Faculty Bibliography

BANGKOK, THAILAND - A day after Thai and international officials confirmed the first probable human-to-human transmission of a virulent strain of avian influenza in this country, public health systems around the globe were scrambling to prepare for a possible pandemic. The United States, like governments in Australia, Japan, New Zealand and a small number of other countries, is also stockpiling the only antiviral medicine that may work against the strain, Tamiflu, but there have been too few human cases to document its effectiveness. The symptoms of human bird flu appear to be indistinguishable from severe cases of conventional flu, with fevers, sneezing, coughing and aches. Only Aventis Pasteur Inc. of Swiftwater, Pa., and the Chiron Corp. of Emeryville, Calif., are braving a thicket of patent issues and financial feasibility concerns to try to use advanced genetic techniques to develop vaccines against so-called bird flu. And they have proceeded only with National Institute of Health contracts to do so

Other drug makers have given several reasons for not making vaccines: that production is expensive and investment may not be recouped if there is no pandemic, and that intellectual property rights on new techniques used to make the vaccine remain unsettled. The standard method for making flu vaccines -- growing virus in chicken embryos -- does not work because the A(H5N1) virus is so deadly that it kills the developing chicks before they can grow enough virus to be worth harvesting. The new techniques alter the strain's genetics so it can be grown in the fertilized eggs. Tamiflu is made only by Roche Holding, a Swiss company, at a single small factory in Europe, although the company has said in recent months that it plans to build another production line in the United States. Some public health experts are strongly critical of Roche for not increasing production of Tamiflu sooner, saying the company should have expanded production early this year, when avian influenza started becoming a problem across much of Asia. ''You're dealing with very conservative Swiss bankers -- to me, they don't see the opportunity yet,'' said Arnold Monto, a University of Michigan influenza expert, pointing out that Tamiflu not used for an avian influenza pandemic could be used instead to make human influenza less severe

Health officials would normally look to vaccines and antiviral drugs to control a pandemic, but in this case, those tools have yet to be fully developed and tested. Conventional flu vaccines are not believed to provide any protection against A(H5N1) avian influenza. Human trials of the new vaccine ordered by the U.S. government are not expected to begin until the end of this year, at the earliest. The United States -- like governments in Australia, Japan, New Zealand and a small number of other countries -- is also stockpiling the only antiviral medicine that may work against the strain, Tamiflu, but there have been too few human cases to document its effectiveness. The symptoms of human bird flu appear to be indistinguishable from severe cases of conventional flu, with fevers, sneezing, coughing and aches

P/>BANGKOK, Thailand - A day after national and international officials confirmed the first probable human-to-human transmission of a virulent strain of avian influenza in this country, public health systems around the globe were scrambling to prepare for a possible pandemic.<P/>Scientists say they can't predict how quickly, if at all, the strain may develop the ability to spread easily among people, or whether it will remain as lethal as it has proved so far.<P/>The strain, A(H5N1), has killed 30 of the 42 Southeast Asians it infected in the past year, and millions of chickens and wild birds, across wide areas of Asia.<P/> It also has infected pigs, household cats and even zoo tigers.<P/>A handful of cases of human-to-human transmission may have occurred during bird flu outbreaks in Hong Kong in 1997 and in Europe a year ago, but neither resulted in a pandemic.<P/>Nevertheless, public health experts say it would be irresponsible not to prepare for a worst-case scenario.<P/>The so-called Spanish Flu pandemic of 1918 to 1919 - believed, like the current strain, to have been a mutant virus that jumped from animals - killed an estimated 20 million to 100 million people.<P/>And that was before the development of the modern transportation system, with its fleets of jets linking remote..

Health officials would normally look to vaccines and antiviral drugs to control a pandemic, but in this case, those tools have yet to be fully developed and tested. Conventional flu vaccines are not believed to provide any protection against A(H5N1) avian influenza. Human trials of the new vaccine ordered by the U.S. government are not expected to begin until the end of this year, at the earliest

According to Fred Feit, director of interventional cardiology at New York University Medical School, the goal these days is to 'come with the treatment that is least invasive.' Feit said that over a recent two-day period, he catheterized 17 patients, snaking a tiny tube from the groin up into the coronary arteries. He sent only one for bypass; the rest received stents. Stents are tiny mesh cylinders are made of metal and coated these days with a drug that retards clogging. They are floated into the artery with a catheter and then snapped into place. With the latest technology, each stent appears to have less than a 10 percent chance of closing up over the first six months. Feit says stent placement is safer, with an in-hospital mortality rate of only 0.7 percent, compared with 1.4 to 2.1 percent for bypass surgery. In addition, bypass surgery poses other risks: heart attack immediately after surgery (3 percent), wound infection (3 percent), bleeding (3 to 5 percent) and heart arrhythmias (30 percent). After recommending surgery, [Craig R. Smith] had a second major decision to make: whether to operate on a beating heart. That was his initial preference because of the lower risk of complications. But after Smith opened [Bill Clinton]'s chest, he reversed his decision after discovering that one of the arteries he had to bypass was buried within a thickened heart muscle. Stopping the heart allowed him better access. Cooling and potassium-containing solution stops the heart, and the patient is kept alive by filtering the blood through a heart lung machine until the heart is restarted with a shock

The other reason I enjoy our visits is that [Wilamena Hernandez] is from Peru. Peruvian Spanish is clear and steady. Each word is fully articulated, and every letter is pronounced -- crucial elements for a mid-level Spanish speaker like me. In these visits I feel as if I have truly mastered the language, because I can understand just about every word she says. I'm confident that almost nothing is shortchanged in our encounter and that language is not an impediment to good medical care. In the ideal world, I would have been able to stay there with Hernandez and understand every word she uttered. But my Spanish simply wasn't that good. However, if an interpreter had been present, would Hernandez have spoken as freely about her painful memories and current anxieties? With languages such as Cantonese or Bengali I have no choice: I must use some sort of go-between to communicate with my patients. But with my Spanish-speaking patients I face an odd dilemma: I speak enough Spanish to cover most situations, but not enough to call myself fully fluent. I could conduct the interview in Spanish and offer my patients the comfort of communicating directly in their native language. Or I could use an admittedly awkward interpreter to ensure that I get all the details. Are the gains in comfort and connection worth the loss of detail? Are the gains in accuracy worth the loss of intimacy? In either case, it seems, I'm practicing medicine with imperfect skills

Dr. [Craig R. Smith] said in an interview that this was ''pretty common.'' He added that stress tests ''are simply imperfect ways to assess the situation,'' whether the tests are the type in which patients are hooked up to an electrocardiogram or scans taken after patients have received a radioisotope like thallium. ''They have a fairly high false negative rate,'' Dr. Smith said. In Mr. [Bill Clinton]'s case, the timing of the exercise test may have been critical. It can take years for fatty deposits to build up enough to block coronary arteries, producing angina and ultimately, a heart attack. But angina and heart attacks also can result from so-called vulnerable plaques, when small deposits in largely open coronary arteries rupture and cause the sudden formation of blood clots to block an artery. So results before and after such rupture could differ. Standard exercise tests measure the heart's physiologic responses and cannot show the anatomical contour of coronary arteries, as angiogram X-rays do. But standard angiograms have risks because they are invasive techniques, involving the insertion of a tube into an artery in the leg or arm to inject dye to outline blood vessels