Antibodies to Staphylococcus aureus heat shock proteins (Hsps) are present in the sera of patients with S. aureus endocarditis (M. W. Qoronfleh, W. Weraarchakul, and B. J. Wilkinson, Infect. Immun. 61:1567–1570, 1993). Although these proteins are immunogenic, their role in infection has not been established. We developed a cell culture system as a model to examine the potential involvement of staphylococcal Hsps in the initial events of infection. This study supports a model in which a clinical endocarditis isolate responds to host cell signals by selectively regulating the synthesis of numerous proteins, including the stress proteins Hsp60 (GroEL homolog) and Hsp70 (DnaK homolog) and a unique 58-kDa protein.

PROBLEM: ACGME requires cultural competency training. Yet, trainees often do not receive formal training in the setting of cultural competency. We propose to apply the use of medical students as simulated patients to teach these skills. INTERVENTION: At orientation our interns participated in a workshop involving case-based scenarios created to include culturally sensitive topics simulated by medical students. CONTEXT: Small group sessions included 5-6 interns, a faculty member, student actor and expert. Immediate feedback was given. Each intern completed a brief pre-and post- survey and a reflection essay. A checklist created using the ETHNIC model was used. Medical students and faculty attended a didactic training session, and faculty received the cases and learning objectives prior to the workshop. OUTCOME/LESSONS LEARNED: Statistically significant improvements were noted in familiarity with cultural competency (P = 0.0001), comfort with medical needs of patients from different cultural backgrounds (p = 0.0016), understanding individual’s cultural background can be a health determinant (p = 0.0001), understanding how differences between cultures and personal healthcare practices can affect the perception of care (p=0.001), importance of negotiating a mutually acceptable treatment plan that may differ based on the patient’s cultural background (p = 0.0001), and understanding that it is the physician’s job to create a culturally sensitive environment (p = 0.0001). No statistically significant differences were noted in understanding how a patient explains/perceives illness or importance of collaboration with patient's other health providers. These outcomes will be used to improve the case-based scenarios.

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A 2-year-old boy presents to the emergency department with a 24-hour history of progressive malaise, ataxic gate, and somnolence. He has had bilious vomiting 4 to 5 times a day unrelated to food consumption and constipation for nearly a week. His mother states that he has had no fever, convulsions, diarrhea, jaundice, or symptoms of viral upper respiratory tract infection. There is no history of trauma, exposure to toxic substances, or drug use. He was born from a consanguineous marriage. His medical history is significant for cholestasis that developed during his second month after birth. There is no family history of neonatal cholestasis.On physical examination, the boy has normal vital signs. He has incomprehensible speech, makes purposeless movement in reaction to stimuli, and has hyperactive deep tendon reflexes. His Glasgow Coma Scale score is 9. There are no signs of meningeal irritation and no focal neurologic deficits. The rest of his findings on physical examination are normal.Laboratory studies reveal a normal complete blood cell count, serum electrolyte levels, and blood gas test results. He has mildly elevated aminotransferase levels (alanine aminotransferase [ALT], 85 U/L; aspartate aminotransferase [AST], 131 U/L; and g-glutamyl transferase, 8.6 U/L). The direct bilirubin level is 0.29 mg/dL (5.0 mmol/L), total bilirubin level is 1.05 mg/dL (18.0 mmol/L), serum glucose level is 101 mg/dL (5.6 mmol/L), albumin level is 3.5 g/dL (35 g/L), and international normalized ratio (INR) is 1.73 (reference range, 0.86-1.20). Urine toxicology screening results are negative. Cerebrospinal fluid analysis results are normal. However, his blood ammonia level is elevated at 398 mg/dL (reference range, 15-45 mg/dL). Additional medical history and imaging studies reveal the diagnosis. CASE 1 DISCUSSIONReview of the patient's medical records revealed that he was evaluated at age 9 months and found to have hepatomegaly, jaundice, and a cardiac murmur. He had significantly elevated aminotransferase levels and direct hyperbilirubinemia. Viral serologic test results were negative for acute viral infections. Hepatobiliary THE CASE