Publications

A new regulatory T (T reg) cell-specific, FoxP3-GFP-hCre bacterial artificial chromosome transgenic mouse was crossed to a conditional Dicer knockout (KO) mouse strain to analyze the role of microRNAs (miRNAs) in the development and function of T reg cells. Although thymic T reg cells developed normally in this setting, the cells showed evidence of altered differentiation and dysfunction in the periphery. Dicer-deficient T reg lineage cells failed to remain stable, as a subset of cells down-regulated the T reg cell-specific transcription factor FoxP3, whereas the majority expressed altered levels of multiple genes and proteins (including Neuropilin 1, glucocorticoid-induced tumor necrosis factor receptor, and cytotoxic T lymphocyte antigen 4) associated with the T reg cell fingerprint. In fact, a significant percentage of the T reg lineage cells took on a T helper cell memory phenotype including increased levels of CD127, interleukin 4, and interferon gamma. Importantly, Dicer-deficient T reg cells lost suppression activity in vivo; the mice rapidly developed fatal systemic autoimmune disease resembling the FoxP3 KO phenotype. These results support a central role for miRNAs in maintaining the stability of differentiated T reg cell function in vivo and homeostasis of the adaptive immune system.

BACKGROUND

Climate models project that heat waves will increase in frequency and severity. Despite many studies of mortality from heat waves, few studies have examined morbidity.

OBJECTIVES

In this study we investigated whether any age or race/ethnicity groups experienced increased hospitalizations and emergency department (ED) visits overall or for selected illnesses during the 2006 California heat wave.

METHODS

We aggregated county-level hospitalizations and ED visits for all causes and for 10 cause groups into six geographic regions of California. We calculated excess morbidity and rate ratios (RRs) during the heat wave (15 July to 1 August 2006) and compared these data with those of a reference period (8-14 July and 12-22 August 2006).

RESULTS

During the heat wave, 16,166 excess ED visits and 1,182 excess hospitalizations occurred statewide. ED visits for heat-related causes increased across the state [RR = 6.30; 95% confidence interval (CI), 5.67-7.01], especially in the Central Coast region, which includes San Francisco. Children (0-4 years of age) and the elderly (> or = 65 years of age) were at greatest risk. ED visits also showed significant increases for acute renal failure, cardiovascular diseases, diabetes, electrolyte imbalance, and nephritis. We observed significantly elevated RRs for hospitalizations for heat-related illnesses (RR = 10.15; 95% CI, 7.79-13.43), acute renal failure, electrolyte imbalance, and nephritis.

CONCLUSIONS

The 2006 California heat wave had a substantial effect on morbidity, including regions with relatively modest temperatures. This suggests that population acclimatization and adaptive capacity influenced risk. By better understanding these impacts and population vulnerabilities, local communities can improve heat wave preparedness to cope with a globally warming future.

OBJECTIVE

Because self-rated health (SRH) is strongly associated with health outcomes, it is important to identify factors that individuals take into account when they assess their health. We examined the role of valued life activities (VLAs), the wide range of activities deemed to be important to individuals, in SRH assessments.

STUDY DESIGN AND SETTING

Data were from three cohort studies of individuals with different chronic conditions--rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and chronic obstructive pulmonary disease (COPD). Each cohort's data were collected through structured telephone interviews. Logistic regression analyses identified factors associated with ratings of fair/poor SRH. All analyses included sociodemographic characteristics, general and disease-specific health-related factors, and general measures of physical functioning.

RESULTS

Substantial portions of each group rated their health as fair/poor (RA 37%, SLE 47%, COPD 40%). In each group, VLA disability was strongly associated with fair/poor health (RA: OR=4.44 [1.86,10.62]; SLE: OR=3.60 [2.10,6.16]; COPD: OR=2.76 [1.30,5.85]), even after accounting for covariates.

CONCLUSION

VLA disability appears to play a substantial role in individual perceptions of health, over and above other measures of health status, disease symptoms, and general physical functioning.

Teaching and assessment of communication and interpersonal skills, one of the American Council for Graduate Medical Education-designated core competencies, is an important but difficult task in the training of physicians. Assessment of trainees offers an opportunity to provide explicit feedback on their skills and encourages learning. This article describes a pilot study in which clinician-educators affiliated with the geriatrics training programs at Beth Israel Deaconess Medical Center and Boston University Medical Center designed and piloted a novel Objective Structured Clinical Examination (OSCE) to assess the communication and interpersonal skills of medical, dental, and geriatric psychiatry fellows. The OSCE consisted of three stations where geriatricians and standardized patients evaluated candidates using specifically designed checklists and an abbreviated version of the Master Interview Rating Scale. Communication skills were assessed through performance of specific "real life" clinical tasks, such as obtaining a medical history, explaining a diagnosis and prognosis, giving therapeutic instructions, and counseling. Interpersonal skills were assessed through the effect of the communication between doctor and standardized patient on fostering trust, relieving anxiety, and establishing a therapeutic relationship. This pilot study demonstrated that the OSCE format of assessment provides a valid means of evaluating the communication and interpersonal skills of interdisciplinary geriatric trainees and provides a valuable forum for formative assessment and feedback. Given that geriatricians and non geriatricians involved in elder care both need communication and interpersonal skills, this novel OSCE can be used for assessment of these skills in trainees in diverse healthcare subspecialties.