Yale University School of Medicine: 2007 student thesis abstracts

. 2007 Nov;80(1):1–38.

Yale University School of Medicine

2007 student thesis abstracts

PMCID: PMC2048992 PMID: 18170929

Yale J Biol Med. 2007 Nov;80(1):1–38.

Methicillin-Susceptible Staphylococcus aureus Colonization in the Neonatal Intensive Care Unit

Shoaib S Ahmed ¹, Robert S Baltimore ¹

Nasal carriage of Staphylococcus aureus is a sensitive indicator of staphylococcal colonization and is considered a source of subsequent infection. When the incidence of S. aureus colonization increased in our neonatal intensive care unit (NICU), resulting in three methicillin-resistant Staphylococcus aureus (MRSA) infections over a three-month period, we sought to further our understanding of S. aureus epidemiology and response to infection control practice. The purpose of this investigation was to study the methicillin-susceptible Staphylococcus aureus (MSSA) and further determine the clonal spread of MSSA strain types. Since few studies have analyzed the clinical profile of MSSA in neonates, we hypothesized the incidence of MSSA colonization would follow a mixed endemic and epidemic pattern over the period of the study. We further compared the MSSA colonization data to that of MRSA, in order to get a more complete picture of the S. aureus strains circulating in the NICU.

This retrospective longitudinal study consisted of infants hospitalized in a Level III-IV NICU (approximately 45 beds) from April 2003 to December 2004. Nasal surveillance cultures of all infants were obtained on admission and weekly. Pulsed-field gel electrophoresis (PFGE) was used to determine S. aureus strain type. Transmission of identical strains among infants was noted. By testing for antibiotic susceptibilities, the prevalence and transmission data of MSSA were calculated. Thereafter, epidemiologic data such as birth weight, age, therapeutic modalities, length of admission, and antibiotic use were obtained from clinical summaries and used to characterize patients who had been colonized with MSSA.

During the 21-month study period, 1,081 infants were screened for S. aureus. Of these, 877 (81.1 percent) tested negative and 156 (14.4 percent) tested positive for MSSA. The prevalence of colonization with MSSA approached 45 percent by the fifth week of hospitalization for any given infant and 70 percent in nine weeks. Following the institution of routine nasal surveillance in April 2003, the incidence of MSSA cases fell from 6.5 to 1.5 per 1,000 patient-days per month. Molecular typing using PFGE revealed three prevalent MSSA clones: clone "4" (7 percent), clone "15" (11 percent), and clone "23" (12 percent), which correspond to periods of increased incidence. The median length of stay was significantly longer for the intensive care infants compared to the continuing care, i.e. "feed-and-grow," infants (median 77 vs. 44 days, Wilcoxon P = .05). The mean length of stay was also longer in the intensive care infants, although this did not reach statistical significance (86 vs. 66 days, Student’s t-test P = .18). On chi-square analysis, infants in intensive care rooms were found to have a significantly higher prevalence of MSSA isolates than those in continuing care rooms in the nursery (54 vs. 35 percent of the total pool, P < 0.04). By comparison, 48 (4.4 percent) infants tested positive for MRSA, and the incidence of MRSA cases fell from 5.8 to 0.4 per 1,000 patient-days per month during the study period. One predominant MRSA clone, clone "9," was identified and controlled.

Control of MSSA is challenging because colonization is expected, endemic infections are tolerated, and surveillance usually focuses on drug-resistant pathogens. During the period of study for this critically ill infant population, the incidence of both MSSA and MRSA colonization fell dramatically in response to the reinforcement of hand hygiene and contact precautions. We also identified an increased risk for MSSA colonization among intensive care infants as compared to continuing care infants, most likely connected to the significantly longer hospital stays among intensive care infants. The findings emphasize the need for cost-effective surveillance strategies in order to monitor progression from colonization to endemic infections. Finally, knowledge of the pattern of healthcare-associated infections can contribute to the intensification of infection control measures and the updating of antibiotic usage guidelines.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Clinical Predictors of Drug Resistance and Mortality among Tuberculosis Patients in a Rural South African Hospital: A Case-Control Study

Jason R Andrews ¹, Neel R Gandhi ¹, Anthony P Moll ¹, Gerald H Friedland ¹

The recent discovery of the high prevalence of multi-drug-resistant (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) in rural South Africa, where HIV is rampant, has provoked alarms about the future of tuberculosis control in the region. Little is known about the clinical manifestations of MDR-TB in general, and XDR-TB in particular, in the high HIV prevalence settings of sub-Saharan Africa.

We performed a retrospective, case-control study of patients diagnosed with tuberculosis at a rural hospital in KwaZulu-Natal, South Africa, where large numbers of MDR-TB and XDR-TB cases have been identified. Eligible MDR-TB and XDR-TB patients began treatment for TB between June 1, 2005, and August 31, 2006, and had charts available for review. The comparison group was comprised of patients without concurrent resistance to isoniazid and rifampicin (non-MDR-TB), matched 1:1 with the size of the MDR-TB and XDR-TB groups. Clinical and laboratory data were obtained through review of hospital records, clinic registers, and the laboratory system. We compared clinical characteristics to identify risk factors for MDR-TB, XDR-TB, and mortality. Bivariate and multivariate analyses were performed.

One hundred seventy patients were enrolled in the study: 52 MDR-TB, 61 XDR-TB, and 57 non-MDR-TB patients. More than 75 percent of patients from all groups were tested for HIV; HIV prevalence among those tested was 93 percent in the MDR group, 100 percent in the XDR-TB group, and 94 percent in the non-MDR group (P = 1.000 for MDR vs. non-MDR; P = .089 for XDR vs. non-MDR). Forty percent of MDR-TB patients and 57 percent of XDR-TB patients had no previous history of TB treatment, strongly suggesting transmitted drug resistance.

Significant associations and risk factors for MDR-TB and XDR-TB in bivariate analysis included: positive sputum smear (P = .015, P = .005, respectively), treatment for TB in the past year (P < .0001, P < .001), and hospitalization in the past two years (P = .007, P = .004). In multivariate logistic regression, positive sputum smear remained a significant risk factor only for XDR-TB (adjusted odds ratio (AOR) 2.79, 95 percent CI 1.20-6.47), whereas TB treatment in the past year remained a risk factor for both MDR-TB and XDR-TB (AOR 8.33, 95 percent CI 1.64-42.33; AOR 7.19, 95 percent CI 1.35-38.17).

Mortality for the non-MDR, MDR, and XDR groups was 36.8 percent, 73.1 percent, and 85.3 percent, respectively (P = .0001 for MDR vs. non MDR; P < .0001 for XDR vs. non-MDR; P = .109 for XDR vs. MDR); median survival from TB diagnosis was 199 days, 103 days, and 92 days, respectively (P < .001). In a Cox Proportional Hazards model, positive sputum smear (P = .003), MDR-TB (P = .028), XDR-TB (P = .002), and CD4 cell count less than 200 cells/mm³ (P = .037) were significant risk factors for mortality.

Forty of the 170 patients had sputum isolates with differing resistance patterns; 18 moved from a lower to a higher resistance category. This increasing drug resistance appeared to be more likely the result of super-infection than amplification.

A significant proportion of MDR-TB and all XDR-TB infections appear to be due to primary resistance, with nosocomial transmission playing a critical role; MDR-TB and XDR-TB carry extraordinarily high mortality rates in this setting. Previous hospitalization, previous TB treatment, positive sputum smear, and low CD4 count may be used to target drug susceptibility testing for patients at high risk of drug resistant TB and mortality.

Yale J Biol Med. 2007 Nov;80(1):1–38.

The Impact of Prenatal Discussion of Breast-feeding by Healthcare Providers on Feeding Choice

Karen Archabald ¹, Jessica Illuzzi ¹

Breast-feeding initiation rates in the United States remain below the Healthy People 2010 goals. Research indicates patient interaction with healthcare providers may play an important role in women’s ultimate feeding choice. This study sought to examine the impact of provider counseling during the prenatal period regarding breast-feeding on feeding outcome by evaluating: 1) if providers addressed women’s concerns regarding breast-feeding, and 2) how providers responded to a woman’s feeding choice. We also sought to examine whether the type of counseling provided regarding infant feeding is influenced by patient socio-demographics and stated feeding plans. This study is cross-sectional with convenience sampling of all English- or Spanish-speaking women on the postpartum floor at Yale-New Haven Hospital. One hundred thirty women participated. Overall, 95.4 percent of women identified a concern they had about breast-feeding during the prenatal period, and one quarter of patients had their concerns about breast-feeding addressed. The majority of patients (74.6 percent) were asked about their feeding plans, and 50.5 percent were encouraged to breast-feed. The majority of studies indicate young, African American, poorly educated, unmarried, and low income women are less likely to receive counseling from providers to breast-feed. However, providers in our study area focused their efforts on this population. In multivariate analysis, neither having concerns addressed nor being encouraged to breast-feed was associated with increased likelihood of breast-feeding. Addressing patients’ concerns may be most relevant in the small subset of patients who make their feeding choice during pregnancy. Finally, women who were asked about their plans and had their concerns addressed (p = .01) or were encouraged to breast-feed (p = .04) were more likely to make their decision during pregnancy, compared to before pregnancy, than women whose providers did not discuss these issues. Likewise, mixed feeders were more likely to make their decision regarding infant feeding during rather than before pregnancy. These data suggest providers may be encouraging women to think more thoroughly about the possibility of breast-feeding, thus delaying their decision. In conclusion, many women are not being encouraged to breast-feed or having their concerns about breast-feeding addressed. All women would benefit from prenatal discussion of these topics. However, the effect may be most profound in women who make their decision regarding feeding during pregnancy.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Stigma Perceived by Persons with Human Immunodeficiency Virus Attending the Infectious Diseases Clinic of Centre Hospitalier Univérsitaire De Fann in Dakar, Senegal

Nana Akua Asafu-Agyei ¹, Papa Salif Sow ¹

Human Immunodeficiency Virus (HIV)-associated stigma is pervasive throughout the world. This stigma affects the ability of HIV-positive individuals to cope with their illness, sexual practices, disclosure to others, and the use of healthcare. The purpose of the research project was to examine the experiences related to internalized stigma among HIV-positive persons and their perceptions of stigmatizing attitudes in the community. The study also examined disclosure of HIV serostatus and identified factors contributing to disclosure and stigma in Senegal, a low prevalence Muslim country in West Africa. A cross-sectional study was conducted at Centre Hospitalier Univérsitaire de Fann in the form of a structured interview using a newly developed stigma instrument. The interviews were carried out in French and/or Wolof, and the participants were interviewed during a routine visit to Fann Hospital. Fifteen men and 28 women aged 19 to 55 years participated in the study. The mean period of time since diagnosis was 3.6 years (± 2.5 years). The stigma instrument showed a mean internalized stigma score of 5.4 ± 3.5 (maximum score: 15) and an even higher level of perceived stigmatizing attitudes in the community of 7.9 ± 4.8. Males had greater stigma scores than females. Almost 80 percent of the people interviewed had received some counseling, yet fewer than two-thirds of the study participants had disclosed their HIV status to others. The level of internalized stigma and the perception of stigmatizing attitudes in the community are high, with males experiencing more guilt. About three-fifths of the participants in the study had not disclosed their HIV status to even one other person; men disclosed their serostatus more frequently than women. Women were more likely to use counseling services compared to their male counterparts, and individuals who had disclosed their serostatus attended counseling less. Finally, despite the level of stigma perceived, the majority of people interviewed reported positive experiences with healthcare personnel in the Infectious Diseases Clinic of Fann Hospital.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Does Response to Glaucoma Therapy in One Eye Predict Response in the Fellow Eye?

Omar R Chaudhary ¹, Ron A Adelman ¹, M Bruce Shields ¹

The purpose of this investigation was to study whether the intraocular pressure (IOP) change observed after starting a glaucoma medication in one eye is predictive of the IOP change observed in the fellow eye after starting the same medication in the second eye. In a retrospective study, 55 patients with glaucoma underwent monocular drug trials with various medications before the drug was administered to the second eye. The change in IOP of the first treated eye during monocular therapy was compared with the IOP change of the second eye during binocular therapy. Relative changes in IOP of each eye were calculated by subtracting the change in IOP of the fellow eye from the treated eye. The IOP of the first eye decreased 5.8 ± 6.1 mmHg (mean ± standard deviation) during monocular therapy, while the IOP of the second eye decreased 3.4 ± 5.7 mmHg during binocular therapy. The absolute IOP changes in the first and second eyes were poorly correlated (r = .095, p = .49). When relative changes in IOP were used, the first eye decreased 6.3 ± 5.3 mmHg and the second eye 4.2 ± 4.5 mmHg. The relative changes were well correlated (r = .404, p = .002). In addition, excellent correlation was noted in the subset of glaucoma-suspect patients when using absolute IOP changes (r = .590, p = .001). The data support that the absolute response of one eye to a medication is predictive of the future response of the fellow eye to the same medication in patients with glaucoma suspect, but not in the overall glaucoma population. If one eye is used as a control in assessing the efficacy of a drug in the fellow eye, the response of one eye to a glaucoma medication is predictive of the response of the fellow eye.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Vaccination with Her2/Neu Peptides Elicits an Endogenous Anti-Her2/Neu Antibody Response in Mice

Bridget F Collins ¹, Mark J Mamula ¹

The Her2 protein, a member of the epidermal growth factor receptor family, is overexpressed on 25 to 30 percent of invasive breast cancers. In this study, Her2 peptides of various lengths were tested to determine their potential to induce endogenous anti-Her2 antibodies with a long-term goal of abrogating the need for breast cancer patients to receive repeated therapeutic infusions of trastuzumab (Herceptin, Genentech), an anti-Her2 monoclonal antibody. In addition, autoantigens in various autoimmune diseases have undergone isoaspartyl modification. Therefore, an additional hypothesis of the study was that isoaspartyl modification of these Her2 peptides would increase their immunogenicity, in essence using protein modifications featured in autoimmune reactions to enhance the anti-breast tumor immune response.

Balb/c and Her2 transgenic FVB/N mice were immunized with a specific Her2 peptide with Complete Freund’s Adjuvant (CFA). Sera were collected from the Balb/c mice via retro-orbital bleed. ELISA, Western Blot, and FACS analysis using two human breast cancer cell lines, BT474 and SKBR3, were used to study the antibody response to immunization. Her2 Transgenic FVB/N mice were examined for the development of palpable mammary tumors.

Results showed immunization with the Her2 peptide 21mer sequences P601-621 and P601-621Iso resulted in the formation of anti-Her2 antibodies that bound the full length Her2 protein in Western blotting and also bound Her2 on the cell surfaces of both breast cancer lines. Sera from these mice also inhibited BT474 cell proliferation in vitro, and immunization with these peptides delayed the development of palpable mammary tumors in Her2 transgenic FVB/N mice. Modified and unmodified peptides of nine and 10 amino acids (P602-610 and P602-611) also were tested as vaccine candidates, but antibodies raised to these peptides bound Her2 on the cell surface with less affinity and were of lower number than antibodies from mice immunized with either 21mer peptide.

In conclusion, the 21mer peptides are strong potential vaccine candidates for breast cancers overexpressing Her2. Based on cell surface antibody binding, as noted on FACS, the unmodified 21mer, P601-621, is a slightly better candidate than P601-621Iso. Therefore, it seems the immunogenicity of the 21mer peptides is due to the exposure of a peptide sequence normally hidden from the immune system rather than isoaspartyl modification.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Sex and the Elderly: What Physicians Should Know About Their Older Patients

Jana A Colton ¹

This study is intended to explore how physicians can best help their older patients attain a better quality of life through sexual healthcare by eliciting older patients’ perceptions and experiences regarding their sexual health needs and what role their physician should play in meeting those needs. Participants included individuals and couples over the age of 65, recruited from a continuing care retirement community and from a VA Geriatric Clinic. Twenty in-depth, one-on-one interviews were conducted, and transcripts were analyzed using qualitative methodology. Analysis of transcripts revealed a broad range of findings, including seniors’ perceptions of: the definitions of "sexual activity" and "sexual health," their own sexual status; their own sexual health needs; the barriers to meeting their sexual health needs; and the ageist beliefs of others and themselves. This study exposed older patients’ self-perceived sexual health needs and the barriers to having those needs met; this knowledge should help physicians improve the quality of life for their senior patients through improved sexual healthcare.

Yale J Biol Med. 2007 Nov;80(1):1–38.

The "Power Mix" Tolerizing Regimen: Novel Tolerizing Regimens to be Applied in the Cynomolgus Model

Bidhan B Das ¹, Joren C Madsen ¹

The purpose of the study was to analyze three novel tolerizing regimens and to compare and contrast them to determine the most potent strategy for inducing tolerance. It was expected that the "Power Mix" regimen, a strategy combining an interleukin-2 (IL-2) agonist, IL-15 antagonist, and rapamycin, would be the most efficacious. The methods used include murine skin and cardiac allotransplantation, porcine skin and cardiac allotransplantation, cynomolgus islet and cardiac allotransplantation, as well as in vitro studies of cytokine profiling by enzyme-linked immunospot (ELISPOT) cultures, Mixed Lymphocyte Reaction (MLR), and binding efficacy of fusion proteins by flow cytometry. The results demonstrated the ability of each regimen to produce tolerance of allografts in particular models, but not in every type of graft or across every species. The "Power Mix" data specifically demonstrated that in primary cynomolgus MLR and ELISPOT, the agonist IL-2/Fc is able to increase alloreactivity and the mIL-15/Fc can decrease alloreactivity, but through a dose-response/kinetics study, the fusion proteins seem to bind effectively only at concentrations that are much higher than previously understood. Given the results from comparing the three regimens, it is evident the "Power Mix" regimen is not yet able to produce robust tolerance as expected. In the absence of an outstanding protocol, all three regimens should be pursued with further experimentation.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Efficacy of Neoadjuvant Chemotherapy Regimens Prior to Resection of Colorectal Liver Metastases

Farrah M Datko ¹, M Wasif Saif ¹

While new treatments for metastatic colorectal cancer continue to be developed, the ideal neoadjuvant regimen prior to resection of liver metastases is still unknown. The primary goal of this study was to compare disease-free survival outcomes in patients who received oxaliplatin- or irinotecan-based neoadjuvant chemotherapy regimens prior to resection of colorectal liver metastases.

A retrospective chart review was performed for all 27 patients who underwent liver resection of colorectal cancer metastases at Yale-New Haven Hospital between January 2003 and December 2005. Records were reviewed for details of initial diagnosis, treatment regimen(s) prior to resection of hepatic metastases, results of surgical liver resection, adjuvant treatment after liver resection, post-operative disease recurrence and overall survival. Median disease-free survival calculations were based on survival curves drawn according to Kaplan-Meier methods.

Out of 15 patients with at least one year of follow-up, six were treated with neoadjuvant FOLFOX (oxaliplatin-based) prior to liver resection; three with first-line FOLFOX followed by second-line FOLFIRI (irinotecan-based); two with FOLFIRI; and one with IFL (irinotecan-based). Three patients had no neoadjuvant chemotherapy. Median disease-free survival was 15.5 months in patients treated with neoadjuvant FOLFOX; 16.3 months in patients treated with first-line FOLFOX followed by second-line FOLFIRI; 16.3 months in patients treated with irinotecan-based neoadjuvant therapy; and it was not reached in the group that did not receive any neoadjuvant treatment (p = .84). Actual one-year disease-free survival rate was 67 percent, regardless of neoadjuvant treatment group. The sample size was too small to determine which patient, tumor, and treatment variables were associated with disease recurrence.

The majority of patients undergoing liver resection of colorectal metastases at Yale-New Haven Hospital in recent years were treated with neoadjuvant FOLFOX. Median disease-free survival and actual one-year disease-free survival were almost identical among patients receiving FOLFOX, irinotecan-based regimens, or first-line FOLFOX followed by second-line FOLFIRI, although analysis was limited by a small sample size. Larger prospective trials are needed to effectively compare oxaliplatin- and irinotecan-based neoadjuvant chemotherapy regimens for patients with either resectable or unresectable colorectal hepatic metastases.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Inflammatory and Thrombotic Responses to Microbial Products in Fetal Vessels are Mediated through Divergent Toll-Like Receptor Signaling Pathways: Implications in Fetal Inflammatory Response Syndrome

Shekar L Davarya ¹, Yuehong Ma ¹, Seth Guller ¹

Placental vessels and the umbilical circulatory network function to carry oxygen and nutrients to the fetus. It is at this level that placental lesions such as villitis, obliterative vasculopathy, and thrombotic vasculopathy have been observed in association with fetal inflammatory response syndrome (FIRS) and cerebral palsy. We used human umbilical vein endothelial cells (HUVECs) as a model to study the regulation of inflammation and thrombosis in fetal vessels by microbial products. In this thesis, we measured interleukin-8 (IL-8) and tissue factor (TF) expression by HUVECs treated with lipopolysaccharide (LPS), poly (I:C) (PIC), and peptidoglycan (PG). Our results show a profound induction of IL-8 by PIC, a Toll-like receptor 3 (TLR3) ligand. We also show a moderate induction of tissue factor expression in PIC-treated HUVECs. These results show that HUVECs are exquisitely sensitive to PIC and suggest an important role for viral infection in umbilical vessel inflammation. We also treated HUVECs with dexamethasone (DEX), an anti-inflammatory steroid, and melatonin (MT), a pineal gland product with immunomodulatory and antioxidant properties. DEX reduced the level of both IL-8 and TF expression in PIC-treated cells. However, MT further enhanced IL-8 expression in PIC-treated cells. Our results indicate a potential role for glucocorticoid (GC) therapy in reducing placental vessel inflammation and thrombosis. Thus, intervention with GC in pregnancies with FIRS may reduce the severity of placental lesions associated with cerebral palsy.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Mitral Cell Dendritic Development in the Mouse Main Olfactory Bulb

Masha Rand Diede ¹, Charles A Greer ¹

Correct targeting and differentiation of the mitral cell (MC) dendrites in the olfactory bulb (OB) are clearly essential for the development of functional neuronal circuits. MCs, the primary OB projection neurons, receive odor information from olfactory sensory neuron (OSN) axons via axodendritic synapses on their apical dendrite. The signal is further processed via dendrodendritic synapses on MC lateral dendrites. In the adult, each MC cell apical dendrite targets a single glomerulus, ending in a characteristic glomerular tuft and receiving input from molecularly defined subsets of OSNs. MC lateral dendrites segregate deep to the glomerular layer, in a sublamina of the external plexiform layer. MC dendrites are initially undifferentiated and often supernumerary; the adult form of one apical and several lateral dendrites emerges postnatally. We sought to define more clearly the emergence of MC apical vs. lateral dendrites using DiI fills. We also used a dendritic growth cone specific antibody, CDA 1, to assess spatiotemporal patterns of development in the OB.

MCs progressed through a broad spectrum of transitional morphologies ― from a broadly spread arbor of supernumerary dendrites in the embryo to the characteristic single apical dendrite and lateral dendrites of the adult. At P0, MCs exhibit the immature dendritic morphology with a broadly spread arbor of a large number of relatively uniform dendrites. By P1, this arbor appears to have narrowed, and one dendrite appears thicker than the others, probably on its way to differentiating into an apical dendrite. At P4, two clearly distinguishable subpopulations of neurons have clearly emerged, but some cells exhibit two apical dendrites. By P8, MCs appear to have an adult dendritic morphology.

Quantitative analyses of CDA 1 expression patterns in the OB at postnatal days 0, 2, 4, and 8 suggest intra- and inter-laminar patterns of dendritic development. Preliminary data further suggest distinct temporal windows of MC dendritic development along the rostrocaudal axis. CDA 1 expression in all laminae decreases significantly by postnatal day 8 and appears indistinguishable from background in the adult. Thus, both lines of data show evidence of significant postnatal dendritic remodeling.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Sciatic Nerve Remyelination and Nodal Formation Following Olfactory Ensheathing Cell Transplantation

Mary A Dombrowski ¹, Masanori Sasaki ¹, Karen L Lankford ¹, Hajime Tokuno ¹, Christine Radtke ¹, Jeffery D Kocsis ¹

Transplantation of olfactory ensheathing cells (OECs) into an injured spinal cord results in improved functional outcome through axonal regeneration, remyelination, and neuroprotection. However, because little is known of the fate of OECs transplanted into injured peripheral nerves, their myelin-forming potential requires investigation. To study these issues, OECs were isolated from the olfactory bulbs of adult green fluorescent protein (GFP)-expressing transgenic rats and transplanted into sciatic nerve crush lesions. Five weeks to six months after transplantation, the nerves were studied histologically, and it was determined that GFP-expressing OECs survived in the lesion and distributed longitudinally across the lesion zone. Immunostaining revealed a high density of isoform Na_v1.6 at the newly formed nodes of Ranvier, which were flanked by paranodal Caspr staining. Immunoelectron microscopy for GFP revealed transplanted OECs form peripheral type myelin. These results indicate transplanted OECs are extensively integrated into transected peripheral nerves, form myelin on regenerated peripheral nerve fibers, and reconstruct nodes of Ranvier with proper sodium channel structure.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Bone Marrow Contribution to Renal Repair Following Ischemic Injury

Matthew C Egalka ¹, Sujata Kale ¹, Lloyd Cantley ¹

Repair of the mammalian renal tubular epithelium following ischemia/reperfusion injury is largely affected by surviving epithelial cells and other cells resident in the kidney interstitium. However, the precise nature of the contribution of circulating extrarenal cells is unknown. The purpose of this study is to determine whether bone marrow cells have the capacity to differentiate into renal tubular epithelium. This was investigated using an ex vivo transplantation model as well as an attempt to grow epithelial cells from bone marrow in a liquid culture system.

Recipient female C57BL/6 mice were myeloablated via irradiation and transplanted intravenously with lineage-depleted syngeneic male bone marrow. Following this, renal ischemia was induced by surgical interruption of the renal vascular pedicle. Thin sections were assayed for donor contribution by examination by fluorescence in situ hybridization (FISH) for the Y-chromosome. Tubules incorporating donor (Y-chromosome positive) cells were only rarely found (< 2 percent) in the outer medulla of damaged kidney; far more frequent were donor-derived interstitial cells, which appear not to be entirely inflammatory in phenotype.

For the tissue culture experiments, collagenase-released marrow stromal cells were obtained by collagenase treatment of bone chips following mechanical dissociation of bones harvested from C57BL/6 mice. These cells were grown in culture and examined via immunostaining and reverse-transcription polymerase chain reaction for epithelial markers. Unfortunately, the resultant cells, although appearing to form epithelial colonies, were found not to express the epithelial markers cytokeratin and ZO-1 by RT-PCR and immunostaining. Instead, they appeared to be fibroblasts with a novel morphology. In summary, bone marrow contribution to the renal epithelium appears to be a rare phenomenon and, as of now, cannot be replicated in vitro.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Cadherin-Based Adhesion Molecules for Classification of Melanoma with AQUA Technology

Gretchen M Graff ¹, Aaron J Berger ¹, David L Rimm ¹

Cadherin and catenin family proteins regulate adhesion in malignant melanoma. Using AQUA (Automated Quantitative Analysis) to quantitate the levels of alpha-catenin, beta-catenin, p120-catenin, N-cadherin, E-cadherin, and P-cadherin in melanoma on tissue microarrays (TMAs), we classified 513 patients by protein expression using hierarchical clustering and regression analysis. The dendrogram supported positive correlations of P-cadherin and beta-catenin (Spearman rho, r = .5238, p < .0001) and negative, weak correlation of N-cadherin with other markers. Patients with high expression of N-cadherin had the highest 20-year survival rate (p = .0003). Our adherens protein molecular classification of melanoma defines at least two distinctive sub-populations of melanoma patients: those with high expression of N-cadherin and those with low expression, who have decreased survival. These results extend previous cDNA array-based findings of epithelioid class and neural crest class melanomas.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Inhibition of ErbB2 and Thymidylate Synthase by a Multi-Targeted Small-Interfering RNA in Human Breast Cancer Cell Lines

Rebecca Hunter ¹, Edward Chu ¹

The therapeutic potential of a novel multi-targeted small-interfering RNA (siRNA) was investigated in human breast cancer cells. Previous studies identified a siRNA that specifically and potently inhibited expression of thymidylate synthase (TS) by directly targeting human TS mRNA. TS is a folate-dependent enzyme that catalyzes the key reaction involved in synthesizing nucleotide precursors for DNA biosynthesis, and as such, it plays a critical role in maintaining cell growth. The goal of this thesis was to design and develop a novel siRNA molecule that targeted TS mRNA as well as a cellular mRNA that encodes a different cellular protein involved in cancer cell growth and proliferation, such as a member of the ErbB family. Gene sequence analysis was performed and identified an overlapping sequence between TS and ErbB2 mRNAs. An siRNA duplex then was designed to simultaneously target human TS and ErbB2 mRNA. Transfection of the multi-targeted siRNA (TS1M17) revealed that both ErbB2 and TS proteins were significantly suppressed in a time and dose-dependent manner in ErbB2-overexpressing human breast cancer SKBR3 cells. The corresponding mRNA levels, as determined by RT-PCR, also were decreased. Protein levels of other ErbB family members, including ErbB1 and ErbB3, remained unchanged with siRNA treatment. An ErbB2-specific siRNA (B2450) inhibited ErbB2 but had no effect on TS expression, demonstrating the specificity of the multi-targeted siRNA against both TS and ErbB2. Mismatched (TS1-Mismatch) and control (GL2) siRNAs had no inhibitory effects on expression of the two target proteins. Suppression of activated ErbB2, as determined by expression of phosphorylated ErbB2 protein, was observed with transfection of TS1M17 siRNA. In addition, the expression of downstream signaling proteins, such as phosphorylated mitogen activated protein kinase (p-MAPK), p27^Kip1, p21^Cip1, cyclin D1, and survivin were significantly changed. In contrast, control siRNAs did not exert any inhibitory effects on downstream signaling. Taken together, these findings suggest TS1M17 siRNA inhibits signaling of the ErbB2 pathway. The effect of TS1M17 siRNA on cytotoxicity was analyzed by WST-1 assay. Upon transfection into SKBR3 cells, the TS1M17 siRNA significantly suppressed cell proliferation with an IC₅₀ value of 0.65 nM, which is 154-fold more potent than ErbB2- and TS-specific siRNAs. This study suggests that targeting expression of ErbB2 and TS, two key proteins involved in distinct and critical pathways for cancer growth and proliferation, with a single siRNA molecule may provide a novel approach for cancer chemotherapy.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Interactions between fMRI BOLD-Activation during Reading Tasks and MRS-Measured Metabolite Levels

Hassana Aisha Ibrahim ¹, Stephen Frost ¹, Kenneth Pugh ¹, Robert Fulbright ¹

Recent studies in the field of dyslexia have used magnetic resonance spectroscopy (MRS) to explore neurochemical manifestations of neurobiological differences in the brains of dyslexic adults compared to controls. This study examines the potential relationship between functional magnetic resonance imaging (fMRI) BOLD (blood oxygen level demand) activation scores in response to cognitive tasks and MRS-measured levels of a metabolite and a neurotransmitter, N-acetylaspartate (NAA) and gamma-aminobutyric acid (GABA) respectively, in the occipital region of brains of 7-year-old children. Preliminary results from this multi-arm, longitudinal study indicate a significant positive correlation between fMRI BOLD signal elicited in response to picture-cues in the occipital region of interest bilaterally and both GABA (R² = 0.477 p = 0.05, 2-tailed) and NAA (R² = 0.587 p = 0.01, 2-tailed) levels. The results suggest that the functional neuroanatomical circuitry involved in a cognitive task also has neurochemical indicators.

Yale J Biol Med. 2007 Nov;80(1):1–38.

"No Observed Adverse Effects": Developing Neurons, Organo-Phosphate Insecticides, and the 1996 Food Quality Protection Act

Brendan R Jackson ¹, John Harley Warner ¹

Physicians are familiar with organophosphates (OPs) as a classic, though obscure, cause of cholinergic poisoning. Many opportunities for human exposure exist ― 60 million pounds of OPs are applied as insecticides to 60 million acres in the United States each year, and, until recently, more than one-fifth of Americans used these chemicals in their homes. Most physicians, however, still know little about the dangers these pesticides pose to the developing nervous system. By the late 1980s, toxicologists increasingly recognized that toxicants such as lead and mercury, even at doses well below the level required to cause symptomatic poisoning, could induce subtle, yet permanent, neurological deficits if the exposure occurred during critical periods of brain development. In the early 1990s, scientists and regulators began to realize that developmental neurotoxicity (DNT), as this phenomenon was called, also could result from OPs. In 1996, Congress passed the Food Quality Protection Act (FQPA), marking a major turning point in the regulation of hazardous chemicals. Prior to the FQPA, the Environmental Protection Agency (EPA) based its calculations of pesticide risk on adults and largely neglected the increased susceptibility of infants and children. The new law took a precautionary stance, protecting the vulnerable neural and physical development of the fetus and child with the inclusion of a 10-X safety factor, and shifting the burden of proof from health advocates to the pesticide manufacturers. The ensuing 10-year battle between health groups, pesticide manufacturers, and the EPA over the law’s enforcement now provides an instructive lesson into the complex scientific, political, and economic world of environmental health and serves as a relatively successful example of effective policy improving public health.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Marriage and Divorce in Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study

Christopher M Janson ¹, Amanda M Termuhlen ¹, John A Whitton ¹, Leslie L Robison ¹, Lonnie K Zeltzer ¹, Nina S Kadan-Lottick ¹

In this report from the Childhood Cancer Survivor Study (CCSS), we described marriage and divorce rates in survivors of childhood cancer, as compared to a sibling control group and the general population in the United States. We also sought to identify patient and treatment characteristics associated with survivor marital status. This study included 8,930 five-year survivors of childhood malignancy and 2,855 sibling controls participating in the CCSS. Data on marital status, sociodemographic factors, and current health status were obtained from questionnaires; detailed disease and treatment histories were available from medical records. Marital status of the U.S. population was obtained from the 2002 Current Population Survey of the U.S. Census. We found that survivors were more likely to have never married than both sibling (odds ratio [OR] = 1.79; 95 percent CI = 1.65-1.94; p < 0.0001) and population controls (OR = 2.29; 95 percent CI = 2.19-2.38; p < 0.0001), with persistence of trends across age and gender strata. Once married, survivors divorced at rates equivalent to controls. In adjusted analysis, we found that several survivor characteristics predicted never-married status, including treatment involving cranial radiation (OR = 2.41; p < 0.0001), CNS tumor diagnosis (OR = 2.05; p < 0.0001), history of growth hormone deficiency (OR = 2.02; p < 0.0001), and unemployment secondary to disability (OR = 1.78; p = 0.0001). Survivor characteristics predictive of divorce included unemployment (OR = 1.91; p < 0.0001, for unemployed or disabled), lower educational achievement (OR = 1.74; p < 0.0001, for non-college graduates), and psychological distress (OR = 1.60; p < 0.0001). This study confirms prior reports of lower marriage rates in survivors of childhood cancer, providing further evidence that this population struggles with psychosocial adjustment to adult life.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Changes in the Optic Disc after Pan-Retinal Photocoagulation for Proliferative Diabetic Retinopathy

David J Jeng ¹, M Bruce Shields ¹, Ron A Adelman ¹

This study aims to examine the possible effect that pan-retinal photocoagulation (PRP), performed as treatment for proliferative diabetic retinopathy (PDR), has on the optic disc. In a retrospective study, photographs of the optic disc before and after PRP, as well as photographs of untreated eyes for the control group, were evaluated for cup-to-disc ratio and optic disc pallor as gross measures of optic nerve health. A five-grade scheme for optic color was devised for this study by selecting representative photographs for each grade, where five indicated the healthiest-appearing color.

Kappa statistics indicated strong intra- and inter-observer consistency of observations for both cup-to-disc ratio and optic color (0.61 and 0.79, respectively). A paired t-test showed that change in optic pallor was significant after treatment with PRP (p = 0.0004). However, when comparing to the change in the control group using a Student’s t-test, no significance was found (p = 0.387). No significant change was found in cup-to-disc ratio.

Several conclusions can be made from this study. First, the newly created grading scheme for optic pallor is both reliable and reproducible. While PRP treatment may cause an increase in optic pallor, the change is not significantly different from that seen with merely the passage of time. Lastly, cup-to-disc ratio was not significantly affected by PRP treatment. Further studies may be required to elaborate on the effect of PRP on the optic nerve.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Cost Analysis of Clinic and Office-Based Treatment of Opioid Dependence

Emlyn S Jones ¹, Brent A Moore ¹, Jody L Sindelar ¹, Patrick G O'Connor ¹, Richard S Schottenfeld ¹, David A Fiellin ¹

The cost of methadone and buprenorphine treatment in office and clinic-based settings may determine their adoption in a healthcare system. To compare the cost of office-based buprenorphine (OBB), office-based methadone (OBM), and clinic-based methadone outpatient treatment program (OTP) among stabilized patients, we analyzed costs for six months of treatment from the societal perspective, considering provider and patient variables. All patients had demonstrated clinical stability on an opioid agonist for at least 12 months prior to study entry. OBB (n = 34) and OBM (n = 21) patients completed monthly physician visits with bi-weekly or weekly medication visits, while OTP (n = 23) patients were seen once to thrice weekly. Provider costs included clinician, laboratory, medication, and administrative costs. Patient costs included transportation, lost wages, and childcare expenses. Statistical comparisons were performed using ANOVA and chi-square analyses. At baseline, the OBB group was younger (mean = 35.6 years vs. 42.8 in OBM and 41.0 in OTP, p < 0.001), was less likely to have a history of IV drug use (29.4 percent vs. 57.1 percent in OBM and 87.0 percent in OTP, p < 0.001), had fewer years of regular opioid use (mean = 7.7 years vs. 12.0 in OBM and 15.2 in OTP, p = 0.001), and had a higher monthly income (mean = $2,537 vs. $1,375 in OBM and $1,192 in OTP, p = 0.017). Both the OBB and OBM groups had fewer known HIV-positive subjects than the OTP group (2.9 percent and 4.3 percent vs. 28.6 percent, p = 0.005). There were no differences between the groups in sex, marital, educational, and work status. Six-month treatment retention (85.3 percent in OBB, 90.5 percent in OBM, and 82.6 percent in OTP, p = 0.749) and percentage of urine samples free of illicit opioids (82.7 percent in OBB, 95.3 percent in OBM, and 85.7 percent in OTP, p = 0.159) did not differ between groups. The cost of providing one month of treatment per patient was $411 (OBB), $239 (OBM), and $179 (OTP) (p < 0.001). Mean monthly medication costs were $257 (OBB), $86 (OBM), and $93 (OTP). The cost of receiving treatment was $58 (OBB), $68 (OBM), and $99 (OTP), (p = 0.312). The total annual cost to society was $5,679 (OBB), $3,578 (OBM), and $3,343 (OTP), (p < 0.001). Sensitivity analysis indicates that variation in clinical contact and cost estimates result in total costs between $4,488 and $13,176 (OBB), $2,528 and $4,923 (OBM), and $2,611 and $8,095 (OTP). Patient costs, however, were lower for the OBB group, $33.55 to $64.92 vs. $49.18 to $105.02 (OBM) and $83.87 to $254.12 (OTP). We conclude the following: Office-based treatment with buprenorphine is more expensive than treatment with methadone in most scenarios; the price of buprenorphine accounts for a major portion of the difference in costs; the value placed on patient time is an important part of determining total cost; and office-based treatment puts less economic burden on patients. As patients are likely to base their decision to enter treatment on economic factors, this has important implications for the expansion of treatment.

Yale J Biol Med. 2007 Nov;80(1):1–38.

The Epidemiology and Incidence of Visual Deficits Following Ocular Trauma in Pediatric Patients

Viral V Juthani ¹, M Bruce Shields ¹

Ocular trauma has long been a significant disabling American health problem and a leading cause of unilateral visual loss in children. These injuries have many diverse costs, including human suffering, long-term disabilities, loss of productivity, and economic hardship. Although several studies have evaluated the epidemiology of specific types or mechanisms of ocular trauma, there are few that describe the epidemiology and visual outcomes of a comprehensive set of ocular trauma diagnoses. The purpose of this thesis is to describe the incidence of significant deficits in visual acuity following pediatric ocular trauma and describe the overall epidemiology of pediatric ocular trauma presenting to the Yale Eye Center or Yale Ophthalmology consult service between 1999 and 2006.

A retrospective analysis of 396 cases of pediatric ocular trauma that presented to the Yale Eye Center or Yale Ophthalmology Consult Service between 1999 and 2006 was performed, in which the study population was defined as children between 0 and 18 years of age with the following ICD-9 codes: 802.4-802.9 (malar, maxillary, orbital floor, and facial bone fractures), 870.0-870.9 (open wounds of the ocular adnexa), 871.0-871.9 (open wounds of the eyeball), 918.0-918.9 (superficial injury of the eye and adnexa), 921.0-921.9 (contusion of the eye and adnexa), 950.0-950.9 (injury to optic nerve and pathways), and 951.0-951.4 (injury to the other ocular cranial nerves). All data were examined for any correlation between parameters studied. Statistical significance for categorical data was performed using 2x2 contingency tables, Fisher’s exact test, and two-tailed P values.

Sixty-one patients (15.4 percent) had a final visual acuity with some degree of deficit. However, only a small proportion (7.3 percent) of children seen for an ocular injury was significantly visually impaired in the affected eye as a result of the injury. Males had a disproportionately large representation in the blindness category, in which they made up 77.3 percent compared to 65 percent of the overall patient population. Males in the 10- to 14-year age group were at the highest risk for eye injury (20.9 percent), and females in the 5- to 9-year age group were at the lowest risk (8.7 percent). The most common injuries were superficial injuries to the eye and ocular adnexa (33 percent) and contusions of the eye and adnexa (27.6 percent). In all age groups, the most common sites of injury were in the home (30.6 percent) and on streets/roads (30.6 percent).

The data presented demonstrate a clear need for primary prevention and control of pediatric ocular trauma. Education targeting parents, teachers, and children regarding hazardous objects, toys, and the devastating consequences of seemingly innocuous actions is needed to reduce the incidence of ocular trauma and its consequences. It will also be important to continue to recognize the geographic variability and dynamic changes throughout time in the epidemiology of ocular trauma.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Effects of the New Histone Deacetylase Inhibitor PXD101 in Bladder Cancer

Hristos Z Kaimakliotis ¹, Marcia Wheeler ¹, Robert M Weiss ¹

Histone deacetylase inhibitors (HDACIs) mediate gene expression and chromatin assembly and induce growth arrest and apoptosis of tumor cells, thus representing a new strategy for human cancer therapy. This study examined the effect of a new HDACI, PXD101, on apoptosis signaling pathways, cell growth, and cell-cycle arrest.

T-24 cells were incubated with PXD101 at varying concentrations and times, and viable cell count and proliferation curves were constructed. Cell cycle analysis was conducted with Fluorescent Activated Cell Sorting (FACS), and changes in apoptosis signaling proteins previously found to be regulated by survivin-siRNA in T-24 cells were assessed by Western blot.

Treatment of T-24 bladder cancer cells with the HDAC inhibitor PXD101 causes a profound decrease in cell growth and viability, a specific G2/M phase arrest, and an increase in apoptotic cells populations. PXD101 treatment also causes changes in upstream mitochondrial apoptosis mediators, including TNFR1 and caspases 2 and 8, and downstream apoptosis mediators, such as caspase 3 and survivin. PXD101 treatment of tumor cells is associated with a profound decrease in survivin and caspase levels and an increase in TNFR1 protein levels. Both aforementioned changes indicate induction of apoptosis.

Therefore, the new HDACI PXD101, alone or in combination with inhibitors of other tumor relevant factors and chemotherapies with complementary mechanisms of action, shows promise for its use as a suitable new agent for bladder cancer treatment.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Placental Localization and Perinatal Outcome

Lucy E G Kalanithi ¹, Jessica L Illuzzi ¹, Errol R Norwitz ¹

This retrospective case-control study was designed to investigate the relationship between placental localization and intrauterine growth restriction (IUGR). Pregnant women with an anatomic survey from January 1, 2000, to December 31, 2005, and delivery of the pregnancy at Yale-New Haven Hospital (YNHH) were identified using clinical and billing records. Multiple gestation, fetal anomaly, and incomplete medical information were reasons for exclusion. Cases (N = 69) were consecutive pregnancies with evidence of IUGR (estimated fetal weight < 10^th percentile for gestational age) at last follow-up ultrasound. Randomly selected controls (N = 258) from the same time period had no evidence of IUGR. Maternal, ultrasound, delivery, and perinatal data were collected by retrospective medical record review. IUGR cases and non-IUGR controls were compared using the Student’s t-test, Wilcoxon test, Chi-square analysis, Fisher’s exact test, and ANOVA. Placental location was determined from the anatomic survey record (obtained at 18.4 ± 1.2 weeks gestation in the IUGR group and 18.2 ± 1.0 weeks gestation in the control group; P = .18). Multivariate logistic regression with adjustment for confounders was used to investigate the association between IUGR and placental localization. Consistent with known predictors of IUGR, the IUGR group had a higher proportion of black women (36.4 percent vs. 19.8 percent, P = .03), chronic hypertension (26.0 percent vs. 3.5 percent, P < .001), and hypertensive disorders of pregnancy (36.2 percent vs. 5.0 percent, P < .001). Mean birth weights of IUGR and non-IUGR pregnancies differed by 2 kilograms (3,244 ± 625 grams vs. 1,277 ± 637 grams, P < .001). IUGR infants were more likely to receive antenatal steroids, deliver preterm, deliver by Cesarean section, and be admitted to the neonatal intensive care unit. In both IUGR and non-IUGR pregnancies, the placenta was most commonly anterior or posterior. Unilateral placentas were three times more common in the IUGR group than in the non-IUGR group (17.4 percent vs. 5.0 percent, P = .01). IUGR pregnancies were over four times as likely as control subjects to have unilaterally located placentas compared to anterior placentas (OR 4.8, 95 percent confidence interval, 1.9-11.7). Adjusting for ethnicity, chronic hypertension, and hypertensive disorders of pregnancy did not affect this finding (OR 4.6, 95 percent confidence interval 1.6-13.5). In conclusion, we compared a group of 69 IUGR pregnancies to 258 non-IUGR controls and found intrauterine growth restriction to be associated with unilateral placentation.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Altered Parvalbumin-Positive Neuron Distribution in Basal Ganglia of Individuals with Tourette Syndrome

Paul Kalanithi ^a, Wei Zheng ^a, Yuko Kataoka ^a, Marian DiFiglia ^c,^e, Heidi Grantz ^a, Clifford B Saper ^d,^e, Michael L Schwartz ^b, James F Leckman ^a, Flora M Vaccarino ^a,^b

The neuropathology of Tourette Syndrome (TS) is poorly characterized. This thesis provides the first quantitative stereologic immunohistochemical study of the basal ganglia in TS. TS is a childhood neuropsychiatric disorder characterized by motor and vocal tics. Previous imaging studies found alterations in caudate (Cd) and putamen (Pt) volumes. To investigate possible alterations in cell populations, postmortem basal ganglia tissue from individuals with TS and normal controls (NC) was analyzed using unbiased stereological techniques. A markedly higher (> 160 percent of control) total neuron number and density was found in the internal segment of the globus pallidus (GPi) of TS (p < 0.025). An increased number (> 220 percent of control) and proportion of these GPi neurons were positive for the calcium-binding protein parvalbumin (PV) in the tissue from TS subjects (p < 0.025). In contrast, a lower number (< 60 percent of control) of neurons was observed in the external segment (GPe) (p < 0.025). In addition, there was a lower density of PV-positive interneurons in both Cd (< 50 percent of control) and Pt (< 65 percent of control) (p > 0.025). The imbalance in striatal and GPi inhibitory neuron distribution suggests that the functional dynamics of cortico-striato-thalamic circuitry are fundamentally altered in severe, persistent TS.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Infants and Parental Presence during Induction of Anesthesia

Deborah E Kaplan ¹, Zeev N Kain ¹

Previous studies have investigated the physiological and behavioral effects of parental presence in the operating room (OR) during the induction of anesthesia (PPIA), both on the child and the parent. Since the characterization of anxiety in infants presents a unique challenge due to their inability to communicate verbally, these studies have typically focused on children greater than 2 years old. In the present study, we addressed this understudied population directly by using highly reliable and validated behavioral instruments as well as analyzing sleep patterns and signs of distress in the infants. The hypothesis tested was the same as in the older child populations: Parents and infants of parents who are present in the OR during the induction of anesthesia will demonstrate less behavioral and physiological anxiety than those parents and infants who do not experience PPIA.

According to randomized controlled study design, the subjects were randomly assigned into either (1) the PPIA group (parents present in the OR until the infant is asleep) or (2) the Control group (parents not present in the OR).

To date, we have enrolled 10 patients to this study (n = 10). Patient recruitment is ongoing. Because of the small sample size, data are unstable, and thus, a detailed discussion is beyond the scope of this abstract.

Parental presence is a highly significant issue for parents of children undergoing induction of anesthesia. This topic is particularly important within the context of family centered care. Further data are needed to finalize our conclusions.

Yale J Biol Med. 2007 Nov;80(1):1–38.

The Use and Safety of Vascular Occlusion Techniques: A Survey of Practicing Surgeons

Ryan P Kelly ¹, Amy L Friedman ¹

Vascular occlusion techniques can be divided into two categories: transfixion and non-transfixion. Transfixion techniques are defined by the passage of suture material or staples through the vascular tissue. Non-transfixion techniques are defined as suture, metal, or polymer material placed solely around the vascular tissue.

The purpose of this study was to survey surgeons in various specialties to determine which vascular control technique they believe is safest and most appropriate to manage medium-sized arteries 6 to 10mm in diameter.

A survey was distributed to surgeons in the following specialties: general surgery, urology, thoracic surgery, vascular surgery, obstetrics and gynecology, and colon and rectal surgery. Survey recipients were all members of the American College of Surgeons practicing in New York and New England. The survey asked questions focused on the use, perceived safety, and technical failure of vascular occlusion techniques applied to the renal, splenic, and cystic arteries. The smaller cystic artery was included as a control.

Five hundred six surgeons completed the survey. The survey found that more surgeons chose transfixion techniques vs. non-transfixion techniques to occlude the renal artery in both open and laparoscopic operations (open = 72 percent vs. 28 percent, p < 0.0001; laparoscopic = 55 percent vs. 45 percent, p < 0.01). More surgeons chose transfixion techniques vs. non-transfixion techniques to occlude the splenic artery (open = 68 percent vs. 32 percent, p < 0.0001; laparoscopic = 60 percent vs. 40 percent, p < 0.0001). In contrast, fewer surgeons chose transfixion techniques vs. non-transfixion techniques to occlude the cystic artery (open = 15 percent vs. 85 percent, p < 0.0001; laparoscopic = 4 percent vs. 96 percent, p < 0.0001).

Respondents were asked to rate the safety of vascular occlusion techniques on a five-point Likert scale ranging from 1 "unsafe" to 5 "extremely safe." Transfixion techniques were considered safer than non-transfixion techniques to occlude the renal artery (mean safety rating: 3.9 ± 0.5 vs. 2.6 ± 0.7). Transfixion techniques were considered safer than non-transfixion techniques to occlude the splenic artery (mean safety rating: 3.9 ± 0.4 vs. 2.6 ± 0.6). Transfixion and non-transfixion techniques were considered equally safe to occlude the cystic artery (mean safety rating: 3.9 ± 0.5 vs. 3.8 ± 0.5).

Respondents reported more cases of technical failure and severe hemorrhage associated with non-transfixion techniques than transfixion techniques for all three arteries: renal, 44 cases (89 percent non-transfixion, 11 percent transfixion; p < 0.0001); splenic, 50 cases (74 percent non-transfixion, 26 percent transfixion; p < 0.0001); cystic, 68 cases (96 percent non-transfixion, 4 percent transfixion; p < 0.0001).

In conclusion, to occlude blood vessels 6 to 10mm in diameter, surgeons chose transfixion techniques more frequently than non-transfixion techniques for both open and laparoscopic operations, considered transfixion techniques safer than non-transfixion techniques, and reported fewer cases of technical failure and severe hemorrhage associated with transfixion techniques than non-transfixion techniques.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Adolescent Medicine: Attitudes, Training, and Experience of Pediatric, Family Medicine, and Obstetric-Gynecology Residents

Rebecca Kershnar ¹, Jessica Illuzzi ¹

Several studies have documented a deficiency in the delivery of preventive services to adolescents during physician visits in the United States. In many instances, a correlation has been noted between insufficient training and provision of adolescent medicine services in the practicing physician population. The American Medical Association, American Academy of Pediatrics, American Academy of Family Physicians, American College of Obstetrics and Gynecology, and Society for Adolescent Medicine recommend adolescent providers deliver comprehensive health services to teenagers. This study sought to assess and compare pediatric, family medicine, and obstetric-gynecology resident perceptions of their responsibility, training, experience, and comfort with providing comprehensive healthcare services to adolescents. We asked residents to identify the following: (1) adolescent health services they considered part of their scope of practice in their respective field; (2) the level of training they had received with regard to select adolescent health services; (3) the experience they had with performing select clinical activities with adolescents; and (4) their comfort with aspects of adolescent care. We also asked two questions to test resident knowledge of an adolescent’s right to consent to contraception or an abortion without parental notification in the state of their residency. Eighty-seven residents (31 obstetric-gynecology, 29 family medicine, and 27 pediatric) were surveyed. Most residents from all three fields felt the full range of adolescent preventive and clinical services represented in the survey fell under the scope of their practices. Most residents also reported high levels of comfort with examined aspects of adolescent care. In regard to some activities, the positive scope and comfort responses were matched by high reported levels of training and experience, including defining confidentiality; counseling about eating, exercise, and obesity; counseling about substance abuse; and discussing STDs, sexual partners, and contraception. However, for multiple key adolescent services, considerable discrepancies existed between reported levels of training and experience and the positive responses concerning scope and comfort. In particular, the results of the study suggested all residents need considerably more training and experience with mental health issues, referring teenagers for substance abuse treatment, and addressing physical and sexual abuse. Overall, there were also significant differences between fields. Family medicine residents reported the greatest potential for providing comprehensive healthcare. However, they suffered from the overall deficiencies in training and experience noted above. Obstetric-gynecology residents reported deficiencies in the provision of several preventive counseling and general health services. Pediatric residents reported multiple deficiencies in the provision of sexual health services. Our results indicate that at this time and in the near future, it is unlikely adolescents will be able to obtain the full range of recommended preventive and clinical services in a single physician visit, unless residency programs actively incorporate increased training in the full range of adolescent preventive and clinical health services.

Yale J Biol Med. 2007 Nov;80(1):1–38.

CT Scan Findings of the Thoracic Aorta Following Surgical Repair

Jessica L Kirk ¹, Anne McBride Curtis ¹

This study evaluated post-operative CT scans to determine the normal postoperative appearance following thoracic aorta surgery. One hundred eighty-eight CT studies in 102 patients were analyzed for presence of perigraft fluid collections and pleural effusions and other abnormalities of the mediastinum. Fifty-seven of 102 patients (56 percent) had perigraft fluid at the time of their first postoperative CT scan. The majority of collections disappeared over time, but some persisted with 22 percent scans showing fluid at greater than 24 months post-operatively. Pleural effusions were present on 86 percent of scans in the first post-operative month and only 9 percent of scans after one year. Pseudoaneurysms occurred in three of 48 ascending aortic procedures (6.2 percent) and four of 38 descending aortic procedures (10.5 percent). Complications were rare, and no radiographic findings were predictive of such. Knowledge of operative procedures and normal postoperative appearance is essential for correct interpretation of postoperative CT scans.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Educating Adolescents about Acne Vulgaris: A Comparison of Written Handouts with Audio-Visual Computerized Presentations

Phoebe E Koch, Hilary F Ryder ^a, James Dziura ^b, Valentine Njike ^c, Richard J Antaya ^d

This randomized clinical study aimed to compare the efficacy of written handouts with that of audio-visual computerized presentations in educating adolescents about acne vulgaris. The study included 101 adolescent patients, aged 13 to 17 years, presenting to a private dermatology practice or one of three pediatric clinics in New Haven, Connecticut. All participants completed a brief enrollment questionnaire to gauge baseline knowledge about acne vulgaris. Subjects were then randomized to receive either a written handout or an audio-visual computerized presentation. Immediately following the intervention, and again at one month, patients were asked to complete identical questionnaires to assess change in knowledge about acne. The main outcome measure was change in knowledge about acne vulgaris, as indicated by performance on pre-intervention, post-intervention, and one-month follow-up questionnaires. Baseline questionnaires were completed by 21 patients in the pilot study and 80 subjects in the revised study; 17 (80.95 percent) and 77 (96.25 percent) completed the respective studies. In both the pilot and revised studies, there was no significant difference between intervention groups in terms of baseline knowledge or gain-in-knowledge. Immediately post-intervention, both groups showed significant improvement from baseline (P < .0001 revised study, P < .01 pilot study). At the one-month follow-up, patients in the pilot study randomized to receive the computerized presentation still showed significant gain in knowledge from baseline (p < .05), while those in the handout group did not. Meanwhile, both intervention groups in the revised study continued to show significant gain in knowledge from baseline at one month (p < .0001). From the above results, it appears that both written handouts and audio-visual computerized presentations about acne vulgaris confer significant and equivalent benefits in terms of short- and long-term knowledge gains among adolescent patients with acne.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Gene Expression Patterns in Patients with High-Altitude Pulmonary Edema: A Gene Microarray Analysis

Lauren Kendall Krause ¹, Robert Roach ¹

Multiple modulating genes and environmental factors have been implicated in the pathogenesis of high-altitude pulmonary edema (HAPE). However, at the present time, there exists an incomplete understanding of the molecular mechanisms and pathways that underlie constitutional susceptibility. Genome-wide measurements of gene expression in peripheral blood mononuclear cells (PBMCs) were performed using microarray technology. Comparison of gene expression profiles of HAPE-susceptible and resistant individuals resulted in the identification of several previously undescribed candidate genes. RhoA and Rho-kinase (ROCK), regulators of vascular smooth muscle contraction, were differentially regulated in the HAPE-susceptible cohort, as compared to both HAPE-resistant patients with acute mountain sickness (AMS+) and healthy controls (p = 0.0014; p = 0.0020). Furthermore, biological pathways involving RhoA and Rho-kinase were strongly upregulated in subjects with HAPE. These findings represent the first description of the RhoA/Rho-kinase signaling pathway in HAPE. Currently, few pharmacologic therapies have been demonstrated to be effective in the prevention and treatment of HAPE. The results of this study provide early evidence that Fasudil, a selective Rho-kinase inhibitor, may represent a novel therapeutic intervention effective in the prevention and/or treatment of high-altitude pulmonary edema.

Yale J Biol Med. 2007 Nov;80(1):1–38.

The Relationship Between Direct-to-Consumer Marketing and the Self-Perception of GERD Symptoms in the Young Adult Population

Sheila Kumar ¹, Priya Jamidar ¹

The purpose of this study was to determine the prevalence of gastroesophageal reflux disease (GERD) symptoms in a young adult population of university students and to examine the relationship between direct-to-consumer (DTC) marketing and the self-perception of GERD symptoms.

GERD is defined as the spectrum of disease usually producing symptoms of heartburn and acid regurgitation. Previous studies have varied prevalences in the adult population ranging from 5 percent to 45 percent, depending on the method of diagnosis. However, very little is known about the prevalence of GERD in the young adult population. Proton pump inhibitors (PPIs) are widely utilized to control GERD symptoms and have been available without a prescription since 2003. During this period, the use of DTC marketing of prescription medications was permitted in the United States. The prevalence of GERD in the young adult population, as well as the impact of DTC advertising on the self-reporting of GERD symptoms, is largely unknown.

A group-administered questionnaire of 168 graduate and undergraduate students at Yale University was performed between September 2006 and December 2006. The mean age of respondents was 22.26 years; 68.64 percent of respondents were female. When using a diagnostic qualification of mild symptoms at least one day a week, 3.57 percent of the subject population reported heartburn symptoms, 8.92 percent reported regurgitation symptoms, and 1.79 percent reported both heartburn and regurgitation symptoms. Of the respondents, 92.3 percent reported exposure to DTC ads, with 89.83 percent exposed to PPI advertisements. There was no correlation between exposure to advertisements for heartburn/reflux medications and the self-reporting of GERD symptoms.

The prevalence of GERD symptoms in this young adult population is lower than that reported in adult populations. Direct-to-consumer marketing does not appear to influence the way this population perceives GERD symptoms.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Penile and Scrotal Human Papillomavirus Infection in HIV-Positive And HIV-Negative Men Who Have Sex with Men: Relationship with Anal Human Papillomavirus Infection

Victoria Kuohung ¹, Joel Palefsky ¹

We assessed the prevalence of human papillomavirus (HPV) infection at the penis and scrotum in HIV-positive and HIV-negative men who have sex with men (MSM), who were all patients with preexisting anal HPV disease attending the Anal Neoplasia Clinic at the University of California, San Francisco (UCSF). Between January and May 2006, we recruited 169 (79.0 percent) HIV-positive and 45 (21.0 percent) HIV-negative MSM and collected cell samples from the anus, penis, and scrotum. To identify HPV infection in these samples, we performed polymerase chain reaction (PCR) with a generic HPV probe, 29 specific HPV probes, and a mixed probe for 10 different nononcogenic HPV types.

Of all subjects, 85.1 percent had anal HPV infection, 47.3 percent were infected with HPV at the penis, and 35.1 percent were infected at the scrotum. Of HIV-positive MSM, 52.5 percent had penile HPV (0.60 times this group’s anal HPV infection rate), and 41.0 percent had scrotal HPV (0.47 times this group’s anal HPV infection rate). Of HIV-negative MSM, 27.9 percent had penile HPV (0.38 times their anal infection rate), and 15 percent had scrotal HPV (0.20 times this group’s anal HPV infection rate).

For all subjects, anal HPV infection was strongly associated with penile HPV infection (p < 0.0001), leading to a statistically significant odds ratio (OR) of 6.13 for penile HPV. Anal HPV infection was also strongly associated with scrotal HPV infection for all subjects (p < 0.0001), leading to a 1.87 OR for scrotal infection. Penile HPV infection was associated with scrotal HPV infection (p = 0.0247), with a statistically significant 3.5–fold greater risk of developing scrotal HPV infection given penile HPV. In contrast to nononcogenic infection, oncogenic anal HPV infection led to statistically significant increased risks for oncogenic penile (4.50 OR) and scrotal (4.22 OR) HPV infection. Oncogenic penile HPV infection led to a 20.44 OR for oncogenic scrotal infection.

Compared to HIV-negative MSM, HIV-positive MSM were at a 1.88 relative risk for penile HPV infection and a 2.74 relative risk for scrotal infection. Statistically more HPV types were detected at the penis in HIV-positive MSM than HIV-negative MSM. For HIV-positive MSM only, anal HPV infection led to a statistically significant 9.79 OR for penile HPV infection, and penile HPV infection led to a statistically significant 3.8 OR for scrotal HPV.

Of all subjects, 31.1 percent shared a specific HPV type at exactly two sites, and 22 percent shared a specific type at all three anogenital sites. Of HIV-positive MSM, 26.7 percent shared a specific HPV type in common at all three sites, compared to only 3.7 percent of HIV-negative MSM, a statistically significant difference.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Understanding the Role of the Epithelial-Mesenchymal Transition in Prostate Cancer

Aram J Lee ¹, Robert Reiter ¹

The purpose of this study was to characterize the role of the epithelial-mesenchymal transition (EMT) in the transformation of local, noninvasive prostate cancer to more invasive, metastatic subtypes. EMT is a process during early tumorigenesis by which epithelial cells exhibit reduced cell-cell adhesion and increased motility. This process has been implicated in various types of cancer. Through quantitative RT-PCR analysis, members of Dr. Reiter’s lab demonstrated that some clinical metastatic prostate cancer samples express high levels of N-cadherin (neuronal-cadherin), a mesenchymal marker. Through DNA analysis, we found that N-cadherin is a gene product that is highly upregulated in androgen-independent LAPC4 and LAPC9 prostate cancer xenografts, compared with isogenic androgen-dependent xenografts. Protein studies of the xenografts confirmed the upregulation of N-cadherin. We then examined the role of N-cadherin in vitro studies utilizing human androgen-dependent LNCaP prostate cancer cells. Overexpression of N-cadherin in LNCaP cells initiated a morphological change from an epithelial to a mesenchymal phenotype. This overexpression also suppressed the expression of epithelial markers such as E-cadherin (epithelial-cadherin) and B-catenin and induced the expression of the mesenchymal markers N-cadherin and vimentin. Furthermore, increased N-cadherin was positively correlated with increased invasiveness of cells using Matrigel chamber assays. N-cadherin upregulation also triggered increased cellular growth, androgen independent cell behavior, and the downregulation of inhibitors of proliferation such as p21. In summary, these in vitro studies confirmed that increased N-cadherin expression in prostate cancer is intimately correlated with increased cellular proliferation and invasion and provides a promising antigenic target for prostate cancer therapy.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Early Seizure Blockade: Preventing Long-Term Epileptic Activity in WAG/Rij Rats

April R Levin ^a, Matthew L Vestal ^a, Frederick Wang ^a, Kathryn Giblin ^a, Crystal Paul-Laughinghouse ^a, Tim Rice ^a, Anne M Phadke ^a, Davender S Khera ^a, Joshua P Klein ^a, John Mission ^a, Chhitij Bashyal ^a, Joshua Motelow ^a, Hrachya Nersesyan ^a, RK Agarwal ^a, Dario J Englot ^a, Ulrich Schridde ^a, Steven G Waxman ^a, Hal Blumenfeld ^a,^b,^c

The purpose of this study was to determine how early seizure blockade with ethosuximide (ESX) would influence ion channel expression and long-term spike-wave discharge (SWD) activity in epileptic WAG/Rij rats. The goal was to elucidate the question "Do seizures beget seizures?" in a genetically prone model and, if so, to attempt to interrupt this cycle by early intervention. In our first experiment, we used immunocytochemistry to determine the effect of ESX on cortical expression of ion channels in treated and untreated WAG/Rij rats and age-matched Wistar controls. This experiment revealed that treatment with ESX blocked the upregulation of Nav1.1 and Nav1.6 as well as the downregulation of HCN1 associated with epileptic activity in rats (p < .05). In a second experiment, WAG/Rij rats were divided into three groups: untreated (H₂O), temporary early treatment (ESX 4 month), and continuous early treatment (ESX continuous). SWD activity was measured by electroencephalogram (EEG) at various timepoints. This second experiment revealed that animals in the ESX 4 month group spent less percent time in SWD (0.242 ± .068 SEM) than animals in the H₂O group (0.769 ± .060 SEM, p < .001), although they spent slightly more percent time in SWD than animals in the ESX continuous group (0.020 ± .065 SEM, p = .003). This effect was predominantly due to seizure number, and average seizure duration did not vary among the three groups. Additionally, power spectrum analysis revealed a significant correlation when the difference between power spectra for H₂O and ESX 4 month rats was compared to the power spectrum of a seizure (Pearson correlation equals 0.955, 2-tailed significance < .000000001), suggesting quantitatively that seizures were reduced by temporary early treatment. This suggests that early prevention of SWD may reduce the burden of seizures later in life and possibilities for prevention of genetic absence epilepsy should be further investigated.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Mechanical Properties of Aneurysms of the Descending Human Aorta

Peter Lin, Raj Modak ^a, Maryann Tranquilli ^b, Paul Barash ^a, John Elefteriades ^b

Objective: Treatment decisions for aortic aneurysms are currently based on size criteria originally developed in the 1960s, even though we now have more sophisticated methods that can refine interventional criteria. In this project, we applied engineering principles in order to generate a comprehensive picture of the mechanical properties of descending thoracic aortic aneurysms, including their ability to deform in response to pressure, as well as the stresses that cause wall stretch or rupture. Our goal was to use these mechanical properties to understand, explain, and predict the tendency of descending aneurysms to rupture or dissect.

Methods: Using an epi-aortic ultrasound probe, we intra-operatively measured aortic wall thickness during systole and diastole, circumference during systole and diastole, and blood pressure on 12 patients undergoing elective resection of their descending aortic aneurysms. From these measurements, we calculated the distensibility, wall stress, elastic modulus (E_inc), and pulse wave velocity (PWV) for the neck (narrow portion) and belly (widest portion) of fusiform aneurysms. We compared these mechanical properties between the neck and belly of descending aortic aneurysms with a paired t-test, as well as between ascending and descending aortic aneurysms with an unpaired t-test.

Results: The average aneurysm belly was 4.1 cm in diameter compared to 2.7 cm in the neck (p = 0.0002). Distensibility was higher in the neck than the belly (p = 0.02), the wall stress was higher in the belly (p = 0.01), and E_inc was non-significantly higher in the belly (p = 0.08). There was no significant difference in PWV (p = 0.33). There were no significant differences in any of the mechanical properties between descending and ascending aortic aneurysms.

Conclusion: Larger aneurysms are at increased risk of rupture because 1) they experience greater circumferential wall stress tending to expand the lumen, and 2) they are less distensible with a higher elastic modulus, which indicates they have less reserve stretch capacity. We also showed that different sections of the same aneurysm behave differently, but the ascending and descending aortic aneurysms behave similarly. These findings have implications on the validity of using mechanical parameters to predict the natural course of aortic aneurysms. Finally, we demonstrated that there may be better ways to predict aortic rupture or dissection than current standards using diameter or growth rate alone.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Mapping the Interaction of TUG With GLUT4, a Major Insulin-Responsive Glucose Transporter

Stefan Mansourian ¹, Johnathan Bogan ¹

The glucose transporter 4 (GLUT4) is the major insulin-responsive glucose transporter in adipose and muscle tissues. Although the early steps in the insulin signaling pathway governing translocation of GLUT4 to the plasma membrane are well understood, the final steps in this pathway are not. TUG, tethering protein containing a UBX domain for GLUT4, is a protein that has been shown to affect trafficking of GLUT4 both in the basal state and in response to insulin. One protein-protein interaction between TUG and the large cytosolic loop of GLUT4 previously has been identified. Based on reports of the requirement of the GLUT4 N-terminal domain for its proper targeting to the plasma membrane, we postulated that an interaction might also exist between TUG and the N-terminal domain of GLUT4, and we tested this hypothesis using two sets of pull-down experiments. In the first set, using the N-terminal domain of GLUT4 fused with glutathione S-transferase (GST), we were able to pull TUG down from the lysates of TUG-transfected HEK 293 cells. TUG also was pulled down by the GLUT4 cytosolic loop and, to a much lesser extent, its C-terminal domain. However, there was no specific interaction between these fusion proteins, and the lysates of cells transfected with a truncated form of TUG lacking its own N-terminal domain. In the second set of experiments, using a biotinylated synthetic GLUT4 N-terminal peptide, we pulled down a protein detected by an anti-TUG antibody and running at ~64 kDa, a slightly higher molecular weight than wild-type TUG. We believe that this band represents modified full-length TUG. This interaction was not seen using synthetic GLUT4 N-terminal peptide mutated at four amino acids previously identified as necessary for proper GLUT4 retention and insulin-responsive trafficking. We conclude that TUG interacts not only with the large cytosolic loop of GLUT4, but also with the N-terminal domain of GLUT4, and this latter interaction can be disrupted by mutations in GLUT4 that cause defective trafficking, suggesting that this interaction is critical for GLUT4 intracellular retention and insulin-responsive GLUT4 trafficking.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Cellular and Synaptic Organization of the Human Olfactory Bulb

Alison Maresh ¹, Charles A Greer ¹

The distribution of cell types and synapses is well characterized in the rodent olfactory bulb (OB), and from that, plausible models of odor processing have been constructed. Individual olfactory sensory neurons (OSNs) express only one of ~1000 odorant receptors (ORs) and send their axons to specific synaptic targets in the OB glomerular neuropil. Each glomerulus is innervated exclusively by OSN axons expressing the same OR. The distribution of these glomeruli is conserved across animals, as is the numerical relationship between number of expressed ORs and number of glomeruli in the OB. Our objective is to extend such results to the level of the human OB to determine how its cellular and synaptic organization, and more specifically how the number and distribution of its glomeruli, compare to what has been elucidated in mice. As there are ~2,000 glomeruli for ~1,000 ORs in mice, we predicted ~700 glomeruli in humans, based on the ~350 intact OR genes identified in the human through genomic studies. Using immunohistochemistry, the organization of cells and synapses in human OBs was evaluated and quantified. While the laminar structure of the OB is broadly conserved between species, in the human OB the laminar organization as well as additional structural features suggest a less rigorously organized OB than in rodents, perhaps suggesting that odor processing in the human OB may be less efficient than in mice. Of particular note, the total number of glomeruli in the human OB differs significantly from predicted and demonstrates a high degree of variability among specimens, thus far ranging from approximately 3,000 to 9,000/OB. These results indicate that the principles of OR-homotypic axon convergence developed from mouse studies may not be readily applicable to the human, and central processing of odor signals in the human may differ from those characterized in the mouse.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Hypnosis for Relief of Pain and Anxiety in Children Receiving Intravenous Lines in the Pediatric Emergency Department

Maya Maxym ¹, Linda Arnold ¹

Intravenous line placement is one of the most common procedures performed on children presenting to the Emergency Department. Anxiety about needles is widespread, and many children experience high levels of fear and/or pain with their IV line placements. Hypnosis is a behavioral intervention that shows significant promise for alleviating procedure-related pain and anxiety in children. Twenty-five developmentally normal, English-speaking children between the ages of five and 15 who required IV line placement in the Pediatric Emergency Department at Yale-New Haven Children’s Hospital were randomized to receive either the standard of care or standard of care plus a brief hypnotic intervention. The groups were similar with regard to baseline demographic and socioeconomic status, previous experience with medical care, and presence or absence of chronic medical conditions. Children’s pre-procedural anxiety ratings on a 10cm visual analog scale (VAS) and expected procedural pain ratings by 10-point oucher and 10cm VAS were not significantly different between the groups. Children randomized to the hypnosis group reported less anxiety during the procedure (mean 5.0 vs. 3.1, median 7.2 vs. 2.2, p = 0.28) than children randomized to the standard of care group. Cases also had a decrease in anxiety from expected to actual of 1.6 on a 10cm scale, while those randomized to the control group had an increase from expected to actual anxiety of 1.1 (p = 0.01). A smaller trend toward decreased pain in the hypnosis group was also present. As measured by VAS, cases had lower mean pain scores (3.4 vs. 4.3) than controls. In a comparison of anticipated and actual pain scores between groups, the hypnosis group had a mean decrease of 0.8 on a 10cm VAS , while the control group had a mean increase of 0.5 (p = 0.14). Recruitment of subjects is ongoing, but preliminary results suggest that hypnosis is effective for alleviating needle-related anxiety in children undergoing IV line placement and may be helpful for alleviating the pain of IV line placement as well.

Yale J Biol Med. 2007 Nov;80(1):1–38.

The Role of Bone Marrow Derived Cells in a Model of Hepatic Regeneration

Maria Mazzeo ¹, Scott Swenson ¹, Diane Krause ¹

To examine the relationship between liver injury and the appearance of bone marrow-derived hepatic cells, we performed sex-mismatched bone marrow transplants in mice with subsequent liver injury. Co-labeling for a marker of donor bone marrow origin and a marker of liver epithelial phenotype allowed us to identify rare marrow-derived hepatocytes at various time points following liver damage. The number of marrow-derived hepatocytes was low, however, and did not allow us to determine if liver-specific injury upregulated this process from baseline. We conclude that while marrow-derived hepatocytes are found, the low level of occurrence in this study makes it impossible to draw a clear temporal relationship between liver damage, recovery, and the appearance of donor-derived cells. In addition, we cannot say whether liver-specific damage upregulates this phenomenon.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Efficacy of 180 vs. 360 Degrees of Selective Laser Trabeculoplasty on Lowering Intraocular Pressure

Robert H McGlynn ¹, M Bruce Shields ¹

The purpose of this study was to determine if the application of 360° of selective laser trabeculoplasty (SLT) to the trabecular meshwork (TM) is more effective than 180° in the lowering of intraocular pressure (IOP) in glaucoma. This issue was addressed in the form of a retrospective chart review of patients treated consecutively with SLT for primary open angle glaucoma, pseudoexfoliation glaucoma, or ocular hypertension. Patients were treated with either 180° of SLT by Dr. Wand or 360° by Dr. Martone using a 532nm, Q-switched, frequency doubled Nd:Yag laser. Only the initial treatment with SLT of a given eye was analyzed. There were 108 patients per group. Patient age, type of glaucoma, history of previous argon laser trabeculoplasty (ALT), number of medications, lens status and visual acuity pre-and post-treatment, and the number and power of laser spots were compared between the treatment groups. The mean IOP from three consecutive visits prior to treatment was compared with post-operative IOPs measured at one hour, six weeks, and three months. Patients were classified as responders if the three-month postoperative IOP was reduced by more than or equal to 3 mmHg compared to baseline. At three months post-op, the 360° group had a response rate of 60 percent and a mean IOP drop of 3.6 mmHg (17.8 percent). The 180° group had a response rate of 29 percent with a mean IOP drop of 1.5 mmHg (7.5 percent). The number of pre- and post-treatment medications, eye treated, gender, phakic status, number of spots delivered, and pre-op IOP were equivalent for the two study groups. The 180° group subjects had more overall energy delivered during treatment and had previous ALT more frequently than the 360° group. The 180° group also was significantly older and less likely to have non-open angle glaucoma. This study suggests that with a 2.1 mmHg greater drop in IOP and 31 percent greater response rate at three months post-op, 360° of SLT is more effective in lowering intraocular pressure than 180°.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Nicotine Replacement Therapy and Brief Motivational Interview for Emergency Department Smokers with Asthma

Rebecca McNutt ¹, Harry Moscovitz ¹

The purpose of this study was to determine if the combined use of nicotine replacement therapy (NRT) in the form of patches and lozenges along with a Brief Motivational Interview (BMI) would have a higher quit rate and improvement of asthma symptoms among asthmatic smokers who present to the emergency department with an acute asthma exacerbation than controls who received the standard of care currently offered in the emergency department (ED). METHODS: Test subjects were recruited from the Yale-New Haven Emergency Department and randomly assigned to the NRT/BMI or standard care group. Patients answered a questionnaire and had their peak flow and exhaled carbon monoxide (CO) measured. Seven days following their presentation to the ED for their asthma exacerbation, patients were to return to the ED for follow-up. There, patients answered another survey and had their peak flow and exhaled CO remeasured. Thirty days following enrollment, patients were contacted by phone to answer a questionnaire about their smoking and asthma. The two groups were analyzed for significant differences in demographics, smoking habits, and asthma. RESULTS: The percentage of patients who quit in the NRT/BMI group was 28.6 percent and the standard care group was 42.9 percent (n = 14). These results were not statistically significant. However, the percentage of smokers who decreased the number of cigarettes in the NRT/BMI group was 100 percent and the standard care group was 40 percent. This p-value was calculated to be .027. When measuring severity of asthma symptoms, the average weekly use of rescue inhalers in the NRT/BMI group was 2.15 and 3.14 in the standard care group. Only one patient required a return trip to the ED for asthma treatment in the standard care group and none in the NRT/BMI group. CONCLUSIONS: NRT/BMI caused a decrease in smoking. No difference was seen in quit rates or asthma severity.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Social Support and Reproductive Health in 15- to 24-Year-Old Immigrant Latinas in the San Francisco Bay Area

Ahou Meydani ¹, Craig R Cohen ¹, Alexandra Minnis ¹

This study examines how social support is related to reproductive health risk among 15- to 24-year-old immigrant Latinas residing in the San Francisco Bay area. This is a cross-sectional, clinic-based study, composed of a sample of 68 immigrant Latina women, aged 15-24 (mean 18.7, S.D. 2.2), recruited from waiting rooms at two clinics in Oakland. Participants completed an interviewer-administered questionnaire and provided blood and self-obtained vaginal swab specimens to test for sexually transmitted infections. Three dimensions of social support were assessed: 1) functional support, using the Medical Outcomes Study (MOS) Social Support Survey; 2) structural support (quantity of support sources); and 3) social network characteristics. Primary reproductive health outcomes assessed included: 1) high risk sexual behaviors; 2) history of teen pregnancy and/or abortion; and 3) prevalence of Herpes Simplex Virus 2 (HSV-2), Chlamydia trachomatis, and Trichomonas vaginalis. Analyses examined relationships between social support measures and reproductive health behaviors and outcomes using multivariate logistic regression, adjusting for age, religiosity, length of stay in the United States, and socioeconomic and marital status. Of the participants, 95.6 percent were sexually active, with the mean age of sexual initiation being 15.6 years (S.D. 1.7); 30.8 percent had more than one sexual partner over the past year; 44.6 percent reported a teen pregnancy; and 12.3 percent had an abortion. Overall STI prevalence was 13.3 percent. Compared to those with lower support measures, participants with higher functional tangible support scores, as well as those who identified more people available for affectionate support and positive social interactions (structural support measures), were significantly more likely to have used condoms in the past year (adjusted odds ratios [A.O.R.s]: 2.31, 4.59, and 4.0, respectively, p < 0.05). Several measures of structural social support were protective against teen pregnancy: Participants who identified more people they could count on for informational, affectionate support, and positive social interactions were less likely to have had a teen pregnancy (A.O.R.s: 0.27, 0.36, and 0.32, respectively, p < 0.05,). Overall functional social support was protective against abortion (A.O.R. 0.16, p < 0.05). No significant associations were found between measures of social support and STI prevalence; however, a trend was noted whereby participants with higher measures of perceived functional support were more likely to have an STI. Social network characteristics found to be related to outcomes included gender proportions of the network and presence or absence of U.S.-born people in the network. Several different dimensions of social support are associated with decreased risk of specific reproductive health behaviors and outcomes among young Latina immigrants. Use of a multi-dimensional social support instrument provides for richer analyses of these relationships, generating information that could be utilized for targeting support interventions and risk prevention in this population.

Yale J Biol Med. 2007 Nov;80(1):1–38.

The Founding of the National Medical Association

Karen Sarena Morris ¹, Susan E Lederer ¹

In 1869, a mere four years after the end of the Civil War and during a time when Southern sentiment ran high in Washington, D.C., three African-American physicians applied for membership into the all-white Medical Society of the District of Columbia (MSDC). Though meeting all eligibility requirements, they were denied admission into this society based solely on their race. Amidst much publicity in the local newspapers, the three physicians and their supporters sought remedy of the exclusionary practices of the MSDC on the floor of Congress and at the American Medical Association’s (AMA) annual meeting. However, those opposed to integrating the society proved formidable. Despite pitched battles in both the Congress and the AMA, African-American physicians did not succeed in their quest for acceptance into the all-white medical societies. Following the opening of "Negro" medical schools throughout the country, the number of African-American physicians slowly increased. Still unable to join local medical societies and the AMA, many of these physicians practiced in a professional vacuum devoid of opportunities to interact with and learn from other physicians. Recognizing the need for continuing education, social camaraderie, and professional unity, the African-American physicians began to form their own local medical societies. In 1892, a call went out in an editorial printed in the Medical and Surgical Observer, the first "Negro" medical journal, for a national voice for "colored" physicians. In 1895, three years after the call, several physicians met in an Atlanta church and founded the National Medical Association (NMA). No single document chronicles the significant events that preceded the founding of the NMA or examines the biographies of the key figures involved in this historic event. Through a review of primary and secondary sources, this study provides a complete account by examining the personal backgrounds and motivating factors of the African-American physicians who originally applied for admission into the MSDC in 1869. Further, this thesis analyzes the stories of the physicians who ultimately created their own national medical organization in 1895 following the many failed attempts to integrate the all-white societies. In addition to a thorough review of the battles that ensued in Congress and the AMA, this study considers the personal and group motivations for excluding African-American physicians.

Yale J Biol Med. 2007 Nov;80(1):1–38.

The Impact of Briefings on Sentinel Events and Unexpected Delays in the Operating Room

Arnab Mukherjee ¹, Martin A Makary ¹, J Bryan Sexton ¹, Peter J Pronovost ¹

Wrong-site surgery can be a catastrophic event for patients, caregivers, and institutions and often results from failures in communication and teamwork. Although breakdowns in communication are known to be the leading cause of wrong-site surgery, little is known about the efficacy of strategies to decrease the risk of these preventable events. Operative delays are also often the result of failures in communication and teamwork. Much of the attention toward improving operating room efficiency has focused on operating room (OR) logistics and has not addressed the critical issue of improved teamwork. The specific aim of this study is to evaluate the impact of operating room briefings on frontline caregiver perceptions of unexpected delays, care coordination, and the risk for wrong-site surgery. A case-based version of the Safety Attitudes Questionnaire was administered to OR staff at an academic medical center before and after the initiation of an OR briefings program to measure the change in perceptions of unexpected operative delays, care coordination, and risk associated with wrong-site surgery. Items question a caregiver’s perception of coordination, unexpected operative delays, and awareness of the surgical site. Response options ranged from 1 (disagree strongly) to 5 (agree strongly). MANOVA was employed to test for changes in overall caregiver assessments before and after the implementation of briefings, and the percentage of OR staff who "agree" or "disagree" with each question was reported. The pre-briefing response rate was 85 percent (306 out of 360 respondents), and the post-briefing response rate was 75 percent (116 out of 154). Respondents included surgeons (34.9 percent), anesthesiologists (14.0 percent), and nurses (44.4 percent). The use of briefings was associated with frontline caregiver assessments of a reduced risk for wrong-site surgery and improved collaboration (F (6, 390) = 10.15, p < .001). OR caregiver assessments of briefing and wrong-site surgery issues improved for five out of the six items, e.g., "Surgery and Anesthesia worked together as a well-coordinated team," (67.9 percent agreed pre, 91.5 percent agreed post). The only item that did not improve significantly was "A team discussion before a surgical procedure is important for patient safety," for which responses were favorable pre- and post-intervention (94.0 percent vs. 93.3 percent, respectively). The use of briefings was associated with fewer unexpected delays, with 30.9 percent of OR personnel reporting a delay pre-briefings, and only 23.3 percent reporting delays post-briefings (F (1, 397) = 7.66, p < 0.001). In the post-briefing group, a linear relationship between elements of ORBAT and the assessments of unexpected delays was found, e.g., "A preoperative discussion included planning for potential problems" (beta = -0.34, p < 0.001). OR briefings significantly reduce perceptions of risk for wrong-site surgery and improve perceptions of collaboration among OR personnel. OR briefings also have the potential to increase OR efficiency by significantly reducing unexpected delays in the operating room.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Dynamic Mechanical Properties of Intact Human Cervical Spine Ligaments

Anthony Ndu ¹, Paul Ivancic ¹, Marcus Coe ¹, Yasuhiro Tominaga ¹, Erik J Carlson ¹, Wolgang Rubin ¹, Manohar Panjabi ¹

Most previous studies have investigated ligament mechanical properties at slow elongation rates of less than 25 mm/s. The purpose of this study was to determine the tensile mechanical properties at a fast elongation rate of intact human cervical anterior and posterior longitudinal, capsular, and interspinous and supraspinous ligaments, middle-third disc, and ligamentum flavum. Ninety-seven intact bone-ligament-bone specimens (C2-C3 to C7-T1) were prepared from six cervical spines (average age: 80.6 years, range, 71 to 92 years) and elongated to complete rupture at an average (SD) peak rate of 723 (106) mm/s using a custom-built apparatus. Non-linear force vs. elongation curves were plotted and peak force, peak elongation, peak energy, and stiffness were statistically compared (P < 0.05) among ligament. A mathematical model was developed to determine the quasi-static physiological ligament elongation. Highest average peak force, up to 244.4 and 220.0 N in the ligamentum flavum and capsular ligament, respectively, were significantly greater than in the anterior longitudinal ligament and middle-third disc. Highest peak elongation reached 5.9 mm in the intraspinous and supraspinous ligaments, significantly greater than in the middle-third disc. Highest peak energy of 0.57 J was attained in the capsular ligament, significantly greater than in the anterior longitudinal ligament and middle-third disc. Average stiffness was generally greatest in the ligamentum flavum and least in the intraspinous and supraspinous ligaments. For all ligaments, peak elongation was greater than average physiological elongation computed using the mathematical model. Comparison of the present results with previously reported data indicated that high-speed elongation may cause cervical ligaments to fail at a higher peak force and smaller peak elongation and may be stiffer and absorb less energy, as compared to a slow elongation rate. These comparisons may be useful to clinicians for diagnosing cervical ligament injuries based upon the specific trauma.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Chronic Inflammation-Driven Tumor Promotion Associated With CD8+ T Cells

Bernice Y Ng ¹, Scott J Roberts ¹, Renata B Filler ¹, Julia Lewis ¹, Earl J Glusac ¹, Adrian C Hayday ¹, Robert E Tigelaar ¹, Michael Girardi ¹

Chronic inflammation is associated with carcinoma development in several clinical settings, and we sought to investigate the role of T cells in this phenomenon, using the DMBA/TPA two-stage chemical carcinogenesis protocol. We demonstrate that, paradoxical to models of immunosurveillance, wild-type (WT) mice have a markedly higher rate of tumor formation relative to strains lacking CD8+ T cells. Adoptive transfers of antibody-coated magnetic bead-enriched peripheral CD8+ T cells into TCRαβ-/- mice confirmed that the increased mean tumor area and progression to carcinoma was attributable to the presence of CD8+ T cells. All analyzed strains of mice in which the CD8 compartment was intact (WT, CD4-/-) showed significant increases in tumor susceptibility. Putative tumor-promoting (T-pro) cells (TCRαβ+CD8+CD44+CD62L- tumor infiltrating lymphocytes, TILs) were directly compared to their phenotypic equivalents in peripheral blood lymphocytes (PBLs). In WT and CD4-deficient mice, CD8+ TILs consistently revealed a markedly higher relative expression, by RT-PCR, of IFNγ, TNFα and COX-2, and a striking decrease in expression of perforin. Cytokine-bead analysis (CBA) comparison of CD8+ and CD4+ TIL in tumors from WT mice confirmed the increased expression by the CD8+ TIL of IFNγ and TNFα. To our knowledge, this is the first demonstration of increased carcinogenesis attributable to CD8+ TILs, characterized by their high IFNγ, TNFα, and COX-2 production and defective perforin production relative to phenotypically equivalent PBLs. These studies may have mechanistic implications for the role of T cells in inflammation-associated carcinogenesis.

Yale J Biol Med. 2007 Nov;80(1):1–38.

The Acute Effects of High Lipid Levels on Endothelial Function

Alexander Nissen ¹, Lisbeysi Calo ¹, David G Silverman ¹

The association between prolonged elevation of blood lipid levels and coronary artery disease is well established. Research focusing on the acute effects of hyperlipidemia is not as abundant and often looks only at large-sized arteries. The purpose of our study was to measure the acute effects of elevated blood lipid levels on microvascular endothelial function, non-invasively, by means of laser Doppler flowmetry and the administration of vasoactive challenges. With IRB approval, six healthy subjects were recruited for a three-session study in which they were given isocaloric meals with variable fat content (non-fat meal = NM; fatty meal = FM; or fatty meal with atorvastatin = FML). Two hours after ingesting the meal, the subjects’ microvasculature was examined using laser Doppler flowmetry. Our analysis looked at the ratio of low to high frequency microvascular oscillations (increases if parasympathetically mediated oscillations are inhibited) both at baseline and during a vasoconstrictive challenge; as well as endothelium-independent vs. endothelium-dependent vasodilation using topical administration of acetylcholine and nitroglycerin. We found a greater low to high frequency ratio after the FM compared to the NM both at baseline (mean ratio after FM was 222 +/-109 percent of that after NM, p = 0.016) and during the vasoconstrictive challenge (mean ratio after FM was 321 +/-242 percent of that after NM, p = 0.05), indicating a relative impairment in parasympathetic oscillations after the FM. Additionally, the mean ratio of endothelium-independent to endothelium-dependent vasodilation after the FM was 177.6 +/-98 percent of that after the NM, p = 0.036. We concluded that elevated blood lipid levels acutely impair endothelial function.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Use of a Help-Wanted Index to Assess Marketplace Demand for Ophthalmologists

Chukwuemeka C Nwanze ¹, Ronald A Adelman ¹

The objective of this study was to develop a help-wanted index (HWI) to measure trends in marketplace demand for ophthalmologists, then identify the economic drivers of these trends and the responsiveness of the ophthalmology community to marketplace demand. A retrospective review of physician recruitment advertisements appearing in Ophthalmology, American Journal of Ophthalmology, and Archives of Ophthalmology from January 1980 through June 2006 was performed. Over the 26-year study period, a consistent increase in the demand for academic ophthalmologists was noted (34 percent of HWI in 1980 to 74 percent in 2005). There was also a consistent increase in the demand for specialists (31 percent of HWI in 1980 to 80 percent in 2005), especially demand for retina specialists. There were no consistent geographical trends in demand. Need for academic ophthalmologists seems to be correlated with national research expenditure and stock market gains (p = 0.00191), while demand for private practice ophthalmologists seems to be correlated with the national economic well being, as measured by Gross Domestic Product (GDP) (p < 0.001). Further analysis indicated that training programs (p = 0.0456), residency applicants (p = 0.0128), and fellowship applicants (p = 0.0198) respond to marketplace demand. Furthermore, salaries of academic ophthalmologists (p = 0.0226) and retina specialists (p = 0.0418) are statistically influenced by marketplace demand.

Long-run trends in the HWI data suggest a chronic scarcity of academic ophthalmologists and the emergence of need for a more specialized workforce, which may lead to increased competition for fellowship positions. This study suggests that the ophthalmology community is quick to respond to marketplace demand. Since HWIs are useful tools for assessing the marketplace need for ophthalmologists, an ongoing HWI will provide timely information about the demand for physicians in a rapidly changing healthcare system.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Nigerian Women Living in the United States are More Hirsute than Those Living in Nigeria

Kikelomo Olorunrinu ¹

This study was to determine if there is a difference in the rate of hirsutism in genetically similar women in two different environments. One hundred twelve Nigerian women living in the United States and 70 women living in Nigeria were surveyed. All women completed a pictorial survey scoring peripheral hair growth in six body areas from 0 (no significant hair growth) to 4 (severe hair growth). Total hirsutism score was calculated as a sum of individual scores. The survey also included demographic data, menstrual history, and data regarding use of hormonal treatments. Statistical comparisons between groups included t-test, nonparametric tests and chi-square test. Multiple regression analysis was carried out to identify independent predictors of peripheral hair growth. Women residing in the United States had a 31 percent higher total hirsutism score than those residing in Nigeria. This difference was not related to irregular menstrual cycle. To account for possible effects of age, BMI, and differences in tribal origin, multiple regression analysis was performed. Location (living in the United States vs. Nigeria) remained the strongest predictor of total hirsutism score (P = 0.02); tribal origin was also significant (P = 0.04), while age and BMI had no independent predictive value (P > 0.1). It was concluded that this difference is not explained by factors such as age, obesity, and ethnic origin. We propose that this difference may be due to differences in environmental or lifestyle factors of the women.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Serum Proteomic Profiles in Inflammatory and Non-Inflammatory Cardiomyopathies: A Novel Approach for Diagnostic Biomarker Discovery

Oyere Kalu Onuma ¹

The aim of this project is to develop a noninvasive serum test that predicts histologic forms of myocarditis (inflammatory) and dilated (non-inflammatory) cardiomyopathy using proteomic techniques to analyze serum proteins. Idiopathic dilated cardiomyopathy (DCM) and myocarditis (myocardial inflammation) represent a spectrum of heart muscle disease of various etiologies that usually present with progressive heart failure. Together, they constitute the leading cause of heart transplantation in the United States. Currently, the gold standard of diagnosis of myocarditis is by endomyocardial biopsy (EMB) and histopathological classification, according to the Dallas Criteria. However, this diagnostic technique is severely limited by its invasiveness, a lack of sensitivity, and an attendant sampling error, yielding diagnostic information in only 10 to 20 percent of the cases. As such, the development of a non-invasive highly specific test for myocarditis is of great value and importance particularly in the diagnosis of giant cell myocarditis, a rare but very fulminant form of autoimmune myocarditis in which timely institution of appropriate immunosuppressive therapy significantly increases transplant-free survival. We propose, using an observational case-control study, to undertake a proteomic analysis to compare serum proteomic profiles determined by mass spectroscopy and isotope tagging with histologic findings on endomyocardial biopsy. Our hypothesis is that different forms of myocarditis and dilated cardiomyopathy have distinct serum protein profiles and these unique profiles, which correlate with specific histologic types, will allow for noninvasive diagnosis of major forms of myocarditis and DCM.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Surrogate Markers of Success in the Bariatric Surgery Population

Alain Ramirez ¹, Daniel Eisenberg ¹, Robert Bell ¹

The purpose of this study was to examine the associations between pre-operative weight loss, weight loss programs, and clinic attendance relative to the success of gastric bypass in class II and III obese patients. The increasing number of obese children and adults in the United States poses an extensive social problem in the era of managed care. Notwithstanding the stigmatization associated with obesity, the considerable health implications, along with the financial burden it imposes, create a formidable adversary. Surgical procedures have proved to be superior to conservative and pharmacotherapeutic interventions in the morbidly obese. Despite the overall success of bariatric surgery, little information exists in the medical literature to predict patient outcome. Our study was subdivided into three sections. First, we investigated the effects of patient adherence to pre-operative dietary and exercise recommendations. The change in body mass index (BMI) between initial consultation and pre-operative workup (average six to eight weeks) was compared to change in BMI at the one year post-operative period. The second study compared the maximum weight loss achieved by popular dietary programs to a physician monitored plan. On initial evaluation, patients were asked to report information regarding weight loss attempts, including program used and weight loss achieved. All individuals who had accurate records of their dieting attempts were included. We performed an ANOVA analysis and then Pearson and Spearman correlations between maximum pre-operative weight loss and one year post-operative weight loss. The last study conducted analyzed the association between clinic attendance and weight loss at yearly intervals. We also inquired about reasons for non-attendance and patient adherence in regard to vitamin supplementation, exercise regimen, and dietary intake.

Results: From August 26, 2002, to July 31, 2006, 404 laparoscopic Roux-en-y gastric bypass procedures were performed by Dr. Bell at Yale-New Haven Hospital. Of these patients, 256 had one year post-operative weight data and were included in the first portion of the study. These subjects had an average pre-operative BMI 51.4 kg/m² and ages that ranged from 17 to 64. At the one year post-intervention period, the mean percentage excess weight loss and percentage BMI loss were 62 percent and 34.5 percent respectively. Patients were categorized into two groups: those who had lost weight and those who had no change or gained weight after initial consultation. A multiple regression analysis and ANOVA showed no statistical difference between the two groups at the one year post-operative period. The second portion of the study had 384 participants. A least squares analysis showed that physician-monitored weight loss did not confer an advantage over popular commercial programs. In addition, linear regression analysis showed no correlation between maximum weight loss during dieting attempts and success at the one year post-operative period measured by percentage of excess body weight loss. Lastly, in our evaluation of clinic attendance as a marker of success, 283, 157, and 56 patients at the one-, two-, and three-year interval, respectively, met inclusion criteria. A t-test at years one and two showed no statistically significant difference between those who attended clinic and those who did not.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Platelet-Derived Growth Factor Enables Direct Derivation of Oligodendrocyte Progenitors from CNS Stem Cells

Rajesh C Rao ¹, Ronald D McKay ¹

Oligodendrocytes derived in the laboratory from stem cells have been proposed as a treatment for acute and chronic injury to the central nervous system (CNS). Platelet-derived growth factor-receptor alpha (PDGFRα) signaling is known to play an important role for regulation of oligodendrocyte progenitor cell numbers, both during development and adulthood. Here, we analyze the effect of PDGFRα signaling on CNS stem cells derived from embryonic day 13.5 murine cortex and cultured in monolayer. Fetal and adult CNS stem cells express PDGFRα, and PDGF-AA treatment increases viability and proliferation of these cells. In the absence of insulin, this effect of PDGF-AA is very clear. Consistent with this result, PDGF-AA strongly stimulates glycolytic rate. PDGF-AA treatment rapidly induces morphological changes in the cells although the cells maintain expression of a wide range of precursor markers. We show that a brief exposure to PDGF-AA rapidly and efficiently induces oligodendrocytes from CNS stem cells. Our data suggest that phosphoinositide kinase-3 (PI3K)/Akt, mitogen-activated protein/extracellular signal-regulated kinase kinase/extracellular signal-related kinase (MEK/Erk), and mammalian target of rapamycin (mTOR) regulate survival, proliferation, glycolytic rate, and oligodendrogliogenesis induced by PDGF-AA. By treating with PDGF-AA, progenitor cells directly from embryonic cortex can be expanded and differentiated into oligodendrocytes with high efficiency. Our results show that PDGF-AA promotes oligodendrocyte progenitor generation from CNS stem cells and supports their survival and proliferation. The derivation of oligodendrocytes demonstrated here may support the safe and effective use of stem cells in the development of new therapies targeting this cell type.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Mammalian Dcn-1-Like Proteins Enhance Neddylation of CUL3 and Vary in Localization and Tissue-Specific Expression

Russell Ryan ¹, Alex Kim ¹, Yoshi Yonekawa ¹, Lydia Choi ¹, Andrew Kaufman ¹, Y Ramanathan ¹, Lyann Mitchell ¹, KeumSil Hwang ¹, Patricia Morris ¹, Bhuvanesh Singh ¹

The Squamous Cell Carcinoma-Related Oncogene (SCCRO/DCUN1D1), located at 3q26.3, is a candidate oncogene that is gene-amplified and overexpressed in squamous-cell carcinomas of the upper aerodigestive tract and lung. The SCCRO protein is a member of a phylogenically conserved protein family, the Defective in cullin neddylation-1-like domain-containing (Dcun1d) proteins, which have been shown to promote the covalent modification of cullin proteins by the ubiquitin-like protein Nedd8.

In this study, we sought to characterize the expression and molecular interactions of vertebrate Dcun1d proteins, in order to better understand the normal function of genes in this family. We demonstrate that the majority of SCCRO protein in cultured human epithelial cell lines is not found in stable complexes with known interactors, including cullins, UBC12, and CAND1, a regulator of cullin–RING-finger ubiquitin ligases (CRL). We show that SCCRO expression is not cell-cycle regulated in HeLa-S cells. In describing five highly conserved vertebrate Dcun1d genes, we show that the products of all five genes interact with cullins and with CAND1. Four of the five proteins enhance the neddylation of CUL3 in a dose-dependent fashion in vitro, and the UBA domain-containing SCCRO and Dcun1d2 proteins are pan-cellular in localization, while other family members contain alternate N-terminal domains that mediate their exclusive localization to the nucleus (Dcun1d4 and Dcun1d5) or to cellular membranes (Dcun1d3). We further report that expression of alternate Dcun1d1 transcripts is specifically regulated in mouse germ cells during spermatogenesis, and we present evidence for specific expression of Dcun1d2 in brain and muscle tissue. In conclusion, spermatogenesis and myogenesis could serve as valuable model systems for future studies of the interaction between expression levels of vertebrate Dcun1d proteins and the activity of CRL complexes. Such work could be valuable in understanding how SCCRO overexpression contributes to cancer.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Epigenetic Abnormalities in Infantile Hemangiomas: Regulation of the IGF2/H19 Locus

Brent Schultz ¹, Ruth Halaban ¹, Elaine Cheng ¹, John Persing ¹, Deepak Narayan ¹

Purpose: To investigate the epigenetic regulation of Insulin Like Growth Factor 2 (IGF2) and its reciprocally imprinted transcript H19 in infantile hemangiomas.

Introduction: Infantile hemangiomas (IH) are the most common childhood tumor of the head and neck. Despite their prevalence and potentially morbid sequelae, little is known about the pathogenesis of this disease. However, a tumorigenic molecule, IGF2, has been implicated by microarray and confirmatory real-time PCR (RT-PCR) studies. There is substantial documentation that methylation abnormalities within the IGF2 and neighboring H19 loci are related to the overproduction of IGF2 in many distinct tumor types. An investigation of the methylation status of this region, as well as the factors modifying methylation, may explain pathologic IGF2 overproduction in hemangiomas.

Methods: Using bisulfite specific methylation sensitive PCR with quantitative pyrosequencing, confirmatory genomic southern analysis, and quantitative RT-PCR, the methylation status of multiple regions within the IGF2/H19 locus were correlated with two potential transcriptional consequences and/or causes of aberrant regulation.

Results: This study identifies IH as the first non-malignant neoplasm expressing ectopic BORIS, an oncogene with expression normally limited to adult testes. The paradoxically benign nature of IH, despite BORIS expression, could be explained by a 13-fold increase in CTCF, BORIS’ only known antagonist, from proliferating to involuting IH. Interestingly, both proteins bind to IGF2 and H19. In the IH samples, as CTCF levels rose compared to BORIS, the IGF2 transcript decreased six-fold. CTCF and BORIS likely regulate IGF2 by altering methylation of the region. The difference between CTCF and BORIS is most predictive of methylation levels at several imprinted sequences (R² = .9). Throughout the 130 kb regulatory region controlling IGF2 and H19, BORIS favored methylation specific activation of IGF2 and repression of H19, while CTCF favored the converse. The degree of these effects strongly correlated with a common C/T polymorphism at the IGF2 imprinting control region. Here, the T allele was strikingly more sensitive to CTCF and BORIS than the C allele. Hence, the C/T polymorphism may be an important disease modifier of IH.

Conclusion: Identifying the aberrant expression of a known oncogene, BORIS in IH, suggests one factor driving early proliferation. Furthermore, the steady increase in the production of BORIS’ antagonist, CTCF, may support the involutionary process. The interplay between these two proteins likely takes place at the level of DNA imprinting, as the difference between CTCF and BORIS was highly predictive of methylation levels within key regulatory regions of the IGF2/H19 locus, a region previously demonstrated to control the relative expression of both genes. A potentially important disease modifier may be the C/T polymorphism within CTCF binding site six, which strongly affects methylation of the region relative to the CTCF-BORIS difference. As 400,000 children are born each year in the United States with IH, a clinical blood test resulting from this finding may be highly useful in predicting eventual tumor size and time to involution.

Yale J Biol Med. 2007 Nov;80(1):1–38.

A Comparison of Cyclic Valgus Loading on Reconstructed Ulnar Collateral Ligament of the Elbow

Roshan P Shah ¹, Derek P Lindsey ¹, Gannon W Sungar ¹, Timothy R McAdams ¹

This study compares the biomechanics of early cyclic valgus loading of the ulnar collateral ligament (UCL) of the elbow repaired by either the Jobe technique or the docking technique. Better understanding of the biomechanical properties of each reconstruction may help surgeons choose the optimal surgical technique, particularly in planning earlier rehabilitation programs. Sixteen fresh frozen cadaver limbs (eight pairs) were randomized to either the Jobe cohort or the docking cohort. First intact UCLs were tested, followed by the repaired constructions. A Bionix MTS apparatus applied a constant valgus load to the elbows at 70° flexion, and valgus displacement was measured and then used to calculate valgus angle displacement. The docking group had significantly less valgus angle displacement than the Jobe group at cycles 100 and 1,000 (p = 0.0189 and 0.0076, respectively). Four of the eight specimens in the Jobe group failed at the tendon-suture interface before reaching 1,000 cycles, at cycles 7, 24, 250, and 362. None of the docking specimens failed before reaching 1,000 cycles. In this cadaveric study, the docking technique resulted in less angulation of the elbow in response to cyclic valgus loading as compared to the Jobe technique. The better response to valgus loading of the docking reconstruction may translate into a better response to early rehabilitation. Further study is needed to determine if this difference translates into improved clinical outcomes.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Cost-Effectiveness of Hepatitis A and Hepatitis B Vaccination for Jail Inmates

Aditya Sharma ¹, Frederick L Altice ¹

Despite evidence that viral hepatitis poses a significant risk to public health, universal vaccination has not yet been implemented. The risk for viral hepatitis infection is particularly high among injection drug users and other individuals who do not attend regular healthcare visits. Jails provide a structural opportunity to vaccinate these high risk individuals. HAV and HBV vaccines administered on an accelerated three-week schedule could dramatically decrease the lifetime risk for contracting viral hepatitis among jail detainees. Assuming that 75 percent of detainees would accept vaccination, 33 percent have previous exposure to HAV, 25 percent have previous exposure to HBV, and independent future healthcare costs were US $317,000, the U.S. healthcare system would save $12 per individual with a vaccinate-upon-entry program in comparison to no intervention. This savings translates into an economic benefit amounting to about US $5,000,000 saved if all new inmates in a given year were immunized. A vaccinate-upon-entry program for HAV/HBV in jails should be widely implemented with coordination between the corrections system and public health agencies to reduce the growing cost of viral hepatitis infection.

Yale J Biol Med. 2007 Nov;80(1):1–38.

The Immunoepidemiology of Hookworm Infection in the Peruvian Amazon

Priya Shete ¹, Michael Cappello ¹

Hookworm infection caused by Ancylostoma duodenale or Necator americanus is a significant global health threat, causing chronic anemia, malnutrition, developmental delay, enteritis, and increased susceptibility to non-parasitic diseases. One of the most prevalent of the "neglected" tropical diseases, hookworm infection affects almost 1 billion people worldwide, particularly in developing countries. Current methods for diagnosis and treatment of hookworm infection are largely the same as they have been for the past century. However, several recent advances in the molecular characterization of hookworm virulence factors now provide researchers with an improved understanding of disease pathogenesis, potential targets for treatment, and novel antigens for vaccine development. In order to better understand hookworm pathophysiology and immunology in human populations, a comprehensive, cross-sectional immunoepidemiologic survey of approximately 200 villagers in a remote area of the Peruvian Amazon was conducted. Hookworm prevalence rates were found to approach 40 percent by microscopic diagnosis. Additionally, molecular speciation techniques showed that both A. duodenale and N. americanus are endemic to this region. Reagents from a laboratory model of hookworm disease were then utilized to characterize human immune responses to hookworm specific antigens. By studying the immunoepidemiology of an endemic community, we have found that a laboratory strain of hookworm, Anyclostoma ceylanicum, is a useful tool for describing species specific immune responses to disease. This work lays the foundation for future development of improved hookworm diagnostic techniques by molecular and immunologic methods.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Neonatal Respiratory Distress Syndrome as a Function of Gestational Age and the Lecithin/Sphingomyelin Ratio

Caryn M St Clair ¹, Jessica L Illuzzi ¹, Errol R Norwitz ¹

This study was designed to derive predictive logistic regression equations to allow the risk of neonatal respiratory distress syndrome (RDS) to be defined as a function of both the lecithin/sphingomyelin (L/S) ratio and gestational age. We hypothesize that the optimal cutoff value will vary significantly depending on gestational age, and our data will support the need to account for gestational age when interpreting test results.

Data was collected via a retrospective chart review. Women who underwent amniocentesis for the purpose of assessing fetal lung maturity at Yale-New Haven Hospital from 1998 to 2004 were identified and included if delivery of a live born, singleton, non-anomalous infant occurred within 72 hours of the lecithin/sphingomyelin ratio assay. Maternal and neonatal data were collected regarding demographics, pregnancy complications, and neonatal outcomes, including respiratory distress syndrome.

Two hundred ten mother-neonate pairs met criteria for analysis, with eight cases of RDS. Both gestational age and L/S ratio were independent predictors of RDS. By modeling the odds of RDS using logistic regression, a probability of RDS approximating 10 percent was noted at an L/S cutoff of 3.6 at 32 weeks, 2.8 at 34 weeks, 1.8 at 36 weeks, and 1.4 at term. Under 32 weeks of gestation, a probability as low as 10 percent was not observed by this model. We conclude that stratifying risk of neonatal RDS using both the L/S ratio and gestational age may aid in clinical decision-making concerning the timing of delivery.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Anemia among HIV-Infected Individuals in South India

Ramnath Subbaraman ^a, Anitha J Cecelia ^b, Sonia Singh ^c, Bella Devaleenal ^b, Tokugha Yepthomi ^b, Sunil S Solomon ^b, Kenneth H Mayer ^d, N Kumarasamy ^b

Objective: Although highly active antiretroviral therapy (HAART) resolves a significant proportion of anemia among HIV-patients in Western cohorts, outcomes may vary in developing countries, due to a higher prevalence of nutritional deficiencies, intestinal parasites, tuberculosis, and opportunistic infections. The purpose of this study is to describe the prevalence of, factors associated with, and influence of HAART on anemia among HIV-infected individuals in South India.

Methods: To examine factors associated with anemia, the first-recorded hemoglobin values for adults who visited an HIV tertiary care center in Chennai, India, between January 1996 and April 2006 were collected (n = 7069). Univariate and multivariate regression analyses were performed to examine associations between anemia and stage of HIV disease, co-morbidities, and medications. To examine the influence of HAART use on anemia on a smaller subset of patients (n = 401), the mean of baseline hemoglobin values measured within three months prior to HAART initiation was compared to the mean of follow-up hemoglobin values collected between three and 12 months after HAART initiation. A similar analysis based on the time of AIDS onset was performed for a control group of patients with clinical/immunological AIDS who never received HAART (n = 77).

Results: The prevalence of anemia in the overall cohort was 40 percent by the WHO definition. While 22 percent of patients with CD4 counts > 500 cells/µL had anemia, this increased to 60 percent for those with CD4 counts < 100 cells/µL (p < 0.001). In multivariate analysis, CD4 count < 100 cells/µL, underweight body mass index, female sex, active tuberculosis, and lack of cotrimoxazole prophylaxis had significant associations with anemia. In the analysis of the influence of HAART on anemia, median baseline CD4 count and mean time to follow-up hemoglobin value were similar for both the HAART and control arms. For patients who initiated HAART, the mean baseline hemoglobin of 10.7g/dL significantly increased to 12.4g/dL during the year of follow-up (p < 0.001). While 46.6 percent of patients were not anemic at HAART initiation, this increased significantly to 78.1 percent during follow-up (p < 0.001). Severe grades 3 and 4 anemia decreased from 12.5 percent to 2 percent for those on HAART (p < 0.001). For the control arm of patients who never received HAART, the increase in mean baseline hemoglobin from 10.50 to 11.10g/dL did not reach significance (p = 0.06). While the percent of non-anemic patients increased from 40.3 percent to 54.5 percent on follow-up in this group, this was not significant (p = 0.291).

Conclusion: Anemia is strongly correlated with the severity of immunosuppression in this population seen at an HIV tertiary referral center. Endemic malnutrition and tuberculosis further exacerbate the level of anemia. Anemia resolved in a large proportion of patients within the first year of HAART use. Therefore, antiretroviral therapy, nutritional supplementation, and aggressive tuberculosis treatment should be the cornerstones of anemia management in this setting. The high prevalence of anemia among patients with immunological AIDS complicates the rollout of antiretroviral regimens containing zidovudine, a drug that may exacerbate anemia, and highlights the need for increased access to alternative nucleoside reverse transcriptase inhibitors in developing countries.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Depression Treatment in HIV-Infected and Uninfected Veterans: Do Treatment Rates Vary by HIV Status?

Kristen Sueoka ¹, Amy Justice ¹

Despite a higher prevalence of depression among HIV-infected veterans, previous research has shown that infectious disease (ID) medical providers report substantially less comfort with depression treatment than do general medicine (GM) providers. We examined whether HIV-infected veterans who are treated by ID providers are less likely to have their depressive symptoms treated compared to uninfected controls managed by GM providers.

We used survey, service utilization, and pharmacy data on veterans from the Veterans Aging Cohort Study (VACS), a prospective cohort study of HIV-infected and age-, race-, and site-matched uninfected subjects at eight Veterans Affairs Healthcare Centers. We used the Patient Health Questionnaire (PHQ-9) to identify veterans with depressive symptoms. Each of nine survey items was rated by the veteran as being present 0 (not at all) to 3 (nearly every day). Veterans were considered to have active depressive symptoms if they had a PHQ-9 score of 10 or greater, which constituted a positive screen for major depressive disorder. Of the 5,998 VACS patients, 19.7 percent of uninfected and 21.3 percent of HIV-infected veterans had PHQ-9 scores of 10 or greater. Of these veterans with active depressive symptoms, those receiving mono-amine oxidase inhibitors (MAOIs) (n = 3), female veterans, and men with diagnoses of schizophrenia (n = 511) or PTSD (n = 689), were excluded. A small number of patients receiving tricyclic antidepressants (TCAs) were excluded for criteria other than TCA use. Depression treatment was defined as receipt of a selective serotonin reuptake inhibitor (SSRI) or any VA mental health utilization in the six months prior to or after survey. Bivariate comparisons by clinic type were assessed using chi-square and t-tests. Logistic regression was used to determine whether clinic type was associated with receipt of SSRI, adjusting for potential confounding variables such as demographics and clinical factors.

Of the 5,998 veterans in VACS, 732 met our criteria: males with PHQ-9 scores greater than 10, without schizophrenia, PTSD, or MAOI use. Of the 732 eligible veterans, 59 percent were HIV-infected and 41 percent were uninfected. The sample was predominantly African American (58 percent) and had a median age of 48 years. There was no significant difference in the proportion of veterans with depressive symptoms who were treated by HIV status (38 percent of HIV-infected veterans vs. 34 percent of uninfected veterans, p = 0.4). This remained true even when mental health service utilization was included (48 percent vs. 49 percent, p = 0.8). Caucasian veterans were significantly more likely than African Americans to have received SSRI (48 percent vs. 30 percent, p < 0.01). After controlling for veteran age, race, and comorbid conditions, HIV-infected veterans did not differ significantly in receipt of SSRI (OR = 1.16, 95 percent CI = 0.84, 1.58). However, there were significant differences in treatment rates by site and by individual clinic. Despite previous analysis demonstrating substantial differences in provider comfort with depression treatment, both HIV-infected and uninfected veterans were equally unlikely to be treated for depressive symptoms. While treatment rates did not vary by HIV status, they varied significantly by geographic site and individual clinic, suggesting that provider practices have considerable influence over receipt of treatment.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Time Interval to Diagnosis of Bladder Cancer and Its Associated Outcomes

Lara K Suh ¹, Edward M Uchio ¹

The purpose of this study was to investigate whether a prolonged delay in diagnosis of bladder cancer will result in worse outcomes for those patients, compared to those patients with a shorter diagnostic time interval. Data was collected on 247 patients newly diagnosed with transitional cell carcinoma of the bladder from January 1996 to December 2006 (10 years). The medical records of these patients were reviewed for demographics, pathological stage, date of consultation to the genitourinary (GU) service, and date of diagnosis by transurethral resection of bladder tumor (TURBT). The specialty delay was calculated as the time between the date of consultation to the GU service to the establishment of a diagnosis by TURBT. Univariate analyses were performed to test the association of specialty delay with clinical features and all-cause mortality. The median specialty delay in this study was 100 days. There was a trend toward a longer specialty delay for muscle-invasive disease (T2-T4) in comparison to superficial disease (Ta and T1). There was a significant correlation between all-cause mortality and increasing clinical stage (p = 0.01). There was also a paradoxical finding that patients with a specialty delay greater than 100 days had a significant reduction in all-cause death in comparison to patients with a specialty delay of 100 days or less (relative risk = 0.59; 95 percent CI 0.36-0.90; p = 0.01). In conclusion, this study did not confirm the hypothesis that a prolonged specialty delay in patients diagnosed with bladder cancer would result in a worse prognosis. In fact, there was a paradoxical finding that patients with a specialty delay greater than the median delay of 100 days had a better prognosis.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Biomechanical Testing of Charité Disc Replacements vs. Fusion Using Hybrid Testing Protocol and Follower Load

Edward Teng ¹

The purpose of this study was to quantify adjacent level effects following Charité disc replacement compared to fusion, using the follower load and the new standard hybrid testing method in flexion, extension, and torsion. As opposed to fusion, artificial discs not only preserve motion, but may diminish adjacent level effects and thus slow adjacent disc degeneration. This study aimed to use hybrid test protocol and follower load to perform in vitro multidirectional testing and quantify adjacent- and other- level (AOL) effects following one- and two-level disc implants compared to fusion.

Five intact human cadaveric lumbar specimens underwent multidirectional testing in flexion, extension, and bilateral torsion loading with ±10Nm unconstrained pure moments under 400N follower load. Intact specimen (T12-S1) total ranges of motion were first determined for each loading direction and then used as input for the five subsequent hybrid tests: 1) one-level Charité disc implant at L5-S1; 2) one-level simulated 3600 fusion at L5-S1; 3) two-level Charité disc implants at levels L4-L5 and L5-S1; 4) combined one-level Charité disc implant at L4-L5 and one-level simulated 3600 fusion at L5-S1; and 5) two-level simulated 3600 fusion at L4-S1. Using repeated measures single factor ANOVA and Bonferroni statistical tests (p < 0.05), intersegmental motion redistribution was compared between intact and testing conditions.

The results of the study yielded the preservation of one- and two- level Charité disc physiological motion, whereas one-level L5-S1 fusion increased intersegmental motions at proximal levels. Two-level fusion at L4-L5-S1 produced markedly increased motions at proximal levels, but converting the L4-L5 fusion to a Charité produced results equivalent to a one-level L5-S1 fusion. In axial torsion, both one- and two-level disc implants preserved motions at all levels. Although the one-level fusion did not produce significant changes, the two-level fusion did result in significant increases in motion at proximal levels. The fusion simulations did not only affect motion redistribution at adjacent-levels, but also at other-levels cephalic to the fusion. A prosthetic disc placed above a fusion could not buffer the proximal levels from increased motion from the fusion.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Clinical Characteristics and Treatment Response to Radiotherapy of Optic Nerve Sheath Meningiomas

Silas L Wang ¹, James B Yu ¹, Robert L Lesser ¹, Jonathan P Knisely ¹

Recent reports of success with conventional, conformal, and stereotactic radiotherapy in stabilizing or improving visual function in patients with primary optic nerve sheath meningiomas have reduced the controversy surrounding the optimal treatment of these rare tumors. To analyze trends in the clinical presentation and diagnosis of optic nerve sheath meningiomas and to evaluate the effectiveness and side-effect profile of three-dimensional conformal radiotherapy vs. other treatment modalities, a retrospective chart review was performed on patients with optic nerve sheath meningiomas treated at The Eye Care Group and at the Department of Therapeutic Radiology, Yale University School of Medicine in New Haven, Connecticut, ending in September 2006. Fourteen patients were identified, with a mean age of 45.6 (range 16-63). Abnormal color vision and proptosis were less frequent than in historical comparisons with published series. Four patients had normal initial imaging, underscoring the importance of clinical suspicion and appropriate imaging protocols. One patient was solely observed, and one received surgery as primary treatment. Nine patients were treated with three-dimensional conformal radiotherapy at Yale, one with conformal intensity-modulated radiotherapy at Yale, one with three-dimensional conformal radiotherapy at another center, and one with stereotactic fractionated radiotherapy at another center. The overall visual and radiographic control rate for patients treated with radiotherapy was 100 percent with one late complication of mild dry-eye syndrome and one of pituitary toxicity. Outcomes in this series compare favorably with those in the published literature.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Significance of "Atypia" Found On Needle Biopsy of the Breast: Correlation with Surgical Outcome

Anika Nina Watson ¹, Liane E Philpotts ¹

Although core needle biopsy has been shown to be effective in diagnosing both benign and malignant mammographically detected lesions in the breast, it has also been shown to underestimate cancer due, most likely, to sampling error. Since a diagnosis of atypical hyperplasia vs. malignancy is based on quantitative factors (which could be affected by an error in sampling), the current recommendation is surgical excision for atypical hyperplasia diagnosed on core biopsy. The purpose of the study was to determine if a subset of patients with atypia diagnosed by core biopsy fit the Breast Imaging Reporting and Data System’s (BI-RADS) Category 3 "probably benign" definition of having a less than 2 percent chance of being carcinoma at subsequent surgical excision when comparing histologic subtype, mammographic findings, core biopsy factors, and clinical factors. For this subset of patients, imaging follow-up rather than surgical excision could be recommended.

Retrospective searches of the breast imaging and pathology databases from 1992 to August 2005 were performed to identify all cases of atypia found on core biopsy. The data collection and database used were HIPAA-compliant and followed the protocols of the institutional review board. The pathology reports were reviewed to determine the histologic type: atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), mixed, or "other" atypia. The ADHs were further classified as to focal/mild, not otherwise stated (NOS) or marked based on the pathology reports. Follow-up information was obtained to identify cases in which lesions initially diagnosed as atypia at the time of core biopsy were later upgraded to malignancy after subsequent surgical excision or mammographic follow-up. The histologic subtype, mammographic findings, core biopsy factors, and clinical factors were compared to lesions not upgraded to carcinoma. The results were analyzed with a Chi-square test, with p < 0.05 indicative of significant difference.

There were 327 cases of atypia found in the 3,898 (8 percent) core needle biopsies performed during the study’s time period. The histologic subtypes were: ADH (75 percent), ALH (13 percent), mixed (4 percent), and "other" (7 percent). There was an overall malignancy rate of 13 percent. Malignancy was found in 14 percent of ADH lesions, 5 percent of ALH, 20 percent of mixed, and 10 percent of "other" atypias on excision. The 215 ADH cases were further examined in their histologic subtypes (37 percent were focal/mild, 42 percent NOS, and 20 percent ADH marked). Malignancy was found in 6 percent focal/mild ADH, 10 percent NOS ADH, and 40 percent ADH marked. When comparing all the factors, the lowest underestimation rate (3 percent) was found in patients with focal/mild ADH diagnosed with a vacuum-assisted 11-gauge biopsy needle.

Upgrade rates vary significantly depending on classification of ADH and the type of atypia. While severe forms of atypia (NOS ADH, ADH marked, mixed atypias, and "other" atypias) should continue to receive routine surgical excision, there are selected subsets of patients with whom other management options could possibly be considered. For patients with focal/ mild atypical ductal hyperplasia diagnosed at the time of core biopsy with a vacuum-assisted 11-gauge needle, imaging follow-up (mammography or MRI) could be considered on an individual basis.

Yale J Biol Med. 2007 Nov;80(1):1–38.

University Policy and Procedural Responses to Students with Risk of Suicide

Marlynn Wei ¹

Colleges and universities recently have faced several lawsuits brought by parents of students who committed suicide or attempted suicide. The lawsuits are based on varying claims, including negligence, breach of contact, and discrimination. In crafting policies to respond to these lawsuits, universities should not simply seek limiting institutional liability but should balance the private interest of their students, the relationship of the school to parents of the students, requirements of due process, and their commitment to antidiscrimination principles. This paper focuses on the current procedural protections in university policies handling students at risk of suicide. I argue that suicidal ideation or attempt should not be treated as if the student has committed a disciplinary infraction but should be treated as a mental health issue that does not trigger a disciplinary proceeding. However, institutions should not be so quick to dismiss using disciplinary proceedings as a last resort since such a process affords students protections of minimal due process. I propose that the objectives of procedural due process, fairness, preserving the student-institutional relationship, and fact-finding in this situation should include an intermediate mediation step before resorting to disciplinary hearings or involuntary medical withdrawal.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Response of Choroid and Forehead Blood Flow to Systemic Phenylephrine Infusion

William L Worden ¹, Robert B Schonberger ¹, Vicente A Diaz ¹, Kwang Suh ¹, Rafat A Ansari ¹, David G Silverman ¹

The present study used laser Doppler flowmetry (LDF) to non-invasively evaluate changes in blood flow and microvascular oscillations in both the choroid and forehead in response to phenylephrine infusion.

Six healthy volunteers were recruited for forehead and choroidal LDF monitoring during phenylephrine infusion. Data were analyzed with the Wilcoxon Signed Ranks Test. Choroid and forehead flux increased in five out of six subjects in response to phenylephrine by an overall mean of 22.8 percent (range -87.2 to +109.4) and 21.7 percent (range -10.3 to 48.0), respectively. Choroid and forehead flux did not differ significantly from baseline or from each other (p = 0.5). Spectral domain analysis of forehead flux showed that the power of the dominant parasympathetic oscillations increased in all six subjects, (p = 0.03) for increase from baseline. Analysis of the choroid demonstrated that five out of six subjects showed increased oscillatory power in the parasympathetic range following phenylephrine administration (p = .048).

In light of the preservation of forehead and choroid blood flow, the observed increase in oscillations within the parasympathetic frequency range may constitute a manifestation of a generalized autoregulatory mechanism in the microvasculature that permits the maintenance of regional perfusion despite systemic vasocontriction.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Qualitative Assessment of Adherence to Antiretroviral Therapy Among Chinese Intravenous Drug Users

Charlotte Wu ^a, Kaveh Khoshnood ^b, Fujie Zhang ^c, Jessica Haberer ^c, Paul Bouey ^d

Injection drug users (IDUs) account for an estimated 44 percent of people living with HIV/AIDS in China and are the major driving force behind the expanding epidemic. Developing effective antiretroviral therapy (ART) adherence interventions in the Chinese IDU population is a major challenge. In conjunction with ART scale-up in Yunnan province, our goal was to gather patient perspectives on ART and ideas for feasible adherence support. Between December 2005 and March 2006, eight focus groups with a total of 55 HIV positive IDUs were conducted at three sites in Yunnan to ascertain ART knowledge, barriers to adherence, and acceptable adherence support methods. Focus groups included ART experienced and naïve participants, and HIV positive IDUs in methadone maintenance clinics. Discussions were audiotaped; notes were transcribed and coded for analyses. All participants were former or current IDUs. Thirty-one were from the rural countryside (59.6 percent), and 19 (36.5 percent) resided in a small city.

ART was viewed positively, but the principal barriers for urban IDUs were stigma and discrimination, while geography was the main problem for rural IDUs. Major themes were stratified between four components: knowledge, motivation, cues to action, and access to care. Adherence tools that were spontaneously endorsed included watches, pill boxes, and diaries. Directly observed therapy (DOT) within methadone programs was acceptable, but community-based DOT would need to address stigma issues in urban areas. Two separate HIV epidemics exist within IDUs in China: those stratified between small-city urban and rural populations. No single model for adherence will work, and interventions must be broad-based. This study provides an expanded conceptual framework for ART adherence in the HIV positive IDU population which includes the unique barriers posed by the ecological context surrounding this doubly discriminated population.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Determinants of Student Preferences for Teaching Behaviors in the Ambulatory Setting

Brian R Yablon ¹

The purpose of this research was to examine the influence of demographic and cultural factors on learner preferences for teaching behaviors in the ambulatory internal medicine clerkship. To that end, 50 medical students at each of four U.S. institutions (BU, Tufts, UMass, and Yale) and 50 British medical students at the University of Cambridge were invited to complete a survey on teaching behaviors in the ambulatory setting, evaluating items on two scales: the behavior’s importance and how highly the student recommended the behavior. Behaviors rated highly on both scales were considered "valued" by the student. Students’ values of the teaching behaviors were compared by gender, race/ethnicity, age, institution, and country, with 15 percent maximum difference among groups and p-value < 0.05 conferring significant value difference, 10 to 15 percent maximum difference with p-value < 0.05 "near-significant," and 15 percent maximum difference with p ≥ 0.05 deemed "notable."

The aggregate U.S. response rate to the survey was 82 percent, while the British response rate was 46 percent. Among the four U.S. schools, response rates varied from 64 percent to 98 percent. Significant differences were seen among groups of medical students in their values of ambulatory teaching behaviors, and distinct patterns emerged for gender, race, age, school, and country. Female students valued patient communication behaviors more than male students. Under-represented minority students valued orientation to the practice, patient care responsibility, and comfortable learning environment more than white and Asian students did. Older students valued give-and-take discussion with preceptors more than younger students. Among the four medical schools, Yale students most highly valued a preceptor who delegated responsibility for patient care and responded to student needs while valuing least a preceptor who asked the students probing questions. UMass students most highly valued patient autonomy. British medical students were less interested in functioning independently and more interested in being observed than the American students while also placing less value on patient privacy.

Differences among student groups raise important questions about causes and consequences of these discordant values in the ambulatory setting. The variability among medical schools and between countries provides novel evidence for limits in the applicability of single-institution studies, thus suggesting a new methodological standard for the community of medical education researchers.

Yale J Biol Med. 2007 Nov;80(1):1–38.

Why Do Patients Seek Emergency Psychiatric Care? Their Reasons and Characteristics

Peter C Yang ¹, Seth Powsner ¹

Many believe that psychiatric emergency services (PES) are misused, but there is little empiric data available addressing this issue. We investigated reasons why patients actually sought emergent care and whether alternative facilities could have addressed their needs.

We reviewed 200 consecutive evaluations in a teaching hospital emergency department via chart review. Data collected included psychiatric history, substance use, and contributing etiologies. PES clinicians involved were asked directly about underlying reasons for emergent care and whether suitable care could have been provided in a less acute setting.

Acute behavioral disturbances proved to be the most frequent reason for emergency visits. Half of all visits were because of uncontrollable, potentially uncontrollable, or unacceptable behavior. Direct provider referrals accounted for 31 percent of visits. Inability to cope with life events accounted for another 6 percent. Traditional psychiatric illness was a contributing factor in most visits (67.5 percent); other significant factors were relationship problems (20 percent) and substance abuse (16.5 percent). Alternative facilities could have taken care of 26 percent of visits.

We found that the vast majority of emergent psychiatric visits warranted immediate attention; only a minority (13 percent) of visits were not urgent. Patients who did not require emergency care could have been served by walk-in clinics, drug detoxification facilities, or faster access to outpatient treatment.

PERMALINK

Yale University School of Medicine

Methicillin-Susceptible Staphylococcus aureus Colonization in the Neonatal Intensive Care Unit

Shoaib S Ahmed

Robert S Baltimore

Clinical Predictors of Drug Resistance and Mortality among Tuberculosis Patients in a Rural South African Hospital: A Case-Control Study

Jason R Andrews

Neel R Gandhi

Anthony P Moll

Gerald H Friedland

The Impact of Prenatal Discussion of Breast-feeding by Healthcare Providers on Feeding Choice

Karen Archabald

Jessica Illuzzi

Stigma Perceived by Persons with Human Immunodeficiency Virus Attending the Infectious Diseases Clinic of Centre Hospitalier Univérsitaire De Fann in Dakar, Senegal

Nana Akua Asafu-Agyei

Papa Salif Sow

Does Response to Glaucoma Therapy in One Eye Predict Response in the Fellow Eye?

Omar R Chaudhary

Ron A Adelman

M Bruce Shields

Vaccination with Her2/Neu Peptides Elicits an Endogenous Anti-Her2/Neu Antibody Response in Mice

Bridget F Collins

Mark J Mamula

Sex and the Elderly: What Physicians Should Know About Their Older Patients

Jana A Colton

The "Power Mix" Tolerizing Regimen: Novel Tolerizing Regimens to be Applied in the Cynomolgus Model

Bidhan B Das

Joren C Madsen

Efficacy of Neoadjuvant Chemotherapy Regimens Prior to Resection of Colorectal Liver Metastases

Farrah M Datko

M Wasif Saif

Inflammatory and Thrombotic Responses to Microbial Products in Fetal Vessels are Mediated through Divergent Toll-Like Receptor Signaling Pathways: Implications in Fetal Inflammatory Response Syndrome

Shekar L Davarya

Yuehong Ma

Seth Guller

Mitral Cell Dendritic Development in the Mouse Main Olfactory Bulb

Masha Rand Diede

Charles A Greer

Sciatic Nerve Remyelination and Nodal Formation Following Olfactory Ensheathing Cell Transplantation

Mary A Dombrowski

Masanori Sasaki

Karen L Lankford

Hajime Tokuno

Christine Radtke

Jeffery D Kocsis

Bone Marrow Contribution to Renal Repair Following Ischemic Injury

Matthew C Egalka

Sujata Kale

Lloyd Cantley

Cadherin-Based Adhesion Molecules for Classification of Melanoma with AQUA Technology

Gretchen M Graff

Aaron J Berger

David L Rimm

Inhibition of ErbB2 and Thymidylate Synthase by a Multi-Targeted Small-Interfering RNA in Human Breast Cancer Cell Lines

Rebecca Hunter

Edward Chu

Interactions between fMRI BOLD-Activation during Reading Tasks and MRS-Measured Metabolite Levels

Hassana Aisha Ibrahim

Stephen Frost

Kenneth Pugh

Robert Fulbright

"No Observed Adverse Effects": Developing Neurons, Organo-Phosphate Insecticides, and the 1996 Food Quality Protection Act

Brendan R Jackson

John Harley Warner

Marriage and Divorce in Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study

Christopher M Janson

Amanda M Termuhlen

John A Whitton

Leslie L Robison

Lonnie K Zeltzer

Nina S Kadan-Lottick

Changes in the Optic Disc after Pan-Retinal Photocoagulation for Proliferative Diabetic Retinopathy

David J Jeng

M Bruce Shields

Ron A Adelman

Cost Analysis of Clinic and Office-Based Treatment of Opioid Dependence

Emlyn S Jones

Brent A Moore

Jody L Sindelar

Patrick G O'Connor