vital
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F A C T S
&
F I G U R E S
Hard hat area
Silver screen
is a smoking gun
for adolescents
Young adolescents who watch a
lot of R-rated movies are up to
three times more likely to start
smoking than peers whose viewing habits are restricted by their
parents, according to a DMS research group that has studied
many aspects of teen smoking.
Exposure: James Sargent, M.D.,
a professor of pediatrics, and
Madeline Dalton, Ph.D., a research associate professor of pediatrics, both published recent
articles on the link between
teens’ exposure to smoking in
the movies and their adoption of
the habit. The studies were based
on surveys in which 10- to 14year-olds were asked which of a
random set of 50 R-rated movies
(from a total of 601 box-office
hits) they’d seen.
According to Sargent’s article, which was published in the
July Archives of Pediatrics and
Adolescent Medicine, the study
participants had been exposed to
an average of more than 1,000
depictions of smoking. For some,
the number was over 4,000. The
total number of smoking occurrences in all 601 movies was
5,335. Not surprisingly, the most
relevant factor in reducing a
teen’s number of exposures was
parental restrictions on movieviewing.
Dalton then conducted a longitudinal study of 3,547 adolescents who, according to their
initial surveys, had never
smoked. She was able to follow
up a year or two later with 2,603
Fall 2003
DHMC’s Project for Progress expansion is slated for completion in
March 2006. In the meantime, here are some facts about the project.
Square feet of new space
470,000
Cost of design and construction for the entire project
$210 million
Number of new parking spaces for patients
540
Square feet of asphalt paving
500,000
Cubic yards of concrete
15,000
Tons of structural steel
2,300
Square feet of drywall
1.9 million
Square yards of carpeting
24,000
Square feet of vinyl flooring
54,000
Miles of mechanical piping
44
Number of new doors
2,500
of these respondents to determine how many had since taken
up smoking. Her article, published in the June 10 online edition of Lancet, states that “even
after controlling for all other covariates, 52.2% of smoking initiation in this cohort can be attributed to exposure to smoking
in movies.” Those teens who had
the greatest exposure to smoking
in movies were nearly three
times as likely to have started
smoking as those with the least
exposure.
Sargent says that Dalton’s
study “is really powerful evidence
that seeing smoking in movies is
a causal element of smoking.”
However, he acknowledges a
need to confirm the finding in
additional population samples;
they are currently conducting a
national survey of 6,000 adolescents. The just-published work
involved only white adolescents
from northern New England,
while the follow-up study will
survey various ethnic and racial
groups in both urban and rural
settings.
Restrictions: At the same time,
Dalton is looking at how restricted movie-viewing fits with
other restrictions set by parents.
“Watching movies influences behaviors,” says Dalton. “We want
to know what would motivate
parents to restrict” their children’s viewing habits.
Wonders Sargent, “Is it the
violence, the sex, the bad language? It’s not smoking,” he believes. “Smoking is the last thing
[parents] think about. We need
to figure out what’s the lever that
will get their attention.”
But it may be all those things
Dartmouth Medicine 3
vital
signs
“Sister” schools
program tackles
AIDS in Africa
Movies that glamorize smoking—as illustrated by this scene of Renée Zellweger in
Bridget Jones’s Diary—are coming under increasing fire, as a result of the continued productivity of a research group in the Dartmouth Department of Pediatrics.
in combination that incite adolescents to smoke. “Watching
smoking in the context of other
adult behaviors makes it more
salient to the kids than watching
smoking in a G-rated movie,”
says Dalton. “I don’t think a lot
of kids are setting out to emulate
Cruella DeVille,” the chainsmoking cartoon villainess in
Disney’s 101 Dalmations.
Best medicine: Having parents
who don’t smoke, and who restrict their kids’ movie-viewing,
is the best medicine for teens,
the DMS team has determined.
According to Sargent, “Of 400
kids who had low exposure to
smoking in the movies due to
parental restriction [and] whose
parents didn’t smoke, over a twoyear period only three . . . tried
smoking.”
Without any restrictions on
movie-viewing, he adds, kids
whose parents (and friends)
don’t smoke are most affected by
seeing smoking in the movies. In
other words, the impact of smoking in the movies on adolescents
whose parents smoke is lower—
perhaps because they have a
more realistic view of smoking so
4 Dartmouth Medicine
are less easily influenced by the
glamorized smoking in films.
“Seeing your mother smoke is
definitely different than seeing
Cameron Diaz smoke on screen,”
says Dalton.
She adds that reaction to the
study has generally been positive, noting that schools and
principals where the study was
conducted were helpful, and participating children and their parents very supportive. But the
publication of their articles did
elicit some mixed reactions, generally from people worried about
censorship. (See page 22 for media coverage of the studies.)
The team is now looking for
effective techniques to motivate
parents to restrict their kids’
viewing habits. It’s a highly
charged issue, however, and Sargent and Dalton know they must
proceed with care.
Message: “For now,” concludes
Sargent, “what we’re trying to do
is get pediatricians to start to
communicate that media restriction is every bit as important as
knowing where your kid is after
school.”
Katharine Fisher Britton
“AIDS statistics are numbers
with the tears washed off them. I
think we’re dealing with the
tears,” says one of the African
health-care workers interviewed
in a documentary about AIDS in
Africa. In an effort to bridge the
gap between the tears and the
numbers, DMS infectious disease
experts are teaming up with their
counterparts in Tanzania.
One of the Tanzanian collaborators, Muhammad Bakari,
M.D., says the first time he heard
about HIV was as a fourth-year
medical student in the 1980s. He
thought it was a disease that occurred only in America. “I have
witnessed the huge increase” in
AIDS in Africa since then, he
says. Sub-Saharan Africa is now
the worst-affected region in the
world, with the prevalence of
HIV exceeding 30% of the population in some countries.
Bakari visited DMS for three
weeks recently to learn about the
clinical use of HIV antiviral
medications in anticipation of
their wider availability in Africa.
“We don’t have a lot of expertise,” he says. Very few HIV-infected or AIDS patients in Tanzania are on them now.
Bakari is one of the principal
investigators of what’s called the
DARDAR Health Study, a fiveyear trial, sponsored by the National Institutes of Health, of a
vaccine aimed at preventing tuberculosis among people with
HIV. The word “DARDAR” is a
contraction of “Dartmouth-Dar
es Salaam”; it also mimics the repeated syllables common in Kiswahili, one of the languages spoken in Tanzania, and is close to
the word for “sister” (dada), thus
representing the relationship between DMS and Tanzania’s Muhimbili University College of
Health and Sciences.
Infectious diseases: The DARDAR study has enrolled 600 patients so far and will ultimately
include 2,300 people with HIV.
Fordham von Reyn, M.D., chief
of infectious diseases at Dartmouth, is a principal investigator, and Richard Waddell, Sc.D.,
director of HIV research studies,
is a coinvestigator.
DARDAR is being conducted to determine why so many
AIDS patients in Africa develop
a severe form of tuberculosis
DMS’s Ford von Reyn (top, in the dark
suit) helped cut the ribbon to open a
new cooperative clinic in Tanzania.
Fall 2003
vital
signs
ANDY NORDHOFF
(TB) that involves the spread of
the organism through the bloodstream. They hope to prevent
this complication—known as
disseminated TB—with a Mycobacterium vaccae vaccine. Disseminated TB occurs in 10% to
25% of those infected with HIV
in Africa.
A new 10-room clinic building, funded by the DARDAR
Study, opened in Dar es Salaam
in June. The clinic includes a
waiting room, exam rooms, and
an x-ray facility, plus an office for
DMS students who will help out
there on electives.
“Approaches to care [in Tanzania] are more challenging because of the lack of availability
of medications and antivirals,”
says Waddell. “The economic
and cultural differences are dramatic. So it’s critical for us to
provide a venue for DMS students. They get experiences in
infectious diseases first-hand that
they [otherwise] only read about
in textbooks.”
Extreme poverty: TB flourishes
where there’s malnutrition and
AIDS. Tanzania had a good TB
control and prevention program
until the mid 1980s, says Bakari.
But extreme poverty, malnutrition, and overcrowding have
been compounded by excessive
debt and drug-patent issues that
make medications unavailable to
the poor.
It’s surprising to Bakari that
some people in the U.S. prefer
not to take antiviral medications
for HIV and AIDS because they
don’t like the side effects. “That
would be unheard of ” in my
country, he says.
Laura Stephenson Carter
Fall 2003
To treat breast
cancer, look on
the sunny side
There’s a promising new treatment in the fight against breast
cancer—one that’s been right
under our noses. Or, more precisely, right over our heads. Vitamin D, which our bodies generate naturally with the help of
sunlight, has been shown to seek
and destroy cancer cells that are
not knocked out by radiation
therapy.
Tumor: A recent DMS study
demonstrated in an animal model that a form of vitamin D called
EB1089, when combined with
radiation, was capable of wiping
out any radiotherapy-resistant
cells that remain following the
surgical removal of a tumor. Researchers at Dartmouth’s Norris
Cotton Cancer Center found
that animals given EB1089 with
radiation had an average final tumor volume approximately 50
percent less than that of animals
given radiation alone.
Sujatha Sundaram, Ph.D., a
research assistant professor of
surgery and lead author of the
study, finds the results encouraging. “The vitamin D analog has
proven effective in enhancing
radiation treatments in our prior
studies with cell cultures, and
now in live mice,” she says. “We
are eager to push ahead to clinical trials . . . in humans.”
According to the American
Cancer Society, about 200,000
women in the U.S. are diagnosed
with breast cancer each year.
About 40,000 of them die from
the disease, making breast can-
Dartmouth researcher Sujatha Sundaram was the lead author on a recent study
showing that vitamin D can boost the effect of radiation against breast cancer.
cer the leading cause of cancer
deaths among women aged 20 to
59. Radiotherapy, usually called
simply radiation, is a common
treatment for breast cancer, both
before and after surgery, but often some cancer cells are resistant to the therapy.
If vitamin D appears to help,
why don’t doctors just dose us up
with the “sunshine vitamin”? Vitamins are safe, right? According
to Sundaram, the amount of vitamin D needed to produce the
desired effect has been found to
induce excessive amounts of calcium, which can affect bone metabolism and structure.
But EB1089, recently developed in Denmark, has a modified
structure that causes significantly fewer calcium-related side effects. In fact, EB1089 is currently being tested in Europe on other forms of cancer, and many of
these studies are already at the
clinical trial stage. But Dartmouth’s study, published in the
June issue of the journal Clinical
Cancer Research, is the first to
combine the vitamin with radiation therapy.
Sundaram and her coauthor,
David Gewirtz, Ph.D., of Virginia Commonwealth University, say the next step is conducting a clinical trial of their protocol. But it will be at least a year
before they can start enrolling
patients, because FDA approval
of EB1089 will be required for its
use in humans. And it will be
several years after that before the
trial results are in hand.
“It’s really much more difficult with clinical trials,” explains
Sundaram. “Patients are getting
a lot of different drugs, so to control and observe the response is
much more complicated—and
much more regulated.”
Cell cultures: In the meantime,
Sundaram and her colleagues
will continue to use cell cultures
and animal models to examine
other uses of EB1089, including
to treat brain tumors, prostate
cancer, and metastatic cancers—
both with and without radiation.
But although the use of vitamin D in the U.S. as a standard
treatment for cancer is many
years and many trials down the
road, the prospects still appear to
be . . . well, sunny.
Joyce Wagner
Dartmouth Medicine 5
vital
signs
Record number of
Ph.D.’s awarded
at Class Day 2003
Although cloudy skies threatened DMS’s Class Day celebration on June 7, attendees had
many reasons to remain in bright
spirits. DMS awarded not only a
record number of Ph.D.’s—22—
in the biomedical sciences, but
the School’s first master’s of public health (M.P.H.) degrees.
Acting Dean Ethan Dmitrovsky, M.D., opened the ceremony
by reminding graduates that family and friends had helped them
get to that point. He then turned
the lectern over to U.S. Surgeon
General David Satcher, M.D.,
Ph.D., who started by encouraging students to serve their country if given the chance and “to
set lofty goals and make a difference in your life and [for] those
around you.”
Quality of life: Satcher devoted
most of his speech to delineating
the goals of the Healthy People
2010 campaign, emphasizing—
in light of the U.S.’s aging population—the importance of improving not only life’s length but
also its quality.
The M.D. student speaker,
Seth Crockett, echoed that sentiment as he reminded his classmates that “our time together,
though brief, was dense.” Drawing laughter from the audience,
Crockett noted that during their
time at DMS, the graduates “sat
through an estimated 1,300
PowerPoint presentations, spent
30-plus Saturday nights studying
in the library, . . . [and] completed over 1,200 residency inter-
6 Dartmouth Medicine
1
Behind them lay hours of lectures and
labs, before them hours of toil—but for
one day in June the DMS ’03s put such
concerns aside. With sunny spirits (albeit under skies that were threatening
rain), 1 M.D. grad Agnes Graves and 2
Ph.D. grad Tom Kirn acquired their
hard-earned velvet-trimmed doctoral
hoods. Adding pomp to the ceremony
were 3 a recitation of the Hippocratic
Oath in its original Greek by Dartmouth
College language professor John Rassias; 4 some words of wisdom from the
event’s keynote speaker, U.S. Surgeon
General David Satcher; and 5 bagpipe
music played by Travis Matheney, a
DMS ’00, and his classmate James
Feeney (not pictured). Among the graduates who reveled in the festivities, together with an assortment of friends
and family members, were M.D. grads
6 Lisa Chong, 7 Amy Amend (right), and
8 Adrienne Williams (this year’s winner
of the Dean’s Medal); 9 CECS grad
Calvin Thomas (center); 10 Ph.D. grad
My Nga Dang Helms (right), pictured
with her faculty adviser, Anikó NárayFejes-Tóth; and M.D. grads 11 Sanjoy
Bhattacharya, 12 Derek Barclay, and
13 Nilton Medina. But there is always
a bittersweet note to such occasions,
too, for at their conclusion it is time for
14 good friends to say goodbye.
2
3
4
5
Fall 2003
vital
signs
ALL: FLYING SQUIRREL GRAPHICS
7
8
6
9
12
Fall 2003
10
13
11
14
Dartmouth Medicine 7
vital
signs
Student Prizes & Awards
views all over the country. To finance our medical education,
collectively we’ve borrowed almost $6 million from various
sources, to be paid back in 10 to
30 years, with interest.”
He added that despite the
rigors of medical school, 21 classmates got married (including
four couples who met at DMS)
and nine children were born to
’03s. “We made friendships that
will endure,” Crockett said.
“We’ve shared an indelible experience here that the passage of
time will not erase.”
The Ph.D. student speaker,
Neema Ganju, who earned her
doctorate in pharmacology and
toxicology, echoed Crockett’s
quantitative perspective. She reminded her fellow Ph.D. graduates that “at this point, we’ve
completed approximately 20
years of school—try telling a
third-grader that you’re in 20th
grade, and his reaction will give
you a good sense of the feat
we’ve accomplished.”
Hunch: She also praised the intimacy of Dartmouth and said
she hoped her fellow graduates’
paths “on this incredible journey
cross again—I have a hunch that
they will some day.”
Then came the hooding of
the 22 biomedical Ph.D.’s plus
32 M.P.H.’s, 60 M.D.’s, and 20
M.S.’s and three Ph.D.’s in the
evaluative clinical sciences.
Next, Dmitrovsky and Associate Dean David Nierenberg,
M.D., presented the top two student awards. Adrienne Williams
earned the Dean’s Medal as the
M.D. with the best overall record
of achievement, and Thomas
Kirn was awarded the John W.
8 Dartmouth Medicine
Dean’s Medal
Merck Manual Awards
Adrienne Williams
Paul Sanchez,
Amy Vinther
John W. Strohbehn Medal for Excellence in
Biomedical Research
Thomas Kirn, Jr.
Department of Anesthesiology Outstanding
Graduating Student Award
Adrienne Williams
Arthur Naitove Surgical
Scholar Award
Sarah Greer
American Academy of Neurology Prize
for Excellence in Neurology
Angela Sanchez
Saul Blatman Award for Excellence in Maternal
and Child Health
New England Pediatric Society Award
Elizabeth Bassett
Katherine O’Donnell
Harte C. Crow Award in Radiology
Department of Psychiatry Award for
Excellence in Clinical Psychiatry
Paul Farris
Jennifer Rhodes
Dartmouth-Mosenthal Surgical Society
Katherine Bardzik, Nilton Medina,
Junko Ozao
John F. Radebaugh Community Service Awards
Amy Madden, Timothy Pieh
French Distinguished Student Award in Pathology
Rural Health Scholar Awards
Matthew Leavitt
Linda Armstrong, Michael Bartholomew,
David Gibbons, Amy Madden,
Timothy Pieh
Janet M. Glasgow Memorial Award
Adrienne Williams
Janet M. Glasgow Achievement Citations
Elizabeth Bassett, Sara Inati,
Katherine O’Donnell, Jennifer Plant,
Blair Seidler
Stanley J. Sarnoff Cardiovascular Science
Fellowship Award
Aaron Kirkpatrick
American Medical Association Rock Sleyster
Memorial Scholarship
Arnold P. Gold Foundation Humanism
in Medicine Awards
Jennifer Plant
Amy Madden
Hilda Weyl Sokol Award
Junko Ozao
Good Physician Award
Amy Madden
Rolf C. Syvertsen Fellow
Elizabeth Bassett
Hitchcock Foundation Student Research Prizes
Heidi Becker, Paige Wickner
Rolf C. Syvertsen Scholars
Sharon Johnston
Amy Madden, Katherine O’Donnell,
Jennifer Plant, Blair Seidler,
Adrienne Williams
Frederic P. Lord Award in Anatomy
John and Sophia Zaslow Prize
Adrienne Williams
Seth Crockett
Department of Medicine Award
Douglas P. Zipes, M.D., Research Prize in Medicine
Tamas Gonda
Tamas Gonda
Julian and Melba Jarrett Memorial Prize
Fall 2003
vital
signs
Strohbehn Medal for Excellence
in Biomedical Research. All the
student prizes presented during
graduation week are listed in the
box on the facing page.
Nierenberg also noted the
conclusion of Dmitrovsky’s service as acting dean, joking that
although he hadn’t remedied
DMS’s chronic parking shortage,
he’d initiated a popular distinguished lecture series and overseen major curricular changes.
Honors: The students bestowed
some awards, too—for basic science teaching to virologist Elmer
Pfefferkorn, Ph.D., and for clinical teaching to surgeon Kenneth Burchard, M.D., as well as
the Thomas P. Almy Housestaff
Teaching Award to internal
medicine resident Timothy
Gardner, M.D. In addition, two
of the College’s honorary degree
recipients this year came from
the realm of biomedicine—Marilyn Hughes Gaston, M.D., the
first African American woman
to head the federal Bureau of Primary Health Care, and Rita Colwell, Ph.D., the first woman to
head the National Science
Foundation.
Class Day concluded with
renowned Dartmouth language
professor John Rassias chanting
the Hippocratic Oath in Greek.
Then Dmitrovsky led the 2003
M.D. graduates—and all physicians present—in reciting a
translation of it. As the Vermont
Brass Quintet struck up the recessional, the graduates had just
enough time to make it into the
reception tent before the clouds
offered up their first raindrops of
the day.
Katrina Mitchell
Fall 2003
PainFree Program
at CHaD garners
a national award
health-care professionals, doing
sedations was not their primary
job responsibility, and 15 percent
of the time children were not being sedated sufficiently for their
For Joseph Cravero, M.D., medprocedures. Under the new proical director of the PainFree Program, if kids need sedation, their
gram at the Children’s Hospital
parents bring them to a centralat Dartmouth (CHaD), teamized location where they meet
work is everything. That’s why
with the whole PainFree team: a
when the program was honored
program coordinator, a child-life
with a national VHA leadership
specialist, a nurse, a patient-care
award—as the best new program
technician, and one or more pein an individual hospital emphadiatric anesthesiologists.
sizing safety and patient care—
Procedures for which chilCravero made sure his whole
dren need sedation run the
staff was at the ceremony.
gamut from nuclear medicine
“Everybody has input here in
scans to bone marrow biopsies to
terms of what we do,” he says.
cast removals. The team also
“Any recognition that we get, we
works extensively with developmake sure everybody gets it.”
mentally delayed children who
Sedations: VHA, Inc. (formerneed immunizations and dental
ly known as the Voluntary Hosand gynecological exams, which
pital Association), is a cooperacan be difficult for them to retive of 2,200 health-care organiceive elsewhere.
zations. The group noted the
“The whole idea here is that
clinical effectiveness of CHaD’s
we involve the nurses, the pediPainFree Program, which in its
atricians, and the child-life spefirst year—2001-02—cared for
cialist, and we try to do whatevover 1,000 patients and reduced
er is required for the kid,” says
the number of sedations judged
Cravero. This can include gento be inadequate from 15 percent
eral or local anesthesia or someto zero percent.
times simply a movie or music
Before the PainFree Program
via headphones. “We really enexisted, about 30 different areas
courage the kids to take the acat DHMC were performing peditive role. . . . They get to pick
atric sedations. For many of the
how they want to fall asleep,” explains Kristin
King, CHaD’s
child-life specialist.
The benefits from the
PainFree
Program have
been considerable. For exCHaD’s PainFree Program recently won a national award for
dropping its rate of inadequate pediatric sedations to zero.
ample, it of-
ten took more than half a day to
do a 30-minute procedure; now,
families can be in and out of the
hospital in two to three hours.
Kids see the same caregivers each
time they visit. And the pediatric staff, says Cravero, “is generally very fun and friendly, so it’s
just a nicer environment in
many ways for parents and kids
having something done.”
Not only are the patients
happier, but productivity has
been increased. With more reliable and quicker medications
and full-time pediatric anesthesiologists, the program has made
it possible to do seven or eight
MRIs a day, whereas before the
average was four or five a day.
King says kids’ and parents’
reactions have been remarkable.
“We actually had one child who
was hanging onto the door jamb
trying not to leave, and that is
definitely something we did not
think we would see,” she says.
“It’s been really fantastic listening to family after family moved
to tears, saying, ‘We had horrible
experiences before and now my
child is not afraid of the doctors.’
We’ve had. . . young children
writing to say, ‘Thank you for
making this easy for me.’”
Plan: King assesses each child
ahead of time by contacting the
family. She then meets with the
rest of the PainFree team to develop a specific plan for that
child. “It’s a very cooperative
program,” she says. “Everybody
has an equal voice.”
The program, like its young
patients, continues to grow—
more than 1,200 were seen in
the program’s second year.
Matthew C. Wiencke
Dartmouth Medicine 9
vital
signs
C L I N I C A L
O B S E R V A T I O N
n this section, we highlight the human side of
clinical academic medicine, putting a few
questions to a physician at DMS-DHMC.
I
Kathryn Zug, M.D., DC ’84 and DMS ’88
Associate Professor of Medicine (Dermatology)
Zug, who joined the faculty in 1995, practices general dermatology and has an interest in allergic contact dermatitis and cutaneous lymphomas. She is
also director of the dermatology residency program.
What famous doctor, living or dead, would you most like to
spend a day shadowing?
Barbara Gilchrest, chair of Boston University’s
dermatology department. She’s a leader in dermatology and a brilliant scientist. Recently she
wowed our dermatology section with a presentation about her research on telomeres and their
potential role in cancer therapy.
medicine at Emory, who
hired me for my first job in
academic medicine. He also
suggested that I work with Dr. Frances
Storrs—an expert in contact dermatitis, a researcher, and a politically minded, devoted humanitarian—through the Women’s
Dermatologic Society Mentorship Program. She
has had a profound influence on my career.
What are the greatest joy and the greatest frustration in
your work?
The joy is the daily interaction with patients, a
sense that well-applied skills are helping people
with difficult problems, and the creative aspects
of directing the residency program. The frustration is paperwork, phone messages piling up, not
having time to spend with patients.
Of what professional accomplishment are you most proud?
What was the last book you read?
Bill Bryson’s A Walk in the Woods. I laughed out
loud and dreamt of hiking the Appalachian
Trail. Other recent reads were the Archer Mayor mystery books. But [my time for] pleasure
reading has been minimal.
What’s the last movie you saw in a theater?
Mary Poppins—maybe. Does that tell you something about my home life with three children
under the age of five? I’m definitely going to see
Seabiscuit at the theater!
What’s your favorite nonwork activity?
Spending time with my kids either playing at
home or outdoors. I also enjoy gardening, hiking, and running.
If you could travel anywhere you’ve never been, where
would it be?
Rome or Greece—to see the ancient sites of historical and artistic interest. I would also love to
visit the world’s great botanical gardens, like
Kew Gardens in Great Britain.
Being elected to the North American Contact
Dermatitis Group. [It] affirms that my work has
value and promise.
What do family and colleagues give you a hard time about?
Working too much; worrying too much; being
too cautious; and
loving Vermont,
Dartmouth, and
the Upper Valley.
What about you would
surprise most people
who know you?
I was a Spanish major at Dartmouth
and spent several
terms as a teaching
assistant. I still keep a picture of [Dartmouth language professor] John Rassias in my desk!
What music or radio programs do you listen to most?
National Public Radio. I love the variety of stories, the topical information.
Who was your medical mentor?
If you weren’t a physician, what would you like to be?
While I was a medical student, Dick Baughman
inspired me to do research on psoriasis. Another mentor was Tom Lawley, the current dean of
When I retire, I would like to raise awareness
and money for efforts that benefit the welfare of
children and their families.
10 Dartmouth Medicine
Prion expert sorts
through pieces of
the protein puzzle
Prions are almost as much of a
mystery now as they were 20
years ago when scientists began
studying them in earnest—
around the time that mad cow
disease surfaced in Great Britain.
In 2001, DMS assembled its own
team of prion researchers—led
by biochemist Surachai Supattapone, M.D., Ph.D., who had
worked for six years in the lab of
prion guru Stanley Prusiner,
M.D., winner of the 1997 Nobel
Prize. Supattapone’s team has
been taking a biochemical approach to unraveling the prion
mystery and reported some recent findings in the journal Biochemistry.
Prion proteins are thought to
be responsible for causing mad
cow disease and several other fatal brain diseases called transmissible spongiform encephalopathies (TSEs). TSEs leave the
brain riddled with Swiss-cheeselike holes. Such neurodegenerative diseases—there are inherited, sporadic forms and infectious
forms—are rare but frightening.
People and animals who are
stricken lose all control of their
bodies, descend into dementia,
and finally die.
Hypothesis: “Prusiner’s hypothesis is that the TSE infectious
agent was not a virus but rather
a protein,” Supattapone says. A
normal mammalian brain protein, called PrPC, misfolds into
the infectious form of the prion
protein, called PrPSc. The PrPScs accumulate to form plaques
Fall 2003
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Fall 2003
biochemical
approach to
studying how
PrPC converts into
PrPSc in a
test tube. “We
found that
chemicals
that block
disulfide formation [also]
block the forma t i o n o f
PrPSc,” he
explains.
“This is
the first discovery that
the formation
of PrPSc requires a reactive chemical
group.”
Surachai Supattapone, center, and his collaborators—Nathan
S&H: These
Deleault, left, and Koren Nishina, right—have been taking
a biochemical approach to the puzzle of prion diseases.
chemicals—
called sulfhydryl groups—are made of sulfur
Likewise, the chemicals used
and hydrogen (S and H) molein Supattapone’s experiments incules. In nature, their chemical
terfere with the formation of
bonds can break and reform, so
disulfide bonds. “It is a clue that
two S-H molecules could break
there may be a cofactor containapart and the two sulfur moleing the free sulfhydryl group,
cules would form a disulfide
such as an enzyme that helps to
bond, or S-S.
catalyze the process of forming
“My analogy for this is hair,”
PrPSc from PrPC,” he says. The
Supattapone explains. “Hair has
team has another paper coming
a lot of free sulfhydryl groups.”
out soon, in the journal Nature.
Therapeutic strategy: The work
Over a few weeks’ time, the S-H
may be a first step in finding a
groups break apart and reform as
therapeutic strategy against priS-S bonds, and “the hair beon diseases. “This is simpler than
comes very coarse. That’s the
a virus,” Supattapone says. Virusdisulfide bonds coming together.
es can evolve to be resistant to
Then you come in with your hair
treatment, but prions can’t. “So
conditioner, which contains a
if we could interfere, we could
chemical that reduces the disulactually stop it forever.”
fide bonds back to free S-H, so
Laura Stephenson Carter
your hair becomes soft again.”
WILL ELWELL
in the brain. “Normal PrPC
changes shape to become infectious, and this process is catalyzed by the PrPSc,” says Supattapone. Until Prusiner’s discovery, no one was aware of any infectious agent that did not contain genetic material.
Cows: Prion diseases have been
around for at least 300 years, first
as scrapie, which occurred in
sheep initially and is now known
to also occur in humans, deer,
elk, mink, rats, mice, hamsters,
possibly monkeys, and, of course,
cattle. In fact, the appearance of
bovine spongiform encephalopathy (the scientific name for mad
cow disease) in Great Britain in
the mid-1980s was thought to be
linked to cattle feed that included ground-up sheep bones, some
of which may have been from
scrapie-infected sheep.
Although mad cow disease
seemed to disappear once the
practice of adding sheep products to cattle feed was stopped, it
resurfaced recently and is now
spreading throughout Europe. A
few people in Great Britain have
died from its human form—
Creutzfeldt-Jakob disease—apparently as a result of eating infected beef.
Diseases don’t usually jump
from one species to another, but
scientists have found that spongiform encephalopathies can be
transmitted between species.
Mice injected with TSE-infected brain tissue from cows will
usually contract the fatal disease
within a year.
No one understands the exact mechanism for this, but Supattapone hopes to shed new
light on the process. He’s using a
Income-mortality
link is revealed by
study of CF registry
DMS researchers have nailed
down an interesting fact about
cystic fibrosis (CF): the CF death
rate is related to income. In a
study published in Pediatrics, the
researchers showed that CF patients in families with a lower
household income have an increased risk of death from the
disease.
Median: The study looked at
patients in the national CF registry who had been diagnosed
with the disease before the age of
18 and linked them by zip code
to median household income.
After adjusting for cost of living, age at diagnosis, and other
factors, they found that the lowest income category (below
$20,000 a year) had a 44% higher rate of death than the highest
income category (above $50,000
a year). They also determined
that there was a steady increase
in the risk of death as income
dropped. “It wasn’t that the mortality rates are low until you get
poor and that’s that,” explains
Gerald O’Connor, Ph.D., D.Sc.,
a professor of medicine and the
lead author of the study.
O’Connor and his team also
discovered that the CF patients’
lung function and body weight
started declining at about age six
across all income categories—
but that in the lower income categories, both lung function and
body weight were consistently
worse. In addition, the study revealed that treatment recommendations for CF patients did
Dartmouth Medicine 11
vital
signs
FLYING SQUIRREL GRAPHICS
Gerry O’Connor, pictured above making
a presentation about the death rate
from coronary bypass surgery, used similar methodology to more recently show
a link between family income and the
death rate from cystic fibrosis.
12 Dartmouth Medicine
Students’ deafness
presents a challenge,
but not a barrier
Nothing could stop them. Once
Robert Nutt and Wendy Osterling, both members of the DMS
Class of 2004, had their hearts
set on a career in medicine, not
even being deaf was going to get
in their way. Medical school is “a
new realm” for students with disabilities, Nutt concedes. The
question he asked himself prior
to entering DMS was, “Have I
fine-tuned my survival skills adequately?”
Both he and Osterling had already demonstrated remarkable
survival skills—qualities they
identify as creativity, innovation,
persistence, and patience. After
graduating from Dartmouth College in 1995, Osterling—who
grew up in Sudbury, Mass., and
has been deaf since birth—trav-
eled to Ecuador as a Peace Corps
volunteer and taught environmental education and forestry
for two years. While medicine
had been “an idea” since high
school, Osterling says, the choice
became clear during her Peace
Corps days.
Care: “I saw the need for preventive medicine while I was in
developing countries,” she says.
There was so little care available
in the region where she worked
that people often came to her to
ask for medicine and advice,
even though she was not affiliated with a clinic and had had no
medical training.
Upon her return to the U.S.,
Osterling lived in Boston, doing
research in microbiology at Harvard Medical School while taking courses at the Harvard Extension School to fulfill her
premed requirements.
Nutt, who was born with a
condition that causes progressive
JON GILBERT FOX
not vary by income category.
These findings prompted the
Northern New England Cystic
Fibrosis Consortium, of which
DHMC is a member, to do a
localized socioeconomic study.
This will involve collecting detailed data about socioeconomic
status, treatment adherence, education, and environmental
conditions from CF patients in
Maine, New Hampshire, and
Vermont. Social workers from all
the CF centers in the consortium
are also conducting detailed interviews with patients. “This pilot study will eventually result in
a national way of more directly
collecting socioeconomic status
[data],” says O’Connor.
By understanding more about
socioeconomic status and CF patients, researchers can then lay
the groundwork for better-in-
formed care and treatment. Cystic fibrosis is a progressive genetic condition in which the body is
unable to move salt and water in
and out of cells properly. This
creates a thick, sticky mucus in
various passageways of the body,
including the lungs and pancreas, causing difficulties in
breathing and digestion. The
mucus also serves as a breeding
ground for bacteria.
About 30,000 children and
young adults in the U.S. today
have cystic fibrosis, and about
1,000 new cases of CF are diagnosed every year. While 30 to 40
years ago, most children with the
disease died by the age of two, today many people with CF live
beyond 30, thanks in part to better nutrition and better medications, such as Pulmozyme, which
decreases the viscosity of the mucus in the lungs.
Time-consuming: Treating the
disease is time-consuming, however. Patients need medicines
with every meal and snack, antibiotics two or three times a day,
and regular vitamin supplements. They also need to have
their chests percussed—clapped
hard—for 15 to 20 minutes several times a day to drain the mucus from their lungs.
“So you can imagine people
who have less social support,
who have less resources of all
kinds, and it being very hard to
be attentive completely to that
kind of regimen,” says O’Connor. “That’s what we’re doing
with this [pilot] study—to try to
find out about socioeconomic
status, to try to find out about adherence.”
Matthew C. Wiencke
Wendy Osterling and Rob Nutt give a thumbs-up—in sign language—to Dartmouth’s creativity in accommodating their hearing impairment. Both students have
just started their fourth year of M.D. studies at Dartmouth Medical School.
Fall 2003
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I N V E S T I G A T O R
hearing loss, grew up on a farm in
Blue Bell, Pa., near Philadelphia.
Though the farm wasn’t the family’s main source of income—
Nutt’s father is an orthopaedic
surgeon—he says he and his
brothers “learned how to work,”
haying in the summers and doing farm chores year-round.
From the time he was in 10th
grade, Nutt knew he wanted to
be a doctor, a goal he was determined to pursue when he graduated from Dartmouth College in
1998.
Though equipped with determination, Nutt and Osterling
still had to find the right medical
school. In general, Osterling observes, “the medical world is not
set up for people with disabilities.” Since they knew from previous experience that Dartmouth was “willing to be openminded and accommodating,” as
Nutt puts it, DMS seemed the
natural choice.
Boon: In fact, Osterling says,
“DMS has surpassed my expectations.” For classroom work, the
school has provided sign-language interpreters and Computer-Assisted Real-Time Captioning (CART), which produces a
written transcript of a lecture as
it’s being delivered. The latter is
both a boon and a liability, Nutt
says, because it takes as long to
read through the lecture notes as
to sit through the class.
Now that more of their time
is spent in direct contact with
patients, they find communication less of a problem. “I have yet
to encounter a patient who reacts adversely to learning that
I’m deaf,” Nutt says. While they
use interpreters in clinical set-
Fall 2003
I N S I G H T
I
n this section, we highlight the human side of
biomedical investigation, putting a few questions to a researcher at DMS-DHMC.
breathe a helium-oxygen mixture during intense exercise.
Eugene Nattie, M.D., DC ’66 and DMS ’68
Professor of Physiology
Someone who tries to figure out how groups of
people work—a historian or sociologist. This
would apply the same personal traits that a scientist must have to different problems.
If you weren’t a scientist, what would you like to be?
Nattie, who joined the DMS faculty in 1975, has a
special interest in respiratory physiology and sudden
infant death syndrome.
What’s your favorite nonwork activity?
What are your primary research interests?
I’m interested in central chemoreceptors, which
detect levels of carbon dioxide and pH and
change breathing; they are widespread within
the brain stem. At one extreme, my interest is
purely basic science curiosity—why do we have
so many central chemoreceptors? At the other
it may be practical—in many cases of sudden infant death syndrome, there are abnormalities in
brainstem serotonergic neurons, which are also
chemoreceptors.
Of what professional accomplishment are you most proud?
Being able to teach and do physiology research
at Dartmouth Medical School. It is a great
school with wonderful students in a very nice
natural setting.
What made you decide to become a scientist?
Two teachers: Both Derek Phillips, a professor of
sociology at Dartmouth, and Marsh Tenney, a
professor of physiology at DMS, showed me how
much fun it was to
try to figure out
how things work.
When I was an undergraduate, Derek
Phillips guided me
on a project examining the geographic colocalization of patients
with mental illness
and psychosomatic
diseases in New Hampshire. And Marsh Tenney
let me work for a full year in the middle of medical school in his physiology lab, on a project in
which we “unloaded” the respiratory system by
having subjects—fellow medical students—
I have very much enjoyed, together with my
wife, watching our two daughters grow up. The
daily activities of a scientist include trying to
have total control of a situation, such as a controlled experiment. This does not always apply
to parenting, but it has not diminished our enjoyment of it.
What are the greatest joy and the greatest frustration in
your work?
There is joy in figuring out how things work
physiologically speaking, which entails understanding a problem through reading and discussion and then designing and completing an experiment in which results are clear, although often unanticipated. There is also joy in sharing
this process with students. I’m not sure about
frustration—there is disappointment at times.
And it is sometimes difficult to share my enthusiasm about experimental physiology with nonscientists.
What music or radio programs do you listen to most?
Light country, folk, opera, and National Public
Radio—especially Prairie Home Companion.
What book do you keep meaning to read?
Don Quixote—we all have our own windmills.
If you could have one question answered truthfully, what
would it be?
Is it possible to understand and control aggressive, destructive individual or group behaviors?
Serotonergic neurons—some large fraction of
which are chemosensitive and possibly involved
in sudden infant death syndrome—are also involved in non-premeditated aggression. Low
serotonin levels in humans and experimental
animals correlate with aggressive behavior.
Dartmouth Medicine 13
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T H E D AY T H E M U S I C E N D E D
klahoma may have taken Broadway by storm in the 1940s,
but the hit musical—or at least one of its songs—didn’t play
very well in New Hampshire during the 1950s, according to a
former orthopaedic surgeon at the Hitchcock Clinic.
The local daily paper, the Valley News, published a feature
recently about area surgeons’ musical choices in the OR. That
prompted Dr. Robert Shoemaker of
Claremont, N.H., to write the following
letter to the editor:
“The article regarding music in the
operating room was interesting, and it
reminded me of an occurrence during
the late ’50s. It was decided to have
music in the recovery room at Mary
Hitchcock Hospital in Hanover. Unfortunately, the music played was from Oklahoma. A patient whose
name was Jud awoke to hear ‘Poor Jud Is Dead.’ That put an
end for a while to music,” Shoemaker concluded.
A.S.
O
HAIL TO THE CHIEFS
or three of the past four years, a DMS graduate has held the
position of chief resident in Stanford University’s prestigious
Department of Medicine residency program. What is Dartmouth doing right? “We have enjoyed having Dartmouth students at Stanford because of their initiative, commitment, desire to make a difference, and desire to contribute to their colleagues and to patients and the science of medicine,” says Kelley Skeff, who directs the medicine
residency at Stanford and was a protégé of Harold Sox, M.D., former
chair of medicine at Dartmouth.
“These characteristics are what we
like all future physicians to have.”
This year’s chief resident, Pamela Kunz ’01, observes that “Stanford has a very similar feel to Dartmouth—
there’s a collegial environment and a strong work ethic at both.”
The DMS dynasty started with Christopher Sharp ’98, who was
followed by Ross Downey ’00. Kunz thinks an important characteristic that she, Sharp, and Downey share is a history of extracurricular and leadership responsibilities at DMS. “We’re
good at managing a lot of things,” she says.
Will the dynasty continue? Kunz thinks so. “We’ve got an intern here . . . and we’ll groom him to be chief, too.” M.M.C.
F
14 Dartmouth Medicine
tings, Nutt and Osterling communicate well one-on-one, even
without assistance. “Patients
have told me that I really listen,
since I look directly at their faces
in order to lip-read and understand, instead of looking at the
charts while they’re talking,” Osterling says. “Empathy is a twoway street,” Nutt adds. “As a
doctor, you’re giving something
to patients and attaining their
trust at the same time.”
Deaf: Osterling hopes to go
into pediatrics and would like to
work with disabled and underprivileged children. Nutt, who is
considering a surgical subspecialty such as urology or otolaryngology, has already performed a valuable service for disabled children locally. During his
second year at DMS, he received
a Schweitzer Community Service Fellowship, which enabled
him to found Upper Valley
DEAF (Deaf/Hard of Hearing
Education and Advocacy for
Families), a group for parents
and children that brings together the services and expertise of
many area organizations.
It’s still rare to find a deaf
medical student. The Association of American Medical Colleges does not keep such records,
but Osterling and Nutt say
they’re aware of only “a few” nationally. They see the medical
world becoming more diverse
and accepting of differences,
however. “With a little education, people are very understanding,” Osterling says. This is
especially true of staff at DHMC,
they agree. “They’ve learned really quickly,” Nutt says.
Catherine Tudish
Five new emeriti
have lots of plans
for their retirement
From building stone walls to
tending family farms, the new
emeritus members of DMS’s faculty are keeping busy in retirement from their long service to
the institution.
Allergists Frances and Harold
Friedman provided allergy care
for several decades to patients at
DHMC as well as at outreach
clinics throughout New Hampshire and Vermont. Both also enjoyed teaching medical students
and residents. Their daughter,
Elizabeth, a 1997 DMS graduate,
continues the family tradition as
an allergist in Rochester, N.Y.
Frances Friedman, M.D., an assistant professor of medicine, has
been on the faculty since 1970
and “followed three previous
generations in the field.” She recalls with pleasure a time when a
patient said her doctor had told
her that “he was sending her to
see Fran Friedman, who was ‘the
best.’”
She recently received a Laureate Award from the American
College of Physicians (ACP).
She’s been governor of the New
Hampshire ACP chapter and
president of the New England
Society of Allergy. “Now, in retirement, I am busy in my garden,” she says. “I built a stone
wall and a flagstone terrace.”
Harold Friedman, M.D., an associate professor of medicine,
joined the faculty in 1968 and
continues to chair the DMS Admissions Committee. He expects
to step down as chair in June
Fall 2003
vital
signs
Fall 2003
though her Ph.D. is in cell bioland treatments are determined
ogy, she’s spent the last 20 years
based on pathologists’ interprebuilding up DHMC’s continuing
tations”—and has found it “gratmedical education for doctors,
ifying to work with first-rate
nurses, and other health-care
pathologists.” He enjoys teachprofessionals. She was appointed
ing medical students and appreDHMC’s first community health
ciates having been able to teach
education coordinator in 1981,
as much as he wants. He is still a
and she became director of its
member of the DMS Admissions
Center for Continuing EducaCommittee, as he has been altion in the Health Sciences in
most continuously since he came
1995. She attributes much of the
to Dartmouth.
program’s success to institutionHe’ll be plenty busy with othal support for the importance of
er projects, too. He oversees a
continuing education. “In many
family property in southern New
institutions, continuing educaHampshire that includes a mantion relies solely on tuition, comaged forest, blueberry fields, and
munity support, and grants,” she
a cattle farm. He’s also on the
says. Here, DHMC and DMS
Hanover Planning Board and
subsidize the program.
the board of the Society for the
Her retirement plans include
Protection of New Hampshire
traveling in this country as well
Forests. And he still finds time to
as abroad with her husband,
sing in Dartmouth’s Handel SoDartmouth biology professor
ciety chorus, as well as to hike
Richard Holmes, Ph.D., an avian
and bike.
ecologist.
Several additional new emerCharles Faulkner, M.D., an assoiti will be profiled in Dartciate professor of pathology, has
mouth Medicine’s Winter issue.
been on the faculty since 1969
Laura Stephenson Carter
and was director of autopsy
services for
many years.
He plans to
keep working
part-time, doing clinical
pathology and
some teaching, at least
until June of
2004. He has
loved surgical
pathology—
“an exciting
s p e c i a l t y,
where diseases
These recent retirees are, from the front, Hal and Fran Friedman, Deb Holmes, Bill Mosenthal, and Charles Faulkner.
are diagnosed
Counterterrorism
training for
first-responders
FLYING SQUIRREL GRAPHICS
2004 but hopes to stay on as a
member of the committee. He,
too, has served as governor of the
state ACP chapter and earned
an ACP Laureate Award. In addition, he was recently made a
Master of the ACP.
William Mosenthal, M.D., a professor of anatomy and of surgery,
retired from surgery in 1981 but
wasn’t ready to stop working—
so he spent the next 22 years
teaching anatomy. Now he’s retiring again, but the 1938 Dartmouth College graduate expects
to keep plenty busy—with family activities, gardening, and
woodworking projects.
Since joining the faculty in
1948, Mosenthal has accomplished plenty, too. He reorganized surgical nursing and created a school for postgraduate
training of OR nurses. In 1955,
he established the first intensive
care unit in the U.S.—at Hitchcock. He also “integrated basic
surgical anatomic and physiologic knowledge into the clinical
thinking of fourth-year students,” he says. And he’s taught
students to “consider moral and
ethical principles essential to
proper surgical practice.”
He is a three-time recipient
of the fourth-year Basic Science
Teaching Award. In addition,
students created in his honor the
Dartmouth-Mosenthal Surgical
Society (in 1995) and the annual Mosenthal golf tournament
(in 1985), the latter to raise
funds for David’s House, a residence for parents whose children
are patients at DHMC.
Deborah Holmes, Ph.D., an assistant professor of medicine,
joined the faculty in 1967. Al-
DMS’s master of interactive media, Professor of Community and
Family Medicine Joseph Henderson, M.D., is at it again. This
time he is training his arsenal of
video simulation expertise at terrorism.
Incidents: With support from
the U.S. Department of Homeland Security, Henderson’s group
is working on the first offering in
an eventual series of educational CD-ROMs for first-responders
to terrorist incidents—police,
firefighters, and emergency medical services (EMS) personnel.
The program is being designed to deliver core knowledge
applicable to all three fields—
about such topics as hazardous
materials (known as “hazmats”),
including nuclear, radiological,
chemical, biological, explosive,
or incendiary devices—as well as
specialized training particular to
each field.
For a recently released CD on
clinical genetics, Henderson’s
group created a virtual “clinic”
in which the trainee can interview a “patient,” confer with a
“colleague,” or attend a “lecture.” This new project is being
cast as a “Virtual Terrorism Response Academy.” The Academy’s faculty consists of top experts—who are represented by
video clips—from the law enforcement, firefighting, EMS,
and hazmat fields.
Encounter: If you log onto the
program as a police officer, for
example, you encounter a law
Dartmouth Medicine 15
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F
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his section includes brief accounts of selected Dartmouth research projects on
biomedical and medical policy issues.
T
Supplementary information
Smokers and drinkers who take betacarotene supplements in the hope of
staving off cancer may actually be raising
their risk, according to a recent study in the
Journal of the National Cancer Institute.
DMS epidemiologist John Baron found
that in those who smoked or had more
than one alcoholic drink a day, betacarotene doubled their risk of recurring
adenomas—benign tumors that can lead to
colorectal cancer. In nonsmokers or nondrinkers, beta-carotene was associated with
a 44% decrease in risk compared to subjects
in a control group receiving a placebo.
The little pill that could
Aspirin is proving to be an ever more powerful medication. The latest on the humble
white pill is that it may help reduce infection. A study by DMS microbiologist Ambrose Cheung, M.D., showed
that salicylic acid—produced when
the body breaks down aspirin—disrupts the ability of Staphylococcus
aureus bacteria to adhere to host tissue. Staph infections are the leading cause of death in noncoronary
ICUs. Aspirin does not cure infections, notes Cheung, but reduces
the ability of bacteria to cause them.
The work was published in the July 15 issue of the Journal of Clinical Investigation.
Battling fatal bulges
“Aneurysms—bulges in weakened artery
walls that are almost always fatal when ruptured—may be the most preventable common killer that doctors rarely warn about.”
So reported the Wall Street Journal this past
June. Researchers at Dartmouth were already on the case, however. DMS surgeon
Mark Fillinger, M.D., and colleagues at
Dartmouth’s Thayer School of Engineering, published a study in the Journal of Vas-
16 Dartmouth Medicine
R
E
C
E
N
T
R
E
cular Surgery on a noninvasive method of
assessing the risk of an aneurysm’s rupture—by measuring stress on the vessel’s
wall using computerized analysis of CT
scans. The new technique predicts rupture
risk better than aneurysm diameter, the
method used for more than 40 years.
A matter of some substance
Anne Brisson, Ph.D., an adjunct assistant
professor of community and family medicine, will work during 2003-04 as a Fulbright Scholar on substance abuse issues in
Kosova. She will help the Kosovar Ministry
of Health develop a substance abuse strategic plan and will lecture on public policy at
the University of Prishtina. “There is virtually no prevention or treatment system”
there, she says. Before the 1999 Balkans
war, substance abusers in Kosova traveled
to Belgrade for treatment, “but now this is
not an option,” Brisson notes. Furthermore, Kosova “is on one of the main trafficking routes of heroin . . . with the result
of cheap and pure heroin available.” She
expects the plan to emphasize developing
treatment services and creating prevention
materials for parents and drug-users.
These flies lay golden eggs
Dartmouth researchers have determined
that the fruit fly Drosophila can be used to
study why more cell-division mistakes occur as eggs become older. Biologist Sharon
Bickel, Ph.D., reported in Current Biology
that fruit flies are an excellent model organism to study how age affects meiosis, the
specialized cell division involved in reproduction. In humans, meiotic errors can
cause Down syndrome, the incidence of
which increases with the mother’s age.
“Age-related meiotic defects are hard to
study in humans, because it’s difficult to examine how this process deteriorates in females over a span of 20 years,” explains
Bickel. “Because flies are easy to grow in
the lab, it’s possible to look at thousands of
flies and determine how frequently mistakes during meiosis are occurring.” Her
S
E
A
R
C
H
team included M.D.-Ph.D.
student Peter Burrage.
Gaze can faze, cause malaise
The direction of someone’s
gaze appears to affect how your brain interprets that person’s emotions. A group of
researchers in the Dartmouth psychology
and brain science department found that
whether or not someone is looking at you
influences how your brain—specifically,
your amygdala, which regulates emotions
and detects threats—responds to fear or
anger. Published in Science, the study
showed that people exhibit more amygdala
activity when an angry person in a picture
is looking away. But when people view expressions of fear, their amygdala is more active when there is eye contact. According
to the paper, this study was the first one to
show that gaze direction figures in the perception of facial expressions.
Not just for wrinkles any more
Dartmouth neurologists Thomas Ward,
M.D., and Morris Levin, M.D., are exploring a new use for a potent neurotoxin best
known as a treatment for wrinkles. Botulinum toxin, which prevents the release of
several key neurotransmitters, “may have
analgesic properties beyond merely muscle
relaxation and paralysis,” explains Ward. It
thus holds potential for treating headaches,
spasticity, and the abnormal muscle movements of Parkinson’s and other diseases. Ward and Levin
were involved in
some of the original studies using
botulinum toxin
for headache, and
they just received a
two-year grant to teach
physicians about the treatment of headache, including with
botulinum toxin. The grant came through
Thomas Jefferson University from the
pharmaceutical company Allergan and was
one of just six awarded nationwide.
Fall 2003
vital
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Fall 2003
coming from the building. A
peek through the windows reveals many bags of fertilizer. Another room looks something like
a laboratory. A portable radio on
the lab bench is tuned to a
weather station and plays eerily
on and on. Not a living soul
seems to be around.
It’s time to enter the building,
but first your team checks the
door carefully for booby traps.
Once inside, you find that the radiation intensity is much higher.
Let’s turn off that pesky radio,
you think. Suddenly, the computer screen goes white. That
was a big mistake—the radio was
booby-trapped. This is not going
to help your final score on the
simulation!
Dirty bomb: But you still have
to figure out what all the evidence means. It looks as if many
of the ingredients for a dirty
bomb are present, but where
could it be planted? As you agonize over the possibilities, the
simulation moves on to an even
more complicated scenario.
But it’s all just an elaborate
video game, isn’t it? Well, yes
and no. Certainly the technology is similar to that used in video
games, but the purpose of this
exercise is quite different.
Video games are playthings,
intended for amusement and
fantasy. The CD-ROMs that are
produced by Dartmouth’s Interactive Media Lab are deadly serious tools, intended for education and training. They contain
factual information from the best
minds in the field—and may
someday save lives in a dangerous world.
Roger P. Smith, Ph.D.
Study shows that in
pediatric residencies,
size doesn’t matter
complexity—to see if there was
any relationship between inpatient illness severity and program
size. They found there was no relationship at all.
“There’s basically no difference between small, medium,
and large programs if you look at
the severity of medical admissions,” says Thompson. Diagnostic severity for surgery patients
was higher at larger programs,
but this finding was not unexpected. Larger programs traditionally offer cardiac surgery, organ transplants, and other complex surgeries that are not available at smaller programs. But
“high-level pediatric surgery is
much less relevant [than medical
pediatrics] in terms of the training of pediatricians,” explains
Goodman.
Team: Jennings and her team
also looked at the diversity of illnesses across programs and found
that larger programs actually had
slightly less diversity than smaller programs. The published article shows the top five medical di-
At small pediatric residency programs, the diversity of inpatient
educational opportunities is just
as good as at larger, more urban
programs, according to a DMS
study published in the July 2003
issue of the Archives of Pediatrics
and Adolescent Medicine. The
lead author on the study was an
undergraduate—Rebecca Jennings, DC ’03. She examined illness severity and diagnostic diversity for inpatients at small,
medium, and large pediatric residency programs.
“There’s a general perception
that larger pediatric programs are
better just because they’re larger,
and urban centers offer more diverse patients and more severely
ill patients than smaller programs,” she says.
Lindsay Thompson, M.D.,
who just finished a postdoctoral
fellowship at DMS, and David
Goodman, M.D., an associate professor of pediatrics, were coauthors and
guided Jennings through
the research and publication process.
The study drew on a
national sample of university-affiliated pediatric residencies. Jennings divided
the programs into three
sizes: small, medium, and
large, based on number of
residents. The researchers
then used Diagnosis-Related Group weights—a
Dartmouth undergraduate Rebecca Jennings,
standard means of measurright, was the lead author on a recent study.
Pediatrician David Goodman, left, advised her.
ing illness severity and
JOSEPH MEHLING
enforcement faculty member
who takes you in tow. This mentor explains the resources available to you, such as lectures, descriptions of the experiences of
other first-responders, and links
to Web resources.
Exposure: The mentor then introduces you to the HazMat
Learning Lab. One of the exercises there involves the effects of
time, distance from the source,
and shielding on your radiological exposure. As you approach
the source of radiation, the intensity of your exposure—indicated on a virtual Geiger counter
—increases.
You can interpose different
kinds of shielding between yourself and the source to learn what
the most efficient protection is
in different circumstances. The
effect of the duration of your exposure is also shown on simulated instrumentation. After a series of exercises of that type, you
are then invited to take an examination. A trainee who passes
is allowed to enter the secure
“Simulation Area.”
Complicated and spooky: There,
things quickly become more
complicated and even a little
spooky. You hear a 911 call reporting a possible threat of terrorist activity, and you listen as
the dispatcher mobilizes the appropriate personnel. You must
then plan the best route to the
site—a building located in an
old industrial park.
As your team approaches the
building, a crow caws in the
background (in some societies
crows are an omen of danger or
evil). A Geiger counter shows
that there is significant radiation
Dartmouth Medicine 17
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A VERY PLUGGED-IN PLACE
HMC has once again been deemed a paradise for technophiles—it was ranked as one of the nation’s “100 Most
Wired” hospitals for the fourth year in a row by Hospitals &
Health Networks magazine. The publication’s July 2003 issue
also recognized DHMC in its “25 Most Wireless” category.
The magazine surveys the nation’s hospitals annually on
their use of information technology to handle processes ranging from safety to workforce management. This year
more than 400 organizations, representing
1,128 hospitals, completed the survey.
Dartmouth’s cyber-savviness also brought
some notoriety as well as note. The Centers for
Disease Control released a report in June suggesting that a campus pink-eye epidemic last winter could have been spread via computer keyboards.
Dartmouth students are so attuned to checking their
e-mail that they log on regularly in public clusters situated all over campus. Noted the New York Times of the outbreak: “A possible culprit may have been the public terminals,
touched by hundreds of unwashed fingers each day. ‘It brought
up the whole question of whether computer keyboards could
be a vector for disease,’ said Dr. John Turco, the director of Dartmouth’s health services. He said the school was considering
putting antibacterial hand gel next to each terminal.”
A.S.
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CANCER CARE RANKS HIGH
nly four New England institutions—including DHMC’s
Norris Cotton Cancer Center—made the top-50 ranking in
the cancer category in this year’s U.S. News & World Report
“Best Hospitals” issue. Norris Cotton was ranked 30th this year,
a jump of 10 places over its 2002 rank, and had the same overall score as Yale-New Haven Hospital. The other
two New England hospitals on this year’s top-50 list
were Boston’s Dana-Farber Cancer Institute and
Massachusetts General Hospital. The rankings are
based on such factors as volume, mortality, national reputation, and nurse-patient ratios.
Norris Cotton is also one of only 39 institutions nationwide designated by the National Cancer Institute as a comprehensive cancer center.
Since the appointment in 2001 of Mark Israel, M.D., as
its director, the center has undertaken a doubling in the size of
its facility and has recruited 20 new faculty members.
A.S.
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18 Dartmouth Medicine
agnoses for each type of residency program. Large programs had
the highest percentage of discharges for their five most common diagnoses (29.9%); small
programs had a lower percentage
(24.9%) for their five top conditions, indicating more diversity
of illness at those programs.
Overall, a residency program’s
size was not a strong indicator of
illness diversity. Patients with severe and diverse illnesses were
present in both large and small
residency programs.
Useful: The study could prove
useful to smaller residencies, like
DHMC’s. “If you are thinking of
specializing in pediatrics, you
still can get a great education at
a small program. . . . [It’s] not
necessarily inferior to a large program,” says Jennings.
Before getting involved in
the study, Jennings, a biology
major who is interested in becoming a doctor, was shadowing
Goodman once a week. He suggested the study to her and she
took it on as a part-time job.
“Rebecca absolutely earned her
first authorship,” he says. “It was
a mentored research environment, and she definitely took the
torch and ran with it.”
For Jennings, learning about
the publication process while
still an undergraduate “was really rewarding.” She was even selected to present her work at the
Pediatric Academic Societies
annual meeting in May 2003.
“This is the single largest national pediatric research meeting
each year,” says Goodman. “Getting selected for an oral presentation is very competitive.”
Matthew C. Wiencke
Construction project
is taking account
of the environment
“With construction costs of more
than $200 million, Project for
Progress is a pretty darn unusual
project,” says Rick Nothnagel,
vice president of facilities at
Dartmouth-Hitchcock.
He’s right on several counts
about the major addition and
renovation project now well under way at DHMC. There are
only a handful of hospital expansions of this size today—and
even fewer so thoroughly taking
the environment into account.
Such a project has the potential
to disrupt wildlife habitats and
ecosystems. But DHMC is taking
steps, inside and outside the facility, to minimize its impact.
While building a new employee parking lot, for example,
DHMC went above and beyond
state regulations to preserve wetlands, which are valuable because they filter water, reduce
flood risks, and provide fish and
wildlife habitats. The 956-car lot
was designed to incorporate both
existing and replacement wetlands. In between rows of parked
cars, irregularly shaped buffer islands of native plants, grasses,
and trees make use of natural water on the property.
Species: And while some plants
were added to the new lot, some
were taken away. Invasive
species, such as purple loosestrife, can grow rapidly, colonizing disturbed areas such as construction sites. DHMC worked
with city officials in Lebanon,
N.H., to identify three invasive
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Stories from student’s Chinese heritage are incorporated into award-winning poetry
‘I
try to make it really absurd, like a story that . . . has no ending,”
says second-year medical student Sai Li of his approach to writing poetry. One of his poems—reproduced here—recently won second prize in the national William Carlos Williams Poetry Competition. Open to all U.S. medical students, the competition is run
by the Northeastern Ohio Universities College of Medicine.
Li’s prize-winning poem is based loosely on his family’s experiences in China during the 1950s and ’60s. After his father and
grandfather were branded as capitalists for selling clothes, his father was sent to work in the granaries as an accountant—with an
“old abacus” like the one mentioned in the poem. The poem’s reference to killing sparrows actually happened as well—during the
Great Leap Forward of 1958 to 1961 under Mao Tse-tung—and led
to a huge locust infestation.
Also editor-in-chief of the new DMS literary journal, Lifelines
(see the Summer issue of Dartmouth Medicine for details), Li
DMS student Sai Li is pictured here a couple of years ago in Beijing.
species—loosestrife, glossy buckthorn, and barberry—and remove them in an environmentally sound way. Barberry, for example, was chipped and then
burned to produce energy.
Behind the facility’s cinderblock walls lie more conservation features. All building operations are completely automated
Fall 2003
via computer. “We know we’re
running everything at the optimal level,” says Nothnagel.
DHMC has five different-sized
chiller-compressors that run the
refrigeration and central air-conditioning equipment, each with
a different level of efficiency.
“Some operate better at a lower
capacity, while others work bet-
plans to keep writing poetry through and after medical school. His
dream is to be based in the U.S. and spend summers in China—
practicing in villages outside Beijing, while writing down his patients’ life stories and incorporating them into poetry.
M.C.W.
Red East
By Sai Li
This is my father performing tai-chi, hair hit
By silver circles through canopies of moon-lit
Pine trees, swift and sharp, like impromptu ant
Migrations. The hands move with wind, slant
In East and West, mystical planes intersecting.
He was a painter, brave strokes attracting
Black chicks with seven well-placed dots
Of his sable brush, as imperfect circle blots
Onto soft paper, taking shape, and becoming
Alive. Until the Red Guards broke in drumming.
A counter-revolutionary, they sent him to Dalian
With an old abacus, to count the kilos of oat bran.
At dawn, they made him slap his hands in the air,
Shake the trees to rouse the sparrows, scare
The vermin eating all the rice in the granaries.
He watched intently as they flew from trees to trees,
Awakened from sleep by rattles of willow branches.
He laughed as their tired bodies fell, appendages
Flapping in momentary unison before the crash
In impossible angles, amazed at how clean the flesh
On the backs of their wings were. Soon, locusts invaded
The fields and devoured the green in sight, this negated
The need for granaries. So they told him to read the Red
Book. Wave the Red Book. But he didn’t drop dead
Like the hungry teacher who gorged on too many dried
Yams and bowls of wintermelon soup. But he cried.
ter at full capacity. We’re constantly analyzing the load and
running a combination of equipment that gives us the most energy-efficient operation.”
Other features include highefficiency motors in the power
plant and a new mall that is illuminated with skylights. There is
also natural lighting on the top
floor of the addition to the Rubin
Building; there, Cancer Center
administrative offices along the
building’s perimeter on Level 8
don’t have a solid wall facing the
interior hallway; instead, an 18inch glass strip at the top allows
natural light to filter into the
center of the building.
“From the very beginning,
Dartmouth Medicine 19
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DHMC was designed to be energy efficient. We were able to ‘go
green’ with a new facility,” says
Nothnagel. In fact, the original
DHMC building, which opened
in 1991, won two awards for its
best practices: the 1994 National Energy Award for Utility
Technology from the U.S. Department of Energy and the 1994
Governor’s Energy Award. “Project for Progress has continued
these same design principles,”
Nothnagel concludes.
Laura Jean Whitcomb
BOTH: MARK AUSTIN-WASHBURN
Both inside (above) and outside (below),
DHMC’s “Project for Progress” expansion takes account of the environment.
20 Dartmouth Medicine
Like its peers,
DHMC is facing
fiscal challenges
Language instruction by Dartmouth’s Rassias Method is very intense.
A little Spanish with that stethoscope?
cott Early, M.D., a 1986 graduate of DMS, learned Spanish
on the job at the Greater Lawrence Family Health Center
(GLFHC) in Massachusetts. But as the residency director at
this busy community clinic, he didn’t want his residents to have
to follow that path. Learning Spanish was essential, though, as
almost 90% of GLFHC’s 35,000 patients are Latino.
In 1993, Early invited a local high school Spanish teacher
to provide his residents with 30 hours of instruction. But the residents wanted more. Recalling the intensive Rassias Method of
teaching languages from his days as an undergraduate at Dartmouth, Early contacted the Rassias Foundation. He found that
its 10-day Accelerated Language Program coincided perfectly
with his residents’ orientation period.
The Rassias Method’s immersion technique—developed to
train Peace Corps volunteers in the early 1960s and adapted to
college-level instruction in 1967—was perfect for busy residents. Now, a dozen GLFHC residents and faculty spend 10
days at Dartmouth every year in a basic Spanish course; it’s a required part of the Lawrence family practice residency.
“Fluency is not the goal,” explains Early. “Sometimes interpreters are still needed, but residents develop a great understanding of the language, and most of the visit is done in Spanish. It’s been a big component of their job satisfaction. When
you can’t speak directly to patients, something is lost. . . . And
patients really appreciate the effort.”
Hispanics are the largest ethnic minority in the U.S., so for
many physicians Spanish is as important a tool as a stethoscope.
Sally Pruszenski, business manager for the Rassias Foundation,
says DMS faculty and students often attend Spanish courses offered for the community. And the Rassias Foundation is in the
process of expanding its medical Spanish program. “Many individuals are recognizing the importance of learning Spanish,”
says Pruszenski. “We are happy to go on the road and teach
medical Spanish wherever it is needed.” Bueno!
L.J.W.
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“Most of the country’s academic
medical centers are feeling the
effects of . . . this ‘perfect storm’
of financial pressures,” Daniel
Jantzen, DHMC’s vice president
for finance, told the New Hampshire legislature a few months
ago. “These are very challenging
times for all providers, but particularly for DHMC.”
Costs: Cuts in Medicare and
Medicaid reimbursements, rising
drug prices, escalating salary
costs, and labor shortages in key
areas such as nursing, pharmacy,
and radiology, are all contributing to very challenging times for
teaching hospitals.
For the first time in its history, DHMC has had five consecutive months of losses because of
lower-than-expected revenues
and higher-than-expected expenses in some areas. In the most
recent quarter, however, the
Medical Center has made some
gains and hopes to end the fiscal
year in the black.
DHMC has been hurt by its
inability to open beds and treatment areas to meet patient demand. In many cases, this is due
to being unable to hire nurses to
staff those beds. DHMC has also
been affected by some key physician vacancies.
To address the situation,
DHMC is opening additional
clinical capacity where it is able
to, in specialties where demand
is high. In addition, there is a
Center-wide effort to reduce expenses—by limiting hiring in all
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FLYING SQUIRREL GRAPHICS
areas except those that have a direct bearing on patient care or
patient safety and by trimming
nonwage expenses. And for the
first time in DHMC history, employees worked as a group to persuade state legislators—via hundreds of letters, phone calls, and
e-mails—to restore Medicaid
funding after a 31% cut in state
reimbursements was proposed.
DHMC will continue to be financially challenged in 2004,
because regional and national
pressures are not expected to improve soon. When the new space
currently under construction
opens, the Medical Center will
be able to increase patient volumes (see pages 3 and 18 for the
latest on the expansion project).
The capital costs of the new facilities are being funded from
sources other than the operating
budget, though their opening
will also bring additional upkeep
costs in the short run.
Solid: “These are sobering
times for all of us in academic
medicine,” says executive vice
president Paul Gardent. “Nevertheless, I am optimistic because
DHMC, as an academic medical
center, plays a unique and important role in improving health
care in the region. We are fortunate to have some very solid cornerstones on which to build our
economic recovery. These include our commitment to our
mission and to our patients,
which is foremost in the minds
of everyone who works in this
Medical Center. Most important, we have extraordinarily talented and committed staff who
work together as a team.”
Laura Stephenson Carter
Bill Emerson has been playing the Steinway at DHMC for 10 years.
Music has a grand effect at DHMC
atients who walk into DHMC for appointments may be met
by the strains of Debussy’s “Claire de Lune,” Johnny Mercer’s “Autumn Leaves,” or Rodgers and Hammerstein’s “Edelweiss.” That’s just a sampling of the music played each day on
the mahogany Steinway grand that sits in DHMC’s main rotunda. Nine volunteers play the piano on a regular basis.
William Emerson (pictured above) has been one of those volunteers for 10 years. “It is a lovely instrument,” he says. “You get
a following playing for so long.”
The piano was given to DHMC by James Walker and his
family in memory of Walker’s wife, Christine, who died of breast
cancer in 1992, and in appreciation of the DHMC oncology
staff who cared for her. During Christine Walker’s illness, her
nephew, a pianist and the owner of a record company, played
for her in the DHMC oncology unit on an old upright wheeled
in for the occasion. “It was unbelievable to see patients who
hadn’t been out of their beds . . . walking down the hall with
their IV poles to listen to the music,” recalls Jim Walker.
After his wife’s death, he and his family had Steinway custom build a piano for DHMC. It was dedicated at a 1993 concert that featured excerpts from Schubert’s German Mass and
the music of Andrew Lloyd Webber, performed by the St. Mary’s
Choir of Long Island, where the Walkers lived. The piano was
rededicated in a 10th-anniversary concert this past June during
the activities of National Cancer Survivors Day.
Jim Walker says that the effect of the gift has far exceeded
his family’s expectations. In addition to the regular volunteer pianists, patients often come down to the rotunda to play. “I get
two or three letters a year from people who have played,” Walker says. A book is also kept at the rotunda information desk, in
which players can record their impressions and feelings. Wrote
one: “Playing at DHMC is healing, not only for those who listen and stop by, but for the pianist!”
M.C.W.
P
Worthy of Note:
Honors, awards,
appointments, etc.
John Wennberg, M.D., director of the
Center for the Evaluative Clinical Sciences,
was named
once again to
Modern Healthcare magazine’s
annual list of
the “100 Most
Powerful” individuals in the health-care field.
He was ranked 85th on the list.
Thomas Ward, M.D., an associate
professor of medicine, is the president of the National Board for
Certification in Headache Management.
Kenneth Burchard, M.D., a professor of surgery and of anesthesiology, was a recent recipient
of the Association for Surgical Education’s
Outstanding
Te a c h i n g
Award, which
is bestowed “for national recognition of outstanding abilities as
a teacher of surgery.”
Jocelyn Chertoff, M.D., an associate professor of radiology and of
obstetrics and gynecology, was
selected as a
2003-04 fellow
by the Hedwig
van Ameringen Executive
Leadership in
Academic
Medicine Program for Women. The program
prepares women on the faculty of
Dartmouth Medicine 21
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academic health centers for senior leadership positions.
James DiRenzo, Ph.D., an assistant professor of pharmacology
and toxicology, was named a VScholar by the V Foundation for
Cancer Research.
Henry Higgs, Ph.D., an assistant
professor of biochemistry, was
named a 2003 Pew Scholar in
the Biomedical Sciences.
Michael Whitfield, Ph.D., an assistant professor of genetics, received the
12th Annual
MBC Paper
o f t h e Ye a r
Aw a r d f r o m
the American
Society for
Cell Biology.
His paper was titled “Identification of Genes Periodically Expressed in the Human Cell Cycle
and their Expression in Tumors.”
Adam Keller, M.P.H., former associate dean and chief operating
officer of DMS, was appointed
executive vice
president for finance and administration of
Dartmouth
College. He
continues to
hold an appointment as an instructor in
community and family medicine.
Steven Atkins, Psy.D., a clinical
associate and instructor in psychiatry, was named a board
member of the New Hampshire
Psychological Association. He
also received the Independent
Publishers’ Best Parenting Book
of 2003 Award for his book Talking to Your Kids About Sex.
Lee Dunn, J.D., an adjunct asso-
22 Dartmouth Medicine
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mong the people and programs coming in
for prominent media coverage in recent
months were a pair of studies about the effect of smoking in movies on teens’ propensity to
take up the habit. First, the publication of the two
papers attracted wide media attention. For example, the Washington Post reported: “Madeline Dalton of Dartmouth
Medical School, lead author of
[one] study, said she was surprised by the strength of the
connection between movies and
teen smoking.” Then, a couple
of months later, 24 state attorneys general cited the work in a joint letter to the
president of the Motion Picture Association of
America, asking for a reduction in onscreen smoking; that inspired another flurry of press coverage.
A story about the action in the
Los Angeles Times noted that
“James Sargent, a pediatrician who
was the lead author of the [other] Dartmouth study, said if studios are willing to recut movies’
endings because focus groups
don’t like them, they should be
willing to cut smoking to protect children.” See
page 3 for details on the two studies.
A
BBC News crossed the Atlantic to research a story about growing evidence that “bedwetting could
be linked to breathing problems.
. . . Dr. Dudley Weider of Dartmouth-Hitchcock Medical
Center in New Hampshire has
followed over 300 children with
bedwetting problems who had
surgery for airway obstruction.
He said a quarter stopped wetting their beds virtually straight away. Another
50% stopped within six months.”
The Dartmouth Atlas of Health Care continues to
make waves in the world of health policy.
Newsweek noted that “if you live in Boise, Idaho,
for example, you’re five times more likely than
people in Terre Haute, Ind., to have back surgery,
according to Dartmouth Medical School’s Atlas
of Health Care.” And BusinessWeek said that “not
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surprisingly, money often comes into the equation. ‘The system does not reward doctors for talking. It rewards them for doing,’ says Megan Cooper,
editor of the Dartmouth Atlas project.” And Reader’s Digest said one outcome of Oregon’s law allowing physician-assisted suicide “has been expanded hospice care. Statistics from the 1999
Dartmouth Atlas of Health Care showed that while
most Americans still die in hospitals, in Oregon
over half die at home or in a hospice.”
The Spokane Spokesman-Review quoted an East
Coast expert in a story on heartburn. “What can
you do about heartburn if you
don’t want to take a pill?
‘Lifestyle modifications can be
an effective first step in the
management of heartburn,’ says
Dr. Douglas Robertson, an assistant
professor of medicine at Dartmouth Medical School.” He
suggested “avoiding foods that promote acid reflux, like caffeine and alcohol . . . eating smaller
meals and avoiding late-night snacks [and] . . .
smoking cessation and weight loss.”
A recent clinical study—of whether finasteride, a
drug used to slow baldness, might also prevent
prostate cancer—was halted
early because the results appeared so positive. But there was
a confounding twist. As CNN
put it: “While the men who
took finasteride were diagnosed
with fewer cases of the disease,
they had more high-grade prostate cancers, which typically are more aggressive
than other forms. . . . Dr. John Wasson, director of the
Center for Aging at Dartmouth Medical School
and a member of the study’s safety monitoring
committee, said the tumor findings raised a number of questions: ‘What really is finasteride doing
here? Is it a promoter of mean types of cancer, or
a suppressor of meaningless types?’”
The Miami Herald looked north for commentary
on the crisis brewing in Florida regarding the price
of health insurance, citing a 10-year study of disparities in health-care costs. “Elliott Fisher, the Dart-
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mouth physician, says doctors aren’t consciously running up big tabs. ‘Most physicians are trying to do a good job. They’re
under the assumption that doing more tests,
having more office visits, makes for better
care.’ About 80% of seniors prefer to die at
home, says Fisher, ‘but their wishes don’t
make any difference.’ The only factor in
Dartmouth’s 10-year study that predicts
whether a person will die in a hospital is the
number of beds in the area.”
“Cord-Blood Controversy: Some parents are
paying more than $1,300 to bank their babies’ umbilical-cord blood in case a transplant is needed later in life,” noted a recent
article in Newsweek. “There are also public
banks that collect cord blood in the United
States free of charge. The blood isn’t saved
for the donor’s family, but
instead made available to
patients lucky enough to
find a genetic match. ‘In
ideal scenarios, we should
use cord blood for public
banks, where it can actively save lives,’ says Dr.
Zbigniew Szczepiorkowski, who chaired the Cellular Therapy Standards Committee for the
American Association of Blood Banks.” He
is a DMS assistant professor of pathology.
The debate over how widespread the U.S.
smallpox-vaccination program should be
continues to occupy the attention of immunization experts. That means the press continues to turn to the Dartmouth faculty
member who chairs the federal Immunization Advisory Committee. “Offering [the
vaccine] to medically trained people within
a medical setting seemed a manageable risk
to many on the advisory committee,” wrote
USA Today, “but widening the program dramatically did not. ‘The committee has believed from the beginning that we need to
put safety above and beyond all other concerns,’ said committee chair John Modlin, a professor at Dartmouth Medical School. A
pause in the smallpox program, he said, ‘will
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allow us to buy some time and better understand both sides of the equation—the safety and the threat.’”
From BBC to the Pittsburgh Post-Gazette, the
media picked up word of another beneficial
effect from aspirin. Said
the latter outlet, “Salicylic
acid, the major byproduct
of aspirin, disrupts two key
genes of staph bacteria.
. . . ‘It may be that an aspirin a day is better for you
than we thought,’ said
Ambrose Cheung, a microbiologist at Dartmouth.” See page 16 for more on the study.
An Associated Press report on summertime
hazards said that “some of the most serious
injuries come from the bane of many kids’
lazy summer days—mowing the lawn. Often, kids will get seriously injured when
their feet slip beneath the blades of a lawn
mower as they mow hills, said Dr. William Boyle,
a member of the poison and injury prevention section of the American Academy of
Pediatrics.” Boyle is a professor of pediatrics
at Dartmouth.
“A Dartmouth Medical School study shows
that even small amounts of arsenic in drinking water may make people more vulnerable
to cancer,” read the lead on a story in Nevada’s Reno Gazette-Journal, adding that a city
in the Reno area “has the nation’s highest
levels of the metal. . . . ‘We
were primarily interested
in uncovering the mechanism to explain how arsenic causes cancer,’ said
Dr. Angeline Andrew, the lead
author of the study, published in the International
Journal of Cancer. ‘This study supports the
hypothesis that arsenic may act as a cocarcinogen—not directly causing cancers,
but allowing other substances, such as cigarette smoke and ultraviolet light, to cause
mutations in DNA more effectively.’”
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The Los Angeles
Times recently
cited a Dartmouth
study on a subject that
is popularly known as
“chemo brain,”noting that “at Dartmouth
Medical School, psychologist Tim Ahles and his
team studied 71 men and women who had
had chemotherapy for lymphoma or breast
cancer and 57 similar people who had received only surgery and localized radiation
for those cancers. Five years after treatment,
all were cancer-free, but those treated with
chemotherapy fared worse on paper-andpencil cognitive tests than those who did
not get chemotherapy.”
Nobel Laureate Michael Bishop—in an interview on NPR’s “Talk of the Nation”—cited a DMS faculty member as having had a
seminal effect on his career. “When I returned to medical school,” Bishop said, “I
took an elective course about viruses. . . . I
was fascinated by the ability of these truly simple devices to seduce the cell
into replicating them. . . .
I hooked up with an instructor at Harvard Medical School, Elmer Pfefferkorn,
who later became chair of
microbiology at Dartmouth, and worked in
my spare time during the third year of medical school studying a virus—trying to figure
out a particular aspect of how it replicated.
That’s what started it.”
“Medicare cures prove easy to prescribe,
tricky to predict” wrote the Wall Street Journal about federal health-care funding. “Predicting the speed and direction of medical
progress has proved impossible,” noted the
article, “and it hasn’t been much easier to
predict how patients and the health-care industry will react to governmental fine-tuning. ‘It’s policy wonks and politicians trying
to pull levers that control things that they
can’t control,’ says Jonathan Skinner, a Dartmouth health economist.”
Dartmouth Medicine 23
vital
signs
P A G E S
P A S T
n this section, we highlight tidbits from
past issues of the magazine. These messages from yesteryear remind us of the pace
of change as well as of some timeless truths.
I
From the Spring 1987 issue
In 1987, when DHMC’s Lebanon campus was only a blueprint,
we wrote about the process of planning it: “It’s a rare thing for
the people who use a hospital to be asked to help design one,
but this is the opportunity some Hitchcock patients have had
in a recent series of meetings. Selected DHMC patients, organized in focus groups, have been telling the experts—the architects and caregivers planning the new Medical Center—
what they hope to see in their hospital of the future.
“Senior citizens were the first to meet with planners. They
praised the naturally lighted areas designed by the architects
but also pleaded for more private or semiprivate rooms. . . .
“The handicapped participants . . . pointed out [that]
handrails are usually placed at a level convenient for ambulatory patients, not those in wheelchairs. . . .
“Planners heard at the next focus meeting, attended by 15
women who have had babies at MHMH, that what is good for
handicapped patients is also good for parents with baby strollers.
. . . One mother asked if there would be a place for a parent of
an ill baby to stay overnight. Lloyd Acton of the architectural
firm said this was something they had not thought of. ‘I’m glad
you brought that up,’ he said.
“All the focus participants were curious to know if their suggestions could be implemented at this stage of planning. JoAnn
Kairys, an administrative director at the Hitchcock Clinic and
chair of the focus meetings, explained that although the square
footage of the planned new hospital is set, the configuration of
rooms is still open.” Many of the participants’ suggestions, including all those mentioned here, have been implemented.
This photo of DHMC being built—from our Spring 1990 issue—
dates from a couple of years after the focus groups described above.
24 Dartmouth Medicine
ciate professor of community and
family medicine, was reelected as
a corporator of the New England
Baptist Hospital in Boston. He
also was inducted into the Society of Beechers, an honorary society for alumni, faculty, and
friends of the Case Western University School of Law.
Madge Buus-Frank, M.S.N., an instructor in pediatrics, was named
editor-in-chief of Advances in
Neonatal Care, the journal of the
National Association of Neonatal Nurses.
Four faculty members and
two students were elected to the
DMS chapter of Alpha Omega
Alpha, the national medical
honor society: Donald Bartlett, M.D.,
a professor and the chair of physiology; Deborah Peltier, M.D., an assistant professor of medicine;
Donald Kollisch, M.D., an associate
professor of community and family medicine; Charles Wira, Ph.D., a
professor of physiology; and
fourth-year medical students
Symeon Missios and Sarah Pitts.
Karen Coffey, the manager of the
Lifeline Program at DHMC, received the Lifeline Systems, Inc.,
Leadership Award.
An ABC News broadcast titled “A Little Bit of Hope,”
which included interviews with
James Filiano, M.D., an associate
professor of pediatrics, was nominated for an Emmy Award in
the category “Outstanding Feature in a Regularly Scheduled
News Broadcast.” The program
covered Filiano’s treatment of
two children with dopa-responsive dystonia. Before the children came to DHMC, they were
in wheelchairs, and now not
only can they walk, but they take
gymnastics and karate lessons.
All of DHMC’s new first-year
residents were listed in the Summer issue of Dartmouth Medicine. In addition, the following
specialties welcomed residents
with advanced standing into
their programs:
Anesthesiology: Leslie Engles, U of
Colorado; William Harrison, U
of Colorado; Jeffrey Inman, East
Carolina U; Tabitha Washington, U of Colorado.
Cardiovascular Interventional Radiology:
Erik Rhodes, Dartmouth.
Dermatology: Denise Maloney, U
of Texas; Peter Schalock, Oregon
Health Sci U.
Neurology: Helen Barkan, Dartmouth; John Taylor, U of New
England.
Neurosurgery: Michael Wolak,
Chicago Med Sch.
Obstetrics and Gynecology: Thusitha
Cotter, Memorial U of Newfoundland.
Otolaryngology: Matthew Zavod,
Jefferson Med Coll.
Pediatrics: Thomas DePaola,
George Washington U.
Plastic Surgery: Walter Chang,
Dartmouth.
Preventative Medicine: R i c h a r d
Kutz, Penn State; Stephen Liu,
Eastern Virginia Med Sch; John
Su, U of Texas.
Psychiatry: Rita Gelsomini-Gruber, U of Zurich; Stephen Grant,
U of Colorado; Erica O’Neal,
Wayne State U; Barbara Steinbrecher, U of New England.
Radiology: Les Benodin, Dartmouth; Elizabeth Dann, U of Miami; Michael Meszaros, SUNY at
Syracuse; Gerald Riley, Dartmouth.
Urology: Catherine Schwender,
Med Coll of Georgia.
Fall 2003
vital
signs
A legacy from heroes of World War II
he late Sherwin Staples, M.D., the founder and first chief of
DHMC’s orthopaedics section, didn’t think of himself as a
hero when he was tending to wounded soldiers during World
War II. But today, all the orthopaedic surgeon veterans of that
war are being honored by the American Academy of Orthopaedic Surgeons (AAOS) with an exhibit commemorating
their heroic stories.
As part of the recent launch of orthopaedics as a separate department, not just a section within the surgery department,
DHMC hosted the AAOS’s “Legacy of Heroes” exhibit and invited one of the veterans celebrated in it, Zachary Friedenberg,
M.D., to speak at Dartmouth. Friedenberg enthralled the
DHMC audience with his retrospective review of surgery in a
WWII field hospital. He had been a tent mate and friend of
Staples, who went on to head DHMC’s orthopaedics section
for nearly 30 years. The AAOS’s project includes a documentary film, a book, a Web site, and the traveling exhibit—which
comprises 20 seven-foot-tall multisided towers. Friedenberg, a
professor of orthopaedic surgery at the University of Pennsylvania, considers Staples, who died last year at the age of 94, to
have been one of his mentors. He recalls him fondly as a “deliberate, conscientious individual, full of good cheer.”
But the two were far from cheerful when they discovered, to
their horror, that some of the wounded American soldiers who
had been prisoners of war had had metal rods placed inside fractured leg bones. “We thought it was one of [the Germans’] experiments on human guinea pigs,” says Friedenberg. In those
days, fractures were typically treated by putting the leg in traction for four to six weeks. The Germans, however, had found a
better way to set the bones, but the war had impeded the free
exchange of scientific information so U.S. doctors
didn’t know about the advance. The use of intramedullary nails has since
become standard practice,
Friedenberg says.
In fact, many advances
in orthopaedics had their
origins during WWII. Orthopaedic surgeons were
once called “strap and
buckle doctors,” because The WWII “Legacy of Heroes” exhiball they could do was put it contained many striking images.
people in braces. But during the war, surgeons developed better techniques for setting
fractured bones, performing hand surgery, and minimizing infections in wounds, as well as providing physical therapy and
prosthetics for those who’d had had limbs amputated. L.S.C.
T
New on the bookshelf:
Recent releases by
DMS faculty authors
Physiology. Edited by Robert
Berne, M.D., D.Sc.; Matthew
Levy, M.D.; Bruce Koeppen,
M.D., Ph.D.; and Bruce Stanton,
Ph.D., professor of physiology a t D M S .
Mosby; 2004.
Emphasizing
broad principles in physiology, the fifth
edition of this textbook includes
revised illustrations, figures, and
equations to reinforce quantitative understanding. A section on
cellular physiology discusses iontransporting ATPases and membrane transport proteins. The
book also includes new information on sensory and motor systems, the cardiovascular system,
and hormone mechanisms.
Dementia Presentations, Differential Diagnosis, and Nosology. Edited by V. Olga
Emery, Ph.D.,
adjunct associate professor of
psychiatry at
DMS; and
Thomas Oxman, M.D.,
professor of psychiatry and of
community and family medicine
at DMS. Johns Hopkins University Press; 2003. This book covers the spectrum of dementing
disorders and explains their overlap, presentation, and differential diagnosis. This second edition has new material on genet-
Fall 2003
ics, neuroimaging, the role of inflammation in Alzheimer’s disease, and HIV/AIDS dementia.
The Neurolab Spacelab Mission:
Neuroscience Research in Space.
Edited by Jay Buckey, M.D., associate professor of medicine
at DMS; and
Jerry Homick,
Ph.D. National Aeronautics
and Space Administration;
2003. This book provides an
overview of the 1998 Neurolab
space mission, which studied the
brain and nervous system during
space flight. It includes scientific reports on sensory integration
and navigation, the balance system, blood pressure-control, and
circadian rhythms. It also describes equipment developed for
the flight and crewmembers’ perspectives on the mission.
Because I Said So: Family Squabbles and How to Handle Them. By
Lauri Berkenkamp and Steven
Atkins, Psy.D., clinical associate
and instructor in psychiatry at
DMS. Nomad Press; 2003. This
guide offers
practical advice on how to
handle the
everyday
squabbles and
hassles that
parents experience with their children. Areas
covered include dealing with
bickering and tattling, keeping a
household running smoothly,
handling punishment, and maintaining family serenity. ■
Dartmouth Medicine 25