Faculty Bibliography

Marc Siegel comments on caring for a hospitalized patient with heart disease without ever having met her face to face.

If experience from the time when smallpox vaccine was routinely administered to the public is a guide, doctors say, some of the 15,000 ''first responders'' who receive the vaccine may suffer serious -- potentially even deadly -- complications. Steps may also have to be taken to protect certain people who come in contact with others who receive the vaccine, which infects recipients with live vaccinia virus, a relative of smallpox. Because those vaccinated can shed this virus, they can spread its smallpox protection as well as its complications. If the panel's recommendations are adopted as policy, the immunizations would be the largest number given in this country since it stopped routine smallpox vaccinations in 1972. Until now, the government has restricted use of smallpox vaccine to scientists who work with smallpox and related viruses in a laboratory. About 11,000 such workers have received the vaccine since 1983, said Dr. Harold Margolis, an official with the Centers for Disease Control and Prevention here. When about 125 health workers were vaccinated at the disease centers last fall, doctors who gave the injections were surprised by the number and severity of adverse reactions. Many recipients were treated with antibiotics in the erroneous belief that the site of vaccination had become infected. Older doctors who had given smallpox vaccine in decades past told their younger colleagues that the skin reactions were from the vaccine. Doctors who conducted recent trials to test the safety and effectiveness of diluting the vaccine had a similar experience

A panel of specialists advising the federal government on smallpox vaccinations unanimously rejected a proposal today to offer vaccines to every American. Instead, the panel recommended immunizing only the estimated 15,000 health care and law enforcement workers who would be most likely to respond to a biological attack and come in contact with victims. After the anthrax attacks last fall, the government ordered millions of doses of smallpox vaccine and the Centers for Disease Control and Prevention asked a 14-member panel to determine whether changes were needed in current recommendations, which limit smallpox vaccine to scientists working with smallpox and related viruses in a laboratory. During the two days of the meeting, panel members said their intent was to allow flexibility in administering their recommendations. The panel said it expected to review its recommendations ''periodically, or more urgently if necessary,'' to consider new developments related to smallpox, the vaccine, the risk of an attack and other factors

A panel of specialists advising the federal government on smallpox vaccinations unanimously rejected a proposal yesterday to offer vaccine to every American. Instead, the panel recommended immunizing only the estimated 15,000 health care and law enforcement workers who would be likely to respond to a biological attack and come in contact with victims. After the anthrax attacks last fall, the government ordered millions of doses of smallpox vaccine and the Centers for Disease Control and Prevention asked a 14-member panel to determine whether changes were needed in current recommendations, which limit smallpox vaccine to scientists working with smallpox and related viruses. During the two days of the meeting, panel members said their intent was to allow flexibility in administering their recommendations. The panel said it expected to review its recommendations 'periodically, or more urgently if necessary,' to consider new developments related to smallpox, the vaccine, the risk of an attack and other factors

The last case of smallpox in the United States occurred in 1949, and no case of the disease has been identified anywhere in the world since 1978. The United States stopped routine smallpox vaccinations in 1972, leaving most Americans susceptible to smallpox infection if a terrorist released the virus. After the anthrax attacks last fall, the Centers for Disease Control and Prevention asked a 14-member panel to determine whether changes were needed in the recommendations it made last year. Current recommendations limit smallpox vaccine to scientists working with smallpox and related viruses in a laboratory. The panel, the Advisory Committee on Immunization Practices, was asked whether all Americans should be allowed to get smallpox vaccine if they wanted it. The panel was also asked whether to limit the vaccine to certain groups like health and emergency-response workers who very likely would be the first to care for anyone who developed smallpox from a bioterrorist attack

Over the past five years the drug companies have struggled to create name recognition using extensive television and magazine ads. The major effect of this has been to raise drug prices and overall costs as patients pressure doctors to prescribe drugs that often aren't needed. A report from UCLA last year concluded that doctor/patient roles may be damaged

The grueling schedule that many doctors go through to train as specialists is about to ease

Claudin-2 is a structural component of tight junctions in the kidneys, liver, and intestine, but the mechanisms regulating its expression have not been defined. The 5'-flanking region of the claudin-2 gene contains binding sites for intestine-specific Cdx homeodomain proteins and hepatocyte nuclear factor (HNF)-1, which are conserved in human and mouse. Both Cdx1 and Cdx2 activated the claudin-2 promoter in the human intestinal epithelial cell line Caco-2. HNF-1alpha augmented the Cdx2-induced but not Cdx1-induced transcriptional activation of the human claudin-2 promoter. In mice, HNF-1alpha was required for claudin-2 expression in the villus epithelium of the ileum and within the liver but not in the kidneys, indicating an organ-specific function of HNF-1alpha in the regulation of claudin-2 gene expression. Tight junction structural components, which determine epithelial polarization and intestinal barrier function, can be regulated by homeodomain proteins that control the differentiation of the intestinal epithelium.

New York is the only state with a law limiting such work hours, to 80 a week for all residents. The council's action coincides, however, with the introduction of federal legislation by Senator Jon Corzine, Democrat of New Jersey, and Representative John Conyers Jr., Democrat of Michigan, that would also limit residents' hours. Concern about residents' schedules has intensified, the council noted, now that hospitals are under ever greater pressure to discharge patients quickly as a way to control costs. Last month the council threatened Yale-New Haven Hospital, a teaching affiliate of the Yale School of Medicine, with loss of accreditation of its surgical program because residents were on call too many nights and were working weeks of 100 hours or more. Although existing rules place no specific limit on the workweek of surgical residents, in general the council can act when it finds that a hospital has breached the rules' spirit. In separate interviews, Dr. [David Leach] and Dr. [Ruth Potee] noted that budget constraints had forced many teaching hospitals to reduce their staffs, including nurses and workers who draw blood and move patients. Although many hospitals have hired aides called ''physician extenders'' to help with such work, much of the burden has fallen on residents, increasing their hours and interfering with their education