Faculty Bibliography

Prescription drugs have certainly been taking a hit lately in terms of public perception. Drug safety has become a popular topic, and many classes of drugs, from COX-2 inhibitors to psychiatric drugs like SSRIs and Adderall, for ADHD, have been repeatedly criticized. Any substance, whether in pill or herbal form, has an effect on the body and must be studied. It is wrong to assume that a prescription drug is automatically toxic, while untested alternative medicines are presumed safe

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

Polls show that our overall fear has remained fairly constant since 2001. An Associated Press/Ipsos poll the week after the July 7 bombings in London found 57% of us believe an attack on mass transit is inevitable, and 37% are concerned they or their loved ones will be the victims. These percentages have remained steady over the past year. But polls also indicate that recent attacks -- including the failed bombings July 21 in London and the successful ones two days later in Sharm el-Sheik, Egypt -- increase the public expectation elsewhere that the next strike might come soon. A USA TODAY/CNN/ Gallup Poll just after the London bombings found that 55% said an act of terrorism on U.S. soil was likely in the next few weeks. Elizabeth Phelps, professor of psychology and neural science at New York University, has been researching the effects of perceived danger on the human brain. She has added her findings to the pioneering work of Joe LeDoux, another neuroscientist at NYU. It turns out that the brain has a fear center, known as the amygdala. It's a tiny almond-shaped structure deep inside the brain that emits fear signals and initiates an outpouring of stress hormones. Though Ledoux's work on the amygdala is well established in animals, Phelps' applications to humans are still somewhat preliminary. Using the latest techniques in magnetic resonance imaging exam, Phelps has studied the brain's response to videos of dangerous situations rather than real dangers. She has shown that the effects on the brain's physiology are the same with a simulated attack as with a real one. Internet, television, movies -- these are all vehicles for the type of response that Phelps has studied. Visualized threats get our juices going, and we are ready to respond

In order to safely produce a multi-dose vial it is often necessary to add a chemical such as thimerosal. Unfortunately, when the questions about this additive were first raised, vaccine manufacturers did not quickly shift production to another product, Instead, they left themselves open to accusations that they have caused thousands of cases of autism. Thimerosal is not a crucial part of vaccines, it could have been removed long before the current outcry

At a time when drug safety is being questioned, and side effects of common drugs are often magnified, it is reasonable to question whether antidepressant medications are being properly utilized. Depression and anxiety are prevalent in an internist's practice, and in fact generalists diagnose and treat most of these conditions. The art of medicine is helping a patient distinguish between a sad mood and a clinical depression requiring medication. And with depression, the effects of the illness are often more severe than the side effects of the drug being considered

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

Remarkably, I found that she was also much less confused. A lung doctor who had treated Pearl for many years for occasional bronchitis came to visit her in the hospital, and she cheerfully complimented the doctor on her new hairstyle. The lung doctor remarked to me that she thought Pearl was very observant -- and grumbled that her own husband hadn't noticed her hairstyle change. At first, the neurologist didn't agree. Ultimately, when Pearl resumed doing crossword puzzles and knowing the details of others' lives, even the neurologist -- though still not convinced -- admitted that the sodium aberration had been the more likely culprit. Because 4 million Americans suffer from Alzheimer's disease, including almost half of people older than 85 (Pearl was close at 83), it was understandable that the neurologist had considered this disease. Alzheimer's has a devastating outcome attached, and because there are many other conditions that can cause similar memory loss and confusion (depression, infection, metabolic disturbances of all kinds), rushing to give a stigmatizing diagnosis such as Alzheimer's is unwise unless a doctor is almost certain. Without absolute tests at this point, and because Alzheimer's disease evolves, diagnosing it properly means observing a trend, not making a pronouncement on one day's observations

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

Combining prescription drugs has advantages, but various combinations can have conceptual differences. When 2 medications are combined in 1 pill, as in 2 new statin combos, a doctor may not be able to identify which drug is causing a side effect. Packaging 2 drugs physically separate but together in a blister pack makes the most sense for initial therapy