Faculty Bibliography

''We'd have no difficulty recognizing'' the chemical and providing the appropriate care, Dr. [Lewis R. Goldfrank] said. But the Moscow disaster and a theoretical attack on this country differ in crucial ways. If the agent is a narcotic like fentanyl or heroin, victims will probably be calm, their pupils pinpoint size, their breathing and heart rates slow and their blood pressures low. Other types of drugs could produce opposite symptoms. If it is scopolamine, an anti-motion sickness drug that robbers have used to incapacitate victims, people may be delirious. While treatment progresses, toxicologists will use laboratory tests to try to quickly identify the chemical used in the attack. All major cities have equipment to identify or rule out certain classes of chemicals. Many hazardous materials teams carry mass spectrometers and other analytical tools that can screen a large number of chemicals and provide specific identification of an agent, said Jerome M. Hauer, who directs the Office of Public Health Preparedness in the Department of Health and Human Services

The sheer number of medical errors, whether due to poor clinical judgment, laziness, arrogance, false leads, or just plain bad luck, is enough to make any clinician shudder, and none of the errors, of course, manage to enter the official H&P. But the starkest conclusion that materializes when these two recountings of the same events are exhibited side by side is that the standard H&P is inherently, and disastrously, ill equipped to convey the interconnecting and conflicting layers of a patient's experience

OBJECTIVE: To determine whether the extent of coronary obstructive disease is similar among black and white patients with acute coronary syndromes. DESIGN: Retrospective chart review. PATIENTS: We used administrative discharge data to identify white and black male patients, 30 years of age or older, who were discharged between October 1, 1989 and September 30, 1995 from 1 of 6 Department of Veterans Affairs (VA) hospitals with a primary diagnosis of acute myocardial infarction (AMI) or unstable angina (UnA) and who underwent coronary angiography during the admission. We excluded patients if they did not meet standard clinical criteria for AMI or UnA or if they had had prior percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. MEASUREMENTS AND MAIN RESULTS: Physician reviewers classified the degree of coronary obstruction from blinded coronary angiography reports. Obstruction was considered significant if there was at least 50% obstruction of the left main coronary artery, or if there was 70% obstruction in 1 of the 3 major epicardial vessels or their main branches. Of the 628 eligible patients, 300 (48%) had AMI. Among patients with AMI, blacks were more likely than whites to have no significant coronary obstructions (28/145, or 19%, vs 10/155 or 7%, P =.001). Similarly, among patients with UnA, 33% (56/168) of blacks but just 17% (27/160) of whites had no significant stenoses (P =.012). There were no racial differences in severity of coronary disease among veterans with at least 1 significant obstruction. Racial differences in coronary obstructions remained after correcting for coronary disease risk factors and characteristics of the AMI. CONCLUSIONS: Black veterans who present with acute coronary insufficiency are less likely than whites to have significant coronary obstruction. Current understanding of coronary disease does not provide an explanation for these differences

OBJECTIVE: Over the course of their education, medical students must develop an identity that involves a deep understanding of professional principles and the skills to apply these ideals. This task is so important that it cannot be left to informal means and should be cultivated by a structured system that is focused on professionalism. The overall goal of our student-mentoring program is to advance the professional development of our students during the first two years of medical school through regular group meetings with skilled, trained faculty facilitators. DESCRIPTION: We shaped the program to foster meaningful mentoring relationships among students and faculty, facilitate personal reflection, and encourage exploration of larger questions related to professional development. This program has evolved from a model of individual student-faculty pairings that resulted in uneven experiences. It is organized through a new 'Master Scholars Program' (MSP), inaugurated in 2001-2002. The MSP features five theme-based societies composed of students and faculty who share interests in the theme (e.g., bioethics/human rights, health policy/public health, arts/humanities in medicine, biomedical/health sciences, medical informatics/biotechnology). Approximately once per month, eight students and two faculty members from each society meet over lunch for student-led discussions on topics related to their own professional development. In the first session, structured exercises enable students to get to know one another and brainstorm a curriculum for the year. In subsequent sessions, student pairs lead discussions on topics of interest to the group ranging from 'the role of medical professionals in the aftermath of the World Trade Center attacks' to 'balancing careers in medicine with family.' A list of each group's discussion topics is posted on an electronic bulletin board to inform others. Two faculty mentors lead each group to ensure continuity and diversity over the two-year course of their meetings. A total of 57 out of 78 (73%) attended workshops to learn about the program and enhance their facilitation skills. Professional behaviors are explicitly emphasized in the materials outlining expectations of both students and faculty. Students are expected to attend, participate in and lead discussions, be constructive, respectful, and supportive, and accept/act on constructive feedback. Mentors are to facilitate the group's process, and provide feedback and guidance about the students' ideas and passions and the challenges they encounter. The faculty mentors will contribute descriptive material for the dean's letter on each student. We assessed student understanding of the definition of professionalism prior to the mentoring program and will follow up at regular intervals. Formative evaluation of the program includes surveys and focus groups with students and faculty to assess the effectiveness of the group process in accomplishing the stated goals of the program. DISCUSSION: Our medical school has committed resources, and our faculty and students have given thought, energy, and enthusiasm, to our mentoring program. This innovative new model has the potential to deepen and enrich the culture of medicine by providing a forum and skills for students to reflect on their own professional development and interact in a meaningful way with committed and skilled faculty who share similar interests

We present a short summary of recent observations on the global distribution of the major clades of the Mycobacterium tuberculosis complex, the causative agent of tuberculosis. This global distribution was defined by data-mining of an international spoligotyping database, SpolDB3. This database contains 11708 patterns from as many clinical isolates originating from more than 90 countries. The 11708 spoligotypes were clustered into 813 shared types. A total of 1300 orphan patterns (clinical isolates showing a unique spoligotype) were also detected

Spacer oligonucleotide (spoligotyping) analysis is a rapid polymerase chain reaction-based method of DNA fingerprinting the Mycobacterium tuberculosis complex. We examined spoligotype data using a bioinformatic tool (sequence logo analysis) to elucidate undisclosed phylogenetic relationships and gain insights into the global dissemination of strains of tuberculosis. Logo analysis of spoligotyping data provides a simple way to describe a fingerprint signature and may be useful in categorizing unique spoligotypes patterns as they are discovered. Large databases of DNA fingerprint information, such as those from the U.S. National Tuberculosis Genotyping and Surveillance Network and the European Concerted Action on Tuberculosis, contain information on thousands of strains from diverse regions. The description of related spoligotypes has depended on exhaustive listings of the individual spoligotyping patterns. Logo analysis may become another useful graphic method of visualizing and presenting spoligotyping clusters from these databases

In 1998-1999, the Baltimore TB control program detected a cluster of 21 tuberculosis (TB) cases. Patients reported frequent travel to various East Coast cities. An investigation was conducted to determine whether transmission of the same Mycobacterium tuberculosis strain was occurring in these other localities. A collaborative investigation among federal, state, and local TB controllers included TB record reviews, interviews of patients, and restriction fragment length polymorphism (RFLP) analysis of selected M. tuberculosis isolates from diagnosed TB patients in several cities in 1996-2001. A national TB genotyping database was searched for RFLP patterns that matched the outbreak pattern. Eighteen additional outbreak-related cases were detected outside of Baltimore-the earliest diagnosed in New Jersey in 1996, and the most recent in New York City in late 2001. The outbreak demonstrates the need for strategies to detect links among patients diagnosed with TB across multiple TB control jurisdictions

From January 1, 1995, to December 31, 1997, we reviewed records of all New York City patients who had multidrug-resistant tuberculosis (MDRTB); we performed insertion sequence (IS) 6110-based DNA genotyping on the isolates. Secondary genotyping was performed for low IS6110 copy band strains. Patients with identical DNA pattern strains were considered clustered. From 1995 through 1997, MDRTB was diagnosed in 241 patients; 217 (90%) had no prior treatment history, and 166 (68.9%) were born in the United States or Puerto Rico. Compared with non-MDRTB patients, MDRTB patients were more likely to be born in the United States, have HIV infection, and work in health care. Genotyping results were available for 234 patients; 153 (65.4%) were clustered, 126 (82.3%) of them in eight clusters of >or=4 patients. Epidemiologic links were identified for 30 (12.8%) patients; most had been exposed to patients diagnosed before the study period. These strains were likely transmitted in the early 1990 s when MDRTB outbreaks and tuberculosis transmission were widespread in New York