University Of Texas Medical Branch Research Articles

539: The effect of natural disasters on maternal morbidity

Alissa Carver, Marlo Cochran, Gayle Olson, Mary Munn, Gary Hankins University of Texas Medical Branch, Ob/Gyn Maternal-Fetal Medicine, Galveston, TX, The University of Texas Medical Branch, Obsterics & Gynecology, Galveston, TX OBJECTIVE: Exposure to natural disasters may affect pregnancy outcomes. The objective of this study was to compare maternal morbidity in pregnancies prior to and following Hurricane Ike in September of 2008. STUDY DESIGN: Retrospective case-control study examining triage visits to our institution over an 18-month period after Hurricane Ike (1/2009-6/2010) in comparison to pre-hurricane controls (3/2007-9/ 2008). 10/2008-12/2008 was excluded due to interruption of hospital services from storm damage. Antepartum complications were evaluated as follows: chronic hypertension (CHTN), pregnancy-induced hypertension (PIH), diabetes (DM), vaginal bleeding (VB), pyelonephritis, pancreatitis, cholecystitis, hyperemesis gravidarum/nausea and vomiting (HEG/NV), oligohydramnios, preterm premature rupture of membranes (PPROM), threatened preterm labor (PTL), intrauterine growth restriction (IUGR), decreased fetal movement (Dec FM), and abnormal fetal testing. Comparison of demographic information, individual and composite maternal morbidity were calculated using chi-squared and t-test analyses. RESULTS: Out of 21,202 triage visits, 11,280 (53%) occurred prior to the storm and 9,922 (47%) after. Only 8 % of patients resided on Galveston Island while the remainder resided on the Texas mainland where any impact from this natural disaster would be expected to be minimal. Composite maternal morbidity increased significantly following Hurricane Ike (OR 1.53, 95% CI 1.44-1.63, p 0.0001). When examined separately, this shift remained true for the following variables: CHTN, DM, pyelonephritis, oligohydramnios, PPROM, Dec FM, and abnormal fetal testing. Episodes of pancreatitis fell significantly (Table 1). Despite a small proportion of patients originating from Galveston proper, this effect was seen in our entire patient population. CONCLUSION: Evidence suggests an overall increase in maternal complications based upon demand for care in a triage setting following Hurricane Ike. Clinicians should be prepared for increased morbidity and associated obstetric care requirements in pregnant women exposed to natural disasters.

43: The role of cell signaling mechanisms in the downregulation of antioxidant enzymes in the fetal brain in a mouse model of fetal alcohol syndrome

downregulation of antioxidant enzymes in the fetal brain in a mouse model of fetal alcohol syndrome Nathan Drever, Talar Kechichian, Nkechi Okonkwo, Debdeep Banerjee, Monica Longo, George Saade, Egle Bytautiene The University of Texas Medical Branch, Obstetrics & Gynecology, Galveston, TX OBJECTIVE: Fetal alcohol syndrome (FAS) is the most common non genetic cause of mental retardation. Prenatal alcohol exposure decreases antioxidant enzymes in the fetal brain in a mouse model of fetal alcohol syndrome. Exposure to alcohol is known to decrease expression of Glycogen Synthase Kinase-3 (GSK-3 ) a serine threonine kinase that regulates glycogen synthesis through phosphorylation and inactivation of glycogen synthase. In addition to regulation of glycogen, GSK-3 is positively correlated with expression of nuclear transcription factors, NFand Nrf2, which are inactive in the cytosol and active within nucleus. Our objective was to evaluate if the effect of prenatal alcohol exposure on fetal brain antioxidants can be explained by an effect on GSK-3 , NFand Nrf2. STUDY DESIGN: A well-characterized FAS model was used (Webster, 1980). Timed, pregnant C57BL6/J mice were treated on gestational day 8 (E8) with alcohol (0.03 mL/g) or vehicle. Fetuses were harvested on gestational day 18 (E18), and the brain prepared for protein analysis. Western Blots were performed assessing the protein expression of GSK-3 and cytosolic and nuclear expression of NFand Nrf2 normalized to Glyceraldehyde 3-phosphate dehydrogenase (GAPDH). Statistical analysis was performed using Student t-test (significance: p 0.05). RESULTS: GSK-3 protein levels were significantly lower (0.73 vs 1.06 ratio protein/GAPDH; p 0.01) and cytosolic Nrf2 protein levels were significantly higher (0.72 vs 0.43 ratio protein/GAPDH; p 0.01) in the brain of pups exposed to alcohol compared with control. There was no significant difference in cytosolic expression of NFor nuclear expression of NFand Nrf2 between the two groups. CONCLUSION: In utero exposure to alcohol reduces GSK-3 and increases cytosolic Nrf2 protein levels in the fetal brain. These findings provide a mechanism for the decrease in antioxidants in the brain of FAS offspring, and a potential target for preventive strategies. Oral Plenary Session II General www.AJOG.org

739: Abnormalities in platelet reactivity in preeclampsia

Aoife Murray, Naomi Burke, Karen Flood, Brian Cotter, Zara Fonseca-Kelly, Mark Hehir, Mark Dempsey, Louise Fay, Jennifer Catherine Donnelly, Patrick Dicker, Michael Geary, Dermot Kenny, Fergal Malone Royal College of Surgeons in Ireland, Obstetrics and Gynecology, Dublin 1, Ireland, Rotunda Hospital, Obstetrics and Gynecology, Dublin 1, Ireland, National Maternity Hospital, Obstetrics and Gynaecology, Dublin, Ireland, Royal College Of Surgeons in Ireland, Epidemiology and Public Health, Dublin, Ireland, Rotunda Hospital, Obstetrics and Gynaecology, Dublin, Ireland, Clinical Research Centre, Royal College of Surgeons in Ireland, Dublin 2, Ireland, Royal College of Surgeons in Ireland, Obstetrics and Gynaecology, Dublin, Ireland OBJECTIVE: To determine abnormalities in reactivity of platelets in cases of pre-eclampsia and gestational hypertension using a novel platelet function assay. STUDY DESIGN: Thirty patients diagnosed with either pre-eclamspia or gestational hypertension were recruited. Inclusion criteria were singleton pregnancies between 24 0 and 39 6 with either pre-eclampsia or gestational hypertension as defined by ACOG criteria. Exclusion criteria included diabetes, clotting disorders, aspirin usage or BMI 30. All patients were in the third trimester of pregnancy and the values obtained were compared to patients (N 30) who were in the third trimester of uncomplicated normal pregnancy not affected by either pre-eclamspia or gestational hypertension. A 30ml whole blood sample was drawn according to a strict protocol to maintain platelet integrity. A platelet function assay was performed on each sample within 30 minutes of blood draw. A modification of standard light transmission aggregometry was used to assess platelet function, with light absorbance measured following addition of 5 different agonists at maximal and sub-maximal concentrations. Since platelets have multiple receptors it is necessary to study more than one receptor with the various agonists. The percentage aggregation response for each concentration of each agonist was calculated. RESULTS: Platelet reactivity differed significantly between the two groups of patients for each agonist. Platelet aggregation to arachidonic acid (p 0.0042), epinephrine (p 0.00001) and collagen (p 0.00001) was less reactive in pre-eclamptic and gestational hypertension than in uncomplicated third trimester patients. This pattern of platelet aggregation was not repeated for the agonists TRAP and ADP. CONCLUSION: We have demonstrated a significant reduction in platelet reactivity in patients with both pre-eclampsia and gestational hypertension compared to patients with uncomplicated pregnancies in the third trimester. These data may be of value when designing interventions for prevention or treatment of pre-eclampsia. 740 Effect of postnatal angiotensin-converting enzyme inhibition on fetal vascular programming in a transgenic mouse model lacking endothelial nitric oxide synthase Arshag Kalanderian, Giuseppe Chiossi, Maged Costantine, Phyllis Orise, Gary D.V. Hankins, George R. Saade, Monica Longo The University of Texas Medical Branch, Obstetrics & Gynecology, Galveston, TX OBJECTIVE: Angiotensin converting-enzyme (ACE) inhibitors have been used in adults to prevent progression of hypertension and altered vascular remodeling. We have previously shown that heterozygous offspring developing in an adverse uterine environment lacking endothelial nitric oxide synthase (NOS3) have altered vascular function, and develop hypertension later in life. Our objective was to determine whether captopril, an ACE inhibitor, prevents the fetal programming of adult vascular function in this murine model. STUDY DESIGN: Homozygous NOS3 knockout (KO) and wild type (WT) mice were cross-bred to produce heterozygous offspring developing in a WT mother with a normal uterine environment (KOP) versus a KO mother lacking a functional NOS3 (KOM). Osmotic minipumps were placed in female offspring at 4 weeks of age to deliver captopril or vehicle at 0.25 l/hr for 4 weeks. At 14 weeks, the offspring were sacrificed, and carotid arteries were isolated for in vitro vascular reactivity studies. Contractile responses to phenylephrine (PE), in the presence and absence of the nitric oxide synthase inhibitor L-NAME, and angiotensin (ANG), as well as vasorelaxant responses to acetylcholine (Ach) and isoproterenol (ISO) were determined. ANOVA followed by Neuman-Keuls post hoc test were used for statistical analysis (significance: P 0.05). RESULTS: Contractile responses to PE were significantly increased in KOM offspring compared with KOP, and treatment with captopril corrected this response without any effect on responses in KOP (Figure A). The difference between KOM-CAP vs KOM was decreased by L-NAME, although the response in KOM remained higher. No significant differences were seen in response to ANG between the groups. Vasorelaxant responses to Ach (Figure B) and ISO were significantly improved in KOM treated with captopril compared to untreated KOM offspring (p 0.05). CONCLUSION: Treatment with an ACE inhibitor at a young age prevents the vascular dysfunction seen with fetal programming of adult hypertension. ACE inhibition may represent a potential strategy for postnatal prevention of adult hypertension. Poster Session V Academic Issues, Antepartum Fetal Assessment, Genetics, Hypertension, Medical-Surgical-Disease www.AJOG.org

67: Single nucleotide polymorphisms (SNPs) in endothelial nitric oxide synthase (eNOS) gene and unexplained stillbirth

nitric oxide synthase (eNOS) gene and unexplained stillbirth Francesca Ferrari, Fabio Facchinetti, Huaizhi Yin, George Saade, Monica Longo Obstetrics and Gynaecology, University of Modena and Reggio Emilia, Mother-Infant department, Modena, Italy, The University of Texas Medical Branch, Obstetrics & Gynecology, Galveston, TX OBJECTIVE: Altered utero-placental perfusion has been implicated in the pathogenesis of unexplained stillbirth (SB). We previously reported that genetic polymorphisms of VEGF affecting placental vasculogenesis are associated with unexplained SB. Nitric oxide (NO) plays a critical role in regulation of uterine perfusion, and eNOS is the rate limiting enzyme in the NO production cascade. Previous studies suggest that eNOS gene SNPs may be associated with preeclampsia and idiopathic recurrent pregnancy loss. Our objective was to evaluate the presence and distribution of eNOS gene SNPs between unexplained SB and controls in a well-characterized cohort. STUDY DESIGN: Placentas were obtained from 50 unexplained SB and 46 livebirth controls. Classification of “unexplained” stillbirth was by Wigglesworth and Aberdeen criteria and included both appropriate (AGA-SB) and small for gestational age (SGA-SB, 10th%) SB. Placental DNA was extracted (Qiagen) and evaluated for 4 eNOS SNPs (rs1007311 A/G, rs891512 A/G, rs1800779 A/G and rs1800783 A/T) by real time PCR using specific taqman probes. The genotype and allelic distributions were compared between the groups using Chisquare (significance: p 0.05). RESULTS: All SNPs were in Hardy-Weinberg equilibrium. None of the SNPs were associated with SB overall. However, significant different genotype distribution emerged for eNOS-SNP rs1800783 A/T when comparing the subgroups of SGA-SB and AGA-SB to controls (p 0.004). Allele-A carriers of rs1800783 were more frequent in AGA-SB compared to both controls (p 0.003) and SGA-SB (p 0.001)(Fig. 1). CONCLUSION: This is the first study to report on placental eNOS polymorphisms and unexplained SB. Importantly we found that Allele A of rs1800783 eNOS SNP might play a role in the occurrence of unexplained stillbirth in the setting of adequate growth. Our results warrant further population-based analysis. 68 The influence of a mediolateral episiotomy during an operative vaginal delivery on the risk for Obstetric Anal Sphincter Injuries (OASIS) Joey de Vogel, Anneke van Beek, Dirk Gietelink, Marijana Vujkovic, Jan Willem de Leeuw, Dimitri Papatsonis Amphia hospital, Department of Obstetrics and Gynecology, Breda, Netherlands, Erasmus Medical Center, Department of Obstetrics and Gynecology, Rotterdam, Netherlands, Ikazia Hospital, Department of Obstetrics and Gynecology, Rotterdam, Netherlands OBJECTIVE: Operative vaginal delivery is associated with an increased risk of Obstetric Anal Sphincter Injuries (OASIS). It’s unclear if structural use of a mediolateral episiotomy at operative vaginal delivery will decrease this risk. The aim of our study was to evaluate the incidence of OASIS in women with operative vaginal delivery, and to assess if a mediolateral episiotomy is preventive for OASIS in these deliveries. STUDY DESIGN: A retrospective cohort study was performed using the obstetric-database of the Amphia Hospital, The Netherlands of deliveries from 2001 up to 2009. All patients with live born infants delivered by an operative vaginal delivery at a gestational age 34 weeks were included. Exclusion criteria were: multiple gestations, breech deliveries and the use of a median episiotomy. Continuous variables were compared using the Students t test or Mann-Whitney U test, the 2 test for categorical variables. Continuous variables were summarized as means with standard deviations, or medians with interquartile ranges. A logistic regression model was used for the risk assessment for OASIS when a mediolateral episiotomy was performed. Treatment effect was presented as adjusted odds ratio with 95% confidence interval. RESULTS: There were 2970 operative vaginal deliveries in the study period meeting the inclusion and exclusion criteria (Figure 1). The prevalence of OASIS was 5.7%. The absolute risk was 3.3% in the MLE group, compared to 15.5% in the MLEgroup (OR 0.19; 95% CI: 0.14-0.26). The risk estimation for OASIS remained similar (adjusted OR 0.20; 95% CI: 0.12-0.34), after logistic regression analysis with correction for gestational age, parity, birth weight, maternal age, use of epidural analgesia, indication for operative vaginal delivery, cephalic fetal position, and duration of the second stage. CONCLUSION: The use of a mediolateral episiotomy in operative vaginal delivery is associated with a fivefold decreased risk for developing OASIS. Therefore we advocate the structural use of a mediolateral episiotomy during an operative vaginal delivery in order to prevent OASIS. www.AJOG.org Intrapartum Fetal/Clinical Obstetrics Oral Concurrent Session 6

Majority Rule as a Novel Way to Determine Rapid Streptococcus aureus Testing Results

From the University of Texas Medical Branch, Galveston, TX. Reprints: Peggy Mann, MS, MT(ASCP), University of Texas Medical Branch, Galveston, TX. E-mail: [email protected]. The author declares no conflict of interest.

Point-Counterpoint: It Is Time To Use Treponema-Specific Antibody Screening Tests for Diagnosis of Syphilis

ABSTRACT Assays that detect treponema-specific antibodies, which are either automated or can be done as point-of-care tests, have been developed, some of which are FDA approved. These assays have the advantage of being easily performed and demonstrate high sensitivity, both key features of an infectious disease screening test. As a result, many high-volume clinical laboratories have begun to offer a reverse syphilis testing algorithm where a treponema-specific test is used for screening, followed by a nontreponemal test (i.e., rapid plasma reagin [RPR]) to assess disease activity and treatment status. Concerns about physicians being able to understand and apply this new testing algorithm have been expressed (8). In this point-counterpoint, Michael Loeffelholz of the University of Texas Medical Branch at Galveston explains why his laboratory has adopted this reverse algorithmic approach. Matthew Binnicker of the Mayo Clinic, Rochester, MN, explains why the reverse algorithm may not be suitable for all clinical laboratories and every clinical situation.

When a Natural Disaster Occurs: Lessons Learned in Meeting Students' Needs

Across the nation, weather-related natural disasters-tropical storms, floods, tornadoes, and earthquakes-struck even areas where weather concerns are not paramount on the minds of most people. These natural disasters heightened awareness that all geographic areas are susceptible to aberrant weather conditions. The purpose of this article was to relate the lessons learned by one academic health center in meeting students' emergency preparedness and disaster recovery needs following a major hurricane in fall 2008. To gauge students' storm-related needs, a Hurricane Needs Survey (HNS) was conducted in spring 2009, 7 months after the hurricane. Students responded to 26 structured response items and 3 open-ended questions. Five hundred fifteen surveys were completed, constituting a response rate of 37.2%. Data were analyzed by creating frequencies to profile students' hurricane experiences. Results indicated that all students left the island under mandatory evacuation orders; most stayed with their families, and most experienced moderate material losses. For some students, the evacuation process and life after the storm contributed to ongoing problems, worries, and academic performance issues. Qualitative content analysis was used to derive themes from the students' narrative responses to the HNS open-ended questions about their perceptions of the extent to which the University of Texas Medical Branch met their needs. When students' hurricane response comments were analyzed, three major themes emerged: being prepared, needing to be connected, and returning to normalcy. The major lessons learned are that the emergency preparation of students requires greater specificity and that discussion about poststorm recovery expectations is essential. Following a natural disaster, students experience more distress than may be readily apparent.

Five-Year Outbreak of Community- and Hospital-Acquired Mycobacterium porcinum Infections Related to Public Water Supplies

Mycobacterium porcinum is a rarely encountered rapidly growing Mycobacterium (RGM). We identified M. porcinum from 24 patients at a Galveston university hospital (University of Texas Medical Branch) over a 5-year period. M. porcinum was considered a pathogen in 11 (46%) of 24 infected patients, including 4 patients with community-acquired disease. Retrospective patient data were collected, and water samples were cultured. Molecular analysis of water isolates, clustered clinical isolates, and 15 unrelated control strains of M. porcinum was performed. Among samples of hospital ice and tap water, 63% were positive for RGM, 50% of which were M. porcinum. Among samples of water from the city of Galveston, four of five households (80%) were positive for M. porcinum. By pulsed-field gel electrophoresis (PFGE), 8 of 10 environmental M. porcinum were determined to belong to two closely related clones. A total of 26 of 29 clinical isolates subjected to PFGE (including isolates from all positive patients) were clonal with the water patterns, including patients with community-acquired disease. Fifteen control strains of M. porcinum had unique profiles. Sequencing of hsp65, recA, and rpoB revealed the PFGE outbreak clones to have identical sequences, while unrelated strains exhibited multiple sequence variants. M. porcinum from 22 (92%) of 24 patients were clonal, matched hospital- and household water-acquired isolates, and differed from epidemiologically unrelated strains. M. porcinum can be a drinking water contaminant, serve as a long-term reservoir (years) for patient contamination (especially sputum), and be a source of clinical disease. This study expands concern about public health issues regarding nontuberculous mycobacteria. Multilocus gene sequencing helped define clonal populations.

Editorial introductions

Current Opinion in Infectious Diseases was launched in 1988. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of infectious diseases is divided into 11 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. Section Editors Joseph M. VinetzJoseph M. VinetzDr Vinetz graduated from Yale University and received his medical degree from the University of California, San Diego (UCSD), USA. He completed a residency in internal medicine and a fellowship in infectious diseases at Johns Hopkins School of Medicine, and he was a Howard Hughes Medical Institute Physician Postdoctoral Fellow at the National Institutes of Health. Prior to joining the UCSD faculty in 2003, he was an infectious diseases specialist at the University of Texas Medical Branch, Galveston and of the World Health Organization's Collaborating Center for Tropical Diseases at Galveston. His research focuses on tropical infectious diseases. His laboratory takes a comprehensive approach from laboratory bench to bedside, encompassing mechanistic molecular biology, biochemistry, immunology and cell biology approaches to the study of malaria transmission and leptospirosis, a disease transmitted from infected mammals (wild and domestic) to humans via infected urine. A key component of his research program is field work in the Peruvian Amazon city of Iquitos, where he maintains a state-of-the-art laboratory in collaboration with investigators from Peru and the United States. He is program director of a training program supported by the US National Institutes of Health, in partnership with the Universidad Peruana Cayetano Heredia, Lima, Peru entitled ‘Endemic Infectious Diseases of the Peruvian Amazon’. His research is supported by grants from the United States Public Health Service, National Institutes of Health. Nicholas J. BeechingNicholas J. BeechingAfter undergraduate studies and clinical medical school in Oxford, UK, Nicholas Beeching qualified in 1977 and subsequently worked in training posts in Liverpool, Adelaide, Birmingham and Auckland. He was a consultant physician (with gastroenterology) in Khamis Mushayt, southern Saudi Arabia, for two years before taking up his current posts in Liverpool in 1987. He combines teaching and research activities as Senior Lecturer in Infectious Diseases at the Liverpool School of Tropical Medicine with clinical and administrative duties as Lead Consultant, Tropical and Infectious Disease Unit, Royal Liverpool University Hospital. Among his clinical and research interests are parasitic infections of the bowel, salmonella infections, HIV, hepatitis and ‘emerging’ and imported diseases and zoonoses. He also has a strong interest in postgraduate medical education and has served as Chair of the Specialist Advisory Committee in Infectious Diseases and Tropical Medicine and of the DTM&H examinations board of the Royal College of Physicians of London. He has published over 150 peer-reviewed papers, numerous book chapters and five books, and has recently stepped down after a three year term as President of the British Infection Society. A. Clinton WhiteA. Clinton WhiteDr White completed his undergraduate studies at Dartmouth College and medical studies at Indiana University School of Medicine, USA. He qualified in internal medicine at the University of Washington and in infectious diseases at Yale University. He completed six months as a visiting scientist in Venezuela before coming to Texas in 1989. He currently directs the Infectious Disease Division, in the Department of Internal Medicine at the University of Texas Medical Branch in Galveston, USA. Among his clinical and research interests are host-parasite interactions for Cryptosporidium and other interstinal protozoa, clinical studies in cysticercosis, host responses controlling strongyloidiasis, opportunistic infections in HIV, and immunoregulation in HIV-TB co-infection. He has published over 100 peer-reviewed publications in addition to numerous book chapters. He is a past president of the clinical group and a councilor of the American Society for Tropical Medicine and Hygiene and serves on the examination committee for the ASMTH certificate of knowledge in tropical medicine and travel health.

Evidence Does Not Show that Pregnancy Is a Risk Factor for Latex Allergy

University of Texas Medical Branch, Galveston, Texas. aaboulei@utmb.eduTo the Editor: I read with interest the report by Draisci et al. on the prevalence of latex allergy in obstetrical patients.1Although there was a statistical difference between the obstetrical patients (OB) and the nonobstetrical women (non-OB), I must disagree with the author's conclusion that the results prove that higher prevalence is due to the factor of pregnancy alone.Unfortunately, the two groups were not matched for risk factors. As noted in the same issue of ANESTHESIOLOGY, Sampathi and Lerman described the risk factors for developing latex allergy: congenital abnormalities (spina bifida, genitourinary abnormalities), multiple surgeries, atopy to drugs or food, exposure to latex, and healthcare worker.2In table 1, Draisci et al. list the prevalence of latex sensitization and the risk factor prevalence. The authors did not find a statistical difference for risk factors between the two groups (OB and non-OB). But if one looks closer, one would see that there might be a difference that could result in the difference in latex sensitization found.In absolute numbers, the OB group had 15 patients who were positive for latex sensitization, whereas the non-OB group had 5 such patients, with both groups having 294 patients in each. In other words, the OB group had 10 more patients who tested positive for latex allergy than did the non-OB. Looking at the risk factors listed, one finds that the OB group had six to seven more patients with positive results than did the non-OB: specifically, drug allergy (atopy), seven more; food allergy (atopy), six more; other allergy (atopy), seven more; multiple surgeries, six more; and healthcare workers, six more. If this difference of six to seven patients accounts for the majority of difference in latex sensitization, the findings of higher prevalence in the OB group is because of the higher prevalence of risk factors.Unfortunately, the authors do not discuss this confounding issue in their report. Thus, I must conclude that the authors did not have enough evidence to make the conclusion that pregnancy is a risk factor for latex allergy.

Sustained Impact of MBSR on Stress, Well-Being, and Daily Spiritual Experiences for 1 Year in Academic Health Care Employees

The objectives of the study were (1) to evaluate self-reported stress levels and daily spiritual experiences in academic health care employees before, immediately after, and 1 year after enrolling in a mindfulness-based stress reduction (MBSR) course; and (2) to evaluate the correlation between a potential measure of pulse rate variability and self-reported stress levels. Fifty-nine (59) participants in the MBSR course offered to employees at the University of Texas Medical Branch in Galveston (UTMB) comprised the intervention group, and 94 health care providers in the neonatal nurseries comprised the control group. MBSR is an 8-week course that introduces mindfulness meditation practices. No intervention was offered to the control group. All participants were employees (or relatives of employees) at UTMB. All MBSR participants completed Cohen's Perceived Stress Scale, the SCL-90, the SF-36 Measure of Health and Well-Being, the Daily Spiritual Experiences Scale, and a 5-minute measure of pulse rate coherence. This testing was done before and after the MBSR course and 1 year later. Ninety-four (94) neonatal health care providers completed the same series of questionnaires and pulse rate variability (PRV) measures, with 49 of the 94 completing the questionnaires 2 months and 1 year later. MBSR participants improved on all measures except the physical component score of the SF-36 upon completion of the MBSR course, and these results were maintained at the 1-year follow-up. The control group did not significantly change on any of the measures. PRV as measured by the Heart Math system did not correlate with any of the self-report questionnaires. MBSR effectively reduces self-report measures of stress and increases daily spiritual experiences in employees in an academic health care setting, and these effects are stable for at least 1 year. Using a simple measure of PRV was not a clinically reliable biologic measure of stress.

The Gravedigger

On Being a Doctor20 September 2011The GravediggerJames S. Goodwin, MDJames S. Goodwin, MDFrom The University of Texas Medical Branch, Galveston, TX 77555-0177.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-155-6-201109200-00012 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail I go to my patients' funerals whenever possible. It is a way of showing respect for the patient and the patient's family. Depending on the denomination, a funeral also provides me with 1-, 2-, or 3-hour periods to sit and think. My funeral thoughts relate to the big issues of life and death, and I come away with a feeling of peace and of being part of a community.Nothing in these funeral-going experiences prepared me for gravedigging, however. Digging a grave is like a funeral, raised to the tenth power.The call came at about 2:00 a.m. on a ... Author, Article, and Disclosure InformationAffiliations: From The University of Texas Medical Branch, Galveston, TX 77555-0177.Corresponding Author: James S. Goodwin, MD, Department of Internal Medicine, Sealy Center on Aging, The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0177; e-mail, [email protected]edu. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 20 September 2011Volume 155, Issue 6Page: 398-399KeywordsAgingAnxietyBrainEmotionsFoodMemorySuicideSweat ePublished: 20 September 2011 Issue Published: 20 September 2011 Copyright & PermissionsCopyright © 2011 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

My Disaster Recovery: a pilot randomized controlled trial of an Internet intervention

This pilot study tested the efficacy of the My Disaster Recovery (MDR) website to decrease negative affect and increase coping self-efficacy. Fifty-six survivors of Hurricane Ike were recruited from a larger study being conducted at the University of Texas Medical Branch at the first anniversary of the storm. Restricted randomization was used to assign participants to the MDR website, an information-only website, or a usual care condition. Group×time interactions indicated that MDR reduced participant worry more than the other conditions. A similar trend was also identified for depression. Both websites were accessed a small to moderate amount and participants reported mixed satisfaction for both websites. Although the effect sizes for worry and depression were in the moderate to large range, small sample size and timing of the intervention qualify the findings. These preliminary findings encourage further evaluation of MDR with a larger, demographically diverse sample and indicate that the MDR website might be helpful in reducing worry and depression.

My Life With Hurricanes

Geographic circumstances: During Hurricane Katrina I received and triaged evacuees 325 miles from ground zero. I subsequently moved to Galveston, Texas, a town ravaged more than once by powerful hurricanes. About the author: I am currently working on the Gulf Coast in the division of general pediatrics at the University of Texas Medical Branch (UTMB) in Galveston. In the 1970s I attended medical school at Louisiana State University in New Orleans. After that I went to UTMB for my general pediatrics residency. I practiced general pediatrics in Longview, Texas, for 32 years afterward. I served as president of the Texas Pediatric Society. Currently, I am chapter vice-chair for the Texas chapter of the American Academy of Pediatrics (AAP) and a member of the AAP Committee on Practice and Ambulatory Medicine. I made a practice change partially because of Katrina but more as a result of an intense period of storms that affected the central Gulf Coast during the last 5 years. As a result of these storms UTMB has more actively sought innovative ways to meet the needs of people it serves so as not leave medical services vulnerable to hurricanes. I am the medical director of a new outpatient facility that serves both subspecialty pediatrics and general pediatrics. I am now living on the Texas coast as part of the faculty and am keenly aware of the needs for organized responses for the benefit of children in particular. I am a New Orleans native and have lived my entire life in the Gulf South region. I was reared in a family with strong Acadian heritage thanks to my mother and her forebears. The existence and effects of hurricanes have been part of a way of life for my family and countless others in this region. Stories that I can … Address correspondence to O. W. “Skip” Brown, MD, Department of Pediatrics, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0351. E-mail: owbrown{at}utmb.edu

Implementation of Health Information Technology to Maximize Efficiency of Resource Utilization in a Geographically Dispersed Prenatal Care Delivery System

This study investigated the utilization of health information technology (HIT) to enhance resource utilization in a geographically dispersed tertiary care system with extensive outpatient and delivery services. It was initiated as a result of a systems change implemented after Hurricane Ike devastated southeast Texas. A retrospective database and electronic medical record review was performed, which included data collection from all patients evaluated 18 months prior (epoch I) and 18 months following (epoch II) the landfall of Hurricane Ike. The months immediately following the storm were omitted from the analysis, allowing time to establish a new baseline. We analyzed a total of 21,201 patients evaluated in triage at the University of Texas Medical Branch. Epoch I consisted of 11,280 patients and epoch II consisted of 9922 patients. Using HIT, we were able to decrease the number of visits to triage while simultaneously managing more complex patients in the outpatient setting with no clinically significant change in maternal or fetal outcome. This study developed an innovated model of care using constrained resources while providing quality and safety to our patients without additional cost to the health care delivery system.

Practicing Medicine and Studying Law”: How Medical Schools Used to Have the Same Problems We Do and What We Can Learn from Their Efforts to Solve Them

Practicing Medicine and Studying Law”: How Medical Schools Used to Have the Same Problems We Do and What We Can Learn from Their Efforts to Solve Them

Evolution of Student Assessment Following Implementation of an Integrated Medical Curriculum: Contribution to Improved Educational Outcomes

This paper describes the stimuli and rationale for and the nature of assessment changes implemented after embarking on a new student-centered, problem-based learning curriculum. In 1998, the University of Texas Medical Branch implemented the Integrated Medical Curriculum (IMC), a problem-based curriculum with sequential, interdepartmental, clinically relevant basic science courses and a concurrent Practice of Medicine course. The IMC’s aim was to improve educational quality by emphasizing knowledge application over rote memorization, student-directed learning, problem-solving skills development, basic science and clinical concepts integration, early acquisition of clinical skills, and professional teamwork. During the initial years of the IMC, students’ learning outcomes did not improve over those of the former curriculum because, in part, we did not initially modify student assessment (a driving force for student study habits) to align with the new curricular goals and philosophies. We subsequently took several steps to modify our assessment practices in order to improve student learning and understanding. These steps included (1) increasing the number and quality of higher -order exam questions, (2) sequestering examinations, (3) increasing the number of practice exam items in each course, (4) and emphasizing in-depth discussion in problem-based learning sessions by introducing small-group quiz exercises. Following the assessment modifications, our students’ USMLE Step 1 scores and our pass rate for first-time test takers rose from being consistently below the national Step 1 average to above the national average. This improvement has been sustained for the past seven years. We believe that implementing those assessment modifications within the framework of the newly devised student-centered, problem-based curriculum in an interdepartmental environment resulted in a critical mass of “local” changes. The changes, initiated and supported by students, faculty and administration, catalyzed, produced and sustained more “global” changes that improved students’ learning, thus better preparing them for the USMLE Step 1 examination.

A Dozen Eggs

On Being a Doctor3 May 2011A Dozen EggsGulshan Sharma, MD, MPHGulshan Sharma, MD, MPHFrom The University of Texas Medical Branch at Galveston, Galveston, TX 77555-0561.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-154-9-201105030-00011 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Not every physician gets patted down daily in his own hospital. The security guard ran his fingers over my picture ID to ensure authenticity.“Sir, you are clear to enter.”As I walked the long tunnel connecting the outside world to the prison hospital, I couldn't prevent mixed feelings, but there was no time to explore them. At the end of the tunnel, I was buzzed in through a second hefty barred door. It opened into a circular enclosure housing the “command center,” manned by a uniformed guard. Seven doors defined the perimeter, with each door definitively shut. I stood ... Author, Article, and Disclosure InformationAffiliations: From The University of Texas Medical Branch at Galveston, Galveston, TX 77555-0561.Corresponding Author: Gulshan Sharma, MD, MPH, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, The University of Texas Medical Branch at Galveston, 301 University Boulevard, JSA-5.112, UTMB, Galveston, TX 77555-0561. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 3 May 2011Volume 154, Issue 9Page: 640-641KeywordsChemotherapyEmotionsHispanic peopleIntensive care unitsNursesNutrientsOutpatient clinicsOxygenRespiratory rateWalking ePublished: 3 May 2011 Issue Published: 3 May 2011 Copyright & PermissionsCopyright © 2011 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

A Note from the Editor

A Note from the Editor Virginia M. Brennan, PhD, MA Four themes run through this issue of the Journal of Health Care for the Poor and Underserved: Theme 1: Immigrant Health Theme 2: Women's Health Theme 3: Health Disparities Theme 4: Health Policy The issue closes with several book reviews. Theme 1: Immigrant Health. Two commentaries initiate the theme of immigrant health. Still Missing: Undocumented Immigrants in Health Care Reform (by Charlene Galarneau) and Improving Medical Care for Detained Immigrants (by Nicole Therrien and Angela Mattie) both explore the intersections of immigration status, the law, and health. Sanchez-Youngman and colleagues empirically studied popular opinion regarding health coverage for undocumented immigrants in New Mexico and report on that research here. Ramin Asgary and Nora Segar conducted qualitative research with 35 people (mostly male and African) seeking asylum in the U.S. and 15 expert providers and advocates concerning access to health care. They report on individual, structural, and assimilation-related barriers and recommend specific policy-related and clinical improvements. Blanchfield and colleagues from Massachusetts General Hospital and the Cambridge Health Alliance studied the costs associated with providing language interpretation services for patients, and propose a framework for identifying such costs here. Guendelman and colleagues from UC-Berkeley and UCSF studied the interaction of birthplace, body size, and gender among Mexican Americans. They report that Mexican American immigrant women are at greater risk than Mexican American immigrant men for large body size, as are U.S.-born Mexican American women whose preferred language is Spanish. Theme 2: Women's Health. The theme of women's health begins with a commentary by Christine Dehlendorf and Tracy Weitz on the vanishing availability of abortion services for women with low incomes and racial/ethnic minority women in the United States. Next, Cheryl Cooper and Joyce Ballard contribute a literature review on bone mineral density in Hispanic women, and explore the implications for culturally-specific osteoporosis education as the proportion of Hispanics in the U.S. continues to increase. The rate of breast-feeding initiation among patients at eight Philadelphia Health Centers, as reported here by Robbins and colleagues, was 42%—i.e., less than optimal but still sizeable. Whether or not breastfeeding was initiated and sustained appeared to vary more by health center and hospital than by patient characteristics such as the mother's race and age, which gives rise to system-level recommendations for improvement. Roncancio and colleagues from the Center for Interdisciplinary Research in Women's Health at the University of Texas Medical Branch (UTMB) in Galveston [End Page vi] studied the extent to which Hispanic women believe their health care providers have primary control over the woman's health, with survey data from over 1,000 women at the UTMB clinic. The more acculturated to the U.S. the respondent was, the less she believed her provider controlled her health, and the more fatalistic she was, the more she believed it. The study has implications for culturally tailored women's health care in Hispanic communities. Abraído-Lanza and colleagues studied health care satisfaction by means of 220 structured interviews with Latina immigrants in New York City (the sample was predominantly from the Dominican Republic and older than 40 years of age). Waiting times worked against satisfaction and better physician-patient interactions in its favor. Finally, Bynum and colleagues looked at HPV vaccine uptake among 363 young (ages 18–26) African american women, who are at elevated risk for cervical cancer. Knowing more about the HPV vaccine increased the likelihood of uptake, giving a clear pointer for educational interventions. Theme 3: Health Disparities. Always with us, it seems, are disparities in health and health care between populations overall and medically underserved populations. In this issue, we see the broad scope of socioeconomic, regional, and gender health disparities within the Caribbean country of Jamaica (Paul Bourne) and the deeply impoverished West African country of Burkina Faso (Okolo et al.) Additionally, three papers explore health disparities in the U.S.: Valerie Johnston and Yuhua Bao, using a nationally representative sample, studied the timeliness with which individuals received care (±60 minutes) in emergency departments (EDs). They found some significant race-ethnicity differences and...

The cAMP-responsive Rap1 Guanine Nucleotide Exchange Factor, Epac, Induces Smooth Muscle Relaxation by Down-regulation of RhoA Activity

Agonist activation of the small GTPase, RhoA, and its effector Rho kinase leads to down-regulation of smooth muscle (SM) myosin light chain phosphatase activity, an increase in myosin light chain (RLC(20)) phosphorylation and force. Cyclic nucleotides can reverse this process. We report a new mechanism of cAMP-mediated relaxation through Epac, a GTP exchange factor for the small GTPase Rap1 resulting in an increase in Rap1 activity and suppression of RhoA activity. An Epac-selective cAMP analog, 8-pCPT-2'-O-Me-cAMP ("007"), significantly reduced agonist-induced contractile force, RLC(20), and myosin light chain phosphatase phosphorylation in both intact and permeabilized vascular, gut, and airway SMs independently of PKA and PKG. The vasodilator PGI(2) analog, cicaprost, increased Rap1 activity and decreased RhoA activity in intact SMs. Forskolin, phosphodiesterase inhibitor isobutylmethylxanthine, and isoproterenol also significantly increased Rap1-GTP in rat aortic SM cells. The PKA inhibitor H89 was without effect on the 007-induced increase in Rap1-GTP. Lysophosphatidic acid-induced RhoA activity was reduced by treatment with 007 in WT but not Rap1B null fibroblasts, consistent with Epac signaling through Rap1B to down-regulate RhoA activity. Isoproterenol-induced increase in Rap1 activity was inhibited by silencing Epac1 in rat aortic SM cells. Evidence is presented that cooperative cAMP activation of PKA and Epac contribute to relaxation of SM. Our findings demonstrate a cAMP-mediated signaling mechanism whereby activation of Epac results in a PKA-independent, Rap1-dependent Ca(2+) desensitization of force in SM through down-regulation of RhoA activity. Cyclic AMP inhibition of RhoA is mediated through activation of both Epac and PKA.