Faculty Bibliography

Most neurologists would contend that [Terri Schiavo] cannot feel anything, even pain or thirst. The problem with this assertion is that no one has come back from such a state of neurological impairment to verify or dispute this contention. She reportedly lacks upper brain function, meaning her thinking centers are still, but it cannot be proved that the lower brain would not allow her to feel discomfort. It is generally accepted that a physician's role in health care is to prolong life or relieve undue suffering. The only time a true medical debate emerges is when these two roles come into conflict. The Schiavo case is not such a time. It is difficult to argue for euthanasia because she does not appear to be suffering. Working to prolong her life simply means providing nutrition, which physicians usually do without endless debate. The most disturbing aspect of the Schiavo case is that the doctors are portrayed as those who will simply abide by the final decision and either put the tube back in or keep it out -- a job for a medical yo-yo rather than a professional. But doctors are not court-appointed mechanics. Our own code of ethics and standards must drive us. Removing feeding tubes is not part of my job description. It should not be part of a physician's job at a Florida hospice either

The greatest problem among my patients right now isn't bird flu; it is fear of bird flu. The greatest risk of an epidemic is of a fear epidemic. For one thing, comparisons to the terrible scourge of 1918 -- when another bird flu mutated and passed human to human -- have dilated the sense of danger. But there are many differences between 1918 and now. Many of the 1918 flu victims died of pneumonia because of a lack of antibiotics, which we now have in ample supply. There were also no flu vaccines or antiviral drugs back then, and people lived (and died) in wartime conditions of deprivation and sometimes squalor. This is how fear works, how the fear epidemic -- as opposed to a flu pandemic -- spreads. Fear is supposed to be our warning system against imminent dangers, but as a deep-rooted emotion, it interferes with our ability to make sound judgments. And if anything is contagious right now, it's judgment clouded by fear

He acknowledged my suggestion that he go see a gastroenterologist, writing down the doctor's name -- but he never made an appointment. [FRANK] returned to his lifestyle of heavy eating and smoking. He said the negative results in the ER had reassured him, and now he seemed to be in even more denial. He popped a Prevacid whenever he felt the slightest discomfort. He continued to experience chest pains, and after a few months, he was back in the ER. The initial tests were once again negative, but this time I kept him overnight for observation and arranged for a stress test before discharging him. Frank's cycle of worry and denial is common among men with a poor self-image and untreated depression. Many fail to respond to the warning signs, no matter how serious. Luckily, in Frank's case, the second shock of the ER was enough

Each terror alert, too, triggers a wave of often unjustified fear. Anthrax infected 22 people through the U.S. mail in the fall of 2001, killing five. Yet 30,000 people began taking the powerful antibiotic Cipro, many indiscriminately and without a doctor's prescription. In 2002 news reports began to circulate that some of the smallpox virus that had been stockpiled in the former Soviet Union might have found its way into the hands of rogue dictators or terrorists. There hasn't been a case of smallpox in the United States since the 1940s and if it ever reappears it is likely to spread slowly, but the fear of smallpox raced virulently through the public. New York neuroscientist Joseph Ledoux, whose book 'The Emotional Brain' describes how the brain processes emotions, has studied fear extensively. 'When a rat is afraid and when a human is afraid, very similar things occur in the body,' he told me. But Ledoux also believes that triggers of fear vary dramatically from species to species. Ledoux described the amygdala, the almond-shaped brain structure that interprets emotion, as 'the hub in the brain's wheel of fear.' When the amygdala is stimulated, there is an outpouring of stress hormones, causing a state of hyper-vigilance. The amygdala processes the primitive emotions of fear, hate, love, bravery and anger -- all neighbors in the deep limbic brain that we derive from lower animals. When the amygdala malfunctions, a mood disorder, or state of uncontrollable apprehension, results

Early detection centers focus on women who may be at high genetic risk for ovarian cancer -- women like Cara Kealy, a 36-year-old mother of two from Mount Vernon, N.Y. After Kealy developed breast cancer at age 30, she was found to have a BRCA-1 gene mutation, which is associated with a high risk of ovarian cancer. [David Fishman] was thus able to tell her, based on established pathological testing of ovaries removed from other patients, that her ovaries have a 20 percent chance of having premalignant changes. This was enough to make Kealy decide to have her ovaries removed once she no longer wants the option of becoming pregnant again. 'I know I'll have them out. It won't be this year, but it will be soon,' she said. The spirit of international cooperation that Fishman envisions for the acceptance of his protein test doesn't yet exist. Critics of his spectrometric blood analysis haven't been able to reproduce his findings of almost 100 percent specificity, which were published in 2000. Fishman says improvements in technology -- he can now look at millions of protein fragments at once -- make his results far more reliable and reproducible. But a group of researchers at Yale remain unconvinced. They also say the state-of-the-art computer required for Fishman's method is too costly to be practical for broad use in a clinical setting. Led by Gil Mor and David Ward, the Yale group published a study in the May 10 issue of the Proceedings of the National Academy of Sciences, identifying four proteins -- leptin, prolactin, osteopontin and insulin-like growth factor-II -- that all tend to be abnormal in ovarian cancer more than 95 percent of the time. True, the abnormalities aren't unique to ovarian cancer, acknowledges Mor, director of the Reproductive Immunology Unit at Yale University School of Medicine, but identifying abnormalities in four complete proteins -- not just protein fragments -- is 'a good start,' he says; he intends to end up with 12 or more in an assay, or blood analysis, that will cost $10 to $20 to run -- instead of thousands of dollars

The article suggests that a baby whose mother is using SSRIs may suffer withdrawal symptoms including seizures when the child is born and abruptly stops getting the drug through the mother's bloodstream. But the study -- based on a survey of reports of adverse drug reactions -- contains no definitive evidence of this effect. There has been no clinical trial comparing infants whose moms did and didn't take Paxil during pregnancy. (Paxil is available to pregnant women by prescription, though manufacturer GlaxoSmithKline says on its Web site that some complications, including seizures, have been reported in babies whose mothers had used the drug during pregnancy.) More important, numerous studies have documented the adverse effects of maternal depression on fetal and infant well-being. Untreated depression during pregnancy has been associated in several studies with premature labor and low birth weight. A Danish study published in The Lancet in 2000 reported that maternal emotional distress led ultimately to congenital malformations. A study from Emory University in 2001 revealed that infants whose mothers had been depressed during pregnancy showed a higher than normal stress response at the age of 6 months. Depressed women are also at higher risk for using alcohol, drugs and tobacco, as well as for very poor diet and sleep habits, all of which have been shown to impair fetal development more than antidepressants do. [Shari Lusskin] has identified several risk factors for depression during pregnancy, including a history of depression, a family history of mental illness, a lack of social support from spouse and friends, and anxiety about the fetus, especially if the pregnancy is unplanned. Screening for such factors is vital, Lusskin said

Even if we accept the Spanish flu scenario, health conditions in 1918 were far worse in most of the world than they are now. Many people lived in squalor. There were no flu vaccinations, no antiviral drugs, and containment by isolating infected individuals wasn't effective, largely because of poor information and poor compliance. Today's media reach could be a useful tool to aid compliance. Of course, the concern that air travel can spread viral infections faster may be valid, but infected migratory birds were sufficient in 1918

Last September, the giant drug company Merck announced that it was pulling its popular arthritis drug, Vioxx, off the market, even though it racked up $2.5 billion a year in sales. This happened on the heels of the publication of three separate books dealing with drugs and health care