Faculty Bibliography

BACKGROUND: Studies of the nursing work environment are increasingly common in developed countries, but few exist in developing countries. Because of resource differences between the two contexts, researchers need to clarify what aspects of the work environments are similar and different. OBJECTIVES: To study the perspectives of Mexican nurses about their work environments to determine similarities and differences to results from developed world studies. DESIGN: A secondary, directed content analysis of qualitative data from 46 Spanish language interviews using workplace-oriented themes. SETTING: Purposively selected Mexican states from four regions of the country that reflect the country's socioeconomic differences. PARTICIPANTS: Practicing Mexican nurses with at least 1year of clinical experience and currently working in nursing. Participants were recruited through convenience and snowball sampling techniques. METHODS: Initial data collection occurred in 2006 and 2008 during a broader study about professionalization processes that occurred in Mexican nursing between 1980 and 2005. The secondary, directed content analysis focused on an in-depth exploration of a central theme that emerged from the two original studies: the workplace. The directed content analysis used themes from the global nursing work environment literature to structure the analysis: professional relationships, organizational administrative practices, and quality of care and services. RESULTS: The three themes from the global literature were relevant for the Mexican context and a new one emerged related to hiring practices. By category, the same factors that created positive or negative perceptions of the work environment matched findings from other international studies conducted in developed countries. The descriptors of the category, however, had different conceptual meanings that illustrate the health system challenges in Mexico. CONCLUSIONS: Findings from this study suggest that studies that seek to measure nursing work environments will most likely apply in Mexico and other Latin American or middle-income countries. Instruments designed to measure the work environment of nurses in these countries may prove relevant in those contexts, but require careful adaptation and systematic translations to ensure it.

Objectives. We estimated and compared total costs and costs per dose administered for 2 influenza A 2009 monovalent vaccine campaigns in New York City: an elementary school-located campaign targeting enrolled children aged 4 years and older, and a community-based points-of-dispensing campaign for anyone aged 4 years and older. Methods. We determined costs from invoices or we estimated costs. We obtained vaccination data from the Citywide Immunization Registry and reports from the community points of dispensing. Results. The school campaign delivered approximately 202,089 vaccines for $17.9 million and $88 per dose. The community campaign delivered 49,986 vaccines for $7.6 million and $151 per dose. At projected capacity, the school campaign could have delivered 371,827 doses at $53 each or $13 each when we excluded the value of in-kind resources. The community points of dispensing could have administered 174,000 doses at $51 each or $24 each when we excluded the value of in-kind resources. Conclusions. The school campaign delivered vaccines at a lower cost per dose than did the community campaign. Had demand been higher, both campaigns may have delivered vaccine at lower, more comparable cost per dose.

The objective of this study was to test the hypothesis that corticosteroid and nonsteroidal anti-inflammatory drug (NSAID) medications are associated with less global and regional Alzheimer's disease (AD) neuropathology. This postmortem study was based on 694 brains of subjects from the Mount Sinai School of Medicine Brain Bank who did not have neuropathologies other than neuritic plaques (NPs), neurofibrillary tangles (NFTs), or cerebrovascular disease. Densities of NPs and of NFTs were assessed in several neocortical regions and in the hippocampus, entorhinal cortex, and amygdala. Counts of NPs in several neocortical regions were also assessed. For each neuropathology measure, analyses of covariance controlling for age at death and sex compared subjects who received only corticosteroids (n = 54) or those who received only NSAIDs (n = 56) to the same comparison group, subjects who received neither (n = 576). Subjects receiving corticosteroids had significantly lower ratings and counts of NPs for all neuropathological measures, and NFTs overall and in the cerebral cortex and amygdala. In contrast, no measures were significant for subjects who received NSAIDs. Use of corticosteroids was associated with approximately 50% fewer NPs and NFTs in most brain regions examined, compared with nonmedicated subjects. In contrast, use of NSAIDs was not substantially associated with the reductions in hallmark lesions of AD. Because corticosteroids have anti-inflammatory as well as a myriad of other neurobiological effects, more direct studies in model systems could reveal novel therapeutic targets and mechanisms for AD lesion reduction.

An agar-plate assay was developed for detecting the induction of drug-resistant mycobacterial mutants during exposure to inhibitors of DNA gyrase. When Mycobacterium smegmatis was plated on drug-containing agar, resistant colonies arose over a period of two weeks. A recA deficiency reduced mutant recovery, consistent with involvement of the SOS response in mutant induction. The C-8-methoxy compounds gatifloxacin and moxifloxacin allowed recovery of fewer resistant mutants than either ciprofloxacin or levofloxacin when present at the same multiple of MIC; a quinolone-like 8-methoxy-quinazoline-2,4-dione was more effective at restricting the emergence of resistant mutants than its cognate fluoroquinolone. Thus, the structure of fluoroquinolone-like compounds affects mutant recovery. A spontaneous mutator mutant of M. smegmatis, obtained by growth in medium containing both isoniazid and rifampicin, increased mutant induction during exposure to ciprofloxacin. Moreover, the mutator increased the size of spontaneous, resistant-mutant subpopulations, as detected by population analysis. Induction of ciprofloxacin resistance was also observed with Mycobacterium tuberculosis H37Rv. When measured with clinical isolates, no difference in mutant recovery was observed between multidrug-resistant (MDR) and pan-susceptible isolates. This finding is consistent with at least some MDR isolates of M. tuberculosis lacking mutators detectable by the agar-plate assay. Collectively the data indicate that the use of fluoroquinolones with tuberculosis may induce resistance and that choice of quinolone may be important for restricting the recovery of induced mutants.

BACKGROUND:Current guidelines recommend the use of coronary artery calcium (CAC) scoring for intermediate-risk patients; however, the potential role of CAC among individuals who have no risk factors (RFs) is less established. We sought to examine the relationship between the presence and burden of traditional RFs and CAC for the prediction of all-cause mortality. METHODS AND RESULTS/RESULTS:The study cohort consisted of 44,052 consecutive asymptomatic individuals free of known coronary heart disease referred for computed tomography for the assessment of CAC. The following RFs were considered: (1) current cigarette smoking, (2) dyslipidemia, (3) diabetes mellitus, (4) hypertension, and (5) family history of coronary heart disease. Patients were followed for a mean of 5.6 ± 2.6 years for the primary end point of all-cause mortality. Among individuals who had no RF, Cox proportional model adjusted for age and sex identified that increasing CAC scores were associated with 3.00- to 13.38-fold higher mortality risk. The lowest survival rate was observed in those with no CAC and no RF, whereas those with CAC ≥ 400 and ≥3 RFs had the highest all-cause fatality rate. Notably, individuals with no RF and CAC ≥ 400 had a substantially higher mortality rate compared with individuals with ≥3 RFs in the absence of CAC (16.89 versus 2.72 per 1000 person-years). CONCLUSIONS:By highlighting that individuals without RFs but elevated CAC have a substantially higher event rates than those who have multiple RFs but no CAC, these findings challenge the exclusive use of traditional risk assessment algorithms for guiding the intensity of primary prevention therapies.

Objectives. We have described and evaluated the impact of a unique fellowship program designed to train postdoctoral, physician fellows in research at the interface of medicine and public health. Methods. We developed a rigorous curriculum in public health content and research methods and fostered linkages with research mentors and local public health agencies. Didactic training provided the foundation for fellows' mentored research initiatives, which addressed real-world challenges in advancing the health status of vulnerable urban populations. Results. Two multidisciplinary cohorts (6 per cohort) completed this 2-year degree-granting program and engaged in diverse public health research initiatives on topics such as improving pediatric care outcomes through health literacy interventions, reducing hospital readmission rates among urban poor with multiple comorbidities, increasing cancer screening uptake, and broadening the reach of addiction screening and intervention. The majority of fellows (10/12) published their fellowship work and currently have a career focused in public health-related research or practice (9/12). Conclusions. A fellowship training program can prepare physician investigators for research careers that bridge the divide between medicine and public health. (Am J Public Health. Published online ahead of print May 17, 2012: e1-e7. doi:10.2105/AJPH.2011.300486).

LEARNING OBJECTIVE 1: Distinguish clinical clues to assess for Lemierre's Syndrome. LEARNING OBJECTIVE 2: Manage Lemierre's Syndrome when appropriate anaerobic antibiotics are not sufficient. CASE: A 24-year-old healthy female was admitted after presenting with fever, sore throat, neck and pleuritic chest pain that started 3 days prior to admission. On physical examination, the patient appeared in mild respiratory distress requiring supplemental oxygen, and noted to have swelling and tenderness along the left sternocleidomastoid muscle with associated left tonsillar exudate and bibasilar pulmonary rales. Her initial complete blood count revealed isolated mild thrombocytopenia and a bandemia of 79%. A rapid strep test returned negative and a rapid influenza A/B RNA test also was negative. Following admission, a CT scan of the neck with contrast showed left peritonsillar abscess extending into the hypopharyngeal region with extensive lymphadenopathy. The patient was subsequently started on piperacillin-tazobactam and metronidazole after her admission blood culture began growing gram-negative anaerobes, which later speciated as Fusobacterium necrophorum. As the patient continued to spike high grade fevers, metronidazole was switched to intravenous sulbactam-ampicillin. On appropriate antibiotic coverage, the patient continued to complain of worsening dyspnea requiring increased supplemental oxygen by nasal cannula. A CT scan of the chest then showed multifocal pneumonia and multiple lung nodules concerning for septic emboli. In search for the source of her septic emboli, an echocardiogram showed normal findings, while a repeat CT of the neck with contrast revealed new findings of multiple necrotic lymph nodes and left internal jugular vein thrombus leading to a diagnosis of Lemierre's Syndrome. Subsequently, given clinical deterioration, patient was initiated on intravenous anticoagulation and the left internal jugular vein was resected. Over the ensuing several days, the patient's clinical pictur!

LEARNING OBJECTIVE 1: Recognize that TMP/SMX can induce a severe, potentially life-threatening, isolated thrombocytopenia. CASE: A 50-year-old healthy female without significant medical history presented with a day history of non-pruritic red rash on her torso. The patient was in her usual state of good health until three days prior to admission when she starting trimethoprim/sulfamethoxazole (TMP/SMX) for a possible dental infection. Except TMP/SMX, she was not taking any other prescribed or over the counter medication. Two days after starting taking TMP/SMX, she noticed the rash and presented to the hospital. On initial physical examination, the patient noted to have scattered nonblanching red petechial rash over her torso extending down to the bilateral lower extremities. The rest of her physical exam and review of systems were unremarkable. Her initial complete blood count (CBC) revealed an isolated thrombocytopenia with a platelet count of 4.000/mm3. The rest of her blood work including chemistry, coagulation, liver function and hemolysis panels were all within normal range. A subsequent peripheral smear confirmed thrombocytopenia with large platelets, but otherwise was normal. Bactrim was held off as a possible causative agent, and the patient was being evaluated for possible idiopathic thrombocytopenic purpura (ITP). Patient's platelet count responded poorly to the first unit of single donor platelets (SDP) transfusion, while a second unit of SDP tranfusion led to appropriate increase in platelet count. Within 36 hours of her hospital stay, the platelet count recovered to a normal range without any further transfusion requirement or glucocorticoids for initially presumed ITP. This led to a diagnosis of TMP/SMX-induced severe thrombocytopenia. Her presenting petechial rash also gradually resolved over hospital course. Patient was discharged on hospital day 3 with a platelet count of 202.000/ mm3. A week after discharge, her repeat platelet count was 425.000/mm3. DISCUSSION: Based on the N!

PURPOSE: Bone marrow-derived mesenchymal stem cells (MSCs) hold great promise for wound healing and tissue regeneration. In the present study, we investigated the impact of corneal injury on the homeostasis of endogenous MSCs, and the potential of MSCs to home to injured tissue and promote corneal repair. METHODS: Corneal injury in mice was induced by thermal cauterization. Circulating MSCs were quantified by flow cytometric analysis. Ex vivo expanded red Q-dot-labeled or GFP+ bone marrow-derived MSCs were intravenously injected after injury and detected using epifluorescence microscopy. Corneal fluorescein staining was performed to evaluate epithelial regeneration. RESULTS: Following the induction of corneal injury in mice, a 2-fold increase in the frequency of circulating endogenous MSCs was observed within 48 hours of injury, which was accompanied by increased levels of the stem cell chemoattractants, substance P and SDF-1, in both the injured cornea and blood. Systemically administered MSCs homed to the injured cornea, but not to the normal cornea, and showed long-term survival. In addition, in the setting of corneal injury, MSC administration showed significant and rapid corneal epithelial regeneration. CONCLUSIONS: These findings provide novel evidence that corneal injury causes significant mobilization of endogenous MSCs into blood, and that MSCs home specifically to the injured cornea and promote regeneration, highlighting the therapeutic implications of MSC-mediated tissue repair in corneal injury.