Community health workers' critical role in trust building between the medical system and communities of color.

The authors interrogate elements of routine medical practice in New York City to argue for reforms of hospital culture through relational trust-building capabilities of community health workers.

'A local habitation and a name': how narrative evidence-based medicine transforms the translational research paradigm.

RATIONALE: We propose narrative evidence-based medicine as a necessary elaboration of the NIH translational research roadmap. The roadmap defined two complex obstacles, T1 and T2, to the progress of research from the 'bench' or basic laboratory science to the 'bedside' or clinical application, the traversal of which requires emergence of complex transformative relationships between the parties and stakeholders. It fails to encompass patient interactions, hesitancies and alliances with medical care. AIMS AND OBJECTIVES: We suggest a third transformative or translational step, T3, that begins at the point that practitioners have themselves elected to adopt and recommend strategies and interventions based on high-level evidence and guidelines. In our model, T3 encompasses all aspects of care that converge on the practitioner-patient relationship and ultimately determine what therapies and choices patients actually make regarding their care. RESULTS: Learning from the biopsychosocial model, patient-centred care and shared decision making while attending to the ethical injunction of Emmanuel Levinas to know the other, we have developed a medical practice and theory that unites the local and specific concerns of narrative medicine with the generalizability and power of evidence-based medicine. CONCLUSIONS: We offer innovative approaches to study, teach and improve the therapeutic intimacy and integrative effectiveness of the practitioner-patient relationship.

Severe protracted fever following pneumococcal vaccine.

Streptococcus pneumoniae is one of the most common virulent pathogens in the world, causing the vast majority of cases of community-acquired pneumonia in patients who are hospitalized as well as a host of other illnesses, ranging in severity from otitis media to septic shock. Primary prevention with pneumococcal vaccines has effectively reduced the rates of associated morbidity and mortality. These various vaccine formulations have all shown excellent safety profiles. Since 1977, when commercial pneumococcal vaccine first became available, fewer than 10 case reports have been published describing the development of serious side effects in adults after their first vaccination. We describe a 40-year-old healthy man who, after receiving polyvalent pneumococcal polysaccharide vaccine, developed severe protracted fever for 9 days.

Risk of malignancy in patients with celiac disease.

PURPOSE: Studies from Europe have demonstrated an increased risk of malignancy, especially non-Hodgkin's lymphoma, in patients with celiac disease. However, there are no data on the risk for similar patients in the United States. Our aim was to estimate the risk of malignancy in a cohort of patients with celiac disease compared with the general U.S. population and to determine if a gluten-free diet is protective. METHODS: Patients with celiac disease seen between July 1981 and January 2000 at a referral center were included. Standardized morbidity ratios (SMRs) (ratio of observed to expected) and corresponding 95% confidence intervals (CI) were calculated, using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. RESULTS: Forty-three (11%) of 381 celiac disease patients had a diagnosis of cancer; 9 were after the diagnosis of celiac disease, 7 were simultaneous (during same month or admission), and 27 were before the diagnosis. The standardized morbidity ratio for all cancers combined was 1.5 (95% CI: 0.3 to 7.5), with significantly increased values for small bowel cancer (SMR = 34; 95% CI: 24 to 42), esophageal cancer (SMR = 12; 95% CI: 6.5 to 21), non-Hodgkin's lymphoma (SMR = 9.1; 95% CI: 4.7 to 13), and melanoma (SMR = 5.0; 95% CI: 2.1 to 12). Following the diagnosis of celiac disease, patients were at increased risk of non-Hodgkin's lymphoma only (SMR = 6.2; 95% CI: 2.9 to 14), despite adherence to a gluten-free diet. The non-Hodgkin's lymphoma included both T-cell and B-cell types and occurred in both gastrointestinal (n = 5) and extraintestinal sites (n = 4). CONCLUSION: In this cohort of patients with celiac disease, we observed increased risks of small intestinal adenocarcinoma, esophageal cancer, melanoma, and non-Hodgkin's lymphoma. The risk of non-Hodgkin's lymphoma persisted despite a gluten-free diet.