Faculty Bibliography

The Accutane case could force a reappraisal of legislation governing the F.D.A.'s powers to regulate drugs after they are marketed. But for now, the experience with Accutane throws a stark light on the problems doctors have in dealing with powerful, dangerous drugs. Accutane, whose generic name is isotretinoin, was the first to be licensed in what is expected to be a series of drugs derived from Vitamin A, called retinoids. The drugs were developed under the direction of Werner Bollag, M.D., when he was chief of cancer research for F. Hoffmann-La Roche & Company of Basel, Switzerland. The Swiss company's American arm, Hoffmann-La Roche Inc., is based in Nutley, N.J., and is the parent of Roche Laboratories, which makes Accutane. Many doctors also demand agreement from a patient before prescribing the drug that she would terminate a pregnancy that occurred while using it, although, of course, this could not be enforced. (In Britain, women taking Accutane actually sign a written agreement they will abort accidental pregnancies while on the drug.) Then, after repeated warnings, many doctors, mindful of potential malpractice suits, insist on having a patient sign a form in the chart stating that they have read the literature and understand the complications. In filling a prescription for Accutane, a pharmacist is supposed to point to the warning against pregnancy on the bottle, even to affix an extra sticker to the cap. But not all pharmacists take such steps

''State government regulation may be having unintended effects'' on the quality of health care, said Dr. Stephen M. Shortell of Northwestern University in Evanston, Ill., a co-author of the study. He said the findings ''raise serious concerns about the welfare of patients who are admitted to hospitals'' that have stringent state regulations. The researchers said their findings ''underscore the need for improved monitoring of the issue of quality of care and patients' outcomes as regulatory and competitive approaches to hospital cost containment continue to become more stringent.''

Tests of the HGP-30 vaccine, which will involve 24 infected volunteers who will receive injections of varying doses, are designed to determine the safety of the vaccine and to see what kind of immune reactions it stimulates. They are not intended to test the vaccine's effectiveness in preventing infection with the virus or, in already infected patients, suppressing it. The vaccine is believed to be safe because it contains no AIDS virus. The HGP-30 vaccine is a synthetic version of a string of amino acids in a core protein, p17, in the inner shell of the AIDS virus. West German researchers have shown that p17 lies adjacent to the porous outer surfaces of the virus. Other AIDS vaccines, are based on proteins found only in the virus's outer shell

''Somewhat to everyone's surprise'' Dr. [Jonathan Mann] said, in Thailand, ''rather than sex or prostitution being the entry point for AIDS and the real point of amplification, the intravenous drug user is playing that role.'' Dr. Mann added, ''This Thai experience shows very clearly that Asia is just as vulnerable to an explosion of HIV infection as any other part of the world.'' The W.H.O. plans to step up activities to control AIDS in Asia as part of its global program while the incidence of infection there is low. There has been rapid movement over the last two years from ''chaos to a measure of order and rational planning in how the world is going about approaching AIDS control,'' though it is not yet ideal, Dr. Mann said. Focus on Africa Dr. Samuel Adeniyi-Jones, a Nigerian working at the National Institutes of Health in Bethesda, Md., testified as a private person, urging development of health education programs that emphasize AIDS prevention. He also suggested providing training and equipment to test for AIDS in blood banks. In addition, he backed improved care for AIDS patients in clinics and counselling as part of the testing for AIDS infection.

The specialty of internal medicine can loosely trace its heritage to Sir William Osler, a Canadian who also practiced in the United States and England and who came to prominence in the late 1800's. At the time, the specialty had not been defined as such, but Sir William is credited with profoundly influencing medical education by broadening the scope and structure of clinical training. (Internists, however, are not to be confused with interns who are in their first year of hospital training after school. Such doctors are now also called first-year residents.) ''The profession has a responsibility to maintain the generalist whose chief function is the continuous care of patients, a professional ombudsman who will look out for me and my problems no matter what their cause,'' said Dr. John S. Graettinger, executive vice president of the National Resident Matching Program in Evanston, Ill. ''There was probably complacency to the point of smugness,'' said Dr. Frank Davidoff of the education division of the American College of Physicians in Philadelphia. ''As long as the more visible training programs filled their slots, everybody thought the world was just hunky-dory.'' ''There are strong lures from other disciplines in which the science and art of medicine can be practiced without the disappointments of therapeutic failure and the grief of unrealized patient expectations,'' said Dr. Lawrence Scherr, who heads the department of internal medicine at North Shore University Hospital in Manhasset, L.I. Dr. Scherr is also a professor at Cornell Medical School

Under the program, phsicians will determine the eligibility of patients. Searle will provide to physicians and clinics certificates that a patient can exchange for the medication at a local pharmacy, which will then be reimbursed by Searle. In challenging other drug companies to start similar programs, Dr. Sheldon G. Gilgore, Searle's chairman, said that ''the American pharmaceutical industry can satisfy the unmet prescription needs of the medically indigent patient population in this country.'' Judee Shuler, a spokeswoman for the Pharmaceutical Manufacturers Association in Washington, said it would be ''up to individual member companies to respond.'' Praise From A.M.A. The American Medical Association complimented Searle on the program. ''The A.M.A. is certainly pleased to see a major phamaceutical firm taking steps to make important drugs available free of charge to patients who could not otherwise afford them, and is also pleased that physicians are rightly being made a key part of the process,'' said Dr. James H. Sammons, executive vice president of the Chicago-based organization

''We can put a skinny needle about anywhere in the body and make multiple thrusts with impunity to take biopsies that once could be obtained only through major surgery,'' said Dr. Joseph T. Ferrucci Jr., a radiologist and an expert in the technique at the Massachusetts General Hospital in Boston. ''CT scans cannot give us a pathological diagnosis,'' Dr. Ferrucci said. Such diagnoses are based on examination of tissue or cells, and they are needed before treatment of cancer and other serious diseases can begin. Moreover, a lymph node that doctors fear may have cancerous cells may appear to be of normal size on CT scan, but still contain malignancy. Generally, and especially when the tissue to be tested lies deep in the body, a patient receives injections of Valium or Demerol and a local anesthetic such as novocaine before a skinny needle is inserted through the skin. Measurements made from X-rays or pictures obtained by ultrasound determine the angle of the thrusts and the depth of the penetration of the needle. Often, when the needle reaches a tumor, it meets more resistance and there is a feeling of ''grittiness.''

Another puzzle is why almost all attacks follow sore throats caused by streptococcal bacteria, but only a few ''strep'' throats lead to rheumatic fever. The particular subgroup of strep bacteria cited in rheumatic fever cases is called group A. Rheumatic fever usually occurs in childhood but can cause long-term damage. In 1985, about 6,600 Americans died of heart disease resulting from bouts with the fever decades ago. There can be repeated attacks of rheumatic fever after additional attacks of strep throat; once the damage has occurred, it can be chronic and progressive. The minor indications are fever, joint pains and a history of previous attacks of rheumatic fever. The presence of two major, or one major and two minor manifestations signals a high likelihood of rheumatic fever. The decline of rheumatic fever began before the introduction of penicillin, which led many experts to say that antibiotics were not the chief cause of its disappearance. Antibiotics have a limited role in preventing first attacks because many occur after strep throats that did not cause symptoms or were so mild that patients did not consult a physician. However, penicillin has been effective in preventing recurrent attacks of rheumatic fever

With an ultrasound machine like those commonly used in studying the fetus, doctors find the gallstones and position the patient so that the shock waves are focused on the stones, sparing surrounding tissue. (Older machines used on kidney stones typically use X-rays to find stones.)

Dr. [Devra Lee Davis], who is an epidemiologist and toxicologist, said in an interview that she included such factors as nutrition, life style, stress, workplace and housing in her definition of environment. She said ''we need to move away from the notion of single causes'' of cancer and ''need to ask new questions.'' Dr. [David Schottenfeld] said that interpreting trends in cancer deaths ''is very tricky'' but that ''the challenge they are throwing out to us is valid.'' He said the researchers ''are being provocative and stimulating us to think about environmental chemical exposures'' and to do additional studies. Dr. Davis noted that many years ago, some experts doubted early reports of the increase in lung cancer deaths that experts later attributed mainly to smoking. Because of unanswered questions about the rise in some cancers in the elderly, Dr. Davis said, ''the burden of proof should be on researchers to come up with an explanation rather than to continue to say that the increasing trends are artifacts.''