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A pediatrician’s
frank talk about fibs
Long before
Independent Counsel Kenneth Starr’s report and possible
presidential lies were the topic of the day, Diane M. Komp, M.D.,
professor of pediatrics, decided to explore the issue of lying:
why people do it and whether lies are ever justified. Her book
on that topic, The Anatomy of a Lie: The Truth About Lies
and Why Good People Tell Them, makes only one small mention
of President Clinton and the Lewinsky affair, yet the coincidence
of the book’s release and the release of Independent Counsel
Kenneth Starr’s report couldn’t have been more appropriate,
according to its author.
Her own soul
searching inspired Dr. Komp to write her book, which was published
in the fall by Zondervan, a HarperCollins imprint. Dr. Komp,
a pediatric oncologist, has written five other books, including
A Window to Heaven and Children Are … Images of
Grace. She began to examine her personal standards of honesty
after she came upon a memoir by American Civil War veteran H.
Clay Trumbull titled A Lie Never Justifiable. Trumbull,
a Yankee chaplain, describes how he would rather kill one of
his Confederate captors than lie to him to cover an escape attempt.
Perplexed by
Trumbull’s reasoning, Dr. Komp began to question whether
there are, at times, good reasons for lying. She devotes a chapter
to a Dutch family who sheltered Jews during the Holocaust and
asks whether lying to the Gestapo is justifiable. She questions
her own lie of omission to the mother of a child stricken with
cancer. The cancer, she told the mother, had not progressed.
But, seeing the mother’s need for hope, she left out the
bad news—the cancer was not going away either.
While examining other people’s
dishonesty and tracking her own “white lies” in a journal, she
couldn’t help noting that while we condemn dishonesty in political
leaders, police officers, doctors and others we expect to trust, many
of us pay little heed to the impact of our own falsehoods. “There
may be a personal price to pay in downsizing duplicity, but we can’t
afford not to pay it,” Dr. Komp writes in her book.
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Improving
public health from the ground up
Faculty in epidemiology
and public health are joining forces with Griffin Hospital in
Derby to create an innovative program to improve health in Connecticut’s
Naugatuck River Valley region northwest of New Haven. The hospital
will house a new prevention research center focusing on cardiovascular
disease, the area’s leading cause of death, with programs
in smoking cessation, obesity management and cardiac screening.
The center will design future interventions based on health surveys
in six Naugatuck Valley towns and discussions with community
representatives. The federal Centers for Disease Control and
Prevention have provided $2.9 million for the efforts and follow-up
studies to determine which interventions should be maintained.
“It is a major philosophical shift in public health—the notion
that experts can’t simply go into a community and tell people what
they need,” says David L. Katz, M.D., M.P.H. ’93, director of
preventive medicine at the hospital and assistant clinical professor of
public health and medicine. “It just doesn’t work. You need
community buy-in. The best way to get it is to ask people what they want.”
Dr. Katz will serve as director of the center, which will
be staffed at Griffin Hospital. Physicians from the hospital
will collaborate on the project with Yale faculty and students.
A community advisory committee will work with center staff, faculty,
community leaders and citizens to identify health needs and recommend
initiatives. Each project will have a community action team to
target public health priorities. “Whatever the community
asks us to do over the next five years, we will find someone
who has that expertise,” says Dr. Katz. “This new center,”
adds Michael H. Merson, M.D., dean of public health, “has
great potential for improving the health of the population living
in the lower Naugatuck Valley.”
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Lessons
of healing: Exploring the link between spirituality and health
Throughout the ages, men
and women have thanked deities for favors bestowed. Such blessings may
be good health, fortune or romance, and their commemoration has taken
the form of sculptures, paintings, carvings and pilgrimages. Artists Melinda
Bridgman and Ana Flores traced the history of ex-votos, also known as
milagros, the Spanish word for miracles, as part of a two-day symposium
on Health and Spirituality held in October at the medical school.
The conference brought together health professionals and academic researchers
from mainstream and alternative medical worlds. Talks and workshops covered
topics such as the relationship between health and the environment in
a talk by William Foege, M.D., professor at the Rollins School of Public
Health at Emory University, and the value of religion for health in a
lecture by Dale Matthews, associate professor of medicine at Georgetown
University.
“We all had much to think about,” says Howard M.
Spiro, M.D., professor of medicine and director of the Program
for Humanities in Medicine, one of the sponsors, “but my
conclusion was that mainstream doctors have got to take the lessons
of alternative medicine, the lessons of healing, more to heart
than they do. We should consider mind and spirit as well as the
body.”
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With
a mechanical heart, a patient goes home—and waits
Everywhere Robert
Kenyon goes these days a bundle of electrical wires connects
him to a battery pack that powers an artificial heart embedded
in the walls of his abdomen. His life literally depends on the
device, a left ventricular assist system, or LVAS, designed to
sustain heart patients until a donor heart becomes available.
When Mr. Kenyon, who suffers from cardiomyopathy, a fatal degenerative
heart disease, left Yale-New Haven Hospital in September, he
became the first patient in New England and one of only about
20 around the country to return home with this type of device.
Without it, his chances of surviving the wait for a scarce donor
heart would be small. Since leaving the hospital, the life-sustaining
booster for his diseased heart has allowed him to resume many
aspects of a normal life.
“I’m fully employed,” says Mr. Kenyon, 60,
a reinsurance broker who lives in Darien. “I work from a
computer in my house, which I have been doing for the last 15
months. I’m still developing new business for my company.”
His need for a dependable power supply keeps him close to
home, and his status at the top of the heart recipient waiting
list keeps him no more than an hour’s drive away from New
Haven. The batteries and backups he carries in a bag over his
right shoulder have become his inseparable companions. His wife,
Kathy, also carries spares in a backpack, and at home he plugs
the artificial heart into a monitor that provides direct current.
The LVAS keeps Mr. Kenyon alive by providing support to the diseased left
side of his heart, which pumps blood to the body. “The left heart
has a real heavy load,” says John A. Elefteriades, M.D. ’76,
HS ’76-83, professor and chief of cardiothoracic surgery. Working
with George Tellides, M.D., Dr. Elefteriades implanted the device.
Some 28 years in the making, the LVAS is the latest generation
of artificial hearts. Made by Novacor, a California-based division
of Baxter Health Care Corporation, the LVAS received approval
in September from the Food and Drug Administration as a bridge
to transplant. In Europe, where the LVAS was approved for use
several years ago, some patients have already lived up to three
years connected to the device.
Mr. Kenyon received his LVAS under an experimental protocol during a five-hour
operation that required the services of a dozen surgeons, anesthesiologists
and nurses and an engineer from Novacor. After a month in the hospital,
Mr. Kenyon went home. “I’m glad this technology is available,”
he says, “but I’ll be glad when I can get rid of it. This thing
allows me to live at about 50 percent of where I was 10 years ago. I want
to be at 90 percent.”
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Yale epidemiologist
leads study of risks from radon in drinking water
Radon in Connecticut’s
drinking water poses a minimal health risk, primarily when it
is released into household air, according to a recent study by
experts convened by the Connecticut Academy of Science and Engineering.
The state Department of Public Utility Control requested the
study after receiving reports of radon in drinking water and
requests for treatment of public drinking water supplies to reduce
radon content.
The panel, chaired by Jan A. Stolwijk, Ph.D., Susan Dwight Bliss Professor
Emeritus of Epidemiology, found that the major adverse health effect of
radon is a possible increase in lung cancer risk resulting from inhalation.
According to the report, some adverse health effects, primarily in the
stomach, may result also from the ingestion of drinking water containing
radon, although the effect is “expected to be less than for inhalation.”
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School,
government settle suit over credit balances
A federal investigation into
the medical school’s billing practices ended in September with a
$5.6 million settlement over credit balances accrued during the last 20
years. The school has also agreed to abide by a four-year corrective action
plan that includes annual audits, establishment of a credit balance department
and biannual instruction programs for those involved in resolution of
credit balances. The settlement includes no admission of liability on
the part of the School of Medicine.
The U.S. Attorney’s office in New Haven had contended
that the medical school improperly handled a significant number
of credit balances, billing insurers and individuals more than
once for the same procedure. “As the government recognized
in the settlement, the complexity of health insurance payment
systems makes credit balances unavoidable,” says Irwin M.
Birnbaum, the medical school’s chief operating officer.
“Nevertheless, in past years Yale failed to have adequate
administrative and billing systems in place to process all payments
properly.” The disputed credit balances accrued prior to
the installation of a new computer billing system in 1995. They
represent a small fraction of the payments for clinical services
made to the school during the period in question. Payments are
expected to reach $120 million in this academic year alone.
The $5.6 million settlement includes a $500,000 refund to
the federal government for Medicare and other federal health
programs. In addition, Yale will provide $1.8 million to certain
health care carriers, $2.5 million to individuals and other entities,
and $700,000 to the federal government to resolve all claims.
As part of an overall modernization of accounting and information systems,
Yale has completed a $15 million upgrade of its systems and management,
including major improvements to its computer billing and information systems.
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State-of-the-art
imaging for neurovascular disease
One of the nation’s
most advanced diagnostic neuroangiography suites for diagnosis
and treatment of neurovascular system disease opened recently
at Yale-New Haven Hospital. The $2.3 million suite is the only
one of its type in the country outside the National Institutes
of Health and is considered the most advanced anywhere. It features
a Philips biplane imaging system that offers radiologists simultaneous
front and side views of vascular images, along with ultrasound
and CT scanning. This markedly decreases the time it takes to
perform complex examinations and allows performance of life-saving
embolization procedures. A table-side module provides on-the-spot
processing of results and image analysis. “The combination
of all these features in the neuroangiography suite represents
the pinnacle of today’s medical imaging technology,”
says Barbara Maione, manager of special procedures and intervention
services.
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New
research clinic seeking to identify schizophrenia earlier
While traditional
treatment of schizophrenia, or psychosis, seeks to reduce symptoms
after they have affected people’s lives, the psychiatry
department’s new PRIME Research Clinic is launching the
first study in the country to explore the prevention, delay or
reduction of serious symptoms. Through early identification and
treatment, the clinic hopes to address the disease before it
becomes debilitating.
The PRIME clinic, which stands for Prevention through Risk Identification,
Management and Education, will study individuals who, while in the prime
of their lives, show signs of being at risk for developing a debilitating
mental illness. It includes people from ages 14 to 45 who are concerned
with a recent change in their thoughts or feelings.
Possible signs that someone may be at risk for mental illness
include a sudden decline in work or school performance, social
withdrawal, trouble concentrating or thinking clearly, feelings
of suspicion or worry about the intentions of other people without
apparent justification, and bizarre changes in the way things
look or sound. These experiences may be accompanied by mood shifts
such as depression, anxiety or angry outbursts, explains Thomas
H. McGlashan, M.D., professor of psychiatry, executive director
of the Yale Psychiatric Institute and leader of the study.
Dr. McGlashan and the PRIME clinic plan to provide those entering
the study with preventive counseling as well as participation
in a medication trial. The experimental program will offer treatment
for one year followed by one year of monitoring.
Preliminary results from research conducted in Australia indicate
that early intervention may prevent symptoms from developing
or may significantly reduce symptoms of psychosis. “Most
people diagnosed with serious mental disorders encounter sometimes
irreversible reduction in quality of life, including failure
at work or school, loss of sense of self, social estrangement,
or distractions from persistent voices and fear of persecution,”
Dr. McGlashan says. “Because of its early onset—typically
in the late teens and early twenties—schizophrenia robs
society of its victims’ intellectual and physical productivity.”
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‘Jumping
DNA’ may help explain evolution of immune system
A bit of DNA
that has the ability, heretofore unseen in humans, to “jump”
from one organism to another may have given rise to the human
immune system, according to Yale researchers. A team led by David
G. Schatz, Ph.D., associate professor of immunobiology and an
HHMI investigator, has found evidence that tiny gene particles
vital to the task of producing millions of different kinds of
antibodies in humans act like a gene segment that can “jump”
into foreign DNA. Their findings were published in the Aug. 20
issue of the journal Nature. Although such genes abound
in lower organisms, the “jumping DNA” is the first
cut-and-paste “transposase” ever found in humans. Dr.
Schatz theorizes that such a jump may have happened within the
mammalian genome some 450 million years ago. “This helps
explain why the jawed vertebrates—including humans—are
the only species that have a second, adaptive immune system in
addition to the innate immune system that all other species have,”
says Dr. Schatz. Any clinical applications of this knowledge
are speculative, he says, although there may be implications
for the diagnosis or prevention of lymphoma.
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Early
study suggests new way to treat schizophrenia
A drug under development
for anxiety has been found to reverse schizophrenia-like effects of “angel
dust” in rats without apparent side effects, according to a School
of Medicine study. The drug, designated LY354740, offers a possible alternative
to current schizophrenia therapies, which affect the brain’s dopamine
system and may cause side effects such as Parkinsonian-like tremors. LY354740
acts by lowering levels of the chemical glutamate, one of the neurotransmitters
responsible for relaying messages between neurons. Bita Moghaddam, Ph.D.,
associate professor of psychiatry and neurobiology, who led the study,
cautions that the new drug has only worked in animal models. “This
is just rats, which do not get complex cognitive disorders like schizophrenia,”
she says. She and research associate Barbara W. Adams reported their findings
in the Aug. 28 issue of the journal Science. Clinical trials for
the drug’s use in treatment of schizophrenia are expected to begin
later this year.
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Women
under 75 fare worse than men after heart attacks
Many clinicians have long
believed that men were more prone to death from heart attack than women.
Evidence from a Yale study suggests that age, as well as sex, determines
the outcome. “We found that the younger the age of the patient, the
worse the outcome for women compared with men,” says Viola Vaccarino,
M.D., assistant professor of epidemiology and public health, who led the
study. In the 1,000 cases studied, women under 75 were almost twice as
likely as men to die in the hospital following a heart attack, according
to findings published in the Oct. 12 issue of Archives of Internal
Medicine. Conversely, women 75 or older had a significantly lower
risk of death than men that age. Dr. Vaccarino said the age 75 cut-off
was chosen only for description of the results. However, no clear dividing
line at age 75 was found. On the contrary, there was a gradual increase
of risk of dying for women compared with men going from older ages to
younger ages. A follow-up study that reviewed about 400,000 cases confirmed
the original findings, she says. Further investigations are being planned
to look at the reasons for the relatively poor prognosis after heart attacks
for younger female patients.
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A
little testosterone may aid estrogen replacement therapy
A dose of testosterone
may be a good thing for post-menopausal women undergoing hormone
replacement therapy. Estrogen mixed with an equal amount of methyl-testosterone,
also known as androgen, improved sexual desire and response in
women who were dissatisfied with estrogen alone, according to
a study in the October issue of The Journal of Reproductive
Medicine. “Giving estrogen alone to menopausal women
helped a little bit, but gradually over time the effectiveness
was lost,” says Philip Sarrel, M.D., professor of obstetrics
and gynecology and of psychiatry, and principal investigator
for the study. “What we found in our study was the missing
part—the lack of androgen replacement.” Side effects
and failure of the treatment to meet the patient’s needs
are the most common reasons women give for discontinuing hormone
replacement therapy.
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Many
heart-failure patients would rather not be revived
Nearly one-quarter
of all patients hospitalized for severe congestive heart failure
say they do not wish to be resuscitated if their hearts stop
beating, according to a study authored by Harlan M. Krumholz,
M.D., associate professor of medicine and epidemiology, in the
Aug. 18 issue of Circulation, the journal of the American
Heart Association. Another 69 percent definitely wanted resuscitation
and 8 percent were uncertain. Patients who perceived that they
would live less than two more months were the most likely to
reject the prospect of resuscitation, researchers found. Patients
who were older, wealthier and less able to take care of their
own basic needs in the two weeks before hospitalization also
were more likely to reject resuscitation. The study, Dr. Krumholz
says, points up the need for discussions of end-of-life care.
“We, as a profession, need to develop approaches so we can
talk about these issues without extinguishing hope,” says
Dr. Krumholz. “In many cases these discussions are not happening.”
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Imaging
RNA enzyme a step toward understanding hepatitis
Using X-ray
crystallography, researchers have solved the three-dimensional
structure of an RNA enzyme that plays a role in the replication
of the hepatitis delta virus. It is the only example of an RNA
catalyst found in a human pathogen and the second example of
a fully visualized RNA enzyme. Jennifer Doudna, Ph.D., professor
of molecular biophysics and biochemistry and an investigator
with the Howard Hughes Medical Institute (HHMI), led the research.
Hepatitis delta, a secondary infection that sometimes occurs
in patients with hepatitis B, is a significant problem in developing
countries, where it is often fatal. “It is known that this
RNA enzyme is essential for replication of the virus,” says
Dr. Doudna. “Using our knowledge of its molecular structure,
it may be possible to design pharmaceuticals that interfere with
its function and stop the progression of the disease.”
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