New doctors need more support as they begin their careers, survey finds

Almost three quarters (73%) of junior doctors say they do not have enough time to give patients the care they require. Photograph: Martin Argles for the Guardian

Over the coming weeks about 6,000 new junior doctors will start life on the wards. It is a tough and daunting experience, as they put into practice all the training they have received over the past four or five years.

Predictably, there is negative press coverage around this time, based on research from the Dr Foster unit and the department of acute medicine at Imperial College London. The article, published four years ago, did show a small increase in deaths at the start of August – but the findings did not demonstrate a causal link between the rise in mortalities and the influx of new doctors.

Since that research was first published, junior doctors have become better prepared for the transition from medical student to junior doctor: training is far more patient-focused at medical school, and there is a period of pre-job shadowing, dedicated induction programmes and close clinical supervision. But there is no doubt that this is a challenging time for both junior doctors and senior colleagues.

We conducted a survey of about 350 junior doctors who are just completing their first year on the hospital wards, which produced some interesting findings. It was encouraging to see that more than two thirds had chosen a career to help people, but disheartening that a third were re-considering their career choice due to their early experiences. After years of dedicated study, it is a telling sign of the major stresses placed on the shoulders of young doctors so early in their careers.

We must do more to support junior doctors. Though the profession clearly has a role to play, so too do NHS managers. They have the power to provide appropriate resourcing and support on the ward, which can affect morale. As our survey shows, three quarters of respondents said that they had struggled with long hours. A similar number had difficulty with heavy workloads, and more than a third had felt isolated.

When asked what they had found most challenging when dealing with patients during their first year, 73% of junior doctors said they didn't have enough time to give patients the care they required, and nearly half were working beyond the maximum working hours stipulated by European law.

Managers have an important role in providing a safe learning environment. They should be accessible, and receptive to concerns, queries and new ideas. They will have a pivotal role in delivering Sir Bruce Keogh's vision, set out in his recent review into the quality of care and treatment provided by 14 hospital trusts in England.

I share his belief that junior doctors should not just be seen as the clinical leaders of tomorrow, but the clinical leaders of today. We must harness their enthusiasm and support them to become a valuable and respected member of the team.

Junior doctors are at the frontline of patient care, they understand the challenges faced by both patient and management and are, therefore, a valuable source of intelligence. They are capable of providing real insights and seeing things that affect patient safety.

The NHS has come under sustained fire and we need to nurture it back to health. Junior doctors represent the present and our future, and have a core role in restoring pride in our healthcare system, which we often forget is the envy of many countries.

So spare a thought for the thousands of young doctors who have embarked on a lifetime of dedicated hard work and study, and whose actions are a matter of life and death.

Dr Pallavi Bradshaw is medicolegal adviser at the Medical Protection Society.

This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.

View the original article here

New doctors need more support as they begin their careers, survey finds

Almost three quarters (73%) of junior doctors say they do not have enough time to give patients the care they require. Photograph: Martin Argles for the Guardian

Over the coming weeks about 6,000 new junior doctors will start life on the wards. It is a tough and daunting experience, as they put into practice all the training they have received over the past four or five years.

Predictably, there is negative press coverage around this time, based on research from the Dr Foster unit and the department of acute medicine at Imperial College London. The article, published four years ago, did show a small increase in deaths at the start of August – but the findings did not demonstrate a causal link between the rise in mortalities and the influx of new doctors.

Since that research was first published, junior doctors have become better prepared for the transition from medical student to junior doctor: training is far more patient-focused at medical school, and there is a period of pre-job shadowing, dedicated induction programmes and close clinical supervision. But there is no doubt that this is a challenging time for both junior doctors and senior colleagues.

We conducted a survey of about 350 junior doctors who are just completing their first year on the hospital wards, which produced some interesting findings. It was encouraging to see that more than two thirds had chosen a career to help people, but disheartening that a third were re-considering their career choice due to their early experiences. After years of dedicated study, it is a telling sign of the major stresses placed on the shoulders of young doctors so early in their careers.

We must do more to support junior doctors. Though the profession clearly has a role to play, so too do NHS managers. They have the power to provide appropriate resourcing and support on the ward, which can affect morale. As our survey shows, three quarters of respondents said that they had struggled with long hours. A similar number had difficulty with heavy workloads, and more than a third had felt isolated.

When asked what they had found most challenging when dealing with patients during their first year, 73% of junior doctors said they didn't have enough time to give patients the care they required, and nearly half were working beyond the maximum working hours stipulated by European law.

Managers have an important role in providing a safe learning environment. They should be accessible, and receptive to concerns, queries and new ideas. They will have a pivotal role in delivering Sir Bruce Keogh's vision, set out in his recent review into the quality of care and treatment provided by 14 hospital trusts in England.

I share his belief that junior doctors should not just be seen as the clinical leaders of tomorrow, but the clinical leaders of today. We must harness their enthusiasm and support them to become a valuable and respected member of the team.

Junior doctors are at the frontline of patient care, they understand the challenges faced by both patient and management and are, therefore, a valuable source of intelligence. They are capable of providing real insights and seeing things that affect patient safety.

The NHS has come under sustained fire and we need to nurture it back to health. Junior doctors represent the present and our future, and have a core role in restoring pride in our healthcare system, which we often forget is the envy of many countries.

So spare a thought for the thousands of young doctors who have embarked on a lifetime of dedicated hard work and study, and whose actions are a matter of life and death.

Dr Pallavi Bradshaw is medicolegal adviser at the Medical Protection Society.

This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.

View the original article here

New doctors need more support as they begin their careers, survey finds

Almost three quarters (73%) of junior doctors say they do not have enough time to give patients the care they require. Photograph: Martin Argles for the Guardian

Over the coming weeks about 6,000 new junior doctors will start life on the wards. It is a tough and daunting experience, as they put into practice all the training they have received over the past four or five years.

Predictably, there is negative press coverage around this time, based on research from the Dr Foster unit and the department of acute medicine at Imperial College London. The article, published four years ago, did show a small increase in deaths at the start of August – but the findings did not demonstrate a causal link between the rise in mortalities and the influx of new doctors.

Since that research was first published, junior doctors have become better prepared for the transition from medical student to junior doctor: training is far more patient-focused at medical school, and there is a period of pre-job shadowing, dedicated induction programmes and close clinical supervision. But there is no doubt that this is a challenging time for both junior doctors and senior colleagues.

We conducted a survey of about 350 junior doctors who are just completing their first year on the hospital wards, which produced some interesting findings. It was encouraging to see that more than two thirds had chosen a career to help people, but disheartening that a third were re-considering their career choice due to their early experiences. After years of dedicated study, it is a telling sign of the major stresses placed on the shoulders of young doctors so early in their careers.

We must do more to support junior doctors. Though the profession clearly has a role to play, so too do NHS managers. They have the power to provide appropriate resourcing and support on the ward, which can affect morale. As our survey shows, three quarters of respondents said that they had struggled with long hours. A similar number had difficulty with heavy workloads, and more than a third had felt isolated.

When asked what they had found most challenging when dealing with patients during their first year, 73% of junior doctors said they didn't have enough time to give patients the care they required, and nearly half were working beyond the maximum working hours stipulated by European law.

Managers have an important role in providing a safe learning environment. They should be accessible, and receptive to concerns, queries and new ideas. They will have a pivotal role in delivering Sir Bruce Keogh's vision, set out in his recent review into the quality of care and treatment provided by 14 hospital trusts in England.

I share his belief that junior doctors should not just be seen as the clinical leaders of tomorrow, but the clinical leaders of today. We must harness their enthusiasm and support them to become a valuable and respected member of the team.

Junior doctors are at the frontline of patient care, they understand the challenges faced by both patient and management and are, therefore, a valuable source of intelligence. They are capable of providing real insights and seeing things that affect patient safety.

The NHS has come under sustained fire and we need to nurture it back to health. Junior doctors represent the present and our future, and have a core role in restoring pride in our healthcare system, which we often forget is the envy of many countries.

So spare a thought for the thousands of young doctors who have embarked on a lifetime of dedicated hard work and study, and whose actions are a matter of life and death.

Dr Pallavi Bradshaw is medicolegal adviser at the Medical Protection Society.

This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.

View the original article here

Study finds physicians need to better recognize use of herbal supplements while breastfeeding

Main Category: Complementary Medicine / Alternative Medicine
Also Included In: Primary Care / General Practice;  Pediatrics / Children's Health
Article Date: 05 Aug 2013 - 0:00 PDT Current ratings for:
Study finds physicians need to better recognize use of herbal supplements while breastfeeding

In an article published in this month's issue of Pediatrics In Review, researchers from Boston University School of Medicine (BUSM) stress the importance of physicians recognizing that many mothers use herbal supplements while breastfeeding in order to make accurate health assessments for both mother and child.

In the US, no existing regulatory guidelines set a standardized risk assessment of herbal supplement use during breastfeeding. Because of the highly limited number of studies on herb use during lactation, numerous resources have mixed reports and safety recommendations, making it confusing for both mother and clinician.

After completing a systematic review of human lactation and herbal medicine literature, the researchers found poor methodology in the few available studies and concluded that further research is needed to assess the prevalence, efficacy and safety of commonly used herbs during breastfeeding.

"It is important for physicians and clinicians to be more aware that mothers are using herbal supplements and how vital it is to ask the mothers, who are seeking a doctor's opinion when having trouble breastfeeding, about their use before making an assessment," said senior author Paula Gardiner, MD, MPH, assistant professor at BUSM and a physician of family medicine at Boston Medical Center.

Although there is little scientific evidence to support the efficacy or safety of herbal supplements, it is a common practice both nationally and internationally.

"The use of herbal supplements while breastfeeding is two-sided - there are benefits, but there are also safety concerns," she added. "About 18 percent of the US population use herbs and dietary supplements. We just want to make sure physicians and clinicians are aware of this prevalent use when communicating with breastfeeding mothers about their health."

Herbal remedies may be used to increase the milk supply, relieve engorgement, treat mastitis, or for other therapeutic uses unrelated to lactation.

"Since there is very limited research, it is difficult to develop accurate information on the safety and effectiveness of specific herbs during breastfeeding," said Gardiner. "It is crucial that more research is conducted in this area, including national prevalence studies and safety and efficacy studies."

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our complementary medicine / alternative medicine section for the latest news on this subject.

Gardiner is supported by grant K07AT005463 from the National Center for Complementary & Alternative Medicine. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Complementary & Alternative Medicine or the National Institutes of Health.

Boston University Medical Center

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Study finds physicians need to better recognize use of herbal supplements while breastfeeding

Main Category: Complementary Medicine / Alternative Medicine
Also Included In: Primary Care / General Practice;  Pediatrics / Children's Health
Article Date: 05 Aug 2013 - 0:00 PDT Current ratings for:
Study finds physicians need to better recognize use of herbal supplements while breastfeeding

In an article published in this month's issue of Pediatrics In Review, researchers from Boston University School of Medicine (BUSM) stress the importance of physicians recognizing that many mothers use herbal supplements while breastfeeding in order to make accurate health assessments for both mother and child.

In the US, no existing regulatory guidelines set a standardized risk assessment of herbal supplement use during breastfeeding. Because of the highly limited number of studies on herb use during lactation, numerous resources have mixed reports and safety recommendations, making it confusing for both mother and clinician.

After completing a systematic review of human lactation and herbal medicine literature, the researchers found poor methodology in the few available studies and concluded that further research is needed to assess the prevalence, efficacy and safety of commonly used herbs during breastfeeding.

"It is important for physicians and clinicians to be more aware that mothers are using herbal supplements and how vital it is to ask the mothers, who are seeking a doctor's opinion when having trouble breastfeeding, about their use before making an assessment," said senior author Paula Gardiner, MD, MPH, assistant professor at BUSM and a physician of family medicine at Boston Medical Center.

Although there is little scientific evidence to support the efficacy or safety of herbal supplements, it is a common practice both nationally and internationally.

"The use of herbal supplements while breastfeeding is two-sided - there are benefits, but there are also safety concerns," she added. "About 18 percent of the US population use herbs and dietary supplements. We just want to make sure physicians and clinicians are aware of this prevalent use when communicating with breastfeeding mothers about their health."

Herbal remedies may be used to increase the milk supply, relieve engorgement, treat mastitis, or for other therapeutic uses unrelated to lactation.

"Since there is very limited research, it is difficult to develop accurate information on the safety and effectiveness of specific herbs during breastfeeding," said Gardiner. "It is crucial that more research is conducted in this area, including national prevalence studies and safety and efficacy studies."

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our complementary medicine / alternative medicine section for the latest news on this subject.

Gardiner is supported by grant K07AT005463 from the National Center for Complementary & Alternative Medicine. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Complementary & Alternative Medicine or the National Institutes of Health.

Boston University Medical Center

Please use one of the following formats to cite this article in your essay, paper or report:

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'Study finds physicians need to better recognize use of herbal supplements while breastfeeding'

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Study finds potential well water contaminants highest near natural gas drilling

Main Category: Water - Air Quality / Agriculture
Also Included In: Public Health
Article Date: 30 Jul 2013 - 0:00 PDT Current ratings for:
Study finds potential well water contaminants highest near natural gas drilling

A new study of 100 private water wells in and near the Barnett Shale showed elevated levels of potential contaminants such as arsenic and selenium closest to natural gas extraction sites, according to a team of researchers that was led by UT Arlington associate professor of chemistry and biochemistry Kevin Schug.

The results of the North Texas well study were published online by the journal Environmental Science & Technology. The peer-reviewed paper focuses on the presence of metals such as arsenic, barium, selenium and strontium in water samples. Many of these heavy metals occur naturally at low levels in groundwater, but disturbances from natural gas extraction activities could cause them to occur at elevated levels.

"This study alone can't conclusively identify the exact causes of elevated levels of contaminants in areas near natural gas drilling, but it does provide a powerful argument for continued research," said Brian Fontenot, a UT Arlington graduate with a doctorate in quantitative biology and lead author on the new paper.

He added: "We expect this to be the first of multiple projects that will ultimately help the scientific community, the natural gas industry, and most importantly, the public, understand the effects of natural gas drilling on water quality."

Researchers believe the increased presence of metals could be due to a variety of factors including: industrial accidents such as faulty gas well casings; mechanical vibrations from natural gas drilling activity disturbing particles in neglected water well equipment; or the lowering of water tables through drought or the removal of water used for the hydraulic fracturing process. Any of these scenarios could release dangerous compounds into shallow groundwater.

Researchers gathered samples from private water wells of varying depth within a 13 county area in or near the Barnett Shale in North Texas over four months in the summer and fall of 2011. Ninety-one samples were drawn from what they termed "active extraction areas," or areas that had one or more gas wells within a five kilometer radius. Another nine samples were taken from sites either inside the Barnett Shale and more than 14 kilometers from a natural gas drilling site, or from sites outside the Barnett Shale altogether. The locations of those sites were referred to as "non-active/reference areas" in the study.

Researchers accepted no outside funding to ensure the integrity of the study. They compared the samples to historical data on water wells in these counties from the Texas Water Development Board groundwater database for 1989-1999, prior to the proliferation of natural gas drilling.

In addition to standard water quality tests, the researchers used gas chromatography - mass spectrometry (GC-MS), headspace gas chromatography (HS-GC) and inductively coupled plasma-mass spectrometry (ICP-MS). Many of the tests were conducted in the Shimadzu Center for Advanced Analytical Chemistry on the UT Arlington campus.

"Natural gas drilling is one of the most talked about issues in North Texas and throughout the country. This study was an opportunity for us to use our knowledge of chemistry and statistical analysis to put people's concerns to the test and find out whether they would be backed by scientific data," said Schug, who is also the Shimadzu Distinguished Professor of Analytical Chemistry in the UT Arlington College of Science.

On average, researchers detected the highest levels of these contaminants within 3 kilometers of natural gas wells, including several samples that had arsenic and selenium above levels considered safe by the Environmental Protection Agency. For example, 29 wells that were within the study's active natural gas drilling area exceeded the EPA's Maximum Contaminant Limit of 10 micrograms per liter for arsenic, a potentially dangerous situation.

The areas lying outside of active drilling areas or outside the Barnett Shale did not show the same elevated levels for most of the metals.

Other leaders of the Texas Gas Wells team were Laura Hunt, who conducted her post-doctoral research in biology at UT Arlington, and Zacariah Hildenbrand, who earned his doctorate in biochemistry from the University of Texas at El Paso and performed post-doctoral research at UT Southwestern Medical Center. Hildenbrand is also the founder of Inform Environmental, LLC. Fontenot and Hunt work for the EPA regional office in Dallas, but the study is unaffiliated with the EPA and both received permission to work on this project outside the agency.

Scientists note in the paper that they did not find uniformity among the contamination in the active natural gas drilling areas. In other words, not all gas well sites were associated with higher levels of the metals in well water.

Some of the most notable results were on the following heavy metals:

Arsenic occurs naturally in the region's water and was detected in 99 of the 100 samples. But, the concentrations of arsenic were significantly higher in the active extraction areas compared to non-extraction areas and historical data. The maximum concentration from an extraction area sample was 161 micrograms per liter, or 16 times the EPA safety standard set for drinking water. According to the EPA, people who drink water containing arsenic well in excess of the safety standard for many years "could experience skin damage or problems with their circulatory system, and may have an increased risk of getting cancer." Selenium was found in 10 samples near extraction sites, and all of those samples showed selenium levels were higher than the historical average. Two samples exceeded the standard for selenium set by the EPA. Circulation problems as well as hair or fingernail loss are some possible consequences of long-term exposure to high levels of selenium, according to the EPA. Strontium was also found in almost all the samples, with concentrations significantly higher than historical levels in the areas of active gas extraction. A toxicological profile by the federal government's Agency for Toxic Substances and Disease Registry recommends no more than 4,000 micrograms of strontium per liter in drinking water. Seventeen samples from the active extraction area and one from the non-active areas exceeded that recommended limit. Exposure to high levels of stable strontium can result in impaired bone growth in children, according to the toxic substances agency.

"After we put the word out about the study, we received numerous calls from landowner volunteers and their opinions about the natural gas drilling in their communities varied," Hildenbrand said. "By participating in the study, they were able to get valuable data about their water, whether it be for household or land use.

"Their participation has been incredibly important to this study and has helped us bring to light some of the important environmental questions surrounding this highly contentious issue."

The paper also recommends further research on levels of methanol and ethanol in water wells. Twenty-nine private water wells in the study contained methanol, with the highest concentrations in the active extraction areas. Twelve samples, four of which were from the non-active extraction sites, contained measurable ethanol. Both ethanol and methanol can occur naturally or as a result of industrial contamination. Historical data on methanol and ethanol was not available, researchers said in the paper.

The paper is called "An evaluation of water quality in private drinking water wells near natural gas extraction sites in the Barnett Shale formation." A Just Accepted version is available on the journal website.

Many from the research team are now conducting well water sampling in the Permian Basin region of Texas, establishing a baseline set of data prior to gas well drilling activities there. That baseline will be used for a direct comparison to samples that will be collected during and after upcoming natural gas extraction. The team hopes that these efforts will shed further light on the relationship between natural gas extraction and ground water quality.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our water - air quality / agriculture section for the latest news on this subject.

The paper is called “An evaluation of water quality in private drinking water wells near natural gas extraction sites in the Barnett Shale formation.” A Just Accepted version is available on the journal website.

Other co-authors include: Qinhong “Max” Hu, associate professor of earth and environmental sciences at UT Arlington; Doug D. Carlton Jr., a Ph.D. student in the chemistry and biochemistry department at UT Arlington; Hyppolite Oka, a recent graduate of the environmental and earth sciences master’s program at UT Arlington; Jayme L. Walton, a recent graduate of the biology master’s program at UT Arlington; and Dan Hopkins, of Carrollton-based Geotech Environmental Equipment, Inc.

Alexandria Osorio and Bryan Bjorndal of Assure Controls, Inc. in Vista, Calif., also are co-authors. The team used Assure’s Qwiklite™ system to test for toxicity in well samples and those results are being prepared for a separate publication.

The research published this week is representative of the important work going on at The University of Texas at Arlington, a comprehensive research institution with about 33,800 students and more than 2,200 faculty members in the heart of North Texas.

University of Texas at Arlington

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Study finds druggable target for pulmonary hypertension

Main Category: Respiratory / Asthma
Also Included In: Hypertension;  Genetics
Article Date: 27 Jul 2013 - 0:00 PDT Current ratings for:
Study finds druggable target for pulmonary hypertension

Columbia University Medical Center (CUMC) scientists have identified new genetic mutations that can cause pulmonary arterial hypertension (PAH), a rare fatal disease characterized by high blood pressure in the lungs. The mutations, found in the gene KCNK3, appear to affect potassium channels in the pulmonary artery, a mechanism not previously linked to the condition. Cell culture studies showed that the mutations' effects could be reversed with a drug compound known as a phospholipase inhibitor. The study was published in the online edition of the New England Journal of Medicine.

"The most exciting thing about our study is not that we've identified a new gene involved in pulmonary hypertension, but that we've found a drug that can 'rescue' some mutations," said co-senior author Wendy K. Chung, MD, PhD, associate professor of pediatrics and medicine at CUMC. "In genetics, it's common to identify a gene that is the source of a disease. However, it's relatively rare to find potential treatments for genetic diseases."

PAH is a progressive disorder characterized by abnormally high blood pressure in the pulmonary artery, which reduces blood flow from the right side of the heart to the lungs. The heart can compensate by pumping harder, but over time this can weaken the heart muscle and lead to right-sided heart failure. Common symptoms of PAH include shortness of breath, dizziness, and fainting. About 1,000 new cases are diagnosed in the United States each year. The disorder is twice as common in females as in males. There is no cure for PAH and few effective treatments. Most patients with PAH die within 5-7 years of diagnosis.

Some cases of PAH are caused by inherited genetic defects. Most of these "familial" cases have been linked to mutations in a gene called BMPR2 (bone morphogenetic protein receptor, type II), which was identified simultaneously in 2000 by two independent research teams, one led by the late Robin Barst and Jane Morse, CUMC researchers. However, the majority of cases are idiopathic in origin (of unknown cause). Other forms of PAH can be triggered by autoimmune diseases, congenital heart defects, infections (such as schistosomiasis), and medications (such as the now-banned diet-drug combination commonly known as fen-Phen).

Dr. Chung and her colleagues discovered the new mutations by sequencing the exomes (the portion of the genome that codes information to make proteins) of families with PAH without identified mutations. KCNK3 mutations were found in 3.2 percent of those with familial disease and in 1.3 percent of those with idiopathic PAH.

The team found that the mutations alter the function of potassium channels by reducing the activity of these channels. Potassium channels help maintain the vascular tone of the pulmonary artery and help it respond to low levels of oxygen.

"We were surprised to learn that KCNK3 appears to play a role in the function of potassium channels in the pulmonary artery," said Dr. Chung. "No one had suspected that this mechanism might be associated with PAH." The other gene linked to the disorder, BMPR2, is thought to cause PAH by ultimately promoting growth and multiplication of smooth muscle cells in the pulmonary artery, thereby restricting blood flow.

Dr. Chung also found, working in collaboration with co-senior author, Robert S. Kass, PhD, the Alumni and David Hosack Professor of Pharmacology, chair of the department, and vice dean for research at CUMC, that the effects of the KCNK3 mutations could be reversed with an experimental phospholipase inhibitor called ONO-RS-082. The findings were made in cell cultures. Further study is needed to determine whether treatment with this or other drugs that affect potassium channels might be useful in the treatment of people with PAH, said Dr. Chung.

"KCNK3 mutations are a rare cause of PAH, so I don't want to oversell our findings," said Dr. Chung. "Still, it's exciting that we've found a mechanism that can lead to the disease that is a new, druggable target. It's also possible that targeting KCNK3 may be beneficial for patients who have PAH independent of their KCNK3 genetic status."

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our respiratory / asthma section for the latest news on this subject.

The paper is titled, "A Novel Channelopathy in Pulmonary Arterial Hypertension." The other contributors are: Lijiang Ma, Danilo Roman-Campos, Eric D, Mélanie Eyries, Kevin Sampson, Florent Soubrier, Marine Germain, David-Alexandre Trégouët, Alain Borczuk, Erika Berman Rosenzweig, Barbara Girerd, David Montani, Marc Humbert, and James E. Loyd.

The authors declare no financial or other conflicts of interests.

The study was supported by grants from the National Institutes of Health (R01 HL060056, P01 HL072058, K23 HL098743, and R01 HL56810) and by a Vanderbilt Clinical and Translational Science Awards (UL1 RR024975) from the National Center for Research Resources.

Columbia University Medical Center

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