Faculty Bibliography

BACKGROUND: A vaccine to prevent herpes zoster was recently approved by the United States Food and Drug Administration. We sought to determine the cost-effectiveness of this vaccine for different age groups. METHODS: We constructed a cost-effectiveness model, based on the Shingles Prevention Study, to compare varicella zoster vaccination with usual care for healthy adults aged >60 years. Outcomes included cost in 2005 US dollars and quality-adjusted life expectancy. Costs and natural history data were drawn from the published literature; vaccine efficacy was assumed to persist for 10 years. RESULTS: For the base case analysis, compared with usual care, vaccination increased quality-adjusted life expectancy by 0.0007-0.0024 quality-adjusted life years per person, depending on age at vaccination and sex. These increases came almost exclusively as a result of prevention of acute pain associated with herpes zoster and postherpetic neuralgia. Vaccination also increased costs by $94-$135 per person, compared with no vaccination. The incremental cost-effectiveness ranged from $44,000 per quality-adjusted life year saved for a 70-year-old woman to $191,000 per quality-adjusted life year saved for an 80-year-old man. For the sensitivity analysis, the decision was most sensitive to vaccine cost. At a cost of $46 per dose, vaccination cost <$50,000 per quality-adjusted life year saved for all adults >60 years of age. Other variables related to the vaccine (duration, efficacy, and adverse effects), postherpetic neuralgia (incidence, duration, and utility), herpes zoster (incidence and severity), and the discount rate all affected the cost-effectiveness ratio by >20%. CONCLUSIONS: The cost-effectiveness of the varicella zoster vaccine varies substantially with patient age and often exceeds $100,000 per quality-adjusted life year saved. Age should be considered in vaccine recommendations.

''Quite honestly, I didn't believe it,'' said Dr. [Steven E. Ross], who directs the level one, or most highly accredited, trauma center at the hospital. But he immediately alerted security guards and the public relations staff so they would ''keep people out of my hair'' and help him avoid ''the distractions'' that can interfere with the care of V.I.P.'s. ''All of us thought he would survive,'' Dr. [Robert F. Ostrum] said. He did not ''paint a bleak picture,'' he said, adding, ''but I wanted them to understand the severity of the injuries.'' ''It's counterproductive to tell somebody everything's going to be fine, and then when you do have problems, hear, 'Doctor, you told us everything was going to be fine,' '' Dr. Ross said. ''I would rather tell them about the realities and have everybody happy when things go well.''

Stranger's Heart [Television Program] -- Another patient in the ward, Jasper Kates (Peter Dobson), reassures her that she will soon have a heart because type A blood is easier to match. Jasper, a big man who loves to dance, says he has been waiting three months because large hearts are more difficult to find. Ultimately, they receive their hearts around the same time. [Callie Morgan] recovers quickly, complaining only of bleeding gums and some emotional difficulties, but Jasper develops a life-threatening infection, a risk of the immuno-suppressive therapy (cyclosporine). It turns out that Callie and Jasper have received their hearts from a married couple who died in a car accident, and when they are drawn to each other and to the couple's surviving daughter, Callie calls it 'cell memory.'

'Calling in Dr. [Michael DeBakey] was very important, a signal that he was in very serious condition, and consulting with a world leader in surgery this way was almost unthinkable in the Soviet period,' said Marshall Goldman, a Russian expert and senior scholar at Harvard. 'It was a measure of Dr. DeBakey's stature in Russia.' As a patient, [Boris Yeltsin] 'was not as bossy with me as he was with some of his Russian doctors,' DeBakey said, adding: 'He didn't get along with some of the doctors there. But he took a liking to me, listened, and that made things much better.' My requests for interviews with Yeltsin were always denied, so I was never able to ask him about DeBakey. But in a foreword to the Russian edition of DeBakey's book The New Living Heart (Adams, 1997), written with Antonio Gotto Jr., Yeltsin described DeBakey as 'a magician of the heart' and 'a man with a gift for performing miracles.'

'Dr. [Albert Herrera] talked to me for over an hour and asked about my job,' [Andrea Untrojb] told me by e-mail. 'He not only wanted to know about my physical pain, but wanted to find out what else could be causing my emotional distress. I told him that my job put such a strain on me that I was coming home crying every day, yelling at my kids and arguing constantly with my husband. Dr. Herrera reassured me that many suffered with this problem. He gave examples from his own life and told me what I could do to relieve the stress,' including routines, meditation and exercise. While doctors often blame their lapses in attention and rushed demeanor on time pressures exerted by managed care, others say they can only preserve their identity as healers by remaining engaged and caring, regardless of the reimbursement. Pauline Chen, transplant surgeon and author of 'Final Exam: A Surgeon's Reflections on Mortality' (Knopf, 2007), writes: 'That honor of worrying -- of caring, of easing suffering, of being present -- may be our most important task, not only as friends but as physicians, too.' As for the personal approach, [Linda Donald] is sold. 'If a physician is able to completely focus on you as a patient, the likelihood of an accurate diagnosis and appropriate treatment individualized to you is much greater. Not just an 'it seems like this, and therefore let's try that and see what happens -- come back next week.' '

''Calling in Dr. [Michael E. DeBakey] was very important, a signal that he was in very serious condition, and consulting with a world leader in surgery this way was almost unthinkable in the Soviet period,'' said Marshall I. Goldman, a Russian expert and senior scholar at Harvard. ''It was a measure of Dr. DeBakey's stature in Russia.'' As a patient, Mr. [Boris N. Yeltsin] ''was not as bossy with me as he was with some of his Russian doctors,'' Dr. DeBakey said, adding: ''He didn't get along with some of the doctors there. But he took a liking to me, listened, and that made things much better.'' My requests for interviews with Mr. Yeltsin were always denied, so I was never able to ask him about Dr. DeBakey. But in a foreword to the Russian edition of Dr. DeBakey's book ''The New Living Heart'' (Adams, 1997), written with Antonio Gotto Jr., Mr. Yeltsin described Dr. DeBakey as ''a magician of the heart'' and ''a man with a gift for performing miracles.''

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is a threat to human health worldwide. Although progress has been made, mechanisms of CA-MRSA pathogenesis are poorly understood and a comprehensive analysis of CA-MRSA exoproteins has not been conducted. To address that deficiency, we used proteomics to identify exoproteins made by MW2 (USA400) and LAC (USA300) during growth in vitro. Two hundred and fifty unique exoproteins were identified by 2-dimensional gel electrophoresis coupled with automated direct infusion-tandem mass spectrometry (ADI-MS/MS) analysis. Eleven known virulence-related exoproteins differed in abundance between the strains, including alpha-haemolysin (Hla), collagen adhesin (Cna), staphylokinase (Sak), coagulase (Coa), lipase (Lip), enterotoxin C3 (Sec3), enterotoxin Q (Seq), V8 protease (SspA) and cysteine protease (SspB). Mice infected with MW2 or LAC produced antibodies specific for known or putative virulence factors, such as autolysin (Atl), Cna, Ear, ferritin (Ftn), Lip, 1-phosphatidylinositol phosphodiesterase (Plc), Sak, Sec3 and SspB, indicating the exoproteins are made during infection in vivo. We used confocal microscopy to demonstrate aureolysin (Aur), Hla, SspA and SspB are produced following phagocytosis by human neutrophils, thereby linking exoprotein production in vitro with that during host-pathogen interaction. We conclude that the exoproteins identified herein likely account in part for the success of CA-MRSA as a human pathogen