Faculty Bibliography

A patient with newly diagnosed end-stage renal disease (ESRD) received a femoral catheter for hemodialysis (HD). Shortly thereafter he developed fever, and blood cultures grew methicillin-resistant Staphylococcus aureus. The catheter was removed and the patient was treated with both vancomycin and rifampin; however, blood culture positivity persisted. The cerebrospinal fluid showed sterile meningitis. Subsequent imaging studies demonstrated aortic valve endocarditis and multiple mycotic aneurysms that appeared to include the intra- and extracranial vessels. The patient eventually died from sepsis. This case illustrates the aggressive and invasive nature of systemic infection with S. aureus and underscores the high morbidity and mortality associated with infections related to HD catheters.

SETTING/METHODS:Large urban tuberculosis control program. OBJECTIVES/OBJECTIVE:To determine the frequency and characteristics of treatment interruptions, and the factors associated with the different types of treatment interruptions. DESIGN/METHODS:This was a case-control study using culture-positive tuberculosis (TB) patients verified in 1998-1999. Case patients included those in whom any of the following mutually exclusive categories of treatment interruption: default with return to therapy, directly observed therapy nonadherence, default without return to therapy, or multiple types of interruptions. Controls were selected randomly from the cohort. RESULTS:Overall, 6.0 percent of patients had treatment interruptions. All types of treatment interruption were associated with prolonged treatment course and decreased treatment completion rates. The median number of months to treatment interruption was 4.0 (range, 0.5-28.9 months). Two factors were significantly associated with every type of interruption: homelessness and lack of awareness of the severity of TB disease. In multivariate analysis, only lack of awareness of the severity of disease remained independently associated with all interruption types. CONCLUSION/CONCLUSIONS:Efforts to improve patients' understanding of TB disease and related treatment issues may be an important TB control program strategy and should be emphasized at the initiation of therapy and at intervals throughout the treatment course to minimize treatment interruption.

How the Food and Drug Administration (FDA) responds to criticism of its drug safety process will determine whether drug safety actually improves. Propping up the Office of Drug Safety with more bureaucratic prominence or adding new requirements to the preapproval process will add to the cost of drug development and not make drugs safer. New information tools can dramatically improve postmarketing surveillance and collection of data on safety. This information could then be used to reach more definitive regulatory conclusions sooner. New incentives will be needed to entice payers and product developers to work on building a broader, more robust system for collecting data on drug safety

Surgeons can generally learn the on-pump operation faster than the off-pump technique because it is technically less demanding. Also, the report said, surgeons can generally perform more grafts, if necessary, in an on-pump bypass, and the grafts may stay open longer. A controversy has developed over some evidence that a small but significant number of on-pump bypass patients suffer a degree of cognitive impairment like memory and attention deficits and language problems. Such problems tended to occur less among patients whose bypasses were performed with the beating-heart technique compared with the stopped-heart technique, the team said. The extent of the decrease was not detailed. The most conclusive benefit of off-pump over on-pump operations was for patients who had deposits of calcium in their aortas, the body's main artery. When surgeons clamp the aorta in the on-pump technique, small pieces can break off to cause disabling and fatal strokes

The vaccine, sold as Menactra by Sanofi Pasteur, protects against infections caused by meningococcal bacteria. Such infections include a form of meningitis that can be rapidly fatal. In a third recommendation, the agency recommended that all college freshmen living in dormitories be immunized against meningococcal disease. The new recommendation strengthened an earlier one that said freshmen should consider such protection. Menactra does not protect against type B meningococcal infection, for which no vaccine is licensed or available in the United States, the agency said

The vaccine, sold as Menactra by Sanofi Pasteur, protects against infections caused by meningococcal bacteria. Such infections include a form of meningitis that can be rapidly fatal. In a third recommendation, the agency recommended that all college freshmen living in dormitories be immunized against meningococcal disease. The new recommendation strengthened an earlier one that said freshmen should consider such protection. Menactra does not protect against type B meningococcal infection, for which no vaccine is licensed or available in the United States, the agency said

The vaccine, sold as Menactra by Sanofi Pasteur, protects against infections caused by meningococcal bacteria. Such infections include a form of meningitis that can be rapidly fatal. In a third recommendation, the agency recommended that all college freshmen living in dormitories be immunized against meningococcal disease. The new recommendation strengthened an earlier one that said freshmen should consider such protection. Freshmen living in close quarters of dormitories are at a higher risk for meningococcal disease compared with peers the same age who are not at college

The study's authors, from Tufts University, said it was prudent for doctors to consider prescribing rival statins instead of Crestor as a first therapy to prevent heart attacks and stroke. They said Crestor could be useful for high-risk patients for whom rival statins did not lower cholesterol levels to recommended ranges

Dr. [Sandra J. Horning], who practices and does research on lymphomas at Stanford, wanted to be a doctor since she was 14. Her father died of cancer when she was 21 and a medical student. Her mother has survived two types of cancer. That family experience ''helped me in a way understand and perhaps be better prepared to deal with some of the emotional issues that are related to cancer diagnosis, treatment and survival,'' Dr. Horning said. ''But at the same time I thought about my career,'' Dr. Horning said. ''Medicine is more than a career. For me it is a passion.'' As an oncologist, she was better informed than other people. Still, she said, she sought opinions from breast cancer specialists elsewhere, and she avoided directing her care. So she bought a wig. Her patients, friends and family, said Dr. Horning, who is a blond, ''saw me as a redhead.'' Dr. Horning said that in caring for patients she placed communications at the top of the list. The reason, she said, is that while she was training to become an oncologist, a patient told her that whenever Dr. Saul A. Rosenberg, Dr. Horning's mentor, entered the room, his presence made that seriously ill patient feel better

The study's authors, from Tufts University, said it was prudent for doctors to consider prescribing rival statins instead of Crestor as a first therapy to prevent heart attacks and stroke. They and other experts like Dr. Valentin Fuster, chief of cardiology at Mount Sinai Medical Center, said Crestor could be useful for high-risk patients for whom rival statins did not lower cholesterol levels to recommended ranges. After an exhaustive review of the same information used by Dr. [Richard H. Karas]'s team and Public Citizen, the drug agency concluded that ''all of the available evidence'' showed that Crestor had no greater risk of muscle toxicity or serious kidney damage than the rival statins Lipitor, Pravachol and Zocor. Patients taking Crestor were eight times more likely to develop rhabdomyolysis, kidney failure or spillage of protein in the urine than patients taking Pravachol, 6.5 times more likely to develop such complications than patients taking Lipitor, and 2.2 times more likely than those taking Zocor