Contents:

• Introduction
• Research Activities

Introduction

It should be noted that Rheumatology’s 2008 first year fellowship position is filled.  We are accepting applications for the 2009 fellowship position through the Electronic Residency Application Service (ERAS), a web-based system.  Fellowship applications can be submitted to ERAS beginning on December 1, 2007.  Applications will be reviewed and interviews conducted during winter 2007/2008.  There will be a June 2008 Match for the position starting July 2009, utilizing the services of the National Residency Matching Program (NRMP).

The Rheumatology training program is designed to train physicians for careers in academic or clinical rheumatology. Although the required fellowship program is two years in duration, trainees with a special interest in laboratory research or an academic career are encouraged to stay for additional training. The Rheumatology training program has six faculty members and two fellows, a first year and second year fellow.

The Medical Center Campus is the main teaching hospital of Fletcher Allen Health Care (FAHC). It is a tertiary and primary care facility with 420 beds and over 20,000 admissions per year. The Medicine Health Care Service consists of 160 beds divided among general medical, subspecialty services and intensive care units.

The Rheumatology and Clinical Immunology outpatient service is located in the Gartman Medicine Specialty Center in the Ambulatory Care Center (ACC) at FAHC.  It consists of 10 exam rooms, 2 consult rooms, a nurses station, The Osteoporosis Center, which is equipped with Lunar dual photon x-ray for analysis of bone density, and an IV fusion center. The rheumatology outpatient service operates from 8:00 am to 5:00 pm, Monday through Friday, with between 25-50 patients seen daily and approximately 8,000 patient visits per year. Satellite outpatient services are offered at Central Vermont Hospital in Montpelier, Copley Hospital in Morrisville,  Northwestern Medical Center in St. Albans, and Champlain Valley Physicians’ Hospital in Plattsburgh NY. The patient mix is excellent, and includes rheumatoid arthritis, psoriatic arthritis, spondyloarthropathy, systemic lupus erythematosus, other connective tissue diseases, vasculitis, osteoarthritis, regional musculoskeletal problems and fibromyalgia. The clinical service operates like a private group practice, so that the trainee's experience is similar to what one would experience in a private rheumatology office.

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Research Activities

The Rheumatology training program is part of the Rheumatology and Clinical Immunology Unit of the Department of Medicine, and was reaccredited by the Residency Review Committee of the Accreditation Council of Graduate Medical Education in December 1997.

The faculty has varied interests in both basic laboratory investigation and clinical research. The laboratory research program, which is supported by research technicians and graduate students, is in the Given Building of the College of Medicine contiguous to the MC Campus. The Rheumatology and Clinical Immunology Unit and Immunobiology Program have combined laboratory space of approximately 4,500 square feet, including laboratory bench space, tissue culture facilities, incubators, and specialized work areas for radioisotopes, biochemistry, and molecular biology. Core facilities include a Coulter Elite Flow Cytometry Facility and an animal facility with transgenic capabilities. Within the research complex are an imaging facility with confocal, electron and atomic microscopy, and a DNA sequencing core laboratory. The clinical research programs are housed at the ACC and the Clinical Research Center at the MC Campus.

Dr. Sheldon Cooper's laboratory research focus is directed at understanding the immune mechanisms operative in rheumatoid arthritis. Cellular and molecular biology methods are used to dissect the role that the immune system plays in perpetuating the inflammatory synovitis. One question that is being addressed is whether pathogenic T lymphocytes can be identified by analysis of the T cell antigen receptor repertoire of synovial T lymphocytes. In rheumatoid arthritis, psoriatic arthritis, and Lyme arthritis, a biased T cell receptor repertoire has been found, and there are similarities in the T cells that accumulate in the joints of these patients. Another research interest is to determine how therapy with immune modifiers, such as monoclonal antibody to CD4, exert their therapeutic effect. The studies are designed to identify which immune cells may be undergoing apoptosis or programmed cell death as a result of therapy. Results suggest that there may be apoptosis of monocytes and macrophages, which could lead to changes in cytokine patterns. Dr. Cooper has a special interest in the use of minocycline for rheumatoid arthritis, and the potential for using metalloprotease inhibitors to limit progression in both rheumatoid arthritis and osteoarthritis.

Dr. Ralph Budd's research focus is T lymphocyte function. He is studying the signaling molecules that promote proliferation and death of lymphocytes, particularly molecules of the Fas family that regulate programmed cell death or apoptosis. Considerable use is made of the lupus-prone lpr mouse, which bears a mutation in the fas gene. Dr. Budd is also studying the role of T lymphocytes in Lyme arthritis, the most common vector-borne disease in the United States. Lyme synovial fluids contain large numbers of gamma delta T cells which appear to respond to the causative organism, Borrelia burgdorferi. One of the questions under study is what is recognized by these gamma delta T cells and how are they activated. Since these gamma delta T cells express Fas ligand and are cytotoxic to cells that express Fas, the possibility that they have an immunoregulatory function in Lyme arthritis is under investigation.

Dr. Mercedes Rincón's research has been focused on understanding the regulation of gene expression and signaling pathways involved in T cell mediated immune response. Using reporter transgenic mice, she has shown that AP-1 and NFAT transcription factors are differentially regulated during the development of T cells in the thymus, activation of naive CD4+ T cells, and differentiation of these cells into effector Th1 and Th2 cells. To complement these studies, her research is currently focused on the regulation and role of specific signaling pathways that lead to activation of transcription factors. Genetically modified mouse models (transgenic or knock out mice) are used to determine the role of JNK and p38 MAP kinase pathways in thymic development and the balance of Th1/Th2 responses. Dr. Rincón's group is also investigating the role of the cytokine IL-6 in the development of Th1 and Th2 responses, anti-tumor response, and cancer cell survival.

Dr. Edward Leib is involved in the study of new and already approved agents for the treatment of osteoporosis. Dr. Leib is also performing comparative studies of different methods for quantifying bone mineral density, and with Dr. Cooper is examining the risk factors for developing osteoporosis in patients with rheumatoid arthritis.

Several other clinical research projects are underway. Dr. Cooper is studying newly developed cytokine antagonists for the treatment of rheumatoid arthritis. Dr. Bonita Libman is studying light therapy for patients with fibromyalgia. Dr. Libman has a special interest in polymyositis and the therapeutic use of intravenous IgG. Dr. Chi Chi Lau is investigating the specificity of antinuclear antibodies in drug-induced lupus.

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