Faculty Bibliography

[...] today it was me with the white coat, and her with the death sentence. A senior resident rescued him before he had a cardiac arrest, then screamed her lungs out at me in front of the entire emergency room staff.

When [Julia] walked out of our hospital without full knowledge of her prognosis, I had been derelict in my duty as her physician. I was fully aware that my job was to have "open and honest" communication with her, in a "patient centered" manner. But I couldn't. I couldn't bring myself to tell this young mother that she was going to die. The emotional layers in medicine, however, are far more pervasive. Emotions have been described by the neuroscientist Antonio Damasio as the "continuous musical line of our minds, the unstoppable humming ..." This basso continuo thrums along, modulating doctors' actions and perceptions, while we make a steady stream of conscious medical decisions that have direct consequences for our patients. Emotions can overshadow clinical algorithms, quality control measures, even medical experience. We may never fully master them, but we must at least be conscious of them and of how they can sometimes dominate the symphony of our actions. I'd like to say that I'd handle the situation better now, with another decade of clinical experience under my belt, but I'm not sure. Today, at least, when my medical team faces the prospect of giving bad news or admitting a medical error, I try to help my students and interns pay attention to the basso continuo running underneath. I try to point out when our emotions might be impeding us, and when, as sometimes happens, they might be assisting us in caring for our patients. Doctors can't -- and shouldn't -- eradicate the emotions that grease the wheels of patient care. But being alert to them can help us minimize where we fall short, and maximize where we succeed.

(Damage from attacks had long been detected in autopsies.) In time, doctors learned the myriad symptoms that can accompany a heart attack -- among them

The issues Mr. Cheney considered included his risk of infection from the pump line to his heart, the risk of blood clots that can cause strokes and the

Dr. Reiner has cared for Mr. Cheney for many years at George Washington University Hospital in Washington. Because that hospital does not perform heart

Abstract Background: Early identification of coronary artery disease (CAD) among symptomatic women is critical given their worse outcomes as compared to men. We evaluated the value of the Morise score, a simple clinical risk score, for the assessment for CAD as determined by computed tomography coronary angiography (CTCA) and compared it to the Diamond-Forrester risk assessment. Methods: One hundred forty women (mean age, 64+/-11 years) with chest pain syndromes and no known CAD referred for CTCA were analyzed. Patients were risk stratified for likelihood of CAD by Morise and Diamond-Forrester scores. The presence and degree of CAD were determined by CTCA and classified as normal, nonobstructive (<50% stenosis), or obstructive (>50% stenosis). Total coronary calcium was calculated based on Agatston scores. Results: When risk was assessed by Morise vs. Diamond-Forrester, 5% vs. 7% of women were stratified as low, 41% vs. 82% as intermediate, and 54% vs. 11% as high risk for CAD, respectively. CAD was present in 95 (68%) patients; 22 (16%) had obstructive CAD, and 73 (52%) had nonobstructive CAD. Morise scores significantly correlated with calcium scores (p<0.001) as well as the presence and degree of CAD (p<0.0001). Morise scores also demonstrated significantly higher accuracy (66% vs. 48%, p<0.005) and higher sensitivity (56% vs. 16%, p<0.001) but lower specificity (82% vs. 97%, p<0.05) when compared to Diamond-Forrester risk assessment. Conclusions: The Morise score performed better than Diamond-Forrester for CAD risk assessment, which highlights the importance and power of a simple history and physical examination in determining women at risk for CAD.

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.

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).