Faculty Bibliography

In the tests, injections of the vaccine, called Remune, will be added to standard combination drug therapy for HIV, the AIDS virus. Such drugs can halt reproduction of HIV in infected cells, but do not eradicate the virus from those who are infected. Remune is intended to be a therapeutic vaccine, to stimulate the immune system to destroy HIV-infected cells

The National Institutes of Health is poised to begin its first full-scale tests of a vaccine for people already infected with the HIV virus, the vaccine's manufacturer said Wednesday. In the tests, injections of the vaccine, called Remune, will be added to standard combination drug therapy for HIV, a virus that can develop into AIDS. Such drugs can halt reproduction of HIV in infected cells, but do not eradicate the virus from those who are infected. Remune is intended to be a therapeutic vaccine, to stimulate the immune system to destroy HIV-infected cells. The study aims at determining whether Remune will keep the levels of HIV in the blood suppressed longer than anti-HIV drug therapy alone, and thwart progression of infection to AIDS

Injections of the vaccine, called Remune, will be added to standard combination drug therapy for HIV, the AIDS virus. Such drugs can halt reproduction of HIV in infected cells, but do not eradicate the virus from those who are infected. The study aims at determining whether the vaccine will keep the levels of HIV in the blood suppressed longer than anti-HIV drug therapy alone, and thwart the onset of AIDS proper. The vaccine, developed in the late 1980s by Dr. Jonas Salk, the polio vaccine pioneer, is derived from HIV that is grown in test tubes and then killed by chemicals and irradiation. It is later mixed with mineral oil as an adjuvant aimed at boosting its power to stimulate the immune system

Like Mayor Rudolph W. Giuliani, 180,000 American men will suddenly learn this year that they have prostate cancer, and what makes their decisions about treatment so difficult is that doctors do not know which one is most effective. Alternatives include surgical removal of the prostate, radiation (delivered externally or implanted as ''seeds''), techniques to freeze and destroy the prostate, early hormonal therapy and watchful waiting. While there is no standard plan for such observation, it usually involves monitoring blood tests to determine if the prostate specific antigen level rises, rectal examinations to determine if prostate nodules develop and checking for developing symptoms. ''We don't know what the best treatment option is for men who are found to have prostate cancer and doctors do not always clearly say that to patients,'' said Dr. Timothy J. Wilt, who is directing a national study on outcomes of prostate cancer treatments

BACKGROUND: Black patients undergo coronary artery bypass grafting and percutaneous transluminal coronary angioplasty less often than white patients. It is unclear how racial differences in clinical factors contribute to this variation. METHODS: A retrospective cohort study was performed of 666 male patients (326 blacks and 340 whites), admitted to 1 of 6 Veterans Affairs hospitals from October 1, 1989, to September 30, 1995, with acute myocardial infarction or unstable angina who underwent cardiac catheterization. The primary comparison was whether racial differences in percutaneous transluminal coronary angioplasty and coronary artery bypass grafting rates persisted after stratifying by clinical appropriateness of the procedure, measured by the appropriateness scale developed by the RAND Corporation, Santa Monica, Calif. RESULTS: Whites more often than blacks underwent a revascularization procedure (47% vs 28%). There was substantial variation in black-white odds ratios within different appropriateness categories. Blacks were significantly less likely to undergo percutaneous transluminal coronary angioplasty (odds ratio, 0.30; 95% confidence interval, 0.14-0.63 [P<.01]) when the indication was rated "equivocal." Similarly, blacks were less likely to undergo coronary artery bypass grafting (odds ratio, 0.44; 95% confidence interval, 0.23-0.86 [P<.01]) when only coronary artery bypass grafting was indicated as "appropriate and necessary." Differences in comorbidity or use of cigarettes or alcohol did not explain these variations. Using administrative data from the Veterans Health Administration, we found no differences in 1-year (5.2% vs 7.4%) and 5-year (23.3% vs 26.2%) mortality for blacks vs whites. CONCLUSION: Among patients with acute myocardial infarction or unstable angina, variation in clinical factors using RAND appropriateness criteria for procedures explained some, but not all, racial differences in coronary revascularization use.

Although clinicians without a sense of history may not be condemned to repeat the past, the historical record offers many informative lessons. For one thing, history demonstrates the changing nature of scientific knowledge; current understandings of health and disease may prove as ephemeral as earlier discarded theories. In addition, history reminds us that social and cultural factors influence how physicians diagnose and treat various medical conditions. When attempting to teach the history of medicine at academic medical centers, instructors should be innovative as opposed to comprehensive. Students and residents are likely to find recent historical issues to be more relevant, particularly when such material can be integrated into the existing curriculum. Provocative topics include depictions of medicine in old Hollywood films, the contributions made by famous physicians at one's own institution, and historical debates over controversial events, such as the Tuskegee syphilis study and the use of lobotomy in mental institutions in the 1950s.

BACKGROUND: Previous research has provided evidence for brain abnormalities in schizophrenia, but their relationship to specific clinical symptoms and syndromes remains unclear. METHODS: With an all-male demographically similar sample of 53 schizophrenic patients and 29 normal control subjects, cerebral gray and white matter volumes (adjusted for intracranial volume and age were determined for regions in the prefrontal lobe and in the superficial and mesial temporal lobe using T1-weighted magnetic resonance imaging with 2.8-mm coronal slices. RESULTS: As a group, schizophrenic patients had wide-spread bilateral decrements in gray matter in the pre-frontal (7.4%) and temporal lobe regions (8.9%), but not in white matter in these regions. In the temporal lobe, gray matter reductions were found bilaterally in the superior temporal gyrus (6.0%), but not in the hippocampus and parahippocampus. While there were no overall group differences in white matter volumes, widespread decrements in prefrontal white matter in schizophrenic patients (n = 53) were related to higher levels of negative symptoms (partial r[49] = -0.42, P = .002), as measured by the Scale for the Assessment of Negative Symptoms. A post hoc analysis revealed that schizophrenic patients with high negative symptoms had generalized prefrontal white matter reductions (11.4%) that were most severe in the orbitofrontal subregion (15.1%). CONCLUSIONS: These results suggest that gray matter deficits may be a fairly common structural abnormality of schizophrenia, whereas reductions in prefrontal white matter may be associated with schizophrenic negative symptoms

BACKGROUND: The authors have reviewed their initial experience with laparoscopic splenectomy (LS) to identify the indications, success rate, and complications associated with this procedure compared with a series of children undergoing open splenectomy (OS) during the same time period. METHODS: The records of 51 children who underwent splenectomy from 1993 through 1998 were reviewed retrospectively. RESULTS: Thirty-five patients aged 1 to 17 years (mean, 9.4 years) underwent LS for the following indications: ITP (n = 20), sickle cell disease or thalassemia (n = 6), hereditary spherocytosis (n = 5), other hematologic disorders (n = 4). Seventeen patients aged 2 to 17 years (mean, 11.8 years) underwent OS during the same time period for ITP (n = 4), sickle cell disease or thalassemia (n = 4), hereditary spherocytosis (n = 5), and other indications (n = 4). Concomitant cholecystectomy was performed in 4 of 35 LS and 4 of 17 OS. Accessory spleens were identified in 10 of 35 LS and 2 of 17 OS cases. Eleven spleens were enlarged in the LS group, and 8 were enlarged in the OS group. One LS required conversion to an open procedure because the spleen did not fit in the bag. No other cases were converted. Median estimated blood loss was 50 mL for both the LS and OS groups. The only intraoperative complication in the LS group was a splenic capsular tear, which had no effect on the successful laparoscopic removal of the spleen. No patient in either group required a blood transfusion. The LS patients had a shorter length of hospital stay (1.8 +/- 1 versus 4.0 +/- 1 day, P = .0001). Total hospital charges were not significantly different. Follow-up ranged from 6 to 40 months. One LS patient died 47 days postoperatively from unrelated causes. Two LS patients had recurrent ITP; accessory spleens were found in one and resected laparoscopically. CONCLUSION: LS in children can be performed safely with a low conversion rate (2.9%) and is associated with a shorter hospital stay and comparable total hospital cost when compared with OS.

OBJECTIVES: To measure the frequency of people reporting torture among patients in a medical outpatient clinic and to determine primary care physicians' awareness of their patients' exposure to torture. DESIGN: Cross-sectional survey followed by selected in-depth interviews of participants reporting a history of torture. Medical record review and interview of torture survivors' primary care physicians. SETTING: The internal medicine clinic of a large, urban medical center. PARTICIPANTS: A convenience sample of 121 adult patients who were not born in the United States and who were attending the adult ambulatory care clinic. INTERVENTIONS: All participants were interviewed using the Detection of Torture Survivors Survey, a validated instrument that asks about exposure to torture according to the World Medical Association definition of torture. Participants who reported a history of torture were interviewed in depth to confirm that they had been tortured. We reviewed the medical records of participants who reported a history of torture and interviewed their primary care physicians. MAIN OUTCOME MEASURES: Self-reported history of torture. The awareness of primary care physicians of this history. RESULTS: Eight of 121 participants (6.6% [95% confidence interval: 3.1%-13.1%]) reported a history of torture. None of the survivors of torture had been identified as such by their primary care physician. CONCLUSIONS: Physicians of patients who have not been born in the United States and who attend urban general medical clinics frequently are unaware that their patients are survivors of torture. Primary care physicians can be the locus of intervention in the care of torture survivors. The first step is for physicians to recognize the possibility of torture survivors among their patients

Lamm discusses his mission as a doctor: to continue to serve as a repairman and fix people who are ill and to become a "coach" for his healthy patients. Lamm keeps abreast of the latest medical studies and breakthroughs and recommends any appropriate screening tests