Faculty Bibliography

Because blood is involved in the natural transmission of West Nile -- through mosquito bites -- doctors have theorized that West Nile could be transmitted through transfusions and organ transplants. Two weeks ago, health officials said they reminded the nation's blood banks to enforce a standard procedure -- rejecting donations from patients with fever and flulike symptoms, which could be symptoms of mild West Nile fever. Dr. [Jesse Goodman] said he would not expect people who have recovered from an infection to have West Nile virus in their blood for long because by the time symptoms develop, the virus is difficult to detect. In such cases, evidence of West Nile infection is based on detecting the specific antibodies that a patient's immune system develops in response to the infection. ''It is very important to recognize that unlike H.I.V. or hepatitis, West Nile virus is an acute infectious disease and we are unaware of any kind of chronic carrier state,'' Dr. Goodman said. He also said: ''If I were a person with severe chronic disease and I needed an organ transplant, concern about this would be right at the bottom of my list of things that I was worried about. Similarly, if I needed a transfusion this would be at the bottom of the list of my concerns. If I lived in an area where West Nile was circulating, which is much of the country at the moment, my greatest concern about West Nile would be to take precautions to minimize my risk of being bitten by mosquitoes.''

West Nile virus is naturally transmitted through mosquito bites. This year, the U.S. is experiencing its worst outbreak of West Nile fever since the virus was first detected in this hemisphere, in 1999 in New York City. Over the weekend, the total number of cases has risen to 638, including 31 deaths. The theoretical possibility of transmitting West Nile Virus through blood transfusions and questions about the nation's blood supply were put to a real test in recent days because of the detection of West Nile infection in one recipient of the donor's organs. That recipient has encephalitis, or inflammation of the brain. Three other recipients, in Georgia and Florida, of the same donor's organs are suspected of developing West Nile fever. Preliminary tests of a patient who died with encephalitis after receiving a kidney from the donor show evidence of infection with a mosquito-borne virus. Further tests are needed to prove it is West Nile virus

One of the four recipients died about four weeks after the transplant. Pathology tests show the recipient had encephalitis, or inflammation of the brain and central nervous system. Tests are planned to determine if the recipient was infected with West Nile virus, which can cause encephalitis. On Friday, Dr. Julie L. Gerberding, the director of the CDC, said that 'transmission of the West Nile virus through blood and organs is biologically plausible' and that 'a leading hypothesis that we are investigating is that it is related to the organ transplant.' Meanwhile, scientists at the CDC are conducting laboratory tests on the organ donor's brain for evidence of West Nile virus or a closely related virus

Three of four patients who received organs from one donor have apparently developed encephalitis and tests show that one recipient is infected with the West Nile virus, raising suspicion that the virus can be transmitted through organ transplants, federal health officials said yesterday. One of the four recipients died about four weeks after the transplant. Standard pathology tests from an autopsy show that the recipient had encephalitis, or inflammation of the brain and central nervous system. Tests are planned to determine if the recipient was infected with West Nile virus, which causes encephalitis. One of the four organ transplant recipients developed a mild fever that resolved. Tests are planned to determine whether that recipient had a mild case of West Nile fever. Most people infected with the virus develop a mild flu-like illness or experience no symptoms

A method to produce highly purified thrombin from salmon blood is described, and a series of biochemical, cell biologic, and biophysical assays demonstrate the functional similarities and some differences between salmon and human thrombins. Salmon thrombin with specific activity greater than 1000 units/mg total protein can be prepared by modifications of the methods used for purification of human thrombin. Using a synthetic substrate based on the human fibrinogen A-alpha polypeptide sequence as an indicator of enzymatic activity, salmon and human thrombin preparations contain similar specific activities per mass of purified protein. Salmon thrombin activates human fibrinogen and initiates the formation of fibrin clots whose structure and rheologic properties are indistinguishable from those of human fibrin clotted by human thrombin. Salmon thrombin also activates human platelets. Approximately 10 times higher activities are needed for the same rate of platelet aggregation compared to human thrombin, and some aspects of platelet activation, most notably phosphatidylserine exposure, are diminished relative to the effects of human thrombin. This latter finding suggests that salmon thrombin may not activate all of the receptors that are targets of human thrombin, although it does appear to activate signals that are sufficient to produce normal rates of activation and aggregation as measured by conventional aggregometry. Together with the recent purification of salmon fibrinogen and its application in mammalian wound healing, the availability of salmon thrombin allows the formulation of biological sealants devoid of any exogenous mammalian proteins and so may aid the design of materials with increased safety from infectious disease transmission.

We demonstrated recently that uninjured C-fiber nociceptors in the L4 spinal nerve develop spontaneous activity after transection of the L5 spinal nerve. We postulated that Wallerian degeneration leads to an alteration in the properties of the neighboring, uninjured afferents from adjacent spinal nerves. To explore the role of degeneration of myelinated versus unmyelinated fibers, we investigated the effects of an L5 ventral rhizotomy in rat. This lesion leads to degeneration predominantly in myelinated fibers. Mechanical paw-withdrawal thresholds were assessed with von Frey hairs, and teased-fiber techniques were used to record from single C-fiber afferents in the L4 spinal nerve. Behavioral and electrophysiological data were collected in a blinded manner. Seven days after surgery, a marked decrease in withdrawal thresholds was observed after the ventral rhizotomy but not after the sham operation. Single fiber recordings revealed low-frequency spontaneous activity in 25% of the C-fiber afferents 8-10 d after the lesion compared with only 11% after sham operation. Paw-withdrawal thresholds were inversely correlated with the incidence of spontaneous activity in high-threshold C-fiber afferents. In normal animals, low-frequency electrocutaneous stimulation at C-fiber, but not A-fiber, strength produced behavioral signs of secondary mechanical hyperalgesia on the paw. These results suggest that degeneration in myelinated efferent fibers is sufficient to induce spontaneous activity in C-fiber afferents and behavioral signs of mechanical hyperalgesia. Ectopic spontaneous activity from injured afferents was not required for the development of the neuropathic pain behavior. These results provide additional evidence for a role of Wallerian degeneration in neuropathic pain.

OBJECTIVE: Medical students are presented with unique challenges when they care for patients with limited English proficiency. Students must learn a complex set of skills needed to care for patients across cultural and language barriers and to understand the impact of their own attitudes and beliefs about caring for these patients. We developed and piloted a multimedia interactive Web-based module aimed at teaching students effective strategies for working with interpreters and diverse patient populations, and at raising their awareness of important legal, ethical, and cultural issues. DESCRIPTION: First the learner completes a 37-multiple-choice-question (MCQ) pre-test that assesses attitudes, factual knowledge, and ability to analyze written clinical scenarios relevant to the module's content. Learners are then shown a series of professionally produced video vignettes, which reflect diverse patient populations, interpreters, and effectiveness of interpretation strategies (e.g., a Russian-speaking woman with chest pain whose daughter interprets, a medical student interpreting for a Chinese-speaking man using herbal medication, a Haitian woman told of an abnormal mammogram through a trained simultaneous interpreter). In each case, learners submit short answers to on-screen questions analyzing the effectiveness of the interpretation strategies demonstrated. Immediate feedback is given comparing student responses with those of experts. At any time during the module, the learners may view video commentary by legal, ethics, and cultural experts, or access a glossary and Web site links. Students conclude the module by again taking the MCQ test. A final screen compares their pre- and post-MCQ test responses and shows best answers, allowing them to assess their learning. The learners also complete a survey, providing personal cultural information and feedback on the module. DISCUSSION: All 160 first-year medical students completed the module and evaluated its effectiveness this year. On average, students improved by 20% on the MCQ post-test and 86% of the students were satisfied with the learning experience and acquired new knowledge. As a result of their participation in the module, students examined their own cultural and linguistic backgrounds and made the following comments: 'I am interested in exploring the way my own culture and cultural biases could impact my working with patients from other cultures'; 'This module has opened my eyes to the fears and concerns of immigrants who do not speak English.' Therefore, this pilot of the module effectively imparted guidelines for, and raised awareness of, medical interpreting. The most common critique of the module was that as a result of technical difficulties, it was time-consuming. A more rigorous evaluation is planned for the next academic year. We are also working to enrich and enhance the module for more experienced clinicians (GME and CME). As a complementary educational tool, the Internet has the advantages of allowing students to work at their own paces, view engaging video clips, and participate in interactive learning with immediate feedback and self-assessment

The American College of Women's Health Physicians has been exploring an on-line educational tool-concept mapping-to facilitate the development of an interdisciplinary and woman-centered women's health curriculum, and to implement The Women's Health Care Competencies for Medical Students. By using an on-line concept map of the menstrual cycle, we have built upon a standard piece of curricula that describes a unique aspect of female physiology and transformed it into a knowledge framework that builds capacity. The concept map highlights relationships between concepts and across disciplines, connecting the competencies to enable meaningful learning so that a learner can adapt their knowledge to multiple settings, incorporate new learning, and generate new knowledge to grow the interdisciplinary field of women's health. The on-line format allows access from multiple sites and courses, and allows the curricula to grow organically over time without upsetting current curricular design