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Hearing loss may affect critical domains of health and functioning in older adults. This article describes the rationale and design of the Studying Multiple Outcomes After Aural Rehabilitative Treatment (SMART) study, which was developed to determine to what extent current hearing rehabilitative therapies could mitigate the effects of hearing loss on health outcomes. One hundred and forty-five patients ≥50 years receiving hearing aids (HA) or cochlear implants (CI) were recruited from the Johns Hopkins Department of Otolaryngology-HNS. A standardized outcome battery was administered to assess cognitive, social, mental, and physical functioning. Of the 145 participants aged 50 to 94.9 years who completed baseline evaluations, CI participants had significantly greater loneliness, social isolation, and poorer hearing and communicative function compared with HA participants. This study showed that standardized measures of health-related outcomes commonly used in gerontology appear sensitive to hearing impairment and are feasible to implement in clinical studies of hearing loss.

Abstract Background To examine whether whole genome expression profiling could reveal changes in mRNA expression of peripheral blood mononuclear cells (PBMC) from allergic patients undergoing rush immunotherapy (RIT) that might be manifest within the first few months of treatment. Methods For this study, PBMC from three allergic patients undergoing RIT were assessed at four timepoints: prior to RIT, at 1 week and 7 week post-RIT, during build-up and at 4 months, after establishment of a maintenance dose. PBMC mRNA gene expression changes over time were determined by oligonucleotide microarrays using the Illumina Human-6 BeadChip Platform, which simultaneously interrogates expression profiles of > 47,000 transcripts. Differentially expressed genes were identified using well-established statistical analysis for microarrays. In addition, we analyzed peripheral blood basophil high-affinity IgE receptor (Fc epsilon RI) expression and T-regulatory cell frequency as detected by expression of CD3+CD4+CD25bright cells at each timepoint using flow cytometry. Results In comparing the initial 2 timepoints with the final 2 timepoints and analyzing for genes with ≥1.5-fold expression change (p less than or equal to 0.05, BH-FDR), we identified 507 transcripts. At a 2-fold change (p less than or equal to 0.05, BH-FDR), we found 44 transcripts. Of these, 28 were up-regulated and 16 were down-regulated genes. From these datasets, we have identified changes in immunologically relevant genes from both the innate and adaptive response with upregulation of expressed genes for molecules including IL-1β, IL-8, CD40L, BTK and BCL6. At the 4 month timepoint, we noted a downward trend in Fc epsilon RI expression in each of the three patients and increased allergen-specific IgG4 levels. No change was seen in the frequency of peripheral T-regulatory cells expressed over the four timepoints. Conclusions We observed significant changes in gene expression early in peripheral blood samples from allergic patients undergoing RIT. Moreover, serum levels for allergen specific IgG4 also increased over the course of treatment. These studies suggest that RIT induces rapid and dynamic alterations in both innate and adaptive immunity which can be observed in the periphery of allergic patients. These alterations could be directly related to the therapeutic shift in the allergen-specific class of immunoglobulin.

Background: Limited health literacy has been associated with poorer health outcomes and increased morbidity and mortality. Though caring for surgical patients requires communication about complex topics, there is limited literature on health literacy competency in this population. The objective of this study was to assess health literacy in an adult surgical outpatient clinic population, to explore potential determinants of adequate health literacy, and to assess patient satisfaction with physician-patient communication., Materials and Methods: A prospective cross-sectional study was performed and anonymous data including health literacy, demographics, and patient satisfaction with provider communication were collected. The study population included adult patients who visited an outpatient surgical practice over a one-month period. Health literacy was assessed using the Newest Vital Sign while the satisfaction questions came from the Outpatient Satisfaction Survey (Press-Ganey Associates, Chicago, IL)., Results: 148 patients participated in the study. The mean age was 49 years, 41% of those who gender identified were male, and 76% were White/Caucasian. 34 (27%) of those who answered the question had received a four-year undergraduate/university degree. 55 (37%) of the patients were identified as having low health literacy. More years of education was significantly associated with adequate health literacy and those patients who were more educated and had adequate health literacy were more satisfied with provider communication., Conclusion: Patients on average were highly satisfied with provider communication in this outpatient surgical clinic. Higher education levels were associated with better health literacy and patients with both characteristics were more satisfied with provider communication.

Objectives: To determine if there is a correlation between the numbers of evaluations submitted by faculty and the perception of the quality of feedback reported by trainees on a yearly survey., Method: 147 ACGME-accredited training programs sponsored by a single medical school were included in the analysis. Eighty-seven programs (49 core residency programs and 38 advanced training programs) with 4 or more trainees received ACGME survey summary data for academic year 2013-2014. Resident ratings of satisfaction with feedback were analyzed against the number of evaluations completed per resident during the same period. R-squared correlation analysis was calculated using a Pearson correlation coefficient., Results: 177,096 evaluations were distributed to the 87 programs, of which 117,452 were completed (66%). On average, faculty submitted 33.9 evaluations per resident. Core residency programs had a greater number of evaluations per resident than fellowship programs (39.2 vs. 27.1, respectively, p = 0.15). The average score for the "satisfied with feedback after assignment" survey questions was 4.2 (range 2.2-5.0). There was no overall correlation between the number of evaluations per resident and the residents' perception of feedback from faculty based on medical, surgical or hospital-based programs., Conclusions: Resident perception of feedback is not correlated with number of faculty evaluations. An emphasis on faculty summative evaluation of resident performance is important but appears to miss the mark as a replacement for on-going, data-driven, structured resident feedback. Understanding the difference between evaluation and feedback is a global concept that is important for all medical educators and learners.

Objective: To define clinical and laboratory features that identify patients with neurosyphilis., Methods: Subjects (n=326) with syphilis but no previous neurosyphilis who met 1993 Centers for Disease Control and Prevention criteria for lumbar puncture underwent standardized history, neurological examination, venipuncture, and lumbar puncture. Neurosyphilis was defined as a cerebrospinal fluid (CSF) white blood cell count >20 cells/ microL or reactive CSF Venereal Disease Research Laboratory (VDRL) test result., Results: Sixty-five subjects (20.1%) had neurosyphilis. Early syphilis increased the odds of neurosyphilis in univariate but not multivariate analyses. In multivariate analyses, serum rapid plasma reagin (RPR) titer > or =1 : 32 increased the odds of neurosyphilis 10.85-fold in human immunodeficiency virus (HIV)-uninfected subjects and 5.98-fold in HIV-infected subjects. A peripheral blood CD4+ T cell count < or =350 cells/ microL conferred 3.10-fold increased odds of neurosyphilis in HIV-infected subjects. Similar results were obtained when neurosyphilis was more stringently defined as a reactive CSF VDRL test result., Conclusion: Serum RPR titer helps predict the likelihood of neurosyphilis. HIV-induced immune impairment may increase the risk of neurosyphilis.

In 1989, the New York State Legislature enacted New York State Code 405 in response to the death of a patient in a New York City hospital. Code 405 was the culmination of a report (the Bell Commission Report) that implicated the training of residents as part of the problem leading to that tragic death. This paper explores the consequences of the regulatory changes in physician training. The sleep deprivation of house officers was considered a major issue requiring correction. There is little evidence to support the claim that sleep deprivation is a serious cause of medical misadventures. Nevertheless, the changes in house officers' working hours and responsibilities have profound implications. Changes in the time allotted to teaching, the ability to learn from patients admitted after a shift is over, and the increasing loss of continuity, all may have a negative impact on physician training. It is not clear that trainees are being realistically prepared for the actual practice of medicine - physicians often work extended hours. The most serious concern that has been raised is the loss of professionalism by physicians. Residents are now viewing themselves as hourly workers, and the State has intervened in an area of training formerly left to the profession to manage. We are now training doctors in New York State who will be comfortable working in an hourly wage setting, but not in the traditional practice of medicine as it has been in the United States during this century. We are concerned that this may sever the bond between doctor and patient - a bond that has been the bedrock of our conception of a physician.

To provide optimal care for their patients, clinicians must be able to locate and interpret the most current literature. Teaching the necessary skills to medical students is essential, if we wish to train clinicians to be able to keep up with the expansion of biomedical knowledge for their entire working lives. In this paper, we describe our school's four-year curriculum in evidence-based medicine and the performance of three senior classes on the summative evaluation exercise devised to measure the program's success.

The primary goal of Medical Education Grand Rounds is to enhance the overall educational mission of the Mount Sinai School of Medicine. This editorial describes the first four years of this unique and innovative educational program, and serves as a prelude to a new feature of The Journal.

Objective: To assess the efficacy of salvage therapy containing ritonavir and saquinavir after failure of indinavir- or nelfinavir-containing regimens, and to determine correlates of success or failure., Design: Retrospective chart review. SETTING. The Moore Clinic - the HIV clinic of Johns Hopkins Hospital., Patients: Forty-one HIV-infected patients were identified through physician contacts, referrals from other providers, and review of a comprehensive clinical database., Main Outcome Measures: To determine response to salvage therapy, HIV-1 viral RNA (absolute and log10-transformed) was measured using the Roche Amplicor quantitative HIV-1 RNA assay after initiation of the salvage regimen. Potential correlates of response included: viral RNA at the time of switch; viral RNA at the time of switch as a percentage of baseline viral RNA; magnitude of decline in viral RNA; and the interval between virologic failure of single protease inhibitor therapy and switch to the salvage regimen., Results: Thirteen (56.5%) of 23 patients failing indinavir responded to salvage therapy (HIV RNA < 400 copies/ml) with persistence throughout the follow-up period (median of 37 weeks; range 18-67 weeks). Mean absolute viral RNA at the time of switch was 20 238 copies/ml (median, 9281) compared with 42 953 copies/ml (median, 24 650) for the 10 non-responders. Mean log10 viral RNA at switch was 3.804 for responders versus 4.405 for non-responders (P = 0.040). Among four responders who had failed nelfinavir, mean viral RNA was 9634 copies/ml and mean log10 viral RNA was 3.749 at the time of switch. Two non-responders had a mean viral RNA of 21 551 and a mean log10 viral RNA of 4.037 at switch., Conclusions: In contrast with previous reports, salvage regimens containing ritonavir and/or saquinavir can be effective and durable following the failure of combination regimens containing either indinavir or nelfinavir. Salvage therapy may be more likely to succeed when it is initiated early in failure at low viral loads.

Twenty-four, adult, female Beagles were arranged by body weight from greatest to least and allocated to 2 groups of 12 dogs, using random numbers. Dogs were housed collectively in 2 adjacent metal buildings, each divided into 4 rooms measuring 2.1 x 3.7 m. Each room was paneled and carpeted and had an access door to the outside with a connecting run that measured 2.1 x 9.1 m. Each run had a surface consisting of 5 cm of pea gravel overlaying 5 cm of sand, and was partially covered by an awning that provided shade at its proximal end. For placement in room/run units, dogs in each of the treated and control groups were alloted to 4 subgroups of 3 dogs each. Each subgroup of dogs was placed in a separate room/run unit. Units containing treatment or control subgroups were alternated to avoid placing identically treated subgroups adjacent to each other. Dogs of subgroups A, C, E, and G were treated with lufenuron monthly at a minimal target dosage of 10 mg/kg of body weight; those of subgroups B, D, F, and H were treated with excipient tablets. Dogs were treated on study days 7, 37, 68, and 98. Each dog was infested with 100 newly emerged, unfed, insectary-reared, adult Ctenocephalides felis on each of study days 0 and 2. Thereafter, infestations on all dogs were dependent on continued development of fleas either in the indoor or outdoor environment. Numbers of fleas on each of the treated and control dogs were determined, using a nondestructive counting technique on days 6, 14, 21, 28, 35, 56, 70, 84, 98, 112, and 119.(ABSTRACT TRUNCATED AT 250 WORDS)

The risk of infection after rape is believed to be low. The use of presumptive treatment is, therefore, controversial. Some experts recommend treatment of all patients, and others suggest treatment if the doctor suspects infection, if the patient requests it, if follow-up examination of the victim cannot be ensured, or if the assailant has a known infection. No regimen will cover all possible pathogens. The Centers for Disease Control's empiric regimen for victims of sexual assault is effective against gonorrhea, chlamydia, and, most likely, syphilis. We present a case of incubating syphilis following rape, that did not respond to ceftriaxone.

A previously healthy 2-year-old girl, who presented with transient neurologic dysfunction manifested mainly by absence and atonic seizures, was treated with large doses of the antihelminthic piperazine hexahydrate. The role of piperazine salts and piperazine-containing compounds in producing neurotoxic side effects is discussed. We suggest that these drugs be considered as a possible cause of transient encephalopathy and nonepileptic seizures in previously healthy individuals.