Faculty Bibliography

The woman who received the transplant Sunday had been attacked by a dog in May. [Jean-Michel Dubernard] said she was transferred Tuesday from Amiens to the Edouard-Herriot Hospital in Lyon, where Dubernard works, for long-term monitoring of the immunosuppressive therapy that she will need to prevent rejection of the new partial face

The woman who received the transplant on Sunday had been attacked by a dog in May. Dr. [Jean-Michel Dubernard] said she was transferred Tuesday from Amiens to the Edouard-Herriot Hospital in Lyons, where he works, for long-term monitoring of the immunosuppressive therapy that she will need to prevent rejection of the new partial face. The relatively short interval of about six months between the dog bite and the surgery also raised questions in the minds of some experts about what, if any, efforts had been made to perform reconstructive surgery before the transplant. 'The major question is: what were the indications' for the transplant, said Dr. Maria Siemionow, a surgeon at the Cleveland Clinic who plans to perform a full face transplant. PHOTO; Associated Press: French surgeon Jean-Michel Dubernard, who performed the face transplant, is famous in his field. In 1976, he performed Europe's first pancreas transplant. He also led teams that performed a hand transplant in September 1998 and the world's first double forearm transplant in January 2000

CONTEXT/BACKGROUND:Physiological changes in thyroid hormone concentrations might be related to changes in the overall physical function in the elderly. OBJECTIVE:We determined to what extent thyroid hormone concentrations are related to physical function and mortality in elderly men. DESIGN/METHODS:A longitudinal population study (the Zoetermeer study) was conducted. Mortality was registered in the subsequent 4 yr. PARTICIPANTS/METHODS:Four hundred three independently and ambulatory living men (aged 73-94 yr) participated. MAIN OUTCOME MEASURES/METHODS:The study examined the association between serum thyroid hormones and parameters of physical function as well as the association with mortality. METHODS:TSH, free T4 (FT4) total T4, T3, rT3, and T4-binding globulin were measured. Physical function was estimated by the number of problems in activities of daily living, a measure of physical performance score (PPS), leg extensor strength and grip strength, bone density, and body composition. RESULTS:Serum rT3 increased significantly with age and the presence of disease. Sixty-three men met the biochemical criteria for the low T3 syndrome (decreased serum T3 and increased serum rT3). This was associated with a lower PPS, independent of disease. Furthermore, higher serum FT4 (within the normal range of healthy adults) and rT3 (above the normal range of healthy adults) were related with a lower grip strength and PPS, independent of age and disease. Isolated low T3 was associated with a better PPS and a higher lean body mass. Low FT4 was related to a decreased risk of 4-yr mortality. CONCLUSIONS:In a population of independently living elderly men, higher FT4 and rT3 concentrations are associated with a lower physical function. High serum rT3 may result from a decreased peripheral metabolism of thyroid hormones due to the aging process itself and/or disease and may reflect a catabolic state. Low serum FT4 is associated with a better 4-yr survival; this may reflect an adaptive mechanism to prevent excessive catabolism.

OBJECTIVE:Cardiac surgery with cardiopulmonary bypass (CPB) is associated with a systemic inflammatory response, which is correlated with outcome. We hypothesized that ventilation according to the open lung concept (OLC) attenuates cytokine release. METHODS:A prospective, single center randomized controlled clinical study containing 62 patients scheduled for elective coronary artery bypass graft and/or valve surgery with cardiopulmonary bypass. Before surgery, patients were randomly assigned to three groups: (1) conventional mechanical ventilation (CV), (2) OLC started after arrival on the ICU (late open lung, LOL), and (3) OLC started directly after intubation (early open lung, EOL). In both OLC groups, recruitment maneuvers were applied until PaO(2)/FiO(2)>50. The CV group received no recruitment maneuvers. Interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor (TNF)-alpha, and interferon (IFN)-gamma were measured preoperatively, immediately after cessation of CPB, and 3h, 5h, 24h, 2, and 3 days after cessation of CPB. RESULTS:CPB caused a significant increase of IL-6, IL-8, and IL-10 in all groups. Thereafter, IL-8 decreased significantly more rapidly in both OLC groups compared to CV. IL-10 decreased significantly more rapidly after CPB only in the EOL group, compared with CV. Three hours after cessation of the CPB, IL-10 was already comparable with preoperative levels in the EOL group, but not in the LOL or CV group. IL-6, TNF-alpha, and IFN-gamma did not differ significantly between groups. CONCLUSIONS:OLC ventilation leads to an attenuated inflammatory response, presumably by reducing additional lung injury after cardiac surgery. Studies on cytokines after cardiac surgery should take these findings into account.

BACKGROUND:Cases of early-onset Alzheimer disease (AD) with an autosomal dominant inheritance pattern (familial AD [FAD]) are rare but have greatly advanced our understanding of the molecular pathogenesis of AD. We describe herein a kindred with very early-onset FAD (age, <40 years) with unusual pathological features and a novel mutation in the presenilin 1 (PSEN1) gene (S170F) and review the existing literature on very early-onset FAD. OBJECTIVE:To analyze the neuropathological and genetic features of a family with onset of AD in the third decade of life. DESIGN, SETTING, AND PARTICIPANTS/METHODS:The proband underwent full clinical assessment and postmortem examination at the Washington University Alzheimer's Disease Research Center, St Louis, Mo. Limited pathological samples and autopsy records of 2 affected family members were available. The proband underwent screening for mutations in genes linked with FAD. RESULTS:Dementia developed in 3 family members in this kindred at a mean age of 27 years; the proband had myoclonus, seizures, and rigidity, similar to findings in previously described kindreds with PSEN1 mutations. All 3 family members were confirmed to have AD by neuropathological examination. The proband also had widespread Lewy body pathology in the brainstem, limbic areas, and neocortex; specific staining for Lewy bodies was not performed in the other 2 family members. The proband had a single mutation (S170F) in exon 6 of the PSEN1 gene, which segregates with disease. CONCLUSIONS:A novel PSEN1 mutation causes very-early-onset FAD with associated Lewy bodies. To our knowledge, this kindred has the earliest reported onset of pathologically confirmed FAD and dementia with Lewy bodies.

OBJECTIVES: Consultations for tracheotomy are often sought on aged and severely ill patients with respiratory insufficiency. This patient population has high short-term mortality rates and is difficult to stratify on the basis of expected outcome. We examined whether APACHE III (Acute Physiology and Chronic Health Evaluation III) scores or neurologic status assessment (NSA) scores in sedated individuals are predictive of outcome. METHODS: We performed a retrospective study examining aged patients who underwent tracheotomy for respiratory insufficiency and prolonged intubation. The APACHE III scores (n = 30) and NSA (based on a modified Glasgow Coma Scale) scores (n = 37) were calculated before tracheotomy. All patients were mildly sedated. Using APACHE III and NSA scores as predictor variables and using death and ability to be weaned from the ventilator as outcome variables, we performed a Kaplan-Meier survival analysis and a Cox proportional hazard regression. RESULTS: The APACHE III was not significantly predictive of either outcome. Higher NSA scores were associated with increased survival rates (log rank = 19.7, p < .0001) and longer median survival (88 days versus 16 days for lower scorers). Higher NSA scores also predicted a higher rate of ventilator independence. CONCLUSIONS: Neurologic function in sedated patients (and not APACHE III scores) can be used to stratify aged individuals with respiratory insufficiency on the basis of expected outcome

Because of the public fear of bird flu, there has been a lot of pressure on Roche to produce more supply -- even political pressure to break the patent on Tamiflu and allow the drug to be sold generically before the patent expires. Tamiflu is the newest of the neuramidase inhibitors, drugs that work by blocking the transmission of the influenza virus from cell to cell. As a drug to treat the fear of, rather than the effect of bird flu, Tamiflu can easily be misused

BACKGROUND: Physician communication skills, linked to important patient outcomes, are rarely formally addressed after the pre-clinical years of medical school. We implemented a new communication skills curriculum during the third year Surgery Clerkship which was part of a larger curriculum revision found in a controlled trial to significantly improve students' overall communication competence. DESCRIPTION: In three 2 hour workshops students, learned to address common communication challenges in surgery: patient education, shared decision-making, and delivering bad news. Each 2 hour, surgeon facilitated session was comprised of a 30 minute introductory lecture, a 15 minute checklist driven video critique, a 15 minute group discussion, a 45 minute standardized patient (SP) exercise with feedback from the SP, peers, and faculty member, and a 15 minute closing summary. To date, over 25 surgery faculty have been trained to conduct these sessions. In an end-of-clerkship survey, students reported on skill changes and assessed the curriculum's educational effectiveness. EVALUATION: A survey was completed by 120 of the 160 (76%) third year students who participated in the curriculum. Fifty-five percent of students reported improvement in their communication skills and ability to address specific communication challenges. Students were satisfied with the amount and quality of teaching. CONCLUSIONS: Communication skills teaching can be implemented in the surgery clerkship, and surgeons are particularly well suited to teach about patient education, discussing informed consent and shared decision making, and delivering bad news. Structured case-based sessions are acceptable to, and improve the self-assessed skills of, surgery clerkship students. Faculty development geared toward such sessions has added benefits to educational activities in a clinical department overall.

OBJECTIVES: The authors examined whether African Americans, compared with whites, received guideline-concordant care for bipolar I disorder. METHODS: A retrospective analysis was conducted of data for patients who received a diagnosis of bipolar I disorder in fiscal year 2001 and received care in facilities in the Department of Veterans Affairs (VA) mid-Atlantic region. Indicators of guideline-concordant care were based on prescription data and data on utilization of inpatient and outpatient services from VA databases. RESULTS: A total of 2,316 patients with a diagnosis of bipolar I disorder were identified. Their mean age was 52 years; 9.4 percent (N=218) were women, and 13.1 percent (N=303) were African American. Overall, mood stabilizers were prescribed for 74.6 percent (N=1,728) of the patients; 67.1 percent (N=1,554) had an outpatient mental health visit within 90 days after the index diagnosis, and 54.3 percent (N=1,258) had an outpatient visit within 30 days after discharge from a psychiatric hospitalization. Multivariate logistic regression analyses with adjustment for sociodemographic and facility factors revealed that African Americans were less likely than whites to have an outpatient follow-up visit within 90 days after the index diagnosis. Race was not associated with receipt of mood stabilizers or use of outpatient services after a hospital discharge. CONCLUSIONS: Although a majority of patients received guideline-concordant care for bipolar disorder, potential gaps in continuity of outpatient care may exist for African-American patients

The purpose of this study was to identify potential barriers and facilitators to Chinese immigrant participation in cancer screening and clinical trials. A series of focus groups, in English, Cantonese, and Mandarin, were conducted with physicians, community leaders, and first generation members of the Manhattan Chinatown community. Participants were asked to discuss their beliefs about cancer, cancer screening, clinical trials, and cancer health education materials. Focus group data were stratified by respondent group and analyzed for thematic content. Eleven physicians, 15 community leaders, and 38 community members participated. Some community members were not familiar with cancer screening as a preventive measure and had not received common screens such as PAP smears or mammograms. They described widespread misconceptions about cancer that act as screening deterrents, e.g. testing for cancer can cause cancer. Community members were unfamiliar with clinical trials and would not participate in a clinical trial unless 'sick,' and only on the recommendation of their physicians. Physicians did not see the relevance or value of clinical trials for their patients. Among first generation Chinese immigrants, there are many perceptual barriers to cancer screening and clinical trials recruitment. There is a need for effective culturally tailored health education on these health topics to address persistent misconceptions about cancer and to increase knowledge about cancer screening and clinical trials. Health education efforts and clinical trial recruitment in this community must involve community physicians