SCOPE More News		Lab testing may allow earlier cancer diagnosis If promising research at the Yale Cancer Center is proven effective, a simple blood or tissue test may be able to provide earlier diagnosis of breast cancer than is now possible with mammograms. To pursue this new technology, the Cancer Center last fall established a new specialized laboratory with $500,000 in seed money provided by Los Angeles philanthropist Marcia Israel. Investigators are developing new tests capable of detecting very small clusters of cells before they become visible on a mammogram. New technologies already make it possible to determine mutations in single cells as well as in genetic material extracted from a very small number of cells. The biological materials obtained through such methods as fine needle aspiration can then be analyzed with great sensitivity and specificity for the genetic alterations that are the hallmark of cancerous cells. New technologies also make it possible to look for mutated cancer molecules in the blood of patients. “Researchers at the Yale Cancer Center have hopes not only of improving the detection of small cancers, but also of being able to identify women whose breast tissue is about to become cancerous,” said Jose Costa, M.D., the Cancer Center deputy director under whose supervision the new laboratory falls. “These are the patients on whom we will ultimately want to test new cancer-preventing therapies.”
Top    More		Worry about Lyme disease may be worse than the illness Lyme disease was first identified and named by researchers at Yale more than a decade ago. Now, Yale investigators have shown that fear of Lyme disease may in some cases cause more problems than the disease itself. According to a study published in the Annals of Internal Medicine in March, anxiety about possibly getting Lyme disease following a deer tick bite can result in over-treatment by doctors and is associated with a high incidence of depression and stress among patients. That worry is often unfounded and may result in harm, especially from overuse of antibiotics. Lyme disease is caused by bacteria spread through extended feeding on human blood by the tiny deer tick. The tick must be embedded in the flesh for at least 24 hours to spread the bacteria into the host. In the vast majority of cases, an infected bite will cause a bull's eye rash. Lyme disease can cause flu-like symptoms, swelling of the knees and, in very unusual cases, arthritis, facial paralysis and neurological disorders. A single course of antibiotics usually eradicates the disease and even later-stage manifestations normally respond to antibiotic therapy. According to the Yale study, however, many patients don't believe it, or believe they have the disease when they do not. Out of 209 patients evaluated for this infectious disorder, 60 percent turned out not to have Lyme disease at all. Yet they still made an average of seven visits to the doctor, had four blood tests and underwent 42 days of antibiotic treatment. High levels of depression (42 percent) and stress (45 percent) were present in those who turned out not to have the disease and more than half reported adverse drug reactions after taking antibiotics. Assistant professor of medicine M. Carrington Reid, M.D., who co-authored the study with clinical professor of medicine Robert T. Schoen, M.D., says, “We're not helping these patients if we simply give them a label of Lyme disease.” The study points to the need for better information for patients and physicians about Lyme disease.
Top    More		Attention deficit study finds no evidence of overdiagnosis The number of children being diagnosed and treated for attention deficit/hyperactivity disorder (ADHD) has risen sharply in recent years, and parents and child-health advocates have raised concerns about possible overdiagnosis of the disorder. The Council on Scientific Affairs of the American Medical Association reviewed studies in the field over more than the last two decades and concluded that those worries are unfounded. The council's chair-elect, Myron Genel, M.D., professor of pediatrics and associate dean of government and community affairs at the School of Medicine, says, “The preponderance of evidence is that ADHD is not diagnosed lightly. ADHD is one of the best studied and characterized disorders.” For the council's report, which appeared in the April 8 issue of The Journal of the American Medical Association (JAMA), studies published from 1975 through March 1997 were reviewed and analyzed. The council found little evidence of widespread overdiagnosis or misdiagnosis of ADHD, or of widespread over-prescription of Ritalin, the most commonly prescribed drug for treatment of ADHD. The council concluded: “Epidemiologic studies using standardized diagnostic criteria suggest that 3 percent to 6 percent of the school-aged population may have ADHD. The percentage of U.S. youth being treated for ADHD is at most at the lower end of this prevalence range.”
Top    More		A brain structure that keeps confusion at bay Animals are constantly gathering signals from the surrounding environment, yet somehow they learn to focus on stimuli important to survival and to ignore, or fail to learn to respond to, other stimuli. Otherwise, a survival-threatening confusion could result. A team of investigators, including Yale neuroscientist Jeansok J. Kim, Ph.D., has found a neurological explanation for this phenomenon called blocking, and has identified the brain structure involved in the blocking process. Dr. Kim and colleagues found that when they chemically severed a brain structure called the inferior olive in rabbits, blocking disappeared and the animals responded to redundant and irrelevant stimuli. “In order to adapt to its environment,” says Dr. Kim, an assistant professor of psychology, “an animal must respond selectively to stimuli that reliably predict biologically significant events, such as food availability. In the interest of efficiency and simplicity, animals must avoid forming associations with other stimuli that provide no new information. Blocking appears to circumvent such redundant learning.” The study appeared in the journal Science.
Top    More		Wider use of medication could prevent many strokes An irregular heartbeat, or atrial fibrillation, affects some 2.5 million Americans. Clot formation associated with atrial fibrillation is believed to be a contributing factor in about 15 percent of the 740,000 strokes that occur each year in the United States, yet very few of the people who would benefit from a medication to treat atrial fibrillation receive it. According to a study directed by Lawrence M. Brass, M.D., professor of neurology and chief of the neurology service at the VA Connecticut Healthcare System in West Haven, only 38 percent of patients who had atrial fibrillation received warfarin, a blood thinner used to reduce the tendency for blood to form clots. Researchers believe that if more patients took warfarin, tens of thousands of strokes could be prevented, saving thousands of lives each year. “We have a medication that has been shown to be highly effective,” says Dr. Brass, “but we have found that the medical community is not getting this therapy to all of the patients who need it.” The results of the study appeared in the December issue of Stroke and are part of the ongoing efforts to enhance clinical practice in the Center for Outcomes Research and Evaluation at Yale-New Haven Hospital, Dr. Brass says.
Top    More		A web of New Haven health information Already an important tool for public health investigators, the World Wide Web now offers a new site for one-stop local research in the field: New Haven Health. The Cushing/Whitney Medical Library received a grant from the National Library of Medicine this past winter to create a publicly accessible Web site that will function as a central repository for information about public health in the greater New Haven area. The Web site includes vital and health statistics, current and historical public health documents, community organization listings, aids in the search for related non-digital holdings, and historical images. Browsers will find links to related sites and a listserv for the discussion of public health research. Go to http://www.med.yale.edu/newhavenhealth.
Top    More		New Haven's mayor visits medical school New Haven and Yale University have never had better relations, Mayor John DeStefano told students and faculty during a visit to the medical school March 5. “The University and the city understand their need to grow together,” he said at a Medical School Council lunch in the Beaumont Room. “I feel better about understanding each other and supporting each other than I have in my lifetime.” Noting that the largest taxpayers and employers in two neighboring communities are a pharmaceutical company and a medical research company, he cited the importance of the medical school to the region's and the city's economy. “I think that finding a way to grow the medical school towards the central campus of Yale is a good idea.” Mr. DeStefano said he has plans for developing downtown New Haven and Long Wharf. “I think you're going to see the growth south of Howard Avenue towards Church Street South and the train station,” he said. He is also trying to improve transportation by promoting ferry service to Long Island, a fast rail link to New York City and an expanded runway at Tweed-New Haven Airport. A lack of space, an unwarranted image as crime-ridden, and a disproportionate share of social ills such as poverty have hobbled development in New Haven, he said. Since the 1950s the city has lost residents and businesses to the suburbs. Restrictive zoning laws and the lack of affordable housing in the suburbs and a higher proportion of multi-family dwellings in the city lead to a larger concentration of poor people in the city, he said. Median income, which in 1950 was about the same in the city and its suburbs, has shifted. For every dollar of income in neighboring towns, New Haven has 67 cents. “The fact of housing segregation and the racial and economic isolation that flows out of that is a real challenge,” he said. On top of its economic woes, the city is unfairly portrayed as a place of crime and that keeps people away, he said. He said that in 1994, Bridgeport had 54 murders, nine of which made the front page of the newspapers. Hartford had 61 murders, with seven making the front page. All but one of New Haven's 34 murders that year were front-page news. “New Haven is the murder capital of the state not because we had the most murders,” Mr. DeStefano said, “but because we did the best job of publicizing them.” Since 1990 crime has dropped by nearly 40 percent, Mayor DeStefano said, noting that in early 1998 the city's murder rate was the lowest in generations. “Real growth will occur when we move past perceptions and ignorance,” he said.
Top    More		Using art to sharpen observational skills Medical education took an artistic turn for a group of Yale students this past spring. Professor Irwin M. Braverman, M.D. '55, and museum curator Linda Friedlaender combined their expertise to produce a tutorial using works of art to sharpen the observational skills of aspiring physicians. In a collaboration between the medical school and the Yale Center for British Art, 56 medical students spent time looking at selected paintings, described them for the group and made thoughtful judgments about what was being communicated visually. Students were assigned a painting and given time to observe and study it–“like a rash that has been framed,” says Dr. Braverman, a dermatologist. The goal of the exercise is to produce more careful observers by training students to decode an object's meaning and to extract useful information. Physicians with superior observational skills ask the questions necessary to diagnose illness without relying excessively on tests, says Dr. Braverman, adding, “Doctors have to be taught to pick up on details that are often overlooked.” He came upon the idea last November while thinking of ways to teach his dermatology residents to notice more in the clinic. He discussed the idea with Mrs. Friedlaender, curator of education at the Yale Center for British Art, who had been thinking about the same kind of observational exercise for residents in the Department of Orthopaedics and Rehabilitation, chaired by her husband, Gary E. Friedlaender, M.D. The students who participated in the tutorial found it to be a significant step in their training. “Like very detailed paintings, the human body is complex,” says Leo Kim, a first-year student. “Learning to look at, and really see, all the details of a painting helps in diagnosing patients.”
Top    More		Child Study Center aids Arkansas town after shootings The day after four girls and a teacher were shot to death at a middle school in Arkansas, Yale psychologist Steven Marans, Ph.D., was on a plane. Two boys, ages 11 and 13, were accused of setting off a fire alarm on March 25, then ambushing schoolmates as they ran from the building. As the small city of Jonesboro tried to make sense of the incident, one of nearly a dozen violent outbursts in schools around the nation this past school year, Dr. Marans was summoned as an observer and consultant. The reason was Yale's Child Development-Community Policing Program, a unique collaboration between mental health professionals at the Child Study Center and New Haven's police department. The CDCP Program, which provides counseling and other support to children who have witnessed violence, has been replicated in four U.S. cities with funding from the U.S. Department of Justice. “The partnership between mental health and law enforcement in New Haven has given us a unique opportunity to think about violence from many perspectives,” says Dr. Marans, who helped launch the program in 1991 with center Director Donald J. Cohen, M.D. '66, and city police leaders. “We have gained an awful lot of experience over the last seven years.” During his two days in Jonesboro, Dr. Marans talked with counselors, parents, teachers and students and attended a meeting of about 500 students and parents. “They have a very arduous task at hand, which is to mourn the loss of life and to mourn their loss of friends and children,” says Dr. Marans, the Harris Assistant Professor of Child Psychoanalysis. Those who saw the shootings or lost friends may experience depression, eating and sleeping disorders, a sense of disbelief, psychological numbing and a degree of fearfulness. Children may be more clinging and dependent and needy than they are typically. The town of 50,000 people is left to wonder why two children would set out to kill other children. “Having the easy availability of guns and inadequate supervision has been a potent and lethal combination. But every human being has anger and feelings of rage at times and longings for attention. Those feelings that are common to all of us do not typically find expression in murdering one another,” says Dr. Marans. “We know this behavior is not typical in the majority of children, and our children need to know that as well.”
Top    More		Exercise science soars on human powered wings As a physiologist, Ethan Nadel, Ph.D., knows a great deal about what happens to the body during exertion and the causes of fatigue. Even he didn't know just what to expect, however, when he helped to plan a world-record, human-powered flight. In his March 27 lecture, Dr. Nadel, professor of cellular and molecular physiology and of epidemiology and director of the Yale-affiliated John B. Pierce Laboratory, described the challenges planners faced when preparing the pilot 10 years ago for Project Daedalus, a modern day reenactment of the mythical Greek inventor Daedulus' 74-mile passage between the Greek islands of Crete and Santorini. Dr. Nadel selected the pilot team and developed a drink to prevent dehydration and boost the pilot's energy supply during the grueling but ultimately successful flight. His talk inaugurated a new series of campus lectures, along with a new summer research internship program for seven Yale College students, sponsored by Gatorade Inc.
Top    More		Cardiologists combine to form statewide network In today's managed care world, consolidation of health care delivery services is the order of the day, including the practices of Yale faculty members. The Yale Cardiology Network, a faculty-practice organization, has merged with CardioNet of Connecticut, LLC, a community-practice group, to form a statewide heart-care network. Its more than 90 university- and community-based physicians, cardiologists and cardiac surgeons also serve parts of Rhode Island and New York. The network, the first of its kind in Connecticut, will operate under the name of the Yale Cardiology Network and will be headed by an executive committee chaired by Barry Zaret, M.D., chief of the section of cardiovascular medicine.
Top    More		A genetic intervention for children with rare disease Yale investigators are evaluating a potential therapy for Canavan disease, a rare neurological disorder in children that is usually fatal. Eight children have been cared for at Yale this year as part of a clinical trial to test the safety of the treatment, which uses gene therapy techniques to replace a critical enzyme in the brain. Children with Canavan disease cannot hold their heads up, have trouble eating and may suffer seizures. Few live past the age of 10. The genetic disease strikes children of all ethnic groups, occuring most frequently among Ashkenazi Jews. According to Margretta R. Seashore, M.D., the principal investigator in the study, the current phase of the trial will assess its safety. Yale's Human Investigation Committee and its Biosafety Committee are also monitoring the study. A ninth child is undergoing the therapy at Thomas Jefferson University Hospital in Philadelphia. If the procedure proves safe, the FDA may allow researchers to add six more children to the trial. Although the Phase I trial is focused on the safety of the procedure, researchers are watching for signs of improvement in the children. “It's really too early to know whether we've got some encouraging signs of therapeutic effect,” said Maurice J. Mahoney, M.D., a member of the Human Investigation Committee. The only reported side effect among the children has been a high fever that is typical of gene therapies and easily treated, said Dr. Seashore, professor of genetics and pediatrics. Treatment starts with the insertion of a 2-inch-wide rubber reservoir under the scalp. A slender catheter carries the gene to synthesize aspartoacylase (ASPA), an enzyme missing in Canavan disease, into the ventricle of the brain. Although researchers are still trying to understand the exact mechanism, without ASPA a chemical called N-acetylaspartic acid builds up and myelin, the “white matter” that protects nerves and allows messages to be transmitted to and from the brain, becomes deficient. Researchers hope their therapy will stimulate the brain to produce ASPA and slow down or reverse the progress of the disease. Parents recognize that the therapy is experimental and may not help their children. “There will either be a benefit or there will be nothing,” said Howard Gluckman of Johannesburg, South Africa, who calls his son, Asher, 9, the granddaddy of the group. The youngest child in the group is 19 months. “At least they're not in danger from the procedure.” “It's a first step,” said Matthew During, M.D., a visiting professor at the medical school who conducted previous gene therapy trials in New Zealand. “It gives us a level of comfort and confidence in moving forward.”
Top    More		Probing the hazards of autobody work Walk into an autobody shop and you may be greeted by a curious cocktail of chemical fumes. Posted signs keep customers out of work areas, but painters and repairers must stay in that environment for hours each day. Although most shops take safety precautions, research shows that exposure to chemicals in autobody paint can trigger respiratory ailments. To determine how exposure to a class of chemicals known as isocyanates causes asthma, researchers at Yale's Occupational and Environmental Medicine Program have launched a study of shops in two Connecticut counties. The study, called the Survey of Painters and Repairers in Autobodies by Yale, or SPRAY, is also directed at finding better ways of protecting workers' health. Workers in autobody shops are exposed to many potentially harmful materials, such as paints and solvents. Paints often contain isocyanates, which are highly reactive chemicals known to induce respiratory symptoms and asthma. According to Mark R. Cullen, M.D., director of the Occupational and Environmental Medicine Program and the study's principal investigator, isocyanates account for the highest number of reported cases of occupational asthma in the United States and other developed countries. Approximately 5 to 10 percent of workers exposed to isocyanates may be affected nationally. SPRAY, which is funded by a five-year, $2 million grant from the National Institute for Occupational Safety and Health, provides participating autobody shops with free industrial hygiene evaluations. Yale researchers evaluate the working environments in several shops for isocyanate exposure, make recommendations to reduce their exposure to chemicals, and give workers free respiratory health evaluations.
Top    More		A “natural” tan to beat the sun With skin cancer rates soaring, dermatologists have been warning people to protect themselves from the sun, but the popularity of tanning means the advice often goes unheeded. Thanks to a new cosmetic tanning lotion developed by Yale senior research scientist John M. Pawelek, Ph.D., tanners will soon be able to get that sun-soaked look without sitting under the sun or in a tanning booth. Dr. Pawelek's medical research focuses on therapies for melanoma and other forms of skin cancer. While doing basic research with professor of dermatology Jean Bolognia, M.D., on melanocytes, the pigment cells that color skin and provide protection from the sun, he came upon a method for producing a water soluble form of melanin derived from the aloe vera plant. The extract, which is chemically indistinguishable from natural human melanin, immediately changes the skin's color to a natural-looking tanned hue and has skin cancer-protective qualities similar to real melanin. In an added bonus, it also has remarkable chameleon-like characteristics that cause it to blend its hue to that of the individual's surrounding skin. To Dr. Pawelek's surprise, following early publicity about the product, he has received a flood of inquiries from people who suffer from vitiligo, a skin disorder causing a progressive loss of pigmentation cells that affects 1 percent of the world's population. San-Mar Laboratories Inc., which licensed the discovery from Yale, will be producing cosmetic products containing it for marketing worldwide before year's end “It may prevent many cases of skin cancer,” says Dr. Pawelek “and should bring relief to at least some people with vitiligo.”
Top    More		Confronting violence in the home Domestic violence is rarely thought of as a public health issue, yet it has a massive impact on the health care system, accounting, for instance, for more than a third of all women seeking emergency treatment from U.S. hospitals. Understanding the phenomenon and seeking ways to reduce its incidence were among the topics explored at the third annual Domestic Violence Seminar Series, held this spring by the Department of Epidemiology and Public Health. The series is part of the Pew Urban Health Program, a research and teaching collaboration among students and faculty from the schools of medicine, public health and nursing. Addressing an audience of Yale and New Haven community members, the three principal speakers focused on different aspects of the issue of domestic violence. Sujata Warrier, Ph.D., director of the New York City Program of the New York State Office for the Prevention of Domestic Violence, spoke about ways to assist victims from a variety of ethnic and social backgrounds. Donna Edward, J.D., executive director of the National Network to End Domestic Violence, discussed new federal legislation aimed at curbing violence against women. Yolanda Haywood, M.D., an associate professor of emergency medicine at George Washington University Medical Center, who treats domestic violence victims, was herself in an abusive relationship. By recounting the struggles she faced in leaving that violent situation, she sought to provide attendees with a clearer understanding of the complex motivations that underlie domestic violence.
Top    More		Focus on fitness The Yale Conference on Women's Health & Fitness in May brought together some of the nation's leading experts on physical activity, menopause, cancer and nutrition to discuss the latest findings for the treatment of women and the diseases that affect their health. Keynote addresses were given by Stephen Blair, director of epidemiology and clinical applications at the Cooper Institute for Aerobics Research in Dallas and author of the surgeon general's report on physical activity; and Rebecca and Ruthann Lobo, co-authors of Home Team: of Mothers, Daughters & American Champions. The Lobos spoke about how they handled Rebecca's success on the basketball court and Ruthann's battle with breast cancer. Pictured at a reception at the Yale Sports Medicine Center are (back row, from left) Larry Matthews, Ph.D., conference co-chair; Rebecca and Ruthann Lobo; and (front row, from left) conference co-chairs Ann Cowlin and Peggy DeZinno.
Top    More		Bringing public health education to a changing China The explosive growth of the economy of the People's Republic of China brings with it many benefits–and a set of daunting new public health challenges. Already closely allied with efforts to improve public health education in China, Yale faculty and student efforts will expand significantly as a result of a five-year, $400,000 grant from The Procter & Gamble Co. The funds will support a collaboration between the Department of Epidemiology and Public Health and Beijing's 10-year-old Union School of Public Health, the nation's first graduate-level public health training program. The main focus of the collaboration will be on strengthening the Union School curriculum in public health law, health economics, environmental health, smoking control and other areas. The grant will also fund summer internships in China for Yale students in public health. Those students will face a broad range of problems. “Fundamental political and economic changes,” says Michael H. Merson, M.D., dean of public health and director of the Yale-Union collaboration, “are presenting China with not only many health risks associated with developing nations–such as infectious and parasitic diseases–but also rising rates of diseases associated with lifestyle changes, including cancer, heart disease and sexually transmitted diseases such as AIDS. In addition, 70 percent of adult men in China smoke, creating a huge need for anti-smoking campaigns organized by public health workers.” Yale first collaborated with Union School in 1996 when University faculty helped develop a public health law curriculum. Part of the new collaboration will involve refining that curriculum and disseminating it to faculties at some 30 other public health schools in China. Procter & Gamble's chairman and chief executive officer, John E. Pepper, is a member of the Yale Corporation, the governing board of the University.
Top    More		Discovery of how a brain tumor travels may pave way to treatment Yale researchers have discovered a molecule that speeds the growth and spread of a form of brain cancer that afflicts some 20,000 Americans annually and proves lethal in half of the cases within 18 months. Glioma, as the form of cancerous brain tumors is termed, is particularly resistant to standard treatments such as surgery because its cells zoom through normal brain tissue to other sites where new tumors can grow rapidly. According to a study directed by neurobiologist Susan Hockfield, Ph.D., gliomas move through healthy brain tissue with the help of a tumor-specific protein, which acts like a set of wheels on the cancer cells. The researchers hope that a therapy that blocks the function of the protein molecule, called brain-enriched hyaluronan binding protein (BEHAB), or reduces a tumor cell's ability to generate it, may slow tumor progression. Dr. Hockfeld's study, which was published in the April 1 issue of The Journal of Neuroscience, provides the first clear understanding of how glioma cells invade healthy brain tissue. The work also resulted in a new animal model for the disease that can be used to evaluate future therapies. “One approach to controlling the cancer,” says Dr. Hockfield, the new dean of the Graduate School of Arts and Sciences, “would be to block the glioma cells' ability to travel, without harming healthy cells.” She notes that BEHAB may prove a prime candidate for this type of therapy because it exists in glioma tumors but not in other kinds of brain tumors or tissue in the body.
Top    More		Yale appeals verdict in Dr. Doe case In December a New Haven jury awarded $12.2 million to a former medical resident who became HIV-positive after an accidental needle stick in 1988. The resident, known in court documents as “Dr. Doe,” sued Yale, alleging that inadequate training and supervision caused the accident. The University is appealing the verdict. Dr. Doe, then 25, was a first-year resident seven weeks into her internship at Yale-New Haven Hospital when she pricked her right thumb while inserting a line into the artery of a patient with AIDS. Dr. Doe said she had tried the procedure only three times before the accident and that the supervising physician, a third-year resident, failed to monitor the procedure properly. The University is challenging the jury's verdict in two areas. First, its appeal argues that Connecticut law does not recognize such a claim for educational malpractice. It also argues that the University should not be held liable because, as an employee and resident at Yale-New Haven Hospital, Dr. Doe's exclusive remedy is a workers' compensation claim rather than a civil suit. Dr. Doe is already receiving workers' compensation benefits through the hospital. Both sides in the case expect to file briefs this summer and present arguments later this year. As of December 1996, 52 health care workers around the country had acquired HIV through occupational transmission, 24 of whom developed AIDS, according to the federal Centers for Disease Control and Prevention (CDC) in Atlanta. Another 111 may have acquired HIV on the job, but the source of transmission hasn't been determined in those cases, according to the CDC. Contributors: Susan Alksnis, Cynthia Atwood, John Curtis, Michael Fitzsousa, Katie Krauss, Helaine Patterson, Karen Peart, Marc Wortman.

Also in Scope: A plan for new space  |  Five new biotech ventures  |  Earlier cancer diagnoses  |  Lyme disease anxiety  |  Public health in China  |  How a brain tumor travels  |  Preventing stroke  |  New Haven Health online  |  An Everest expedition  |  Tobacco Wars  |  ADHD overdiagnosed?  |  Battling confusion  |  Closer town-gown ties  |  Art and medicine  |  Making sense of school violence  |  Human powered wings  |  Cardiology network forms  |  Canavan disease  |  Autobody distress  |  Dr. Doe verdict appealed  |  A "natural" tan  |  Confronting violence  |  Focus on fitness < top of page | next >   Originally published in Yale Medicine, Summer 1998. Copyright © 1998 Yale University School of Medicine. All rights reserved.