Faculty Bibliography

Focus groups conducted for a panel of scientists advising the government uncovered a catalog of misinformation about the smallpox vaccine -- the first vaccine to be developed (in 1796) and considered to be the most dangerous. Unlike most other immunizations, smallpox vaccine can harm recipients and their contacts. Resumption of vaccination on a large scale would probably lead to thousands of serious complications and hundreds of deaths, as it did when millions of Americans were routinely vaccinated. Current guidelines, published in June 2001, do not recommend smallpox vaccine for the public. Vaccination is limited chiefly to laboratory workers directly involved with smallpox virus or its close virological cousins. The limits were based largely on the lack of enough vaccine. At the time, the government had only 15 million doses. In the wake of the anthrax attacks last fall, the government has expanded its stockpile of smallpox vaccine. Tests have shown that the 15 million doses can be diluted to 75 million. The drug company Aventis Pasteur has donated about 80 million doses that have been frozen since 1958 and that the government says would be used only in an emergency. The government is also buying 220 million doses made by a new laboratory technique. Delivery is expected by year's end

Focus groups conducted for a panel of scientists advising the government uncovered a catalog of misinformation about the smallpox vaccine -- the first vaccine to be developed (in 1796) and considered to be the most dangerous. Unlike most other immunizations, smallpox vaccine can harm recipients and their contacts

BACKGROUND: Over the past decade, there has been a reduction in the incidence of tuberculosis in New York City and in the United States. However, the reduction has been confined mainly to U.S.-born persons. Understanding the reasons for the lack of reduction among non-U.S.-born persons may lead to new strategies for tuberculosis control. METHODS: We performed DNA fingerprinting with the IS6110 insertion sequence of the organisms isolated from patients with culture-positive tuberculosis in northern Manhattan from 1990 to 1999. The goal was to identify the strains responsible for multiple infections, presumably through recent transmission (clusters of cases), as well as the strains found in only one patient, presumably representing reactivation of latent infection. RESULTS: Of 546 available isolates of Mycobacterium tuberculosis, 261 (48 percent) belonged to a cluster and 285 (52 percent) did not. In multivariate analysis, significant predictors of noncluster status included birth outside the United States (odds ratio for a strain causing a cluster among non-Hispanic foreign-born patients, 0.31; 95 percent confidence interval, 0.14 to 0.66; odds ratio among Hispanic foreign-born patients, 0.51; 95 percent confidence interval, 0.30 to 0.88), age greater than 60 years (odds ratio, 0.37), and diagnosis after 1993 (odds ratio, 0.50). All these characteristics appeared to be associated with reactivation disease rather than with tuberculosis due to recent transmission. Homelessness was associated with clustering (odds ratio, 1.78; 95 percent confidence interval, 0.99 to 3.20) and therefore with recent transmission. CONCLUSIONS: These findings from northern Manhattan suggest that among foreign-born persons, tuberculosis is largely caused by reactivation of latent infection, whereas among U.S.-born persons, many cases result from recent transmission. Strategies for the control and elimination of tuberculosis among foreign-born persons at high risk should be directed toward the treatment of latent tuberculosis infection

Splice variants of the Nmp4 gene include nuclear matrix transcription factors that regulate the type I collagen alpha1(I) polypeptide chain (COL1A1) promoter and several matrix metalloproteinase (MMP) genes. To date, these are the only Cys(2)His(2) zinc finger proteins known to bind within the minor groove of homopolymeric (dA.dT) DNA. Nmp4 isoforms contain from 5 to 8 Cys(2)His(2) zinc fingers, an SH3-binding domain that overlaps with a putative AT-hook and a polyglutamine-alanine repeat (poly(QA)). To determine the mechanistic significance of Cys(2)His(2) zinc finger association with this unusual consensus DNA binding element, we identified the Nmp4 DNA-binding and transcriptional activation domains. Zinc fingers 2, 3, and 6 mediated association with the homopolymeric (dA.dT) COL1A1/MMP DNA consensus element. The N terminus of the Nmp4 protein exhibited a strong trans-activation capacity when fused to the GAL4 DNA-binding domain, but this activity was masked within the context of the full-length Nmp4-GAL4 DNA-binding domain chimera. However, upon binding to the COL1A1/MMP homopolymeric (dA.dT) element, the native Nmp4 protein up-regulated transcription, and the poly(QA) domain acquired a significant role in trans-activation. We propose that allosteric effects induced upon zinc finger association with the homopolymeric (dA.dT) minor groove confer context-specific functionality to this unusual family of Cys(2)His(2) transcription factors.

Effective antiretroviral therapy initially resulted in large decreases in hospitalization rates of HIV-infected patients. The goal of this study was to determine whether these gains were being maintained in 2001. A cross-sectional study of hospital admission characteristics during four time periods was performed. All patients receiving care at the HIV clinics of New York Presbyterian Hospital-Cornell Medical Center (NYPH) in New York City were included. In 1995, 883 outpatients were receiving care for HIV infection at NYPH; this increased to 1990 outpatients by 2001. Demographic and laboratory information was obtained for these outpatients, and diagnoses were recorded for all patients requiring hospitalization on at NYPH during the time periods January 1 through June 30, in 1995, 1997, 1999, and 2001. The incidence of hospital admission declined in all four time periods: 1995 (95 per 100 patient-years [pt-yr]), 1997 (48 per 100 pt-yr), 1999 (38 per 100 pt-yr, p < 0.05), and 2001 (25 per 100 pt-yr). The incidence of bacterial pneumonia and opportunistic infections (OIs) decreased in all four time periods. The median hospitalization were CD4(+) cell count for outpatients increased from 231 (1995) to 364 (2001). Important predictors of hospitalization were CD4(+) < 200, and IVDU as an HIV risk factor. Since 1995 and the introduction of highly active antiretroviral therapy, continuing increases in CD4(+) cell counts of outpatients has been reflected in persistent declines in hospitalization rates. Large decreases in OIs and pneumonia have been minimally offset by stable rates of hospital admissions for diagnoses such as hepatitis, cirrhosis, and cellulitis

Medicare has always provided compensation for 80 percent of what it sets as the bill, an amount that, if no longer gilded, still compensates doctors adequately. And as long as it pays the bills, Medicare is preferable to the strictures of most health maintenance organizations. It allows us to choose what tests we order and to refer our patients to specialists as we think is necessary. For doctors, Medicare is usually free of the problems that plague many H.M.O.'s -- the excess paperwork, the referral requests, the insurance-company arbiter who has the power to deny essential tests. With Medicare covering 80 percent of the bill, the greater difficulty often lies in collecting the remaining 20 percent from the patient or his secondary insurance

Acute Care of the Elderly (ACE) units have been shown to improve outcomes for hospitalized elders. Because the literature offers little to describe the appropriate staffing of such units, we surveyed ACE units about their size, configuration, staffing, patient selection, training, and outcomes data. Although we had anticipated speaking with staff from 30 to 40 units, we were able to poll key personnel on only 18 ACE units. This article describes staffing and continuous quality improvement data for these sites.