Faculty Bibliography

When former President Reagan disclosed in November 1994 that he had Alzheimer's disease, many people could not help suspecting that the illness had begun to rob him of memory while he was in the White House. 'There was never anything that would raise a question about his ability to function as president,' said Dr. Lawrence C. Mohr, one of Reagan's physicians in his second term. 'Ronald Reagan's cognitive function, belief structure, judgment, ability to choose between options, behavior and ability to communicate were totally and completely intact.' Dr. John Hutton, the chief White House physician during Reagan's last two years in office and a close family friend, said he was speaking out with the permission of the former president's wife, Nancy, chiefly to rebut published statements questioning Reagan's mental status in office

At one point in the visit, Reagan had left the room briefly with a nurse. When they came back, Nancy Reagan went on, ``he said to the nurse: `Who is that man sitting with Nancy on the couch? I know him. He is a very famous man.''' It has been almost three years since Reagan disclosed that he had the memory-destroying neurological illness known as Alzheimer's disease. If, at 86, the old movie actor still looks the image of vigorous good health, the truth is that the man behind the firm handshake and barely gray hair is steadily, surely ebbing away. Reagan still plays a little golf, works out lightly in his basement and walks amid eucalyptus and day lilies in parks close to home. He puts on a suit and is driven to his office in nearby Century City. As he rides the elevators or walks the corridors, he remains the perfect gentleman, sweeping a hand through the air to let a woman pass by. Well-wishers are ushered into the office, and the 40th president of the United States obliges them with a warm welcome and a photo op

By 1998, a Medicare prospective payment system for home care is expected to be in place. Physicians must become more involved in home care, because they will be held accountable for the patients they refer and the services they order.

OBJECTIVE: To characterize the susceptibility to levofloxacin of clinical isolates of Mycobacterium tuberculosis (MTB) obtained from patients with HIV-related tuberculosis and to characterize the molecular genetics of levofloxacin resistance. DESIGN AND METHODS: Isolates from culture-positive patients in a United States multicenter trial of HIV-related TB were tested for susceptibility to levofloxacin by minimum inhibitory concentration (MIC) determinations in Bactec 7H12 broth. Automated sequencing of the resistance determining region of gyrA was performed. RESULTS: Of the 135 baseline MTB isolates tested, 134 (99%; 95% exact binomial confidence interval, 95.9-99.9%) were susceptible to levofloxacin with an MIC < or = 1.0 microg/ml. We identified a previously unrecognized mis-sense mutation occurring at codon 88 of gyrA in a levofloxacin mono-resistant MTB isolate obtained from a patient with AIDS who had received ofloxacin for 8 months prior to the diagnosis of tuberculosis. CONCLUSIONS: Clinical MTB isolates from HIV-infected patients were generally susceptible to levofloxacin. However, the identification of a clinical isolate with mono-resistance to levofloxacin highlights the need for circumspection in the use of fluoroquinolones in the setting of potential HIV-related tuberculosis and for monitoring of rates of resistance of MTB isolates to fluoroquinolones

The [Bhagwan Shree Rajneesh] outbreak and the multiple murders are likely to raise suspicions among public-health investigators. The idea that criminal activity is responsible 'needs to be in the back of our mind in an investigation when things do not add up,' says Dr. [Thomas J. Torok]. 'But usually it should be at the bottom of the list.'

One-third of humans are infected with Mycobacterium tuberculosis, the causative agent of tuberculosis. Sequence analysis of two megabases in 26 structural genes or loci in strains recovered globally discovered a striking reduction of silent nucleotide substitutions compared with other human bacterial pathogens. The lack of neutral mutations in structural genes indicates that M. tuberculosis is evolutionarily young and has recently spread globally. Species diversity is largely caused by rapidly evolving insertion sequences, which means that mobile element movement is a fundamental process generating genomic variation in this pathogen. Three genetic groups of M. tuberculosis were identified based on two polymorphisms that occur at high frequency in the genes encoding catalase-peroxidase and the A subunit of gyrase. Group 1 organisms are evolutionarily old and allied with M. bovis, the cause of bovine tuberculosis. A subset of several distinct insertion sequence IS6110 subtypes of this genetic group have IS6110 integrated at the identical chromosomal insertion site, located between dnaA and dnaN in the region containing the origin of replication. Remarkably, study of approximately 6,000 isolates from patients in Houston and the New York City area discovered that 47 of 48 relatively large case clusters were caused by genotypic group 1 and 2 but not group 3 organisms. The observation that the newly emergent group 3 organisms are associated with sporadic rather than clustered cases suggests that the pathogen is evolving toward a state of reduced transmissability or virulence

Using the latest computer tomography (CT) and X-ray (DEXA) technology to measure body fat in 224 Caucasian women, researchers confirmed that abdominal fat, particularly internal fat wrapped around the liver and other internal organs, is linked to heart disease. According to their report in the American Journal of Clinical Nutrition, leg fat was actually associated with better cardiovascular health

Consider two outbreaks that were initially attributed to an unusual natural accident and a hereditary disorder. Later they were found to have been caused by criminal acts, something that doctors generally have little reason to consider in most cases of disease, as opposed to cases of physical violence, long recognized as a public health problem. And even when doctors do find a criminal cause for a medical problem, they have tended not to report the cases in medical journals, partly, they say, to avoid further incidents. That attitude has begun to change, albeit slowly. Last week Federal health officials focused new attention on one such criminal outbreak 13 years after it happened. They published a report in The Journal of the American Medical Association about 751 cases of salmonella infection that occurred in 1984 among the 10,500 residents of The Dalles, Ore., because followers of Bhagwan Shree Rajneesh had deliberately contaminated restaurant salad bars there. ''The possibility of deliberate contamination has been on every investigator's list since the Rajneesh incident and it has greatly influenced how we approach outbreaks of illness,'' said Dr. Thomas J. Torok, an epidemiologist at the Federal Centers for Disease Control and Prevention in Atlanta who participated in the Oregon investigation

OBJECTIVE:To determine whether IV pyelography (IVP) is required routinely for all patients presenting to the ED with ureteral colic. METHODS:A randomized prospective study was conducted with 2 patient groups-a routine IVP group, in which all patients underwent IVP, and a selective IVP group, in which patients were treated, observed, and released without undergoing IVP unless they experienced continued symptoms. The study was performed in a large university-affiliated, community hospital ED. Participants were patients aged 18-65 years with signs and symptoms consistent with ureteral colic. RESULTS:Among the 40 patients enrolled in the routine IVP group, 26 had positive studies, 8 of which necessitated hospitalization. Among the 41 patients randomized to the selective IVP group, there were only 19 IVPs performed, of which 6 were positive and 4 necessitated hospitalization. Compared with the routine IVP group, there were 54% fewer FVPs performed and a 51 % lower admission rate in the selective IVP group. Despite the fact that fewer IVPs were performed in the selective IVP group, clinical outcomes in the 2 groups were similar, without significant complication in either group. CONCLUSIONS:IVPs do not need to be routinely performed for all patients presenting to the ED with ureteral colic. The decision to perform an IVP may be dictated by symptoms that persist after initial evaluation and treatment.