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Some experts have recommended the use of anthrax vaccine in combination with antibiotics to treat the inhalation form of the disease. But the agency does not support such a treatment, because evidence is lacking about the vaccine's benefit in treating inhalation anthrax, [Julie L. Gerberding] said

Officials are recommending a 10-day course of the powerful antibiotic Cipro for thousands of postal workers around Washington while epidemiologists figure out who among them were most likely to have been infected. Those at risk would receive a 60-day course of Cipro or other equally effective antibiotics.Dr. Anne Schuchat, an epidemiologist at the Centers for Disease Control and Prevention in Atlanta, said in an interview that the four Washington postal workers who came down with inhaled anthrax -- two of whom died on Monday -- experienced initial symptoms of fever, headache, chills, sweating and malaise for a couple of days -- in short, the symptoms of flu. The recommendations apply only to areas where inhaled anthrax has been diagnosed or is strongly suspected. Elsewhere, flulike symptoms ''would not make us think of anthrax,'' said Dr. Schuchat, who is an expert in the epidemiology of respiratory illness. Because chest X-rays of postal workers in the early stage of inhalation anthrax have shown the swollen lymph nodes, Dr. Schuchat said, her agency is urging doctors to consider taking X-rays and carefully examining them for the abnormality. ''The mediastinal X-ray findings were immediate clues that something unusual was going on,'' she said, and led to more extensive testing that detected anthrax in the patients

Dr. Anne Schuchat, an epidemiologist at the Centers for Disease Control and Prevention, said in an interview that the four Washington postal workers who came down with inhaled anthrax -- two of whom died on Monday -- experienced initial symptoms of fever, headache, chills, sweating and malaise for a couple of days -- in short, the symptoms of flu. Anthrax bacilli that reach the small air sacs of the lung are carried by scavenger cells to the mediastinum, a space between the back of the lungs and the spine, where they cause lymph nodes to swell. Those swollen nodes are a characteristic finding in inhalation anthrax. Because chest X-rays of postal workers in the early stage of inhalation anthrax have shown the swollen lymph nodes, Schuchat said, her agency is urging doctors to consider taking X-rays and carefully examining them for the abnormality

What the drug company is not telling either patient or doctor is that [Cipro] was originally tested as an alternative treatment for anthrax only for penicillin-allergic patients. Antibiotics have never been properly tested for prophylaxis, so Cipro's usefulness for prevention is speculative, though there is clearly some rationale for prophylaxing patients with close exposure. But doxycycline, a generic, is just as effective and costs one-tenth of what Cipro costs. A month's supply of Cipro costs more than $300 US; the equivalent amount of doxy is $32

Yesterday's decision by public health officials to treat thousands of postal workers with Cipro just days after warning against over-prescribing the antibiotic was essentially an acknowledgment that they are struggling to contain an outbreak of anthrax for which there is no precedent. There is hardly any human data on the effects of inhaled anthrax spores. The only known epidemic in the history of the United States occurred at a mill in New Hampshire in 1957, when four of five workers infected died from the disease. The dose was uncertain because the workers might have inhaled differing amounts over several days. Dr. [Donald A. Henderson] said he hoped public health officials could persuade people to trust penicillin and doxycycline, antibiotics that animal experiments have shown to be as effective as Cipro in treating inhalation anthrax

Anthrax was not suspected when Mr. [Ernesto Blanco], who suffered from chronic lung disease, was admitted to Cedars for pneumonia on Oct. 1. The underlying lung disease might have made him more susceptible to inhalation anthrax. Because he worked at American Media, a swab of his nose was taken, and it showed anthrax spores. He did not show classic symptoms of inhalation anthrax, which suggests that doctors may need to modify their description of the condition, and his case was re-classified as ''atypical inhalation anthrax.'' The change was based on laboratory tests that showed evidence of Bacillus anthracis in bloody fluid in the sac covering his lungs. Anthrax spores can cause different types of infection, depending on where they enter the body. If they invade via a break in the skin, the result is cutaneous anthrax, which often resolves without treatment and is easily cured by antibiotics. But if the spores are breathed into the lungs, inhalation anthrax can occur. Doctors believe that the inhalation form is often fatal because by the time the symptoms of infection appear, a bacterial toxin is already doing its deadly work, and it may be too late for antibiotics to help. Second, an epidemiologic study in 1957 found that four of five workers died after contracting inhalation anthrax at a goat-hair processing plant in Manchester, N.H., over 10 weeks. The workers were all too familiar with anthrax; in the previous 16 years, 136 had developed cutaneous anthrax, the most curable form. Although air sampling showed that workers often breathed Bacillus anthracis spores at the plant, none developed inhalation anthrax until 1957

An envelope that might (or might not) be filled with ominous powder, the possibility that someone might slip across a border with a jar of viruses, the impossibility of guarding every subway entrance and roof ventilator against a terrorist with a spray can: ''In these times,'' said Dr. Frank Bia, an expert on infectious diseases and microbiology at Yale, ''the unthinkable has become thinkable.'' The response to confirmed anthrax cases in Florida, New Jersey, New York and Washington, is being viewed as a painful drill that has exposed gaping deficiencies in the country's ability to cope with bioterrorism. Experts on infectious diseases cited a number of areas that needed to be improved, including these: ''Our imaginations have not been broad enough,'' said Dr. Frank Bia, an expert in infectious diseases and microbiology at Yale. ''When someone comes to the emergency room with something unusual, doctors must trust their instincts and sixth sense to make the pieces fit together.''

Under the lights of my examination room, I realized that it was his manner that had altered the most; formerly confident, even strident, now he leaned against the counter, not wanting to sit. He hunched over, wringing his hands, looking every few seconds toward the window. In my consultation room I explained to the patient that the risks of taking this expensive antibiotic for an extended period far outweighed any potential benefit against an inconceivable microbe; that with prolonged use of the medicine he might develop diarrhea, colitis, rash, even bleeding or insomnia. ''Wait,'' I said. But he ignored me. He was heading for my supply closet at the front of the office. Without hesitation, he began rummaging through it. My nurse, who had never before seen a patient so boldly enter a private area of the office, seemed afraid to intervene. The patient knocked over pill boxes until he found the antibiotic he was looking for, and then he stuffed it into his pockets until my supply was exhausted. He left the office then, without saying goodbye to anyone

The CBS News building, on West 57th Street in Manhattan, was not evacuated. Workers -- including the woman who tested positive for anthrax spores -- remained at their jobs. And health officials did not recommend antibiotic treatment for large numbers of workers. All this was in sharp contrast to the response at NBC when a case of cutaneous anthrax was diagnosed in an assistant to Tom Brokaw on Oct. 9, said Dr. Stephen M. Ostroff, an epidemiologist from the Centers for Disease Control and Prevention. It is not clear when she was exposed to anthrax spores, but the normal incubation period for cutaneous anthrax is one to seven days. Anthrax is not contagious, so the risk of her co-workers' developing it is almost negligible, said Dr. Ostroff, who is in New York City supervising the agency's investigation of cases associated with NBC, ABC and CBS. Only one person has developed cutaneous anthrax at each network, Dr. Ostroff said. Also, anthrax spores have not been identified in any of the nasal swabs taken among more than 300 co-workers of Erin O'Connor, the NBC employee who developed cutaneous anthrax, Dr. Ostroff said

The nuclear receptors liver X receptor alpha (LXRalpha) (NR1H3) and LXRbeta (NR1H2) are important regulators of genes involved in lipid metabolism, including ABCA1, ABCG1, and sterol regulatory element-binding protein-1c (SREBP-1c). Although it has been demonstrated that oxysterols are LXR ligands, little is known about the identity of the physiological activators of these receptors. Here we confirm earlier studies demonstrating a dose-dependent induction of ABCA1 and ABCG1 in human monocyte-derived macrophages by cholesterol loading. In addition, we show that formation of 27-hydroxycholesterol and cholestenoic acid, products of CYP27 action on cholesterol, is dependent on the dose of cholesterol used to load the cells. Other proposed LXR ligands, including 20(S)-hydroxycholesterol, 22(R)-hydroxycholesterol, and 24(S),25-epoxycholesterol, could not be detected under these conditions. A role for CYP27 in regulation of cholesterol-induced genes was demonstrated by the following findings. 1) Introduction of CYP27 into HEK-293 cells conferred an induction of ABCG1 and SREBP-1c; 2) upon cholesterol loading, CYP27-expressing cells induce these genes to a greater extent than in control cells; 3) in CYP27-deficient human skin fibroblasts, the induction of ABCA1 in response to cholesterol loading was ablated; and 4) in a coactivator association assay, 27-hydroxycholesterol functionally activated LXR. We conclude that 27-hydroxylation of cholesterol is an important pathway for LXR activation in response to cholesterol overload.