Yale-New Haven Medical Center Research Articles

A Tale of Two Cities: Evolution of Academic Physiatry in Boston and Baltimore: Part 1: The Boston Marathon

A Tale of Two Cities: Evolution of Academic Physiatry in Boston and Baltimore: Part 1: The Boston Marathon

In-Hospital Mortality Among California’s Jail and Prison Inmates: The Need for Improved Data on the Causes of Death (TH360A)

Tips for Being an Excellent (and Helpful) Reviewer for Professional Journals (TH359) David Casarett, MD MA FAAHPM, University of Pennsylvania, Philadelphia, PA. Keela Herr, PhD RN FAAN, University of Iowa, Iowa City, IA. Joan Penrod, PhD, Icahn School of Medicine at Mount Sinai, New York, NY. Sree Battu, MD, Cleveland Clinic Foundation, Cleveland, OH. Felicia Hui, MD, Yale-New Haven Medical Center, New Haven, CT.

The Journal Loses Its Founding Editor

Edmund Daniel Pellegrino, the founding editor of The Journal of Medicine and Philosophy, died on June 13, 2013. He served as editor from 1976 to 1984. The journal came into existence through his vision, energy, and direction; it would never have existed without Edmund D. Pellegrino. Dr. Pellegrino was also one of the founders of contemporary bioethics, philosophy of medicine as it is now known, and medical humanities. He shaped the emergence and development of these fields. The Journal of Medicine and Philosophy mourns his passing. At his death, Edmund Pellegrino was 92 years old; he would have turned 93 on June 22. He was preceded in death by his wife of 67 years, Clementine, who passed away the previous June. He is survived by five children, two grandchildren, and one great-grandchild. His son Stephen died in 1980, and his son Thomas passed away in 2011. Pellegrino was born in 1920 in Newark, New Jersey, received his bachelor’s degree from St. John’s University in New York City, and his MD from New York University. He was the recipient of 54 honorary degrees. He served residencies in medicine at Bellevue, Goldwater Memorial, and Homer Folks Tuberculosis Hospitals; afterward, he was a research fellow in renal medicine and physiology at New York University Medical Center. Dr. Pellegrino, who developed medical programs at the University of Kentucky, the State University of New York at Stony Brook, and the University of Tennessee, was the first president of the Yale-New Haven Medical Center. In 1978, he was appointed professor of clinical medicine and community medicine at Georgetown University and also that year became the 11th president of The Catholic University of America, serving from 1978 to 1982. Dr. Pellegrino was a former director of Georgetown University’s Kennedy Institute of Ethics, and he founded and directed the university’s Center for Clinical Bioethics, which just this year was renamed the Edmund D. Pellegrino Center for Clinical Bioethics in his honor. From 2005 to 2009, he served as chairman of the President’s Council on Bioethics. Pellegrino was the author of more than 600 published articles in medicine, philosophy, and ethics and author or coauthor of 23 books. A selection from his papers is available through the University of Notre Dame Press (2008): The Philosophy of Medicine Reborn: A Pellegrino Reader.

Effect of Military Conflicts on the Formation of Emergency Medical Services Systems Worldwide

This article briefly reviews the evolution of medical support during wars and conflicts from ancient to modern times and discusses the effect warfare has had on the development of civilian health care and emergency medical services (EMS). Medical breakthroughs and discoveries made of necessity during military conflicts have developed into new paradigms of medical care, including novel programs of triage and health assessment, emergency battlefield treatment and stabilization, anesthesia, and other surgical and emergency procedures. The critical role of organizations that provide proper emergency care to help the sick and injured both on the battlefield and in the civilian world is also highlighted.

Terminating Resuscitation for Cardiac Arrests Outside of the Hospital

Transport Medicine| July 01 2008 Terminating Resuscitation for Cardiac Arrests Outside of the Hospital AAP Grand Rounds (2008) 20 (1): 4. https://doi.org/10.1542/gr.20-1-4 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Terminating Resuscitation for Cardiac Arrests Outside of the Hospital. AAP Grand Rounds July 2008; 20 (1): 4. https://doi.org/10.1542/gr.20-1-4 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All AAP SitesAll PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP News Search Advanced Search Topics: cardiac arrest, resuscitation Source: O’Brien E, Hendricks D, Cone D. Field termination of resuscitation: analysis of a newly implemented protocol. Prehosp Emerg Care. 2008;12(1):57–61; doi:10.1080/10903120701707989 The authors, from Yale-New Haven Medical Center in New Haven, CT, performed a retrospective review of all adult out-of-hospital cardiac arrest (OOHCA) patients transported to two emergency departments (ED) during a 3.5-year interval to determine how often patients were transported despite meeting termination-of-resuscitation (TOR) protocols for traumatic and nontraumatic OOHCA. Emergency Medical Services (EMS) and ED records were evaluated to assess for the presence of TOR protocol criteria and to determine whether the patients should have been transported or pronounced dead on the scene. Records were also examined for extenuating circumstances that may have prompted the transport despite meeting TOR criteria. The outcome measures were survival to discharge from the hospital and survival... Copyright © 2008 by the American Academy of Pediatrics2008 You do not currently have access to this content.

LAWRENCE SOREL COHEN, MD: A Conversation With the Editor

Larry Cohen was born on 27 March 1933 in Brooklyn, New York, and that is where he grew up. After finishing public schools in Brooklyn in 1950, he went to Harvard College in Cambridge, Massachusetts, graduating in 1954. From there, he returned to New York City to New York University School of Medicine, where he finished in 1958. He completed his internship and his first 2 years of medical residency at Yale-New Haven Medical Center in New Haven, Connecticut. In 1962, he went to Boston, Massachusetts, as a research fellow in cardiology at the Peter Bent Brigham Hospital, completing that training in June 1964, and the next month he returned to New Haven as a senior assistant resident at the Yale-New Haven Medical Center.

Ranking the dermatology programs based on measurements of academic achievement

The only dermatology rankings in the past were based on National Institutes of Health (NIH) funding and journal citations. To determine the highest ranking academic dermatology programs based on 5 outcome measures and on an overall ranking scale. To the best of our knowledge, this is the first report to rank the dermatology programs on 4 of the following outcome measures of academic achievement and with an overall ranking. We collected extensive 2001 to 2004 data ranging from total publications to grant funding on 107 U.S. dermatology programs and their full-time faculty. Data from part-time and volunteer faculty were not used. Publications in 2001 to 2004; NIH funding in 2004; Dermatology Foundation grants in 2001 to 2004; faculty lectures in 2004 delivered at national conferences; number of full-time faculty members who were on the editorial boards of the top 3 U.S. dermatology journals and the top 4 subspecialty journals We used the 5 outcome measures to tabulate the highest ranking programs in each category. Using a weighted ranking system, we also tabulated the overall top 30 dermatology programs based on these 5 outcome measures. We were not able to determine the total amount of NIH funding in dollars of the dermatology divisions. The impact factors of the journal in which these publications appeared was not factored into our calculations. Since faculty members may collaborate on the same publication, some publications may have been double-counted. In descending order, the 5 highest ranked academic programs are the University of Pennsylvania; University of California, San Francisco; Yale-New Haven Medical Center; New York University; and University of Michigan. This ranking system may allow residents and faculty to improve the academic achievements at their respective programs.

Michael Emmett, MD, MACP: A Conversation with the Editor

Michael Emmett (Figure ​(Figure11) was born in a displaced persons camp near Linz, Austria, on October 29, 1945, and he and his family came to Philadelphia 4 years later. After attending public schools, he went to Pennsylvania State University, graduating magna cum laude in 1967, and then to Temple University School of Medicine in Philadelphia, graduating in 1971 first in his class. In medical school he received 4 major awards and was president of the local chapter of the Alpha Omega Alpha Honor Society. His internship and 2 years of medical residency were at the Yale-New Haven Medical Center in New Haven, Connecticut, and his 2-year fellowship in nephrology was at the Hospital of the University of Pennsylvania.

Psammoma bodies in cervicovaginal smears

Objective: To estimate the prevalence of psammoma bodies in routine cervical cytology specimens and describe clinical diagnoses associated with them in pre- and postmenopausal women. Methods: We identified all reports that contained psammoma bodies from a retrospective review of 34,816 cytology reports over 4 consecutive years from the computerized pathology database at Yale New-Haven Medical Center. Slides were reviewed to confirm and qualify psammoma bodies. Medical records of women with psammoma bodies were reviewed and information on follow-up was collected. Results: We identified 18 women with psammoma bodies on their Papanicolaou smears. The median age was 49.5 years (range 17–78 years). Seven of eight postmenopausal women had gynecologic malignancies. Five presented with postmenopausal bleeding and had uterine serous or clear-cell carcinomas. One presented with a pelvic mass that was ovarian serous carcinoma. Another had a serous carcinoma of the fallopian tube with only psammoma bodies on Papanicolaou smears. Only one of the remaining 11 nonmalignant cases was a postmenopausal woman. Conclusion: The prevalence of psammoma bodies in consecutively screened Papanicolaou smears was 18 of 34,816. Psammoma bodies on Papanicolaou smears are ominous in postmenopausal women. Their presence in asymptomatic premenopausal women warrants further evaluation, but not necessarily surgical exploration.

Physician gender and cesarean sections

Background: Among consumers insurers, and providers there is pervasive concern regarding the high incidence of cesarean section delivery. To date, attempts to reduce these rates have focused on the clinical behavior of providers resulting in only minimal changes. Therefore, non-medical variables must be investigated as potential explanatory factors for the decision to perform cesarean delivery. Methods: Data were collected on clinical and non-clinical factors for obstetrician-gynecologists delivering at Yale-New Haven Medical Center to measure the impact of these factors on the performance of cesarean sections. Specifically, variation in patient demographic, ante- and intra-partum risk variables, practice setting, and doctor-specific characteristics were examined. Using contingency table and logistic regression analyses the contribution of selected factors was evaluated. Results: Multivariate modeling revealed that male physicians were significantly more likely than their female colleagues to perform cesarean section. This relationship was particularly strong in the university practice setting. Conclusions: Efforts to reduce the incidence of cesarean section need to focus on the continuing education of health care providers and the delineation of non-clinical factors as essential elements in the election of specific clinical therapies.

The MEDLINE Experience at Yale

The Cushing/Whitney Medical Library began providing end-user access to MEDLINE in 1986 and switched to the OVID system in 1993. MEDLINE is a core service of the library, and the choice of delivery systems has had a significant impact throughout the Yale-New Haven Medical Center. This paper describes the user response to MEDLINE, discusses the effects of MEDLINE on other library services, and suggests ways in which technology, policy, and funding have influenced use. Yale's experience suggests that removing barriers in all three areas can dramatically expand the points of access, the number of users, and the amount of use with manageable effects on other library services.

Evaluating IAIMS at Yale: information access.

To evaluate use of information resources during the first year of IAIMS implementation at the Yale-New Haven Medical Center. The evaluation asked: (1) Which information resources are being used? (2) Who uses information resources? (3) Where are information resources used? (4) Are multiple sources of information being integrated? Measures included monthly usage data for resources delivered network-wide, in the Medical Library, and in the Hospital; online surveys of library workstation users; an annual survey of a random, stratified sample of Medical Center faculty, postdoctoral trainees, students, nurses, residents, and managerial and professional staff; and user comments. Eighty-three percent of the Medical Center community use networked information resources, and use of resources is increasing. Both status (faculty, student, nurse, etc.) and mission (teaching, research, patient care) affect use of individual resources. Eighty-eight percent of people use computers in more than one location, and increases in usage of traditional library resources such as MEDLINE are due to increased access from outside the Library. Both survey and usage data suggest that people are using multiple resources during the same information seeking session. Almost all of the Medical Center community is using networked information resources in more settings. It is necessary to support increased demand for information access from remote locations and to specific populations, such as nurses. People are integrating information from multiple sources, but true integration within information systems is just beginning. Other institutions are advised to incorporate pragmatic evaluation into their IAIMS activities and to share evaluation results with decision-makers.

Extramammary Paget's Disease of the Vulva

Fourteen patients with extramammary Paget's disease of the vulva treated at Yale-New Haven Medical Center from 1982 through 1993 were reviewed to evaluate the accuracy of methods used to delineate surgical margins and to determine if radical operations or surgical margin status was associated with likelihood of recurrence. These 14 patients underwent at total of 25 operations for extramammary Paget's disease. In 8 operations, a total of 44 separate frozen-section biopsies were performed to determine extent of disease with a mean of 5.5 biopsies per patient. Visual judgment alone was used to determine margin status in 17 operations. The ability to delineate free surgical margins on permanent sections was not different, whether judged visually or by frozen-section analysis. Frozen-section analysis was misleading in 3/8 (37.5%) cases, while visual judgment was in error in 6/17 (35%) cases. Moreover, permanent margin status was not found to be predictive of disease recurrence. Two of 5 (40%) patients with positive margins recurred after initial surgery compared with 3 of 9 (33%) patients with negative margins. Of the 14 primary operations, there were 8 wide local excisions, 3 simple vulvectomies, and 3 modified radical vulvectomies. The radicality of the operation as initial treatment did not statistically correlate with disease recurrence.

Extramammary Paget's Disease of the Vulva

Fourteen patients with extramammary Paget's disease of the vulva treated at Yale-New Haven Medical Center from 1982 through 1993 were reviewed to evaluate the accuracy of methods used to delineate surgical margins and to determine if radical operations or surgical margin status was associated with likelihood of recurrence. These 14 patients underwent at total of 25 operations for extramammary Paget's disease. In 8 operations, a total of 44 separate frozen-section biopsies were performed to determine extent of disease with a mean of 5.5 biopsies per patient. Visual judgment alone was used to determine margin status in 17 operations. The ability to delineate free surgical margins on permanent sections was not different, whether judged visually or by frozen-section analysis. Frozen-section analysis was misleading in 3/8 (37.5%) cases, while visual judgment was in error in 6/17 (35%) cases. Moreover, permanent margin status was not found to be predictive of disease recurrence. Two of 5 (40%) patients with positive margins recurred after initial surgery compared with 3 of 9 (33%) patients with negative margins. Of the 14 primary operations, there were 8 wide local excisions, 3 simple vulvectomies, and 3 modified radical vulvectomies. The radicality of the operation as initial treatment did not statistically correlate with disease recurrence.

Early detection and screening for ovarian cancer.

Ovarian cancer is associated with postmenopausal women of North American or European descent, nulliparous women, and women with a first-degree relative with an epithelial ovarian cancer. Methods for early detection of ovarian cancer are the pelvic examination, ultrasound techniques, and CA-125 monitoring, none of which are highly sensitive or specific for the disease. At the Yale-New Haven Medical Center, first-degree relatives of women with epithelial ovarian cancer were invited to participate in an intense ovarian cancer screening program consisting of tumor markers, endovaginal ultrasound and color Doppler flow studies, and physical examinations performed in a serial fashion. The false-positive rate for the tumor markers varied from 2 to 9% at initial evaluation of the first 247 participants. Endovaginal ultrasound and color Doppler flow techniques were used to evaluate 326 ovaries in 169 women. Resistive indices < 0.5 were present in 26 ovaries (8.4%), and peak systolic velocities > 30 cm/sec occurred in 7 ovaries (2.3%). To date, four breast cancers have been detected, three cervical intraepithelial neoplasias have been identified, and three atypical adenomatous hyperplasias were diagnosed. No epithelial ovarian cancer was found. Isolated screening for ovarian cancer even in high-risk women is not cost effective. Women screened for ovarian cancer should also be evaluated for cancers of the breast, cervix, colon, rectum and endometrium. Isolated abnormal screening test values are not an indication for surgery.

Mechanical circulatory support decreases neurologic complications in the treatment of traumatic injuries of the thoracic aorta.

The surgical treatment of traumatic injuries of the thoracic aorta is controversial because a number of technical approaches have been recommended. Despite the technique employed, spinal cord ischemia continues to be a persistent problem. Nineteen patients with confirmed aortic injuries secondary to blunt trauma were treated at the Yale-New Haven (Conn) Medical Center from 1984 to 1991. The patients were analyzed in two groups: group 1 (n = 10) underwent repair using mechanical circulatory support and group 2 (n = 9) underwent repair without mechanical circulatory support. Sixteen patients survived. Three patients died of complications of multiple trauma. The groups were comparable with respect to aortic cross-clamp time, preoperative systolic blood pressure, and Injury Severity Score. Three patients in the nonmechanical support group developed neurologic complications (P less than .05). No patient in the mechanical support group had a neurologic complication. We believe that mechanical circulatory support reduces the incidence of neurologic complications following traumatic injuries of the thoracic aorta and should be used whenever clinically feasible.

Treatment of fetal supraventricular tachyarrhythmias.

Supraventricular tachyarrhythmia has been encountered in 18 fetuses at the Yale-New Haven Medical Center during the past 4 years. Fourteen of these fetuses had supraventricular tachycardia and underwent in utero antiarrhythmic therapy with maternally administered digoxin either alone, or on combination with verapamil, propranolol, or procainamide. Thirteen of the 14 fetuses had successful in utero conversion of cardiac rhythm to normal sinus rhythm. The 14th patient underwent successful therapy after birth. All 14 fetuses survived despite severe fetal hydrops at the time of diagnosis in 13 of 14. The four remaining fetuses had either atrial flutter (3) or fibrillation. Two of the fetuses with atrial flutter died at birth, the 3rd survived after electrical cardioversion at birth. The fetus with atrial fibrillation converted to normal sinus rhythm and survived after maternal administration of digoxin. Using M-mode and pulsed Doppler echocardiography, the nature and electrophysiologic mechanism of the arrhythmia may be deduced. The latter information is reviewed along with the fetomaternal pharmacology of various antiarrhythmic agents to devise a rational antiarrhythmic treatment program.

Fallopian tube carcinoma

Twenty-one patients with fallopian tube carcinoma from Yale-New Haven Medical Center are reviewed. Most patients who died of disease did so in the first two years after diagnosis, even following complete resection, clearly indicating the need for adjuvant therapy. Negative second-look surgery did not provide assurance of permanent remission. There was a high recurrence rate with Stage I and completely resected Stage II and III disease (8 of 14 patients). Some recurrences occurred late, up to nine years after initial diagnosis. We recommend whole abdomino-pelvic radiation if no disease greater than 2 cm 3 bulk exists after surgery. Chemotherapy may be an alternative to radiation as primary adjuvant treatment in early stage disease. Chemotherapy for unresectable disease or recurrent disease has shown palliation with occasional prolonged survival but no patient with recurrent disease survived longer than two years.

Temperature elevation during brachytherapy for carcinoma of the uterine cervix: Adverse effect on survival and enhancement of distant metastasis

Possible effects of fever during intracavitary radiation therapy on patient survival, local-regional control or metastatic spread of disease were analyzed in a group of 398 patients with previously untreated, invasive carcinoma of the uterine cervix, managed with a combination of external beam irradiation and intracavitary radium (ICR) applications at Yale-New Haven Medical Center and affiliated hospitals from January 1953 through December 1977. Cox step-wise proportional hazard models were used to test for the influence of elevated temperatures during ICR placements, controlling for the influence of other pretreatment patient parameters, including FIGO stage, age, blood count, prior supracervical hysterectomy and number of prior pregnancies. Increasing maximum temperatures noted during ICR placements were associated with: a) decreased patient survival ( p = 0.014) and b) increased frequency with time of distant metastasis as the initial sites of treatment failure ( p = 0.038). When patients were dichotomized on the basis of maximum temperature during ICR, distant metastasis as the initial site(s) of treatment failure was noted twice as frequently in patients with maximum temperatures greater than or equal to 101.0°F (12.5%; 10/80 patients) than in those with maximum temperatures less than 101.°F during ICR placement (6.3%; 20/318 patients). No statistically significant differences were noted between the two groups in their distributions by stage, age, histology, year of diagnosis, or pretreatment hemoglobin, and the sites of distant metastasis and time course for clinical detection were similar in both groups. These results are in agreement with prior clinical studies in cancer of the uterine cervix which noted a poor prognosis in patients with cancer of cervix who developed fever during treatment. In addition, the finding of an association between an increased frequency of distant metastasis and temperature elevation during the ICR provides, for the first time, clinical data supporting the reports of an alteration or enhancement of distant metastasis following the application of whole body hyperthermia in murine, rabbit and canine tumors.

Is Routine Cesarean Section Necessary for Vertex-Breech and Vertex-Transverse Twin Gestations?

Ninety-three vertex-breech and 42 vertex-transverse twin gestations were managed at Yale-New Haven Medical Center during a 5-year period. Antepartum diagnosis of twin gestation occurred in 93% of the cases, and diagnosis was made before delivery of the second twin in 97% of the cases. Seventy-two (78%) of the vertex-breech and 22 (53%) of the vertex-transverse twins were delivered vaginally. Breech extraction was used for delivery of 76 second twins. Below a birth weight of 1,500 gm, there were six neonatal deaths, four cases of documented intraventricular hemorrhage, and a 67% occurrence of depressed 5-minute Apgar scores. Above a birth weight of 1,500 gm, there were no cases of neonatal death or documented intraventricular hemorrhage and a 5% occurrence of moderately depressed 5-minute Apgar scores. Birth trauma occurred in a 3,420 gm second twin delivered by breech extraction. This infant suffered a greenstick fracture of the right clavicle and a nondisplaced fracture of the right humerus that was not associated with permanent residual injury. We think that, for birth weights >1,500 gm, routine cesarean section for vertex-breech or vertex-transverse twin gestation may not be necessary.