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Letters of Recommendation vs Questionnaires, Schaider et al. 805predict actual resident performance. Given this preliminary information, we believe that the PPQ may substitute for the LOR in the evaluation of resident applicants. The use of a standardized LOR based on our PPQ concept has other inherent advantages.The authors thank Mark Langdorf, MD, Harold Thomas, MD, and Richard Wolfe. MD, for their participation in reviewing the letters of recommendation and preprinted questionnaires, and Velma Richmond for her assistance in the preparation of the manuscript. I REFERENCES Wound Botulism Associated with Black Tar HeroinMichael W Anderson, MD, Kanika Shama, MD, Colin M. Feeney, MD I ABSTRACTThe incidence of wound botulism is increasing and the epidemiology of the disease is changing. The majority of new cases are associated with injection drug use, in particular, the use of Mexican black tar heroin. This case report and discussion of wound botulism illustrate the following important points: Dysphagia, dysphonia, diplopia, and descending paralysis, in association with injection drug use, should alert the treating physician to the possibility of wound botulism. In such patients, the onset of respiratory failure may be sudden and without clinically obvious signs of respiratory weakness. For the reported patient, maximum inspiratory force measurements were the only reliable indicator of respiratory muscle weakness. This is a measurement not routinely performed in the ED, but may prove essential for patients with suspected wound botulism. To minimize the effect of the botulinum toxin and to decrease length of hospital stay, antitoxin administration and surgical wound debridement should be performed early.

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