Faculty Bibliography

Ten years ago I assumed the care of a woman with advanced pancreatic cancer that had spread to her spine. She was a well- known writer, and we quickly became friends. I would travel to her apartment and visit her for hours there, something I'd rarely done before and haven't done since. She had a close group of friends who visited her constantly, and an Irish nursing agency that cared for her impeccably around the clock. At first her cancer wasn't causing her pain, though it paralyzed her below the waist and bound her to her bed and wheelchair. Still, she enjoyed the visits, mine and everyone else's, until the fateful day when the cancer spread to her bones and began what was clearly an escalating pain. I dialed up the morphine to compensate, until the day came when the amount of morphine necessary clearly hastened her death. I was able to predict roughly the time she would die, and her friends said their goodbyes. I used morphine in the name of relieving suffering, not as a murder weapon. No one who knew her seemed upset by the trade-off, a tortured life for a peaceful death, and all thanked me for my care at the end

[Robert Webster]'s statement is the latest Hitchcockian pronouncement about H5N1 bird flu, a virus that is deadly in birds. But humans are different. We are protected by a species barrier, and serological surveys conducted in 1997 in Hong Kong and since have detected antibodies in thousands of humans who never got sick, showing that bird flu isn't as deadly to the few who come in contact with it as has been reported. If H5N1 takes hold in pigs and exchanges genetic material with another flu virus, the result is likely to be far less deadly. The swine flu fiasco of 1976 is an example of the damage that can be done from fear of a mutated virus that can theoretically affect us. More than 1,000 cases of paralysis occurred from a rushed vaccine given to more than 40 million people in response to a pandemic that never came

E. Coli is a common bacteria; trillions of strains that don't make us ill thrive and multiply in our intestines. But the 0157:H7 strain, which has been found in cow intestines, makes a toxin that damages human blood vessels and can cause blood clots and damage kidneys, especially in children. Cows don't have the receptors in their blood vessels to pick up the toxin, so they are asymptomatic carriers. What to do about the bacteria? Some studies suggest that feeding cattle hay rather than grain, or injecting them with 'pro-biotic' bacteria may help to reduce the prevalence of 0157:H7. At the national level, we need more integrated food-safety measures, a better way to coordinate the FDA and the USDA animal and food inspections. This could be accomplished by a new food-safety agency that acts as a bridge, or by expanded regulatory roles in both the FDA and the USDA

I acknowledged that one 85-year-old patient, Anne, who had been coming to see me for 20 years, had been placed on Zyprexa when she became demented and paranoid that ruffians who had harassed her as a child had somehow re-entered her life (they hadn't). A small dose of Zyprexa had helped Anne enormously, and she was now much calmer and no longer paranoid. I mentioned that most of the psychiatrists I knew used milder and better-tolerated mood-stabilizing drugs such as Depakote for bipolar disorder, that they didn't rely on the more powerful and side- effect-plagued Zyprexa as a mainstay of treatment. And neurologists had told me that antipsychotics such as Zyprexa are often over- prescribed for dementia and are not indicated if the patient is relatively calm. I don't deny I can play a role in the treatment of mental illness, but this is best accomplished in conjunction with a true expert. For instance, when I learned that Zyprexa can cause weight gain, I called Anne's psychiatrist and together we made the decision not to stop Anne's prescription because she had not gained weight on it. She already had diabetes, which has recently been associated with Zyprexa, but the pill had not worsened her condition

Less than 100 mg/dL -- optimal; 100 to 129 mg/dL -- near optimal; 130 to 159 mg/dL -- borderline high; 160 to 189 mg/dL -- high; 190 mg/dL and above -- very high. Many practicing cardiologists and lipid experts say these target numbers are far too high, and shoot for LDL cholesterols of 70 or 80 even in patients who lack known heart disease. I suggested a high-speed CT scan of the chest for calcium scoring, evidence of calcified coronary plaques. I would also order an ultrasound of her carotid arteries (in the neck), which would provide easy evidence of the kind of plaques that correlate with plaques in the coronary arteries of the heart

This scenario reads like something from our near future. Experts predict that the bird flu virus might hit our shores within a year. In fact, it's a news flash from three decades ago. The events of the so-called swine flu in the USA seem hauntingly familiar to those of us who are focused on the current bird flu, and they can serve as a useful guide on what to do now and -- perhaps as important -- what not to do. The rush to make vaccines for a flu virus to which we have no immunity is not a new concept. This is what happened during the swine flu fiasco of 1976, when the fear of another killer outbreak provoked a national political response and a rushed vaccination program. More than 40 million people received the swine flu vaccine that year against a new pig virus that ultimately never took hold. It was later determined that the swine flu wasn't as virulent or as deadly as originally thought. But more than 1,000 cases of Guillain-Barre syndrome, a life-threatening ascending paralysis, occurred in those who received the vaccine, which had been rushed into production. The public relations nightmare and lawsuits against the government helped to drive many drug companies away from making flu vaccine at all. (Of 27 companies that manufactured flu vaccines at the time, only three still do.)

About 36,000 Americans die each year from the flu, and 200,000 are hospitalized. Though a relatively small number of the deaths -- 100 -- are children 5 or younger, 20,000 hospitalizations include children in this age group. Inoculating children won't end this annual misery, but if more kids receive the vaccine, the impact of the flu virus could be softened considerably. *Efficacy. In addition, the flu shot's effectiveness in children has been questioned. Indeed, recent studies have indicated that the shot might be less effective in children younger than 2 because of weaker immune reactions. Two shots appear to be necessary to achieve comparable results. Does this mean these children shouldn't receive the shot -- or shots? No, it means parents and the children's doctors need to be vigilant in ensuring that these infants build up the required immunity. As for older children, the flu vaccine has proved highly effective. A 2001 study in the Journal of Pediatric Infectious Diseases showed a 77%-91% effectiveness against influenza in inoculated children ages 1-15. *Myths. The National Foundation of Infectious Diseases found that nearly half of the people surveyed this year believed erroneously that the flu vaccine, which uses a dead virus, can cause influenza. Another myth: A shot must be administered by November for it to be effective during the flu season, which generally runs from October through May. Because it takes less than a month for most patients to develop antibodies, and because flu season tends to peak in most parts of the USA in January, December is still a reasonable time to get the shot

Fatal Contact: Bird Flu in America [Television Program] -- IN 'Fatal Contact: Bird Flu in America,' which aired Tuesday night on ABC, a businessman returns to the U.S. from Hong Kong, where he has unwittingly picked up a newly mutated strain of the H5N1 bird flu from being coughed on by a factory worker. DO flu viruses mutate so rapidly that a bird flu can be transformed to a human killer flu overnight with a second, even more sinister, change occurring a few months later? And is the H5N1 bird flu virus close to mutating to a form that can go from human to human and cause the next pandemic? Are we so defenseless to flu that we will require mass graves when the next pandemic hits us? ALTHOUGH flu viruses mutate rapidly, the changes necessary to cause even a mild pandemic would take at least several weeks and several steps as a newly evolving strain attempted to adapt to a human host. The idea that H5N1 could transform instantly from a bird virus to a human virus, jump to a businessman who becomes 'patient zero' and spreads it throughout the U.S., is dramatic hype, not science