Faculty Bibliography

PURPOSE: To evaluate whether patients with isolated elevation of umbilical artery (UA) systolic/diastolic (S/D) ratio are at increased risk for adverse perinatal outcome. METHODS: This is a retrospective cohort study of 330 patients who underwent routine evaluation at our maternal fetal medicine center. We regularly perform UA S/D ratio analysis with every third trimester sonogram. All identified patients were included and divided into four groups based on estimated fetal weight (EFW) and UA S/D ratio. Perinatal outcome was compared between the groups. RESULTS: Regardless of the EFW, fetuses with persistent elevated UA S/D ratio showed significantly more preterm deliveries (p < .001), neonatal intensive care unit (NICU) admissions (p < .001), longer stay in the NICU (p < .001) and lower birth weight (p < .001) relative to controls. Stepwise logistic regression analysis demonstrated that being a member in any study group significantly and independently predicted birth weight less than the 10th percentile and preterm delivery. Patients with persistently elevated S/D ratio were significantly and independently from other factors, more likely to have a newborn admitted to the NICU. CONCLUSION: Our results indicate a suboptimal perinatal outcome in all pregnancies with an elevated UA S/D ratio. These fetuses may benefit from intensive monitoring.

Correctional health systems represent some of the largest health systems in the United States, caring for patients with high rates of morbidity and mortality. The poorly understood realm of correctional health care represents a missed opportunity to integrate care for these patients with care provided by community health providers. Three aims are integral to effective correctional health: patient safety, population health, and human rights. Patient safety and population health are well-defined aims in community health care systems and emerging in correctional settings. Dual loyalty and other unique challenges in correctional settings make the human rights aim absolutely essential for promoting correctional health.

We present the first reported infection caused by Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacter gergoviae. The patient had leukemia and neutropenia and died of septic shock from KPC-producing E. gergoviae bacteremia. The emergence of KPCs in additional species of Enterobacteriaceae is alarming and may disproportionately affect patients with hematologic malignancies.

PURPOSE: Higher physical activity (PA) has been associated with greater attenuation of body fat gain and preservation of lean mass across the lifespan. These analyses aimed to determine relationships of change in PA to changes in fat and lean body mass in a longitudinal prospective study of postmenopausal women. METHODS: Among 11,491 women enrolled at three Women's Health Initiative clinical centers who were selected to undergo dual-energy x-ray absorptiometry, 8352 had baseline body composition measurements, with at least one repeated measure at years 1, 3, and 6. PA data were obtained by self-report at baseline and 3 and 6 yr of follow-up. Time-varying PA effect on change in lean and fat mass during the 6-yr study period for age groups (50-59 yr, 60-69 yr, and 70-79 yr) was estimated using mixed effects linear regression. RESULTS: Baseline PA and body composition differed significantly among the three age groups. The association of change in fat mass from baseline and time-varying PA differed across the three age groups (P = 0.0006). In women age 50-59 yr, gain in fat mass from baseline was attenuated with higher levels of PA. Women age 70-79 yr lost fat mass at all PA levels. In contrast, change in lean mass from baseline and time-varying PA did not differ by age group (P = 0.1935). CONCLUSIONS: The association between PA and change in fat mass varies by age group, with younger, but not older, women benefiting from higher levels of aerobic PA. Higher levels of aerobic activity are not associated with changes in lean mass, which tends to decrease in older women regardless of activity level. Greater attention to resistance training exercises may be needed to prevent lean mass loss as women age.

BACKGROUND: This study employed the risk perception attitude (RPA) framework to determine whether health care personnel (HCP) influenza-related risk perceptions and efficacy beliefs could be used to segment individuals into meaningful groups related to vaccination uptake, absenteeism, and patient safety beliefs. METHODS: After pilot interviews, a questionnaire was administered to 318 hospital-based HCP (80%) and nonclinical support staff (20%) in Lexington, KY, in 2011. Follow-up interviews were conducted with 29 respondents. RESULTS: Cluster analysis was used to create 4 groups that correspond to the RPA framework: responsive (high risk, strong efficacy), avoidance (high risk, weak efficacy), proactive (low risk, strong efficacy), and indifference (low risk, weak efficacy). A significant association was found between membership in 1 or more of the 4 RPA groups and the 3 study variables of interest: influenza vaccination uptake (F7,299 = 2.51, P < .05), influenza-related absenteeism (F7,269 = 3.6, P < .001), and perceptions of patient safety climate (F7,304 = 6.21, P < .001). A subset of respondents indicated the principal reasons for not getting vaccinated were "had one before and got sick anyway," "concerned about vaccine safety," and "no convenient time." In follow-up interviews, HCP indicated that employee vaccinations were altruistic, increased herd immunity, and important for patient safety. CONCLUSION: The RPA framework is a valid health promotion tool for improving patient safety, targeting specific groups for interventions, and improving HCP influenza vaccination rates.

Participant attrition may be a significant threat to the generalizability of the results of educational research studies if participants who do not persist in a study differ from those who do in ways that can affect the experimental outcomes. A multi-center trial of the efficacy of different computer-based instructional strategies gave us the opportunity to observe institutional and student factors linked to attrition from a study and the ways in which they altered the participation profile. The data is from a randomized controlled trial conducted at seven US medical schools investigating the educational impact of different instructional designs for computer-based learning modules for surgical clerks. All students undertaking their surgical clerkships at the participating schools were invited participate and those that consented were asked to complete five study measures during their surgery clerkship. Variations in study attrition rates were explored by institution and by participants' self-regulation, self-efficacy, perception of task value, and mastery goal orientation measured on entry to the study. Of the 1,363 invited participants 995 (73 %) consented to participate and provided baseline data. There was a significant drop in the rate of participation at each of the five study milestones with 902 (94 %) completing at least one of two module post-test, 799 (61 %) both module post-tests, 539 (36 %) the mid-rotation evaluation and 252 (25 %) the final evaluation. Attrition varied between institutions on survival analysis (p < 0.001). Small but statistically significant differences in self-regulation (p = 0.01), self-efficacy (p = 0.02) and task value (p = 0.04) were observed but not in mastery or performance goal orientation measures (p = NS). Study attrition was correlated with lower achievement on the National Board of Medical Examiners subject exam. The results of education trials should be interpreted with the understanding that students who persist may be somewhat more self-regulated, self-efficacious and higher achievers than their peers who drop out and as such do not represent the class as a whole.

In those days there were no neonatal I.C.U.'s, and ventilators, a standard therapy today, had yet to be used for premature babies. [...]it was August, and most of the senior physicians were on vacation, recalled a third doctor, Welton M. Gersony, then training in pediatric cardiology

Treatment philosophies in multiple myeloma (MM) debate the relative merits of achieving the deepest possible remissions ("curative" doctrine) vs sequential delivery of antimyeloma agents ("control" doctrine). In this paper, we highlight the relevant strengths of each doctrine in the context of modern patient selection strategies, fresh biological insights on MM pathogenesis, agents with improved safety profiles, and emerging molecular and imaging tools. Paramount fundamental questions remain unanswered that require an intense research focus as we pursue a cure for this devastating disease.

When doctors tolerate a culture of disrespect, we aren't just being insensitive, or obtuse, or lazy, or enabling. We're in fact violating the first commandment of medicine

"When we read or hear a poem that's truly effective," says [Rafael Campo], "we feel what the speaker is feeling. We experience an entire immersion of ourselves in another's consciousness." 'So opens Campo's prize-winning poem, Morbidity and Mortality Rounds. It's an immersion into the maw of death. I've read textbooks and articles about facing death, but they don't capture the essence of the experience the way these few lines do. Every doctor and nurse will recognize "when I look at you, I see myself laid bare." It's the fierce existential tie between caregiver and patient. Campo's newest book of poetry, Alternative Medicine, will be published this fall. "A good poem engulfs us," says Campo, "takes hold of us physically. Its concision and urgency demand the participation of another in order to achieve completeness, to attain full meaning. In these ways, it's not so different from providing the best, most compassionate care to our patients."