A public health certificate for all medical students: concepts and strategies

INTRODUCTION

The goal of integrating a Public Health Certificate (PHC) into the medical school curriculum is meant to provide basic public health skills and knowledge to all future physicians, ultimately broadening the health workforce's capacity to address community health needs. The faculty at the University of New Mexico's (UNM) School of Medicine (SOM), in collaboration with multiple community stakeholders, created a PHC equivalent to 15 graduate level units. The PHC will be required of all medical students matriculating in 2010.

METHODS

The authors, community leaders, university administrators, faculty, staff, and students met to address the many tasks required of such broad curricular and policy change. The tasks required piloting innovations in curriculum design and implementation, working within the bureaucratic structure, fostering collaboration, nurturing leadership skills, marketing the new ideas, and designing credible evaluation strategies.

RESULTS

We have engaged the stakeholders; surveyed our resources; produced and implemented ongoing evaluation; examined implementation strategies; developed, implemented and pilot tested the PHC courses; and engaged faculty from the Department of Family & Community Medicine in faculty development seminars.

CONCLUSION

Introduction of a PHC for all students is feasible with planning tools such as the Logic Model.

Anthracycline and trastuzumab in breast cancer treatment

This study was designed to evaluate the cardiac safety of the combined treatment of HER2-positive metastatic breast cancer patients with trastuzumab (Herceptin) plus epirubicin and cyclophosphamide (EC) in comparison with EC alone in HER2-negative metastatic breast cancer patients. Patients included those with metastatic breast cancer without any prior anti-HER2 treatment, anthracycline therapy, or any other chemotherapy for metastatic disease. This was a nonrandomized, prospective, dose-escalating, multicenter, open-label, phase I study in Germany. A control group of 23 patients received EC 90/600 mg/m2 3-weekly for six cycles (EC90 alone). A total of 26 HER2-positive patients were treated with trastuzumab, or H (2 mg/kg weekly after an initial loading dose of 4 mg/kg), and EC 60/600 mg/m2 3-weekly for six cycles (EC60+H); another 25 HER2-positive patients received H and EC 90/600 mg/m2 3-weekly for six cycles. Asymptomatic reductions in left ventricular ejection fraction (LVEF) of more than 10% points were detected in 12 patients (48%) treated with EC60+H and in 14 patients (56%) treated with EC90+H vs 6 patients (26%) in the EC90 alone cohort. LVEF decreases to <50% occurred in one patient in the EC60+H cohort and in two patients in the EC90+H cohort during the H monotherapy. No cardiac event occurred in the cohort with EC90 alone. The overall response rates for EC60+H and EC90+H were >60%, vs 26% for EC90 alone. The interim results of this study approve the cardiac safety of the combination of H with EC, with low risk of cardiac toxicity. The combination regimen revealed promising efficacy.

Cardiac safety of trastuzumab in combination with epirubicin and cyclophosphamide in women with metastatic breast cancer

This prospective, parallel-group, dose-escalation study evaluated the cardiac safety of trastuzumab (Herceptin) plus epirubicin/cyclophosphamide (EC) in women with human epidermal growth factor receptor-2 (HER2)-positive metastatic breast cancer (MBC) and determined an epirubicin dose for further evaluation. HER2-positive patients received standard-dose trastuzumab plus epirubicin (60 or 90 mg/m(2))/cyclophosphamide (600 mg/m(2)) 3-weekly (EC60+H, n=26; EC90+H, n=25), for four to six cycles; 23 HER2-negative patients received EC alone (90/600 mg/m(2)) 3-weekly for six cycles (EC90). All patients underwent thorough cardiac evaluation. Two EC90+H-treated patients experienced symptomatic congestive heart failure 4.5 and 6 months after the end of chemotherapy. One EC60+H-treated patient experienced an asymptomatic decrease in left ventricular ejection fraction (LVEF) to <50% 6 months after the end of chemotherapy. No such events occurred in control patients. Asymptomatic LVEF decreases of >10% points were detected in 12 (48%), 14 (56%) and 5 (24%) patients treated with EC60+H, EC90+H, and EC90. Objective response rates with EC60+H and EC90+H were >60%, and 26% for EC90 alone. These results indicate that trastuzumab may be combined with EC with manageable cardiotoxicity and promising efficacy.

A meta-analysis of the Papanicolaou smear and wet mount for the diagnosis of vaginal trichomoniasis

PURPOSE

To obtain reliable estimates of the sensitivity and specificity of the cervical Papanicolaou (Pap) smear and wet mount to diagnose vaginal trichomoniasis.

METHODS

Articles indexed in MEDLINE (1976-1998) about diagnostic tests for trichomoniasis and their listed references were retrieved. Thirty studies (9,501 patients) that used trichomonas culture as a gold standard were selected. Studies were defined as level I if they fulfilled at least two of the following three criteria: consecutive patients were evaluated prospectively, the decision to culture was not influenced by test results, and there was independent and blind comparison with culture. Studies were classified as level II if one criterion was fulfilled, and as level III otherwise.

RESULTS

The pooled sensitivity of the Pap smear for the diagnosis of trichomoniasis among level I studies was 57% (95% confidence interval [CI]: 51% to 63%) and the pooled specificity was 97% (95% CI: 93% to 100%). The likelihood ratio for a positive Pap smear was 19 among level I studies (range: 8 to 62). The pooled sensitivity of the wet mount among level I studies was 58% (95% CI: 51% to 66%); among level II studies, the sensitivity was 72% (95% CI: 62% to 81%), and among level III studies, the sensitivity was 82% (95% CI: 67% to 97%). The overall specificity of the wet mount was 99.8%.

CONCLUSIONS

A positive Pap smear for trichomonads in settings in which trichomoniasis is common (prevalence > or =20%) requires treatment. A positive Pap smear is indeterminate when the prevalence of trichomoniasis is about 10%; thus, clinicians should either confirm the diagnosis by culture or treat all such patients, recognizing that some patients will be treated unnecessarily. A culture should be obtained in women with a positive Pap smear who are unlikely to have trichomoniasis (prevalence < or =1%). While a positive wet mount is diagnostic, a negative wet mount does not exclude trichomoniasis.

Reporting and concordance of methodologic criteria between abstracts and articles in diagnostic test studies

OBJECTIVE

To evaluate the quality and concordance of methodologic criteria in abstracts versus articles regarding the diagnosis of trichomoniasis.

STUDY DESIGN

Survey of published literature.

DATA SOURCES

Studies indexed in MEDLINE (1976-1998).

STUDY SELECTION

Studies that used culture as the gold or reference standard.

DATA EXTRACTION

Data from abstract and articles were independently abstracted using 4 methodologic criteria: (1) prospective evaluation of consecutive patients; (2) test results did not influence the decision to do gold standard; (3) independent and blind comparison with gold standard; and (4) broad spectrum of patients used. The total number of criteria met for each report was calculated to create a quality score (0-4).

MEASUREMENTS AND MAIN RESULTS

None of the 33 abstracts or full articles reported all 4 criteria. Three criteria were reported in none of the abstracts and in 18% of articles (95% confidence interval [95% CI] 8.6% to 34%). Two criteria were reported in 18% of abstracts (95% CI, 8.6% to 34%) and 42% of articles (95% CI, 27% to 59%). One criterion was reported in 42% of abstracts (95% CI, 27% to 59%) and 27% of articles (95% CI, 15% to 44%). No criteria were reported in 13 (39%) of 33 abstracts (95% CI, 25% to 56%) and 4 (12%) of 33 articles (95% CI, 4.8% to 27%). The agreement of the criteria between the abstract and the article was poor (kappa -0.09; 95% CI, -0.18 to 0) to moderate (kappa 0.53; 95% CI, 0.22 to 0.83).

CONCLUSIONS

Information on methods basic to study validity is often absent from both abstract and paper. The concordance of such criteria between the abstract and article needs to improve.

Hurricane Floyd. Response of the Pitt County Medical Community

The financial impact of Hurricane Floyd on the medical community is still being tabulated. Initial estimates indicate a $5.8 million loss to UHS in operating revenue. Additional hospital costs include $568,000 for overtime pay, $310,000 for special equipment including helicopters and general supplies, and $1.2 million in "bonus pay" to the hospital's 6000 employees. The ECU School of Medicine suffered losses estimated at $3.6 million, including lost revenue, overtime, and salaries paid when clinics and services were shut down. Most private offices suffered from lost revenues and occasionally from flood damage to property. Hurricane Floyd was the most costly disaster to hit Eastern North Carolina and the Mid-Atlantic United States. The medical community and its patients were severely challenged from the terrible effects of flooding, but the collaborative efforts of a great number of individuals and a spirit of teamwork came together to provide continued health care to the region. It is very likely that the preventive measures enacted both before and after the storm averted illness and injury, and saved lives. Ingenuity, innovation, and optimal use of available resources allowed Pitt County Memorial Hospital and its surrounding medical community to stay in operation. We have learned a great deal from these experiences that will help us plan for future natural disasters.

Systematic review of diagnostic tests for vaginal trichomoniasis

OBJECTIVE

To review critically and to summarize the evidence of diagnostic tests and culture media for the diagnosis of Trichomonas vaginitis.

METHODS

We performed a systematic review of literature indexed in MEDLINE of studies that used Trichomonas culture as the reference standard (9,882 patients, 35 studies). Level I studies (5,047 patients, 13 studies) fulfilled at least two of three criteria: 1) consecutive patients were evaluated prospectively, 2) decision to culture was not influenced by test results, and 3) there was independent and blind comparison to culture.

RESULTS

The sensitivity of the polymerase chain reaction technique (PCR) was 95% (95% CI 91% to 99%), and the specificity was 98% (95% CI 96% to 100%). One study was classified as Level I evidence (52 patients). The sensitivity of the enzyme-linked immunosorbent assay was 82% (95% CI 74% to 90%), and the specificity was 73% (95% CI 35% to 100%). The sensitivity of the direct fluorescence antibody was 85% (95% CI 79% to 90%), and the specificity was 99% (95% CI 98% to 100%). Sensitivities of culture media were 95% for Diamond's, 96% for Hollander, and 95% for CPLM.

CONCLUSIONS

The sensitivity and specificity of tests to diagnose trichomoniasis vary widely.

Fostering the health of communities: a unifying mission for the University of New Mexico Health Sciences Center

Fostering the health of communities can serve as a unifying mission of the academic health center (AHC), which can set the AHC apart from other health providers in the community. To achieve this mission, the University of New Mexico's AHC is increasingly focusing education, research, and service upon the identified health and service needs of communities in its state. Since major health problems in our society have social, behavioral, and economic roots, New Mexico's AHC has tapped into the broad expertise of its different components as well as that of its state and community partners to adequately address health problems in the community. Its hospitals offer financing and management resources, its colleges offer innovative approaches to community-based education, and the state department of health offers expertise in health policy development. To adequately respond to the complexity of community health needs, the different colleges and departments at New Mexico's AHC are increasingly merging into integrated governance units. Measures of community outreach success include evidence of strengthened community development, increased health care access, and improved indices of community health. New Mexico's AHC formed an interdisciplinary rural outreach task force, which has demonstrated its ability to form partnerships with state and local agencies and to mobilize institutional resources in education, research, and service from the AHC's different departments, colleges, and hospitals to respond promptly to unique community health needs. Evidence shows that such an integrated, coordinated AHC intervention can generate strong and lasting AHC-community alliances, improve the quality and economic viability of community health systems, and enhance the financial resources of the AHC.

Structural organization and differential expression of three stilbene synthase genes located on a 13 kb grapevine DNA fragment

A 13 kb DNA fragment was isolated from a grapevine (Vitis var. Optima) genomic library by hybridizing with elicitor-induced stilbene synthase cDNA as a probe. After fragmentation with Eco RI, subcloning and sequencing, two full-size stilbene synthase genes (Vst1 and Vst2) and the 3' end of a third stilbene synthase gene (Vst3) were located within the 13 kb fragment. Vst1 and Vst2, differing only slightly in the coding region, are distinguished in the intron size and in the structure of the promoter region. The 5' flanking region of gene Vst1 contains a TATAA box at nucleotide -48. The substantial structural differences found for the promoters of the two genes are paralleled by a striking difference in the expression of the two genes in elicitor-treated cells. Moreover, the accumulation upon elicitation of six different stilbene synthase mRNAs was studied and found to differ by two orders of magnitude.

Disease resistance results from foreign phytoalexin expression in a novel plant

Although phytoalexins have long been inferred to be important in the defence of plants against fungal infection, there are few reports showing that they provide resistance to infection. Several plants, including grapevine, synthesize the stilbene-type phytoalexin resveratrol when attacked by pathogens. Stilbenes with fungicidal potential are formed in several unrelated plant species, such as peanut (Arachis hypogaea), grapevine (Vitis vinifera) and pine (Pinus sylvestris). Stilbene biosynthesis only specifically requires the presence of stilbene synthase. Furthermore, the precursor molecules for the formation of hydroxy-stilbenes are malonyl-CoA and p-coumaroyl-CoA, both present in plants. To investigate the potential of stilbene biosynthetic genes in a strategy of engineering pathogen resistance, we isolated stilbene synthase genes from grapevine, where they are expressed at a high level, and transferred them into tobacco. We report here that regenerated tobacco plants containing these genes are more resistant to infection by Botrytis cinerea. This is, to our knowledge, the first report of increased disease resistance in transgenic plants based on an additional foreign phytoalexin.

[Autolymphocytotoxins (CoCoCy) in different forms of hepatitis and cirrhosis (author's transl)]

Sera of altogether 282 patients with different forms of hepatitis and cirrhosis were screened for cold reacting complement dependant auto-lympho-cytotoxins (CoCoCy). These antibodies are 19S-IgM-immunoglobins and have no HLA-antigen-specificity. CoCoCy occurred in 48% of the patients with chronic aggressive hepatitis (CAH), in 14% of the patients with chronic persistent hepatitis (CPH) and in intermediate rates in the sera of patients with acute hepatitis. No correlations was found between CoCoCy and hepatitis B-antigen (HB-Ag). CoCoCy could be demonstrated also in 20% of the sera of a HB-Ag-positive and in 6% of a HB-Ag-negative control group. The serum concentration of CoCoCy is low. CoCoCy seems to be of T-cell-specificity and to reflect the overall-immunoreactivity without relation to the specificity of the antigenic stimulus. Thus demonstration of CoCoCy may be of pathogeneic and pathodynamic rather than of diagnostic interest.