 91.1%:/85.7%; Physician: 66.1%/45.1%; Nurse: 65.7%/ 47.3%; tibial length: 66.1%/63.7%; and 70 kg male/60 kg female standard 46%/75%. Validation set: tibial length-IBW estimates were within 5 kg of true height-ideal body weight in only 56.2% of men and 42.2% of women. CONCLUSIONS: PATIENT-reported height is the best bedside method to estimate true height to calculate ideal body weight. Physician and nurse estimates of true height are substantially less accurate, as is true height obtained from a regression formula that uses measured tibial length. All methods were more accurate than using the conventional 70 kg male/60 kg female IBW standard.

Treatment of suspected symptomatic cholelithiasis with glycopyrrolate: a prospective, randomized clinical trial.

STUDY OBJECTIVE: Glycopyrrolate is advocated for the treatment of acute pain from suspected symptomatic cholelithiasis. However, there is no clinical evidence to substantiate its use. This study is designed to evaluate the efficacy of glycopyrrolate in relieving acute abdominal pain of suspected biliary tract origin. METHODS: Between July 2002 and April 2003, a convenience sample of patients presenting to the emergency department with upper abdominal pain of suspected biliary tract origin was randomized to receive either intravenous glycopyrrolate or placebo (normal saline solution). Pain level was assessed at baseline using a visual analog scale, with a repeat assessment 20 minutes after intervention. Patients and clinicians were blinded to the study drug. RESULTS: Because of difficulty with patient enrollment, the trial was terminated before achievement of the initial goal of 54 patients. On analysis of the 38 patients completing the study protocol, glycopyrrolate and placebo groups had similar demographic and baseline characteristics. There was no significant difference in pain relief between patients receiving glycopyrrolate and those receiving placebo (median decrease in visual analog pain scale pain 3 mm [95% confidence interval -2 to 17 mm] versus 8 mm [95% confidence interval -2 to 20 mm], respectively). CONCLUSION: Although limited by small size and convenience sampling, these results fail to demonstrate any improvement in pain of suspected biliary tract origin with the administration of glycopyrrolate. Further study is needed to determine whether intravenous glycopyrrolate has any significant analgesic effect for patients with this condition.

HPMA copolymers platinates containing dicarboxylato ligands. Preparation, characterisation and in vitro and in vivo evaluation.

N-(2-Hydroxypropyl)methacrylamide (HPMA) copolymer platinates were prepared from polymeric intermediates containing Gly-Phe-Leu-Gly side chains terminating in either malonate or aspartate dicarboxylato ligands. Platinum(II) was bound by reaction of the dicarboxylato ligands with cis-[Pt(NH3)2(H2O)2]2+. The HPMA copolymer platinates obtained had a Mw of 29,000-31,000 Da and a platinum loading of approximately 10wt% (by AAS). This is close to the theoretical maximum value. The release rate of platinum species in vitro at pH 7.4 correlated with the expected stability of the 6 and 7 membered chelate rings; 14%/24 h platinum released in the case of the malonate and 68%/24 h platinum released in the case of the aspartate. Cisplatin and the aspartate conjugate displayed similar toxicity in vitro against B16F10 and COR-L23 cells while the malonate was at least 8-fold less toxic. The malonate conjugate showed significantly improved activity (T/C = 1.27-1.5) when compared with cisplatin (T/C = 1.18) that was not active when administered intravenously to treat a subcutaneous B16F10 tumour. The conjugate was at least 20-fold less toxic than cisplatin in vivo. After i.v. administration, the platinum accumulation in B16F10 tumour tissue showed a 19-fold increase in Pt AUC for the malonate conjugate when compared to cisplatin administered equi-dose at its maximum tolerated dose (MTD) (1 mg/kg).

Serum progesterone testing to predict ectopic pregnancy in symptomatic first-trimester patients.

STUDY OBJECTIVE: This study was conducted to prospectively measure the accuracy of serum progesterone levels to detect ectopic pregnancy. METHODS: Seven hundred sixteen symptomatic first-trimester emergency department patients with abdominal pain or vaginal bleeding at a tertiary care military teaching hospital had progesterone levels measured by radioimmunoassay with results unavailable to the treating physician. All patients were monitored until a criterion standard diagnosis of intrauterine pregnancy or ectopic pregnancy was confirmed. RESULTS: A 14-month derivation phase (n=399) used receiver operating characteristic curve testing to select a cutoff value of progesterone less than 22 ng/mL. A 12-month validation phase (n=317) then retested this cutoff value. Combining both phases, there were 434 (61%) viable intrauterine pregnancies, 229 (32%) nonviable intrauterine pregnancies, and 52 (7. 3%) ectopic pregnancies, of which 17 were ruptured. Sensitivity, specificity, positive predictive values, and negative predictive values (95% confidence intervals) for progesterone levels less than 22 ng/mL to detect ectopic pregnancy were 100% (94% to 100%), 27% (23% to 30%), 10% (7% to 12%), and 100% (98% to 100%), respectively. CONCLUSION: Given similar disease prevalence, roughly one fourth (178/716) of symptomatic patients can be classified as low risk (0%, 95% confidence interval 0 to 2%) for having an ectopic pregnancy using a progesterone cutoff of 22 ng/mL. Whether implementation of rapid progesterone testing can safely expedite care and reduce the need for urgent diagnostic evaluation or admission remains to be determined.

Chemical and Biological Studies of Dichloro(2-((dimethylamino)methyl)phenyl)gold(III).

Several new organogold(III) derivatives of the type [AuX(2)(damp)] (damp = o-C(6)H(4)CH(2)NMe(2)) have been prepared [X = CN, SCN, dtc, or X(2) = tm; dtc = R(2)NCS(2) (R = Me (dmtc) or Et (detc)); tm = SCH(CO(2))CH(2)CO(2)Na] together with [AuCl(tpca)(damp)]Cl (tpca = o-Ph(2)PC(6)H(4)CO(2)H), [Au(dtc)(damp)]Y (Y = Cl, BPh(4)) and K[Au(CN)(3)(damp)]. The (13)C NMR spectra of these and previous derivatives have been fully assigned. In [Au(dtc)(2)(damp)] and K[Au(CN)(3)(damp)], the damp ligand is coordinated only through carbon, as shown by X-ray crystallography and/or NMR. [Au(detc)(2)(damp)] has space group C2/c, with a = 29.884(4) Å, b = 13.446(2) Å, c = 12.401(2) Å, beta = 99.45(3)(o), V = 4915 Å(3), Z = 8, and R = 0.057 for 1918 reflections. The damp and one detc ligand are monodentate, the other detc is bidentate; in solution, the complex shows dynamic behavior, with the detc ligands appearing equivalent. The crystal structure of [Au(dmtc)(damp)]BPh(4) [Pna2(1), a = 26.149(5) Å, b = 11.250(2) Å, c = 11.921(2) Å, V = 3507 Å(3), Z = 4, R = 0.073, 1772 reflections] shows both ligands to be bidentate in the cation, but the two Au-S distances are nonequivalent. The crystal structure of [Au(tm)(damp)] has also been determined [P2(1)/n, a = 18.267(7) Å, b = 9.618(3) Å, c = 18.938(4) Å, beta = 113.45(3)(o), V = 3053 Å(3), Z = 8, R = 0.079, 1389 reflections]. The tm is bound through sulfur and the carboxyl group which allows five-membered ring formation. In all three structures, the trans-influence of the sigma-bonded aryl group is apparent. [AuCl(2)(damp)] has been tested in vitroagainst a range of microbial strains and several human tumor lines, where it displays differential cytotoxicity similar to that of cisplatin. Against the ZR-75-1 human tumor xenograft, both [AuCl(2)(damp)] and cisplatin showed limited activity.