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Dr. Matthew Risken: Today’s case is that of an 81year-old man who presented to the emergency department (ED) with a chief complaint of cough and fever. The patient had been on vacation in Spain when he developed malaise, myalgias, and a mild non-productive cough. During the next 24 h he developed shortness of breath. He terminated his vacation, flew back to Boston, and came directly to our ED. On presentation, the patient stated that the shortness of breath, malaise, and cough all had become much worse during the flight back to the United States. The patient also stated that he had begun to have mild abdominal pain and distension. Much of the history was obtained from his wife, as he was unable to speak in complete sentences. She mentioned that he had become more confused over the last 24 h. The past medical history was significant for chronic atrial fibrillation, coronary artery bypass grafting in 1990, hypertension, hyperlipidemia, and an episode of upper gastrointestinal bleeding in 1994. His medications included Warfarin, Lisinopril, Simvastatin, and Isosorbide dinitrate. There were no known allergies. Dr. Eric S. Nadel: Are there any questions about the initial presentation? Dr. Chris Moore: Any source of fever can cause mental status changes in the elderly. Did the patient complain of neck pain or headache that might suggest meningitis? Dr. Risken: The patient did not complain of headache, neck stiffness, or photophobia. There were complaints of diffuse myalgias. Dr. Laura Macnow: Was there any more information regarding his travel? How long had he been out of the country? Was he in an area where tuberculosis (TB) was endemic? Dr. Risken: He had been in Spain for approximately two weeks and had visited only major tourist areas. There were no other countries visited. He had no known prior TB exposure. Dr. Eric Legome: The previous questions appropriately focus on infectious sources of the patient’s symptoms. In addition, pulmonary embolism should be considered in any elderly patient with sudden onset of shortness of breath, especially one who had an airplane flight two weeks earlier. Did the patient have any pleuritic chest pain, or leg pain or swelling? Dr. Risken: The patient did not complain of chest or leg pain. On physical examination, the patient was an ill-appearing elderly man in moderate respiratory distress who was unable to speak in complete sentences. Vital signs were a temperature of 39.2°C (102.5°F), pulse of 120 beats/min, respiratory rate of 38 breaths/min, blood pressure of 125/72 mmHg, and O2 saturation of 90% on room air. Examination of the head was normal. The neck was without jugular venous distension. Lung auscultation was significant for coarse breath sounds bilaterally and fine crackles at the bases. The cardiac examination revealed an irregularly irregular heart rate without any significant murmurs or extra heart sounds. The abdomen was mildly distended and tympanitic, non-tender, and had decreased bowel sounds. The extremities showed no

We conducted a retrospective descriptive study to determine the value of plain abdominal radiographs in emergency department (ED) patients also receiving abdominal computed tomography scans (CT) for the evaluation of nontraumatic abdominal, back and flank pain (NTAP). Cases were identified through radiology log books. Medical records and radiology reports were reviewed to determine whether the CT confirmed the findings of the plain abdominal radiographs, and whether the clinical course confirmed the results of either. Test characteristics for the plain abdominal radiograph and for the CT, using the clinical course including subsequent invasive procedures as the gold standard, were calculated. Of 177 patients who received CTs, 97 (55%) also received plain abdominal radiographs. Among the 74 patients who were admitted to the hospital and had complete data, the sensitivity and specificity for the plain abdominal radiographs were .43 and .75 respectively, compared to .91 and .94 for the CT scan (P(sens.) < .05, P(spec.) < .05). In 4 patients (5%), both studies failed to identify pathology shown in a subsequent procedure. In ED patients with NTAP, the plain abdominal radiograph may have some value as a screening tool; however, in patients in whom a CT is likely to be ordered anyway, a plain abdominal radiograph is unhelpful and often misleading.

Dr. Michelle Finkel: Today’s case is that of a 32-yearold woman in her third trimester of pregnancy who presented by ambulance to the Emergency Department (ED) in respiratory distress. Her adolescent daughter had awakened to find the patient in the bathroom extremely short of breath. Initial information via radio indicated that the patient was seated on the toilet in severe respiratory distress with altered mental status when the paramedics arrived on the scene. The patient was initially noted to have an oxygen saturation of 80% on room air. She was intubated and brought to the ED. Her past medical history was significant for systemic lupus erythematosus; however, no other medical history was available. Her gravida/para status was unknown as was her prenatal course. Her medications, allergies, and social history were also unknown. Are there any initial questions? Dr. Andrew Reisner: With regard to the airway management, what medications were given by the paramedics? Dr. Finkel: The paramedics administered 2 mg of midazolam and intubated the patient with an 8.0 endotracheal tube (ETT). No paralytics were used. Rapid sequence intubation was not used here but would have been an acceptable alternative. Dr. William Zirkin: The patient’s fetus had passed the viability threshold and should have been carefully considered. Did the paramedics obtain a fetal heart rate? Dr. Finkel: The paramedics reported that they were unable to find a fetal heart rate. After receiving the radio call we immediately informed the obstetrical service of the patient’s imminent arrival. Dr. Won Chung: When was the patient last seen? Had she been ill or was this a sudden change in her health? Dr. Finkel: We did not have that information at the time. We believed the patient had been in her usual state of health until her daughter found her that morning. The patient arrived in the ED intubated, obtunded, and unarousable. We placed her on her left side. The heart rate was 160 beats/min, blood pressure 188/136 mm Hg, and oxygen saturation 100% with ventilation. The HEENT examination demonstrated reactive and equal pupils bilaterally without any evidence of head or oral trauma. Endotracheal tube (ETT) placement was confirmed by end tidal CO2 detector. The neck was supple with jugular venous distension. The patient’s heart was tachycardic without murmurs, gallops, or rubs. The lungs demonstrated rales bilaterally throughout all lung fields. The abdomen was gravid with an approximately 32week uterus. There was bilateral pitting edema to her knees. The neurologic examination demonstrated occasional spontaneous movement of all extremities. Are there any questions about the initial presentation? Dr. Zirkin: It is impossible to ignore the patient’s elevated blood pressure. In a patient in her third trimester of pregnancy, any blood pressure above 140/90 mm Hg must be considered abnormal, and pregnancy-induced hypertension (PIH) must be assumed. The altered mental

*Tufts University School of Medicine, Boston, Massachusetts, †Faculty of Medicine, University of Brussels, Brussels, Belgium, ‡Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts, §Department of Emergency Medicine and Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, ¶Massachusetts General Hospital, Boston, Massachusetts, and #Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts Reprint Address: John T. Nagurney, MD, MPH, MGH Clinics 115, 55 Fruit St., zero Emerson Place, Suite 3B, Boston, MA 02114

We performed a prospective study of patients with suspected ureteral colic to evaluate the test characteristics of bedside renal ultrasonography (US) performed by emergency physicians (EPs) for detecting hydronephrosis, and to evaluate how US can be used to predict the likelihood of nephrolithiasis. Thirteen EPs performed US, recorded the presence of hydronephrosis, and made an assessment of the likelihood of nephrolithiasis. All patients underwent i.v. pyelography (IVP) or unenhanced helical computed tomography (CT). There were 126 patients in the study: 84 underwent IVP; 42 underwent helical CT. Test characteristics of bedside US for detecting hydronephrosis were: sensitivity 72%, specificity 73%, positive predictive value (PPV) 85%, negative predictive value (NPV) 54%, accuracy 72%. The PPV and NPV for the ability of the EP to predict nephrolithiasis after performing US were 86% and 75%, respectively. We conclude that bedside US performed by EPs may be used to detect hydronephrosis and help predict the presence of nephrolithiasis.

To examine temporal trends in the US incidence of childhood asthma hospitalizations, in-hospital mortality, mechanical ventilation use, and hospital charges between 2000 and 2009.This was a serial, cross-sectional analysis of a nationally representative sample of children hospitalized with acute asthma. The Kids Inpatient Database was used to identify children aged18 years with asthma by International Classification of Diseases, Ninth Revision, Clinical Modification code 493.xx. Outcome measures were asthma hospitalization incidence, in-hospital mortality, mechanical ventilation use, and hospital charges. We examined temporal trends of each outcome, accounting for sampling weights. Hospital charges were adjusted for inflation to 2009 US dollars.The 4 separate years (2000, 2003, 2006, and 2009) of national discharge data included a total of 592805 weighted discharges with asthma. Between 2000 and 2009, the rate of asthma hospitalization in US children decreased from 21.1 to 18.4 per 10000 person-years (13% decrease; Ptrend.001). Mortality declined significantly after adjusting for confounders (OR for comparison of 2009 with 2000, 0.37; 95% CI, 0.17-0.79). In contrast, there was an increase in the use of mechanical ventilation (from 0.8% to 1.0%, a 28% increase; Ptrend.001). Nationwide hospital charges also increased from $1.27 billion to $1.59 billion (26% increase; Ptrend.001); this increase was driven by a rise in the geometric mean of hospital charges per discharge, from $5940 to $8410 (42% increase; Ptrend.001).Between 2000 and 2009, we found significant declines in asthma hospitalization and in-hospital mortality among US children. In contrast, mechanical ventilation use and hospital charges for asthma increased significantly over this same period.

It is unclear whether advanced airway management such as endotracheal intubation or use of supraglottic airway devices in the prehospital setting improves outcomes following out-of-hospital cardiac arrest (OHCA) compared with conventional bag-valve-mask ventilation.To test the hypothesis that prehospital advanced airway management is associated with favorable outcome after adult OHCA.Prospective, nationwide, population-based study (All-Japan Utstein Registry) involving 649,654 consecutive adult patients in Japan who had an OHCA and in whom resuscitation was attempted by emergency responders with subsequent transport to medical institutions from January 2005 through December 2010.Favorable neurological outcome 1 month after an OHCA, defined as cerebral performance category 1 or 2.Of the eligible 649,359 patients with OHCA, 367,837 (57%) underwent bag-valve-mask ventilation and 281,522 (43%) advanced airway management, including 41,972 (6%) with endotracheal intubation and 239,550 (37%) with use of supraglottic airways. In the full cohort, the advanced airway group incurred a lower rate of favorable neurological outcome compared with the bag-valve-mask group (1.1% vs 2.9%; odds ratio [OR], 0.38; 95% CI, 0.36-0.39). In multivariable logistic regression, advanced airway management had an OR for favorable neurological outcome of 0.38 (95% CI, 0.37-0.40) after adjusting for age, sex, etiology of arrest, first documented rhythm, witnessed status, type of bystander cardiopulmonary resuscitation, use of public access automated external defibrillator, epinephrine administration, and time intervals. Similarly, the odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.41; 95% CI, 0.37-0.45) and for supraglottic airways (adjusted OR, 0.38; 95% CI, 0.36-0.40). In a propensity score-matched cohort (357,228 patients), the adjusted odds of neurologically favorable survival were significantly lower both for endotracheal intubation (adjusted OR, 0.45; 95% CI, 0.37-0.55) and for use of supraglottic airways (adjusted OR, 0.36; 95% CI, 0.33-0.39). Both endotracheal intubation and use of supraglottic airways were similarly associated with decreased odds of neurologically favorable survival.Among adult patients with OHCA, any type of advanced airway management was independently associated with decreased odds of neurologically favorable survival compared with conventional bag-valve-mask ventilation.

In Reply: As we indicated in our article, our study did not collect information on the process of advanced airway management, which would require independent observers. This information would have been beneficial to assess the potential mechanisms between airway management and survival outcomes. In contrast, our nationwide study reflects the effectiveness of advanced airway management in the setting of current practice in a developed nation.

Introduction: Red cabin lighting is often used for nighttime patient transports in helicopters. This study was conducted to determine if red lighting results in impairment of color-dependent tasks. Methods: An emergency medical services pilot adjusted red lighting in a BO-105 cabin to maximum acceptable intensity. Thirteen emergency room residents were shown positive and negative C0 2 detectors and skin-colored and cyan-tinted rubber masks; percentages of correctly identified masks and detectors were noted. Subjects also read drug name and amount from 12 medication labels. Wilcoxon analysis ( p = 0.05) was used to compare label reading accuracy between two groups: control (black/white lettering/background) and red (red lettering or background). Results: Percentages of accurately identified masks and detectors in the red light setting were as follows: normal mask 61.5%, cyanotic mask 30.8%, negative and positive C0 2 detectors 46.2%. Ability to correctly read medication labeling was significantly ( p = 0.003) greater in control (76.9 ±10.9%) as compared to red groups (16.3 ±13.4%). Conclusion: Red cabin lighting appears to impair performance of certain critical tasks requiring color discernment. Consideration of this by medical crews working under red light conditions could reduce risk for patient-care errors.

Background Emergency department (ED) visits in the US have risen dramatically over the past 2 decades. In order to meet the growing demand, mid-level providers (MLPs) – both physician assistants (PAs) and nurse practitioners (NPs) – were introduced into emergency care. Our objective was to test the hypothesis that MLP usage in US EDs continues to rise. Findings We analyzed ED data from the National Hospital Ambulatory Medical Care Survey to identify trends in ED visits seen by MLPs. We also compared MLP-only visits (defined as visits where the patient was seen by a MLP without being seen by a physician) with those seen by physicians only. During 1993 to 2009, 8.4% (95%CI, 7.6–9.2%) of all US ED visits were seen by MLPs. These summary data include marked changes in MLP utilization: PA visits rose from 2.9% to 9.9%, while NP visits rose from 1.1% to 4.7% (both Ptrend

Objective The study investigated differential microRNA (miRNA) expression patterns in acute myeloid leukemia (AML) patients with intermediate-risk (IR) characteristics. After characterization and validation of miR-10a , which was specifically upregulated in nucleophosmin 1 ( NPM1 ) mutant AML samples, functional consequences of miR-10a overexpression were further delineated in vitro. Materials and Methods Microarray analysis of miRNAs in bone marrow samples from AML (IR) patients with NPM1 mutations and healthy donors was performed to detect differential expression patterns. After validation of miRNA expression specific for NPM1 mutation in AML patients by quantitative reverse transcription polymerase chain reaction, a functional target gene search was conducted using complementary DNA microarray data from samples transfected with miR-10a . Potential target gene validation was done using transient transfection of K562 cells followed by Western blotting and luciferase reporter assay. Results In comparison with wild-type samples, NPM1 mutant AML samples were shown to markedly overexpress miR-10a . Subsequent in vitro miR-10a overexpression induced differential gene expression as determined by microarray analysis. Here the murine double minute 4 ( MDM4 ) gene turned out as a candidate gene for miR-10a . Validation of MDM4 in leukemic cells revealed a robust negative relationship between miR-10a overexpression and MDM4 downregulation. Furthermore, we determined an inverse association between miR-10a and MDM4 expression in AML (IR) samples with respect to their NPM1 mutational status. Conclusions miR-10a expression is highly characteristic for AML (IR) patients with NPM1 mutations and may influence its biological properties in AML by interfering with the p53 machinery partly regulated by MDM4 .

Background: Cancer stem cells represent the cell population responsible for tumor initiation and progression. Resistance to cell death induced by cytotoxic agents is a characteristic shared by most identified cancer stem cells. In ovarian cancer, the CD44+/MyD88+ epithelial ovarian cancer (EOC) stem cells do not only represent the chemoresistant population, they are also able to repair the tumor and serve as tumor vascular progenitors. Targeting these cells is therefore necessary to improve treatment outcome. However, the previous demonstration that these cells are extremely chemoresistant, suggests that other forms of targeted therapy should be explored. We previously showed that the novel isoflavone derivative, NV-128, can induce caspase-independent cell death in ovarian cancer cells by inducing loss of mitochondrial membrane potential. We hypothesize that targeting mitochondrial bioenergetics may be a potent stimulus to induce cell death in the EOC stem cells. We demonstrate in this study that NV-128 is able to depress mitochondrial function leading to the activation of two independent pathways and cell death in these chemo-resistant cell population. Methods: A panel of CD44+/MyD88+ EOC stem cells was treated with NV-128 (1–10μg/ml). Inhibitory studies were done using the specific MEK inhibitor, U0126, or the ROS scavenger, MnTBAP. Mitochondrial integrity and function were assessed using Mitotracker Red, Mitotracker Green, MitoSox, and ApoSENSOR ADP/ATP kit. Cytoplasmic and mitochondrial fractions were prepared using the ApoAlertTM Cell Fractionation kit. Protein levels were determined using Western Blot. Results: NV-128 (10 μg/ml) significantly depressed mitochondrial function within 2h in all EOC stem cells tested. Treated cells had lower levels of ATP and Cox-IV, and higher levels of mitochondrial superoxide. Low cellular ATP led to mTOR inhibition through AMPKα1, while increased mitochondrial superoxide activated the mitochondrial MEK/ERK pathway and promoted Bax-dependent loss of mitochondrial membrane potential. Resulting cell death was characterized by Endo-G-induced but caspase-independent DNA fragmentation, as well as formation of autophagic vacuoles. Conclusion: We demonstrate that targeting the mitochondria in the EOC stem cells promotes a state of “cellular starvation” capable of activating two independent pathways: 1) AMPKα1 pathway leading to mTOR inhibition; and 2) mitochondrial MEK/ERK pathway leading to mitochondrial depolarization. The simultaneous activation of these pathways is a potent stimulus to induce cell death in cells. The demonstration that a compound can specifically target the mitochondria to induce cell death in this otherwise chemo-resistant cell population opens a new venue for treating ovarian cancer patients. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr LB-221. doi:10.1158/1538-7445.AM2011-LB-221

The purpose of this study was to describe the epidemiology of emergency department (ED) visits for vaginal bleeding during early pregnancy (VBEP).We analyzed data from the National Hospital Ambulatory Medical Care Survey, 1993-2003. Cases presented with a complaint of vaginal bleeding and had diagnoses consistent with presentation during early pregnancy.Over the 11-year period, there were 5.4 million visits for VBEP, which represents 1.6% of all ED visits or almost 500,000 visits/year. ED visits for VBEP increased from 5.6-7.8 visits per 1000 US population (P for trend.01). The population rates were highest in the 20-29 year age group. ED patients with VBEP were more likely to be black, Hispanic, and uninsured, as compared to women presenting for other reasons.ED visits for VBEP are rising, particularly among younger and Hispanic women. Programs that ensure primary obstetric care would help decrease reliance on the ED for this important condition.

Objectives. —To provide an update of the international experience with carrier screening and prenatal diagnosis for Tay-Sachs disease (TSD), to assess the impact of these efforts, and to review the recent developments in DNA technology with application to TSD carrier detection and screening. Design. —Through the International TSD Testing, Quality Control, and Data Collection Center, all testing centers in the world were surveyed annually to assess overall experience with carrier testing and prenatal diagnosis. Quality control and laboratory surveillance of testing centers were performed through an annual assessment, using samples provided by the center. Setting. —Tay-Sachs disease testing centers around the world. Participants. —Nearly 1 million young adults from both Jewish and non-Jewish populations. Intervention. —Gene product screening (enzyme testing) and DNA-based mutation analysis (in some populations). Main Outcome Measure. —Impact of screening program on disease incidence. Results. —Data from all centers in the international TSD network on experience with TSD carrier testing and prenatal diagnosis since 1974 indicated that more than 36 000 heterozygotes were identified and 1056 couples found to be at risk for TSD in their offspring. A total of 2416 pregnancies at increased risk for TSD were monitored by amniocentesis or chorionic villus sampling. A dramatic decrease in the incidence of TSD in the Jewish populations was demonstrated. With both serum and leukocyte proficiency testing, there have been only 16 instances (of 845 cumulative laboratory evaluations) of one or more errors reported by a laboratory since 1983 resulting in nonaccreditation. Conclusions. —This analysis represents a prototypic effort in coordinating adult education, carrier testing, and genetic counseling directed toward prospective prevention of a uniformly fatal childhood disease and demonstrates that such an effort can dramatically affect disease incidence. ( JAMA . 1993;270:2307-2315)

IT has long been recognized that patients with ischemic heart disease may exhibit abnormalities in serum lipid patterns. Although cholesterol metabolism in ischemic heart disease has received a vast amount of study over the years, emphasis has only recently been placed on the possible role of abnormal triglyceride metabolism in this disorder. Albrink and Man1 have described elevated fasting triglyceride levels in ischemic heart disease. Differences in serum triglyceride levels have recently been reported in racial groups with widely differing incidence of ischemic heart disease.2 Brown et al.3 have shown that elevated cholesterol levels tend to be paralleled by an . . .

Serum parathyroid hormone and total and ionized Ca, Mg, and P levels were determined serially from birth to 96 hr of age in 28 infants of diabetic mothers (IDM, 15 Class A, 13 Class B, C, D) and their respective mothers at the time of delivery. In spite of marked decreases in concentrations of serum total and ionized Ca from birth to 24 to 48 hr, there was an insignificant increase in serum PTH values over this period in infants of insulin-dependent mothers. Infants of Class A diabetic mothers had an equivocal PTH response. Nineteen term control infants were similarly examined and had a significant increase in serum PTH postnatally. Relatively higher values of serum ionized Ca at birth in IDM were followed by greater decreases in ionized Ca from birth to 24-48 hr of age, and by decreased neonatal parathyroid function. The data support functional hypoparathyroidism as a basis for the hypocalcemia and hyperphosphatemia of IDM. It is speculated that increased concentrations of serum ionized Ca in utero and suppression of activity in the fetal parathyroid glands may be a cause for the functional hypoparathyroidism.

Sixty patients with FIGO stage IIb, IIc, III and IV ovarian cancer were entered into a randomized Phase III study of cyclophosphamide 600 mg/m2 with cisplatin 100 mg/m2, iproplatin 240 mg/m2 or carboplatin 300 mg/m2. Dose modifications were made according to renal function and myelotoxicity. The arms containing carboplatin (CBDCA) and iproplatin (CHIP) were not shown to be significantly different from the cisplatin containing arm with regard to response rate, duration of response and survival. Subjective toxicity showed that cisplatin and cyclophosphamide therapy was associated with more nausea and vomiting (P = 0.0005). The duration of vomiting showed a significant increase with successive courses of chemotherapy for the cisplatin containing arm only (P less than 0.003). The cyclophosphamide/CHIP combination caused significantly more diarrhoea (P less than 0.0006). Alopecia was more severe (P less than 0.02), and neurotoxicity was more common, in patients who received cyclophosphamide and cisplatin (paraesthesiae P = 0.0007, tinnitus P less than 0.00005, deafness P = 0.0018). All three combinations caused cumulative toxicity on haemoglobin (Hb) (P less than 0.001 for each treatment), leukocyte count (WCC) (P less than 0.0005 for each treatment), and platelet count (P less than 0.0005 for each treatment). The degree of fall in Hb for each course of therapy was greater in the cisplatin containing arm compared with the CHIP and CBDCA arms which were not significantly different from each other (P = 0.0005). For WCC the cisplatin/cyclophosphamide regimen was significantly less toxic than CHIP/cyclophosphamide, with CBDCA/cyclophosphamide falling between the two and not being significantly different from either (P = 0.0005). The CHIP containing arm caused more thrombocytopenia than the other arms which were of equal toxicity (P less than 0.0005). Serum creatinine showed a gradual significant overall rise with each course of cisplatin/cyclophosphamide therapy (P less than 0.0005), whereas the CBDCA arm showed no change and the CHIP arm showed a small fall in serum creatinine after most courses of therapy. This study showed that CHIP or CBDCA in combination with cyclophosphamide was less toxic than cisplatin/cyclophosphamide therapy with regard to alopecia, degree and duration of nausea and vomiting, renal toxicity, neurotoxicity and anaemia. The CHIP/cyclophosphamide regimen caused more thrombocytopenia and diarrhoea. The CHIP and CBDCA containing arms caused more leukopenia than the cisplatin containing regimen. Either iproplatin or carboplatin would be an acceptable alternative to cisplatin in chemotherapy regimens, and would result in reduced toxicity.

SINCE 1959, when Albrink and Man1 suggested that elevated serum triglyceride levels might be related to the pathogenesis of ischemic heart disease, several investigators2 3 4 5 6 have measured the lipid in health and in this disease. No information is available on the possible value of elevated triglyceride levels in predicting the occurrence of the disease in apparently healthy men. Accordingly, in this study, serum triglyceride and cholesterol levels were measured in 1851 fasting middle-aged men who remained under clinical observation for the next four years (1959–1964). It was thus possible to relate triglyceride and cholesterol levels to both the incidence and the . . .

The top comes off with a perfect bevel; it won't fall in, ever. A nose close to the edge catches the mysterious air drawn from the ground (it seems) to fill this extravagant space, air sweet as August and cool as October, this unbreathed air. The seeds cling to the sides in their slimy tendrils as if the yellow vortex had slung them there as the flower (long gone) pulled a fecund darkness from behind. But that is not the point tonight. The seeds come our— whether to roast up, salt-encrusted, like a school of fish left high and dry, or throw away, as in the way— there's no tradition here. Out they go this year. The empty belly is made emptier, and the cutting begins. One takes the eyes and nose, the other the mouth; there are no triangles, no cuts for a small hand guiding a blade, but

Infants with intrauterine growth retardation (IUGR) often exhibit signs of neuromuscular irritability, even without associated hypoglycemia. Little is known about serum Ca in such infants. In this study 47 IUGR infants and 70 infants with birth weights appropriate for gestational age (AGA) were studied serially in the first 3 days of life. Serum Ca in AGA infants was correlated with gestational age; serum Ca in IUGR infants was within the 95% confidence limits for AGA infants of comparable gestation. Forty IUGR infants were matched with 40 AGA infants for birth weight and birth asphyxia (1 minute Apgar Score≤6, or necessity for resuscitation): neonatal serum Ca was not significantly different between the 2 groups. Among IUGR infants postnatal serum Ca was not correlated with birth weight, but correlated significantly with Apgar Scores(r=0.471, p

Small as a day in a year, this trickle has come out of the glacial rocks to make a pool no wider than two spread hands. The sphagnum makes a forest at its edge. The water is cool, dark with shade and tannin; it will stay at least beyond this evening when the sun, holding as much, as much of day as it ever can, lets go to run down its own declivity, as this water will run through blanched roots to the river with equally little choice in the matter. What the hill above will give, or the streams below will take from this pool tomorrow is today beyond our actual knowing. What is here today is what we know: a seep of ancient water just now flowing into this pool, the flecks of larvae swimming, the jay in the tree nervously racing from limb to limb, the spider