Faculty Bibliography

BACKGROUND: Some institutions require patients and families to give signed consent for Do Not Resuscitate (DNR) orders, especially in New York State. As this may be a barrier to discussions about DNR orders, we changed a signed consent policy to a witnessed verbal consent policy, simplified and modified the DNR order forms, and educated the staff at 1 hospital, comparing the effects with an affiliated hospital where the policy was not changed. DESIGN: Prospective natural experiment with intervention and comparison sites. SUBJECTS AND MEASUREMENTS: Pre- and postintervention, we surveyed house officers' confidence and attitudes, reviewed charts to assess the number of concurrent care concerns (CCCs) addressed per DNR order (e.g., limits on intubation or blood products or need for hospice), and at the intervention hospital, measured the stress levels of surrogates consenting for DNR orders using the Horowitz Impact of Event Scale. We also surveyed staff perceptions about the policy following the change. RESULTS: At the intervention hospital, the percentage of house officers reporting low confidence in their ability to obtain consent for DNR orders declined postintervention (24% to 7%, P=.002), while there was no significant change at the comparison hospital (20% vs 15%, P=.45). Among intervention hospital house officers, there were declines in percent reporting difficulty talking to patients and families about DNR orders, but no significant changes at the comparison hospital. At the intervention hospital, the mean number of CCCs/DNR order increased (1.0 pre to 4.2 post, P<.001), but did not change significantly (1.2 pre to 1.4 post) at the comparison hospital. The mean total stress score for intervention hospital surrogates declined postintervention (23.6 to 17.3, P=.02), indicating lower stress. House officers (98%), attendings (59%), and nurses (79%) thought the new policy was better for families. CONCLUSIONS: The policy change was well received and associated with improved house officer attitudes, more attention to patients' concurrent care concerns, and decreased surrogate stress. The results suggest that DNR orders can be made simpler and clearer, and raise questions about policies requiring signed consent for DNR orders.

OBJECTIVES: Within the tumor microenvironment the invasiveness of epithelial ovarian carcinoma (EOC) cells is stimulated by biologically active lipids such as lysophosphatidic acid (LPA). We tested the in vitro effect of another bioactive lysophospholipid, sphingosine-1-phosphate (S1P), on the invasiveness of EOC cells. METHODS: Dov13 EOC cells were tested for invasion through matrigel-coated chambers and for gelatinase activity using a fluorogenic assay. cDNA was analyzed through real-time PCR. Cell surface proteins, isolated through biotinylation and affinity purification, were analyzed by Western blots. RESULTS: Invasion of Dov13 cells was enhanced by low (0.5 microM) and inhibited by high (20 microM) concentrations of S1P, which correlated with increased and reduced gelatinase activity in conditioned media. Low and high S1P dose also differently affected the presentation of surface S1P receptors; low S1P dose increased S1P1 and decreased S1P2, while high S1P increased S1P3. LPA and S1P differently altered transcript levels of their respective and reciprocal receptors; receptors that were upregulated by one lysophospholipid (S1P2,3 and LPA1 by LPA, LPA3,4 and S1P1,4,5 by S1P) were downregulated or unchanged by the other. CONCLUSIONS: The dual effect of high and low S1P concentration on invasion was probably caused by the diverse changes to the presentation of surface S1P receptors. The opposite effect of S1P and LPA on expression of each receptor suggests a homeostatic transcriptional mechanism that abrogates the effects of LPA and S1P on EOC cells. Altogether this study demonstrates a complex role of S1P in EOC cell invasion, a process highly balanced and regulated by LPA and S1P within the tumor microenvironment

BACKGROUND: beta-Blockers reduce mortality in patients with systolic chronic heart failure (CHF), yet prescription rates have remained low among primary care providers. OBJECTIVE: To determine the beta-blocker prescription rate among patients with systolic CHF at primary care Veterans Affairs (VA) clinics, its change over time; and to determine factors associated with nonprescription. DESIGN: Retrospective chart review. SUBJECTS: Seven hundred and forty-five patients with diagnostic codes for CHF followed in primary care clinics at 3 urban VA Medical Centers. MEASUREMENTS: Rate of beta-blocker prescription and comparison of patient characteristics between those prescribed versus those not prescribed beta-blockers. RESULTS: Only 368 (49%) had documented systolic CHF. Eighty-two percent (303/368) of these patients were prescribed a beta-blocker. The prescription rate rose steadily over 3 consecutive 2-year time periods. Patients with more severely depressed ejection fractions were more likely to be on a beta-blocker than patients with less severe disease. Independent predictors of nonprescription included chronic obstructive pulmonary disease, asthma, depression, and age. Patients under 65 years old were 12 times more likely to receive beta-blockers than those over 85. CONCLUSION: Primary care providers at VA Medical Centers achieved high rates of beta-blocker prescription for CHF patients. Subgroups with relative contraindications had lower prescription rates and should be targeted for quality improvement initiatives

Eli Lilly was the winner for the best unbranded television ad award. Their television commercial on depression -- done in black and white -- clearly showed the conditions of a patient who is clinically depressed and badly in need of treatment. There was no mention of a product, but anyone watching this ad became instantly more aware of the symptoms and signs of an underdiagnosed, treatable disease. Lilly continues to have a stake in the proper recognition and treatment of depression

BACKGROUND: Medical schools must address the fact that students embarking on careers in medicine are idealistic but have a vague understanding of the values and characteristics that define medical professionalism. Traditionally, we have relied primarily on unsystematic role modeling and lectures or seminars on related topics to teach professionalism. METHODS: A committee of students and a faculty advisor created a curriculum, based on a needs assessment of the targeted learners, to raise students' awareness of professional tenets and provide them with the skills to recognize and analyze conflicts between the values of professionalism and the daily pressures of medical school training. The student-run professionalism curriculum begins during medical school orientation and is followed by three student-facilitated case-based workshops over the next two years. All of the workshops involve small group discussions led by trained upperclass student facilitators. The workshops address the application of professional values to both the preclinical and clinical situations and prepare students for self-reflection, self-assessment and peer evaluation. We evaluated students' satisfaction following each workshop and pre/post attitudes for the first workshop. RESULTS: Twenty five upper-class student facilitators were trained in the first year. Student attendance ranged from 80-100% of the class (N=160), the proportion of students who agreed or strongly agreed that the workshops were educationally useful ranged from 60-75% for each workshop. Certain student attitudes improved immediately after the first workshop. These workshops continue annually. CONCLUSIONS: Students have been a driving force behind this curriculum, which is a model for professionalism education. It was accepted by students and, although somewhat controversial, created a level of awareness and discussion regarding professional behavior in medical school that had previously been absent.

At the same time, the prevalence of HIV, the virus that causes AIDS, among young people has declined in eight countries in Africa, showing that prevention efforts can work, U.N. officials said. The global death total would be even higher without the efforts in recent years to provide antiretroviral therapy to hundreds of thousands of AIDS patients in poor countries, said Dr. Kevin De Cock, the World Health Organization's chief AIDS official. Still, he said, such drug therapy has not reached enough poor people to match the degree of decline in death rates in wealthy countries

At the same time, the prevalence of HIV, the virus that causes AIDS, among young people has declined in eight countries in Africa, showing that prevention efforts can work, UN officials said Tuesday. 'Even limited resources can give high returns when investments are focused on reaching people most at risk and adapted to changing national epidemics, said Dr. Paul De Lay of the international body's AIDS program, known as Unaids. Nevertheless, 'these estimates are amongst the most robust for any disease of global public health importance,' said Dr. Kevin De Cock, the World Health Organization's chief AIDS official. The global death total would be even higher without the efforts undertaken in recent years to provide anti-retroviral therapy to hundreds of thousands of AIDS patients in poor countries, De Cock said. Still, he said, such drug therapy has not reached enough poor people to match the degree of decline in death rates seen in wealthy countries

At the same time, the prevalence of HIV, the virus that causes AIDS, among young people has declined in eight countries in Africa, showing that prevention efforts can work, UN officials said Tuesday. 'Even limited resources can give high returns when investments are focused on reaching people most at risk and adapted to changing national epidemics, said Dr. Paul De Lay, of the international body's AIDS program Unaids. Nevertheless, 'these estimates are amongst the most robust for any disease of global public health importance,' said Dr. Kevin De Cock, the World Health Organization's chief AIDS official. The global death total would be higher without the efforts undertaken in recent years to provide anti-retroviral therapy to hundreds of thousands of AIDS patients in poor countries, De Cock said. Still, he said, such drug therapy has not reached enough poor people to match the degree of decline in death rates seen in wealthy countries