Terry MacMath - Academia.edu (original) (raw)
Papers by Terry MacMath
Archives of Internal Medicine, 1990
In Reply .—We appreciate the comments of Dr Burnside; however, we feel that the thrust of his arg... more In Reply .—We appreciate the comments of Dr Burnside; however, we feel that the thrust of his arguments is misdirected. Our triage algorithm assumes, as have others, 1-5 that only patients with life-threatening complications clearly benefit from intensive care unit monitoring. Of the 57 low-risk patients, seven patients had four interventions, five non-life-threatening complications, and two myocardial infarctions. No intervention was emergent, and no life-threatening complication occurred in this group. Furthermore, of the two patients diagnosed as having an acute myocardial infarction, both had normal electrocardiograms on presentation, with only nondiagnostic ST-T changes appearing on serial electrocardiograms. Thus our low-risk group has a false-negative rate of 0% and not the 10% as stated in Dr Burnside's letter. While we agree that should the data be extended, life-threatening complications and/or death will ultimately occur in the low-risk group, the results to date indicate that this risk will be small. Dr Burnside's
Annals of Emergency Medicine, 1988
A case of paroxysmal supraventricular tachycardia (PSVT) in a child with successful termination o... more A case of paroxysmal supraventricular tachycardia (PSVT) in a child with successful termination of the arrhythmia by military antishock trouser (MAST) application is described. The use of MAST application in terminating PSVT in adults has been previously reported. Ours is the first such case reported using this method in the therapy of PSVT in children. Our report suggests that MAST application may be another maneuver to add to those vagal maneuvers known to be of benefit in the termination of PSVT in children as well as in adults.
Emergency medicine clinics of North America, 1990
Ethanol has experimentally been shown to be "ulcerogenic," independent of gastric intra... more Ethanol has experimentally been shown to be "ulcerogenic," independent of gastric intraluminal pH. Ethanol remains ulcerogenic despite antisecretory doses of H2-receptor antagonists. Low-dose alcohol stimulates acid secretion in man, an effect possibly mediated by histamine or gastrin. High-dose alcohol reduces intraluminal acid by damaging mucosa, thereby enhancing back diffusion of hydrogen ion, and also by direct damage to oxyntic (parietal) cells. Ethanol is capable of increasing gastric mucosal permeability as evidenced by the increase in back diffusion (increases intraluminal pH) and by the characteristic fall in transmucosal potential difference which reflects surface cell layer exfoliation. This exfoliation may offer an explanation for the potentiating effect of alcohol on gastric mucosal injury when it is ingested simultaneously with other gastric irritants. Ethanol of greater than 20% concentration can rapidly destroy the gastric mucus-bicarbonate layer, which ma...
Annals of Emergency Medicine, 1987
A 71-year-old woman with an episode of paroxysmal supraventricular tachycardia (PSVT) complicated... more A 71-year-old woman with an episode of paroxysmal supraventricular tachycardia (PSVT) complicated by angina pectoris and hypotension had her arrhythmia abruptly terminated by digital rectal massage (DRM) after other vagotonic maneuvers had failed. DRM termination of PSVT has not been heretofore reported. In treating PSVT by physical vagotonic maneuvers, DRM may be preferable to other techniques because of the decreased likelihood of complications noted with other such maneuvers.
Annals of Emergency Medicine, 1988
A case of paroxysmal supraventricular tachycardia (PSVT) in a child with successful termination o... more A case of paroxysmal supraventricular tachycardia (PSVT) in a child with successful termination of the arrhythmia by military antishock trouser (MAST) application is described. The use of MAST application in terminating PSVT in adults has been previously reported. Ours is the first such case reported using this method in the therapy of PSVT in children. Our report suggests that MAST application may be another maneuver to add to those vagal maneuvers known to be of benefit in the termination of PSVT in children as well as in adults.
Annals of Emergency Medicine, Nov 30, 1987
A 71-year-old woman with an episode of paroxysmal supraventricular tachycardia (PSVT) complicated... more A 71-year-old woman with an episode of paroxysmal supraventricular tachycardia (PSVT) complicated by angina pectoris and hypotension had her arrhythmia abruptly terminated by d~gital recta] massage (DRM) after other vagotonic maneuvers had failed. DRM termination of PSVT has not been heretofore reported. In treating PSVT by physical vagotonic maneuvers, DRM may be preferable to other techniques because of the decreased likelihood of complications noted with other such maneuvers.
Journal of surgical case reports, 2015
Transitional cell carcinoma (TCC) and large bowel obstructions are both common disease processes ... more Transitional cell carcinoma (TCC) and large bowel obstructions are both common disease processes typically considered unrelated. Presented below is the case of a 49-year-old male with a large bowel obstruction caused by a bladder TCC metastasis. One year prior to large bowel obstruction presentation, the patient had a T2, Grade III TCC of the bladder with no nodal involvement or metastasis, which was removed via radical cystoprostatectomy. This case serves as a reminder that cancer, despite common pathogenesis patterns, can present in atypical ways.
Archives of Internal Medicine, Jun 1, 1989
Previously developed initial electrocardiogram (ECG) prediction rules were modified to stratify 4... more Previously developed initial electrocardiogram (ECG) prediction rules were modified to stratify 426 patients with suspected acute myocardial infarction into low-, intermediate-, and high-risk groups (normal, abnormal, and positive ECG categories) for development of acute myocardial infarction and complications of coronary ischemia. Compared with patients with normal ECGs, patients with positive ECGs had a 2.9 times greater risk of interventions, a greater risk of life-threatening complications, and a 14.2 times greater risk of acute myocardial infarction. Compared with patients with abnormal ECGs, patients with positive ECGs had a 1.7 times greater risk of interventions, a 2.6 times greater risk of life-threatening complications, and a 4.9 times greater risk of acute myocardial infarction. This prediction scheme was further improved by assigning "high" risk to any patient requiring an acute intervention during the initial evaluation in the emergency department. Otherwise, risk was assigned according to the ECG category, with normal, abnormal, and positive ECGs corresponding to "low," "intermediate," and high risk, respectively. Hospitals with limited intensive care beds may be able to use these prediction rules as an aid in determining in-hospital disposition of patients with suspected acute myocardial infarction.
Digestive diseases and sciences, 1997
Gastroesophageal reflux (GER) occurs in 22-66% of patients with noncardiac chest pain (NCCP). Alt... more Gastroesophageal reflux (GER) occurs in 22-66% of patients with noncardiac chest pain (NCCP). Although open-label investigations have shown beneficial effects of antireflux therapy in NCCP, no double-blind, prospective, placebo-controlled studies have been conducted. The purpose of this study was to evaluate the effects of omeprazole compared to placebo in a prospective, double-blind, randomized trial of patients with NCCP and GER. Thirty-six consecutive patients with NCCP and GER documented by 24-hr ambulatory pH testing entered this study. The subjects were randomized to omeprazole, 20 mg by mouth twice a day (17 patients), or placebo (19 patients) for eight weeks. Patients on omeprazole obtained significantly more improvement in the fraction of chest pain days (P = 0.006) and severity (P = 0.032) when compared to placebo. More patients in the omeprazole group reported improvement in individual daily pain scores (81% vs 44%, P = 0.03) and individual severity scores (81% vs 50%, P ...
Southern medical journal, 1984
We have presented a case of mesenteroaxial volvulus in a 12-year-old girl. Since this entity is r... more We have presented a case of mesenteroaxial volvulus in a 12-year-old girl. Since this entity is rare in children, one must be especially alert to its possibility for early diagnosis and treatment of this potential catastrophe.
The Journal of Emergency Medicine, 1985
0 Abstract -A case of primary aortoduodenal fistula, which presented as an upper gastrointestinal... more 0 Abstract -A case of primary aortoduodenal fistula, which presented as an upper gastrointestinal bleed, is described, including a brief review of the literature. Since 1952, with the advent of homograft replacement, there has been a significant decrease in the number of reported cases of aortoenteric fistulas of the primary type.' 0
The Journal of Emergency Medicine, 1988
0 Abstract-The initial ECG is the most rapid and readily available tool in the emergency departme... more 0 Abstract-The initial ECG is the most rapid and readily available tool in the emergency department for the evaluation of patients presenting with suspected myocardial infarction. However, studies have shown that the initial ECG is diagnostic of acute myocardial infarction in only a minority of patients. This paper discusses the importance of the initial ECG and other information in aiding the disposi-.l-_ l,on of patients -with suspected myo~ardiai infarction. ~,as_ sic electrocardiographic descriptions are discussed as well as the newer terminology of Q wave versus non-Q wave infarction and ST segment versus T wave infarction. A brief review is made of the electrophysiology of the ECG changes seen in myocardial infarction. Finally, clinical studies are presented that establish a definite role for the use of the initial ECG.
The Journal of Emergency Medicine, 1993
0 Abstract-We present a fatal case of primary Vibrio vulnificus septicemia in a patient with chro... more 0 Abstract-We present a fatal case of primary Vibrio vulnificus septicemia in a patient with chronic alcoholic liver disease. The patient had recently consumed raw seafood. The epidemiology and clinical presentation of Vibrio vulnificus infection is discussed. Preventive, early empiric therapy, and aggressive search for this organism in patients at risk is stressed. 0
The Journal of Emergency Medicine, 1985
Journal of Clinical Gastroenterology, 1992
We describe a 40-year-old black North American woman with isolated hepatic tuberculosis and an in... more We describe a 40-year-old black North American woman with isolated hepatic tuberculosis and an incidentally elevated alkaline phosphatase. Imaging studies of the liver showed a lesion suggesting primary or metastatic disease, which turned out to be the so-called pseudotumoral form of hepatic tuberculosis. We believe this is the first case recorded in the English language literature of isolated hepatic tuberculosis manifesting first as an incidentally elevated alkaline phosphatase. It seems to be the third documented case in the English literature of a patient with this rare form of tuberculous involvement without systemic manifestations. The patient responded to antituberculous therapy and is healthy 4 years after treatment.
Archives of Internal Medicine, 1989
Previously developed initial electrocardiogram (ECG) prediction rules were modified to stratify 4... more Previously developed initial electrocardiogram (ECG) prediction rules were modified to stratify 426 patients with suspected acute myocardial infarction into low-, intermediate-, and high-risk groups (normal, abnormal, and positive ECG categories) for development of acute myocardial infarction and complications of coronary ischemia. Compared with patients with normal ECGs, patients with positive ECGs had a 2.9 times greater risk of interventions, a greater risk of life-threatening complications, and a 14.2 times greater risk of acute myocardial infarction. Compared with patients with abnormal ECGs, patients with positive ECGs had a 1.7 times greater risk of interventions, a 2.6 times greater risk of life-threatening complications, and a 4.9 times greater risk of acute myocardial infarction. This prediction scheme was further improved by assigning "high" risk to any patient requiring an acute intervention during the initial evaluation in the emergency department. Otherwise, risk was assigned according to the ECG category, with normal, abnormal, and positive ECGs corresponding to "low," "intermediate," and high risk, respectively. Hospitals with limited intensive care beds may be able to use these prediction rules as an aid in determining in-hospital disposition of patients with suspected acute myocardial infarction.
Annals of Emergency Medicine, 1989
The initial ECGs in 440 patients admitted for suspected acute myocardial infarction were retrospe... more The initial ECGs in 440 patients admitted for suspected acute myocardial infarction were retrospectively analyzed to determine predictive values of these ECGs for acute myocardial infarction and to determine differences in the initial ECG for Q wave and non-Q wave myocardial infarction. One hundred (23%) of the study patients were diagnosed as having an acute myocardial infarction. Acute injury was seen in 47% of these patients (positive predictive value [PPV], 84%; 95% confidence interval/CI], 72% to 92%), ischemia in 15% (PPV, 39%; 95% CL 24% to 57%), and left ventricular hypertrophy with strain in 11% (PPV, 19%; 95% CL 4% to 29%).
Annals of Emergency Medicine, 1991
Study objective: To determine point and range estimates of the cumulative career risk of occupati... more Study objective: To determine point and range estimates of the cumulative career risk of occupationally acquired human immunodeficiency virus (HIV) infection by emergency physicians as well as to determine if the efficacy of universal precautions was seriously diminished by prolonged risk over time. Design: Monte Carlo estimation of a mathematical model of cumulative risk. Eight scenarios were estimated for high versus low prevalence of HIV, no precautions versus universal precautions, and prevalence increasing to a steady state versus peaking and then declining. Measurements and main results: For high-prevalence areas, not using universal precautions, and assuming HIV seroprevalence increases to a steady-state level, the median estimate of cumulative risk of HIV infection over a 30-year career was 1.4% (90% tolerance range, 0.2% to 14.0%); for low-prevalence emergency departments, the median was 0.1% (0.001% to 3.6%). Universal precautions w~th a presumed effectiveness of approximately 40% resulted in an approximate 30% decrease in risk. Conclusions: Although the per-exposure risk is small, the cumulative risk of HIV infection may be disproportionately large. The efficacy of universal precautions does not appear to be substantially diminished over time.
Archives of Internal Medicine, 1990
In Reply .—We appreciate the comments of Dr Burnside; however, we feel that the thrust of his arg... more In Reply .—We appreciate the comments of Dr Burnside; however, we feel that the thrust of his arguments is misdirected. Our triage algorithm assumes, as have others, 1-5 that only patients with life-threatening complications clearly benefit from intensive care unit monitoring. Of the 57 low-risk patients, seven patients had four interventions, five non-life-threatening complications, and two myocardial infarctions. No intervention was emergent, and no life-threatening complication occurred in this group. Furthermore, of the two patients diagnosed as having an acute myocardial infarction, both had normal electrocardiograms on presentation, with only nondiagnostic ST-T changes appearing on serial electrocardiograms. Thus our low-risk group has a false-negative rate of 0% and not the 10% as stated in Dr Burnside's letter. While we agree that should the data be extended, life-threatening complications and/or death will ultimately occur in the low-risk group, the results to date indicate that this risk will be small. Dr Burnside's
Annals of Emergency Medicine, 1988
A case of paroxysmal supraventricular tachycardia (PSVT) in a child with successful termination o... more A case of paroxysmal supraventricular tachycardia (PSVT) in a child with successful termination of the arrhythmia by military antishock trouser (MAST) application is described. The use of MAST application in terminating PSVT in adults has been previously reported. Ours is the first such case reported using this method in the therapy of PSVT in children. Our report suggests that MAST application may be another maneuver to add to those vagal maneuvers known to be of benefit in the termination of PSVT in children as well as in adults.
Emergency medicine clinics of North America, 1990
Ethanol has experimentally been shown to be "ulcerogenic," independent of gastric intra... more Ethanol has experimentally been shown to be "ulcerogenic," independent of gastric intraluminal pH. Ethanol remains ulcerogenic despite antisecretory doses of H2-receptor antagonists. Low-dose alcohol stimulates acid secretion in man, an effect possibly mediated by histamine or gastrin. High-dose alcohol reduces intraluminal acid by damaging mucosa, thereby enhancing back diffusion of hydrogen ion, and also by direct damage to oxyntic (parietal) cells. Ethanol is capable of increasing gastric mucosal permeability as evidenced by the increase in back diffusion (increases intraluminal pH) and by the characteristic fall in transmucosal potential difference which reflects surface cell layer exfoliation. This exfoliation may offer an explanation for the potentiating effect of alcohol on gastric mucosal injury when it is ingested simultaneously with other gastric irritants. Ethanol of greater than 20% concentration can rapidly destroy the gastric mucus-bicarbonate layer, which ma...
Annals of Emergency Medicine, 1987
A 71-year-old woman with an episode of paroxysmal supraventricular tachycardia (PSVT) complicated... more A 71-year-old woman with an episode of paroxysmal supraventricular tachycardia (PSVT) complicated by angina pectoris and hypotension had her arrhythmia abruptly terminated by digital rectal massage (DRM) after other vagotonic maneuvers had failed. DRM termination of PSVT has not been heretofore reported. In treating PSVT by physical vagotonic maneuvers, DRM may be preferable to other techniques because of the decreased likelihood of complications noted with other such maneuvers.
Annals of Emergency Medicine, 1988
A case of paroxysmal supraventricular tachycardia (PSVT) in a child with successful termination o... more A case of paroxysmal supraventricular tachycardia (PSVT) in a child with successful termination of the arrhythmia by military antishock trouser (MAST) application is described. The use of MAST application in terminating PSVT in adults has been previously reported. Ours is the first such case reported using this method in the therapy of PSVT in children. Our report suggests that MAST application may be another maneuver to add to those vagal maneuvers known to be of benefit in the termination of PSVT in children as well as in adults.
Annals of Emergency Medicine, Nov 30, 1987
A 71-year-old woman with an episode of paroxysmal supraventricular tachycardia (PSVT) complicated... more A 71-year-old woman with an episode of paroxysmal supraventricular tachycardia (PSVT) complicated by angina pectoris and hypotension had her arrhythmia abruptly terminated by d~gital recta] massage (DRM) after other vagotonic maneuvers had failed. DRM termination of PSVT has not been heretofore reported. In treating PSVT by physical vagotonic maneuvers, DRM may be preferable to other techniques because of the decreased likelihood of complications noted with other such maneuvers.
Journal of surgical case reports, 2015
Transitional cell carcinoma (TCC) and large bowel obstructions are both common disease processes ... more Transitional cell carcinoma (TCC) and large bowel obstructions are both common disease processes typically considered unrelated. Presented below is the case of a 49-year-old male with a large bowel obstruction caused by a bladder TCC metastasis. One year prior to large bowel obstruction presentation, the patient had a T2, Grade III TCC of the bladder with no nodal involvement or metastasis, which was removed via radical cystoprostatectomy. This case serves as a reminder that cancer, despite common pathogenesis patterns, can present in atypical ways.
Archives of Internal Medicine, Jun 1, 1989
Previously developed initial electrocardiogram (ECG) prediction rules were modified to stratify 4... more Previously developed initial electrocardiogram (ECG) prediction rules were modified to stratify 426 patients with suspected acute myocardial infarction into low-, intermediate-, and high-risk groups (normal, abnormal, and positive ECG categories) for development of acute myocardial infarction and complications of coronary ischemia. Compared with patients with normal ECGs, patients with positive ECGs had a 2.9 times greater risk of interventions, a greater risk of life-threatening complications, and a 14.2 times greater risk of acute myocardial infarction. Compared with patients with abnormal ECGs, patients with positive ECGs had a 1.7 times greater risk of interventions, a 2.6 times greater risk of life-threatening complications, and a 4.9 times greater risk of acute myocardial infarction. This prediction scheme was further improved by assigning "high" risk to any patient requiring an acute intervention during the initial evaluation in the emergency department. Otherwise, risk was assigned according to the ECG category, with normal, abnormal, and positive ECGs corresponding to "low," "intermediate," and high risk, respectively. Hospitals with limited intensive care beds may be able to use these prediction rules as an aid in determining in-hospital disposition of patients with suspected acute myocardial infarction.
Digestive diseases and sciences, 1997
Gastroesophageal reflux (GER) occurs in 22-66% of patients with noncardiac chest pain (NCCP). Alt... more Gastroesophageal reflux (GER) occurs in 22-66% of patients with noncardiac chest pain (NCCP). Although open-label investigations have shown beneficial effects of antireflux therapy in NCCP, no double-blind, prospective, placebo-controlled studies have been conducted. The purpose of this study was to evaluate the effects of omeprazole compared to placebo in a prospective, double-blind, randomized trial of patients with NCCP and GER. Thirty-six consecutive patients with NCCP and GER documented by 24-hr ambulatory pH testing entered this study. The subjects were randomized to omeprazole, 20 mg by mouth twice a day (17 patients), or placebo (19 patients) for eight weeks. Patients on omeprazole obtained significantly more improvement in the fraction of chest pain days (P = 0.006) and severity (P = 0.032) when compared to placebo. More patients in the omeprazole group reported improvement in individual daily pain scores (81% vs 44%, P = 0.03) and individual severity scores (81% vs 50%, P ...
Southern medical journal, 1984
We have presented a case of mesenteroaxial volvulus in a 12-year-old girl. Since this entity is r... more We have presented a case of mesenteroaxial volvulus in a 12-year-old girl. Since this entity is rare in children, one must be especially alert to its possibility for early diagnosis and treatment of this potential catastrophe.
The Journal of Emergency Medicine, 1985
0 Abstract -A case of primary aortoduodenal fistula, which presented as an upper gastrointestinal... more 0 Abstract -A case of primary aortoduodenal fistula, which presented as an upper gastrointestinal bleed, is described, including a brief review of the literature. Since 1952, with the advent of homograft replacement, there has been a significant decrease in the number of reported cases of aortoenteric fistulas of the primary type.' 0
The Journal of Emergency Medicine, 1988
0 Abstract-The initial ECG is the most rapid and readily available tool in the emergency departme... more 0 Abstract-The initial ECG is the most rapid and readily available tool in the emergency department for the evaluation of patients presenting with suspected myocardial infarction. However, studies have shown that the initial ECG is diagnostic of acute myocardial infarction in only a minority of patients. This paper discusses the importance of the initial ECG and other information in aiding the disposi-.l-_ l,on of patients -with suspected myo~ardiai infarction. ~,as_ sic electrocardiographic descriptions are discussed as well as the newer terminology of Q wave versus non-Q wave infarction and ST segment versus T wave infarction. A brief review is made of the electrophysiology of the ECG changes seen in myocardial infarction. Finally, clinical studies are presented that establish a definite role for the use of the initial ECG.
The Journal of Emergency Medicine, 1993
0 Abstract-We present a fatal case of primary Vibrio vulnificus septicemia in a patient with chro... more 0 Abstract-We present a fatal case of primary Vibrio vulnificus septicemia in a patient with chronic alcoholic liver disease. The patient had recently consumed raw seafood. The epidemiology and clinical presentation of Vibrio vulnificus infection is discussed. Preventive, early empiric therapy, and aggressive search for this organism in patients at risk is stressed. 0
The Journal of Emergency Medicine, 1985
Journal of Clinical Gastroenterology, 1992
We describe a 40-year-old black North American woman with isolated hepatic tuberculosis and an in... more We describe a 40-year-old black North American woman with isolated hepatic tuberculosis and an incidentally elevated alkaline phosphatase. Imaging studies of the liver showed a lesion suggesting primary or metastatic disease, which turned out to be the so-called pseudotumoral form of hepatic tuberculosis. We believe this is the first case recorded in the English language literature of isolated hepatic tuberculosis manifesting first as an incidentally elevated alkaline phosphatase. It seems to be the third documented case in the English literature of a patient with this rare form of tuberculous involvement without systemic manifestations. The patient responded to antituberculous therapy and is healthy 4 years after treatment.
Archives of Internal Medicine, 1989
Previously developed initial electrocardiogram (ECG) prediction rules were modified to stratify 4... more Previously developed initial electrocardiogram (ECG) prediction rules were modified to stratify 426 patients with suspected acute myocardial infarction into low-, intermediate-, and high-risk groups (normal, abnormal, and positive ECG categories) for development of acute myocardial infarction and complications of coronary ischemia. Compared with patients with normal ECGs, patients with positive ECGs had a 2.9 times greater risk of interventions, a greater risk of life-threatening complications, and a 14.2 times greater risk of acute myocardial infarction. Compared with patients with abnormal ECGs, patients with positive ECGs had a 1.7 times greater risk of interventions, a 2.6 times greater risk of life-threatening complications, and a 4.9 times greater risk of acute myocardial infarction. This prediction scheme was further improved by assigning "high" risk to any patient requiring an acute intervention during the initial evaluation in the emergency department. Otherwise, risk was assigned according to the ECG category, with normal, abnormal, and positive ECGs corresponding to "low," "intermediate," and high risk, respectively. Hospitals with limited intensive care beds may be able to use these prediction rules as an aid in determining in-hospital disposition of patients with suspected acute myocardial infarction.
Annals of Emergency Medicine, 1989
The initial ECGs in 440 patients admitted for suspected acute myocardial infarction were retrospe... more The initial ECGs in 440 patients admitted for suspected acute myocardial infarction were retrospectively analyzed to determine predictive values of these ECGs for acute myocardial infarction and to determine differences in the initial ECG for Q wave and non-Q wave myocardial infarction. One hundred (23%) of the study patients were diagnosed as having an acute myocardial infarction. Acute injury was seen in 47% of these patients (positive predictive value [PPV], 84%; 95% confidence interval/CI], 72% to 92%), ischemia in 15% (PPV, 39%; 95% CL 24% to 57%), and left ventricular hypertrophy with strain in 11% (PPV, 19%; 95% CL 4% to 29%).
Annals of Emergency Medicine, 1991
Study objective: To determine point and range estimates of the cumulative career risk of occupati... more Study objective: To determine point and range estimates of the cumulative career risk of occupationally acquired human immunodeficiency virus (HIV) infection by emergency physicians as well as to determine if the efficacy of universal precautions was seriously diminished by prolonged risk over time. Design: Monte Carlo estimation of a mathematical model of cumulative risk. Eight scenarios were estimated for high versus low prevalence of HIV, no precautions versus universal precautions, and prevalence increasing to a steady state versus peaking and then declining. Measurements and main results: For high-prevalence areas, not using universal precautions, and assuming HIV seroprevalence increases to a steady-state level, the median estimate of cumulative risk of HIV infection over a 30-year career was 1.4% (90% tolerance range, 0.2% to 14.0%); for low-prevalence emergency departments, the median was 0.1% (0.001% to 3.6%). Universal precautions w~th a presumed effectiveness of approximately 40% resulted in an approximate 30% decrease in risk. Conclusions: Although the per-exposure risk is small, the cumulative risk of HIV infection may be disproportionately large. The efficacy of universal precautions does not appear to be substantially diminished over time.