Guiding patients through heart disease

A cardiologist provides a handbook so patients can better understand their disease and how to treat it.

By Cathy Shufro

Half of all patients don’t take the medications that their doctors prescribe. And the majority of cardiac patients leaving the hospital don’t know the target numbers for optimal blood pressure or cholesterol. For cardiologist Harlan M. Krumholz, M.D., M.Sc., the Harold J. Hines Jr. Professor of Internal Medicine and of Epidemiology and Public Health, these findings reflect lost opportunities for patients to participate in their care. Hopes of fostering better patient involvement in their care motivated Krumholz to write The Expert Guide to Beating Heart Disease: What You Absolutely Must Know (HarperResource, $14.95).

Krumholz said that patients who understand their disease and the options for treating it can collaborate more effectively with their physicians in choosing and following the strategies that are most likely to help them reach their goals. “If patients understand the rationale behind the strategies, they’re more likely to follow them.” Krumholz also argued that informed patients are more likely to get good care.

“We have this illusion that medicine is being practiced uniformly and is of high quality throughout the country,” he said. “That perception is just not true. There is ample evidence that treatment strategies that are well-established by the literature and endorsed by national guidelines are not uniformly being recommended by doctors or pursued by patients.”

Unfortunately, patients are not often encouraged to become well-educated about their condition, said Krumholz. “We’re still in an era when most people come in, they’re told what to do and given a prescription, and if they don’t comply, they’re seen as letting down the physician.”

Patients seeking to educate themselves about heart disease may feel overwhelmed, however. “If you got sick, where would you start? There’s such an avalanche of information,” said Krumholz. He views his 152-page book as a “travel guide” that provides essential facts about how heart disease develops and what can be done to treat it. The book describes seven key strategies: controlling blood pressure, managing cholesterol, exercising, maintaining a healthy weight, managing blood sugar, quitting smoking and using medication effectively.

Krumholz chose these seven strategies based on national guidelines and his expertise in evaluating the quality of heart disease care. A prolific researcher himself, he has helped set national standards for cardiovascular care for organizations ranging from the American College of Cardiology to the Department of Defense. Based on the published evidence, his book describes approaches that work (such as taking beta-blockers after a heart attack or controlling cholesterol with statins), those that probably help (eating fish regularly), those of uncertain value (taking vitamins) and those that have proven harmful (hormone replacement therapy for women).

A grant from the John A. Hartford Foundation in New York allowed Krumholz to hire a researcher—Susan Cheng, M.D., then a medical student at McMaster University in Ontario, now a resident in internal medicine at Johns Hopkins. Krumholz and Cheng field-tested the book: they sent about 100 copies to relatives, friends, friends of friends with heart disease and patients, asking them to circle sections that were confusing and to pencil in questions.

“We said, ‘Write all over this. It won’t hurt our feelings.’ ” Their approach seems to have worked; a critic for Kirkus Reviews writes that “Dr. Krumholz has a gift for translating jargon into clear, accessible language that the concerned reader can easily absorb.”

Writing for a general audience was a departure for Krumholz. He has clinical responsibilities one day each week, and as director of the Robert Wood Johnson Clinical Scholars Program at Yale, he spends a lot of his time guiding postdoctoral fellows in the program as they do research on improving clinical care and population health. His own research appears in 40 to 50 articles annually. But he called those papers “just a means to an end.”

“At the end of the day, it’s not about the number of publications but about whether people can benefit from the work we’ve done. The book is a tool to help promote that.”

For more on the book, visit www.expertheartguide.com

Bookshelf is a column in Yale Medicine focusing on matters related to books and authors at the School of Medicine. Send ideas to Cathy Shufro at cathy.shufro@yale.edu.

Book notes

Nanoscale Technology in Biological Systems
by Ralph S. Greco, M.D. ’68, HS ’73, et al. (CRC Press) This book presents the latest information on the interface between nanotechnology and biology, examining the principles underlying the application of nanotechnology to basic science research, applied research and clinical practice.

Songs From the Black Chair: A Memoir of Mental Interiors
by Charles Barber, M.H.A., associate of the Yale Program for Recovery and Community Health (University of Nebraska Press) In his account of working with homeless mentally ill patients in New York, Barber tells their tales of prison, AIDS, heroin, crack and sexual abuse and of the voices that plague them.

The Craft of Psychodynamic Psychotherapy
by Angelica Kaner, Ph.D., assistant clinical professor in psychiatry, and Ernst Prelinger, Ph.D., clinical professor of psychology and psychiatry (Jason Aronson) Clinical vignettes illustrate the fundamentals of psycho-dynamic theory and technique, tackling questions such as: What is psychotherapy? How long will it take? How does change happen?

Information Systems Research: Relevant Theory and Informed Practice
edited by Bonnie Kaplan, Ph.D., lecturer in anesthesiology (medical informatics), et al. (Springer) This volume is organized in seven sections, with 33 full research papers providing reviews on the Information Systems (IS) discipline. It also includes papers featuring critical interpretive studies, action research, theoretical perspectives on IS research and the methods and politics of IS development.

Attention Deficit Disorder: The Unfocused Mind in Children and Adults
by Thomas E. Brown, Ph.D., assistant clinical professor of psychiatry (Yale University Press) Drawing on recent findings in neuroscience and a variety of case histories from his own clinical practice, Brown defines Attention Deficit Disorder, describes how to recognize it in people of different ages and discusses how it can best be treated.

Heart Care for Life: How to Develop the Long-Term Personal Program That Works Best for You
by Barry L. Zaret, M.D., the Robert W. Berliner Professor of Medicine and professor of radiology, and Genell Subak-Sharpe, M.S. (Yale University Press) The authors outline the constants for the full range of cardiovascular conditions, from angina and heart attacks to high blood pressure and cardiac arrhythmias. They then guide readers through the process of assessing personal variables in order to develop an individual treatment and lifestyle program.

Emotional Comfort: The Gift of Your Inner Guide
by Judith M. Davis, M.D. ’63 (Wilder Press) This book provides a self-hypnotic technique for attaining emotional com-fort. According to Davis, the technique helps its practitioners to resolve chronic difficulties and to handle new ones that may arise.

Multiple Sclerosis as a Neuronal Disease
by Stephen G. Waxman, Ph.D., M.D., professor of neurology, pharmacology and neurobiology (Elsevier Academic Press) This illustrated book brings together the latest information from clinical, pathological, imaging, molecular and pharmacological realms to explore the neurobiology of multiple sclerosis.

One Nation Under Therapy: How the Helping Culture Is Eroding Self-Reliance
by Sally L. Satel, M.D., HS ’88,lecturer in psychiatry, and Christina Hoff Sommers (St. Martin’s Press) The authors believe that talking about problems is no substitute for confronting them. They argue that “therapism” and the “trauma industry” have begun to undermine the self-reliance and fortitude that Americans have traditionally valued.

Physicians’ Cancer Chemotherapy Drug Manual 2005
by Edward Chu, M.D., professor of medicine (oncology) and pharmacology, and Vincent T. DeVita Jr., M.D., HS ’66, the Amy and Joseph Perella Professor of Medicine (Jones and Bartlett Publishers) Completely revised for 2005, this handbook is a guide to all aspects of cancer chemotherapy, including a catalog of over 100 drugs commonly used in cancer treatment.

Bone Regeneration and Repair: Biology and Clinical Applications
edited by Jay R. Lieberman, M.D., and Gary E. Friedlaender, M.D., HS ’74, the Wayne O. Southwick Professor of Orthopaedics and Rehabilitation (Humana Press) This collection of articles by leading orthopaedic and craniofacial surgeons and researchers reviews the biology of bone formation and repair and the basic science of autologous bone graft, allograft, bone substitutes and growth factors, and explores the clinical application of this knowledge to patients with bone repair problems.

The Cadaver’s Ball: A Novel of Revenge
by Charles Atkins, M.D., lecturer in psychiatry (St. Martin’s Minotaur) Atkins creates characters with a range of motivations in this psychological thriller of the lives and loves of three medical school friends.

The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness
by Jack El-Hai (Wiley Publishers) In the early 1940s, lobotomy was the last resort in an attempt to relieve intractable psychiatric symptoms. This type of surgery was first performed in the United States in 1936 by neurologist Walter J. Freeman, M.D., who received his undergraduate degree from Yale in 1916, and neurosurgeon James W. Watts, M.D.—who helped pave the way for psychosurgery by conducting research on chimps at the Laboratory of Primate Physiology at Yale. The practice, now discredited, continued for more than 40 years.

The descriptions are based on information from the publishers.

Send notices of new books by alumni and faculty to Cheryl Violante, Yale Medicine, P.O. Box 7612, New Haven, CT 06519-0612, or via e-mail to cheryl.violante@yale.edu.

In circulation

Personal librarians help students navigate research

Second-year medical student Kurtland Ma ran into a snag while doing research last summer in Hong Kong: he couldn’t download an article on alternative HIV therapies that he’d found online. Luckily, Ma had someone to turn to—his “personal librarian” 8,000 miles away in New Haven.

That librarian was Lynn H. Sette, M.L.S., a reference librarian and one of 10 librarians at the Cushing/Whitney Medical Library paired with students in medicine, in the Physician Associate Program and in the Combined Program in the Biological and Biomedical Sciences. Just as Sette had introduced herself to Ma during his medical school orientation, each of the personal librarians meets new students as they arrive, establishing librarian-student partnerships.

When Ma sought help from Sette via e-mail in July, she sent him the article he needed. Normally, said Ma, he does well on his own. “I’ve done so many PubMed/Ovid searches in the past and the website is so good that I don’t feel like I need all that much help—having a personal librarian seems more like a luxury,” Ma wrote by e-mail from Hong Kong. “I obviously didn’t expect to be asking for her help from here in Hong Kong, but now I’m starting to realize that having her is quite helpful.”

Education Services Librarian Jan Glover, M.L.S., who helped create the program nine years ago, said students often turn to their librarians when they begin third-year clinical rotations. They ask for guidance—in person or by e-mail—when they’re looking for “the perfect bit of information to answer a clinical question.” Students also ask for help with technical problems such as downloading a medication database onto a personal digital assistant.

The most common questions are about complicated literature searches. During the past year, third-year medical student Argo P. Caminis estimated that she has asked Glover for advice two or three times a week while doing research for two journal articles on adolescent sexual behavior. Glover showed Caminis how to avoid being inundated by thousands of citations on a broad topic.

“I was getting tons of hits. She helped me to focus it by the types of journals I was looking at: whether they’d been peer-reviewed, looking for literature review articles, limiting the search to recent or relevant articles. She taught me principles of research that I think were helpful to learn early on in medical school,” said Caminis, who was a co-author on an article published last spring and who will be lead author on a second. “It’s a good way to reach out to students.”

—Cathy Shufro



Melton		Sharp



Steinem		Steinerman

On campus

In the stem cell debate, asking the right question

The intertwined debate that links abortion to embryonic stem cell research has revolved around the wrong question, said Douglas A. Melton, Ph.D., co-director of the Harvard Stem Cell Institute. “I would suggest to you,” he said in his keynote address at the annual meeting in May of the Associates of the Cushing/Whitney Medical Library, “that the question of when does life begin is the wrong question. The real question is: ‘When does personhood begin?’ ”

A sperm and an egg are already alive before they meet, Melton said, rendering the notion of the beginning of life an arbitrary matter of timing. When does personhood emerge? “This is a metaphysical question that everyone should think about.”

Harnessing the plasticity of stem cells and inducing their differentiation into a desired tissue is years away, Melton said, but within reach. “I predict the 21st century will be a century not about genes and DNA, but about cells and stem cell research. … Genes are not the unit of life. Cells are the unit of life.”

—John Curtis

A new role for RNA as a regulatory molecule

In the last few years scientists have been surprised by small nucleotide sequences, microRNAs and siRNAs (small interfering RNAs), that appear to play a role in both suppressing and promoting cancer. “We are at a transition in our understanding of RNA,” said Phillip A. Sharp, Ph.D., Nobel laureate and Institute Professor at the Massachusetts Institute of Technology. “RNA is taking on a new role. It is a regulatory molecule.”

These small RNAs are double-stranded sequences of about 22 nucleotides that act by disrupting messenger RNA. According to Sharp, they regulate up to a fifth of human genes, a function once thought to be the exclusive province of proteins. “The double strand is the signature key that converts the RNA into a regulatory molecule,” Sharp said in June as he gave the Adelberg Lecture sponsored by the Department of Genetics.

This regulatory role could have therapeutic value if it can be harnessed to turn off mutant, disease-causing genes. “The big problem with using siRNAs is how to introduce them into the cell,” Sharp said. “That delivery problem stands between this being a very broad platform for therapeutics and where we are at now.”

—J.C.

Research that makes women visible

Surveying a packed ballroom at New Haven’s Omni Hotel in which women were disproportionately and diversely represented, renowned feminist author and activist Gloria Steinem noted the changes since she first spoke at Yale at the dawn of the women’s movement in the 1960s. “The phrase gender-specific could have applied to all of Yale,” Steinem said in April. “And God and Man at Yale has at least become God and People. There are glorious racial and ethnic and economic differences and diversity and richness. So times have really changed.”

Speaking at a gala event in which she received a Women of Vision award from Women’s Health Research at Yale (WHRY), Steinem lauded the work of WHRY, which supports research on sex-specific factors in health and disease. “Their questions at a time when mostly old answers rule the top are really very, very crucial,” she said. “The rock-solid research that is going on makes the female half of the world visible and is clearly something we all desperately, desperately need right now.”

—Peter Farley

Fuggedaboutit! Transient Global Amnesia

A 62-year-old man led a choir through a flawless rehearsal and performance, but by the end of the day he could remember none of the day’s events.

He was experiencing transient global amnesia (TGA), a malady believed until the 1950s to be the product of hysteria or malingering, said Joshua R. Steinerman, M.D., a senior resident in neurology who described the disorder at clinical neuroscience grand rounds in June.

Physicians now know what triggers TGA, without knowing what causes it. Triggers include swimming in cold water, sexual intercourse, an emotional event, stress and exertion. “The history and proximal events leading to the episode are crucial,” Steinerman said.

Episodes usually last four to six hours. Sufferers—typically people between the ages of 50 and 79—know something’s wrong, but they can’t recall answers to the questions they ask as they try to orient themselves.

Over the years, several theories have been proposed about what causes TGA. “None is entirely satisfactory,” Steinerman said. “The great thinkers who proposed mechanisms have always hedged their bets.”

—J.C.


			Originally published in Yale Medicine, Autumn 2005. Copyright © 2005 Yale University School of Medicine. All rights reserved.